Words&Dirt

Several friends recommended William R. Miller and Stephen Rollnick’s Motivational Interviewing as a reliable and longstanding practice that would be useful for an aspiring counselor to explore. The book is a terrific resource for professionals and laypeople interested in the language of change and dynamics of personal development.

Miller and Rollnick originally invented motivational interviewing (MI) in the 1980s as a talk therapy treatment for alcohol addiction. They have continued to evolve its theory and practice over the last several decades; MI is now used in a variety of contexts and has been fruitfully integrated with other therapeutic methods. The approach borrows the conceptual foundations of Rogerian client-centered therapy, but also departs from it by being considerably more goal-oriented. The explicit purpose of MI is to help clients change their lives in ways that will minimize harm and promote growth and flourishing:

Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion. (29)

In MI, the counselor’s prime directive is to draw out a client’s intrinsic motivations for change, rather than confronting them with extrinsic motivations or taking an authoritative tone:

Telling someone that “You can’t,” and more generally trying to constrain someone’s choices typically evokes psychological reactance, the desire to reassert one’s freedom. On the other hand, directly acknowledging a person’s freedom of choice typically diminishes defensiveness and can facilitate change. This involves letting go of the idea and burden that you have to (or can) make people change. It is, in essence, relinquishing a power that you never had in the first place. (19)

Motivational Interviewing is a process-oriented text that provides many concrete examples of how Miller and Rollnick’s theories succeed or fail in practice, as well as discussions of MI’s efficacy as demonstrated by academic research. The authors also have a talent for metaphor, often invoking creative references to music, dance, travel, and the natural world. The book strikes an excellent balance between instructional information and values-driven reflections on the art of therapeutic consultation.

Miller and Rollnick break down the method of MI into four stages: engaging, focusing, evoking, and planning. Their simplest articulation is as follows:

Engaging is about “Shall we travel together?”
Focusing asks “Where to?”
Evoking is about “Whether?” and “Why?”
Planning is about “How?” and “When?” (271)

The four stages occur in sequence as the client makes their way toward change, but Miller and Rollnick point out that any stage can be revisited as needed.

Engaging is the stage of MI that most closely resembles client-centered therapy. It is all about listening well, creating a safe and acceptant space for the client, and demonstrating empathic attention to the client’s perspective and needs. Miller and Rollnick’s descriptions and examples of “reflective listening” are especially helpful, making it easy to see why their method is so effective when utilized properly. “Processes for engaging do differ across cultures,” they write, “but listening lies at the heart of nearly all of them” (349).

Once a solid rapport has been established, the consultation enters the focusing stage. This is where counselor and client collaboratively explore goals for change and agree on an intended outcome or set of outcomes. Miller and Rollnick recommend that counselors adopt a “guiding” style––a compromise between “following” (allowing the client to dictate the direction of the conversation) and “directing” (taking the reins in order to produce the counselor’s desired outcome):

Midway between directing and following sits a guiding style. Guiding promotes a collaborative search for direction, a meeting of expertise in which the focus of treatment is negotiated. The client’s agenda is important, and any limitations inherent in the context are taken into account. The clinician’s expertise is also a possible source of goals. The focusing process of MI commonly starts in this middle ground between directing and following, where the focus, momentum, and content are mutually forged. (99)

After focusing comes evoking, which is arguably the most crucial and challenging of the four stages. Evoking is the process by which a counselor seeks to elicit and strengthen the client’s personal reasons for change. This is done through delving into the client’s ambivalence––their reasons for and against making the change or changes identified during the focusing stage. Careful attention is paid to “change talk” and “sustain talk”:

Sustain talk and change talk are conceptually opposite––the person’s arguments against and for change––and they predict different outcomes. A predominance of sustain talk or an equal mix of change and sustain talk is associated with maintenance of the status quo, whereas a predominance of change talk predicts subsequent behavior change. (165)

Affirming and encouraging change talk is the main mechanism by which MI practitioners help clients articulate and commit to their intrinsic motivations for change. “Evoking is a co-creative process through which the person’s potential for change is released,” Miller and Rollnick tell us. “The motivation for change is emerging even as you speak together.” (182) Here we see another strong connection to Carl Rogers’s theory of personal growth, which prizes client autonomy and asserts that meaningful and lasting change typically stems from behavioral adaptations that are self-chosen rather than imposed from the outside.

The planning stage is precisely what it sounds like. “Planning is the clutch that engages the engine of change talk,” where client and counselor work out the details of how to transform the client’s desires for change into reality (30). Miller and Rollnick provide many useful examples and resources for how this can be accomplished, all the while staying true to their ethos of supporting the client as they discover what works best for them.

Although MI certainly seems like a great system, there are a couple apparent limitations I’d like to highlight. The first is simply that much of MI won’t apply to clients who aren’t seeking change or don’t need to change their behavior in any profound way. The second is that, by locating the potential and responsibility for change primarily within the client, MI runs the risk of downplaying or ignoring structural factors that may render change difficult or even impossible. To their credit, Miller and Rollnick are aware of this issue and mention it several times in the book. It’s important to remember that, due to external circumstances completely beyond their control, some people seeking counseling may not have the power to transform their lives in the way MI suggests. This isn’t really a criticism, but rather an acknowledgment that MI is just one of many effective tools we can use to meet humanity’s variety of mental health needs.

Rating: 8/10