Psychology Expert Needed

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References

Westra, H. A., & Aviram, A. (2013). Core skills in motivational interviewing. Psychotherapy, 50(3), 273–278.

https://doi-org.library.capella.edu/10.1037/a0032409

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Core Skills in Motivational Interviewing

By: Henny A. Westra

Department of Psychology, York University, Toronto, Ontario, Canada;

Adi Aviram

Department of Psychology, York University, Toronto, Ontario, Canada

Acknowledgement:

Motivational interviewing (MI; Miller & Rollnick, 2002) is an evolution of the client-centered therapy

developed by Carl Rogers, who emphasized empathic understanding of the client’s internal frame of

reference, and therapist communication and provision of core facilitative relational conditions for

client growth and change, including accurate empathy, unconditional positive regard, and therapist

genuineness/congruence (Rogers, 1957). Similar to client-centered therapy, MI is fundamentally a

way of being with clients that seeks to promote a safe, collaborative atmosphere in which clients can

sort out their often conflicting feelings about change. In this sense, MI converges with the client-

centered tradition of prioritizing the therapeutic relationship as an essential vehicle in which greater

self-awareness can be developed and new meanings generated.

In MI, clients are regarded as the best experts on themselves, with the inherent and intrinsic

knowledge of what is best for them, and the freedom to make their own choices. The therapist

operates as an evocative consultant or guide in the client’s journey. In essence, through being

collaborative, evocative, and preserving and supporting autonomy, MI seeks to help clients recognize

themselves as an authority. MI promotes and supports clients’ active use of that authority to make

choices, informed by a heightened awareness of their best interests, values, and valued directions.

MI without this underlying spirit is akin to “words without music,” and is therefore not considered MI

(Rollnick & Miller, 1995). Indeed, in client accounts of their experiences of MI, therapist empathy, the

provision of safety, and the freedom to explore emerged as prominent aspects of this approach

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(Angus & Kagan, 2009; Marcus, Westra, Angus, & Kertes, 2011).

Whereas client-centered approaches are typically considered “nondirective,” MI is defined as a client-

centered, yet directive, approach. First, MI is intentionally focused on the exploration of ambivalence

about change. In that regard, MI therapists seek to create and sustain conversations about change,

as well as listen for and generate opportunities to help clients more fully explore their views on

change, while processing their often conflicting positions regarding change. Second, the core MI

skills (which are the focus of this article) involve a highly active therapist who is deliberately listening

for key process markers (e.g., ambivalence, resistance, and change talk). Stated differently, a key

aspect of MI is “learning to hear” process markers that indicate or signal the therapist to use specific

skills and move in particular directions. Several of these core skills and directions are covered in this

article, including rolling with resistance, expanding change talk, and developing discrepancy. Each of

the skills discussed is illustrated with a clinical example.

Rolling With Resistance

In MI, resistance is considered a product of the client’s ambivalence about change and how the

therapist responds to that ambivalence (Moyers & Rollnick, 2002). Thus, it is useful to consider two

types of resistance: (1) resistance to change or intrapsychic resistance, and (2) resistance to the

therapist and/or treatment (Miller & Rollnick, 2013; Westra, 2012). The first type of resistance occurs

within the client and reflects competing motivational forces, that is, “There is a part of me that knows I

need and want to change and yet, another part of me that stops me from changing.” This type of

resistance can be characterized as ambivalence about change, and reflects a client variable or

characteristic. Clients vary considerably in terms of their degree of ambivalence or “stuckness”

regarding change.

The second type of resistance is interpersonal and reflects opposition to the therapist and/or the

treatment. In this type of resistance, there must be someone or something to resist (i.e., client

resisting the therapist or application of the treatment methods). Although it is tempting to consider

opposition to the therapist and/or treatment as an aspect of the client, it is more typically a reflection

of interpersonal process gone awry. Often, such resistance arises from the therapist’s directive

(rather than supportive or exploratory) management of ambivalence. For example, the therapist may

indicate a preferred or “healthier” way of viewing a stressful situation and the client disagrees (e.g., “I

wish I could see it that way, but I don’t”), or the therapist may suggest a homework assignment and

the client objects (e.g., “That sounds too hard”). The presence of such interpersonal resistance

reflects a lack of collaboration and represents strains or ruptures in the therapeutic alliance, and it is

the responsibility of the therapist to take corrective action to resolve it (typically through the judicious

use of empathy) and reengage the client.

In their review of the literature on resistance, Beutler et al. concluded that there is strong and

consistent evidence that the effectiveness of psychotherapy is associated with the relative absence

of resistance (e.g., Beutler, Harwood, Michelson, Song, & Holman, 2011). Moreover, once identified,

the manner in which therapists respond to resistance plays a major role in its perpetuation or

diminishment. In particular, therapist directiveness has been found to reliably increase resistance

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(e.g., Beutler et al.), whereas supportive approaches have been found to decrease it (e.g., Miller,

Benefield, & Tonigan, 1993). Moreover, Aviram and Westra (2011) found that the use of MI before

cognitive behavioral therapy (CBT) for anxiety, relative to no MI before CBT, was associated with

large reductions in observed resistance, which in turn mediated treatment outcomes. Furthermore,

posttherapy accounts of clients who received MI before CBT revealed that they were more actively

engaged in CBT and experienced their CBT therapists as more collaborative than did participants

who did not receive MI (Kertes, Westra, Angus, & Marcus, 2011).

In many ways, MI may be considered primarily a way of managing resistance (whether intrapsychic

or interpersonal). A major contribution of MI to clinical practice is the provision of an alternative,

nonpejorative framework from which to view resistance, as well as accompanying clinical strategies

for effectively managing it. That is, regardless of whether the client articulates resistance to change

(i.e., arguments against change) or interpersonal opposition to the therapist (e.g., disagreement,

challenging, ignoring), MI provides a valuable way of thinking about and responding effectively in

these moments to foster client engagement. In general, the strategies indicated for responding to

both intrapsychic and interpersonal resistance are to “roll with it” or get alongside of it. Rather than

being considered as an obstacle to therapeutic progress, resistance is viewed as valuable

information to be understood, and one seeks to “hear the wisdom in it” (Miller & Rollnick, 2002;

Westra, 2012).

Clinical Illustration

We will use a consistent example in this article across the various skills discussed, to illustrate the

working through of ambivalence using these skills. Note that commentary on each of the illustrative

clinical dialogues appears in italics. Although we consider the skills separately for the purpose of

illustration, MI is by no means a linear process. Rather, the therapist interpolates the use of the

various skills in response to specific clinical markers in moving the client toward resolution of

ambivalence and, ultimately, the consideration of change.

Consider the case of a mother of a young son who presented with chronic and excessive worry

regarding the health and well-being of others. She presented to this session reporting an incident

with her son that triggered strong self-recrimination and worry. While tobogganing, her son’s

toboggan veered off course and he hit his head on a nearby pole. He was taken to hospital but was

discharged after the assessment revealed no significant injury. The client reported strong feelings of

self-recrimination (e.g., “I should have protected him,” “I’m a bad mother”) and rumination, repeatedly

revisiting and dissecting the accident in her mind. She described even greater worry and vigilance

regarding her son’s safety since the incident, reporting feeling helpless to protect him and

demoralized by this prospect. The client felt both “stuck” and compelled in her need to worry. Given

this ambivalence marker, the therapist sought to further help her reflect on her ambivalence by

moving with what was most alive, in this case the need to worry and ruminate.

C: And I know I shouldn’t dwell on this. I shouldn’t worry. But I can’t stop it. I just can’t help it. It

seems wrong to not worry. (Ambivalence marker).

T: Yes, even though you know it’s not good to dwell on this, something went horribly wrong and it

feels like it’s your job in a sense to worry about it. Is that how it feels?

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C: Yes. I should have done something, even though I know there was nothing I could have done. It

was an accident. But I can’t stop thinking about it.

T: So this is just a guess, but I wonder that by worrying about this and going over it in your mind,

there might be something to be learned here. And by retracing your steps, then maybe you can

prevent it from happening in future. Would that be right, would that be a part of it? (Therapist is

deliberately thinking “What’s good about ruminating and worrying in this context? How is worry

serving this client? What is it trying to help her with?”; the therapist then actively takes a guess at a

positive motive underlying rumination and worry and invites the client to decide whether this fits with

their experience).

C: Yes, It feels like I should be learning something here. There’s a lesson.

T: To help keep him safe in future. And that makes perfect sense. It sounds like you want to be a

good and responsible parent. This comes from a real place of caring. It reflects what a wonderful

mother you are that you are willing to go to great lengths, no matter what the personal cost, to protect

him. (Therapist prizing and actively reframing the “problematic” behavior as coming from and

reflecting a positive part of the person).

C: Yes, I would do anything for him. It scares me so much to know that there are things out there that

could hurt him and I just want to do everything I can to protect him from that.

T: I see. Of course. He’s so precious. And I wonder if it feels like you can’t let this go, because if you

did then that might be reckless in a way, maybe even irresponsible actually. You might worry then

about “What would that say about me… that I don’t care.” And then you might be concerned that you

won’t learn the things you should be learning. (Therapist further guessing at the wisdom of

rumination and the core needs being met by it; i.e., “rolling with resistance”; the therapist here is

thinking, “What’s bad about letting this go… about dropping the rumination? What would be lost if

she changed and stopped ruminating?” and is therefore guessing at fears of change).

C: Yes, it’s so hard to do what we have been talking about… to just accept that bad stuff happens

you know… and to be okay with that.

T: Absolutely. And I’m guessing that doing that, accepting that, might leave you feeling helpless. But

by worrying about it, by keeping it alive in your mind then at least you’re doing something, exerting

some control… because it’s just so awful to think that you don’t always have control, especially over

crucial things like the safety of your son. Would that be right? (Therapist further amplifying and

exploring the possible merits of the status quo position, so the client can more fully hear it for

herself).

C: Yes (pause). But then I think I pay the price, you know. Like he’s okay but I still end up thinking

about it (laughing). (Change talk emerges).

The emergent change talk here is an important marker of protesting the existing way of being,

ruminating, in this case. Here the client “shifts” to begin talking from the part of her that is considering

change and letting go of the worry. This can be thought of as the client bringing in a different part of

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herself, or a different “voice,” that is beginning to “answer” the arguments of the no-change position.

That is, having heard the arguments for continued worry and rumination more clearly, the client

begins to object and reevaluate them. This is ultimately the voice that the therapist is seeking to

expand and presents an emergent opportunity to begin to do so, thus bringing us to another core skill

in MI: expanding change talk.

Expanding Change Talk

One of the distinctive features of MI that differentiates it from client-centered therapy is its focus on

the elicitation and elaboration of change talk (i.e., speech that reflects desire, ability, reasons, need,

and commitment to change; Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003). Regardless of whether

change talk is elicited by the therapist or occurs spontaneously, MI therapists seek to elaborate and

strengthen it (Miller & Rollnick, 2002, 2013). Initially, such change talk can feel weak and fragile, and

requires fostering through invitations (e.g., reflections and open questions) to elaborate. Such

strengthening helps clients to build resolve for change by bringing important motives for change into

awareness, and allows them to engage more fully with these incentives. Accordingly, in exploring and

elaborating the arguments for change, the therapist seeks to deepen an understanding of the ways in

which the problem causes distress and/or interferes with the actualization of the client’s values.

Empathic listening is the major method used in the elaboration of change talk. In general, empathy

has an amplifying function and used here, serves to amplify and extend change talk. This, in turn,

serves to consolidate resolve for change, and paves the way to increasing commitment to change.

Through such responding, clients hear the arguments for change repeatedly: once when they state

them, again when the therapist reflects and deepens them, and again when that reflection or prompt

invites further client elaboration.

Informed by recent research on the role of client language in MI, particular attention is paid to client

speech and therapist behavior in shaping it. The proficient use of MI should ultimately increase

clients’ in-session “change talk” (i.e., talk in the direction of change) and decrease “sustain talk” (i.e.,

talk in favor of not changing). Indeed, experimental studies have demonstrated that MI significantly

increases change talk (Miller et al., 1993; Moyers, Martin, Houck, Christopher & Tonigan, 2009)

relative to control conditions. Moreover, linguistic analysis of MI session videos in the treatment of

substance abuse has demonstrated a particular progression of client speech in good outcome

sessions (Amrhein et al., 2003). In particular, client articulations of desire, ability, reasons, and need

for change have been found to precede client commitment, with the pattern of commitment

statements uniquely predictive of subsequent behavior change. And, increasing strength of

commitment statements over the course of MI sessions has been found to predict abstinence

(Amrhein et al., 2003; Gaume, Gmel, & Daeppen, 2008) as well as reduced alcohol use at follow-up

assessments (Bertholet, Faouzi, Gmel, Gaume, & Daeppen, 2010).

Continuing Clinical Illustration

C: But Then I think I pay the price you know. Like he’s okay but I still end up thinking about it

(laughing).

T: Oh I see. It hurts you to dwell on this. Is that right? And you’re laughing as you say that, what’s the

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laughter about? (Therapist works to expand the client’s change argument by reflecting it, and is also

attuned to the way the client’s statement is uttered, hearing the entire message; i.e., the laughter

implies thinking that likely comes from the change position).

C: Well (smiling), it’s quite ridiculous. The world didn’t end, we coped, and he was all right. It’s so silly

that I continue to dwell on it.

T: It doesn’t sound silly to me at all (Therapist notices a critical voice that comments on the the

client’s insight/expansion of the change voice. Here the therapist works to deliberately counter the

critic and communicate a prizing view of the client). And I hear another part of you talking, maybe the

real you or at least another voice that says “the anxiety tells me it’s the end of the world but I don’t

agree, I think differently.” Would that be right? Say more from that other voice. (Here the therapist is

deliberately bringing in the frame of separate parts of self—the notion of different voices. Moreover,

the therapist is using language that identifies the emergent, change voice as “the real you” to

facilitate critical evaluation and questioning of the status quo position by the client. Additionally, the

therapist externalizes the “anxious voice,” implying that the anxious voice is an introjected position

that the client has not chosen for themselves and that can now be evaluated from their own

perspective. Overall, given that the client’s statement reflects change talk, the therapist’s response

encourages her to speak further from the change position).

C: (indignant, disgusted) yes, like he was fine and when we came home, I was the one who cried and

had a meltdown!

T: Ouch. I’m hearing, all this worry causes you a lot of stress and overreacting to things. And I’m

hearing “I don’t like myself when I do that. It turns me into someone that I am not and that I don’t

want to be.” Would that be true? (Using reflection to further underscore and invite expansion of the

emergent change position; moreover, the continual “checking in” with the client on the therapist’s

offerings is highly consistent with the MI spirit of regarding the client as the expert on their

experience).

C: (quietly, tearfully) Yes. And I don’t want to model that for my son. (Client continuing to accept

therapist invitation to expand the change position by elaborating costs of continued worry).

T: That really touches you. That sounds important. You don’t want him to suffer like you do. You don’t

want him to be anxious like you are sometimes. Talk from the tears. (The client’s affect

communicates an important incentive for change, fears of modeling anxiety for her son. Thus, the

therapist seeks to further expand this important emergent consequence of continued worry).

C: There’s more to life than worry.

T: I see. You’re saying, “I want him to know that there are other priorities in life. That you don’t have

to be worried all the time.” Is that right? If you’re willing, say more. (Therapist gently encouraging

continued expansion of costs of worry and desires for change).

The emergence of change talk, or the protest of the status quo position, is an important process

marker, which the therapist seeks to nurture and expand to allow the client to more fully hear and

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elaborate incentives for change. Moreover, the change or protest voice can often be quite muted

secondary to a dominant anxious voice, and thus gently encouraging its further expansion is key to

facilitating movement away from the status quo and toward change. Importantly, it is the client, and

not the therapist, who is making the arguments for change; this is a central aspect of MI. The

therapist should not “take all the good lines” (Miller & Rollnick, 2002), but rather continually seek to

put the client in the position of evaluating the reasons to changing (or not) for themselves.

Note that the process of resolving ambivalence is typically not a linear one. When clients more fully

articulate desired directions (reasons to change) or limitations of existing ways of being (downsides

of the status quo), they often go back and forth, revisiting the status quo position. This is a natural

fluctuation in the process of exploring ambivalence. In the process of elaborating the change

position, clients are repeatedly making arguments for change and, consequently, experience

mounting or increasing pressure to change. Although increasing such internal advocacy and

momentum for change in the client is a focus of MI, given the potential of this process to evoke

resistance to change (i.e., retreat to the status quo position), it is important to be prepared to roll with

resistance in this process. In essence, the therapist is creating a dialogue between the two positions.

And just as a therapist should not persist with examination of the benefits to staying the same if the

client is articulating significant change talk, the therapist should also not perseverate or insist on

elaborating change talk in the face of significant resistance to change (i.e., arguments for not

changing).

Developing Discrepancy

Having helped the client achieve a fuller understanding of the forces for and against change,

opportunities can arise to systematically further the development of discrepancy between these

positions. Systematically seeking to identify discrepancies between what the client intrinsically values

and desires on the one hand, and the current behaviors that are inhibiting or are inconsistent with

those directions on the other, can be powerful in building resolve toward change. Discrepancy can

also arise between the “promises” of and reasons for the status quo on the one hand, and the

consequences or outcomes of these on the other (e.g., “While perfectionism is an important way of

motivating yourself to do well, you are also finding it paralyzing/exhausting”). MI therapists seek to

evoke, actively identify, and reflect such discrepancies to bring these to the client’s attention.

Importantly, the therapist working within MI spirit does not do so to “confront” the client, but rather to

invite them to wrestle with and ultimately resolve such discrepancies for themselves.

Although research in MI has not focused specifically on incremental or relative value of the skill of

developing discrepancy, more broadly, research in social psychology supports the importance of

discrepancy to change. In particular, inconsistency between one’s attitudes/values and one’s

behavior produces a state of tension known as cognitive dissonance (Festinger, 1957). The

experience of dissonance is uncomfortable, thus motivating individuals to reduce this tension by

seeking resolution to such discrepancies and reestablishing behavior-value consistency. Indeed,

studies have found that heightening awareness of one’s values can exert strong influence on one’s

behavior in areas such as social activism (Rokeach & Cochrane, 1972; Rokeach & McMillan, 1972),

weight loss (Schwartz & Inbar-Saban, 1988), adolescent disruptive behaviors (Thompson & Hudson,

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1982), and smoking behavior (Conroy, 1979).

Continuing Clinical Illustration

C: I want him (my son) to have fun too you know. Not just worry about getting hurt (pause). My

parents were really overprotective. They were always saying “watch out, be careful, you could get

hurt.”

T: Always warning (C: Yes, warning me). And I could be wrong about this, but I think I hear that, “I

have or want a different philosophy. The anxious philosophy of my parents is all about safety first!

Who cares if you are not having a good time, as long as you are safe!” and you seem to be saying,

“You know what, other things are important too, like maybe joy or… ” Would that be right? Say more.

(Therapist is beginning to differentiate or demarcate the client’s own position from the anxious or

status quo position, and to develop discrepancy between the two sides of the argument regarding

change; i.e., “On the one hand, the anxiety says… and now you seem to be saying…” The therapist

is also seeking to further expand the client’s own values to create opportunities for evaluation of the

status quo from the perspective of the client’s intrinsic values and/or authentic, valued directions).

C: Yes, like living your life!

T: Yes, I hear, “I have other priorities. Sure, safety is a part of my philosophy but other things are

priorities too, like living and having fun. And I worry that that gets squeezed out, for me and my son,

when I take on my parents’ way of thinking, thinking only about safety.”

C: Yes. Like I find myself acting like them with my son… “Watch out, be careful…” And I don’t like it. I

don’t want to pass that on.

T: It makes a lot of sense that you would do that because it is what you learned. You had to be that

way. But I hear that, “I don’t want to be that way. I want to be a different way… a more relaxed or

balanced way.” Is that right? Say more about your philosophy, how you want and need to be. (The

therapist is highlighting discrepancy between the existing self or the anxious self and the desire for

difference).

C: I don’t want him to be a hermit you know. He needs to learn that safety isn’t everything. I don’t

want to be so overprotective, like my parents. I want him to have a life.

T:… and to take some risks. Is that right…? That that might involve taking some risks… not always

“safety first and always.”

C: Absolutely. You know people can break things just walking out the door!

T: I see. You’re saying that it doesn’t always work to be vigilant anyway. Is that right? That even if you

are 100% on guard… like your anxiety tells you that you should be, it doesn’t always work, it’s not

fool-proof. The anxiety tells you that if you are only vigilant enough and worry enough then you can

prevent bad things from happening. But now, you are saying, “wait a minute, I don’t know that that’s

true.” Say more. (Here, the therapist is developing discrepancy between the intended functions of the

worry or status quo position—what it is intending to help with—and a critical evaluation of how well it

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actually accomplishes those important goals. In essence, the therapist is helping the client to

reevaluate the promises of the anxiety and worry in this case, for themselves. Given that this material

is emerging from the client, the therapist here does this through reflection. However, the therapist can

also do this by asking the client, e.g., “If I hear you correctly, the anxiety is intended to help you relax

and keep bad things from happening. How well would you say that it’s working? It might be spot on

and highly effective and only you can know. What’s your sense?”)

C: It makes me more anxious to be so overprotective all the time!

T: Yikes. So the anxiety says once you have dotted all the I’s and crossed the T’s… thought of

everything… then you can relax! You won’t have to worry anymore. But now you’re saying, actually,

truth be told, it makes me more anxious to be so vigilant and overprotective, not less. All this

overprotectiveness is not paying off the way it should. Is that right?

C: Absolutely. You know the other day I was telling my mom about a trip that we were thinking about

taking and the first thing she said was, “Well, you know it might snow, and it’s pretty far away…” and

blah, blah, blah.

T: Anything can happen. Safety first! And even the way you say that “and blah, blah, blah…” you’re

saying, “that’s ridiculous” or something. Is that right?

C: Yes, it is ridiculous! Gee, what about having a good time… where does that come in? What about,

“Have a wonderful time dear. That sounds exciting.” No, that never enters in the conversation.

T: And you sound angry about that… a bit resentful. Like I want and need something else.

C: (pause) I’m so sick of safety first!

T: I see, you’re saying, “I’ve had enough of that! And it’s limited my life and now it’s threatening to

limit my son’s life. And that price is too high. I had to think that way but I choose to think a different

way… to adopt a different philosophy. I have other needs too… like being more relaxed, having

fun…”

C: You know, as we’re talking, I’m realizing how much of that is my mother. It’s amazing to me.

T: That’s your mother’s voice and not yours. That is not your philosophy. Say more from your voice.

(Further demarcation of the existing self-anxious position from the true self or change position).

Concluding Comments

MI was initially developed in the addictions domain, but its applications are rapidly expanding to

encompass other health and mental health domains (e.g., Arkowitz, Westra, Miller & Rollnick, 2008).

Moreover, it can be added to or integrated with many approaches when resistance and ambivalence

are encountered. In addition, the underlying spirit can serve as a foundational platform from which

other therapies can be conducted (Westra, 2012).

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MI is based on a way of being or spirit, which is foundationally client-centered; emphasizing client as

expert and the creation of a safe space in which clients can freely unpack, explore, and sort through

often conflicting and contradictory views of change. Although MI appears deceptively simple, it is far

from easy in practice. It involves a complex set of skills that are used flexibly, in response to moment-

to-moment changes that occur in the client. A common metaphor for capturing the process of MI is

dancing, rather than wrestling, with the client (Miller & Rollnick, 2002). Dancing in harmony with

another requires a continuous, high level of attunement and responsivity to one’s partner, noticing

moment-to-moment fluctuations to know where to move next. In that sense, MI is far from passive

and deviates from client-centered therapy, in that it is explicitly directive, with the therapist playing an

active role in identifying key process markers (e.g., ambivalence, resistance, change talk) that

indicate the use of specific skills. This article has attempted to highlight a few of these core skills,

including rolling with resistance, expanding change talk, and developing discrepancy. Although

research remains to be conducted to delineate the specific elements that are most effective in the

practice of MI, these skills emerge for us as necessary to productive MI.

In conclusion, MI makes good clinical sense. Ambivalence about change is ubiquitous and a core

aspect of clinical practice, as well as a foundational component of change that is typically fraught with

uncertainty, fear, conflict, and ambiguity. Thus, having a way of being that facilitates working through

the dilemmas that often derail movement toward change represents a welcome and significant

clinical advancement.

Footnotes

To ensure client anonymity, de-identification was applied by changing genders and ages and

omitting various demographic details that would facilitate identification.

References

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Submitted: January 24, 2013 Accepted: January 29, 2013

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Source: Psychotherapy. Vol. 50. (3), Sep, 2013 pp. 273-278)

Accession Number: 2013-30487-003

Digital Object Identifier: 10.1037/a0032409

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