Do you want to be a wrestler or a dancer?
This question stands at the center of motivational interviewing (MI), which emerged more than three decades ago to assist people in making difficult changes like overcoming addiction. Health coaches can use MI to help people stop harmful behaviors and start helpful ones. Consider a likely scenario:
A new client has prediabetes and needs your help. Her doctor says she needs to lose 5% of her body weight and exercise 150 minutes per week—the standard advice for preventing type 2 diabetes. While she doesn’t want to get diabetes, she hates exercise and has never succeeded at losing weight and keeping it off. She has little confidence that this time will be any different.
As her health coach, you might try
A: explaining the reasons why she should exercise and eat a healthy diet and giving her a plan showing her what to do
B: exploring her concerns about developing diabetes and figuring out why she wants to be healthy
These options use contrasting communication styles that have a profound impact on people’s receptiveness to change. Option A is a “directing” communication style—gathering information, determining what’s wrong and telling the client how to fix the problem. It’s like wrestling because the client often strikes a defensive pose. Option B is a “guiding” communication style—helping the client explore reasons to change. This is like dancing because the two of you cooperate to reach a common goal.
The co-founders of motivational interviewing say dancing is the better way to use talk to encourage behavior change: “A good MI conversation looks as smooth as a ballroom waltz. Someone is still leading in the dance . . . without tripping or stepping on toes” (Miller & Rollnick 2013).
Learning MI: The Fundamentals
With motivational interviewing, you’re helping clients talk themselves into changing for the better. MI evolved in response to behavior change strategies that focused on either telling people what to do or letting them call their own shots with little direct guidance. Both of these approaches tend to suffer from poor follow-through from the person trying to change.
MI skills are most critical—and effective—with ambivalent clients, those who are not quite certain they need to change but who acknowledge the benefits and downsides of moving in a new direction.
The effectiveness of motivational interviewing has been extensively studied and evaluated. More than 25,000 scientific papers and 200 randomized controlled trials have been published since MI was first described in the treatment of alcohol addiction in the 1980s (Miller & Rollnick 2013). A recent review of more than 130 review articles and meta-analyses from 2000 to 2018 evaluated MI’s role in stopping or preventing unhealthy behaviors (substance use, gambling), promoting healthful behaviors (oral health, nutrition, exercise, weight management, medication adherence) and addressing multiple health-related problems (excess drinking, smoking, physical inactivity). Note that, for all this research, the reviewers concluded that the quality of the evidence was limited and more high-quality research is needed (Frost et al. 2018).
The Spirit of MI
While motivational interviewing methodologies have been refined over time, the original spirit remains unchanged: “MI involves a collaborative partnership with clients, a respectful evoking of their own motivation and wisdom, and a radical acceptance recognizing that ultimately whether change happens is each person’s own choice, an autonomy that cannot be taken away no matter how much one might wish to at times” (Miller & Rollnick 2013).
THE FOUR PILLARS
Client-coach conversations in MI have four requirements:
Collaboration. The client and coach are partners. As Miller & Rollnick put it: “Without partnership, there is no dance.”
Acceptance. An MI-centric coach demonstrates “unconditional positive regard” for the client, rooted in respect, trust and empathy.
Compassion. Motivational interviewing benefits the client—not the coach.
Evocation. Clients are the experts on themselves. The coach’s role is to “call forth . . . strength and wisdom from the client” (Miller & Rollnick 2013).
THE FOUR PROCESSES
Motivational interviewing goes through four phases:
- Engaging. The coach and client build rapport and trust.
- Focusing. The coach and client develop a shared agenda for coaching sessions.
- Evoking. This is the heart of motivational interviewing. Coaches help clients explore their motivation to change and resolve their ambivalence about it. Much of MI’s power lies in the art and science of evoking.
- Planning. Finally, the client resolves to change and is ready to develop and implement an action plan. Here, the client is “thinking and talking more about when and how to change and less about whether and why” (Miller & Rollnick 2013).
Key Skills: OARS
Motivational interviewing helps people reorient how they think—and feel—about change. An MI interview guides a client toward “change talk”—statements by the client (not the coach!) arguing why he or she needs to change.
Trying to convince someone to change will often make an unwanted behavior more likely to stick. By contrast, when people talk themselves into changing, they are much more likely to turn intention into action. As Miller & Rollnick say, “If you are arguing for change and the client is arguing against it, you’ve got it exactly backward.”
To evoke change talk, MI uses four communication techniques, summed up in the mnemonic OARS.
For more information, including a description of the OARS techniques and 10 motivational interviewing strategies, see “Motivational Interviewing: Talking Their Way to Health” or the June 2019 print edition of Fitness Journal. If you cannot access the full article and would like to, please contact the IDEA Inspired Service Team at 800-999-4332, ext. 7.