What is Motivational Interviewing
Motivational interviewing (MI) is a patient-centered counseling method that increases intrinsic motivation for behavior change by helping patients explore and resolve their ambivalence through strategic questioning, reflective listening, and emphasizing patient autonomy rather than direct persuasion. 1
Core Definition and Mechanism
MI represents a directive yet collaborative counseling style originally developed for addiction treatment that has expanded across healthcare settings. 2, 3 The approach works by helping patients identify discrepancies between their current behaviors and their personal values or life goals, then supporting them in resolving this ambivalence. 1 Rather than telling patients what to do—which generates resistance—MI helps patients generate their own arguments for change. 4, 5
Foundational Principles
The "MI Spirit" requires maintaining an empathetic, collaborative, and nonjudgmental demeanor that respects patient autonomy throughout the encounter. 1, 6 This stands in direct contrast to confrontational approaches, which decrease motivation and are typically unsuccessful. 5
The OARS Framework
MI conversations are structured using four core techniques: 1, 6
- Open-ended questions that invite exploration rather than yes/no responses
- Affirmations that promote self-efficacy, particularly important since patients often experience guilt and shame about their behaviors 4, 5
- Reflections that mirror back statements supporting change, highlighting the patient's own reasons 4, 5
- Summaries that periodically recap conversations to reinforce commitment 6
Key Clinical Strategies
Resisting the "Righting Reflex"
Physicians naturally want to correct unhealthy behaviors, but directly telling patients to change generates resistance. 4, 5 Instead, MI practitioners help patients articulate their own motivations, which are far more powerful than clinician-imposed reasons. 4, 5
Elicit-Provide-Elicit Technique
This nonconfrontational approach to giving advice allows patients to express their feelings about change while helping clinicians assess readiness. 4, 5 The pattern involves asking what the patient knows, providing targeted information, then asking what they think about it.
Managing Ambivalence
MI specifically targets patients experiencing defensiveness, ambivalence, guilt, shame, and lack of concern about their behaviors—common presentations in substance use disorders and other health behavior challenges. 4, 5 The technique of "rolling with resistance" means avoiding direct confrontation when met with pushback, waiting for patients to find their own answers. 4
Clinical Applications and Evidence
Strongest Evidence Base
MI demonstrates most robust support for substance abuse and dependence disorders, where it manages resistance and increases readiness to change. 4, 5 Brief MI counseling helps ambivalent patients enter treatment programs, engage with mutual help meetings, or agree to pharmacotherapy trials. 4, 5
Adolescent Health
Increasing evidence shows MI is most effective for adolescent counseling about contraception and sexual health when using patient-centered approaches. 4, 1 The technique addresses discrepancies between adolescents' sexual behaviors, their relationship values, and future life goals (school completion, college, marriage timing). 4
Cardiovascular and Metabolic Health
MI should be used when patients are resistant or ambivalent about behavior change related to diet, physical activity, and cardiovascular risk reduction. 4 The approach fits naturally into the "5 A's" framework (Assess, Advise, Agree, Assist, Arrange), particularly strengthening the latter three steps that have greatest impact but are least frequently performed. 4
Brief Interventions
Even single MI sessions under 20 minutes show efficacy, making this feasible for busy clinical settings. 1 MI by primary care physicians appears somewhat more successful than by counselors, though both are effective. 1
Practical Implementation
Decision Analysis
Help patients articulate advantages and disadvantages of changing their behavior through structured "pros and cons" discussions. 4, 5 This technique makes ambivalence explicit and workable.
Exploring Goals and Discrepancies
Ask patients about their life goals, then help them identify inconsistencies between those goals and current behaviors. 4 For example, an adolescent expressing desire to attend college while frequently engaging in unprotected sex faces clear discrepancy that MI can address. 4
Harm Reduction Framework
For patients not committed to complete behavior change (such as abstinence from substances), MI supports harm reduction as an appropriate intermediate goal—examples include providing clean needles or avoiding driving while intoxicated. 4, 5
Integration with Other Approaches
MI naturally extends youth development principles through its focus on goals, future orientation, belief in capacity to change, and engagement in health-promoting behaviors. 4 The approach can be combined with cognitive-behavioral therapy, contingency management, or pharmacotherapy for enhanced outcomes in substance use disorders. 5