When an individual wants to improve their life in some way, end bad habits, or restore their mental health but is feeling insecure about moving forward, motivational interviewing (MI) could help. MI is a counseling method that can assist a person in resolving ambivalent feelings and nervousness about initiating change, helping them to foster an internal motivation to alter their behaviors.
Therapists who utilize MI employ a person-centered approach, encouraging patient-led decision-making and leadership. Patients are given the chance to come up with their own strategies for treatment, working collaboratively with their therapist to create plans of action initiating positive change.
MI was originally developed in the area of addiction treatment, used to work with individuals who had ambivalence about changing their lifestyle or substance use. At first, maybe someone doesn’t realize they have a problem, or the idea of change is unfamiliar and therefore anxiety provoking. Another scenario might be that a person is trying to change but the way they are going about it is currently ineffective or does not fit well with their future goals. MI has since been used more widely as a treatment for conditions like anxiety and depression.
There are four main values MI therapists apply to their treatment. The first is displaying empathy, which involves showing respect for the patient, validating their feelings and concerns, and understanding the unique experiences and challenges they possess. This value can help establish the patient/therapist alliance and build patient confidence and assertiveness.
The second value of MI is developing discrepancy, or helping the patient to realize differences between who they want to be and who they are today. As Michael Constantino, professor of clinical psychology and director of the Psychotherapy Research Lab at UMass Amherst whose team researches how to improve psychotherapy, states: “Part of what MI therapists do is to help people see that change is most effectively motivated when a patient realizes that they’re somewhat distant from the most ideal and valued person they'd like to be.”
The third value is rolling with resistance. This entails showing empathy and humility right at the moment when a therapist encounters patient resistance to a treatment direction. One MI technique is to recognize and reflect this resistance rather than confront it—by reiterating and respecting the patient’s concerns and collaboratively determining ways to move forward.
The final value MI therapists bear in mind is supporting self-efficacy, or the idea that patients are capable of guiding their own care. Therapists can help support this value by recognizing and commending any personally meaningful steps forward that the patient initiates.
Reflecting one way MI can be administered, Constantino and Alice Coyne ‘21PhD, clinical psychology alumna and assistant professor of psychology at American University, have investigated whether integrating MI into Cognitive Behavioral Therapy (CBT) to specifically address moments of patient resistance would improve outcomes. Historically CBT has been the treatment of choice for generalized anxiety disorder (GAD), but research has shown that it may only help about 50 percent of people who receive it.
Coyne states, “The idea of our main form of integration is that it's about doing the right thing at the right time. In these key moments when a person expresses ambivalence about change through resistance, that's when the therapist needs to hear it, take a step back, and use MI strategies…explore it and help the person hopefully resolve it by coming to their own reasons and intrinsic motivation for change before then going back to CBT.”
Constantino adds, “Instead of pushing forward or doubling down on CBT in those moments, we could instead train CBT therapists to put their usual strategies to the side for a moment and use this more person-centered, validating, MI-like spirit and strategy.”
In the initial 2016 study testing this type of integration, patients were randomly assigned to receive either typical CBT or CBT with MI. Results showed that after a 12-month follow-up period, patients who received CBT with MI exhibited greater improvement in their GAD-related symptoms than those who received typical CBT. In a follow-up 2019 study, the team found that the main factor contributing to this enhanced improvement in the MI-CBT group was the successful management of resistance during treatment. Thus, when therapists encounter a certain contextual scenario (in this case patient resistance), they can utilize tools like MI to keep treatment moving forward in a positive way. This finding has contributed to the context-responsive psychotherapy integration (CRPI) framework developed by the team.
Former Psychotherapy Research Lab member Heather Muir ‘23PhD, now a clinical psychology postdoctoral fellow at Harvard Medical School, performed a related study for her master’s thesis which concluded that a treatment combination of MI and CBT for GAD also outperformed CBT alone by improving interpersonal relationships in the patient’s life.
“Our hope is that MI not only has an impact on symptoms that are the primary characteristics of a disorder, like worry for GAD, but also on improving relationships,” says Constantino.
Coyne adds, “We found that the MI-CBT intervention was most helpful for people who reported prior to treatment having difficulties asserting their interpersonal needs. Something about a therapist validating, expressing empathy, and encouraging autonomy was particularly helpful for these individuals.”
MI has also been used as a pre-treatment—a prelude to another type of psychotherapy or intervention. This can help someone who is considering making changes to their life get to a point where they feel like they have a solid plan and a desire to act. Used in this way, MI can better prepare a patient to enter a longer-term therapy of any type.
Overall, the importance of a healing relationship between therapist and patient is at the center of the MI belief system. Overcoming challenges together can build a stronger alliance and lead to better treatment outcomes.
“One of the ways I like thinking about MI is as a spirit or stance of collaboration and a way to help people resolve their own complicated feelings or ambivalence,” says Coyne. “It's not telling people how to change…it’s like leading from the back seat.”