Question 1

Is Motivational Interviewing a form of intervention? Why?

Bill Miller · Accepted Answer

If by "intervention" you mean what the Johnson Institute used to do (but no longer does), or what is featured on Arts & Entertainment, no.  MI is almost an opposite style of working with people.  However, the original reason I developed MI was to do what "interventions" hoped to do:  to help people look in the mirror, take a good look at their drinking (in a safe and supportive environment), and decide what if anything they might like to do differently.  I originally thought that it would be a prelude to treatment, like priming the pump to respond to treatment, and indeed MI seems to do that.  When MI is added to other evidence-based treatment methods, both work better.  The surprise, though, was how often MI along was enough to prompt change similar in size to the effects of other forms of treatment.   Once you get people over the hump of ambivalence, sometimes that's all that is needed.
If you're asking whether MI is a specific kind of behavioral health intervention, yes and no.  We can and do specify what constitutes good practice of MI that is associated with subsequent change.  What seems to be happening, though, is that MI is usually being combined with other evidence-based treatment methods.  MI is like a way of doing what else you do.

Question 2

How do you know if MI has been effective? Is there a way of measuring success?

Bill Miller · Accepted Answer

Well, it depends on the presenting issues.  When treating someone with a substance use disorder, for example, you probably haven't helped much if substance use doesn't change.  With that said, though, movement one stage forward in the transtheoretical stages of change IS progress.  Moving from precontemplation to contemplation, or from contemplation to preparation would increase the chances of subsequent action and change.  I don't think you need to have clients fill out a stages questionnaire for clinical purposes.  You can hear the stage of change readiness from a client's in-session language.  The ratio of change talk to sustain talk is a pretty good predictor of proximal movement toward behavior change, and therapists definitely influence that ratio.

Question 3

When a client asks what to do next, how much should I suggest?

Theresa Moyers · Accepted Answer

Think of Giving Information and Advice like chili powder when you are cooking a stew.  Add a little and see how it tastes (how the client responds).  You can always add more, but if you put in too much it is a big setback.  Like chili powder, a little direction goes a long way.

Bill Miller · Answer

When a client asks for your advice,  you have permission to offer it, but here are some caveats.  First I usually want to know what ideas the client has.  I have also found it wise not to offer one suggestion, because the natural client response is to tell you what's wrong with your suggestion.  Instead, offer a menu of options.  A great thing about addiction treatment is that we have a variety of evidence-based approaches, none of which works for everyone.  I usually describe several possibilities and ask for the client's hunches about which might be best to try first.  It also helps to acknowledge the client's autonomy, in essence giving the person permission to disagree.  "I don't know if this will make sense to you,"  etc.

Question 4

Is MI effective for managing relapse?

Theresa Moyers · Accepted Answer

Yes, but you need a different model for thinking about relapse as Bill is saying.  In particular, if people are ambivalent about changing after their relapse (for example, they’ve decided that giving up smoking isn’t that important after all), MI is optimal.  If they are ready to move forward with a plan (I have to get right back to quitting!), MI might not be as important.

Bill Miller · Answer

Well, first of all let me say that I favor scrapping the term "relapse" from our vocabulary.  It carries so much moralistic and black-and-white-thinking baggage that I believe it does more harm than good.  When a person with diabetes comes into the emergency department, no one says, "You relapsed!"  The focus is on life-saving first and then figuring out what adjustments are needed in treatment and recovery.   Imperfection is human nature, and "relapse" implies that there are only two outcomes: perfection or disaster.  Recovery and treatment outcomes are mostly somewhere in between - successive approximations.   The answer to your question, though, apart from my relapse sermon, is Yes, of course.  When a person who intended to abstain comes back to treatment (thank goodness) having used alcohol or another drug, MI still applies and is a good tool for focusing on how the person will choose to proceed.

Question 5

What are some client indicators that MI may not be a suitable approach?

Bill Miller · Accepted Answer

First of all, MI is not needed when a person is already ready to change.  Actually it's the evoking process that isn't as important.  We now teach MI as comprising four processes:  engaging, focusing, evoking, and planning.  If someone is ready to change, don't spend much time evoking motivation for change because it's already there.  Engage, have a clear focus, and go on to planning.  If a client seems to be in "precontemplation" they are not ambivalent, and there the task is actually to foster some ambivalence.  It's what we now discuss as developing discrepancy (chapter 18 in our 3rd edition), a phrase that we formerly used in a more generic sense.  We haven't yet found a diagnosis where MI is unhelpful, though there may be some.  Probably children need to reach a certain level of cognitive development for MI to be effective, since it is intended to trigger self-regulation, but for younger children you really need to be working with the parents anyhow.  Perhaps the simplest answer is: when it's not working for you.

Question 6

Is there an adjacent therapeutic approach that MI works particularly well with?

Theresa Moyers · Accepted Answer

What I will also say here is that MI cannot be your only tool.  MI is not appropriate for every client, so it does not replace your other skills or expertise.  There are times it must be combined with other approaches.  If you like the idea of combining MI with cognitive-behavioral treatments, have a look at the work of Henny Westra (Westra & Arkowtiz, 2010) who has a very sophisticated way of blending these two approaches.

Bill Miller · Answer

I am increasingly saying that MI is a way of doing what else you do, whether it's addiction counseling, diabetes education, teaching, coaching, whatever form of helping relationship is yours.  In my own training I learned a person-centered way of counseling before I began learning and practicing behavior therapy, and they always fit together well for me.  A common combination has been MI and cognitive behavior therapy.

Question 7

Can MI only be used by a licensed mental health professional?

Theresa Moyers · Accepted Answer

Even more good news!  The type of profession you practice and your years of experience do not seem to predict who is good at learning MI.  Of course, when you are a licensed professional, you must abide by the guidelines of your chosen field.  But there is nothing about any particular profession that bodes well or poorly.

Bill Miller · Answer

That's easy to answer.  We have never found any relationship between years of education and the ability to learn and use MI.  Even doctoral-level people can learn it!   It has been used effectively by peer health visitors in Africa, brand new therapists in training, and paraprofessionals.  It seems to be about human relationship, not degrees or licenses.

Question 8

Won’t MI make my consultations/sessions more time consuming?

Theresa Moyers · Accepted Answer

Maybe MI will take longer.  Sometimes giving people time to say why they might want to change does take longer than just asking questions to get facts.  But we have all had the experience where it feels like pulling teeth trying to get answers to simple questions from our clients.  They need to be listened to before they are ready to move forward.  Sometimes when you behave as if you have all day, it just takes minutes; whereas if you act like just have minutes, it can take all day.

Bill Miller · Answer

I don't know the context in which you work, but MI has been used effectively in relatively brief contact settings like primary care.  In part, the question is more time consuming as compared with what?  If what is needed is a change in the person's behavior or lifestyle, it is not more efficient to just tell the person what to do.  Practitioners have told us that MI actually saves them time.  MI is a particular way of doing that tasks you already do.

Question 9

Does MI fit with a harm minimization approach to substance use?

Bill Miller · Accepted Answer

Harm reduction is what we all hope to do in helping professions, in addition to promoting positive heath and growth.   The phrase "harm reduction" in addiction treatment usually refers to a willingness to work with people to make changes that are less extensive than a clinician might wish.  I did ten years of research on helping people moderate their drinking, at a time (1970s) when that was highly controversial.  Now it's mainstream, at least in health care, to screen for heavy drinking and help people reduce their use.  One thing we found, by the way, was that most people trying this moderation approach ultimately decided to quit drinking.  It's not that they tried and failed.  They were moderating their drinking, and found it wasn't worth the effort that it required.  Working with people where they are at present is central to MI.

Question 10

Is MI appropriate for group settings?

Theresa Moyers · Accepted Answer

To me one of the most fascinating things about MI in groups is how to think about change talk. Is it the average frequency of change talk in the group that makes an impact on the individual or do they have to offer their own? Does change talk from people who talk a lot get “count” less than change talk from people who almost never speak? One of my favorite studies about change talk in groups comes from Shorey, Martino, Lamb, La Rowe and Santa Ana (2015). They study the synergistic exchange of change talk among and between group members, which they call “relatedness”. Group MI is associated with more of this kind of language than other kinds of groups. So maybe there is a special kind of exchange of words that happens in MI groups that is important.

Bill Miller · Answer

Definitely.  I usually recommend developing your MI skills in individual conversations first, because there is more to manage in group settings, but the spirit and method are the same.  Wagner and Ingersoll wrote a book specifically on Motivational Interviewing in Groups (Guilford Press) and there are clinical trials of MI in group format.

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