Question 1

Can motivational interviewing help with the hopelessness of depression?

Stephen Rollnick · Accepted Answer

I am worried about expert judgment here!  This field of "evidence-based treatment" and the striking elevation of CBT (and its relatives) over 30+ years sometimes feels like a competition between therapies. So I dont want to replicate that kind of judgment about which therapy helps with depression. I suspect that for most practitioners the conversations with people who are depressed have more in common than differences. Where are the accounts of what MI looks like with people feeling depressed?  I hear colleagues, in primary healthcare for example, say that they find MI very useful when talking to people who experience low mood. Bill's observation about ambivalence is striking and valid in my experience. Whatever approach you take to depression, surely you will want to establish good engagement, and draw out the client's own good sense of why and how they might change? That's the way I see MI in practice.

Bill Miller · Answer

I have been saying that MI is a way of doing what else you do.  Whatever treatment for depression you may provide, be it cognitive therapy, behavioral activation, or pharmacotherapy, it matters HOW you provide it, your way of being with the client.  MI is not an alternative to evidence-based treatments for depression.  It is a way of delivering them.  Often treatment for depression involves helping people to DO something different - exercise, engage in pleasant activities, change thinking, take medication - even though they may not feel like it.  That is a clear example of ambivalence that can be addressed by MI.

Question 2

How do we maintain a 'non-judgemental' stance when there is risk involved?

Stephen Rollnick · Accepted Answer

That's a nice distinction Bill made between the person and the behaviour or its consequences. Yes you also want to be authentic in the conversation, and if you have concerns about risk you also want to be authentic and address them.  Two vehicles come to mind: first, a solid platform of engagement, and secondly, asking permission to share your concerns about risk to the client or to others.

Bill Miller · Answer

In addiction treatment, the field in which I worked for most of my career, risk is always involved.  "Nonjudgmental" is about how we treat the person, rather than the problem.  Carl Rogers described it as unconditional positive regard - that the client does not need to earn our respect or compassion.  It's more than attitude - it's specific clinician responses.   Lecturing, scolding, labeling, shaming, and such are judgmental responses, and are unlikely to inspire change.  Acceptance, ironically, facilitates change.  Rogers described the paradox:  when we feel unacceptable, it is paralyzing and makes it difficult to change.  In experience acceptance as we are, it becomes possible to change.

Question 3

Isn't there a tension between wanting to promote the well-being of the client but supporting their autonomy? Aren't we often disguising giving advice as eliciting certain change talk?

Bill Miller · Accepted Answer

Again, patient autonomy is a fact.  We can acknowledge it or ignore it, but people can and do make their own choices.  When someone walks through the door of a smoking cessation clinic or an addiction treatment center, it's no secret what the providers' goals are.  The question is: how shall we interact with autonomous people as caregivers?  If we pretend that people don't have autonomy, we can take on a prescriptive expert role:  You have to . . .  You must . . .  Do this, do that.  The normal expected outcome is no change, and then we blame people for not changing and "resisting."   When what needs to change is a client's behavior or lifestyle, we need their collaboration and expertise.

Question 4

Has motivational interviewing been used in couples counselling?

Bill Miller · Accepted Answer

In two multisite trials of treatment for alcohol use disorders (Project MATCH and the COMBINE trial), the manual urged clinicians to include a significant other in at least early treatment sessions, and MI was the prescribed clinical style.  In those studies, the partner was engaged to help the primary client make specific changes.  In couples counseling more generally I found it helpful to identify the relationship as my client, rather than one partner or the other.  A challenge in doing MI with a couple is that while you're doing your best to listen well, the partner may jump in with communications that evoke sustain talk and discord, so you have to manage that.  One approach is to teach the couple the very communication skills that you are practicing, particularly the engaging/listening skills.

Question 5

What do you do when your client's confidence or perceived ability to change is low?

Stephen Rollnick · Accepted Answer

I forgot to add this: the challenge here is all but universal in settings of poverty, where economic and social conditions render people much less able to control outcomes in their lives, so no wonder they dont feel confident. So its not just some psychological challenge, yes?  Important to acknowledge this dont you agree?

Stephen Rollnick · Answer

I don't want to sound strange, but ask the client?   I say this because while there's lots of guidance and wisdom in the view of experts, and I agree with what Bill says above, there's wisdom in the client too.  Asking the client also relieves you from the burden of having to be clever and find the answer?   Celeverness never did me any good!  I got on top of Mi when I consciously tried to let go of my cleverness, so that my mind was clear and focused on the client's needs.  In one sense, the client is our best teacher.  Just one way of looking at it. hope this helps?

Bill Miller · Answer

That is the main focus of chapter 16 in our 3rd edition: Evoking Hope and Confidence.  It certainly happens that people see change as important, but they experience little confidence or self-efficacy for making the change.  That is one of Steve Rollnick's important contributions to MI.  There are some familiar strategies, such as reviewing past successful changes.  Interviewing people about and affirming their strengths is another, which is a purpose of the "Characteristics of Successful Changers" tool.  Evoking, reflecting, affirming, and summarizing ability language (one kind of change talk) is a mainstream strategy in MI.   It is also worth noting that sometimes people are reluctant to acknowledge the importance of change until they see that it's possible.  If you increase someone's perceived importance of change without also evoking hope, you haven't done them a favor.

Question 6

Do I need to be thinking about/using the Stages of Change Model in order to effectively engage in Motivational Interviewing?

Stephen Rollnick · Accepted Answer

No no no!  While the stages model is a useful background framework, I would rather allow people to shift in and out of different stages as a conversation unfolds!

Bill Miller · Answer

Definitely not.   MI and the transtheoretical model grew up together in the early 1980s, and they make sense together, but we don't fret over what stage a person is in, partly because it can change so quickly (in either direction) over the course of an interview.  We try to stay with people wherever they are, and I think that an MI style can be helpful at any stage of change.  The four processes in our 3rd edition can also be helpful here.  If somebody seems to be ready for change, I wouldn't spent a lot of time evoking.  If there is already a clear focus, take some time to engage, but the primary task would be planning, and evoking commitment to a provisional plan.  The processes are flexible, not linear.

Question 7

I'm interested in how you balance patient autonomy with eliciting change talk. What are some strategies to do this effectively?

Stephen Rollnick · Accepted Answer

I really have little to add to Bill's thoughtful comment, and I only wish I could understand better what your interest is? the question is quite nuanced! My sense is that if you are genuinely guided by curiosity and compassion, the respect for autonomy is quite easy?

Bill Miller · Answer

Interesting question, and I hope I understand your meaning.  Patient autonomy is a fact, and not something we can "give" to people.  Explicitly acknowledging and honoring autonomy can diminish defensiveness, and it is always a background assumption in MI that people get to make their own choices.  Because what we are eliciting as change talk is the person's own motivations for and ideas about change, I don't see a conflict with patient autonomy.  Knowing that people make their own choices can lift from the practitioner the burden of imagining that we have to make people change.

Question 8

Is MI particularly effective in certain settings? For instance, one-on-one sessions versus group or family?

Bill Miller · Accepted Answer

It is certainly easier to practice one-to-one, and I usually suggest developing your MI skills with one person at a time before starting to practice it in working with relationships, families, or groups.  You are managing relationship or group dynamics in addition to practicing MI.  Wagner and Ingersoll published a very helpful book on Motivational Interviewing in Groups, and outcome research shows it can also be effective in that context.

Question 9

Have you found that there are particular substance dependancies that people are particularly ambivalent about?

Bill Miller · Accepted Answer

Ambivalence is a characteristic of addictions more generally.  Within any particular substance use disorder, people vary widely in their ambivalence, the balance of perceived pros and cons, and that is what the transtheoretical stages of change describe.  In precontemplation the pros of use far outweigh the cons.  The contemplation stage is more of a counterbalance, and as the cons of substance use (and especially the pros of change) increase, people move into preparation and action.  I'm not aware of a difference in average ambivalence across substances, and studying it would involve measuring decisional balance in a general population of substance users, because those in treatment are a selected subsample.

Question 10

Are there particular areas of MI research that you'd love to see developed further?

Bill Miller · Accepted Answer

If I were still doing research myself, I would be trying to understand how learning and practicing MI changes practitioners themselves.  Clinicians often tell us how their lives and work were changed in important ways through the practice of MI, but there has been no prospective research on this so far.

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