Motivational interviewing is a therapeutic framework focussed directly and specifically on change. In this excerpt from Psychwire’s Motivational interviewing Foundational course, trainer Theresa Moyers breaks down the processes of this conversational change model. At its core are four interlocking processes: Engaging, Focusing, Evoking, and Planning.
While the process of Evoking differentiates the model from other therapeutic ideologies and gives it its distinctive power, each process is enacted with specific attention to maintaining what researchers, clinicians, and teachers have come to call ‘the spirit of motivational interviewing’.
Engaging: Establishing Solid Ground
While the processes of MI are all relevant at different stages and can be returned to again and again, the work always begins with Engaging. This stage includes the rapport building essential to any therapeutic endeavor, but with some considerations unique to MI. The engagement process is characterised by focussed, wholehearted listening, with the aim of recognising and acknowledging the patient’s strengths, honouring their autonomy, and demonstrating that you see them as someone with inherent capabilities and discernment.
While the early phase of therapy can often be characterised by giving particular attention to the problems the therapist perceives as relevant to treatment, engaging in MI is a more neutral, holistic attempt to gain a balanced view of where the patient is at. As Stephen Rollnick points out, this process can be simple and beautiful, but is difficult to do, as it requires unusual restraint and focus. Emphasis is given in this stage to engaging without trying to include any other elements of treatment, as this allows the treatment to progress quickly, and forms the strongest foundation for later stages.
Focusing: What is the Work About?
The second process addresses a problem familiar to many clinicians: sessions that cover a great deal of ground without ever making meaningful progress in any one direction. Focusing is the process by which therapist and client arrive at a shared understanding of what change they are actually working toward. Sometimes focusing is simple - if the client is attending a substance abuse program, it is usually clear what the focus of treatment is going to be. Other times, therapist and patient might be exploring a number of different potential directions to treatment, or begin with no clear underlying cause for the patient’s suffering.
There is a tension in the focusing stage between the importance of narrowing the conversation, versus becoming too directive in a way that runs counter to the aims of the model. This is where a strong theoretical knowledge in the modality and good clinical judgement play a significant role. Crucially, focusing must precede evoking and planning - without a clear, mutually agreed upon point to the work, motivational interviewing is not possible.
Evoking: The Linchpin of MI
Once the conversation has a clear focus, the therapist then moves on to evoking the client’s own arguments for change. The client themselves speaking their own hopes, desires, and inspiration for change forms what Dr Moyers refers to as the golden thread of motivational interviewing. The process of evoking what is known in MI as change talk is where the model becomes genuinely distinctive. It is also the most challenging of the four stages.
Evoking requires the clinician to actively suppress what MI trainers call the “righting reflex” - the well-intentioned impulse to lay out the reasons why a client should change. It is a deeply human response, and one that most people, therapists and health practitioners as much as anyone, find genuinely difficult to resist.
The MI practitioner is aware that when a therapist argues for change, clients frequently argue back - by taking one side of the client’s internal conflict, the clinician inadvertently strengthens the other. By moving away from the educational or corrective stance of many other therapies and aiming instead to surface the patient’s own particular language for change, the therapist can come alongside the patient’s own intrinsic motivations as a source of support and collaboration.
Evoking meets the client in their ambivalence, and gets behind the parts of them that already have ideas and desires about how change might look in their life. By treating the client’s mixed feelings as an ordinary aspect of the human experience, and not some kind of unusual psychopathology, the therapist is better placed to direct their energies to align with the client’s strengths and readiness, rather than arguing with their hesitation or doubt.
Planning: Change on the Client’s Own Terms
Planning is the fourth and final process in MI, and it should only begin when the client feels genuinely ready to envision a life inclusive of change. This is indicated when enough change talk has accumulated that mapping out the practical steps to change becomes a natural next step.
Planning is not so different from evoking, in the sense that the therapist’s role is still evocative, rather than prescriptive, and they are still attending closely to the presence of change talk. The planning process is carried out in the same spirit as the other three stages, with the client’s autonomy and own motivations at the centre, and with the therapist only offering practical help in response to invitations.
What Sets MI Apart
Although many aspects of these processes may be found in part within other models, motivational interviewing is unique in the spirit and focus of how each stage is enacted. The MI clinician has two important beliefs: that ambivalence about change is a normal part of the human condition, and that the patient possesses their own instincts and ideas about change within themselves that will provide a greater foundation for success than any expertise offered from outside. It is this underlying philosophy, accompanied by skillful, empathic attunement and listening that contributes to MI’s effectiveness, which has been well established by hundreds of randomized controlled trials (Frost et al., 2018).
For those wanting to develop a more detailed understanding of how to move through these four processes in real clinical conversations, the Motivational Interviewing courses offer detailed instruction, filmed demonstrations, and direct guidance, including a forum attended to by expert trainers, MI founders William Miller and Stephen Rollnick, and world-leading MI researcher, Theresa Moyers.
