Motivational Interviewing Steps: 4 Key Processes for Change

If you are a therapist, coach, medical professional, or business leader, then you are in the business of changing behavior.

Think about it: therapists help clients overcome mental illness; coaches help clients solve problems; medical professionals help patients live healthy lives; and business leaders motivate employees to work toward a goal.

Since you are likely in the behavior change business, you might add motivational interviewing (MI) to your toolbox.

MI interventions consist of four steps that build on each other to create behavior change. Understanding these steps will allow you to use MI effectively.

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Process 1: Engaging

Before we discuss the different processes of motivational interviewing theory, it is important to note that these four processes are not always as discrete and separate as they appear. Instead they overlap, meaning that there is not a defined beginning or end to any of these processes (Schumacher & Madson, 2014).

As an example, engaging with the client is not something that simply occurs in the first session and then is finished. The clinician should attend to client engagement throughout the treatment or intervention, even when working on things that fall within the other categories.

Establishing a working alliance

Engaging the client is the first step in any treatment or coaching. It is the process through which the clinician builds a working alliance with their client. It is also the part of the process when the clinician begins to understand exactly what is going on with their client.

In order to engage the client effectively, it is important to create a safe and comfortable environment for the client to discuss their concerns. The clinician does this by adopting a person-centered style of interaction, acting in a way that is welcoming and accepting, and showing a genuine interest in not only the client’s problems but also their goals and values (Schumacher & Madson, 2014).

Professionals in the four spheres mentioned above can benefit from taking this approach. The trick is to focus on the person in front of you, rather than on identifying and solving the problem. In MI, these tasks are the client’s job.

Pitfalls of engagement

Engagement is a vital building block for the rest of the MI processes, and therefore, MI clinicians need to be vigilant for signs of disengagement throughout the other processes (Schumacher & Madson, 2014).

These signs include:

• Giving short or vague answers
• Closed-off body language
• Changing the topic
• Interrupting
• Passive agreement
• Silence

Clinicians can run into common barriers when trying to engage the client (Schumacher & Madson, 2014). Behaviors to avoid include:

• Question and answer
  The Q&A rhythm results from asking too many closed questions. In MI this is sometimes called the question-and-answer trap (Rosengren, 2017).
• Premature focus
  Narrowing in on a problem too quickly, ignoring the person in the process.
• Taking sides
  Ignoring ambivalence and prescribing a solution.
• Flexing expertise
  Trying to convince the client you have all the answers. This is sometimes called the expert trap (Rosengren, 2017).

As we will see, the MI clinician gives the client permission to express and explore ambivalence about change in the session. They do this by using their OARS skills (more about that below) and demonstrating empathy for the client by listening deeply.

If at any point the client seems disengaged and/or displays any of the above warning signs, the client will be best served by the clinician returning to basic clinical skills and refocusing on the alliance.

Process 2: Focusing

MI, like many other interventions, aims to help clients resolve the concerns or issues that made them seek treatment.

Once the client has been engaged, the clinician can focus on what needs to change, referred to in MI as the “change target” (Schumacher & Madson, 2014). Although the clinician does not tell the client what or how they need to change, they play an active role in guiding the client toward the target.

Sources of focus

There are three sources of focus in an MI intervention (Levounis, Arnaout, & Marienfeld, 2017):

1. The patient
2. The setting
3. The clinician

The first source involves the stated goals of the patient. Examples include a patient who comes into treatment wanting to decrease their alcohol use or improve their sleeping habits.

The next source, the setting, involves the context of the engagement. For example, treatment at a weight-loss clinic usually has a clearly defined focus of losing weight and improving health behaviors.

Finally, the clinician can be the source of focus. An example would be a bipolar patient who does not want to take medication (Levounis et al., 2017). The clinician would likely choose to shift focus toward building a medication regimen. In these cases it is important to remember the spirit of MI, which we will explain later in this piece.

Zooming in

The process of the MI engagement is one of gradual zooming in on a change target. Depending on how the engagement began, the change target may be more or less clearly defined at the start. For example, the change target in a treatment for alcohol dependence is typically more defined than one involving more amorphous issues such as depression and anxiety.

Picture zooming in as if you were looking at a map online. Using the + and – buttons, you and the client can zoom in and out of the issue at any point during the treatment. When beginning the engagement, it is helpful to zoom in on the target destination so that the clinician can help the client plot a course of travel to this desired place (Levounis et al., 2017).

Zooming in is especially important when a treatment begins without a clear focus. Often people enter therapy with undefined treatment goals. This may be because of lack of experience with therapy or because they do not know why they are struggling or feeling bad. Zooming in involves sifting through the person’s story to find the target of the MI intervention.

Collaborative agenda setting

Since the MI clinician plays the role of guide, rather than expert, they allow the client to discuss what they feel is most important during the session. They can accomplish this through “agenda setting,” which is a shared and collaborative process. The clinician can begin the session by opening up the floor with the question “What would be most helpful to discuss first?”

Motivational interviewing questions such as the one above allow the client to take the responsibility of focusing on the change target from the beginning of the session. Since agenda setting is collaborative, the clinician is also free to suggest agenda items if they feel the need to guide the focusing process more directly.

Collaborative agenda setting is consistent with the spirit of MI, which involves respecting the client’s innate wisdom and autonomy. It is a way to ensure that the client is heading in the direction that they desire, rather than being steered by the clinician’s unstated goals.

MI-consistent focusing is occurring when the client has a significant say about what they discuss during the session. During this process, the clinician learns a lot about the values and goals of the client. These will be especially important during the next phase.

The clinician also needs to pay close attention to any discrepancies between their own goals and those of their client. This may be a potential trap, pulling the clinician into the role of expert, rather than guide.

Process 3: Evoking

After a focus is developed and a change target is identified, the clinician can work on eliciting the client’s own motivations for their desired change (Schumacher & Madson, 2014). This is the part of the MI process that gets the most publicity because it involves “change talk,” a major goal of the MI intervention.

MI spirit

MI is characterized by a “spirit” of interacting with the client. The “spirit” can be broken down into four qualities. (Levounis et al., 2017).

1. Partnership
   It is ultimately up to the client to decide to change or not. Although the clinician can and should provide some guidance, this is done with a thorough understanding of the client’s goals and values, and respect for their autonomy.
2. Acceptance
   Even when disagreeing with the client’s behavior, the clinician accepts them because of their intrinsic value as a human being.
3. Compassion
   This is an action, rather than an emotional experience. The clinician pledges to act within the best interests of the client.
4. Evocation
   This is the belief that the potential for change exists within the client. The clinician then seeks to draw this motivation out of them.

Change talk vs. sustain talk

The goal of the “evoking” stage is to elicit change talk. Change talk is a statement revealing consideration of, motivation for, or commitment to change (Miller and Rollnick, 2013). The opposite of change talk is “sustain talk,” or arguments in favor of maintaining the status quo (Levounis et al., 2017).

Because ambivalence is a natural part of change, all clients are likely to express both change and sustain talk. The clinician’s job is to hone in on the aspects of the person that are in favor of change, emphasizing and encouraging more change talk. Clinicians in MI use a group of skills, grouped in the acronym OARS, to evoke their client’s natural motivation.

Coaching toward change

In MI, the clinician can be thought of as a coach or guide for the change process. Coaches help their clients or players use their strengths to achieve a goal. They are skilled listeners who get to know their clients intimately and harness their motivations. They also know when to push and when to back off.

Most of all, they believe in the efficacy of the people that they are working with. They work to empower their clients to set their own goals, rather than pushing their own agenda.

The evoking stage is a subtle push and pull, through which the clinician unearths the internal motivation that brought the client into therapy. As we will see in the fourth process – planning – MI clinicians have a variety of motivation tools to accomplish these aims.

Process 4: Planning

During the process, the client may begin to show signs of being ready to change.

At this point, you have entered the fourth process: planning. Some signs of readiness for change include (Levounis et al., 2017):

• Increased ratio of change talk versus sustain talk
• Increased strength of change talk statements
• Spontaneous planning for change

The magic question

When a clinician notices the above signs, they should begin the planning process with the client. MI-consistent planning involves reflecting back the client’s previous change talk and then asking the magic question: “What would you like to do next?”

This question emphasizes the collaborative approach of MI. Beginning planning from this collaborative standpoint differs from prescribing a plan of action for the client to follow. It allows the client to be the architect of their own plan. This ensures that the actions they take toward change are for their own benefit, rather than a desire to be compliant to the therapist.

SMART goals

Consistent with behavioral therapy, MI involves setting sequential goals for the client to accomplish over time. Clinicians may be well served by helping clients develop SMART goals for these purposes.

SMART is an acronym that stands for (Doran, 1981):

• Specific
• Measurable
• Action-oriented
• Realistic
• Time-bound

These adjectives describe the kinds of goals that MI clinicians help their clients develop during the planning phase. MI goals are small and successive.

With substance abuse, this may first take the form of “harm reduction,” using successively less of the substance over time. The point here is that the goals set in MI are tangible, can be tracked, and are not so difficult as to be unattainable.

Check out this article for a more thorough overview of SMART goals and other helpful information for helping clients set effective goals.

Using OARS: 3 Techniques for Success

OARS is a collection of clinical skills that MI clinicians use to elicit change talk and work through ambivalence. Although OARS skills are used in many other types of therapy, it is the combination of these skills, within the context of these processes, that makes this intervention unique.

OARS stands for:

• Open questions
• Affirmations
• Reflections
• Summarizing

Check out our motivational interviewing article for a more thorough overview of OARS. What follows are three techniques for using these skills successfully within a clinical engagement.

Learn MI inside and out

Motivational interviewing is about more than just OARS. OARS, after all, are used in almost all therapeutic interventions and by clinicians from all orientations.

What sets MI apart are the steps and processes defined above, including “change talk,” use of the “MI spirit,” and patient-directed focusing. The best way to learn MI is by obtaining training and supervision in your work with clients.

Track the process

An MI intervention requires the use of different aspects of OARS. For example, when working on the first process – engaging – it may be more helpful to use affirmations and summarizations to bolster client confidence and reassure the client you are understanding them.

In the third process, evoking open-ended questions is a useful tool for helping clients define their values and elicit their motivations. Tracking where you are in the engagement will help you use OARS more skillfully and effectively.

Mind your question-to-reflection ratio

In MI, the desired ratio of reflections to questions is 2:1 (Rosengren, 2017). Clinicians are very good at asking questions and learning about their clients, but asking too many questions can lead to both the question-and-answer and expert traps.

These traps occur when the session takes on an investigative tone, with the clinician asking many questions. It often coincides with the belief that the examining clinician has the expertise to solve all the problems. Both traps make the relationship less collaborative and therefore less MI consistent. To avoid these traps, focus on using your reflection skills.

PositivePsychology.com Relevant Tools

Many of the tools within our toolkit are impressive additions to MI work. Some are listed below, with an indication of which part of the process they correspond to.

• Powerful Change Questions
  This tool is useful for helping your clients to reflect on the bigger picture when considering what they really want.
• Personal Values Worksheet
  This tool fits well under the “evoking” process, as it helps clients to concretely define and prioritize their own values.
• 3-Month Vision Board
  This tool fits under both the “evoking” and “focusing,” as it helps the client to both build motivation and define their goals.
• Setting Valued Goals
  This tool fits under the “planning” phase and will assist your clients in setting adaptive and meaningful goals.

Besides these exceedingly useful tools, we also offer the ultimate motivational interviewing toolkit. In addition, this article regarding motivational interviewing principles is a must-read if becoming an MI expert is on your agenda.

17 Motivation & Goal-Achievement Exercises – If you’re looking for more science-based ways to help others reach their goals, this collection contains 17 validated motivation & goals-achievement tools for practitioners. Use them to help others turn their dreams into reality by applying the latest science-based behavioral change techniques.

A Take-Home Message

Motivational interviewing is a process that can help your clients accomplish their goals.

By mastering the above steps, you will have an incredibly powerful tool at your disposal for working with your clients, patients, or employees.

Reading about MI is an important first step, but if you really want to learn how to work this way and how to motivate yourself, consider attending training or getting supervision in this work. It takes practice to work within the “spirit” of MI, but if you do, you may see incredible results.

MI engagements are motivating not only to clients, but to the clinicians who do them. It is a wonderful thing to see someone change themselves for the better. MI clinicians are lucky to accumulate many of these stories to give them both hope in humanity and motivation in their everyday lives.

We hope you enjoyed reading this article. Don’t forget to download our three Goal Achievement Exercises for free.