The Essentials of … Series

Motivational Interviewing www.ccsa.ca • www.ccdus.ca

What Is Motivational Interviewing?

According to founders William Miller and Stephen Rollnick, “Motivational
Interviewing (MI) is a person-centered counseling method for The Essentials of…. is a
addressing the common problem of ambivalence about change.”1MI is series that offers
a conversational style of interviewing used in counselling to address the evidence-based guidance
ambivalence that clients often experience when faced with the need to and practical information
change. Collaborative, person-centred and goal-oriented, MI aims to to enhance practice in
strengthen the client’s motivation toward healthy behaviour change.1 the substance use field.
The topics complement
MI’s roots go back to the humanistic psychology of Carl Rogers,2 whose CCSA’s Competencies
client-centred counselling emphasized reflective listening based on for Canada’s Substance
unconditional regard and accurate empathy. MI emerged in the 1980s Abuse Workforce.
in reaction to conventional treatment approaches that saw people with
addiction problems as being in denial, unwilling to take responsibility and needing to be confronted
to accept abstinence-based addiction treatment. Miller observed that people with addictions behave
in ways that are surprisingly similar to other people with health challenges who commonly have mixed
feelings about the need for change, as well as their ability to enact change.3
Miller and his colleagues noted that the ways counsellors interact with clients can have powerful
effects on how the client’s ambivalence is resolved.1,4 Pressuring an ambivalent person to accept
change often results in pushback. Rollnick, Miller and Butler refer to the urge to correct the client
and prescribe solutions as the righting reflex, a problematic response, but also a valuable signal.5
They advise counsellors to respond by following the mnemonic RULE:
 Recognize and resist the righting reflex; focus instead on
 Understanding the client by
 Listening reflectively to
 Empower the client to explore change.
Rather than wrestling with a person about the need to change, MI avoids confronting and opposing
the client by aligning with him or her in a collaborative partnership to co-develop practical goals for
change.
What Does the Evidence Say?
Miller worked initially with problem drinkers with mild to moderate drinking problems, observing that
MI helped clients move from ambivalence to becoming mobilized to try change. The initial focus was
on preparing people for change. Once prepared, a more practical, skills-based treatment such as
cognitive behavioural therapy (CBT) would take over with the concrete task of behaviour change.3
But since Miller’s research was released in the early 1980s, MI has emerged as a therapy with efficacy

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Motivational Interviewing

comparable to other evidence-based approaches to addictions treatment.6,7 Not only does it prepare
people to change, but it helps people initiate and maintain change. MI, with its focus on how to engage
and work with ambivalent clients, is now recognized and used in the treatment of a wide range of
populations with mental and physical health problems and in the broad domain of health behaviour
change, in both individual and group therapy formats.5,8,9 Ambivalence is not a unique problem of
people with addictions, but a common problem with people facing the need to give up old behaviours
and take up new ones. Being able to work more skillfully with ambivalent clients improves engagement,
retention and therapy outcome.

How Does It Work?

Building on the reflective listening skills of Rogerian client-centred therapy, the MI approach adds an
active, more intentional dimension to the counsellor’s role to guide the client towards healthy change.
Rather than just following the client or directing and pushing for change, MI opens up a middle way,
called guiding.1
MI replaces notions of denial and resistance toward change (traditionally used to blame the client for
treatment avoidance and failure) with the concept of ambivalence to change. MI takes the compassionate
view that people faced with the need to make significant behavioural change often feel stuck. In fact,
people stuck in addictive behaviours often see clearly the pros and cons of both staying the same and
changing to new behaviours. The counsellor works to engage the client and focus on understanding
the client’s dilemma about change options. Even when the client admits to the importance of change,
the client might lack confidence or knowledge about how to change. As the client talks and the
counsellor listens reflectively, the counsellor guides the conversation towards the practical goals the
client wants to work on, the reasons for doing so and the plan of action that will help the client get to
where he or she wants to be.
Not only does research support the efficacy of MI in addictions treatment,7,10 it also suggests how it
works. Moyers and colleagues found that talk consistent with MI led to clients talking more about
change (self-motivational statements), whereas talk inconsistent with MI (directing, advising,
confronting and warning) led to more talk by clients about sustaining behaviour (statements in favour
of the status quo).11 Gaume and colleagues found that MI-consistent skills were linked with better
recovery outcomes.12 This finding suggests that MI-consistent behaviour based on reflective listening
leads to enhanced talk of change by the client, which results in better outcomes in treatment.
While most well-developed therapies for addiction or other behavioural problems do equally well,
clients with therapists who measure higher in empathy have better therapy outcomes than those
with therapists lower in empathy, regardless of the method of therapy they use.13,14 MI is a
communication style that aims to make an empathic connection with the client and build on that to
work collaboratively for change.
What is MI Spirit?
The heart of MI is empathy and MI spirit manifests empathy in the counselling relationship in four ways:1
 Partnership: the counsellor joins with the client to work collaboratively on change goals;
 Acceptance: accepting the client as he or she is, the counsellor affirms the client’s autonomy and
need to make his or her own decisions;
 Compassion: the counsellor holds nothing higher than the client’s well-being, working to
understand what that means from the client’s perspective; and
 Evocation: rather than seeing the client as in need of instruction and direction, the counsellor
evokes from the client what the client’s goals are and how he or she wants to be helped.

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Motivational Interviewing

In MI, skills are not mere techniques, but MI spirit put in practice. The skills appear to be simple, but
grounding the counselling process in them is not easy. It takes practice, feedback and commitment.
In practice, the MI counsellor has three key tasks:15
1. To listen reflectively;
2. To elicit client change talk; and
3. To offer information, feedback and advice using the MI style.
Task One: Listen Reflectively
Of the five core skills in MI, four are used to listen reflectively. They can be remembered by the
mnemonic OARS:
 Open questions
 Affirmations
 Reflections
 Summaries
Open questions seek to get the client to say more, unlike closed questions that can be answered
“yes” or “no.” A goal in MI counselling is for the client to speak at least half the time. Open questions
invite the client to elaborate, and show that the counsellor is interested in listening to and
understanding the client.
Affirmations are how the counsellor using MI takes an active curiosity in interacting with the client.
Providing affirmations is unlike unfocused cheerleading or, even worse, treating the client suspiciously.
Where there are things about the client’s values and behaviours that can be credited, the MI
counsellor seeks to do that. Such affirmations can be as simple as acknowledging that the client
made the effort to come to the appointment or recognizing the client’s willingness to persist in
seeking healthy change, especially if the client has experienced slips and relapses in the past.
Reflections are statements, not questions. They are based on what the counsellor observes in interacting
with the client. Simple reflections stay on the surface, mirroring or paraphrasing what the client is
saying, always in a tentative way that seeks to check with the client that you are understanding as
you listen actively. Complex reflections go beneath the surface in a variety of ways, such as reflecting
what the counsellor thinks the client might be thinking or feeling, even if not stated explicitly. A
reflection might also note the client’s ambivalence about change: on the one hand, you want a better
life; on the other hand, you are not confident you can give up old behaviours. The skillful MI counsellor
is able to intentionally choose the reflective response made to the client. The evidence suggests that
when the counsellor makes more reflections than asks questions, and more complex reflections
than simple ones, the more effective the counselling and the stronger the empathic connection.1
Summaries allow the counsellor to draw on his or her active listening by pulling together key points in
what the client says and offering it back to the client for confirmation and comment. Summaries are
ways of keeping track of what is important for the client, wrapping up one part of the conversation
and shifting to another, and ending an interaction by highlighting important points in the conversation.
They are an important way the counsellor can guide the counselling process so that the client feels
understood and the process is guided towards change.
Learning MI can be thought of as becoming progressively skillful at reflective listening, starting with
moving from asking closed questions to using open questions. Building on open questions, the MI
counsellor learns to make reflections, first, ones that are simple, and then those that are complex.
Affirmations are a particular kind of reflection: statements that aim to recognize and acknowledge

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Motivational Interviewing

the positive values and behaviours of the client. Summaries allow the counsellor ways of organizing
and giving feedback to the client about what has been talked about in ways that can be powerfully
effective in shaping movement towards change. Together, these four skills form the skillset the
counsellor relies on to build an empathic connection with the client, leading to a compassionate
understanding of the client and setting the stage for eliciting talk of change in the client.
Task Two: Elicit Change Talk
In using the MI skills, the counsellor actively pays attention to what is happening with the client. Is
the client speaking more? What is the client saying? Is it talk in favour of change or talk about the
status quo? Change talk is client speech in favour of healthy behavioural change. Sustain talk is
client talk against change and in favour of leaving things alone. Change talk comes in two forms: talk
in preparation of change and talk about change that is already happening. Altogether there are
seven types of change talk, remembered by the mnemonic DARN CATs.1
DARN describes preparatory change talk, which occurs whenever the client speaks about:
 Desire to change: “I want to get better; I hope I can do this”;
 Ability to change: “I’ve been able to stop at times in the past; I’m able to do this”;
 Reasons for change: “If I can do this, my health will improve; I don’t want to lose my job”; and
 Need to change: “I can’t stand living like this; I need to stay out of jail.”
CATs describes talk of active change, which occurs whenever the client speaks about:
 Commitment: “I am going to get help for this problem”;
 Actions: “I have talked to my boss about needing time off to get help”; and
 Taking steps: “I’ve started cutting back on my drug use to make it easier later to stop.”
Task Three: Offering Advice and Sharing Information
The fifth core skill in MI is sharing information and offering advice. When done in MI style, it is used
to give feedback to the client, when requested, that draws on the counsellor’s knowledge, expertise
and experience. Providing information and advice are important parts of the helping process. In MI,
the counsellor works to get the client to ask for advice rather than foisting it upon them. Offering
advice is always preceded by asking the client’s permission to share feedback with the client, as well
as inviting the client to give his or her ideas and thoughts first.
When giving advice or information to the client, MI emphasizes the importance of sharing it in small
chunks, stopping to ask the client what he or she is hearing and what it means for them. This process
has various descriptions including Check — Chunk — Check, and Elicit — Provide — Elicit. That is,
Check (for permission), then Chunk (offer a short bit of advice or information), and then Check (for
feedback and if it is ok to go on); or Elicit (permission), then Provide (advice, information), then Elicit
(feedback and permission to proceed). MI shifts the focus of giving advice, information and feedback
to include not just what the counsellor says, but also what the client hears, what it means to the
client and what it inclines the client to want to do.
The measure of how I am doing as a counsellor is not so much what I think, say and do, but the
effect it has on the client. In earlier years, MI keyed on OARS skills and reflective listening, perhaps
underplaying the important role of information, feedback and advice in counselling. More recently
the value of sharing information, advice and feedback effectively using an MI style has been given
more explicit attention.1,5 It is now an integral feature of MI training and practice.

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Motivational Interviewing

The Four Processes of MI: Engaging, Focusing, Evoking and Planning

Miller and Rollnick observe that counsellors are often in a hurry to take action.1 However, the
evidence suggests that if the client is not really engaged, if there is no shared sense of focus, and
the client’s motives and goals are not clearly understood, action will be ineffective. Before moving to
action planning, the MI counsellor ensures that the client feels connected and understood, which
does not need to take a long time. In brief interventions, it can occur in one session. With clients who
have more chronic and extended problems, it will likely need more time, and is crucial in building
ongoing care and support.
MI sees counsellor engagement with the client as a necessary process to be maintained through all
the phases of care. By connecting with the client, counsellor and client can both develop an effective
understanding of one another, allowing them to collaboratively focus on goals and evoke reasons for
change. That collaboration sets the stage for the final step: planning for change and setting a change
agenda.1,16 By drawing attention to the importance of engaging the client, focusing on goals and
evoking reasons for change, the counsellor using MI skills builds a foundation for plans and actions
that are more likely to be effective because the client is committed to them.
One guiding metaphor in MI is that counselling is about dancing, rather than wrestling, with the client.
MI counselling is about building rapport. By using the MI skills, the counsellor nurtures the empathic
connection that is at the heart of MI practice. MI practice brings skills and spirit together. The skills
can be learned and sharpened. Spirit provides the compass points that guide the counsellor in the
challenging situations he or she will experience in counselling. Miller and Rollnick suggest that having
skills without spirit is like reading the words of a song without playing the music.1 Spirit without skills
is like feeling moved to play the music without having an instrument to perform it on. Skills and spirit
working in concert is what makes counselling effective.

Implications for Substance Use and Allied Professionals

Clinical research has repeatedly found that the methods and techniques that counsellors use in their
work might not be as important in affecting clinical outcome as their ability to make empathic
connections with their clients.17,18,19 Studies have repeatedly shown that well-conceived and well-
supervised interventions by well-trained counsellors usually have comparable efficacy and produce
good outcomes. What makes a bigger difference than the method of treatment is the empathic
abilities of the counsellor. Clients of counsellors demonstrating higher levels of empathy have been
shown to have better outcomes that those of counsellors with lower empathy. Being empathic is an
evidence-based practice that has dramatic implications in the recruitment and training of counsellors
in addiction and allied health domains.13
MI started as an effective way of working with problem drinkers who had mixed feelings about changing
their behaviour. Decades later it is now recognized as an evidence-based practice in the treatment of
substance use problems and other addictive behaviours, and as an effective way of helping people
who are ambivalent about health behavioural change across many domains of mental and physical
health. Its relevance today in clinical practice is increasingly supported by the clinical research literature
and the growing number of counsellors who either make it a foundational part of their clinical work
or have added to their clinical approach by making it MI-enhanced. It is also emerging as an element
in the curriculum in the colleges and universities that train healthcare and social service professionals,
including psychologist, social workers, psychiatrists, family doctors, nurses, pharmacists and addiction
workers across Canada.
The MI goal is a modest one: to help people who could benefit from behavioural change. The skills it
relies on are easy to understand and difficult to practice. While conveying acceptance and compassion,
the counsellor gives special attention to the language of change, using the skills of reflective listening

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Motivational Interviewing

to engage the client in a process that leads to setting a specific goal that leads to an action plan. MI
is described by its practitioners as a style of counselling and a way of being with clients.20
Practicing MI requires more than knowing about MI. It requires knowledge and that comes from
practice. Workshops and readings offer energizing starting points. Moving from novice to expert is a
gradual practice. One of the heartening things about MI is that most people recognize MI spirit and are
already familiar with some of the skills described above. MI training is about becoming better at
connecting with clients and helping them succeed at making healthy changes. The practice of
improving clinical skills is a continuing one.
The Motivational Interviewing Network of Trainers (MINT) is an international body that offers training
for practitioners who want to be recognized as MI trainers. Trainers with good standing in MINT have
access to emerging knowledge and approaches in MI and to approved training materials and tools.
MINT is developing policies and protocols for more formal certification of MI practitioners and trainers.
Learning MI is a matter of practice. Miller and colleagues offer these suggestions for starters:13
 Listen actively before jumping in with questions;
 If you find you have asked three questions in a row, use one of the other OARS skills;
 Try to make at least half your questions be open ones, rather than closed; and
 Aim to offer two reflections for each question.
In MI, the focus is on what the client is saying and helping the client decide what he or she will do
next. MI counsellors work to give the client the good lines. As the client feels heard and hears him or
herself speak, the counsellor guides the process in ways that evoke change talk from the client,
rather than as something the counsellor feels obliged to provide. Engagement is the foundation
stone, which leads to the collaborative focus and goal setting that result in plans for change. And it
starts with this invitation to the counsellor: Always connect.

Prepared by Wayne Skinner, Deputy Clinical Director, Ambulatory Care and

Structured Treatment Program, Centre for Addiction and Mental Health

References
1. Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: helping people change (3rd ed.). New York,
N.Y.: Guilford Press, p. 29.
2. Rogers, C. (1951). Client-centered therapy: its current practice, implications and theory. London, U.K.:
Constable.
3. Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioral Psychotherapy, 11(2),
147–172.
4. Moyers, T. B., & Miller, W. R. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors,
27(3), 878–884.
5. Rollnick, S., Miller, W. R., & Butler, C. C. (2008). Motivational interviewing in health care: helping patients
change behavior. New York, N.Y.: Guilford Press.
6. Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a
practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232–1245.

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Motivational Interviewing

7. Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational
interviewing: twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137–160.
8. Stinson, J. D., & Clark, M. D. (2016). Motivational interviewing with offenders: engagement, rehabilitation
and reentry. New York, N.Y.: Guilford Press.
9. Wagner, C., & Ingersoll, K. (2014). Motivational interviewing in groups. New York, N.Y.: Guilford Press.
10. Allen, J. P., Mattson, M. E., Miller, W. R., Tonigan, J. S., Connors, G. J., Rychtarik, R. G. ... Sturgis, E. (1997).
Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes.
Journal of Studies on Alcohol, 58(1), 7–29.
11. Moyers, T. B., Martin, T., Christopher, P. J., Houck, J. M., Tonigan, J. S., & Amrhein, P. C. (2007). Client
language as a mediator of motivational interviewing efficacy: where is the evidence? Alcoholism: Clinical
and Experimental Research, 31(s3), 40s–47s.
12. Gaume, J., Gmel, G., Faouzi, M., & Daeppen, J. B. (2009). Counselor skill influences outcomes of brief
motivational interventions. Journal of Substance Abuse Treatment, 37(2), 151–159.
13. Miller, W. R., Forcehimes, A. A., & Zweben, A. (2011). Treating addiction: a guide for professionals. New
York, N.Y.: Guilford Press.
14. Norcoss, J. (Ed.). (2011). Psychotherapy approaches that work: evidence-based responsiveness (2nd ed.).
London, U.K.: Oxford University Press.
15. Cohen, S., Dragonetti, Herie, M., & Barker, M. (2014). Motivational interviewing. In C. Els, D. Kunyk, & P.
Selby (Eds.), Disease interrupted: a clinical guide to tobacco reduction and cessation. Montreal, Que.: Les
Presses de l’Université Laval.
16. Skinner, W., & Cooper, C. (2013). Motivational interviewing for concurrent disorders. New York, N.Y.:
Norton and Sons.
17. Norcross, J. C. & Wampold B. E. (2011). Evidence-based therapy relationships: research conclusions and
clinical practices. Psychotherapy, 48(1), 98–102.
18. Allen, J., Anton, R. F., Babor, T. F., Carbonari, J., Carroll, K. M., Connors, G. J. ... Zweben, A. (1998).
Matching alcoholism treatment to client heterogeneity: Project MATCH three year drinking outcomes.
Alcoholism: Clinical and Experimental Research, 22(6), 1300–1313.
19. Zuroff, D. C., Kelly, A. C., Leybman, M. J., Blatt, S. J., & Wampold, B. E. (2010). Between-therapist and
within-therapist differences in the quality of the therapeutic relationship: effects on maladjustment and
self-critical perfectionism. Journal of Clinical Psychology, 66(7), 681–697.
20. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: preparing people to change (2nd ed.). New
York, N.Y.: Guilford Press.

Selected Resources
Motivational Interviewing: Helping People Change (3rd ed., 2012)
An authoritative clinical guidebook on MI by William R. Miller & Stephen Rollnick for professionals and
students, focusing on the four processes of MI. Includes vignettes and interview examples.
Source: Guildford Press
Available at www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781609182274
Motivational Interviewing Network of Trainers (MINT)
MINT is an international organization of MI trainers that promotes quality practice, use research and
training in MI. The website includes an extensive list of MI resources.
Available at www.motivationalinterviewing.org

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Motivational Interviewing

Pour les professionnels de la santé: l’entrevue motivationnelle

Website that provides downloadable practical tools and worksheets that can be used by all types of
healthcare professionals using motivational interviewing.
Source: PSYMontréal
Available at psymontreal.com/pour-les-professionnels-de-la-sante/
Motivational Interviewing Step by Step (2012)
Series of four videos; the first video includes foundational principles of MI. Subsequent videos
feature vignettes that demonstrate how various MI strategies can be applied.
Available at www.psychotherapy.net/video/motivational-interviewing-series
Cost: see website
Motivational Interviewing for Tobacco Cessation (2014)
Series of videos on using motivational interviewing in tobacco cessation. Select Motivational
Interviewing (English or French) video playlist from youtube.
Source: Centre for Addiction and Mental Health
Available at www.youtube.com/user/teachproject/playlists
Motivational Interviewing in Respiratory Health Care: Trainers’ Toolkit (2014)
MI toolkit for those who are training practitioners working in respiratory healthcare. Includes
facilitation tips, learning objectives, lesson plans, presentation slides, video vignettes, interactive
exercises and more.
Source: Centre for Addiction and Mental Health
Available at www.nicotinedependenceclinic.com/English/teach/Pages/OLA-toolkit.aspx

ISBN 978-1-77178-419-7 © Canadian Centre on Substance Use and Addiction 2017

CCSA was created by Parliament to provide national leadership to address substance use in
Canada. A trusted counsel, we provide national guidance to decision makers by harnessing
the power of research, curating knowledge and bringing together diverse perspectives.
CCSA activities and products are made possible through a financial contribution from
Health Canada. The views of CCSA do not necessarily represent the views of the
Government of Canada.

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