Motivational Interviewing (MI)

Usability

Motivational Interviewing (MI) is a person-centred, counselling approach used to address difficulties in changing unhelpful behaviours (e.g. substance use disorder). MI is particularly focused on change, and applies collaborating conversation as a means of helping people build their motivation for change, and strengthen their commitment to change. At its core, MI applies the three key elements of collaboration, evocation of the patient’s ideas on change, and respect of patient’s autonomy, to facilitate the identification, evaluation, and resolution of ambivalence towards behavioural or attitudinal change. This is guided by a therapist who acts as a facilitator, and adopts a nonconfrontational approach to elicit the patient’s intrinsic resource for change. Hence, MI differs from other externally driven approaches. It does not apply coercive methods to impose change, but supports change in ways that are compatible with the patient’s beliefs and values.

In practice, the application of MI has four key tasks - engaging, focusing, evoking, and planning. These tasks are not linear but engaging is often a key first step in order to build engagement in preparation for conversations about change.

• MI includes basic counselling techniques that build motivation for change. It is represented by the acronym OARS that represent asking Open-ended questions, making Affirmations, using Reflections, and using Summaries.
• MI includes goal setting and a ‘change plan of action’ as a means of strengthening commitment to change. The strategies applied in this phase provide guidance to patients as they apply change talk (i.e. patient statements that express consideration of, motivation for, and commitment to change) as a path to change.    

Alongside the tasks above, four principles guide the practice of MI, and should be adhered to by practitioners employing it. These are; 1) the expression of empathy by applying a non-judgemental approach to understanding the patient’s perspective; 2) supporting patient’s self-efficacy for the purpose of enhancing confidence in their capacity for change; 3) rolling with resistance in a non-judgemental manner, and applying strategies that prevent resistance from interfering with patient engagement; 4) helping patients see the discrepancies between current behaviours and future goals in order to strengthen motivation for change. MI can be delivered to children, adolescents and adults.

Fidelity

Motivational interviewing is delivered by trained practitioners with ongoing supervision. Rating scales that can be used to assess fidelity to the MI approach are outlined below and details can be found at motivationalinterviewing.org;

• Motivational Interviewing Skill Code (MISC)
• Motivational Interviewing Assessment – Supervisory Tools for Enhancing Proficiency (MIA – STEP)
• Motivation Interviewing Treatment Integrity (MITI) code
• Motivational Interviewing Target Scheme (MITS)
• Behaviour Change Counselling Index (BECCI)

Modifiable Components

MI recognises the three key components of motivation, i.e. willingness to change, the confidence to change, and readiness for change. Hence, motivational strategies applied can be tailored to suit the patient’s stage of change. MI can be delivered in a variety of settings (e.g. GP surgery, mental health settings, other health care settings), and to different target groups (e.g. probation and youth offenders, pain management, stroke recovery, and child care settings).  MI has been delivered in individual and group formats (https://pubmed.ncbi.nlm.nih.gov/31821350/), and has been evaluated as a smartphone application (https://link.springer.com/article/10.1007/s41347-020-00135-w). Available evidence for MI is limited for people with substantial learning disabilities. MI can be delivered alone or integrated with CBT.

Interventions that draw on the core concepts and principles of MI include;

• Brief Interviewing (BI): This is a time-limited, structured, and goal-oriented counselling intervention to address substance use problems or other health-risk behaviours. BI can be used to prevent the development of substance use problems, protect against its progression, and help identify individuals requiring more intense intervention. BI can vary in the model used to influence change, and can adopt a range of similar yet differing techniques to achieve this. Hence, it may be entirely founded on MI core components and principles; only partly reflect MI principles and techniques; and may contain brief advice. There is also variability in BI delivery format, as it can be delivered in single or multiple sessions (e.g. one to five sessions), of varying lengths (e.g. 5-15 minutes, or 30-45 minutes), with or without written materials, or opportunities for follow-up visits. BI can include motivational interviewing, information, education and counselling on problem-solving strategies. It can commonly be delivered as an opportunistic intervention by non-specialists in primary care settings to non-treatment seeking individuals, but can also be delivered in specialist settings for substance use problems.
• Motivational Enhancement Therapy (MET): MET is a person-centred approach to therapy that is founded on the basic principles of motivational psychology. The key goal of MET is resolving or overcoming ambivalence to behaviour change. Hence, it focuses on increasing patient’s motivation to change by enhancing patient’s understanding of the problem, addressing self-defeating thoughts as it relates to the problem, and building self-confidence as it relates to the patient’s ability to change. An initial assessment is conducted prior to delivering MET for the purpose of collating information on behaviours that are associated with the problem. Following the initial assessment, MET is typically delivered over four sessions. The first two sessions focus on structured feedback (from initial assessment), future plans, and motivation for change, while the latter two sessions provide opportunities for the practitioner to reinforce progress, conduct reassessments, and provide an objective perspective on the change process. MET can be delivered as a standalone intervention or in conjunction with other psychological interventions (e.g. CBT).

Supports

Implementation support

NHS Education for Scotland and The Scottish Drug Forum (SDF) offer a range of training and workforce development options designed to enhance both individual and team skills and knowledge. This is to ensure that service users, staff, and management benefit from an ongoing learning culture in all relevant areas of service provision. Core training for MI is offered through Alcohol and Drug Partnerships (ADPs) on an agreed programme reviewed on an annual basis with the Substance Misuse Unit of Scottish Government. The MI Coach training programme builds on the principles of implementation science. This training is supported by a TURAS Learning Programme that facilitates the selection of coaches, tracks training and coaching experience, and documents observed practice. https://www.sdf.org.uk/what-we-do/improving-services/workforce-development-programme/; https://www.nes.scot.nhs.uk/news/motivational-interviewing-training-programme-2021-2022/

Start-up Costs

No start-up costs associated with training provided through the NHS or by NES (https://www.nes.scot.nhs.uk/news/motivational-interviewing-training-programme-2021-2022/). Costs apply when training is provided by private organisations and can vary depending on the organisation providing training. E.g. practitioner introductory training, advanced training, and training bundle (i.e. introduction plus advanced) cost £375, £375 and £720 respectively when accessed via organisations such as NHS Tavistock and Portman.

Building Staff Competency

Qualifications Required

MI can be delivered by practitioners from a diverse range of backgrounds. These include registered psychologists (e.g. clinical, counselling, educational, and forensic), registered mental health nurses, registered social workers, and psychiatrics. Counsellors/ psychotherapists with full or provisional accreditation, and General Practitioners (GPs) who meet specific experience and accreditation requirements can also deliver MI. Additionally, a wide range of health and social care practitioners can be trained in brief MI to incorporate MI skills into their working practices.

Training Requirements

Accessible learning opportunities are available to a range of practitioners across the NHS, social care and the third sector through online modules: Two eLearning modules that introduce Motivational Interviewing are available to all practitioners through TURAS Learn (https://www.nes.scot.nhs.uk/news/motivational-interviewing-training-programme-2021-2022/. Modules within the training offers an introduction to the underlying skills needed for motivational conversations. Training offers an introduction to the strategic elements of MI practice. Skills in MI can be developed through further training via a two-day ‘Introduction to MI workshop’ for mental health and physical health practitioners with subsequent coaching. A Motivational Interviewing Coach training programme is available for practitioners with extensive MI experience.

Training modules for people supporting changes in health behaviour are supporting by the MAP training resources see https://www.nes.scot.nhs.uk/our-work/behaviour-change-for-health/; https://www.nes.scot.nhs.uk/news/motivational-interviewing-training-programme-2021-2022/. Further training is offered through the developing Scotland’s workforce learning site https://learn.nes.nhs.scot/19054/developing-scotland-s-substance-use-workforce/motivational-interviewing.

Connecting with Parents’ Motivations is a one-day training course for all practitioners who work with children and their families. It is based on a motivational interviewing informed approach and aims to enhance practitioners’ existing communication skills to talk with parents about the social, emotional and developmental needs of their child Connecting with Parents’ Motivations (CwPM) | The Knowledge (nhs.scot).

Training in Psychological Skills – Paediatric Healthcare (TIPS-PH) programme offers two modules with a focus on motivational interviewing skills and approaches for all health and social care staff working with children and young people with long-term physical health conditions; Motivational Interviewing Approaches and Promoting Engagement with Healthcare for Children and Young People with Long-Term Health Conditions.  Both modules offer training in skilled psychological care and are supported by Putting it Into Practice Sessions. https://www.nes.scot.nhs.uk/our-work/paediatric-psychology-tips-ph

Supervision Requirements

Practitioners delivering brief MI or MI skills as part of their health and social care role can be supported by coaching, reflective practice sessions and line management structures. Coaching and reflective practice sessions are provided by NES Psychology workstreams and local NHS psychology departments to support MI practice amongst health and social care professionals.

When MI is delivered as a psychological intervention (enhanced and specialist psychological practice) it is recommended that it is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available on supervision of psychological interventions that specifically supports MI supervision skills. 

Theory of Change

MI is founded on the principles of motivational psychology, and it applies motivational strategies to elicit the patient’s intrinsic resource for change. The MI approach also adopts a transtheoretical perspective, in which the individual is viewed as moving through a series of stages of change as they progress towards modifying their problem behaviour and achieving successful and sustained change.

Research Design & Number of Studies

Values

Motivational Interviewing (MI) is a person-centred, counselling approach used to address difficulties in changing unhelpful behaviours (e.g. substance use, offending). It is founded on the principles of motivational psychology, and it applies motivational strategies to elicit the patient’s intrinsic resource for change. MI does not apply coercive methods to impose change, but supports change in ways that are compatible with the patient’s beliefs and values.

• Do the underpinning theory and change focus of the intervention align with the requirements of your organisation?

Priorities

MI is particularly focused on change, and applies collaborating conversation as a means of helping people build their motivation for change, and strengthen their commitment to change. MI can be delivered in a variety of settings, to different target groups, and in different formats.

• What substance misuse problem will this intervention aim to address (e.g. alcohol, cannabis)?
• In what setting and format will MI be delivered?
• Will MI be offered alone or in conjunction with other psychological therapies?

Existing Initiatives

• Does your service currently deliver interventions to treat substance misuse problems?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

MI can be delivered by practitioners from a diverse range of backgrounds, e.g. registered psychologists, registered mental health nurses, registered social workers, counsellors, and General Practitioners (GPs).

Technology Support

MI can be delivered without access to technology but access to video platforms for remote delivery can be useful.

• Will MI be delivered in-person or remotely?
• Does your service have the technology to support MI remote delivery?

Administrative Support

Face-to-face therapy sessions can be held in several settings including community health centres, outpatient clinic settings, hospitals, and schools. Administrative support may be needed to manage appointments, collate and process written reports.

• In what setting will MI be delivered?
• Does your service have a venue to deliver MI sessions?
• Can administrative supports needed to deliver this intervention be provided?

Financial Support

Scottish Government/NES Psychology routinely funds training programmes in MI. Training is available from other organisations at a cost.

• Can your service financially support practitioner training costs if accessed outside NES?

Comparable Population

MI has been shown to be effective in the treatment of substance misuse problems (including cannabis and alcohol) in adolescents and adults.

• Is this comparable to the population your service would like to serve?

Desired Outcome

MI is associated with significant improvements across several outcomes including reductions in substance use, symptoms of dependence, substance use related problems, as well as increases in substance use abstinence.

• Is delivering MI for the treatment of substance use disorder a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?