Introduction to the Special Series on Motivational

Interviewing and Psychotherapy

m

Hal Arkowitz
University of Arizona
m

Henny A. Westra
York University

Clinical and research applications of motivational interviewing (MI)

have grown at a remarkable pace over the past 25 years. Most of this
work has targeted the addictions and health-related behaviors. The
series of articles in this issue highlight a rapidly accelerating recent
trend: the application of MI to other problems typically seen in clinical
practice. This introductory article describes MI, its core principles,
treatment methods, and the variety of ways in which it has been
employed. The 6 case reports in this issue are then described. They
illustrate how MI can be employed with generalized anxiety,
adolescent depression, lifestyle changes, social anxiety disorder,
suicidality, and intimate partner violence. The series of articles in this
issue concludes with a commentary on the cases and a practice-
friendly review of outcome research on MI. & 2009 Wiley Periodicals,
Inc. J Clin Psychol: In Session 65: 1149–1155, 2009.

Keywords: motivational interviewing; psychotherapy; motivational

enhancement

Motivational interviewing (MI) was first described a little over 25 years ago in a
seminal paper by William R. Miller (1983). Subsequently, a fruitful collaboration
between Miller and Stephen Rollnick led to their classic book Motivational
Interviewing: Preparing People to Change (1991) and then to a revised second
edition (Miller & Rollnick, 2002). MI is clearly attracting the attention of both
clinicians and researchers. Since its inception, over 800 publications on MI have
appeared, including approximately 200 clinical trials. The number of publications

Correspondence concerning this article should be addressed to: Hal Arkowitz, Department of Psychology,
University of Arizona, Tucson, Arizona 85741; e-mail: [email protected] or Henny A. Westra,
Department of Psychology, York University, 4700 Keele Street, Toronto, Ontario, Canada M3J 1P3;
e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 65(11), 1149--1155 (2009) & 2009 Wiley Periodicals, Inc.
Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20640
1150 Journal of Clinical Psychology: In Session, November 2009

has approximately doubled every 3 years over the past decade. There is already great
interest in MI, and it is catching on in the United States and abroad.
Until recently, most work on MI was focused on problems of substance abuse and
health-related behaviors (e.g., decreasing unprotected sex and increasing exercise).
The research has demonstrated the efficacy of MI for these problems as well as
finding that MI seems to work more quickly than other treatments (see Lundahl &
Burke, 2009).
In the past few years, there has been growing interest in the value of MI for other
problems typically seen by practitioners. Clinical reports and research trials of such
applications have been appearing at an increasingly rapid rate. Some of the problems
addressed include anxiety, depression, suicidality, eating disorders, medication
compliance, and pathological gambling (e.g. Arkowitz, Westra, Miller, & Rollnick,
2008). MI even appears to be useful in training correctional system workers to be
more effective in their interactions with prison inmates (Fabring & Johnson, 2008).
The six case reports in this issue of the Journal of Clinical Psychology: In Session are
presented in the spirit of further exploration of the value of MI for a variety of
clinical problems.

What is MI?
Miller and Rollnick (2002, p. 25) defined MI as ‘‘a client-centered directive method
for enhancing intrinsic motivation to change by exploring and resolving
ambivalence.’’ MI is strongly rooted in the client-centered therapy of Rogers
(1951, 1957) in its basic relational stance emphasizing the importance of under-
standing the client’s internal frame of reference and displaying unconditional
positive regard. This is also reflected in the relational context of MI, which is referred
to as ‘‘MI spirit,’’ which comprises the therapist being collaborative (avoiding a
persuasive or authoritarian stance, view clients as partners), evocative (drawing on
the client’s ideas rather than instilling the therapist’s expertise), and preserving client
autonomy (recognizing and acknowledging that all choices ultimately reside with
clients and cannot be externally imposed). Ultimately, improving intrinsic
motivation in MI is accomplished by helping the client become the advocate for
and primary agent of change. In addition, MI consists of specific principles (express
empathy, develop discrepancy, roll with resistance, and support self-efficacy) and
methods, including eliciting and differentially reinforce change talk.
MI can be thought of as client-centered therapy with a ‘‘twist’’ (Arkowitz &
Miller, 2008). The ‘‘twist’’ involves the directive components in MI which are not
present in client-centered therapy. These include the goal-orientation of MI to
change problem behavior by methods designed to increase intrinsic motivation to
change. That is, in MI, the therapist keeps the focus on change and enhancing
motivation for change specifically, rather than on other possible behavioral targets.

MI Principles and Strategies

Miller and Rollnick (2002) described the following four basic principles of MI along
with specific clinical strategies that are derived from them. These strategies are often
used early in therapy to address motivational problems, but they may also be woven
into the entire course of any treatment.
Journal of Clinical Psychology DOI: 10.1002/jclp
 Motivational Interviewing and Psychotherapy 1151

Express empathy. An empathic therapist strives to experience the world from

the client’s perspective without judgment or criticism to help the client more clearly
understand and reflect on their own experience, values, ideas, and choices.

Develop discrepancy. When discrepancies between the client’s values and

behaviors are reflected back to the client, it creates discomfort that can motivate
the person toward behavior change. An example of such a reflection in someone with
agoraphobia might be, ‘‘So, it’s really important to you to be a good mother, but
staying home all the time interferes with that goal.’’ This is not done in the spirit of
confronting clients but rather helping them move forward in resolving their
ambivalence about change.

Roll with resistance. In MI, resistance to change is conceptualized as

ambivalence about changing. This ambivalence is viewed as a normal experience
in contemplating change. Although clients may be aware of the advantages of
changing, they also have concerns about changing including, for example, the
unknown or unpredictable aspects of change or fears of failure if their attempts to
change do not work. MI therapists see such ambivalence as a source of important
information about the client rather than as an annoying obstacle to be overcome.
Ambivalence can help therapists better understand their clients’ hopes, desires, and
fears and how to work with them. Moreover, resistance is considered to be relational
in MI, rather than a client problem and, therefore, when the therapist rolls with
resistance this plays a pivotal role in reducing it.

Support self-efficacy. In MI, the therapist evokes and supports the client’s beliefs
that they can successfully carry out the necessary actions required to change. MI
therapists seek to enhance client agency about change and show patience and
curiosity about client ideas about change.

MI Therapist Skills
Several MI skills, which come directly from Rogers’ client-centered therapy (1951),
include asking open-ended questions, listening reflectively, affirming, and summarizing.
However, eliciting and reinforcing change talk is intentionally directive and specific
to MI.

Use open-ended questions. Such questions reflect therapist curiosity about the
client’s experience, encourage client elaboration, and ensure that the client rather
than the therapist will do most of the talking during the session.

Listen reflectively. Miller and Rollnick suggested that ‘‘the essence of a reflective
listening response is that it makes a guess as to what the speaker means’’ (2002,
p. 69). People are often unaware of the meanings underlying their statements or the
implicit message conveyed by these statements. They may simply not be able to find
the proper words to convey their experience or they may fear having to confront the
reality of their experience (e.g., coming face to face with the knowledge of having a
difficult problem). Reflective listening helps clients to make these meanings more
explicit. Reflections may comprise rephrasing to emphasize a point, paraphrasing
that includes a guess about the meaning of what the client has said, and feeling
reflections that reflect the emotions underlying the client’s statements.
Journal of Clinical Psychology DOI: 10.1002/jclp
1152 Journal of Clinical Psychology: In Session, November 2009

Affirm. The MI therapist frequently affirms and supports the client in the form
of statements of appreciation or understanding, such as: ‘‘It took courage to do
that’’ or ‘‘It’s very difficult to be uncertain about changing.’’
Summarize. Summaries during and at the end of the session can serve to link
material together and can help emphasize key points. They are particularly useful in
collecting and reinforcing client change talk or statements involving positive
motivation to change.
Elicit and reinforce change talk. Although the four methods discussed are basic
MI skills, their use doesn’t necessarily provide clients with a way out of their
ambivalence. It is possible to use these methods and go around in circles by asking,
reflecting, affirming, and summarizing. This is where eliciting and reinforcing client
change talk (e.g. ‘‘I’m tired of being anxious all the time and I think I’d like to do
something about it’’). Statements reflecting commitment to change were particularly
important in this regard (Amrhein et al., 2003). Although the therapist intentionally
elicits and reinforces change statements, this is done without the therapist explicitly
taking the role of advocate for change. In MI, the therapist always works with what
the client says and emphasizes the importance of helping the client become the
advocate for change.

Working With Ambivalence

All of the methods discussed above are used in working with ambivalence. In
addition, MI therapists often use a decisional balance method in which they elicit the
client’s perceptions of the pros and cons of change. If this balance is not clearly
tipped toward change, the therapist continues with the methods described above
until it is.
When the therapist senses that the client is ready for change, the discussion shifts
toward the development of a change plan and strengthening the client’s commitment
to it. In developing and implementing a change plan, the client is the primary agent
and the therapist serves as a consultant to the client in the change endeavor rather
than as a director of it.

Variations in MI Practice and Goals

MI has been delivered in different forms and with different goals, reflecting the
flexibility and robustness of the method. Although MI can be used as a ‘‘stand-
alone’’ therapy (see Brody, 2009), it is a flexible clinical approach that can be
employed in a variety of other ways as well. One of the most common and effective
applications of MI is that of a pretreatment to other treatments, such as cognitive
behavior therapy (CBT; see Angus & Kagan, 2009; Buckner, 2009; Musser &
Murphy, 2009). MI can also be used during the course of therapy as problems in
motivation arise (Arkowitz & Westra, 2004). Further, MI can be employed as an
integrative framework for the treatment of depression and other problems into
which a variety of other psychotherapies can be incorporated (Arkowitz & Burke,
2008).
Another common use is combining or integrating MI with another treatment
approach (see Wagner & Ingersoll, 2009; Zerler, 2009). MI has also been used
as a brief intervention to facilitate entry into treatment for those who need it
but are reluctant to seek it (Buckner, 2009), including court-ordered clients
(Musser & Murphy, 2009). It has even been used with those who refuse treatment
Journal of Clinical Psychology DOI: 10.1002/jclp
 Motivational Interviewing and Psychotherapy 1153

(Tolin & Maltby, 2008) to help them overcome their concerns about participating in
treatment.

This Issue
The case reports in this issue expand the scope of MI by painting a valuable picture
of how it can be used for different clinical problems typically encountered in clinical
practice. These articles also demonstrate the flexibility of MI by illustrating its use as
a stand-alone treatment, a pretreatment, combined or integrated with other
treatments, and as a method to motivate reluctant clients to seek treatment.
Angus and Kagan (2009) discuss a client with generalized anxiety disorder (GAD)
and who was seen for a four-session MI pretreatment followed by CBT. These
authors suggest that the relationship in MI, similar to that of client-centered therapy,
may itself be healing in GAD. They make the interesting case that MI spirit is best
exemplified by empathic attunement, which can serve as a positive corrective
emotional experience, help clients regain a sense of mastery over their worry, and
facilitate a strong therapeutic relationship. Although their discussion focuses on
GAD, their points may apply to other clinical problems as well. Their paper
stimulates us to think about the role of the therapeutic relationship in MI and
psychotherapy more broadly.
Brody (2009) illustrates the use of a MI stand-alone treatment with a depressed
adolescent who was confused and ambivalent about important choices. The client
struggled with a conflict between her desire to live up to her mother’s expectations
and making her own life choices. Brody hypothesized that this conflict was at the
core of the client’s depression. This case illustrates the value of MI with a depressed
adolescent. It is one of the few reports in the literature on MI with an adolescent and
MI for depression.
Wagner and Ingersoll (2009) used a slightly modified form of MI as a stand-alone
therapy with a woman whose drinking and sexual behavior put her at risk for an
alcohol-exposed pregnancy. The authors make the important point that although
most MI therapy to date has been focused on a single behavior change (e.g., problem
drinking), the majority of clients seeking therapy experience more than one problem
and need a therapy that addresses their multiple needs. Their report suggests that MI
might hold up well with more complex cases that are often seen in clinical practice.
Buckner (2009) describes the case of a socially anxious young woman who
participated in a research project relating to social anxiety. The therapist employed
motivational enhancement therapy (a variation of MI that includes problem
feedback) to encourage the client to seek CBT for her anxiety problem. This case
nicely illustrates how MI can be used to facilitate treatment seeking and subsequent
participation in psychotherapy among people who might need but not otherwise
seek it.
Zerler (2009) described the use of MI combined with a method called the
collaborative assessment and management of suicidality (CAMS) to treat suicidal
ideation in a middle-aged woman. The client appeared in the emergency room of a
community hospital with physical complaints but made comments suggesting that
she was suicidal. As a result, she was referred for a psychological evaluation in which
MI and CAMS were employed. At the end of the session, the client seemed more
motivated to live and follow the plans made during the session to reduce suicidality.
Perhaps the most fascinating aspect of this case is the nature of the problem to which
MI was applied. As Zerler points out, professionals often respond directively to
Journal of Clinical Psychology DOI: 10.1002/jclp
1154 Journal of Clinical Psychology: In Session, November 2009

suicide risk, whereas an approach like MI, which is more supportive and enhances
client agency and self-efficacy, may be more useful.
The case reported by Musser and Murphy (2009) illustrates the potential value of
MI with highly treatment-resistant clients. A two-session MI intervention was
employed with a man who was court-ordered to receive treatment for committing
intimate partner violence. The goals of the two-session MI pretreatment included
reducing hostility and increasing receptivity to structured group therapy for men
with this problem. Given the difficulties of working with clients who are coerced or
pressured into treatment, this report suggests the potential of using MI to work with
these difficult populations.
The six case reports illustrate promising and innovative applications of MI to a
variety of clinical problems. They are followed by an up-to-date practice-friendly
review of MI research by Lundahl and Burke (2009). The special issue concludes
with a commentary by Constantino, DeGeorge, Dadlani, and Overtree (2009) that
raises important clinical issues relating to MI.
Many fascinating questions remain about the efficacy of MI and its variations
with different clinical problems. We hope the articles in this issue of the Journal of
Clinical Psychology: In Session will contribute to the rapidly growing clinical interest
in extending MI to populations outside of addictions and health behaviors. In so
doing, we can all be more effective in motivating people to seek psychotherapy as
well as increasing motivation for change among those already in treatment.

Selected References and Recommended Readings

Amrhein, P.C., Miller, W.R., Yahne, C.E., Palmer, M., & Fulcher, L. (2003). Client
commitment language during motivational interviewing predicts drug use outcome.
Journal of Consulting and Clinical Psychology, 71, 862–878.
Angus L.E., & Kagan F. (2009). Therapist empathy and client anxiety reduction in
motivational interviewing: ‘‘She carries with me, the experience.’’ Journal of Clinical
Psychology, In Session, 65, 1156–1167.
Arkowitz, H., & Burke, B.L. (2008). Motivational interviewing as an integrative
framework for the treatment of depression. In H. Arkowitz, H.A. Westra, W.R. Miller,
& S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems
(pp. 109–144). New York: Guilford Press.
Arkowitz, H., & Miller, W.R. (2008). Learning, applying, and extending motivational
interviewing. In H. Arkowitz, H.A. Westra, W.R. Miller, & S. Rollnick (Eds.),
Motivational interviewing in the treatment of psychological problems (pp. 1–25).
New York: Guilford Press.
Arkowitz, H., & Westra, H.A. (2004). Integrating motivational and cognitive behavioral
therapy in the treatment of depression and anxiety. Journal of Cognitive Psychotherapy,
18, 337–350.
Arkowitz, H., Westra, H.A., Miller, W.R., & Rollnick, S. (Eds.) (2008). Motivational
interviewing in the treatment of psychological problems. New York: Guilford Press.
Brody, A.E. (2009). Motivational interviewing with a depressed adolescent. Journal of Clinical
Psychology, In Session, 65, 1168–1179.
Buckner, J.D. (2009). Motivation enhancement therapy can increase utilization of cognitive-
behavioral therapy: The case of social anxiety disorder. Journal of Clinical Psychology,
In Session, 65, 1195–1206.
Constantino, M.J., DeGeorge, J., Dadlani, M.B., & Overtree, C.E. (2009). Motivational
interviewing: A bellwether for a context-responsive paradigm of psychotherapy integration.
Journal of Clinical Psychology, In Session, 65, 1246–1253.
Journal of Clinical Psychology DOI: 10.1002/jclp
 Motivational Interviewing and Psychotherapy 1155

Fabring, C.A., & Johnson, W.R. (2008). Motivational interviewing in the correctional system.
In H. Arkowitz, H.A. Westra, W.R. Miller, & S. Rollnick (Eds.), Motivational interviewing
in the treatment of psychological problems (pp. 304–323). New York: Guilford Press.
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, In Session, 65, 1232–1245.
Miller, W.R. (1983). Motivational interviewing with problem drinkers. Behavioural
Psychotherapy, 11, 147–172.
Miller, W.R., & Rollnick, S. (1991). Motivational interviewing: Preparing people to change
addictive behavior. New York: Guilford Press.
Miller, W.R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change
(2nd ed.). New York: Guilford Press.
Musser, P.H., & Murphy, C.M. (2009). Motivational interviewing with perpetrators of
intimate partner abuse. Journal of Clinical Psychology, In Session, 65, 1218–1231.
Rogers, C.R. (1951). Client-centered therapy. Boston, MA: Houghton-Mifflin.
Rogers, C.R. (1957). The necessary and sufficient conditions of therapeutic personality
change. Journal of Consulting Psychology, 21, 95–103.
Tolin, D.F., & Maltby, N. (2008). Motivating treatment-refusing patients with obsessive-
compulsive disorder. In H. Arkowitz, H.A. Westra, W.R. Miller, & S. Rollnick (Eds.),
Motivational interviewing in the treatment of psychological problems (pp. 85–108).
New York: Guilford Press.
Wagner, C.C., & Ingersoll, K.S. (2009). Beyond behavior: Eliciting broader change with
motivational interviewing. Journal of Clinical Psychology, In Session, 65, 1180–1194.
Zerler, H. (2009). Motivational interviewing in the assessment and management of suicidality.
Journal of Clinical Psychology, In Session, 65, 1207–1217.

Journal of Clinical Psychology DOI: 10.1002/jclp