Staff Perspective: Motivational Interviewing - Just Good Clinical Skills

Staff Perspective: Motivational Interviewing - Just Good Clinical Skills

Dr Diana Dolan

You have probably heard of motivational interviewing (MI), a therapeutic approach to working with patients who are considering making a behavior change. Initially developed with alcohol use disorders, it has spread to other types of behavior change, including health-related behaviors. The goals is to help patients generate change from within, arguably making it more lasting. Since I work in health psychology, largely with sleep disturbances and pain conditions, as well as in primary care, I tend to incorporate the spirit of MI into my practice.

You may also be interested in learning more about MI and using it in your practice. However, you may not have ready access to a workshop, or may have difficulty finding a trainer or consultant (some providers are ‘certified’ as trainers and provide formal training, see That said, in my humble opinion, you don’t need to specialize in MI or attend a formal training in MI to learn about the spirit of MI and incorporate some of the best practices.

Rather, I would suggest that some basic elements of MI are really just good clinical skills that all behavioral health providers should engage in, with all of our patients. Not only have I noticed these have benefited my practice, as a consultant who has sat in on or reviewed recordings of hundreds of hours of sessions, I have observed that not including these elements are a barrier to patient improvement. Here are the top elements of MI I would encourage you to consider:

Avoid the ‘righting reflex’
Often, when we hear patients report behavior we know is detrimental, we want to tell them to stop right away. I am reminded of the MAD skit with Bob Newhart in which the therapist loudly says “stop it!” to a new patient every time she describes a problem. With sleep, I often hear patients report consuming large amounts of caffeine or playing on their phone in bed before trying to fall asleep. Don’t get me wrong, I want to say ‘stop it’ too! This is what in MI is called our ‘righting reflex’, the urge we have to correct behavior.

Of course, if we take a step back and think about it, this is destined to fail. Telling anyone what to do is going to result in defensiveness. In the skit, the patient demands her money back and hightails it out of the office. If I walked up to you out of the blue and said “I think you should stop doing what you’re doing,” I can almost guarantee that interaction won’t go well. It would shut you down, invalidate you, and definitely not change behavior. So why on earth do we do this to our patients? Yet time and time again I have witnessed therapists correct their patients repeatedly, sometimes even in the first appointment where the intent is simply to learn about the patient. Observe yourself and ask if outside of collaboratively setting plans or homework, you give your patient ‘tips’ or correct them. If so, stop it!

If your patient hasn’t requested advice and you must give it, ask permission
In a similar vein, we may sometimes hear about a behavior that is important to address and is relevant to treatment and the patient’s goals. For example, if I know my patient with insomnia is using their phone in bed, when we get to the stimulus control intervention in therapy, I will need to specifically guide them to find a different place to do so. Rather than ‘telling’ my patient what to do based on a desire to fix them, I help them decide how to implement this evidence-based intervention.

To do so, MI offers the elicit-provide-elicit or EPE approach. First, ask permission or query the patient’s interest in the topic. Then, provide information in straightforward language with a style that is respectful versus parental or coercive; no ‘musts’ or ‘shoulds’ or ‘if-you-don’ts’ about it! Lastly, check in with the patient as to how they make sense of the information you have provided. The patient may have questions, and hearing the patient’s response helps gauge what was helpful for the patient and whether the patient would like to incorporate anything into treatment.

Selectively reflect ‘change talk’
Instead of trying to argue patients into change, selectively reflect and follow-up on comments patients make so that they themselves verbalize the change. People are more likely persuaded by what they hear themselves say! Think about how debating a position when on the debate team might actually influence your pre-existing opinion. If my patient says “This sounds hard!” after I share sleep restriction steps, I might say “I know, it definitely isn’t easy. I guess your sleep now isn’t easy either-ugh. Well, what are we hoping to get out of this at least?” I do not argue, I just encourage and then reward with attention when they say anything positive about trying sleep restriction.

Think verbal behaviorism in a way! Ignore negative comments and move back into change talk. If my patient says “I’m still not sure I can do this” instead of saying “why not?” which will result in arguing against change, I might say “You’re saying some things that might get in the way are not just external, but internal, maybe that little voice in the back of your head. At the same time, you feel something needs to be done about your sleep. What could you tell that voice to help you give this strategy a real try?”

There are many elements of MI that resonate with me as good clinical skills no matter what therapy I am using. General cognitive behavioral therapy, specific evidence-based protocols such as for trauma, sleep, and pain, and yes, I confess to even having engaged in supportive therapy. You name it, you would benefit from the MI spirit. I found it difficult to narrow down these skills to the three above, and am sure there are others. Ultimately, what underlies the skills I chose to highlight is the concept of autonomy; respect for and acceptance of my patient’s choices on what, if anything, to change. I acknowledge the difficulty in change and the valid reasons for the patient’s current situation. If now is not the best time to make a change, that is alright, there is no need to take it personally. Sometimes, it is enough simply for the patient to know what choices are available, and at the very least perhaps a good clinical experience leaves the door cracked for the future.

The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.

Diana Dolan, Ph.D., CBSM, DBSM, is a clinical psychologist serving as a Senior Military Behavioral Health Psychologist with the Center for Deployment Psychology at the Uniformed Services University of the Health Sciences in Bethesda, Maryland. In this capacity, she develops and presents trainings on a variety of EBPs and deployment-related topics, and provides consultation services.