Sam is a smoker. He was a late starter. He smoked his first cigarette in the ‘smokers area’ near to the outpatient clinic he was attending. He was chatting with another client of the service who offered him a smoke. He is not sure why but he accepted. He still does not know quite how he got into it, but these days it is a regular thing. He prefers to buy ‘tailor-made’ cigarettes but they are expensive and he always has a pouch of tobacco and some papers as well as some nicotine stains. He knows smoking is bad for his health and his doctors regularly remind him of the fact. However, his long-term health is not a major issue at the moment. The only times he ever thinks about trying to quit is when he runs out of money.

Population studies indicate that people with a mental illness are twice as likely to smoke as people with no mental illness (Lasser et al., 2000). People with a diagnosis of schizophrenia have especially high rates of smoking (de Leon & Diaz, 2005; Ziedonis et al., 2008). The reason why people with mental illness smoke more than the general population is unclear but it appears that some combination of the nicotine and the act of smoking provides some stimulation and/or comfort that alleviates some of the symptoms of mental illness. It is also likely that the high rate of smoking among people with severe mental illness normalizes it. Smoking is one of several lifestyle factors that have been identified as contributing to higher rates of physical illness and shorter lifespan among people with severe mental illness (de Hert et al., 2011).

Sam’s smoking is unhealthy, but he does not appear motivated to change. Change will require motivation because most people find it difficult to stop smoking and people with chronic mental illness may find it more difficult than most. Sam’s rehabilitation worker knows that telling Sam that smoking is unhealthy or ‘nagging’ him will not motivate him. Instead, she decides to use motivational interviewing (Miller & Rollnick, 2002; Rollnick et al., 2008) as a strategic approach to engaging him and possibly increasing his motivation to change.

Three independent meta-analyses (de Leon & Diaz, 2010; Heckman et al., 2010; Hettema & Hendricks, 2010) have found motivational interviewing to be effective, and probably more effective than other psychological interventions designed to assist people to quit smoking. Motivational interviewing is also effective in helping people with a range of other important lifestyle changes in areas such as alcohol use, substance use, weight loss and exercise.

Of particular relevance to Sam, interventions that assist people without mental illness to quit smoking have been found to have equal impact for people with severe mental illness, and there is no evidence that trying to quit worsens psychiatric symptoms (Banham & Gilbody, 2010). In addition, motivational interviewing has demonstrated a positive impact on other substance use by people with severe mental illness (Baker et al., 2009; Kavanagh et al., 2004), although the evidence for more sustained and wide-ranging treatment is somewhat stronger than that for brief interventions (Kavanagh & Mueser, 2010).

What is motivational interviewing?

Motivational interviewing (MI) creates conditions for change. MI is a brief intervention designed to provide conditions that accentuate existing motivations to change, and assist people to make their own decisions about change. It is not a tool to get people to change.

Motivational interviewing acknowledges that ambivalence about change is normal. It helps people work through the ambivalence and encourages their discussion of change and of core values. It increases their confidence in making a change, by helping them remember other self-control challenges they were successful in meeting. When they do decide to make a positive lifestyle change, MI helps them turn intentions into sustained action, by creating a detailed plan.

Motivational interviewing is not a programmatic therapy. It is about engaging the person in rehabilitation or in changing their behaviour, and can therefore be used in brief interventions (e.g. 1–2 sessions) or woven into an extended rehabilitation programme. When used thematically in rehabilitation, its focus is on maintaining or regaining motivation and engagement, as well as on initial engagement. While its focus is on the person’s own motivation, the approach has also been adapted for use in groups. In that case, individuals are encouraged to consider whether ideas presented by other group members also apply to them.

Empathy and warmth are at its core; confrontation is not used. MI was originally derived from Bill Miller’s observation that therapist empathy was a strong predictor of change in problem drinkers (Miller & Baca, 1983), which in turn reflected an influence of Carl Rogers’ therapeutic approach (Rogers, 1959). This led Miller to develop MI as an approach to development of motivation, culminating in the first book on the topic with Stephen Rollnick (1991) and its later edition in 2002.

Empathy and warmth help the person feel safe to acknowledge problems with their current behaviour: empathy for problems can also help to augment their emotional impact. On the other hand, confrontation undermines the therapeutic relationship and tends to elicit withdrawal from the situation or defensive arguments for the status quo. These arguments have the effect of increasing commitment to the dysfunctional behaviour. So, if a client resists change, an MI practitioner avoids putting pressure on them and gives them the option to stop the discussion (deflecting or ‘rolling with’ resistance).

Motivational interviewing encourages clients to talk about change. MI tries to reverse the usual roles, where a practitioner is trying to convince a person to change. Instead, MI encourages clients to talk about change: about the benefits it may bring and about its possibility.

Motivational interviewing is person centred. While MI has an agenda, it is the person’s own motivations that are elicited. So, it encourages the client to do most of the talking. In practice, practitioners often find it hard to adapt their practice to this approach, and may confuse the approach with clinical assessments, which tend to use convergent questions (e.g. ‘Have you been coughing a lot in the mornings lately?’) to provide a comprehensive examination of symptoms. In MI, the person is encouraged to explore their experiences (e.g. ‘… any health issues that could be related to smoking?’). MI does not necessarily cover every potential problem: It is about the issues that are salient for that person.

Motivational interviewing is about emotional reactions. In essence, MI acknowledges that motivation is about emotional reactions: anticipated pleasure, worries or concerns about unwanted outcomes. Salient benefits or costs tend to swamp attention so people may find it hard to think of the downsides of drinking when faced with a drink, and find it hard to think of the upsides of drinking when they have a hangover.

A common component of MI is a decisional balance. Creating a decisional balance (i.e. considering good/not so good things about current and alternative behaviours) helps clients to pit benefits and costs against each other at once, so they can make a more rational and functional decision.

Balance sheets are best developed as collaborative activities, and are usually written on a sheet of paper or whiteboard. The client should be encouraged to take the more active role. If a whiteboard is used, hand the marker to the client. However, if practitioners become aware that a client is anxious about writing, they write the issues down themselves, using the client’s own words. If clients have trouble reading, they use drawings.

Motivational interviewing is not about making lists or being more knowledgeable. Since decisions are about how we feel, and whether those feelings tip us towards change, MI practitioners probe emotional reactions to costs (e.g. ‘does that concern you?’) or may play devil’s advocate (‘but that hasn’t really affected you much, has it?’) in order to encourage clients to consider whether an impact is significant. In addition, since dysfunctional behaviour is typically inconsistent with core values (long life, not hurting others, being a good parent, etc.), practitioners may elicit those values and encourage the client to consider whether there are discrepancies between core values and current behaviours. This consideration tends to elicit discomfort and provides powerful motivation for change.

Motivational interviewing is informed by theories of change. MI has often been linked with Prochaska & DiClemente’s (1982) transtheoretical model of change, which proposes that people typically pass through identifiable stages in the process of achieving lasting change.

Precontemplation, when the person does not acknowledge the need for change.
Contemplation, when the need for change is acknowledged but there is no resolution to achieve change.
Determination or Preparation, when the person decides to make a change and develops concrete plans.
Action, when change commences.
Maintenance, when change is sustained.

If relapse occurs, the person may revert to one of the previous ‘stages’ or states in the cycle of change.

The transtheoretical model of change can be helpful in the application of motivational interviewing, because the focus of MI interventions will be different depending on the stage of change that the person is currently in. However, it is important to understand that change is not a simple linear process. People can move between stages quite fluidly. The practitioner needs to be alert to the person’s current state of mind, rather than assuming that someone who was in contemplation last week will continue to be in contemplation or will have moved forward to determination.

Contemplation is the prototypical stage for using MI and helping the person decide what they want to do. However, MI can be used at any stage, although it changes its nature depending on where the person is in relation to the decision.

In Precontemplation, people are typically happy to talk about the benefits of their current behaviour and may be tempted to admit to some downsides. They may also agree on a situation where they would consider the issue further (e.g. ‘if I got a smoker’s cough, I would probably think more seriously about it’). This gives the practitioner a context where they clearly have permission to return to the subject.
If people are in Determination/Preparation, reviewing their key motivations for change, self-challenging beliefs about the costs of change, consolidating confidence and making detailed plans can help to move them to Action.
In Action and Maintenance, the focus tends to be similar, except that new benefits of change emerge, current concerns about the costs of change may need to be addressed, and emerging problems need to be met with effective plans.
If relapse occurs, the person may revert to Precontemplation or Contemplation thinking. However, there may be an additional problem of feeling disheartened about falling back into the old behaviour: major foci therefore are usually building confidence by highlighting (and praising) successes and helping the person solve problems they previously encountered.

Does motivational interviewing require the practitioner to endorse unhealthy lifestyles?

Practitioners are sometimes concerned that the focus of exploring client decision-making processes, and especially being willing to consider the benefits or advantages of inherently unhealthy activities such as smoking, might endorse or even encourage such behaviour.

Motivational interviewing requires a genuine interest in client motivations and an openness to learning about them. It also requires practitioners to accept that clients must take responsibility for their own lifestyle decisions and any consequences that occur. This does not mean that practitioners are endorsing these decisions either tacitly or explicitly.

How can MI help Sam with his smoking?

At the moment, Sam does not think he has made any decision about smoking. He is not even thinking about it most of the time. He would prefer not to think about it because if he does, he would have to acknowledge that it is costing him a lot of money and damaging his health. When people like his doctor force him to think about it, Sam’s main aim is to extricate himself so he can avoid it. So, when his doctor last mentioned that he should quit smoking, Sam responded by saying ‘I’ll think about it’. What he actually meant was ‘I won’t think about it’.

Making the external internal

As noted above, a core aim of MI is to shift the change discourse from an argument between one person and another to a debate within the person.

Sam is pretty comfortable with the dialogue he has with his doctor. He has had a thousand such discussions before, starting in childhood with his mother. He does not enjoy them, but he knows what to do to escape. Most importantly, they don’t make him want to quit. As far as he is concerned, they are just more nagging from people who think they know what is good for him – they don’t understand how he feels about smoking, and it seems they don’t want to know.

Sam is in ‘Precontemplation’ most of the time. Every now and then, especially when he is short of money, he thinks, ‘I wish I could give up these damn things’ and moves temporarily into Contemplation, but that is usually as far as it goes. Once he did try some action: at the recommendation of his doctor, he agreed to try nicotine patches. However, he discovered that it was not just the nicotine but something about the act of smoking that kept him going. He went back to smoking after a day or two.

Choices are often made after some kind of internal debate. This internal debate reflects our ambivalence. Once we make a decision, we tend to put the debate behind us because it hinders the execution of our decisions. Motivational interviewing reactivates that internal debate, which allows reconsideration of the decision.

In reading the example below, notice that Sam’s practitioner does not volunteer information. In MI, information is offered sparingly in the interview, usually to validate and augment the impact of a concern Sam has or to answer a question. Occasionally, it may also be offered to gently correct a false belief. The emphasis is on information that Sam wants to have, and on his feelings about it. Other information may be offered via handouts or other resources Sam can choose to view, so that the practitioner can avoid lecturing Sam or dominating the conversation.

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