Patients come into therapy at varying stages of change. Some patients may be extremely motivated to engage with you and the therapy whereas others may be quite ambivalent about whether therapy is the right course of action.

One example of treatment ambivalence is a person coming into therapy because their family pushed them to reduce their substance use. In these cases, the patient may feel ambivalent about reducing or stopping their substance use because they may not see a huge problem with their use themselves. 

We can often see this ambivalence play out in therapy in many interfering ways. For example, patients may skip therapy, not complete their assigned home practice, or not want to collaborate with the therapist.

Therefore, therapeutic intervention is needed to resolve ambivalence or increase motivation to engage in treatment in cases where the patient is not sure if change is a necessity.

Motivational Interviewing

Motivational Interviewing (MI) is a therapeutic skill that works to reduce ambivalence in patients by identifying their values. That is, the therapist helps to determine what is truly important in a patient’s life and determine what actions are most aligned with these values.

Examples of values include:

  • Family
  • Romantic relationships
  • Career
  • Health
  • Finances
  • Activity/lifestyle
  • Kindness/compassion/generosity
  • Among many others!

In the case above, the patient may come to realize that their substance use is negatively affecting important values in his life: his relationship with his family, his ability to support loved ones financially, and his productivity in his career.

By elucidating these values, the patient is better able to resolve his ambivalence towards making a change and gains a newfound commitment to therapy.

How do we use motivational interviewing?

One simple way to engage in motivational interviewing is by asking a few questions to elicit values from the patient.

Examples include:

  • Why is it important for you to make a change?
  • What might be some benefits of changing versus not making a change?
  • How might life be different if you decided to change?

In some cases, you may want to question about the patient’s life. Through this exploration, you may gain insight into areas that the behaviour in question could be impacting and query about whether these areas are important values.

If you deem it helpful, a more formal pros and cons list can be useful. Patients would have space to write down short and long-term benefits and costs of making a change compared to staying the same. Afterwards, they would consider whether the benefits outweigh the cons and make an informed decision consistent with their values.

Motivational Interviewing does not always lead to greater commitment to therapy

We sometimes think of MI as a way to get a patient to follow through therapy. But that’s not always the case nor should it always be the goal.

All we are doing is exploring a patient’s values and helping them decide what actions are best suited for these values. In a case where a patient realizes that their values don’t really work for therapy, that’s completely okay.

For example, some patients come into therapy for insomnia thinking that they really want to get their sleep back on track. However, they realize that some of the recommendations do not align with their values of having a flexible schedule and following their feeling of sleepiness (CBT for insomnia asks patients to keep to a regular schedule and avoid naps).

In this case, the patient may decide that CBT doesn’t align with their values and realize that they are okay with the consequences of their actions (like napping) because they truly enjoy them. And that’s okay – clinicians should take a very open stance to the patient’s values and not let their own values get in the way of exploration.

Final tips when using Motivational Interviewing

  1. Motivational interviewing can be used at any time during therapy whenever therapists notice some ambivalence in their patient. It can also be useful to apply a little MI during the initial session, by asking questions like “why have you decided to make a change now?” and “why is it important to make a change?”. These questions elicit responses that help therapists get a good sense of patient values.
  2. To get a sense of patient’s current level of motivation, it can be helpful to provide information on the different stages of change and give them some examples. You can then query their current stage of change and ask about what makes them more (or less) ambivalent.
  3. Stay open and flexible your conversations about patient values. It may be possible that your own goals and values are not the same as the patient’s goals and values. This is completely okay! I like to think our job is to simply follow the patient in terms of what is important to them and help align their actions with their values. Sometimes the patient is not quite ready for therapy, and it has nothing to do with you as the therapist. Your patient will also appreciate your flexibility.  

Best wishes,