Beyond Cognition: Broadening the Emotional Base of Motivational Interviewing

Abstract

Motivational interviewing (MI) techniques have been described in cognitive and behavioral terms, as means to positively resolve tension created by unresolved ambivalence about change. This view of motivation is consistent with a negative reinforcement model, in which behaviors are performed to escape from negative states. In contrast, the concept of positive reinforcement involves seeking positive states through behaviors that lead toward more satisfying conditions. From this perspective, motivation involves a desire to experience positive emotions. This paper focuses on the potential role that emotions may play in MI, particularly positive emotions. The authors posit that MI elicits positive emotions of interest, hope, contentment and inspiration by inviting clients to envision a better future, to remember past successes, and to gain confidence in their abilities to improve their lives.

Motivational interviewing (MI; Miller & Rollnick, 2002) can be conceptualized as a therapy of emotional emancipation. MI focuses on freeing clients from the constraints of unresolved ambivalence that otherwise keeps them unsure of what to do and lacking confidence in their ability to change. MI is intended to help clients resolve this ambivalence by increasing their sense of desire, need, ability and commitment to change. With ambivalence diminished and commitment to change increased, clients are empowered to seek lives more of their choosing.

MI integrates findings from social and cognitive psychology research with concepts from humanistic, cognitive and behavioral therapies. Although client-centered, MI is semidirective, using a guiding therapeutic style with a bias toward change, based on the assumption that clients generally present for clinical services when their lives are not working well. Despite this bias toward change, therapists remain client-centered, respecting and supporting client autonomy. Over 90 controlled studies have generated considerable evidence for the efficacy of MI, often in short timeframes of one to four sessions (Dunn, Deroo, & Rivara, 2001; Burke, Arkowitz, & Menchola, 2003; Hettema, Steele, & Miller, 2005; Miller, 2005).

Although MI is focused on enhancing autonomous motivation, it is not built upon a well-defined model of motivation, and descriptions of MI have not thoroughly addressed the potential role of client emotions in this psychotherapy. Descriptions of MI generally emphasize cognitive strategies for helping clients broaden conceptualization of their options and make choices that they anticipate will bring greater satisfaction (Miller & Rollnick, 2002; Prescott, 2005). Unresolved ambivalence is assumed to be at the core of client inertia, constraining clients from pursuing more satisfying lives. From a cognitive perspective, unresolved ambivalence is the inability to decide which of two (or more) choices is better—the person’s reasons for changing have similar weight to the reasons for remaining the same. From this perspective, resolving ambivalence involves helping clients to carefully consider their options and reach a decision about which path to pursue.

However, ambivalence can also be viewed from an emotional perspective, in which the person’s reluctance about change may feel equal to their desire for change. From this perspective, resolving ambivalence involves reaching a tipping point beyond which clients resonate more deeply to their desires and hopes for change than to their reluctance about change. Miller and Rollnick (2002) discuss this perspective briefly in their consideration of the kinds of conflicts clients may face (approach-approach, avoid-avoid, double approach-avoidance), but on the whole, resolution of ambivalence in descriptions of MI has focused more on cognitive than emotional elements—on reaching a decision about which choice to make.

When emotion has been addressed in descriptions of MI, a central focus has been on the tension created by unresolved ambivalence, with procedures intended to increase this tension in service of increasing motivation to change. This view of motivation is consistent with a negative reinforcement model in which behaviors are performed in order to escape from a negative state. In contrast, the concept of positive reinforcement involves seeking positive states through behaviors that lead toward more satisfying conditions. From this perspective, motivation involves a desire to experience positive emotions. Although descriptions of MI have not entirely overlooked positive emotions, the focus has more often been the role of tension states in motivation. We believe that both paradigms are relevant to MI, and that strategies intended to facilitate clients’ resolution of internal tensions are usefully complemented by strategies intended to build momentum toward change by increasing positive emotions such as interest, hope, contentment and inspiration. In this paper, we focus on the potential role that emotions may play in MI, particularly positive emotions. We describe ways that conceptualizations based on both positive and negative reinforcement may be used to explain current practice of MI and provide a framework for development of additional targeted strategies that may lead toward even more effective practice of this therapy. In order to lay a foundation for this discussion, we first briefly review positive emotions theory.

POSITIVE EMOTIONS THEORY

Over the past decade, psychologists have become interested in the role of positive emotions in human growth and change and the potential role of positive emotions in psychotherapy. Positive emotions are described as existing on a continuum distinct from that of negative emotions and are not merely the absence of negative emotion. Some commonly researched positive emotions include joy, interest, and contentment (Fredrickson & Joiner, 2002), and recently, elevation, which is conceptualized as the opposite of disgust (Haidt, 2000). Distinguishing emotions from cognitions is not always clear cut, with some positive states considered emotions by some and cognitions by others, including hope, love, gratitude, and trust. Overall, research on positive emotions has lagged behind research on negative emotions, mirroring the tendency of psychologists to focus more on pathology than health (Gable & Haidt, 2005; Seligman, 2002).

A promising model of positive emotions is Fredrickson’s broaden-and-build model (Fredrickson, 2000, 2003). As a complement to the widely held view that negative emotions narrow subjective experiencing and cognitive focus, resulting in specific action tendencies (e.g., anger to attack, fear to escape), the broaden-and-build model suggests that positive emotions broaden experiencing and cognitive focus, leading to positive “thought-action tendencies.” Because of the nature of positive emotions, these tendencies are often less focused on discrete behaviors than are the action tendencies related to negative emotions. The function of negative emotions is to focus cognition on a specific threat to the exclusion of other stimuli, readying the person for the fight-or-flight response. In contrast, the broadening function of positive emotions is to open the person up to receive new information or to reframe existing information. The presumed evolutionary function of the broadening process is to prime the person to use the time when not under threat to build increased physical, social, cognitive, and emotional resources upon which the person may later draw. These include better health, better relationships, greater psychological resilience, and greater subjective well-being (Fredrickson, 2000, 2003; Joiner et al., 2001).

This model of positive emotions provides an interesting lens through which to consider MI. In older conceptualizations, motivation can be viewed as an action tendency facilitated by an urge to decrease a negative tension state. In contrast, the positive emotions model encourages a view of motivation that emphasizes opening up to new experiences and actively seeking to build resources to support change. For example, elicitation of the positive emotion of interest may lead to greater openness to experiencing. Interest involves “a feeling of wanting to investigate, become involved, and expand the self by incorporating new information and having new experiences” (Izard, 1977). When a client experiences interest (or related emotions such as wonder or curiosity), his or her cognitive focus broadens to consider options that previously had been overlooked or rejected. This increased flexibility in conceptualizing situations may then facilitate resolution of ambivalence and increased openness to engage in activities that lead toward change. As the person acts in the newly considered direction, he or she may improve certain skills and increase the likelihood of achieving a desired outcome. Movement in this positive direction may increase confidence, sense of accomplishment, self-esteem and mood, thus establishing these increased resources for the person to draw upon in service of even more profound changes. This perspective is offered as a complement to the prevailing implicit negative reinforcement model of motivation in motivational interviewing. In order to increase appreciation for the way this complements the prevailing view, we review some concepts and practices that have been integrated in the development of MI to date.

CONCEPTS AND TECHNIQUES INTEGRATED INTO MOTIVATIONAL INTERVIEWING PRACTICE

Motivational interviewing developed as an essentially atheoretical approach, pragmatically integrating concepts and techniques from theories and research in personality, social, clinical and cognitive psychology (Miller, 1998a, 1998b, 1999, 2000a, 2000b, 2005; Zuckoff, 2002), but without a clear model of its putative processes or mechanisms of action. Some of the integrated aspects reflect a negative reinforcement paradigm—motivation as discontent. With somewhat less emphasis, positive motivation—inspiration—has also been reflected in writings about MI. We review each of these perspectives below.

Motivation as Discontent

Festinger’s (1957) cognitive dissonance theory was used as a model of motivation in early descriptions of MI (Miller & Rollnick, 1991). Clients were believed to be motivated to resolve the tension created by dissonant cognitions, guiding therapists to help clients identify and focus on such cognitions. Festinger’s complex model eventually was dropped in favor of the simpler concept of discrepancy, but the basic idea of motivation as a desire to decrease tension was retained. Clinicians help clients’ develop greater awareness of the discrepancy between the future they desire and the future they are likely to experience if changes are not made. The clinician helps the client experience the tension that results from this contradiction. The client is then presumably motivated to do something in order to reduce the negative tension state.

Rokeach’s (1979) values clarification procedures were integrated into MI to further help develop discrepancy. These involve examining the degree of fit between a person’s current behaviors and deeply held values. To the extent that there is discrepancy between values and behavior, the person presumably experiences a conflict that results in lower self-regard (for not living up to one’s values) and is motivated to reduce that discrepancy.

Another concept integrated into MI practice is decisional balance, from Janis’s (1982) model of decisional conflict. In a decisional conflict, a person who is ambivalent about available opportunities may experience “apprehensiveness, a desire to escape the dilemma, and self-blame for being in a situation of having to choose between unsatisfactory alternatives” (Zuckoff, 2002, pp. 94–95). Individuals are motivated to eliminate discomfort, either by impulsive decision-making, excessive rumination, or careful consideration of pros and cons in a decisional balance exercise. Regardless of the decision-making process used, the motivational basis is negative reinforcement, and motivation is essentially cast as discontent with one’s current status, one’s path toward the future, or one’s success at living in consonance with one’s values.

Motivation as Inspiration

Despite their basis in a negative reinforcement paradigm, discrepancy and decisional balance can also be cast in a way that emphasizes positive motivation, or inspiration. Developing discrepancy can focus on helping clients conceptualize more clearly what could be, how things could be better now, and how life could be better in the future. Decisional balance can be performed in a way that emphasizes the positives about change instead of the negatives related to the status quo, defining and moving toward a future positive state rather than escaping an undesirable current state or avoiding a negative future state.

Consistent with a positive perspective, MI also integrates concepts and practices from sources emphasizing positive states, including focus on a desire for change, confidence about one’s ability to change, and hope for success in change. As a client-centered therapy, MI is indebted to Carl Rogers’ client-centered approach to psychotherapy, which also fits with a positive perspective. In Rogers’ personality theory, individuals have a natural tendency toward personal growth, toward a more positive future. However, differential reinforcement of behaviors and attributes during development leads to distorted perceptions of thoughts and feelings that constrain the person’s natural tendency toward growth. This leads to incongruency between the person’s self-perceptions and his or her “real self,” and anxiety when elements of the disowned aspects of personality begin to emerge in awareness. When therapists can understand the clients’ lives from client perspectives (empathy), accept clients fully as unique and worthwhile human beings (unconditional positive regard), and remain perceptive and transparent about their own reactions (congruence), an atmosphere is created that allows clients to understand themselves, accept themselves to a greater degree, and move toward congruence with their real selves. MI builds upon Rogerian client-centered therapy, adding motivational strategies to Roger’s supportive conditions.

Building further upon humanistic concepts, self-determination theory (SDT) provides an additional frame of reference for conceptualizing motivation as inspiration rather than discontent (Foote et al., 1999; Markland, Ryan, Tobin, & Rollnick, 2005). SDT proposes that individuals have innate needs for competence, autonomy and relatedness, and that motivational processes leading toward personal growth are activated when these needs are met with environmental structure, autonomy support and involvement, respectively. Like humanistic theory, SDT posits that individuals have an innate propensity for personal growth toward cohesion and integration (Markland et al., 2005, p. 825), and suggests that if barriers to growth are removed by providing these environmental supports, individuals will autonomously move toward positive change. These outcomes may involve extrinsic gain or increased coordination with one’s values and self-identity. These authors further contrast these autonomous motivations with introjected motivations. Introjected motivations are those adopted from others without conscious consideration (through operant conditioning), and are characterized by a sense of pressure to act and resultant negative emotions (e.g., shame) if the action is unsuccessful at reaching a goal. Whereas introjected motivations involve goals that individuals do not truly value, autonomous motivations are based on goals that individuals do genuinely value, and are thought to lead to greater persistence, learning, congruence between values and behavior, and well-being. Autonomous motivation is more consistent with a positive emotions model of MI. With autonomous motivation, the individual increases well-being through pro-active seeking of a better state, often leading to an increased experience of positive emotions such as interest, satisfaction, and joy.

Thus, motivational interviewing is based upon both negative and positive views of motivation, upon motivation both as discontent and as inspiration. However, as this framework has not previously been made explicit, we explore it here in hopes of providing greater clarity to the potential functions of motivational interviewing practices and to further build the foundation for development and integration of new practices.

EMOTIONS IN MOTIVATIONAL INTERVIEWING

Emotions and the Therapist Stance

Miller (1999) has conceptualized the therapist’s role as providing agape, a selfless form of love intended to enhance clients’ well-being and growth. We believe that therapist agape may enhance clients’ sense of contentment and deep acceptance of themselves as humans, independent of any discontent they may feel about the choices they have made. This acceptance may fuel increase clients’ interest in themselves and the inspiration to become better versions of themselves.

When the therapist provides agape, he or she figuratively embraces the client’s ambivalence and struggle. This leads the therapist to protect the client by prizing both sides of his or her ambivalence. In this way, the client’s wholeness of experience is respected, because the “want to change” side and the “want to stay the same” side are explored, understood, and even affirmed. The client then experiences a feeling of safety in which ambivalence can emerge undefended. In this atmosphere of nonjudgmental acceptance, the client is free to explore his or her own concerns about changing, and even about the status quo.

The Emotional Impact of MI Principles

MI is organized by four principles that guide therapist behavior. Here we consider the emotional and cognitive experiences these principles may evoke in clients. The first principle, express empathy, involves the therapist reflecting an understanding of issues from the client’s perspective. With empathic therapists, clients may perceive themselves as being understood. This perception may soothe clients’ negative emotions, lessening the sense of being isolated and alone, of being too different for others to understand. An empathic stance may thus promote a sense of safety in the therapeutic situation, a sense of calmness.

Roll with resistance, the second principle, involves warmly accepting client concerns, fears and frustrations about change, and the defensive behaviors that result from these experiences. Clients are supported and met with warmth, regardless of the interpersonal behaviors they display. Withdrawal, coldness, hostility, and anger all elicit therapist acceptance, and therapists do not comment on or actively address these behaviors except to reflect the client’s feelings or concerns that may lie behind them. Clients are never confronted by therapists, but supported in addressing their concerns themselves. Resistance is defined in interpersonal terms in MI, and is assumed to continue only if it is met with therapist nonacceptance. Rolling with resistance likely reduces client negative emotions and promotes a sense of self-acceptance, allowing clients to broaden their thinking about the issues being addressed instead of remaining in a constricted defensive posture.

Develop discrepancy, as mentioned previously, involves exploring discrepancies between values and behavior or between two possible futures related to whether the person makes changes or not. The tension produced by focusing on these discrepancies presumably increases motivation to change. Thus, developing discrepancy is generally described within a negative reinforcement paradigm. It is possible that the development of discrepancy could be perceived by the client as admonition by the therapist, or could experience the discrepancy as shame-inducing, and this could result in increased distress and possibly an abandonment of the change effort. Yet, with guidance from the positive emotions perspective, developing discrepancy can also be viewed as a positive reinforcement tactic, involving positive reenvisioning of the future, with resulting emotions of interest and curiosity.

The fourth principle, support self-efficacy, guides therapists to help build clients’ confidence about changing. Bandura (1977) suggested that high self-efficacy (belief in ability to successfully perform a desired task) facilitates behavior change attempts. Once initial changes are made, one is more likely to continue to make positive changes due to a cascading of confidence. Success thus breeds success in an upward positive reinforcement spiral. In motivational interviewing, confidence can be increased by reviewing past successes at changing, reframing failures as learning experiences, and carefully planning upcoming change attempts. Confidence is often presented as a cognitive state, but likely includes emotional elements such as calmness, interest, inspiration, and hope.

Thus, the four principles may elicit the experience of being understood and accepted, a vision of a better future, and a sense of confidence that this future is achievable. Calmness, openness, interest and curiosity, inspiration and hope are all potentially important elements of clients’ experiences in the context of motivational interviewing. In motivational interviewing practice, these principles are incorporated into an interactional style that emphasizes collaboration and active support of client autonomy. This atmosphere likely fosters trust, while the hypothetical nature of many of the strategies invites clients to consider their options without the pressure of having to commit in the moment. This may maximize interest while minimizing reluctance.

Below we summarize how the use of these principles in a single MI session appears to have facilitated such a process in a recent qualitative study that solicited client recall of experiences through a tape-review procedure (Zuckoff, 2002).

The client enters the clinic anxious, hoping he can trust his therapist. At the same time, he feels apprehensive about being judged, criticized. The therapist informs the client that he wants to understand the client’s situation from the client’s perspective (express empathy), prompting the client to feel surprised and pleased. The therapist emphasizes that he won’t pressure the client to change: that any changes the client may make are entirely at the client’s discretion (support self-efficacy). The client perceives the therapist as warm, yet he remains somewhat apprehensive about the interaction. The therapist shows non-judgmental interest (roll with resistance), and the client feels more trusting, spontaneous, and interested. The therapist explores the client’s situation and behavior patterns and elicits the client’s perspective on them (express empathy). The client continues to feel somewhat cautious, but also pleasantly surprised and increasingly relaxed. The therapist explores whether there is anything that the client wants to change (develop discrepancy). As the therapist shows understanding, interest and support for the client’s autonomy, the client feels safer and discloses further. The client feels somewhat embarrassed and self-conscious, but perceiving true empathy from the therapist, becomes increasingly open ….

This example shows how the MI approach avoids eliciting negative emotion. MI also transforms potentially negative reactions into neutral or positive reactions, including increased openness, interest, comfort, surprise. Once positive emotions develop, clients can more freely examine their life situation and consolidate formerly disconnected thoughts into a more coherent perspective that allows them a greater ability to choose how they want to become. These positive emotions can then provide a foundation for further growth and change, as emphasized in Zuckoff’s (2002) description of the outcome of one client interviewed nearly a year after his MI session:

… S feels a sense of gratitude and appreciation for a very positive and validating experience, and an increased sense of clarity about the issues discussed and his thoughts and feelings about them. …S attributes lasting positive changes in himself and in long-established patterns of behavior to the session, including an increase in assertiveness; a greater sense of clarity and awareness in his thinking; and an improved ability to make, and sense of confidence in, choices that are in his own interest. (p. 260)

The Emotional Impact of Common MI Strategies and Practices

Below we review some common MI strategies and consider their possible emotional impacts. One common strategy in MI is to conduct a discussion of the decisional balance (Janis & Mann, 1977). This exercise is a cognitive problem-solving technique in which the client is asked to consider the pros and cons of changing a habit, and the pros and cons of staying the same, or of failing to change the habit. When done by an MI practitioner, this exercise can reduce negative emotions related to consideration of change while facilitating positive emotions about change. The therapist asks the client to consider the pros of staying the same, because it is in this area that the client may feel defensive and need “protection” in the form of full acceptance. The experienced MI practitioner uses MI core skills of open questions, reflections, affirmations, and summaries to demonstrate empathy and develop understanding of each element of the client’s discussion of the pros of the status quo. By asking about the attachment the person has to the current behavior, the therapist effectively joins with the client and understands one side of the ambivalence. The client experiences relief because the therapist understands the attachment to the behavior. The client then, often quickly jumps to this other side without prompting from the therapist, almost wanting to explain why the habit is problematic. The therapist then asks about barriers to change, or what might be the difficulties, should the person decide to change. Thus, although the discussion of staying the same generally asks the person to discuss realistic experiences, the discussion of changing is overtly hypothetical, and thus, reassuring to the patient that the therapist is not persuading him or her to change. After reflecting, affirming, and summarizing the barriers or difficulties of change, the MI practitioner last asks the patient a variant of the question, “but if you were to make this change, what would be the benefits? What might be good about it?” The same process of open questions, affirmations, reflections and summaries is utilized to debrief the client’s answers. While this strategy is overtly a cognitive problem-solving method, discussing the benefits of change after a thorough discussion of the other sides, elicits positive emotions of interest and motivation from the client. A common client comment is “Now that I realize how good it could be, I feel more ready to make this change.”

In building momentum toward change, therapists may also help clients focus on looking back, and its converse, looking forward. The MI practitioner asks the client to consider how the habit has changed (usually for the worse) over time, and/or what might happen if the client chooses to remain the same. This strategy is usually used as a way to develop discrepancy. This strategy can result in negative emotions including discomfort, discontent, and possibly mild anxiety. The client may then attempt to “undo” this negative emotional state by moving toward change, but also might reduce discomfort by distancing from the discussion or the therapist.

Bill Miller (Miller, Rollnick, & Moyers, 1998) demonstrates this strategy with a client whose employment drug screen revealed that he had used marijuana, and who came to counseling with positive beliefs and feelings about continuing his drug use but also concerns about a potential job loss if he failed to change.

Miller: Yeah, that’s what I’m asking about. I really appreciate how honest you are being, and how you’re struggling with this with me. (Affirmation). But, there was a line that you drew and said okay, that’s where I’m going to stop, then you stepped over it, then you stepped over another line, then another line. (Looking backward). That is what I’m asking about, is…are there moments where you say, gee, where am I headed here? (Looking forward.)

A related strategy is envisioning. A possible advantage of envisioning over looking forward is that envisioning is more likely to elicit positive emotions. A central element of MI is consideration of the future. Although some focus in MI practice is given to negative possibilities (e.g., “what will happen if you don’t change?” an example of looking forward), much of the focus can be on hope. Clients are encouraged to envision the future they desire, and their optimism about achieving that future is developed. This focus on the future can facilitate positive emotions of interest and curiosity. A simple example of a counselor question about envisioning is “How might you like things to be different?” Often this strategy has been demonstrated with clients who are presumably “resistant.” In the following example, Bill Miller works with a smoker and drinker who is considering making changes in one or both behaviors (Lewis, Carlson & Miller, 2001). Instead of eliciting negative emotions about the client’s current behaviors, or asking for any cognitive appraisal of the costs and benefits, Miller engages the client in a discussion of his future, and how he defines himself.

Miller: It sounds like you want to have an active life. So for you, the question is, what am I going to be doing? How do I spend my time? And for you what matters is having something that you are going toward, not something you run away from.

The outcome is that the client experiences an increasing interest in change, pursuing a nontraditional, active method to quit smoking and drinking.

A related strategy with potential for eliciting positive emotion is values clarification (Rokeach, 1979; Wagner & Sanchez, 2002). In values clarification, clients examine their behaviors and habits in light of their values. Alternatively, therapists may utilize a values card sort procedure to have clients rank their values, then review the rankings and explore how current lifestyle choices or habits fit with the values. As the client examines and describes a value and its importance, the client may experience interest, possibly excitement, and often, momentum to bring lifestyle choices in alignment with the value. Discovering behavior patterns that do not align well with values can unsettle a person yet can also elicit a sense of possibility.

Change Talk and Emotions

Much of the conversation in MI sessions focuses on change. Amrhein and colleagues (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003) identified five types of “change talk.” Change talk was categorized into statements of desire, reasons, need, ability, and commitment. Change talk often expresses clients’ evaluations of the importance of change, or their confidence to make changes. We view desire, reasons, and need as aspects of the clients’ sense of the importance of change, while ability is related to confidence that they can change. Change talk has momentum built in, and may be related to key positive emotions including inspiration, excitement, and hope.

Below are some examples of therapist reflective statements and summaries that may elicit change talk and subsequent positive emotion, drawn from MI video demonstrations (Lewis, Carlson, & Miller, 2001; Miller et al., 1998).

• So, it’s having something to pursue, having something to live for really. (Evokes discussion of desire to change.)

• My own sense is it’s that internal reason that really makes the difference. When instead of there being somebody out there telling you, what’s telling you is something inside of you. (Evokes discussion of reasons to change.)

• As you step back and look at yourself here and you’re saying where am I going in my life? What have you thought about that? (Evokes discussion of perceived need to change.)

• Why would you make a change in your drug use? (May elicit discussion of desire, need or reasons to change. Client may focus on avoiding negative consequences or envisioning a positive future.)

Regarding confidence, therapists may emphasize changes clients have made successfully or hypothetical changes that seem nonthreatening, or simply guide clients toward finding solutions that they can have high confidence in their ability to achieve. Examples of evoking confidence-related change talk:

• Right, you were successful in changing that in the past and sounds like you’d kind of like to be successful changing this. (Evokes discussion of ability and desire.)

• I hear a confidence that if you were to decide that you need to make a change there; if you were having a baby, for example, that you could make that change. You feel pretty confident that you’ve got that ability within you and it’s more that you haven’t seen the need in doing that yet. (Evokes discussion of perceived ability.)

Therapists may also assess and build confidence in the case where the client’s confidence level is unknown, or low. In this example, the therapist assesses confidence, reflects the low confidence, and encourages confidence through reminding the client of a previous positive emotional state.

Therapist: How confident are you that you can do it? (Direct evocation of confidence)

Client: That’s the problem. I don’t know.

Therapist: You’re not sure. (Reflection of lack of confidence)

Client: I’m not too sure. I’m really not too sure.

Therapist: It’s not so much the wanting to do it as I don’t know if I could if I make the decision… (Reflection of desire and lack of confidence)

Client: It’s a confidence problem.

Therapist: Well, and that’s what would help. Something that you could really be confident in. Like the way you lit up when we talked about the Grand Canyon or something. Like I could get through five days that way. I could do that. (Brainstorming ways to feel more confident)

Many of the previous strategies have in common a hypothetical aspect. They rely on creating safety and emotional neutrality by posing questions in a hypothetical manner, allowing the client to consider different aspects of change without having to commit. Thus, they take pressure off, reducing the likelihood of negative emotional reactions (fear of change, reactance to pressure to change), and increasing the chance of positive emotions (interest, hope, etc.). As clients become increasingly open to such considerations, therapists may transition from hypothetical change possibilities to actual change planning. The following segment illustrates a simple discussion of aspects of a plan to change drinking and smoking by withdrawing from certain friends who drink and smoke:

Miller: There you go. People who make it through change usually do it…usually do what you are saying, which is for a while avoid the valley of the shadow of death, you know. I mean avoid the difficult place. And then it gets more okay. You’ve got to not rush too quick back in there, but it gets to be okay. You don’t then have to stay away …

Client: Forever.

Miller: Right. So It’s not forever and ever. But for a while you are probably right.

These examples demonstrate how motivational interviewing focuses on eliciting client consideration of change in such a way as to minimize negative emotions about the difficulties change and accentuate positive emotions about the possibilities of change.

SUMMARY AND CONCLUSIONS

Through developing an atmosphere of safety and openness, the MI approach allows the client to lower defenses and facilitate the exploration of conflictual beliefs, discrepancies between values and current behavior, and the unlikelihood that current behavior patterns will lead to future life satisfaction. The client begins to conceptualize living in a way that reduces conflicts, discrepancies and comfortable but unproductive behaviors, consistent with the negative reinforcement paradigm. We believe that MI also elicits positive emotions by inviting clients to envision a better future, to remember past successes, and to gain confidence in their ability to improve their lives. These positive strategies complement those that focus on resolving client tensions, and may be less likely to lead to defensive responding and avoidance of the issues and tasks at hand.

Clinical descriptions of MI have included positively focused therapist strategies that can lead to increases in client motivation, such as supporting self-efficacy, envisioning, and remembering successes. Practitioners and clients who have experienced this approach can attest to its emotional impact. However, explanations of motivation in MI have not fully integrated the potential role of positive emotions. We believe that many MI strategies can lead to enhanced motivation through increases in positive emotions such as interest, hope, contentment and inspiration. Eliciting these positive emotions can help build momentum toward change.

Focusing on the role of emotions in motivational interviewing is essential to a complete understanding of its impact. Models that emphasize only cognitions and behavior overlook the importance of emotion in motivation. Explicitly considering emotional aspects of motivation has the potential to better explain the current clinical practice of MI and provide a framework for continued integration of concepts and practices, and development of additional practices that may elicit motivation to change even more effectively.