The most advanced skills of MI relate to a practitioner's flexibility in switching between various counselling approaches or integrating MI with other treatment models. As Miller and Moyers (2006) point out, "MI was never meant to be the only tool in a clinician's repertoire.
Example: MI to enhance cognitive behaviour therapy
Clients who present as ready and committed to changing may benefit more from other, more directive evidence-based interventions. However, client commitment often fluctuates over the course of treatment.
Practitioners' ability to cycle in and out of MI approaches as the need arises can enhance clients' engagement and retention regardless of the type of treatment they are receiving.The spiritof MI—emphasizing client autonomy, collaboration and evocation—is at the core of any client-centred approach.
Table 5-5 shows how an integrated MI plus cognitive-behavioural therapy (CBT) approach differs from CBT alone. In this example, MI provides a "platform" for delivering the ingredients of the CBT intervention, and actively addresses any ambivalence or resistance that arises during treatment.
Table: Using MI to Enhance CBT
|CBT||MI + CBT|
|Treatment begins with overview and rationale for treatment followed by functional analysis of target behaviour. (Functional analysis explores relationships between antecedents, or triggers, to the problem behaviour and consequences of the behaviour.)||Treatment begins by evoking client's view of the problem and increasing motivation for change by eliciting and reinforcing change talk|
|Functional analysis of target behaviour is completed by asking a series of questions.||Functional analysis is completed in the context of an OARS conversation (open-ended questions, affirmations, reflective listening and summary statements).|
|Practioner selects skill-building modules based on functional analysis of triggers and consequences.||Practioner elicits client's thoughts and ideas about how to manage triggers, and guides client toward skillbuilding modules that meet client's change plan goals.|
|Homework is assigned with a rationale provided by the practitioner.||Practioner asks permission to suggest homework that meets client's goals using a framework of (1) eliciting client's perspective; (2) providing information; (3) eliciting client's response to the information.|
Source: Naar-King, S. & Suarez, M. (2011). Motivational Interviewing with Adolescents and Young Adults (p. 78). New York:Guilford Press. © Guilford Press. Adapted with permission.
MI is primarily a way of being with clients that incorporates a set of specific learnable skills. Ongoing practice and clinical reflection are needed in order for counsellors to be able to practise MI with fluency and facility. Clients are our best teachers in this endeavour, since they provide immediate, proximal feedback about our effectiveness. Increased resistance and sustain talk signal that MI is not taking place and that the practitioner may be pushing for change prematurely or attempting to direct the client toward a course of action that he or she does not find helpful. This is a sign that we should probably switch strategies. On the other hand, change talk and commitment language tell us that we are "doing it right" and are heading in a positive direction.
Summary of Moyers, T. B., & Houck, J. (2011). Combining Motivational Interviewing with cognitive behavioral treatments for substance abuse: Lessons from the COMBINE Research Project. Cognitive and Behavioral Practice, 18 (1), 38-45.