Instructors Manual

for

WILLIAM MILLER
ON MOTIVATIONAL
INTERVIEWING

with

William R. Miller, PhD

Manual by
Ali Miller, MFT
WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

The Instructors Manual accompanies the DVD William Miller on

Motivational Interviewing with William Miller, PhD (Institutional/Instructors
Version). Video available at www.psychotherapy.net.
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Miller, Ali, MFT

Instructors Manual for William Miller on Motivational Interviewing

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 Psychotherapy.net

Instructors Manual for

WILLIAM MILLER ON MOTIVATIONAL

INTERVIEWING

Table of Contents
Tips for Making the Best Use of the DVD  4
Millers Approach to Motivational Interviewing  5
Discussion Questions  8
Reaction Paper Guide for Classrooms and Training  11
Role-Plays  12
Related Websites, Videos, and Further Readings  14
Video Transcript  16
Video Credits  42
Earn Continuing Education Credits for Watching Videos  43
About the Contributors  44
More Psychotherapy.net Videos  45

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Tips for Making the Best Use of the DVD

1. USE THE TRANSCRIPTS
Make notes in the video Transcript for future reference; the next time
you show the video, you will have them available. Highlight or notate
key moments in the video to better facilitate discussion during and after
the video.

2. FACILITATE DISCUSSION
Pause the video at different points to elicit viewers observations and
reactions to the concepts presented. The Discussion Questions section
provides ideas about key points that can stimulate rich discussions and
learning.

3. ENCOURAGE SHARING OF OPINIONS

Encourage viewers to voice their opinions. What are viewers
impressions of what is presented in the interview?

4. SUGGEST READINGS TO ENRICH VIDEO MATERIAL

Assign readings from Related Websites, Videos, and Further Reading
before or after viewing.

5. ASSIGN A REACTION PAPER

See suggestions in the Reaction Paper section.

6. CONDUCT A ROLE-PLAY
The Role-Play section guides you through an exercise you can assign to
your students in the classroom or training session.

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 Psychotherapy.net

Millers Approach to Motivational

Interviewing*
Motivational interviewing (MI) refers to a counseling approach
developed by clinical psychologists William R Miller, PhD, and Stephen
Rollnick, PhD. The concept of motivational interviewing evolved from
experience in the treatment of problem drinkers.
MI is a semidirective, client-centered counseling style for eliciting
behavior change by helping clients to explore and resolve ambivalence.
Compared with nondirective counseling, it is more focused and goal
directed. This method works on facilitating and engaging intrinsic
motivation within the client in order to change behavior. The
examination and resolution of ambivalence is a central purpose, and the
counselor is intentionally directive in pursuing this goal.
MI recognizes and accepts the fact that clients who need to make
changes in their lives approach counseling at different levels of readiness
to change their behavior. If the counseling is mandated, they may never
have thought of changing the behavior in question. Some may have
thought about it but not taken steps to change it. Others, especially
those voluntarily seeking counseling, may be actively trying to change
their behavior and may have been doing so unsuccessfully for years.
Four Principles of Motivational Interviewing
So what does the therapist actually do? MI involves collaboration,
not confrontation, evocation, not education, autonomy rather than
authority, and exploration instead of explanation. Effective processes for
positive change focus on goals that are small, important to the client,
specific, realistic, and oriented in the present and/or future.
Four key aspects of the MI approach are:
1) Express empathy:
Empathy involves seeing the world through the clients eyes,
thinking about things as the client thinks about them, feeling
things as the client feels them, sharing in the clients experiences.
Expression of empathy is critical to the MI approach. When clients
feel that they are understood, they are more able to open up to their
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

own experiences and share those experiences with others. In short,

the counselors accurate understanding of the clients experience
facilitates change.
2) Develop discrepancy:
This guides therapists to help clients appreciate the value of change
by exploring the discrepancy between how they want their lives to
be versus how they currently are (or between their deeply held values
and their day-to-day behavior). MI counselors work to develop this
situation through helping clients examine the discrepancies between
their current behavior and future goals. When clients perceive that
their current behaviors are not leading toward some important
future goal, they become more motivated to make important life
changes.
3) Roll with resistance:
In MI, the counselor does not fight client resistance, but rolls with
it. Statements demonstrating resistance are not challenged. Instead,
the counselor uses the clients momentum to further explore the
clients views. Using this approach, resistance tends to be decreased
rather than increased, as clients are not reinforced for becoming
argumentative. MI encourages clients to develop their own solutions
to the problems that they themselves have defined. In exploring
client concerns, counselors may invite clients to examine new
perspectives, but counselors do not impose new ways of thinking
on clients. Rolling with resistance allows therapists to accept client
reluctance to change as natural rather than pathological.
4) Support self-efficacy:
This guides therapists to explicitly embrace client autonomy (even
when clients choose to not change) and help clients move toward
change successfully and with confidence. As clients are held
responsible for choosing and carrying out actions to change in the
MI approach, counselors focus their efforts on helping clients stay
motivated, and supporting clients sense of self-efficacy is one way to
do that. One source of hope for clients using the MI approach is that
there is no right way to change, and if a given plan for change does
not work, clients are only limited by their own creativity as to the
number of other plans that might be tried.
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Spirit of Motivational Interviewing

While there are as many variations in technique as there are clinical
encounters, the spirit of the method, however, is more enduring and can
be characterized in a few key points:
1. Motivation to change is elicited from the client, and is not
imposed from outside forces.
2. It is the clients task, not the counselors, to articulate and
resolve his or her ambivalence.
3. Direct persuasion is not an effective method for resolving
ambivalence.
4. The counseling style is generally quiet and elicits information
from the client.
5. The counselor is directive, in that he or she helps the client to
examine and resolve ambivalence.
6. Readiness to change is not a trait of the client, but a fluctuating
result of interpersonal interaction.
7. The therapeutic relationship resembles a partnership or
companionship.
The style of the therapist using MI is nonjudgmental,
nonconfrontational and nonadversarial. The approach attempts to
increase the clients awareness of the potential problems caused,
consequences experienced, and risks faced as a result of the behavior in
question. Therapists help clients envision a better future, and become
increasingly motivated to achieve it. The MI approach seeks to help
clients think differently about his or her behavior and ultimately to
consider what might be gained through change. It is critical to meet
clients where they are, and to refrain from forcing clients toward change
when they have not expressed a desire to do so.

*Adapted from http://en.wikipedia.org/wiki/Motivational_interviewing

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Discussion Questions
Professors, training directors, and facilitators may use some or all of
these discussion questions, depending on what aspects of the video are
most relevant to the audience.
1. Change: What do you think helps people change? In your personal
experience, what has helped you make changes in your own life?
In your work with clients, what do you see has helped them make
changes in their lives? Why do you think it can be so hard for
people to change?
2. Ambivalence: Miller describes ambivalence as wanting two
different things at the same time. How does ambivalence show up
in your own life? How do you see it showing up in your clients
lives? Can you think of something in your own life that has
both positive and negative consequences? What has helped you
move in the direction of positive change when youve felt stuck?
How does this compare to what Miller does with clients through
Motivational Interviewing?
3. Spirit of Motivational Interviewing: What do you think about
the spirit of Motivational Interviewing: collaboration, evocation,
and honoring the persons autonomy? What do you think about
working collaboratively with clients as opposed to being the expert
who tells people what to do? What do you think about Millers
emphasis on honoring the persons autonomy, that each person
gets to ultimately decide for themselves whether to change or not?
How is it for you as a therapist to work with people who dont seem
to want to change when you strongly believe they need to? What
helps you to honor peoples autonomy?
4. The Righting Reflex: Miller talks about the righting reflexthe
tendency to want to jump in and say, Youve got to stop doing
that!and how following that gut reaction with people who are
ambivalent tends to lead them to argue against change. Can you
think of a time in your life when someone has told you reasons
why you shouldnt do what youre doing? How did that impact
your behavior? How did that impact your motivation to change?

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Did you feel more or less open to talking about your struggle to
this person afterwards?
5. Evocation: What do you think about the Motivational
Interviewing approach of eliciting arguments for change from the
client, rather than giving them to the client? How is it for you to
not tell people what you think they should do, especially when you
feel very strongly about it? What do you think are some benefits
of holding back from giving advice or arguing for change? What
concerns do you have about holding back?
6. Installation vs. Calling Forth: What do you think of Millers
opinion about the deficit model? How do you see the role of
therapist in terms of installing something new versus calling
forth what is already within the client?
7. Confrontation vs. Acceptance: What do you think about the
two contrasting approaches to change that Miller discusses:
confrontation and acceptance? Do you feel partial to one of these
approaches more than the other, or do you see a place for both?
How do you feel when you imagine offering acceptance to a person
who is engaging in self-destructive behavior, such as alcohol or
drug abuse?
8. Rolling with the Resistance: What do you think of Millers
approach to working with resistance? What challenges have you
faced in working with resistance to change? What comes up
for you when you imagine simply reflecting when a client says
something like, I dont really have a drinking problem?
9. Self-Efficacy: What do you think of Millers confidence-building
approach to supporting self-efficacy? What has helped you
experience a sense of self-efficacy in your own life? In your
observations, what has helped your clients feel more confident in
their ability to change?
10. Discrepancy: What do you think the value is of focusing on
the discrepancy between where the client is now and where the
client would like to be? How do you think these questions might
contribute to motivation for change?

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

11. Trusting the Process: What helps you work with the righting
reflex when it arises in your work with clients? What helps you
trust the process and remain patient? Are there particular clients
with whom you have more difficulty remaining patient than
others? What is it about those particular clients that contributes
to a sense of impatience in you? How do you imagine Miller
responding to those clients?

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Reaction Paper for Classes and Training

Video: William Miller on Motivational Interviewing
Assignment: Complete this reaction paper and return it by the
date noted by the facilitator.
Suggestions for Viewers: Take notes on these questions while
viewing the video and complete the reaction paper afterwards.
Respond to each question below.
Length and Style: 2 to 4 pages double-spaced. Be concise. Do NOT
provide a full synopsis of the video. This is meant to be a brief
paper that you write soon after watching the videowe want your
ideas and reactions.
What to Write: Respond to the following questions in your reaction
paper:
1. Key points: What important points did you learn about
Motivational Interviewing? What stands out to you about how
Miller works?
2. What I found most helpful: As a therapist, what did you find most
beneficial about the model presented? What tools or perspectives
did you find helpful and might you use in your own work? What
challenged you to think about something in a new way?
3. What does not make sense: What principles/techniques/
interventions did not make sense to you? Did anything push your
buttons or bring about a sense of resistance in you, or just not fit
with your own style of working?
4. How I would do it differently: What might you do differently from
Miller when working with clients? Be specific about what different
approaches, interventions and techniques you would apply.
5. Other Questions/Reactions: What questions or reactions did you
have as you viewed the interview with Miller? Other comments,
thoughts, or feelings?

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Role-Plays
After watching the video and reviewing Millers Approach to
Motivational Interviewing in this manual, break participants into
pairs and have them role-play two different sessions so they can
get a feel for the difference between the MI approach and a more
confrontational approach.
In both sessions, clients will express ambivalence about changing a
chosen behavior, such as drinking, smoking, drug use, eating, exercise,
or internet usage. Clients can play either someone who was mandated
to therapy or someone who came voluntarily. Students can play
clients they have worked with, people they know personally, or even
themselves.
First, have therapists embody a non-MI approachthat is, one
characterized by confrontation, persuasion, explanation, and
authority. The therapist should try to convince the client to change, by
arguing for change, offering advice, and giving them reasons why they
should stop. If the client appears resistant, then the therapist may
confront them about being in denial if this seems appropriate. Both
the therapist and client should avoid the tendency to overact; try
to make this as realistic as possible. Then have the dyad debrief the
experience: how did clients and therapists feel during this exchange?
Next, have therapists practice the spirit and techniques of
Motivational Interviewing. The MI therapist will focus on establishing
a therapeutic relationship based on collaboration with the client,
evoking the reasons for change from the client, and honoring the
clients autonomy. Invite the therapist to try out techniques such as
reflection, affirmation, empathy, eliciting change talk, developing
discrepancy, supporting self-efficacy/ confidence building, and rolling
with resistance. Remind therapists that the spirit of Motivational
Interviewing is more important than any specific technique.
After both sessions are complete, have participants switch roles, so
that each gets to try out being therapist and client.

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After the role-plays, have the groups come together to discuss their
experiences. First, have the clients talk about what each session was
like for them. What differences did they notice between the two
approaches? Did they feel more inclined to change their behavior after
either of the sessions? What do they think are the benefits and risks of
an MI approach and a non-MI approach? Then have the therapists talk
about their experiences. Which approach felt more natural for them?
What do they like and dislike about the MI approach? Do they have
the sense that they helped the client change? How was it to work with
clients resistance? Which approach seemed more effective for eliciting
change? Finally, open up a general discussion of the strengths and the
challenges in applying Millers Motivational Interviewing approach.
An alternative is to do these role-plays in front of the whole group with
one therapist and one client; the entire group can observe, acting as
the advising team to the therapist. Before the end of each session, have
the therapist take a break, get feedback from the observation team,
and bring it back into the session with the client. Other observers
might jump in if the therapist gets stuck. Follow up with a discussion
on what participants learned about using Motivational Interviewing
with ambivalent clients.

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Related Websites, Videos and Further

Reading
web resources
Motivational Interviewing
www.motivationalinterview.org
William R. Millers website
www.williamrmiller.net
Stephen Rollnick
www.stephenrollnick.com

Related Videos Available at

www.psychotherapy.net
Motivational Interviewing with William R. Miller
7 Skills for Addiction-Free Living (7-DVD Series)
Brief Therapy for Addictions (7-DVD Series)
Harm Reduction Therapy for Addictions with G. Alan Marlatt
Stages of Change for Addictions with John C. Norcross
Treating Alcoholism in Psychotherapy (2-Volume Set) with Stephanie Brown

Recommended Readings
Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (Eds) (2008).
Motivational interviewing in the treatment of psychological
problems. New York: Guilford.
Miller, W.R. & Carroll, K. M. (Eds) (2006). Rethinking substance abuse:
What the science shows, and what we should do about it. New York:
Guilford.
Miller, W. R. & Rollnick, S. (2002). Motivational interviewing: Preparing
people for change. New York: Guilford.
Miller, W. R., & Rollnick, S. (2009). Ten things that motivational
interviewing is not. Behavioural and Cognitive Psychotherapy,
37(2), 129-140.
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 Psychotherapy.net

Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational

interviewing. American Psychologist, 64(6), 527-537.
Rollnick, S. & Miller, W.R. & Butler, C.C. (2007). Motivational
interviewing in health care: Helping patients change behavior. New
York: Guilford.
Rosengren, D. B. (2009). Building motivational interviewing skills: A
practitioner workbook. New York: Guilford.

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Complete Transcript of
William Miller on Motivational
Interviewing
Accidental Beginnings
Randy Wyatt: Bill, its really good to have you here today to talk about
Motivational Interviewing and all the areas that its being applied to
today.
William Miller: Theres quite a few.
Wyatt: Yes. Just to start with, your first book was Motivational
Interviewing: Preparing People to Change Addictive Behavior.
You also have Motivational Interviewing and the Treatment of
Psychological Problems. Then theres also Motivational Interviewing
and Health Care: Helping Patients Change Behavior. And these are
just a few of the areas motivational interviewing is being applied in.
But lets step back a few steps.
Miller: OK.
Wyatt: How did this whole thing start?
Miller: By happenstance. I was on sabbatical in Norway working at
an alcoholism treatment facility there, and the director asked me,
in addition to the lectures that I was giving, if I would meet with
a group of young psychologists that were working there, most of
whom were pretty recently out of school. And they were working
with primarily people with alcohol problems. And what they wanted
to do, as we began meeting and talking, was to role-play their most
difficult patients. So they would come in and do that, and portray in
Englishsince my Norwegian wasnt very goodthese patients they
were seeing, and essentially said, Show us what you would do with
this. Well, I did my best to demonstrate that, and they would stop
me regularly and say, Now, what are you thinking when youre doing
this? Whats going on right now?
Wyatt: All right.

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Miller: Where are you going? Why did you ask that question? Or,
Of all the things that you could have reflected, why did you reflect
that? And they [inaudible**] me to verbalize some decision rules that
had to do with causing the patients to make the arguments for change,
that I wasnt really aware of but I was clearly using. I had acquired,
somewhere along the line, this style, and it was even somewhat
different from what I was lecturing on, which was cognitive-
behavioral treatment of addictions at the time. So I wrote down these
decision rules, these guidelines for doing this style of interviewing,
and hadnt really meant to do much with them except think about
them. And I sent them to a few colleagues for discussion, and one said,
Id like to publish it. Which was surprising, because I had no data at
all.
Wyatt: Who was that? Lets give them credit.
Miller: Ray Hodgson was his name. He was the editor of Behavioral
Psychotherapy, a British journal. And he said, Its fine you dont have
any data. I think this is something important. Id like to publish it.
So I cut it down some and did publish it, and thought that was pretty
much the last Id hear of it. But instead, it took off.
Encountering Ambivalence
Wyatt: It certainly did. Lets put these books away and dig into what
motivational interviewing is. The first question I want to focus on is:
your books are all about change, people being stuck somewhere
addiction and depression, or disease, heart disease, diabetesand not
doing well at dealing with the treatment. So why it is so hard, what is
so hard about people changing when they know they should, but yet
they get stuck? How do you think about that?
Miller: Well, its a very old problem, of course
Wyatt: Of course.
Miller: that you know you should do something, but you havent
done it yet. And Steve Rollnick, my coauthor, and I have talked a good
bit about ambivalenceabout wanting two different things at the
same time. So with drinkers, which was the group with whom I was
originally doing this, they both enjoy drinking and like it, and there
are things about drinking that are positive for them, and also they
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

know that theyre doing themselves in, and so are perfectly aware of
the negative consequences that its having. So they both want to drink
and want to not drink, simultaneously. And thats a pretty common
human phenomenon. Nothing unique to addictions about thatto
want this relationship and not want it, or to want this relationship or
that relationship, or...
Wyatt: To be or not to be.
Miller: To be or not to be, thats right, yeah, sure. To change jobs
or keep the same job. And usually what happens when somebodys
ambivalent is theyll think of a reason for changing, then theyll think
of a reason for not changing, and then theyll stop thinking about it
because its uncomfortable to be ambivalent. And so the whole thing
doesnt move at all. And thats a place where people get stuck and can
be stuck for quite a while. Motivational interviewing is about helping
people move off of that place and move in the direction of positive
change, to actually get going and get out of the woods, get unstuck.
Wyatt: So you were doing work with cognitive-behavioral therapy and
alcoholism and so forth.
Miller: Yes.
Wyatt: Where did you jump off from there and develop something
different? How was it different, what you developed?
Miller: Actually, the first thing that caused me to begin thinking
this, even before that sabbatical, was a study in which we were doing
behavior therapy for problem drinkers, and we found that therapists
were widely different in their ability to do this.
First of all, the outcomes were quite different. And we could predict
two thirds of the variance in outcome, that is, two thirds of the
variance in drinking six months after treatment, from how empathic
the therapist was, in the sense that Carl Rogers meant thathow
well they were listening to their patient and actively reflecting back
what they heard and getting an accurate understanding. So behavior
therapists, while doing behavior therapy, the majority of the variance
was being driven by how empathic they are, by the relationship
quality. That said to me theres something that were missing here,
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something we need to be paying attention to. And even a year and two
years out from treatment, still, substantial proportions of variance
were being predicted by the therapists empathy. So even within
behavior therapy, how well youre listening to the person is a very
important determinant of how much they change. That was striking
to me.
So I began to pay more attention to relationship, and in particular,
then, to whats going on within the relationship. And whos making
the arguments for change? And if you sit down with an ambivalent
person, as a therapist, and you argue for change
Wyatt: Youve got to stop. Youre drinking too much; youve got to
stop drinking; obviously its hurting you; it affects your family; it
affects your health; you could lose your job. You know these things,
yet you still do it.
Miller: Exactly, thats right. And all of those things you feel like
saying. Thats what Steve and I call the righting reflex: you want to
fix it, you want to set it right. So its natural to take up that side of the
argument. The question is, what happens when you do that with an
ambivalent person? And what typically happens is youll then hear
from the client the other side of the ambivalence. So if you say to a
person what you just said, theyre likely to say, Well, Im not sure its
that bad. You know, I dont know if I really need to do this. And we
used to call that denial in the addiction field.
Wyatt: OK.
Miller: And its simply the predictable result of talking to an
ambivalent person and taking up one side of the argument. And they
would naturally respond with the other. So you wind up acting out,
almost like psychodrama, what is really their internal ambivalence,
between the two of you, with the therapist having the good lines and
the client having the counterchange lines. And that might be sort of
fun, except that clients tend to believe themselves, so as they hear
themselves arguing against change, theyre literally talking themselves
out of change.
So what we were doing in the addiction field, I realized, was exactly
backwards. It was precisely the wrong thing to be doing, to be the
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

champion of change and elicit from the client all of the arguments
against making change. Really, we should be counseling in a way that
caused the clients to make the arguments for change. And that was the
fundamental insight at the beginning of motivational interviewing.
Much of what weve done since then is get clear how you can do that,
and how well this works, and why it works, and how to teach it.
Eliciting Change Talk
Wyatt: Give me an example, then, of, you know, I have an addiction,
drinking or drugs. How do you talk to a person? I have some idea,
but right now Im not thinking of it. How do you then elicit reasons
for change from them instead of beating them over the head with why
to change?
Miller: You know, the simplest of all the methods we use is simply to
ask for change talkto ask an open question, the answer to which is
change talk. So, Why would you want to make this change? What
might be good about quitting drinking?or whatever the change is
that were focusing on. If you did decide to do this, how would you
go about it? What would you say are the three best reasons for you to
make a change in your drinking? How important is it to you? We
have a simple little scaling technique that we use from 0 to 10. We ask
people, How important is it to you, from 0 to 10, to stop smoking?
or, again, whatever the change is. And people give you a number. And
the follow-up question to that is, Why are you at that number and
not zero, or not a lower number?
Wyatt: Oh. Turn it around.
Miller: Your righting reflex wants to ask the other oneHow could
you be at 6 and not 10?right?
Wyatt: Yeah.
Miller: But actually wed say, How come youre at 6 and not 0?
Because the answer to that is change talk. The answer to that is the
persons own reasons for change, which is much better than the
reasons that I have for them to change. So the real gold is in the
persons own motivations that are already there. This is very different
form the idea that you have to install something. Some approaches,
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including, I think, cognitive behavior ones, often come from a deficit

model, that the clients missing something: They dont have the right
skills or theyre not logical, or whatever it is. And I have the thing they
need, so Im going to install it like software into the person and then
theyll run better. This approach assumes that the person has much
of what they need already, and the therapists job is to call it forth.
Wyatt: So, in terms of the word motivation, who has motivation?
Whose do we want to increase? Where do you come down on... I
mean, Im thinking of addiction, or something like diabetes, the
doctor will say, Hey, youve got to do better, youve got to take that
medication, youve got to run more. If you dont do this One day,
the doctor told my mother, You either take that medication or youre
really going to be in bad shape. Doesnt sometimes that confrontation
have some impact?
Miller: Well, you certainly find the anecdotes of people saying, That
really helped me when the person told me that. So sometimes it does,
but in general, the effect of argumentation or confrontation like that
is actually to elicit the opposite from the client. And our data indicate,
when you do that, the persons actually less likely to change, whereas if
you counsel in a way causing them to make the arguments for change,
theyre much more likely to go ahead and do it, I think because youre
calling on their own motivations rather than what you imagine to be
the best reasons.
Wyatt: Im thinking that somebody can confront me on something
a few times, but if they keep bugging me all the time, Ill quit telling
them what Im doing.
Miller: You just shut down.
Wyatt: Ill shut down. If you feel too judged Most people drinking
too much or doing drugs certainly oftentimes feel some shame about
that.
Miller: Sure, when they know what theyve been doing is harmful.
Wyatt: So what about that? How do you deal with that element in
terms of your approach orshaming them? Theyre already feeling
shame.
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Miller: Right.
Wyatt: Yet, typically in our field, and particularly in addictions or
health care, the helper oftentimes is trying to elicit more shame to
help the person.
Miller: Well, its an odd idea that if you can just make people feel bad
enough, then theyll change. And I dont know of any evidence for
that, and in my experience the opposite is so. A lot of what we do is
very much built on the work of Carl Rogers.
Wyatt: All right.
Miller: And Rogers maintained that its the experience of acceptance
as you are that makes it possible to change. And feeling unacceptable
actually tends to freeze the person, immobilize the person. So I dont
know why that is, but when you feel unacceptable, its difficult to
change. When you experience acceptance as you are now, it becomes
possible to change.
The Spirit of MI
Wyatt: In your books, you often talk about the spirit of motivational
interviewing
Miller: Yes.
Wyatt: that theres acceptance, yet an encouragement to change.
Can you talk about what you mean by the spirit of motivational
interviewing?
Miller: Steve and I began emphasizing this underlying spirit of
motivational interviewing when we saw people that we had trained
basically doing what we had told them, and we didnt like what we
saw. It was the words without the music; it was technique without
really understanding why youre doing this or what youre doingthe
spirit in which youre doing it. So we began to describe three aspects
that are in the mind and heart of the therapist in doing this. One of
them is collaborationthat its a partnership. Its like sitting side by
side and having a conversation with someone, rather than being the
expert, pronouncing and telling people what to do. So thats first of all,
and an important piece of the mindset. Then evocationthat youre
calling forth rather than installing things into the person. Its not, I
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have what you need. Its, You have what you need, and together were
going to find that. And then, thirdly, theres honoring of the persons
autonomythat each person gets to make the choices about how
theyre going to live their life and whether theyll make a change or
not, and you cant take that away from a person even if you want to.
Wyatt: Yeah.
Miller: That is just a part of being human. So those three things
together form the basis on which one proceeds with a motivational
interview.
Rolling with the Resistance
Wyatt: With that said, I do want to ask youweve talked about one
technique, eliciting change, change talk. Another technique thats
relatively uniquesome others may be taking some of it too, but this
idea of rolling with the resistance. I love the sound of it.
Miller: Yes.
Wyatt: Tell us what that means, and perhaps give us an example of
that.
Miller: Well, the thing you dont do when you meet what feels like
resistance is push against it. If you disagree with it and push against
it, it tends to strengthen it; you tend to get more. So if, for example,
a person begins arguing they dont really need to make the change,
and you respond to that by saying, Oh yes, you do, and make the
arguments, you again will be in the situation where youre acting
out the ambivalence that the person has, with them having all the
counterchange lines. And thats where you dont want to be.
So instead of pushing against it, you do something that more moves
with it. And there are many ways to do it, but the common example
is simply to reflect what the person says. So in one interview that I
did, the client was saying, I dont really have a problem with alcohol.
My problem is smoking. To which I reply, So alcohol isnt really
a problem for you. Just saying what he had said, basically. He said,
Yeah, well, it is. Drinking as much as I do would be a problem for
anybody. Now, what is it thats happened there? He was voicing the
counterchange side of ambivalence, and rather than arguing with it, I
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

came along and stood beside him, basically, and reflected what he said,
and now he comes back and tells me the other side of the ambivalence
again. So hes now back on course, from a motivational interviewing
perspective, of exploring the reasons why he would make the change.
So thats one simple example. But basically, youre not arguing with,
fighting with, pushing against, trying to defeat what looks like
resistance.
Wyatt: Lets go with an emotional difficulty, say a phobia. Say, I get
so anxious when I go out that I stay home. My wife thinks I should
get out more, but to me, I talked to my boss and he said I could work
at home. So I just stay home. Im glad that youre nearby and I can see
you and go back home. So thats where Im at on it.
Miller: Right. To which I might respond, You really like the way
things are now. This is how youd like to continue.
Wyatt: Well...
Miller: Instead of disagreeing with it. Instead of pushing against it.
Wyatt: And telling me how I should get out more.
Miller: Right. Because if I take up the change side of the argument,
youll just defend all the more why thats there. So, again, Im in some
way joining with that. And the usual result of that, with a person
whos ambivalent, is that they come back and say, Well, no, Im not
real pleased with how things are right now. It doesnt always happen
that way, but in general, thats what occurs. And thats where Im
trying to have the person focusto focus on, What are the reasons
for change? Why is it important? How would you do it? What would
be good about making that change? And to have them give voice to
those arguments, which are already inside them.
Wyatt: Might you ask, Your wife says it could be a problem; do you
think theres anything she said that is of interest to you? Would that
be okay to ask him?
Miller: Possibly. You know, What is it that your wifes concerned
about? sometimes is a way around it. The nice thing about
motivational interviewing is there are a lot of right ways to do it.

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Wyatt: OK.
Miller: You dont have to do it the way I do it. Steve Rollnick and I
have very different styles.
Wyatt: How would you distinguish your styles, so we can get a feel for
two different styles?
Miller: Well, I think I probably tend to focus much more on emotion,
on affect, than Steve might, and I do more reflective listening than
Steve might. Some of thats British versus American styles, as well.
Wyatt: OK.
Miller: But if you watch different therapists doing motivational
interviewing, theres not one way of doing it. It can fit within a
pretty broad range of individual differences in style as long as that
underlying spirit is there. That seems to be the key piece: that it be
collaborative and evocative and honor the persons autonomy.
Wyatt: So motivational interviewing, then, doesnt have to be stand-
aloneit can be grafted onto therapies, or physicians working with
patients, pretty freely.
Miller: Well, in fact, that was my original intention. I hadnt originally
thought of it as a psychotherapy itself
Wyatt: OK.
Miller: but as something you would do in preparation for some
other treatment, to increase the persons motivation for it, and
retention and adherence in it. And it does seem to do that, so when
you add it on to another active treatment, you do tend to see better
outcomes. Motivational interviewing has a bigger effect, and the
actual treatment has a bigger effect, when theyre put together. So
that is legitimate. At the same time, one of the early surprises in our
research was that when we did motivational interviewing, people
rarely went and got treatment for what it was they were talking
aboutin that case, it was drinkingbut they went ahead and made
a change after the interview itself. So it looked like this conversation
in and of itself was an active treatment, was actively precipitating a
change in a behavior that had been pretty stubbornly persistent for
often a decade.
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Fostering Readiness for Change

Wyatt: So Bill, when youre helping the client make a list, say, of pros
and cons on substance abuse or changing the behavior, exercising or
habithow do you balance those? Do you just have them list the pros
and the cons?
Miller: I wouldnt normally construct a list like that. I guess thats
one way of thinking about how to help people with ambivalenceto
make the old Ben Franklin list of what are all the pros and what are all
the cons. From my perspective, thats where the person is when they
came in. Theyre already ambivalent and already stuck with these kind
of counterbalancing forces, and Im interested in having them give
voice to the pro-change arguments. Now, if they raise the other side,
which of course they do, I will respond to it in a non-confrontive way,
which generally brings them back to the change direction anyhow. So
its not a matter of thoroughly exploring all the pros and thoroughly
exploring all the cons, so much as continuing to explore their positive
reasons for change. An example I use from scouting is getting out of
the woods. If youre out in the middle of the woods and dont have a
compass, how do you walk in a straight line? Because the danger is
youre going to wander around in a circle and come back to where you
were before. Well, you do it by lining up three trees: one close, one a
little further away, and one still further in the distance. And you walk
from tree number one to tree number two, keeping tree number three
in line. When you get to tree number two, what was tree number three
becomes tree two, and you find another one past it, and you walk
in a straight line in that direction. And motivational interviewing,
when well directed, is kind of like that. Youre helping the person
keep moving in the direction of change and get unstuck from the
ambivalence. I cant see a reason why giving equal weight to pros and
cons would help a person get unstuck, because that is where they were
stuck.
Wyatt: Thats an important distinction. I think that might have been
one of the ways you saw people practice.
Miller: Well, people get it confused. And they get motivational
interviewing confused with techniques in generalthat you have

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to do the 0-to-10 ruler or youve got to do a decisional balance or

whatever it is. And much more important is understanding what
youre trying to do, which is, first of all, to express empathy and create
this accepting atmosphere for the person in which they can talk about
whatever theyre talking about and not be judged and disapproved
of; to be eliciting change talk and having the person move in that
direction with their own speech; to roll with the resistance and not
push against that; and to support the persons self-efficacy, their
belief that they actually can do it. If you persuade a person that its
very important to make a change, but they think they cant do it, you
havent done them any favors.
Wyatt: Their confidence that they can follow through.
Miller: Thats right. You want importance and confidence to begin
going up over the course of motivational interviewing.
Wyatt: This person might say, Yeah, I want to start exercising and
dieting more because of my heart problems. And then you ask,
Whats your confidence? Well, Im not so sure I can do it.
Miller: Right, right. Its a different challenge, when importance is high
and confidence low, than the opposite, than the person who says, Im
sure I can do it but I dont see any reason to. Thats low importance,
high confidence. And you do somewhat different things depending
which of those it is. For smokers, its more often high importance, low
confidence.
Wyatt: High importance. So, Its really important I quit smoking.
Miller: You know, I really should. I know Im harming myself, but
Ive tried and I havent been successful, so.
Wyatt: So give me some thoughts on how you approach that.
Miller: Well, thats more confidence building. And within a
motivational interviewing style, I might be exploring other things
theyve changed successfully in their life and how they went about
thatwhat strengths they have to draw on, what is it about them that
would help them to make successful changes. I might give them a
menu of different options of things that people have done that have
been successful for them, and ask for their wisdom about which of
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

these things seems to them like it has the most promisewhat would
their hunch be? So theyre sort of my consultant, in a way, in whats
likely to be effective with them.
Wyatt: Say, with a smoker, youre building them up, youre finding
what they did well in other areas. I didnt hear a super-focus on their
smoking and how bad it is for them.
Miller: Well, remember, we started with this scenario where this
person knew that they should stop smoking but they werent
confident.
Wyatt: OK.
Miller: If its the opposite situation, or if you have a person that
doesnt really see a reason to stop smoking, you would probably start
thereyoud probably start by focusing on the importance side of the
equation rather than the confidence side.
Wyatt: OK. Well, youre hitting on something I was just about to get
to, and this whole idea of where the person is at in terms of readiness
to change. Can you speak to the whole idea of stages of change and
readiness to change?
Miller: Yeah. That model of Jim Prochaska and Carlo DiClemente
kind of grew up side-by-side with motivational interviewing. We
were both working on it in the late 70s, early 80s, and they emerged
in the literature about the same time. And they fit together nicely in
a way. One of the most helpful things, I think, about their model,
heuristically, is to realize that some peoplein fact, often a majority
of peoplewho need to make a change arent ready to do that.
And if you charge in with what I was trained in, which is cognitive-
behavioral strategiesHeres how you can do itthey dont come
along with you. Thats an appropriate strategy at the action stage, but
not back at contemplation.
Wyatt: Or precontemplation.
Miller: Or precontemplation. And so one of the fundamental
insights, I think, was clients are different places in readiness, and
you should be doing different things for them depending where
they are. Well, what do you when a person isnt ready for change?
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Motivational interviewing came along at the same time and said,

Heres something actually designed exactly to do that, and so it
fit in nicely to the model, I think. Theyve gotten a little confused
with each other sometimes, but I think this makes sense within that
model, as something to help people move from precontemplation
and contemplation on to preparation and action. And with addictive
behaviors, for example, most people are not at the place where theyve
decided to make that change. Carlo and Jim think something like 80
percent of people are back at precontemplation or contemplation. So
if you want to put together a program to help people make healthy
changes in their drinking or smoking, youd better be attending
to readiness; youd better be attending to helping people build a
motivation to decide to do it. Then you can help them with how to do
it.
Wyatt: So if a persons just ready to change, fine. Stop drinking,
exercise, change your diet. We dont need much treatment, right?
Miller: Well, you dont need motivational interviewing. And, in
fact, we have some evidence that its a bad idea to do motivational
interviewing at that point.
Wyatt: OK.
Miller: You can imagine a person coming to you and saying, I need
to stop drinking. Tell me how to do it, and you sit back and say,
Well, lets think a bit about whether you want to do this and what
might be some reasons for making the change. Youre also not where
they are. Theyre ready to go, and in a way youre holding them back
by that. So you wouldnt do motivational interviewing at that point,
but you might very well, if they want help in making that change, offer
that. Maybe thats the place for some skill building to be able to live
without the substance thats causing them problems, whatever it is. So
it is very much a process of, What does the person need right now,
and what could I provide that might be helpful, and does the person
want that help that I have to provide?
R: All right.

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Applications to Health Care

Bill, weve talked quite a bit about addictions. I want to dive into
health care directlyhealth care behaviors. How did it make the shift
from addictions, emotional issues, to health care behaviors and habits?
Miller: It was just picked up by health care practitioners, because
whats one of the primary frustrations if you are a health care provider
working with people with chronic illnesses? One of the principal
frustrations is something like, I tell them, I tell them, and I tell them,
and they still dont change.
Wyatt: Yeah.
Miller: And what the patient does makes lots of difference in their
health in the future. In all the chronic diseases, the way you live your
life has a huge impact on the course of that disease, your mortality
Wyatt: Your lifestyle
Miller: All of that. So with the chronic diseases, youre really dealing
with behavior change. And in fairness, most people who went into
health care professions outside of psychology and social work and so
forth just dont get that much training how to change behavior.
Wyatt: They make the diagnosis, they make the recommendation.
Miller: Tell people what to do. Thats right.
Wyatt: Whats your prescription? Walk, exercise, take the pill.
Miller: Steve Rollnick has described a continuum of communication
styles, which I think is very helpful here with health care providers,
from directing, at one end, which is telling people what to doand
thats something that is important to do in health care, thats a
legitimate part of health careto just following and listening to the
patient. There are places for that too, in the beginning when youre
trying to understand whats going on with the person, or if you have
a patient whos dying and youve done everything you can to alleviate
their pain, to just sit and be a human being and listen to them.
Wyatt: Be with them.
Miller: Entirely appropriate. And in between those two is this area
called guiding
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Wyatt: Right.
Miller: which is kind of a mixture of directing and following. Its
an interesting, skillful mixture. And thats the area that seems to
change behaviorwhere youre not pushing people and telling them
what to do, youre not just passively following whatever theyre saying,
but youre sort of steering and moving them in the right direction.
Thats where motivational interviewing livesin that middle, guiding
domain.
Wyatt: Can you give an example of that in a health care situation?
Miller: Certainly.
Wyatt: Yeah.
Miller: If you think of one particular behavior that the person ought
to changemedication adherence, for example, is a common one. So
youve got a clear focus there. I would be, first of all, finding out what
the person knows about the medication already, what concerns they
have. Once they have some information about what the medication is
likely to do, to ask them how that might be good for them, what might
be the advantages of taking that medication on a regular basis, what
they hope would happen as a result of that. We might talk about side
effects, also, since thats often a reason why people get concerned or
back off from it. So theres some education in that, of: You may feel
this side effect for a few weeks; it tends to go away after that. So you
need to hang in there if you are feeling it, and by all means, call me if it
comes up. So theres a certain amount of educating, but also a certain
amount of having the person buy into this and come to an agreement
together. You negotiate with the person their willingness to actually
do this, rather than just telling them and having them be passive and
shake their head and walk out the office. And often, you find that they
dont follow through.
A more common situation in health care is when there are multiple
things the person could change, and diabetes is a good example there.
If youre newly diagnosed with Type II diabetes, you could make a
change in the way you eat, your diet, cutting down carbohydrates
and sugars and so forth. You could make a change in your exercise,

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because exercise influences insulin resistance. You could take

medications that are helpful with this. You could be decreasing stress
level that is contributing to the blood sugar dysregulation. There are a
whole variety of things that you can do. And there, youre more in the
domain of agenda setting.
Wyatt: Let me...
Miller: Go ahead.
Wyatt: I know that you mentioned to me that you have diabetes, Type
II.
Miller: Yes, I do. I have Type II.
Wyatt: How did it apply to you as far as the agenda setting? Can you
think back on that, when you first heard, and
Miller: Oh, absolutely. It was quite a shock because I did not expect
at all to receive this diagnosis, and so it was a big surprise. I didnt
personally need a motivational interview at that point. The diagnosis
did it for me.
Wyatt: Shocked you.
Miller: And what I wanted was information.
Wyatt: You were ready for action.
Miller: And I went through a whole series of peoplea dietitian, my
primary care provider, a podiatristpeople that just have important
pieces of the puzzle. I said, Tell me what I need to do. What are the
things that I can do to be healthy? So, for me, importance was very
high, and what I needed was some help with knowing what to do and
how to do it. Also, blood testingyou know, just pricking your finger
and looking at your levels several times a dayand other kinds of
things. So, sometimes, when you throw all of that at people all at once,
its overwhelming.
Wyatt: Yeah.
Miller: And so you may have a discussion about, Where would you
like to start? Of these things, what are you doing already? And which
things do you have some room for improvement? You can imagine

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yourself exercising more, or eating more healthy, or testing more

frequently, whatever it is. And you come to an agreement about
where to go next, because taking a step in the right direction is a
step in the right directionrather than, I want you to change all of
this right away. So people are different. For me, I didnt need much
encouragement. But very often, when people had a heart attack or
are diagnosed with diabetes or asthma, they dont make the changes
that they ought to make to take care of themselves, and this can be
quite helpful to get people to a place where they make the decision
to actually do itits important enough to them and looks feasible
enough to them that theyll say, OK, thats what Im going to do.
Wyatt: So there is some step between You said a physician
oftentimes will direct the personor the therapist or the counselor
could direct the person if theyre involved in their health careand
the person doesnt do it. Has heart problems, had heart surgery, and
keeps eating foods that make their health worse.
Miller: Right. The temptation is to wag your finger and say, Youve
got to do this, which for some people does work. I mean, it worked
often enough to keep us doing it.
Wyatt: Its an option.
Miller: A partial reinforcement schedule. Every thirtieth patient
actually does change; what Im doing must be a good thing. Youll
get a much higher percentage of change with this style of listening to
people, hearing their concerns, negotiating whats feasible.
Wyatt: My uncle who had heart surgery, he goes, Hey, the doctor said
I should exercise. But lets say he says, I exercise too much, Ill have a
heart attack.
Miller: Right. And that fear of exercise is often a significant factor in
people whove had a heart attack. Theyre afraid theyll overdo it.
Wyatt: Yeah. And it could be a problem, if they overdo it.
Miller: So they need good advice. Much more likely is that theyre
going to strengthen themselves and decrease their likelihood of
heart attack, but of course you get physician advice about whats safe
exercise, and whats going to move you in the right direction. But its
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

exactly that. Exercise more is a general prescription. But what kind

of exercise? How could it fit into your life? Which things do you enjoy
doing? For me, I use an elliptical to exercise regularly. I just dont
enjoy standing there and exercisingits not much fun. But put in a
DVD of something that I can listen to and follow while Im doing it,
and the hour goes by really quickly. So its finding the kind of exercise
and the time of day and the length of time and how you can make
that be fun, be enjoyable for you and fit into your lifestyle. And thats
often the work that doesnt get done when you just get the general
prescription of Exercise more. Thats really what it takes. Same
thing with diet: Eat more healthy is a broad, general prescription,
but it isnt terribly helpful. What changes do you need to make in your
diet? What are you eating now? Could you imagine shifting here to
move in a direction of a healthier kind of diet? So thats some work
with a dietitian whos good at motivational interviewing as well as
helping people come up with specifics.
Wyatt: Youve talked about, in all these categories, this whole idea of
discrepancy interviewing.
Miller: Yes.
Wyatt: Can you speak to that?
Miller: Well, its creating a discrepancy between where you are and
where you want to be, and making that salient to the person. So,
much of what Im doing in motivational interviewing is focusing on
that Where are you now, and where would you like to be? And the
more those two things are apart from each other, the more, in a way,
motivational juice there is. Its just a natural part of human nature
that when youre here and youd like to be there, theres a kind of draw
to move in that direction. So Im looking to understand: What are the
persons values? What do they care about? What do they want from
life? What are their goals? And how is their present lifestyle doing for
them in terms of getting them there? That can build importance. And
also you want to focus on confidencethat there actually are things
you can do to move in that direction, as well.

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Outcome Studies
Wyatt: All right. Bill, it all sounds great, and Ive read your book and
so forth, but Id like to hear it from you: what is your sense of what
the research and outcomes data says on the impact of motivational
interviewing?
Miller: There are almost 200 outcome studies now in the literature,
so its growing very fast. And there are a number of meta-analyses
published that try to pull all that together. And on average, youre
getting whats called a medium effect size: not an enormous,
miraculous change, but on average, across all the people receiving
it, and across all the problems areas focused on, you get a decent
significanceclinically meaningful change in behavior. Within that
are some people who are making a lot of changes and some people
who arent making changes, so you get the same variety of outcomes
around whats a respectable amount of change on average. So many
groups that are compiling evidence based treatment lists now have
motivational interviewing on that list as there being enough evidence
from clinical trials that it works. Now, the interesting thing is there
also are negative clinical trials, including one that I did
Wyatt: What happened?
Miller: in which we got absolutely positively zero impact in
motivational interviewing. And in our case, I think I understand why.
Thats a story I could tell you in and of itself.
Wyatt: Lets hear it.
Miller: All right.
Wyatt: Usually we only hear the good stories. Its good to hear what
doesnt work to confirm.
Miller: Yeah, well, this was a spectacular negative trial. It really was.
Wyatt: Yeah.
Miller: I wrote a manual. This was in drug abuse treatment, so
these were people coming into a drug abuse treatment program
adultsfor mostly heroin, cocaine, occasionally marijuana, and
alcohol is usually mixed in there as well. Some amphetamines, but
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

mainly opiates and stimulants. And we built in a single motivational

interview around intake period. And they either got or didnt get
that motivational interview, to see if we could improve retention,
adherence, and outcome. And I wrote a manual for doing motivational
interviewing in a single session. And actually, it was whats called
Motivational Enhancement Therapy, which includes assessment
feedback as well as motivational interviewing. So the therapist would
start off doing motivational interviewing, then give the assessment
feedback, then go back to doing motivational interviewing, and then
develop a change plan at the end of the session. And theyre supposed
to do all those things.
I worked with a psycholinguist named Paul Amrhein, who has
made tremendous contributions to our understanding motivational
interviewing, and he first of all differentiated people in terms of
how they did with outcomes. And the people who essentially quit
using drugs, which was about two thirds of the sample, showed a
nice, steady increase in their commitment for change over the course
of the motivational interviewing session. It just was a nice, steady
slope upwards. So they started out essentially motivated to continue
using drugs, and at the end of the session are making the arguments
for abstinence from drugs, themselves. And that was the pattern
of speech within the session that was related to positive outcomes.
Then he looked at people who werent doing so well, who were still
using drugs a year laterat about half the level they had been, but
nonetheless, a level you wouldnt be pleased with as a clinician. And
whats happening with them is their motivation goes up a little bit,
then it goes down. Then it goes up a lot, and at the end of the session it
crashes down to zero againcommitment.
He said, What are you doing to these people? Whats going on?
Because you dont usually see that picket-fence kind of thing. Well,
while were doing motivational interviewing, their commitments
going up. Then we start giving assessment feedback, and these people
are now backpedaling; theyre going down a little bit. We finally finish
the assessment feedback, go back to motivational interviewing, and
their commitment goes up again and actually goes up just as high
as the group with positive outcomes. Then comes the change plan.
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And at that point, they backpedal again and arent ready to say, Yes,
Im going to do this, and so their commitment level crashes back to
zero. Now, any decent motivational interviewer, if they began giving
assessment feedback and saw the patient beginning to get resistant and
back away, would stop that. But my manual said they had to do that,
so they went ahead with the assessment feedback.
Wyatt: The dangers of manual treatment.
Miller: Exactly, exactly. And you get to the end of the session, and
if you try a change plan, say, Well, lets say what you might do
differently, if the person begins to get resistant and back off from
that, you wouldnt press ahead. But the manual that I wrote said youre
supposed to get a change plan the first session. And so they went ahead
and did itcrash, down goes the motivation.
Wyatt: People did what you told them!
Miller: They did what I told them! Exactly. Thats been one of the real
challenges: people sometimes do what you tell them. So the problem
there, I think, was the manual, the way I wrote it, that didnt give
people the flexibility that you need to do motivational interviewing,
to respond to what the patient is telling you right now rather than to
have a preset agenda of, Do this, then this, then this, then this. It
just doesnt work well that way. But there are other negative trials, as
well. There were multi-site trials with negative outcomes, and within
those, sometimes motivational interviewing works at one site and
not another, which is intriguing. And usually when you look at the
therapist, some therapists are doing better with it than others are. So
theres something about who provides it, and how they provide it, and
the context within which its done, that influences whether it has an
impact or not. And I think were just beginning to understand what
thats about. So its a long answer to your question. I think theres
clearly enough evidence to say theres something going on with this
approach. Theres enough to call it an evidence-based treatment. And
also, we need to know more about why it works and whats going on,
and why it is that sometimes, in the hands of some therapists, or at
some sites, you dont get an effect. Its not as 100-percent reliable in
producing effects as you would like. I suppose thats true of many
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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

kinds of treatment, and its even true of medications, in medication

trials weve done.
Wyatt: Of course.
Miller: So theres still more to understand, but I think theres enough
evidence there now to say, This is worth learning; this is worth
pursuing.
Wyatt: It reminds me ofwe talked to Scott Miller, and hes done
work on evidence-based practice, and he really pointed out the key
part of client feedback
Miller: Yes.
Wyatt: and responding and tailoring. If an evidence-based practice
is not tailoring it to the client feedback, its not a very good evidence-
based practice. If youre a surgeon, you open the person up, and
something changes, youd better change your surgery.
Miller: Exactly. Its one of my reservations about whats become of the
trans-theoretical model as well, which is: put in a dipstick, find out
what stage a persons at, and pull off the shelf the intervention for that
stage. I think thats not nearly responsive enough to the person. And I
find people moving around the stages within a session, even.
Wyatt: Yeah.
Miller: So more staying with the person where they are rather than
some pre-fixed intervention that you imagine, because of some
questionnaire youve given, is the right thing to do for them.
Wyatt: So, regardless of the techniqueCBT, solution-focused,
motivational interviewingWhats the feedback of the client, whats
working, not working? Using your mind in the therapy, in the
counseling, in your physicians, nurses office.
Miller: Well, in fact, thats how you learn this approach. And when
youre getting change talk from the patient, youre doing it right.
Thats the patient telling you this is moving in the right direction. And
when resistance arises, thats a signal from the person not to do more
of what you just did. But in addiction treatment, at least, and in other
areas of care still, weve done just the opposite, that when resistance
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arises we push harder against it, and the resistance rises more, and
youve got to push harder still. And the whole thing becomes a self-
fulfilling prophecy. Resistance actually is the patient teaching us how
to talk to them and how not to evoke the walls of resistance.
Challenges of Learning MI
Wyatt: When you have taught people or trained people in seminars
and workshops and so forth, you and your colleagues, what are some
things that are particularly difficult or hard to get for people youre
training in motivational interviewing?
Miller: Its something you learn over time, of course. Some people
have difficulty even with the spirit of motivational interviewing.
Theyre so convinced that youve got to just tell people.
Wyatt: OK.
Miller: And again, especially in the addiction field, their patients
are in denial, and youve got to get in their face, and they wont
hear it unless youre very aggressive. But you dont do motivational
interviewing with that kind of mindset. So sometimes thats where
people will get stuck, and this isnt the approach for them, basically.
Wyatt: All right.
Miller: Then you learn good client-centered counseling skills
and there I find, often, learning how to do complex reflection is a
challenge. When someone tells me, I tried reflectionit didnt go
anywhere, almost always what that means is the reflections were too
simple. They were staying too close to what the patient said.
Wyatt: Content versus affect.
Miller: And not just affect, but seeing where its going. I say, rather
than repeating the sentence the patient just gave you, say what might
be the next sentence in the paragraph. Its a guess, but if youre wrong,
its no problem because the patient corrects you. But its moving
forward. So its not the parroting parodies of Rogers, of saying the
same thing back to them like theres an echo in here. Its hearing what
hasnt been said yet and testing it out as what might be the patients
meaning. And you get immediate feedback, again, as to whether

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

that was right, so you get better at it over time. But learning complex
reflection is a skill, and its hard to move on with motivational
interviewing without that. Then, knowing what youre listening for
what we call change talk. And tuning your ear so that you can hear, of
all the things the client tells you, which things matter the most, which
are the signals that you are moving in the right direction. So, learning
to recognize change talk. And once you recognize it, learning to evoke
it: how do you behave so the person gives you more of it? And how do
you respond to it? When I look at a transcript or listen to a tape, and
I hear from a patient some change talk, there are only two or three
things, really, that should come nexta reflection, or an affirmation,
or a summary, or asking for detail. So there are a variety of responses
that you would give after change talk to strengthen it. So that comes
there. Knowing when to move on to a change plan, knowing when its
time to maybe draw this motivation together. Knowing how to deal
with resistance when it arises and not push back against it.
Wyatt: Thats a lot of stuff.
Miller: Its a lot of stuff. And when youve done all that, its learning
to intermix it with what you ordinarily do, because youd never have
a practice where all you do is motivational interviewing. It wouldnt
make any sense.
Wyatt: Because it doesnt always apply to the stage theyre at.
B: No. Its a tool for when a person needs to make a change and
isnt quite there yet, isnt quite to the place of doing that. So then its
blending with whatever else you do in health care or in corrections or
in psychotherapy or counselingwhatever else youre doing. Its one
tool that finds its place among the rest, and then its knowing when to
use this tool and when to put it down.
Wyatt: Let me ask you this question. Its been brewing in me. These
things matter a lot: addictionsdrug, alcohol, smoking
Miller: Life and death.
Wyatt: Life and death. Diabetes, heart. Sometimes you want to just
reach across and, Hey, youve got to stop doing that. And maybe
sometimes you will, but how do you stay patient and trusting the
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process when the provider, the physician, the nurse, the therapist, the
family is so frustrated?
Miller: Now, that righting reflex againyou want to reach in and fix
it. The answer to your question, for me, is thats not the right thing
to do most of the time, and that if, instead, I listen to the patient in
a collaborative way and evoke from them their own motivations for
change and their own ideas about how to do that, and support their
autonomy, that they get to make the choice, whether they do this or
not, Im much more successful.
Wyatt: So remembering that when you care so much.
Miller: Yeah.
Wyatt: It works more.
Miller: This is the right way to express that caring. So theres a
lot in motivational interviewing that is suppressing what your gut
immediately wants to do, and instead trusting this process of going
with it and seeing the change that follows. And that is, of course,
the thing that is most persuasive. And a nice thing in learning
motivational interviewing is a little bit seems to go a long waythat
you dont have to get really, really good at this before you begin seeing
people respond to you in a pretty different style, particularly if you
were a finger-wagging, directing, shaming, warning, persuading kind
of person to begin with, which is what helpers do about it, with the
best of intentions.
Wyatt: Well, thank you so much for sharing this with us today. I really
appreciate it.

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

Video Credits
Interviewer: Randall C. Wyatt, PhD
Produced by Victor Yalom, PhD
Video Production: Ludlow Media
Post Production and DVD Authoring: John Welch
DVD Cover Design: Julie Giles
Thank you to William R. Miller, PhD, for sharing his expertise and
wisdom

Copyright 2012, Psychotherapy.net, LLC

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

About the Contributors

Video Participants
William R. Miller, PhD, the originator of Motivational Interviewing,
is Emeritus Distinguished Professor of Psychology and Psychiatry
at the University of New Mexico. He served as Director of Clinical
Training for UNMs doctoral program in clinical psychology and as
Co-Director of UNMs Center on Alcoholism, Substance Abuse and
Addictions (CASAA). Dr. Millers publications include 40 books and
over 400 articles and chapters. He has served as a consultant to many
organizations including the United States Senate, the World Health
Organization, the National Academy of Sciences, and the National
Institutes of Health. In recognition of his research contributions, Dr.
Miller is a recipient of the international Jellinek Memorial Award,
two career achievement awards from the American Psychological
Association, and an Innovators in Combating Substance Abuse award
from the Robert Wood Johnson Foundation.
Randall C. Wyatt, PhD, Featured Interviewer, is the former Editor-
in-Chief of Psychotherapy.net. He is a practicing psychologist
specializing in posttraumatic stress, couples and family therapy,
and cultural diversity in Oakland, California, and he has extensive
teaching experience.

Manual Authors
Ali Miller, MA, MFT, is a psychotherapist in private practice in San
Francisco and Berkeley, CA. She works with individuals and couples
and facilitates therapy groups for women. You can learn more about
her practice at www.AliMillerMFT.com.

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 Psychotherapy.net

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WILLIAM MILLER ON MOTIVATIONAL INTERVIEWING WITH William R. Miller, PhD

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