Motivational enhancement is a style of person-centred counselling developed to facilitate change in health-related behaviours. The core principle of the approach is negotiation rather than conflict. It aims to help people explore and resolve their ambivalence about behaviour change.

It combines warmth and empathy with focused reflective listening and the development of discrepancy between where the person is and where they would like to be. A core principle is that the person’s motivation to change is enhanced if there is a gentle process of negotiation in which the client, not the counsellor, explores the benefits and costs involved in change.

Another strong principle of this approach is that conflict is unhelpful and that a collaborative relationship is essential between counsellor and client, in order to tackle the problem together (Miller & Rollnick, 1991).

Motivational enhancement was initially used in the treatment of alcohol abuse where it was recognised that progress in treatment was limited by a person’s level of motivation to change (Miller & Rollnick, 1991). Similar difficulties with motivation and the ego-syntonic nature of the problem were recognised in eating disorders by Treasure & Ward (1997).

The approach was modified to help eating disorder sufferers move from the pre-contemplation or contemplation stages to an action stage where he or she was more likely to make behavioural changes. Motivational enhancement helps change patterns of behaviour that have become habitual. It works in small doses to produce a large effect by reducing behaviours in the person that interfere with therapy. The 4 central principles of motivational enhancement are shown below.

  1. Express empathy by using reflective listening to convey understanding of the person’s point of view and underlying drives
  2. Develop the discrepancy between the person’s most deeply held values and their current behaviour (i.e. tease out ways in which current unhealthy behaviours conflict with the wish to ‘be good’)
  3. Roll with resistance by responding with empathy and understanding rather than confrontation
  4. Support self-efficacy by building the person’s belief that change is possible

(Miller & Rollnick, 1991)

Motivational enhancement has many applications since it is helpful for use in settings where there is resistance to change. The principles are simple but practical application is less easy, however once the overall skill is developed, it can be adapted to many situations.

Counsellors following the Transtheoretical Model of Change* might use motivational enhancement for people who are undecided about change (in the pre-contemplation and contemplation stages) and later shift to a more structured treatment approach such as cognitive–behavioural techniques once the person is committed to change.

*The Transtheoretical Model of Change has been the basis for developing effective interventions to promote change in health-related behaviours (Prochaska & DiClemente, 1983). The model is one of intentional change which uses a stage theory to illustrate how people modify a problem behaviour and acquire a new positive behaviour. It focuses on a person’s decision making processes and has previously been applied to a wide variety of problem health behaviours, such as smoking, exercise, alcohol abuse, medical compliance and stress management. (Velicer, Prochaska, Fava, Norman & Redding, 1998)

There needs to be room for flexibility to adjust for individual differences in the readiness to change and an empathic counsellor will know when to switch from a skills-based approach to a more motivational stance.

Treatment interventions often assume that people are ready for an immediate and permanent behaviour change. In contrast, the Transtheoretical Model makes no assumption about a person’s readiness for change. It recognises that different people will be at different stages and that appropriate interventions must be developed for everyone.

Treatment interventions often have high dropout rates as participants find a mismatch between the treatment program and their readiness. The Transtheoretical Model is designed to develop interventions that are matched to the specific needs of the individual.

Motivational enhancement highlights the importance of change by reflecting the discrepancy between the person’s current and ideal worlds and helps them to see themselves as others see them. It also bolsters confidence in making changes by reflecting a positive view of the person and belief in their ability to make behaviour change.

The counsellor reinforces commitment to change and supports small steps towards it. Rollnick & Miller (1995) defined specific behaviours used by counsellors that would lead to a stronger therapeutic alliance and a more effective outcome, summarised below.

The first four items explore the reasons the person sustains the behaviour and aim to create a shift in the balance of ‘pros’ and ‘cons’ towards the decision to change.

The last two items in the list cover the interpersonal aspects of the relationship. The counsellor provides warmth and optimism and takes a subordinate position, putting the person in a position of power and emphasising their autonomy and right to choose.

  1. Understand the person’s frame of reference
  2. Filter the person’s thoughts so that statements encouraging change are amplified and statements that reflect the status quo are dampened down
  3. Elicit from the person statements that encourage change, such as expressions of problem recognition, intention to change and recognition of ability to change
  4. Match the processes used in treatment to the stage of change; ensure treatment does not jump ahead of the person
  5. Express acceptance
  6. Affirm the person’s freedom of choice and self-direction

(The Key Skills of Effective Motivational Enhancement – Rollnick & Miller, 1995)

Instead of trying to ‘fix’ the person’s eating disorder by forceful instruction, counsellors need to use warmth and respect to show the person the value of change. Motivational counsellors need to suppress any inclination they might have to try to solve the client’s problems and instead remain flexible and able to provide an appropriate balance between acceptance and drive for change.

The process of change within motivational enhancement interventions has been studied in order to highlight the key strategies. Miller, Benefield & Tonigan (1993) found that a low level of resistance within the counselling session predicts change.

Resistance often arises in the presence of confrontation, so if the counsellor behaves in a way that minimises resistance, change follows. An increase in the rate of ‘self-motivational statements’ by the person, those that express interest in and intent to change, is positively associated with behaviour change.

References

  1. Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.
  2. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.
  3. Prochaska, J. Q., & Di Clemente, C. C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390-395.
  4. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334.
  5. Treasure, J. L., & Ward, A. (1997) Cognitive analytical therapy (CAT) in eating disorders. Clinical Psychology and Psychotherapy, 4, 62-71.
  6. Velicer, W. F., Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. (1998). Smoking cessation and stress management: Applications of the Transtheoretical Model of Behaviour Change. Homeostasis, 38, 216-233.