There are two theoretical bases for Motivational Interviewing: these are the elements that make up MI as well as the Transtheoretical Model of Behavior Change. I have found that utilizing both of these theories together gives the provider a complete understanding of behavior change processes and how to utilize motivational interviewing to assist patients to change their behavior.
The Transtheoretical Model of Health Behavior Change (TTM)
The TTM was developed in the early 1980’s at the same time MI was developed (Miller & Rollnick, 2009). The TTM started with research with smokers attempting to understand how people change their behavior independently, and progressed to exploring how change activities could be measured as well as trying to understand if identifying common elements could assist with the prediction of maintenance in cessation efforts (Prochaska, DiClemente, & Norcross, 1992; Werch, Ames, Moore, Thombs, & Heart, 2009). Over time, DiClemente and colleagues have progressed from smoking cessation to evaluating other health behavior topics including alcohol use, diet, exercise, sun protection, condom use, mammography screening, medication adherence, stress management, substance abuse, and many others (Prochaska, Norcross, & DiClemente, 2007: Redding, Rossi, Rossi, Velicer, & Prochaska, 2000; Werch et al., 2009).
Stages of Change
According to DiClemente and Prochaska (1998), the stages of change, of the TTM, represent processes of behavior change and segment the overall change process into meaningful steps. Each stage contains specific tasks that are required to achieve successful and sustainable behavior change. Stages of change also represent an arrangement of attitudes, intentions, and behaviors that are significant to an individual’s progression in the process of changing his or her behavior (Prochaska et al., 1992). Progression through the stages of change are not linear, patients will progress and then regress before making greater progress (Redding et al., 2000).
Precontemplation stage
Patients in this stage typically do not think that their smoking habit is problematic or that they need to change their behavior. Some patients in this stage may be committed to continuing to smoke. They may avoid thinking, reading, as well talking about their behavior (Redding et al., 2000; Prochaska & Velicer, 1997) Individuals in the precontemplation stage have no intentions of changing their behavior in six months.
Contemplation stage
In this stage individuals are actively considering change and are considering changing their behavior within the next six months but have yet to commit to action. Those in the contemplative stage struggle with the positive aspects of current behavior continuation and the struggle, effort, as well as the risk required to make a change (Prochaska et al., 1992; DiClemente & Prochaska, 1998). This ambivalence is the hallmark of the contemplation stage (Redding et al., 2000; Tomlin & Richardson, 2004).
Preparation stage
Individuals in the preparation stage have resolved to take action to change their behavior (DiClemente & Prochaska, 1998; Prochaska, & DiClemente, 1992). Those in the preparation stage will take action in the near future, most often within the next month and/or have taken action unsuccessfully within the past year (Prochaska, & DiClemente 1992; Prochaska et al., 1992). Individuals, in this stage, have learned from previous attempts at changing their behavior and have committed to an action plan. Some may have begun to make small changes or reductions in their behavior already.
Action stage
The action phase includes individuals that have changed their behavior in the last six months (Redding et al., 2000). During this phase individuals actively engage in modification of their behavior, experiences, and their environment to overcome their problematic behavior (Prochaska et al., 1992). Individuals in the action phase are prone to relapse and need support to prevent this (Prochaska & DiClemente, 1992)
Maintenance and Termination stages
The maintenance phase begins when successful action has been maintained for six months (DiClemente & Prochaska, 1998; Redding et al., 2003). Individuals in the maintenance phase are more confident, have to apply change processes less frequently than in other stages, and their behavior change is becoming more of a habit (Prochaska & Velicer, 1997; Redding et al., 2000). Individuals in this phase are not static and must actively continue to work at preventing relapse (Prochaska et al., 2007; Redding et al., 2000). Termination is the ultimate goal for behavior change and this phase represents the absence of risk for relapse as well as lack of temptation (Prochaska & Velicer, 1997; Prochaska et al., 2007). Patients in the termination stage have complete self-efficacy. During this phase, the problem behavior is thought to be resolved, and the original behavior is no longer a part of the individual’s thought process.
Motivational Interviewing (MI)
It is a common misconception that MI is based on the TTM. However, both theories were developed in the 1980’s (Miller & Rollnick, 2009). According to Miller and Rollnick (2009), development of the TTM helped to create the understanding that most people in treatment are not yet committed to change and debunked the myth that patients lack the motivation needed for change. While the TTM was not the basis for the development of MI, the TTM provides the conceptual model of understanding change processes, which is essential for applying MI. MI can be used as an intervention for patients in each of the TTM stages of change (Miller & Rollnick, 2002).
Elements
There are four elements that are interrelated and are the core of MI. This includes partnership, acceptance, compassion, and evocation. Each of these four elements has an experiential and behavioral component. The first element is partnership. Partnership involves mutual respect and awareness, which represents the collaborative process between the patient and the provider. Acceptance involves four additional concepts including: absolute worth, autonomy, accurate empathy, and affirmation. Absolute worth involves valuing and understanding the worth as well as the potential of every human. Accurate empathy includes actively attempting to understand another person’s perspective and understanding an individual’s personal perspective. Autonomy support involves recognizing, respecting, and valuing another persons right as well as ability to self-direct. The final component of acceptance is affirmation, which includes acknowledgement of an individual’s strengths, work, and effort. Compassion is a new core element in the latest editions of MI texts. Compassion involves putting an individual’s needs before your own and to promote a person’s welfare. Evocation involves activation of an individual’s own resources and motivation for change (Miller & Rollink, 2013; Rollnick et al., 2008).
Processes
Engaging, focusing, evoking, and planning are the four processes of MI. Each of these four processes overlap but also typically emerge in sequence and build on each other. Engagement occurs at the start of a therapeutic relationship and is the establishment of a connection and a working relationship. Engagement leads to focusing, which involves the development and maintenance of direction when talking about change. Focusing clarifies direction and reveals goals for change. Once goals are identified, the third process of MI, evoking is initiated. Evoking involves the utilization of the client’s ideas and feelings about change as well as eliciting the patient’s own personal motivation for changing. Evoking, or the process of drawing out an individual’s motivation for change, is considered the centerpiece of MI. Planning is the final process of MI and includes both fostering a commitment to changing behavior as well as creating a plan to accomplish behavior change. Using open ended questions, affirming, reflecting, summarizing, as well as providing information and advice with permission are the communication skills that MI practitioners use along with the processes of MI to assist patients to change their behavior (Miller & Rollnick, 2013).
Guiding Principals
MI is based on four guiding principles. Resisting the righting reflex is the first of these four principles and involves the natural inclination that health practitioners have to tell those who are engaging in unhealthy behaviors to stop. This natural inclination can have the opposite effect as humans, especially those who are ambivalent about needed change, have a natural tendency to resist persuasion. The second principle is understanding what motivates the patient because behavior change is more likely when working within an individual’s personal motivations. Listening to the patient is another guiding principle of MI. MI is based more on listening and understanding individual patients than the provision of information. Empowerment is the final principle of MI and involves assisting patients to explore how they can change their own behavior to improve their health (Rollnick et al., 2008).
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Motivational Interviewing for Smoking Cessation 