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TMT as a Theory of Motivational Interviewing


William Miller and Stephen Rollnick’s motivational interviewing (MI) is an approach to conversations that promotes behavior change. Its creators define MI as “a method for exploring and resolving ambivalence.” This method is undeniably effective in promoting behavior change, even among people who don’t initially want to change — MI is supported by over 100 randomized controlled trials with a wide range of problematic behaviors. But why MI is helpful remains an open question. Miller has identified a set of principles underlying the method, and Rollnick suggested that a newer model called self-determination theory might explain why MI works. But at its heart the approach is atheoretical, a set of techniques that works rather than a methodology derived from theory. Miller says that he developed MI in an early practice experience when everything he learned in school had failed, and he stopped to ask the substance abuse patients he was supposed to be treating what he could do that would be most helpful to them. In other words, MI is something that he learned from his patients.

Although MI clearly has been successful without any theory, it is still interesting to consider why this approach works. Miller proposed two pathways by which MI might exert effects on behavior, later referred to as the "technical hypothesis" and the "relational hypothesis." The technical hypothesis says that MI has its effects because counselors use specific skills (e.g., open-ended questions, reflective listening statements, the elicit-provide-elicit method of education) and avoid others (e.g., closed questions, giving direct advice). This hypothesis was supported by a recent meta-analysis that found counselors' use of MI skills was related to greater behavior change. The relational hypothesis, on the other hand, says that counselors' adherence to the "spirit" of MI (e.g., counselors' level of acceptance, egalitarianism, empathy, genuineness, and warmth) is what predicts positive outcomes. This hypothesis has also been supported by previous process studies and in a 2010 meta-analysis that found counselors' level of MI-consistent skills did not predict outcomes. The 2018 meta-analysis, although primarily supporting the technical hypothesis, also did find indirect evidence for relationship variables as moderators of skill-based effects.

From the perspective of two minds theory, MI is conducted as a conversation about past or future behavior and therefore clearly engages the Narrative System. Neurocognitive research shows that the brain areas involved in the Narrative System are highly proficient at tasks involving "social imagination" or "mentalizing," which is humans' ability to predict what other people might be thinking. Although other brain regions may be involved (e.g., the amygdala in producing fear responses related to social judgment), the prefrontal cortex seems central to the perception of what others are thinking -- and, we have argued elsewhere, is central to the ability to create Narratives. What is specifically social about the narratives produced in motivational interviewing? First, MI is itself a social exercise, in which a client is encouraged to explore the positive and negative aspects of some behavior and to talk about whether he or she wants to change that behavior. Doing so in front of another person (the counselor) naturally prompts the client's Narrative brain to wonder what the therapist is thinking -- a process that might have been called "transference" in earlier approaches to counseling. Second, in MI the counselor gives feedback through the use of targeted questions or reflective statements; as Miller argues, it is a directive technique in which the counselor is actively steering the conversation. The direction of the conversation gives the client additional clues on which to construct a social narrative. Finally, although MI is not specifically a social imagination technique, many of the prompts used in MI do have a social component: "what do other people say about this behavior?" "what might you tell a friend in this situation?" or "how can I help you?" are all good open-ended questions that can be used to prompt change talk, and all have a social component. The role of social imagination in crafting compelling narratives may help to explain the relational or "spirit" component that helps MI work.

What about the technical components of MI -- for instance, using open-ended versus closed questions? Although research is inconsistent and the required levels of adherence to MI techniques may not be as high as is commonly presumed (see Table 2 in our glaucoma MI study for details), the 2018 meta-analysis does show an important role for techniques. We suggest that using MI techniques shortcut some of the barriers to change that would ordinarily arise from the Intuitive System. First, Miller describes MI as non-confrontational and collaborative, which helps to avoid psychological reactance -- people's inherent objection to being told what to do. The more a person perceives him- or herself to be making a free choice, the less objection there is to making a change in behavior. MI techniques promote that sense of free choice. Second, we suggest that MI's focus on collaboration and empathy is facilitated specifically by the use of reflective listening statements. Reflection is a form of behavioral "mirroring" that creates a sense of connection between people; this same process is involved in the development of empathy in infants. Once a connection is established, fear responses may be suppressed and willingness to experiment with new behaviors may in turn be higher. Third, we suggest that the MI technique of affirmation helps to elicit clients' sense of themselves as capable and successful. A focus on clients' strengths in MI may increase their use of positive coping strategies (e.g., approach rather than avoidance), which in turn enables them to make changes in their behavior. Finally, the goal of eliciting client change talk related to potential solutions, which is generally more positive and future-focused than sustain talk about problems, may lead to better outcomes. It is even possible that engaging in change talk about a problem produces a different physiological response at the Intuitive System level, for instance the hormonal and neurocognitive responses involved in the "tend and befriend" response to stress, as opposed to the more commonly known alternative "fight or flight" stress response that might be triggered by problem-focused sustain talk.

There is plenty of room for more research on why motivational interviewing works, and there is at this point little question that the approach is helpful across a wide range of problem behaviors. Knowing more about the Narrative and Intuitive systems might help us to fine-tune our MI skills, and to capitalize on strengths like social imagination and the Intuitive-system capacity for empathy. As suggested on our interventions page, MI can also be usefully integrated with other techniques that work with people's two minds in different ways. We remain great admirers of MI as a method for health behavior change, and hope that TMT can enhance and help to explain this approach.

For our online motivational interviewing courses, see https://www.regonline.com/cumotivate

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