Motivational Interviewing 4th Edition: What's New?

Drs. Bill Miller and Steve Rollnick have published a new edition of their bestselling psychotherapy book, Motivational Interviewing. Similar to past editions, this is not just a minor update. Every time that Miller and Rollnick revise their work, they seem to sit down with a blank screen and start to explain their method from scratch, resulting in a completely new book about motivational interviewing. So what's in the new version?

One update in the 3rd edition was the introduction of 4 "tasks" of motivational interviewing: engaging, focusing, evoking, and planning. In the new 4th edition, these tasks have become the overarching structure of the book, with a chapter on each one. Other frameworks, like the "MI micro-skills" of OARS (open-ended questions, affirmation, reflection, summarizing) are subsumed into the four tasks (OARS is in the "evoking" chapter now). The new book flows in a way that prior editions didn't always -- they more often had collections of lists, catchy acronyms, tables, etc., but they could end up feeling disjointed. The fourth edition is more like listening to a wise old mentor reflect on their work. Miller says that they were aiming this time for "the simplicity on the other side of complexity." In that way, the book is a delight to read, especially if you already know something about MI. I do wonder, though, if all of the acronyms and lists of techniques were more helpful to someone who is just learning MI for the very first time. The details don't stand out as clearly in this presentation format as they did in the 3rd Ed.

With 13 years having passed since the prior edition, the book includes a wealth of new research citations. A chapter on MI research near the end now includes several "summaries of summaries" on MI (I guess there have been enough meta-analyses already!) and Miller reports that this approach is now supported by more than 2000 randomized controlled trials. Here's one from 2017 by Carlo DiClemente. As I like to tell MI trainees, that level of research support likely makes it the best-documented medical intervention in history. There's also a nice new list of citations on MI with diverse populations, including various Asian groups, Black people, Native American clients, and Latinx populations, showing the cross-cultural applicability of MI. 

In the area of theory, I have argued that Two Minds Theory offers an explanation for MI's effects. But I'm in good company, as Miller used the new book to continue his tradition of not endorsing any single theory as an explanation for why MI works. He reiterates the story of MI's atheoretical development -- in this telling, it came from a meeting of Norwegian therapists reflecting on their practice, when previously he has said he learned it from his patients. And he draws connections to many different theories across the field of psychology: the transtheoretical model, theory of planned behavior, self-efficacy, self-determination theory, Rogerian psychotherapy, constructivism, evolutionary psychology, Gestalt therapy, attachment theory, behavioral family therapy, self-management theory, and the decisional balance approach to decision making (and I have probably missed some). True to form, Miller says that all of these and none of these are probably true. Throughout the book, pull-out boxes labeled "for therapists" and "personal perspective" let the authors reflect on MI as a mature approach in the context of the rest of the field of psychology.

On the other hand, the authors take pains to identify four things that are not MI: The stages of change, the decisional balance exercise, motivational enhancement therapy (MET, which Rollnick developed as a brief adaptation of MI to facilitate other therapies), and Rogerian therapy. Over the years various people have claimed that MI is identical to one or another of these things, and one gets the sense that the method’s creators are tired of these arguments. MI has also sometimes been summarized as just a "common factors" approach to therapy, and the authors take pains to comment on what's unique about their approach, and the fact that it's an active approach to helping, not just listening.

There are some minor terminology changes throughout, although none as large as the removal of the word “resistance” (as in “roll with resistance,” a key principle of MI), which happened for the first time in the 3^rd edition. Now, as in the prior book, resistance is called “sustain talk” to avoid pathologizing it – talking about reasons one might not want to change is just part of the process of change. Miller also now explicitly disavows the concept of MI as “psychological jujitsu” that he put forth in earlier editions, writing that MI is a journey taken with clients rather than a sparring match against them. The word “partnership” has also been added to the ACE acronym for the spirit of MI (acceptance, compassion, empowerment), making it PACE instead. All of this seems entirely consistent with the view of MI as a relationship not a technique – and yet, as with some of the other changes, I wonder if it makes the approach more opaque to new learners looking for tools.

The examples in the 4^th Edition are now mostly focused on health behavior change, a big shift from the first two editions where addictions were the typical example. Alcohol and drug problems are still included, but they take up much less room in the examples and discussion, reflecting the wide range of health care settings in which MI is now routinely used. Addiction topics make their strongest appearance in a section on “conflicting goals,” where Miller talks about clients who say they want to participate in treatment but at some level don’t really want that, because the impetus for making a change is really someone else’s agenda. Working with this type of “unmotivated client” is where MI began, even though it now has a vastly broader scope. In a section on ethics, Miller also gives updated examples of when not to use MI, reflecting his own experiences of problematic areas where people have asked him for advice. For instance, sales, organ donation, or consenting to be in a research study are all domains where someone should be free to make decisions without undue influence. Other topics like COVID vaccination and parenting are presented as areas for discussion, where experts might disagree about the ethics of using MI to promote behavior change. Miller is even more clear in this edition that MI is a directive technique, and in fact he recommends against using a free-form list of pros and cons on decision-making because it may have the unintended effect of working against change.

I was very interested by the newly introduced idea of high versus low levels of “experiencing” in language, which can be used as a diagnostic tool – for instance, “I will be there on Tuesday at 9” is more experiential than “I will try to get there pretty early.” Miller cites Eugene Gendlin for this idea, but I think that it was first expressed by Albert Mehrabian in his 1968 book Language within Language, where he called this same concept “immediacy.” Jay Efran and I cited it in a 1994 book chapter about using language as a diagnostic tool in constructivist psychotherapy.

On no single theme, here's a grab-bag of thoughts and pithy quotes from the new edition. Many of these I definitely plan to incorporate into my own MI training activities:

• On the time required to do MI: “if you act and feel like you only have a few minutes, it may take all day; if you feel and act as though you have all day, it may only take a few minutes.” (pp. 27-28)
• On engagement: try a “rapid engagement” technique, where for the first 20% of your time with someone you do nothing but reflect and allow them to tell their story, which might make the rest of the session go much faster and smoother.
• On letting the client’s ambivalence do the work: “when someone is ambivalent, a decisional balance is already in motion.” (p. 83)
• On the importance of understanding a client’s values: “one way to think about how MI works, then, is that it triggers self-regulation by enhancing awareness of current behavior, and judgment about its acceptability in relation to important personal values.”
• The interviewer can sometimes prompt movement by “lending change talk,” extending the client’s latest statement into something about change that they could have said or thought, even though they didn’t do it yet (also called “continuing the paragraph,” this amounts to a change-focused generous understanding – or even a deliberate therapeutic misunderstanding - of what point the client was driving towards).
• Planning can sometimes be unnecessary, when a properly motivated client says “I can take this from here.” Other times it is important because the client isn’t sure of the way. There is a risk of backsliding in either case, if the interviewer jumps in too soon with their own preferred solutions.
• Clients can have “embedded change talk” without appearing strongly interested in change. For example, a question about vaccine safety (even a hostile-seeming one) can suggest openness to a conversation. Skillful choice of what to respond to (what Miller in this edition calls “directional reflection,” e.g., “you would be interested in learning more”) can move the conversation quickly from an offer to argue into a genuine discussion about change.
• Miller also talks about “vertical ambivalence,” reflecting on his own experience uncovering unconscious motivations in psychodynamic therapy. This is the psychodynamic idea that the client may have goals or beliefs that aren’t available to their own conscious mind. It’s new to the MI literature, I think, but definitely compatible with Two Minds Theory’s claim that a lot of our actions happen for nonconscious reasons.
• The book now includes a section defining the “MI-consistent” target behaviors that are counted in research using the MITI coding scale, and a couple of pages on using MI in groups (once its own separate book), that are likely to be useful to researchers as well as clinicians.
• The “elicit-provide-elicit” technique for delivering patient education is now framed in simpler terms as “ask-offer-ask” (ASA), although it is still basically the same approach.

I enjoyed Miller’s story about a behaviorist mentor, Gerald Patterson, who talked about theory and technique, but in practice was fully present with clients and seemed to do much of the work through his relationship skills. It reminded me of my own experience watching another cognitive-behavioral expert, Aaron Beck, doing psychotherapy.

·       This edition is also maybe the first time that I have seen MI’s originators describe the way in which doing MI lets helpers “lay down the burden” of having to come up with solutions to everyone’s problems. I have told trainees for years that MI is not only the best research-supported way to help clients change, it is also an antidote to burnout. I was happy to see the same observation in this latest edition of the MI textbook.

Finally, I particularly liked the idea of the MI practitioner being focused on the present moment, but with one eye toward the horizon – a way of talking about the skill of being fully present and listening to a client, while also having some flywheels spinning in the background, analyzing what’s going on and where to push just a little in order to build up momentum for change.