Lesson 5 – Motivational Interviewing
1. Introduction
Motivational Interviewing is a collaborative communication approach designed to help people explore uncertainty about change and strengthen their own motivation for making changes that matter to them.
It is particularly relevant to mental health practice because patients are not always ready to make the changes that professionals believe might help them.
A person may understand that alcohol is affecting their mental health but still feel reluctant to reduce their drinking. Someone may recognise that avoiding social situations is increasing their isolation but feel frightened about changing this pattern. A patient may be uncertain about starting medication, attending therapy, improving their sleep routine or making changes to their lifestyle.
In these situations, repeatedly telling someone what they should do is often ineffective.
The more strongly we argue for change, the more likely the person may be to explain why change is difficult or why they are not ready.
Motivational Interviewing offers a different approach.
Rather than asking:
"How can I convince this person to change?"
we begin to ask:
"How can I help this person explore their own reasons for change?"
This distinction is central to the approach.
Why This Topic Matters
Ambivalence is a normal part of behaviour change.
People can genuinely want two conflicting things at the same time.
Someone might say:
"I know cannabis makes my anxiety worse, but it is also the only thing that helps me relax."
Both parts of that statement may be true from the patient's perspective.
A practitioner could respond by explaining all the reasons why the patient should stop using cannabis. However, this risks creating an argument in which the practitioner argues for change while the patient argues against it.
A Motivational Interviewing approach would instead explore both sides:
"Part of you is worried about what cannabis is doing to your anxiety, but another part feels that it is helping you cope."
The aim is not to force the patient towards a particular answer.
It is to help them understand their own ambivalence.
Motivation Is Not Something a Patient Either Has or Does Not Have
Patients are sometimes described as being "unmotivated".
This can be misleading.
A person who repeatedly misses appointments may be frightened about what will happen during them.
Someone who continues drinking despite harmful consequences may desperately want their life to improve but feel unable to imagine coping without alcohol.
Someone who does not take medication may have concerns about side effects that they have never felt comfortable discussing.
Instead of asking:
"Why won't this person engage?"
a more useful question may be:
"What is making engagement difficult for them?"
This shift from judgement to curiosity is an important part of Motivational Interviewing.
The Spirit of Motivational Interviewing
Motivational Interviewing is not simply a collection of communication techniques.
It is based on a particular way of working with people.
The approach emphasises:
Partnership – working with the patient rather than positioning ourselves as the person who has all the answers.
Acceptance – respecting the person's autonomy and recognising that decisions ultimately belong to them wherever they have the capacity and freedom to make them.
Compassion – keeping the person's wellbeing at the centre of the conversation.
Evocation – helping the person identify their own motivations, values, strengths and reasons for change.
These principles are sometimes collectively described as the spirit of Motivational Interviewing.
Without this collaborative attitude, techniques associated with Motivational Interviewing can easily become another way of trying to persuade someone.
The Righting Reflex
Healthcare professionals naturally want to help.
When we see a problem, our instinct is often to fix it.
A patient says:
"I'm only sleeping four hours each night."
We immediately want to explain sleep hygiene.
A patient says:
"I keep forgetting my medication."
We want to suggest reminders.
A patient says:
"I know I need to exercise more."
We start discussing exercise plans.
This instinct is understandable and often well intentioned. In Motivational Interviewing it is sometimes referred to as the righting reflex.
The difficulty is that we may begin offering solutions before we understand the person's perspective.
The patient may already know what they are "supposed" to do.
The difficulty may be that they are not yet ready, do not believe the change is achievable or have competing reasons for continuing their current behaviour.
Motivational Interviewing teaches us to resist the immediate urge to correct and instead become curious.
Change Talk
One of the central concepts within Motivational Interviewing is change talk.
Change talk refers to statements from the patient that suggest movement towards change.
For example:
"I don't want to keep feeling like this."
"I'd probably have more energy if I drank less."
"My relationship would be better if I could control my temper."
"I think I could manage one appointment a week."
These statements are important because the patient is providing their own reasons for change.
The practitioner can explore and strengthen these statements rather than immediately adding their own arguments.
Autonomy Matters
Motivational Interviewing recognises that sustainable change is difficult to impose from outside.
We can provide information.
We can explain risks.
We can make recommendations.
We can offer support.
But in many situations, the patient ultimately decides what they will do.
Acknowledging this can actually make conversations about change easier.
For example:
"It is completely your decision whether you make this change. Would it be helpful if we explored what you see as the advantages and disadvantages?"
This reduces the sense of confrontation and allows a more honest discussion.
Respecting autonomy does not mean ignoring risk or withholding professional advice. Safeguarding responsibilities, capacity considerations and significant risks still require appropriate clinical action.
Motivational Interviewing Is Not Manipulation
A common misunderstanding is that Motivational Interviewing is a technique for persuading patients to do what professionals want.
It is not.
The practitioner should not secretly decide what the patient must choose and then use communication techniques to steer them towards that decision.
The aim is to help the person explore their own motivations and make informed decisions.
Sometimes the patient may decide that they are not ready to change.
That does not necessarily mean the conversation has failed.
Understanding their ambivalence may itself be an important step.
How This Fits Into the Course
Motivational Interviewing brings together many of the communication skills developed throughout Part 2 of this course.
Building rapport creates the trust necessary for honest conversations about change.
Active listening allows us to hear both the reasons someone wants to change and the reasons they are reluctant.
Empathy and validation allow us to acknowledge that change can be genuinely difficult.
Effective questioning helps people explore their motivations, values and concerns.
Motivational Interviewing combines these skills into a structured but collaborative approach to conversations about change.
It also connects with principles introduced earlier in the course, particularly recovery-oriented and psychologically informed care. Rather than assuming that professionals should direct every decision, we work alongside people to understand what matters to them and support their autonomy.
What This Lesson Will Cover
Throughout this lesson, we will explore the practical principles of Motivational Interviewing, including:
the spirit of Motivational Interviewing
partnership, acceptance, compassion and evocation
the righting reflex
ambivalence about change
the OARS communication skills
open questions
affirmations
reflective listening
summaries
recognising change talk
responding to sustain talk
exploring importance and confidence
providing information without lecturing
supporting autonomy
knowing when Motivational Interviewing is appropriate
recognising when immediate clinical or safeguarding action takes priority
The aim is not for assistant practitioners to become specialist Motivational Interviewing therapists after one lesson.
Instead, the goal is to develop a Motivational Interviewing-informed communication style that can be incorporated into ordinary clinical conversations.
The central principle is:
People are often more persuaded by the reasons for change that they discover themselves than by the reasons we give them.
Our role is therefore not always to provide the argument.
Sometimes our most useful role is to create the conversation in which the patient begins making that argument for themselves.
2. Learning Outcomes
By the end of this lesson, learners should be able to:
Explain the purpose and core principles of Motivational Interviewing and describe how it differs from persuasion, confrontation and advice-giving.
Recognise ambivalence as a normal part of behaviour change and explore competing reasons for changing and remaining the same without judgement.
Apply the core OARS communication skills of open questions, affirmations, reflective listening and summaries within everyday clinical conversations.
Recognise and respond appropriately to change talk and sustain talk, helping patients explore their own reasons, confidence and readiness for change.
Identify the righting reflex and use collaborative approaches to providing information, advice and recommendations whilst respecting patient autonomy.
Recognise the limits of a Motivational Interviewing approach and identify situations where immediate concerns about risk, safeguarding, capacity or significant clinical deterioration require appropriate escalation and senior clinical involvement.
3. The Lecture
Motivational Interviewing becomes particularly useful when you find yourself having the same conversation with a patient repeatedly.
You have explained why reducing alcohol would help.
You have discussed the importance of taking medication consistently.
You have encouraged them to attend therapy.
You have explained why their sleep routine matters.
They understand everything you have said.
And nothing changes.
At this point, our instinct is often to explain it again, perhaps more strongly.
Motivational Interviewing asks us to do something different.
Instead of giving the patient more reasons to change, we become interested in their reasons.
That is the central shift we will explore throughout this lesson.
What Is Motivational Interviewing?
Motivational Interviewing is a collaborative communication approach that helps people explore their own motivation for change.
It is particularly useful when someone feels ambivalent.
Ambivalence means having competing feelings about something.
A patient might say:
"I want to stop drinking, but alcohol is the only thing that helps me switch off."
Or:
"I know therapy might help, but I really don't want to talk about everything."
Or:
"The medication helps my concentration, but I don't like how I feel when I take it."
These patients are not necessarily refusing help.
They are describing two sides of a genuine dilemma.
Motivational Interviewing helps us explore both.
The Spirit of Motivational Interviewing
Before learning techniques, it is important to understand the attitude behind the approach.
Four principles are particularly important:
Partnership
Acceptance
Compassion
Evocation
These principles influence the whole conversation.
Partnership
Motivational Interviewing is something we do with a patient rather than to them.
The practitioner brings clinical knowledge.
The patient brings expertise about their own life.
For example, you may know that regular exercise can improve wellbeing.
The patient knows whether exercise feels achievable when they are working long hours, caring for children and struggling with depression.
Both forms of knowledge matter.
Acceptance
Acceptance includes respecting the person's autonomy.
Where a patient has the capacity and freedom to make a decision, they may make choices that differ from our recommendations.
We can advise.
We can explain.
We can explore consequences.
But repeatedly arguing with someone rarely increases their motivation.
Acknowledging autonomy may actually reduce resistance.
For example:
"Ultimately, whether you reduce your drinking is your decision. Would it be useful to look at what you like about drinking and what concerns you about it?"
Compassion
Motivational Interviewing should be used in the patient's interests.
The aim is not to manipulate somebody into making the decision we prefer.
We remain focused on their wellbeing, values and goals.
Evocation
Evocation means drawing out what is already within the person.
Instead of assuming:
"I need to give this patient motivation."
we ask:
"What reasons for change does this person already have?"
The difference is subtle but important.
The Righting Reflex
Healthcare professionals are trained to identify problems and respond to them.
This creates a natural righting reflex.
We see something going wrong and immediately want to correct it.
Patient:
"I barely exercise anymore."
Practitioner:
"You should start walking for 30 minutes every day."
Patient:
"I don't have time."
Practitioner:
"Even 20 minutes would help."
Patient:
"I'm exhausted after work."
Practitioner:
"You could exercise before work."
Patient:
"I'm not getting up earlier."
Notice what has happened.
The practitioner is arguing for change.
The patient is arguing against change.
The stronger the practitioner pushes, the more the patient practises explaining why change is impossible.
A Motivational Interviewing approach might sound different.
Patient:
"I barely exercise anymore."
Practitioner:
"How do you feel about that?"
Patient:
"I don't like it. I used to feel much better when I exercised."
Practitioner:
"What was different when you were exercising regularly?"
Patient:
"I had more energy and probably slept better."
Now the patient is providing the reasons for change.
Resist the Urge to Fix
This does not mean withholding useful advice.
It means understanding before advising.
Before providing a solution, consider:
Does the patient already know this?
Have I understood what is stopping them?
Are they actually asking for advice?
Sometimes the patient knows exactly what they need to do.
The difficulty lies elsewhere.
Ambivalence Is Normal
We sometimes interpret ambivalence as resistance.
It is usually more helpful to view it as a normal part of change.
Consider someone thinking about stopping cannabis.
They may recognise:
Reasons to stop
Better concentration.
Less anxiety.
Saving money.
Improved relationships.
But they may also recognise:
Reasons to continue
It helps them relax.
Their friends use it.
They enjoy it.
They worry about coping without it.
If we only discuss the reasons to stop, we ignore half of the patient's experience.
A more useful conversation explores both sides.
"What do you enjoy about using cannabis?"
Then:
"And what are the things you like less about it?"
This is not encouraging cannabis use.
It is creating an honest conversation about ambivalence.
OARS: Four Core Communication Skills
A useful framework within Motivational Interviewing is OARS.
OARS stands for:
O – Open questions
A – Affirmations
R – Reflections
S – Summaries
These should already feel familiar because they build directly on the communication skills covered earlier in this course.
Open Questions
Open questions encourage exploration.
Instead of:
"Do you want to stop drinking?"
try:
"How do you feel about your drinking at the moment?"
Instead of:
"Are you worried about your medication?"
try:
"What concerns do you have about taking the medication?"
Useful Motivational Interviewing questions include:
"What would you like to be different?"
"What concerns you about things continuing as they are?"
"What might be good about making this change?"
"What makes changing difficult?"
"What would need to happen for you to feel ready?"
The purpose is exploration rather than interrogation.
Affirmations
Affirmations recognise strengths, effort or values.
They are not generic praise.
Saying:
"Well done."
may be pleasant but tells us relatively little.
A more meaningful affirmation might be:
"You've kept attending appointments even though talking about this has been difficult."
Or:
"It sounds as though you've put a lot of thought into how this affects your family."
Or:
"You managed to reduce your drinking for three weeks before, so you already know that you can make changes when the circumstances are right."
Affirmations can help people recognise strengths that they may overlook.
They should always be genuine.
Reflective Listening
Reflection is central to Motivational Interviewing.
A reflection takes what the patient has said and returns the meaning to them.
Patient:
"Everyone keeps telling me to stop smoking cannabis, but nobody understands that it's the only time my mind slows down."
Simple reflection:
"Cannabis helps your mind feel quieter."
More complex reflection:
"People are focusing on the problems cannabis might be causing, but from your perspective it is also doing something important for you."
The second reflection captures more of the underlying dilemma.
This can encourage deeper exploration.
Summaries
Summaries bring together important parts of the conversation.
For example:
"So part of you enjoys drinking because it helps you relax socially. At the same time, you're worried about the arguments with your partner and you've noticed that your mood is worse the following day. You're not sure whether you want to stop completely, but you are beginning to wonder whether something needs to change."
A good summary helps the patient hear their own ambivalence clearly.
It also allows them to correct your understanding.
Change Talk
Change talk is language suggesting movement towards change.
It may involve wanting change:
"I'd like to stop relying on alcohol."
Reasons for change:
"I'd probably have more energy if I drank less."
Ability:
"I managed to stop for a month last year."
Need:
"I can't keep going like this."
Commitment:
"I'm going to speak to the alcohol service."
These statements are clinically important.
When you hear change talk, do not immediately move on.
Explore it.
Patient:
"I think I'd sleep better if I stopped using cannabis at night."
Practitioner:
"What makes you think your sleep might improve?"
The patient is now invited to develop their own argument for change.
DARN-CAT
A more detailed framework for recognising change talk is DARN-CAT.
D – Desire
"I want to feel healthier."
A – Ability
"I think I could reduce it."
R – Reasons
"I'd save a lot of money."
N – Need
"Something has to change."
These can develop into stronger commitment language:
C – Commitment
"I'm going to cut down."
A – Activation
"I'm ready to start."
T – Taking steps
"I didn't buy any alcohol yesterday."
You do not need to label these categories during a conversation. The framework simply helps you recognise language suggesting movement towards change.
Sustain Talk
Patients will also give reasons for maintaining their current behaviour.
This is called sustain talk.
Examples include:
"Drinking is how I socialise."
"I don't think medication is worth it."
"Therapy isn't going to change anything."
Do not argue with sustain talk.
If you respond:
"But therapy has been shown to work."
the patient may reply:
"Not for me."
You have created an argument.
Instead, reflect:
"At the moment you're not convinced therapy would make enough difference to justify going through it."
This communicates understanding.
You can then continue exploring.
Do Not Label Patients as Resistant
The word "resistant" can encourage us to see the patient as the problem.
Sometimes apparent resistance is actually a response to how the conversation is being conducted.
If the patient becomes increasingly defensive, consider:
Am I pushing too hard?
Am I arguing for change?
Have I understood their concerns?
Am I giving advice they did not ask for?
Changing our own approach can sometimes change the conversation.
Exploring Importance
A patient may recognise that change would be helpful but not see it as particularly important.
One useful approach is an importance scale.
Ask:
"On a scale from 0 to 10, where 0 means this isn't important at all and 10 means it is extremely important, how important is it for you to make this change?"
Suppose they answer:
"Six."
A particularly useful follow-up is:
"Why a six rather than a three?"
Notice the direction of the question.
It encourages the patient to explain why change matters.
If you ask:
"Why only a six?"
you may encourage them to explain why change does not matter.
Exploring Confidence
Importance and confidence are different.
Someone may think stopping smoking is extremely important but have little confidence that they can do it.
You can ask:
"On a scale from 0 to 10, how confident are you that you could make this change if you decided to?"
If they answer four:
"What makes it a four rather than zero?"
This can identify strengths.
Then:
"What might help move it from four to five?"
This begins to identify practical support.
Looking Back
Past success can help strengthen confidence.
Ask:
"Have there been times when you managed this differently?"
"What was different then?"
"What helped?"
Someone who reduced their drinking previously may already possess useful strategies.
The aim is to help them rediscover those resources.
Looking Forward
Future-focused questions can help patients connect change with their goals.
For example:
"If things continued exactly as they are for another year, how would you feel about that?"
Or:
"If you did make this change, what might be different six months from now?"
These questions can help make the consequences of changing or not changing more concrete.
Values and Goals
Motivation becomes stronger when behaviour change connects with something personally meaningful.
A patient may not be motivated by:
"You should exercise because it improves cardiovascular health."
They may care deeply about:
"I want enough energy to play football with my children."
Explore what matters.
Questions might include:
"What is most important to you at the moment?"
"What kind of parent would you like to be?"
"What would you like your life to look like in a year's time?"
Then explore whether current behaviour is moving them towards or away from those goals.
Developing Discrepancy Carefully
Motivational Interviewing can help patients notice differences between what they value and what is currently happening.
For example:
Patient:
"Being reliable for my children is the most important thing to me."
Later:
"I've missed picking them up from school twice because I'd been drinking."
You do not need to confront them aggressively.
You might reflect:
"Being dependable for your children really matters to you, and you're also noticing that drinking has sometimes got in the way of that."
Allow the patient to respond.
The discrepancy belongs to them.
Giving Advice: Ask Before You Tell
Motivational Interviewing does not mean that clinicians never provide information.
Patients need accurate clinical advice.
A useful approach is Ask–Offer–Ask.
First ask:
"Would it be alright if I explained what we know about alcohol and sleep?"
Then provide concise information.
Afterwards ask:
"What do you make of that?"
This turns information giving into a conversation.
Elicit–Provide–Elicit
A related approach is Elicit–Provide–Elicit.
First elicit what the patient already knows:
"What have you heard about how cannabis can affect anxiety?"
Then provide relevant information:
"Would it be okay if I added a little to that?"
Give clear, neutral information.
Then elicit their response:
"How does that fit with your own experience?"
This avoids giving lengthy explanations about information the patient may already know.
Avoid the Information Dump
When practitioners become concerned, we sometimes respond by providing increasing amounts of information.
More information does not necessarily produce more motivation.
If the patient is ambivalent about medication, giving them a ten-minute lecture about medication may simply overwhelm them.
Provide information in manageable amounts.
Then check:
"What are your thoughts about that?"
When the Patient Decides They Want to Change
Once a patient begins showing clear readiness for change, the conversation can move towards planning.
Do not continue exploring ambivalence indefinitely.
Ask:
"What do you think your first step might be?"
Or:
"How would you like to approach this?"
Try to let the patient generate ideas before offering your own.
If they struggle, you can offer options.
"Would it be helpful if we thought through a few possibilities together?"
Make the Plan Specific
A vague intention such as:
"I'll try to exercise more."
may benefit from clarification.
Ask:
"What would that look like this week?"
The patient might decide:
"I'll walk for 20 minutes after work on Tuesday and Thursday."
A specific plan is easier to act upon and review.
Support Self-Efficacy
Self-efficacy refers to someone's belief that they can successfully make a change.
Help patients notice evidence that they are capable.
For example:
"You've already managed three alcohol-free days this week. What helped you do that?"
The focus remains on their abilities rather than your expertise.
If the Patient Is Not Ready
Sometimes the outcome of a Motivational Interviewing conversation is:
"I'm not ready to change."
Do not automatically treat this as failure.
You might respond:
"That's okay. It sounds as though you're not ready to make that change at the moment. Would it be alright if we came back to it another time?"
The conversation may have planted a seed.
Maintaining the therapeutic relationship can be more valuable than winning an argument.
Motivational Interviewing and Medication
Medication conversations are a common place to use these principles.
Patient:
"I don't want antidepressants."
Avoid immediately listing reasons why antidepressants are beneficial.
Explore:
"What concerns you most about taking them?"
Perhaps they are worried about dependency.
Perhaps a family member had side effects.
Perhaps medication feels like admitting they are unwell.
Perhaps they simply prefer another treatment.
Until you understand the concern, you cannot have a meaningful discussion about it.
Motivational Interviewing and Engagement
The same approach can help when someone repeatedly misses appointments.
Instead of:
"You need to attend your appointments."
explore:
"What makes getting to appointments difficult?"
The answer might reveal anxiety, transport problems, forgetfulness, ambivalence about treatment or previous negative experiences with services.
The appropriate solution depends on the actual barrier.
Motivational Interviewing and Lifestyle Change
Motivational Interviewing can be useful when discussing:
physical activity
sleep routines
alcohol
smoking
substance use
diet
medication adherence
engagement with therapy
attendance at appointments
social activity
daily structure
However, remember that not every difficulty is a motivation problem.
Someone may desperately want to attend appointments but have no transport.
Someone may want to exercise but have significant physical limitations.
Someone may want to improve their sleep but live in an unsafe or noisy environment.
Do not use Motivational Interviewing to individualise problems that are actually practical or social.
When Motivational Interviewing Is Not Enough
Motivational Interviewing is not appropriate as the sole response to every situation.
Imagine a patient says:
"I've taken an overdose and I'm starting to feel sleepy."
This is not the moment to explore how important seeking treatment feels on a scale from 0 to 10.
Immediate safety takes priority.
Similarly, significant concerns involving:
immediate suicide risk
serious self-harm
acute intoxication
severe mental state deterioration
significant psychosis or mania
safeguarding concerns
serious risk to others
urgent physical health problems
require appropriate clinical action.
Therapeutic communication remains important, but it must not delay necessary intervention.
Working Within Your Competence
Assistant practitioners can use Motivational Interviewing-informed communication during ordinary patient interactions.
However, this does not mean independently managing complex substance dependence, severe eating disorders, high-risk behaviour or other specialist clinical problems.
If the conversation reveals concerns outside your competence, involve the appropriate senior clinician.
Knowing when to stop exploring and escalate is part of safe practice.
A Practical Motivational Interviewing Conversation
Imagine a patient who is drinking heavily.
Instead of beginning with advice, the conversation might develop like this:
Practitioner: "How do you feel about your drinking at the moment?"
Patient: "I know it's probably too much, but it helps me relax."
Practitioner: "So it gives you something you value, but you're also beginning to wonder whether it's become too much."
Patient: "Yes. My partner keeps complaining about it."
Practitioner: "What concerns you personally about it?"
Patient: "I'm exhausted every morning and I've started being late for work."
Practitioner: "You're noticing that it's beginning to affect things that matter to you."
Patient: "Yes. I can't keep turning up late."
Practitioner: "If you decided you wanted things to be different, what do you think you might change first?"
Notice what the practitioner has not done.
They have not lectured.
They have not argued.
They have not labelled the patient.
They have helped the patient hear their own reasons for change.
A Simple Structure to Remember
When discussing behaviour change, consider the following sequence:
1. Engage
Build a collaborative relationship.
2. Focus
Agree what change or difficulty you are discussing.
3. Evoke
Explore the patient's own motivations, concerns and reasons for change.
4. Plan
When the patient is ready, help translate motivation into practical action.
These are the four broad processes of Motivational Interviewing.
They are not rigid stages. Conversations may move backwards and forwards between them.
Final Thoughts
Motivational Interviewing requires a subtle change in how we think about helping.
Our instinct is often:
"I can see what needs to change, so I need to explain it clearly enough for the patient to do it."
Sometimes that works.
Often it does not.
Motivational Interviewing asks us to become more curious.
"What does this person want?"
"What matters to them?"
"What are they worried about?"
"What makes change difficult?"
"What reasons for change do they already have?"
"What would help them believe that change is possible?"
This does not remove our responsibility to provide clinical information, make recommendations or respond appropriately to risk.
It changes how we have conversations about change.
The aim is not to win an argument.
The aim is to help the patient explore their own position honestly and move towards change when they are ready.
A useful principle to remember is:
Do not work harder for change than the patient does.
Instead of carrying the argument for change yourself, create the conditions in which the patient can begin identifying their own reasons, strengths and next steps.
That is where sustainable motivation is much more likely to develop.
4. Clinical Perspective
Motivational Interviewing can look deceptively simple. When done well, it often sounds like an ordinary conversation. The practitioner listens carefully, reflects what they hear and asks questions that help the patient think more clearly about change.
The challenge is resisting our natural instinct to solve the problem.
In clinical practice, you will often know more than the patient about the medical consequences of a particular behaviour. You may know that their alcohol use is worsening their mood, that taking medication consistently would probably help or that avoiding every anxiety-provoking situation is maintaining their difficulties.
Knowing this does not necessarily mean that repeating it will change their behaviour.
A useful clinical principle is:
Before trying to increase someone's motivation, understand what is competing with it.
Clinical Pearls
Do Not Work Harder for Change Than the Patient
This is one of the most useful principles to remember.
If you find yourself repeatedly explaining why someone needs to change while they repeatedly explain why they cannot, notice what is happening.
You are arguing for change.
They are arguing for staying the same.
Try changing direction.
Instead of:
"You really need to reduce your drinking."
ask:
"How do you feel about your drinking at the moment?"
Allow the patient to begin doing some of the thinking.
Listen Carefully for Change Talk
Patients often make small statements that indicate motivation.
For example:
"I suppose I would have more money if I stopped smoking."
It is easy to respond:
"Exactly, and smoking is also bad for your health."
But the patient has already provided a reason.
Stay with it.
Ask:
"What difference would having that extra money make?"
You are helping them develop their own reason for change.
Explore What the Behaviour Does for the Person
Problem behaviours usually persist because they serve some function.
Alcohol may reduce social anxiety.
Cannabis may provide temporary relief from distress.
Avoidance may reduce anxiety.
Staying awake gaming may provide social connection.
Repeated reassurance seeking may temporarily reduce uncertainty.
If you understand only the disadvantages of the behaviour, you understand only half of the problem.
Ask:
"What do you get from it?"
This is not approving the behaviour.
It is understanding why change is difficult.
Ambivalence Is Useful Information
If someone says:
"I want to stop, but I'm not ready."
do not immediately focus on the contradiction.
Explore it.
"What makes you want to stop?"
Then:
"And what makes you feel that now isn't the right time?"
Both answers matter.
Confidence Can Be More Important Than Importance
A patient may tell you that changing is extremely important but still do nothing.
The problem may not be motivation.
It may be confidence.
Ask:
"If you decided to make this change, how confident are you that you could do it?"
Low confidence may indicate that the conversation needs to focus on barriers, previous successes and practical support rather than providing more reasons why change matters.
Practical Tips for Everyday Practice
Ask Permission Before Giving Advice
Before launching into an explanation, try:
"Would it be okay if I shared some information about that?"
This small change can make advice feel collaborative rather than imposed.
Once you have provided the information, return the conversation to the patient:
"What do you make of that?"
Find Out What They Already Know
Before explaining something, ask:
"What have you already heard about this?"
You may discover that the patient already understands the information perfectly well.
Their difficulty may be something completely different.
This also prevents lengthy explanations of information they already know.
Use Importance Scales Carefully
Ask:
"On a scale from 0 to 10, how important is making this change to you?"
If they answer six, avoid:
"Why only six?"
That invites reasons against change.
Instead ask:
"Why six rather than three?"
This encourages the patient to identify what already makes change important.
You can then ask:
"What might move it from six to seven?"
Use Confidence Scales
Similarly:
"On a scale from 0 to 10, how confident are you that you could make this change?"
If they answer four:
"What makes it four rather than zero?"
This may reveal strengths.
Then:
"What might help move it to five?"
This may reveal practical solutions.
Ask About Previous Success
People sometimes forget that they have already demonstrated an ability to change.
Ask:
"Have you ever managed to change this before?"
Then explore:
"What helped?"
"What was different then?"
"Is there anything from that experience that could help now?"
This can strengthen self-efficacy.
Keep Goals Small
Once somebody becomes motivated, practitioners can accidentally overwhelm them with a large plan.
A patient says:
"I think I need to become more active."
You do not necessarily need to develop a complete exercise programme.
Ask:
"What feels like a realistic first step?"
Small successful changes can build confidence for larger ones.
Notice Your Own Language
Compare:
"You need to..."
with:
"What do you think might help?"
Compare:
"You should..."
with:
"Would you like to hear some options?"
Compare:
"Why haven't you...?"
with:
"What's made that difficult?"
Small differences in language can significantly change the tone of a conversation.
Common Pitfalls and Misconceptions
Motivational Interviewing Is Not Persuasion
One of the biggest misconceptions is that Motivational Interviewing provides clever techniques for getting patients to agree with professionals.
That is not its purpose.
If you have secretly decided what the patient must choose and are simply trying to guide them towards saying it themselves, the conversation is no longer genuinely collaborative.
Motivational Interviewing Is Not Avoiding Advice
You are still a healthcare practitioner.
There will be situations where patients need clear information and professional recommendations.
The difference is how that information is provided.
You can say:
"Based on what you've described, I am concerned that alcohol is contributing to your low mood. Would it be alright if I explained why?"
You have not withheld your clinical opinion.
You have communicated it respectfully.
Do Not Turn OARS Into a Checklist
You do not need to think:
"I've asked an open question. Now I need an affirmation. Now I need a reflection."
That will make the conversation mechanical.
OARS describes communication skills rather than a script.
Use whichever skill helps the conversation at that moment.
Avoid Empty Affirmations
Statements such as:
"That's amazing!"
can sound artificial if the achievement does not warrant that response.
Affirm something genuine.
For example:
"Even though last week was difficult, you still attended today's appointment."
Specific affirmations are usually more meaningful.
Do Not Praise Every Change
Motivational Interviewing is not about constantly rewarding the patient with approval.
The aim is to help them recognise their own reasons and abilities.
Instead of:
"I'm proud of you for doing that."
consider:
"You decided you wanted to make that change and managed to follow through with it."
The achievement belongs to the patient.
Do Not Argue With Sustain Talk
Patient:
"I don't think therapy will help."
Practitioner:
"But therapy is evidence based."
Patient:
"It didn't help my friend."
Practitioner:
"Everyone responds differently."
Patient:
"Well, I'm still not going."
The conversation has become a debate.
Try:
"You're not convinced that the potential benefit is worth going through therapy at the moment."
Then explore what sits behind that concern.
Do Not Assume Every Failure to Change Is About Motivation
This is particularly important.
Someone may want to change but face genuine barriers.
These might include:
poverty
housing difficulties
caring responsibilities
transport problems
physical illness
cognitive difficulties
executive functioning difficulties
medication side effects
unsafe relationships
limited access to services
Do not use Motivational Interviewing to turn structural or practical difficulties into a problem with the patient's motivation.
Sometimes the correct intervention is practical support.
Advice for Newly Qualified Practitioners
New practitioners often feel that they need to provide an answer whenever a patient describes a problem.
You do not.
Sometimes your most useful contribution is helping the patient think.
If a patient says:
"I know I need to change something, but I don't know what."
You do not necessarily need to immediately provide three suggestions.
Ask:
"What have you already considered?"
You may discover that the patient has several good ideas.
Another common anxiety is that allowing the patient autonomy means you are not doing your job.
It does not.
You can have a clear professional opinion whilst recognising that the patient has their own perspective.
For example:
"From a clinical perspective, I would recommend reducing your alcohol intake because I think it is contributing to your difficulties. Ultimately, the decision about whether you want to make that change is yours. How do you feel about it?"
This is both clinically clear and respectful of autonomy.
When You Feel Frustrated
There will be patients who repeatedly make decisions that you believe are unhelpful.
You may feel frustrated.
Notice that reaction.
Frustration can make practitioners become increasingly directive.
You may start thinking:
"Why won't they just do what we've suggested?"
Try reframing the question:
"What makes this change difficult from their perspective?"
If frustration persists, use supervision.
The aim is not to become indifferent to harmful choices.
It is to prevent your frustration from turning the clinical relationship into a struggle for control.
When the Patient Says "I Don't Know"
Motivational Interviewing contains many reflective questions.
Patients will sometimes respond:
"I don't know."
Do not immediately ask the same question differently five times.
Give them time.
You might reflect:
"You're not sure at the moment."
Or make the question easier:
"What would be your best guess?"
Sometimes the person genuinely does not know.
That is also useful information.
When Someone Is Already Motivated
Do not continue trying to increase motivation when the patient is already ready to act.
Patient:
"I've decided I'm going to stop smoking on Monday."
This is probably not the time for another lengthy exploration of advantages and disadvantages.
Move towards planning.
Ask:
"What do you think will help you make that work?"
Motivational Interviewing should respond to where the person actually is.
When Someone Is Not Ready
Likewise, do not force a plan onto somebody who has clearly said they are not ready.
You might say:
"It sounds as though you're not ready to change this at the moment. Would it be okay if we came back to it in future?"
Maintaining engagement may be more valuable than obtaining superficial agreement.
Situations Requiring Escalation to Senior Clinicians
Motivational Interviewing is useful when there is genuine space for exploring choices.
There are situations where immediate clinical responsibilities take priority.
Seek appropriate senior clinical support when you identify:
suicidal thoughts with significant concerns about intent, planning or immediate safety
significant or escalating self-harm
serious risk of harm to another person
abuse, neglect, exploitation or safeguarding concerns
significant psychosis or mania
severe deterioration in mental state
severe substance dependence or concerns about medically risky withdrawal
significant eating disorder symptoms or physical health compromise
acute intoxication or overdose
serious medication concerns
concerns about the person's capacity to make a particular decision
behaviour presenting immediate safety concerns
any situation that falls outside your competence
Do not allow a Motivational Interviewing conversation to delay necessary clinical action.
If someone has taken an overdose, for example, the priority is urgent medical assessment rather than exploring their motivation to seek treatment.
Autonomy and Risk
Respecting autonomy is central to Motivational Interviewing but autonomy does not remove professional responsibilities.
There may be circumstances where safeguarding, capacity legislation, risk management or other clinical responsibilities require action even when the patient would prefer otherwise.
Where possible, remain transparent.
For example:
"I understand that you don't want anyone else involved. What you've told me makes me concerned about your immediate safety, so I need to discuss this with a senior clinician. I want to be open with you about that."
Compassion, honesty and appropriate escalation can exist together.
A Useful Supervision Question
After a difficult conversation about change, consider asking yourself:
"Who was doing most of the arguing for change?"
If the answer is you, think about how the conversation might have been approached differently.
Could you have asked more?
Reflected more?
Provided less information?
Explored ambivalence?
Allowed more silence?
Asked about the patient's own goals?
This can be a particularly useful discussion during clinical supervision.
Final Clinical Reflection
Motivational Interviewing requires us to tolerate something that healthcare professionals often find difficult:
The patient may understand our advice and still choose not to follow it.
Our response should not automatically be to explain ourselves more forcefully.
Instead, remain curious.
Understand what the behaviour provides.
Explore what makes change difficult.
Listen for reasons the patient already has for doing something differently.
Support confidence.
Provide information when it is useful.
Help develop a plan when the patient is ready.
And recognise when the issue has moved beyond a conversation about motivation and requires senior clinical involvement.
A useful principle to carry into practice is:
Before telling someone why they should change, find out what might make them want to change.
The goal is not to make the patient's decisions for them.
It is to help them understand their choices, recognise their own motivations and develop confidence that change is possible.
5. Summary
Motivational Interviewing is a collaborative approach to conversations about change. Rather than attempting to persuade patients to follow professional advice, it helps them explore their own motivations, concerns, values and confidence.
Ambivalence is a normal part of behaviour change. A person may genuinely recognise the benefits of changing whilst also having important reasons for maintaining their current behaviour. Understanding both sides of this dilemma is often more useful than repeatedly explaining why change would be beneficial.
The spirit of Motivational Interviewing is based on partnership, acceptance, compassion and evocation. Practitioners work alongside patients, respect their autonomy and help them identify their own reasons for change.
A central challenge is recognising the righting reflex: the natural professional instinct to immediately correct problems, provide solutions or persuade someone to change. Advice remains important but understanding the patient's perspective should usually come first.
The OARS skills provide a practical framework for Motivational Interviewing:
Open questions encourage exploration.
Affirmations recognise genuine strengths, effort and values.
Reflective listening demonstrates understanding and encourages deeper consideration.
Summaries bring together important themes and help patients hear their own motivations and ambivalence.
Practitioners should listen carefully for change talk, including statements suggesting desire, ability, reasons, need or commitment to change. Rather than immediately adding professional arguments, these statements can be explored so that the patient develops their own reasons for doing something differently.
Sustain talk describes reasons for maintaining the current behaviour. This should not automatically be challenged or argued against. Exploring it can help practitioners understand what the behaviour provides and why change may be difficult.
Importance and confidence should be considered separately. Someone may believe that change is extremely important but have little confidence that they can achieve it. Exploring previous successes, existing strengths, practical barriers and small achievable steps can help strengthen confidence.
When providing information or advice, approaches such as Ask–Offer–Ask or Elicit–Provide–Elicit can keep the conversation collaborative rather than turning it into a lecture.
Once someone is ready to change, the focus should move towards practical planning. Goals should ideally come from the patient and be realistic, specific and achievable. If someone is not ready, maintaining engagement and leaving the possibility of future discussion open may be more helpful than forcing a plan.
Not every difficulty is caused by poor motivation. Practical, social, financial, cognitive and environmental barriers should always be considered. Sometimes the most appropriate response is practical support rather than further exploration of motivation.
Motivational Interviewing also has limits. Significant concerns involving suicide, self-harm, safeguarding, acute intoxication, severe substance dependence, psychosis, mania, physical health compromise or other serious risks require appropriate clinical assessment and escalation. Motivational Interviewing should never delay necessary action.
The central principle is:
People are often more persuaded by the reasons for change that they identify themselves than by the reasons we give them.
The practitioner's role is therefore not always to provide the argument for change. It is often to create a safe, collaborative conversation in which the patient can explore their own reasons, recognise their strengths and decide what they are ready to do next.
6. Further Reading
Motivational Interviewing has developed over several decades and has a substantial evidence base across mental health, substance use and health behaviour change. The following resources provide useful opportunities to consolidate the principles covered in this lesson.
Relevant NICE Guidance
NICE Guideline CG115
Alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence
This guideline is particularly relevant to Motivational Interviewing because ambivalence about reducing alcohol use is common. It discusses motivational approaches alongside psychological and pharmacological interventions for alcohol-related difficulties.
When reading the guidance, consider how a collaborative approach can help patients explore the benefits and disadvantages of changing their alcohol use.
NICE Guideline CG120
Psychosis with coexisting substance misuse: assessment and management in adults and young people
This guidance highlights the importance of developing a respectful and non-judgemental therapeutic relationship when working with people experiencing both psychosis and substance misuse.
It provides useful context for applying Motivational Interviewing principles without losing sight of mental state, risk and safeguarding considerations.
NICE Guideline CG185
Bipolar disorder: assessment and management
This guideline provides broader guidance on collaborative care, treatment engagement and supporting people to make informed decisions about their treatment.
It is useful for considering how collaborative communication can be maintained whilst recognising situations where significant changes in mental state require more active clinical intervention.
NICE Guideline NG222
Depression in adults: treatment and management
This guidance emphasises shared decision making, understanding patient preferences and discussing treatment options collaboratively.
Although Motivational Interviewing is not the central focus of the guideline, many of its communication principles are relevant when patients feel uncertain about medication, psychological therapy or behavioural change.
National Guidance and Professional Standards
NHS England
Shared Decision-Making
Shared decision making has considerable overlap with the collaborative principles of Motivational Interviewing. Both approaches recognise that clinical expertise and patient preferences need to be brought together when making healthcare decisions.
This resource is particularly useful for considering how practitioners can provide professional recommendations whilst respecting patient autonomy.
Office for Health Improvement and Disparities
Health Behaviour Change and Making Every Contact Count
Making Every Contact Count encourages healthcare professionals to use everyday interactions as opportunities to support healthier behaviours.
Motivational Interviewing-informed communication can be particularly useful in these conversations because it avoids turning brief discussions about health behaviour into lectures.
NHS England
Personalised Care
NHS personalised care resources emphasise working collaboratively with people, understanding what matters to them and supporting informed choices.
These principles fit closely with the partnership and autonomy emphasised within Motivational Interviewing.
Key Research and Foundational Literature
Miller, W. R. (1983)
Motivational Interviewing with Problem Drinkers
Behavioural Psychotherapy.
This landmark paper introduced many of the ideas that subsequently developed into Motivational Interviewing.
It challenged more confrontational approaches to alcohol treatment and proposed a collaborative style designed to increase people's motivation for change.
Miller, W. R. and Rollnick, S.
Motivational Interviewing: Helping People Change and Grow
This is the central text for understanding contemporary Motivational Interviewing.
It explores the spirit of Motivational Interviewing, the processes of engagement, focusing, evoking and planning and practical communication strategies for helping people explore behaviour change.
Moyers, T. B., Miller, W. R. and Hendrickson, S. M. L. (2005)
How Does Motivational Interviewing Work? Therapist Interpersonal Skill Predicts Client Involvement Within Motivational Interviewing Sessions
Journal of Consulting and Clinical Psychology.
This paper is useful for understanding why the interpersonal style of the practitioner matters.
It reinforces the principle that Motivational Interviewing is not simply a collection of techniques. How the practitioner communicates can influence how actively patients explore their own motivations.
High-Quality Reviews
Lundahl, B. and colleagues (2010)
A Meta-Analysis of Motivational Interviewing: Twenty-Five Years of Empirical Studies
Research on Social Work Practice.
This meta-analysis examined Motivational Interviewing across a wide range of settings and behaviours.
It provides useful evidence for the effectiveness of Motivational Interviewing whilst also demonstrating that outcomes vary according to the population, setting and way the intervention is delivered.
Rubak, S., Sandbæk, A., Lauritzen, T. and Christensen, B. (2005)
Motivational Interviewing: A Systematic Review and Meta-Analysis
British Journal of General Practice.
This review examined Motivational Interviewing across healthcare settings and provides useful evidence for its application beyond specialist substance misuse services.
Smedslund, G. and colleagues
Motivational Interviewing for Substance Abuse
Cochrane Database of Systematic Reviews.
This review examines the evidence for Motivational Interviewing in substance misuse treatment.
It is particularly useful for understanding both the potential benefits and limitations of the approach.
Recommended Books
Miller, W. R. and Rollnick, S.
Motivational Interviewing: Helping People Change and Grow
This is the principal recommended text for anyone who wants to develop a deeper understanding of Motivational Interviewing.
The book moves beyond individual techniques and explains the underlying philosophy and clinical reasoning behind the approach.
Rosengren, D. B.
Building Motivational Interviewing Skills: A Practitioner Workbook
This is a particularly practical resource.
It contains exercises designed to develop skills including reflective listening, recognising change talk, responding to sustain talk and strengthening motivation.
It can be useful for practitioners who want to practise Motivational Interviewing rather than simply read about it.
Rollnick, S., Miller, W. R. and Butler, C. C.
Motivational Interviewing in Health Care: Helping Patients Change Behavior
This book applies Motivational Interviewing specifically to healthcare conversations.
It is particularly useful for understanding how Motivational Interviewing principles can be incorporated into relatively brief clinical interactions rather than only formal therapy sessions.
Professional Learning Resources
Motivational Interviewing Network of Trainers
The Motivational Interviewing Network of Trainers provides educational materials and information about training in Motivational Interviewing.
Practitioners who develop a particular interest in the approach may wish to undertake formal skills-based training.
Reading about Motivational Interviewing provides useful knowledge but developing competence requires practice, observation and feedback.
Patient and Public Resources
NHS
Better Health
NHS Better Health provides patient-facing resources relating to areas such as smoking, alcohol, physical activity and healthy lifestyle changes.
These resources may be useful once a patient has identified an area they would like to change.
NHS
Alcohol Support
The NHS provides information about reducing alcohol consumption, alcohol dependence and accessing support.
These resources can support conversations with patients who are considering changing their drinking.
FRANK
Information and Advice About Drugs
FRANK provides accessible information about recreational drugs, their effects and available support.
It can be useful when patients would like factual information to help them make informed decisions about substance use.
Mind
Mind provides accessible information about mental health conditions, treatment and accessing support.
Its patient-facing resources can complement collaborative conversations about treatment choices and engagement with mental healthcare.
Suggested Learning Activity
Choose a behaviour-change conversation from your recent clinical practice.
It might involve medication, alcohol, substance use, sleep, exercise, appointment attendance or engagement with treatment.
Think about how the conversation developed.
Ask yourself:
Who did most of the talking?
Who provided most of the reasons for change?
Did I feel an urge to immediately solve the problem?
Did I explore what the current behaviour provides for the patient?
Did I acknowledge both sides of their ambivalence?
Did I hear any change talk?
If so, did I explore it or immediately add my own reasons?
Did I argue against sustain talk?
Did I ask permission before providing advice?
Did I explore confidence as well as importance?
Did I recognise any practical barriers that were unrelated to motivation?
Did I respect the patient's autonomy?
Was the patient ready to make a plan or was I trying to move towards planning too quickly?
Now imagine having the conversation again.
Instead of beginning with advice, identify three questions you could ask that might help the patient explore their own position.
For example:
"How do you feel about this at the moment?"
"What are the things you like about how things are now and what are the things you like less?"
"If you did decide to make a change, what would be your reason for doing it?"
The aim is not to avoid giving clinical advice.
It is to become more deliberate about when you give it.
A useful question to ask yourself during future conversations is:
"Am I currently helping this person explore their motivation or am I doing the motivating for them?"
Developing Motivational Interviewing skills requires practice. Reading provides the principles but supervision, role-play, observation and feedback are particularly valuable for developing the communication style required to use the approach effectively.
7. Knowledge Check
The following questions are designed to reinforce the principles of Motivational Interviewing and help you apply them to everyday clinical conversations. Select the single best answer for each question.
Question 1
Which statement best describes the purpose of Motivational Interviewing?
A. To persuade patients to follow professional advice.
B. To help patients explore their own motivation and ambivalence about change.
C. To provide patients with detailed information about why their behaviour is harmful.
D. To avoid making clinical recommendations.
Correct Answer
B. To help patients explore their own motivation and ambivalence about change.
Explanation
Motivational Interviewing is a collaborative approach that helps people explore their own reasons for change, the factors making change difficult and their confidence in making changes.
Why the Other Answers Are Incorrect
A. Motivational Interviewing is not a method of persuading or manipulating patients into making the decision preferred by the practitioner.
C. Information can be useful but providing information alone is not Motivational Interviewing.
D. Practitioners can still provide clear clinical recommendations. The aim is to do this in a collaborative way that respects patient autonomy.
Question 2
Which four principles are commonly associated with the spirit of Motivational Interviewing?
A. Assessment, diagnosis, treatment and review.
B. Questioning, confrontation, education and persuasion.
C. Partnership, acceptance, compassion and evocation.
D. Listening, reassurance, advice and instruction.
Correct Answer
C. Partnership, acceptance, compassion and evocation.
Explanation
The spirit of Motivational Interviewing emphasises working alongside the patient, respecting their autonomy, acting in their interests and helping them identify motivations that already exist within them.
Why the Other Answers Are Incorrect
A. These may describe elements of clinical care but they are not the spirit of Motivational Interviewing.
B. Confrontation and persuasion are generally inconsistent with the collaborative approach.
D. Some of these communication skills may be useful but they do not represent the four underlying principles.
Question 3
Clinical Scenario
A patient says:
"I know I drink too much, but having a few drinks is the only way I can relax after work."
Which response is most consistent with Motivational Interviewing?
A. "You need to find a healthier way to relax."
B. "Alcohol is probably making your mental health worse, so you should stop."
C. "Part of you is concerned about how much you're drinking, but another part feels that alcohol is helping you cope."
D. "If you know you're drinking too much, why haven't you stopped?"
Correct Answer
C. "Part of you is concerned about how much you're drinking, but another part feels that alcohol is helping you cope."
Explanation
This reflection acknowledges both sides of the patient's ambivalence without judgement. It creates an opportunity to explore their own reasons for changing and remaining the same.
Why the Other Answers Are Incorrect
A. This moves immediately into advice without understanding the patient's perspective.
B. This places the practitioner in the position of arguing for change.
D. This may sound judgemental and fails to recognise that behaviour change can involve genuine ambivalence.
Question 4
What does the term righting reflex describe?
A. A patient's tendency to change their mind during treatment.
B. The practitioner's natural tendency to identify a problem and immediately try to correct it.
C. The process of correcting inaccurate information in clinical records.
D. A patient's tendency to disagree with healthcare professionals.
Correct Answer
B. The practitioner's natural tendency to identify a problem and immediately try to correct it.
Explanation
Healthcare professionals naturally want to help. When we identify a problem, our instinct may be to explain why the person should change and tell them what they need to do.
Motivational Interviewing encourages us to notice this instinct and understand the patient's perspective before immediately trying to fix the problem.
Why the Other Answers Are Incorrect
A. Ambivalence may involve changing views but this is not what the righting reflex means.
C. The term is unrelated to clinical documentation.
D. The righting reflex describes the practitioner's behaviour rather than the patient's.
Question 5
What does OARS stand for?
A. Observation, Assessment, Risk and Safety.
B. Open questions, Affirmations, Reflections and Summaries.
C. Options, Advice, Recommendations and Support.
D. Objectives, Actions, Review and Supervision.
Correct Answer
B. Open questions, Affirmations, Reflections and Summaries.
Explanation
OARS describes four important communication skills used within Motivational Interviewing.
Open questions encourage exploration.
Affirmations recognise strengths and effort.
Reflections demonstrate understanding and encourage deeper exploration.
Summaries bring together important parts of the conversation.
Why the Other Answers Are Incorrect
A, C and D are not recognised meanings of OARS within Motivational Interviewing.
Question 6
Clinical Scenario
A patient who uses cannabis regularly says:
"I suppose I'd probably have more money and concentrate better if I stopped."
What is the best response?
A. "Exactly. Cannabis is also associated with several mental health problems."
B. "So why don't you stop?"
C. "What difference would having better concentration make for you?"
D. "You definitely need to stop using cannabis."
Correct Answer
C. "What difference would having better concentration make for you?"
Explanation
The patient has produced change talk by identifying a potential benefit of changing their cannabis use.
Rather than immediately adding professional reasons, the practitioner can explore the patient's own reason and encourage them to elaborate.
Why the Other Answers Are Incorrect
A. The practitioner takes over the argument for change instead of exploring the patient's motivation.
B. This may sound confrontational and ignores the possibility of ambivalence.
D. This is directive and does not explore the patient's perspective.
Question 7
Clinical Scenario
A patient rates the importance of reducing their alcohol intake as 6 out of 10.
Which follow-up question is most likely to encourage change talk?
A. "Why isn't it a 10?"
B. "Why only six?"
C. "Why six rather than three?"
D. "Don't you think it should be higher?"
Correct Answer
C. "Why six rather than three?"
Explanation
This question encourages the patient to explain why change is already important to them.
They might respond:
"Because I'm worried about my health and my partner is getting frustrated."
The patient is now identifying their own reasons for change.
Why the Other Answers Are Incorrect
A. This may encourage the patient to explain why change is not sufficiently important.
B. This similarly focuses attention on reasons against change.
D. This is judgemental and suggests that the practitioner believes the patient's answer is incorrect.
Question 8
Clinical Scenario
A patient says:
"Therapy isn't going to help me. I've tried talking before and nothing changed."
Which response best demonstrates an appropriate response to sustain talk?
A. "That's not true. Therapy has a strong evidence base."
B. "You need to give it another chance."
C. "At the moment you're not convinced that talking again would make enough difference to be worthwhile."
D. "If you refuse therapy, there isn't much we can do."
Correct Answer
C. "At the moment you're not convinced that talking again would make enough difference to be worthwhile."
Explanation
Sustain talk describes the patient's reasons for maintaining their current position.
Arguing against it can result in the patient defending that position more strongly. Reflecting their concern demonstrates understanding and creates an opportunity for further exploration.
Why the Other Answers Are Incorrect
A. Providing evidence in a confrontational way may turn the conversation into a debate.
B. This tells the patient what to do without exploring why previous therapy felt unhelpful.
D. This may feel punitive and could damage engagement.
Question 9
Which approach is most appropriate when providing information within Motivational Interviewing?
A. Avoid providing clinical information because it interferes with patient autonomy.
B. Provide all relevant information at once so the patient understands the seriousness of the situation.
C. Ask what the patient already knows, offer relevant information with permission and then explore what they make of it.
D. Only provide information if the patient has already agreed to make the recommended change.
Correct Answer
C. Ask what the patient already knows, offer relevant information with permission and then explore what they make of it.
Explanation
Approaches such as Elicit–Provide–Elicit and Ask–Offer–Ask help practitioners provide clinical information whilst maintaining a collaborative conversation.
For example:
"What have you heard about how alcohol affects sleep?"
Then:
"Would it be okay if I added something to that?"
After providing information:
"How does that fit with your own experience?"
Why the Other Answers Are Incorrect
A. Motivational Interviewing does not require clinicians to withhold professional knowledge.
B. Large amounts of information can overwhelm patients and may not address the actual reason for their ambivalence.
D. Patients may need accurate information before they can make an informed decision about change.
Question 10
Clinical Scenario
During a conversation about reducing alcohol use, a patient tells you:
"Actually, I stopped drinking completely yesterday. I've been drinking heavily every day for years and this morning I've been shaking and sweating. I'm starting to feel really unwell."
You are an assistant practitioner.
What is the most appropriate response?
A. Explore their confidence in remaining alcohol-free using a 0–10 scale.
B. Congratulate them on stopping and arrange to review them next week.
C. Recognise that abrupt withdrawal following prolonged heavy alcohol use may require urgent clinical assessment and seek appropriate senior clinical support.
D. Encourage them to continue without alcohol because returning to drinking would reduce their motivation.
Correct Answer
C. Recognise that abrupt withdrawal following prolonged heavy alcohol use may require urgent clinical assessment and seek appropriate senior clinical support.
Explanation
Motivational Interviewing does not replace clinical assessment or risk management. Alcohol withdrawal can become medically serious and requires appropriate clinical assessment.
The practitioner should recognise that the situation has moved beyond a routine conversation about motivation and seek appropriate senior support.
Why the Other Answers Are Incorrect
A. Exploring motivation should not delay assessment of a potentially serious physical health problem.
B. A routine review is not sufficient where potentially significant withdrawal symptoms are developing.
D. Advising on the management of potentially dangerous withdrawal without appropriate clinical assessment would be unsafe.
Reflection Exercise
Think about a recent clinical interaction where a patient was considering changing something.
This might have involved medication, alcohol, substance use, sleep, exercise, attendance, therapy or another aspect of their care.
Consider:
Did the patient appear ready to change or ambivalent?
What reasons did they give for changing?
What reasons did they give for remaining the same?
Did I explore both sides?
Did I notice any change talk?
Did I explore it when it appeared?
Did I argue against sustain talk?
Did I experience the righting reflex?
Who provided most of the reasons for change: me or the patient?
Did I ask permission before giving advice?
Did I explore confidence as well as importance?
Were there practical barriers that had little to do with motivation?
Was the patient ready for planning?
Did anything emerge that required senior clinical involvement?
Choose one future behaviour-change conversation and deliberately practise the OARS skills.
Try to use an open question, a genuine affirmation, a reflection and a summary during the interaction.
The central question to consider afterwards is:
"Who did most of the arguing for change?"
If it was you, consider whether greater curiosity and reflection might have allowed the patient to identify more of their own reasons.
Motivational Interviewing is not about finding the perfect phrase that makes someone change.
It is about creating a conversation in which change can be considered openly, without judgement or unnecessary pressure.
The patient brings their experiences, values and choices.
The practitioner brings clinical knowledge, curiosity and support.
Effective Motivational Interviewing brings those two perspectives together.
