Motivational Interviewing: A Dialogue with the Practice's Co-founder William R. Miller

Origins of Motivational Interviewing (MI)

William R. Miller said MI did not begin as a planned theory or established treatment model. While working at an alcoholism treatment hospital in Norway, he discussed his work with a group of psychologists who asked him to demonstrate how he worked with clients. Their questions helped him identify patterns in his approach: he tried to arrange conversations so clients would make their own arguments for change, rather than telling them what they should do.

Miller wrote up these ideas and named the approach motivational interviewing. He liked “interviewing” because it describes a conversation with different roles without implying that one person necessarily holds the power. MI initially focused on problem drinking. Miller later collaborated with Steve Rollnick, who had begun teaching MI in the UK and helped expand its use in healthcare.

Core Ideas and Practice

MI builds on a person-centered foundation, including accurate empathy and respect for the client. But it is more directional than a purely nondirective approach: when a particular change is the goal, the practitioner uses specific conversational strategies to help the client explore and move toward it.

The conversation is shaped by several ideas:

• Ambivalence is normal. People can want to change while also feeling comfortable with their current behavior or worried about what change will require.
• Avoid the “righting reflex.” When practitioners push, advise, or argue for change, clients may respond by defending the status quo. The practitioner should avoid becoming the one making the case for change.
• Elicit the client’s own reasons for change. MI aims to help clients voice and develop their own motivations rather than simply comply with someone else’s argument.
• Listen selectively and responsively. Practitioners can emphasize particular material through reflective listening, questions, and summaries.
• Notice and strengthen “change talk.” Miller highlighted research on client language that is especially relevant to change. Practitioners can attend to, evoke, and reinforce this language.
• Use accurate empathy as a foundation. Miller described empathy as central to MI and emphasized that practitioners may believe they are listening well without doing so effectively in practice.

Applications and Evidence

MI grew beyond addiction treatment because ambivalence about change appears in many settings. The discussion mentions healthcare—for example, lifestyle changes after a diabetes diagnosis—as well as probation and corrections, social work with families, education, management, and organizational or community settings. Miller described MI as an approach grounded in human nature that may apply wherever people are considering change.

Miller cited research showing that therapist empathy was strongly associated with better outcomes in a study of behavioral self-control treatment for alcoholism. He also said that, at the time of the interview, there had been roughly 470 controlled trials of MI. Overall findings were positive, but results varied substantially across studies, sites, and practitioners. He stressed that MI is not a standardized intervention that works identically every time: the quality of its delivery matters.

Learning and Implementation

A major challenge is that attending a workshop does not necessarily produce skillful practice. Miller said evaluations of his own training found that participants often believed they had learned MI, while recordings of their work showed little evidence of it. He compared learning MI to learning to fly, play an instrument, or play tennis: complex skills require more than classroom instruction.

The discussion identifies these elements as important for developing competence:

• Practice over time, rather than relying on a one-time workshop.
• Ongoing feedback and coaching.
• Listening to recorded sessions to compare intended practice with what actually happened.
• Measuring and coding the interaction, including reflective listening and other practitioner behaviors.
• Testing assumptions about practice, rather than relying only on practitioners’ impressions of their own skill.

Miller linked this attention to measurement and recorded sessions to the influence of Carl Rogers. He described MI as retaining much of the person-centered foundation while adding strategies that can further support behavior change.

Future Questions

Miller expected MI to reach additional fields, while hoping that training would improve and become more sustained. He also identified important unanswered questions: how learning MI affects practitioners personally, how its adoption changes service systems and client treatment, and what precisely happens in conversations that helps change occur.

Speakers and Sources Mentioned

• Speakers: Allen Zweben (interviewer) and William R. Miller (interviewee).
• People referenced: Carl Rogers, Steve Rollnick, and Paul Amrhein.
• Research and publications referenced: Miller’s early article on motivational interviewing with problem drinkers; the 1991 book Miller co-wrote with Rollnick; studies of therapist empathy and alcoholism treatment; and research on change talk and controlled trials of MI.