Motivational interviewing (mi).

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   Motivational interviewing (MI) is a psychotherapeutic
method that was developed by William Miller and Stephen
Rollnick, originally described in 1983 (Miller, 1983). Miller
and Rollnick (2002) define MI as “a client-centered, directive
method for enhancing intrinsic motivation to change by
exploring and resolving ambivalence.” Its original application
was in substance abuse treatment with adults, where it was
developed in response to confrontational methods used in
this field during the 1970s and 1980s. Since then, it has been
used in many different areas, including “general medical care,
health promotion, social work and corrections” (Miller &
Rollnick, 2002, p. xiv) 

– Explore your reactions to the readings and to what you have learned about Motivational Interviewing (MI).  Explain how MI can be applied to clinical practice.

-Write one independent paragraph that includes a reference, explaining how Motivational Interviewing can be used by a psychiatric nurse practitioner to help a specific patient (for example, a drug addict or alcoholic patient that is non-complaining with his or her medications) and what considerations you need to be aware of to achieve success.

Responses will be checked by Turnitin for originality. It should be a minimum of 350 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). *Information about motivational interviewing is attached.

Issues in Mental Health Nursing, 32:436–440, 2011
Copyright © Informa Healthcare USA, Inc.
ISSN: 0161-2840 print / 1096-4673 online
DOI: 10.3109/01612840.2011.565907

Motivational Interviewing: A Valuable Tool for the
Psychiatric Advanced Practice Nurse

Abby Karzenowski, BSN, RN and Kathy Puskar, MN, MPH, DrPH, FAAN
University of Pittsburgh, School of Nursing, Pittsburgh, Pennsylvania, USA

Motivational Interviewing (MI) is well known and respected by
many health care professionals. Developed by Miller and Rollnick
(2002), it is a way to promote behavior change from within and
resolve ambivalence. MI is individualized and is most commonly
used in the psychiatric setting; it is a valuable tool for the Psychi-
atric Advanced Nurse Practice Nurse. There are many resources
that talk about what MI is and the principles used to apply it. How-
ever, there is little information about how to incorporate MI into
a clinical case. This article provides a summary of articles related
to MI and discusses two case studies using MI and why advanced
practice nurses should use MI with their patients.

Motivational interviewing (MI) can be used by all health care
professionals in any health care setting where a patient’s behav-
ior affects the outcome. MI is a valuable tool for the Psychiatric
Advanced Practice Nurse because it is useful in establishing the
therapeutic alliance and assuming a non-judgmental position as
a therapist. It was first described by Miller and Rollnick (2002)
as a way to elicit behavior change by exploring and resolving
ambivalence. The purpose of this article is to discuss MI, its use
in two case studies, and its value for the psychiatric advanced
practice nurse. Skills of MI include reflective listening, asking
open ended questions, affirming, and summarizing. The ability
to use MI as a tool to support and develop self-efficacy is
an important issue in behavioral counseling. Motivational
interviewing is defined as “a client-centered, directive method
for enhancing intrinsic motivation to change by exploring and
resolving ambivalence” (Miller & Rollnick, 2002, PowerPoint
Slide No. 2) and is a way of “combining elements of both style,
warmth, empathy, and techniques, key questions and reflective
listening” (W. R. Miller, 1996, p. 839).

The authors acknowledge Lindsay Starner for her editorial contri-
butions to this manuscript.

Address correspondence to Kathy Puskar, School of Nursing, Uni-
versity of Pittsburgh, 3500 Victoria Street, Room 415, Pittsburgh, PA
15261. E-mail: [email protected]

LITERATURE REVIEW

MI Definitions
Bundy (2004) explains that the basis of MI comes from

the Transtheoretical Model of Change. The Transtheoretical
Model of Change was developed by James O. Prochaska and
his colleagues at the University of Rhode Island; the model
posits that health behavior change involves progress through
six stages of change (Prochaska & Velicer, 1997, p. 38). There
are six stages of change: (1) pre-contemplation, where the per-
son is not thinking about change at all, (2) contemplation,
where the person is thinking about change, but has not made
any plans, (3) planning, where the person has made plans to
change, but has not started the plan yet, (4) action, where
the person starts the plan, and (5) maintenance, and (6) ter-
mination, where the person continues with the plan. Strate-
gies to increase motivation in a person include giving advice,
removing barriers, providing choice, decreasing desirability,
practicing empathy, providing feedback, clarifying goals, and
providing active helping. MI has five basic principles of
change: expressing empathy, avoiding arguments, supporting
self-efficacy, rolling with resistance, and developing discrep-
ancy. There are eight steps of MI that promote the therapeutic
process and they are: establishing rapport (a basis of trust is es-
sential), setting the agenda (without an agenda the patient can at-
tempt too much too quickly), assessing readiness to change (help
identify barriers and supports for change), sharpening the focus
(focus on what the patient wants to change), identifying ambiva-
lence (show that there are reason for and against change the pa-
tient can identify), eliciting self-motivating statements (promote
the patient making positive statements and identify successes),
handling resistance (use reflection to help with resistance) and
shifting the focus (also helpful in handling resistance).

N. H. Miller (2010) identifies two phases to MI. “Phase one
elicits change talk to promote intrinsic motivation for change”
(N. H. Miller, 2010, p. 248). In phase one, the health care profes-
sional helps the patient express his opinions using open-ended
questions, reflective listening, affirmation, and summarization.
Phase two focuses on strengthening the commitment to change
once the person is motivated. Health care providers should

436

MOTIVATIONAL INTERVIEWING: A VALUABLE TOOL 437

encourage and listen for “change talk” where the patient is influ-
enced by hearing themselves talk rather than by what someone
else says. When a patient is closer to the preparation or ac-
tion stage of change, coaching can be used. Coaching involves
educating and assessing willingness, setting goals, assessing
confidence, and following up. In the steps of coaching there are
barriers and problems. Common barriers consist of misinforma-
tion or lack of information, previous negative experiences with
the change process, and lack of support. To problem solve these
barriers, “[identify] the problem and reason for it, [select] the
main reason and possible solutions, weighting the pros and cons
of each solution, [select] one or two solutions to try, [attempt]
that solution, and [repeat] the process if the initial solution is
not successful” (N. H. Miller, 2010, p. 250).

Levensky, Forcehimes, O’Donohue, and Beitz (2007) intro-
duce the five stages of the Transtheoretical Model of Change
associated with MI and report that people will often relapse and
move through the stages multiple times and in different orders
before reaching the maintenance stage. It is important for health
care professionals to work with patients at whatever stage of
change the patient is at to promote collaboration and reduce
resistance. There are three steps to provide information to pa-
tients when using MI. First, the health care professional asks
the patient what he already knows. Second, the health care pro-
fessional asks permission to provide information to the patient.
Third, the health care professional asks the patient to discuss
his thoughts and reactions to the information given. The most
common traps with unmotivated patients are the confrontation-
denial trap, question-answer trap, expert trap, and premature
focus trap.

MI Use
Rubak, Sandbaek, Lauritzen, and Christensen (2005) talked

about ways MI is useful for the client who is reluctant or am-
bivalent to change. MI strategies are persuasive and supportive
rather than coercive and argumentative. This is to motivate the
person to change from within. This study looked at 72 random-
ized controlled trials. It showed that in 74% of the trials MI was
effective and that the longer each individual session was the
more effective MI was. Also, the more individual MI sessions a
patient receives the better. “No studies showed motivational in-
terviewing to be harmful or to have any kind of adverse effects”
(Rubak et al., 2005, p. 308). MI can be used with patients with
psychological or physiological disorders. Although the greater
the length and number of sessions the better, it is shown that
even 15-minute encounters can be beneficial. Rollnick, Butler,
Kinnersley, Gregory, and Mash (2010) discuss how MI can be
used in a wide range of health care settings and actually lead to a
better relationship between the health care provider and patient.
It also can save time by avoiding the typical lecture health care
providers so often given patients. The goal of MI is to be an
informed guide rather than a dictator. Engaging and collabo-
rating with patients, emphasizing their autonomy, and eliciting

their motivation for change are ways to make sure the patient is
responsible for their own change. This can be done by asking
open-ended questions, listening to the patient to really under-
stand what they are saying, and asking permission to provide
information to the patient. Some additional useful strategies to
use when engaging a patient with MI include having the patient
choose one issue they want to work on, talking about the pros
and cons of change, spending time where it is most needed, and
making listening a priority.

Polcin (2006) focuses more on using MI for patients with ad-
dictions by applying supportive and directive intervention. This
helps the patient explore the actual or potential consequences
of their actions. Directive intervention includes developing dis-
crepancies and helping the patient realize that their substance
use is inconsistent with their goals and values, exchanging feed-
back (objective and nonjudgmental information or knowledge
that the health care professional shares with the patient), en-
gaging ambivalence by exploring pros and cons for using, and
giving straightforward—yet reserved—advice for patients in the
preparation or action phase. Polcin (2006) discusses MI issues
related to avoiding confrontation, including the issue of a wan-
dering session, which is when a session gets sidetracked and is
not about the related problem. Polcin also discusses the avoid-
ance of ambivalence and discrepancy (maintaining a balance
between supportive statements and confrontation); weak or in-
complete feedback, advice, and sharing of information; and a
weak therapeutic alliance with a decrease in empathy, reflection,
and affirmation. Using MI with special populations is discussed
with mixed results noted. With criminal justice mandated clients,
MI showed very little if any advantages. With women mandated
by child welfare, MI had little added benefit. With those referred
to their Employee Assistance Program (EAP), MI was found to
be no more effective than standard treatment. In these special
populations of mandated clients, the use of MI warrants further
consideration and research.

Emmons and Rollnick (2001) discuss key principles of MI,
including expressing empathy, developing discrepancy between
patient goals and current problem behavior, avoiding arguing,
rolling with resistance, and supporting self-efficacy for change.
Technical aspects of MI include focusing on client-centered
counseling, determining internal motivation using reflective lis-
tening, and decreasing patient resistance. These strategies can
help put the patient in the expert role. For health care profession-
als in the community setting, it can be more difficult to imple-
ment MI than for health care professionals in the inpatient psy-
chiatric setting. Common issues in the community include time
constraints and adapting a brief version of MI in the community
setting. Strategies to help strengthen brief sessions include pro-
viding additional materials, like printed pamphlets and video-
tapes. In the community setting, it is difficult to find a balance
between intervention and training. Ways to facilitate this include
having researchers be familiar with the population being served,
the setting, working with the target group, working with the prac-
titioner group, and having a comprehensive evaluation process.

438 A. KARZENOWSKI AND K. PUSKAR

In summary, although there are many principles and
theories to MI, generalized ideas are noted. These include
being supportive of patients and helping them explore their
behaviors. Most importantly, MI is patient focused and
emphasizes what the patient needs. Based on the litera-
ture, MI can be a useful tool to support client growth and
change.

CASE STUDY #1
S.K. is a 21-year-old single Caucasian male in an intensive

outpatient treatment facility after completing a four-week stay
at an inpatient psychiatric unit following a suicide attempt by
overdose on Abilify. He received 12 weekly sessions of support-
ive psychotherapy including MI. He was diagnosed with Bipolar
II, Most Recent Episode Depressed, and Sedative/Hypnotic de-
pendence. He is ambivalent about getting off prescription drugs,
mainly Vicodin and Xanax. He also is ambivalent about taking
an anti-depressant prescribed for him. The notes from his in-
patient stay talk about the huge amount of resistance he has
towards getting clean. He has many supports, including family
and friends. He is well-educated, a college graduate who aspires
to be a computer programmer. He has had multiple legal trou-
bles, first as a teenager for dealing drugs in New York, then in his
senior year of college for assault related to drugs. In the opening
phase of treatment, MI was an extremely important and a valu-
able tool especially since he was in the precontemplation stage
of change. The first sessions were used to establish rapport,
set the agenda, and assess his readiness for change. Express-
ing empathy, avoiding arguments, and rolling with resistance
was beneficial. The therapist acknowledged that S.K. believes
that drugs help his depression and that he has little interest in
quitting. Rolling with resistance seemed to help S.K. realize he
would not be judged and lectured on his drug use but that he
could talk about it openly and honestly. S.K. was initially very
passive when talking about his drug use. He would respond to
open-ended questions with short, blunt answers. It was helpful
to use reflection when the therapist noticed him starting to shut
down and lose interest. During the opening phase he also veri-
fied what he might want to change. He was okay talking about
his drug use, but refused to discuss his non-compliance with
medications. He was reminded that not taking his medication
is his decision as an adult and, as an adult, he would have to
handle the consequences if any occur. After the opening phase
of treatment, trust was established and S.K. started to open up a
little more.

During the middle phase of treatment, S.K. was able to focus
on his drug use. He was encouraged to use self-motivation and
recognize his accomplishments. In one session, a scale of 0 to
10 was used to help identify his motivation to stop using drugs.
With 10 being the most likely to use drugs and 0 being the least
likely, S.K. was a 6. When he was asked why he wasn’t a 7
he identified his family as a support for keeping him clean. He
enjoys going to his parents’ house, but he is not allowed over

if he is high, and his parents can tell if he has been using. He
was then asked what was keeping him from being a 5 and he
identified his social circle and lack of structured activities as
barriers to his sobriety. Reflection was then used to review the
pros and cons of using. He identified that the cons of using were
more than the pros, especially since he has had legal problems
due to his drug use. After realizing S.K. was comfortable, the
therapist began to gently challenge his thinking. The therapist
revisited the barriers to his drug use and challenged S.K. by
asking for clarification that he has more interest in his social
circle rather than his family since he continues to use drugs.
He denied this. The therapist then supported his self-efficacy by
telling him he is in counseling now and willing to accept help
because he wants to change his behaviors. The therapist then
had S.K. repeat that back in his own words.

At the terminal phase of treatment, S.K. continued using
drugs, but the therapist was able to challenge him more. The
therapist again used a 0–10 scale to assess his readiness for
change and barriers for changing. His barriers were still his
social circle and boredom, but he was agreeable to discussing
different coping techniques and activities to help him remain
clean, such as joining a team, spending time with family and
different friends, and joining Narcotics Anonymous. S.K had
progressed to the preparation stage of change at this point. He
was receptive to the therapist, so giving advice was another
intervention utilized. S.K. was told the physical problems that
would occur if he continued to use drugs and that spending time
with other people using drugs was not conducive to his recovery.
He also was reminded of the legal consequences of his drug use,
and that he was no longer in college so if he was caught dealing
or in possession of drugs, he would face legal charges.

CASE STUDY #2
R.P. is a 16-year-old African American girl who was admitted

to the hospital related to manifestations of severe hypoglycemia.
While she was in the hospital she was diagnosed with Type I
Diabetes. Once her blood glucose levels were brought back up
and stabilized, she stayed in the hospital for an additional three
days, as per the protocol of the hospital. During those three days
she and both of her parents, who were very supportive of their
daughter, attended educational and counseling sessions with
nurses, counselors, dieticians, and other clinicians discussing
and learning about diabetes and what that meant in regards to
necessary lifestyle adaptations and medical adherence.

Throughout the sessions on the three days R.P. remained in
the hospital, she was agreeable and willing to go to the sessions
and listen to what she was being told by the medical staff, but
she made it quite clear to everyone, including her parents, that
she was not interested in following the strict routine the nurses
were proposing related to using insulin and adhering to a diet.
R.P. repeatedly stressed that she was in high school, and she did
not want to have to carry around syringes and medicine vials
all day and then have to go to the bathroom a couple times a

MOTIVATIONAL INTERVIEWING: A VALUABLE TOOL 439

day to prick herself and give herself shots of insulin. She also
was not fond of talks with the nutritionist who described to her
how her diet would need to change and be tightly monitored
and managed. All R.P. could think of was her weekly nights
out with her girlfriends when they would go to the pizza shop
and get pizza and sodas, and she quite adamantly expressed an
unwillingness to give those nights up. She was ambivalent to
making the necessary changes for proper diabetes management,
which put her at risk for serious complications upon leaving the
hospital. Therefore, arrangements were made for her to have 12
weekly psychotherapy counseling sessions with a therapist who
would use MI techniques to help R.P. work through coping with
her new diagnosis.

Following discharge from the hospital, R.P. met with her
therapist on a weekly basis. In the first couple sessions, the
therapist developed rapport with her client. The therapist gave
R.P. time to openly share whatever her thoughts were about her
diabetes diagnosis, and during that time the therapist actively
listened without any suggestions or advice shared, and without
any judgmental or challenging remarks. At this stage in the ther-
apeutic relationship, the goal was to develop rapport so that the
client would feel safe and comfortable sharing her feelings and
struggles with someone who would openly listen, not condemn
her frustrations, or argue with her about her unwillingness to
change. The therapist empathetically acknowledged how diffi-
cult a diagnosis of diabetes can be to cope with, especially as a
young teenager.

After a couple sessions, R.P. became more and more willing
to share her feelings with the therapist. From that point, the
therapist could then move into the working phase of the thera-
peutic relationship when she began to challenge some of R.P.’s
ambivalence and encourage her to recognize where her resis-
tance to change could be detrimental to her health and other life
goals. The therapist encouraged R.P. to process and share both
the pros and cons of resisting medical and nutritional guidelines
and then had her consider how her other life goals might be
affected by those pros and cons. As the therapist continued to
openly and actively listen to and help the client work through
these challenges, R.P. began to take more ownership of her
thoughts and actions. As she showed increasing willingness to
change, she and the therapist began to identify and develop other
unique ways to work the management of diabetes into R.P.’s life
without forcing her to compromise everything she loved as a
teenager. The therapist’s use of MI techniques provided time
and opportunity for R.P. to develop self-efficacy and recognize
for herself why her attitudes needed to change and how she
could most effectively make those necessary changes.

SUMMARY AND CONCLUSION
Psychiatric clinical nurse specialists or nurse practitioners

can use MI in all aspects of their practice. Since many people
who suffer from mental illness also have comorbid substance
abuse/dependence problems, MI can be particularly helpful.
Many times it is difficult to determine if a substance is causing

the mental illness. For example, if a patient is using cocaine,
it may be difficult to determine cocaine abuse from mania. If
someone is using LSD, they may have hallucinations, but not
truly be psychotic. If substance abuse is not a factor, health
care professionals can better treat the illness. Also, parts of an
illness may not need to be treated when the substance is not
being abused. If a person is having hallucinations when sober,
it is much more clear they have actual psychotic symptoms and
medication should be started. MI is also useful for medication
compliance, which is another problem for people with mental
illness. For advanced practice nurses not in the mental health
field, MI can also be used for a wide range of health practices.
It has been shown effective for weight loss, smoking cessation,
medication compliance, dietary compliance, and establishing an
exercise routine.

The American Psychiatric Nurses Association Stan-
dard of Practice for Psychotherapy is 5F and reads, “The
Psychiatric-Mental Health Advanced Practice Registered Nurse
conducts individual, couple, group, and family psychotherapy
using evidence-based psychotherapeutic frameworks and
nurse-patient therapeutic relationships” (American Nurses
Association, 2007, p. 42). The use of MI is a key element within
the nurse’s scope of practice per the standards of practice as
documented by the American Psychiatric Nursing Association.

MI is considered a valuable tool for the psychiatric advanced
practice nurse. It has been proven to be successful in changing
behavior and decreasing resistance in patients with many dif-
ferent diagnoses. For psychiatric advanced practice nurses, the
tools are knowledge and communication skills. Without stetho-
scopes or blood pressure cuffs to provide concrete evidence to
patients, psychiatric nurses must present patients with methods
of therapy that have been proven to work. MI not only works,
but has the evidence to back up its success.

Declaration of interest: The authors have no financial or
personal relationships with any persons or organizations that
would bias this manuscript.

REFERENCES
American Nurses Association. American Psychiatric Nurses Association and In-

ternational Society of Psychiatric-Mental Health Nurses. (2007). Psychiatric-
mental health nursing scope & standards of practice. Silver Spring, MD:
Nurse Books. Nursesbooks.org

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