Patients often come to therapy with conflicting feelings about change. They may express ambivalence, frustration, or feel overwhelmed by the gap between how they’re living and how they’d like to be. Others may have been encouraged—or even required—to pursue care by a third party, which can lead to skepticism about how therapy may benefit them.
This can be challenging for therapists, who naturally want to support progress, but may feel uncertain about how to engage patients who are struggling with initiating change behavior.
Motivational Interviewing (MI) offers a framework for engaging patients in meaningful conversations about change without pressure, resistance, or rupture. It’s an evidence-based approach that supports patient autonomy, improves clinical outcomes, and makes therapy more collaborative and rewarding.
This article will walk you through:
- How to identify moments where MI is most useful
- Specific MI skills to apply (with examples)
- Why these approaches reduce resistance and improve outcomes
- How to integrate MI with culturally responsive care
How to Recognize an Opportunity for MI
Watch for patient language or behavior that signals:
- Ambivalence (“I want to stop drinking, but I also need it to sleep.”)
- Low self-efficacy (“Even if I wanted to change, I don’t think I could.”)
- External pressure (“Everyone thinks I should get better, but I don’t know.”)
- Disengagement (Short answers, minimal eye contact, missed sessions)
- Difficulty with developing or initiating a plan for change (“I would try that, but…”)
- Lack of clarity regarding what they want (frequent “I don’t know”s)
- Not making progress toward goals
This can be an opportunity to pause and reflect about the dynamics at play:
- What purpose does the behavior serve, and what might it be protecting the client from?
- What internal or external factors influence their readiness and confidence to change?
- How do they perceive the role of the therapist in this process—supportive, pressuring, or something else?
What to Do: MI Skills in Action
Here are 5 core MI strategies that can assist with supporting a client in therapy, when to use them, and how to apply them in session.
1. Reflect Change Talk
What it is: Repeating or paraphrasing what the patient says, especially their desire, ability, reasons, or need for change.
Use it when:
- The patient hints at wanting things to be different
- You hear tension between values and current behavior
- You want to reinforce motivation without pushing
Example:
- Patient: “I hate how anxious I get before work, but I don’t know what to do about it.”
- Therapist: “Part of you really wants to feel more in control of your mornings.”
Why it works: Reflecting change talk helps patients hear their own motivation more clearly- without you needing to convince them.
2. Use Evocative Questions (When the Patient Isn’t Sure What They Want)
What it is: Open-ended questions that explore values, goals, and reasons for change.
Use it when:
- The patient is ambivalent or unsure
- You want to move the conversation from problems to possibilities
Examples:
- “What would be different if this felt a little more manageable?”
- “What’s something you’ve thought about changing, even just a little?”
- “What do you wish was different about how this impacts your relationships?”
Tip: Start where the patient is, not where you want them to be. MI supports the patient’s pace, not the therapist’s plan.
3. Affirm Strengths (When the Patient Feels Defeated or Powerless)
What it is: Highlighting the patient’s values, efforts, and resilience—not just progress.
Use it when:
- The patient expresses self-doubt
- Change feels overwhelming
- You want to build momentum or hope
Examples:
- “You’ve already survived so much—and you’re still showing up.”
- “Even thinking about change takes courage. That’s already happening here.”
- “You care about being a good parent- and that’s showing up in this conversation.”
Why it works: Affirmations shift the frame from what’s not happening to what’s possible, increasing patient confidence and deepening alliance.
4. Double-Sided Reflections (When the Patient Feels Torn)
What it is: Reflecting both sides of ambivalence in a nonjudgmental way.
Use it when:
- The patient says “yes, but…” or expresses two conflicting desires
- You want to validate the tension and avoid pushing either side
Example:
- “You want to feel more present with your family- and you’re also worried that cutting back at work could put your job at risk.”
Why it works: It shows the patient you understand the complexity of their experience, and that you trust them to sort through it.
5. Ask Permission Before Giving Advice (When You Have a Recommendation)
What it is: Respectfully offering ideas only after the patient is ready or gives permission.
Use it when:
- You have a helpful tool or suggestion
- You want to avoid triggering resistance
- The patient has shared a clear need but isn’t acting on it yet
Examples:
- “Would it be okay if I shared something that’s helped other patients in similar situations?”
- “I have a thought- would it be helpful to hear it, or would you rather keep exploring a bit first?”
Why it works: This respects patient autonomy and avoids the “righting reflex” (our urge to fix), which often leads to pushback.
Why This Approach Works: Research and Outcomes
- MI improves engagement, retention, and adherence across a range of presenting concerns including depression, anxiety, trauma, and substance use.
- MI is particularly effective across diverse racial, ethnic, and cultural groups, and aligns with culturally responsive, equity-focused care (Hettema et al., 2005; Díaz & González, 2020).
- Therapists report lower burnout and higher satisfaction when using MI techniques, especially with patients who are unsure, ambivalent, or stuck.
Overall, MI helps patients feel empowered and understood, while helping therapists feel more connected, effective, and grounded.
Integrating MI into Your Practice: Getting Started
You don’t need to master MI overnight. Try this:
- Start with one skill (e.g., reflections) and increase your use each week.
- Track your ratio of questions vs. reflections in session.
- Practice affirmations intentionally—look for what’s going well, not just what needs to change.
- Reflect after session: When was your impulse to give advice strongest? What happened when you paused?
Motivational Interviewing is not about getting patients to do something. It’s about creating the kind of relationship where patients can imagine and pursue change on their own terms.
When you listen deeply, reflect thoughtfully, and trust the process, you help patients step into their own agency—and you make therapy more collaborative, sustainable, and impactful.
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