Motivational Interviewing
Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change, used to strengthen a person's own motivation and commitment to a specific goal by drawing out and exploring their reasons for it in an atmosphere of acceptance and compassion. William Miller and Stephen Rollnick developed the method and set out its current form in the third edition of Motivational Interviewing: Helping People Change in 2013, organized around four processes: engaging, focusing, evoking, and planning. Its core skills are usually taught as OARS, meaning open questions, affirmations, reflections, and summaries.
Source: Miller WR and Rollnick S, Motivational Interviewing: Helping People Change, 3rd edition, 2013
What makes motivational interviewing distinctive is what the clinician stops doing. The instinct when a patient is not taking a medication is to supply reasons they should, and MI treats that instinct, the righting reflex, as the thing to hold back, because arguments the clinician supplies tend to produce arguments the patient supplies against them. The clinician's job is to draw the reasons out of the patient and then help the patient hear their own.
The four processes describe a sequence without being a script. Engaging is establishing the working relationship the rest depends on. Focusing is negotiating what this conversation is actually about, which is often not what the visit was booked for. Evoking is where the specific work happens, exploring the patient's own motivation and their ambivalence rather than resolving it for them. Planning follows once the patient's reasons are on the table. A clinician can find themselves back in engaging halfway through planning, and that is normal rather than a failure.
Of the four OARS skills, reflections are the one that has to be trained. Asking open questions is a habit most clinicians can adopt in an afternoon, and affirmations and summaries follow. Reflecting well means saying back what the patient meant, not what they said, at a level that moves the conversation forward, and getting it slightly wrong is often more useful than getting it exactly right because the patient corrects you. That skill needs repetition with feedback, which is why MI training has always leaned on recorded practice and coding rather than lecture. The Motivational Interviewing Treatment Integrity code exists precisely because MI fidelity is judged from a recording rather than assumed from attendance.
For a graduate medical education program, MI is the natural companion to the high-stakes conversation curriculum rather than a competitor to it. Breaking bad news, goals of care, and error disclosure all involve moments where the clinician has to hold back the answer and let the patient speak, and MI is the method that names and drills that discipline. Its usual clinical home is behavior change, meaning adherence, substance use, weight, and smoking, but the underlying skill shows up in every conversation where the patient's own reasoning is the thing that has to move.
What this looks like in a program
- Programs that add MI usually find open questions arrive quickly and reflections do not, so the practice time belongs on reflections.
- MI fidelity is coded from a recording. A curriculum that cannot produce recordings cannot tell whether its learners are doing MI or doing advice with a friendlier tone.
- The righting reflex is the behavior to watch for in a debrief, because it is the one a well-intentioned clinician defaults to under time pressure.
Last updated August 2026