Table 6. Components of Motivational Interviewing (MI)
Components1,2DefinitionExamples/Rating Scheme
Relational domain
    MI SpiritMI spirit is exemplified by collaboration in all areas of MI practice; eliciting and respecting the client's ideas, perceptions, and opinions; eliciting and reinforcing the client's autonomy and choices; and accepting the client's decisions.
The spirit of MI has 3 foundations:
  1. Collaboration: Collaboration between the primary care provider and the patient or “client” builds a trusting relationship.

  2. Evocation:- Helping the client to voice their own ideas and reasons for change.

  3. Autonomy/support: The provider supports the patient as the agent of change, and the patient is responsible for following through or not. The provider is supportive of the patient regardless of whether and how they decide to change.

Average of global scores of evocation, collaboration, and autonomy/support (scales of 1 to 5; percentage highest; average, 3); providers score high on collaboration when they negotiate with the client, respect the client's ideas about how change can occur, avoid persuasion, and focus on supporting the client's own concerns and ideas. Confrontational, authoritative, and rigid providers score low on collaboration.
Higher scores on evocation result when the provider draws out the client's ideas as opposed to instilling knowledge, insights, and advice. Lower scores are ascribed to providers who show little interest in the client's perspective or display cynicism about prospects for change.
Higher scores for autonomy/support occur when the provider readily accepts the client's decisions not to change at that particular moment. This provider recognizes that critical factors predicting change reside within the client. Low autonomy/support is typified by an urgency to change and lack of acceptance of the client's capability to decide to change or not; client freedom of choice and self-determination is not recognized in this instance.
    EmpathyExpressing empathy includes expressing understanding of the patient's lived experience or seeing, feeling, and experiencing the world through the patient's eyes.Range 1 to 5 (higher is better; average, 3); high empathy is characterized by the provider showing active interest in the client's perspectives, including situation, meaning, perceptions, and feelings. Low empathy is characterized by a lack of interest in the client's perspectives and experiences. Probing for factual information and pursuing an agenda are examples of low empathy.
Technical domain
    MI-adherent statementsThis category is used to capture particular interviewer behaviors that are consistent with a motivational interviewing approach.
Affirmation: The provider says something positive or complementary to the client; may be in the form of appreciation, confidence, or reinforcement. The provider comments on the client's strengths or efforts.
Emphasize autonomy: The provider recognizes the client's freedom of choice, autonomy, and ability to decide.
Asking permission before giving advice or permission: Asking what the client already knows or has already been told about a topic before giving advice or information.
Support: The provider makes a statement that takes on a compassionate, sympathetic, supportive, or agreeing quality.
“It takes courage to come in and talk about depression.” (Affirm)
“You've got a point there.” (Emphasizing the client's control)
“May I share some information about antidepressant medications?” (Ask permission)
“Well, there is really a lot going on for you right now.” (Support)
    Open-ended questionsAn open question is coded when the interviewer asks a question that allows a wide range of possible answers. The question may seek information, invite the client's perspective, or encourage self-exploration. The open question allows the option of surprise for the questioner.
“Tell me more” statements are coded as open questions unless the tone and context clearly indicate a direct or confront code.
“What is your take on that?” (Open question)
    Reflective statements (simple and complex)This category is meant to capture reflective listening statements made by the provider in response to client statements. A reflection may introduce new meaning or material, but it essentially captures and returns to clients something about what they have just said.
Simple: Simple reflections typically convey understanding or facilitate client/provider exchanges. These reflections add little or no meaning (or emphasis) to what clients have said.
Complex: Complex reflections typically add substantial meaning or emphasis to what the client has said. These reflections serve the purpose of conveying a deeper or more complex picture of what the client has said. Sometimes the provider may choose to emphasize a particular part of what the client has said to make a point or take the conversation in a different direction.
“You are determined to start an antidepressant medication.” (Simple reflection)
“On the one hand you perceive potential benefit from the medicine, and on the other hand you are terrified of getting addicted.” (Complex reflection)
    MI-consistent languageMI adherent statements + reflections + open questions
    RulersThe confidence and importance rulers invite the client to rate their confidence or importance on a 0 to 10 scale regarding making a target behavior change.The provider may implement the rulers to evoke client “change talk,” or language toward making a specific behavior change. When the client provides a number, eg, “5,” the provider can ask, “Why did you say ‘5’ and not ‘2’?” which evokes reasons for change. Alternatively, the provider might say, “What would it take to raise the ‘5’ to an ‘8’?,” which also evokes change talk. The process involves 2 open questions.
    Ask–provide–ask or elicit–provide–elicitThe ask—provide–ask tool is an MI-consistent approach to sharing information. First, the provider asks permission to share information, then with permission shares information, and follows by asking the client what they think or how they are reacting to the information. A variant is the elicit–provide–elicit approach for garnering learning about a client's thoughts or perspectives, sharing information or one's perspectives with permission, then eliciting more of the client's perspectives and change talk.The provider firsts asks permission to share information by asking, for example, “Would you be interested in hearing more about possible treatment options for depression?” If the patient assents, the provider can then provide information, then ask about or elicit the client's thoughts, eg, by asking “What do you think about those options?”
    Elaborate, affirm, reflect, summarizeWhen a provider recognizes change talk, the goal is to reinforce the change talk. The provider then asks the patient to elaborate on what they meant using evocative questions, affirms the patient's statements toward positive change, and reflects the change talk. This approach often elicits more change talk. The provider then summarizes the patient's change talk, any plans to change, and strengths.
    Giving informationIf the provider gives information, educates, provides feedback, or discloses personal information, it is considered “giving information.”An example would be feedback from a depressive symptom scale. “You scored a 19 on the depressive symptoms scale, which is consistent with moderately severe depressive symptoms.”
    Closed questionsClosed questions can be answered with a “yes” or “no.”“Have you been taking your antidepressant medication as prescribed?”
    MI-nonadherent statementsAdvising, directing, confronting
Advising without permission involves uninvited advice, suggestions, or a solution.
Direct- involves a command, direction, or order.
A confrontation involves expert-like responses that have a particular negative/parental quality, an uneven power relationship accompanied by disapproval, disagreement, or negativity.
The provider may directly disagree, argue, correct, shame, blame, seek to persuade, criticize, judge, label, moralize, ridicule, or question the client's honesty.
“I'd recommend that you start an antidepressant medication.” (Advising)
“At this point, you really need to get some therapy.” (Direct)
“It's evident to me that you are not taking your medicine.” (Confrontation)