The widely-disseminated clinical method of motivational interviewing (MI) arose through a convergence of science and practice. Beyond a large base of clinical trials, advances have been made toward "looking under the hood" of MI to understand the underlying mechanisms by which it affects behavior change. Such specification of outcome-relevant aspects of practice is vital to theory development, and can inform both treatment delivery and clinical training. An emergent theory of MI is proposed, emphasizing two specific active components: a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and reinforcement of client change talk A resulting causal chain model links therapist training, therapist and client responses during treatment sessions, and post-treatment outcomes.

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Background: A recommendation in original descriptions of motivational interviewing (MI) was to "explore ambivalence". Contrasting procedures for doing so have been clarified through the evolution of MI. Aims: This article describes two conceptually distinct methods for responding to ambivalence: decisional balance (DB) and MI's evocation of change talk, and reviews empirical evidence to recommend when each procedure is appropriate (and inappropriate) in clinical practice. Method: The authors summarize findings of clinical outcome research to examine how these two interventions impact the resolution of client ambivalence. Results: With ambivalent people, a DB intervention tends to decrease commitment to change, whereas evocation (a key element of MI) promotes change. When a person has already made the decision to change, evocation is unnecessary and may deter change, whereas DB may further strengthen commitment. Conclusions: DB is an appropriate procedure when the clinician wishes to maintain neutrality and not favor the resolution of ambivalence in any particular direction. Evocation is appropriate when the clinician intends to help clients resolve ambivalence in the direction of change.Keywords: Motivational interviewing, motivational enhancement therapy, cognitive therapy, cognitive appraisals, health psychology, psychotherapy process. BackgroundAmbivalence is normal when considering a change. The transtheoretical model (TTM; Prochaska and DiClemente, 1984), for example, describes a sequence of stages through which people pass toward change. In the "precontemplation" stage the person is not ambivalent, not even considering change. Ambivalence is characteristic of the "contemplation" stage, wherein the person experiences motivations both for and against change. The resolution of ambivalence frees the person to consider alternatives, "preparation" stage, and take "action".Health professionals are commonly trained to help people who are at least in the preparation stage, already wanting and intending to make a change. Many who seek treatment, however, W. R. Miller and G. S. Roseare still ambivalent about changing. Thus the clinician's solutions and proffered treatment plan can be met with reticence or noncompliance, sometimes causing clients to be regarded as "unmotivated" or "in denial". Historically in addiction treatment, such individuals were sometimes told, "Come back when you're serious about changing." In contrast, a TTM perspective indicates that helping clients resolve ambivalence is a key part of a clinician's role, presaging movement to the action stage of change.How, then, can clinicians best help clients to resolve ambivalence and move toward change? This article contrasts two different clinical approaches that are often confused with each other: motivational interviewing (MI) and decisional balance (DB). Each, we believe, has appropriate but different applications in clinical practice. Early development of Motivational InterviewingMotivational Interviewing (MI) was introduced as a clinical tool to ...