If you have ever tried to convince someone to take a medication they are sceptical of, you have probably noticed that pressure backfires. The harder you push, the more they dig in. Motivational interviewing (MI), developed by William Miller and Stephen Rollnick in the 1980s, is a counselling style built around the opposite assumption: that pressure activates the part of a person that argues against change, and that real change tends to come from inside, when ambivalence is explored rather than fought.
MI started in the alcohol and addiction field. Over the past two decades it has been adapted for schizophrenia — for medication adherence, substance use, smoking cessation, and engagement with treatment more broadly.
Motivational interviewing is a collaborative, person-centred conversational style that helps people resolve their own ambivalence about change — without arguing, lecturing, or trying to install motivation from the outside.
The four MI processes
Miller and Rollnick describe MI as moving through four overlapping processes:
- Engaging — building a working relationship rooted in respect.
- Focusing — agreeing on what change might be worth talking about.
- Evoking — drawing out the person's own reasons for change rather than supplying them.
- Planning — supporting concrete next steps when readiness is there.
The "spirit" of MI
MI is sometimes summarised by its underlying stance, abbreviated PACE:
- Partnership — the clinician and patient are working together; the clinician is not the expert on the patient's life.
- Acceptance — affirming the person's autonomy, worth, and right to make their own choices.
- Compassion — prioritising the person's welfare over the clinician's agenda.
- Evocation — drawing out, not putting in.
Core skills (OARS)
- Open questions — "What do you notice when you skip a dose?"
- Affirmations — naming strengths, even small ones ("You came to this appointment even though you didn't really want to.")
- Reflective listening — feeding back what you hear, including the underlying feeling.
- Summaries — pulling together what the person has said so they can hear it themselves.
Why it suits schizophrenia care
People with schizophrenia have often experienced years of being told what to do — by clinicians, family members, hospitals, and sometimes courts. Adversarial conversations are exhausting, and many people have learned to say what others want to hear and then quietly disengage. MI offers a different path. It does not pretend that medication or treatment doesn't matter. It just doesn't try to win an argument that has never been won by argument.
Where MI has the strongest evidence in psychosis
Substance use
Cannabis, alcohol, and stimulant use are common in schizophrenia and worsen outcomes. MI, often combined with CBT, has the strongest evidence base of any psychosocial intervention for co-occurring substance use in serious mental illness. The NICE guideline on coexisting psychosis and substance misuse (CG120) recommends MI-based approaches as part of integrated treatment.
Medication adherence
Trials of MI-based "compliance therapy" (Kemp and colleagues, 1996, 1998) showed improvements in adherence and insight, though replication has been mixed. MI is now most often used as one ingredient in broader adherence interventions rather than a standalone treatment.
Engagement
Early intervention services use MI extensively to keep young people coming back to appointments after a first episode. Engagement, not insight, is often the limiting variable in early psychosis care.
Smoking cessation
Roughly 60% of people with schizophrenia smoke, and quit attempts succeed less often than in the general population. MI-based smoking cessation, often combined with nicotine replacement and varenicline, is widely recommended.
What MI looks like in practice
A typical MI exchange about medication might sound like this. The patient says, "I don't see why I have to keep taking this stuff, I haven't been sick for months." A non-MI response might be, "Because you'll relapse if you stop." An MI-style response might be, "It sounds like you're noticing how much better you've been feeling, and you're wondering whether you still need the medication. What's been going through your mind?" The conversation that follows is led by the patient's own thinking, not the clinician's.
What MI is not
- It is not a manipulative trick to get people to do what you want.
- It is not avoidance of difficult topics.
- It is not endless reflection without direction — the focusing and planning processes are real.
- It is not a substitute for medication or hospitalisation when those are clinically necessary.
Can families use MI ideas?
Yes, with caveats. Families are not therapists, and applying MI inside a household can feel artificial. But the underlying spirit — listening more than arguing, affirming autonomy, exploring ambivalence rather than rushing past it — overlaps significantly with the LEAP method and is genuinely useful in everyday conversations about treatment, sleep, substance use, and goals.
Finding an MI-trained clinician
The Motivational Interviewing Network of Trainers (MINT) maintains a directory. Many community mental health centres now train staff in MI as part of their standard onboarding. When asking, the more useful question is not "Are you trained in MI?" but "Tell me how you typically work with people who are unsure about medication."
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.