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Peer Support:

Why Motivational Interviewing Does Not Align with Peer Support Skills

Psychotherapy session, woman talking to psychologist

Peggy Swarbrick Ph.D., FAOTA, Research Professor, Rutgers Graduate School of Applied and Professional Psychology and Associate Director of the Center of Alcohol & Substance Use Studies; Director, Collaborative Support Programs of New Jersey Wellness Institute

Motivational Interviewing and peer support skills are both approaches used in healthcare and mental health settings to support individuals in achieving their wellness goals. While they share some similarities, they differ greatly in their underlying principles, techniques, and the roles of the individuals involved. Here’s an overview of the key distinctions:

Motivational Interviewing is an evidence-based approach commonly used to facilitate behavior change and promote engagement. Motivational Interviewing (MI) is a client-centered counseling approach designed to help individuals explore and resolve ambivalence toward behavior change. It’s often used in healthcare settings to address issues such as addiction, chronic diseases, and mental health concerns. MI is grounded in collaboration, evocation, autonomy, and compassion. It recognizes that individuals have the intrinsic motivation for change and aims to enhance that motivation by resolving ambivalence and building confidence. MI employs specific techniques such as reflective listening, open-ended questioning, affirmations, and summarizing. The counselor or healthcare professional using MI seeks to guide the individual in exploring their values, goals, and reasons for change.  The counselor comes in with an agenda which is very different from peer support where the agenda is set by the person. 

The professional using MI takes on the role of a facilitator who actively listens, reflects, and helps the individual articulate their motivations for change. The focus is on guiding rather than directing the conversation.  Though not directive there is a tendency to guide and focus on a stage of change which can detract the counselor from listening attentively to the persons. MI is often aligned with the Transtheoretical Model of Change, recognizing different stages individuals go through in the process of behavior change.

Peer support involves individuals with similar lived experiences providing assistance, encouragement, and understanding to one another. It aims to create a supportive and empathetic environment for individuals facing challenges. Peer support is built on shared experiences, empathy, trust, and a non-hierarchical relationship between peers. The focus is on the mutuality of the relationship, where both individuals can learn from and support each other. Peer support relies on active listening, sharing personal experiences, providing emotional support, and offering practical assistance. It’s about creating a space where individuals feel understood, accepted, and empowered. Peer supporters leverage their own experiences to provide insights, understanding, and encouragement. The relationship is often more reciprocal, with both parties contributing to the support process and both learning something beneficial,which is part of what makes it mutual even when the peer supporter is in a paid position. Peer support often extends beyond one-on-one interactions to include group settings, creating a sense of community. Shared experiences within the group contribute to a supportive network for individuals facing similar challenges.

The following are Key Differences:

Professional vs. Peer Relationship:

MI is typically conducted by healthcare professionals or counselors, whereas peer support involves individuals with similar lived experiences supporting each other.

Directive vs. Collaborative:

MI involves a more directive approach where the professional guides the individual through reflective processes. Peer support is collaborative, with both individuals actively contributing to the support relationship.

Focus on Ambivalence vs. Shared Experiences:

MI addresses ambivalence and explores motivations for change. Peer support focuses on shared experiences, empathy, and understanding between individuals facing similar challenges.

Motivational Interviewing and peer support skills differ in their underlying principles, techniques, and the roles of those involved. MI is a counseling approach often used by professionals, emphasizing ambivalence, focused on labeling or assessing someone to a stage of change they perceive so they can guess the person’s motivation for change. Peer support, on the other hand, relies on shared experiences and mutual support among individuals facing similar challenges.  

I have very serious concerns that peer support specialists are being trained extensively to use MI especially when a person is in crisis.  There are limitations and potential dangers when applying MI skills and approaches to individuals experiencing an acute crisis, especially those at imminent risk for suicide. 

  1. Time Sensitivity:
    • MI is typically a time-intensive approach, focusing on building rapport and exploring ambivalence. In a crisis situation, there may not be enough time to employ MI techniques effectively, and a more relevant and immediate intervention might be necessary.
  2. Intensity of Emotions:
    • During a crisis, individuals may be overwhelmed by intense emotions, making it challenging to engage in reflective conversations. Emotionally charged situations may not align with the calm and collaborative atmosphere typically created in MI.
  3. Cognitive Impairment:
    • Acute crises, especially those related to mental health, may involve cognitive impairment or altered states of consciousness. In such cases, the person may have difficulty engaging in reflective and goal-oriented conversations.
  4. Risk of Miscommunication:
    • MI relies on effective communication and understanding the client’s perspective. In crisis situations, miscommunication may occur due to heightened emotions, leading to misunderstandings and potential escalation of the crisis.

Dangers:

  1. Delay in Immediate Intervention:
    • The primary goal during a crisis, especially when there is imminent risk of suicide, is immediate intervention to ensure the person’s safety. Using MI may delay the implementation of critical crisis interventions.
  2. Overemphasis on Collaboration:
    • MI emphasizes collaboration and autonomy. In a crisis, there might be a danger of overemphasizing collaboration, potentially allowing the individual to avoid necessary immediate interventions.
  3. Inadequate Assessment of Risk:
    • MI may not provide the structured assessment needed to evaluate the severity of the crisis and the potential for harm. It may not be sufficient for identifying and managing acute suicidal ideation and plans.
  4. Potential for Escalation:
    • The reflective nature of MI might not be suitable for managing crises where there is a risk of escalation or violence. Encouraging individuals to explore ambivalence might be inappropriate in situations where immediate safety is a concern and may pose a risk to the peer staff as well as the person being supported. 


For these reasons, there are concerns about peer staff being trained extensively to use MI as a clinical tool as it conflicts with some of the core values and practices of peer support.If you do train peer staff to use MI as an intervention consider the limitations and potential dangers, particularly in crisis situations.