Motivational Interviewing Case Formulation: Worked Example

A structured way to understand ambivalence, select the next motivational interviewing process, and keep treatment planning collaborative.

Related articles: Change Talk vs Sustain Talk: A Practical MI Guide, Using Motivational Interviewing to Address Client Resistance.

More resources: Explore Motivational Interviewing Training.

Clinical note: This fictional example is for practitioner education. An MI formulation complements, but does not replace, comprehensive assessment, diagnosis where relevant, cultural formulation, risk assessment, medical review, informed consent, or discipline-specific obligations.

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What is a motivational interviewing case formulation?

A motivational interviewing (MI) case formulation is a concise, collaborative, and revisable account of what change the client is considering, why the status quo currently makes sense, what personally meaningful reasons for change are emerging, how confident the client feels, and which MI process is most useful next. It converts assessment information into a working guide for the conversation without turning ambivalence into a character flaw (Bischof et al., 2021; Gilboa-Schechtman, 2024; Miller & Rollnick, 2023).

Like other clinical formulations, it is a hypothesis rather than a verdict. It should organise relevant information and guide intervention and change as new evidence emerges (Gilboa-Schechtman, 2024). What makes an MI formulation distinctive is its attention to autonomy, language, and timing: the client’s own values and arguments for change matter, sustain talk is treated as one side of ambivalence, discord is understood relationally, and planning waits until readiness is present.

MI’s four processes – engaging, focusing, evoking and planning – provide the organising spine. They are not rigid stages. A practitioner may move forward, step back, or revisit a focus as the conversation changes (Miller & Rollnick, 2023).

In one sentence: An MI formulation explains what the client is ambivalent about, how the current behaviour serves them, what might pull them towards change, and what the practitioner should do next without getting ahead of the client.

What an MI formulation should contain

• Define the possible change. What specific behaviour, decision, or treatment task is under consideration? Use neutral, observable language and check that the client recognises it as a relevant focus.
• Describe the current pattern and function. When does the behaviour occur, what precedes it, what immediate benefit does it provide, and what longer-term effects has the client noticed?
• Name the client’s values and preferred future. Which relationships, roles, hopes, identities, or values could make change personally meaningful? Avoid substituting the practitioner’s reasons.
• Map both sides of ambivalence. Record representative sustain talk and change talk in the client’s own words. Do not count all negative statements as resistance or assume that more change talk automatically means readiness.
• Estimate importance and confidence separately. A client may believe change matters but doubt they can do it, or feel capable but see little reason to begin. Each pattern calls for a different conversation.
• Identify strengths and prior exceptions. What has the client already done, learned, or survived that supports hope and self-efficacy? Include supportive people and practical resources.
• Check engagement, discord, and power. How safe, understood, and autonomous does the client feel? Could referral pressure, professional authority, culture, identity, discrimination, or material constraints be shaping the conversation?
• Locate the current MI process. Is the immediate task to strengthen engagement, agree a focus, evoke motivation, or develop a plan?
• Write a tentative working hypothesis. Link function, ambivalence, values, confidence, and context in plain language. Mark inference as inference and invite correction.
• Choose the next conversational direction. Specify what the practitioner will listen for and which MI-consistent strategies may help, while leaving the decision about change with the client (Gilboa-Schechtman, 2024; Miller & Rollnick, 2023).

A reusable MI formulation template

The template below is deliberately brief. It can sit inside a fuller biopsychosocial or Five Ps formulation rather than replace it.

Formulation field	Clinical prompt
Possible change	The behaviour, decision, or treatment task under consideration
Client’s description	What the client says is happening; their preferred language
Function and context	Triggers, immediate benefits, social context, and longer-term costs
Values / preferred future	What matters and how life might be different
Sustain talk	Client’s reasons for keeping things as they are
Change talk	Desire, ability, reasons, need, commitment, activation and steps
Importance / confidence	Separate ratings, evidence and what could raise each rating
Strengths and supports	Past successes, skills, relationships, and practical resources
Discord / power / culture	Signs of mismatch, external pressure, cultural meanings, and structural constraints
Current MI process	Engaging, focusing, evoking or planning – and why
Working hypothesis	One tentative paragraph linking the information
Next MI direction	What to listen for; possible prompts; safety or referral actions

Sources: Gilboa-Schechtman (2024) and Miller and Rollnick (2023).

Worked example: Daniel and after-work drinking

Daniel is a fictional 42-year-old project manager who attends after his GP raises concerns about blood pressure, sleep, and alcohol use. Daniel reports drinking four to six standard drinks on most weeknights and more on some Fridays. He says alcohol is the fastest way to switch off after work. He dislikes labels, does not want to be told to abstain and is unsure whether his drinking is ‘bad enough’ to justify treatment. At the same time, he is tired of poor sleep and being irritable with his eight-year-old daughter during weekend contact.

Daniel has reduced his drinking for several weeks on two previous occasions. He rates the importance of making some change as 6/10 and his confidence as 4/10. He is willing to examine the pattern but is not yet asking for a reduction plan.

Assessment boundary: This information is insufficient to diagnose an alcohol use disorder or determine whether abrupt reduction would be medically safe. The clinician would clarify quantity, pattern, withdrawal history, other substance use, medication, physical and mental health, risk, and relevant safeguarding concerns; use validated screening where appropriate; and coordinate medical review within scope.

Step 1 – Define the possible change

The initial focus is not ‘make Daniel stop drinking’. A neutral possible change is: examine whether and how Daniel wants to alter his after-work alcohol use. This wording preserves direction while leaving the outcome open.

Step 2 – Understand function and context

Daniel’s drinking is negatively reinforced: it quickly reduces tension and marks the transition out of work. It also has relational and health-related costs that are becoming harder for him to ignore. A useful formulation must hold both truths. If the clinician records only the costs, the case will look simpler than Daniel experiences it and the righting reflex will be difficult to resist.

Step 3 – Identify values and preferred future

Daniel wants to be an energetic and patient father, perform well at work, and retain control over his own decisions. These values create possible discrepancy, but the practitioner does not announce it for him. The task is to help Daniel hear the relationship between his behaviour and what matters to him.

Step 4 – Map ambivalence in Daniel’s own language

Language	Daniel’s words	Formulation meaning
Sustain talk	‘It is the only reliable way I switch off.’	Immediate relief; perceived lack of alternatives
Sustain talk	‘I still get to work and pay my bills.’	Questions severity; protects competence and identity
Change talk – desire	‘I would like to wake up clearer.’	Preferred experience
Change talk – ability	‘I cut back for a month last year.’	Evidence of capacity
Change talk – reason	‘I hate being short with my daughter.’	Parenting value and relational cost
Change talk – need	‘I cannot keep pretending the sleep is fine.’	Growing urgency

The table does not function as a scoreboard. Process research generally supports close attention to therapist behaviour and client language, but the pathway from change talk to outcome is complex and conditional (Magill et al., 2018; Miller & Rose, 2009; Pace et al., 2017). The clinician listens for quality, context, and movement rather than mechanically tallying phrases.

Step 5 – Separate importance from confidence

Daniel’s importance rating of 6 suggests meaningful concern without settled commitment. His lower confidence rating of 4 suggests that repeated attempts and limited stress-management alternatives may be holding him back. Arguing that the problem is more serious would miss the confidence issue. Helpful exploration may include why his rating is 4 rather than 1, what worked during the month he cut back, and what support would make a small experiment feel more achievable.

Step 6 – Identify strengths and resources

• Daniel has made a sustained change before, even if it did not last.
• He is observant about links among drinking, sleep, and irritability.
• He values his relationship with his daughter and protects time with her.
• He attended despite discomfort and is willing to examine the pattern.
• His GP may be a practical source of medical assessment and ongoing support.

Step 7 – Check discord, power and cultural meaning

Daniel’s dislike of labels and referral by a health professional create a risk that he will experience the conversation as judgmental or coercive. The clinician should ask how he understood the referral, acknowledge his right to decide, use his preferred language, and explore what alcohol means within his work and social context. The formulation should remain open to cultural, socioeconomic, and identity-related influences that have not yet been discussed.

Step 8 – Locate the current MI process

Engagement is adequate but still vulnerable. A tentative shared focus exists. Daniel is expressing preparatory change talk, yet he is not asking how to change. The best fit is therefore late focusing / early evoking, with continued attention to engagement. Planning would be premature.

Step 9 – Write the working hypothesis

Concise MI formulation: Daniel uses alcohol as a rapid and socially familiar way to regulate after-work tension. The immediate relief and his wish to avoid judgment sustain the pattern. Concern about sleep, health, and being the father he wants to be is generating change talk, while low confidence and limited alternatives weaken movement towards action. Because referral pressure and labels may evoke discord, the clinician should emphasise autonomy, continue evoking Daniel’s own reasons and strengths, and defer detailed planning until he signals readiness. Medical assessment is needed before advising substantial reduction.

Step 10 – Choose the next MI direction

The formulation points to an immediate conversational task rather than a predetermined treatment package. The clinician will:

• affirm Daniel’s honesty, persistence, and previous success;
• use complex reflections that hold relief and cost together;
• invite elaboration of values-linked reasons for change;
• explore confidence by drawing out prior success and possible supports;
• ask permission before sharing medical information; and
• watch for stronger change talk, spontaneous ideas, or questions about next steps before moving into planning.

How the formulation shapes the conversation

Process	Speaker	Illustrative dialogue
Engaging	Daniel	‘I do not want this to turn into someone telling me I am an alcoholic.’
Engaging	Clinician	‘Keeping control of the decision matters to you, and labels would get in the way of an honest conversation.’
Focusing	Clinician	‘Would it be useful to look at what drinking does for you and what, if anything, you might want to be different?’
Evoking	Daniel	‘It helps me switch off, but I am sick of losing half my Saturday.’
Evoking	Clinician	‘It gives you relief quickly, and you are becoming less willing to pay for that relief with your weekends.’
Evoking	Clinician	‘Why is making some change a 6 rather than a 2?’
Confidence	Daniel	‘I did manage a month. I was running after work then.’
Confidence	Clinician	‘You have evidence that you can change the pattern when another way of decompressing is available.’
Transition	Clinician	‘What, if anything, do you feel ready to do next?’
Planning	Daniel	‘First I should talk to my GP about doing it safely. I can also track what I drink and what is happening beforehand for a week.’

The clinician does not insert a plan merely because the session is ending. Planning becomes appropriate when Daniel begins to mobilise: he asks about options, proposes steps, visualises change, or uses stronger commitment language. Even then, plans remain voluntary, specific, and linked to safety.

A formulation-to-plan bridge

Decision point	MI-consistent direction
Immediate aim	Strengthen Daniel’s own reasons and confidence while maintaining engagement and autonomy
What to listen for	Increasing strength or frequency of change talk; spontaneous problem-solving; reduced defensiveness; questions about how
Possible MI strategies	Complex reflections; values questions; importance/confidence rulers; looking back/forward; affirming prior success; summaries that collect change talk
Information exchange	Use elicit-provide-elicit and seek permission before discussing health effects or support options
Safety action	Encourage timely GP assessment before a substantial reduction if physiological dependence or withdrawal risk is possible
Planning threshold	Daniel indicates readiness and chooses a direction; do not infer readiness solely from attendance or practitioner concern
Review	Revisit the formulation after new assessment information, a change attempt, increased discord, or a shift in goals

Source: Miller and Rollnick (2023).

How MI formulation changes clinical thinking

Unhelpful shorthand	More useful MI formulation
‘Daniel is resistant.’	Daniel is voicing sustain talk, and referral pressure may be creating discord.
‘He lacks insight.’	He sees some costs and some benefits; the discrepancy is not yet resolved.
‘He needs abstinence.’	A safe clinical assessment is needed; the change goal must be discussed collaboratively within legal and ethical limits.
‘He failed before.’	A prior month of change provides evidence about ability, conditions for success, and barriers.
‘He is in the contemplation stage.’	Readiness is dynamic and topic-specific; the current conversational task is early evoking.
‘The next step is a treatment plan.’	The next step is to strengthen motivation and confidence until Daniel signals readiness for planning.

The MI formulation principles illustrated in this table are based on Miller and Rollnick (2023).

Common formulation mistakes

• Turning formulation into persuasion. If the document is written to prove why the client must change, it has already lost the MI spirit.
• Confusing sustain talk with discord. Sustain talk concerns the target behaviour; discord concerns the working relationship. They may occur together but call for different responses.
• Using fixed readiness labels. A client can be ready to discuss one change and not another, or move between processes within one conversation.
• Collecting only deficits. Past successes, strengths, values, and environmental supports are not decorative; they shape confidence and options.
• Moving to planning on weak signals. Agreement with the practitioner is not the same as autonomous commitment.
• Ignoring risk and scope. MI does not suspend safeguarding, medical assessment, mandatory obligations, or evidence-based care.
• Writing culture as a client variable only. Formulation should also consider practitioner power, service structures, discrimination and whether the proposed goal reflects the client’s community and context (Gilboa-Schechtman, 2024; Miller & Rollnick, 2023).

Clinical and cultural safeguards

MI is compatible with a broad range of settings, but a formulation remains ethically sound only when it is collaborative, proportionate, and responsive to context. Practitioners should:

• distinguish client language from clinician inference and invite the client to correct the formulation;
• ask what the behaviour and proposed change mean within the client’s cultural, family, and community contexts;
• consider structural barriers, including cost, housing, discrimination, work demands, and access to care;
• adapt language and communication for disability, neurodivergence, health literacy and interpreter needs;
• avoid using MI to secure compliance with a goal the client has not chosen, except that practitioners must still communicate clearly and act when safety or legal duties require it; and
• document uncertainty and update the formulation when the client’s goals, risks or circumstances change (Gilboa-Schechtman, 2024; Miller & Rollnick, 2023).

Develop your MI formulation skills

A useful learning sequence is to consolidate the spirit, OARS and four processes before applying MI to more complex cases.

Motivational Interviewing: The Basics

• Format: Text
• Duration: 4 hours

A current foundation in MI spirit, OARS, four processes, ambivalence, change talk, sustain talk, and relational repair.

View course details >

Introduction to Motivational Interviewing: Resolving Ambivalence and Changing Behaviour

• Format: Video
• Duration: 1 hour

A concise demonstration of DARN-CAT, confidence rulers, and OARS for moving from ambivalence towards resolution.

View course details >

Using Motivational Interviewing with Alcohol Dependence and Depression

• Format: Video
• Duration: 1 hour

A case-based demonstration of open questions, affirmations, reflections, summaries, and eliciting change talk in a clinically complex presentation.

For a broader pathway across foundational and applied topics, explore the MHA course catalogue’s motivational interviewing course suite.

Related practitioner reading

• Motivational Interviewing: Update Your Understanding  –  review how the language and emphasis of MI have evolved.
• Using Motivational Interviewing to Address Client Resistance  –  distinguish sustain talk from discord and explore broader response strategies.
• Treating Generalised Anxiety with Motivational Interviewing  –  examine MI within a specific clinical application.

Conclusion

Motivational interviewing case formulation offers practitioners a structured way to understand not only what a client may want to change, but also what is maintaining the current behaviour, what makes change personally meaningful, and what kind of conversation is most useful next.

As Daniel’s example demonstrates, an effective MI formulation holds both sides of ambivalence at once. It recognises the benefits a behaviour currently provides alongside its emerging costs, while attending to the client’s values, confidence, strengths, context and autonomy. Rather than labelling a client as resistant, unmotivated or lacking insight, it asks a more clinically useful question: What makes sense about the client’s current position, and what might help them move towards change in their own way?

Importantly, formulation should guide rather than dictate intervention. The practitioner may need to strengthen engagement, clarify the focus, evoke the client’s own motivation or, when readiness emerges, support planning. Moving ahead too quickly risks replacing collaboration with persuasion.

An MI formulation is therefore best understood as a living hypothesis: concise enough to guide the next conversation, flexible enough to change as new information emerges, and collaborative enough for the client to recognise themselves within it. Used this way, formulation helps practitioners maintain the spirit of MI while making deliberate, clinically informed decisions about what to do next.

Key takeaways

• An MI formulation is a working hypothesis, not a verdict. It should be collaborative, concise and revised as the client’s circumstances, goals, risks, and motivation change.
• Formulate the ambivalence, not just the problem. Understand both what the current behaviour provides and what is pulling the client towards change.
• Use the client’s own reasons for change. Values, goals and preferred future should come from the client rather than being supplied by the practitioner.
• Distinguish change talk, sustain talk, and discord. Sustain talk reflects one side of ambivalence; discord signals strain in the therapeutic relationship and requires a different response.
• Assess importance and confidence separately. A client may see strong reasons to change while having little confidence that they can succeed—or feel capable without yet seeing sufficient reason to act.
• Include strengths, previous successes and supports. These provide important evidence about self-efficacy, resources, and the conditions under which change may be possible.
• Identify the MI process that fits the client now. Decide whether the immediate task is engaging, focusing, evoking, or planning rather than automatically progressing towards an action plan.
• Do not mistake discussion for readiness. Planning becomes appropriate when the client begins to mobilise through stronger commitment, questions about how to change, spontaneous ideas, or concrete next steps.
• Keep autonomy, culture, power, and context visible. Referral pressure, practitioner authority, cultural meanings, and structural barriers can all shape motivation and the therapeutic relationship.
• MI formulation complements rather than replaces comprehensive assessment. Diagnosis, risk assessment, medical review, safeguarding, and professional or legal responsibilities remain essential where relevant.

Questions therapists often ask

Q. Is an MI case formulation the same as a Five Ps formulation?

A. No. A Five Ps formulation organises presenting, predisposing, precipitating, perpetuating and protective factors. An MI formulation focuses more narrowly on the change target, function, ambivalence, values, confidence, relational context, and current conversational process. They can be used together.

Q. Does motivational interviewing have its own formal case-formulation model?

A. MI is most commonly organised around its spirit, core skills, and four processes rather than a single mandatory formulation form. The template in this article is a practical synthesis designed to make those elements explicit; it should be adapted to setting, discipline, and client need.

Q. Should I record every example of change talk and sustain talk?

A. Usually not. Record representative statements and clinically meaningful shifts. The aim is to preserve the client’s reasoning and guide your next response, not to turn ordinary practice into a transcript-coding exercise.

Q. When should an MI formulation move into planning?

A. Move towards planning when the client begins to mobilise – for example, by expressing stronger commitment, asking how, proposing steps, or imagining implementation. Planning is optional and should not be forced simply because time is short.

Q. Can I use an MI formulation when the client did not choose the referral?

A. Yes, but external pressure and power must be part of the formulation. Clarify what is and is not voluntary, acknowledge the client’s autonomy, and look for a focus that is honest, relevant, and ethically permissible.

Q. How often should the formulation be revised?

A. Revise it whenever new assessment information emerges, the focus changes, a change attempt provides new evidence, risk shifts, or the practitioner notices discord. A good formulation is a living hypothesis.

Q. Can MI replace diagnosis or risk assessment?

A. No. MI can improve the quality of conversations about assessment and care, but it does not replace diagnostic, medical, cultural, functional, or risk assessment, nor professional and legal duties.

References

• Bischof, G., Bischof, A., & Rumpf, H.-J. (2021). Motivational interviewing: An evidence-based approach for use in medical practice. Deutsches Arzteblatt International, 118(7), 109-115. https://doi.org/10.3238/arztebl.m2021.0014
• Gilboa-Schechtman, E. (2024). Case conceptualization in clinical practice and training. Clinical Psychology in Europe, 6(Special Issue), Article e12103. https://doi.org/10.32872/cpe.12103
• Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. F., Tonigan, J. S., & Moyers, T. (2018). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of Consulting and Clinical Psychology, 86(2), 140-157. https://doi.org/10.1037/ccp0000250
• Miller, W. R., & Rollnick, S. (2023). Motivational interviewing: Helping people change and grow (4th ed.). Guilford Press.
• Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527-537. https://doi.org/10.1037/a0016830
• Pace, B. T., Dembe, A., Soma, C. S., Baldwin, S. A., Atkins, D. C., & Imel, Z. E. (2017). A multivariate meta-analysis of motivational interviewing process and outcome. Psychology of Addictive Behaviors, 31(5), 524-533. https://doi.org/10.1037/adb0000280