Motivational Interviewing and Substance Abuse

Motivational interviewing (MI) is a collaborative conversation style for strengthening a person’s own motivation and commitment to change because addiction is a threat that needs to be taken seriously. As the definition would imply, this type of therapy is more guiding than directing, and it focuses on the client’s own strengths, abilities, and motivation toward positive change. It is a therapeutic intervention that was originally developed for addressing alcoholism and substance abuse and has since expanded to encompass all types of life changes, both minor and major.  Research has consistently demonstrated the efficacy of motivational interviewing in increasing one’s readiness to stop drug use, reducing the severity of substance use, and in lengthening periods of abstinence. MI utilizes a wide variety of therapy techniques, overflowing from a spirit of partnership, acceptance, compassion, and evocation.

The Development of Motivational Interviewing

The MI approach evolved from William R. Miller’s work with alcoholism. In the past, it was commonly thought that those who drank too much were unable to see how their use was harming themselves and others, that they didn’t truly want to quit, and that they were in denial. Addiction counselors, therapists, family, and friends who wanted to help would try to break through this denial by using harsh confrontation and shame, in an attempt convince individuals of their need to change. Historically, this approach has not worked well at all. Even if they have good intentions, when someone uses a directing style and argues for change with a person who is ambivalent, it naturally brings out resistance and the person’s opposite arguments. No one appreciates when some else insists that they think they know what’s best for us, or they try to force us to change. We want to decide for ourselves and retain the right to make the choices that affect our own lives. Drawn from this insight, the strengths-based message of motivational interviewing is, “You have what you need, and together we will find it.” Evoking change from those who are seeking therapeutic interventions is far more effective than attempting to solve their problems as an outsider. As a result of this conclusion, Miller and his colleague Stephen Rollnick authored the pioneer publication about motivational interviewing, titled Motivational Interviewing: Preparing People to Change Addictive Behavior (1991). Later, they wrote two additional editions: Motivational Interviewing: Preparing People for Change in 2002, and Motivational Interviewing: Helping People Change in 2013. The first edition explained how to talk with people about their alcohol and drug use in ways that respected their ability to decide for themselves about whether or not they wanted to change. The authors described the core attitudes and beliefs (“The spirit of MI”), as well as the specific skills, strategies, and techniques of this approach. In the second and third editions, Miller and Rollnick further explained how motivational interviewing works, the research behind it, and how to improve and become truly proficient at practicing MI. It also described the implementation of this approach in other areas beyond addiction, such as nutrition, healthcare, mental health, criminal behaviors, and academics. The authors also expanded the intervention in the last edition to incorporate new ideas such as the four processes of MI conversations: engaging, focusing, evoking, and planning.

How Motivational Interviewing Works

Values

Motivational interviewing utilizes a wide variety of therapy techniques that have been proven effective for addressing addiction. Each aspect of the intervention is rooted in the “Spirit of MI,” or its core attitudes and beliefs. These four, interrelated elements are as follows:

1. Partnership: Collaboration between the practitioner and the client, grounded in the point of view and experiences of the client.
2. Acceptance: Acknowledging and prioritizing the absolute worth, dignity, and potential of each individual client.
3. Compassion: Actively promoting the client’s welfare and giving priority to their needs. The practitioner makes a deliberate commitment to the client’s best interests, seeking to understand their experiences, values, and motivations without engaging in explicit or implicit judgment.  
4. Evocation: The interviewer seeks to draw out the individual’s own thoughts and ideas (rather than imposing their opinion), as motivation and commitment to change is most powerful and durable when it comes from the client.

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Goals

Motivational interviewing seeks to address ambivalence, or the state of having mixed feelings or contradictory ideas about something is a completely normal part of preparing for change and is a place where a person may remain stuck for a long time. Most of us can recognize when we need to make a change in our lives but lack the necessary motivation to get there. In regards to substance abuse, motivational interviewing contends that all individuals who are dealing with addiction are at least partially aware of the negative consequences of their behaviors. Each individual is also currently in varying stages of readiness when it comes to changing. Therefore, the goal of Mi is to facilitate the process of heightening the patient’s readiness to change by overcoming ambivalence or a fear of change, thereby increasing the client’s own motivation.

Process

The motivational interviewing model proposes that the process of change occurs in five stages. Firstly, in the Precontemplation stage, the client has little or no motivation to change their behavior, and may not see a need to change at all. Stage two is Contemplation, in which the individual may realize that their behavior is problematic for them, but they are ambivalent about making any changes. Next is Preparation, where the individual has made a commitment to a behavior change and accepted responsibility for doing so. The fourth stage takes place when the client moves into action and is actively involved in changing their behavior. Finally, the Maintenance stage occurs when the individual has developed some aspect of efficiency that has allowed them to change their behavior. As a general rule, individuals must have made changes that have been in place for a minimum of six months in order to qualify for this stage.

Motivational Interviewing Techniques and Strategies

To help clients move through these stages of change, practitioners of motivational interviewing utilize specific techniques, that are derivative of patient-centered counseling strategies. One acronym that is commonly used for the strategies of motivational interviewing is O.A.R.S. O: Open-Ended Questions

• Open questions gather broad descriptive information
• Facilitate dialogue
• Require more of a response than a simple yes or no
• Often start with words like “how” or “what” or “tell me about” or “describe”
• Usually go from general to specific
• Convey that our agenda is about the consumer

A: Affirmations

• Sincere acknowledgment and commentary on the client’s strengths and efforts
• Will promotes and support self-efficacy
• Acknowledges the difficulties the client has experienced
• Validates the client’s experience and feelings
• Emphasizes past experiences that demonstrate strength and success
• Used to prevent discouragement

R: Reflections

• Reflective listening begins with a way of thinking
• It includes an interest in what the person has to say and a desire to truly understand how the person sees things
• It is essentially hypothesis testing
• What you think a person means may not be what they mean
• Reflections can take the form of  repeating (simplest), rephrasing (substitutes synonyms), paraphrasing (major restatement), and/or reflection of feeling (deepest)

S: Summaries

• Summaries reinforce what has been said, show that the practitioner has been listening carefully, and prepare the client to move on
• Summaries can link together the client’s feelings of ambivalence and
• Promote perception of discrepancy

In the midst of implementing the O.A.R.S. techniques, motivational interviewing focuses on four specific principles during the therapeutic process: Expressing empathy

1. Acceptance facilitates change
2. Skillful reflective listening is fundamental to expressing empathy
3. Ambivalence is normal

1. Developing Discrepancy:
   1. This is accomplished by thorough goal and value exploration
   2. Interviewers help the client identify their own goals/values
   3. Identify small steps toward goals
   4. Focus on those that are feasible and healthy
   5. Explore the impact of substance abuse on reaching goals, as well as the consistency with personal values
   6. List pros and cons of using/quitting (referred to as a decisional balance worksheet or payoff matrix)
   7. Therapists should allow the client to make their own arguments for change
2. Rolling with Resistance
   1. The interviewer avoids argumentation
   2. Acknowledges that human beings have a built-in desire to set things right (righting reflex)
   3. When the righting reflex collides with ambivalence, the client begins defending the status quo
   4. If a person argues on behalf of one position, they usually become more committed to it
   5. Resistance is a signal to change strategies
3. Supporting Self-Efficacy
   1. Express optimism that change is possible
   2. Review examples of past successes to stop using
   3. Using reflective listening, summaries, affirmations
   4. Validating frustrations while remaining optimistic about the prospect of change

Motivational Enhancement Therapy and Substance Abuse

While Motivational Interviewing is the broad therapeutic approach, Motivational Enhancement Therapy (MET), is a specific type of motivational interviewing that involves structured feedback and future planning. MET is often combined with other forms of counseling or treatment for individuals in the midst of the recovery process. Without motivation for change, clients may be resistant to the lessons that rehab tries to teach. Motivated clients are more likely to engage in the recovery process and benefit from other therapies as well. Individuals who are struggling with an addiction to drugs and alcohol may often find it difficult to stop using, due to the reinforcing effects of these habits. Fortunately, Motivational enhancement therapy is particularly beneficial because it can be used regardless of an individual’s commitment level, and also among individuals who have a strong ambivalence or even resistance to change. Motivational enhancement therapy also serves to treat patients who have co-occurring mental health disorders, or a “Dual Diagnosis.” For example, the rate of a diagnosable level of PTSD among those receiving substance abuse treatment is 12%-34%, and the rates are even higher among women (30%-59%). As a result, those with PTSD and substance abuse have a more severe clinical profile than those with just one of those disorders. Not only are they seeking treatment for their substance abuse, but they are facing recovery while also dealing with the lingering effects of intense trauma. This is often true of individuals with other co-occurring mental health conditions as well. Up until recently, dually diagnosed patients were treated separately for their addiction and mental health problems, which was proving to be an incomplete form of care. Fortunately, dual diagnosis therapy now merges treatment for both mental disorders and substance abuse. Both of these can now be viewed as part of a continuum, rather than as two strictly different problems. While there is no single formula for treating dual diagnosis, motivational enhancement therapy can help treat addiction and a co-occurring disorder at the same time to prevent future relapse. MET recognizes the unique difficulties that arise with a dual diagnosis and begins with an extensive assessment of the client’s history of substance use disorders and any possible co-occurring mental health issues. After the assessment, MET typically consists of two to four sessions. During session one, the therapist provides structured feedback based on the initial assessment of the client’s history. The practitioner will likely encourage the client to address and explore any concerns they may have about a particular issue they are experiencing, as well as identify a few short-term and long-term goals, as well as how they may be impacted by substance abuse. The goal of the second session is to enhance motivation and build commitment to change. If MET continues, the overall goal of sessions three and four is to reinforce motivations that were discussed in earlier sessions. Clients have an opportunity to review their progress and reaffirm commitment to change. Overall, both Motivational Enhancement Therapy specifically and the Motivational Interviewing framework as a whole can help individuals make significant life changes to end substance abuse and complement other forms of treatment. It can also help turn around the negative impact of addiction on the family of the addict. While change is difficult for everyone, it is possible to gain the motivation needed to change your lifestyle and reach your goals.