Change is hard. Anytime a person is considering making a change, whether minor or major, it requires a committed decision to act. However, when the change is particularly life-altering, it is often difficult to find enough motivation to act. This is especially true when addressing a substance abuse disorder through any type of behavioral therapy. Freedom from addiction lies deeply beyond a mere desire to change, but the recognition of a need and the desire to change are the first steps in recovery. 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. Furthermore, when a well-meaning individual (such as a family member, friend, or therapist) uses a directing style and argues for change with a person who is ambivalent, it naturally brings out resistance and the person’s opposing arguments. On the basis of these principles, Motivational Interviewing (MI) was developed. Simply put, motivational interviewing has been defined as follows (Miller & Rollnick, 2013): What is motivational therapy interviewing? Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change. The “conversation about change” that motivational interviewing presents can be brief or prolonged and can take place in a number of contexts, from individual therapy sessions to large groups. As the definition would imply, this type of client-centered therapy is more guiding than directing, and it focuses on the patient’s own strengths, abilities, and motivation toward positive change. Motivational interviewing utilizes a wide variety of therapy techniques within its methodology, which have been proven effective for addressing addiction. However, before exploring the specific techniques used in motivational interviewing, it is important to take a look at the underlying “spirit” of MI, it’s “mindset” and “heart-set” (Miller & Rollnick, 2013).
The Spirit of Motivational Interviewing
The creators of motivational interviewing identified four vital aspects of the spirit of MI, or the underlying perspective that anyone who wishes to practice this type of therapy should have. These four, interrelated elements are partnership, acceptance, compassion, and evocation. These aspects are truly the backbone and foundation of motivational interviewing as a whole.
Motivational interviewing contends that the practitioner is not the expert; the client is. The interviewer acts more as a companion in the conversation, who typically does less than half of the talking. A common metaphor used to explain this principle is dancing versus wrestling. Wrestling is about a struggle for power and dominance, with a winner and a loser. It is the act of overpowering and stifling, and the individuals are on opposing teams. On the other hand, when two individuals dance, partners move with each other and not against each other. One individual may take the lead and utilize skillful guidance, but equal collaboration is needed in order for the partners to truly flow with the music. This is extremely important, as the goal of MI is for another person to change, and the interviewer cannot accomplish this alone. The client has an expertise of their own, that must be released in order for change to occur. In regards to substance abuse disorder, no one but the individual can force them to quit using. Only that person can truly make a commitment to take the steps necessary toward recovery. Overall, motivational interviewing is done “for” and “with” the client, and the interviewer is simply seeking to create a positive, interpersonal atmosphere that is conducive (but not coercive) to change.
Related to partnership, the element of acceptance is foundational to the success of MI. Approval does not necessarily mean acceptance, as an interviewer can fully accept a client where they are at without condoning destructive behaviors. According to theorist Carl Rogers (1980), this principle of acceptance is rooted in four interlocking components. Firstly, acceptance requires the acknowledgment and prioritization of the absolute worth, dignity, and potential of each human being. Every individual, regardless of their choices, is worthy of respect. In order for a beneficial interaction to take place, this basic trust and expectation must be incorporated throughout the conversation and overall therapeutic atmosphere. The second aspect of acceptance is accurate empathy. Empathy is not sympathy, pity, or personal identification with an individual’s struggles. The dictionary definition of empathy is: The action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another of either the past or present without having the feelings, thoughts, and experience fully communicated in an objectively explicit manner; also: the capacity for this. Furthermore, Alfred Adler, an Austrian medical doctor, psychotherapist, and founder of the school of individual psychology, beautifully described empathy in this way: “Empathy is seeing with the eyes of another, listening with the ears of another and feeling with the heart of another.” Overall, empathy is an ability to understand another’s frame of reference and conviction that it is worthwhile to do so. The opposite of empathy is the imposition of one’s own perspective, usually with the assumption that the other’s views are misguided or irrelevant. Empathy is at the core of motivational interviewing, and foundational to the act of acceptance. Thirdly, acceptance involves autonomy support. Each client has a fundamental right to self-determination, and the capacity and freedom to make the choices that affect their own lives. The opposite of this is to try to make someone do something, through coercion, manipulation, or control. As previously mentioned, MI fights against this “wrestling” tendency of dominance, and seeks to bring clients into a collaborative “dance.” Interviewers recognize that telling someone that they can’t do something only brings about resistance and pushback. Instead, acknowledging their freedom and self-control typically diminishes defensiveness and helps to facilitate a willingness to change. Finally, acceptance involves affirmation or the intentional recognition and communication of a client’s strengths. Overall, these four aspects describe acceptance beautifully. As an interviewer, “One honors each person’s absolute worth and potential as a human being, recognizes and supports the person’s irrevocable autonomy to choose his or her own way, seeks through accurate empathy to understand the other’s perspective, and affirms the person’s strengths and efforts” (Miller & Rollnick, 2013).
The third element of the Spirit of MI is compassion. Compassion builds upon empathy but moves an individual to action. In a nutshell, compassion is a deliberate, intentional commitment to pursue the best interests and general welfare of another. Practitioners of motivational interviewing should be driven by this guiding principle.
Lastly, the spirit of motivational interviewing involved evocation. This strengths-based message of MI 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.
Motivational Therapy Techniques
Helping individuals find motivation for recovery is easier said than done. Using the spirit of MI as a framework, therapists use a variety of techniques to elicit responses that change the ways that clients think about their ability to change. Overall, motivational interviewing techniques are based upon patient-centered counseling strategies. Specifically, these include open-ended questions, reflections, affirmations, and eliciting self-motivating statements (referred to as “change talk”).
Open-ended questions foster collaborative communication because the phrasing of the question prevents clients from answering with a single word or phrase, such as “yes” and “no” statements, or “good” and “fine”. Open-ended questions encourage the client to do most of the talking, while also helping therapist avoid making judgement statements or imposing their own advice and opinions.
When clients are speaking during a motivational interviewing session, the counselor is engaging in reflective listening. Then, the interviewer selectively issues reflective statements to clarify what the client intended to say, and to demonstrate their understanding and empathy. The reflective responses also elicit responses from the client. Reflections can range from simple to complex, attempting to verbalize and understand a client’s motivation and emotions behind their actions and words. At the end of a session, therapists also summarize earlier conversations to identify and promote their understanding of any discrepancies.
Because motivational interviewing relies on the client’s own strengths, abilities, and efforts, affirmations are an essential part of the process. Affirmation is both general and specific within the framework of MI. The interviewer is intentional about recognizing and commenting on the client’s strengths, good intentions, abilities, efforts, and expressed desires to change. Affirmations serve to build trust and support a client’s belief in his or her own ability to change.
Eliciting Change Talk
Throughout each session, therapists try to elicit self-motivational statements, or “change talk” that help clients recognize that life can be better if they choose to change. These statements can be elicited through reflections, affirmations, and nonverbal cues. A client’s change talk is the key to moving past ambivalence toward a true commitment to change, which occurs in stages.
5 Stages of Motivational Interviewing
The motivational interviewing model proposes that the process of change occurs according to the following stages:
- Precontemplation: The client has little or no motivation to make a behavior change as they do not view themselves as having a problem.
- Contemplation: The individual may realize that their behavior is problematic for them, but they are ambivalent about making any changes.
- Preparation: The individual has made a commitment to changing their behavior and accepted responsibility for doing so.
- Action: The person is actively involved in changing their behavior.
- Maintenance: the individual has developed some aspect and finds that therapists support self-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 Enhancement Therapy
Overall, motivational interviewing is a broad therapeutic approach to helping clients overcome ambivalence toward change. Motivational enhancement therapy (MET), on the other hand, is a specific type of motivational interviewing that involves structured feedback and future planning. MET is particularly beneficial because it can be used regardless of an individual’s commitment level. It has also been shown to be especially effective among individuals who have a strong ambivalence to change. For example, 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 and it may be hard to know how to avoid alcohol withdrawal. Research has consistently demonstrated the efficacy of MET in increasing one’s readiness to change and to stop drug use, reducing the severity of substance use, and in lengthening periods of abstinence. Motivational enhancement therapy begins with an extensive assessment of the client’s history of substance abuse and co-occurring mental health issues. Treatment is typically brief, consisting of approximately four sessions. In the first of the four MET sessions, the therapist will generally provide structured feedback based on the initial assessment. This feedback helps the clients to see how their unhealthy behavior compares to that of the wider population, and it can allow an individual to view any concerns in a new light. During the session, the therapist will likely encourage the person in therapy to address and explore any concerns they may have about a particular issue they are experiencing, including any observations that others have made about the person in therapy’s behavior. The therapist may also ask an individual about short-term and long-term goals and evaluate any ways that a problem behavior may interfere with those goals. Next, the goal of the second session is to enhance motivation and build commitment to change. Finally, sessions three and four serve to reinforce motivations that were discussed in earlier sessions. Clients have an opportunity to review their progress and reaffirm commitment to change. Overall, motivational interviewing with substance abuse and addiction cases is an important complement to traditional therapies. Without motivation for change, clients may be resistant to the lessons that rehab programs try to teach. Motivated clients are more likely to engage in the recovery process and benefit from other therapies as well.