November/December 2015 Issue
Motivational Interviewing and Addictions: Collaboration, Not Confrontation
Though it has its critics, motivational interviewing has proven effective with clients capable of engaging with clinicians who operate from a strengths-based perspective, tapping into internal wisdom and resources, rather than viewing the client as someone with deficits that need to be "fixed."
Ambivalence about change is part of the human experience. You want to exercise more, but you'd rather watch your favorite TV show than go to the gym. You want to lose weight, but the sweets displayed in the window of the neighborhood bakery look so good.
Substance abusers face ambivalence, too. On one hand, they see how addiction has damaged their health, their families, their careers. On the other hand, they don't want to give up that pill, that drink, that high.
Many clinicians trying to help clients resolve this ambivalence turn to advice giving in an effort to persuade the user to give up drugs or alcohol. These helpers are often surprised when their efforts backfire, and the client continues to use.
Motivational interviewing (MI) provides an alternative to this destructive cycle of confrontation and resistance. MI is built on the premise that the clinician is not there to force clients to change but instead should facilitate the capacity clients already have within themselves to change. Although now used in fields as diverse as health care, education, and criminal justice, MI's roots are in addiction, and clinicians working with substance abusers from all walks of life are increasingly using the approach.
"[MI] gets clients thinking on a different level because they're the ones making the decisions," says Daryl Cioffi, MEd, CAGS, LMHC, co-owner of Polaris Counseling & Consulting in Rhode Island. "You get people to tap into their own power. You're just there to help them along the way."
MI: An Overview
MI is not a therapy itself, but a conversational style or way of being that a clinician uses when interacting with clients. The approach is focused on conversations around change, primarily those involving ambivalence when clients are going back and forth about making changes.
Underpinning MI is the idea that people tend to rebel when they feel that they are being forced to choose a certain course of action in resolving ambivalence. Unfortunately, this urge to pressure people to make the "right" decision about change—what Miller and Rollnick call the "righting reflex"—is prevalent among many well-intentioned helpers, including those working in professional settings.
Miller and Rollnick argue that people are more likely to change when hearing themselves speak about the reasons to change and how that change might be accomplished. MI is designed to gently guide clients toward focusing on that change talk—statements that promote change—and away from sustain talk—statements that promote the status quo. Clinicians create an environment that fosters change talk by embodying Miller and Rollnick's "spirit of MI," which includes the following elements:
• Partnership: The clinician and client collaborate in the journey toward change. The clinician's role is to listen to and support the client, not to tell the client what to do.
• Acceptance: The clinician accepts what the client brings to the partnership. This acceptance involves respecting the client's inherent worth, practicing empathy with the client, supporting the client's autonomy, and affirming the client's strengths.
• Compassion: The clinician commits to promoting the client's welfare and best interests.
• Evocation: The clinician operates from a strengths-based perspective and helps the client tap into internal wisdom and resources instead of seeing the client as someone with deficits that need to be "fixed."
Practicing in the spirit of MI involves more than an intellectual belief that these elements are important for a good therapeutic relationship. Clinicians must put these elements into action during interactions with clients, says Paul Burke, MA, RSW, team leader at Paul Burke Training & Consulting Group, which provides MI training throughout Canada. "It's a set of interviewing habits you have to get into," he says.
In addition to the four elements of the spirit of MI, the following four processes that emerge in MI (Miller & Rollnick): engagement (building rapport, developing a therapeutic alliance); focusing (seeking clarity in the direction of the change discussion and change goals); evoking (guiding clients to voice arguments that support change); and planning (committing to change and discussing how to pursue change). Each process builds the foundation for subsequent processes. The five key communication skills used by clinicians during these processes are asking open-ended questions, affirming, reflecting, summarizing, and providing information and advice with permission (Miller & Rollnick).
MI and Addiction
Miller observed that confrontation tended to lead to a vicious cycle (Miller & Rollnick). The confrontation made clients defensive. Clinicians interpreted this defensiveness as resistance, which convinced them that they had to confront even more. MI offered a new way to approach clients in a much more collaborative, nonjudgmental way.
MI has been used in a variety of interventions addressing issues such as alcoholism, heavy drinking, drinking and driving, smoking, marijuana use, and cocaine use. Evidence suggests that MI can be useful in helping people change problematic behaviors related to substance use and abuse. Studies that point to MI as a promising practice in the addictions field include the following:
• A review of four meta-analyses by Lundahl and Burke (2009) found that MI was significantly more effective than no treatment and generally as effective as other approaches for treating substance abuse to increasing client engagement in treatment.
• Smokers in Spain who were randomly assigned to MI were more likely to have remained abstinent from smoking after six and 12 months than those assigned to an intervention where they received antismoking advice (Soria, Legido, Escolano, Yeste, & Montoya, 2006). The authors surmised that participants in the group receiving advice might have perceived such advice as preaching and thus engaged in contrarian behavior.
• A study of 423 substance users entering outpatient treatment in five community-based settings in Oregon, Virginia, and New York showed better treatment retention rates for clients randomly assigned an intake that integrated MI techniques vs. a standard intake. The MI-adapted intake, however, did not lead to any difference in substance-use outcomes at 28-day or 84-day follow-ups (Carroll et al., 2006).
• Problem drinkers randomly assigned to directive-confrontational counseling showed significantly more resistance than those assigned to client-centered counseling. The resistance predicted poorer outcomes at 12-month follow up (Miller, Benefield, & Tonigan, 1993).
Both MI and motivational enhancement therapy (an adaptation of MI) appear on the Substance Abuse and Mental Health Services Administration's National Registry of Evidence-based Programs and Practices (NREPP). Information about additional research on these interventions can be found on NREPP's website (www.nrepp.samhsa.gov).
MI is especially useful in working with clients struggling with addiction because these clients tend to be incredibly ambivalent about their substance use, says James M. Walsh, PhD, LPCMH, BACC, a pastoral counselor in Delaware and a former program assistant in the MS in Clinical Mental Health Counseling program at Wilmington University. Walsh says MI also can be used to help clients move to a place where they are willing to explore painful experiences or situations that have contributed to their substance abuse.
MI is not intended to replace other therapeutic approaches, such as cognitive behavioral therapy, but instead can be used as a tool within other approaches to resolve ambivalence whenever it arises. "The integration of [MI] into my practice is seamless," Walsh says. "It's something that I may work on with a person a minute here and there, or it may take up most of a session."
Burke first learned about MI in 1993 when he was in the addictions field and attended a training conducted by Rollnick, MI's codeveloper. Burke says he was immediately struck at how nonconfrontational and respectful the approach was—leading to a much more positive and engaging experience for clients.
Maryellen Evers, LCSW, CAADC, who has a private practice at Ronald J. Refice & Associates in Pennsylvania, has noticed that MI works particularly well in helping her forge therapeutic alliances with adolescent clients. Adolescents who come into therapy expecting to be lectured like they have by their parents or other adult authority figures are pleasantly surprised when they are trusted to make their own decisions. In addition, Evers says, MI engages clients who are not ready for complete abstinence from substances because by putting clients in control of their decisions, MI leaves open harm reduction or moderation as options.
Perhaps the most surprising thing about MI is not the impact it has on clients struggling with substance use but the impact it has on clinicians. Behavioral health professionals discussing MI repeatedly use words like "enjoyable," "energized," "easy," and "enthusiastic" to describe their experiences practicing MI.
MI releases the clinician from having to struggle with clients to get them to make changes in their lives, says Brian Hurley, MD, MBA, an addiction psychiatrist and Robert Wood Johnson Foundation clinical scholar at UCLA. "I found MI to be transformative in my practice. It's made my practice fun because I am working with patients on goals they define rather than those I define."
These benefits do not have to be limited to clinicians. At Hazelden Betty Ford Foundation's facilities in the Tribeca and Chelsea neighborhoods of New York City, even nonclinical staff receives training about MI so the approach is infused into all the services clients encounter. "[MI] is used from the start, from the moment that someone participates in an assessment," says Barbara Kistenmacher, PhD, executive director of Hazelden Betty Ford Foundation's New York campus. "It's woven into everything we do."
Easier Said Than Done
Another red flag with MI is if clients are already committed to change and confident about making it, says Sarah A. Suzuki, LCSW, CADC, of Chicago Compass Counseling. In that case, discussing ambivalence may stymie clients' progress.
MI has acquired a certain cachet as it has become more well-known and popular, with more and more behavioral health professionals claiming that they practice MI or in the MI style. But many of these practitioners—both in addictions and in other fields—have misconceptions about MI. One of these misperceptions, Burke says, is that MI is the same as motivational speaking—a kind of pep talk that gets people pumped up and enthusiastic.
Another misperception centers on how MI can be learned. Miller and Rollnick, for example, express their dismay about some clinicians' perceptions of MI as being a simple set of verbal tricks that can be taught to staff during the lunch hour. In fact, it takes a lot of time and hard work to master the approach, Cioffi says. "You're not just going to be able to watch a YouTube video and learn it," she says.
Cioffi and several other addiction treatment professionals offered the following advice to clinicians who want to become proficient in MI:
• Learn about MI. Reading about MI, looking at articles, and watching videos are among the many activities addictions professionals can engage in to learn about the method of MI and the concepts behind it.
• Learn how to do MI. Taking the leap from knowing MI to doing it requires intensive training, preferably training that includes role plays, teach-backs, and other opportunities to demonstrate MI skills. The Motivational Interviewing Network of Trainers is a good way to find out about upcoming trainings (www.motivationalinterviewing.org). Try to bring at least one other person with you to trainings so you can continue to practice together and provide feedback to one another once the training is over.
• Do MI. Practicing MI is key to becoming skilled at it. Get clinical supervision from someone who is well-experienced in MI. Record your sessions and use a coding tool to assess the quality of and the fidelity to the MI approach.
Practicing MI is essential to getting to a point where MI comes naturally when interacting with clients, Suzuki says. She likens the process to learning how to play the piano. Listening to music and reading books about the piano are only going to get you so far; it takes practice to truly become prepared to perform.
Mastering MI may be harder than some clinicians think it will be because practicing the radical acceptance MI requires is difficult, and it can be easy to slide back into directing, advice-giving behavior, Walsh says. It may be especially challenging for clinicians working in addictions, Hurley adds, because of addiction treatment's long history of confrontation. "Sometimes people have a fair amount of unlearning to do of well-worn patterns that are not compatible with [MI]," Hurley says.
Just as MI practitioners must practice patience with and acceptance of their clients, they also must be patient with and accepting of themselves as they try to use MI, Suzuki says. "It's OK to make mistakes; even the most experienced practitioners aren't perfect," she says. "The only way I can do it is to keep practicing. It becomes more fun and easier and more fulfilling the more you do it."
— Christina Reardon, MSW, LSW, is a freelance writer based in Harrisburg, PA, and a contributing editor at Social Work Today.
Lundahl, B., & Burke, B.L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245.
Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 6(3), 455-461.
Miller, W.R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. 3rd ed. New York, NY: The Guilford Press.
Soria, R., Legido, A., Escolano, C., Yeste, A.L., & Montoya, J. (2006). A randomised controlled trial of motivational interviewing for smoking cessation. British Journal of General Practice, 56(531), 768-774.
White, W.L., & Miller, W.R. (2007). The use of confrontation in addiction treatment: History, science and time for change. Counselor, 8(4), 12-13.