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May/June 2007

Motivational Interviewing With Substance Abusers — The Power of Ambivalance
By Lynn K. Jones, DSW
Social Work Today
Vol. 7 No. 3 P. 34

An increasingly popular interviewing technique channels the strength of resisting change into motivation to make change.

Caught in the ambivalence trap of making a tough personal change? Do the contradictory thoughts of “I want to… I don’t want to…” sound familiar? Don’t feel bad; you’re not alone. Feeling 100% about something important is the exception, not the norm.

Sometimes the ambivalence is never resolved, but when it is, the results are magical. Like flipping a switch, what seemed nearly impossible just falls into place. The pounds start dropping off; the cravings for nicotine seem manageable; the recovery program for alcohol and drug addiction starts to make sense.

Is it possible to resolve ambivalence in just one interview? William R. Miller, PhD, says it is. Motivational interviewing is the process he developed to prepare people for making challenging behavior changes. Used extensively with substance abusers, the results can be dramatic.

According to Miller, independent research shows that people who have had one motivational interview at their intake for treatment were rated by staff as more motivated. Not only that, they also have double the abstinence rate of those who did not have a motivational interview. “Two interviews are even better than one,” Miller adds.

“It’s astonishing. I would not have believed it, had I not seen it in my own data, that you could talk to someone who had a self-destructive behavior pattern going on for a decade or more and, in the course of a conversation, see the person turn a corner,” he says.

These outcomes seem to go against the belief system of psychology—Miller’s own profession—that more therapy is almost always better.

Teeter-totter of Change
Struggling with ambivalence is like being on a teeter-totter. One minute, one argument makes sense, and the next minute, the opposite argument tips the balance. People argue with themselves because there are costs and benefits to both sides. Substance abusers typically recognize there are valid reasons for changing their behavior but also reasons not to.

In motivational interviewing, this conflict is embraced, not challenged. Instead of trying to convince the substance abuser of the benefits of a particular course of action, clinicians using motivational interviewing techniques help them to weigh the pluses against the minuses.

Margo Hendrickson, LCSW, frequently encounters ambivalence in her work as the manager of clinical services at the University of Pennsylvania Treatment Research Center. Using motivational interviewing, she helps clients weigh it out: “Gee, it seems that you really, really like what alcohol does for you. You like the feeling that it gives you. I wonder if we could get this down on paper? Then, I would like to have you weigh it out for yourself, here today, what you want to do. What are the good things about continuing to drink, and what are the not-so-good things?”

In her experience, alcoholics may have two or three items on their lists that they like about drinking, such as: “I like the high”; “I like being with my friends”; “I am more social.” There is usually a longer list of more serious reasons to give it up, such as: “My spouse is always mad at me”; “I have a DUI hanging over my head”; “My kids don’t respect me anymore”; “My boss is on my case.” Hendrickson claims, “It is that simple.”

Activating Motivation
Miller explains that once clients have weighed the costs and benefits of making the change, the motivational interviewer then asks them to make the argument for change. It doesn’t matter what stage of change they’re in. In fact, motivational interviewing is particularly effective for people in the early stages of change, when they tend to be sensitive to being lectured and resent feeling forced to make a change.

A typical way to make an argument for change using motivational interviewing is to pose the following question: On a scale of 0 to 10, how important is it for you to change your drinking behavior? In response to the answer—say it is a 5—a follow-up question is asked: Why are you at a 5 and not 0? The answer to that question is their reason for change.

Miller cautions not to ask the obvious question: Why are you at a 5 and not a 10? The answer to that question is the reason against change. “Fundamentally, I want the arguments for change coming in the client’s voice and not from me. The natural expected outcome of my making the argument for change is for the client to argue against change—not because they are so sick and pathological but because that is human nature. If you are ambivalent about something and someone takes up one side of the argument, you take up the other side. That might be OK, except we tend to believe ourselves. You hear yourself talk, and you get committed to what you hear yourself saying. And so, if you cause people to argue against the need for change, you are actually moving them away from change. Confrontational approaches are counter therapeutic. They move people in the wrong direction.”

G. Alan Marlatt, PhD, a clinical psychologist and director of the Addictive Behaviors Research Center at the University of Washington, has seen this work effectively in the program he developed for binge drinking students. After two motivational interviews, students in his program not only alter their binge drinking behavior, but four years later, they still behave significantly differently from students who did not receive motivational interviews.

Debunking Denial
The treatment of substance abuse is fraught with beliefs about denial. Miller says when he first started studying treatment approaches for alcoholics, he read that alcoholics are liars, in denial, pathologically defensive, and impossible to work with. But that view didn’t square with his experience.

Trained in the client-centered approach of Carl Rogers, Miller did his best to listen to and understand what the alcoholics he was working with were saying. He asked how they had gotten where they were, where they saw themselves going in the future, and what they thought about their situations. “By virtue of ignorance, I fell into reflective listening as a way of understanding the stories of these people with alcoholism. And it dawned on me eventually that the way you treat people had a large effect on the way they behaved,” Miller explains.

Denial, Miller believes, is a reflection of the person they are talking to. “It takes two to deny. Nobody stands on the beach alone and denies. If you approach someone by saying, ‘You’re an alcoholic, and you had better stop drinking,’ the natural human response is to deny. If you come to them in a respectful manner that assumes they make choices about their lives and it is in their hands, that they’re smart people who have reasons for what they are doing and also have within them the motivation for change, you get a very different response,” he says.

Dance of Discrepancy
Miller describes how change is motivated by the discrepancy between where you are and where you want to be. A bigger discrepancy leads to stronger motivation for change.

Hendrickson finds herself reflecting discrepancies to her clients all the time. “They come in and tell me how drugs are ruining their life, and then in the next breath, they are telling me that they don’t think that they can quit. I reflect that back to them: ‘I am not sure that you are going to do this. What do you think?’” she says. In motivational interviewing, that is described as rolling with resistance. Hendrickson says that when discrepancies are reflected to them, people turn around. A typical response is: “What are you talking about? That is why I am here!”

Miller says there is an interdependency between discrepancy and ambivalence. Without some discrepancy, there is no ambivalence. For some people, the first step toward change is to become ambivalent. Ambivalence may look like an obstacle, but actually, it is ambivalence that makes change possible. “Motivational interviewing is like dancing. Rather than struggle against each other, the partners move together smoothly. The fact that one of them is leading is subtle and is not necessarily apparent to the other. Good leading is gentle, responsive, and imaginative,” he says.

We’re in This Together
Michael Chenkin, MSW, LCSW, LCADC, who is in private practice in New Jersey, was, in 1993, among the first group of people trained for motivational interviewing by Miller and his colleague and coauthor Stephen Rollnick. Since that time, Chenkin has used motivational interviewing in private practice and psychiatric facilities with people with co-occurring disorders.

Sold on the value of the motivational interviewing approach, he says, “What surprised me was how simple, how elegant it was. When I use the methods of motivational interviewing, people respond as if they have never been listened to before. People say, ‘I really appreciate this. You are really hearing what it is that I have to say,’” Chenkin says. “For many people, that experience is rare, or maybe not existent, in their lifetime. It also stands in contrast to how substance abuse treatment tends to be done, which is: ‘You don’t know anything; listen to me.’ Or in other words, ‘Do as I say, or you are going to fail.’ It seems so common sense, but very often, that is not the treatment experience of clients—to be listened to and treated the way that you would want to be treated.”

Usually, we think of motivation as an internal process. If someone doesn’t follow through with making a change, we tend to think that it is the result of a personal failing. Miller sees it differently. He believes that motivation is an interpersonal process—something that arises from the interaction of two people.

Hendrickson says a metaphor that has helped her understand this distinction is to think of sitting next to a client, pulling your chair alongside him or her and looking at an imaginary album of the client’s life. Rather than sitting across from a client, you explore his or her album. As you page through it together, you are collaborating with the client about what he or she wants to do next.

“I think that our clients feel more respected. They will say to me that I am not trying to get them to do something. It is all about really listening to the clients and then helping them to make the change that they want to make, not that I want to make. I don’t put forward my agenda—it has to be their agenda. We meet the clients where they are at and move from there,” Hendrickson says.

“The students like it and they recommend it to their friends, and if they are mandated into it, at the end they say, ‘You know, this was helpful, I liked it,’” Marlatt adds.

The key from Miller’s perspective is to be genuinely interested in and curious about the person’s own motivations for change. Questions likely to be asked in a motivational interview include: What do you want in your life? Where would you like to be five years from now? Why would you want to change your drinking? If you decide to stop drinking or stop using cocaine, how would you do it? What reasons do you have?

“Rather than telling the person how to make a change, I’m curious to know what he or she would do. And you know what? People are pretty smart about these things. Often they have a good sense about what would be the most successful way for them if they decide to do it,” Miller says.

Resonance With Social Work
When Chenkin started using motivational interviewing with his clients, he was struck by how consistent it is with social work. “I said to myself, ‘Boy, if this isn’t social work, I don’t know what is.’” The client-centered approach that is the hallmark of social work is reflected in motivational interviewing, as are the social work values of starting where the client is and the right to self-determination.

“It is right out of our book,” comments Hendrickson. Marlatt sees motivational interviewing as compatible with social work because it is not a top-down, authoritarian approach.

Motivational interviewing seems to integrate well with other treatment interventions. It has been particularly useful in managed care settings, where treatment sessions are limited and where early dropout rates tend to be high. Motivational interviewing increases the likelihood that a person will return for additional treatment.

Miller says motivational interviewing has proved useful in thorny social work problems, including child protective services cases. “The more adversarial the situation, the bigger the advantage. With court mandated clients, for example, we find that this is so much better than trying to make anyone do something,” Miller says. “It is not a way of tricking people. It is a way of engaging their own interest and motivation in what they want in life and putting that side by side with their current situation and saying, ‘What do you want to do?’ ‘I want to change… I am not sure I want to.’” It all starts there, and a creative listener can tip the balance.

— Lynn K. Jones, DSW, is a freelance writer and an executive coach and organizational consultant in Santa Barbara, CA. As a specialist in organizational culture, she supports leaders and organizations in developing mission-driven cultures.