CHAPTER 5: Motivational Interviewing

1. CHAPTER 5: Motivational Interviewing Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory First Edition Todd F. Lewis Developed by Katie A. Wachtel, University of North Carolina at Greensboro

2. Introduction • Defined as a collaborative, person-centered, form of guiding to elicit and strengthen motivation to change • Born out of the substance abuse field and is becoming more accepted amongst other clinical issues • The goals of this chapter are to share the history and goals of MI, discuss theoretical influences on MI, and to outline how to use MI with substance abuse clients

3. History of MI • Created in early 1980’s by William R. Miller and Stephen Rollnick • Started in response to then current beliefs about substance abuse counseling that stated: • Substance abusers are defective and must be “fixed” • Substance abusers offer nothing in counseling • Use of confrontation is necessary to break down denial • Clients must admit to being addicts before they can change • These beliefs increased client resistance

4. Goals of MI • Increase intrinsic motivation to change a behavior • Help lower resistance during counseling • Help clients resolve ambivalence

5. Influences on MI • Client-centered counseling • MI is considered a gentle, persuasive style, but can differ from client-centered counseling in that it has a directive quality as well • Transtheoretical model of change • The stages of change (precontemplation, contemplation, preparation, action, maintenance) provides a model for how to implement MI techniques • It is important to note that MI is not the same as either theory; but rather, it uses each theory to inform it’s techniques and principles

6. MI Spirit • The foundation of MI • Adherence to MI spirit requires • Collaboration • Evocation • Client autonomy • Compassion • Techniques and principles of MI must be implemented in a way that highlights the MI spirit • Consistent with a guiding communication style

7. Principles of MI • Avoiding argumentation • Arguments are counterproductive and increase resistance • Rolling with resistance • Understanding and accepting clients’ resistance increasing feelings of respect in the counseling relationship • Expressing empathy • Clients can identify their own reasons for change when they feel unconditionally accepted in the counseling relationship

8. Principles of MI Continued • Developing discrepancy • In order for change to take place, it is helpful for clients to experience a discrepancy between their goals and the problematic behavior • Supporting self-efficacy • Enhance clients’ perceptions of their ability to change • Remember: RULE • Resisting the righting reflex • Understanding the client’s own motivations • Listen with empathy • Empower client

9. The Four Key Processes of MI • Engaging • Establishing a solid, collaborative relationship with the client • Focusing • Help clients find direction in terms of what they want • Evoking • Explore client ambivalence • Planning • Strengthening commitment and developing a collaborative plan to move ahead

10. Increasing Importance • The more important change is perceived to be by the client, the more effort they will put in to working toward change • Techniques to facilitate increasing importance • Reflective listening • OARS: open-ended questions, affirmations, reflections, and summary • Develop discrepancies • Ruler exercise • Roll with Resistance • Worst-case/best-case outcomes • Find out what is important and negotiate for change • Explore importance of events that instigated counseling

11. Resolving Ambivalence • MI considers ambivalence to be normal. • One goal of MI is to decrease ambivalence so clients do not feel stuck between feelings (giving up substances vs. continuing to use substances) • Eliciting change talk • MI highlights clients’ natural statements about making changes and reinforcing them in order to decrease ambivalence

12. Resolving Ambivalence Continued • Methods for eliciting change talk • DARN: desire to change, ability to change, reasons to change, need for change • Commitment language • Taking steps • Problem recognition • Expression of concern • Intention to change • Optimism • Handling resistance • Low resistance in the counseling environment is necessary to resolving ambivalence

13. Resolving Ambivalence • Strategies for handling resistance • Reflective responses • Strategic responses • Strategies to resolve ambivalence • OARS • Clarify target behavior • Importance ruler exercise • Explore both sides of ambivalence • Decisional Balance (pro/con exploration)

14. Enhancing Confidence • Clients may place high importance on changing behaviors but have difficulty making changes because they lack confidence • Strategies for building confidence • Open-ended questions focused on ability and strengths • Ruler exercise focused on confidence • Personal supports • Past successes at changing a behavior • Offering information and advice-MI consistent • Hypothetical change, envisioning change, anticipating barriers • Explore barriers to change

15. Strengthening Commitment • Clients are ready for change when they express a lot of change talk and are high on importance, confidence and readiness. • Clinicians assist in developing a plan and encouraging action • It is importance for clinicians to be sure the client is ready for change rather than pushing for change (collaboration) • Change plans should be specific, include awareness of barriers and plans to overcome barriers, include personal supports and time frames

16. MI in the Treatment of Diverse Populations • The basic tenets of MI seem to be well suited for work with diverse populations; however, little research has been done to support this • MI has gained support worldwide and is used with a variety of client populations • Most research supports MI as effective with diverse populations, but more research is needed

17. Running Case Study: Michael • Michael is high on importance related to his drinking, but continues to feel strong ambivalence about stopping • Clinician uses affirmations while setting the agenda. He uses open questions, affirming, reflecting, summarizing, the ruler exercise, pro/con exploration, best-case/worst-case outcomes, and emphasizing change talk throughout the session in order to resolve ambivalence and enhance client confidence. • Client and clinician collaboratively developed an action plan • Michael remained non-defensive and demonstrated little resistance

18. Strengths, Limitations, and Ethical Issues of MI • Strengths • Applicable with diverse populations • Respectful and strength-based • Applicable across a wide range of behavior problems • Places greater responsibility on clinician when resistance is high • Offers skills for “difficult” clients • Empirically supported • Can be integrated into other approaches to substance abuse treatment

19. Strengths, Limitations, and Ethical Issues of MI Continued • Limitations • Some situations may warrant education, advice, and direction • Little is known about when MI is most and least effective • More research is needed on use with diverse populations • Ethical issues • Some concern about manipulation • Can be unethical if the clinician has bias about the needs of the client, has influence over the client, or is personally invested in the outcome of the client