Motivational Interviewing for Addiction

Motivational Interviewing (MI) is a type of brief intervention for substance abuse disorders. At its core is the idea of motivation.

Many people with substance abuse problems lack the motivation to get clean. Indeed, the lack of motivation is one of the biggest obstacles to sobriety.

MI aims to rectify this. It uses therapeutic methods to draw out patients’ motivations. It uses these motivations to inspire people to change.

MI differs a lot from therapies like Cognitive Behavioural Therapy (CBT). Sessions tend to be shorter, and the aims tend to be more modest. For instance, MI often aims to get patients into further treatment.

MI is an interesting form of therapy which has a lot to offer.

What exactly is Motivational Interviewing?

Motivational Interviewing was created by William Miller. He first outlined it in 1983, in a journal called Behavioral Psychotherapy.

MI originated as a therapeutic approach for people with substance abuse disorders. It provided an alternative to common therapies such as CBT. It aimed to help people solve problems for themselves, rather than solving problems for them.

One thing which makes MI different from other forms of therapy is the way it is delivered. Whereas other therapies tend to be delivered over the course of months, MI is often limited to a few sessions. These sessions are called ‘interviews’.

Another thing which makes MI unique is that it is non-confrontational. This means that the therapist does not pass judgement on what the patient says. The spirit of MI is therefore one of collaboration.

One final point about MI is that it tends to focus on the patients’ goals. Other forms of therapy may impose goals on the patient. MI takes a more patient-centred approach. The idea behind this is that patients will be more motivated if they set their own goals.

MI does not focus on past trauma or root causes of addiction. It tends to look more towards the future. This is why it is best used in concert with talking therapy.

The assumptions behind Motivational Interviewing

One of the main goals of Motivational Interviewing is to ‘overcome ambivalence’. Ambivalence means being in two minds about something, in this case, substance abuse.

Often those with substance abuse problems will know, on some level, that their drug abuse is bad for them. However, they may not have fully accepted that fact. It may be useful for them to deny it to themselves. MI tries to help people work through this ambivalence.

There are a few assumptions that underpin this way of looking at addiction recovery. They are:

1. Ambivalence is normal. Many people with substance abuse problems feel ambivalent about their addiction.
2. Getting to the root of a person’s values and motivations can help them overcome ambivalence. This can lead to change.
3. The therapist and client are a team. They work together to get through problems.
4. By collaborating, the therapist can help the client to change their habits.

Understanding these assumptions is key to understanding MI. It is all about helping the client to help themselves.

Five principles of Motivational Interviewing

William Miller and Stephen Rollnick discussed five core principles of MI in their book, Motivational Interviewing: Preparing People to Change Addictive Behaviour (1991).

We’ve listed them below:

1. Use reflective listening to show empathy.
2. Try to highlight any gaps between a clients’ goals and their current way of life.
3. Do your best to avoid conflict and confrontation.
4. Do not directly contradict your client when they show unwillingness to change. Try to adjust to it instead.
5. Help your client to take control of their own lives. If they show a desire to change of their own accord, support it.

There are a few points to consider about these principles.

First, it is important to note that MI encourages openness. Honest dialogue is the most helpful thing for therapy. Keeping judgement to a minimum helps foster honesty.

Secondly, while the therapist does not judge their client, they can point out any gaps between the clients’ goals and their current state. This is a subtle way to bring about the desire to change.

Finally, MI treats resistance as natural. It is merely taken as evidence that the current approach needs adjusting. This is called ‘rolling with resistance’. It is a technique used by many MI therapists.

RULE: Guidelines for Motivational Interviewing

Miller and Rollnick have also outlined some more basic rules for Motivational Interviewing. These rules can be applied in a range of health care contexts.

They are:

• Resist the righting reflex
• Understand the patient’s motivations
• Listen with empathy
• Empower the patient [1]

Just as with patients who have substance abuse disorders, RULE recommends a similar approach in other contexts. It pushes the idea of helping the patient to help themselves. It also warns against judgement or the ‘righting reflex’.

Processes in Motivational Interviewing

Miller and Rollnick have also given us an insight into the main processes involved in Motivational Interviewing. These four processes all focus on the client. They are intended to help the client move towards change.

They include:

• Engaging: The client and the therapist need to reach a level of collaboration which allows them to work together. This stage is all about building trust and rapport. The therapist should not rush into anything. They need to take their time to earn the trust of their client. Putting the client at their ease is key to opening up an honest dialogue
• Focusing: This means working out what the main focus, or goal, of the client’s recovery is. Some clients will already have a good idea of the focus of their recovery. However, the majority will not. The focusing stage of MI treatment allows the therapist to get an idea of what the client’s goals are. These goals can then be used to shape the course of treatment. Although the therapist can give their input on these goals, they need to be the client’s own goals for MI to work
• Evoking: The therapist evokes, or brings out, the client’s motivations for getting clean. This is a key stage in the MI process. Many clients feel ambivalent about change. The therapist can help them by reinforcing their desire for change. They can do so by finding out why the client wants to get clean. It might be for health reasons, financial reasons, family reasons, or a combination of all three. Whatever the reasons are, the therapist needs to focus on them and amplify them. Increasing ‘change talk’ is crucial
• Planning: The client, with the help of the therapist, works out how they are going to change. This stage is important for several reasons. Most obvious is the fact that the client will meet with stumbling blocks in their road to recovery. These include changes in routine, toxic friendships, and stressors such as work, money and relationships. All of these will require careful planning so as to avoid relapse. With the help of the therapist, the client can devise coping mechanisms and plan for specific situations. This will help to ensure sobriety in the future

The Stages of Change

Carlo DiClemente gave us the ‘stages of change’ model. This is a good way of understanding the cycle that all people in recovery go through.

Here it is:

• Precontemplation: At this stage you have not even thought about change.
• Contemplation: This is when you begin to consider making a change.
• Preparation: Here, you start to get ready for a change.
• Action: You carry out the change.
• Maintenance: You attempt to stick with the change you have made.
• Relapse: You give up on the change, and the cycle begins again.

Built into this notion of change is the idea of relapse and failure. MI accepts that relapse is a natural part or recovery. It tries to plan for and work around inevitable relapses.

OARS

OARS are a set of skills designed to promote good conversations in MI sessions. First outlined by Miller and Rollnick in Motivational Interviewing: Helping People Change (2013, 3^rd edn.), these skills are now used by many MI counsellors.

• Open questions: Open questions are encouraged because they allow the client do develop their answers as they wish. Open questions are better than closed questions, which are factual in nature. By leaving the client space to speak, the therapist can put them more at their ease
• Affirming: It is common for people with substance abuse problems to have low self-worth. They may feel that they are incapable of getting clean. Affirming is about trying to highlight good thoughts or actions which the client mentions. By doing so, the therapist can help to build up the client’s sense of self-worth. They can also give the client more confidence in their ability to get clean
• Reflecting: There are two types of reflection: simple and complex. Simple reflection means just repeating something a client says. This helps the client know that the therapist is listening. It also helps them feel valued. Complex reflection is when the therapist makes a guess at an implied message in what the client is saying. This requires skill and care, but when done correctly can be very effective
• Summarizing: It can be useful for the therapist to bring together the things that the client tells them. When the client hears this summary, it can help them to understand their situation better. It may clarify their desire for change

When is Motivational Interviewing most effective?

Research suggests that Motivational Interviewing is an effective method of treatment for many substance abuse disorders. It is especially effective with alcohol-dependent people. [2] This could be explained in many ways.

One explanation is that alcohol is the most socially acceptable drug. It is also the most widely available. Therefore, it is likely that people who are addicted to alcohol may feel ambivalent about their drinking.

They are perhaps more likely to feel ambivalent than heroin users. Since MI aims to overcome ambivalence, heavy drinkers might benefit the most from this treatment.

It is important to note that MI is now used in a range of contexts. This goes beyond substance abuse disorders. It includes gambling addictions, gaming addictions, eating disorders and more.

Could Motivational Interviewing help patients who have had limited success with other treatments?

One benefit of Motivational Interviewing is that it is different from the more conventional talking therapies. This could allow it to help patients who have struggled with CBT, DBT and so on.

For a patient who has tried talking therapy, and has relapsed many times, MI could be just what they need. It stresses the need for a friendly relationship between client and therapist. It also focuses on the client’s own goals, as opposed to goals they may not have chosen. These two factors can appeal to some clients.

Whilst MI is by no means a silver bullet, its uniqueness might make it a good alternative to other therapies.

Drawbacks of Motivational Interviewing

There are three main drawbacks of Motivational Interviewing.

One drawback is that it is not a standalone treatment. It is best used in concert with other therapies. In fact, its main purpose is to increase motivation and to get people into other therapy. This is not a problem exactly, but we need to bear it in mind when we think about MI.

Another drawback of MI is that it does not address underlying issues. These include mental health problems and trauma. For this reason, someone suffering from mental health problems, or someone who has been through trauma, may not benefit from MI.

A third drawback is that MI is not suited to those who find it difficult to think logically. MI relies on the ability to evaluate. It requires clients to think about pros and cons.

This may be hard for people with severe mental health problems. For instance, someone with bipolar disorder might struggle with this. Those with severe mental health problems might benefit more from something like Dialectical Behavioural Therapy (DBT).

Motivational Interviewing Outcomes

A range of studies have been conducted into Motivational Interviewing. The majority point towards MI being an effective treatment for a variety of substance abuse disorders.

To take one example, this meta-analysis looked at 59 different studies of MI. It found that ‘MI showed a significant effect on substance use’. [3] It did, however, note that more evidence was needed to make a definite conclusion.

Meanwhile, this study [4] used a randomized controlled trial to look at Motivational Interviewing, substance abuse and depression. It found that ‘MI can be an effective intervention for cannabis use and hazardous drinking among patients with depression.’

Kinds of Motivational Interviewing

A Motivational Interviewing approach can be taken in many different kinds of context. Perhaps the most common variety of MI is Motivational Enhancement Therapy.

Motivational Enhancement Therapy (or MET) is a standalone treatment. It typically comprises four to six short sessions. It uses lots of assessment and feedback.

Motivational Interviewing techniques can also be used in brief interventions. They are often used when the intervention is moving in a problematic direction.

The versatility of MI is one of its strengths.

Final thoughts

Motivational Interviewing can be a very effective method of treatment. It works best for those who are at the start of their recovery. It is also more suited to those who are mentally stable.

It does have drawbacks, as we have discussed. However, if used in the right context, the benefits outweigh the negatives.

References

[1] https://www.racgp.org.au/afp/2012/september/motivational-interviewing-techniques/

[2] https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/article/abs/motivational-interviewing-with-alcohol-outpatients/F2256F62EA570B46F886BB422B5EA52B

[3] https://pubmed.ncbi.nlm.nih.gov/21563163/

[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4919182/