Motivational Interviewing for Addiction Treatment
Motivational Interviewing (MI) is a therapeutic technique used to address addiction and substance use disorders in patients by strengthening one’s motivation and commitment to a particular goal, such as sobriety. When battling an addiction, one of the most difficult hurdles to overcome is a lack of motivation. Many people develop an addiction as a coping mechanism to deal with other traumas or other issues that stem from their everyday life.
Despite the inevitable health issues, financial costs, and social and legal consequences of substance abuse, the idea of living without drugs or alcohol can be intimidating. The idea of giving up one’s drug of choice can outweigh these negative consequences, ultimately resulting in a lack of true motivation to get sober. For others, a pessimistic attitude keeps them from recovery. They feel like sobriety is not a realistic goal, that they do not need to quit because they aren’t ready, or it will be too hard. Motivational interviewing helps people overcome their fears or uncertainty, fostering patients’ ambition to get sober and begin their journey to recovery.
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What Is Motivational Interviewing?
Motivational Interviewing was developed by Dr. William R. Miller, an Emeritus Distinguished Professor of Psychology and Psychiatry at the University of New Mexico. He first referenced the technique in a 1983 issue of Behavioral Psychotherapy and has since published numerous books and other writings about its implementation and effectiveness. Based upon similar principles of experimental social psychology, practitioners of MI treat motivation as an interpersonal process as opposed to a personality trait, meaning motivation is a mindset that can be taught and encouraged.
The perspective is different-you adopt a different style from solving problems for people to encouraging them to solve them for themselves. That’s what Motivational Interviewing is focused on.
There are three key concepts that make MI stand out from most other types of treatment. First, the sessions themselves are called interviews. Rather than a confrontation by a therapist, it is considered a collaboration between the facilitator and the patient. Next, patients are encouraged to create their own goals as opposed to a therapist trying to impose sobriety or whatever the therapist believes their patient needs.
When individuals in recovery feel as though they are the one in control of their own recovery, it encourages them to continue setting goals and be self-motivated moving forward. This is very effective when trying to achieve long time sobriety. This leads to the third concept: the patient’s autonomy. Often times, going to treatment can feel like a surrender of a patient’s freedom to the authority of their therapist. MI focuses on making sure that patients feel empowered, as the true ability for making changes lies within the patient, not within the therapist. When a patient feels responsible for their actions and confident in their recovery, they are more likely to stay sober and not relapse after treatment.
MI does not focus on the underlying causes of an addiction, such as past traumas or mental illnesses. It is intended to be used in addition to other forms of therapy, such as cognitive behavioral therapy. It is also an effective part of an inpatient treatment regiment, or before seeking other recovery treatment options. Though MI pulls from various therapeutic styles and theories, such as humanistic therapy, cognitive dissonance theory, therapeutic relationship building, and positive psychology, it is most effective when used in conjunction with one of these other forms of treatment.
The Four Processes of Motivational Interviewing
Motivational Interviewing is described by its founders, Dr. William Miller and Dr. Stephen Rollnick, as a therapeutic tool intended to be used in addition to other forms of therapy or addiction treatment. MI is meant to inspire change in clients who may otherwise feel reluctant to do so. To achieve this, Dr. Miller and Rollnick formulated four, client-centered processes to help patients identify their goals and begin to work towards them. They are as follows:
- Engaging – Getting to know the client and establishing a trusting and respectful alliance.
- Focusing – Coming to a shared idea about the main focus of a client’s recovery.
- Evoking – Bringing out the client’s own arguments for change.
- Planning – The client is willing and able to envision change and how they will manifest it.
This is a good way of being with people, that helps people be less defensive, less resistant, and more able to think about how to make changes and move in that direction.
One of the most imperative aspects of Motivational Interviewing is establishing a strong and trusting relationship with a client. Therapists and clients must form an alliance of sorts, working together towards a client’s self-realized goals. This alliance is strengthened through mutual respect and focused on the client’s own strengths. Counselors must be empathetic and make sure that the client knows that setting and working towards goals is a collaborative effort. This ensures that the assumed power dynamics of a counselor-patient relationship does not diminish the patient’s sense of control over their own recovery.
While conversations during this phase can concern goal setting and other topics regarding change, this is not the focus of the engaging process. The therapist should prioritize developing rapport with their patient, reducing their resistance/defensiveness, and resolving some uncertainty about the recovery process. While engaging, the practitioner strives to create an environment that is comfortable for the client and helps facilitate change talk.
There are two main scenarios that can bring a person to treatment; either they have come to the realization they want/need to change their behaviors on their own, or it was mandated by their family or a judge as the result of a drug or alcohol-related crime. In certain situations, a client may come in already having goals or focal points that they wish to focus on. Sometimes specific criteria must be addressed in treatment, as in the case of court-order rehabilitation. However, most patients lack clear insight and direction regarding their journey to recovery.
In the focusing phase of Motivational Interviewing, the counselor helps the client determine what is truly important to them and what they want to get out of going to treatment. Using this information, the counselor can set the tone for their sessions moving forward and help their patient find their own desire to change.
While these goals should be mutually agreed upon by both the patient and their therapist, it is key that with MI the patients themselves do the work of identifying their own problems and set goals accordingly. The focusing process provides an opportunity for the therapist to narrow the conversation to the topic of patterns and habits that the client ultimately wants to change. It is about finding a clear direction and goal when it might not be clear from the outset. For some clients, it may take many weeks to get to this point. For others, it may become apparent in the first session.
The evoking process of Motivational Interviewing involves uncovering a client’s personal motivations for change. After finding their focus, a facilitator must address and bring their patient’s attention to why they want to recover. Therapists must recognize even subtle instances where their client brings up their desire to change and bring attention to this internal motivation.
Inciting this ‘change talk’ in clients and bringing out their own arguments and motivations for recovery is the most unique and important aspects of MI. During this phase, the therapist increases their client’s sense of the importance of change, confidence that change can occur, and readiness for change. Once a patient is engaging in change talk, it is the counselor’s job to reflect and summarize what they are saying. They should also hope to see an increase in the amount and strength of their patient’s change talk.
The planning stage can be the most important part of motivational interviewing in terms of its ability to aid in a long-term recovery. Patients don’t stay in treatment facilities for the rest of their lives, and often as time goes on, they may go to therapy or other treatment programs less and less. Part of the planning process is about developing the skills and knowledge so that clients can catch themselves before they fall. Whether by using coping mechanisms when they have the urge to use or knowing who to reach out to and how when things get difficult, the planning stage decreases the chance that a patient will relapse.
It is important that during this stage, the therapist is able to use his or her expertise to help give advice and coping mechanisms without ‘taking the reins’ and undermining or reversing the client’s sense of empowerment. The patient must be reminded about the motivation and self-worth they found throughout the previous sessions. However, it is still the responsibility of the counselor to insert their expertise when needed. For instance, often times even after a client has found the motivation to change, they do not know how to go about doing so or feel stuck. Situations like these, where a patient is wanting advice, a therapist’s advice can be a valuable skill. This guides the client towards forming a plan that they feel confident in and motivated to stick with.
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OARS is a series of interpersonal communication skills that facilitate clear conversations and a collaborative working relationship. OARS involves asking Open questions, Affirming a clients’ strengths, Reflecting to clients what they seemingly wish to express but might not have spoken aloud, and Summarizing what has occurred throughout their session and their therapeutic interactions as a whole. OARS was first introduced to the Motivational Interviewing process by Dr. Miller and Dr. Rollnick in the 3rd edition of Motivational Interviewing: Helping People Change (2013). It outlines an addition four counseling techniques to be used primarily (but not exclusively) in the engaging process of MI. In MI, the OARS are used to “row” in a particular direction.
O: Asking Open questions refers to a technique which encourages patients to become more involved in the conversation. Rather than asking ‘closed’ or fact-gathering questions, patients are inclined to elaborate on their answers and do most of the talking. The counselor is there to listen and empathize with the patient, helping build a stronger relationship and a trusting, comfortable atmosphere.
A: Affirming involves bringing attention to a client’s strengths. During this process, it is important for the counselor to comment positively on their patient’s progress, efforts, attributes, and the steps they have taken towards recovery rather than any short comings or stumbles they have had along the way. This helps make sure that patients don’t feel the need to defend their worth or their progress, and therefore they can be more open to self-examination and further goal setting.
R: Reflecting can be done in two ways: simple reflections and complex reflections. Both involve a counselor showing empathy and understanding to their client. Simple reflections are carried out by reiterating something the client has said, either word for word or slightly rephrasing what has been said. Complex reflections entail making skillful guess about something the client has implied, but maybe hasn’t said aloud. Reflections are usually portrayed as statements rather than questions, as it shows a deeper level of understanding in regard to the counselor’s patient. Questions can sometime provoke more defensive response from patients, so when a therapist gives input via statements it helps the patient see something they might not have before without potentially offending them.
S: Summarizing allows the therapist to compile all of the information, concerns, and revelations that a person has shared with them. When the patient is able to consider all of this together, it can be easier for them to realize that they want to recover and get sober. Summaries are particularly effective at helping a patient realize their own “change talk.” Change talk is a concept usually initiated by a therapist trying to encourage a patient to change their ways and seek sobriety. However, with MI, the patient is able to initiate their own change talk, making their desire to recover even stronger.
OARS and the Four Processes
None of the aforementioned process are intended to be a linear, step-by-step guide to Motivational Interviewing. The engaging process will naturally occur first, as it is important to build a strong foundational relationship with your client before delving into conversations about motivation and change. However, engagement can be lost as time goes on or as conversations become more difficult for the client to deal with, therefor the therapist must go back and once again build up that sense of trust and security through engaging. OARS is used throughout the engagement process but can also be used to assist in the other three stages of MI. OARS during engaging is used to develop a rapport and create the environment for those further conversations. In focusing, OARS helps to establish and narrow in on a target change behavior. OARS in evoking is used to elicit and reinforce motivation for change. It can also help guide a client towards addressing and resolving their ambivalence for change. Finally, OARS in planning helps develop and reinforce the plan for change.
When to Use Motivational Interviewing
Motivational Interviewing as a method of counseling is especially effective for alcohol addiction. Research shows that because of the greater social acceptance and the legality of alcohol use, people with alcohol use disorders tend to be more ambivalent regarding their addiction. According to a study out of Utah published in the Journal of Clinical Psychology, MI is up to 20% more effective that other methods of treatments when addressing alcohol use disorder.
Due to its continuous success, MI is becoming more commonly used to address other substance and behavioral addictions as well as mental illness. These include gambling addictions, eating disorders, internet addiction, and low self-esteem. MI can also be used to increase motivation for positive behaviors, like healthy eating and exercise.
Motivational Interviewing and Treatment Resistant Addiction
Motivational Interviewing has shown to be a highly effective form of treatment and often helps patients who have relapsed or not had good results with other forms of therapy such as cognitive behavioral therapy. When seeking treatment, a lack of motivation can make staying on task and valuing long-term results quite difficult. MI helps patients hold themselves accountable during and after treatment. It is also helpful for patients looking for a close relationship with their counselors, as opposed to the sometimes cold, stark, and strictly professional relationships patients form with therapists during other forms of treatment. MI places a high value on the trusting and empathetic relationship between clients and their counselors, providing a lot of support and validation towards patients and their feelings.
If a patient has relapsed in the past, after receiving some other type of treatment, it can often strengthen their uncertainty and indifference towards the consequences of their drug use. This attitude and lack of confidence is a significant contribution to potential repeated relapse, even if traditional treatment is undergone. However, with MI, patients are able to find their own inspirations for change and are more dedicated to the idea of staying sober. MI is one of the only forms of treatment that emphasizes internal motivation rather than just the result of one’s sobriety. In order to achieve long term sobriety and reduce the chance of a relapse, a patient must find inspiration to quit that isn’t based on guilt or pressure from loved ones and health professionals.
Limitations of Motivational Interviewing
As stated, Motivational Interviewing is most effective when used in addition to other forms of treatment and therapies. It does not address any of the underlying reasons for an addiction, which is very important to confront for successful results. MI also does not address co-occurring disorders, when a patient has both a substance use disorder in addition to some other diagnosed mental illness or trauma that requires treatment and attention. In some cases, if there are severe underlying mental health issues, trying to inspire interpersonal motivation would be completely futile. This is particularly problematic for individuals with major depressive disorders, which are often characterized by a lack of motivation. Additionally, patients who lack the ability to focus on the concept of pros and cons are unlikely to be helped by MI. This may include patients with severe mental illnesses such as bipolar disorder, schizophrenia, or individuals with intellectual or developmental disabilities.
Outcomes of Motivational Interviewing
Despite its limitations, there is an abundance of research that suggests that Motivational Interviewing is an effective form of treatment for substance use disorders of all kinds. It is adaptable and can be used with a wide variety of patient populations with various levels of care. This is because MI is an application of a treatment philosophy, with flexible guidelines giving facility staff and therapists the ability to encourage their patients when they see it fit and step back as their patients take the reins on their own sobriety. Motivational interviewing is an evidence-based practice (EBP) and has reported successful outcomes in over 300 peer-reviewed research studies.
One such study looked to create a compilation and analysis of the overall effectiveness of MI. To do so, they reviewed over 115 studies to sum the average effects that influence MI outcomes. They examined treatment length, the most effective time to use MI, diverse deliveries of MI, manual use, ideal populations, specific problematic behaviors, and use with other EBPs and treatment methodologies as well as the varying levels of care. Overall, the results concluded the following:
- MI was effective for 75% of all participants, significantly effective overall compared to no treatment, and as effective as other evidence-based treatments for substance use disorder (such as cognitive-behavioral therapy and/or Twelve-Step Facilitation).
- MI is most effective when used as a prelude to other treatments or in addition to other treatments.
- MI is typically completed in one to two sessions and/or four to six sessions with Motivational Enhancement Therapy (MET), a standalone variation of MI. Research is unclear on ideal treatment length; however, more sessions tend to lead to better long-term outcomes.
- No MI manual use in sessions is significantly more effective than strict use of a manual.
- MI is ideal for all populations regardless of gender, age, or problem severity and shows the greatest impact in minority populations when compared to other common substance use disorder treatments..
- MI can increase client engagement up to 15 % and increase treatment retention when given at intake assessment.
All in all, there is a large body of research that consistently supports MI as an effective, evidence-based practice. The longer this type of treatment is implemented, the more significant and long-lasting the results tend to be. Especially when used as a prelude of in addition to other forms of treatment, MI is a particularly successful form of treatment. It is also very diverse and adaptable, making it a desirable form of treatment for anyone looking for mental health and substance abuse disorder treatment. If you or a loved one are struggling with an addiction, speak with a dedicated treatment provider today.