MOTIVATIONAL INTERVIEWING

Dr. Patrizia Collard
Stress Management Consultant and Psychotherapist

"MOTIVATIONAL INTERVIEWING Preparing People to Change Addictive Behaviour" by: W.R. Miller & S. Rollnick, The Guildford Press, New York, London, 1991


When I was initially introduced to the subject, I immediately felt that Motivational Interviewing was an approach I would like to incorporate in my counselling skills. I felt very strongly that here was an alternative to the traditional approach in dealing with addiction, an approach that attempted to reinstate a person's lost self-esteem and self-control. In my work as a counsellor for clients with anxiety and compulsive-obsessive disorder, I constantly strive to facilitate people in taking back control over their own lives, and so this notion is one of the essential goals in my work.
MI has been described as "one of the most important and innovative therapeutic intervention of the 1980s" (Whitehead 1992).

The book under discussion is the only in depth compilation of training material and analysis of MI available, and has been edited and partially written by its founder W.R. Miller.
It offers an abundance of material (24 articles in all) contributed by no less than 19 practitioners.
The book represents one aspect of the larger topic of change: what motivates change in people struggling with personal problems. And Miller states:

"What we hope to offer in this book is a clear understanding of how people can be trapped by ambivalence, and how those who want to help them can strengthen their motivation for change." (Preface, p. ix)
MI is an approach designed to help clients build commitment and reach a decision to change.
Historical and geographical perspectives:
It was in the mid 1970s that William Miller began to develop MI. At first he claims it was mere intuition, but when challenged by Norwegian psychologists on the nature of his seemingly successful techniques, he decided to attempt an interpretation and outline of his approach, and published it in 1983 under the title: Motivational Interviewing with Problem Drinkers.
I personally felt that this first article was rather long-winded, and at times not specific enough in the actual practical application of the theory it presented. Miller seems to agree when he writes in the book under discussion: "In the ensuing years, much progress has been made toward clarifying and specifying processes of motivational interviewing." (Miller, 1991, p. 51).

Today MI is practised in many countries, particularly English speaking ones, The Netherlands and Scandinavia.
The book is divided into three parts, each containing several articles. Part One is entitled BACKGROUND and deals with questions such as 'Motivation as a Personality Problem', 'Search for an Addictive Personality' or 'Prochaska & Di Clemente's Stages of Change Model'. Miller tries to challenge the idea of the 'addictive personality' (he very much opposes 'labelling') and the notion that people with addictive behaviours are constantly in denial. He rather blames the overconfrontational therapist for the behaviour mentioned above (see below).

In the somewhat longer Part Two, entitled PRACTICE we learn about the principles of MI:

*Motivation: here it is not defined as a personality trait but as an interpersonal process. In order to motivate a client to change, you attempt to encourage him to make the decisions that he deems necessary to improve his life. You avoid to impose change from without, as this might often lead to rebellion, thus decrease of motivation.

*Denial: Miller believes that it is not inherent in the alcoholic, but rather that it is a reaction to the counsellor's (therapists) approach; i.e. man tends to do the opposite of what he is told to do. Thus telling somebody that they have an alcohol problem might lead them to take the opposite point of view, traditionally then labelled as denial.

Miller further explains that MI attempts to encourage people to take on responsibility for their own life and to deal with their problems themselves. It acknowledges that unless people themselves see the need to change, no lasting change will ever be achieved. In order to create an openness to change the therapist has to be a good listener and interpreter, as he will feed back to the client in a structured and thus more potent form the reasons for change the client has mentioned himself. At first the client may be very reluctant to come forward with such information. So it is of utmost importance to read between the lines, to remember the little dissatisfactions the client mentions and to tease out whether their importance has not been undervalued.

The goal is to increase the client's intrinsic motivation and is achieved by adhering to five general principles:

1) Express Empathy: accept people as they are and where they are (based on C. Roger). Ambivalence to change is seen as normal, consistent with reality. The therapist tries to elicit self-motivational statements.

2) Develop Discrepancy: "Motivation for change is created when people perceive a discrepancy between their present behaviour and important personal goals." (Miller, 1991, p. 57)

3) Avoid Argumentation: Start with the client where he is. Avoid direct confrontation in order to avoid resistance and avoid labelling.

4) Roll with Resistance: Reframe statements of client to create a new momentum towards change. The therapist invites the client to consider new information and perspectives. The client is actively involved in finding solutions for his problem.

5) Support Self-Efficacy: The therapist is an enabler to help the client help himself. We are supposed to help the client to believe in himself and to have confidence that he can carry out the changes he has chosen (i.e. reduced drinking, occasional use or possibly abstinence).

The theoretical background of MI is contained in the principles of Egan (i.e. Problem Solving), Rogers (i.e. Accurate Empathy) and Behavioural Psychology (i.e. by changing what you do, you change what you think). Miller goes so far as to call it a non-directive approach (Miller, 1991, p. 54).

Coming from a cognitive-behavioural therapy background myself I would like to argue, that firstly, many of the so called 'new ways' of MI are actually basic principles of counselling that most therapists would want to adhere to anyway. Secondly, MI is a lot more directive then it gives itself credit for.

Firstly, any counselling relationship is meant to start of with empathic listening, reflections and the aim to establish what it is that the client wants. If Miller intended his book for counsellors/therapists he is preaching to the converted. As however his aim is to reach everyone (i.e. doctors, nurses, social workers etc.) working with problems of addiction, his approach is certainly very valuable.

Secondly, in creating a cognitive dissonance, however subtly or gently you may do that, you are inevitably directing the client to where, in many ways, you  as the therapist want him to be, viz. to get him to be open to change. Of course, there is no doubt that, for example, REBT (Rational Emotive Behaviour Therapy/Ellis) would be a lot more direct in its approach, but not necessarily more directive, as both approaches very much agree on wanting to help the client to achieve his goals. Thus the therapeutic style is not truly reflective, as the client's comments are fed back in a modified form and are selected to create dissonance.

MI puts large emphasis on personal choice and responsibility. In my own experience as a therapist, however, I have come across many clients who would deny the existence of concepts such as  personal choice and responsibility. In such circumstances I would find myself having to use cognitive restructuring: i.e. the empirical evidence of personal choice. I was unable to find an answer to this problem in any of the articles contained in the book.

Part Three, CLINICAL APPLICATION OF MOTIVATIONAL INTERVIEWING, is the largest part of the book and contains a wide selection of articles from all over the globe. No. 13, for example, explores MI  within the context of Prochaska and DiClemente's model of change. This model describes a series of stages the individual may enter during the process of change (Precontemplation, Contemplation, Decision, Action, Maintenance and Relapse). Most treatment programs have been concentrating on the Action stage (i.e. how to overcome addiction) and might have been unsuccessful, for failing to recognise the client's lack of motivation to carry out the action.. MI on the other hand intends to 'help the person move from precontemplation to action' (Miller, 1983, p.166). It tries to establish first of all, whether the client is ready for change, if not, how to help him to decide whether change is desired in his case, what this change would entail and how to go about it.

Some authors describe in their articles why they needed to find a new approach to treatment in their work with addicted clients. Reasons mentioned amongst others were:

*staff dissatisfaction with the confrontational style of management of 'addicts'

*users dissatisfaction with traditional programs

*staff having attended an MI seminar finding it a lot more positive in its approach

*growing concern about HIV infection indicated the need to attract more addicts to the program

*staff spent a lot of time arguing with clients rather than building a therapeutic relationship

*Clients seemed much less eager than therapists to change their addicted lifestyle

*large number of burn-out among staff/drop out among clients

In general it can be said that all the centres applying MI as part of their treatment program seem to indicate an improvement in their service.

Another very interesting analyses with hands-on advice is Gillian Tober's article 'Motivational Interviewing with Young People' (article no. 18). It is probably the most explicit case-study on MI contained in the volume. Thus I would like to present here some of the main features in concise form:

Lisa (16) had been taken into care 8 months prior to this interview. Her mother had no longer been able to control her stealing or her vanishing for up to 3 days at a time. She now lived in a hostel under supervision. Again she routinely disappeared from Friday after work until Sat/Sun.

When Lisa went to see the therapist it had been her social worker's idea, thus Lisa behaved initially quite stubbornly. Nevertheless the therapist persisted in enquiring why Lisa thought the social worker had made the appointment. At this point Lisa mentioned alcohol for the first time. Thus the 'dreaded' word was initially used by the client rather than by the therapist and 'denial' was avoided. The next aim was to elicit concern about Lisa's drinking. As the therapist knew about her elopements she simply asked Lisa to tell her what she tended to do from Friday to Sunday. When Lisa described her drinking sprees with her mates she spontaneously mentioned concern about the fact of loss of memory. The next step for the therapist was to focus immediately upon this expression of concern. Thereupon further concerns where elicited and eventually the therapist summarised all of them: "You don't like forgetting what you have done, not knowing how you ended up where you did, although you do want to get out of your head and forget about not going home {cost-benefit analysis}. You don't particularly like alcohol, but it's there, so it's the easiest way to get out of your head. And you don't like ending up with no money,..." (p. 252-253). [Notice how the therapist focused in on the client by using the client's language]. This summary of concerns reinforced the negative side of the client's drinking. It did however also point out the positive side for her. Now one needed to build up motivation to change. The therapist asked Lisa what made her go out every Friday and elicited that Lisa's main reason was to avoid having to go back to the hostel which was not home. Lisa went as far as saying that she wanted to go home to her mother. The therapist expressed empathy at this level and elicited further, that the client was not allowed to move back home until the social workers could tell her mother that she did not get drunk any more. The therapist stayed with the client at this point and inquired what her mother did not like about her drinking.

A sheet was drawn up on which the therapist and the client together listed the pros and cons of her maintaining her present behaviour. This led on to eliciting desires to change. The client actually thought at this point that the list made drinking look pretty stupid.

Therapist: "So this must seem like a very difficult situation to you. You drink because you don't want to go back to the hostel, and you have to stay at the hostel because you drink."

Lisa: "If I stopped drinking, though, I could go home."

When the client had decided that she wanted to stop drinking (her 'nasty' stepfather had recently left her mother), they worked out a trial program which would last four weeks. She would attempt to stay sober for a month and would thereafter be allowed to return home. They also worked out an activity program which would replace Lisa's drinking sprees. All the idea's came from her, ie. putting most of her earnings in a bank account, play table tennis, watch videos etc. She had a number of accomplices (mother, social worker) to help her carry out her plan. And it worked!

Conclusion:

The book is an excellent manual for practitioners wanting to implement MI into their work. There remains however the problem that all contributors to the volume are supporters of MI, which must have lead to a somewhat biased evaluation. There is, it seems,  the need for comparative research so as to evaluate the effectiveness of MI in motivating clients to change.

 

BIBLIOGRAPHY: 

MILLER W. R. Motivational Interviewing with Problem Drinkers. In:
Behavioural Psychotherapy, 1983, 11, p.147-172.

FLEMMING P. A  Low Threshold Methadone Programme. In:
Druglink, 1989, 4 (2), p.13.

BOLTON K., Watt R. Motivating Change. In:
Druglink, 1989, 4 (4), p. 8-9.

VAN BILSEN H., Van Emst A. Motivating Heroin Users for Change. In:
Bennet G. ed. Treating drug abusers. London, New York: Tavistock/Routledge, 1989, p. 29-47.

VAN BILSEN H., Whitehead B. From Addiction to Control. In:
Druglink, 1991, 6 (2), p. 8-10.

HODGSON R. J. Substance Misuse. In:
Behav. Psychother., 1991, 19 (1), p. 80-87.

VAN BILSEN H., Whitehead B. Motivating Selfcontrol, In:
Conference Report of the British Assoc. for Behav. Psychoth., Oxford, 1991, p. 1-7.

WHITEHEAD B. Motivational Interviewing. In:
Executive Summary, The Centre for Research on Drugs and Health Behav., 1992, Nr. 17.

MILLER W. R. Principles of Motivational Interviewing. In:
Miller W. R., Rollnick S., Motivational Interviewing, New York, London: Guilford Press, 1991, p. 51-63.

DICLEMENTE C. Motivational Interviewing and the Stages of Change. In:
Miller W. R., Rollnick S., op.cit., p. 91-201.

TOBER G. Motivational Interviewing with Young People. In:
Miller W. R., Rollnick S., op.cit., p. 248-259.

Patrizia Collard (PhD) Stress Management Consultant and Psychotherapist

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