A Guide to Motivational Interviewing

Motivational interviewing is a type of counseling that is used to help patients who are ambivalent about their substance abuse recovery.

In this therapy, they can begin to understand how their addiction is affecting their life and then create a plan to overcome their dependence issues.

What Is Motivational Interviewing?

Motivational interviewing (MI) was first developed in 1983, as a form of counseling.

MI for treating substance abuse takes its name from the literal system of therapists trained in this practice motivating their patients to change their harmful and destructive behavior. Motivational interviewing is often used for addiction because a lack of desire to go into recovery is usually one of the greatest barriers that people face, even as their life falls apart around them because of their substance use.

Motivational interviewing is based on the theory that everyone who struggles with addiction has some understanding that their substance abuse is hurting them and the people who care for them. MI further works on the basis that a patient who is currently going through an addiction also wants to change their behavior and will respond positively to treatment overtures.

A therapist who is trained to use motivational interviewing gets the ball rolling by helping the patient overcome their uncertainty or ambivalence toward recovery by having in-depth conversations that work on increasing the patient’s own motivation to change.

Many people who need treatment for their respective addiction disorders have reasons for why they might not want to break out of their self-destructive cycles.

  • They may feel that they are in control of their substance use, that it is not as bad as others are saying it is, that other people have worse problems, or that substance use helps them to stay balanced.
  • They may worry that they can’t afford treatment.
  • They may be afraid of the guilt or shame of acknowledging an addiction.

Additionally, many people become psychologically dependent on the positive sensations they get from their drug use and are very reluctant to give them up. They may also be afraid of the withdrawal symptoms that come from breaking the physical dependence, so they continue to find some escape in their chemical substances.

How Does It Work?

Motivational interviewing has seven key approaches that every therapist will impart to their patients:

  1. The motivation has to come from the patient, not from anyone else.
  2. When there is ambivalence surrounding treatment, the resolution has to come from the patient, not the therapist.
  3. Persuasion cannot resolve ambivalence.
  4. The therapist gets their information from the patient through conversation.
  5. The therapist is responsible for guiding the patient to recognize and resolve their ambivalence toward treatment.
  6. The readiness to change will fluctuate, and this is a natural part of the process.
  7. The patient and the therapist work together, like partners.

Motivational interviewing is a straightforward approach to treat substance abuse, and it can be completed in a relatively short amount of time. In general, it follows this pattern:

  • The therapist engages the patient, talking about their concerns and their hopes, thereby establishing a relationship based on trust.
  • The patient and the therapist focus on the patterns and habits of drug use that the patient wants to change.
  • The therapist evokes the patient’s motivation for wanting to change by drawing attention to how necessary the change is. The therapist imparts their confidence that the change will occur, and that the patient is ready to move on from their addiction.
  • Therapist and patient work together to plan a series of practical steps that the patient will undertake to bring about the change they want to see in their life.

Patient-Centered Care

One of the characteristics of motivational interviewing is that it is centered on the patient. The focus of MI sessions is not what the therapist thinks is best for the patient, but what the patient wants to see happen.

In order to conceptualize and articulate this, MI therapists need to have very keenly developed senses of empathy, reflective listening (a communications skill whereby the therapist will listen to their patient’s idea and then offer the idea back to the patient, to confirm that they understand each other), and the ability to form a strong bond with their patient in a relatively short timeframe.

Not everybody is a candidate for motivational interviewing, but when it is used properly, it can be very effective. The Alcohol and Alcoholism journal wrote of a study where students who were addicted to tobacco and received motivational interviewing were four times more likely than those in a control group to either cut down on their smoking or completely quit.

The Landscape of Quitting

Motivational interviewing posits that everyone who is addicted to drugs or alcohol is in an internal battle over whether they really want to quit. From the perspective of someone engaged in substance abuse, every reason to stop consuming dangerous substances has an opposite reason to continue using, no matter how harmful it might be. These opposite reasons might be selfish or short-lived, but they are powerful and compelling, and this is what traps most people in their addictions.

As a result of this, motivational interviewing understands that patients can have periods when they are focused and intent on quitting (usually after suffering a negative consequence of their habit and vowing to change their behavior), followed shortly afterward by periods of doubt and selfishness, where the desire to break free is diminished.

The way motivational interviewing works is to clearly lay out the landscape of quitting, and the landscape is largely determined by what the patient thinks is important. When patients overcome denial about their problem, and understand the lure and risks of addiction on their own terms, they can also better think of the desire to change, what the change will cost them, and how they can go about putting that change into effect. When they can think in this way, it becomes much easier to do the work of recovery.

Ultimately, motivational interviewing seeks to help a patient go after this change that they have chosen.

Who Will Benefit From Motivational Interviewing?

Motivational interviewing can be especially useful for patients who have not enjoyed success with cognitive behavioral therapy (CBT). Cognitive behavioral therapy works by the patient changing their negative thought patterns and behavior. For patients who struggle to find the motivation to improve, this ambivalence will likely derail any attempts to use CBT for their treatment.

It is for that reason, writes the Cognitive and Behavioral Practice journal, that motivational interviewing might help patients start the wheel turning, and that process might eventually lead them to CBT. MI might also be enough on its own for them to overcome their addictions.

Additionally, patients who need a lot of emotional validation, and those who would benefit from a close partnership with their therapists, might also do better with motivational interviewing than they would with cognitive behavioral therapy.

The Journal of Drug Issues wrote that motivational interviewing might be very beneficial for patients who have relapsed. Research has indicated that patients who have repeated relapses reach a certain point of ambivalence about their recovery — that their repeated relapse leaves them with mixed feelings about the work (and worth) of recovery. Motivational interviewing can help patients navigate through the complexities and the toll of relapse, incentivizing them to rediscover the spark of inspiration to quit.

Crucially, MI removes the element of guilt or pressure to make this change. For some patients, not having the weight of expectations from loved ones can free them to make the improvements themselves.

Treating Alcoholics

Some addiction professionals have speculated that motivational interviewing can be most useful for alcohol addiction, possibly because alcohol consumption is legal and less stigmatized than drug use. The theory is that it is easier to be nonchalant about using legal substances, compared to knowing the social and health risks of using illegal drugs. The Journal of Clinical Psychology wrote that motivational interviewing can be 20 percent more effective in treating alcohol addiction than other methods.

This success has led to using motivational interviewing being trialed for other forms of behavioral disorders and mental illnesses. For example, it has been successfully used to increase motivation for people with eating disorders to recover. The Psychiatry Research journal wrote that MI could help patients with their “readiness to change.”

Limitations of MI

Motivational interviewing is not for everyone. It has certainly helped many people develop the motivation and strength to overcome their addictions, but patients who have co-occurring mental illness and chronic substance use disorders might need more than what MI can offer.

One of the benefits of motivational interviewing is that when it gets patients engaged, it might require as little as four sessions in order for the therapist and the patient to develop a solid recovery plan. On the other hand, a patient who has deep-seated mental health concerns, and whose addiction goes beyond a simple case of motivation, will likely need a significantly more in-depth form of counseling — one that probably includes medication in the regimen as well.

It might well be the case that for patients with severe mental illnesses and long-lasting addiction problems, motivation might not even be a possibility. If so, the approach of motivational interviewing would be the wrong tool for the wrong time.

For example, a patient with major depressive disorder will likely not respond well to MI because depression robs people of their ability to motivate themselves. However, research published in the Journal of Consulting and Clinical Psychology suggests that motivational interviewing can be helpful for patients with depression, and this might eventually offer promise for patients who have co-occurring major depressive disorder and substance use disorder.

Similarly, a patient who does not have the mental clarity to conceptualize the pros and cons of their substance abuse, and come up with a plan based on that conceptualization, will likely not be helped by motivational interviewing. Schizophrenia and bipolar disorder are two examples of these kinds of conditions, but there are others (patients with intellectual disabilities, for instance).

Therapist & Patient Relationship

One of the keys that determines whether or not motivational interviewing will be effective for a patient is the therapist. It is critically important that the patient and the therapist form a deep partnership, so the therapist has to be good at establishing a trusting relationship with different types of people in a short amount of time. This requires patience and nuance. While these skills are important for anyone who wants to get into counseling, motivational interviewing is a particularly demanding application.

In the same way that motivational interviewing is not for every patient, it is also not for every therapist. Some patients and counselors may do better with cognitive behavioral therapy.

Motivational interviewing is centered around the patient. They have to bring their ambivalence about treatment to the fore, and then decide how best to resolve the tension. Indeed, researchers writing in the Addiction journal ask if ambivalence is a “prerequisite for success in motivational interviewing.”

The therapist’s role is to give the patient tools to articulate both sides of the ambivalence, thereby creating clarification. In motivational interviewing, it is not the therapist’s responsibility to provide solutions or to push the patient in one direction or the other.

Asking Open-Ended Questions

This is done by the therapist asking open-ended questions, to prompt the patient to realize the gravity of their situation and to accept responsibility for what has to be done to change it.

Examples of such questions include:

  • What do your family members say your problems are?
  • What do you enjoy about using drugs or alcohol?
  • In what ways does your drug or alcohol use make your life harder? To what degree does this concern you?
  • Why did you decide to get help at this point in time?
  • What do you think you have to do to get better?

The idea behind these kinds of probing questions is to get patients to see the problem for themselves, and put the pieces into place whereby they can work through the problem. The therapist’s role is to affirm their choices, and offer guidance and advice as to how the work can be done.

Not every patient will respond well to this level of freedom and choice, but it does work for many people who are ready and willing to make the change.

The therapist is there to provide feedback about the potential consequences of the different paths that the patient discerns and offer advice on how different outcomes can be achieved. The therapist gives the patient a realistic assessment on how each plan of action can play out.

Treating Substance Abuse

In summary, motivational interviewing can help patients:

  • Understand the severity of their substance abuse.
  • Understand how their quality of life is harmed by their substance abuse.
  • Create a list of reasons for why they should change their behavior.
  • Recognize that change is possible, and that there are tangible and definite steps to take toward this change.
  • And recognize that all these changes come from themselves, not from their families, not from the legal system, and not from their counselor.

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