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Motivational Interviewing

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Motivational interviewing (MI) is a therapeutic technique used to increase a person’s motivation for sobriety from substance abuse and commitment to long-term change. This modality helps individuals strengthen their self-motivation for change. This has a demonstrable advantage over other forms of motivation in which the addict is attempting to change to please others. Through motivational interviewing, the addicted person evaluates the benefits or disadvantages of their life choices and behaviors, as well as what may be stopping them from making healthy choices. The client determines what changes they want to make according to their own needs and goals. This builds their commitment to change their behavior and overcome their substance use disorders, as they are able to use their own ideas to fuel the change rather than attempting to please others. Motivational interviewing is often used in conjunction with other recovery interventions, including Cognitive Behavioral Therapy, stress management techniques, and participation in 12-step and other support groups.

Roots in Behavioral and Cognitive Psychotherapy

Motivational interviewing builds on established principles in behavioral and cognitive psychotherapy. Like Cognitive Behavioral Therapy, it depends on establishing a solid therapeutic relationship between the therapist and the person seeking to change.

While some other therapeutic techniques focus on imposing behavioral changes from the top down, motivational interviewing is a collaboration between the therapist and the addicted person, with a strong emphasis on the client’s ideas, feelings, and decisions. This is because decades of research into behavior and cognition have found that the top down approach is ineffective for treating mental illness, substance use disorders, and other difficulties faced by patients. Although a well-trained clinician can help to facilitate it, behavior change that lasts most often comes from within.

Behavioural And Cognitive Psychotherapy | Turning Point of Tampa

Clinicians who use motivational interviewing are doing so because clinical psychology has recognized and affirmed the primacy of a person\’s own opinions in strengthening commitment to change. Guilford Press has published a guide to motivational interviewing that elaborates on the theory that underpins the practice and illustrates how it developed from other schools of thought. This guide also describes the origins of the technique.

Mental Health | Turning Point of Tampa

Founders of Motivational Interviewing

William R. Miller and Stephen Rollnick are recognized as the founders and creators of motivational interviewing. Both clinicians had worked in health care settings for many years and were seeking to synthesize their knowledge about the best means of helping patients change behavior. They established motivational interviewing’s key points after conducting a meta analysis of other forms of treatment for alcohol abuse and discovering that the most effective treatments worked by facilitating behaviour change through empathic and active means.

Empathic Means of Treatment

The best forms of substance abuse treatment, based on the findings of Miller and Rollnick, are empathic, meaning that the person seeking to change is treated with respect for their needs and desires and is not castigated and shamed for their substance abuse. Their experiences in addiction medicine showed that confrontational approaches, rather than building motivation, often injured the patient’s self esteem, making them more likely to relapse in the long run. An effective clinician will express empathy for a person’s motivation to abuse substances, rather than confronting them or demeaning them.

Looking at other physical health conditions is one way of understanding why empathic treatment is best. Would it be effective to shame or attack a person struggling with diet-related diabetes? Perhaps in the short term, but to build lasting motivation to change, clinicians are not helping clients by making them feel weak. Once they are out of the treatment setting, their lack of intrinsic motivation is likely to guide them back toward the same food-based coping behaviors that landed them in treatment in the first place.

A better way to help clients lose weight and overcome diabetes involves coming alongside them to explore their reasons for overeating. Then clients can recognize how their mental health impacts their behavior, and identify ways to replace the psychological purpose that their unhealthy behavior serves. The same is true for clients with eating disorders; showing empathy for their condition is more effective than berating them about their current behaviors and the associated risks. Positive changes are more likely to last when the motivation comes from within, and empathy is a foundational skill for people practicing empathic means of treatment.

Active Means of Treatment

The other key feature of effective treatments that Miller and Rollnick identified is that they are active. Rather than watching a video or being subjected to a lecture, patients play an active role in developing their treatment plan and maintaining their behavior change. They identify and develop their own reasons for wanting to change, and are able to build on past successes. Motivational interviewing honors client autonomy by letting them make their own decisions, rather than telling them what to do or forcing them into a specific set of actions.

More passive means of treatment have low rates of treatment adherence, because once the patient is removed from the program, they no longer have the fuel to maintain a change. Effective change talk thus revolves around a counseling approach that lets people find their own reasons for personal change. These reasons will continue to hold weight for them later in the change process, and the sense of self efficacy that they develop will help them hold to their identified principals. Building on patient’s strengths is much more effective than highlighting their weaknesses, both in a general practice setting and in more specific settings, as described below.

What the criminal justice system tells us about motivation

An example that illustrates the importance of active means of treatment is the criminal justice system. The modern justice system attempts to treat people with deviant and criminal behaviors by removing them from society and the associated temptations, or by supervising them closely to ensure they do not re-offend (as is the case with many probation and parole programs).

This is not an effective way of preparing people to live normal lives once they leave prison or are discharged from probation, and empirical studies have shown as much. People who are imprisoned are more likely to offend again than people who are not, because they have not been given a chance to develop the underlying spirit necessary to understand why their behavior was harmful. True behavior change is difficult if the main reason for changing is because of an externally enforced barrier. Motivational enhancement therapy and motivational interviewing take the opposite approach by allowing patients to find their own point of preference and use that to motivate personal change.

Motivational Interviewing Begins with Change Talk

Motivational interviewing starts with “change talk.” At this stage, clinicans express empathy for the struggles their clients face, often including mental illness, physical health conditions, and limited feelings of self efficacy. Unlike many other forms of substance abuse treatment, motivational interviewing can be used with clients who are not yet ready to leave their unhealthy lifestyle behind.

Change Talk | Turning Point of Tampa

Stages of motivation: Pre-contemplation

In these cases, the client starts off in the “pre-contemplation” stage; they have not yet begun to even consider abandoning their substance use disorders. Pre-contemplation is one of the Stages of Change identified by James Prochaska, Ph.D. and Carlo DiClimente, Ph.D, in a groundbreaking article called Changing for Good, published in 1994 and building on research they began in the 1970s.

Many people enter treatment in this stage of motivation. Fortunately, motivational interviewing has a clear path for clinicians to guide them toward a willingness to consider changing.

Reflective Listening

Reflective listening is an essential component of motivational interviewing, at every stage. In the pre-contemplation stage, the clinician will patiently listen to the client’s ideas about why they deserve to continue using. In other words, the client and patient will discuss the patient’s motivation to continue their substance use. The clinician will not directly contradict them. Instead, they will seek to understand what the client is saying, and respond by asking clarifying questions to ensure that they are understanding correctly.

This serves multiple purposes: it helps the clinician to accurately grasp the motivating factors at play, and it makes the client feel understood and accepted. Additionally, it lets the client hear their reasons expressed by someone else, which may help them recognize the inherent problems with their reasoning. It may seem counterintuitive to let someone with a substance use disorder explain at length why they feel the need to use. However, the opportunity to honestly explain their use guides the client away from viewing their therapist as an enemy or as someone who doesn’t understand them.

In the case of smoking cessation, the therapist may listen as the patient explains how smoking relieves stress for them, and respond without judgment, affirming that the patient is not inhuman or deviant for their feelings. The clinician may not directly agree with the patient’s reasoning, but they will respond in a way that makes the client feel trusted and understood. This is one of the core concepts of motivational interviewing.

Stages of Motivation: Contemplation

Once the client has laid out their reasons for using, the clinician will shift discussion to other motivating factors in their life, like goals they have in their careers, relationships, and hobbies. The goal is to guide the client into the next stage of change, contemplation.

To continue with the example of smoking cessation, a clinician might ask the client who seeks to cease smoking (and who described the functional purpose of their smoking earlier in treatment) to identify goals that they have around health, physical fitness, and mental health. They may ask them how their ability to breathe, exercise, and self-soothe has been impacted by their smoking, and how they think their smoking might affect them in the future. They may ask about their goals for their relationships, and guide them to consider how people around them might be affected if they were sickened by lung cancer or another smoking-related ailment.

Confrontation vs Exploration

The tone in this stage (and others) is not confrontational, but inquisitive and exploratory; the client must form their own conclusions. Once again, the clinician will demonstrate reflective listening, allowing the client to explain their feelings, then responding to confirm that they are accurately grasping them.

Developing Discrepancy

The goal in this stage is to subtly point out how the client’s short term priorities around their substance abuse contradict their long term priorities. The clinician will help the client develop discrepancy, recognizing the conflict between their substance abuse and their stated goals for life. In cases of adolescent substance use, the clinician might guide the client toward recognizing how their goals in adult life will be impacted if they continue using substances that limit their options for education and employment.

For adults, the clinician can help them see the discrepancy between their stated goals of caring for themselves or their loved ones and the impact of their use. They may also guide them to consider how their career has been impacted by their use. In essence, the goal is to generate insight in the patient into contradictions between the status quo (their current behaviors and patterns of use) and their ideal state of being.

Stages of Motivation: Preparation/determination

As described above, motivational interviewing (MI) focuses on health behaviors that are negatively impacting the person in question and leverages a person’s own opinions to help them recognize the importance of behaviour change. The initial process may seem to be very cerebral and focused on introspection, but the goal is to guide the client toward a holistic and personal understanding of how their use is limiting their self efficacy.

The Importance of Self Efficacy

Motivational interviewing accentuates the positive traits and innate wisdom in each person. When individuals have strong confidence and self-esteem and clear personal values, they can more easily commit to making the healthy life choices necessary for long-term recovery, and once they have recognized how their values conflict with their long term goals and priorities.
Motivational interviewing helping people depends on the client reaching the stage of preparation and determination, in which they are ready to make a change. At this stage, their therapist can begin to suggest an evidence based approach to overcoming their mixed feelings about their substance dependence and committing to a long term strategy for improvement and sobriety. Other mental health challenges that the client is dealing with might also be addressed at this stage.

Stages of Motivation: Action/Willpower

Once the client and clinician have arrived at the point where the client is ready to change and has enough self esteem to feel empowered in making the change, the change talk stage is nearing its end. At this point, the client is asked to start taking action. This is the stage at which abstinence from substances and participation in 12 step programs or other sobriety maintenance methods is suggested by the therapist.

This is the stage at which many clients start to express discomfort. In prior stages, they are able to speak hypothetically about how much better life may be without their substance dependence, but this is the stage where they are asked to actually put that into practice.

Stages of Motivation: Maintenance

The final stage of motivation is maintenance. Once the client has taken action to make a change, the clinician and the client now shift from focusing on the past to the present. They may discuss past successes and highlight what has been effective and ineffective, and will frequently refer back to the status quo and its negative elements to reinforce commitment to the change.

There may be difficulties that the client has to face in remaining committed to the change. Medication adherence is an important factor, particularly for people who have co-occurring mental health diagnoses that accompany their substance dependence.

Sustain Talk

Once the client is committed to change and has begun taking action, the “change talk” is replaced with “sustain talk.” The focus is on staying committed to the transformation that has occurred, and not letting old, damaging behaviors come back into play. Sustain talk frequently revolves around reiterating and reaffirming the values identified in earlier stages, and reminding the client of their own personal reasons for wanting to leave the status quo behind.

Who Can Benefit from Motivational Interviewing?

We incorporate motivational interviewing into treatment for most clients at Turning Point of Tampa. This therapeutic approach helps clients realize that they have the potential and desire to change their behavior for themselves, as opposed to changing due to outside influences or pressure. Anyone who has struggled with finding the strength to make a change can benefit from motivational interviewing, even people who are not certain they are ready to leave their substance dependent behavior in the past.

How Do I Know if Motivational Interviewing is Right for Me?

Motivational interviewing can help anyone in the early stages of their recovery to take the next step on their recovery journey. When used alongside additional clinical therapy, motivational interviewing can provide added clarity and purpose to individuals looking to change addictive or harmful behaviors.

What Should I Expect from Motivational Interviewing?

Motivational interviewing takes place between a client and their therapist, who will lead them through a guided exploration of why they want to recover and the choices they have made up to this point. Insights from this process can help the client as they move through additional forms of therapy, such as Cognitive Behavioral Therapy and therapeutic groups.

The Motivational Interviewing Network of Trainers is a professional organization that helps clinicians to apply the principles of motivational interviewing (MI) to their own practice, whether it be clinical psychology, social work, or a counseling approach. Clinicians interested in learning MI can reach out to this organization to find qualified programs The National Institute of Mental Health has also issued directives on the use of motivational interviewing and can direct professionals who are interested in learning motivational interviewing to the best sources for training.

Turning Point of Tampa employs clinicians trained in motivational interviewing to assist clients who are struggling with their negative impulses to overcome these limitations and achieve their long term goals.

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