Most people fear change. Change causes stress in the brain, specifically the part of the temporal lobe called the amygdala (also known as the lizard or reptilian brain). The amygdala, the most primitive region of the brain, perceives change as a threat to the body and so releases stress hormones that provoke a fight or flight response.
It doesn’t matter if the change is good, bad, or indifferent, the human brain is hardwired to fear it. That’s one reason that people with substance use disorders are afraid to stop using alcohol or drugs.
Intellectually, they may understand that they would be better off if they stopped using, that their substance use is destroying their lives, relationships, and finances. The lizard brain still fears change, as well as the physical changes that come with abstinence such as a drop in the “happy” neurotransmitters and withdrawal symptoms. To argue with them only makes them more determined to resist.
That’s the idea behind motivational interviewing: to encourage clients to want to change without trying to make them, persuade them, or even tell them.
What Is Motivational Interviewing?
Most psychotherapy is non-directive, which means that clients, not therapists, lead the process. These forms of psychotherapy encourage understanding and acceptance that may lead to change. Motivational interviewing, meanwhile, is a form of directive psychotherapy.
Non-directive or client-centered (as opposed to therapist-driven) psychotherapy emphasizes a therapist-client relationship that is non-judgmental, accepting, and respectful. To show that the therapists are paying attention, they repeat the same language the clients use without making suggestions or offering advice (reflective listening).
Motivational interviewing is subtly different. It also uses a form of reflective listening but works to bring out the clients’ ambivalence to change their behaviors. It is gentle guiding through summarizing what the client said and asking open-ended questions to make the clients conclude that they need to change.
What to expect in a motivational interview is a collaborative process between therapist and client, a conversation about change with the client doing most of the talking. Since motivation is both an intrinsic and extrinsic concept, there are specific ways in how a professional should interact in order to spark motivation. Extrinsic motivation can be given at the first part of the intervention, but it should always end with the goal of developing intrinsic motivation to help in long-term addiction recovery. Below are some of the key pointers of motivational interviewing: To gain intrinsic motivation, ideas and narratives should come from the client themselves. It should come from a place where the client resonates with, instead of ideologies forced upon the person being treated. For example, if one prioritizes their loved ones as a motivation for change, this should be the main focus instead of bombarding the client on quitting addictions for the sake of their health. As mentioned, the end goal of motivational interviewing is to help the client become self-reliant and to have the inner determination to recovery. Thus, giving conversations that inspire autonomy rather than being too authoritative helps the client gain confidence and being more open to making a change. Confrontational conversations can bring a client into the defensive. Thus, the professional should come to a target point where the client is willing to collaborate and take the necessary steps in addiction treatment. A specific example would be avoiding triggers in one’s daily schedule. Instead of confronting the patient on what they do ‘wrong’, it is best to ask their own ideas on how to avoid these addiction triggers.
Key Concepts of Motivational Interviewing
Drawing out ideas rather than imposing
Autonomy over authority
Collaboration vs. confrontation
Since motivation is both an intrinsic and extrinsic concept, there are specific ways in how a professional should interact in order to spark motivation. Extrinsic motivation can be given at the first part of the intervention, but it should always end with the goal of developing intrinsic motivation to help in long-term addiction recovery.
Below are some of the key pointers of motivational interviewing:
To gain intrinsic motivation, ideas and narratives should come from the client themselves. It should come from a place where the client resonates with, instead of ideologies forced upon the person being treated. For example, if one prioritizes their loved ones as a motivation for change, this should be the main focus instead of bombarding the client on quitting addictions for the sake of their health.
As mentioned, the end goal of motivational interviewing is to help the client become self-reliant and to have the inner determination to recovery. Thus, giving conversations that inspire autonomy rather than being too authoritative helps the client gain confidence and being more open to making a change.
Confrontational conversations can bring a client into the defensive. Thus, the professional should come to a target point where the client is willing to collaborate and take the necessary steps in addiction treatment. A specific example would be avoiding triggers in one’s daily schedule. Instead of confronting the patient on what they do ‘wrong’, it is best to ask their own ideas on how to avoid these addiction triggers.
When Is Motivational Interviewing Used?
Motivational interviewing was created to treat clients with alcohol use disorders but has since been expanded to treat other types of addiction problems as well as other chronic health conditions, such as diabetes, asthma, and heart problems.
Generally, individuals know they have a problem but lack the urgent motivation to change. If aggressively confronted, they may become defensive and double-down rather than seek help.
Motivational interviewing is most often used and is most effective during the early stages of substance use disorder in the early contemplation stage of change. The individual is sitting on the fence but is at least considering a change. Motivational interviewing helps the individual sort through the pros and cons.
Guiding Principles Behind Motivational Interviewing
One of the goals of the therapist in motivational interviewing is to get the clients to acknowledge that they want to change their destructive behaviors. To accomplish this, they utilize these key elements of motivational interviewing:
- Show empathy. Demonstrate that you are interested in and paying attention to what the clients are saying by restating their words.
- Develop discrepancy. Build on the disparity between the clients’ stated desire for change or goals and their behavior.
- Avoid arguments. When clients resist, don’t argue or confront them directly. Try to reframe the question.
- Support self-efficacy. Express optimism that the client can change. This will motivate the client to change, becoming a self-fulfilling prophecy.
Additionally, another key principle that one can use when facilitating motivational interviewing is the OARS method.
OARS Method (Open Questions, Affirmations, Reflections, Summaries)
- Open questions: The professional is encouraged to ask open-ended questions to draw out ideas, intentions, and other trains of thought that the client may have. These ideas can be used to create an action plan later on.
- Affirmations: It is important to validate the client’s thoughts and feelings on the subject matter. Affirming them about how they feel can bring them to a state of feeling supported, which is essential in making them listen to an action plan.
- Reflections: When a professional allows a client to reflect, what they do is rephrase something that was said. This allows an opportunity to clarify and also for the client to understand their thoughts even more.
- Summaries: At the end of every session, the therapist should have a roundup of what is talked about, the thoughts and feelings on the situation, and a course of action that can help. Summarizing the session helps the client to have organized thoughts and to strengthen the main takeaway for the conversation.
When To Use Motivational Interviewing
At one time, substance abuse counseling was aggressively confrontational because counselors and therapists thought they had to be to get through to their clients. Then research showed that this approach had worse results than “a supportive, compassionate style” an approach “showing high levels of empathy.”
Motivational interviewing won’t work if the clients don’t want to change, but if they do, it can overcome their natural ambivalence and strengthen their resolve in just one or two sessions. According to one motivational interviewing developer, those entering rehab with just one session were more motivated and had “double the abstinence rate” of those who did not.
Other reviews found motivational interviewing outperformed other treatments for alcohol use disorder, particularly among young drinkers with either low or heavy dependencies who voluntarily sought help.
Outcomes of Motivational Interviewing
There are many studies that point to the positive effects of motivational interviewing for both physical and psychological disorders.
It is said that this method of counseling works well for people who desire change but are not sure of the necessary steps that would work for them.
In terms of addiction, it has a significant positive effect on:
- People with mild alcohol addictions
- Individuals who want to quit smoking
- People who have eating disorders
Additionally, it is also discovered to be effective on:
- Those who want a healthier lifestyle
- Mild depression
- People wanting to achieve certain life goals
The underlying principle of using motivational interviewing effectively is finding clients who have an untapped intrinsic desire for change and guiding them towards the right direction for addiction recovery.
What to Look for in a Motivational Interviewer
The qualities required for motivational interviewing are similar to those required for other therapists, with an emphasis on empathy and listening.
Motivational interviewing requires a relationship with the therapist or counselor, so clients must be comfortable with the therapists they choose.
For the large COMBINE study of pharmacotherapy for alcohol dependency, participating motivational interviewing therapists were required to have:
- A master’s degree in a counseling field
- At least two years of counseling experience
- Accurate empathy skills
- The ability to listen without trying to persuade or problem-solve
About one-sixth of the therapists tested couldn’t pass an additional screening test for empathy though they were allowed two attempts. They gave in to the temptation to elicit facts and give advice.
The therapist you choose should be well-versed not only in the techniques and strategies of motivational interviewing but also in the style and spirit of motivational interviewing. The process requires patience, letting the clients put their ambivalence into words, waiting until the clients feel ready to make a change, allowing the clients to make their own choices and face the consequences.
Motivational interviewing has strict rules of behavior for the therapist, but it’s not an either-or treatment. It can be used in conjunction with other therapies such as cognitive-behavioral therapy. If the clients relapse at any stage, they can try again, hopefully having learned something and improving with each attempt.
Recovery from substance use disorders is like any chronic physical or mental health issue. Relapse is common and should not be judged. That’s the best way to ensure that clients keep trying.
Motivational Interviewing: Honing an Internal Desire
There are many approaches to addiction treatment, and motivational interviewing is one of the avenues where professionals can tap a client’s internal desire for change. With the key principles mentioned above, one can use personal motivation as a stepping stone towards substance abuse recovery.
- books.google.com – The Change Book: Change the Way You Think About Change
- health.harvard.edu – Understanding the stress response
- medlineplus.gov – Opiate and opioid withdrawal
- britannica.com – Carl Rogers (Encyclopedia Britannica)
- lib.adai.washington.edu – Motivational Interventions for Special Populations
- britannica.com – Nondirective psychotherapy (Encyclopaedia Britannica)
- maxwell.syr.edu – Reflective Listening
- methoide.fcm.arizona.edu – Use of Motivational Interviewing
- ncbi.nlm.nih.gov – Chapter 3—Motivational Interviewing as a Counseling Style (Enhancing Motivation for Change in Substance Abuse Treatment)
- motivationalinterview.net – All about Motivational Interview (MI)
- jcjc.pa.gov – Motivational Interviewing (Juvenile Justice System Enhancement Strategy)
- Ncbi.nlm.nih.gov – Enhancing Motivation for Change in Substance Abuse Treatment
- socialworktoday.com – Motivational Interviewing With Substance Abusers — The Power of Ambivalence
- ncbi.nlm.nih.gov – Motivational interviewing: a systematic review and meta-analysis
- academic.oup.com – The Efficacy of Motivational Interviewing as a Brief Intervention for Excessive Drinking: A Meta-Analytic Review
- ncbi.nlm.nih.gov – The COMBINE Study: An Overview of the Largest Pharmacotherapy Study to Date for Treating Alcohol Dependence
- media.wcwpds.wisc.edu – The Relationship in Motivational Interviewing
- sharepoint.washington.edu – What Is Motivational Interviewing?
- mayoclinic.org – Cognitive behavioral therapy
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