"Let today be the day you give up who you've been for who you can become." – Hal Elrod There's no judgment. There's no confrontation. There's no arguing or ultimatums. When it comes to treating substance abuse disorders, Motivational Interviewing (MI) can be a highly effective counseling technique. Just as the name implies, the approach helps people find the motivation to make a behavior change. First described by William R. Miller in the 1980s as a method of therapy for problem drinkers, Motivational Interviewing is defined in Behavioral and Cognitive Psychotherapy as "a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence." When individuals are ambivalent about their alcohol or drug addiction, they basically have two contradictory mindsets. On the one hand, they don't want to stop (I like how using makes me feel in the moment); on the other hand, they want to stop (I don't want to drink too much and crash my car, hurting myself or others). The common internal struggle of "to use or not to use" can be difficult either way. The difference? If you stop using, things have a chance of getting better. According to Psychology Today, non-addicted people often can't grasp that an addict will continue to use "despite severe experiences with negative consequences such as arrest or loss of job, family, home and health." That's the problem with ambivalence: those in-the-moment decisions—like having another drink or getting high—can easily win out over the ramifications of future consequences (legal trouble/jail time, failed relationships, financial issues or long-term health complications). Having the MOTIVATION to modify your lifestyle and change your behavior—and the ability to see the bigger picture of your goals—can be a game-changer. That's where Motivational Interviewing comes in. According to Better Health, "MI helps lead a client to see these conflicting goals and actions, and create a self-directed plan to make a change." In a sense, the approach leads to a reawakening. The process helps individuals decide for themselves how to live their best lives (rather than others trying to elicit the change for them). According to the Substance Abuse and Mental Health Services Administration (SAMHSA), Motivational Interviewing is based on the following four assumptions: Ambivalence regarding substance abuse is a normal motivational obstacle for people in recovery Therapists can help resolve ambivalence by working with their clients' intrinsic values and motivations The alliance between therapist and client is a collaborative partnership, and each party brings their own expertise to the table An empathetic therapist's supportive but directive approach to counseling sessions can stimulate the conditions needed for change to occur We asked clinicians at the Hazelden Betty Ford Foundation to discuss this approach in relation to substance use disorders, treatment and recovery. What's the role of the counselor/therapist in Motivational Interviewing? Many individuals who struggle with drug or alcohol addiction feel invalidated and defensive. By taking a completely nonconfrontational approach, the therapist can help the individual find the motivation to change their behavior by asking open-ended questions, listening in a supportive manner, providing affirmations, offering feedback, acknowledging the individual's struggle/pain, showing empathy, and helping individuals recognize and set goals. Because the experience is based on mutual respect, support and an overall belief in the patient's competence, there's a "we're in this together" mentality. Why does Motivational Interviewing work? When individuals discover, on their own, how their negative behavior is at odds with their goals/values/desired outcomes, they are better prepared to make a real commitment to changing their lives. Who can benefit from this therapy? Although the approach was originally designed to address addiction, clinical psychologists Stephen Rollnick and William R. Miller identified further applications of the process in Motivational Interviewing: Preparing People for Change (a second edition to the wildly popular Motivational Interviewing: Preparing People to Change Addictive Behavior). The second edition, published in 2002, explained how Motivational Interviewing can be used in health care, mental health, corrections, social work and school settings—where people may feel ambivalent about making positive behavioral changes. Since then, Rollnick and Miller's observations have helped individuals struggling with eating disorders, thoughts of suicide, smoking, gambling and hoarding issues, and chronic conditions such as diabetes, cardiovascular conditions and asthma (among other life-changing issues). What does the expression "the spirit of Motivational Interviewing" mean? The spirit of MI refers to the frame of mind of the counselor or therapist. The counselor isn't just pretending to care but actually cares. Showing respect, empathy and compassion; working in collaboration (instead of authority) and helping individuals express their ideas—instead of imposing ideas—are core components of this therapeutic alliance. What are the principles of Motivational Interviewing? Express and show empathy toward clients Support and develop discrepancy Support self-efficacy Develop autonomy Roll with resistance What does it mean to "roll with resistance"? The phrase refers to the motivational interviewing technique of validating the thoughts and feelings of the person resisting change, rather than arguing with or confronting the individual. The idea is that people are more likely to change their behavior if they are not feeling threatened or pressured. What are some reasons people are resistant to change? An individual could feel "stuck" in the contemplation stage of change, lack insight about available resources and/or coping strategies, feel unnecessarily pressured by others or might be scared about how difficult the process could be. (Additionally, some mental health conditions could be a factor in fueling resistance to change.) What are some common open-ended questions used in MI? The most effective questions invite self-reflection and self-direction, such as: What is important to you? How do these behaviors conflict with your values? How would you go about making this change? How does substance use conflict with these goals? What does change look like for you? Why is it important for you to make this change? What would your life look like if you did not have this problem? Do you use this therapy in conjunction with other therapies? Since Motivational Interviewing can be used as either an individualized approach or in group therapy, elements of cognitive-behavioral therapy, Gestalt therapy, solution-focused therapy or mindfulness-based therapy can be used effectively in conjunction with MI. What are the limitations to Motivational Interviewing? Insurance companies often require interventions to be conducted swiftly, which doesn't always allow for the time needed with this approach. A professional who is not equipped to "roll with resistance" may struggle. Motivational Interviewing may not work well with individuals who struggle with trauma or depression. The individual needs to be ambivalent about change. MI will not work well if a person is already highly motivated to make a change—or on the flip side, if a person absolutely doesn't believe they have a problem. If a clinician asks a person about consequences to their behavior or reasons to change, and the person does not perceive there to be consequences or reasons to change, then MI will likely not be effective. Time constraints could prevent a therapist from fully adopting the "spirit of MI" if they're managing a high caseload. Are there clients who shouldn't try this clinical approach? MI should not be the primary clinical approach for people with mental health disorders (bipolar disorder, schizophrenia and others). Interventions such as psychiatry, medication management and other specific treatments should be explored first, and then elements of MI can be used in conjunction with other interventions, depending on the individual patient's circumstances and needs. What are some patient-centered counseling strategies? In the addiction treatment setting, patient-centered counseling strategies can include asking the individual about goals they would like to work on while in treatment (instead of the therapist imposing goals), and collaborating with patients about their treatment plans, assignments and aftercare plans. Motivational Interviewing can help counselors as well as patients. When clinicians learn to "roll with resistance," they eliminate the possibility of power struggle scenarios that can arise in the therapeutic setting. This becomes an important long-term skill to acquire, not just to help patients, but also for self-care. Motivational Interviewing is one of many therapies offered at the Hazelden Betty Ford's treatment centers. We can help break down the sometimes overwhelming goal of getting sober into more attainable pieces.