Motivational Interviewing
The Motivational Interviewing approach begins with the assumption that the responsibility and capability for change lie within the client. The therapist's task is to create a set of conditions that will enhance the client's own motivation for and commitment to change. Rather than relying upon therapy sessions as the primary locus of change, the therapist seeks to mobilize the client's inner resources, as well as those inherent in the client's natural helping relationships. MI seeks to support intrinsic motivation for change, which will lead the client to initiate, persist in, and comply with behavior change efforts. Miller and Rollnick (1991) have described five basic motivational principles underlying such an approach:
1. Express Empathy
2. Develop Discrepancy
3. Avoid Argumentation
4. Roll with Resistance
5. Support Self-Efficacy
1. Express Empathy
The MI therapist seeks to communicate great respect for the client. Communications that imply a superior/inferior relationship between therapist and client are avoided. The therapist's role is a blend of supportive companion and knowledgeable consultant. The client's freedom of choice and self-direction are respected. Indeed, in this view, it is only the client who can decide to change and carry out that choice. The therapist seeks ways to compliment rather than denigrate, to build up rather than tear down. Much of MI is listening rather than telling. Persuasion is gentle, subtle, always with the assumption that change is up to the client. The power of such gentle, nonaggressive persuasion has been widely recognized in clinical writings, including Bill Wilson's own advice on "working with others" (Alcoholics Anonymous, 1976). Reflective listening (accurate empathy) is a key skill in motivational interviewing. It communicates an acceptance of clients as they are, while also supporting them in the process of change.
2. Develop Discrepancy
Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be. The MI approach seeks to enhance and focus the client's attention on such discrepancies with regard to drug use. In certain cases (e.g., the "precontemplators" in Prochaska and DiClemente's model) it may be necessary first to develop such discrepancy by raising the client's awareness of the adverse personal consequences of his or her drug use. Such information, properly presented, can precipitate a crisis (critical mass) of motivation for change. As a result, the individual may be more willing to enter into a frank discussion of change options, in order to reduce the perceived discrepancy and regain emotional equilibrium. In other cases, the client enters treatment in a later "contemplation" stage, and it takes less time and effort to move the client along to the point of determination for change.
3. Avoid Argumentation
If handled poorly, ambivalence and discrepancy can resolve into defensive coping strategies that reduce the client's discomfort but do not alter drug use and related risks. An unrealistic (from the client's perspective) attack on his or her drug use tends to evoke defensiveness and opposition, and suggests that the therapist does not really understand.The MI style explicitly avoids direct argumentation, which tends to evoke resistance. No attempt is made to have the client accept or "admit" a diagnostic label. The therapist does not seek to prove or convince by force of argument. Instead, the therapist employs other strategies to assist the client to see accurately the consequences of drug use, and to begin devaluing the perceived positive aspects of drugs. When MI is conducted properly, it is the client and not the therapist who voices the arguments for change (Miller & Rollnick, 1991).
4. Roll with Resistance
How the therapist handles client "resistance" is a crucial and defining characteristic of the MET approach. MI strategies do not meet resistance head-on, but rather "roll with" the momentum, with a goal of shifting client perceptions in the process. New ways of thinking about problems are invited but not imposed. Ambivalence is viewed as normal, not pathological, and is explored openly. Solutions are usually evoked from the client rather than provided by the therapist. This approach for dealing with resistance will be described in more detail later.
5. Support Self-efficacy
A person who is persuaded that he or she has a serious problem will still not move toward change unless there is hope for success. Bandura (1982) has described self-efficacy as a critical determinant of behavior change. Self-efficacy is, in essence, the belief that one can perform a particular behavior or accomplish a particular task. In this case, the client must be persuaded that it is possible to change his or her own drug use and thereby reduce related problems. In everyday language, this might be called hope or optimism, though it is not an overall optimistic nature that is crucial here. Rather, it is the client's specific belief that he or she can change the drug problem. Unless this element is present, a discrepancy crisis is likely to resolve into defensive coping (e.g., rationalization, denial) to reduce discomfort, without changing behavior. This is a natural and understandable protective process. If one has little hope that things could change, there is little reason to face the problem.
