The Tragedy of Motivational Interviewing

Motivational Interviewing is a style of counseling developed by longtime addiction researchers.  As far as what is currently available in the “treatment” world, it’s probably the most useful thing available (not counting solutions outside of the world of formal “treatment” for addictions) and has the most evidence to back it up, ranking #1 in a survey of the effectiveness of known treatments.  Whereas most counselors assume the addict to be “in denial”, lying, diseased, powerless, and fundamentally incapable of controlling themselves or of using moderately – motivational interviewing assumes the opposite.  The tragedy is two-fold.  First, that this approach, which holds that the addict can control his behavior, is currently delivered in settings (treatment centers) which implicitly suggest that an outside force (medical professionals, and medical treatment) is necessary for change.   Secondly, when utilized in these settings, it is likely accompanied or followed up by treatment methods which are more conventional – i.e. those that teach the client they are diseased and powerless and that they must attend 12-step meetings.

The Spirit of Motivational Interviewing

Essentially, the spirit of Motivational Interviewing is a non-confrontational one.  It stays away from coercion, and wishes instead to harness the clients own internal motivation.  It does not impose a way of life, it wants the troubled person to find their own way of life that works better for them.  Here is how Miller & Rolnick, the creators of MI, describe the spirit of it:

Motivation to change is elicited from the client, and not imposed from without. Other motivational approaches have emphasized coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilizing the client’s intrinsic values and goals to stimulate behaviour change.

It is the client’s task, not the counsellor’s, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between two courses of action (e.g., indulgence versus restraint), each of which has perceived benefits and costs associated with it. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict, for example, “If I stop smoking I will feel better about myself, but I may also put on weight, which will make me feel unhappy and unattractive.” The counsellor’s task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that triggers change.

Direct persuasion is not an effective method for resolving ambivalence. It is tempting to try to be “helpful” by persuading the client of the urgency of the problem about the benefits of change. It is fairly clear, however, that these tactics generally increase client resistance and diminish the probability of change (Miller, Benefield and Tonigan, 1993, Miller and Rollnick, 1991).

The counselling style is generally a quiet and eliciting one. Direct persuasion, aggressive confrontation, and argumentation are the conceptual opposite of motivational interviewing and are explicitly proscribed in this approach. To a counsellor accustomed to confronting and giving advice, motivational interviewing can appear to be a hopelessly slow and passive process. The proof is in the outcome. More aggressive strategies, sometimes guided by a desire to “confront client denial,” easily slip into pushing clients to make changes for which they are not ready.

The counsellor is directive in helping the client to examine and resolve ambivalence. Motivational interviewing involves no training of clients in behavioural coping skills, although the two approaches not incompatible. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centred and respectful counselling atmosphere.

Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction. The therapist is therefore highly attentive and responsive to the client’s motivational signs. Resistance and “denial” are seen not as client traits, but as feedback regarding therapist behaviour. Client resistance is often a signal that the counsellor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.

The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client’s autonomy and freedom of choice (and consequences) regarding his or her own behaviour. (Source: What Is MI?)

I have to say, this sounds much more like the approach used in life coaching than anything I’ve ever encountered with a substance abuse counselor.  The spirit and attitude here directly reflect my work as a coach helping people with substance use problems, and the work I did at an educational program aimed at the same population (note, this isn’t to say that I counsel or treat people, I don’t, nor do I wish to, only that my attitudes have been much the same as these, my methods are based on many of the same principles, and that the educational program achieved many of the same things while employing a different non-counseling method which left the responsibility for change squarely on the individual).

Where other counseling approaches have really never been shown to be successful, methods based on motivational interviewing have been subjected to many clinical trials, and been shown to help people to reduce their substance use.  Furthermore, when specifically compared with more intensive approaches, the MI based methods are far superior.  So wouldn’t it be a good thing if treatment centers started using this?  That’s a complex question.  As I said earlier, the settings in which these approaches are delivered are not optimal, and they may be accompanied by more conventional and directly contradictory methods.

The Utilization of Contradictory Methods within the same Treatment Programs / Facilities

In the most recent year for which comprehensive data is available, we see that Twelve-Step Facilitation (TSF) was used by 78.8% of treatment centers, and at the same time MI was used by 85.1% of treatment centers.  These two models are total opposites – and the fact that both are used by such a vast majority of treatment centers tells us that there must be overlap.  What’s more, there are several other methods of counseling which are being used by these treatment centers, but are not specifically reported (although 98.6% report using some method of SAC), and the evidence shows that most methods (9 out of 11 methods reviewed by the NIDA) are heavily involved with 12-step ideology – an approach which makes no bones about teaching people that they are powerless, diseased, in denial, morally and spiritually bankrupt, that they should stop thinking, that they will relapse, that they’re incapable of changing without a miracle from god, and dictating to them that they must be abstinent for the rest of their lives.

Next, we see that Contingency Management (CM) approaches are used by 60.5% of programs, and while CM is usually portrayed as simply positive reinforcement, it can alternately and perhaps more accurately be described as both parental and coercive – two things that directly oppose MI.  On the positive end of things, a CM program may give patients vouchers in return for proof (in the form of clean urine test results) of abstinence.  The vouchers can be traded in for things such as movie tickets.  Indeed, this has proven effective, doubling the success rate of substance abuse counseling.  But by being founded on subjecting the patient to humiliating urine tests which put them in the role of a suspicion-worthy child, this is clearly not in the spirit of MI.

CM often represents only a lifting of the negative aspects of treatment which the patient is subjected to from day one.  For example, CM is most often cited as a part of outpatient methadone programs, which are notoriously difficult to comply with in the first place.  A patient at a methadone program can expect a small window of time each morning when they have to line up outside the clinic and wait to get their dose directly from a nurse.  Upon reaching the counter, they may be told that they need to complete a urine test that day, and beyond that, they may have to attend group and individual counseling sessions every week, or attend various 12-step meetings held within the clinic – all of these before receiving their dose.  Their life is significantly restricted by the methadone program, to the point that traveling becomes impossible as the patient will have to make sure the town they’re going to has a methadone clinic and that their home clinic can arrange with the other clinic to dose the patient while out of town.  So the reward offered in the CM aspect of the program is the ability to take home a dose of methadone, say on a saturday, so that you can take it on sunday without dealing with the clinic for a day.  It typically takes months to meet the qualifications for this, and if you show up 30 seconds late one day, you’ll have to start earning that take home dose again from the beginning.  So the rewards in such a setup are hardly rewards, they are a temporary reprieve from the dismal chore of driving down to the methadone clinic and being treated like an animal every day.  This is inherently parental and coercive – directly contradictory to, and not at all in the spirit of Motivational Interviewing.

We could go on all day reviewing the other components of treatment programs, and showing how they directly clash with the spirit of MI, it’s overwhelming, but these few examples alone suggest that MI is often delivered right alongside methods that will contradict and ultimately undermine it.  One possible scenario of crossover is that a patient may be assigned to individual counseling on one day where she has an enlightening session which helps her to build resolve to change, only to be shuffled into a group counseling session the next day with a 12-step facilitator who browbeats her into admitting she is powerless over drugs and alcohol.  What also likely happens, since many of the methods which use MI are brief, is that the approach is used by some sort of intake counselors to get the patient to agree to enter treatment, and once that phase is done, they enter a confrontational program which drones on about disease, prescribes abstinence as the only choice, and pressures them to follow a spiritual path to recovery – or die an addict.

Now this is all assuming that there is some sort of overlap in services, which the numbers suggest – with 78.8% reporting the use of TSF, 85.1% using MI, and 60.5% using CM.  But let’s assume for a moment that there is no overlap, and some patients are receiving MI based counseling while others are receiving Twelve-Step Facilitation counseling within the same facility.  How does such a setup function?  Can a counselor wholeheartedly embrace MI in one session, believing that she shouldn’t attempt to coerce, persuade, prescribe behavior and goals, or “confront denial” – then switch over to doing all those things in the next session with a client for whom she’s chosen a TSF approach?  How can one operate effectively and with integrity in these two contradictory modes?  How does the philosophical mess left behind affect the patients?

Perhaps different counselors are assigned for different approaches – but there would still be another level of problems involved with employing these contradictory approaches within the same facility – management.  How can supervisors and administrators of such clinics effectively set policies which reinforce their treatment approach when they have no consistent approach.  Many programs based on 12-step and disease models will choose to have a zero tolerance policy towards any substance use, and ask clients to stay sober throughout treatment, imposing sanctions such as asking a client who tests positive to leave the program, be demoted to a lower level of treatment, or require extra meetings until clean urine results resume.  How does one enforce such policies on clients receiving MI, which is open to reductions in use as a viable goal, and doesn’t require abstinence of the client?  Furthermore, how does anyone working in such a facility sit down and explain their approach to a potential client or their family members?  “Sometimes we assume that all addicts are exactly the same, that they’re in denial and have no control over themselves and we confront and attempt to control them, and other times we think they can control their behavior if they simply have an honest and straightforward conversation with a therapist about their substance use”.  Such a statement would be absurd.  There must be some level of logical consistency, and this is impossible while utilizing these different approaches – most methods of substance abuse treatment are the total antithesis of MI.

I must mention that I’m not endorsing MI as the best way to deal with a substance use problem here.  Although I agree with the spirit of it, I don’t know for sure that the major methods based on it are any more effective than receiving no MI at all (some that Miller reviews in the video below are compared to those put on a waiting list for treatment, but he describes the problem of the waiting list as being that these people think they’ll start changing when they eventually get treatment, so it’s not quite the same as being untreated, so I’m not sure how it fares against no treatment/no MI).  What I do know, is that within the world of treatment, that is, when compared to other treatment approaches, it is the one shown to be most effective on many fronts.  Any treatment consumer who really does their homework will come to the same conclusion.  Unfortunately, when they seek out a treatment program they may easily find one which offers MI and jump at it, without realizing that it will probably be delivered incompetently along with other methods which undo it’s effectiveness.

The Beauty and the Tragedy

The beauty is that William Miller has created a great thing with MI, has gotten treatment programs to accept it to some degree, and that it will help a lot of people.  The tragedy is that while MI may be a great approach to helping people with substance use problems, it is probably implemented poorly most of the time, and the very settings within which it is implemented may also cut down the positive effects of it.  This is an inevitable effect of an attempt to change the treatment system from within – a system which was built on principles directly contradictory to those of MI.  Another part of the tragedy is that the research often simply adds MI to the front end of a conventional treatment program which then proceeds with a contradictory spirit afterwards. MI usually doubles the success rates of these programs, and that is a great achievement – but it is also highly likely that the treatment programs which report that they use MI are simply paying lip-service to it, adding it to the front end of their standard programs, and using it because of the pressure within the industry to use “evidence based methods”, but that they are not highly invested in it as it runs counter to their normal way of doing things.  What if they just scrapped their conventional programs and replaced them with something that was fully based on the spirit of MI?  If that happens, then the tragedy may be undone, and the beauty may shine brighter.

Video On Motivational Interviewing

This is a fascinating video of William R Miller explaining how MI was developed, and how it works.