Motivational Interviewing

Motivational Interviewing

Motivational Interviewing

Motivational Interviewing is a method that works on engaging a client’s basic motivations in order to change behavior. This is a goal-oriented, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence (Miller & Rollnick, 2002).

“Dave was your stereotypical intimidating “biker””

To better understand this therapy, I will describe how Motivational Interviewing was used to treat one of my clients Dave Jenkins. At just over 6’ tall with a shaved head, Leather Harley Davidson jacket, combat boots and tattoos covering all of his exposed skin, Dave was your stereotypical intimidating “biker”.

Dave was referred to my office for a court ordered substance abuse evaluation so he could satisfy the terms of his probation. He was visibly anxious, arms crosses, and one leg relentlessly bouncing up and down as if signaling his impatience. He wore his dark sunglasses even though we were indoors. As we began talking, I struggled to get more than guarded one word answers. I asked him if he wore sunglasses indoors because the lights were too bright. “I never take them off in front of people.” He said this in a tone that almost dared me to ask him to remove them.

During the evaluation it became clear that he had a severe substance use problem. Over the past 30 years his addiction had escalated to the point that he was incapable of regulating his mood and after further evaluation he was diagnosis with schizophrenia. According to Dave, he had everything under control and didn’t need treatment. He was comfortable self-medicating, using drugs and alcohol to stabilize his mood and keep him functioning each day. I could see that fighting him on this world view was futile. Instead, I decided use Motivational Interviewing, a therapy which has been shown to be very effective with resistant clients.

“the motivation for change comes from the client and not the therapist”

Motivational Interviewing is particularly effective with resistant clients because the motivation for change comes from the client and not the therapist. The therapist helps the client see how their self-defeating behaviors are limiting their ability to achieve what they most desire.

After the evaluation I contacted his probation officer. Thankfully, he was very open minded and flexible, which allowed us to come up with a plan that provided Dave with a lot of support while addressing his co-occurring mental health and substance use issues at the same time. Dave would still have to complete random drug tests with his probation officer, but the plan allowed him to extend his treatment without being sent back to jail.

Dave was adamant that he didn’t need substance abuse treatment, so instead of forcing him to start group therapy I began calling him once a week. During these initial phone calls I asked him how he was doing, how his day was going, and if there was anything I could do to help him. I never tried to tell him how serious his addiction was or convince him that he needed treatment. For the first month his answers were always the same: He was doing “fine,” his day was “good”. He was usually watching T.V., and didn’t need anything from me. After the fourth week of calling, something changed. When I asked about his day he opened up and we ended up talking for 15 minutes about how much he enjoyed spending time with his grandchildren during a recent trip to the park. I used this conversation as an opportunity to strengthen our therapeutic relationship by simply listening and asking questions about his family.

A key component of motivational interviewing is building a strong therapeutic relationship. Achieving this requires being non-judgmental, non-confrontational and non-adversarial. This style recognizes the fact that clients approach counseling at different levels of readiness to change. This approach attempts to increase the client’s awareness of the potential problems caused, consequences experienced, and risks faced as a result of their addiction or behavior in question. Part of the therapist’s job is to help clients envision a better future, and become motivated to achieve it (Miller & Rollnick, 2002).

“Allowing me to see his eyes for the first time represented a huge step forward”

I knew that our therapeutic relationship had been established when after 2 months of consistent phone calls he agreed to come in for a face-to-face session with me. After calling him week after week he finally trusted me enough to know that I wasn’t going to hurt him or try to convince him of something that he was not ready to admit. During every session he still kept his sunglasses on, still folded his arms and impatiently bounced his leg, but he was sitting in my office talking, which represented real progress. After another five sessions, about three months since the first time we met, he finally took off his sunglasses, cleaned them with his shirt, and then laid them on his lap. Allowing me to see his eyes for the first time represented a huge step forward. This demonstrated he was finally willing to open up and try something more difficult. At the end of the session he agreed to start attending substance use groups.

Another month passed and during one of our sessions he began crying, something he had never done before. He told me that his daughter wouldn’t let him visit his grandson because she didn’t trust him. She was always accusing him of using or being high. He opened up and told me how hurtful this was because he would never do anything to hurt his grandson. This was the perfect opportunity to begin the next phase of motivational interviewing which involves helping the client think differently about their behavior and ultimately consider what might be gained by changing.

Motivational Interviewing wants the client to gain motivation to change a behavior that is not consistent with their personal values or goals. We want to help them start to make positive changes in their lives. For example, we might ask the client questions such as “How might you like things to be different?” or “How does _________ interfere with things that you would like to do?” (Miller & Rollnick, 2002).

“I have to stop using. Drugs are the only thing holding me back from seeing my grandson.”

I jumped on this opportunity to invite Dave to make positive changes by asking him “I know you really love spending time with your grandson; what could you do to help your daughter feel better about letting you see him more often?” He stared silently at me for almost a full minute before he finally whispered “I have to stop using. Drugs are the only thing holding me back from seeing my grandson.” For Dave, this moment of clarity was humbling and enlightening at the same time.  He had adamantly resisted change for the past 30 years; however, in five months with me using Motivational Interviewing he was finally arguing for his own sobriety.

Instead of focusing on why a person doesn’t want to change, this method explores what the person does want. I finally figured out that Dave wanted to spend more time with his grandson, and his substance use was getting in the way of that. This was the motivation that pushed Dave to eventually finish his court mandated treatment so he could spend more time with his grandson, and stay out of jail.

Motivational Interviewing is much like using the martial art of judo. In judo, an attack is not met with direct opposition, such as in boxing, but rather one goes with the attacker’s momentum, using it to their advantage. The counselor does not impose new views or goals on the client; rather, the person is invited to consider new information and is offered new perspectives. Rather than saying “I will change you” a more appropriate message is “If you want, I can help you change” (Miller & Rollnick, 2002).

Motivational Interviewing is one of the many successful therapies we utilize to help our clients overcome the underlying behaviors contributing to their addiction.

Amanda Quist
Licensed Clinical Mental Health Counselor

Citations:

Miller, William R., and Stephen Rollnick. Motivational Interviewing: Preparing People for Change. New York: Guilford, 2002.