July 25th, 2016

The first article in this series focused on describing how psychological change occurs. In this second article of the series, I will focus on an important way clinicians can facilitate the change — or more specifically the recovery – process using Motivational Interviewing.

As you know, people with addictions are often reluctant to pursue treatment; therefore different strategies have emerged to expedite their entry into treatment. One dramatic and somewhat controversial approach, “Intervention,” intentionally creates a crisis in the addict’s life. Motivational Interviewing, on the other hand, is a gentler alternative that has gained widespread acceptance in the field of addiction and beyond.

Based on the work of Carl Rogers, Motivational Interviewing postulates that when a clinician is able to form an empathic connection with patients, the patients will be likely to examine their own internal experiences in a way that leads them to stop using addictive substances. This approach was developed specifically to work with people who are in the Precontemplative and Contemplative phases of the Stages of Change with the goal of getting them to accept the need for treatment. At Kolmac, we have found it useful to extend this approach to working with our patients who have already agreed to treatment and who would be regarded as being in the Action and Maintenance phases of change.

The central psychological concept behind Motivational Interviewing is that addicts are ambivalent about their use of addictive substances. On the one hand, they are unusually responsive to the rewarding effects of the substances so that the substances have come to play an outsized role in their lives. On the other hand, the negative consequences of using these substances have grown to the point that continued, non-problem use is no longer sustainable. The addict “seesaws” between these two sides, a state that can continue indefinitely. This ambivalence persists even after patients initiate abstinence and enter treatment, which is why we find Motivational Interviewing a helpful practice at Kolmac in working to prevent relapses.

Traditional addiction counseling focuses on the negative consequences and pressures addicts directly to stop using substances. Motivational Interviewing was developed from clinical experience that such a direct approach tends to trigger a reactive response from the addict, who then focuses on all the reasons that change cannot occur, often leading to an unproductive and sometimes antagonistic struggle between the clinician and the patient. By interspersing reflections of what the patient has said with occasional open-ended questions, the clinician aims to guide their interaction in a direction whereby patients talk themselves into changing rather than having the clinician make the arguments for the change.

Traditional addiction counseling conceptualizes addicts as being “in denial” of their addiction and having internal “resistance,” which intensifies when their “denial” is addressed. By contrast, in Motivational Interviewing “resistance” is seen as a sign of a disruption in the relationship between the patient and a clinician, who is moving faster toward change than the patient is. The task of the clinician is then to repair the relationship by slowing down and re-establishing the empathic connection.

For those clinicians interested in further developing their skills using this approach, I highly recommend two resources: 1) the third edition of Motivational Interviewing by Drs. William Miller and Stephen Rollnick and 2) some useful videos (available from The Change Companies) of them describing their thinking behind this approach as well as demonstration interviews by master clinicians. Motivational Interviewing is an essential tool that we can use to get our patients into treatment.

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