Psychologist Dr. William Miller was working with people who were suffering with alcohol abuse and observed that many of these individuals differed in their attitude regarding their need for help. Some of these individuals saw no need to change their use of alcohol or their drinking habits, whereas others were questioning whether or not they needed help, or had decided that they needed help. Of those individuals who decided they needed help, some people were trying to cut down on their drinking, and others had decided that they should no longer drink alcohol at all.
Dr. Miller began to formulate an approach to help him identify where individuals with alcohol or tobacco abuse issues stood on their understanding of their behavior and their need to change it. He later consulted with Dr. Stephen Rollnick to develop the overall approach that is now to known as Motivational Interviewing (MI). Since the approach was originally formulated, it has been refined and adapted to be utilized in numerous other instances, especially for people who have other substance use disorders.
The Development of MI
The major approach used in the MI technique is the transtheoretical model of change that was conceptualized by its originators. This model of change was developed to help a therapist or other clinician to first understand how problematic a person perceives their use of tobacco, alcohol, and/or other substances to be.
It is well known that many individuals who develop dysfunctional issues associated with drug or alcohol use often appear to be ambivalent regarding the destructive aspects of their behavior. In spite of what appears to other people as clear indications that the person’s abuse of drugs or alcohol is resulting in severe dysfunction, the person who has the problem often acts as if nothing is wrong with them. This type of unawareness or contradiction in an individual’s behavior and attitude has been given numerous labels, such as denial. Many organizations, such as Alcoholics Anonymous and some treatment providers, consider this denial to be an actual symptom of a substance use disorder. However, as a specific symptom of any type of disorder, the notion of denial is a poor predictor. For instance, denial is a common defense mechanism that occurs when individuals are faced with potential realizations that are very shocking to them.
The concept of denial as a defense mechanism was popularized by Sigmund Freud. Denial as a defense mechanism occurs when people feel they have to deal with very distressing information that threatens their health or self-image. Because the situation is extremely anxiety-provoking, the person protects themselves from the anxiety by simply refusing to believe that the situation exists. This protects the person’s self-image and psyche, but obviously, it is not realistic.
The notion of denial was later incorporated in many theories, such as the famous stages of grief model by Elizabeth Kubler Ross. The use of denial to avoid facing potentially stressful situations was viewed by Freud as an immature defense mechanism, and it has commonly appeared in numerous other theories regarding a person’s adaptability to face their situation and attempt to change it. It is not specific to individuals with substance use disorders, but it is often a common initial reaction to a very distressing situation. In many cases, people can later review their situation and accept reality, but in some situations, people continue with the denial. When the latter situation occurs, the individual appears to be acting irrationally.
Miller and Rollnick realized that there was a sort of continuum of understanding that occurs in individuals with substance use disorders regarding their realization that their behavior might be problematic for them. Some individuals believed that they were totally in control of their behavior even if it appeared to be out of control; others questioned their actions and were debating whether or not they needed help; and still others had come to the realization that they needed help but were unsure of what to do or had started to develop a plan.
The researchers realized that in order for any form of treatment for substance use disorder to be applicable, the treating clinicians would need to be able to work with the person at that person’s level of understanding. Then, the therapist could help the person to objectively understand how their behavior (alcohol abuse or other substance abuse) was dysfunctional for them and how they should go about addressing the situation. This resulted in the development of the transtheoretical model of change that is one of the main components of the MI paradigm.
The Transtheoretical Model of Change
The therapist is challenged with first trying to understand where the client stands regarding their perception of their behavior and their need to change it. Once the therapist and client identify this, the therapist can develop a treatment plan to effectively help the client.
The Motivational Interviewing approach is designed to reduce conflicts between treatment providers and individuals with substance use disorders, such as alcohol use disorders. The goal is to decrease dropout rates for clients in substance use disorder therapy, and help clients grow and develop a positive approach to addressing the situation. A person can start at any particular stage in the model, and go forward or, in some cases, backward. The therapist works with the client to move forward and to help them change their behavior if it is dysfunctional.
The stages of change according to the MI paradigm are:
- Precontemplation: The earliest stage in the model occurs when individuals are actually experiencing issues with their alcohol or substance abuse, but do not believe that these issues are serious enough for them to change their behavior. This stage would represent the denial stage that many refer to.
- Contemplation: In this stage, the person has realized that they may have some sort of problem, but they are unconcerned with making any changes. They may have a desire to stop drinking, but do not feel they need to formulate any plan or approach to quit.
- Preparation: In this stage, the person has decided that they need to stop using alcohol (the need to change), and they realize they are accountable for their behavior. They may have decided that the negative aspects of their alcohol use are greater than any positive benefits they receive. In this stage, they may have even developed a plan to change, but have not yet taken steps to change their behavior.
- Action: In this stage, the person is actively trying to change the behavior. They are taking steps to stop using alcohol. The actual approach the person uses can consist of anything, including trying to control their drinking on their own, going to therapy, seeing an addiction medicine physician, etc. Many people in this stage have come to the realization that they need help and go to some outside source for assistance, but not everyone does.
- Maintenance: In this stage, the person has made some changes to their behavior that have been in place for at least six months. They may be continuing to improve themselves, or they may be attempting to maintain the level of change they have achieved.
- Termination: In this stage, the person has addressed their situation and is now attempting to maintain their changes. The person has not stopped working on maintaining abstinence, controlling drinking, etc. For example, the person may have achieved abstinence and is continuing to work on maintaining abstinence by attending Alcoholics Anonymous, going to therapy, etc., or the person has successfully reduced their use of alcohol to a point where they believe it is no longer problematic for them and is now trying to maintain that level of use.
The stages of change model does not view the process as moving in one direction. For example, a person can start at any of the stages and go backward, skip a stage going forward, or not even advance in the model. People may begin at one stage, go through the model to the termination stage, relapse, and need to start all over, or start from some other step in the model. The job of the therapist is to help the individual to move forward, understand their need for change, and help them implement a plan of action that runs smoothly.
The Motivational Interviewing model accepts the reality of relapse being a common experience among people who attempt to quit using alcohol or other drugs. If a person relapses, the theorists do not consider this a failure; instead, it is viewed as a chance for the person to learn and move forward to improve their situation.
How Does the Therapist Help?
There are numerous articles and books describing Motivational Interviewing techniques, such as Motivational Interviewing in Health Care: Helping Patients Change Behavior. These sources suggest that the therapist should be a guide, helping the client to direct their efforts to change or helping them to understand how to enact change.
- The therapist directs the client to help them understand their situation.
- When the client is motivated to change, it is the client’s decision. The therapist never forces the decision on the client.
- The therapist understands that trying to tell or force the client to change does not result in the client accepting their need to change. The client must make this decision freely.
- Being ready to change is not a trait of the client but instead occurs as the result of the interactions in therapy with the therapist. The client begins to view their situation objectively and realizes they need to address their use of alcohol.
- The concentration is on using the relationship between the therapist and client, often referred to as the therapeutic alliance. This is one of the most powerful facets of successful therapy.
- The therapist helps the client to plan their approach to change once the client has decided to change. Again, it is the client’s decision regarding which plan to use.
- The therapist helps the client develop confidence to increase their motivation to change.
Therapists using the MI paradigm often use cognitive-behavioral techniques to challenge the client’s beliefs, to help them restructure irrational beliefs, and to help them make changes in their behavior regarding their use of alcohol.
Does Motivational Interviewing Work?
Motivational Interviewing is a theoretical approach that looks to be logical and applicable for the treatment of individuals with alcohol use disorders. This appearance of legitimacy is an aspect of what is known as validity in research methods. Validity refers to the actual accuracy or truth of a particular theory or research finding. When something actually looks like it should be true on the surface, the type of validity used to describe the situation is face validity.
MI has significant face validity; however, face validity alone is not sufficient to provide evidence that any theory or research finding is actually valid. Validity is a complex concept that includes numerous facets. In order for a theory to actually satisfy the notion of validity, it must meet several different standards. Face validity may or may not be one of these standards. Regarding the treatment utility of MI, research findings for the effectiveness of the MI approach in the treatment of substance use disorders, such as an alcohol use disorder, are mixed.
Even the two originators of the paradigm, Miller and Rollnick, have criticized the research that is often used to support the notion that the technique is valid. One of the major problems with the research is that many of the studies that have been used to support its effectiveness are not representative of the actual types of clients who come into treatment for alcohol use disorders or other substance use disorders. This means that the findings could only apply to specific clients who have specific situations that resemble the samples used in research as opposed to being applicable as a generalized approach. When the research studies include a more diverse group of research participants, the findings are less supportive.
One approach that researchers used to investigate the effectiveness of different types of therapy is meta-analysis. Meta-analytic studies combine the results of numerous studies to determine if there is an overall effect in a particular type of intervention. This type of research is often considered to have more power compared to the results of any single study in determining whether or not a particular intervention is effective. The results of meta-analytic studies on the effectiveness of Motivational Interviewing are mixed.
Some of these studies find that MI is more effective than trying to force or overtly convince a person that they need to get treatment for their problem, whereas other meta-analytic research has not found significant positive effects using MI. Even though this type of research is considered to be preferable over single studies, the results of meta-analyses can vary, depending on what studies are included to determine the overall effects of the intervention; the researchers’ criteria, which is used to define whether or not the intervention is successful; the types of participants in the studies; and how similar or different the studies are to one another in their approach. The overall body of research regarding Motivational Interviewing suggests that it does have the potential to be useful, but like all interventions, it may not apply to everyone, and the manner in which the approach is delivered can greatly affect the outcome.
The research has determined that being involved in Motivational Interviewing is certainly better than not being involved in any form of treatment for an alcohol use disorder. The research also indicates that MI can help people who have alcohol use disorders determine their need to change their behavior, but success or failure regarding actual change is dependent on numerous factors that include the person’s commitment to change, choosing approaches that address the person’s needs, and being able to deal with the inevitable setbacks that occur in recovery. While MI is certainly useful in addressing issues associated with alcohol abuse, it needs to be part of an overall treatment program that is designed according to the principles of effective treatment for substance use disorders and personalized to fit the specific needs of the case involved.