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Motivational Interviewing in Alcohol Rehab

The Motivational Interviewing approach is designed to address ambivalence and help increase a person’s motivation to change unhelpful or harmful behaviors, such as substance abuse.

Finding the motivation to become sober and quit drinking is incredibly challenging. Regardless of the harms associated with alcohol use disorder, many individuals continue to abuse alcohol for many different reasons.1 If you previously tried to quit drinking on your own but found that it was too difficult for whichever reason, motivational interviewing could be a useful therapeutic approach to help you on your road to sobriety.

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What Is Motivational Interviewing (MI)?

Motivational interviewing (MI) is a technique that was developed to address ambivalence and help increase a person’s motivation to change unhelpful or harmful behaviors, such as substance abuse.1

Additionally, you may come across the term motivational enhancement therapy (MET) in regard to MI since they are often used together or used interchangeably. This is because they are based on the same principles.2

MI is based on respect and empathy. A therapist who provides MI helps you identify reasons to make changes and then collaborates with you to make a plan to implement those changes.3

Goals of Motivational Interviewing

The goals of MI include:3

  • Understanding addiction.
  • Reducing or stopping substance abuse.
  • Improving physical health, mental health and social functioning.
  • Increasing chances of obtaining and maintaining employment.
  • Reducing crime.
  • Reducing the risk of alcohol-related risks, such as sexual, legal, or financial problems.

MI can be useful if you are concerned about your unhealthy pattern of alcohol or substance abuse. It can help you gain clarity or motivation if you’re not entirely sure about the benefits of making changes or if you don’t quite feel ready to change at this point in time.2

History of MI

In the 1980s, psychologist William Miller developed the technique of motivational interviewing based on his experience in the field of addiction, combined with a desire to address ambivalence as an obstacle to recovery and ways to increase motivation to change.4 When Miller met psychologist Stephen Rollnick in 1990, they collaborated to further develop principles of MI.

motivational interviewing

Motivational interviewing is based on the phrase, “ready, willing, and able,” which describes 3 main components of motivation: the importance of change, the confidence to change, and whether change is a necessity.5 Rollnick and Miller’s work eventually led to the publication of their seminal textbook on MI, called Motivational Interviewing: Preparing People to Change Addictive Behaviors.4

Motivational interviewing is the result of a combination of approaches, namely client-centered psychotherapy, reflective listening, and social psychology.4 A client-centered approach emphasizes reflective listening, open ended questions, empathy, acceptance, and optimism and is based on the idea that a person will be able to figure out their own solutions for their problems in therapy.4

Reflective listening involves two main steps, which include a therapist encouraging the client to share their own thoughts followed by the therapist reflecting back what the client said.4 The social psychology perspective encourages people to think about who they are and how they interact in a social environment.4

Finally, the Prochaska and DiClemente model of motivation outlined the 5 phases that people tend to go through when contemplating change, which include:5

  • The precontemplative stage, where you are not considering the need for change.
  • The contemplative stage, where you are actively ambivalent about the need for change.
  • The preparation stage, where you start planning to make changes.
  • The action stage, where you are actively involved in executing your plan to change.
  • The maintenance stage, where you work on maintaining and sustaining long-term change.

Principles of Motivational Interviewing

The 4 key principles of motivational interviewing include:1,5

Express Empathy: Empathy is the ability to imagine and feel what it’s like to be in another person’s shoes. The therapist uses reflective listening skills in order to develop a better understanding of your perspective and experiences by listening to you without judgment, criticism, or blame.

Develop Discrepancy: You are guided to think about the different ways your current behavior might impact your future goals. Together with your therapist, you are encouraged to consider how your substance abuse impacts your entire life and social roles, such as your role as a parent, partner, friend, employee, etc., and the pros and cons of changing your goals for the future.

Roll With Resistance: Resistance is often a part of the change process. It’s not always easy to accept the need for change, even if it’s clear that your current behaviors are negatively impacting your life and wellbeing. Your therapist will encourage you to try to see things from a new or different perspective, but you are also allowed to have your own opinion. Ultimately, the decision to change is up to you.

Support Self-Efficacy: Self-efficacy means that you believe you can make changes that have a positive impact on your life. People may believe that they cannot influence events in their lives or make behavioral changes, and they give up hope because they don’t think change is possible. Your therapist will help you develop a sense of hope and confidence to help you realize that it’s possible for you to change your drinking behaviors.

Goals of the Therapist in MI

In the MI approach, the therapist uses client-centered skills to help promote change. The goals of the therapist in MI include:3,6

  • Engage: The therapist builds a positive working relationship based on trust and respect.
  • Focus: The therapist works with you to help identify the specific behavior you want to improve or change.
  • Evoke: The therapist directs the conversation so that you, not the therapist, are the one making the argument for change. It is called evoke because the therapist asks questions that promote and reinforce your internal motivations to change.
  • Plan: This is the actual “how” of the change process. Together with your therapist, you design a specific plan of action that outlines how you will change the behavior.

OARS & Motivational Interviewing

There are four techniques used in MI, which are known by the acronym OARS. These techniques include:3,5

  • Open-ended questions. The therapist asks questions that don’t have a simple yes or no answer. You are encouraged to reflect on your goals and priorities in life. Examples of open-ended questions that you may experience in a typical session could be, “What brings you here today?” or “Tell me about the last time you used alcohol.”
  • Affirmations. The therapist notices and affirms your strengths and efforts toward desiring or actually making change. They express their genuine positive regard for who you are as a person. It’s not the same as praise, such as just saying “good job,” or “way to go,” as it involves actively taking notice of your successes, efforts to change, and strengths. For example, the therapist might say, “You have worked very hard to get to where you are today,” or “Even though you got discouraged, you kept going to AA meetings.”motivational interviewing for alcoholism
  • Reflective Listening. The therapist rephrases your statements in a way that expresses empathy and helps to clarify your intentions and feelings. It’s not just parroting back what you’ve said, it involves a specific type of listening that shows that the therapist is paying attention to your words and teasing out your underlying feelings, motivations, struggles, and meaning. The therapist then rephrases it to you as a way of capturing the underlying essence of the message you have conveyed.
  • Summaries. This is a type of reflective listening that involves summarizing what you have said in a succinct and easy-to-understand manner as a way of “checking in” with you to make sure that the therapist has fully understood what you have said. For example, at the end of the session, the therapist might say something like, “Just let me make sure that I understand everything we’ve discussed so far. This is what you’ve been feeling/worrying about/struggling with/etc. Is that about, right?”

Motivational Interviewing to Treat Alcoholism

MI is typically used to treat alcohol use disorder by helping individuals overcome their ambivalence about changing their drinking behaviors. At the beginning of treatment, MI may help individuals identify their reasons for wanting to make changes and increase their motivation to implement these changes and engage in treatment.7

MI is usually very effective in the beginning stages of change especially for individuals who don’t want to be criticized or lectured about the need to stop drinking.8 However, MI can also be used throughout the course of alcohol treatment to help strengthen or re-establish your commitment to achieving your goals, while helping you actively re-engage in your treatment plan.6

According to the National Institute on Drug Abuse (NIDA), research has shown that the effectiveness of MI can vary based on the substance of abuse. However, MI has demonstrated to be very effective for people who have an alcohol use disorder because it helps them engage in treatment and reduce problem drinking.2

One study showed that participants who received MI at the beginning of treatment experienced double the rate of total abstinence at 3–6 months after inpatient or outpatient treatment.7

In addition, different meta-analyses have shown that MI is better than or equal to cognitive-behavioral treatments or pharmacotherapy (medication) for helping people decrease alcohol use.5

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Sources
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[1]. Center for Substance Abuse Treatment. (1999). Enhancing Motivation for Change in Substance Abuse Treatment. (Treatment Improvement Protocol (TIP) Series, No. 35.) Chapter 3—Motivational Interviewing as a Counseling Style.

[2]. National Institute on Drug Abuse. (2018). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Motivational Enhancement Therapy (Alcohol, Marijuana, Nicotine).

[3]. Substance Abuse and Mental Health Services Administration. (2019). Enhancing Motivation for Change in Substance Use Disorder Treatment. Treatment Improvement Protocol, TIP 35.

[4]. Moyers, T. (2004). History and Happenstance: How Motivational Interviewing Got Its Start. Journal of Cognitive Psychotherapy, 18(4), 291-298.

[5]. Hall, K., Gibbie, T., & Lubman, D. I. (2012). Motivational interviewing techniques – facilitating behaviour change in the general practice setting. Australian Family Physician, 41(9), 660–667.

[6]. State of Colorado Division of Family Justice. The 4 Processes of MI.

[7]. Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. The American psychologist, 64(6), 527–537.

[8]. Jones, L. (2007). Motivational Interviewing With Substance Abusers — The Power of Ambivalence. Social Work Today, 7(3), 34.