Sep 27, 2019
By Hollie Granato, PhD
“You don’t use any harder substances, do you?” I winced as I heard myself ask the question. After years of motivational interviewing (MI) training, I know that close-ended yes-or-no questions often shut down a conversation. I also know that phrases like “harder substances” carry a judgmental undertone. Yet I caught myself doing the very thing I know to avoid. Was I losing my MI touch?
Motivational interviewing is an approach to discussing substance use that illuminates the ways in which how we discuss behaviors can help or hinder change. Developed by William Miller, PhD, and Stephen Rollnick, PhD, MI has garnered a strong research base and reputation. What follows is an exploration of five commonly asked questions about an MI approach to substance use.
While it makes sense to refer a client with severe substance use issues to another provider or to a higher level of care if treating these issues is outside the scope of your training, my response to this question is a follow-up question: How are your beliefs about substance use informing your approach to treatment?
Studies suggest that approximately 25–50 percent of outpatient clients use substances, regardless of whether substance use is explicitly targeted in treatment (or if we even know it’s happening). My suggestion for clinicians who feel uncomfortable working with clients who use substances is to understand where this discomfort originates. Motivational interviewing asks us to take a non-judgmental approach, increasing our awareness of judgments and unhinging ourselves from them. It’s a mindfulness-based practice that’s founded on awareness of our own biases. Exploring our beliefs can help us shift toward a MI framework where substance use, like any other behavior, is a problem-solving strategy.
Clinicians do not do MI to clients; we facilitate MI with clients. This shift in phrasing is key for emphasizing the collaboration that is central to MI. While this may seem like an overemphasis on semantics, it’s important to note that MI’s effectiveness is rooted in the words we use about change. In fact, research has shown that a higher ratio of “change” statements compared to “sustain” statements made by clients is a key ingredient contributing to MI outcomes.
All of the strategies taught in MI trainings are meant to help clinicians arrange conversations so that the client states their reasons for change. While I recommend learning and practicing these techniques, such as OARS (open-ended questions, affirmations, reflections, and summarizing), remind yourself that they are simply tools for enhancing change talk and decreasing sustain talk. It can be challenging to stick to these strategies when integrating MI into other treatment approaches such as cognitive behavioral therapy (CBT).
When it feels overwhelming to stick exclusively to MI strategies, instead try using MI as a framework for mindfully focusing on what clients are saying. If the client states reasons for not changing, try switching strategies or simply reflecting what you are observing. For example: “When I asked about drinking just now, I noticed your demeanor change”. If the client states reasons for changing, reinforce these using reflections and delve deeper into reasons for changing using open-ended questions.
Follow-up question to ponder: What strategies have you found that work best for you to maximize change talk in sessions?
Motivational interviewing is designed to help clients resolve ambivalence about changing. The goal is to strategically reflect back discrepancies we see between a client’s values and behavior. Confronting these inconsistencies can be a very emotional experience, and clients typically state many reasons for NOT changing. Enter the dreaded resistance and sustain talk.
A framework that I repeatedly come back to is the Stages of Change model. This model posits that behavioral change is a slow and continual process over time, and is a lens through which we can view each behavior we’re targeting with clients. In fact, I often map out my client’s target behaviors using this model in treatment planning. For example, a client with major depressive disorder may be in the action stage for changing jobs, the contemplative stage when it comes to alcohol use, and the pre-contemplative stage for a late-night gaming habit.
I strongly believe that when we feel informed and empowered about what to do in session, judgments and frustration with a client’s resistance to change subsides. So my follow-up question is: Why does it make sense given the client’s conceptualization that this behavior isn’t changing?
Judgments are a natural function of language and provide us with a shorthand for describing our experiences. I often tell clients that judgments only become a problem when they’re running the show. The key to embodying the spirit of MI is awareness, noticing when judgments arise, and striving to ask ourselves where they’re coming from.
Throughout all of my work with clients, substance-using or not, I always return to the question, “What is the function of this behavior?” Considering the function judgments fulfill, perhaps they show up when we’re feeling powerless. More than likely, judgments indicate that we sense some threat, such as fear that a client will be hurt if they continue with their behavior, or fear over our own ability to facilitate change.
My question in response to the above question is: What is the function of your judgment and what would you have to sit with if you were to “drop the rope”?
The focus of motivational interviewing is meeting clients where they are with their substance use goals. If the client’s goal is abstinence, then discussing steps toward maintaining abstinence is entirely consistent with MI. However, as mentioned previously, we must work to unhinge ourselves from any judgments we have about where a client “should” be in terms of their substance use goals. I often remind myself that any change that gets a client closer to their values-based goals is positive change.
My final question for you: How can you infuse an MI approach in all the work you do?
After posing the cringe-inducing close-ended question to my client, I paused. “Wait a minute,” I said. “Mind if we loop back around? What other substances have you used?” We’re all fallible, and the basis of MI is mindful awareness of how we’re discussing substance use. It’s important to remember that clients are not fragile and there is no expectation for perfection in motivational interviewing. Much like behavior change, growing our skills as MI therapists can be slow and circular. Facilitating MI is a journey and a value to strive for, rather than a destination or goal to achieve. Subsequently, the Motivational Interviewing Network of Trainers does not offer a certification, encouraging therapists instead to seek lifelong training in the practice of MI.
The following resources offer additional MI reading and training:
ABOUT THE AUTHOR
Dr. Hollie Granato is an assistant professor at University of California, Los Angeles in the David Geffen School of Medicine and staff psychologist at Harbor – UCLA Medical Center where she is currently assistant training director for the clinical psychological externship training program. Dr. Granato specializes in Motivational Interviewing (MI) and Dialectical Behavior Therapy (DBT).