Motivational Interviewing and Enhancement Therapies
Motivational Interviewing (MI) is a counseling approach designed to help individuals resolve ambivalence about their alcohol and/or drug use, and support efforts to change it.
Motivational Interviewing (MI) is often delivered as a brief intervention based on client-centered principles. Guided by these principles, MI emphasizes strategic use of common counseling skills, such as reflective listening, summarizing, and paraphrasing.
Advice is typically only given on request, and with patient permission. MI is also sometimes combined with other types of interventions (e.g., Cognitive Behavioral Therapy) in order to enhance treatment retention and engagement.
Motivational Enhancement Therapies (METs) are interventions based on the MI approach and practices. Unique to METs is the use of clinically-relevant patient reported assessment data that is summarized and subsequently fed back to the patient in an MI, client-centered counseling style in order to enhance motivation for change.
WHAT HAPPENS IN MOTIVATIONAL INTERVIEWING AND MOTIVATIONAL ENHANCEMENT THERAPY?
The aim of the combined Motivational Interviewing and Motivational Enhancement Therapy is to increase patient motivation and commitment to reduce or quit using substances – usually over the course of 3 to 4 sessions. With this increased commitment to change, the patient is believed to be able to mobilize their own internal and external resources to facilitate change.
MI/MET uses a specific interpersonal style that mixes open-ended questions and other common counseling techniques to facilitate behavior change.
Specifically, Motivational Interviewing employs clinical strategies such as reflective listening, expressing acceptance of the patient’s goals, selective reinforcement of talk that centers on substance use change (“change talk”), helping the patient realize discrepancies between their values or goals and their actual behavior, monitoring of readiness to change, and affirmation of the patient’s freedom of choice. As part of MI, the patient might also engage in some written tasks, like considering both the benefits and costs of changing their substance use versus keeping it the same (known as a “decisional balance” exercise).
Perhaps the core tenet for Motivational Interviewing clinicians is that they do not argue in favor of change or attempt to convince patients that change is in his or her best interest. Rather, they elicit the patient’s own arguments for change. That said, Motivational Enhancement Therapy often involves offering direct advice based on available scientific research, giving the patient an opportunity to set their goals based on empirically-informed clinical guidelines if they wish (e.g., the lower relapse risks associated with abstinence vs. moderate drinking as a path to alcohol use disorder remission).
Examples of commonly-used open-ended questions MET providers might ask to evoke “change talk” include:
“How might you like things to be different?”
“How does ______ interfere with things that you would like to do?”
“Where does this leave you in terms of your drinking? What’s your plan?”
WHAT IS THE THEORY BEHIND MOTIVATIONAL INTERVIEWING AND MOTIVATIONAL ENHANCEMENT THERAPY?
Central Assumptions of Motivational Interviewing:
- It is assumed that patients already have what they need to initiate and sustain changes in their substance use. Thus, the primary MI/MET treatment goal is to help patients resolve any ambivalence they may have about change and catalyze or mobilize that intrinsic motivation or commitment to make those changes. (Note the difference in Motivational Interviewing from cognitive-behavioral approaches, which assume that individuals lack the skills needed to initiate and sustain changes in their substance use but are already motivated to make the change).
- Ambivalence about change is the number one barrier to increasing healthy behaviors and/or decreasing unhealthy behaviors.
- Different patients come to treatment with varying levels of readiness to change and MI/MET is thought to address these individual patient differences based on Prochaska and DiClemente’s Transtheoretical Model of behavior change. It is assumed that working with patients that are not yet “ready to change” – i.e., they are in the precontemplation or contemplation stages of change – on how to reduce or quit substance use will not be fruitful, and likely will produce resistance. The provider must focus first on enhancing motivation to change.
- Direct persuasion techniques (coercion, urgency, confrontation, argumentation, advice-giving, blaming, labeling, etc.) employed by mental health care providers are assumed to be ineffective, and may actually inhibit patient change.
- Patient denial or resistance is not seen as an unhelpful trait of the client, but rather is considered to be valuable feedback to the clinician; that is, the clinician may be assuming a greater degree of readiness to change from the patient than is actually present at that time.
- The clinician/patient relationship is an equal partnership. The right of the patient to autonomy and freedom of choice from behavior – including any resulting consequences – are to be respected.
WHAT ARE THE ORIGINS OF MOTIVATIONAL INTERVIEWING AND MOTIVATIONAL ENHANCEMENT THERAPY?
William R. Miller first alluded to the core foundations and concepts of modern day Motivational Interviewing in a 1983 article published in Behavioural Psychotherapy, stemming from his clinical work with individuals who had alcohol-related problems. At the time, Miller’s writing was in contrast with the more “confrontational” approaches common in residential substance use disorder treatment. Specifically, clinicians and potentially other patients directly challenged individuals about the severity of their drinking if they were resistant to the idea they had a problem.
This was an effort to increase their motivation for abstinence, though Miller deduced this approach was potentially harmful – an observation ultimately supported by scientific research. Along with Stephen Rollick, Miller published the first seminal text outlining MI procedures in 1991, which is now in its third edition.
Motivational Enhancement Therapy techniques have been tested as part of several randomized controlled trials comparing treatments for alcohol and other drug use disorders, including Project MATCH and the United Kingdom Alcohol Treatment Trial (UKATT). MI/MET has also been combined with other types of interventions, such as cognitive-behavioral approaches, serving primarily as an initial way to enhance readiness to change substance use or to engage in treatment.
EVIDENCE FOR MOTIVATIONAL INTERVIEWING AND MOTIVATIONAL ENHANCEMENT THERAPY
Compared to no intervention, or a non-therapy-based intervention (e.g., assessment only or waitlist control), Motivational Interviewing and Motivational Enhancement Therapy has strong empirical support, though they not do any better than other kinds of interventions.
While Motivational Interviewing and Motivational Enhancement Therapy may increase treatment attendance when added to standard treatment over the short-term, they do not appear to outperform other active treatments in the enhancement of readiness to change, and do not typically improve substance use outcomes more than other active therapy approaches, including treatment-as-usual (i.e., what is usually done in clinical care) as well as other manualized, empirically-supported approaches like Cognitive Behavioral Therapy or 12-Step Facilitation.
Although some work suggests there may be a difference between the effects of Motivational Interviewing and Motivational Enhancement Therapy on alcohol versus other drugs, such that MI/MET is a helpful addition to treatment-as-usual for alcohol but not for other drugs, more research is needed to confirm this.
MI/MET FOR ADOLESCENTS AND YOUNG ADULTS
Motivational Enhancement Therapies (METs) have been added to Cognitive Behavioral Therapy (CBT) in the treatment of adolescents because these patients typically come to treatment with less motivation to change than adults; adolescents in outpatient treatment have particularly low initial levels of motivation. This combined Motivational Interviewing and Motivational Enhancement Therapy is supported scientifically in the treatment of adolescents with cannabis use disorder (see also: Relapse Prevention treatment section). Like other MET treatments, MET/CBT does not appear to enhance adolescent treatment outcomes any more than other active treatments, such as family therapy, or the Adolescent-Community Reinforcement Approach (A-CRA).
Similarly, Motivational Interviewing-based interventions have been widely tested as strategies to reduce college student drinking. Based on the evidence, they are likely to help reduce drinking in the short-term compared either to no intervention or to simply assessing students’ drinking. Questions around whether these reductions translate to better functioning and whether MI outperforms other active interventions for college student drinking need further research.
- Ball, S. A., Martino, S., Nich, C., Frankforter, T. L., Van Horn, D., Crits-Christoph, P., . . . Carroll, K. M. (2007). Site matters: Multisite randomized trial of motivational enhancement therapy in community drug abuse clinics. Journal of Consulting and Clinical Psychology, 75(4), 556-567. doi: 10.1037/0022-006X.75.4.556
- Barnett, E., Sussman, S., Smith, C., Rohrbach, L. A., & Spruijt-Metz, D. (2012). Motivational Interviewing for adolescent substance use: A review of the literature. Addictive Behaviors, 37(12), 1325–1334. doi: 10.1016/j.addbeh.2012.07.001
- Dawson, D. A., Goldstein, R. B., & Grant, B. F. (2007). Rates and correlates of relapse among individuals in remission from DSM-IV alcohol dependence: A 3-year follow-up. Alcoholism: Clinical and Experimental Research, 31(12), 2036-2045. doi: 10.1111/j.1530-0277.2007.00536.x
- Foxcroft, D. R., Coombes, L., Wood, S., Allen, D., Almeida Santimano, N. M. (2014). Motivational interviewing for alcohol misuse in young adults. The Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD007025.pub2
- Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change (3rd ed.). New York: Guilford Press.
- Smedslund, G., Berg, R. C., Hammerstrøm, K. T., Steiro, A., Leiknes, K. A., Dahl, H. M., . . . Karlsen, K. (2011). Motivational interviewing for substance abuse. The Cochrane Database of Systematic Reviews. doi: 10.1002/14651858.CD008063.pub2
- UKATT Research Team (2005). Effectiveness of treatment for alcohol problems: Findings of the randomised UK alcohol treatment trial (UKATT). British Medical Journal, 331(7516), 541. doi: 10.1136/bmj.331.7516.541