Double-sided reflection

A third strategy entails acknowledging what the client has said but then also stating contrary things she has said in the past. This requires the use of information that the client has offered previously, although perhaps not in the same session.

Client: I know you want me to give up drinking completely, but I'm not going to do that!

Clinician: You can see that there are some real problems here, but you're not willing to think about quitting altogether.

Shifting focus

You can defuse resistance by helping the client shift focus away from obstacles and barriers. This method offers an opportunity to affirm your client's personal choice regarding the conduct of his own life.

Client: I can't stop smoking reefer when all my friends are doing it.

Clinician: You're way ahead of me. We're still exploring your concerns about whether you can get into college. We're not ready yet to decide how marijuana fits into your goals.

Agreement with a twist

A subtle strategy is to agree with the client, but with a slight twist or change of direction that propels the discussion forward.

Client: Why are you and my wife so stuck on my drinking? What about all her problems? You'd drink, too, if your family were nagging you all the time.

Clinician: You've got a good point there, and that's important. There is a bigger picture here, and maybe I haven't been paying enough attention to that. It's not as simple as one person's drinking. I agree with you that we shouldn't be trying to place blame here. Drinking problems like these do involve the whole family.

Reframing

A good strategy to use when a client denies personal problems is reframing--offering a new and positive interpretation of negative information provided by the client. Reframing "acknowledges the validity of the client's raw observations, but offers a new meaning...for them" (Miller and Rollnick, 1991, p. 107).

Client: My husband is always nagging me about my drinking--always calling me an alcoholic. It really bugs me.

Clinician: It sounds like he really cares about you and is concerned, although he expresses it in a way that makes you angry. Maybe we can help him learn how to tell you he loves you and is worried about you in a more positive and acceptable way.

In another example, the concept of relative tolerance to alcohol provides a good opportunity for reframing with problem drinkers (Miller and Rollnick, 1991). Many heavy drinkers believe they are not alcoholics because they can "hold their liquor."

When you explain that tolerance is a risk factor and a warning signal, not a source of pride, you can change your client's perspective about the meaning of feeling no effects. Thus, reframing is not only educational but sheds new light on the client's experience of alcohol.

Rolling With Resistance

Momentum can be used to good advantage.
Perceptions can be shifted.
New perspectives are invited but not imposed.
The client is a valuable resource in finding solutions to problems.

Siding with the negative

One more strategy for adapting to client resistance is to "side with the negative"--to take up the negative voice in the discussion. This is not "reverse psychology," nor does it involve the ethical quandaries of prescribing more of the symptom, as in a "therapeutic paradox."

Typically, siding with the negative is stating what the client has already said while arguing against change, perhaps as an amplified reflection. If your client is ambivalent, your taking the negative side of the argument evokes a "Yes, but..." from the client, who then expresses the other (positive) side. Be cautious, however, in using this too early in treatment or with depressed clients.

Client: Well, I know some people think I drink too much, and I may be damaging my liver, but I still don't believe I'm an alcoholic or in need of treatment.

Clinician: We've spent considerable time now going over your positive feelings and concerns about your drinking, but you still don't think you are ready or want to change your drinking patterns. Maybe changing would be too difficult for you, especially if you really want to stay the same. Anyway, I'm not sure you believe you could change even if you wanted to.

Support Self-Efficacy

Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change.

This requires you to recognize the client's strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort.

Because self-efficacy is a critical component of behavior change, it is crucial that you as the clinician also believe in your clients' capacity to reach their goals.

Discussing treatment or change options that might still be attractive to clients is usually helpful, even though they may have dropped out of other treatment programs or returned to substance use after a period of being substance free.

It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward.

The AA motto, "one day at a time," may help clients focus and embark on the immediate and small changes that they believe are feasible.

Education can increase clients' sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how substance use progresses to abuse or dependency. Making the biology of addiction and the medical effects of substance use relevant to the clients' experience may alleviate shame and guilt and instill hope that recovery can be achieved by using appropriate methods and tools.

A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.

Self-Efficacy

Belief in the possibility of change is an important motivator.
The client is responsible for choosing and carrying out personal change.
There is hope in the range of alternative approaches available.

Five Opening Strategies For Early Sessions

Clinicians who adopt motivational interviewing as a preferred style have found that the five strategies discussed below are particularly useful in the early stages of treatment.

They are based on the five principles described in the previous section: express empathy, develop discrepancy, avoid argument, adjust to rather than oppose client resistance, and support self-efficacy. Helping clients address their natural ambivalence is a good starting point. These opening strategies ensure your support for your client and help the client explore ambivalence in a safe setting.

The first four strategies, which are derived from client-centered counseling, help clients explore their ambivalence and reasons for change. The fifth strategy is specific to motivational interviewing and integrates and guides the other four.

In early treatment sessions, determine your client's readiness to change or stage of change (see Chapters 1, 4, and 8). Be careful to avoid focusing prematurely on a particular stage of change or assuming the client is at a particular stage because of the setting where you meet.

As already noted, using strategies inappropriate for a particular change stage or forming an inaccurate perception regarding the client's wants or needs could be harmful. Therefore, try not to identify the goals of counseling until you have sufficiently explored the client's readiness.

Ask Open-Ended Questions

Asking open-ended questions helps you understand your clients' point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response.

They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, help you avoid making premature judgments, and keep communication moving forward (see Figure 3-3).

Listen Reflectively

Reflective listening, a fundamental component of motivational interviewing, is a challenging skill in which you demonstrate that you have accurately heard and understood a client's communication by restating its meaning. That is, you hazard a guess about what the client intended to convey and express this in a responsive statement, not a question. "Reflective listening is a way of checking rather than assuming that you know what is meant" (Miller and Rollnick, 1991, p. 75).

Reflective listening strengthens the empathic relationship between the clinician and the client and encourages further exploration of problems and feelings. This form of communication is particularly appropriate for early stages of counseling.

Reflective listening helps the client by providing a synthesis of content and process. It reduces the likelihood of resistance, encourages the client to keep talking, communicates respect, cements the therapeutic alliance, clarifies exactly what the client means, and reinforces motivation (Miller et al., 1992).

This process has a tremendous amount of flexibility, and you can use reflective listening to reinforce your client's positive ideas (Miller et al., 1992). The following dialog gives some examples of clinician's responses that illustrate effective reflective listening.

Essentially, true reflective listening requires continuous alert tracking of the client's verbal and nonverbal responses and their possible meanings, formulation of reflections at the appropriate level of complexity, and ongoing adjustment of hypotheses.

Clinician: What else concerns you about your drinking?

Client: Well, I'm not sure I'm concerned about it, but I do wonder sometimes if I'm drinking too much.

Clinician: Too much for...?

Client: For my own good, I guess. I mean it's not like it's really serious, but sometimes when I wake up in the morning I feel really awful, and I can't think straight most of the morning.

Clinician: It messes up your thinking, your concentration.

Client: Yes, and sometimes I have trouble remembering things.

Clinician: And you wonder if that might be because you're drinking too much?

Client: Well, I know it is sometimes.

Clinician: You're pretty sure about that. But maybe there's more...

Client: Yeah, even when I'm not drinking, sometimes I mix things up, and I wonder about that.

Clinician: Wonder if...?

Client: If alcohol's pickling my brain, I guess.

Clinician: You think that can happen to people, maybe to you.

Client: Well, can't it? I've heard that alcohol kills brain cells.

Clinician: Um-hmm. I can see why that would worry you.

Client: But I don't think I'm an alcoholic or anything.

Clinician: You don't think you're that bad off, but you do wonder if maybe you're overdoing it and damaging yourself in the process.

Client: Yeah.

Clinician: Kind of a scary thought. What else worries you?

Summarize

Most clinicians find it useful to periodically summarize what has occurred in a counseling session. Summarizing consists of distilling the essence of what a client has expressed and communicating it back. "Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on" (Miller and Rollnick, 1991, p. 78).

A summary that links the client's positive and negative feelings about substance use can facilitate an understanding of initial ambivalence and promote the perception of discrepancy. Summarizing is also a good way to begin and end each counseling session and to provide a natural bridge when the client is transitioning between stages of change.

Summarizing also serves strategic purposes. In presenting a summary, you can select what information should be included and what can be minimized or left out. Correction of a summary by the client should be invited, and this often leads to further comments and discussion.

Summarizing helps clients consider their own responses and contemplate their own experience. It also gives you and your client an opportunity to notice what might have been overlooked as well as incorrectly stated.

Affirm

When it is done sincerely, affirming your client supports and promotes self-efficacy. More broadly, your affirmation acknowledges the difficulties the client has experienced. By affirming, you are saying, "I hear; I understand," and validating the client's experiences and feelings.

Affirming helps clients feel confident about marshaling their inner resources to take action and change behavior.

Emphasizing their past experiences that demonstrate strength, success, or power can prevent discouragement. For some clients, such as many African-Americans, affirmation has a spiritual context. Affirming their inner guiding spirit and their faith may help resolve their ambivalence. Several examples of affirming statements (Miller and Rollnick, 1991) follow:

I appreciate how hard it must have been for you to decide to come here. You took a big step.
I think it's great that you want to do something about this problem.
That must have been very difficult for you.
You're certainly a resourceful person to have been able to live with the problem this long and not fall apart.
That's a good suggestion.
It must be difficult for you to accept a day-to-day life so full of stress. I must say, if I were in your position, I would also find that difficult.

Elicit Self-Motivational Statements

Engaging the client in the process of change is the fundamental task of motivational interviewing. Rather than identifying the problem and promoting ways to solve it, your task is to help the client recognize how life might be better and choose ways to make it so.

Remember that your role is to entice the client to voice personal concerns and intentions, not to convince him that a transformation is necessary. Successful motivational interviewing requires that clients, not the clinician, ultimately argue for change and persuade themselves that they want to and can improve.

One signal that the client's ambivalence and resistance are diminishing is the self-motivational statement.

Four types of motivational statements can be identified (Miller and Rollnick, 1991):

Cognitive recognition of the problem (e.g., "I guess this is more serious than I thought.")
Affective expression of concern about the perceived problem (e.g., "I'm really worried about what is happening to me.")
A direct or implicit intention to change behavior (e.g., "I've got to do something about this.")
Optimism about one's ability to change (e.g., "I know that if I try, I can really do it.")

Figure 3-4 illustrates how you can differentiate a self-motivational statement from a countermotivational assertion. You can reinforce your client's self-motivational statements by reflecting them, nodding, or making approving facial expressions and affirming statements. Encourage clients to continue exploring the possibility of change. This can be done by asking for an elaboration, explicit examples, or more details about remaining concerns.

Questions beginning with "What else" are effective ways to invite further amplification. Sometimes asking clients to identify the extremes of the problem (e.g., "What are you most concerned about?") helps to enhance their motivation. Another effective approach is to ask clients to envision what they would like for the future. From there, clients may be able to begin establishing specific goals.

Figure 3-5 provides a useful list of questions you can ask to elicit self-motivational statements from the client.

Effectiveness of Motivational Interviewing

A recent review of 11 clinical trials of motivational interviewing concluded that this is a "useful clinical intervention...[and] appears to be an effective, efficient, and adaptive therapeutic style worthy of further development, application, and research" (Noonan and Moyers, 1997, p. 8).

Motivational interviewing is a counseling approach that more closely reflects the principles of motivational enhancement than the variety of brief interventions reviewed in Chapter 2, and it also links these basic precepts to the stages-of-change model.

Of the 11 studies reviewed, 9 found motivational interviewing more effective than no treatment, standard care, extended treatment, or being on a waiting list before receiving the intervention. Two of the 11 studies did not support the effectiveness of motivational interviewing, although the reviewers suggested that the spirit of this approach may not have been followed because the providers delivered advice in an authoritarian manner and may not have been adequately trained (Noonan and Moyers, 1997).

Moreover, one study had a high dropout rate. Two studies supported the efficacy of motivational interviewing as a stand-alone intervention for self-identified concerned drinkers who were provided feedback about their drinking patterns but received no additional clinical attention.

Three trials confirmed the usefulness of motivational interviewing as an enhancement to traditional treatment, five supported the effectiveness of motivational interviewing in reducing substance-using patterns of patients appearing in medical settings for other health-related conditions, and one trial compared a brief motivational intervention favorably with a more extensive alternative treatment for marijuana users.

Motivational Interviewing and Managed Care

In addition to its effectiveness, motivational interviewing is beneficial in that it can easily be applied in a managed care setting, where issues of cost containment are of great concern. Motivational interviewing approaches are particularly well suited to managed care in the following ways:

Low cost. Motivational interviewing was designed from the outset to be a brief intervention and is normally delivered in two to four outpatient sessions.

Efficacy. There is strong evidence that motivational interviewing triggers change in high-risk lifestyle behaviors.

Effectiveness. Large effects from brief motivational counseling have held up across a wide variety of real-life clinical settings.

Mobilizing client resources. Motivational interviewing focuses on mobilizing the client's own resources for change.

Compatibility with health care delivery. Motivational interviewing does not assume a long-term client-therapist relationship. Even a single session has been found to invoke behavior change, and motivational interviewing can be delivered within the context of larger health care delivery systems.

Emphasizing client motivation.

Client motivation is a strong predictor of change, and this approach puts primary emphasis on first building client motivation for change. Thus, even if clients do not stay for a long course of treatment (as is often the case with substance abuse), they have been given something that is likely to help them within the first few sessions.

Enhancing adherence. Motivational interviewing is also a sensible prelude to other health care interventions because it has been shown to increase adherence, which in turn improves treatment outcomes.

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See Chapter 3 source page for links to diagrams and other references

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SAMHSA/CSAT Treatment Improvement Protocols
TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment
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