Phase 1: Building Motivation for Change

Motivational counseling can be divided into two major phases: (1) building motivation for change, and (2) strengthening commitment to change (Miller & Rollnick, 1991).  The early phase of MET focuses on developing the client's motivation to make a change in his or her drug use. 

Clients will vary widely in their readiness to change.  Some may come to treatment largely decided and determined to change, but the following processes should nevertheless be pursued in order to explore the depth of such apparent motivation, and to begin consolidating commitment. 

Others will be reluctant or even hostile at the outset.  At the extreme, some true precontemplators may be coerced into treatment by family, employer, or legal authorities.  Most clients, however, are likely to enter the treatment process somewhere in the contemplation stage.  They may already be dabbling with taking action, but still need consolidation of motivation for change.

This may be thought of as the tipping of a motivational balance (Janis & Mann, 1977; Miller, 1989; Miller, Sovereign & Krege, 1988).  One side of the seesaw favors status quo (e.g., continued drug use as before), whereas the other favors change. 

The former side of the decisional balance is weighed down by perceived positive benefits from drug use and feared consequences of change. Weights on the other side consist of perceived benefits of changing one's drug use, and feared consequences of continuing unchanged. 

Your task is to shift the balance of weight in favor of change.  Eight strategies toward this end (Miller & Rollnick, 1991) are outlined in this section.

1. Eliciting Self-Motivational Statements

There  is  truth  to  the  saying  that  we  can  "talk  ourselves into" a change.  Motivational psychology has amply demonstrated that when people are subtly enticed to speak or act in a new way, their beliefs and values tend to shift in that direction. 

This phenomenon has sometimes been described as cognitive dissonance (Festinger, 1957).  Self-perception theory (Bem, 1965, 1967, 1972), an alternative account of this phenomenon, might be summarized: "As I hear myself talk, I learn what I believe."  That is, the words which come out of a person's mouth are quite persuasive to that person - more so, perhaps, than words spoken by another.  If I say it, and no one has forced me to say it, then I must believe it!

If this is so, then the worst persuasion strategy is one that evokes defensive argumentation from the person.  Head-on confrontation is rarely an effective sales technique ("Your children are educationally deprived, and you will be an irresponsible parent if you don't buy this encyclopedia"). This is a flawed approach not only because it evokes hostility, but also because it provokes the client to verbalize precisely the wrong set of statements. 

An aggressive argument that "You're an addict and you have to give up all drugs" will usually evoke a predictable set of responses: "No I'm not, and no I don't."  Unfortunately, counselors are sometimes trained to understand such a response as client "denial," and to push all the harder.  The likely result is a high level of client resistance - which we will examine later.

The positive side of the coin here is that the ME therapist seeks to elicit from the client certain kinds of statements that can be considered, within this view, to be self-motivating (Miller, 1983).

These include statements of:

1. being open to input about drug use and effects
2. acknowledging real or potential problems related to drug use
3. expressing a need, desire, or willingness to change
4. expressing optimism about the possibility of change.

There are several ways to elicit such statements from clients.  One is to ask for them directly, via open-ended questions.  Some examples:

I assume, from the fact that you are here, that you have been having some concerns or difficulties related to your drug use.  Tell me about those.

Tell me a little about your drug use.  What do you like most about the drugs you use?  What's positive about these drugs for you?  And what's the other side?  What are your worries about using drugs?

Tell me what you've noticed about your drug use.  How has it changed over time?  What things have you noticed that concern you, that you think could be problems, or might become problems?

What have other people told you about your drug use?  What are other people worried about?
(If a spouse or significant other is present, this can be asked directly.)

What makes you think that you may need to make a change in your drug use?

Once this process is rolling, simply keep it going by using reflective listening (see below), by asking for examples, by asking "What else?", etc.  If it bogs down, you can inventory general areas such  as  those  contained  in the  Self-Evaluation  of  Drug  Use.  This inventory can be used as a structured inquiry, in which the pros and cons of drug use are weighed (see Appendix).  Here are the areas included:
 
Amount and tolerance - Is the client's drug use increasing?  Does the client seem to need larger doses of drugs to  experience the same effect as before, or to tolerate large doses without showing much effect?

Behavior  -   Has  drug  use  caused  trouble  with  the  law,  neglect  of  responsibilities, inconveniences like having to move, financial problems, or embarrassing behavior?

Coping - Is the client using drugs to cope with problems and day to day difficulties?   How well does it work in reducing (versus escaping) problems?

Dependence - How dependent or addicted is the client?  How difficult is it to go without drugs?

Emotional Health - Does the client feel more anxious, guilty, upset, or depressed because of drug use?  How does it affect the client's emotions?

Family - What effects does drug use have on the client's family?

Feeling Good About Self (Self-Esteem) - How does drug use affect the client's self-concept? Does the person feel ashamed, guilty, out of control?

Physical Health - Has drug use contributed to illness, injuries, fatigue, poor eating habits, etc.?

Important Relationships - How does drug use affect the client's relationships with loved ones and friends?

Job: Work and School - How does drug use affect the person's school or employment?

Key People - What do key people in the client's life think about his or her drug use? Loving  Relationships and Sexuality - How does drug use impact the client's physical attractiveness, sexual drive, sexual relationships, safe sex practices, etc.?

Mental Abilities - Has drug use affected the person's memory, ability to concentrate, learning? Information from pretreatment assessment (to be used as feedback later) may also suggest some areas to explore during this open-ended motivational interviewing phase.

If you encounter difficulties in eliciting client concerns, still another strategy is to employ gentle paradox to evoke self-motivational statements.  In this table-turning approach, you subtly take on the voice of the client's "resistance," evoking from the client the opposite side.  Some examples:

You haven't convinced me yet that you are seriously concerned.  You've come down here and gone through several hours of assessment.  Is that all you're concerned about?

I'll tell you one concern I have.  This program is one that requires a fair amount of motivation from people, and frankly I'm not sure from what you've told me so far that you're motivated enough to carry through with it.  Do you think we should go ahead?

I'm not sure how much you are interested in changing, or even in taking a careful look at your drug use.  It sounds like you might be happier just going on as before.

Particularly in the presence of a significant other, such statements may elicit new self-motivational material.  Similarly, a client may back down from a position if you state it more extremely, even in the form of a question.  For example:

So drugs are really important to you.  Tell me about that. What is it about drugs that you really need to hang onto, that you can't let go of?

In general, however, the best opening strategy for eliciting self-motivational statements is to ask for them:

Tell me what concerns you about your drug use. Tell me what it has cost you. Tell me why you think you might need to make a change.

2. Listening with Empathy

The eliciting strategies just discussed are likely to evoke some initial offerings, but it is also crucial how you respond to clients' statements.  The therapeutic skill of accurate empathy (sometimes also called active listening, reflection, or understanding) is an optimal response within MET.

In popular conceptions, empathy is thought of as "feeling with" a person, or having an immediate understanding of their situation by virtue of having experienced it (or something similar) oneself. 

Carl Rogers, however, introduced a new technical meaning for the term "empathy," using it to describe a particular skill and style of reflective listening (Rogers, 1957, 1959).  In this style, the therapist listens carefully to what the client is saying, then reflects it back to the client, often in a slightly modified or reframed form. 

Acknowledgment of the client's expressed or implicit feeling state may also be included.  This way of responding offers a number of advantages: (1) it is unlikely to evoke client resistance; (2) it encourages the client to keep talking and exploring the topic; (3) it communicates respect and caring, and builds a working therapeutic alliance; (4) it clarifies for the therapist exactly what the client means; and (5) it can be used to reinforce ideas expressed by the client.

This latter characteristic is an important one.  You can reflect quite selectively, choosing to reinforce certain components of what the client has said, and passing over others.  In this way, clients not only hear themselves saying a self-motivational statement, but also hear you saying that they said it.  Further, this style of responding is likely to encourage the client to elaborate the reflected statement.  Here is an example of this process.

THERAPIST:  What else concerns you about your drug use?

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

T: Too much for . . .

C: 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.

T: It messes up your thinking, your concentration.

C: Yes, and sometimes I do stupid things.

T: And you wonder if that might be because you're using too much.

C: Well, I know it is sometimes.

T: You're pretty sure about that.  But maybe there's more.

C: Yeah - even when I'm not using, sometimes I get things mixed things up, and I can't think right, and I wonder about that.

T: Wonder if . . .

C: If drugs are frying my brain, I guess.

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

C: Well can't it?  I've heard that drugs can mess up your brain.

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

C: But I don't think I'm an addict or anything.

T: 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.

C: Yeah.

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

This therapist is responding primarily with reflective listening.  This is not, by any means, the only strategy used in MET, but it is an important one.  Neither is this an easy skill.  Readily parodied or done poorly, 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. 

Optimal reflective listening suspends advice, agreement, disagreement, suggestions, teaching, warning, and questioning, in favor of continued exploration of the client's own processes.  (For more detail, see Egan, 1982; Miller & Jackson, 1995).

It may be of further help to contrast reflective with other kinds of possible therapist responses to some client statements:

CLIENT: I guess I do use too much sometimes, but I don't think I have a problem with drugs.

CONFRONTATION: Yes you do!  How can you sit there and tell me you don't have a problem when . . .

QUESTION: Why do you think you don't have a problem?

REFLECTION: So on the one hand you can see some reasons for concern, and you really don't want to be labeled as "having a problem."

CLIENT: My wife is always telling me that I'm a junkie.

JUDGING: What's wrong with that?  She probably has some good reasons for thinking so.

QUESTION: Why does she think that?

REFLECTION: And that really annoys you.

CLIENT: If I quit using drugs, what am I supposed to do for friends?

ADVICE: I guess you'll have to get yourself some new ones.

SUGGESTION: Well, you could just tell your friends that you don't use anymore, but you still want to see them.

REFLECTION: It's hard for you to imagine living without drugs.

This style of reflective listening is to be used throughout MET.  It is not to be used to the exclusion of other kinds of responses, but it should be your predominant style in responding to client statements.  As the following sections indicate, however, the ME therapist also uses a variety of other strategies.

Finally, it should be noted here that selective reflection can backfire.  For a client who is ambivalent, reflection of one side of the dilemma ("So you can see that drugs are causing you some problems.") may evoke the other side from the client ("Well, I don't think I have a problem really.").

If this occurs, the therapist should reflect the ambivalence.  This is often best done with a double- sided reflection that captures both sides of the client's discrepancy.  These may be joined in the middle by the conjunction "but" or "and", though we favor the latter to highlight the ambivalence:

DOUBLE-SIDED REFLECTIONS

You don't think that drugs are harming you seriously now, and at the same time you are concerned that they might get out of hand for you later.

You really enjoy using drugs and would hate to give that up, and you can also see that they are causing serious problems for your family and your job.

3. Questioning

The MET style does include some purposeful questioning as an important therapist response. Rather than telling the client how he/she should feel, or what to do, the therapist asks the client about his/her own feelings, ideas, concerns, and plans.  Elicited information is then responded to with empathic reflection, affirmation, or reframing (see below).

4. Presenting Personal Feedback

The first MET session should always include feedback to the client from the pretreatment assessment.  This is done in a structured way, providing clients with a written report of their results ("Personal Feedback Report"), and comparing these with normative ranges.

To initiate this phase, give the client (and significant other, if attending) the Personal Feedback Report (PFR), retaining a copy for your own reference and the client's file.  Go through the PFR step by step, explaining each item of information, pointing out the client's score, and comparing it with the normative data provided.  The details of this feedback process are provided in the Appendix.

A very important part of this process is your own monitoring of and responding to the client during the feedback.  Observe the client as you provide personal feedback.  Allow time spaces for the client (and significant other) to respond verbally.  Use reflective listening to reinforce self-motivating statements that emerge during this period.  Also respond reflectively to resistance statements, perhaps reframing them or embedding them in a double-sided reflection.

Here are several different examples:

CLIENT: Wow!  This says that I'm using a lot more drugs than most people.
THERAPIST:  And that doesn't seem right to you.

C: I don't see how my drug use can be affecting me that much.
T:  This isn't what you expected to hear.

C: No, I don't really use much more than other people.
T: So this is confusing to you.  It seems like you use about the same amount as your friends, yet here are the results.  Maybe you wonder if there's something wrong with the tests, or if I'm not being honest with you.

C: More bad news!
T: This is pretty difficult for you to hear.

C: This gives me a lot to think about.
T: A lot of reasons to think about making a change.

The same style of responding can be used with the client's significant other (SO).  In this case, it is often helpful to reframe or emphasize the caring aspects behind what the SO is saying:

WIFE: I always knew he was using too much.
THERAPIST: You've been worried about him for quite a while.

HUSBAND: (weeping)  I've told you to quit doing drugs!
THERAPIST: You really care about her a lot.  It's hard to sit there and listen to this.

After reflecting an SO statement, it is often wise to ask for the client's perceptions, and to reflect self- motivational elements:

FRIEND: I never really thought he used that much!
THERAPIST: This is taking you by surprise. (Then to client:)  How about you?  Does this surprise you, too?

WIFE: I've been trying to tell you all along that you drugs were no good for you.  Now maybe you'll believe me.
THERAPIST: You've been worrying about this for a long time, and I guess you're hoping now he'll see why you've been so concerned.  (To client:)  What are you thinking  about all this?  You're getting a lot of input here.
 
Often a client will respond nonverbally, and it is possible also to reflect these reactions.  A sigh, a frown, a slow sad shaking of the head, a whistle, a snort, or tears can communicate a reaction to feedback.  You can respond to these with a reflection of the apparent feeling.

If the client is not volunteering reactions, it is wise to pause periodically during the feedback process to ask:

What do you make of this? Does this make sense to you? Does this surprise you? What do you think about this? Do you understand?  Am I being clear here?

Clients will have questions about their feedback and the tests on which their results are based. For this reason, you need to be thoroughly familiar with the assessment battery and its interpretation. Some additional interpretive information is provided on the PFR, which the client takes home.

The training videotape "Motivational Interviewing" offers one demonstration of this style of presenting assessment feedback to a resistant problem drinker [See Demonstration Videotapes list at the end of this section.]

5. Affirming the Client

You should also seek opportunities to affirm, compliment, and reinforce the client sincerely. Such affirmations can be beneficial in a number of ways, including: (1) strengthening the working relationship, (2) enhancing the attitude of self-responsibility and empowerment, (3) reinforcing effort and self-motivational statements, and (4) supporting client self-esteem.  Some examples:

I appreciate your hanging in there through this feedback, which must be pretty rough for you. I think it's great that you're strong enough to recognize the risk here, and that you want to do something before it gets more serious.

You've been through a lot together, and I admire the kind of love and commitment you've had to stay together through all this.

You really have some good ideas for how you might change.

Thanks for listening so carefully today.

You've taken a big step today, and I really respect you for it.
 
6. Handling Resistance

Client resistance is a legitimate concern.  Failure to comply with a therapist's instructions, and resistant behaviors within treatment sessions (e.g., arguing, interrupting, denying a problem) are responses that predict poor treatment outcome.

What is resistance?  Here are some client behaviors that have been found to be predictive of poor treatment outcome:

Interrupting - cutting off or talking over the therapist

Arguing - challenging the therapist, discounting the therapist's views, disagreeing, hostility

Sidetracking - changing the subject, not responding, not paying attention

Defensiveness - minimizing or denying the problem, excusing one's own behavior, blaming others, rejecting the therapist's opinion, unwillingness to change, alleged impunity, pessimism

What too few therapists realize, however, is that the extent to which such client "resistance" occurs during treatment is powerfully affected by the therapist's own style.  Miller, Benefield and Tonigan (1993) found that when problem drinkers were randomly assigned to two different therapist styles (given by the same therapists), one confrontational-directive and one motivational-reflective, those in the former group showed substantially higher levels of resistance, and were much less likely to acknowledge their problems and need to change. 

These client resistance patterns were, in turn, predictive of less long-term change.  Similarly, Patterson and Forgatch (1985) had family therapists switch back and forth between these two styles within the same therapy sessions, and demonstrated that client resistance and noncompliance went up and down markedly with therapist behaviors.  The picture that emerges is one in which the therapist dramatically influences client defensiveness, which in turn predicts the degree to which the client will change.

This is in contrast with the common view that drug addicts are resistant because of pernicious personality characteristics that are part of their condition.  Denial is often regarded to be a trait of "chemical dependency."  In fact, extensive research has revealed relatively few consistent personality characteristics among drug users, nor do studies of defense mechanisms suggest any  unique pattern associated with addictive behavior (cf. Miller, 1985). 

This suggests that people with drug problems do not, in general, walk though the therapist's door already possessing high levels of denial and resistance.  These important client behaviors are more a function of the interpersonal interactions that occur during treatment, although they may result in part from the context in which therapeutic contact occurs (e.g., mandate by the courts).

An important goal in MET, then, is to avoid evoking client resistance (anti-motivational statements).  Said more bluntly, client resistance is a therapist problem.  How you respond to resistant behaviors is one of the defining characteristics of MET.

A first rule of thumb is never meet resistance head-on.  Certain kinds of reactions are likely to exacerbate resistance, back the client further into a corner, and elicit anti-motivational statements from the client (Gordon, 1970; Miller & Jackson, 1995).  These therapist responses include:

Arguing, disagreeing, challenging Judging, criticizing, blaming

Warning of negative consequences

Seeking to persuade with logic or evidence

Interpreting or analyzing the "reasons" for resistance

Confronting with authority

Sarcasm or incredulity

Even direct questions as to why the client is "resisting" (e.g., Why do you think that you don't have a problem?) only serve to elicit from the client further defense of the anti-motivational position, and leave you in the logical position of counter argument.  If you find yourself in the position of arguing with the client to acknowledge a problem and the need for change, shift strategies.

Remember that you want the client to make self-motivational statements (basically, "I have a problem" and "I need to do something about it"), and if you defend these positions yourself it may evoke the opposite from the client.  Here are several strategies for deflecting resistance (Miller & Rollnick, 1991):

Simple reflection.  One strategy is simply to reflect what the client is saying.  This sometimes has the effect of eliciting the opposite, and balancing the picture.

Reflection with amplification.  A modification is to reflect, but exaggerate or amplify what the client is saying to the point where the client is likely to disavow it.  There is a subtle balance here, because overdoing an exaggeration can elicit hostility.

CLIENT: But I'm not addicted, or anything like that.

THERAPIST: You don't want to be labelled.

CLIENT: No.  I just don't think I have a drug problem.

THERAPIST:  So as far as you can see, there really haven't been any problems or harm because of your drug use.

CLIENT: Well, I wouldn't say that exactly.

THERAPIST:  Oh!  So you do think sometimes your drug use has caused problems, but you just don't like the idea of being called an addict.
 
Double-Sided Reflection.  The last therapist statement in this example is a double-sided reflection, which is another way to deal with resistance.  If a client offers a resistant statement, reflect it back with the other side (based on previous statements in the session).

CLIENT: But I can't just quit drugs.  I mean, all of my friends use!

THERAPIST: You can't imagine how you could not use with your friends, and at the same time you're worried about how it's affecting you.

Shifting Focus.  Another strategy is to defuse resistance by shifting attention away from the problematic issue.

CLIENT: But I can't just quit drugs.  I mean, all of my friends use!

THERAPIST: You're getting way ahead of things.  I'm not talking about your quitting here, and I don't think you should get stuck on that concern right now.    Let's just stay with what we're doing right now - going through your feedback - and later on we can worry about what, if anything, you want to do about it.

Rolling With.  Resistance can also be met by rolling with it instead of opposing it.  There is a  paradoxical  element  in this,  which  often  will bring the client back to a balanced or opposite perspective.  This strategy can be particularly useful with clients who present in a highly oppositional manner, and who seem to reject every idea or suggestion.

CLIENT: But I can't just quit drugs.  I mean, all of my friends use!

THERAPIST: And it may very well be that when we're through, you'll decide that it's worth it to keep on using as you have been.  It may be too difficult to make a change.  That will be up to you.

7. Reframing

Reframing  is  a  strategy  whereby  the  therapist  invites  the  client to examine his or her perceptions in a new light, or a reorganized form.  New meaning is given to what has been said.

When a client is receiving feedback that confirms drug problems, a wife's reaction of "That's what I've been trying to tell you" can be recast from "I'm right and I told you so" to "You've been so worried about him, and you care about him very much."

Reframing can be used to help motivate the client and SO to deal with drug use.  In placing current problems in a more positive or optimistic frame, the counselor hopes to communicate that the problem is solvable and changeable (Bergaman, 1985; Fisch et al., 1982).  In developing the reframe it is important to use the client's own views, words, and perceptions about drug use. 

Some examples of interpretive reframes that can be utilized with drug abusers are:

Drugs as reward.  "You may have a need to reward yourself on the weekends for successfully handling a stressful and difficult job during the week."  (The implication here is that there are alternative ways of rewarding oneself without using drugs.)

Drug use as a protective function.  "You don't want to impose additional stress on your family by openly sharing concerns or difficulties in your life [give examples].  As a result, you carry all this yourself, and absorb tension and stress by using drugs, as a way of trying not to burden your family."  (The implication here is that the user has inner strength or reserve, is concerned about the family, and could discover other ways to deal with these issues besides using drugs.)

Drug use as an adaptive function.  "Your drug use can be viewed as a means of avoiding conflict or tension in your relationship.  Your drug use tends to keep the status quo, to keep things as they are.  It seems like you have been using drugs to keep your relationship intact. Yet both of you seem uncomfortable with this arrangement."  (The implication is that the client cares about the relationship and has been trying to keep it together, but needs to find more effective ways to do this.)

The general idea in reframing is to place the problem behavior in a more positive light, which in itself can have a paradoxical effect (prescribing the symptom), but to do so in a way that causes the person to take action to change the problem.

8. Summarizing

It is useful to summarize periodically during a session, and particularly toward the end of a session.  This amounts to a longer summary reflection of what the client has said.  It is especially useful to repeat and summarize the client's self-motivational statements.  Elements of reluctance or resistance may be included in the summary, to prevent a negating reaction from the client. 

Such a summary serves the function of allowing the client to hear his or her own self-motivational statements yet a third time, after the initial statement and your reflection of it.  Here is an example of how you might offer a summary to a client at the end of a first session:

Let me try to pull together what we've said today, and you can tell me if I've missed anything important.  I started out by asking you to tell me about your drug use, and you told me several things.  You said that your cocaine use has been increasing rapidly, and you notice that you have a high tolerance for it - it's taking more for you to get the high that you want.

You've been spending a lot of money on cocaine, and you're worried that you could lose your job and your house.  There have been some real problems and fights in the family about your drug use, and you're concerned about how all of this is affecting your son. 

On the feedback, you were somewhat surprised to learn that your drug use in general is very high compared to American adults - that very few people use drugs they way you do.  You have seen some signs that your drug use is starting to damage you physically. 

And though you don't want to think of yourself as an addict, you are quickly becoming dependent on cocaine, and you feel scared that it would be very hard for you to give it up.   I appreciate how open you have been to all this feedback, and I can see you have some real concerns now about your drug use.  Is that a pretty good summary?  Did I miss anything?

Along the way during a session, shorter "progress" summaries can be given:

So thus far you've told me that you are concerned you're setting a bad example for your kids by using drugs, and that sometimes you may not be able to be as good a parent to your children as you'd like because of your drug use.  What else concerns you?