Motivational interviewing (MI) has taken the world of addiction therapy by storm. MI was first developed by William Miller, Ph.D., who says that the technique began in a barber shop in Norway that had been vacated to provide space for Miller, who was then a visiting professor from the U.S. at the Hjellestad Clinic. He developed the technique in a series of seminars with Norwegian psychology graduate students, and published his first paper on MI in 1983 (Behavioural Psychotherapy 1983;11:147-172). The technique skyrocketed in popularity in the late 1990s, after the publication of the major textbook of MI in 1991 (Miller and Rollnick, Motivational Interviewing: Preparing People to Change Addictive Behavior. Guilford Press, New York, 1991 and 2nd ed., 2002).
The essence of MI is that the therapist maintains an empathic, supportive stance with patients while gently prodding them to focus on discrepancies between how they would like their life to be and how it actually is.
One of the key ideas of MI is that, at any point in time, patients are in a distinct stage along the “readiness-to-change” continuum:
Precontemplation—“I don’t have a drinking problem.”
Contemplation—“Okay, I might have a problem, but I’m not sure that I need to do anything about it.”
Preparation—“I agree that I have a problem. Help figure out what to do.”
Action—“I’ve made some efforts to stop drinking, but I need more help.”
Maintenance—“I’ve been sober for quite a while, but I know I need help staying sober.”
Viewing patients along this continuum is helpful, particular for those of us who may be overly fatalistic about substance abusing patients. For example, rather than pejoratively viewing active substance abusers as being in “denial,” this continuum recategorizes them, more optimistically, as being in a “precontemplation” stage, encouraging you to help patients find a pathway to a more advanced stage.
A key stage of motivational interviewing begins at the end of the diagnostic interview, after you’ve asked all the right questions about types of substances used, quantity, pattern of use, medical complications, and perceived benefits and risks of use. You should then reserve a good chunk of time for a four-stage “change assessment process:”
1. Summarize your impression. Review your patient’s history as it pertains to substance abuse, highlighting the negative consequences of alcohol.
2. Present and explain your diagnosis. State the DSM-4 diagnosis (usually either alcohol abuse or alcohol dependence) and explain to your patient exactly how you arrived at the diagnosis. Yes, this means going through each of the criteria they meet and providing the evidence from the interview. Then you say, “To meet the criteria for the diagnosis of alcohol dependence, you have to meet three of seven listed criteria—and your drinking pattern meets four of them. That’s the bad news. The good news is that your problem is treatable.” You can go on to say a lot of encouraging stuff to soften the blow.
3. State your clinical concerns. Tell your patient what bad things are going to continue happening if they don’t stop drinking. This may sound like belaboring the obvious after you’ve cited chapter and verse of DSM-4 to them, and you can make this brief, but a little repetition is not a bad thing.
4. Assess your patient’s readiness for change. This is where you want to figure out where, on the readiness-to-change continuum, your patient sits: “To what extent do you feel that your drinking is a problem?” And then, “What kinds of things would you like to do about the problem?”
The “Miracle Question.” While not specifically a part of MI, this “miracle question” is used by many experts to help guide patients to become motivated to change: “Let’s imagine that tonight while you’re sleeping, some miracle happens that makes your drinking problem completely disappear. You’re completely unaware that this has happened because you’re sleeping. What do suppose will be the first small thing that will indicate to you tomorrow morning that there has been a miracle overnight, and the problem has been solved? What will you notice that is different? What will other people notice about you that is different?”
This question helps your patient to notice the discrepancy between who they are as a substance abuser and who they would like to be, instilling hope and motivation for change.
If you are interested in using motivational interviewing in your practice, you may want to read an excellent new book called Treating Alcohol and Drug Problems in Psychotherapy Practice (Washton and Zweben, Guilford Press, New York, 2006), which provides more detail and specific patient examples.