Motivational Interviewing (MI) was developed as a consequence of many of the frustrations that therapists had regarding individuals in treatment for alcohol use disorders. The MI process was originally created to identify where individuals stood regarding their understanding of their need to change and to develop a tailored therapy program to address them based on their own level of understanding and needs. Since its inception, MI has been incorporated into a number of other treatment protocols for a number of different issues.
What Is Motivational Interviewing?
A number of individuals entering therapy for substance abuse, issues that have led to legal problems, relationship issues, etc., are often coerced or convinced to enter therapy by a third-party, such as the court system, a romantic partner or spouse, an employer, etc. There are a number of times, especially with individuals who are forced into treatment for substance use disorders, where individuals are not fully ready to accept that they actually need to change their behavior. In many cases, these individuals are convinced that they are able to continue to act in the same manner, but in such a way that it does not lead to negative consequences.
For example, individuals who are required to enter therapy as a result of obtaining infractions due to driving under the influence of alcohol often believe that they do not need to stop drinking, but they need to just not drink when they are driving. Individuals forced into treatment by the legal system for using drugs like cocaine or heroin often think they just need to cut down and control their use of these drugs. Unfortunately, many of these individuals are unable to control their drinking or drug use patterns and end up with multiple offenses.
In addition, these individuals are often very difficult to treat due to their perception of where they stand in relation to their substance use disorder. The issue with the development of a substance use disorder is mainly one of a lack of control over substance use, and even though clinicians understand this, many individuals beginning treatment for these disorders do not and often cannot be convinced of this. On the surface, they may appear to comply and agree with what they are being taught, but underneath they simply harbor their old belief system.
The original purpose for developing the MI technique was to identify where clients with substance use disorders (particularly alcohol use disorders and tobacco use disorders) stood in regards to their understanding of their need to change their behavior and how serious the implications of their behaviors are.
The aspect of Motivational Interviewing that is most recognizable is the transtheoretical outline of the stages of the process of change that is believed to occur in people changing some aspect of their behavior. The proponents of MI do not assume that individuals entering therapy begin at the same point in understanding their need to change, the impact of their behavior, or what changing really means. Instead, the theory hypothesizes that the process of behavioral change occurs along a series of steps in that a therapist should attempt to understand where an individual entering therapy stands in regards to their conceptualization of their need to change, where they are on the continuum of change, and what actually changing their behavior means. The actual implementation of therapy should consider where the individual stands on the transient medical outline of the stages of change. Thus, the transtheoretical model outlines a series of stages where an individual entering therapy may be.
- Precontemplation: The earliest stage is the stage of precontemplation. In this stage, an individual may not be experiencing negative effects from their behavior and has not yet seriously considered the need to change their behavior. They will typically have very little interest in changing, and many older therapists use the term in denial regarding the presentation of these individuals. While that term is inaccurate, as the defense mechanism of denial has a delusional quality, whereas individuals in precontemplation just have not yet realized that they may have a problem, it is important to understand that if an individual is in this stage, they are not open to changing their behavior. Therapists confronting individuals at the precontemplation stage simply “roll” with the client’s statements that they do not need to change or that their behaviors are not problematic, and point out inconsistencies in the individual’s stated beliefs and reality. This approach assists the client in understanding and discovering that they may need to take a closer look at how their behavior is really affecting them.
- Contemplation: In this stage, the person has realized that they do have some type of a problem; however, they have not yet made a commitment to actually changing their behavior. The individual may want to change but has made no actual movement toward committing to change. Many individuals who are entering treatment for substance use disorders as a result of the consequences of their behavior, such as legal issues, issues at work, relationship issues, etc., often begin at this stage. They are able to see that they have a problem, but they are unsure as to whether they need to actually change their behavior. For instance, individuals who may have legal issues as a result of alcohol or drugs may believe that they were just unlucky and that they can control their issue, whereas in reality, this may not be realistic. Individuals in this stage often realize that there is a problem, but are not sure of the extent of the problem and of the actual type of change they need to implement to solve it. Again, the therapist needs to point out inconsistencies in what they believe and what is actually happening.
- Preparation: Individuals at this point realize that they must change their behavior, and they are evaluating their options to determine the most effective approach to changing their behavior. In this stage, individuals begin to think of their actions, the consequences of their actions, and are readily open to discussing alternatives. Individuals in this stage have fully accepted the notion that the responsibility for change is centered on them and not on other people or on the system. Therapists confronting individuals at this stage need to help the individuals to identify their options and pick the best one.
- Action: Individuals at this stage of the process are involved in real efforts to change their behavior. These individuals are working on specific plans of action to address their issues and implement long-lasting changes. Individuals in this stage may not adhere to any specific plan of action if they find it to be an effective; however, they have made the commitment to change and are actively working on a plan to reach their goals.
- Maintenance: Individuals at this stage have been successful at implementing change and are now at the point in their development where they are attempting to maintain their new skills and the changes they have accomplished. It is not unusual for individuals at the stage to have tried many different approaches to change and to have adjusted their approaches to fit in with their own needs. Therapists working with individuals at this stage need to fine-tune the process, so individuals can anticipate and deal with future situations that may threaten the changes they have already made.
- Termination: At this stage, the person has made changes, confronted any threats to their success, and is continuing to move forward. These individuals are simply moving on with their lives and making minor adjustments as needed to ensure that the positive changes they have made remain in place. In some instances, they may attempt to add new skills or behaviors to their repertoire.
The transtheoretical model assumes that individuals can start at any stage in the model and may experience setbacks and failures and even drop back to earlier stages. Often, the process of real change is not a linear process where individuals simply go through a series of steps, but a trial-and-error process where individuals experience a number of ups and downs in their goals to move ahead. People at any level on the model may experience difficulty and need to start from the very beginning.
The usefulness of the model for therapists is that they are motivated to identify where an individual lies on the continuum of change and then personalize the treatment to assist the individual to move forward. Therapists also understand that individuals may experience failures and setbacks and need to start at a different level. Thus, the model is very flexible and allows therapists to personalize treatment based on where an individual stands. The model can be applied to a number of other issues aside from just the therapeutic treatment of substance use disorders, including the treatment of obesity, diabetes, or high blood pressure. It is also been applied to aspects of management training and education.
Because the MI paradigm requires that individuals actually think about their situation, perceptions, and beliefs, it has adjusted well to the notion of mindfulness, which has become a very popular notion in forms of Cognitive Behavioral Therapy. Mindfulness is being aware of oneself at the moment, and this process can be useful when attempting to explain the trans-theoretical model and trying to understand where an individual stands on the process of change.
There been a number of research studies looking at Motivational Interviewing, and the results are mixed. Typically, when one looks at research, one should give more weight to research that uses the findings from numerous studies as opposed to using a single research study. For example, meta-analysis is a statistical technique that combines the results of a number of similar studies to ascertain overall effects based on a number of different research findings. A meta-analytic study in The British Journal of Medical Practice reported that of the studies selected for the a meta-analysis, nearly 80 percentindicated positive effects for using MI and that using the MI model was more effective than just giving traditional advice. However, the actual magnitude of the effects was modest at best.
A 2010 meta-analysis reported in the journal Research on Social Work Practice indicated that when MI was compared to other specific forms of treatment, the difference between the results was not significant. The researchers indicated that while MI did improve treatment effectiveness, there was evidence to indicate that this effectiveness was dependent on the types of clients it is used for and on how it was delivered. Thus, MI does offer some advantages if the technique is used properly.