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We’ve all experienced crossroads moments at some point in our lives. We’ve all had times when we realized it was time to make a change. It could be about improving our diet or our lifestyle or our relationships. The change can also involve addressing harmful patterns like substance abuse.
But making the desired change isn’t always easy. The mind grows used to routines. Changing them could be met with fear and anxiety. We know these changes would ultimately improve our lives, health and interactions with others but we still resist.
Many face an internal struggle when it comes to making significant behavioral modifications. That struggle is known as ambivalence.
Ambivalence is a natural and predictable part of the change process. It’s a state of having mixed or contradictory ideas about something. In other words being “on the fence” about following through with the change. The clashing ideas can cause unwanted or unexpected roadblocks to a better life.
Take someone who wants to exercise more to improve their health. They may face an internal struggle. They might think I know I should go to the gym today for a short workout but it’s so cold and dreary outside. I’d rather just have a relaxing day. I can work out tomorrow. Repeating this choice can lead to a new habit where exercise takes the back seat.
One key factor for making positive life changes is working through ambivalence.
If you’re not ready for change you won’t be motivated to reach new goals. You could even have the desire to change but you’re not yet ready to do the work to make the change. This inner motivation could quickly diminish and cause you to retreat to old habits.
Ambivalence is especially hard to overcome for those with addiction and substance use disorders. They may see the need to improve their lifestyles but mental and physical blocks keep them from following through with treatment or therapy.
Motivational interviewing is a proven approach to behavior change. The therapeutic method helps empower individuals to explore their meaning and motivations to change. Motivational Interviewing has been successfully applied to reduce uncertainty and increase motivation for a range of behavioral changes including addiction and substance use disorder.
Understanding Motivational Interviewing
Motivational interviewing is a client centered and semi directive method for enhancing intrinsic motivation for change. One of the core elements of motivational interviewing is the belief that people have the ability to change even if they have not been successful in the past.
During motivational interviewing ambivalence is normalized and explored without judgment. Specific motivational interviewing techniques help individuals identify and understand the roots of their ambivalence. The therapist takes a curious and respectful approach to help individuals elaborate on and resolve their indecisiveness.
In a motivational interviewing session the therapist balances following individuals with good listening and guiding them by providing information to help them reach their own conclusions.
Instead of the therapist trying to “fix” a person or hand out advice, collaborative, non-confrontational techniques are used to develop rapport, explore the desired change and reinforce an individual’s intrinsic motivation. Motivational interviewing empowers individuals to identify the problem and solution themselves.
The focus becomes a commitment to a specific goal and individuals draw out their own meaning and importance for improving their lives. They discover their motivations for change and create a plan to reach their goals.
The full framework of motivational interviewing is elaborate and nuanced but the principles have an intuitive appeal. The core elements can be readily applied in practice as a clinician learns this therapeutic approach.
Motivational interviewing has been applied across a broad range of settings and populations including healthcare, corrections, human services and treatment facilities.
The Four Processes of Motivational Interviewing
Motivational interviewing consists of four phases that help develop the therapeutic relationship and set the stage for lasting change.
Engaging
Motivational interviewing begins with establishing a therapeutic rapport. The therapist learns more about the individual and seeks to fully understand their perspectives. This phase also helps the individual build trust and a bond with the therapist.
The therapist withholds judgment and offers compassionate support. Through respectful and curious interactions the therapist begins to understand their readiness and motivation to change.
It’s important that the therapist doesn’t try to repair or correct the problem in this phase. No agenda is presented. The ultimate goal is to gain trust with the therapist and establish a baseline of the individual’s attitude for moving forward.
Focusing
The next phase continues to explore an individual’s ambivalence and struggle to make a change. Discussion narrows to current thoughts and behaviors that may get in the way of moving forward.
The therapist strives to understand the individual’s experiences and perspectives better. These conversations respect the individual’s right to make informed choices about whether or not to change. An individual’s strengths take the spotlight to develop confidence and willingness to change.
The key difference between the engaging and focusing process is that the therapist starts planting “seeds” to help an individual identify the target area that needs to be addressed.
Evoking
Once a target area is established then the therapist encourages individuals to use their inner resources and wisdom to facilitate change. This process draws out an individual’s priorities and values to help them understand the “why” of change.
Ambivalence gets explored without judgment. The therapist uses skillful attention during the conversations. Recognition and elaboration of “change talk” helps an individual understand the motivation for change. The therapist can reinforce “change talk” or summarize it to make it more prominent in an individual’s perspective.
Evoking takes patience. The therapist needs to avoid the expert trap. The goal is for the individual to come to their own conclusions, reasons and motivations for change.
Planning
Once an individual understands their reason and readiness for change then the therapist can help with developing a change plan. The therapist reinforces change talk and commitment language. The therapist also asks key questions to ensure the individual’s stage of readiness.
Change plans are specific to an individual’s situation and level of commitment. The plans may need to be revisited and modified based on an individual’s behaviors outside of treatment sessions.
The planning process is optional in some cases but creating a plan for those with substance use disorder is highly recommended. If an individual experiences high levels of stress, low energy or setbacks then they need to know positive ways to deal with these things to prevent relapse. An established plan can also make it easier to get the support needed if an individual relapses.
Motivational Interviewing Techniques
OARS
OARS is an acronym for open questions, affirmations, reflective listening and summary reflections. These interaction techniques are used early and often during motivational interviewing sessions. An overview of each is available below.
Open Questions
Open questions invite others to “tell their story.” Open questions encourage longer answers and elaboration without constant prodding.
For example a closed question like “Do you think your drug use is affecting your partner?” may give a limited response. Using open questions like “How has your drug use impacted your relationship?” allows the potential for a more detailed response.
Open questions only work when the therapist takes a curious and empathetic approach to listening.
Affirmations
Affirmations allow the therapist to help an individual recognize their strengths and acknowledge desirable behaviors. Affirmations also help an individual build confidence and motivation to change.
Examples of affirmations include:
- You handled that situation very maturely.
- That’s a great point you brought up.
- It’s clear that you are seriously thinking about making changes.
- You are very observant about what’s going on around you.
Effective affirmations need to be genuine and congruent.
Reflective Listening
Reflective listening helps close the loop in communication to ensure conversation breakdowns don’t occur. This technique allows for greater exploration of a topic or clarification when the message isn’t clear.
Questions can sometimes interrupt an individual’s flow if they are getting deeper into a topic. Reflective listening uses techniques like rephrasing, paraphrasing and reflection of feeling to help build trust, rapport and ultimately motivation to change.
Summary Reflections
Summaries involve recapping what the individual discussed and calling attention to salient elements or “change talk” brought up during the session. Effective summaries end with an open ended statement that may encourage an individual to explore a topic more or make a small and specific goal based on what was summarized.
Applying Motivational Interviewing in Substance Abuse Treatment
Motivational interviewing is especially effective for treating alcohol and other addictions. Motivational interviewing can be up to 20% more effective than other treatment methods.
During addiction treatment an individual’s successful recovery is based on their readiness and willingness to change and how they react to ambivalence. Drawing out honest, open conversations during motivational interviewing sessions can help the therapist gauge the individual’s true desire to move forward from substance use and addiction.
In substance abuse treatment settings motivational interviewing is a short term intervention strategy that can take place in single or multiple sessions. It can be conducted in person or virtually. Motivational interviewing can also be effective with small groups.
In many cases motivational interviewing doesn’t address the underlying reasons for addiction, focusing more on the reasons and motivations for change. Addiction treatment is usually most effective when combining a variety of therapeutic techniques.
Motivational interviewing compliments other evidence based therapies such as cognitive behavioral therapy (CBT), support groups, contingency management and anger management.
Conclusion
Motivational interviewing is a powerful tool for treating substance use disorders and other addictive behaviors. The treatment method promotes change through empathetic interviewing techniques targeting ambivalence to change.
Motivational interviewing can be used with other proven therapeutic practices as a holistic approach to treating addiction. The focus on motivation to change provides a solid foundation for individuals to start their journey of recovery.
