Substance Abuse Treatment for Youth and Adults

Clinician's Guide to Evidence-Based Practice

David W. Springer, Allen Rubin

• Publisher: Wiley
• Year: 2009
• ISBN:
  9780470543764
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

State-of-the-art, empirical support for the treatmentof substance abuse

Part of the Clinician's Guide to Evidence-Based Practice Series, Substance Abuse Treatment for Youth and Adults provides busy mental health practitioners with detailed, step-by-step guidance for implementing clinical interventions that are supported by the latest scientific evidence.

Edited by renowned educators David W. Springer and Allen Rubin, this thorough yet practical reference draws on a roster of experts and researchers in the field who have assembled state-of-the-art knowledge into this well-rounded guide. Each chapter serves as a practitioner-focused how-to guide and covers interventions that have the best empirical support for treating substance abuse problems, including:

• Family behavior therapy for substance abuse and associated problems
• Motivational interviewing
• Problem solving and social skills training
• Adolescent community reinforcement approach (A-CRA)
• Cognitive behavioral coping skills therapy for adults
• Seeking Safety treatment for clients with PTSD and substance abuse

Easy-to-use and accessible in tone, Substance Abuse Treatment for Youth and Adults is an indispensable resource for practitioners who would like to implement evidence-based, compassionate, effective interventions in their care of substance-abusing clients.

PART 1

ENGAGING CLIENTS IN TREATMENT AND CHANGE

CHAPTER 1

Motivational Interviewing

McCLAIN SAMPSON, NANETTE S. STEPHENS, and MARY M. VELASQUEZ

WHAT IS MOTIVATIONAL INTERVIEWING?

Many counseling approaches are based on the idea that if people receive enough information (or education) about their problems, they will change. As a consequence, counselors working with substance-abusing clients often rely on providing advice or teaching relapse prevention and other action-related tasks as their primary therapeutic strategies. For clients who are ready to change, these approaches can be effective. If clients are not ready to change their problem behaviors, however, this type of approach can quickly lead to resistance and a lack of progress. There are numerous reasons why a client who is not ready for change might present for treatment such as legal, marital, or job-related problems that have led to coercion or ultimatums that the client attend treatment or face significant consequences. At the same time, some clients who appear ready to change feel quite ambivalent because they may have some very strong reasons to stay the same. In these cases, counselors and clients alike are much better served when counselors refrain from persuading or offering immediate advice and instead utilize an approach that seeks to enhance and reinforce client motivation and commitment to change. This approach is embodied by the Motivational Interviewing (MI) counseling style.

Because the MI approach begins with the assumption that the responsibility for change lies within the client, the counselor’s task is to create an environment that will enhance the client’s intrinsic motivation for and commitment to change. In this type of environment, the counselor elicits the client’s answers and solutions for change, rather than directs, suggests, or provides the answers. In other words, MI is not a top-down, authoritarian approach, but rather a client-centered, respectful, and collaborative endeavor that mobilizes the client’s own resources for change. A second assumption of MI is that unremitting problems are more often due to a lack of this kind of mobilization (i.e., not being motivated to try) rather than to skills deficits (i.e., trying, but not having the necessary tools or skills) or “denial” (i.e., not trying because the client believes there is not a problem in the first place). A third assumption is that when faced with making a difficult change, ambivalence is typical and “normal,” particularly for those who are initially reluctant or resistant to considering change. Thus, the central purpose of MI is to help shift these decisional uncertainties (i.e., ambivalence) in the direction of positive change by creating an atmosphere of respect and acceptance and enhancing the belief that change is possible.

William Miller and Stephen Rollnick (2002), the originators of MI, define MI as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25). The goal of MI is to prepare clients for change—not push or coerce them—by helping them work through their ambivalence about changing through the use of active listening and skilled feedback techniques. To build rapport, reduce resistance, and enhance motivation, the MI counselor elicits the client’s own concerns about the problem behavior. As the clients—rather than the counselors—articulate reasons for change, their internal motivation is harnessed and augments their readiness to change.

As a counseling style, MI is client-centered, collaborative, and goal-oriented. That is, the counselor and the client work together to identify and address the client’s specific behavioral goals. In this “dual expertise” approach, the counselor and the client are both viewed as experts who collaborate in the service of the client’s goals and concerns in terms of what is important and possible in the context of their lives. Because the MI counselor recognizes that all clients—on some level—have the desire and wisdom needed to improve their lives and accomplish their personal goals, the counselor’s job is to elicit answers and solutions from clients rather than directing or providing the answers (Rollnick, Miller, & Butler, 2008). Unlike some nondirective counseling styles where counselors continually “stay with” the clients and avoid providing any type of structure or guidance, MI sessions maintain a purpose, goal, and direction as counselors actively select the right moments in which to intervene with incisive strategies. MI specifically avoids argumentative persuasion and instead accepts the validity of the client’s experiences and perspectives. This involves listening to and acknowledging (though not necessarily agreeing with or approving of) a broad range of a client’s concerns, values, preferences, beliefs, emotions, styles, and rationales.

The MI approach embodies both a relational philosophy described as the MI Spirit, or a “way of being,” with another (Miller & Rollnick, 2002) and a set of strategies and methods that are selectively utilized to develop and strengthen motivation. MI elements and strategies can be utilized in two phases. Phase I, typically most useful for clients who are more reluctant or ambivalent about change, incorporates strategies referred to as OARS (i.e., asking Open questions, Affirming, Reflecting, Summarizing) to build rapport, explore ambivalence, and increase readiness to change. While Phase II also incorporates the OARS strategies, they are utilized to strengthen a growing commitment to change and develop plans of action to accomplish change goals. These strategies will be addressed more fully in the MI counseling strategies section.

THE MYTH OF DENIAL

The substance abuse field has long maintained that most clients are resistant, or “in denial,” about their use. We frequently hear that “alcoholics” and “drug addicts” are liars, pathologically defensive, and nearly impossible to work with, and until they “hit rock bottom,” they will not change. As a result, traditional substance abuse interventions are often based on the idea that change is motivated only by the avoidance of negative consequences. This approach suggests that “alcoholics” will not change their drinking behaviors until the external consequences become sufficiently painful and distressing or until their denial is broken by direct confrontation. In contrast, Miller believes that this sort of approach is not only ineffective, but also detrimental to clients. Instead of seeing denial as characteristic of certain types of clients, he contends that denial is actually a reflection of the interpersonal relationship between the counselor and the client. He states:

It takes two to deny . . . If you approach someone by saying, “you’re an alcoholic, and you had better stop drinking,” the natural human response is to deny. If you come to them in a respectful manner that assumes they make choices about their lives and it is in their hands, that they’re smart people who have reasons for what they are doing and also have within them the motivation for change, you get a very different response (as cited in Jones, 2007, p. 34).

As evidenced by Miller’s comments, practitioners of MI maintain that motivation for change is facilitated by exploring and amplifying clients’ intrinsic motivations to move toward positive consequences, behaviors, or goals rather than by confronting them about the need to avoid negative consequences. Because very often people make difficult changes on their own, we believe that although counseling may help facilitate the change process, the motivation to change comes from within the client.

WHAT MOTIVATIONAL INTERVIEWING IS NOT

Upon receiving their first introduction to MI, many people with training in social work, counseling psychology, or other helping professions say, “Oh, that’s what it is—I already use MI in my practice, and I have been using it for years.” In other words, at first blush MI can appear to some to be simply an empathic approach that uses a set of “good listening skills.” While empathy and listening are certainly foundational elements, reaching proficiency in MI—learning to apply its spirit and artful, strategic principles and skills—typically requires practice and feedback over time. Before we explore the various aspects of MI, we will discuss what MI is not.

First, MI is not directive in the traditional sense, which implies confrontation, persuasion, and indoctrination. Instead, the directiveness of MI is exemplified by sessions that are goal-focused as client and counselor explore specific behavioral goals together such as increased sobriety, improved parenting skills, or smoking cessation.

MI is not just being “warm and fuzzy,” empathic, accepting, and genuine. While empathy and acceptance are essential to the practice of MI, this approach also incorporates directive (in the sense of goal-oriented) strategies and methods that are applied in the service of change.

We have also heard more than one counselor say that he or she is going to do MI with their next client. MI is not something that is done to a client; rather, it is both an art and a craft that integrate relational processes with a set of skills and strategies.

In addition, although numerous studies have documented significant behavior changes after a single MI session, MI is not a “snap your fingers” method that is always instantly transformative; instead, we have learned that MI sessions may simply plant a seed that facilitates more distal behavior changes.

MI is also not a hierarchical, top-down approach in which counselors are viewed as experts who dispense wisdom, advice, and solutions. The term interview itself connotes a desire for an egalitarian exchange that acknowledges and respects the right to socially responsible self-determination. In MI, counselors set aside their own goals and timetables and begin where their clients are, by inviting them to explore and set their own goals. In contrast to the counselor being viewed as an authority on the client’s life and choices, the client is seen as a powerful agent who possesses an inherent will and ability to set meaningful goals and work toward their accomplishment. Therefore, rather than giving incentives, setting goals, and providing solutions for a client, the counselor’s task is to elicit and foster those elements from the client. This relational and respective type of dialogue, which is the hallmark of MI, is of utmost importance in developing a strong working alliance with the client (Miller & Rollnick, 2002).

Finally, MI is not something a counselor continues to utilize until the client agrees to submit to changes seen as necessary or desirable by the counselor. In many instances, MI is often a relatively short-term process that utilizes the key component of highlighting discrepancies the client may feel between a current behavior and personal values, goals, and self-concept. As this awareness grows, a client’s sense of agency is enhanced as he or she increasingly feels an ownership and investment in the development of change options and pathways. While this process of empowerment continues to be fostered by evoking the client’s feelings, desires, and solutions for change, the counselor remains respectful and accepting of the client’s choices rather than conveying an expectation that the client needs to and/or must change.

THEORETICAL UNDERPINNINGS OF MOTIVATIONAL INTERVIEWING

The concept of MI, which evolved from experience in the treatment of problem drinkers, was first described by Miller (1983) in an article published in Behavioral Psychotherapy. The fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. MI draws on Festinger’s (1957) concept of cognitive dissonance, Bem’s self-perception theory (1972), the transtheoretical model of change (Prochaska & DiClemente, 1984), and the health belief model (Rosenstock, 1974). While MI has these theories at its roots, Miller explains that MI actually originated as young protégés observed his approach to enhancing clients’ readiness to change in substance abuse treatment. As Miller began to describe to his colleagues what he did in treatment, the conceptual model for MI evolved (MINUET, 1999).

The earliest conception of MI drew heavily on the stages of change (SOC), first identified by Prochaska and DiClemente in the Transtheoretical Approach: Crossing Traditional Boundaries of Therapy (1984). The SOC represent the temporal, motivational aspects of the change process. According to this model, individuals often enter the change process in the precontemplation stage because they are unconvinced that they have a problem or are unwilling to consider change. Individuals who progress to the contemplation stage begin to consider making changes in the distant future. In the preparation stage, individuals have more proximal goals to change and begin to make commitments and develop plans to change. The action stage of change is characterized by individuals changing the target behavior and adopting strategies to prevent relapse. And in the maintenance stage, the change is solidified and integrated into the individual’s general lifestyle.

Clients vary widely in their readiness to change. Some may come to treatment having already decided to change. Others are reluctant or even hostile at the outset. In fact, some precontemplators are coerced into treatment by families, employers, or legal authorities. Most clients, however, are likely to enter the treatment process somewhere in the contemplation st...

Table of contents

• Praise
• Clinician’s Guide to Evidence-Based Practice Series
• Title Page
• Copyright Page
• Introduction
• Preface
• Acknowledgements
• About the Editors
• About the Contributors
• PART 1 - ENGAGING CLIENTS IN TREATMENT AND CHANGE
• PART 2 - ADOLESCENTS
• PART 3 - FAMILIES
• PART 4 - ADULTS
• Afterword
• APPENDIX A - Research Providing the Evidence Base for the Interventions in this Book
• APPENDIX B - The Evidence-Based Practice Process
• Author Index
• Subject Index