Motivational Interviewing

A Discussion of Evidence Based Practice

By

Danelle Chambers
1/1/2013

Word Count: 1640

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Motivational Interviewing

Introduction This document has at least two purposes. The first of these purposes is to establish the theoretical framework for Motivational Interviewing (MI). Another purpose is to examine the relevant evidence base of MI in relation to the authors practise setting. MI is an approach to counselling, which was developed in the early 1980s (Miller & Rollnick, 2002). The approaches and fundamental concepts were described in the1990s. This approach to counselling involves a semi-directive interview which helps clients discover their ambivalence to change and take action to improve their situation. The initial use of the approach was with individuals suffering from addictions, but it has since been used for a wide variety of other problems (Lundahl & Burke, 2009). The approach works by helping clients come into touch with their intrinsic motivations to change. In this respect, the approach has an underlying theory of cognitive dissonance, which will be described later in this paper. According to MI, clients may seek out treatment when they are at different levels of discomfort (Miller & Rose, 2009). This leads to people having various levels of being ready to change. Despite the differences in stages of addiction, the therapist using MI will need to do reflective listening, provide affirmations, and ask questions, which are open-ended (Lundahl et al., 2010). The remainder of this document will explore the theoretical framework of MI. There will then be a discussion of the evidence base for this approach when treating addictions. This is followed by a discussion on the use of MI at the author's current practise setting and experiences in with this approach. The final section is composed of the conclusions and recommendations regarding the use of MI for individuals suffering from addictions.

Theoretical Framework MI was not originally founded on theory. Instead, it was based on an unexpected finding by Miller, Taylor, & West (1980). Miller trained counselors in the use of accurate empathy and behavioural self-control training. Following the certification process, the counselors were observed by supervisors. They were rated on their ability to exhibit empathy when delivering the behaviour therapy. It was discovered that approximately 66% of the variance in drinking behaviour six months after the treatment was due to the therapist empathy. It was further discovered that the empathy of the counselors accounted for significantly more variance in outcomes than the type of treatment they delivered (Miller, Taylor & West, 1980).

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With this background, it is not surprising that MI is loosely based on Rogers client-centred approach to treatment (Rogers, 1946). With the client-centred approach to treatment, the therapist provides an environment in which the client can become aware of how their feelings, attitudes, and behaviours are negatively affecting their lives. This environment is created when the essential conditions for change are present. These conditions are accurate empathy, unconditional positive regard by the therapist for the client, genuineness of the therapist, the client feeling as though the therapist is sincere, client vulnerability to anxiety, and a trusting relationship between the therapist and client. In general, these conditions must also be present for MI. The consequence of empathy being expressed by the therapist is particularly important for MI (Miller & Rollnick, 2002). Another basis for MI is cognitive dissonance theory (Festinger, 2010). According to this theory, it is uncomfortable for individuals to hold cognitions, which are conflicting. These cognitions can be emotional reactions, values, beliefs, or ideas. Individuals who are experiencing dissonance may suffer from anxiety, embarrassment, anger, guilt, or dread. A therapist using MI may take advantage of cognitive dissonance by helping a client realise that their life is not now how they wish to be. Their lives may also be at odds with their beliefs (Miller & Rollnick, 2002). Self-perception theory (Bern, 1972) is also part of MI. According to this theory, people have attitudes, which have been developed through observations of their own behaviour. The person then makes conclusions regarding the attitudes which caused the behaviour. With MI, the therapist helps the client embrace their behaviour and move toward a more desired goal. Part of this involves the client observing their own behaviour. This can be aided by the therapist asking the client to interpret the behaviour which they have reported (Lundahl & Burke, 2009).

Evidence Base for Treatment of Addictions Recently, a review was done of four meta-analyses, which looked at the evidence base for using MI to treat addictions (Lundahl & Burke, 2009). These authors point out that MI is both a philosophy of treatment and several methods, which can be employed for assisting people in enhancement of their intrinsic motivation for change. It also can help people explore and resolve any ambivalence they may have toward behavioural change. MI is now used in a variety of treatment environments, including public health, medicine, psychotherapy, and addiction treatment (Lundahl & Burke, 2009). It was discovered that there is a growing amount of research, which examines MI as a type of treatment (Lundahl & Burke, 2009). An Internet search for evidence-based effectiveness articles on MI between 1980 and 1989 revealed only six studies. The same search for MI between 1990 and 1999 revealed 78 articles. However, from 2000 until 2009, there were more than 700 articles regarding MI and its evidence of effectiveness. This burgeoning amount of
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data can assist in making judgements regarding the evidence-based effectiveness for MI in treating a variety of conditions (Lundahl & Burke, 2009). Overall, MI is more effective than no intervention for the treatment of a wide variety of addictions (Lundahl & Burke, 2009). For some types of addictions, it has been shown to be superior to other types of treatment. For marijuana dependence, MI was found to be significantly better than no treatment and at least as effective as other types of treatments. The same types of results were found for tobacco. The treatment effects of MI were especially strong for addictions related to alcohol, hair one, and cocaine (Lundahl & Burke, 2009). A meta-analysis (Lundahl et al., 2010) was done, which assessed the effectiveness of MI as compared with other studies over the past 25 years. The findings of this meta-analysis were similar to those of the review article (Lundahl & Burke, 2009) of for meta-analyses previously discussed. It was discovered that MI was substantially better than the new treatment control group for all conditions tested including a wide range of addictions. The effectiveness of MI for treating conditions such as addiction to tobacco, marijuana, alcohol, and other drugs of abuse was similar to that of well accepted treatments. As well, the use of MI for addiction to gambling was superior to any other treatment examined. This is an important consideration for individuals suffering from this type of addiction (Lundahl et al., 2010).

Use at Open Road An important part of any clinician's training is their experience in using different types of treatments (Miller & Rollnick, 2002). I am presently working as a recovery worker at Open Road Recovery Centre in the United Kingdom. Open Road is a treatment centre who helps communities, families, and individuals toward recovery from addictions (Home, 2011). The centre uses a wide range of treatment options for helping individuals with addictions. Treatments include structured recovery, the needle syringe programme, family support, counselling, body therapy, behavioural couples therapy, and access to nature. I have been involved with the counselling programme (Counselling, 2011). As a counsellor at Open Road, are allowed to use different types of treatment protocols. I have used MI for individuals suffering from a wide range of addictions. Like the evidence-based, studies indicate; MI has been successful for a variety of client problems. These have included addictions to alcohol in a wide range of other substances. A significant finding is that MI tends to lead to fewer patients dropping out of counseling. While no statistical analysis has been done, the tendency appears relatively clear with fewer MI clients leaving treatment before it is complete. This is especially important since the substance abuse group can be particularly difficult to maintain in treatment. It should be made clear that this finding is not likely to be completely due to the effectiveness of MI. Instead, there may be an interaction between MI and the counsellor. Since I am comfortable using MI, this most likely
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has a positive effect on treatment outcomes and the completion of therapy by the client. The client might sense that the counsellor is relaxed using this approach. When the client perceives the counsellor as being composed, they can be calm and benefit from the therapeutic experience (Rogers, 1946). Conclusion and Recommendations While MI was not originally based upon theory, it has proven to be supportable by several frameworks. The approach takes advantage of the importance of empathy in a similar fashion to that proposed in the client-centred approach to treatment developed by Rogers (Rogers, 1946). When using MI, it is crucial that the counselor exhibit empathy toward the client. Another theoretical framework which is in line with MI is cognitive dissonance (Festinger, 2010). MI takes advantage of the discomfort that many clients feel from having beliefs, ideas, or goals, which are not aligned with their behaviour. The therapist takes advantage of the situation by pointing this out to the client and the resulting discomfort often helps the client move toward a positive change. Asking the client to observe their own behaviour in this process involves some of the underpinnings of self-perception theory (Bern, 1972). There is a significant amount of evidence that MI can be used as an effective treatment for a wide range of addictions (Miller & Rollnick, 2002). It has been experienced that MI is not only an efficacious treatment, but tends to lead to fewer early discontinuations of treatment. This is an important factor when assisting individuals with addictions. Overall, MI appears to be an excellent choice for helping individuals suffering from addictions.

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References

Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist; American Psychologist, 64(6), 527. Lundahl, B., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a practicefriendly review of four metaanalyses. Journal of Clinical Psychology, 65(11), 1232-1245. Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160. Miller, W. R., Taylor, C. A., & West, J. C. (1980). Focused versus broad-spectrum behavior therapy for problem drinkers. Journal of Consulting and Clinical Psychology; Journal of Consulting and Clinical Psychology, 48(5), 590. Rogers, C. R. (1946). Significant aspects of client-centered therapy. American Psychologist, 1(10), 415-422. Festinger, L. (2010). Cognitive dissonance theory. in R. West and LH Turner Eds. Introducing communication Theory Analysis and Application, 4, 112-128. Bern, D. J. (1972) Self-perception theory. In L. Berkowitz Ed.), Advances in experimental social psychology (Vol. 6). New York: Academic Press, 1972. Miller, W. R., & Rollnick, S. P. (2002). Motivational interviewing: Preparing people for change. The Guilford Press. Counselling (2011). Open road. Retrieved January 10th, 2013, from http://openroad.org.uk/what_we_do/counselling/ Home (2011). Open road. Retrieved January 10th 2013, from http://openroad.org.uk/