Abstract and Keywords
Motivational interviewing (MI) is a collaborative, goal-oriented conversation style designed to strengthen intrinsic motivation for and commitment to change. The spirit of MI includes four elements: partnership, acceptance, compassion, and evocation. MI is often employed as a therapeutic intervention, and it clinical effectiveness is well documented across more than 200 randomized controlled trials. Research has also documented wide variation in MI effectiveness across counselors, studies, and sites within studies.
Motivational interviewing (MI) and other brief motivational interventions have gained considerable popularity as alternative or adjunctive approaches to more traditional psychotherapeutic approaches designed to produce behavior change among clients (Ryder, 1999; Walitzer, Dermen, & Connors, 1999; Yahne & Miller, 1999). As of 2013, there are more than 1,200 publications, including more than 200 randomized controlled trials, about MI (Miller & Rollnick, 2013). While initially used with addictive-behavior problems, such interventions have been implemented with success for a variety of behaviors ranging from diabetes self-management (Doherty, Hall, James, Roberts, & Simpson, 2000) to water disinfection practices (Thevos, Quick, & Yanduli, 2000) to treatment adherence among psychiatric patients (Swanson, Pantalon, & Cohen, 1999) to fruit and vegetable intake (Resnicow et al., 2001).
The empirical literature has demonstrated the effectiveness of brief motivational interventions with substance-abusing populations (Burke, Arkowitz, & Mechola, 2003; DiClemente, Bellino, & Neavins, 1999; Miller, Andrews, Wilbourne, & Bennett, 1998; Vasilaki, Hosier, & Cox, 2006). In a meta-analysis of controlled clinical trials of the briefest form of motivational interventions, motivational interviewing (MI), for drinking problems, Vasilaki et al. (2006) concluded “that brief MI is an efficacious strategy for reducing alcohol consumption.” In a broader meta-analysis, Burke et al. (2003) included studies targeting marijuana and other drug-use problems. These researchers concluded that motivational interviewing was “equivalent to other active treatments and superior to no treatment or placebo controls for problems involving alcohol [or] drugs” (p. 856). Moreover, these investigators documented an average within-treatment-group effect size of 0.82, with MI treatment assignment accounting for a remarkable 48% of the variance in outcomes among marijuana and other drug abusers. Moreover, MI effects were found to generalize beyond substance-use behaviors. Burke, Arkowitz, and Dunn (2002) found a treatment-group effect size of 0.90 for social impact outcomes for marijuana and other drug abusers. Thus, there is strong support for considering MI-interventions to be “empirically supported therapies” (ESTs), which are defined by Hall (2001) as “treatments that have been demonstrated to be superior in efficacy to a placebo or another treatment” (p. 503).
Miller and Rollnick (2013) characterize MI as “a person-centered counseling style for addressing the common problem of ambivalence about change” (p. 24). The underlying spirit of MI includes four key elements: partnership, acceptance, compassion, and evocation. Acceptance is critical for engaging clients and building a working therapeutic relationship, and it includes the four key aspects: absolute worth, accurate empathy, autonomy support, and affirmation. In contrast to traditional approaches, motivational interventions are intended, through support and persuasion, to increase the likelihood that people will make changes in their behavior by helping them to recognize that problems exist in their lives and to overcome ambivalence about change. This directive, client-centered counseling style has as an overarching goal of pinpointing and magnifying discrepancies between client goals and current behavior, and thus increasing ambivalence. Ambivalence is expressed through clients’ change talk (pro-change arguments) and sustain talk (pro-status quo, anti-change arguments), and is considered a normal human process on the pathway to change. Change talk, which MI is designed to promote, is captured by the acronym DARN-CAT; when preparing to make changes, change talk is evidenced by statements expressing: desire, ability, reasons, and need; when mobilizing for change, change talk is evidenced by statements expressing commitment, activation, and taking steps.
Interventions and Techniques
Core therapeutic skills in MI are represented by the acronym OARS: asking open-ended questions, affirming, reflecting, and summarizing. Providing information and advice may also be part of MI, but only with the client’s permission. Therapeutic applications of MI typically involve four sequential processes: (a) engaging, in which both parties establish a helpful connection and a working relationship; (b) focusing, which involves clarifying direction and identifying the agenda; (c) evoking, which involves eliciting the client’s own motivations for change and having the client voice the arguments for change; and (d) planning, in which commitment to change is supported and expanded, and a specific plan of action is formulated. In clinical practice, MI can be used in individual face-to-face consultation, or with couples, families, or groups. Moreover, there is empirical support for its effective delivery via telephone, televideo, computer, and print. Finally, MI has been adapted for use across a variety of cultures and special populations, and it can be implemented as a stand-alone treatment or a component of a larger, integrated-treatment package.
Effectiveness with Adolescents
A growing empirical literature supports the effectiveness of motivational interviewing (MI) with adolescent marijuana users and drinkers (Naar-King & Suarez, 2011). Published reports of randomized controlled trials (RCTs) of MI with adolescent marijuana users (for example, D’Amico, Miles, Stern, & Meredith, 2008; Martin, Copeland, & Swift, 2005; McCambridge & Strang, 2004, 2005; Stein et al., 2006; Walker, Roffman, Stephens, Berghuis, & Kim, 2006) and underage drinkers (for example, Borsari & Carey, 2000; Larimer et al., 2001; Marlatt et al., 1998; Monti et al., 1999; Roberts, Neal, Kivlahan, Baer, & Marlatt, 2000) support its effectiveness for reducing adolescent substance-use problems.
Thus, motivational interviewing, when used with late adolescent drinkers, meets Hall's (2001) criterion for an empirically supported therapy (that is, superior in efficacy to a placebo or another treatment). Across these clinical trials, treatment effects were independent of putative moderator variables including gender, parental history of alcoholism, history of conduct disorder, and stage of change. It should be noted, however, that each study involved predominantly non-Hispanic white youths (80%+), and included only older adolescents. To address these limitations, NIH, in the early 2010s, began supporting major clinical trials examining the efficacy of MI with younger and more diverse adolescent drinkers and drug users (for example, in 2012, NIDA grant R01 DA029779 [Co-PI’s: E.F. Wagner & J. Lowe] examined the impact of MI on drinking and drug use among Native American 9th–12th graders).
Interest in MI has burgeoned since the 1990s, and many social workers and most addiction-treatment clinicians were, 20 years later, at least somewhat familiar with the approach. Certification in MI, both as a practitioner and a trainer, is available, and theoretical and empirical publications on the approach have been widely disseminated. MI may be particularly appealing to social workers because it is consistent with harm-reduction approaches to addictive behaviors. Harm reduction has been conceptualized as a peace movement, and it is aligned with the humanistic values around which social work is organized (Brocato & Wagner, 2003). MI specifically, and harm reduction approaches generally, may reduce the ethical conflicts confronted by social workers conducting more traditional and coercive interventions for substance-use problems. Moreover, MI is strongly consistent with strengths-based practice in social work; as such, MI has been identified as having important implications for social work research, practice, and education (Manthey, Knowles, Asher, & Wahab, 2011).
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Motivational Interviewing: http://www.motivationalinterview.org/
Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov/co-occurring/topics/training/motivational.aspx
Motivational Interviewing Network of Trainers (MINT): http://www.motivationalinterviewing.org/