Motivational Interviewing for Substance Abuse: Does It Work?

Last Updated: October 5, 2021

Authored by Nena Messina, Ph.D.

Reviewed by Michael Espelin APRN

Many addicted people lack the motivation to change as they don’t find their substance abuse issue quite serious or fear the consequences of ceasing substance use. Motivational Interviewing is designed to help clients build motivation for addiction treatment. This post discusses motivational interviewing for substance abuse in detail, its underlying principles and techniques, and how individuals can benefit from it.

What is Motivational Interviewing?

Motivational interviewing (MI) is a collaborative and person-centered psychotherapeutic approach that attempts to help clients explore and overcome ambivalence about changing negative behaviors. It is a counseling style that clinicians use to enable clients to identify their behavior, which puts their health in jeopardy and influences them to make changes. It is often used in conjunction with other therapies, such as cognitive-behavioral therapy (CBT), and has proven to encourage patients with substance use disorders.

In 1983, MI was first introduced by clinical psychologists William R. Miller and Stephen Rollnick to treat alcohol addiction.

The Basic Five Principles of MI Outlined by the Founders That the Interviewers Work to Uphold During Treatment Are:

  1. Express empathy
  2. Develop discrepancy
  3. Avoid arguments
  4. Adjust to resistance
  5. Support self-efficacy

These principles were also adopted by motivational enhancement (MET therapy).

In 2008, Miller and Rollnick further simplified the motivational interviewing principles for their application to other healthcare settings. The principles are symbolized by the RULE acronym, where R is for the resistance of the righting reflex, U is for understanding the individual’s motivations, L is for listening with empathy, and E is for empowering the patient. RULE is based on the exact principles of MI for substance abusers. Healthcare professionals should recognize motivations, use empathy, and empower an individual to select the right path.

MI Is Based on the Following Five Assumptions:

  1. Motivation is a condition, not a characteristic.
  2. Resistance is a sign that strategies need to be changed.
  3. Uncertainty is good.
  4. Clients should be the partner instead of being the antagonist.
  5. Recover and growth are inherent to human experience.

How Does It Work?

MI is quite a simple process that can be completed in a number of sessions. It is a collection of steps that entails carefully listening to the client’s issues or concerns, understanding the habits that the client desires to change, evoking the client’s motivation for change, and developing a series of steps that the client can use for the implementation of the desired changes.

Therapist explains something to a patient at a motivational interviewing session.

This model works best with increased empathy, reflective listening, and a strong connection between the client and therapist.

Motivational Interviewing for Substance Abuse

Addiction can be considered a progressive condition that causes people to abuse certain substances (drugs, alcohol, etc.) despite worsening consequences of that use on health and other life aspects. Millions of people with SUD do not seek treatment in the US because their motivation to change their substance use behaviors is low. Apart from needing long-term care and pharmacotherapy, addiction treatment also needs additional motivation that comes through MI.

Motivational Interviewing for substance abuse encourages patients to think and talk about their reasons to reduce or quit a substance they use. With the various motivational interviewing techniques, this approach increases a person’s willingness to change behaviors around substance abuse while strengthening life skills and supporting other therapy programs. It might occur on a one-to-one or group basis, depending on the needs of the individual.

Motivational Interviewing Principles

During the treatment, the clinicians need to hold to the following motivational interviewing principles:

  • R: Resist the righting reflex. Urging the patient to do something beneficial can have a paradoxical effect in practice. Many people resist persuasion if they are ambivalent about change and respond by recalling their reasons to maintain that unhealthy behavior. Therefore, MI in practice needs the addiction counselor to resist the initial righting reflex to explore the patient’s motivation for change.
  • U: Understand the patient’s motivations. It’s the client’s reasons for change and not the practitioner’s that will elicit any change in the behavior. Therefore, the practitioner should understand and curiously explore the patient’s thoughts, interests, and values and attempt to trigger their underlying motivation for change to begin new healthy behaviors.
  • L: Listen to the patient. MI involves active listening to understand what can motivate the patients and the positives and negatives of their situation. The practitioner needs to listen with a patient-focused, empathetic approach. It involves repeating what the client has shared and attempting to see the situation from the client’s perspective without being judgmental.
  • E: Empower the patient. Outcomes are even better when the patients actively participate in their treatment. Empowering patients involves helping clients explore that they can make a difference in their own health and well-being, drawing attention to past successes, and eliciting strengths, not weaknesses.

In addition, the founders of MI formulated four fundamental processes to help clients identify their objectives and start working towards them.

The Four Main Processes of MI Are as Follows:

Engaging

In this process, the therapist focuses on developing rapport with clients, decreasing their defensiveness, and resolving the ambivalence regarding the recovery process.

Focusing

This process is about developing a single focus to discuss among many potential issues on the agenda. The process focuses on finding a clear direction and objective when it might not be evident from the outset.

Evoking

This process involves eliciting the client’s own motivations for change. Addressing and bringing out the patient’s motivations for recovery is the most critical aspect of MI. This is how the ambivalence is initially explored and then resolved.

Planning

It is an important process of MI in which the patient learns different coping mechanisms and how to make new healthy behaviors and measure success.

Woman writing something in a notebook.

OARS Motivational Interviewing

Also called micro counseling skills, OARS motivational interviewing is the set of interpersonal communication skills that support the process of eliciting change talk. The founders of MI introduced OARS motivational interviewing to the third edition Motivational Interviewing: Helping People Change (2013).

The Detail of These Motivational Interviewing Steps Is Described Below:

  • O: Open-ended questions encourage further collaboration and consideration. Practitioners employ motivational interviewing questions to elicit the client’s history, perspectives, and values. This technique encourages clients to talk freely and gives them control of the session as the therapist follows the lead
  • A: Affirmations are statements of appreciation that recognize the clients’ strengths and acknowledge their positive behaviors towards recovery. When done right, affirmations help build the client’s sense of power and self-confidence. Therefore, affirmations are a core component in facilitating the MI principle of supporting self-efficacy.
  • R: Reflections are the core skill of MI which involves the interviewer showing empathy and understanding to the client. Reflective listening is carried out by repeating or rephrasing what the client has said to build engagement and support the client in reducing the ambivalence.
  • S: Summaries are a different kind of reflection where the MI therapist recaps everything discussed during the counseling session(s). It calls attention to essential elements of the discussion, checks in with the client, and ensures mutual understanding. Effective summarizing helps clients realize their own change talk. Research has shown a clear connection between client statements about change and positive outcomes.

Motivational Interviewing Techniques

To achieve the target, different motivational interviewing steps and techniques are used, which are at the discretion of the counselor and the patient’s needs and anticipated change. Motivational Interviewing techniques used by the therapists include:

Battling Resistance

The therapist asks relevant motivational interviewing questions from patients to understand what factors resist change and encourages them to find other solutions to their problems and overcome the resistance they have developed against change.

Advice Offering

MI therapists provide people with choices without being judgmental. Patients get options and freedom to choose from them so that they feel comfortable. Lastly, the therapist takes feedback to get an idea of the patient’s perception and if the patient will take the advice.

Columbo Approach

It is used to rationalize any discrepancies patients might have about the changes they are supposed to make. Therapists ask questions to find out the reason which is hindering the process of change, rephrase the information in a non-judgmental manner, and ask the patient to reflect on it.

Who Benefits from MI

MI is a collaborative counseling method that has been shown to be efficacious for addiction treatment. Research studies have shown that alcohol addicts tend to be more ambivalent regarding their addiction due to the increased social acceptance and the legality of alcohol use. The benefits of MI are not only limited to alcohol addiction. This technique has also proven to be effective for individuals struggling with other substance and non-substance addictions and mental illnesses.

These Include:

Is It Effective?

Many studies have examined the effectiveness of MI in decreasing alcohol and drug use and smoking cessation when used in conjunction with other therapeutic approaches. According to one study, MI should be considered as a part of treatment for adolescent substance abuse. In addition, a clinical review found a decrease in substance abuse, together with retention in treatment and motivation to change.

How to Get Started

MI works best for individuals who are at the precontemplation stage of the Transtheoretical model and have mixed feelings about changing their behavior. To get started, find a licensed MI counselor with formal training and experience and who is empathetic, as well as a good listener. Though this approach has helped many addicted people draw out the intrinsic motivation to get on the recovery path, it is not an ideal treatment course for all patients with substance use disorders. Every individual may require different types of therapy that will work for them. They can range from standard behavioral therapies to biofeedback, contingency management interventions, or even getting support from a peer recovery coach.

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Page Sources

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Published on: October 5th, 2021

Updated on: October 5th, 2021

About Author

Nena Messina, Ph.D.

Nena Messina is a specialist in drug-related domestic violence. She devoted her life to the study of the connection between crime, mental health, and substance abuse. Apart from her work as management at addiction center, Nena regularly takes part in the educational program as a lecturer.

Medically Reviewed by

Michael Espelin APRN

8 years of nursing experience in wide variety of behavioral and addition settings that include adult inpatient and outpatient mental health services with substance use disorders, and geriatric long-term care and hospice care.  He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture.