TCPR: Hello Dr. Miller. You have developed a method of working with people with substance abuse called motivational interviewing. Please tell us what it’s all about.
Dr. Miller: Motivational interviewing is really a way of talking to people that calls forth their own motivations for change. Instead of telling them that they need to change, it’s a way of encouraging them to want to change.
TCPR: I’d say the goal of most therapists and psychiatrists is to help people with substance abuse problems change. So how is this different from the usual way we work with addicts?
Dr. Miller: Most of us got into this field to help people, but it doesn’t come naturally to let people help themselves. My research partner Steve Rollnick and I have written about the “righting reflex.” That is, the desire to set things right and put people on the right path. Essentially this is telling them what to do. The problem with it is that a lot of people are ambivalent about their addictions. So when you take up one side of an argument—saying, “You have to change,” they instinctively take up the other side of the argument—“No I don’t.”
TCPR: So an example of the usual way of talking to an addict would be if a patient who is an alcoholic comes into the office, saying to him: “Look John, you have a real problem. You are killing yourself. You need to stop this and I am going to help you stop it. You need to go to AA meetings,” et cetera?
Dr. Miller: Right. You’re doing this with the best of intentions. You are trying to set this person on the right path. But what happens is that you activate within that person the opposite argument. If you behave in a way that causes a person to argue against the change, they can actually talk themselves out of it.
TCPR: How did you come up with motivational interviewing?
Dr. Miller: I sort of came about it organically while I was working with a group of young psychologists in an alcohol clinic in Norway. During role-plays, they kept asking me why I would ask a question this way, or why I reflected this instead of that. So I wrote down some decision rules that I seemed to be using and sent the discussion paper around to some of my colleagues. It was published in the British journal Behavioural Psychotherapy as a clinical piece, and I thought that was the last I’d hear about it. Instead, it took off like a rocket, and out of sheer embarrassment, I had to begin doing research.
TCPR: And that research proved that it worked?
Dr. Miller: Well, there are a number of metaanalyses out there now and the results are pretty strong. The effect size is in the small to medium range on average, but highly significant (Lundahl B et al., J Clin Psychology 2009;65(11):1232–1245). There are also quite a few trials in the type of setting some of your readers work in—psychiatric settings with patients with dual diagnoses of a major mental disorder and substance abuse. These trials, too, are showing the same nice effects that we see in other populations (Burke B et al., J Consulting and Clin Psychology 2003;71(5):843–861; Rubak S et al., British Journal of Gen Practice 2005;55:305–312).
TCPR:While I know it takes a long time to master motivational interviewing, can you give us some tips to apply it to our practice now?
Dr. Miller: There are three elements to the underlying spirit of motivational interviewing. The first is collaboration—the doctor/therapist and the patient are working together. The second is evocation—calling forth patients’ own motivation to change, rather than installing motivation in them. And the third is respect for patients’ autonomy—which means truly knowing that they get to make the choices about their own lives. Without this mindset, you’re not likely to be successful with this method.
TCPR: Let’s take my hypothetical patient, John. I’m thinking that since he is coming to see me, he wants to get over his drinking problem. How might I use motivational interviewing to help him?
Dr. Miller: What you should be doing is arranging a conversation in a way that causes him to make the arguments for change. Think about it like this: there is a continuum of clinical styles. At one end is directing, or telling a patient precisely what to do, which is sometimes very appropriate in medicine. At the other end is listening, which is a classic supportive client-centered approach. Somewhere in the middle is motivational interviewing—a style Dr. Rollnick and I call “guiding.” I need to initiate a conversation that will get John, and not me, to argue for quitting drinking—why he should do it, how to go about it, why it is important.
TCPR: How do I get that kind of conversation going?
Dr. Miller: Most simply, you ask open questions, the answers to which are what we call “change-talk.” Change-talk is anything a patient says that’s moving him in the direction of change. There are five questions that can get a person on the path to change. The first four fall into what we call the preparatory category, and the last one is action-oriented and indicates the commitment phase of this process toward change.
TCPR:What are the questions?
Dr. Miller: You can remember the first four with the acronym DARN; for desire, ability, reason and need. The last question is all about committing to the change. The first question is, “Why would you want to make this change?” Everybody wants something. Maybe they want to lose weight, get healthy, live to see their grandchildren. The second question is, “How could you do it in order to succeed?” The person needs to perceive that he or she can actually make the change. The third question is, “What are the three best reasons to change?” This is different from the desire question in that it’s asking for concrete reasons. For example, “My doctor said I am going to get liver cirrhosis if I don’t stop drinking.” The fourth question relates to need: “On a scale from 0 to 10, where 0 is not at all important and 10 is most important, how important is it for you to make this change?” When they give you the number, you then ask, “Why are you at that number and not 0?” It’s helpful to give back to the person a short summary of what they’ve said about their motivations for change. And then there’s a fifth question, which is the action one, “So what do you think you’ll do?” A psycholinguist who works with us found that commitment language is the best predictor of behavior change.
TCPR: Now what happens when you go through this whole process and you determine that your patient is not motivated to make significant change?
Dr. Miller: That’s the autonomy piece of it. That has to be okay. That doesn’t mean that you don’t have any advice for that person or that you can’t voice your concern. You can say, “I am rooting for you to make this change because it will have a huge impact on your life, but it is really up to you.” You can leave the door open and continue to elicit change-talk. Often the change is happening under the surface even if you don’t really see it.
TCPR: Are they any particular books or training methods you can recommend that can help psychiatrists to learn more about this technique?
Dr. Miller: “Motivational Interviewing in Healthcare,” by Steve Rollnick et al., is written specifically for doctors, nurses, PAs, and others whose contact is brief. I would say find a good motivational interviewer in your area and have him or her coach you. You will need to record your sessions, so they can hear exactly what is going on and pick up on opportunities that you may miss. Using just written notes to coach on this method is like teaching someone the piano without hearing them play.
TCPR: Thank you Dr. Miller.