The Joys of Using Motivational Interviewing in Therapy

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A colleague recently consulted me about one of her patients who was struggling with alcohol. The patient was on the fence about whether or not she really had a problem, whereas the therapist believed her continued use of alcohol was likely a major barrier to her recovery from anxiety. My colleague was not well-versed in treating addictions and was calling me because of my background in addictions and my motivational interviewing (MI) experience as a therapist and trainer. Honored she had reached out, I called her right back and we talked. After, she told me that what I had offered her was incredibly helpful. I thought that I’d share a few take-home messages from that conversation here.

Sometimes allying (just a little) with the desire to use can be the key to setting someone free

“At one of our sessions (my patient) confessed that she had had a few drinks the prior week, even though she had promised to stop,” my colleague told me, after presenting the case. “When she did, she gave me a look and a naughty smile, and I think I smiled back in a way that indicated that I was colluding with her drinking. Do you think I might have set her off on a binge the subsequent week?”

I reassured her heartily, and said no, in my opinion, it was very unlikely her look was the cause of the patient’s ensuing drinking, even if the patient had interpreted her smile as a support of her recent use. In fact, I told her it might even have been helpful, in the long run.

MI is an evidence-based therapy that helps patients resolve ambivalence about changing a behavior, like reducing or stopping drinking. According to MI principles, when a patient is backtracking in relation to a change they are considering, the therapist should "roll with resistance," remaining neutral and asking for clarification, rather than engaging in a fruitless battle. It’s human nature: tell anyone to stop doing something and they will just want to do it even more. No matter where a patient is in relation to the issue at hand, their feelings, thoughts, and values should be driving the ship, not the provider.

In my own experience, allying, just a little, with someone’s substance-using side from time to time—especially if they are on the fence—can crack the ice, like magic. Obviously, I’m not advocating we full-on endorse someone going back to using. But empathizing with the reasons why someone might find it hard to give up, and asking them to explore those with you, out loud, can help them feel safe, and make room for exploring the downsides of use, too, without fear of being pushed too fast. I’ve seen time and again how much we can trust the process: patients find their way to their own truths, in their own time.

We are not responsible for the decisions our patients make around substance use

“On the other hand,” my colleague continued, “I think I was too forceful towards the patient (during an earlier visit). I might have asked her to seek more formal alcohol treatment too soon. Because when I did, she seemed to shut down. Do you think I set her back?”

I smiled to myself, recognizing my colleague’s self-doubt as something oh so familiar; it’s how I feel when I treat a patient outside of my comfort zone. But the reality was, my colleague was probably doing just fine. Sure, maybe she had gone a little too far, evoking resistance in that moment. But that kind of energy was easily fixable with a small step back (MI trainers often use a dance-partner analogy to define the relationship between therapist and patient). And I reflected that idea back to her.

Not only that, but it struck me that she was taking on a lot of responsibility for her patient’s drinking behaviors. MI is collaborative and patient-centered above all else. Its core aim is to empower the patient to make the decisions that are best for them, putting behavior change in their hands. In fact, it’s recommended to be overt about this with patients. Statements like, “I'm here to help explore yourself and your relationship with (alcohol) and what you do is completely up to you,” can go a long way.

The more a therapist believes this, instead of just saying it, the better off they will be. For me, learning MI has had a profound impact on my ability to enjoy my job, in large part because, in my core, I know that whether a patient takes that final step is not up to me, in the end. I'm just there to help them shed a light on themselves so they can choose the path that is best for them.

When all else fails, we can always fall back on reflections

My colleague breathed a sigh of relief when I suggested she might be taking on too much responsibility for her patient’s last drinking binge. Next, I reminded her that even though she felt relatively inexperienced in addictions, she was likely already doing loads of great things for her patient, by virtue of the fact she was a seasoned, empathetic therapist, well-versed in active listening. That seemed to make her feel better, too.

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One of the core MI skills is reflective listening. After a patient speaks, the MI provider is encouraged to reflect back to the patient what they heard them say, usually content or emotions. Learning to do reflections can be a bit awkward at first (especially for those of us who started as physicians, and were taught only how to ask questions and diagnose). But once internalized, reflecting feels as natural as breathing.

And it's a hugely effective therapeutic intervention. If we get it right, the patient feels heard. If we get it wrong, they get a chance to correct us. Either way, hearing their own truths repeated in the words of someone else—especially in regard to the ways use a substance might be crippling them—can be a profound catalyst of behavior change.

Once I started reflecting ubiquitously, my relationships with patients changed dramatically, too. “You’re the only doctor that’s ever listened and truly understood me,” I’ve heard numerous times. I know that this isn’t true—lots of providers listen much better than I do—but what is true is that the patient actually knows that I’m listening. Without reflections, they feel like their words float off into the ether.

In conclusion

For those of you who are scared of working with addictions—don’t be. Sure, there are safety issues, and, usually, it’s not a quick fix. But MI makes working with this group of people amazingly satisfying and fun—if you haven't had a training, I highly recommend it. When people do make a change and get clean, and their lives begin to heal and it's a joy to ride along with them. And remember: the patient will teach you what they need.