History
In the past 50 years, many confrontational psychodynamic approaches became popular and almost the expectation of substance abuse and addiction treatment. There was the idea that substance abuse was a symptom of an underlying disorder (Weegmann, 2002). Once the disorder was treated, the secondary substance abuse would clear up on its own. As Weegmann discussed, research has shown that highly confrontational methods often instilled an ever deeper sense of resistance in the client. The percentage of successful outcomes within the field of addiction have been tossed around and range a great deal, however they have always seemed pretty dismal in comparison to the length and cost of many treatment programs. A new approach is necessary and an approach that is more accessible to those in need of it would be highly valuable in the field.
Motivational
Addiction and Substance Abuse
According to Miller (1998), addiction can be described within two conditions: (1) a behavior that persists even though there is apparent risk or harm to oneself or others and (2) to an outside observer the individual demonstrates diminished, but retrievable, capacity for self-regulation of the behavior. Miller also discusses "symptoms" of addiction which include: giving inordinate priority to the addictive behavior; avoidance of situations where the behavior is inaccessible; and giving a high priority to the behavior after a period of abstinence, among others. Miller suggests that the problem of addiction is simply competing motivations. Motivation for the behavior currently outweighs the harm and perceived value of available alternatives to that behavior.
So how does an addicted individual escape addiction? Miller (1998) argues that there can be a sudden shift in how the person perceives the pros and cons of their behavior. This is often seen over time as the suffering directly attached to the addiction increases and the ratio of pros and cons shifts. Through motivational interviewing, Miller suggests that therapists and other helping professionals can lend clients another perspective, a mirror image of themselves, so as to increase the client's conception of the consequences and saliency of their behavior.
Adolescence and Young Adulthood
Within efforts to utilize motivational interviewing within adolescence, motivational interviewing offers several advantages over other treatment options. According to one article (Tevyaw & Monti, 2004), motivational enhancement and other brief interventions have the highest effect sizes among all treatments for alcohol abuse and dependence and evidence similar efficacy rates. Motivational techniques also provide a more flexible continuum of treatment ranging from abstinence to harm reduction within cases where abstinence is not necessary, which is often the case with adolescents with short histories of substance abuse (Tevyaw & Monti, 2004). Adolescents also often end up in a treatment setting due to a decision made by an authority figure such as their parents or the justice system and concerns are often not shared by the adolescent. They are often characterized by resistance to change and a lack of understanding of the consequences of their behavior. Motivational techniques provide clinicians with an attractive method to increase rapport and commitment to change from clients that have been deemed as resistant in the past (Tevyaw & Monti, 2004).
It is often not necessary for adolescents to admit to or acknowledge having substance abuse problems in order for them to benefit from a motivational approach. Motivational techniques also do not rely on diagnostic labels allowing for the client to benefit at any level of readiness to change. It can raise awareness during the pre-contemplation stage, can help in decision-making during contemplation, can enhance a person's resolution to change during the action and maintenance stages, and after a relapse it can provide an opportunity for reassessment (Ford, Oliver & Whitehead, 2006).
Within young adulthood, motivational interviewing provides similar advantages over other treatment options, however the ability to utilize brief interventions becomes incredibly valuable at this stage. Young adults are at a much higher risk of the drastic effects of substance abuse due to their distance from home and authority. As Monti and Tevyaw (2004) point out, young adults in the 18 to 25 age range consistently engage in high rates of risky behavior such as heavy substance abuse and unprotected sex. These individuals are less likely to be confronted by family due to their distance from them or by friends due to the general acceptance of this behavior during this life stage. It is therefore important to utilize brief motivational interventions within areas where young adults present themselves such as the emergency department, college counseling and health centers, and within employee assistance programs. Motivational interviewing provides a simple, trainable technique that can be used in any of these settings in a brief period of time.
Outcomes
Each study agreed that motivational interviewing provided at the very least a comparably effective option for substance abuse treatment. Within one study (Schneider, Case & Kohn, 2000), clients who were placed with counselors practicing motivational interviewing showed higher satisfaction rates with their experience. In another study among heavy drinkers on college campuses, brief interventions of motivational interviewing results in lower self-reported rates of alcohol consumption and lower blood alcohol levels than individuals who simply received feedback (Monti & Tevyaw, 2004). Students mandated into a campus alcohol program were more likely to seek further assistance with their drinking following a brief motivational intervention than students who simply completed the program in one study (Monti & Tevyaw, 2004). In one final study, older adolescents presenting at an emergency department following an alcohol-related event were randomized to one session of motivational interviewing versus typical care. At a 6-month follow-up, those who had received the motivational interview showed a significantly lower rate of drinking and driving, traffic violations, and other alcohol-related problems or injuries (Tevyaw & Monti, 2004).
Conclusion
Motivational interviewing is a simple, highly trainable, and effective technique that approaches addiction in a unique way. It provides a theoretical framework that falls more in line with social work values and ethics than many others. It allows for self-determination, respect, and validation of the client's strengths. An emphasis is on giving the client something new. Especially within substance abuse, the client has heard from multiple authorities and trusted family and friends that their behavior needs to change. The framework also allows for brief interventions that can take place in almost any setting and do not require a professional therapist to initiate. This allows for more manageable, accessible, and cost-effective treatment.
Miller described addiction as when an observer sees the behavior as too high a cost and diminished control within the individual. Motivational interviewing allows for the client to become that observer of their own behavior.
References
Ford, C., Oliver, J., Whitehead, B. (2006). Treating Drug Users: A Collaborative Method. Therapy Today. 17, 2, 17-20
Miller, W. (1998). Toward a Motivational Definition and Understanding of Addiction. Motivational Interviewing Newsletter for Trainers, 5, 3, 2-6
Monti, P., Tevyaw, T.O., Borsari, B. (2004). Drinking Among Young Adults. Alcohol Research and Health, 28, 4, 236-244
Schneider, R. J., Casey, J., Kohn, R. (2000). Motivational versus Confrontational Interviewing: A Comparison of Substance Abuse Assessment Practices at Employee Assistance Programs. The Journal of Behavioral Health Services and Research, 27, 1, 60-74
Tevyaw, T.O., Monti, P. (2004). Motivational Enhancement and Other Brief Interventions for Adolescent Substance Abuse: Foundations, Applications, and Evaluations. Addiction, 99, 63-75
Weegmann, M. (2002). Motivational Interviewing And Addiction: A Psychodynamic Appreciation. Psychodynamic Practice, 8, 2, 179-195
Motivational Interviewing and Substance Abuse
Odyssey House of Utah, a private non-profit organization, has been providing substance abuse education, prevention, and treatment services for adults, adolescents, and parents with dependent children in the Salt Lake City, Utah area for close to 40 years. Please visit one of our Odyssey House of Utah blogs and then take a look at our new Odyssey House Utah profile on Propeller.