Motivational interviewing questions

Caught in the ambivalence trap of making a tough personal change? Do the contradictory
feelings of: I want to... I don't want to... sound familiar? Don't feel bad-you're not alone.
Feeling 100% about something important is the exception, not the norm.

Sometimes the ambivalence is never resolved, but when it is, the results are magic. Like
flipping a switch, what seemed nearly impossible just falls into place. The pounds start
dropping off, the cravings for nicotine seem manageable, the recovery program for
alcohol and drug addiction starts to make sense.

Is it possible to resolve ambivalence in just one interview? William R. Miller, Ph.D. says
it is. Motivational Interviewing is the process he developed to prepare people for making
challenging behavior changes. Used extensively with alcoholics and drug addicts, the
results are dramatic: People who have had one Motivational Interview at their intake of
treatment were rated by staff as more motivated. Not only that, they also have double the
abstinence rate of those who did not have a Motivational Interview. "Two interviews are
even better than one," Miller concedes.

"It's astonishing--I would not have believed it, had I not seen it in my own data--that you
could talk to someone who had a self destructive behavior pattern going on for a decade
or more, and in the course of a conversation, see the person turn a corner." These
outcomes defy the belief system of psychology, his own profession--that more therapy is
almost always better.

Teeter-Totter of Change

Struggling with ambivalence is like being on a teeter-totter. One minute one argument
makes sense and the next minute the opposite argument tips the balance. People argue
with themselves because there are costs and benefits to both sides. Alcoholics and drug
addicts typically recognize that there are valid reasons for changing their behavior, but
there are also reasons not to. In Motivational Interviewing, this conflict is embraced, not
challenged. Instead of trying to convince the alcoholic or drug addict of the benefits of a
particular course of action, social workers using Motivational Interviewing techniques
help them to weigh the plusses against the minuses.

Margo Hendrickson, LCSW, encounters ambivalence all the time in her work as the
Manager of Clinical Services at the University of Pennsylvania Treatment Research
Center. Using Motivational Interviewing, she helps drug addicts and alcoholics weigh it
out: "Gee, it seems that you really, really like what alcohol does for you. You like the
feeling that it gives you. I wonder if we could get this down on paper? Then I would like
to have you weigh it out for yourself, here today, what you want to do. What are the good
things about continuing to drink and what are the not so good things?"
In her experience, an alcoholic may have two or three things on his list that he likes about
drinking, such as: I like the high; I like being with my friends; I am more social. There
usually is a longer list of more serious reasons to give it up, such as: My wife is always
mad at me; I have a DUI hanging over my head; My kids don't respect me anymore; My
boss is on my case. Hendrickson claims, "It is that simple."

Activating Motivation

Miller explains that once the person has weighed out the costs and benefits of making the
change, the Motivational Interviewer then asks him or her to make the argument for
change. It doesn't matter what stage of change he is in. In fact, Motivational Interviewing
is particularly effective for people in the early stages of change, when they tend to be
sensitive to being lectured and resent feeling forced to make a change.

A typical way to have them make their argument for change using Motivational
Interviewing is to pose the question: On a scale of 0 to 10, how important is it for you to
change your drinking behavior? In response to the answer--say it is a 5-a follow-up
question is asked: Why are you at a 5 and not 0? The answer to that question is their
reasons for change.

Miller cautions not to ask the obvious question: Why are you at a 5 and not a 10? The
answer to that question is the reasons against change. "Fundamentally, I want the
arguments for change coming in the client's voice and not from me. The natural expected
outcome of my making the argument for change is for the client to argue against change.
Not because they are so sick and pathological, but because that is human nature. If you
are ambivalent about something and someone takes up one side of the argument, you take
up the other side. That might be OK, except we tend to believe ourselves. You hear
yourself talk and you get committed to what you hear yourself saying. And so, if you
cause people to argue against the need for change, you are actually moving them away
from change. Confrontational approaches are counter therapeutic. They move people in
the wrong direction."

G. Alan Marlatt, Ph.D., a clinical psychologist and director of the Addictive Behaviors
Research Center at the University of Washington has seen this work effectively in the
program he developed for students who are binge drinkers. After two Motivational
Interviews students in his program not only alter their binge drinking behavior, but four
years later they still behave significantly differently from students who did not receive
Motivational Interviews.

Debunking Denial

The treatment of substance abuse is fraught with beliefs about denial. Miller says that
when he first started studying treatment approaches for alcoholics, he read that alcoholics
are liars, in denial, pathologically defensive and impossible to work with. But that view
didn't square with his experience. Trained in the client-centered approach of Carl Rogers,
Miller did his best to listen and understand what the alcoholics he was working with were
telling him. He asked how they had gotten where they were, where they saw themselves
going in the future, and what they thought about their situations. "By virtue of ignorance,
I fell into reflective listening as a way of understanding the stories of these people with
alcoholism.

"And it dawned on me eventually that the way you treat people had a large effect on the
way they behaved." Denial, Miller believes, is a reflection of the person they are talking
to. "It takes two to deny. Nobody stands on the beach alone and denies. If you approach
someone by saying, 'You're an alcoholic and you had better stop drinking,' the natural
human response is to deny. If you come to them in a respectful manner that assumes that
they make choices about their lives and it is in their hands, that they're smart people who
have reasons for what they are doing and also have within them the motivation for
change, you get a very different response."

Dance of Discrepancy

Miller describes how change is motivated by the discrepancy between where you are and
where you want to be. A bigger discrepancy leads to stronger motivation for change.
Hendrickson finds herself reflecting back discrepancies to her clients all the time. "They
come in and tell me how drugs are ruining their life and then in the next breath they are
telling me that they don't think that they can quit. I reflect that back to them: I am not
sure that you are going to do this. What do you think?" In Motivational Interviewing that
is described as "rolling with resistance." Hendrickson says that when discrepancies are
reflected back to them, people turn around. A typical response is: "What are you talking
about? That is why I am here!"

Miller explains that there is an interdependency between discrepancy and ambivalence.

Without some discrepancy there is no ambivalence. For some people, the first step
toward change is to become ambivalent. Ambivalence may look like an obstacle, but
actually it is ambivalence that makes change possible. "Motivational interviewing is like
dancing. Rather than struggle against each other, the partners move together smoothly.
The fact that one of them is leading is subtle and is not necessarily apparent to the other.
Good leading is gentle, responsive, and imaginative."

We're in This Together

Michael Chenkin, MSW, LCSW, LCADC is a licensed clinical social worker and a
licensed clinical drug and alcohol counselor in private practice in New Jersey. He was
among the first group of people trained as a trainer for Motivational Interviewing in 1993
by Miller and his colleague and coauthor Stephen Rollnick. Since that time Chenkin has
been using Motivational Interviewing in private practice and in psychiatric facilities with
people with co-occurring disorders. Sold on the value of the Motivational Interviewing
approach, he says, "What surprised me was how simple, how elegant it was."

"When I use the methods of Motivational Interviewing people respond as if they have
never been listened to before. People say, 'I really appreciate this. You are really hearing
what it is that I have to say.' For many people that experience is rare or maybe not
existent in their lifetime. It also stands in contrast to how substance abuse treatment tends
to be done, which is: 'You don't know anything; listen to me.' Or in another words, 'Do as
I say or you are going to fail.' It seems so common sense, but very often that is not the
treatment experience of clients-to be listened to and treated the way that you would want
to be treated."

Usually we think of motivation as an internal process. If someone doesn't follow through

in making a change, we tend to think that it is the result of a personal failing. Miller sees
it differently. He believes that motivation is an interpersonal process-something that
arises from the interaction of two people.

Hendrickson says that a metaphor that has helped her understand this distinction is to
think of sitting next to a client, pulling your chair along side them and looking at an
imaginary album of their life, rather than sitting across from a client. You explore their
album. As you page through it together, you are collaborating with them on what the
client wants to do next in their life.

"I think that our clients feel more respected. They will say to me, that I am not trying to
get them to do something. It is all about really listening to the client and then helping
them to make the change that they want to make, not that I want to make. I don't put
forward my agenda-it has to be their agenda. We meet the client where they are at and
move from there."

Marlatt echoes Hendrickson's view: "The students like it and they recommend it to their
friends, and if they are mandated into it, at the end they say, 'You know, this was helpful,
I liked it.' It is not what they expected, which was for someone to say, 'That's it!"

The key from Miller's perspective is to be genuinely interested in and curious about the
person's own motivations for change. Questions that are likely to be asked in a
Motivational Interview include: What do you want in your life? Where would you like to
be 5 years from now? Why would you want to change your drinking? If you decide to
stop drinking or stop using cocaine, how would you do it? What reasons do you have?

"Rather than telling the person how to make a change, I'm curious to know what they
would do. And you know what? People are pretty smart about these things. Often they
have a good sense about what would be the most successful way for them if they decide
to do it."

Resonance with Social Work

When Chenkin started using Motivational Interviewing with his clients he was struck by
how consistent it is with social work. "I said to myself, 'Boy, if this isn't social work, I
don't know what is!" The client-centered approach that is the hallmark of social work is
reflected in Motivational Interviewing, as are the social work values of starting where the
client is and the right to self-determination. "It is right out of our book," comments
Hendrickson. Marlatt sees Motivational Interviewing as compatible with social work
because it is not a top-down, authoritarian approach.

Motivational Interviewing seems to integrate well with other treatment interventions. It

has been particularly useful in managed care settings, where treatment sessions are
limited and with clients where early dropout rates tend to be high. Motivational
Interviewing increases the likelihood that a person will return for additional treatment.

Miller says that Motivational Interviewing has proved to be useful in thorny social work
problems, including child protective services cases. "The more adversarial the situation,
the bigger the advantage. With court mandated clients, for example, we find that this is so
much better than trying to make anyone do something. It is not a way of tricking people.
It is a way of engaging their own interest and motivation in what they want in life and
putting that side by side with their current situation and saying, 'What do you want to
do?"

"I want to change...I am not sure I want to." It all starts there and a creative listener can
tip the balance.

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