Reader Request: Motivational Interviewing
"It was as if they were trying to use the techniques on clients, trying to hoodwink them into changing. The words were there, but the music was wrong."
-William R. Miller, 2023
William Miller originated the technique he called "motivational interviewing" (MI) in the early 1980s. Miller was interested in early-stage problem drinking, seeking an intervention to prevent escalation, and developed MI as a way to identify people's motivations to change. MI involves querying the person to determine what matters to them, eventually (in theory) exposing where their current choices may conflict with their goals and priorities. For example, someone who says "family is everything to me" but spends more and more time in isolation to hide their drinking, might recognize this discrepancy through MI. MI also aims to elicit "change talk," in which a person entertaining the possibility of change identifies how change might benefit them, and any remaining obstacles or hesitations. The opposite is "sustain talk," in which the person reaffirms their current choices as working just fine.
MI is now a staple of substance use treatment and has been applied to numerous other areas of health in which behavior change is pivotal (as in smoking cessation or exercise). But as with so many tools in this field, MI is being misapplied, often toward coercive ends. In practice, especially in mandated treatment, the goal of MI is rarely to discover what the person genuinely values or wants to do. The goal is to convince them that any motivation counter to change--a specific change, desired by the clinician--is wrong. What is sold as a gentle, open-ended exploration is actually a browbeating, closed-ended rhetorical exercise.
In the quotation above, Miller was commenting on clinicians using MI manipulatively, as if pressuring people to change was untrue to his technique. But as he acknowledges in the same article, "MI involves preferentially evoking and reinforcing client change talk." Miller seems to believe this effect can be calibrated just so, "preferentially evoking and reinforcing" but not "hoodwinking." I'm not so sure--especially since to my knowledge he has never outlined when and how MI should be terminated. I'm thinking of the (fairly common) scenario in which the person clearly affirms that they want to stay the same. Continuing to ask questions to try to draw out "motivation" to change, at this point, sounds more like a hostile interrogation technique. It is insisting on a model of health or respectability from which any deviation must be a mistake.
Rosalie Genova
This approach becomes especially sinister when some of the "negative consequences" for sustaining can be evoked by the clinician, such as getting kicked out of treatment or reported for a probation or CPS violation.
Here are some iron-clad life priorities you might find dubious, but that cannot be MI'ed away:
- Sensory pleasure, including sex and drug-induced euphoria
- Money and status
- Appearance, image (physical or metaphorical)
- Romantic relationships that they recognize as draining and drama-filled ("toxic")
It is what it is! (And by the way, if the above list sounds like Hollywood or Top 40 radio, that's not a coincidence.)
If someone's "sustaining" in substance use aligns with their values, or if change would involve sacrifices they're not willing to make, then of course they won't be interested. And then there are the people who don't have other ways to cope with internal or external conditions, and the people for whom priorities that look like alternative motivations on paper--such as family, work, or hobbies--include everyone using together. In these cases, change might threaten the person's most important outlets and relationships.
I consider myself a practitioner and fan of MI. But I think it needs a clear end point for any particular idea at the first sign that the person is not open to it. For example, when MI reveals she does not want to change or reduce her drug use, the conversation shifts toward harm reduction practices--which can also be approached with MI. No dice there either? Let it go, again. The therapeutic relationship is much more important than exerting influence, and we know that rarely works anyway.
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