001

Table of Contents
 
Praise
Clinician’s Guide to Evidence-Based Practice Series
Title Page
Copyright Page
Introduction
Preface
ORGANIZATION
REFERENCES
Acknowledgements
About the Editors
About the Contributors
 
PART 1 - ENGAGING CLIENTS IN TREATMENT AND CHANGE
 
CHAPTER 1 - Motivational Interviewing
 
WHAT IS MOTIVATIONAL INTERVIEWING?
THEORETICAL UNDERPINNINGS OF MOTIVATIONAL INTERVIEWING
THE FOUR GUIDING PRINCIPLES OF MOTIVATIONAL INTERVIEWING
THE SPIRIT OF MOTIVATIONAL INTERVIEWING
MOTIVATIONAL INTERVIEWING COUNSELING STRATEGIES
ELICITING CHANGE TALK
OTHER MOTIVATIONAL INTERVIEWING TOOLS
INDICATIONS AND CONTRAINDICATIONS FOR MOTIVATIONAL INTERVIEWING
HOW TO LEARN MOTIVATIONAL INTERVIEWING
TAILORING MOTIVATIONAL INTERVIEWING TO THE POPULATION
CONCLUSION
RESOURCES
REFERENCES
 
PART 2 - ADOLESCENTS
CHAPTER 2 - Problem Solving and Social Skills Training
 
SOCIAL CONTEXT OF ADOLESCENT SUBSTANCE ABUSE
GUIDED ADOLESCENT PROBLEM SOLVING (GAPS)
CONCLUSION
RESOURCES
REFERENCES
 
CHAPTER 3 - Adolescent Community Reinforcement Approach (A-CRA)
 
HISTORY OF CRA
INDICATIONS
CONTRAINDICATIONS
OVERVIEW OF SESSION FLOW AND CONTENT
BASIC SESSION GUIDELINES
A-CRA PROCEDURES
HAPPINESS SCALE AND GOALS OF COUNSELING
A-CRA IN DIFFERENT SETTINGS AND WITH DIFFERENT POPULATIONS
TRAINING RECOMMENDATIONS
CONCLUSION
RESOURCES - WEB-BASED RESOURCES
REFERENCES
 
PART 3 - FAMILIES
CHAPTER 4 - Family Behavior Therapy for Substance Abuse and Associated Problems
 
OVERVIEW OF FAMILY BEHAVIOR THERAPY
FBT ASSESSMENTS
BEHAVIOR INTERVENTION COMPONENTS
METHODS OF ENHANCING MOTIVATION FOR TREATMENT
CONCLUSION
RESOURCES - WEB-BASED RESOURCES
REFERENCES
 
PART 4 - ADULTS
CHAPTER 5 - Cognitive Behavioral Coping Skills Therapy for Adults
 
WHAT IS COGNITIVE BEHAVIORAL COPING SKILLS THERAPY?
HISTORY, THEORY, AND RATIONALE FOR CBST
IMPLEMENTING COGNITIVE BEHAVIORAL SKILLS TRAINING: ISSUES AND CONSIDERATIONS
OVERVIEW OF CBST TREATMENT: CONTENT AND STRUCTURE OF THE SESSIONS
RESOURCES
REFERENCES
 
CHAPTER 6 - Seeking Safety: An Implementation Guide
 
OVERVIEW OF SEEKING SAFETY
SEEKING SAFETY TOPICS
SESSION FORMAT
CLIENT SELECTION
CLINICIAN SELECTION
CLINICIAN TRAINING
GETTING STARTED
IMPLEMENTATION
ADAPTATION
ASSESSMENT
SUMMARY
RESOURCES
ADDITIONAL SUGGESTED READINGS
REFERENCES
 
Afterword
APPENDIX A - Research Providing the Evidence Base for the Interventions in this Book
APPENDIX B - The Evidence-Based Practice Process
Author Index
Subject Index

Praise for Substance Abuse Treatment for Youth and Adults
“David Springer and Allen Rubin have compiled a valuable practice guide for any professional who works with substance-abusing youth or adults. This is a volume that should be on every practitioner’s bookshelf!”
C. Aaron McNeece, Dean, and Walter W. Hudson Professor (Emeritus),
College of Social Work, Florida State University

 
“This edited book is an important addition for clinicians wishing to incorporate the latest in evidence-based practices into their work with substance abusing clients. The detailed descriptions, case examples, and supportive materials in each chapter provide invaluable guidelines to both beginning and experienced clinicians. It is a book that belongs in the libraries of all substance abuse educators, students, and clinicians.”
S. Lala A. Straussner, Professor and Director,
Post-Master’s Certificate Program in the Clinical Approaches to Addictions Treatment,
Silver School of Social Work, New York University
 
“A major stumbling block to adoption of evidence-based practice in the real world of clinical practice has been the absence of clinician-friendly guides. Such guides need to be understandable, free of technical research jargon, infused with clinical expertise, and rich with real-life examples. Rubin and Springer have hit a home run with this series, which has all of these characteristics and more.”
Edward J. Mullen,
Willma & Albert Musher Chair and Professor, Columbia University

Clinician’s Guide to Evidence-Based Practice Series
Treatment of Traumatized Adults and Children Allen Rubin and David W. Springer, Editors
Substance Abuse Treatment for Youth and Adults David W. Springer and Allen Rubin, Editors

001

Series Introduction
ONE OF THE most daunting challenges to the evidence-based practice (EBP) movement is the fact that busy clinicians who learn of evidence-based interventions are often unable to implement them because they lack expertise in the intervention and lack the time and resources to obtain the needed expertise. Even if they want to read about the intervention as a way of gaining that expertise, they are likely to encounter materials that are either much too lengthy in light of their time constraints or much too focused on the research support for the intervention, with inadequate guidance to enable them to implement it with at least a minimally acceptable level of proficiency.
This is the second in a series of edited volumes that attempt to alleviate that problem and thus make learning how to provide evidence-based interventions more feasible for such clinicians. Each volume will be a how-to guide for practitioners—not a research-focused review. Each will contain in-depth chapters detailing how to provide clinical interventions whose effectiveness is being supported by the best scientific evidence.
The chapters will differ from chapters in other reference volumes on empirically supported interventions in both length and focus. Rather than covering in depth the research support for each intervention and providing brief overviews of the practice aspects of the interventions, our chapters will be lengthier and more detailed practitioner-focused how-to guides for implementing the interventions. Instead of emphasizing the research support in the chapters, that support will be summarized in an appendix. Each chapter will focus on helping practitioners learn how to begin providing an evidence-based intervention that they are being urged by managed care companies (and others) to provide, but with which they may be inexperienced. Each chapter will be extensive and detailed enough to enable clinicians to begin providing the evidence-based intervention without being so lengthy and detailed that reading it would be too time consuming and overwhelming. The chapters will also identify resources for gaining more advanced expertise in the interventions.
We believe that this series will be unique in its focus on the needs of practitioners and in making empirically supported interventions more feasible for them to learn about and provide. We hope that you will agree and that you will find this volume and this series to be of value in guiding your practice and in maximizing your effectiveness as an evidence-based practitioner.
 
David W. Springer, Ph.D.
Allen Rubin, Ph.D.

Preface
MENTAL HEALTH CLINICIANS are very likely to encounter a substance-abusing client in their work, with some estimations approximating that half of our clients have problems related to either their own or a family member’s alcohol or drug abuse (Drake & Mueser, 1996; van Wormer & Davis, 2008). For substance abuse counselors, this number no doubt increases!
If you have been treating substance-abusing clients—or just reading about their treatment perhaps in anticipation of treating them—you probably have encountered many comments referring to empirically supported substance abuse interventions that are considered to be evidence-based. Such interventions include problem solving and social skills training, family behavior therapy, and motivational interviewing. You may also have encountered entire books on each of these interventions and wished you had more time to read them. Perhaps you’ve seen some research articles reporting outcome studies providing strong empirical support for one or more of these interventions and wished they provided more clinical guidance as to how you could provide them to your clients. Likewise, you may have read some books that contain chapters on various empirically supported substance abuse interventions, but have been disappointed with the brevity of specific practice guidelines in those chapters. That is because such books typically just provide very brief thumbnail sketches of the interventions, perhaps accompanied by rather lengthy reviews of the studies that supported each.
If you have had the above experiences and reactions, then this book is for you. Its very detailed, lengthy, how-to chapters—with case examples sprinkled throughout—are geared to practitioners who want their practice in treating substance-abusing clients to be evidence-based but who don’t have the time to read each book on empirically supported interventions for substance abuse before feeling that they have enough knowledge to make decisions about which approach to adopt and enough guidance to begin providing the chosen intervention as they learn more about it.
This book is also geared to practitioners who may not have had the time to read research articles about empirically supported interventions for substance-abusing clients or who may be bewildered by some of the complex research concepts in those articles or by the diversity of findings from study to study. By reading this book, you will learn what interventions have had the best research support and how to provide them. That’s because this book has been written in a user-friendly/practitioner-friendly manner for clinicians who want to learn such things without having to struggle with daunting research and statistical terms. For readers who do not want to accept our conclusions just based on our authority, however, this book provides an appendix that reviews the supporting research.
Another aspect of this book that makes it practitioner-friendly and that may enhance its value to practitioners is that every intervention chapter has been authored or co-authored by practitioners who have had extensive experience in the intervention and are clinical experts in it. As you read this book, you may be gratified by the extent to which the chapter authors are communicating more as practitioners and not as ivory tower researchers who don’t understand the needs of practitioners. Although the book’s editors are housed in academia, we have insisted that our chapters be written in ways that maximize their utility to practitioners. Moreover, we too have had extensive practice experience, and the lead editor has vast clinical experience treating substance-abusing adolescents.
Although the lengthy how-to detail in this book’s chapters will not be as extensive as what you will find in an entire book devoted exclusively to the intervention being described in any particular chapter, it should be enough to get you started in providing the intervention and perhaps helping you decide whether you want to pursue further reading and training in that intervention. Toward the latter end, each chapter will also identify recommended additional readings as well as training options.
As mentioned above, this book’s chapters detail how to provide clinical interventions whose effectiveness with substance-abusing clients is currently being supported by the best scientific evidence. Thus, the separate chapters cover the Adolescent Community Reinforcement Approach, problem solving and social skills training, family behavior therapy, motivational interviewing, cognitive behavioral coping skills therapy for adults, and Seeking Safety. In addition to the how-to’s of the interventions, each chapter covers their indications and contraindications.
Key among the commonalities across these six interventions is the prerequisite that the interventions be provided in the context of a strong therapeutic alliance. The importance of the therapeutic alliance should not be underestimated, especially in light of the research supporting it as a necessary component of effective treatment with any specific intervention approach. Moreover, there is a widespread misconception that the guidelines for providing empirically supported interventions devalue the importance of the therapeutic alliance and the related misconception that evidence-based practice requires practitioners to function in a mechanistic way following cookbook-like manuals that disregard their practice wisdom and relationship skills. Readers will not find such guidelines in this volume. Instead, each chapter will reflect our emphasis on the importance of both the need to provide interventions that have had their effectiveness supported by the best research evidence as well as the need to choose, adapt, and provide those interventions in light of their practice expertise, their knowledge of idiosyncratic client characteristics and circumstances, and their relationship skills.
This book is timely as practitioners are increasingly being urged to provide empirically supported interventions and as those interventions are increasingly being required by third-party payers. Although evidence-based practice (EBP) has become part of the definition of ethical practice, various studies have shown that practitioners rarely engage in the EBP process. Various pragmatic factors have been cited regarding this concern—in particular, real-world time constraints and the difficulty practitioners have in obtaining the needed expertise to begin implementing the interventions with the best empirical support. This book aims to provide that beginning level of expertise in a manner that fits clinician time constraints.

ORGANIZATION

Following this Preface, Part 1 of this book examines the importance of engaging substance-abusing clients in treatment and the change process through the use of Motivational Interviewing (Chapter 1). Part 2 provides two chapters on treating substance-abusing adolescents, examining problem solving and social skills training (Chapter 2) and the Adolescent Community Reinforcement Approach (A-CRA) (Chapter 3). Part 3 explores treatment with families through family behavior therapy (Chapter 4), in which the primary client can be either an adolescent or an adult. It is worth noting that the Center for Substance Abuse Treatment (CSAT) funds sites all over the United States to implement A-CRA under the name “Assertive Adolescent Family Treatment,” and this chapter could have just as easily been placed in Part 3 of the book on families. Part 4 provides two chapters that cover cognitive based interventions to treat adults. Chapter 5 addresses cognitive behavioral coping skills therapy for adults. Chapter 6 explores Seeking Safety (developed to treat clients who present with both a substance use disorder and/or posttraumatic stress disorder [PTSD]). The book concludes with a brief Afterword and two appendices. Appendix A reviews the research that provides the empirical support for the interventions covered in this volume. Appendix B describes in detail the evidence-based practice process for readers who would like more detail about that process than is covered in the Preface.
Regardless of which specific approach you use in treating substance-abusing clients, we hope this book helps you get started in making your treatment of substance abuse more evidence-based. In connection to becoming more evidence-based, we hope it also spurs you to pursue further reading, training, and searching for evidence regarding any interventions you decide to adopt or continue using. We would appreciate any feedback you can provide regarding the ways you have found this book to be helpful or any suggestions you may have for improving it. You can email such feedback to dwspringer@mail.utexas.edu or arubin@mail.utexas.edu.

REFERENCES

Drake, R. E., & Mueser, K. T.(1996). Alcohol-use disorders and severe mental illness. Alcohol Health & Research World, 20(2), 87-93.
Van Wormer, K., & Davis, D. R. (2008). Addiction treatment: A strengths perspective (2nd ed.). Belmont, CA: Brooks/Cole.

Acknowledgments
SPECIAL THANKS GO to four Wiley staff members who helped make this series possible. In alphabetical order they are: Peggy Alexander, Vice President and Publisher; Lisa Gebo, Senior Editor; Sweta Gupta, Editorial Program Coordinator; and Rachel Livsey, Senior Editor. For this particular volume, we appreciate the fine work of our chapter authors and the helpful feedback they provided to earlier drafts of the complete volume and for graciously lending their expertise in the writing of Appendix A. Two graduate students who helped at various stages of production also deserve special recognition: Angie Lippman and Melissa Torrente. Thanks also go to the following colleagues who reviewed our submitted manuscript and suggested improvements: Albert R. Roberts, Ph.D. (deceased), of Rutgers University; and Sherry Cormier, Ph.D., of West Virginia University.

About the Editors
David W. Springer, Ph.D., LCSW, is the Associate Dean for Academic Affairs and a University Distinguished Teaching Professor in the School of Social Work at The University of Texas at Austin, where he is also Investigator of the Inter-American Institute for Youth Justice and holds a joint appointment with the Department of Psychology. Dr. Springer’s practice experience has included work as a clinical social worker with adolescents and their families in inpatient and outpatient settings and as a school social worker in an alternative learning center with youth recommended for expulsion for serious offenses. He currently serves on the editorial board of several professional journals and on the National Scientific and Policy Advisory Council of the Hogg Foundation for Mental Health. He has co-authored or co-edited several other books, including Substance Abuse Treatment for Criminal Offenders: An Evidence-Based Guide for Practitioners and Handbook of Forensic Mental Health with Victims and Offenders. Dr. Springer recently served as Chair of a Blue Ribbon Task Force consisting of national and regional leaders, which was charged with making recommendations for reforming the juvenile justice system in Texas. In recognition of his work with the Blue Ribbon Task Force, the National Association of Social Workers, Texas Chapter/Austin Branch selected Dr. Springer as the 2008 Social Worker of the Year.
 
Allen Rubin, Ph.D., is the Bert Kruger Smith Centennial Professor in the School of Social Work at The University of Texas at Austin, where he has been a faculty member since 1979. While there, he worked as a therapist in a child guidance center and developed and taught a course on the assessment and treatment of traumatized populations. Earlier in his career he worked in a community mental health program providing services to adolescents and their families. He is internationally known for his many publications pertaining to research and evidence-based practice. In 1997 he was a co-recipient of the Society for Social Work and Research Award for Outstanding Examples of Published Research for a study on the treatment of male batterers and their spouses. His most recent studies have been on the effectiveness of EMDR and on practitioners’ views of evidence-based practice. Among his twelve books, his most recent is Practitioner’s Guide to Using Research for Evidence-Based Practice. He has served as a consulting editor for seven professional journals. He was a founding member of the Society for Social Work and Research and served as its president from 1998 to 2000. In 1993 he received the University of Pittsburgh, School of Social Work’s Distinguished Alumnus Award. In 2007 he received the Council on Social Work Education’s Significant Lifetime Achievement in Social Work Education Award.

About the Contributors
Daniel N. Allen, Ph.D., is Associate Professor in the Department of Psychology and Director of the Neuropsychology Research Program at The University of Nevada, Las Vegas. His research interests include the neurocognitive effects of substance abuse, severe mental illnesses, and child traumatic brain injury and neurodevelopmental disorders. He has published extensively in these areas and is Fellow of the American Psychological Association (Division 40), National Academy of Neuropsychology, and Western Psychological Association. He is the recipient of several awards, including the Nelson Butters Award and Early Career Award from the National Academy of Neuropsychology, and the Morris Award and Barrick Scholar Award for research contributions from the University of Nevada, Las Vegas.
 
Ashley M. Austin, Ph.D., is Assistant Professor in the School of Social Work at Barry University. Dr. Austin completed postdoctoral training in the area of adolescent substance use problems at the Community-Based Intervention Research Group (C-BIRG) at Florida International University. Dr. Austin was a recipient of the 2008 National Institute on Drug Abuse (NIDA) Early Career Social Work Research Mentoring Initiative Award.
 
Brad Donohue, Ph.D., is Associate Professor in the Department of Psychology and Director of Achievement Center at the University of Nevada, Las Vegas. He is editor of the Journal of Child & Adolescent Substance Abuse, and was one of the developers of Family Behavior Therapy for substance abuse and its associated problems. He has directed projects funded by NIDA, NIMH, and SAMHSA, authored more than 100 professional publications, and is a recipient of several research awards, including UNLV’s Outstanding Faculty Award, Western Psychological Association’s Early Career Research Award, and the Barrick Scholar Award for Distinguished Research.
 
Mark D. Godley, Ph.D., received his MSW from the Worden School of Social Service and his Ph.D. from Southern Illinois University. Since 1987 he has served as the Director of Chestnut Health System’s research and training institute and oversees the work of more than eighty research and training staff conducting NIH, SAMHSA, and foundation-funded research related to treatment and recovery for individuals with substance use disorders. Dr. Godley worked on the early clinical trials (1975-1982) of the Community Reinforcement Approach for alcohol use disorders and is currently leading an NIAAA funded study of Assertive Continuing Care.
 
Susan H. Godley, Rh.D., is a Senior Research Scientist and the EBT Coordinating Center Director at Chestnut Health Systems in Bloomington, Illinois. She is a CSAT and NIH funded investigator. She received her doctorate in rehabilitation from Southern Illinois University. Dr. Godley is the lead author of the Adolescent Community Reinforcement Approach (A-CRA) manual, one of the five Cannabis Youth Treatment (CYT) study treatment manuals, and was the principal investigator for one of the four CYT study sites. She is also the lead author on the companion case management manual used in the Assertive Continuing Care (ACC) approach.
 
Holly B. LaPota, is a clinical psychology doctoral student at the University of Nevada, Las Vegas. She serves as Assessment Coordinator at Achievement Center, where she organizes training seminars for assessment counselors and manages the administration of assessments in a NIDA-funded treatment outcome study involving HIV prevention and concurrent intervention for substance abuse and child neglect. Her research interests include the promotion of healthy lifestyles within the substance abuse and child neglect population. She also serves as editorial assistant for the Journal of Child & Adolescent Substance Abuse.
 
Robert J. Meyers, Ph.D., is Director of Robert J. Meyers, Ph.D. & Associates and a Research Associate Professor Emeritus in Psychology at the University of New Mexico’s Center on Alcoholism, Substance Abuse and Addiction. Dr. Meyers helped develop the first Community Reinforcement Approach for the seminal study published in 1982 and has helped establish the adolescent version of CRA (A-CRA). Dr. Meyers also developed an approach for engaging resistant substance abusers to enter treatment, called Community Reinforcement and Family Training (CRAFT), which has been shown to be superior to more traditional interventions in several empirical studies.
 
Lisa M. Najavits, Ph.D., is Professor of Psychiatry, Boston University School of Medicine; Lecturer, Harvard Medical School; and affiliated with VA Boston and McLean Hospital. She is author of the books Seeking Safety: A Treatment Manual for PTSD and Substance Abuse (2002) and A Woman’s Addiction Workbook (2002), as well as over 125 professional publications. She is currently president of the American Psychological Association Division on Addictions. She is recipient of several awards including the 2009 Betty Ford Award for addictions research from the Association for Medical Education and Research in Substance Abuse; and the 2004 Emerging Leadership Award of the American Psychological Association’s Committee on Women.
 
Danielle E. Parrish, Ph.D., is Assistant Professor in the Graduate College of Social Work at the University of Houston. Dr. Parrish recently completed postdoctoral training with the Health Behavior Research and Training Institute at The University of Texas at Austin, School of Social Work. Prior to obtaining her doctorate, Dr. Parrish worked as a clinical social worker with children, adolescents, and adults in a diverse array of public mental health settings including juvenile justice, infant mental health, and outpatient children’s mental health. Most of her recent research and publications have focused on the implementation of evidence-based practice and the prevention of fetal alcohol spectrum disorders. She also serves on the editorial board of Research on Social Work Practice.
 
McClain Sampson, Ph.D., is a Research Assistant at the Health Behavior Research and Training Institute at The University of Texas at Austin, School of Social Work. She graduated in May 2009 with a Ph.D. in Social Work and earned her M.S.S.W. in 2005 from the University of Tennessee, Knoxville. Her scholarly research and presentations have focused on the efficacy of motivational interviewing in restricted and unrestricted settings. She has also assisted in the coordination of federally funded substance abuse research projects. Ms. Sampson is a motivational interviewing coach.
 
Jane Ellen Smith, Ph.D., is Chair of the Psychology Department and Professor at the University of New Mexico in Albuquerque, where she has also served as the Director of Clinical Training. She received her Ph.D. in Clinical Psychology from the State University of New York at Binghamton. She is also the first author of the book, Motivating Substance Abusers to Enter Treatment: Working with Family Members, and the co-author of the book, Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach. She has received federal grants from NIAAA to test the CRA program with homeless individuals.
 
Nanette S. Stephens, Ph.D., a licensed clinical psychologist, is a research scientist and Director of Training with the Health Behavior Research and Training Institute at The University of Texas at Austin, School of Social Work. She has over eighteen years of experience integrating Motivational Interviewing (MI) in her work as a trainer, supervisor, researcher, clinician, and consultant. In addition, Dr. Stephens has been a therapist in several federally funded MI-based projects (e.g., preventing alcohol-exposed pregnancies, group therapy for cocaine users), and her other clinical and research interests have included working with families with histories of domestic violence and child maltreatment.
 
Mary M. Velasquez, Ph.D., is Professor, Associate Dean for Research, Director of the Center for Social Work Research, and Director of the Health Behavior Research and Training Institute in the School of Social Work at The University of Texas at Austin. Her areas of interest are the development and implementation of interventions using the Transtheoretical Model of Change and Motivational Interviewing and health behavior interventions including HIV prevention, prenatal health, mental health, alcohol and other substance abuse, smoking cessation, and prevention of fetal alcohol spectrum disorder.
 
Eric F. Wagner, Ph.D., is a Professor in the Stempel College of Public Health and Social Work at Florida International University, where he directs the Community-Based Intervention Research Group (C-BIRG). Dr. Wagner earned his Ph.D. in Clinical Psychology from the University of Pittsburgh, completed a postdoctoral fellowship at the Brown University Center for Alcohol and Alcoholic Studies, and is a licensed psychologist in the states of Florida and Rhode Island. Dr. Wagner was recognized for his early career achievements with the New Investigator Award from the Sixth International Conference on Treatment of Addictive Behaviors, as well as being selected to present at the Symposium in Honor of Enoch Gordis at the 25th Annual Scientific Meeting of the Research Society on Alcoholism. Dr. Wagner also is the creator and director of the DIONYSUS <dionysus.fiu.edu>, an annual conference devoted to science-informed approaches to real-life issues in drinking.

PART 1
ENGAGING CLIENTS IN TREATMENT AND CHANGE

CHAPTER 1
Motivational Interviewing
McCLAIN SAMPSON, NANETTE S. STEPHENS, and MARY M. VELASQUEZ

WHAT IS MOTIVATIONAL INTERVIEWING?

Many counseling approaches are based on the idea that if people receive enough information (or education) about their problems, they will change. As a consequence, counselors working with substance-abusing clients often rely on providing advice or teaching relapse prevention and other action-related tasks as their primary therapeutic strategies. For clients who are ready to change, these approaches can be effective. If clients are not ready to change their problem behaviors, however, this type of approach can quickly lead to resistance and a lack of progress. There are numerous reasons why a client who is not ready for change might present for treatment such as legal, marital, or job-related problems that have led to coercion or ultimatums that the client attend treatment or face significant consequences. At the same time, some clients who appear ready to change feel quite ambivalent because they may have some very strong reasons to stay the same. In these cases, counselors and clients alike are much better served when counselors refrain from persuading or offering immediate advice and instead utilize an approach that seeks to enhance and reinforce client motivation and commitment to change. This approach is embodied by the Motivational Interviewing (MI) counseling style.
Because the MI approach begins with the assumption that the responsibility for change lies within the client, the counselor’s task is to create an environment that will enhance the client’s intrinsic motivation for and commitment to change. In this type of environment, the counselor elicits the client’s answers and solutions for change, rather than directs, suggests, or provides the answers. In other words, MI is not a top-down, authoritarian approach, but rather a client-centered, respectful, and collaborative endeavor that mobilizes the client’s own resources for change. A second assumption of MI is that unremitting problems are more often due to a lack of this kind of mobilization (i.e., not being motivated to try) rather than to skills deficits (i.e., trying, but not having the necessary tools or skills) or “denial” (i.e., not trying because the client believes there is not a problem in the first place). A third assumption is that when faced with making a difficult change, ambivalence is typical and “normal,” particularly for those who are initially reluctant or resistant to considering change. Thus, the central purpose of MI is to help shift these decisional uncertainties (i.e., ambivalence) in the direction of positive change by creating an atmosphere of respect and acceptance and enhancing the belief that change is possible.
William Miller and Stephen Rollnick (2002), the originators of MI, define MI as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25). The goal of MI is to prepare clients for change—not push or coerce them—by helping them work through their ambivalence about changing through the use of active listening and skilled feedback techniques. To build rapport, reduce resistance, and enhance motivation, the MI counselor elicits the client’s own concerns about the problem behavior. As the clients—rather than the counselors—articulate reasons for change, their internal motivation is harnessed and augments their readiness to change.
As a counseling style, MI is client-centered, collaborative, and goal-oriented. That is, the counselor and the client work together to identify and address the client’s specific behavioral goals. In this “dual expertise” approach, the counselor and the client are both viewed as experts who collaborate in the service of the client’s goals and concerns in terms of what is important and possible in the context of their lives. Because the MI counselor recognizes that all clients—on some level—have the desire and wisdom needed to improve their lives and accomplish their personal goals, the counselor’s job is to elicit answers and solutions from clients rather than directing or providing the answers (Rollnick, Miller, & Butler, 2008). Unlike some nondirective counseling styles where counselors continually “stay with” the clients and avoid providing any type of structure or guidance, MI sessions maintain a purpose, goal, and direction as counselors actively select the right moments in which to intervene with incisive strategies. MI specifically avoids argumentative persuasion and instead accepts the validity of the client’s experiences and perspectives. This involves listening to and acknowledging (though not necessarily agreeing with or approving of) a broad range of a client’s concerns, values, preferences, beliefs, emotions, styles, and rationales.
The MI approach embodies both a relational philosophy described as the MI Spirit, or a “way of being,” with another (Miller & Rollnick, 2002) and a set of strategies and methods that are selectively utilized to develop and strengthen motivation. MI elements and strategies can be utilized in two phases. Phase I, typically most useful for clients who are more reluctant or ambivalent about change, incorporates strategies referred to as OARS (i.e., asking Open questions, Affirming, Reflecting, Summarizing) to build rapport, explore ambivalence, and increase readiness to change. While Phase II also incorporates the OARS strategies, they are utilized to strengthen a growing commitment to change and develop plans of action to accomplish change goals. These strategies will be addressed more fully in the MI counseling strategies section.

THE MYTH OF DENIAL

The substance abuse field has long maintained that most clients are resistant, or “in denial,” about their use. We frequently hear that “alcoholics” and “drug addicts” are liars, pathologically defensive, and nearly impossible to work with, and until they “hit rock bottom,” they will not change. As a result, traditional substance abuse interventions are often based on the idea that change is motivated only by the avoidance of negative consequences. This approach suggests that “alcoholics” will not change their drinking behaviors until the external consequences become sufficiently painful and distressing or until their denial is broken by direct confrontation. In contrast, Miller believes that this sort of approach is not only ineffective, but also detrimental to clients. Instead of seeing denial as characteristic of certain types of clients, he contends that denial is actually a reflection of the interpersonal relationship between the counselor and the client. He states:
It takes two to deny . . . 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 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 (as cited in Jones, 2007, p. 34).
As evidenced by Miller’s comments, practitioners of MI maintain that motivation for change is facilitated by exploring and amplifying clients’ intrinsic motivations to move toward positive consequences, behaviors, or goals rather than by confronting them about the need to avoid negative consequences. Because very often people make difficult changes on their own, we believe that although counseling may help facilitate the change process, the motivation to change comes from within the client.

WHAT MOTIVATIONAL INTERVIEWING IS NOT

Upon receiving their first introduction to MI, many people with training in social work, counseling psychology, or other helping professions say, “Oh, that’s what it is—I already use MI in my practice, and I have been using it for years.” In other words, at first blush MI can appear to some to be simply an empathic approach that uses a set of “good listening skills.” While empathy and listening are certainly foundational elements, reaching proficiency in MI—learning to apply its spirit and artful, strategic principles and skills—typically requires practice and feedback over time. Before we explore the various aspects of MI, we will discuss what MI is not.
First, MI is not directive in the traditional sense, which implies confrontation, persuasion, and indoctrination. Instead, the directiveness of MI is exemplified by sessions that are goal-focused as client and counselor explore specific behavioral goals together such as increased sobriety, improved parenting skills, or smoking cessation.
MI is not just being “warm and fuzzy,” empathic, accepting, and genuine. While empathy and acceptance are essential to the practice of MI, this approach also incorporates directive (in the sense of goal-oriented) strategies and methods that are applied in the service of change.
We have also heard more than one counselor say that he or she is going to do MI with their next client. MI is not something that is done to a client; rather, it is both an art and a craft that integrate relational processes with a set of skills and strategies.
In addition, although numerous studies have documented significant behavior changes after a single MI session, MI is not a “snap your fingers” method that is always instantly transformative; instead, we have learned that MI sessions may simply plant a seed that facilitates more distal behavior changes.
MI is also not a hierarchical, top-down approach in which counselors are viewed as experts who dispense wisdom, advice, and solutions. The term interview itself connotes a desire for an egalitarian exchange that acknowledges and respects the right to socially responsible self-determination. In MI, counselors set aside their own goals and timetables and begin where their clients are, by inviting them to explore and set their own goals. In contrast to the counselor being viewed as an authority on the client’s life and choices, the client is seen as a powerful agent who possesses an inherent will and ability to set meaningful goals and work toward their accomplishment. Therefore, rather than giving incentives, setting goals, and providing solutions for a client, the counselor’s task is to elicit and foster those elements from the client. This relational and respective type of dialogue, which is the hallmark of MI, is of utmost importance in developing a strong working alliance with the client (Miller & Rollnick, 2002).
Finally, MI is not something a counselor continues to utilize until the client agrees to submit to changes seen as necessary or desirable by the counselor. In many instances, MI is often a relatively short-term process that utilizes the key component of highlighting discrepancies the client may feel between a current behavior and personal values, goals, and self-concept. As this awareness grows, a client’s sense of agency is enhanced as he or she increasingly feels an ownership and investment in the development of change options and pathways. While this process of empowerment continues to be fostered by evoking the client’s feelings, desires, and solutions for change, the counselor remains respectful and accepting of the client’s choices rather than conveying an expectation that the client needs to and/or must change.

THEORETICAL UNDERPINNINGS OF MOTIVATIONAL INTERVIEWING

The concept of MI, which evolved from experience in the treatment of problem drinkers, was first described by Miller (1983) in an article published in Behavioral Psychotherapy. The fundamental concepts and approaches were later elaborated by Miller and Rollnick (1991) in a more detailed description of clinical procedures. MI draws on Festinger’s (1957) concept of cognitive dissonance, Bem’s self-perception theory (1972), the transtheoretical model of change (Prochaska & DiClemente, 1984), and the health belief model (Rosenstock, 1974). While MI has these theories at its roots, Miller explains that MI actually originated as young protégés observed his approach to enhancing clients’ readiness to change in substance abuse treatment. As Miller began to describe to his colleagues what he did in treatment, the conceptual model for MI evolved (MINUET, 1999).
The earliest conception of MI drew heavily on the stages of change (SOC), first identified by Prochaska and DiClemente in the Transtheoretical Approach: Crossing Traditional Boundaries of Therapy (1984). The SOC represent the temporal, motivational aspects of the change process. According to this model, individuals often enter the change process in the precontemplation stage because they are unconvinced that they have a problem or are unwilling to consider change. Individuals who progress to the contemplation stage begin to consider making changes in the distant future. In the preparation stage, individuals have more proximal goals to change and begin to make commitments and develop plans to change. The action stage of change is characterized by individuals changing the target behavior and adopting strategies to prevent relapse. And in the maintenance stage, the change is solidified and integrated into the individual’s general lifestyle.
Clients vary widely in their readiness to change. Some may come to treatment having already decided to change. Others are reluctant or even hostile at the outset. In fact, some precontemplators are coerced into treatment by families, employers, or legal authorities. Most clients, however, are likely to enter the treatment process somewhere in the contemplation stage. They may be thinking about taking action, but still need consolidation of their motivation for change. The MI focus in this period, termed Phase I (Miller & Rollnick, 2002), may be thought of as tipping the motivational balance (Janis & Mann, 1977; Miller, 1989). One side of the seesaw favors keeping the status quo, whereas the other favors change. The counselor’s task is to create opportunities for shifting the balance in favor of change. MI is especially useful for clients in the earlier SOC because it promotes the exploration and resolution of ambivalence about change by highlighting and increasing an individual’s perceived discrepancy between current behavior and personal goals and values (Miller & Rollnick, 1991, 2002). Thus, in MI, a client’s ambivalence, which is common in the earlier SOC, can be used to enhance his or her intrinsic motivation to begin to initiate behavior change efforts.
Counselors have also found MI to be a very effective style to use with clients in the later stages as they prepare for change, take action, and maintain the change over time. Miller and Rollnick (2002) have called this Phase II of Motivational Interviewing. This is the point at which the client has made a decision to change. In this phase, the counselor’s job changes from enhancing motivation to collaborative problem-solving and coaching as the client develops a workable change plan, anticipates barriers to change and ways to address them, and identifies potential support systems. Although most change strategies in this phase (the preparation, action, and maintenance stages) are more behavioral or action-oriented, we believe clients are more engaged, and ultimately more successful, when they are treated in the empathic, caring style that is inherent in MI. For clients in action and maintenance, by helping to increase self-efficacy and reinforcing accomplishments, MI promotes sustained, long-term change (DiClemente & Velasquez, 2002).
The SOC concept can assist counselors in that they may select and utilize very different strategies, depending on clients’ stage of readiness for change. Rather than being conceptualized as discrete, static periods, the SOC are a useful template for understanding the dynamic change process. The SOC are also helpful for clients in that they provide a framework by which clients can better understand where they are, where they have been, and where they are going. It is important for counselors to remember that not only can a client’s stage of readiness for changing a behavior fluctuate from day to day, but a client may also be in different stages for changing different behaviors. For example, a client might want to change her alcohol use but not be at all ready to give up her use of marijuana. The skilled MI counselor will be attentive to possible variations in a client’s readiness for change and apply selective MI strategies in a flexible, adaptive manner.

WHY MOTIVATIONAL INTERVIEWING?

MI is one of the most carefully designed and rigorously studied treatments for substance abuse (see Appendix A in this volume for a summary of MI’s effectiveness). Moreover, we believe that many elements of MI can often be effectively integrated with a number of other counseling methods. For example, the MI OARS strategies, to be discussed more fully later, are especially applicable to many other approaches. Expressions of empathy and respect of client personhood and autonomy—central MI constructs—are also congruent with other therapeutic models.
In addition, in today’s climate counselors are being called upon to use strategies that are clearly specifiable. That is, there is a call in the behavioral therapies arena for providers to define the “active ingredients” or “mechanisms of action” that are being used in each therapeutic encounter. In MI, the strategies are clearly defined, and supervisors listening to recordings of client encounters can identify the extent to which MI is being used by the counselor in the session. Behavioral coding systems such as the Motivational Interviewing Treatment Integrity (MITI) scoring system (Moyers, Martin, Manuel, Hendrikson, & Miller, 2005) can be used to assess counselor adherence to the MI style and use of strategies. The MITI assesses treatment quality by coding global MI concepts such as empathy (the extent to which the counselor understands and/or makes an effort to grasp the client’s perspective) and MI spirit (how much the counselor supports the client’s autonomy, collaborates, and evokes the client’s goals and concerns). In addition to these global ratings, several counselor behavioral counts are assessed, such as use of closed or open questions, simple and complex reflections, and MI-Adherent (e.g., affirming, asking permission to give information or advice, expressing support) or MI-Nonadherent responses (e.g., advising without permission, confronting, arguing).

THE FOUR GUIDING PRINCIPLES OF MOTIVATIONAL INTERVIEWING

EXPRESS EMPATHY

The expression of empathy, based on the teachings of the humanistic psychologist Carl Rogers (1951), is an essential building block for a MI session. In the MI approach, the counselor actively listens to and reflects the meaning and feelings conveyed by the client. The accurate expression of empathy by the counselor conveys not only an understanding, but also an acceptance, of the client’s perspective and experience. Thus, the client feels heard and accepted rather than judged or discounted. This element sets the stage for building rapport and creating a safe environment rather than one that pushes for change in a particular direction. The following scenario demonstrates this principle.
 
CLIENT: My wife and I had a lot of trouble . . . we got into it when she pushed and pushed me about getting a different job.
COUNSELOR: You felt pushed to the limits. . . . It got out of control.
CLIENT: Yeah, but it shouldn’t have happened like it did.
COUNSELOR: You wished it could have been handled in a different way.
CLIENT: I could have done better.

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