Notes on Motivational Interviewing

Having here praised William R. Miller, whose book, co-authored with Theresa Moyers, was unexpectedly helpful, I realized I could now go back and read Miller's famous work on motivational interviewing. As so often seems to happen with me (a phenomenon first noted by Nina Coltart), current clinical work brings certain books back to mind and unconsciously nudges them up the priority list, on which reside, at any given moment, at least a dozen other works in various stages of being read, marked, and inwardly digested. So I found my copy of Motivational Interviewing and cracked it open again. 

Psychoanalytic snob that I have so often been, when I first heard that phrase years ago my eyes instinctively rolled so far back into my head they were able to watch old episodes of WKRP in Cincinnati. Herb Tarlek instantly came to mind--he who was always arrayed in a hideous jacket and had the oily demeanour of the salesman that he was. That is what I thought of "motivational interviewing": some smarmy technique devised by the more revolting apologists for "dollarland," Freud's acid nickname for America. 

But Adam Phillips taught me (this appears in many of his books, but perhaps most especially The Cure for Psychoanalysis) that ideological thinking is the antithesis of a psychoanalytic mind, and snobbery and defensiveness around it are both false to its promises and unnecessary to its survival (indeed, are fatal to its survival). 

My Canadian and Catholic instincts here further remind me that many differences are frequently exaggerated, and a careful work of "translation" will often reveal how similar things are. Though I have often thought the contemporary academy (especially in the humanities) is too enamoured of works of intellectual genealogy, they have their place, perhaps especially in the clinical sciences as we see just how much covert borrowing there is, especially by those (e.g., Aaron Beck, Marsha Linehan) who had analytic training but went to great pains to downplay or disown it in order to promote or tolerate the spread of myths of their own putative originality. 

Many concepts later "pioneered" (and trademarked and copyrighted) by others are demonstrably and indisputably analytic in origin. This is not noted smugly, but simply as a matter of honest intellectual history. Freud himself in several places notes how much he borrowed from others (Feuerbach, Schopenhauer), and I have myself noted his debts to monastic practices of late antiquity. There really is very little new underneath the sun. 

So if, in what follows--some selective, non-systematic notes on the second edition of Miller's Motivational Interviewing, bought years ago but left mostly unread--you find my taking particular pains to relate these to my analytic training, or to find psychoanalytic antecedents and analogues, you will understand why. (Others have done this with greater skill than I--Glen Gabbard for one, including in this article; see also Stanley Messer here; and perhaps most especially D. Westen's 1998 article--showing how often extremely similar techniques are to be found in differently labelled theories under different terms.) 

And the first note of significance comes at the start of the Acknowledgements page, where the authors note that "there is little that is truly original in motivational interviewing," referring to their debts to Carl Rogers in particular. 

It is an interesting exercise to return to this book after having read the more recent treatment of effective therapists. For much of that latter book is foreshadowed in Motivational Interviewing, as when they note already on p.6 that across different theories and types of treatment, common factors "frequently make a difference," and these factors are bound up with "certain characteristics of therapists." Therapists who consistently manifest empathy, avoid being high-handed, and do not infantilize their patients have better outcomes than those who view it as their mission to engage in "confrontation" and advice giving.  

I am also heartened that this book's second chapter is "Ambivalence: the Dilemma of Change." (Miller has a more recent book entirely on ambivalence.) Freud brought ambivalence to common awareness, though I sometimes fear it has largely disappeared from the clinical landscape, full as it often seems to be of much boosterish talk of techniques and tool boxes and work-sheets promising transformational change in 6 sessions or fewer (most of these barbaric self-promoters would write "less"). In any event, our authors note that ambivalence is universal and natural, and hectoring people who are ambivalent only serves to deepen the defenses and make change harder. 

Instead of that, you need to see what does motivate someone, for we are all motivated by something, and often several things. Discover what continues to motivate your patient even as they remain ambivalently attached to the thing they are trying to give up or alter. And while you're about it, do not--these authors strongly suggest--be a purist about this but a pragmatist: how much of the thing are they willing to give up? Go with that rather than pushing for total abstinence or complete change. (I am heartened to read this, because it seems to accord with something I've been calling "partial victories" with my patients who are inclined to totalized thinking.)

Developing Discrepancy: Our authors note that discrepancy is a good thing, and sometimes may actively need to be cultivated. Help the patient come to see the gap between where they claim to want to be, and where they are now. This then leads into what is called "change talk," which manifests itself in four ways:

1) Recognizing disadvantages of the status quo
2) Recognizing advantages of change
3) Hope for change
4) Intention to change.

This leads the authors to recognize the entire process of motivational interviewing is one led by the patient, and not an imposition on them--or a panacea either. It takes time and patience, and consists in the clinician giving space to talk through the ambivalence and bring patients to decide for themselves what they want to do. (That, of course, sounds very much like the kind of free and freeing environment that most of us try to create in psychodynamic treatment, which resists imposing our ideas upon, and thus infantilizing, the patient.) As they say a little later, the key here is "exploration more than exhortation" (p.34), and the exploration and decision-making sees the patient very much in the lead. 

All of this is premised upon something I have heard attributed to Rogers, and occasionally to Jung: "paradoxically, this kind of acceptance of people as they are seems to free them to change" (p.37). (So many people seem to come into my consulting room full of zeal for change which is motivated entirely by masses of self-loathing. They therefore find the idea of working from a place of self-acceptance utterly baffling.) Once people feel accepted as they are, and not forced prematurely into change by the therapist, then it is your next job with them to bring forward what they are already motivated by, and use that as a spring-board for action. Discovering a sense of self-motivation and self-efficacy will be key to everything that follows. 

At the outset of treatment the authors warn clinicians off the use of questions--closed are worse than open-ended, but both invite superficial and often defensive answers. (Other traps to avoid: labelling, instructing, playing the expert, taking sides, blaming, and going to fast--what a friend of mine calls a failure of pacing). 

At this stage, minimize the use of questions. Reflective listening and the use of statements are better. (In saying this, our authors remind me of Brodsky and Lichtenstein's useful article, "Don't Ask Questions.") Affirmation and elaboration are also useful techniques, particularly when the latter involves questions of values. Ambivalence can often be worked through if the desired change is in keeping with the patient's values.

Chapter 8: Responding to Resistance. I know that word has increasingly been avoided by some, but the authors note that no good alternatives have yet been found so they keep using it. Every time I hear it, I think of an example my first supervisor gave me. His besetting sin, he said, was getting too far out in front of the patient by moving too fast. He would look around and see how far behind him the patient was. Instead of chiding the patient for being a slow-poke, he realized he had gone too far too fast and had, he said, "humbly to walk back where they were and come along side them again." I think this example nicely illustrates Miller and Rolnick's ideas of resistance. Do not, they say, see this as something to blame the patient for: it is the fault of the clinician, just as my old supervisor recognized. 

So what do you do--how ought you to respond? You meet resistance with non-resistance. Shifting the focus (what I've heard called "lowering the anxiety temperature in the room" by changing the subject) is useful, along with exaggerated (but calm and sincere) reflection back are useful here. 

Ch.9: Enhancing Confidence: Not surprisingly, the authors recognize two traps at the outset to be avoided: one is to fall into the patient's totalized gloom-mongering and not have hope that things can change; the other is to be a mindless booster, offering cheap, soothing encouragement that is equally totalized and simplistic. You need to have and hold out hope for the patient, but it needs to be tempered and realistic hope. It also needs to be discerning enough that you know when to hope for change and when to gently bring the patient (as the Serenity Prayer reminds us) towards some reality-testing so they can see what is unlikely to change. 

Having found realistic hope, the process next moves on to actual planning of the change--lists of ideas, desires, hopes, obstacles, and strengths. At every stage this is led by the patient and your job as clinician is not to be the expert dispensing advice or telling them what and how to do something. This is repeated, along with many of the observations briefly noted above, throughout the first half of the book, which is easily twice as long as it needs to be. Overall, the summary of MI's "four general principles" occurs early in the book (p.36), thus:

1) Express empathy
2) Develop discrepancy
3) Roll with resistance
4) Support self-efficacy.

Part IV: Applications of Motivational Interviewing features nearly a dozen chapters by invited contributors focusing on specialized populations (groups, couples, adolescents, criminals et al) or issues. There are also chapters reviewing the evidence on the efficacy of MI and its application in medical and other contexts. 

Miller and Moyers on Effective Psychotherapists

If you're like me, you've already somewhat obsessively read at least forty-seven articles on the working alliance and an array of related topics to discover what the best therapists do. One of the reasons I started this wee blog was to share such findings as I come across them.

Over the past few years a picture has built up. It is simultaneously reassuring and terrifying that much of psychotherapy turns not on technique nor years of practice (nor still less--thankfully--on the absurd array of trademarked acronyms promising to move the sun and the other stars), but on certain gifts and characteristics that the therapist either seems to have--or not. In this, it puts me in mind once again of Anna Freud's aphorism (recorded in Robert Coles' workable biography of her) that therapists are either technicians or healers. 

This brand new book does not put it quite so bluntly, but the authors do repeatedly note that the best healers in psychotherapy seem to have certain qualities in abundance and to exercise them rather freely. This book is eminently useful in putting before the reader the latest data on what makes for a masterful therapist: Effective Psychotherapists: Clinical Skills That Improve Client Outcomes by William R. Miller and Theresa B. Moyers (Guilford Press, 2021), 213pp. 

Miller, of course, is the author of the famous work Motivational Interviewing, which generations of clinicians have heard about if not actually read. (I have read it. It was ever so slightly underwhelming.) Here he teams up with Moyers to write several very workable chapters that eschew fulgurating fireworks and convey some basic qualities and characteristics with clarity. 

Right from the get-go the authors reveal the crucial finding: already by the end of the first session, much of the outcome of therapy can be predicted. How is that possible? On what is success predicated so swiftly?

The answer will not surprise you if you are familiar with contemporary research into effective psychotherapists, who have compassion, empathy, and the ability to build a partnership with their patients in what is called the working alliance. These qualities are not time-dependent, either: a novice intern can have them and use them as or even more effectively than someone in practice for thirty years. More on all this in a moment. 

This book, Effective Psychotherapists, is divided into three unequal sections. The first, the shortest, nonetheless lays out the centrality of effective empathy as key to the working alliance. The second part, the longest, focuses on what the authors call the eight therapeutic skills you can develop and improve so that patient outcomes also improve. The third and final section contains three chapters and broadly focuses on ongoing training and future developments.

Chapter II, in the first section, is they key to the entire book. Here the authors review more than half a century of research into therapist effects to show that "the answer...is startlingly clear" to the question: what distinguishes a great therapist from the rest? In one study, that answer was almost immediately manifest: a "higher expression of therapist empathy" was found to predict "greater reduction in alcohol use" (p.10) and this could already be noted "as early as the first session" (p.11). 

They go on to note that therapists vary in their abilities and successes both between each other and with different patients: "even the best therapists are not effective with every client" (p.13). As a result, it is important not to overlook "the fit between client characteristics and therapist skills" (p.14). Nina Coltart first alerted me to this in her writing on the importance of careful intake assessment to see whether there is a good fit, and, if not, to carefully consider whom one might refer a patient to for a better fit. 

Chapter III gets into empathy in detail, considered here as "accurate empathy." The authors introduce the qualifier "accurate" to reflect the fact that a good psychotherapist will modify his or her own affect in response to what the patient is manifesting in the moment. They will also draw on their own curiosity to find out more about what the patient is feeling and experiencing. 

Accuracy may also enjoin patience upon the patient and therapist alike. That is to say, psychotherapy may be seen as an invitation to slow down to engage in Listening with the Third Ear for the voices of (in Eliot's lovely words) 

the children in the apple-tree/Not known, because not looked for

But heard, half-heard, in the stillness/Between two waves of the sea.

Quick now, here, now, always—/A condition of complete simplicity

(Costing not less than everything)

Accurate empathy's power, the authors flatly note in this chapter, is well documented now. Drawing on the results of "a meta-analysis of 82 independent" studies, it is clear that "of all the therapeutic factors that have been studied, accurate empathy has the most consistent relationship to positive client outcomes" (p.29).

Chapters IV-VI strike a very Rogerian note. Chapter IV, on Acceptance, stresses the need for psychotherapists to manifest "nonjudgmental acceptance" of everyone who comes before them. Later in the book they will note that "there is a direct relationship between your ability to extend acceptance to others...and your self-acceptance" (p.57). 

Chapter V discusses Positive Regard, calling it "a major curative factor in any approach to therapy" (p. 43). What does it look like concretely? The authors suggest that a psychotherapist shows positive regard for patients in "a commitment to their well-being and best interests" (p.44). Towards the end of the chapter they caution that this must be finely "titrated" depending on patient and circumstance. This is especially true--as I have noted in previous entries on here--with patients having psychotic or schizophrenic disorders. With them, excessive or even moderate expressions of positive regard can be taken as serious threats, provoking unexpected and unhelpful reactions. 

Chapter VI, Genuineness, may be found in such qualities as "spontaneity, humour, and vulnerability," all of which aid in building and strengthening the working alliance. 

Also in this chapter--though, alas, without citing him--they authors refer to the need, precisely to maintain your genuineness as a psychotherapist, to deal with negative feelings towards patients, which D.W. Winnicott famously called "Hate in the Counter-Transference." This remains my favourite of DWW's papers, and I have written about it in several places.  

Chapter seven, Focus, looks at the importance of setting goals that both psychotherapist and patient agree to as a way of staying on track and strengthening the working alliance. (Chapter XII will note the common finding that ruptures in the working alliance are associated with poorer outcomes for psychotherapy. But these are rarely irreparable, and the very act of openly repairing such breaches can itself strengthen the alliance new.) 

In addition, goals remind both parties that this is not just an ordinary sympathetic chat, which one can get without payment over some tea with a close friend. As my first supervisor drilled into me, the very fact that money is involved (however regrettable that may be, and however much that disturbs some of us!) means that you can never be friends with your patients. It also means that you need a treatment plan, but not one carved in stone. It can and should be revisited on a regular basis to see if we are on track, or if we need to make changes, or to consider moving towards termination--or, in a perhaps better formulation I recently came across, discontinuation of services.

Focus also helps with the ever-present and universal problem of ambivalence. The authors review the evidence to indicate how unhelpful it is to push too far and too fast for change when ambivalence has manifested itself. Your job, rather, is to help your patients talk themselves into change. For some, getting past this ambivalence is all that is necessary: the patient is then off to the races and requires little help. Others, however, may require different skills and assistance from you once they start pursuing change seriously. 

Still others may need neutrality from you, or you may deliberately choose that for a variety of reasons. This is my own default position, influenced as I am by psychoanalysis and its very high respect for patient freedom, perhaps most sharply captured by Bion's famous counsel to the psychotherapist to begin every session "without memory and desire" so as to avoid unduly pushing the patient in one direction or another. I do not find a literal and strict interpretation of Bion entirely feasible in most cases, but it remains a useful counsel of perfection as it were. 

In all cases, a fine balance must be struck: your job is not to carry patients across the finish line of change, nor to ignore their efforts to get there. And these authors also have a high respect for patient autonomy (p.78) which needs to be set alongside shared goals for "when the goals of therapy are agreed upon, progress is much more likely" (p.79). 

Chapter VIII, Hope, reflects longstanding research (going back to the famous HARP studies first published in 1961) that if the psychotherapist is hopeful, even if the patient is not or cannot be just then, such hopefulness can have a very positive effect on outcomes. Hope here extends not just to the prospects of patient improvement, but also to your own attitude towards treatment: do you yourself believe that what you are doing, the treatment you are offering, is effective and important? Hopefulness is, they say, "contagious" and in some cases you can "lend...some of yours" to your patients if they cannot find it just yet. I have done this on occasion with severely traumatized patients feeling overwhelmed by their many challenges and not seeing much light on the horizon. (Of course, like all things, your extension of hope must be finely judged so that you are not foolishly prattling on about the hope of a total, immediate, and facile "recovery" to someone who has been, say, a heavy addict for thirty years, or a lifelong victim of sexual abuse.) 

Additional techniques here include asking patients to narrate past experiences where they had some success over a particular challenge. Another is to focus on their strengths. 

Hope for change can be seriously undermined, the authors note at the conclusion of this chapter, by a waiting list, for the research indicates that patients do exactly that: sit and wait. They do not, in other words, get started on any changes. This can be demoralizing and deflating of their discipline and desire to get started on change. For this reason, then, I here recall the words of an addictions psychologist I knew: you or your staff who answer the phones (e-mails, etc.) from people seeking services should give the warmest possible response with the utmost dispatch--within 24 hours at the most. People have often taken weeks, months, sometimes years to work up the courage to call for help, and you need to meet them at that moment wherever possible. Do not leave them hanging for days or weeks, even if you are very busy and cannot fit them in at that moment. 

Chapter IX, Evocation, focuses on a skill the authors see as uncommon and infrequently developed in the training of therapists. They do so based on the conviction that patient characteristics play a huge role in the success of therapy just as those of the clinician do. So the task of the therapist here is to evoke in the patient his or her own skills at self-healing. This is a position that starts from the assumption that the patient is in not just a state of deficit but also a position of having riches to offer they may not be aware of or able to access just yet. To access these riches, they may need your curiosity as a clinician to call them forth.

One way to help patients do this is summed up as O.A.R.S.: Open Questions, Affirmation, Reflection, and Summary. All this is to evoke that "change talk" that Miller first made famous in Motivational Interviewing. 

Chapter X, Offering Information and Advice, is one that, admittedly, I read with the greatest resistance, especially when flatly told by these authors that "Advising is a part of your job" (p.110). I make it very clear to my patients that I am not in the advice business. I think offering advice almost always infantilizing and counter-productive, and I loathe doing it. I am never so much a student of Erich Fromm as here in wanting people to live out their own freedom without fear and to find their own way. 

That said, these authors point to an example that I have myself done: recommending reading material. I once had a patient who for several months was manifesting great ambivalence, bordering on anxiety, between two very different career paths, each of which I thought she was romanticizing unduly while being very anxious about what she would miss in choosing one over another. So when she asked for something to read about this my mind shot immediately to Adam Phillips' Missing Out: In Praise of the Unlived Life, which I tried to mention as neutrally as possible so that my great enthusiasm for all of Phillips' works would not come out unduly. I made it clear--I think!--that I was simply reflecting how valuable I have found Phillips, and not telling her that she had to read him. But she turned up at the next session with the book under her arm, half of it read and heavily underlined in parts, and we had two or three sessions profitably discussing the book.

Chapter XI, The Far Side of Complexity, is a bit of a jumble as the authors seem clearly at pains to take avoid taking a clear stand on things bolder clinicians like Coltart have just come out and forthrightly spoken of as "faith; faith in ourselves and in this strange process which we daily create with our patients." For Miller and Moyers, they dance around such seemingly "spiritual" or "theological" language by invoking slogans like "simplicity on the far side of complexity" and talking about transcendence and shoveling in a few gratuitous bits of Buddhism that have too little context or elaboration to be useful. 

Coltart is again much better here in capturing this simplicity-within-complexity dynamic in describing the therapist as engaged in

sharply focusing, and scanning; complex involvement in feelings, and cool observation of them; close attention to the patient, and close attention to ourselves; distinguishing our own true feelings from subtle projections into us; communicating insight clearly, yet not imposing it; drawing constantly on resources of knowledge, yet being ready to know nothing for long periods; willing the best for our patients and ourselves, yet abandoning memory and desire; a kind of tolerant steadiness which holds us while we make innumerable, minute moral decisions, yet steering clear of being judgmental (Slouching Towards Bethlehem, p.119). 

Chapter XII stands at the start of Part III of Effective Psychotherapists, which, with the exception of the previous chapter, has so far been written with wonderful and admirable cogency and clarity, making this an ideal text for undergraduates or graduates alike. (I am very warmly recommending it to my students next semester in my Introduction to Counselling course.) 

This chapter, Developing Expertise, records the startling but simultaneously reassuring and "widely replicated finding that therapists' years of experience are unrelated to their actual expertise" (p.127). Left unsaid here is a tempting line of thought I might have developed about the need for more careful screening of students into training programs to see if some of the attributes discussed earlier in this book are in evidence or not. 

Also left unsaid here is any discussion about the centrality of the psychotherapist's own psychotherapy. Raising this point seems to generate a lot of controversy and resistance among some, for reasons which are not clear to me. I regard it as de rigueur that a psychotherapist must have done their own in-depth work. I know I could never do this myself without having spent years on the analytic couch, as I have done in three separate periods. Freud was right, in one of the last essays he wrote, "Analysis Terminable and Interminable," in seeing that one's own analytic therapy offers both skills and insights which are "not ceasing when it ends." But the gains may be limited, which is why he rightly goes on, later in that essay, to call for the therapist "periodically--at intervals of five years or so--[to] submit himself to analysis once more, without feeling ashamed of taking this step." 

In addition to one's own semi-regular therapy, Miller and Moyers argue there are things a clinician can do to improve in certain areas or to acquire or reinforce certain skills. These they treat under the heading of "deliberate practice" which has two components: some skill you very consciously focus on developing, and some supervision of it or feedback about it you also consciously cultivate and seek out.

The book concludes with Chapters XIII and XIV, which may be of some limited interest to academics teaching courses in psychotherapy and counseling, including courses in skills and techniques. 

Overall, the book is a very useful and up-to-date summary of what we know about Effective Psychotherapists and their clinical skills, and it is written in a way that allows its summaries of relevant and recent research to be made easily accessible to general readers, students, and scholars alike.