Motivation and emotion/Book/2021/Brief motivational interviewing as an intervention for addiction

Overview
People are the undisputed experts on themselves. No one has been with them longer or knows them better than they do themselves. In MI, the helper is a companion who typically does less than half of the talking.

This chapter provides an overview of how brief motivational interviewing (MI) is used as an intervention for addiction. In MI, it is assumed that people are the undisputed experts on themselves. Brief motivational interviewing (MI) is a counselling method that uses a client-centred approach to change health behaviour. It uses a collaborative conversational style to strengthen a client's motivation and commitment to change (Miller & Rollnick, 2012). The role of MI therefore is to explore the person's own reasons for change within an atmosphere of acceptance and compassion (Miller & Rollnick, 2002). MI has the goal of creating an internal desire for a change from the client. The therapist listens more than talks and draws out the client's own perceptions instead of imposing perceptions on him. In this way, the client is inclined to be more interested in maintaining the change over a longer period (Miller & Rollnick, 2012).


 * What is brief MI and how it is different from MI?
 * What theory supports that brief MI works?
 * Is brief MI effective for different addictions?

What is brief MI?
The following fictional case study aims to assist readers with theory-in-action:

 John, a problem drinker, has been working with his counsellor and has identified getting employment as his most important goal. His therapist does not confront John's perspective and tells him that his drinking is a problem and how he lost several jobs because of it. Rather, they engage in a review of past work experiences and in an exploration of what would need to be different in order to make this next employment attempt successful. This example showcases how brief MI can be used as an intervention for addiction.



MI was founded in the 1980s by clinical psychologists William R Miller and Stephen Rollnick and was initially developed as a brief intervention for problem drinking. In today's day and age, the applications of brief MI have expanded to include other types of addiction, such as gambling and smoking (DiClemente et al., 2017). Brief MI was proposed to meet the needs of clinicians who have little time to use the full range of MI techniques in practice (Fontaine et al., 2016). Brief MI is typically provided as a brief intervention, within one to four sessions (Burke et al., 2003). However, there is no consensus on how much time should be left between sessions (Rubak et al., 2005).

The key differences between MI and brief MI are summarised in the table below: Source: Adapted from Miller and Rollnick, (2002)

Four fundamental processes of brief MI
There are four fundamental processes which take place during a session of MI. These processes describe how a typical MI conversation is to go, although practitioners may move back and forth among processes as needed (Miller & Rollnick, 2002). The following section elaborates on each of these processes and includes a case study of a gambling addict at each stage of the MI process.

Engaging is the first process for motivational interviewing and refers to the process in which a productive working relationship is established. In this process, careful listening is used to understand the person’s perspectives and accurately reflect the person’s experience.  Engaging 

Counsellor: What brings you to counselling?

Client: I am concerned about my gambling, but I do not know if I can stop. I have tried so many times to stop, but I have failed. I enjoy it too much, I think.

Counsellor: You wonder if you can give up your gambling and it worries you?

Client: Yes, but it's for my good, I guess. I mean it's really serious. I am gambling a lot, spending most of my pay which my partner has indicated is upsetting to her. Sometimes when I wake up in the morning, I feel really awful, and I can’t think straight.

Counsellor: You have a strong sense it is harming you which shows that you have a great insight into the impact your addiction is having on your life.

Focusing is the next process. Within this process, the client and practitioner will move to focus on the issue at hand. In this process, an agenda or shared purpose is negotiated between the two parties. This allows the therapist to move into a directional conversation about change. Focusing 

Counsellor: If it is okay with you, let me check I understand everything that we've been discussing so far. You have been worrying about how much you've been gambling in recent months because you recognise that you have experienced some health issues associated with your gambling, and you've had some feedback from your partner that she isn't happy with how much you’re spending on gambling. But the few times you've tried to stop gambling have not been easy, and you are worried that you can’t stop. How am I doing?

Client: Yes, that is correct.

Counsellor: Are we happy to negotiate that reducing your gambling is currently what is on your agenda right now?

Client: Yes, that is currently what I would like to work on.

Evoking involves eliciting the client's motivations for change. In this process, ambivalence becomes normalised and explored without judgement. Hence, it is during this process that ambivalence is resolved. This process requires skilful attention to the person's talk about change. Evoking 

Counsellor: On a scale from 0 to 10, where 0 means "not at all important" and 10 means "the most important thing for me right now", how important is it for you to change your gambling behaviour?

Client: I think I would say that I am at a 5.

Counsellor: Why are you a 5 and not a 1?

Client: I chose a 5 and not a 1 because I know if I don’t stop losing money on the pokies, my rent is going to get further behind and my partner and I could get kicked out of the house which would also put further strain on our marriage.

Counsellor: So, let me try to pull together some of what we’ve talked about so far. Things have been quite difficult for you over the past few months because your gambling has been causing financial stress. You think it is going to be hard work to change the gambling behaviour and you also know how important it is for you to make a change to improve your marriage.

Client: Yes, indeed.

Planning is the final process. Planning refers to the process in which commitment to change is developed as well as when a specific action plan is formulated. Planning like the other stages should be revisited from time to time as change proceeds and is an ongoing process (Miller & Rollnick, 2012).

 Planning 

Counsellor: Well, we've covered a lot of ground today in a short time. Help me remember it all. First and foremost, you are choosing to think about these past few months as an opportunity for you to make some good changes in your life and to get your priorities straight.

Client: Yes, that is right.

Counsellor: Ok perfect, if you are interested, I can give you a number for a self-exclusion program that can help you to reduce your gambling?

Client: Yes, I would be interested. Thank you for the help.

Counsellor: Amazing, and what other steps will you take to reduce your gambling?

Client: I think I'll create a budget with my wife and take up a hobby together.

Counsellor: I think that sounds great. Telling your wife keeps you accountable and I'm sure she will be happy to support you to reach your goal.

Theoretical basis of brief MI


To understand how brief MI can be used as an intervention to treat addiction it can be useful to look at the theoretical underpinnings of the intervention itself. Although MI is not based on any one theory it has been linked to a number of social-psychological models of health behaviour (Hardcastle et al., 2012). Three theories of motivation which are commonly associated with brief MI include the Transtheoretical model, Self-perception theory and the Theory of planned behaviour. Each of these theories offers some form of explanation as to why MI works and how it can be used as an intervention for addiction.

Transtheoretical model
MI can help enhance the motivation of clients by resolving their ambivalence to change (Feldstein Ewing et al., 2016). According to the transtheoretical stages of change model developed by Prochaska and Diclemente, MI helps clients overcome hesitation toward change during the early stages of the change cycle. The model states that behaviour changes encompass a cycle of stages (see Figure 2). At the earliest stages, while people rarely make changes, they do often ponder change. Studies show that implementing motivational interviewing in these early stages can lead to positive results (Miller & Rollnick, 2002). Precontemplators do not want to be lectured to or given “action” techniques when they are not ready to change. Likewise, contemplators, who are considering the possibility of making a change but are not quite ready to commit, are resistant to more traditional approaches that encourage (or try to force) them to make changes for which they are not yet ready. Although motivational works best in the early stages it is also helpful in the later stages of therapy (Wilson & Schlam, 2004). A limitation of MI is that it works best during the early stages of the change model and has limited application during the later stages.

Self-perception theory


Self-perception theory focuses on the language processes and explains how client behaviours during the motivational interviewing process may initiate behaviour change. Self-perception theory states that the expression of change talk by the client during motivational interviewing facilitates behaviour change (Miller & Rollnick, 2002). Change talk refers to the clients' statements about their desire, ability, reasons and need for change. The reason that change talk is thought to facilitate behaviour change is because in voicing and hearing their own arguments for change, clients adopt new attitudes and beliefs about change and essentially “talk themselves into” the change process (Miller, 1983). It is also suggested that the therapist further facilitates this process by being empathic and accepting. Showing empathy enhances acceptance as an accurate understanding of the client’s circumstances can facilitate the client’s sense of being accepted. If the client feels accurately understood, then acceptance by the therapist is perceived to be more genuine and reliable and less contrived. This leads to a greater probability that the client will emit previously punished, painful, or sensitive verbal behaviour about their addiction (Christopher & Dougher, 2009).

Theory of Planned Behaviour
According to the theory of planned behaviour beliefs provide the basis for attitudes, subjective norms and perception of behavioural control. These factors are proposed to influence one’s intention to perform a behaviour (see Figure 3). The key determinant of behaviour in the theory of planned behaviour is the intention to perform the behaviour in question (Steinmetz et al., 2016). Using this theory as a theoretical framework, brief MI aims to change behavioural, normative, and/or control beliefs, and consequently, motivating performance of the behaviour. Research suggests that brief MI is closely linked with self-efficacy and in particular attitudes and perceived behavioural control (Hall et al., 2021). Components of MI such as setting personal goals, providing individualised feedback, and using visual imagery are all motivational interviewing components that enhance self-efficacy (Hardcastle et al., 2012).

Review Questions
{The key determinant of behaviour in the theory of planned behaviour is the intention to perform the behaviour in question?}

+ True - False

{Self-perception theory focuses on the language processes of MI?}

+ True - False - Neither

Efficacy of brief MI as an intervention


Brief MI has been proven to be effective in treating drug and alcohol addiction. It is an evidence-based practice supported by strong empirical evidence with 200+ randomised clinical trials on brief motivational interviewing (Cushing, Jensen, Miller & Leffingwell, 2014). Results show that it is efficacious in the treatment of many conditions including addictions such as gambling and smoking (Nastally & Dixon, 2012).

Problem drinking
Studies have shown that motivational interviewing results in favourable outcomes in patients experiencing substance use disorders (Vasilaki et al., 2006; Miller, 1983). Vasilaki and colleagues (2006) conducted a meta-analysis that focused exclusively on studies of excessive alcohol consumption. To be included, studies needed to claim that MI principles were adopted as well as include a comparison group and utilise random assignment. The aggregate effect size for the 15 included studies, when compared to no-treatment control, was d = 0.18 and, when compared to other treatment groups, was d = 0.43. However, this difference by comparison group was not statistically significant. The meta-analytic review of 15 randomised controlled trials reveals that brief MI is an efficacious strategy for reducing alcohol consumption. A limitation of the findings from the review are that it can only be generalised to heavy or low-dependent drinkers (Vasilaki et al., 2006).

Gambling


According to the research literature, brief MI is an effective treatment for problem gambling. Several randomised clinical trials have been conducted to establish the efficacy of brief MI in the treatment of gambling disorders and have yielded promising results (Hodgins et al., 2004; Hodgins et al., 1999). Yakovenko and colleagues (2014) conducted a meta-analysis reviewing five randomised controlled trials (N = 477) published between 2001 and 2009, each using a single session of MI ranging between 20 and 75 min, with three including a CBT-based workbook. Results of the meta-analysis showed modest but significant effects post-treatment (1–3 months), in days of gambling per month and money spent (approximately 10% reduction in log units). However, at short-term (6 months) and long-term (9-12 months) follow-ups, only decreases in gambling frequency were maintained. Tests of heterogeneity were significant at long-term follow-up and should be interpreted cautiously. Treatment fidelity was not assessed systematically, but the authors stated that each single session trial adhered to the principles outlined by Miller and Rollnick (2002).

Smoking cessation
Smoking cessation compared with substance use disorders, however, has been less responsive to brief MI (DiClemente et al., 2017; Lindson et al., 2019). A Cochrane review conducted by Lindson and colleagues (2015) provides the most rigorous and comprehensive review of the evidence on smoking cessation and included 28 studies, with over 16,000 adults in the meta-analysis. Their review included studies of telephone counselling in addition to individual, in-person sessions. Overall, they found a weighted average 16.9% quit rate for those receiving an MI intervention across all 28 studies compared with 14.2% in control groups indicating a moderate level of support. When comparing MI interventions to controls, this resulted in an RR of 1.69 (95% CI 1.34 to 2.12; 9 trials; N = 3651) (Lindson et al., 2019). Surprisingly, they also found that MI was not more effective when compared with no treatment or self-help controls but did show benefits over an in-person health warning. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision, and inconsistency (Lindson et al., 2019). It has been hypothesised that because there are legal implications behind drug abuse and not smoking, it is therefore seen to be less debilitating and the consequences less fatal to clients (Burke et al., 2003).

Conclusion
Brief MI has become increasingly more popular in psychology as an evidence-based practice to treat addictions. Therefore, it is important to understand what brief motivational interviewing is, how it works, and how it is used to treat addiction. This chapter discussed the aim of MI and the different processes of motivational interviewing. We also discussed through a case study how these different processes are reflected in a brief motivational session. Various studies were also discussed which showcased the efficacy of brief motivational interviewing as an intervention in treating problem drinking, smoking, and gambling. Overall, there is strong empirical evidence of the efficacy of brief MI as an intervention for addiction, with variety in effectiveness depending on addiction type. However, future studies should be conducted so that standardised methods can be developed for the intervention.

Although not everyone with an addiction will seek treatment, those suffering should be aware that brief MI can be used as a treatment option. Brief MI is both non-invasive and the outcomes of brief MI are promising. Many treatments for addiction include medication which might be a frightening thought for some. Therefore, brief MI is a suitable alternative as it is a gradual process and occurs within an accepting and compassionate environment. Research has shown that it is a beneficial tool in dealing with addictions such as gambling, smoking and problem drinking. Theories of motivation offer some form of explanation as to why MI works and how it can be used as an intervention for addiction. Theories suggest that brief MI can motivate an individual to change their behaviour as individuals unpack their reasons for change. Self-perception theory also suggests that people talk themselves into changing via this process and in turn this reduces their addiction. It is hopes that this chapter offers insight into brief MI and how it can be used to recover from addiction.