It is one of several interventions which can help facilitate change. Other motivational approaches have also been provides in addition to Motivational Interviewing (See A note on context and Pleasure and Pain Re-Conditioning: 14 Steps to Change and Personal Growth)

For example, removing external barriers to change and providing social supports which facilitate change can motivate.  Another strategy for those finding change difficult involves shifting the associations around pain of changing (it's too hard to change) to a motivating force for change (changing will remove pain) as well as shifting the association of pleasure of drug use to one of pain.

However, motivational interviewing is a refreshing and very important intervention in the context of decision making and enhancement of resolution to change. Its success is born out of its novel approach, well structured format and underlying processes based on self-confrontation.

Also available as a PowerPoint presentation at Motivational Interviewing pp.

Uses of Motivational Interviewing

Different from traditional approaches of motivation

Strategies

Motivational Interviewing steps

If no decision or decision is to continue to use drugs

The involuntary client

A note on context

Pleasure and Pain Re-Conditioning: 14 Steps to Change and Personal Growth

Stage of change. Motivational Interviewing can be used at all stages of change for differing reasons. It can raise awareness at the precontemplation stage. It can help in decision making during contemplation. During action and maintenance it can enhance and remind of resolution to change. Following relapse it enables reassessment.

Its greatest use tends to be around contemplation.

Provides clarification. Clients with confusion around issues often find the process of motivational interviewing helps to sort thing out for them.

Applies to most behaviours where there is a degree of ambivalence.

Assessment As clients identify their benefits, costs, life goals, decision and subsequent goals, they have uncovered a lot of information for themselves and their counsellor.

Counsellor can enhance motivation Which is different from the notion that the client either is or is not motivated to change. It's also different from the notion that you have to hit rock bottom to change.

Self-confrontation is the key Traditional approaches use direct confrontation in order to break through denial. This can result in even greater resistance. Motivational Interviewing uses the psychological law, "I learn what I believe as I hear myself speak" - i.e. self-confrontation.

Client has a right to choose Rather than deciding what is best for the client, this approach asks the client to make that decision.

Miller and Rollnick (1991) described five strategies which are at the heart of motivational interviewing:

Express empathy: Reflecting back to the client his/her feelings and thoughts not only helps build rapport, but in this process, helps mirror the clients experience in a way which allows him/her to fully experience their dilemma.

Develop discrepancy: The discrepancy is not so much between the positives and not positives of the behaviour but between the present behaviour and significant goals which will motivate change.

Avoid argumentation: Arguments are counter-productive and results in defensiveness.

Roll with resistance: Otherwise know as verbal judo. The use of reframe or simply changing tack may help maintain momentum towards change.

Support self-efficacy: Motivation is partly made up of two main factors - importance and confidence. While it may be important to change, it won't happen if the client feels unable to do it. Every opportunity is taken to support the client's abilities to aid motivation to change.

1. Set the Agenda: Set the Agenda: It can be useful to 'make a space' in which to conduct Motivational Interviewing. Having clarified the agenda around which there is ambivalence, ask for 20 minutes or so to try a series of special questions called "Motivational Interviewing" to help sort things out.

2. Ask about the positive aspects of the drug use: This is often an engaging surprise for the client. However, it will only work if you are genuinely interested. Use questions like:

What are some of the good things about…?

People usually use drug because they help in some way - how have they helped you?

What do you like about the effects…?

What would you miss if you weren't..?

What else, what else..?

Give praise and support self efficacy - You really know how to have a good time..

SUMMARISE positives

3. Ask about the less good things: Use questions like:

Can you tell me about the down side?

What are some aspects you are not so happy about?

What are the things you wouldn't miss?

If you continued as before, how do you see yourself in a couple of years from now if you don't change?

If they run out of steam too early, use prompts from Liver, Lover, Livelihood, Law. However, don't suggest or put words in their mouth.

Give praise and support self efficacy: You've done well to have survived all of that…

SUMMARISE less good things

4. Life goals: These goals will be the pivotal point against which costs and benefits are weighed. Ask questions like:

What sort of things are important to you?

What sort of person would you like to be?

If things worked out in the best possible way for you, what would you be doing in one year from now?

What are some of the good things your friends and family say about you?

How does your drug use (or you as a drug user) fit in with your goal(s)?

Give praise and support self efficacy: I can see you've got some great vision for yourself…

SUMMARISE life goals

5. Ask for a decision: Restate their dilemma or ambivalence then ask for a decision:

You were saying that you were trying to decide whether to continue or cut down…

After this discussion, are you more clear about what you would like to do?

So, have you made a decision?

6. Goal setting: Goal setting: Use SMART goal setting (Specific, Meaningful, Assessable, Realistic, Timed)

What will be your next (first) step now?

What will you do in the next one or two days (week)

Have you ever done any of these things before to achieve this? What will you need to do to repeat these?

Who will be helping and supporting you?

On a scale of 1 to 10, what are the chances that you will do your next step? (be hesitant about accepting anything under a seven - their initial goal or next step may need to be more achievable)

If no decision, empathise with difficulty of ambivalence. Ask if there is something else (information, time, etc.) which would help to make a decision? Ask if they have a plan to manage not making a decision. Ask if they are interested in reducing some of the problems (restate problems) while they are trying to make a decision.

If decision to continue use, accept decision. Ask if they are interested in reducing some of the problems (restate problems). Use problem solving and harm reduction strategies as necessary.

While this technique can be used with precontemplators, caution should be used if the client - counsellor relationship is still in conflict (eg early stages of investigation of statutory issues). It may be preferable to employ Barber J. (1991) six steps first. See The Involuntary Client

Motivational Interviewing is a useful intervention to enhance the internal motivation of clients. 
However, other external influences can also help or hinder change.  These factors might include structural issues such as accommodation, employment and recreation opportunities, transport, quality of peers, supports etc).  Internal factors such as fear of failure, lack of skills can also inhibit change.

These factors combine to give a more complete picture of the factors which relate to:
Importance, Confidence and Willingness. While these key components of motivation are related to decisional balance, they tend to also be strongly related to these factors.

This can be seen in the Motivation Matrix below:

Goal (eg to improve life
           to stop drug use)

There can be a tendency to focus on internal motivations because these appear to be most accessible (can be conducted in the counsellor's office) and the belief that internal decision making is a strong predictor of change.

While there is some evidence which correlates the quality of decision making to behavioural change, other models such as Behavioural, Systemic and Public Health Models can add more powerful factors. 

This can be especially true when an individual's primary motivating factors are based on external factors (external locus of control).  As many younger and more entrenched drug users motivations are based on external locus of control (particularly male) this should be considered. 

For example, working on safe and supportive accommodation may have a greater effect on a homeless young person's drug use as compared to making a firm decision to cut down drug use.

An example of an alternative motivation towards change model is given in The Emergency Services Child Abuse Prevention Program (ESCAPP) (see below).  The assessment-intervention instrument demonstrates use of a range of motivational factors which are both internal and external and which can either inhibit or facilitate change.  They refer to these as "Components of Individual Functioning" and then spell out a menu of resources which can influence these components.

------------Components of Individual Functioning------------

INDIVIDUAL

INTERPERSONAL

ENVIRONMENTAL

Personal Strengths

Limitations

Supports

Stresses

Resources

Pressures

Augment

Reduce

Augment

Reduce

Augment

Reduce

ASSESS

1. Cognitive functioning/ability
2. Behavioural functioning (coping skills)
3. Affective functioning (emotions & mood)
4. Health
5. Holistic resources/needs

ASSESS

1. Social skills
2. Primary supports (family, etc.)
3. Secondary supports (formal, organisations)

ASSESS

1. Access to resources
2. Availability of resources
3. Noxious stimuli (negative or unpleasant environmental factors)
4. Living conditions

RESOURCES

1. Public, technical schools
2. Mental health agencies
3. Hospitals
4. Vocational training
5. Self-help groups
6. Private/public healthcare
7. Youth service bureaus
8. Drug/alcohol programs

RESOURCES

1. Self-help groups
2. Mental health agencies
3. Social clubs
4. Respite child care
5. Family support centres
6. Churches
7. Home-based services
8. Family servicing agencies

RESOURCES

1. Municipal/state agencies
2. Transportation services
3. Shelters
4. Consumer advocacy groups
5. Youth service bureaus
6. School-based services
7. Police departments
8. Local/state legislators

Click here for more detail on this program.

For most people, reducing or stopping drug use is linked to pain.  Pain avoidance is one of the strongest biological urges.

This method aims to shift negative associations which stops change to become a motivating  force for change.  Subsequently, reinforcement of positive outcomes from small action steps builds over time to develop positive change habits.

This is particularly useful for those who have previously tried changing and not been successful.  Its application can be generalised to other life issues which can also improve motivation.

The key points are:

- Know what you really want
- Know what's been stopping you
- Shift focus to the pain of not changing
- Shift association of drugs use from pleasure to pain
- Enhance confidence
- Use coaches, role models, buddy
- Take immediate, small ACTION
- Notice positive differences (less pain, more pleasure & confidence)

Step 1. 
Start with the end in mind. If everything went well in life, how would you be living? Consider life areas of: physical, social, emotional, financial, relationships, family, recreation & employment.

Step 2. 
How does your drug use get in the way of you goals, your life?
(The Life/Drug connection as it relates to you and your goals)

Identify where drug use inhibits the development of these life areas

Step 3.
Develop goals around what will be achieved (rather than what will be absent).  If reducing or stopping drug use is included, you could say something like "reducing drug use will allow me to create a stronger, more loving relationship with my partner".

Step 4. 
Rate importance.  On a scale of 1-10 how important is making a change?
Rate confidence. On a scale of 1-10 how confident are you about making a change?

Step 5. 
Acknowledge pain associated with changing (physical & psychological & social discomfort - move out of comfort zone).

Step 6.
Shift association to the pain of  not changing (ie if you don't change, what will be the costs in the present and future?).

Step 7.
Shift association with drugs from pleasant to unpleasant. 
a. Tell me what's good about your drug taking.
b. Does thing about these things help you change for the better?
c. Now think about the bad things about your drugs.
d. Possibly use visualisations to strengthen negative associations with drugs by describing scenes where drug use starts of with some positive elements from the client's list and then turns bad.  Try to involve a range of sensory and emotional elements to reinforce negative associations.  You might include an escape scene where the client uses a strategy to get away from drugs towards more positive behaviours.

Step 8.
Link pleasure with changing What are the immediate and longer-term benefits of changing? Link benefits of changing with life goals. Possibly visualise life in one month from now having make positive changes.

Step 9.
Build self-confidence (self-efficacy).  Identify successful steps previously taken towards changing drug use behaviours (times when drugs were used less or not at all).  Identify associated behaviours (the who, how & what - include environmental  influences such as helping others or availability of substances, etc ) and determine willingness to replicate these now.  

Use other confidence building strategies such as positive self-talk (affirmations) challenging negative beliefs, use of positive body language, etc.

Step 10.
Strengthen core beliefs.  Identify other negative, pain associations with making positive changes in life (it's too hard, I'm not worth it, I'm not clever/strong enough, etc) and shift association to success orientation (I have powerful coping mechanisms, I have made changes before, I have resources I didn't consider, etc) I deserve to be successful and free.  Remember times when feeling positive in life and begin to associate the now with those times.

Step 11.
Find a coach/role model/buddy. Find someone who can encourage you, support your energies, bounce strategies off and make suggestions.  Also look for someone you admire who has already achieved the goals you are trying to achieve or has been successful in changing the behaviour you are trying to change.  Find out from them exactly how they did it and copy that.

Step 12.
Strengthen and build ACTION muscle Develop a next step (a short-term goal).  Emphasise that change is an accumulation of taking action through small steps (similar to building muscle with weights).

On a scale of 1-10 how willing are you to carry out this next step? (If under a 7, ask what would be required to bring it up one or two points - if too low, consider an alternative next step which would get a higher rating). 

Step 13.
Reinforce. Review how the action went within 24 hours. Reinforce benefits associated with taking a next step.  

1. Start with the end in mind

2. How does your drug use get in the way of you goals, your life?

3. Develop goals around what will be achieved

4. Rate importance and Confidence

5. Acknowledge pain associated with changing

6. Shift association to the pain of not changing 

7. Shift association with drugs from pleasant to unpleasant

8. Link pleasure with changing

9. Build self-confidence

10. Strengthen core beliefs

11. Find a coach/role model/buddy

12. Strengthen and build ACTION muscle

13. Reinforce

14. Build success habits