Capturing the Spirit of M.I.

As we are about to begin the 2^nd quintile of the 21^st Century, there are likely few readers unaware of Motivational Interviewing (MI). That said, acronyms like OARS, FRAMES, and other similar pneumonic tools from MI are also likely familiar terms. This familiarity, however, may…and I emphasize may…give rise to a problem when practitioners employ these strategies and techniques of MI in their work. This potential problem results from being proficient in their use but lacking when it comes to purveying the spirit of MI.

Although the use of MI strategies and techniques without necessarily conveying the spirit of MI is better than the traditional “attack therapy” approach used when “confronting” substance use disorders (SUD) years ago, when its strategies and techniques are couched in the spirit of MI, that is when the magic truly happens in brief motivational interactions. As an adage in AA goes, people do not care what you know until they know that you care. This sense of “being cared for” does not automatically result from the use of “technique.” Rather, it results from that more intangible “something else” or “extra” that may best be described as the “aura” that surrounds the use of MI’s techniques and strategies.

This brief essay is an attempt to outline what that “aura” might look like:

·      The spirit of MI finds the practitioner less interested with doing something “to” individuals and more focused on doing something “with” them. When a practitioner understands that she or he is a practitioner 2^nd and another human being 1^st, that is when it becomes possible to truly embrace the individual being interviewed as the expert on her- or himself;

·      Related to this, MI is not concerned with “putting in” or “filling up” the individual with what she or he lacks or “needs to know/understand/accept” to change. Rather, the practitioner is interested in “drawing out” what’s what from the individual. To call upon an old counseling 101 reference, Johair’s Window, the practitioner embracing the spirit of MI seeks to help individuals see and then understand those things hidden in the “blind spot” or “unknown-by-the-individual-but-known-by-everyone-else” quadrant;

·      When a practitioner creates an environment where these previous two aspects of MI’s spiritual nature are conveyed, “change talk” becomes possible. Remember: Change is an inside job. As Sandra Anise Barnes writes in her book of poetry, Life is the Way It Is, “It’s so hard when I have to, and easy when I want to.” MI is about helping individuals discover that “they want to change” not that they “need to change.” Like in the adage about leading horses to water but not being able to make them drink, remember…we can always salt the oats.

·      Practitioner’s embracing the spirit of MI conduct interviews that have more in common with an intercession than an intervention. An intervention is when I confront you to stop—or attempt to stop you—doing what I believe is the wrong thing for you to do. An intercession is when I attempt to present a different perspective from which to look at what you believe are the facts for which you have only one possible interpretation. Borrowing from cognitive behavior therapy, an intercession attempts to help you realize that “thoughts are not facts.” When interceding, I neither stop you nor prevent you from deciding what you will or will not do but I do present you with ways of looking at “your facts” from a different perspective, often employing OARS and FRAMES and other such MI techniques and strategies;

A last thought, for this essay anyway—but by no means the end of all that is involved in capturing the spirit of MI—is remembering to use what is called “person-first” language. This means that practitioners conveying the spirit of MI view and respect the individual with whom they are working as an individual. I work with John Jones who is an individual with an alcohol use disorder, not an “alcoholic”; Mary Brown who has a substance use disorder, is not “an addict.” The language we use conveys messages and meaning to not only the individuals with whom we work but also shapes the way we view those individuals and, consequently, interact with them. Even terms like “client” and “patient,” while professional and respectful, nonetheless establish something of an “us/them” relationship. Remember: MI views the individual being interviewed as the expert on her- or himself and when the individual who is an effective practitioner connects with that individual who is the expert on her- or himself, that is when the magic in counseling truly happens, magic being a euphemism for the spirit of MI.

What do you think?

Cognitive Dissonance: The Parable of the College Drinker

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There once was a student who entered college a somewhat experienced drinker, having begun in high school. Upon arrival, absent a curfew and any parental supervision, his periodic drinking expanded in both frequency and consumption. This pattern soon brought him to the attention of residence life officials when following one outing he returned to the residence hall, intoxicated, and mistaking the elevator for a restroom, was written up after relieving himself between the 1^st and 4^th floors of the hall where he resided. As this was the first documented violation of university policy, he was given the option of choosing between a $300 fine and parental notification of the exact nature of his violation or to complete an alcohol assessment led by a practitioner familiar with the principles of Motivational Interviewing and trained in the use of BASICS, Brief Alcohol Screening and Intervention for College Students.

The brief two-session assessment was far more attractive than parental notification and a significant fine so he opted for the screening. Although expecting the sessions to be akin to a mandated “dad-talk” type lecture, he was pleasantly surprised when upon arriving for the first session, the practitioner seemed less concerned with his violation and more interested in initiating an open conversation about the role alcohol and drinking play in his social life. As a result, a decision he made to avoid parental repercussions and to save money presented him with an opportunity to step back from his drinking and consider if the price he was paying for a good time was worth what he was consistently having to pay to realize it. Following the two-mandated sessions, the student agreed to extend his contacts with the practitioner to learn more about how he could moderate his use to avoid further violations and other consequences associated with high-risk drinking yet continuing to socialize with friends and enjoy his college experience.

This parable is far from unique and certainly is not fictional. Such collegiate experiences are realized on campuses across the country on a regular basis. In my own career this very scenario—although the alcohol-related violations resulting in a referral for an assessment would vary tremendously—would occur regularly with outcomes that were frequently the same.

Motivational Interviewing (MI) and its use in BASICS interviews have a long and well-documented history of effectiveness. However, this essay is not intended to champion either MI or BASICS as clinical strategies for addressing high-risk collegiate drinking. Rather, the focus of this essay is the consideration of one possible explanation for why these intercessions with students seem to work so well.

Cognitive Dissonance is a psychological state of emotional discomfort resulting from the presence of opposing beliefs, ideas, or values. A classic example used to illustrate this point  in intro psych courses references a hypothetical child told by its parents that all blue-eyed people are bad and not to be trusted yet when the child meets blue-eyed children and finds them fun to be with and enjoys their company, the beliefs instilled by the child’s parents conflict with the experience the child has in the real world resulting in a state of cognitive dissonance. When experiencing such, there are two primary ways one can assuage this dissonance: (1) change one’s behavior and/or (2) change one’s attitude.

The practitioner utilizing the principles of MI and conducting BASICS interviews is tantamount to the blue-eyed child our student meets who presents an opportunity to consider established beliefs about alcohol as a substance and drinking as a behavior, creating dissonance for the student. One of the primary ways the BASICS practitioner accomplishes this is with a series of very simple open-ended questions, asking, what are the good things about drinking and then following this with, what are the less good things about drinking? Then by presenting an opportunity to overlay the student’s alcohol use history atop this continuum of “good things to less good things” consequences—the good things representing the positive consequences of drinking for the student and the less good things representing the more negative consequences—the student is able to discern that there is a negative correlation between the number of drinks consumed and the cited good things happening (fewer drinks consumed is associated with more of the good things happening) while there is a positive correlation between less good things happening and the number of drinks consumed (as the number of drinks goes up so does the frequency of experiencing the less good things).

Remember that the two primary ways to assuage such dissonance are to change behavior and/or change attitude. In this case, the practitioner, because he or she employed the principles of MI thereby gaining the respect and trust of the student can, therefore, invite the student to continue with additional sessions where they can explore how to moderate consumption and thereby change behavior. There is a saying in A.A., bring the body and the mind will follow or its behaviorist corollary, it is easier to act your way into a new way of thinking than it is to think your way into a new way of acting.

Be that as it may, cognitive dissonance, instilled by the practitioner appreciative of the principles of MI and practicing BASICS, likely explains, in part, why so many students respond to motivational, brief interviews. Avoiding the “dad/mom-talk,” becoming engaged in a nonjudgmental conversation designed to explore one’s drinking history, and presented with the opportunity to conduct a personal cost-benefit analysis of one’s use of alcohol can and does result in changed student behavior, which in turn can result in changed attitudes and beliefs regarding alcohol as a substance and drinking as a behavior.

What do you think?

Dr. Robert

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