—Miller (1995) defines MI as follows:
"Motivational interviewing is a directive, client-centered counseling style of eliciting behavior change by helping clients to explore and resolve ambivalence. Compared with non-directive counseling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal."
MI is a way to help students recognize they have a problem and need to make a change. Many students seeking care in a student health center are already concerned about their drinking, tobacco use, or some other behavior. They just don't know where to start. MI attempts to "unstick" students, so they can begin to change. MI techniques create an openness and readiness to change. Some students will change after one or two MI encounters, while others may require more intensive counseling.
Key Elements of MI
1. Express Empathy
Empathy is based on respect, an acknowledgement of the student's perspective, and acceptance of the student's point of view. The clinician tries to understand without criticizing, judging, or blaming. Reluctance to give up a behavior such as high-risk drinking is a normal psychological process. It is not pathological. However MI does not give the student permission to continue his/her high-risk behavior. Acceptance of a student's position is not the same thing as agreeing with the student's position or condoning high-risk alcohol use. The next principle is designed to change the student's position by developing discrepancy.
2. Develop Discrepancy
Many students understand their alcohol use is having an adverse effect on many aspects of their lives. They understand they are at risk for alcohol-related accidents, injuries, and academic problems, especially if they are under 21 years of age. While they like to drink and party, they also recognize many of the negative things associated with high-risk drinking. Discrepancy seeks to amplify, intensify, and accentuate these negative thoughts and ambiguous feelings about their alcohol use. Discrepancy tries to help students set personal goals such as academic success, health, and strong personal relationships above their desire to use alcohol. MI tries to identify specific examples of how the drinking resulted in an experience that conflicted with the students' personal goals, values, and internal beliefs about themselves.
3. Avoid Argumentation
Direct argumentation often evokes resistance and hardening of the student's position. MI uses low-key persuasion. MI tries to start from the student's position and to work from that point. Strong statements such as - "You are in denial." or "You are alcoholic." - often lead to an increase in student resistance. From a harm-reduction paradigm, clinicians will help more students reduce their alcohol use by spending two minutes with 10 patients using MI techniques than arguing with one student for 20 minutes.
4. Roll with Resistance
Jay Haley, who is an expert on family therapy, coined the term "psychological judo". As with judo and martial arts, one can use a student's own momentum to move them into a fall or a different position. MI can move students such that they say, "How did I get here?" Reluctance to change is acknowledged by the therapist as normative, based on the students' perception of their alcohol use and its relationship to their peers and environment.
5. Support Self-Efficacy
A fifth MI principle is self-efficacy. Students need to believe they can change and successfully reduce their alcohol use. Hope and faith are important elements of change. Clinicians can use positive statements to facilitate the sense that students can alter their behavior. The other element of self-efficacy is taking personal responsibility for change.
Additional points that may be helpful to primary care providers utilizing MI:
Move student From the following position:
"I am not interested in reducing my alcohol use. I drink less than my friends." " I see no reason to change how much I drink. It is part of the college experience. I am not having problems so why should I cut down?"
"If I stop drinking I will feel better and maybe do better in school. However I am not sure what my friends will think. I am not sure how I can party and have fun if I don't drink so much." To: "Maybe I do drink too much. I am willing to try to cut down. How much do you think it is safe for me to drink?"
Provider statements not based on MI:
"If you don't stop drinking, you will be expelled."
"If you don't stop drinking, you will lose your job."
"If you don't stop drinking, you will never get into graduate school."
"If you don't stop drinking now, you will turn into an alcoholic."
Student: "Doc, I don't think I have a problem or need to cut down."
Provider: "John, I have to respectfully disagree. You had a serious accident after you were drinking. You are not doing well in your classes. Your girlfriend left you. I am not sure how serious things are, but I think you should consider how alcohol is contributing to these problems."
"The X-ray on your arm that we took today suggests your broken arm is healing well. Based on the extent of your injuries, it sounds like you had a serious accident. Your medical record says you had a blood alcohol level of 0.16. How about telling me about the accident and the role of alcohol in that accident?"
Provider: "Only you can decide to reduce your alcohol use. This is your decision. I am here to treat your medical problems and to hopefully prevent you from getting into trouble with your drinking. What do you think about agreeing to cut down for a month or two and seeing how it goes?"
An example of brief intervention without the use of MI principles: "John, you drink too much. It is bad for you. It will affect your grades and you may have a serious accident. You may forget to use a condom and acquire an HIV infection. As your doctor, I am recommending that you to cut down to 3 or 4 drinks when you go to party with your friends."
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Handmaker, N.S. & Wilbourne, P. (2001); "Motivational Interventions in Prenatal Clinics;" Alcohol & Research Health, 25, 219-21-9.
Miller, W.R. (1983); "Motivational Interview With Problem Drinkers;" Behavioral Psychotherapy 11, 147-172.
Miller, W.R. (1985); "Motivation for Treatment: A Review With Special Emphasis on Alcoholism;" Psychological Bulletin. 98, 84-107.
Miller, W.R., Benefield, R.G., & Tonigan, J.S. (1993); "Enhancing Motivation for Change in Problem Drinking: A Controlled Comparison of Two Therapist Styles;" Journal of Consulting and Clinical Psychotherapy, 61, 455-461.
Marlatt, G.A., Baer, J.S., Kivlahan, D.R., Dimeff, L.A., Larimer, M.E., Quigley, L.A., Somers, J.M, & Williams, E. (1998); "Screening and Brief Intervention for High-Risk College Student Drinkers: Results From a 2-Year Follow-Up Assessment;" Journal Consult Clinical Psychology, 66, 604 615.
Monti, P.M., Colby, S.M., Barnett, N.P., Spirito, A., Rohsenow, D.J., Myers, M., Wollard, R., & Lewander, W. (1999); "Brief Intervention for Harm Reduction With Alcohol-Positive Older Adolescents in a Hospital Emergency Department;" Journal Consult Clinical Psychologist, 67, 989-994.
Last reviewed: 9/23/2005