Motivational interviewing uses five principles, which are listed below. Counselors should keep these principles in mind during interactions with their clients during the persuasion stage.

Principles of Motivation Interviewing
1. Express empathy (EE)
2. Develop discrepancy (DD)
3. Avoid argumentation (AA)
4. Roll with resistance (RR)
5. Support self-efficacy (SS)

E X P R E S S I N G E M P A T H Y (E E)

To express empathy, the counselor begins by actively listening to the client without offering judgment, criticism, or advice. The goal is to understand fully the client’s situation and perspective. This requires active listening, where the counselor uses body language to show the client he is interested. He faces the client and uses frequent eye contact. He reflects back what he hears the client say. He asks for more information and more details to clarify the client’s view of the world. He does not to give advice, reframe the client’s views, make interpretations, or attempt to persuade the client of anything. The goals of reflective listening are to understand the world through the client’s eyes and to build trust by being a good listener and demonstrating that understanding.

Early in treatment, the client is often not interested in treatment. Pushing for change at this time only turns the client off and increases resistance to change. Thus, initially the focus is on building trust and supporting the client instead of suggesting change. In Kevin’s vignette, the case manager wisely attempts to form a relationship, to listen carefully, and to assure Kevin that change is up to him.

Question 2: What are effective ways of expressing empathy that can help to create the trust and rapport needed to support greater internal motivation to change with a client who is ambivalent about treatment?

1. Listen carefully, then give unsolicited, prescriptive advice.
2. Offer constructive criticism, and reframe the client’s views.
3. Refrain from judging, criticizing or advice-giving, and focus on active and careful listening, with the goal of getting to know the client and his/her situation.
4. Interpret the client’s current circumstances in a negative light, and push the client to change.
D E V E L O P I N G D I S C R E P A N C Y (D D)

One of the goals of motivational interviewing is to identify and amplify discrepancy between behavior and goals in the client’s mind. This is done in two steps. First, the clinician helps the client to clarify what her goals are. It is critical to identify the client’s goals, not the family’s, the clinician’s, or anyone else’s. The clinician does, however, help the client to focus on goals that are feasible and healthy. Together they look carefully at steps needed to reach the goals. Second, when the topic of substance use arises, the clinician helps the client to explore the pros and cons of continued use, especially how the substance use impacts the steps she wants to take towards reaching her goals. This approach assumes that almost everyone who abuses substances is ambivalent about continuing to use. When the client lists pros and cons of substance use and considers them in depth, she will often make her own argument for changing. The clinician then highlights the discrepancy between the goal and the substance use by repeating back to the client her recognition that substance use interferes with her goals. In this process the client may make a statement about concern over her drinking or wanting to change. When this happens, the clinician reflects the statement back.

In Kevin’s case, the case manager helped him with what is called a decisional balance exercise. This exercise is often useful for clients with mental illness. They can be done on simple, structured worksheets that can be used to guide the discussion. The worksheets also serve as visual prompts to focus attention.

In doing this exercise, Kevin identified the “good things” in his life as well as the “not so good” things. The clinician learned that Kevin wished to have his own home rather than live in the shelter, and that he strongly wished to reconnect with his children. He explores in the decision balance some of the steps necessary to getting housing. It might be helpful for the clinician to point out, using Kevin’s own words, the discrepancy between Kevin’s current behavior and his goals. The clinician should emphasize the ways in which Kevin’s use of alcohol and marijuana may be preventing him from living the way he desires. In addition to discussing housing, the counselor might ask Kevin if his use of substances has affected his relationship with his children. Repairing relationships with family can be an important motivator to reduce substance use. However, take care not to overwhelm clients with early discussions of too many areas of behavior change.

Where do you start? When clinicians work with persons with dual disorders, the multitude of problems may seem overwhelming. Some clinicians prefer to focus on the area in which the client is most ready to change; others begin by targeting behaviors that pose the greatest threat to the client’s well-being. In either case, remember that the client is ambivalent. Decisional balance statements should reflect that genuine ambivalence: for example, “I hear you saying that you really enjoy drinking, but that it also keeps you broke and apart from your children.”

Question 3: What are effective steps for developing discrepancy with an ambivalent client that can lead to greater internal motivation to change?
1. Clarify what the client’s own unique goals for their life may be, and help determine which are healthy and achievable.
2. Assist the client in reasoning out how any substance use and/or under-treated symptoms of mental illness either help or hinder them from obtaining their unique life goals.
3. Engage the client in a “decisional balance” exercise, designed to help explore ambivalence about making any changes.
4. All of the above.
A V O I D I N G A R G U M E N T S (A A)

Many people reject being labeled with a mental illness or addiction diagnosis. Motivational interviewing differs from other approaches to treating substance abuse in that it avoids confrontation, especially around diagnostic labels. The principle is to avoid arguments in general, with the assumption that arguments simply strengthen people’s beliefs, rather than helping them change their beliefs. While making a diagnosis is necessary to help clinicians target treatment to mental illness, it may not be helpful to the client. As a general rule, the counselor emphasizes the clients’ perceptions of the consequences of their behaviors rather than the clinician’s model of its causes.

In motivational interviewing, whenever the clinician senses disagreement, it is time to change strategies rather than getting into an argument. The focus should be on discrepancy, or ambivalence, within the client’s thinking, not on discrepancy between the client and the counselor. This is an important principle behind the success of these techniques. Most people do not want to change if they feel they have to defend themselves and that the clinician is unsupportive. The clinician working with Kevin has appropriately focused on Kevin’s life context (homelessness) and behavior (drinking) rather than labeling Kevin as alcoholic or mentally ill. Also of note, Kevin’s case manger did not argue with him about the judge’s pronouncement; rather he offered an empathetic ear to his concerns and an acceptable way for them to meet on Kevin’s own turf.

Question 4: Why is it considered important to avoid arguing with a client experiencing ambivalence about changing?
1. Because arguing FOR change with an ambivalent person usually compels them to defend the position AGAINST changing even more strongly, as well as creating a focus on relational conflict with the practitioner, rather than on the area in which the client needs to change.
2. It’s NOT important to avoid arguing with an ambivalent person – the client needs to accept their diagnosis before anything good can happen in treatment, and if they don’t agree with their need to change, arguing with them about it is better than just letting them continue to live in the problem.
3. Because the client may be better at debating than the practitioner, and may win the argument.
4. It’s NOT important to avoid arguing with an ambivalent person – if the therapist is more skilled at debating than the client, then the client will change as a result of the argument.
R O L L I N G W I T H R E S I S T A N C E (R R)

If a client doesn’t want to go in a certain direction (“resistance”), it is important to let him express his opinions, or to “roll with it” instead of trying to fight it. It is helpful for the counselor to encourage the client to explore all the possible answers to his own questions and concerns. By doing this, the client becomes the source of answers, does not feel defeated in sharing his concerns, and is able to risk expressing true feelings. For example, helping Kevin to develop a pros and cons list about having his own place to live helped him think about the impact of his drinking on housing.

Clinicians also need to be ready to roll with unusual behavior, such as clients’ restlessness, disorganized behavior, and inappropriate speech. The clinician can handle this behavior in a matter-of-fact way, rather than interpreting it as a sign that the client is unmotivated or too ill to participate. In Kevin’s case, since he refuses to go to the mental health center, the case manager has begun meeting with him at the homeless shelter. This is a good example of “rolling with resistance.” It is likely that as Kevin develops further trust in his counselor, they can explore together Kevin’s concerns about going to the mental health center.

The principle of rolling with resistance is simple if one thinks back to the treatment plan. There are always several possible areas to work on, and rather than getting into a struggle, it’s always better to find an area where the client is ready to do some work. For example, if the client begins to express resistance related to discussing medications or drinking, the counselor can move quickly to ask about finances, housing, family, work, or other areas of concern that the client has previously identified.

Question 5: Why is rolling with resistance more effective than direct confrontation, when working with an ambivalent client?
1. It’s not. A resistant or con-compliant client needs to not be in charge – after all, their own best thinking got them into the mess they’re in! Therefore, the practitioner should directly confront the ambivalent client on their “stinking thinking” and let them know who’s in charge.
2. Because when a client is supported in exploring all of the possible answers to his/her questions and concerns, he/she is more likely to own the results, and to act in a more internally motivated, empowered manner in the direction of positive change. The client is also more likely to be honest and vulnerable throughout the treatment process, with correspondingly better outcomes.
3. It’s not. Too many practitioners are pathologically codependent and people-pleasing, and need to do more confrontation with clients, not less.
4. Because directly confronting ambivalent clients usually leads to physical altercations between practitioner and client that should be avoided.
S U P P O R T I N G S E L F - E F F I C A C Y (S S)

Self-efficacy is the belief that one can succeed at change. The final principle in motivational interviewing is to support the client’s self-efficacy. This is particularly critical for people who are demoralized, depressed, or hopeless. Dually diagnosed clients are often reluctant to attempt to change because they have a long history of failing to achieve their goals. The clinician demonstrates optimism and belief in the client’s ability to change by interest, attitude, comments, and behavior.

Self-efficacy can be enhanced by achieving success on small, realistic goals and undermined if the client focuses on unrealistic goals. For dually diagnosed clients, a reduction in dangerous behavior or substance use may be a more realistic early goal than complete abstinence. Remember that success breeds greater self-efficacy and further success.

One strategy for increasing self-efficacy is to discuss examples of positive changes the client accomplished in the past. In Kevin’s case, his former job as a heavy equipment operator seems to be a particular source of pride. The counselor may wish to raise the issue of this past success and explore a time in Kevin’s life when things were going well for him as a way of rekindling optimism, self-efficacy, and remembrance of important goals.

Question 6: Why is supporting self-efficacy critically important when working with ambivalent clients?
1. Because demoralized, hopeless, disempowered clients need this type of approach to help regain hope and confidence in their ability to change.
2. It’s not important. Demoralized, depressed and hopeless clients have been beaten down for so long that they are incapable of responding to attempts at empowerment.
3. Because then clients can be instructed to “just say no” to substance use, and if their self-efficacy is strong enough, they’ll be able to solve their co-occurring addictions problems on their own.
4. It’s not important. If clients just do what they are told by more knowledgeable, experienced practitioners, they’ll get sober and stable regardless of their level of self-efficacy.