The Motivational Interviewing approach differs dramatically from confrontational treatment strategies in which the therapist takes primary responsibility for “breaking down the ‘addicts’ denial.”

Miller (1989, p. 75) provided these contrasts between approaches:

Confrontation-of-Denial Approach:
Heavy emphasis on acceptance of self as “alcoholic”; acceptance of diagnosis seen as essential for change. Emphasis on disease of alcoholism which reduces personal choice and control. Therapist presents perceived evidence of alcoholism in an attempt to convince the addict of the diagnosis. Resistance seen as “denial,” a trait characteristic of alcoholics requiring confrontation. Resistance is responded to by argumentation and correction.

Motivational Interviewing Approach:
Deemphasis on labels; acceptance of “alcoholism” label seen as unnecessary for change to occur. Emphasis on personal choice regarding future use of alcohol or other drugs. Therapist conducts objective evaluation, but focuses on eliciting the loved one’s own concerns. Resistance is seen as an interpersonal behavior pattern influenced by the family member or therapist’s behavior. Resistance is met with reflection, not argumentation or correction.

A goal using Motivational Interviewing as a concerned loved one or therapist, is to evoke the statements of problem perception and a need for change. This is the conceptual opposite of an approach in which the therapist takes responsibility for voicing these perspectives (“You’re an alcoholic, and you have to quit drinking”) and persuading the addict of the truth. Instead, a concerned family member or therapist emphasizes the addict’s ability to change (self-efficacy) rather than the helplessness or powerlessness he or she has over addiction.

Research supports that arguing with an addict should be avoided, and strategies for handling resistance are more reflective than exhortational.

When Using Motivational Interviewing you would not want to:
Argue with loved ones.
Impose a diagnostic label on loved ones.
Tell loved ones what they “must” do.
Seek to “break down” denial by direct confrontation.
Imply loved ones’ “powerlessness.”

Motivational Interviewing, then, is an entirely different strategy from skill training. It assumes that the key element for lasting change is a motivational shift that instigates a decision and commitment to change. In the absence of such a shift, skill training is premature. Once such a shift has occurred, however, people’s ordinary resources and their natural relationships may well suffice. In fact, researchers have argued that for many individuals a skill-training approach may be ineffective precisely because it removes the focus from what is the key element
of transformation: a clear and firm decision to change.1,2

Finally, it is useful to differentiate Motivational Interviewing from nondirective approaches with which it might be confused. In a strict Rogerian approach, the therapist does not direct treatment but follows the loved one’s direction wherever it may lead. In contrast, Motivational Interviewing employs systematic strategies toward specific goals. The family member or therapist seeks actively to create discrepancy and to channel it toward behavior change (Miller 1983). Thus Motivational Interviewing is a directive and persuasive approach, not a nondirective and passive approach.

Resources

1. Syme, S.L. “Changing Difficult Behaviors: How to Succeed Without Really Trying.” Paper presented at a Symposium on Advancing Health Education, Mills College, Oakland, CA, Sept. 1988.

2. Miller, W.R., and Brown, J.M. Self-regulation as a conceptual basis for the prevention and treatment of addictive behaviors. In: Heather, N.; Miller, W.R.; and Greeley, J., eds. Self-Control and the Addictive Behaviours. Sydney: Pergamon Press Australia, 1991. pp. 3–79.

3. Miller, W.R., and Saucedo, C.F. Assessment of neuropsychological impairment and brain damage in problem drinkers. In: Golden, C.J.: Moses, J.A., Jr.; Coffman, J.A.; Miller, W.R.; and Strider, F.D., eds. Clinical Neuropsychology: Interface With Neurologic and Psychiatric Disorders. New York: Grune & Stratton, 1983.