Motivational Interviewing: an evidence-based approach to overcoming ambivalence; Envision the change process as dancing with another, rather than wrestling.

The concept of using Motivational Interviewing (MI) in the addictions field is not new. Thus far, a majority of the MI research has focused on adults, with fewer studies involving adolescents. However, many in the field are finding the basic principles of MI to be a match in treatment for adolescent clients.

[ILLUSTRATION OMITTED]

Two recent research studies used MI or an adaptation for adolescent treatment. In the Cannabis Youth Treatment Series (CYT), Volume One (Sampl & Kadden, 2001), two sessions of MI were used, and MI adaptation was used in a study on Motivation-Adaptive Skills-Trauma Resolution (MASTR) therapy (Greenwald, 2002). Both used MI as a way to help engage adolescents and strengthen their motivation to explore their ambivalence. MI is considered an effective evidence-based approach to overcoming the ambivalence that keeps many people from making desired changes in their lives (Miller & Rollnick, 2002). Several practical interventions can be gleaned for use with an adolescent population.

Motivational Interviewing is a client-centered, yet directive method for enhancing intrinsic motivation. How can adolescent addiction practitioners use MI to engage and retain clients in treatment?

First, we must understand that MI strives to be a free-flowing dance partner for a person's ambivalence about changing, rather than a rival tussling for power.

Adolescents may come to treatment with some level of ambivalence about changing their behavior. Many professionals would suggest that the adolescent-type resistance they encounter is comparable to trying to break a secret code. Since a majority of the treatment referrals to adolescent substance abuse programs are coerced (by the judicial system, parents, or schools), the clients may already be entrenched in the status quo (using AOD). They frequently come to treatment not because of their own desire to change, but because someone else has told them they need to change. It seems likely that everyone else prior to the treatment provider has been telling them they must change or else, which will increase resistance in many adolescents. MI gives the treatment provider an alternate way of engaging the client.

Underlying the core of this practice is what Miller and Rollnick call the "spirit of motivational interviewing." The "spirit" is demonstrated through the connection with others we can establish by making use of collaboration, evocation and autonomy.

Collaboration signifies the importance of relationship by saying, "We are in this together, and you (the client) are the expert." This allows clients to see that they have the information (answers) within them. Evoking change talk is integral to the spirit of MI serving as one method of engagement. The way professionals approach therapeutic exchanges can either elicit change talk or actually increase resistance. Eliciting change talk is a skill set attainable only if the professional chooses to step out of traditional roles that lead to communication roadblocks. Autonomy stresses that the individual, not the practitioner, is responsible for choosing and carrying out change.

MI purports that ambivalence about change is normal. As professionals, we then would view the client's resistance as an indicator of a certain amount of ambivalence rather than being in denial, defensive or unworkable. By helping to resolve that ambivalence, we can guide the person through the change process.

How would that work in adolescent treatment?

* Start by using Motivational Interviewing micro-skills. "OARS" is the acronym used to remind practitioners to incorporate Open-ended questions, Affirmations, Reflections and Summaries into their contact.

* Organize your interaction in a manner that assesses the adolescent's readiness to change, and match your intervention accordingly.

* Avoid communication roadblocks such as presenting yourself as the "expert," prematurely focusing on change, advice giving, or failing to meet the client where s/he is.

* Express empathy, help develop discrepancies in status quo vs. change, roll with resistance, and promote self-efficacy.

* Use exercises that help facilitate the client giving the practitioner the reasons s/he wants to change, not vice versa.

* Avoid listing all the reasons they should change--this will serve only to cause "psychological reactance" (Brehm, 1981). This refers to the normal human tendency to reject the advice or opinions of an individual or system that threatens one's perceived freedom. Freedom can mean freedom from judgment, labeling, diagnosis, or forms of social oppression.

* Come to the therapeutic dance floor with the spirit of MI--a genuine regard for human nature.

We ask/expect clients to change instantaneously, and yet we ourselves often contemplate change for years before ever moving to action. In many ways, coerced treatment or forced compliance can set the stage for change, but only short-lived change. Long-term change takes place with intrinsic motivators, not extrinsic ones.

So isn't it worth our time to find out what really motivates the adolescents with whom we work? As a profession, we can spend more time exercising our dance repertoire rather than struggling to pin change to the mat.

www.motivationalinterview.org

References

Brehm, S.S., & Brehm, J.W. (1981) Psychological reactance: A theory of freedom and control. New York: Academic Press.

CSAT TIP 35 manual, Enhancing Motivation for Change in Substance Abuse Treatment (1999).

Greenwald, R. (2002). Motivation-Adaptive Skills-Trauma Resolution (MASTR) therapy for adolescents with conduct problems: An open trial. Journal of Aggression, Maltreatment, and Trauma, 3, 237-261.

Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing people for change. New York: The Guilford Press

Sampl, S., & Kadden, R. (2001). Motivational Enhancement Therapy and Cognitive Behavioral Therapy for Adolescent Cannabis Users: 5 Sessions, (DHHS Publication No. (SMA) 01-3486, Cannabis Youth Treatment (CYT) Series, Volume 1). Center for Substance Abuse Treatment (CSAT), Rockville, Md.

Tevyaw, T. and Monti, P. (2004) Motivational enhancement and other brief interventions for adolescent substance abuse: foundations, applications and evaluations. Society for the Study of Addiction, 99, 63-75.

RELATED ARTICLE: About the NAADAC Adolescent Committee and This Series

The NAADAC Adolescent Specialty Committee (ASC), begun in the spring of 2004, has its focus and direction in this mission: To advocate for effective clinical services addressing prevention and treatment for adolescent substance use disorders (SUD). The ASC does this through working within NAADAC, The Association for Addiction Professionals toward the goals of: 1) promoting public and professional understanding of the impact of adolescent SUD upon families, schools, juvenile justice, peer influences, and the overall health and emotional well-ness of the adolescent; 2) advocating for adequate substance abuse prevention, education and intervention services; 3) supporting best-practice clinical efforts by NAADAC treatment professionals; and 4) encouraging acceptance of the clinical uniqueness of today's adolescents and their families.

Committee members may submit articles for this column to Addiction Professional editor Gary Enos ([e-mail]). Articles should be around 1,000 words in length, and must be focused to assist readers with hands-on approaches to adolescent treatment (as opposed to theoretical issues). Please include a headshot photograph and biographical information with the article.

Article topic areas related to adolescent substance misuse include but are not limited to: family stress; peer involvement; self-esteem and self-perception; loss and adjustment; emotional problems; co-occurring disorders; and evidence-based practices. The ASC leadership is available to review and comment on article submissions as writers choose, and will be in contact with the editor about topic appropriateness. Reader questions and comments about articles are invited, to the editor and to the committee (at the e-mail address below).

Interested in being a part of this valuable and much-needed committee? You do not have to be an addictions professional to join the committee, although you do have to be a member of NAADAC. To join NAADAC, call [phone] or visit www.naadac.org. If you are already a NAADAC member and are interested in joining the ASC, contact Margie Taber at [e-mail].

Denise Pyle, a licensed professional counselor, is the Endorsement Liaison on the Leadership Group for the Adolescent Specialty Committee at NAADAC, The Association for Addiction Professionals. She is an adolescent specialist for the Mid-Atlantic Addiction Technology Transfer Center (ATTC).