Motivational Interviewing in Action: How Action Methods Cut Through Clients’ Defenses and Ambivalence
Motivational Interviewing in Action: How Action Methods Cut Through Clients’ Defenses and Ambivalence
by Regina Sewell, Ph.D., LMHC, CP
and Rebecca Walters, LMHC, LCAT, TEP
“Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.” *
-Stephen Rollnick and William R. Miller
Motivational Interviewing is more about mindset than techniques. The traditional mindset has been to “make” our clients change. It’s an “us” (the experts) against them (the “damaged in need of fixing”). We rationalize this approach because their behavior heroin use, heavy drinking, cigarette or pot smoking, better living through shopping, gambling, or self-starvation, or couch-potato-ing themselves into a heart attack is dangerous if not deadly and we think we are responsible for their lives because clearly they are not handling things well (This also sounds a lot like co-dependency). And it doesn’t work.
One key to the Motivational Interviewing mindset is to trust that our clients actually want to live healthier, more fulfilling lives and just need help to find their own internal motivation to change. Rather than assuming that our clients are somehow mentally deficient to engage in behaviors that are not rational, the Motivational Interviewing mindset pushes us to see that our clients engage in destructive behaviors as a strategy to get their needs met even when those behaviors are not effective. Therefore, it is the client’s job, not ours, to explore and work through their ambivalence to change. Our job is simply to help them articulate the conflict inherent in their ambivalence to change by helping them explore the costs and benefits associated with each side of the conflict.
This is easier if you can remember your own internal conflicts – the “angel” on your right shoulder that says, “Don’t start reading your Facebook newsfeed. You have work to do,” while the “devil” on your left shoulder counters, “If you don’t check it out, you might miss something. Besides, it’s only a few minutes. You can’t be all work and no play. You deserve a little bit of pleasure….”
The reality is that attempts to “make” our clients change by threatening, bullying, or “persuading,” simply triggers their resistance. Sure, the rational response to, “If you don’t start working out and stop eating high cholesterol foods you’ll be dead of a heart attack in a year” is to join the gym, get a trainer and start on a healthy diet plan. But, the more likely response is, “F-you, I’m doing just fine. I don’t need your advice.” or, “Get off my back.”
From a Motivational Interviewing standpoint, “resistance” and “denial” highlight our failure as therapists to meet our clients where they are at rather than about our clients’ inherent traits. Through the lens of Motivational Interviewing, client “resistance” and/or “denial” is great feedback that tells us that we need to change our strategy to be more in line with where our clients are at in terms of change.
Another key to the Motivational Interviewing mindset is the shift in how we frame the therapeutic relationship. Rather than viewing the relationship as one of “expert” versus “damaged client,” the relationship is seen as a partnership rooted in respect for the client’s autonomy and freedom of choice. The therapeutic relationship has repeatedly been shown to have a larger impact on client outcome than particular treatment interventions. Respect is a cornerstone of relationship. Respect demonstrates to our clients that we value them – that we recognize that they are worth something, even if their behavior has been destructive to themselves and/or others. This is particularly important given that many of our clients don’t respect or value themselves and have experienced disrespect and rejection from others.
It’s only when we approach working with clients from a standpoint of respect for their autonomy and freedom of choice that we can be directive and help them explore the pros and cons of making changes and find their own internal motivations for doing so.
Built on this philosophical mindset, Motivational Interviewing techniques involve engaging in acceptance and affirmation, empathy, and reflective listening. It is helpful to help clients explore their own motivation to change whether it’s a desire to avoid negative consequences such as incarceration, relational conflict, or guilt, or to pursue positive consequences such as better mental and physical well-being, better self-esteem, improved finances, or the ability to pursue deeper, more fulfilling dreams. Motivational Interviewing requires us to be able to monitor our clients’ motivation to change and work with them where they are at on the change continuum.
Why Action Methods?
Psychodrama, Sociodrama and Sociometry are action methods developed by J.L. Moreno. They are particularly useful in cutting through rationalization, denial, justification and various other defenses that people use to avoid change. When you do things in action your body takes over and your mind gets out of the way.
The psychodramatic technique of doubling works well to engage the client and meet them where they are at. Doubling goes beyond the reflective listening and empathy that most of us in the helping professions were trained to do. It enables therapists to help their clients give voice to things they are reluctant to admit or have trouble articulating and/or help clients deepen their emotional response. Doubling is a collaborative, non-judgmental technique that communicates respect for and acceptance of clients and their feelings.
Psychodramatic and Sociodramatic techniques also allow clients to experiment with making different choices, trying on different behaviors and/or roles and looking at how these changes produce different outcomes. It provides an opportunity to practice making positive choices even in the face of temptation and triggers.
– Psychodrama helps clients concretize their conflicts and ambivalences, giving them ‘voice’ and providing the opportunity to interact with the parts of the self.
– Future Projections allow clients to step into their own future to experience the consequences of several different choices.
– Role Reversal allows clients to step into the shoes of someone they love and experience how their current or past behavior has impacted this person. More than simply helping clients think about how their loved one feels, role reversal allows clients to feel the impact of their behavior at the body level. Clients have reported that reversing roles with their loved one has increased their desire to change.
– Psychodramatic Encounters with Higher Powers/Wise Mind help our clients engage with important resources in order to identify their desired change.
– Social Atom of Support helps clients identify current and potential supports for their sobriety and/or desired change
– Sociodramatic and Psychodramatic Role Training provides the space to rehearse situations that may prove challenging to their sobriety
Rebecca Walters, MS, LMHC, LCAT, TEP is the founder (1989) and co-director of the Hudson Valley Psychodrama Institute in Highland, NY. She has utilize action methods with individuals and groups of children, adolescence and adults for over 40 years. She was the director of psychodrama services at Four Winds Hospital in Katona NY where she worked for 25 years. In addition to HVPI, Rebecca has trained throughout United States. She is also an internationaly respected trainer at confereces and institutes in the UK, Europe, Asia and Central America.
Regina Sewell, PhD/ MEd, LMHC, PCC, CP is certified by the American Board of Examiners as Certified Practitioner of Psychodrama. She is on the faculty on the Hudson Valley Psychodrama Institute. In her private practice, Regina specializes in co-dependency, addictions, LGBT issues and stress management.