Enhancing Motivation for Change in Substance Abuse Treatment
Treatment Improvement Protocol (TIP) Series 35

Express Empathy

Empathy "is a specifiable and learnable skill for understanding another's meaning through the use of reflective listening. It requires sharp attention to each new client statement, and the continual generation of hypotheses as to the underlying meaning" (Miller and Rollnick, 1991, p. 20). An empathic style

• Communicates respect for and acceptance of clients and their feelings
• Encourages a nonjudgmental, collaborative relationship
• Allows you to be a supportive and knowledgeable consultant
• Sincerely compliments rather than denigrates
• Listens rather than tells
• Gently persuades, with the understanding that the decision to change is the client's
• Provides support throughout the recovery process

Empathic motivational interviewing establishes a safe and open environment that is conducive to examining issues and eliciting personal reasons and methods for change. A fundamental component of motivational interviewing is understanding each client's unique perspective, feelings, and values. Your attitude should be one of acceptance, but not necessarily approval or agreement, recognizing that ambivalence about change is to be expected. Motivational interviewing is most successful when a trusting relationship is established between you and your client.

Although empathy is the foundation of a motivational counseling style, it "should not be confused with the meaning of empathy as identification with the client or the sharing of common past experiences. In fact, a recent personal history of the same problem area...may compromise a counselor's ability to provide the critical conditions of change" (Miller and Rollnick, 1991, p. 5). The key component to expressing empathy is reflective listening.

If you are not listening reflectively but are instead imposing direction and judgment, you are creating barriers that impair the therapeutic relationship (Miller and Rollnick, 1991). The client will most likely react by stopping, diverting, or changing direction. Twelve examples of such nonempathic responses have been identified (Gordon, 1970):

1. Ordering or directing. Direction is given with a voice of authority. The speaker may be in a position of power (e.g., parent, employer) or the words may simply be phrased and spoken in an authoritarian manner.
2. Warning or threatening. These messages are similar to ordering but they carry an overt or covert threat of impending negative consequences if the advice or direction is not followed. The threat may be one the clinician will carry out or simply a prediction of a negative outcome if the client doesn't comply--for example, "If you don't listen to me, you'll be sorry."
3. Giving advice, making suggestions, or providing solutions prematurely or when unsolicited. The message recommends a course of action based on the clinician's knowledge and personal experience. These recommendations often begin with phrases such as, "What I would do is...."
4. Persuading with logic, arguing, or lecturing. The underlying assumption of these messages is that the client has not reasoned through the problem adequately and needs help to do so.
5. Moralizing, preaching, or telling clients their duty. These statements contain such words as "should" or "ought" to convey moral instructions.
6. Judging, criticizing, disagreeing, or blaming. These messages imply that something is wrong with the client or with what the client has said. Even simple disagreement may be interpreted as critical.
7. Agreeing, approving, or praising. Surprisingly, praise or approval also can be an obstacle if the message sanctions or implies agreement with whatever the client has said. Unsolicited approval can interrupt the communication process and can imply an uneven relationship between the speaker and the listener. Reflective listening does not require agreement.
8. Shaming, ridiculing, labeling, or name-calling. These messages express overt disapproval and intent to correct a specific behavior or attitude.
9. Interpreting or analyzing. Clinicians are frequently and easily tempted to impose their own interpretations on a client's statement and to find some hidden, analytical meaning. Interpretive statements might imply that the clinician knows what the client's real problem is.
10. Reassuring, sympathizing, or consoling. Clinicians often want to make the client feel better by offering consolation. Such reassurance can interrupt the flow of communication and interfere with careful listening.
11. Questioning or probing. Clinicians often mistake questioning for good listening. Although the clinician may ask questions to learn more about the client, the underlying message is that the clinician might find the right answer to all the client's problems if enough questions are asked. In fact, intensive questioning can interfere with the spontaneous flow of communication and divert it in directions of interest to the clinician rather than the client.
12. Withdrawing, distracting, humoring, or changing the subject. Although humor may represent an attempt to take the client's mind off emotional subjects or threatening problems, it also can be a distraction that diverts communication and implies that the client's statements are unimportant.

Ethnic and cultural differences must be considered when expressing empathy because they influence how both you and your client interpret verbal and nonverbal communications.

Develop Discrepancy

Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes for the future. Your task is to help focus your client's attention on how current behavior differs from ideal or desired behavior. Discrepancy is initially highlighted by raising your clients' awareness of the negative personal, familial, or community consequences of a problem behavior and helping them confront the substance use that contributed to the consequences. Although helping a client perceive discrepancy can be difficult, carefully chosen and strategic reflecting can underscore incongruities.

Separate the behavior from the person and help your client explore how important personal goals (e.g., good health, marital happiness, financial success) are being undermined by current substance use patterns. This requires you to listen carefully to your client's statements about values and connections to community, family, and church. If the client shows concern about the effects of personal behavior, highlight this concern to heighten the client's perception and acknowledgment of discrepancy.

Once a client begins to understand how the consequences or potential consequences of current behavior conflict with significant personal values, amplify and focus on this discordance until the client can articulate consistent concern and commitment to change.

One useful tactic for helping a client perceive discrepancy is sometimes called the "Columbo approach" (Kanfer and Schefft, 1988). This approach is particularly useful with a client who prefers to be in control. Essentially, the clinician expresses understanding and continuously seeks clarification of the client's problems but appears unable to perceive any solution. A stance of uncertainty or confusion can motivate the client to take control of the situation by offering a solution to the clinician (Van Bilsen, 1991).

Tools other than talking can be used to reveal discrepancy. For example, show a video and then discuss it with the client, allowing the client to make the connection to his own situation. Juxtaposing different media messages or images that are meaningful to a client can also be effective. This strategy may be particularly effective for adolescents because it provides stimulation for discussion and reaction.

You can help your client perceive discrepancy on a number of different levels, from physical to spiritual, and in different domains, from attitudinal to behavioral. To do this, it is useful to understand not only what an individual values but also what the community values. For example, substance use might conflict with the client's personal identity and values; it might conflict with the values of the larger community; it might conflict with spiritual or religious beliefs; or it might conflict with the values of the client's family members. Thus, discrepancy can be made clear by contrasting substance-using behavior with the importance the clients ascribe to their relationships with family, religious groups, and the community.

The client's cultural background can affect perceptions of discrepancy. For example, African-Americans may regard addiction as "chemical slavery," which may conflict with their ethnic pride and desire to overcome a collective history of oppression. Moreover, African-Americans may be more strongly influenced than white Americans by the expressed values of a larger religious or spiritual community. In a recent focus group study with adolescents, African-American youths were much more likely than other youths to view cigarette smoking as conflicting with their ethnic pride (Luke, 1998). They pointed to this conflict as an important reason not to smoke.

Avoid Argument

You may occasionally be tempted to argue with a client who is unsure about changing or unwilling to change, especially if the client is hostile, defiant, or provocative. However, trying to convince a client that a problem exists or that change is needed could precipitate even more resistance. If you try to prove a point, the client predictably takes the opposite side. Arguments with the client can rapidly degenerate into a power struggle and do not enhance motivation for beneficial change. When it is the client, not you, who voices arguments for change, progress can be made. The goal is to "walk" with clients (i.e., accompany clients through treatment), not "drag" them along (i.e., direct clients' treatment).

A common area of argument is the client's unwillingness to accept a label such as "alcoholic" or "drug abuser." Miller and Rollnick stated that

[T]here is no particular reason why the therapist should badger clients to accept a label, or exert great persuasive effort in this direction. Accusing clients of being in denial or resistant or addicted is more likely to increase their resistance than to instill motivation for change. We advocate starting with clients wherever they are, and altering their self-perceptions, not by arguing about labels, but through substantially more effective means (Miller and Rollnick, 1991, p. 59).

Although this conflicts with some clinicians' belief that clients must be persuaded to self-label, the approach advocated in the "Big Book" of Alcoholics Anonymous (AA) is that labels are not to be imposed (AA, 1976). Rather, it is a personal decision of each individual.

Roll With Resistance

Resistance is a legitimate concern for the clinician because it is predictive of poor treatment outcomes and lack of involvement in the therapeutic process. One view of resistance is that the client is behaving defiantly. Another, perhaps more constructive, viewpoint is that resistance is a signal that the client views the situation differently. This requires you to understand your client's perspective and proceed from there. Resistance is a signal to you to change direction or listen more carefully. Resistance actually offers you an opportunity to respond in a new, perhaps surprising, way and to take advantage of the situation without being confrontational.

Adjusting to resistance is similar to avoiding argument in that it offers another chance to express empathy by remaining nonjudgmental and respectful, encouraging the client to talk and stay involved. Try to avoid evoking resistance whenever possible, and divert or deflect the energy the client is investing in resistance toward positive change.

How do you recognize resistance? Figure 3-2 depicts four common behaviors that indicate that a client is resisting treatment. How do you avoid arguing and, instead, adapt to resistance? Miller and colleagues have identified and provided examples of at least seven ways to react appropriately to client resistance (Miller and Rollnick, 1991; Miller et al., 1992). These are described below.

Support Self-Efficacy

Many clients do not have a well-developed sense of self-efficacy and find it difficult to believe that they can begin or maintain behavioral change. Improving self-efficacy requires eliciting and supporting hope, optimism, and the feasibility of accomplishing change. This requires you to recognize the client's strengths and bring these to the forefront whenever possible. Unless a client believes change is possible, the perceived discrepancy between the desire for change and feelings of hopelessness about accomplishing change is likely to result in rationalizations or denial in order to reduce discomfort. Because self-efficacy is a critical component of behavior change, it is crucial that you as the clinician also believe in your clients' capacity to reach their goals.

Discussing treatment or change options that might still be attractive to clients is usually helpful, even though they may have dropped out of other treatment programs or returned to substance use after a period of being substance free. It is also helpful to talk about how persons in similar situations have successfully changed their behavior. Other clients can serve as role models and offer encouragement. Nonetheless, clients must ultimately come to believe that change is their responsibility and that long-term success begins with a single step forward. The AA motto, "one day at a time," may help clients focus and embark on the immediate and small changes that they believe are feasible.

Education can increase clients' sense of self-efficacy. Credible, understandable, and accurate information helps clients understand how substance use progresses to abuse or dependency. Making the biology of addiction and the medical effects of substance use relevant to the clients' experience may alleviate shame and guilt and instill hope that recovery can be achieved by using appropriate methods and tools. A process that initially feels overwhelming and hopeless can be broken down into achievable small steps toward recovery.

Ask Open-Ended Questions

Asking open-ended questions helps you understand your clients' point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response. They are a means to solicit additional information in a neutral way. Open-ended questions encourage the client to do most of the talking, help you avoid making premature judgments, and keep communication moving forward (see Figure 3-3).

Listen Reflectively

Reflective listening, a fundamental component of motivational interviewing, is a challenging skill in which you demonstrate that you have accurately heard and understood a client's communication by restating its meaning. That is, you hazard a guess about what the client intended to convey and express this in a responsive statement, not a question. "Reflective listening is a way of checking rather than assuming that you know what is meant" (Miller and Rollnick, 1991, p. 75).

Reflective listening strengthens the empathic relationship between the clinician and the client and encourages further exploration of problems and feelings. This form of communication is particularly appropriate for early stages of counseling. Reflective listening helps the client by providing a synthesis of content and process. It reduces the likelihood of resistance, encourages the client to keep talking, communicates respect, cements the therapeutic alliance, clarifies exactly what the client means, and reinforces motivation (Miller et al., 1992).

This process has a tremendous amount of flexibility, and you can use reflective listening to reinforce your client's positive ideas (Miller et al., 1992). The following dialog gives some examples of clinician's responses that illustrate effective reflective listening. Essentially, true reflective listening requires continuous alert tracking of the client's verbal and nonverbal responses and their possible meanings, formulation of reflections at the appropriate level of complexity, and ongoing adjustment of hypotheses.

Clinician: What else concerns you about your drinking?

Client: Well, I'm not sure I'm concerned about it, but I do wonder sometimes if I'm drinking too much.

Clinician: Too much for...?

Client: For my own good, I guess. I mean it's not like it's really serious, but sometimes when I wake up in the morning I feel really awful, and I can't think straight most of the morning.

Clinician: It messes up your thinking, your concentration.

Client: Yes, and sometimes I have trouble remembering things.

Clinician: And you wonder if that might be because you're drinking too much?

Client: Well, I know it is sometimes.

Clinician: You're pretty sure about that. But maybe there's more...

Client: Yeah, even when I'm not drinking, sometimes I mix things up, and I wonder about that.

Clinician: Wonder if...?

Client: If alcohol's pickling my brain, I guess.

Clinician: You think that can happen to people, maybe to you.

Client: Well, can't it? I've heard that alcohol kills brain cells.

Clinician: Um-hmm. I can see why that would worry you.

Client: But I don't think I'm an alcoholic or anything.

Clinician: You don't think you're that bad off, but you do wonder if maybe you're overdoing it and damaging yourself in the process.

Client: Yeah.

Clinician: Kind of a scary thought. What else worries you?

Summarize

Most clinicians find it useful to periodically summarize what has occurred in a counseling session. Summarizing consists of distilling the essence of what a client has expressed and communicating it back. "Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on" (Miller and Rollnick, 1991, p. 78). A summary that links the client's positive and negative feelings about substance use can facilitate an understanding of initial ambivalence and promote the perception of discrepancy. Summarizing is also a good way to begin and end each counseling session and to provide a natural bridge when the client is transitioning between stages of change.

Summarizing also serves strategic purposes. In presenting a summary, you can select what information should be included and what can be minimized or left out. Correction of a summary by the client should be invited, and this often leads to further comments and discussion. Summarizing helps clients consider their own responses and contemplate their own experience. It also gives you and your client an opportunity to notice what might have been overlooked as well as incorrectly stated.

Affirm

When it is done sincerely, affirming your client supports and promotes self-efficacy. More broadly, your affirmation acknowledges the difficulties the client has experienced. By affirming, you are saying, "I hear; I understand," and validating the client's experiences and feelings. Affirming helps clients feel confident about marshaling their inner resources to take action and change behavior. Emphasizing their past experiences that demonstrate strength, success, or power can prevent discouragement. For some clients, such as many African-Americans, affirmation has a spiritual context. Affirming their inner guiding spirit and their faith may help resolve their ambivalence. Several examples of affirming statements (Miller and Rollnick, 1991) follow:

• I appreciate how hard it must have been for you to decide to come here. You took a big step.
• I think it's great that you want to do something about this problem.
• That must have been very difficult for you.
• You're certainly a resourceful person to have been able to live with the problem this long and not fall apart.
• That's a good suggestion.
• It must be difficult for you to accept a day-to-day life so full of stress. I must say, if I were in your position, I would also find that difficult.

Elicit Self-Motivational Statements

Engaging the client in the process of change is the fundamental task of motivational interviewing. Rather than identifying the problem and promoting ways to solve it, your task is to help the client recognize how life might be better and choose ways to make it so.

Remember that your role is to entice the client to voice personal concerns and intentions, not to convince him that a transformation is necessary. Successful motivational interviewing requires that clients, not the clinician, ultimately argue for change and persuade themselves that they want to and can improve. One signal that the client's ambivalence and resistance are diminishing is the self-motivational statement.

Four types of motivational statements can be identified (Miller and Rollnick, 1991):

• Cognitive recognition of the problem (e.g., "I guess this is more serious than I thought.")
• Affective expression of concern about the perceived problem (e.g., "I'm really worried about what is happening to me.")
• A direct or implicit intention to change behavior (e.g., "I've got to do something about this.")
• Optimism about one's ability to change (e.g., "I know that if I try, I can really do it.")

Figure 3-4 illustrates how you can differentiate a self-motivational statement from a countermotivational assertion. You can reinforce your client's self-motivational statements by reflecting them, nodding, or making approving facial expressions and affirming statements. Encourage clients to continue exploring the possibility of change. This can be done by asking for an elaboration, explicit examples, or more details about remaining concerns. Questions beginning with "What else" are effective ways to invite further amplification. Sometimes asking clients to identify the extremes of the problem (e.g., "What are you most concerned about?") helps to enhance their motivation. Another effective approach is to ask clients to envision what they would like for the future. From there, clients may be able to begin establishing specific goals.

Figure 3-5 provides a useful list of questions you can ask to elicit self-motivational statements from the client.