#60 Dr. William Miller on Motivational Interviewing: A Powerful Therapy for Mental Health and...

0:00 hello i'm dr bridget nash and i'd like to welcome you to the therapy show a podcast series that seeks to demystify mental health treatment today i'm honored to welcome dr william miller who is an emeritus distinguished professor of psychology and psychiatry at the university of new mexico and founder of the therapeutic model motivational interviewing dr miller is the author of many books including motivational interviewing helping people change and i encourage you to check out his latest book listening well the art of empathetic understanding which was released in january 2019. dr miller welcome to the therapy show hello can you start by telling us a little bit about your personal background and professional development that led to

0:46 you developing motivational interviewing i originally started out heading into pastoral ministry but found my way into psychology instead and when i went to graduate school at the university of oregon it was a very cognitive behavioral program but in the second year they had a required year-long course on how to talk to clients and it turned out none of the behavioral faculty wanted to teach that course so they went over to the counseling psychology program and got an academic grandchild of carl rogers to come and teach us a person-centered way of being with clients so i learned that before i ever had the opportunity to practice behavior therapy it was a very fortunate experience for me because i always have

1:31 practiced cognitive and behavior therapy in a person-centered style as a result of learning the blend in that in that order and motivationally anything really came out of my initial exposure to and and work with the classic work of carl rogers how would you briefly explain motivational interviewing to a non-professional it's a way of helping people to find and voice their own motivation for change it's kind of the opposite of trying to persuade someone to change i find that when people are considering a change our normal experience is ambivalence part of us can see the reasons to make a change and part of us is comfortable doing life the way we've been doing it and both sides you're true both sides are there in the person

2:18 if i as a counselor argue for the change for example with alcohol problems where my work began if i say you have serious alcohol problems and you need change the person's normal response is no i'm not no i don't and all i have done is to elicit from them the other side of their ambivalence if i keep that up if i keep pushing i literally help the person talk themselves out of making a change because we tend to believe ourselves when we hear ourselves talk more than we believe other people unfortunately that is the way addiction treatment was being done at the time in the 70s and 80s in a very authoritarian confrontational persuasive kind of style

3:04 and the natural response of clients to be defensive was then dismissed as pathological being in denial whereas it's just a normal outcome of that way of arranging the conversation so motivational interviewing is a way instead of helping people to discover and voice their own arguments for change so when and how did you realize that motivational interviewing would be an effective form of therapeutic intervention well it took a while i mean the way it emerged is interesting i i was in norway on my first sabbatical leave and i was working at an alcoholism hospital there actually hired to lecture on cognitive behavioral treatment of alcohol problems but the director also asked me to meet

3:52 regularly with their psychologist most of whom were pretty fresh out of graduate training and just have regular discussions and see what came of it and i was happy to do that and they wanted me to role play to show them how i would work with their clients and happily the psychologist spoke english so they could they could portray their clients in english and just see what i would do in response to these fairly serious alcohol dependent people as i did that as i demonstrated how i would go about it and i had been teaching them both a person-centered approach and behavior therapy as i did that they would stop me they would interrupt me which my american students never did and they would say now

4:37 hold on what are you thinking right now you asked the client a question but you could have asked a lot of questions why did you ask that particular question or you reflected something the client said as you've been showing us to reflect but the client said a lot of things why did you reflect that particular thing and they they literally evoked from me this approach that i was i was not conscious of using but i was doing the essence of which is to arrange the conversation so that the client makes the arguments for change and i'm not the person pushing for it so together we kind of began to formulate what this is and how it works i didn't go to norway with any concept

5:23 of anything like motivational interviewing and that's a name that i assign to this way of working with people because it's about the person's own motivation and i like interviewing because interviewing is a power neutral term you might be uh an employer interviewing potential employees in which case you're in the upper power seat you might be a lowly college student interviewing a famous visitor in which case you're in the lower power seat but interviewing is just different from conversation you you have a different role from the person whom you're interviewing so it just made sense as a as a name to try to describe what we were looking at i had no idea if that was an effective approach at the time

6:09 went to my surprise one of my colleagues wanted to publish the article i sent a just wrote up a discussion of it sent it around to colleagues to say what do you think and he said i want to publish it i said i don't i have no evidence at all that this works we just kind of made it up here in norway but he said not i think it's a good paper let me publish it and so he did i thought that's the last i'd hear about it and in fact it wound up taking over my professional life so who is motivational interviewing most effective for and why would people choose motivational interviewing for an effective intervention well if you're working with someone who is ambivalent about change and that's the normal human situation about change that's where it's particularly useful

6:55 if someone comes into your office they've already made up their mind you know they want to quit smoking or whatever it is i know i want to do it just tell me how there you usually proceed to just help them make the change if they're wanting to but what i quickly discovered in addiction treatment and then more generally in practice is that most people coming in to seek help or were encouraged through the door of someone to seek help really feel too weight about it they're not sure they want to do this and helping people to work that through or kind of get through that ambivalence and really make a decision to move ahead with changes is where this is most useful on average it works just as well as cognitive behavior therapy which we found later in a

7:41 in a big comparative trial and work just as well as a 12-step oriented approach in helping people with alcohol problems on average but it's people who are less sure or ambivalent or more more resistive or defensive or more angry who seem to respond particularly well to this approach so what's the average length of treatment for somebody working with a motivational interviewing modality one or two sessions is the normal length of motivational interviewing itself i had originally thought of this as a kind of preparation for treatment and indeed you can start with motivational interviewing and then transition into a cognitive behavioral approach or whatever else you do our surprise in some of the earliest

8:26 studies was that people went ahead and made the change having had an interview of this kind without any additional help from us and that kind of shocked me because i'd sort of been trained to think the longer you spend with me the better you're going to get but in fact it seemed like once you help people get over the hump to make up their mind or resolve their ambivalence they often have the resources to go ahead and do it if they want additional help at that point fine i mean we've got a whole panoply of evidence-based approaches for helping people to make changes in addictive behaviors or whatever problem they're they're bringing but the surprise which should not have been a surprise i think was that often people have the resources

9:12 to do this themselves and in fact most people who change addictive behaviors do it without ever seeking treatment what skills habits or tactics can patients and therapists adopt either during their sessions or in between sessions to improve the effectiveness of motivational interviewing it's a way of being with people i've been saying lately motivational giving is a way of doing what else you do so it's a person-centered empathic accepting listening respectful strength-focused attitude in a way toward whatever the rest of your work is whether it's primary health care or diabetes education or psychotherapy or academic counseling or whatever it is so

9:58 this particular set of skills that one learns again learning a person-centered approach like motivational interviewing and then it's a matter of learning how to use those in what else you do so it really it's like learning a musical instrument in a way or learning to play a sport it's something you get better at over time but you only get better at it over time if you get some feedback or some coaching from somebody who's a little better at it than you are that's that's what you do if you want to learn tennis you you engage a tennis coach to just watch you for a few times and give you some tips and you never say to the tennis coach don't watch me i'd be too embarrassed you know or or to your piano teacher but don't listen to me because i'd be embarrassed it's by listening to

10:46 you or by watching you that a coach can help you get better at it so i learned that the hard way by evaluating my own two-day workshop and motivational interviewing and what we found i got like a tapes of actual practice before and after my two-day workshop what i found was very little change in actual practice behavior and no change in the way clients were responding however people who had the workshop were now persuaded they had learned this and were doing it in practice even though there was very little evidence on their tapes that i had even been there so that taught me something that a workshop is not enough i don't know why i ever thought it would be but just sitting in and listening and practicing a little

11:32 bit in a workshop is probably not going to change your practice behavior so then the question became well what does it take to help people learn this and it turns out it's feedback and coaching that if you can get it doesn't even take a great deal of it i think we had in our first trial on average six half hour coaching sessions on the telephone but it made a huge difference in the proficiency of people after the workshop so it got me into a terrain i hadn't planned on investigating but just that initially shocking finding that the workshop made no difference in practice skill led me to say well how do i help people learn this then because that's not their fault it's my fault if they didn't learn it over the course of the my training

12:18 so what are the most common obstacles or missteps that prevent therapists and patients alike from seeing the full benefits of motivational interviewing the expert role the idea that we have the answers for people and that kind of gets trained into you in graduate training where you're supposed to have the answers all the time but it's the idea that i'm the expert here and if i if i ask you enough questions and if i collect enough information from you then i will have the answer for you and that turns out not to be true very often when what you're talking about is lifestyle change or behavior change and the person who knows the most about how to do that in their own life is the client and nobody has more experience with them than they do so it's kind of letting go of the you

13:05 know somewhat unhumble way of thinking that that i'm a dispenser of expert knowledge and wisdom and insight and skills and so forth to let go of the message i have what you need and i'm going to give it to you and instead approach practice with the thought of you have what you need and together we're going to find it so it's a sharing of expertise so i think that's the first obstacle that occurs to me is really an attitude is really how you think about what you're doing and carl rogers was all over that he talked about a therapeutic attitude as such a big determinative outcome getting skillful reflective listening is a fundamental skill without which you really can't do motivational interviewing

13:51 and it's something that looks easy or people who are good at it can make it look easy but when you actually begin to try to practice reflective listening you discover it's not as easy as it looks and it again is something that you can get more skillful at over time with praxis when someone comes to us already pretty good at the rogerian accurate empathy this skill that rogers called acure empathy learning the rest of motivational interviewing is relatively easy but that often is what takes the longest time to learn when i had to hire a bunch of therapists to do motivational interviewing in a clinical trial i pre-screened them for the ability to do reflective listening because i knew if i had to teach them that and motivational interviewing

14:37 i wasn't going to have time and it worked out really well so can you share any poignant examples of where motivational interviewing had a major impact in someone's life well there are a lot we've done large clinical trials that we're talking about hundreds and over the course of my career thousands of people but i also treated people personally and so remember particular situations where it just seemed to be a turning point for people and in a relatively short period of time i remember a fellow i worked with who had been pushed through the door by his wife who said you have to do something about your drinking or i'm leaving and taking the kids and he didn't he didn't want to be there but i met with him a couple of times i did a little bit of assessment with them looking for some of the early

15:23 effects of alcohol on brain functions and life patterns and so forth and then we just kind of talked about what he was experiencing he realized his drinking had pretty much crept up over the years and he hadn't been paying a lot of attention to it we figured out that he was driving to work in the morning still intoxicated because of the amount he'd had to drink the night before which he didn't realize he had nothing to drink in the morning but had he been pulled over he would have been arrested for driving under the influence so things like that just kind of got his attention and and so then with this person-centered style i just said well so what do you what do you think you need to do at this point where do you want to go with this and he said well i think i need to quit

16:10 drinking i think i need to let go of it and which which he did now he had a few occasions of drinking a little bit for a few days when he came back hanging his head and he said i have four drinks this week and i said well you used to have 80 drinks a week so that's pretty good progress what do you want to do now i'm gonna go back to not drinking again okay but he did stabilize over over the subsequent year or two it wasn't more than this kind of conversation recognizing that he has the power to decide what he's going to do and how he thinks about his drinking and my job was just to be there and facilitate it so just an endless series of examples like that conversations that honor the person's

16:55 autonomy help them to think through what they already know essentially the the protein side of their own ambivalence and not get in their way by telling them what to do so who is motivational you're doing not appropriate for well you don't really need the evoking piece of what we develop if somebody's ready for change so if somebody comes in and says i want to stop smoking that's not a time to be car rogers and say well what you know what have you liked about smoking in the past and why might you want to do that or not do that and the person's kind of past that reflective stage and ready to move on and so you move on you might subsequently find that they do are still reluctant and have some

17:40 reticence about it but but if they're saying i'm ready to go let's go you go so that i mean that's one group of people we've looked for diagnoses where it doesn't seem to help we thought for sure that it wasn't going to help people with sociopathic tendencies because of the stereotype that people with sociopathy don't form relationships and this is a relationship focused approach and yet we found in the biggest study we ever did that sociopathy did not predict anything about how the person was going to respond to this people with higher sociopathy scores responded just as well as others did psychosis 5 well maybe schizophrenia it's not going to work too well to the contrary there's pretty good evidence for improvement in medication adherence and decreased rehospitalization

18:28 we don't know how old kids need to be before they themselves respond to this there probably is a developmental level a cognitive emotional developmental level that one reaches before this really kicks in but if kids are young enough you know not 8 9 10 you really need to be talking to the parents anyhow and we know that this works with kids who are 16 17 18. so maybe there's an age gradient in there that one we're not too sure about yet but we haven't yet found a dsm diagnosis where you know never mind this isn't going to work we thought it was tobacco smoking initially because the first few trials were not very encouraging but subsequently there's a slew of positive trials

19:14 and they're now met in analysis saying motivational interviewing is an evidence-based tool for helping people quit smoking so there are more than 1100 controlled trials in the literature now of motivational interviewing which i find astonishing and it's been tried in all with all sorts of things and it's not a specialist technique it's a generalist skill what are you most excited about in mental health treatment today 10 years ago i would have said the movement toward evidence-based treatment kind of increasing expectation that treatments that are being provided by counselors and psychotherapists the methods that have a good scientific basis that's what we expect of our health care providers more generally

20:00 and it's a reasonable thing although not a simple thing to to do so more and more states and and third party payers are beginning to require that people at least say they're using evidence-based treatment but there's there's the rub knowing whether people really are requires that you audit listen to sessions and know what's going on because pretty hard to tell from the case notes but now what i'm excited about i think is increase awareness of the impact the large impact of therapeutic relationship i think emphasize too much treatment techniques or evidence-based techniques and here's this manual if you just follow this manual people will get better well it turns out

20:46 that within any theoretical orientation or any particular treatment technique there are large differences in client outcome based on who's providing it and we know something about what that is i mean what is it about providers that makes it more effective and when you compare different theoretical orientations of psychotherapy with each other or different specialist psychological techniques with each other they're pretty similar you don't really get very big outcome differences in that one big study i alluded to we randomly assigned people with alcohol problems to motivational interviewing or to cognitive behavior therapy or to 12-step facilitation and all three finished dead even the outcomes were very good overall

21:32 without much in the way of difference among the three but within each of the three large differences based on who the provider was so if anything what is like most likely to predict the client's outcome is the counselor with whom they work and we're becoming more aware of that again which is exactly what carl rogers was thinking and writing about in the 1950s and 60s and i think that's an important advance over just thinking you know brand name techniques or this particular manual or whatever there really is no no evidence that i know of that following a therapy manual makes treatment more effective and motivational interviewing in fact one meta-analysis found the opposite

22:18 that when the therapists were following a manual the effect size was one-half as when therapists in other studies were not following a manual but doing motivational interviewing and that makes perfect sense to me because if you're paying more attention to a manual into your client you're not doing it right so if you had a magic wand and could improve one thing about mental health treatment today what would that be to humanize mental health treatment to have practice become more empathic more respectful of clients autonomy more interested in their strengths and less interested in their pathology the positive psychology movement has has i think going in that direction there's something else i'm excited about it we spent an awful lot of the history of

23:03 psychology studying what's wrong with people uh and now within positive psychology at least you're interested in what is happiness about and what is it that actually makes people happy what what are virtues i mean how do you become honest how do you become kind what's that look like how do you do that i think that positive mindset that looks for what people are doing right and looks for their own wisdom and resources is so important and i hope that that's an impact i know it is an addiction treatment and impact that that we wind up having on health care more generally a humanizing effect how can my audience learn more about motivational interviewing either online or in print online the motivational leaving network

23:48 of trainers maintains a website with more than you want to know it is www.motivationalinterviewing.org org it will point you to lots of resources there there are 30 some books around now about motivational interviewing the the one that steve rollnick and i wrote is now in the third edition that came out in 2013 and that's kind of our current state of understanding of what's going on there are books in specialty areas i wrote one on motivational interviewing and diabetes management there's one on motivational interviewing in healthcare there's one on working with kids with children and adolescents there's one on applying motivational

24:34 interviewing and corrections i mean just you know all these particular areas where people have done the work to understand when i'm working with this population with brain injury or whatever it is what is it about motivation living is helpful and then and then have shared that information as i said there are more than 1100 clinical trials out there so we have an enormous amount of research and what most people want to do is read the distillations of that meta-analyses or or summary reviews of that you know and there are more than 100 of those now so the extent to which this has grown is just astonishing to me i don't think it's grown primarily because of the science the science has grown but i think it's that that providers

25:21 it's like they recognize this and they begin to hear about and understand it is as if it's something they already knew and wanted to understand more about and that seemed to be what draws people to this and this is all around the world now where it's in more than 50 different languages being taught and practiced so i i think there's something fundamental about human nature going on here that we just happened to tap into and that it's been great fun to watch that but there's no no end of sources of information also on the motivational.org website there's an ongoing list of trainings that are available by geographic area there's lots and lots of those uh introductory and advanced and trainer

26:06 level i know that just reading about it doesn't usually change practice behavior i learned that just going to just going to a workshop doesn't change practice behavior although you might have the illusion that it does and that usually it takes some practice with someone looking over your shoulder and making gentle suggestions just as is the case when you learn a musical instrument or a sport dr miller on behalf of myself my listeners and all of the people that you've helped your work i want to thank you for your contributions to mental health treatment and for taking the time out of your busy schedule to help me and my audience better understand the field of motivational interviewing you're most welcome be sure to check out my website therapyshow.com which has many resources about mental health there you will also find how to

26:53 submit questions stories or insights you have about the mental health system or suggestions about who else i can interview and how i can improve the show i'd like to close by reminding our listeners to please subscribe share and review this podcast so you someone you love and people around the world can gain more benefit from therapy there is no need to suffer in silence get the help that you need to create the life that you want you