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Using Motivational Interviewing to Discuss Substan ...
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This curriculum by Brian Borsari, PhD, for the Addiction Psychiatry Advanced Psychotherapy Curriculum (AAAP) 2022 focuses on using Motivational Interviewing (MI) to address substance use through evoking client motivation and planning change. It provides an in-depth review of MI’s four key processes: Engaging (establishing connection), Focusing (centering the conversation), Evoking (eliciting motivation), and Planning (committing to and strategizing change). <br /><br />Central to MI is its Spirit—partnership, acceptance, empathy, autonomy, and evocation of clients’ own reasons for change. Foundational MI skills include OARS: open-ended questions, affirmations, reflections, and summaries. MI emphasizes balancing "change talk" (client language favoring change) with "sustain talk" (language favoring status quo), with strategies to acknowledge ambivalence without triggering resistance or defensiveness, often caused by the therapist’s "fixing reflex" (urge to direct or lecture).<br /><br />The curriculum outlines the RULE approach to evoking change: Resist fixing, Understand motivations, Listen with empathy, and Empower confidence. It teaches strategies for providing information/advice by first obtaining permission, using a simple elicit-provide-elicit model to maintain client autonomy. Addressing discord (relationship tension or disengagement) is critical, with techniques including supporting autonomy, empathy, reflective listening, affirmations, apologies, and shifting focus.<br /><br />Transitioning to planning is signaled by increased change talk, decreased sustain talk, client envisioning, and discussing concrete steps. Planning involves collaborative goal-setting using SMART (Specific, Measurable, Action-oriented, Realistic, Time-specific) goals and supporting client confidence to foster successful change attempts.<br /><br />Research findings stress that sustain talk predicts poorer outcomes, that clinician questions and reflections directly influence client language, and that ending sessions on change talk and planning statements predicts better behavior change. Avoiding discussion of substance use or off-topic talk undermines change efforts. Overall, MI’s success relies on skillful, empathetic guidance that evokes client motivation and collaboratively builds actionable change plans.
Keywords
Motivational Interviewing
Addiction Psychiatry
Substance Use
Client Motivation
OARS Skills
RULE Approach
Change Talk
Sustain Talk
SMART Goals
Empathy
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