Conceptual Article

Miller, W. R. (1983) Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy, 11, 147-172. 

In the area of substance abuse, it has been traditionally believed that if treatment is successful, it is due to the characteristics of the therapist and the approach itself. On the other hand, if a treatment approach is not successful it is often attributed to a lack of client motivation, persistence or strength. A personality characteristic that is often suggested to be a barrier in the treatment of alcoholism is the client's "denial." However, denial appears to be more often the product of the way counselors interact with clients. The belief in this inner "denial" of the alcoholic patient has led to a confrontational kind of therapy that only leads to increased resistance, and in turn to less success at motivating the patient to seek or remain in treatment.

Motivational Interviewing (MI) is a quite different approach. It uses reflective listening, operationalized by Carl Rogers as the skill of accurate empathy, as its main tool to help clients recognize the problem and think about possible solutions. Its main concern is to tip the balance between the perceived positive consequences of alcohol consumption and its negative consequences, towards the side of seeking help. MI discourages labeling, and emphasizes the client's own perspectives on the negative consequences that alcohol is having on a client's life. It also emphasizes the personal responsibility of the client to decide whether or not he/she has a problem, how serious it is and what to do about it. Similarly, MI gives the client credit for his/her improvement and change by emphasizing the client's internal control of his/her own behavior. MI further suggests eliciting dissonance in a client in order to emphasize the discrepancy between his/her behavior and his/her beliefs, attitudes, values, etc., therefore helping to increase the client's motivation to change behavior. Motivational Interviewing complements a more general transtheoretical model of stages of change, proposed by Prochaska and Diclemente, which includes the person's motivation for change in the first phases of the process as part of a cycle of change. MI complements this model by helping the client move from the precontemplation or contemplation stage to action.
Abstract by Patricia Juarez

Miller W. R. (1985). Motivation for Treatment: A Review with special Emphasis on Alcoholism. Psychological Bulletin, 98, pp. 84-107. 

The lack of client motivation has often been regarded as the cause of treatment failure, and it is usually seen as a result of inner maladaptive defense mechanisms of the client. This has been especially so in the area of alcoholism, where the primary defense mechanism is reputed to be the client's "denial." Therapists often base their perceptions of clients' poor motivation on lack of acceptance of the problem, resistance to accept "alcoholic" label, lack of desire to seek help, lack of distress and lack of compliance with the treatment. A more adaptive approach is to think of motivation as the probability of a desired behavior. Investigating the processes that influence a person to engage in behaviors leading to recovery should lead to a better appreciation of a client's motivation and to better treatment approaches. Motivational interventions attempt to increase the probability of engaging these behaviors. Some motivational interventions that have been successful in evoking behavior change include giving advice, providing feedback, goal setting, role playing, modeling, maintaining contact with client, altering external contingencies, providing choice with a variety of alternatives of goals and change strategies, and decreasing attractiveness of the problem behavior. Other less specific characteristics that also influence the client's motivation to enter treatment and comply with change efforts include characteristics of the client (distress, maintenance of high self-esteem, internal locus of control, severity of the addiction problem and conceptual level as a measure of interpersonal development), characteristics of the environment (waiting time, travel distance and social support) and therapeutic characteristics (hostility, expectancy and empathy). Belief in the trait model of motivation has often led to the use of confrontational therapeutic techniques, which have not shown high rates of success. When motivation is seen as a probability of behavior it may lead to the development of more successful treatment interventions, designed to increase the client's motivation of engaging in recovery related behaviors. 
Abstract by Patricia Juarez 

Miller, W. R. (1987). Motivation and Treatment Goals. Drugs and Society, 1, 133-151.

The goals that therapists set for their clients may not be the same that the clients have for themselves. This can result in client reluctance to comply with these goals. Research indicates that personal goals are an important factor in motivation for change; yet there are very few treatment programs in which the clients are free to choose from an array of alternatives what think is best for them. Treatment failure is often attributed to the client's lack of motivation or to his/her noncompliance with the goals set for them. It is suggested that clients should be matched with the best treatment goal chosen from a set of alternatives (e.g. abstinence, controlled drinking) in order to increase clients' early entry into treatment, compliance to treatment, treatment outcome, prevention through early intervention, service for a wider range of the population, and to decrease the overuse and costs of health-care. Different treatment goals such as abstinence and controlled drinking may be successful for particular individuals, pursuant to an overall goal of reducing problems associated with alcohol abuse.
Abstract by Patricia Juarez

Zweben, A., A., Bonner, M., Chaim, G., & Santon, P. (1988). Facilitative strategies for retaining the alcohol-dependent client in outpatient treatment. Alcoholism Treatment Quarterly, 5, 3-24. 

One of the main problems in the treatment of alcohol abuse and dependence has been the clients' noncompliance with therapy. This noncompliance has often been attributed to personal characteristics of the client, rather than to aspects of the treatment approach or the therapist him/herself. On the contrary, viewed from an interactional perspective, noncompliance arises from the miscommunication between the client and the therapist during therapy. This article provides a set of strategies to increase client compliance, by trying to achieve facilitative goals (necessary for treatment but not enough for change), primarily client "readiness" for treatment. These strategies include role induction, eliciting reflection on treatment, immunization, externalization of the client's ambivalence, eliciting self-motivational statements, delaying commitment to change, and exploring and interpreting noncompliant behavior. It is suggested that therapists should develop an action plan to implement the strategies according to the specific weaknesses and strengths of the client in order to increase treatment compliance. Guidelines for plan development are provided. 
Abstract by Patricia Juarez

Literature Review

Miller, W. R., & Sovereign, R. G. (1989). The Check-up: A model for early intervention in addictive behaviors. In T. Loberg, W. R. Miller, P. E. Nathan, & G. A. Marlatt (Eds.), Addictive behaviors: Prevention and early intervention (pp. 219-213). Amsterdam: Swets & Zeitlinger. 

It is commonly believed that alcoholics show specific internal and enduring personality characteristics such as lack of motivation to change, and the use of defense mechanisms such as denial, projection and rationalization. These "personal and stable" characteristics are believed to prevent alcoholics from recognizing their problem and from trying to do something about it. These beliefs have usually led to the use of confrontational and aggressive strategies in order to break through the client's defense mechanisms. However, research has shown that this view of motivation may not be accurate. There is no uniform "alcoholic personality." Furthermore, research has shown that the outcomes of therapy are often related to the characteristics of the therapist and to other external factors rather than to clients' personality characteristics. Brief interventions (1-3 sessions) can be very effective at reducing alcohol use and related problems. Some of the characteristics that make these interventions successful include feedback, emphasis on personal responsibility, advice, menu of alternatives, and emphasis on self-efficacy, which together have been referred to as motivational interviewing. The Drinkers' Check up (DCU) was developed to address the issue of how to attract people to enter this kind of intervention. The DCU intends to remove common barriers to seeking help, such as being labeled or diagnosed, rejection of a need for "treatment," fear of losing confidentiality, or cost. It consists of a 3-hour assessment followed by a 1-hour feedback session (an oral and written personal profile and a blood concentration table). The feedback session is conducted in a motivational interviewing style. Newspaper announcements of the DCU have attracted people who would be unwilling to enter "treatment," but who are concerned with health risks and with other alcohol-related problems. In an initial evaluation of the effects of the DCU, it was found that it decreased alcohol use and increased future treatment involvement, as compared to a control group that was put on a waiting list. Furthermore, when therapist style was considered, a client-centered style (motivational interviewing approach) elicited more positive responses, less resistance, more motivation to change, and therefore a decrease in alcohol use in the long term. 
Abstract by Patricia Juarez

Book

Miller, W. & Rollnick., S. (Eds.) (1991).  Motivational Interviewing: Preparing people to change addictive behavior. Guilford Press:NY.

This 300+ page text is available in both hardback and paperback and remains the most thorough presentation of MI to date.  The text uses a practical tone and gives many clinical examples.  The book is broken into three parts: Background, Practice, and Clinical Applications (in various settings and with various populations).  Besides a thorough overview, the text offers advice on avoiding typical problems that develop using the approach and on handling other typical and difficult situations, such as working with spouses and coerced clients, dealing with time shortages, and helping clients whose lives are in chaos and who often get sidetracked during sessions.  Other topics addresses in co-authored chapters include MI and the stages of change; brief MI by the nonspecialist; working with heroin-dependent and severely alcohol dependent clients; working with couples, adolescents, and sex offenders; using MI to reduce HIV risk; and incorporating maintenance of change issues into MI treatment. 

You may order the book here: http://views.vcu.edu/vattc/books.html#tx

Conceptual Article

Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behavior change in medical settings: The development of a brief motivational interviewing. Journal of Mental Health, 1, 25-37. 

This article introduces a brief form of motivational interviewing designed to be applied in brief medical consultations, especially for addictive behaviors. Its primary basis is the idea that most clients seek medical help without being ready to change behaviors such as alcohol consumption, smoking, exercise levels, diet or drug use, and they often show ambivalence about changing these behaviors. As a result, attempts to persuade the client to change often lead to client resistance. Therefore, the use of a method including motivational interviewing aspects, in which clients are directed towards realizing their own reasons and arguments for changing their behavior, seems to be most appropriate to motivate and prepare them for change. An important aspect of the brief motivational technique is the use of a set of alternatives from which the health care worker chooses the most appropriate strategy for the client, according to his/her degree of readiness for change. Each of these approaches last from 5 to 15 minutes and their main goal is to give the client information in a client-centered way, in order to increase the client's freedom of choice. The article includes a brief discussion on how to train health care workers to use these techniques, which is recommended to take place in a series of 2-3 hour sessions. It is also emphasized that this interviewing method is a decision making process that allows flexibility.
Abstract by Patricia Juarez

Literature Review

Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, 315-336. 

This article summarizes findings of 32 studies investigating the effectiveness of brief interventions for alcohol problems in general health care settings, with self-referred drinkers, and in specialist treatment contexts. It further attempts to identify those components that make this kind of intervention successful. In general, this kind of brief motivational intervention focuses on eliciting problem awareness and giving advice for change using an empathic therapeutic style. Overall, brief motivational interventions have been found to be relatively effective at reducing alcohol consumption and at motivating clients to enter treatment, when compared with control or more long term interventions. Brief motivational interventions represent a cost-effective method for reducing alcohol consumption and/or for motivating clients to seek further treatment for alcohol problems.
Abstract by Patricia Juarez

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Conceptual Article

Miller, W. R. (1993). What I would most like to know: What drives change? Addiction, 88, 1479-1480. 

This article is an hypothetical "letter to God" asking what are the mechanisms of change in addictive behaviors. There are several factors that have been proposed as the causes of addiction (determinant, predisposing, precipitating and reinforcing factors). Similarly, it has been suggested that relapse is primarily caused by precipitating factors. The author is most concerned, however with the fact that too little investigation has been devoted to studying the causes of change in addiction, including its precipitating causes (what occurs before change), predisposing factors (foundation for change), perpetuating causes (what maintains change), and primary causes (necessary and sufficient conditions for change). Furthermore, it would be useful to know how these factors interact with each other to produce behavior change, and how is it that some people seem to experience drastic and permanent transformations. The article is one in a series of invited short pieces in which senior researchers indicate what they would most like to know. 
Abstract by Patricia Juarez

Conceptual Article

Rollinick, S., Kinnersley, P., & Stott, N. (1993). Methods of helping patients with behavior change. British Medical Journal, 307, 188-190. 

It has become of increasing importance to find better ways to encourage people to change health behaviors, especially in primary health care settings. This article presents the limitations of just giving advice, and provides better techniques to help practitioners motivate their clients to change. Evidence indicates that many clients seem reluctant to accept advice, especially when it is unsolicited and unrelated to their perceived problems, which often causes resistance and disagreement. It is therefore suggested that practitioners use a negotiation method where the clients themselves analyze the positive and negative side of drinking in their lives. It is also important to consider the stage of 'readiness for change' of the patients in order to better match them with the appropriate treatment approach, such that the intervention becomes more intensive as the person is more ready for change. This type of intervention has been referred to as 'motivational interviewing,' which among its basic components includes reflective listening and negotiation of behavior change. It is suggested that the practice of this kind of approach would lead to more positive results, but more research is needed to confidently support this claim.
Abstract by Patricia Juarez

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Therapy Manual

Miller, W.R., Zweben, A., DiClemente, C.C., & Rychtarik, R.G. (1995).  Motivational Enhancement Therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence.  NIH/NIAAA: Rockville, MD.

This 121 page clinical manual describes the MET procedures used in “Project MATCH,” which sought to determine whether subgroups of substance abusers respond differently to 12-Step Facilitation Therapy, Cognitive-Behavioral Coping Skills Therapy, and Motivational Enhancement Therapy.  In this study, MET was used in a structured 4-session, individual format and was preceded by approximately 6-7 hours of intensive biopsychosocial assessment.  The first two sessions focus on structured feedback from the initial assessment, future plans, and motivation for change.  The final two sessions at the midpoint and end treatment provide opportunities for the therapist to reinforce progress, encourage reassessment, and provide an objective perspective on the process of change.  The sessions were delivered in the following format: Session 1 at week 1 of the project, Session 2 at Week 2, Session 3 at Week 6, and Session 4 at Week 12.

Visit the NIAAA web site to learn more about Project MATCH or to obtain this treatment manual:
 http://silk.nih.gov/silk/niaaa1/publication/match.htm 

Conceptual Article

Annis, H.M., Schober, R., & Kelly, E. (1996).  Matching addiction outpatient counseling to client readiness for change: The role of structured relapse prevention counseling.  Experimental and Clinical Psychopharmacology, 4, 37-45.

This article describes a structured, comprehensive cognitive-behavioral outpatient counseling program (SRP) for substance abusers consisting of 5 components: Assessment, motivational enhancement, preparation of individualized treatment plans, “initiation of change” counseling procedures, and “maintenance of change” counseling procedures.  The program includes use of the Inventory of Drug-Taking Situations and homework forms for the initiation and maintenance phases.  SRP has been shown to “dramatically” reduce clients substance use, work effectively in individual or group formats, work best with individuals who use in specific situations or under specific conditions, and good outcome is related to high confidence and good use of coping strategies. 

Conceptual Article

Carey K.B. (1996).  Substance use reduction in the context of outpatient psychiatric treatment: a collaborative, motivational, harm reduction approach.  Community Mental Health Journal, 32: 291-306.

This article describes a model of reducing substance use through psychiatric outpatient treatment that is based on the intensity of treatment, stage of change, motivational psychology, and harm reduction concepts.  Carey describes five steps of treatment, including establishing a working alliance, helping the client to evaluate the costs and benefits of continued substance use, setting individualized goals, creating a lifestyle that can support abstinence, and coping with crises.  The model depends upon a primary therapist or case manager who can coordinate these steps of treatment, and draws heavily from practical experience, as well as the research showing the importance of considering the client’s readiness and motivation to change, and personal values.  The article provides an example of adapting theoretically based treatments to a typical community mental health setting where dual diagnosis is the norm. 

Therapy Manual
Obert, J. L., Rawson, R. A., Miotto, K. (1997). Substance Abuse Treatment for "Hazardous Users": An Early Intervention Journal of Psychoactive Drugs, July-September 1997, Vol. 29(3).

A six-session cognitive behavioral protocol has been developed for substance abusers who meet the description "hazardous users." This category includes individuals evidencing mild to moderate use of alcohol or other drugs, whose lifestyles are minimally disrupted, or who are displaying signs of problem use or abuse, but are unwilling to enter intensive treatment. The treatment model in nonconfrontational and is designed to motivate the individual to recognize the problems associated with his or her substance use and initiate treatment-seeking behavior. The intervention may be particularly useful in situations where employees have tested positive for substances but deny having a problem, where friends or family members report help is needed but the individual denies any problem, or where an alcohol or other drug problem is clearly evidenced but the individual doesn't acknowledge a a problem. A positive outcome is indicated by the client taking action which is consistent with an increased awareness of the problem as conceptualized by Prochaska and DiClemente (1982). This model is an alternative to the traditional confrontational models of "breaking through denial." The philosophies employed by William Miller and associates and by the Matrix treatment models form the basis of the intervention.

Conceptual Article

Sciacca, K. (1997). Removing Barriers: Dual Diagnosis Treatment and Motivational Interviewing. Professional Counselor, Vol. 12, No.1, February 1997, pp. 41-46.

In the past, traditional treatment methods for drug addiction and alcoholism have been intense and confrontational. They were designed to break down clients’ denial, defenses and/or resistance to their addictive disorders, as they are perceived by the provider. Admission criteria to substance abuse treatment programs usually require abstinence from illicit substances; awareness of the problems that substance abuse has caused; and motivation to participate in treatment. In contrast, traditional methods for mental illness have been designed to maintain the client’s fragile defenses, and are non-confrontational. Clients within the mental health system are usually not seeking treatment for their substance abuse and frequently do not meet traditional substance abuse criteria.

In 1984 as treatment evolved for clients with both substance abuse problems and mental illness (including severe, persistent mental illness) it became apparent that new methods and interventions were necessary. The new method was phase specific and engaged clients at all levels of readiness and motivation. Interventions were non-confrontational and allowed clients to comfortably move through the treatment phases as they felt ready to do so. Prior to this approach there were barriers to treatment for the dually diagnosed in both the mental health and substance abuse systems. Clients had no where to go for services and many deteriorated into a downward spiral of detachment, homelessness, and/or incarceration. The barriers included: substance abuse treatment readiness criteria; contrasting, incompatible models of treatment across systems; the lack of education and training among mental health and substance abuse providers and their discomfort in working with disorders they were unfamiliar with. Over the years it has been the contrasting methods and philosophies of treatment that required much of the attention in the development of integrated services within both systems.

In an effort to bridge the gaps across systems the inclusion of motivational interviewing has been invaluable. While dual diagnosis treatment evolved in the mental health system, and motivational interviewing evolved in the field of alcoholism treatment, the similarities across the philosophies, strategies and phase and stage concepts are remarkable. Clarifying these similarities to providers gives all disciplines new skills to bring to their work for all of the different client profiles they encounter. Each model can be used separately or together, and each one enhances the other. By having providers in each system employ stage and phase, non-confrontational models, barriers are removed for all clients. This includes clients within the substance abuse system who are not ready to address their mental health issues.

This article compares the philosophies, phases and stages, interventions and strategies of dual diagnosis treatment and motivational interviewing in some detail. It conveys a message of hope, that of removing barriers and providing services for all symptoms, at all phases of readiness, across systems.
Abstract by Kathleen Sciacca

Book

Daley, D.C. & Zuckoff, A. (1999). Improving treatment compliance: Counseling and systems strategies for substance abuse and dual disorders. Center City, Minn.: Hazelden.

This comprehensive, concise, and practical book integrates extensive clinical experience and an exhaustive review of the psychiatric and addictions literature on compliance-related issues, to help counselors, therapists, and other treatment professionals engage and keep clients in treatment while enhancing their motivation to actively participate in the process of change. The book, written in a style both clear and accessible, and rich in clinical examples and sample dialogues, is organized into three parts. Part I (pages 1-48) provides the overview, describing types of compliance problems, factors that affect compliance, and the effects of limited compliance on clients, family members, and treatment providers. Part II (49-102) presents a menu of counseling and systems strategies to improve compliance. Part III (103-216) builds explicitly on the foundation of motivational interviewing to describe specific, semi-structured interventions for helping clients to enter outpatient treatment, make the transition from residential or inpatient facilities to aftercare, and actively and consistently participate in treatment during the first, crucial weeks.
Abstract by Allen Zuckoff

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Conceptual Article

Miller, W. R., & Jackson, K. A. (1985). "Not listening" and "Listening" chapters. In Englewood Cliffs (Ed.), Practical Psychology for Pastors (pp. 31-59). NJ: Prentice-Hall.

The purpose of these chapters is to teach pastors quality listening skills. They propose a whole new way of listening which may be considered a new way of thinking and relating to other people. The first chapter describes what not listening is in order to set the way to describe what good listening is indeed. Not listening involves signs of lack of interest, a lot of talking and interruption by the listener, signs of boredom, and a lot of fidgeting. Other verbal examples of "not listening" include providing a lot of own opinions and evaluations, or any other way to prevent people from thoroughly expressing their thoughts. A list of 12 common obstacles to good listening and examples are described in detail. Listening, on the other hand, means devoting all attention to the speaker, refraining from giving own opinions, and engaging in active listening (reflecting what the person is saying, feeling and thinking). Therefore reflective listening gives to the client an accurate reflection of his/her own thoughts and feelings. The steps to provide this type of listening include acceptance (listening without judging), learning to think reflectively (alternative interpretations), providing reflective statements rather than questions (a guess about the speaker's meaning), giving deep reflections (rephrase, paraphrase, elaborate), and being alert for feedback from the client. The chapter also presents some points to improve the basic skills of reflective listening, such as understating feelings, reflecting both sides of a conflict, and using appropriate analogies. Finally, the chapter describes situations in which reflection may not be advisable, or may be all it takes. 
Abstract by Patricia Juarez

Miller, W. R. (1987). Techniques to modify hazardous drinking. In M. Galanter (Ed.) Recent Developments in alcoholism, 5, Memory Deficits, Sociology of treatment, Ion channels, Early problem drinking. Plenum Press. New York, NY. pp. 425-438.

This chapter presents a summary of past and recent research on the effectiveness of different treatments and interventions for early alcohol abuse. The type of intervention described in this chapter focuses mainly controlled or moderate drinking. The overall goal is mainly to decrease alcohol use to a level in which it no longer causes problems nor posses significant risks for the individual. The most effective procedure that emerged in the research of the early 70's, was Self-controlled training, which has been extensively evaluated and investigated in the present. This type of interventions commonly include aspects such as goal setting, self-monitoring, reduction strategies, self-reinforcement, functional analysis, and alternatives to drinking. The chapter describes the current research on Behavioral Self-controlled Training (BSCT) in detail. In general, it is suggested that BCST is most effective at achieving moderate drinking for less severely impaired and dependent drinkers, and that abstinence is more likely to be accomplished by more severe and problematic drinkers. This research has now progressed towards the investigation and understanding of motivation for change and its implications for early interventions. This idea has led to the development of interventions attempting to increase this motivation for change (e.g. Drinker's Check-up), which have been shown to be as effective at reducing drinking behavior as treatments using BSCT 
Abstract by Patricia Juarez

Conceptual Article

Botelho, R. J., & Novak, S. (1993). Dealing with substance misuse, abuse and dependency. Primary Care, 20, 51-70.

The present article describes a six-step model, with specific strategies in each plan, for primary care clinicians to deal with the wide range of alcohol and drug related problems. This model can be applied in private offices and in hospital settings. The patient should be first screened for high risk drinking and/or substance abuse, then assessed on their substance abuse related problems and risks. Then patients should be given information on the results of this assessment in order to educate the patients about the health risks associated with their drinking and/or substance abuse. According to the seriousness of the addiction problem, the physician can then select the most appropriate strategy for the particular problem, help the patients become aware of the problem, and negotiate a plan for change. Finally, the last step of the model is one or several follow up visits in order to keep track of the patient and help him keep moving forward on his/her recovery. This six-step model is based on concepts derived from the transtheoretical model of behavior change, brief interventions and motivational interviewing techniques. The transtheoretical model of change suggest that people go through several stages when changing a behavior, and they can dictate the best approach to take with a particular patient. These stages are precontemplation, contemplation, preparation, action, maintenance and relapse. Research in the area of substance abuse treatment has shown that early brief interventions can be as or even more effective than more long term therapies. Finally, motivational interviewing (MI) assumes that it is the patient's responsibility to decide what changes he/she wants to do and how, and it is based on empathy as the key strategy to help patients make these decisions. Specific guidelines and case examples to apply and integrate the bases of these three constructs, are provided for each of the six steps of the model.  
Abstract by Patricia Juarez

Holder, H. D. (1993). Changes in access to and availability of alcohol in the United States: research and policy implications. Addiction, 88, (Supplement), 67S-74S.

In recent years, the availability and access to alcohol has changed significantly in the United States. This article reviews the role that public policy research has played in this change. Two present trends have been observed. The first has been an increase in the availability of alcohol due to the increased availability of wine and spirits, their lower cost and their higher outlet densities. The second trend is a reduction in alcohol availability and access due to higher minimum drinking ages, server intervention and training, server liability, availability of low or non alcohol drinks, and warning labels on alcohol products. The main roles that research has played are in the initiation of discussion, consideration or policy enactment; although it may also be completely disregarded at times.  
Abstract by Patricia Juarez

Conceptual Article

Ames, D. A. (1994). A comparison of Mental Health Center Operated Detoxification Programs in North Carolina. Alcohol, 11, 477-480.

Treatment for alcoholism come in a variety of approaches that may go from brief inpatient hospital treatment to outpatient detoxification programs. The present article compares two community based detoxification programs: "social setting" and "medical nonhospital." The social setting detoxification program was designed for clients who did not need intensive care, but that still required a supportive and structured environment. On the other hand, the medical non hospital programs have medical trained staff, and employ different treatment approaches. It was found that the social setting programs are less expensive in the cost per bed, physicians and drugs. But since the medical programs tend to elicit positive results in a short amount of time, the overall costs per client are comparable.  
Abstract by Patricia Juarez

Conceptual Article

Miller, W. R., Jackson, K. A., & Karr, K. W. (1994). Alcohol problems: There's a lot you can do in two or three sessions. EAP Digest, 14, 18-21, 35-36.

Employee assistance programs (EAP) to help employees have commonly operated on time-limited intervention model, which may consists from two to eight sessions. For this reason, it is often the case that when the presenting problem is alcoholism, it is often just detected and then referred to usually costly in-patient or residential programs. Recent developments in the area of alcoholism treatment suggest first that there is a broad range of different alcohol problems, which suggests that one of approach to treatment may not be the most appropriate for all alcohol problems. Second, research has shown that the intensity of treatment (in-patient vs. out-patient, long-term vs. short-term) does not determine its effectiveness. Third, it has been found then that brief interventions can be very effective at changing clients' drinking. The components that make this kind of brief interventions effective include providing feedback, emphasizing personal responsibility, giving advice, providing a menu of alternatives, showing empathic understanding, and emphasizing self-efficacy. The basic procedure for brief motivational interventions is outlined and the implications of these findings for EAP professionals are discussed.  
Abstract by Patricia Juarez

Miller, W. R., & Sanchez, V. C. (1994). Motivating young adults for treatment and lifestyle change. In G. Howard and P. E. Nathan (Eds.), Alcohol use and misuse by young adults (pp. 55-81). Notre Dame, IN: University of Notre Dame Press.

Motivation for change has often been viewed as a stable personality characteristic. More recently however, research has suggested that motivation is part of a process of stages of change, which go from precontemplation to maintenance of behavior. Furthermore, motivation is also viewed as a product of interpersonal relations and environmental variables rather than as a stable characteristic of the individual. Of similar importance, significant support has been found for the effectiveness of relatively brief motivational interventions, over no treatment and long-term treatment approaches. This type of intervention include elements such as giving feedback, emphasis on personal responsibility, giving advice, providing a menu of alternatives and goals, showing empathetic listening and emphasis on self-efficacy. Other factors that have been found to influence people's motivation for change, and that are approached by brief motivational interventions are how risky is the target behavior perceived, and the individual's perceived self-efficacy to change this behavior. Another crucial recent development is the change in the conception of alcoholism, where rather than being seen as a disease, it is now viewed more in terms of a complex and interactive public health model. The implications of these findings in the development of prevention interventions that include these components are discussed in detail.  
Abstract by Patricia Juarez

Miller, W. R. (1994). Motivational Interviewing: III. On the ethics of Motivational Intervention. Behavioral and Cognitive Psychotherapy, 22, 111-123.

This article discusses the ethical implications associated with Motivational interventions. Motivational interviewing (MI) is a therapeutic technique designed to motivate people to change health behaviors. One of the most important barriers for change that has been typically identified is the person's "denial," which according to recent research can refer to conscious lying, normal self-protective biases, lack of awareness, ambivalence or resistance, rather than as a permanent personality characteristic of the clients. The first ethical question that emerges is under what conditions can a therapist work with an unmotivated client and how? A continuum is suggested in which the therapist goes from passive to more coercive techniques, depending on the client's level of readiness for change and the severity of the problem. The basic goal of motivational interventions is to elicit dissonance between the present behavior, and future goals and values of the client. Another ethical concern that has been identified is whether or not MI is a "manipulative" technique in which clients may seem to be made to change behaviors when they were not intending to, and under processes that are not easily perceived. The basic purpose of MI is to elicit cognitive dissonance by having the person describe how his behavior is interfering with the attainment of other goals that seem important for her/him, so that the motivation for change comes from within the patient and not imposed by the therapist or the technique itself.  
Abstract by Patricia Juarez

Jarvis, T. J., Tebbutt, J., & Mattick, R. P. (1995). Motivational Interviewing. Treatment Approaches for Alcohol and Drug Dependence: An introductory Guide. (ch. 3. pp. 35-50).

Motivational Interviewing (MI) is a therapeutic style that is particularly recommended to be used in the initial sessions of the treatment of drug users. The primary goal of MI is to have the clients voice their own concerns and reasons for changing, emphasizing their own responsibility and choice. The key concepts in MI are empathy (i.e. reflective listening), ambivalence about change, self-motivational statements (e.g. recognition of the problem, desire to change, concerns), counseling microskills (e.g. open-ended questions, affirmations, summaries), and client resistance. This chapter summarizes the basic strategies of MI, which include: exploring the good and less good things about drug use, summarizing, perceptions of past and present, decision making, and providing information for precontemplators. Furthermore, the chapter also presents some other applications of MI strategies, such as presenting personalized feedback on assessment results, and group therapy. Finally, the five basic clinical principles of MI are presented, which are: expression of empathy, development of discrepancy, avoidance of argumentation, rolling with resistance, and support of client responsibility and choice.  
Abstract by Patricia Juarez

Annis, H. M., Schober, R., & Kelly, E. (1995). Matching addiction outpatient counseling to client readiness for change: The role of structured relapse prevention counseling. Experimental and Clinical Psychopharmacology, In press.

It is becoming of greater importance in the area of addiction treatment to recognize the client's readiness for change and to match them to appropriate therapeutic strategies. This idea was developed out of the recent definition of motivation as a process of change in which people move back and ford from one stage of change to another. This paper describes a comprehensive cognitive-behavioral outpatient counseling approach for substance abusers. This program includes five components: assessment, motivational interviewing, preparation of an individual treatment plan, counseling procedures for the initiation of change, and counseling techniques for the maintenance of change. Each of these components are closely related and carefully matched to approach the five stages of change described by Diclemente and Prochasta (1984), which are precontemplation, contemplation, preparation, action and maintenance. The paper further describes the Commitment to Change Algorithm (CCA), which is a measure designed to identify the client's stage of change for alcohol and drug use. Therefore, it is suggested that after an assessment of the clients' stage of change, they should be matched to an individually tailored therapeutic approach which would focus on helping each client move to higher stages of change. However, it is acknowledged that clients may fall back to previous stages, and therefore, appropriate strategies are suggested to cope with these situations. Finally, the paper emphasizes the difference between the homework assignments in the Structured Relapse Prevention (SRP) counseling for the "initiation/action" and the "maintenance" stages of change.  
Abstract by Patricia Juarez

Conceptual Article

Bien, T. H., Miller,. W. R., & Tonigan. (1995) Brief intervention: a reply to a review. Response to a critique by Johnson et al. (1995), about review of brief interventions for problem drinking (Bien, Miller & Tonigan, 1993).

The review includes several definitions for "brief" interventions, due to the variety of different interventions studied in the different articles reviewed, but still, brief interventions referred overall to interventions with 3 or fewer sessions. It is suggested that the confusion involves the distinction between counseling, follow-up or assessment sessions. It is then concluded that there is a lot of evidence for the effectiveness of brief interventions, and there are no differences between in the effectiveness of brief and more long-term interventions, but it still suggested that these techniques may be more appropriate for different patients. Furthermore, a question remains: Why does brief intervention or single assessment sessions work, and for whom?  
Abstract by Patricia Juarez

Conceptual Article

Miller, W. R. (1995). The ethics of motivational interviewing revisited. Behavioral and Cognitive Psychotherapy, 23, 345-348.

This article is a response to two commentaries on a previous article on the ethics of motivational interviewing (MI). First it suggests that the ethical principles that apply to MI also apply to other kinds of psychotherapy, because of its goals for therapy. However, it is argued that the issue of informed consent does not apply in the area of psychotherapy, but rather it is an implied form of consent from the client who is seeking treatment. It is also suggested that the purpose of all psychotherapies is to influence and change behavior and that because of these goals, MI and other similar kinds of psychotherapy should not be seen as unethical. The previous article to which this present article alludes was written in response to some concerns that researchers and therapists were having about MI, and not as an attempt to defend MI from attacks or criticisms. The author claims that one of the most important and current concerns in MI is to investigate the conditions that promote long-term change and under what circumstances should it be applied. Therefore he does not excludes the posibility that other approaches to psychotherapy (e.g. Psychoanalysis) may provide significant contributions to, and may benefit from the MI approach. 
Abstract by Patricia Juarez

Conceptual Article

Rollnick, S., & Morgan, M. (1995). Motivational Interviewing: Increasing readiness to change. In A Washton (Eds), Psychotherapy and substance abuse: A practitioners handbook (pp. 179-191). New York: Guilford Press.

Ambivalence about change is a crucial aspect when talking about addictive behaviors and motivational interviewing (MI) is an approach to help clients resolve this ambivalence. MI views motivation as a fluctuating state of readiness to consider changing a behavior, rather than as a stable personality characteristic. MI is therefore defined as a directive, client-centered counseling style for helping people explore and resolve the ambivalence about changing a behavior. The five basic principles of MI are expression of empathy, development of discrepancy, avoidance of argumentation, rolling with resistance, and emphasis on self-efficacy. MI also has two key components: client-centered counseling skills, and eliciting of self-motivating statements. Furthermore, MI is administered in two phases: one which focuses on the precontemplation and contemplation stages of change, and other which focuses on the preparation stage. The approach taken by MI is very flexible since it can be used for different substances and for different behaviors. And research its beginning to find that this interviewing technique can be very effective at changing behavior, even with just one or two sessions. It is further suggested that MI can be appropriate at all levels of change since people can go through periods of crisis and ambivalence at any point in the process, which suggests that readiness to change can serve as means to match people to the most appropriate type of treatment.  
Abstract by Patricia Juarez

Conceptual Article

Jensen, M. P. (1995). Enhancing Motivation to change in pain treatment. In D. C. Turk & R. J. Gatchel (Eds.), Psychological Treatments for Pain: A Practitioner's Handbook. (in press). New York: Guilford Press.

One of the possible causes of the partial success of current pain treatments is the patients' own motivation for treatment. For this reason it is suggested that an intervention referred to as Motivational Enhancement therapy (MET), designed to increase people's motivation for change, would be beneficial in the area of pain treatment and management. The present chapter intends to introduce the MET procedure to clinicians so that they can help their clients change behaviors that would lead to a better adaptation to pain situations. MET is based on the assumption that people go through a series of stages when trying to change a behavior, which suggest that some approaches to treatment might be most suited for people at different stages of change. Therefore, the main purpose of MET is to provide clients with a therapeutic approach appropriate to their stage of change, so that they can more easily move to higher stages. The main components of MET are empathic reflective listening, discrepancy between present behavior and goals, avoidance of argumentation, rolling with resistance, and the emphasis on the clients' self-efficacy. The main basic strategies that MET uses to achieve these goals are clustered together in three phases which are: strategies that enhance motivation for change, those that strengthen commitment for behavior change, and strategies for follow up or maintenance. In summary, MET may prove a useful approach for the treatment of pain and for the prevention of relapses for patients for whom previous pain treatments have not been effective, by making the process more satisfactory for both the client and therapist.  
Abstract by Patricia Juarez

Miller, W. R. (1995). Increasing motivation for change. In R. K. Hester & W. R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (2nd ed., pp. 89-104).

Until recently, motivation was often seen as a personal characteristic of the client. Similarly, lack of motivation was seen as resulting from defense mechanisms characteristic of alcoholics. Now it has become more widely accepted that external environmental and interpersonal factors play a more crucial role in peoples' motivation for change, and the idea of the "alcoholic personality" has gradually lost support in the research community. Therefore, motivation is now conceptualized as involving the recognition of a problem, a search for a way to change, and implementing and maintaining that change. This definition suggests a process with different and clearly defined stages of change. In order to increase peoples' motivation for change, several strategies have proven successful, which can be conceptualized with the acronym FRAMES. These aspects refer to providing feedback, emphasis on personal responsibility, giving advice, suggesting a menu of alternatives, showing empathic listening, and emphasis on self-efficacy. These elements have lead to the development of an intervention referred to as "motivational interviewing," which is basically a nonconfrontational approach to therapy that emphasizes cognitive dissonance between the present behavior and the future goals and values of the client. Its main purpose is to help the client move from precontemplation or contemplation, to determination and action by emphasizing the clients' personal responsibility in making the choices, and using an empathic therapeutic style that avoids argumentation. Usually, the intervention begins with an assessment (Drinker's Check up), which can be used to give feedback to the client and can even serve as a sole intervention session. Other important aspects of motivational interventions include the removal of barriers, the management of external contingencies, family involvement, some more coercive strategies, and therapist's persistence. All these characteristics and elements of this type of brief motivational interventions have proven to be effective at modifying drinking behavior in research investigations on their impact, making it a promising breakthrough in the area of addiction treatment.  
Abstract by Patricia Juarez

Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioral and Cognitive Psychotherapy, 23, 325-334. Also as: Rollnick, S., & Miller, W. R. (1996). Que es la Entrevista Motivacional? Revista de Toxicomanias, 1(6), 5-9.

The purpose of this article is to clarify what motivational interviewing (MI) is in essence, to differentiate it from similar methods of therapy, and to provide an update of its success, new applications and problems. MI refers to a directive client-centered approach to counseling designed to motivate people for change by helping them to recognize and resolve the discrepancy between a problem behavior, and personal goals and values. The key characteristics of MI are that motivation arises from the client, it is the responsibility of the client to recognize and solve the ambivalence, it doesn't use direct persuasion to solve the discrepancy, the therapist acts in a noconfrontational manner, the therapist directs the client in the recognition and solution to the problem, and that readiness to change emerges from the "partnership" interpersonal interaction between therapist and client. There are other related methods and related interventions that generally comply to these characteristics, but that may not retain the spirit of MI. Some of these interventions include the Drinker's check up, Motivational Enhancement Therapy (MET), Brief motivational interviewing, and Brief interventions. The efficacy of MI has been widely supported through research and further applications have been developed for different populations and for different problems.  
Abstract by Patricia Juarez

Stott, N. C. H., Rollnick, S. R., Rees, M. R., & Pill, R. M. (1995). Innovation in clinical method: diabetes care and negotiating skills. Family Practice, In press.

Detection, treatment, and control of diabetes has improved significantly in recent years. The problem is that there is a very high rate of noncompliance with treatment indications among patients suffering from diabetes. This paper describes a technique designed to improve clinical negotiations with patients suffering from diabetes, which is designed to be implemented at primary care settings. This method includes aspects such as client centered counseling, patients' readiness for change, and some components of motivational interviewing. The major emphasis of this type of intervention is to encourage clients' self-efficacy and personal responsibility to solve the discrepancy between the present behaviors and their future goals, in a nonconfrontational manner. Clients are also provided with several alternatives to change from which they can choose the one best suited for them. This paper describes an attempt to train primary care physicians and nurses to apply this type of intervention for diabetic clients. Data for this randomized trial is going to become public by 1996.  
Abstract by Patricia Juarez

Miller, W. R. (1996). Motivational interviewing: Research, practice and puzzles. Addictive Behaviors, 21, 835-842.

Brief interventions that include some type of feedback, emphasis on personal responsibility, advice, a menu of alternatives, empathy, and emphasis on self-efficacy have been shown to be effective for the treatment of drinking problems. This success has promoted questions and research on the process of motivational interviewing (MI) and on the factors that make it work. MI is a client centered therapeutic approach designed to motivated people to change problem behaviors by promoting the reduction of ambivalence. The present article presents a review of the research that led to the development of this approach. It further presents the current evidence that support the effectiveness of MI at reducing substance abuse. Even though MI has been shown to be effective, the mechanisms of change that it promotes, and why is it that it works, are still puzzling.  
Abstract by Patricia Juarez

Digiuseppe, R., Linscott, J., & Jilton, R. (1996). Developing the therapeutic alliance in child-adolescent psychotherapy. Applied & Preventive Psychology, 5, 85-100.

Research in the area of child and adolescent psychotherapy is scarce in comparison to research in adult psychotherapy. This article reviews the literature on the therapeutic alliance in child-adolescent psychotherapy, and suggests research strategies and techniques to develop this alliance with these populations. A positive therapeutic alliance is that in which there is a warm bond and an agreement between client and therapist on what is hoped to be achieved during therapy. However, most types of psychotherapy are targeted for self-referred clients in the contemplative or action stage, and the majority of young people are not self-referred for treatment and are usually in the precontemplative state of change. This in turn makes the development of the therapeutic alliance, and mainly the agreement on the goals of therapy, harder for these populations. The agreement on therapeutic goals may be attained if self-evaluation skills are taught and strengthened in child and adolescent clients, taking into account their particular developmental stage. The social problem-solving literature, the emotional script construct in the sociology of emotions, strategic family systems, and the concepts of motivational interviewing (MI) may help therapists understand the change processes as applied to the particular characteristics of children and adolescents, and therefore to use age appropriate therapeutic strategies to develop this therapeutic alliance. The main goal of these strategies is basically to help the clients evaluate the consequences of their behavior and the consequences of other alternatives. Thus, when the therapist attempts to achieve the therapeutic alliance, he/she can demonstrate a respect and concern to the client that they may have not experienced before.  
Abstract by Patricia Juarez

Rollnick, S. (1996). Behavior change practice: Targeting the individual. International Journal of Obesity, 20 (suplement 1), S22-26.

This article describes the use of a recent therapeutic approach called motivational interviewing (MI) in the area of addictions, and how it can also be used during medical visits and for a wider range of behaviors. The main goal of this paper is to introduce this method as an effective alternative for the treatment of obesity, for the use of the general practitioner. MI is based in part on the stages of change model, which explains the processes people go through when trying to change a behavior. MI is usually defined as a directive, client-centered counseling style which helps people explore and resolve their doubts about changing a behavior. The author describes four basic negotiation-based strategies that can be employed for the treatment of obesity: 1) The patient sets the session's agenda, 2) Quick assessment of motivation and confidence, 3) Help clients make decisions and set goals for them, and 4) Exchange information on personal behavior and risks. In conclusion, it is argued that patients with obesity problems should take an active role in their own behavior change, and that they way therapists relate to them has a big impact on their success.  
Abstract by Patricia Juarez

Conceptual Article

Miller, W. R., & Bennett, M. E. (1996). Treating alcohol problems in the context of other drug abuse. Alcohol, Health & Research Work, 20, p.118-123.

It is commonly found that people who abuse alcohol tend to also abuse other drugs. This polydrug use may increase the individual's risk for relapse and for more serious alcohol and other drug related problems. Polydrug users in treatment for alcohol problems tend to experience less change in their drinking, which may be due to particular personality characteristics. For this reason, the treatment of only alcohol abuse while relegating other drug use is highly discouraged, and it is suggested that a more comprehensive approach to treatment be taken in these cases. This article discusses the implications of polydrug use for the treatment of alcohol related disorders, in areas such as assessment, motivation, treatment design, and outcome evaluation, which should each be approached in terms of each drug used by the person. Such an approach will provide a better understanding of the interrelationship of drinking, drug use, and the psychosocial context in which these drugs are used. Therefore more comprehensive treatment approaches will be developed, which will have a more general positive effect on the clients' lives.  
Abstract by Patricia Juarez

Conceptual Article

Samet, J. H., Rollnick., S., & Barnes. H. (1996). Beyond CAGE: A clinical approach after detection of substance abuse. Archives of Internal Medicine, 156, 2287-2293.

Recently, physicians have started to address the problems related to alcohol and drug use more directly, rather than just focusing on the medical complications associated with alcohol and drugs. This is has been suggested to be due to the high economic and humane costs if substance abuse. Generalist physicians are more likely to come into contact with people with addiction problems than other more specialized settings. For this reason, physicians should incorporate the detection of substance abuse problems and brief interventions in their education and practice. Physicians may use screening instruments such as the CAGE questionnaire, and include more questions on the client's history. Once a problem is detected, they should also include a more through assessment of the client's own perception and feelings about the problem. It is also crucial that physicians be trained on what they could do when they detect a substance abuse problem, that would indeed have an impact on behavior. In order to do this, physicians should first assess the patients' stage of readiness and then select the most appropriate strategy to use. Next, they should also learn how to conduct brief client-centered motivational interviews (5 to 15 minutes). This type of interventions are based on the concepts of motivational interviewing (MI), and are designed to increase people's motivation to change their harmful behaviors. The main two elements of this brief intervention is the recognition that it is the patient's responsibility to change his/her behavior, and the use of an empathic therapeutic style to help the patient resolve his/her ambivalence to change.  
Abstract by Patricia Juarez

Keller, V. F., & White, M. K. (1997). Choices and Changes: A new model for influencing patient health behavior. Journal of Communications on Medicine, 4(6), 33-36.

The present article describes a new model, based on recent literature, that can be easy to use for clinicians in brief medical interviews, to influence clients' behavior. The purpose of the model is to improve clients' health, to promote adherence to therapy, and to reduce self-destructive behaviors. The therapeutic relationship is based on rapport, trust and respect in order to help clients to change. This relationship is achieved by making open-ended questions, using reflective listening and by empathizing with the client. According to this model, for change to occur, the client must feel convinced that change will improve his/her well being, and confident that he/she can make this change. These two constructs should be assessed in order to understand barriers for change, and therefore to guide the therapist in selecting interventions that would match the level of conviction and confidence in the patient. This article suggests specific guidelines for the treatment of the four different combinations of conviction and confidence that might be encountered in patients.  
Abstract by Patricia Juarez

Conceptual Article

Rollnick, S. (1997). Whither motivational interviewing? Journal of Substance Misuse, 2, 1-2.

This paper presents a discussion on how research on motivational interviewing (MI) is now beginning to reach actual practitioners, and how clinicians are the ones that are conducting most of the research in this area. One of the most crucial issues now is to know what actually happens during an MI session, and what how information is exchanged between the counselor and the client. Some of the main aspects that should be present during an MI session are eliciting the client's own interpretations of the information, minimizing resistance, responding appropriately to the clients' readiness to change, and examining the pros and cons of substance use. Two other important components that still require research are eliciting discrepancy and self-motivational statements. It is also crucial to maintain reflective listening styles and directive client-centered approaches in order to get the best results at dealing with client resistance. Finally, it is imperative that researchers and practitioners describe their therapy approaches and methods in detail so that this information can more easily be shared with other researchers and practitioners. This will result in a more through dissemination of effective therapeutic skills, which will in turn help narrow the gap between research and actual practice.  
Abstract by Patricia Juarez

Conceptual Article

Sciacca, K. (1997). Removing barriers: Dual diagnosis and motivational interviewing. Professional Counselor, February, 41-46.

In traditional addiction treatment approaches, clients are usually expected to be aware of the problems caused by the addictions and to be motivated for change. On the other hand, treatments for mental illness tend to be more supportive, positive and non-confrontational. This article focus on treatment for clients with both substance abuse problems and other mental illnesses. A non-confrontational treatment approach for dually diagnosed patients, who are often reluctant to recognize a substance abuse problem and are therefore less motivated to change, is described and compared to motivational interviewing (MI) strategies. Sciacca's treatment model for dual diagnosis includes a screening for mental health and dual disorders, assessment of readiness to participate in treatment, encouragement to participate, group treatment, comprehensive assessment, monitoring of progress, and maintenance of treatment and relapse prevention. This model and MI are similar in that they both take into account client readiness for change, avoid confrontational styles, emphasize development of trust, encourage acceptance, empathy and respect for the client, and promote hope and self-confidence. These two non-confrontational and non-threatening approaches will provide patients, with singular, dual or multiple diagnosis, with the opportunity to actively explore and participate in their own decisions and goals towards change.  
Abstract by Patricia Juarez

Aubrey Lawendowski, L. (1998). A motivational intervention for adolescent smokers. Preventive Medicine, 27, A39-A46.

Motivational interviewing (MI) is a brief therapeutic intervention designed to increase the likelihood that a person will consider, initiate and maintain behavior change. MI is based on principles of motivational psychology, client-centered therapy, and stages of change. The MI approach is usually applied in 5 to 15 minute sessions, but it can also take the form of Motivational Enhancement Therapy (MET). The basic components that make MI effective include options for change, feedback on personal risk and negative consequences, empathy and respect for the client's individuality, enhancement of self-efficacy and personal responsibility, and advice for change. The main goals of these strategies is to elicit discrepancy between present behavior and future goals and expectations, and to reflect self-motivational statements. Research supporting the effectiveness of this approach is described in detail. MI can be a very useful approach to be used for adolescents with substance abuse problems, who usually don't respond well to more long-term treatments, and who tend to be more ambivalent and resistant about change. Interventions for adolescents are therefore suggested to be brief (one or two sessions), take into account the client's ambivalence, be empathic and supportive, include personally relevant assessment and objective feedback, explore discrepancy, offer a menu of alternatives for change, encourage self-efficacy and responsibility, and select appropriate strategies based on the client's stage of readiness for change. MET for adolescents should also include at least a follow up session, within six weeks of the intervention, in order to reinforce progress, collect outcome information and to conduct a booster motivational session.  
Abstract by Patricia Juarez

Conceptual Article

Rullo-Cooney, D. (1998). La entrevista motivacional: Cambiar al consumidor de substancias en un servicio intensivo de conservacion familiar (Motivational Interview: Changing the drug user into an intense service of family conservation). Revista de Toxicomanias, 15, 34-41.

The use of the concepts of Motivational interviewing (MI) in the Intensive Services of Family Conservation (SICF; Servicios Intensivos de Conservacion Familiar) allows the health care worker to intervene in substance abuse and addiction problems. The main purpose of the SIFC is to prevent the unecessary separation of children from their families, by teaching family members new skills and promoting behavior change. For this reason, the problem of addiction has begun to receive more attention in order to promote family cohesiveness. The main goal of MI is to help the drug user resolve his/her ambivalence about changing, and to express and promote his/her own behavior changes. The MI principles are based on the fact that people are usually resistant to confrontational therapeutic techniques, which in general try to get people to "hit bottom". On the other hand, MI helps the client accept the responsibility of changing his/her own behavior in an empathic manner, without judgements, and with encouragement and support. In summary, incorporating these principles are into the SIFC helps families feel capable of solving their own problems and to suggest their own behavioral change plans.  
Abstract by Patricia Juarez

Conceptual Article

Draycott, S., & Dabbs, A. (1998). Cognitive dissonance 2: A theoretical grounding of motivational interviewing. British Journal of Clinical Psychology, 37, 355-364.

The goal of the present article is to show how the concept of cognitive dissonance can be applied in the area of clinical psychology, especially by explaining how it may form the main theoretical basis of Motivational Interviewing (MI). The authors further suggest that explaining how MI works, through the concepts of cognitive dissonance may provide a better understanding of the processes of change that MI promotes. The article presents a matching of the cognitive dissonance constructs, to the principles of MI, in order to identify areas where MI interventions may be improved or modified. It is concluded that the main goal of MI, in terms of cognitive dissonance theory, is to produce a dissonant state and then to control the direction of the response to it. The authors suggest that there are still several aspects of cognitive dissonance theory, that could improve the MI style and make it even more effective at producing behavior change. These aspects are a visual record of consistent and inconsistent cognitions to emphasize the dissonance further, maximizing dissonance by reinforcing self-motivational statements, the awareness of the different possible client responses to dissonance, immediate therapist responses to the dissonant state, and greater structure of the sessions. In conclusion, the concept of cognitive dissonance can be useful in the theory and practice of clinical psychology in general.  
Abstract by Patricia Juarez

Conceptual Article

Miller, W. R. (1998). Why do people change addictive behavior? The 1996 H. David Archibald Lecture. Addiction, 93, 163-172.

It is widely recognized that addictions are established due to the pleasant effects of the addictive agent. But still some questions remain: Why not all people become addictive? And what are the processes of recovery from addictions? The most common answer to the second question tends to be that it is through some kind of treatment, but this answer only elicits more questions. Some of these questions are: what aspects of the "treatment" process promote the most behavior change? Which therapist characteristics elicit more positive outcomes? Why is it that some people change outside of the context of treatment? Substantial research addressing these questions suggest that treatment doesn't seem to be neither a necessary nor a sufficient condition for change. Therefore, change must be explained through other more natural models and factors, such as different stages of change, self-efficacy, ambivalence, discrepancy, and a shift in meaning. Final remarks for integration of these factors, and future directions for research, are discussed in detail.  
Abstract by Patricia Juarez

Miller, W. R., Andrews, N. R., Wilbourne, P., & Bennett, M. E. (1998). A wealth of alternatives: Effective treatments for alcohol problems. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (2nd ed., pp. 121-132). New York: Plenum Press.

The treatment for alcohol and substance abuse has been relatively reluctant to respond to new scientific developments and results, creating a gap between research and practice. The present chapter presents a summary of the research on alcohol abuse treatment. It specifically focuses on a project called "Mesa Grande", which is an attempt to review and summarize the methodologies and results of controlled trials of treatments for alcohol problems. Each study reviewed was rated in terms of its methodological quality and outcome, giving a rating of the study's overall efficacy. It was found, that treatments differ significantly on their effectiveness. The two treatment approaches found to have the greatest positive impact were brief interventions and MET. When combined, these two approaches attempt to elicit the client's motivation for change, and they generally include six basic components (feedback, emphasis on client's responsibility, advice, menu of alternatives for change, empathic listening, and building self-efficacy). Another strategy found to be very effective was the teaching of general coping, social and/or self-control skills. Community reinforcement approach was also found to be a very effective therapeutic technique. Its main purpose is to change the client's social environment by clients can learn to receive positive reinforcement without alcohol. On the other hand, treatments involving medications, and those referred to as "family therapy" have given generally modest or puzzling results due to the lack of controlled trials or definitional problems. The treatment approaches that were found to result in either no or detrimental impact on drinking were educational approaches, psychodynamic techniques, confrontational approaches, undifferentiated types of individual or group therapy, relaxation and stress management training, and residential treatments. Three other crucial findings of the "Mesa Grande" project were first that therapist styles have significant effects on clients, such that therapist empathy has significant positive and long term effects on drinking behavior. Another crucial finding was that when therapists demonstrate genuine and active interests on their clients, they show significantly better results. Finally, one of the best predictors of change was found to be just doing "something" toward change and adhering to treatment.  
Abstract by Patricia Juarez

Draycott, S., & Dabss, A. (1998). Cognitive dissonance 1: An overview of the literature and its integration into theory and practice in clinical psychology. British Journal of Clinical Psychology, 37, 341-353.

One of the recent concerns in clinical psychology is that experimental research is not reaching actual clinical practice. The present article presents a review of the literature on cognitive dissonance and its possible applications in clinical psychological therapies and practice. In summary, the literature supports the idea that creating inconsistencies in individuals has an impact on attitudes and behavior, that can not be explained by other theories. This state of cognitive dissonance usually lasts for a few minutes but it is argued that its effects can have effects that can last for up to two weeks, and that can be easily back if this dissonance is made to be salient again. It is suggested that the effects of dissonance on behavior are due to the individual's attempts to restore consistency, response which may vary in terms of salience and difficulty or cost. Therefore, it is suggested that this construct may provide important insights into the strategies and mechanisms of therapies, and to the development of more effective interventions to promote behavior change.  
Abstract by Patricia Juarez

Kushner, P. R., Levinson, W., & Miller, W. R. (1998). Motivational interviewing: What, when and why. Patient Care, 32(14), 55-72.

Physicians often have to advice their patients to modify their behavior with usually limited success. It is often assumed that patients would follow the doctor's advice just because it comes from an expert source, but unfortunately, this is not usually the case. This occurs often because client's don't participate in the decision to change and see the advice as a threat to their freedom, or they may simply not be ready or truly motivated to change. According to the theory of motivational interviewing (MI), motivation is not a trait or a defense mechanism, but the likelihood that a person will do something to feel or get better, and the product of the patient-physician interaction. In order to promote behavior change, MI has four basic components: Empathic listening, encourage patients to state their own reasons for change, roll with resistance, and support self-efficacy. The theory of MI also assumes that people are usually ambivalent to change their behavior, so one of the goals of this approach is to help clients explore this conflict of pros and cons. Another crucial factor that makes MI very useful is that it assesses client's readiness for change and then selects an appropriate strategy to use. This readiness for change is usually conceptualized in terms of stages people move from one to another. These states are precontemplation, contemplation, preparation, action, and maintenance. The average MI session lasts from 5 to 20 minutes, which make it a cost-effective way to promote behavior change in health care settings.  
Abstract by Patricia Juarez

Miller, W. R. (1998) Enhancing motivation to change. In W. R. Miller & N. Heather (Eds), Treating Addictive Behaviors: Processes of Change (2nd ed., pp.; 121-132). New York: Plenum Press.

It is now widely acknowledged that motivation is a crucial component of behavior change, especially so in the area of addictive behaviors. People with problems of addiction often recognize the risks involved but nevertheless, they continue engaging in those behaviors. It is therefore suggested that addiction problems could be best approached from the concept of motivation, defined as the probability of behavior to do something better. Therefore the question is how to help clients feel motivated to do something to improve their situation. The purpose of this chapter is to summarize research contributions to the enhancement of client motivation, in three basic topics: therapeutic style, motivational techniques, and the broader context of behavior change. A motivational therapeutic style involves the understanding of ambivalence, avoidance of the confrontational-denial trap, a rejection of the authoritarian approach, understanding of the natural processes of change, recognition of the locus of change within the client, transmit a belief in the possibility of change to clients, empathic listening, and a supportive attitude towards the client. The motivational techniques include facilitating and supporting client compliance, developing discrepancy, and providing a menu of alternatives for change. Finally, in the broader context of change, one has to also consider alternative reinforcers for the client, which may imply working with significant others and modifying the social environment. In summary, the purpose of motivational interviewing is to help people see that their addiction is endangering that which they value most.  
Abstract by Patricia Juarez

Conceptual Article

Rollnick, S. (1998). Readiness, importance, and confidence: Critical conditions of change in treatment. In W. R. Miller & N, Heather (Eds.), Treating addictive behaviors: Processes of change (2nd ed., pp.49-60). New York: Plenum Press.

The main focus of this chapter is to address the question: What are the critical psychological processes that promote behavior change? The answer is based on clinical experience, theory and research. The chapter starts with a discussion of the concept of readiness to change and how clients can be matched to specific treatment strategies depending on their stage of change. Previous research has suggested that clients could be matched to specific therapeutic techniques based on their stage of change, but conflicting support has been found for this assumption. Questions of motivation can arise at all stages of change, and people can switch from one stage to another in a single day. This implies that clinicians should try to match the topic of conversation, and the way of talking to the client, to the present stage and needs of the client, rather than give him an entire therapeutic approach based on his particular stage. Two other concepts of crucial importance, that differ across the different stages of change, are the perceived importance of change and the perceived confidence to achieve this change. These two concepts have been found to be strong predictors of behavior change in different treatment contexts and in everyday life. The three concepts are related together in the sense that readiness could be conceptualized as a state of mind that reflects how important is change, and how able is the person to change, and therefore interventions should focus on this particular state of mind, in each single session, in order to successfully elicit behavior change.  
Abstract by Patricia Juarez

Conceptual Article

Baer, J. S., Kivlahan, D. R., & Donovan, D. M., (1999). Integrating skills training and motivational therapies. Implications for the treatment of substance dependence. Journal of Substance Abuse Treatment, 17, 15-23.

This article discusses how treatments for substance abuse and addictions would benefit from integrating aspects of motivational therapy and skills training approaches. These two approaches have recently received a lot of attention and support in research, but they have not been described as an integrative approach. The article first details the history, theoretical background, and differences between these two strategies. The purpose of skills training is to help clients learn and improve their coping skills. On the other hand, motivational approaches attempt to increase and maintain people's motivation to change, by helping them resolve the ambivalence about change with an empathic therapeutic style. Both approaches share similar assumptions about addictive behaviors, such that motivation is a crucial requisite prior and during behavior change, that there are individual differences in the levels and nature of skills necessary for behavior change, and that the degree of motivation and risk for relapse vary during the course of treatment and everyday life. It is therefore suggested that treatment for addictive behaviors should begin with an assessment of both readiness to change and skills deficits. If these two approaches were integrated, they could provide more flexibility for therapists to better meet clients specific needs.  
Abstract by Patricia Juarez

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