If you work with clients who use marijuana or other substances on a regular basis, the following exchange using Motivational Interviewing might sound familiar:
Client: “It’s weird. I really like hanging out with my friends, but now that I have a job, I’m gone all the time and I feel guilty for not hanging out with my mom as much as she’d like.”
Therapist: “Hmmm.”
Client: “I know my mom misses me. And, well, she has to know that I’m stoned when I come home from hanging out with my friends, but she doesn’t say anything.”
Therapist: “That’s rough. I know how tight you’ve always been with your mom.”
Client: “Yeah – and now that I have a job, I can afford to buy weed. I spend so much money on weed…. I used to bum weed off of everyone else but now, I’m the one with the bag. Sometimes I wonder if I’m smoking too much.”
Therapist: “How would you know if you were smoking too much?”
Client: “I’d want to top it off when I come home – you know – vape when I get home. But I don’t really do that anymore. At least I’m not taking a hit before school – I did that once and was like, ‘What the f*^k am I doing?’ But now, I don’t think I’m smoking that much. I mean, hanging out with my friends, we smoke really slowly and talk a lot. They’re all drinking so it takes them longer and I don’t like to drink so…”.
Therapist: “But you are noticing that you are spending a lot of money….”
Client: “Yeah – a lot of money…. But it’s not a problem because I don’t have anything else I need or want to buy.”
Therapist: “So – your line in the sand – not smoking extra when you get home or getting stoned before school…”
Talking with clients about problematic behavior like substance use can be tricky, especially if there have been no obvious consequences. While it’s tempting to lecture clients about why getting stoned, cutting, or simply not taking their medication is problematic, that approach doesn’t work. If you push too hard or say too much, clients are likely to get defensive, change the subject or clam up entirely. On the other hand, if you don’t push hard enough or say enough, they are likely to feel like you aren’t really “hearing” them or that you are dismissing their concerns. They may even assume that your lack of response means that their behavior is fine.
According to Miller and Rollnick, (1991) “Motivational Interviewing, is a way of being with a client, not just a set of techniques for doing counseling.” Rather than attempting to coerce clients to make changes, Motivational Interviewing encourages us to work with clients as a partnership in which we help clients find their own motivation to change. Motivational Interviewing assumes that while ambivalence is a significant obstacle to change that must be addressed, it is normal and can be resolved by working with a client’s intrinsic motivations and values. The goals of Motivational Interviewing are to help clients see the discrepancy between their goals and values and their current behavior, find hope that change is not only possible but that their life will ultimately be better as a result and to support clients’ efforts at making changes.
In the example above, the therapist used Motivational Interviewing to create a therapeutic alliance with the client, helped the client explore their concerns about smoking so much weed and planted seed to help their client find their own motivation to change their behavior.
Questions like, “How will you know when it’s time to think about changing?” and “What signals will tell you to start thinking about changing?” are helpful. Likewise, questions that address the discrepancy between a client’s current behavior and their deeper goals and values can get clients thinking about their behavior and may inspire them to begin to think about changing. However, thinking only goes so far. When your main “tools” are questions, you are literally only working from the neck up. If you really want to help people connect to their intrinsic motivation to change, it’s helpful to bring in their body.
Techniques and structures that come from psychodrama can bolster Motivational Interviewing by bringing in clients’ whole selves. These methods are particularly useful with people who are stuck in self destructive, self defeating behavior patterns including addiction because they circumvent traditional defense mechanisms such as rationalization, justification, denial and minimization which often get in the way of positive choices that impact success in recovery and exacerbate relapse potential.
Clients report that when they feel the impact of their behavior on others, they are more likely to want to change. Imagine if the counselor had used role reversal to help their client step inside the shoes of their mother and experience how their current/ or past behavior has negatively affected her. Or, what if the counselor had invited the client to step in the shoes of the friends who are always bumming weed off of them, they might realize that the relationship doesn’t really go deeper than weed. The client would be able to feel the impact of their behavior on a body level, rather than only intellectually.
Psychodramatic techniques such as the empty chair, role reversal, and doubling help clients who are ambivalent about making changes because they help clients “play it forward” and explore what is likely to happen if they don’t change and try on different behaviors and/or roles to see how they produce more desirable outcomes. They also can help clients identify obstacles to their recovery and resources to encourage hopefulness, which can help clients increase their commitment to making changes.
