352 Appendix E: Motivational interviewing
Appendix E: Motivational interviewing
A useful tool in AOD client management is motivational interviewing (MI), irrespective of whether the
client is experiencing co-occurring mental health conditions. MI can be beneficial for clients with co-
occurring conditions by increasing treatment motivation, adherence, and readiness to change [762, 947,
1090, 1914, 1915], although it may not prove effective in all cases [762, 947]. A number of useful resources
for MI are given in Appendix B, including Miller and Rollnick [758], the Substance Abuse and Mental
Health Services Administration [1847], Baker and Velleman [122], and Clancy and Terry [448], from which
this section draws upon.
MI is a directive, non-confrontational, client-centred counselling strategy aimed at increasing a
person’s motivation to change. This strategy assumes equity in the client-AOD worker relationship and
emphasises a client’s right to define their problems and choose their own solutions. It is, in this sense, a
counselling style based on collaboration rather than confrontation, evocation rather than education and
autonomy instead of authority, as opposed to a set of techniques [1916].
Principles of MI include:
• Avoid argumentation. Confrontation is unhelpful to change and is likely to increase resistance.
• Express empathy, warmth, and genuineness in order to facilitate engagement and build
rapport.
• Support self-efficacy. Build confidence that change is possible.
• Roll with resistance. Arguing, interrupting, negating and ignoring are signs a client is resistant to
change.
• Develop discrepancy. Generate inconsistency between how the client sees their current situation
and how they would like it to be. This strategy is based on the notion that discomfort motivates
change and internal inconsistency or ambivalence is a cause of human discomfort.
Thus, MI aims to rouse feelings of ambivalence and discomfort surrounding current behaviour in order
to motivate change. Key to facilitating change are the concepts of ‘change talk’ (a process whereby a
person becomes more committed to a position by arguing for that position) and ‘sustain talk’ (the more
argument against change is evoked, the less likely a person is to change).
MI involves four overlapping processes (Figure 22, Table 63) [758]:
• Engaging: the establishment of a meaningful connection and therapeutic relationship between
the client and AOD worker and is a prerequisite for everything that follows.
• Focusing: the development and maintenance of a specific direction in conversation about change.
• Evoking: the elicitation of the client’s own motivations for change, which has always been at the
heart of MI. It can be achieved when there is a focus on a particular change and the client’s own
ideas and feelings about how to achieve it are harnessed (i.e., the client talks themselves into
changing).
• Planning: involves developing commitment to change and formulating a specific plan of action.
It is often the point where a client begins to talk about when and how to change, as opposed to
whether and why.
Appendix E: Motivational interviewing 353
Figure 22: Four processes of MI
Source: Miller and Rollnick [758].
Table 63: Questions regarding each MI process
Engaging
• How comfortable is the client talking with you?
• How supportive/helpful are you being?
• Does this feel like a supportive/collaborative partnership?
Focusing
• What goals for change does the client really have?
• Are you working together with a common purpose?
• Does it feel like you’re moving together or in opposing directions?
Evoking
• What are the client’s own reasons for change?
• Is the reluctance about confidence or importance of change?
• Are you pushing the client too far or too quickly in a particular direction?
Planning
• What would be a reasonable next step towards change?
• Are you remembering to evoke rather than prescribe a plan?
• Are you offering advice or information with permission?
Source: Miller and Rollnick [758].
354 Appendix E: Motivational interviewing
Core skills of MI
Miller and Rollnick [758] identify five core skills that are used throughout the different processes of MI,
which can be remembered with the OARS + I&A acronym:
• Asking Open questions.
• Affirming.
• Reflective listening.
• Summarising.
• Informing and Advising (with permission, elicit-provide-elicit).
Asking open questions
Asking open questions refers to a questioning method that does not invite short answers, which
increases information flow and trust, and invites the client to reflect and elaborate. While there are
times when asking closed questions may be necessary (e.g., gathering information for screening or
assessment), in the engaging and focusing processes of MI, open questions help the AOD worker
understand the client’s frame of mind, find a clear direction for change, and strengthen the relationship
between the client and AOD worker [758]. Certain kinds of open questions are particularly suited to the
different processes involved in MI (e.g., engaging, evoking). Some examples of closed and open questions
are provided in Table 64. AOD workers may also find the range of open questions provided in Table 66
useful [776], which have been grouped according to the stages of change model [446, 1917]. The goal of
open-ended questions is to elicit self-motivational statements from the client [776]. There should be
a balance between asking open questions and reflective listening [1847]. Among clients who may be
experiencing symptoms of co-occurring mental health conditions, these questions should be simplified.
Compound questioning (two questions in one sentence) should be avoided [1847].
Table 64: Examples of closed and open questions
Closed questions Open questions
You’ve come in today because you’re worried about how What brings you in today?
much alcohol you’ve been drinking lately, is that right?
Do you have any children? Tell me about your family.
How old were you when you drank alcohol for the first Tell me about the first time you drank
time? alcohol.
On a typical day, how much cannabis do you use? Tell me about your cannabis use on a typical
day.
Do you think it would be a good idea for you to go into What do you think about the possibility of
detoxification? going through detoxification?
Adapted from SAMHSA [1847].
Appendix E: Motivational interviewing 355
Affirming
Affirming is a way of enhancing the confidence of clients to take action, by the AOD worker showing
their genuine appreciation and positive regard for the client [758]. It is the client, rather than the AOD
worker, who produces change in MI, and as such, the process of MI relies on the client’s own personal
strengths, efforts and resources. Affirming therefore focuses on the positive with direct compliments and
statements of appreciation and understanding rather than attempting to produce change by making
the client feel bad [758]. The technique of affirming helps build rapport, self-efficacy and reinforces open
exploration.
Among clients who may be experiencing symptoms of co-occurring mental health conditions, affirming
can be inspiring and build rapport [1918]. Affirming can be general (the AOD worker respects the client as
a person of worth, who has the capacity for growth, change, and the choice about whether to do so), and
specific (recognition of the client’s strengths, abilities, intentions, and efforts) [758]. AOD workers may
find the following strategies helpful to consider when affirming [1847]:
• Focus on the client’s strengths, previous successes and efforts, however small, to achieve their
change goals.
• Take care not to confuse affirming with praise. Praise implies the worker is approving the client,
expresses judgement (of praise or blame), and is more likely to begin with an ‘I’.
• Use phrases that begin with ‘you’ rather than ‘I’, to maintain focus on the client. For example, rather
than ‘I am proud you came in today’, which shifts the focus to the AOD worker, try ‘You worked really hard
and persisted in being here today’, which illustrates appreciation and maintains focus on the client.
Some other examples of affirming statements that AOD workers may find useful include [758, 1847]:
• ‘You took a big step in coming here today.’
• ‘That is a great suggestion for how you might avoid situations where you might be tempted to use.’
• ‘Your intention was really good, even though it may not have turned out as you would have liked.’
• ‘You were discouraged this week, but you still came back. You are persistent.’
• ‘Welcome back! It’s good to see you.’
Reflective listening
Reflective listening is a key component of showing empathy and a core skill of person-centred therapy. It
involves listening to what the client is saying, forming an understanding of what they are talking about
and then giving voice (reflecting) to that understanding. Reflecting shows respect and acceptance to
clients, establishes trust and helps with the exploration of perceptions and values, enables the building
of a collaborative and non-judgemental relationship, and allows the AOD worker to show their support
without necessarily agreeing with the client’s ideas or statements [758].
Good reflective listening keeps the client talking, exploring, and considering. It is also specific in the
sense that the AOD worker selects specific information on which to reflect. Reflecting can range from
simple (i.e., repeating or rephrasing the client’s words) to complex (i.e., reflecting the underlying meaning
356 Appendix E: Motivational interviewing
or feelings with the use of different words). The depth of reflection increases with the level of the AOD
worker’s experience and expertise. Importantly, reflective listening is not making assumptions about
the underlying meaning of clients’ statements, but rather forming hypotheses about the meaning or
feeling and listening carefully to the client’s response after the hypothesis is tested. Simple reflections
are useful for client engagement and obtaining their perspective but can sometimes lead to slower
progress if the AOD worker is not able to add complexity and depth by interpreting the spoken and
unspoken content, anticipating what may come next. More complex reflections can expand a client’s
self-exploration [758, 1847]. Some examples of simple and complex reflections are provided in Table 65.
Table 65: Examples of reflective listening responses
Client AOD worker
Type Purpose Considerations
statement response
Simple
Repeat My girlfriend is Your girlfriend is Shows empathy. Avoid mimicking.
hassling me about hassling you about Builds rapport.
how much I smoke. how much you
smoke.
Rephrase My girlfriend is Your girlfriend Shows empathy. Moves the
hassling me about is pestering you Emphasises conversation along
how much I smoke. about how much selected but slower than with
you smoke. meaning or complex reflections.
feeling.
Feeling I’d like to give up You’re afraid that Emphasises Reinforce change
smoking pot so your girlfriend’s selected feeling. talk, avoid reinforcing
I don’t make my asthma will get Emphasises sustain talk.
girlfriend’s asthma worse if you keep discrepancy
worse. smoking pot. between values
and behaviour.
Meaning I’d like to stop You want to protect Emphasises Reinforce change
smoking pot your girlfriend from selected talk, avoid reinforcing
because my the possibility that meaning. sustain talk.
girlfriend has her asthma will Emphasises
asthma and I heard get worse if you discrepancy
that second-hand continue to smoke between values
smoke can make pot. and behaviour.
asthma worse, and
I don’t want that to
happen to her.
Appendix E: Motivational interviewing 357
Table 65: Examples of reflective listening responses (continued)
Client AOD worker
Type Purpose Considerations
statement response
Complex
Double- I know I should quit Giving up smoking Resolves Use ‘and’ to join
sided smoking pot but pot would be hard ambivalence. reflections.
it’s the only time I and you recognise Acknowledges Start with sustain talk
have for myself. that it’s time to sustain talk and reflection and end with
stop. emphasises change talk reflection.
change talk.
Amplified I think my pot There are Amplifies Use sparingly.
smoking is just not absolutely sustain talk to Avoid being caught in
a problem for me. no negative evoke change sustain talk.
consequences of talk.
smoking pot.
Adapted from SAMHSA [1847].
Among clients experiencing symptoms of co-occurring mental health conditions, these statements
should be simple, concise, and frequent. Avoid repeated reflecting of the client’s negative statements and
allow them time to consider these reflections [1919].
Summarising
Summarising is a type of reflective listening that links together the core components of several
important client statements and reflects them back to the client. Summaries are useful in collating,
linking, and reinforcing information discussed during the interviewing process, and offer a ‘what
else’ opportunity for the client to add any information that may be missing. Summarising should be
conducted often to promote meaningful relationships and contrasts between statements to enhance
motivation to change [1918]. Some examples of summarising techniques include:
• Linking summary: making associations between two parts of the discussion.
• Collecting summary: gathering a few themes from what the client has said.
• Ambivalence summary: gathering a few client statements about change and sustain talk, to
acknowledge sustain talk but reinforce and highlight change talk.
• Transitional summary: shifting focus from one area to another.
• Recapitulation summary: gathering change talk from many conversations.
358 Appendix E: Motivational interviewing
Table 66: Examples of open questions to elicit self-motivational statements
Stage of Self-motivational
Open question examples
change statement
Pre- Problem recognition • What things make you think that this is a problem?
contemplation (e.g., ‘I guess there • What difficulties have you had in relation to your AOD
might be more of use?
a problem than I • What difficulties have you had in relation to your
mood?
thought’)
• In what ways has this been a problem for you?
• How has your use of AOD stopped you from doing
what you want to do?
Contemplation Expression of concern • What worries do you have about your AOD use?
(e.g., ‘I’m worried about • What can you imagine happening to you?
this’) • Tell me more about preventing a relapse to using…
Why is that so important to you… What is it like when
you are ill?… And how about your family – what effect
did it have on them? How important are these issues
to you?
• Can you tell me some reasons why drinking or using
may be a health risk? Would you be interested in
knowing more about the effects of drinking/using?
How important are these issues to you?
• What would your best friend/mum say were your best
qualities? Tell me, how would you describe the things
you like about yourself?... And how would you describe
you the user?... How do these two things fit together?...
How important are these issues to you?
Action Intention to change • You seem a bit stuck at the moment. What would
(e.g., ‘This isn’t how I have to change to fix this?
want to be’) • What would have to happen for it to become much
more important for you to change?
• If you were 100% successful and things worked out
exactly as you would like, what would be different?
• The fact that you are here indicates that at least a
part of you thinks it is time to do something. What
are the reasons you see for making a change? What
would be the advantages of making a change?
• What things make you think that you don’t need to
worry about changing your AOD use?
• And what about the other side… What makes you
think that it’s time to do things a bit differently?
• If you were to decide to change what might your
options be?
Appendix E: Motivational interviewing 359
Table 66: Examples of open questions to elicit self-motivational statements
(continued)
Stage of Self-motivational
Open question examples
change statement
Maintenance Optimism (e.g., ‘I think I • What would make you more confident about making
can do this’) these changes?
• Are there ways you know about that have worked for
others? Is there anything you found helpful in any
previous attempts to change?
• What are some of the practical things you would need
to do to achieve this goal? Do they sound achievable?
• What encourages you that you can change if you want
to?
• What makes you think that if you did decide to make
a change, you could do it?
Adapted from NSW Department of Health [776].
Informing and advising
Informing and advising refers to the offering of information or advice. Although MI adopts a client centred
approach, this does not mean that offering advice or information to clients is always inappropriate.
There are some circumstances where it is certainly appropriate (e.g., if the client requests information).
However, MI does not involve dispensing unsolicited information in a directive style. Instead, MI involves
[758]:
• Offering information or advice with permission.
• When advice is provided, the perspective of the client is explored, particularly in terms of the
relevance of the information to them and helping them to reach their own conclusions.
Miller and Rollnick [758] recommend using the ‘elicit-provide-elicit’ approach when exchanging
information with a client.
Elicit
• Ask permission to give information or advice: ‘May I…?’
• Clarify the client’s information needs and gaps: ‘What do you know about…?’, ‘Is there any
information I can help you with?’
Provide
• Prioritise: what does the client most want/need to know?
• Be clear: avoid jargon.
360 Appendix E: Motivational interviewing
• Support autonomy: do not offer too much information at once; allow the client time to reflect.
• Do not prescribe the client’s response: acknowledge their freedom to disagree or ignore, present
what you know without interpreting its meaning for the client.
Elicit
• Ask for the client’s interpretation, understanding, or response: ask open questions, use reflection,
allow the client time to process and respond to the information.
Additional strategies
In addition to these five core communication skills, some key strategies have been developed to build
intrinsic motivation for change and resolve ambivalence. This is achieved by assisting the client to
present their own arguments for change in order to [758]:
• Recognise the disadvantages of current behaviour.
• Recognise the advantages of change.
• Express optimism about change.
• Express intent to change.
These strategies include:
• Typical day.
• Decisional balance.
• Elaboration.
• Querying extremes.
• Asking about lifestyle and stresses.
• Looking back.
• Looking forward.
• Exploring goals and values.
• Strengthening commitment.
Typical day
Often a client deems certain aspects of their life irrelevant to treatment or they are insignificant to the
client and overlooked and therefore not disclosed during therapy. However, this information can help
an AOD worker engage with the client. It can also provide a more holistic view of the person as well as
invaluable information concerning daily habits, significant environments, important relationships, and
people in the client’s life. Furthermore, this information can highlight to the client aspects of their life
that they had not been aware of (e.g., ‘I hadn’t realised I was drinking that much’).
Appendix E: Motivational interviewing 361
In order to attain this information, it can be useful to ask the client to explain how they spend an average
day. Encourage the client to pick an actual day (e.g., last Wednesday) rather than what they do most days.
Allow the person to continue with as little interruption as possible. If necessary, prompt with open-ended
questions (e.g., ‘What happened then?’ or ‘How did you feel?’). Review and summarise back to the client
after they have finished and clarify that you have summarised accurately.
Once you have a reasonably clear picture of how the client’s use (and any co-occurring mental health
symptoms) fits into a typical day and any current concerns, ask the client’s permission to provide
feedback from your assessment (e.g., ‘I’m getting a feel for what’s going on in your everyday life at the
moment, you’ve mentioned several things that are concerning you’).
Summarise these problem areas briefly, using those issues raised by the client in the ‘typical day’
discussion (e.g., quality of life, health, mood, AOD use). When the client is providing information about
their typical day, it gives the AOD worker opportunities to ask more detail about behaviour patterns,
feelings, and mood changes. Areas of concern often emerge naturally from such discussions [758].
Decisional balance (good and not so good aspects)
This technique involves a conscious weighing up of the pros and cons of certain behaviours (e.g., AOD
use). Considering the pros and cons can be used as a way of neutral counselling, where the worker is not
trying to steer the client into making one choice over another, but instead allowing the client to make
their own choice about personal change [758]. Clients are often aware of the negative aspects involved
in certain behaviours but have never consciously assessed them. The decisional balance is a frequently
used motivational strategy, particularly when clients are displaying ambivalence regarding their
substance use, and as a useful way of determining their stage of change in regard to their substance use.
Begin by asking questions such as:
• ‘What do you like about your use of…?’
• ‘Tell me about your AOD use. What do you like about it? What’s positive about using for you?’
For clients who have difficulty articulating things they like about using, it may be useful to offer a menu
of options for them to choose from, although this should be done sparingly. Remember the focus should
be on finding out what the client enjoys about using, not making assumptions about why they like it!
Encourage the client to write down good things they have identified (a useful template is included at the
end of this MI summary).
Briefly summarise the good aspects of AOD use that the client has identified. Next, ask the client about
the not-so-good things about their AOD use. Try to avoid using negative words such as the ‘bad things’ or
‘problems’. Questions that may be useful in obtaining this information include:
• ‘So, we have talked about some of the good things about AOD use. Now could you tell me some of
the less good things?’
• ‘What are some of the things that you don’t like about your AOD/substance use?’
• ‘Tell me what some of the not-so-good things about using are’.
362 Appendix E: Motivational interviewing
Again, it may be useful to provide some options or ask questions (based on collateral information),
such as, ‘How does your family feel about your using?’ but avoid suggesting that an issue should be
of concern, and do not put any value judgement on the beliefs of the client by saying something like
‘Don’t you think that getting arrested twice is a bit of a problem?’ The success of MI rests on the client’s
personal exploration of their AOD use, and the good and not-so-good effects that it has on them. Explore
each element in full with appropriate use of the core communication skills, such as the use of open
questions and reflection.
Unlike the good things, the less good things need to be explored in detail. If the client claims AOD use
reduces their mental health symptoms, explore this in particular detail: for instance, enquire about
longer-term effects [1920]. It is important to maintain focus on the client’s perspective of the less good
things. It can be useful to ask follow up questions such as:
• ‘How does this affect you?’
• ‘What don’t you like about it?’
Or ask for more detail:
• ‘Could you tell me a little more about that?’
• ‘Could you give me a recent example of when that happened?’
It can be particularly useful (especially when not-so-good aspects are not forthcoming) to explore
the other side of the positive consequences of using listed. For example, if the high was listed as an
advantage, explore the ‘come-down’ that inevitably followed and the length of this crash (which will
usually have lasted longer than the euphoria).
It is then useful to assess, through the use of a scale from 1-10, the client’s perspective of how important
an issue is. Beside each pro and con the client should rate the importance it holds for them. This exercise
ascertains to what extent cons are a concern for the client. Many workers make the mistake of assuming
that just because the client acknowledges a not-so-good thing about their AOD use, this automatically
presents a direct concern for them.
Now give a double-sided, selective summary. For example:
• ‘You said some of the things you like about using were… and then you said that there was another
side to it… you said some of the not so good things about using were…’
Skill is required here in order to emphasise the not-so-good things. It can be useful to give the client a
chance to come to their own conclusions, for example:
• ‘Now that you’ve gone through both sides, where does this leave you?’
• ‘How do you feel about your AOD use now?’
If ambivalence is evident, attempt to explore the reasons that underlie this imbalance and re-establish
the initial reasons for wishing to quit/cut down. Incorporate information on health and psychological
effects of continued use. Guide the client through a rational discussion of issues involved, and carefully
challenge faulty logic or irrational beliefs about the process of quitting. Positive reinforcement and
encouragement are crucial, but if you encounter resistance from the client, do not push them.
Appendix E: Motivational interviewing 363
NOTE: Use this strategy with caution for clients with high levels of anxiety or those who are not ready
to deal with the pressure of increased ambivalence. In addition, do not leave a depressed client in
psychological distress for too long after using the decisional balance strategy [1920]. Avoid using
this strategy with a client who is currently tempted to use. Distraction is a better strategy to use with
someone who is currently tempted rather than to discuss the things they like about using [448].
Elaboration
Once a motivational topic has been raised, it is useful to ask the client to elaborate, which can help to
reinforce the theme and to elicit further self-motivational statements. One good way of doing this is to
ask for specific examples and for clarification as to why (how much, in what way) this is a concern.
Querying extremes
Clients can also be asked to describe the extremes of their concerns, to imagine worst consequences.
This activity can sometimes help when a client is expressing little desire for change. For instance, you
may ask:
• ‘What concerns you the most?’
• ‘What are your worst fears about what might happen if you don’t make a change?’
• ‘What do you suppose are the worst things that may happen if you keep on the way you’ve been
going?’
It can also be useful to ask the client the best possible consequences that might happen after pursuing
a change (e.g., exploring the opposite extreme), such as:
• ‘What could be the best results if you did make the change?’
• ‘If you were completely successful in making the changes you want, how would things be different?’
Ask about lifestyle and stresses
Asking about lifestyle and stresses involves discussing routines and day-to-day stresses. Examples of
some questions might be:
• ‘How does your AOD use affect your:
• Mental health?
• Physical health?
• Relationships?
• Finances?’
364 Appendix E: Motivational interviewing
Looking back
Sometimes it is useful to have the person remember times before the problem emerged, and to compare
this with the present situation. Ask the client what life was like ‘before’: before substance use problems;
before legal, work or relationship difficulties; before mental health problems etc. Focus on positive
memories, hopes, dreams, plans, or successes the person may have once had. If the person’s history is
negative, it may still be useful to explore ‘what it was like’, not necessarily in an attempt to process or
resolve issues from that time, but primarily to understand what may have brought about the current
situation and behaviours. For example:
• ‘Do you remember a time when things were going well for you? What has changed and how?’
• ‘What were things like before you started using?’
• ‘What were you like back then? What were your plans? What has changed and why?’
• ‘How has your use of alcohol/drugs influenced things?’
The goal is for the client to obtain some perspective from the immediacy of their circumstances and to
observe how things have changed over time. If the client has positive views on how things were before
the problem emerged, highlighting the discrepancy between how things are currently, and the possibility
of life being better again can help motivate them.
NOTE: Among clients experiencing symptoms of a co-occurring depressive condition, this strategy
should be avoided or used with caution [1920].
Looking forward
Similarly, it can be helpful for clients to visualise the future should they embark on the change or should
they remain the same. Some questions might include:
• ‘What would you like to be doing in two years’ time?’
• ‘What do you think will happen if you keep using? How do you feel about that?’
• ‘If you decided to make a change, what are your hopes for the future?’
• ‘How would you like things to turn out for you?’
• ‘I can see that you’re feeling really frustrated right now… How would you like things to be different?’
• ‘What are your options at the moment?’
• ‘What would be the best results you could imagine, if you make a change?’
• ‘If you were to have a week off from your problems/symptoms, what would you do first?’
As with querying extremes, you could also ask the client to anticipate the future if no changes are made
(e.g., ‘Suppose things continue as they are now and you don’t make any changes, what will your life be like
in five years from now?’). The difference between looking forward and querying extremes is that in this
looking forward method, the AOD worker is asking for the client’s most realistic assessment of the future
rather than their imagined ‘extreme’ outcome.
Appendix E: Motivational interviewing 365
NOTE: Among clients experiencing symptoms of a co-occurring depressive condition, this strategy
should be avoided or used with caution [1920].
Exploring goals and values
It can be useful to ask clients about their goals and what is most important to them, comparing their
goals to the current situation. Rather than perceiving a person as unmotivated, it may be more useful to
understand their different goals and priorities [758]. Explore the ways in which the problem behaviour is
inconsistent with, or undermines important values and goals for them. When the highest or most central
values and goals have been defined, you can ask how the problem you are discussing (e.g., AOD use) fits
into this picture.
For example:
• ‘Where do you think your AOD use fits in?’
• ‘What effect is your current behaviour likely to have on your goals and values?’
Exploring what matters most to a person can also help build rapport, and as such, this strategy can be
used in the engaging process. Exploring goals and values need not be limited to benefits that could
result from a particular change; the process can also be used to learn about the client’s priorities and life
values.
Strengthening commitment
Although some people experience a specific moment in which their desire to change suddenly
crystalises, for most people this is a gradual process. As such, it is common for clients’ commitment
to taking action to fluctuate over time [758]. MI is a method of facilitating the natural growth of
commitment. The AOD worker will consolidate all issues raised by the client and help them build their
commitment to change while also planning a concrete action plan. Ambivalence will still possibly be
present, and if encountered, continue the use of the strategies and micro skills outlined above. It can be
useful to encourage the client to confront the idea and process of change. For example:
• ‘Where do we go from here?’
• ‘What does everything we’ve discussed mean for your AOD use?’
• ‘How would your life be different if…?’
• ‘What can you think of that might go wrong with your plans?’
Although abstinence is one possible goal, some people may not be ready to stop completely and may
opt for reduced or controlled use. In MI, the client has the ultimate responsibility for change and total
freedom of choice to determine their goal for treatment. The AOD worker’s role is to assist the client to
determine treatment goals and guide the realisation of those goals. Goals may often change during the
course of treatment, and an initial goal of cutting down may become a goal of abstinence as the client’s
confidence increases.
In clients with co-occurring mental health conditions, abstinence is favoured [131, 1921] as mental health
symptoms may be exacerbated by AOD use. In particular, those with more severe mental disorders (or
366 Appendix E: Motivational interviewing
cognitive impairment) may have adverse experiences even with low levels of substance use [795]. Those
taking medications for mental health conditions (e.g., antipsychotics, antidepressants) may also find
that they become intoxicated even with low levels of AOD use due to the interaction between substances.
Although abstinence is favoured, many people with co-occurring conditions prefer a goal of moderation,
and that goal should be respected. It is possible to accept a client’s decision to use and provide harm
reduction information without condoning use.
Explore any fears or obstacles that are identified in the change process and assist the client with
problem solving for each of these. Explore any concerns with the management of withdrawal symptoms
(e.g., irritability, insomnia, mood disturbances, lethargy, and cravings to use) if this is raised. Education
and support are essential components of getting through withdrawal.
Finally, when the client begins behaviour change, try manipulating the environment to exaggerate
positive outcomes (e.g., involve family, increase social interaction, use encouragers and compliments),
particularly in clients with co-occurring mental health conditions in order to strengthen resolve [1920].
Appendix E: Motivational interviewing 367
Good things & not-so-good things worksheet
Good things about current behaviour Not-so-good things about current behaviour
Good things about change Not-so-good things about change