Motivational Interviewing for Substance Abuse

People addicted to alcohol or other drugs don’t always recognize the need to stop drinking or using. Some may not realize that they’re addicted. Others may not want to change, or they may not think recovery is possible. Motivational interviewing is a counseling technique that helps individuals overcome ambivalence and take advantage of opportunities to achieve their recovery goals.
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Many people approach alcohol or drug rehab with pessimism. They may not think sobriety is realistic, or they may not be ready to quit drinking alcohol or using drugs. A part of them may know that substance abuse is ruining their life. But other factors prevent them from admitting that they need to change.


Robert Fishman of Advanced Recovery Systems describes the importance of building motivation for addiction treatment and recovery.

Motivational interviewing is a counseling technique that helps clients build motivation for treatment. It does not address underlying causes of substance abuse or addiction. It’s usually used as a complement to other therapies, such as cognitive behavioral therapy.

Motivational Interviewing Assumptions

Motivational interviewing focuses on resolving ambivalence toward recovery. Ambivalence refers to conflicting emotions about substance abuse.

People with addiction usually know that alcohol and other drugs are hurting them. A part of them may want to quit, and another part may simultaneously want them to keep using.

Motivational interviewing is based on four assumptions:

  1. Ambivalence toward alcohol and drug abuse is a normal obstacle on the path to recovery.
  2. People possess natural motivations and values that can help them overcome ambivalence.
  3. The relationship between a therapist and client is a collaborative partnership.
  4. An empathetic, supportive and directive approach to counseling can establish conditions for change to occur.

Many people who begin treatment with motivational interviewing sessions are in the early stages of change.

The stages of change include:

No desire to change or no recognition of a problem.
Recognition of a problem but inability to recognize a realistic solution.
Thinking about steps to change but possessing pessimism or doubt.
Taking steps to change but still possessing skepticism.
Continuing new behaviors. If behaviors are discontinued, relapse is likely.

Motivational interviewing is a type of motivational therapy that helps clients recognize a problem and build motivation to pursue a solution. It doesn’t necessarily show patients which actions to take or teach them how to change behaviors.

Principles of Motivational Interviewing

Psychologists William R. Miller and Stephen Rollnick helped develop the motivational interviewing approach to counseling. In their book “Motivational Interviewing: Preparing People to Change Addictive Behavior,” they outlined five principles that therapists should adhere to.

The five principles that therapists should adhere to include:

  1. Express empathy through reflective listening.
  2. Develop discrepancy between client goals or values and their current behavior.
  3. Avoid argument and direct confrontation.
  4. Adjust to client resistance rather than opposing it directly.
  5. Support self-efficacy and optimism.

Empathy refers to displays of understanding and sensitivity that help a person relate to the feelings of another. During motivational interviews, therapists create an open environment where clients feel safe to express emotions and attitudes.

Therapists also help clients recognize discrepancies between their current lifestyle and their future goals. By recognizing discrepancies, clients realize the consequences of their actions.

An honest and safe dialogue is created through understanding and empathy. To prevent hostility, therapists should avoid arguing with clients. Clients and therapists naturally take opposite sides of arguments. Instead of forming sides, therapists and clients need to work together.

Still, clients are often resistant to change. Therapists are taught to “roll with resistance.” Instead of viewing resistance as defiance, therapists should view resistance as an indicator that the current approach isn’t working. They should try a different line of questioning.

Finally, therapists should support a client’s internal optimism. Many clients believe that they are incapable of changing. Through motivational interviews, therapists help them develop hope and faith about recovery.


In 2008, Miller and Rollnick simplified the principles of motivational interviewing so that they could be applied to other health care settings, such as primary care.

The simplified principles are symbolized by the acronym RULE:

  • Resist the righting reflex
  • Understand the patient’s motivations
  • Listen with empathy
  • Empower the patient

RULE is based on the same principles as motivational interviewing for patients with substance use disorders. Doctors and nurses should avoid telling patients about the “right” path to wellness without ensuring that patients are motivated to change. They should recognize motivations, use empathy and empower the patient to choose the right path.

Types of Motivational Interviewing Techniques

Helping clients find motivation for recovery is easier said than done. Therapists use a variety of techniques to elicit responses that change the ways that clients think about their ability to change.

Motivational interviewing techniques are based on patient-centered counseling strategies.

Patient-centered counseling strategies include:

  • Asking open-ended questions
  • Listening reflectively
  • Summarizing
  • Affirming
  • Eliciting self-motivating statements

Open-ended questions enable two-way communication because their phrasing prevents clients from answering with a single word or phrase. The questions force the client to do the talking and help the therapist avoid making judging statements.

Examples of motivational interviewing questions include:

  • Why are you here today?
  • What do you think about going to rehab?
  • What do you like about drinking or using?
  • What makes you think you have a problem?
  • What worries you about substance abuse?
  • Why do you think you need to change?
  • How would you change?

When clients speak, therapists listen carefully. Then therapists issue reflective statements that show clients that they understood what the client meant. The reflective responses also elicit responses from the client.

Therapists can also affirm a client’s difficulties to show that they understand the client’s perspective. Affirming at the right time can build trust and support a client’s belief in his or her ability to change. At the beginning or end of a session, therapists summarize earlier conversations to identify and promote their understanding of any discrepancies.

Throughout each session, therapists try to elicit self-motivational statements that help clients recognize that life can be better if they choose to change. These statements can be elicited through reflective statements, affirming statements and nonverbal cues.

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Motivational Enhancement Therapy

Motivational interviewing is a broad therapeutic approach to helping clients overcome ambivalence toward change. Motivational enhancement therapy is a specific type of motivational interviewing that involves structured feedback and future planning.

Motivational enhancement therapy begins with an extensive assessment of the client’s history of substance abuse and co-occurring mental health issues.

The assessment is followed by four sessions:

Session one
Discuss assessment results, problems with substance abuse, reasons for change and future plans. Identify and enhance motivations for change.
Session two
Enhance motivation and build commitment to change.
Sessions three and four
Reinforce motivations discussed in earlier sessions. Review progress, and reaffirm commitment to change.

The entire process can last multiple weeks. A client may engage in the first two motivational enhancement therapy sessions during the first two weeks of substance abuse treatment. The third and fourth sessions may be held near the middle and end of treatment.

Effectiveness of Motivational Interviewing

The National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration recognize motivational interviewing and motivational enhancement therapy as effective approaches that assist with substance use disorder treatment.

A 1997 review of 11 clinical trials involving motivational interviewing concluded that the therapy appeared “to be an effective, efficient and adaptive therapeutic style” for problem drinkers and drug users. The review was published in the Journal of Substance Misuse.

Nine of the clinical trials concluded that motivational interviewing was more effective than:

  • No treatment
  • Standard treatment
  • Extended treatment
  • Being on a waiting list

Two studies that used authoritarian approaches did not find motivational interviewing to be effective.

Of the nine studies that found motivational interviewing to be effective:

  • Two studied problem drinkers who were given feedback about problem drinking but no additional treatment.
  • Three analyzed motivational interviewing as a complement to other treatments.
  • Five studied patients in general health settings who were receiving treatment for other health conditions.

A2005 analysis of 72 randomized and controlled clinical trials that studied motivational interviewing for a variety of lifestyle problems found that motivational interviewing was more effective than “traditional advice giving.” The review was published in The British Journal of General Practice.

Motivational interviewing is an important complement to traditional therapies for substance abuse and addiction. Without motivation for change, clients may be resistant to the lessons that rehab tries to teach. Motivated clients are more likely to buy into the rehab process and benefit from other therapies.

Medical Disclaimer: aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.

Chris Elkins, MA
Senior Content Writer,
Chris Elkins worked as a journalist for three years and was published by multiple newspapers and online publications. Since 2015, he’s written about health-related topics, interviewed addiction experts and authored stories of recovery. Chris has a master’s degree in strategic communication and a graduate certificate in health communication.

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