Cognitive Behavioral Therapy has been the gold standard for treatment of anxiety disorders, yet the research and clinical literature suggest low engagement and follow-through rates for people in some of the typical CBT practices like behavioral change homework, desensitization and exposure therapies (Westra & Dozois, 2008, pp. 28–29). The literature also suggests that people experience ambivalence about changing beliefs, attitudes and behaviors linked to anxiety. For example, while people see the worry associated with Generalized Anxiety Disorder (GAD) as a problem, they also hold positive beliefs about worry (e.g. that worry actually motivated them to take action to protect themselves from future harm) (Westra & Dozois, 2008, p. 28). Westra & Dozois (2008) recommend the use of MI in combination with CBT for the treatment of anxiety:
Thus, a combination of MI and CBT may be particularly promising for the treatment of anxiety with MI directed at increasing motivation and resolving ambivalence about change and CBT directed at helping the client achieve the desired changes. (p. 29)
So MI can be used in the treatment of anxiety to help people resolve ambivalence about changing the anxiety itself and their ambivalence about applying coping strategies for managing anxiety (Westra & Dozois, 2008, p. 29) like avoidance, doing exposure exercises, practicing mindfulness and other stress reducing strategies, etc.
Westra and Dozois (2008) make the following recommendations for using MI in the treatment of anxiety:
- Normalize ambivalence about change
- Use the decisional balance to explore the pros and cons of the anxiety itself (e.g. what are the good things and not so good things about worry?) as a tool to resolve ambivalence
- Use the decisional balance to explore the pros and cons of engaging in homework and coping strategies (e.g. thoughts/feelings log, exposure practices, mindfulness and meditation practices, etc.) that lessen the impact of anxiety on the person
- Explore the arguments for not making a change first, since this is the side that people with anxiety might have more difficulty exploring
- Explore change statements only after there has been significant understanding of the side of the ambivalence that expresses the status quo
- Be open to hearing the small, spontaneous changes people with anxiety make after the ambivalence is lessened
- Become intensely curious about how and why the person made this change, no matter how small it might appear
- Stay with the Spirit of MI (pp. 29–49)
Arkowitz and Burke (2008) suggest three reasons why MI might be particularly appropriate for improving treatment outcomes in clinical depression:
- MI addresses some of the symptoms of depression including a loss of interest or pleasure in usual activities. Many depressed consumers/clients may lack motivation to engage in psychotherapy. MI can support the exploration of a person’s ambivalence about psychotherapy itself and enhance intrinsic motivation.
- MI has the potential to increase depressed consumer/clients’ activity level without evoking “resistance” to the change goal itself.
- Due to its underpinnings in humanistic and person-centered psychotherapy, MI emphasizes the development of a relationship that is genuine, empathic, and warm. Research has shown that these factors may provide significant healing benefits for consumers/clients who suffer from depression. (pp. 148–149)
In addition, Brody (2009) suggests another important reason for integrating MI into the treatment for depression:
Another potential value of MI is that it affords flexibility in aligning with patients’ conceptualization and attribution of their depression. Other therapies may fail to align with some clients’ understanding of their depression, and they can lead some clients to find a prescribed therapy activity inappropriate or aversive. In MI, the depressed client’s self-efficacy is supported in helping define the ”shape” of his or her treatment, and the resultant treatment may be more tailored to that individual’s formulation and preferences. (p. 1169)
Arkowitz and Burke (2008) have identified three areas of focus when integrating MI into a framework for treating depression:
- The overall symptoms of depression and other depression-related distress identified by the consumer/client
- The problems (i.e. behaviors/attitudes/beliefs) that contribute to the depression and distress
- What the consumer/client needs to do to change the problems that contribute to the depression (p. 151)
Once again the overarching focus in each of these areas is to resolve ambivalence and increase motivation to change beliefs, attitudes and behaviors that alleviate depression symptoms and depression-related distress. As in working with anxiety, Arkowitz and Burke (2008) suggest initially focusing more on reasons not to change, than emphasizing reasons to change during the exploration of ambivalence. The authors state:
Our clinical observations suggest that focusing on reasons not to change as much as reasons to change early in treatment can help deepen the client’s understand and appreciation of that side of their ambivalence as well as bring out emotions associated with those reasons. In fact, the evocation and identification of painful emotions associated with not changing can add strength to the reasons to change by the client’s realization that this distress will be reduced if change does occur. (p. 152)
So MI might be a valuable strategy for helping people with depression engage in counseling or psychotherapy initially, and it can also be useful in resolving ambivalence and increasing motivation to change throughout treatment.
Co-Occurring Conditions: Serious Mental Illness and Substance Abuse
Martine, et al (2002) suggest that the focusing aspect of MI in use with people with persistent, serious mental and substance use disorders should emphasize three behavioral change goals:
- Changing substance use behaviors
- Psychiatric medication adherence
- Participation in a co-occurring specialty treatment program
Due to the cognitive impairments and disordered thinking that often accompany psychosis, the authors recommend some modifications of MI strategies that enhance motivation including:
- Open-Ended Questions: Simplify open-ended questions and make them very concrete. For example, instead of asking “What brings you here today?” ask “What type of psychiatric issues have you been grappling with in your life?” (p. 7)
- Reflective Listening: Use simple and concise language; reflect often, use metaphors, avoid focusing on the negative, organize consumers’ statements with summaries, give people enough time to respond to reflections (p 8).
- Affirmations: Heightening the emphasis on affirmations can counteract some of the negative self-attributions people with chronic, persistent mental and substance use disorders suffer as a result of social stigma and prior negative treatment experiences in which they were labeled “resistant” or “non-compliant” or treated without respect.
Reflective Listening Adaptations for People with Co-Occurring Conditions
Martino, et al. (2002) make the following recommendations for adapting MI reflective listening responses in work with people with substance use issues and persistent, severe mental illness:
1. Reflect in simple and concise terms to reduce the information processing demands placed upon the patients.
“You don’t like the way your medications make you feel” instead of “Your medications are causing a lot of unwanted and negative side effects and that’s why you don’t like taking them.”
2. Reflect often to assist in structuring the interview and maintaining a logical organization to the conversation.
Patient: What’s wrong with me is that my mind and body go in old directions any time I confront new situations of substance with people.
Therapist: You find yourself using again when people who use drugs are around you.
P: Yeah, like I wasn’t planning on it, but it was put before me somehow, like they are setting me up again.
T: Your intention is to not use drugs, but it is hard to not use when you are around people who do.
P: I can’t say I don’t try not to use. But these people are evil, bad. I know what they are thinking. But they won’t get the best of me.
T: They are of no help to you, and you really want to stay way from them to be the best you can be without using drugs.
P: That’s right.
3. Reflect metaphors often embedded in the patient’s psychotically driven statements and nonverbal communication to promote empathetic listening while trying to anchor the patient’s statements in a reality base from which motivational interviewing may proceed.
Patient: I don’t have a problem with cocaine. I stopped using it. It’s tucked under and out. I’ve seen the light, and now I’ve turned it over and off never to witness such events again. (Patient lies down on the floor.)
Therapist: You’ve put your cocaine use to rest.
P: Completely to rest. I ain’t using it no more.
T: How will you pick yourself up now that you no longer want to use cocaine? (Patient sits down in the chair again.)
4. Avoid repeatedly reflecting patients’ despairing statements or negative current or past life events; this reflective listening pitfall can diminish motivation for change and heighten further psychotic symptoms expressed by the patient.
Patient: You know I was hit a lot by my mother growing up. Sometimes she was a vicious, angry woman — very strict. I remember she slapped me so hard I heard my brains rattle… Now I’m told to hit back if someone isn’t treating me right.
Therapist: Told to hit back.
P: I hear voices that tell me to hit people when I don’t like them.
T: Then what happens?
P: I try not to do it. You know my brother used to treat me badly too. That son-of-a-bi…
T: So even though many people have treated you badly, you don’t want to hurt others.
P: Usually, that’s when I get high.
T: Getting high helps you not do what the voices are telling you to do.
P: In the moment, but then it messes up my mind more.
T: So getting high is good in the moment, but over the long haul it makes matters worse for you.
5. Summarize often to promote meaningful relationships among the patient’s statements and to juxtaposition them in a strategic manner that promotes the motivational enhancement process.
6. For patients with a slow response time and other negative psychotic symptoms, pause sufficiently after reflecting the patient’s statement to provide the patient with a sufficient opportunity to consider and respond to the reflection. (pp. 18–19)