Motivation can also be defined as what causes us to take action, as the process that initiates, directs and sustains our behavior towards a goal, and as the strong desire we have to do something. Motivation is an internal state that is affected by external factors, it is the readiness or willingness to change, and it varies according to the situation and time. (Ogel, K. 2009)
Addiction is a chronic disease that goes with relapses. Therefore, it is necessary to establish long-term treatment and follow-up strategies (Dennis and Scott 2007, Dennis et al. 2005). Today, in researches on substance addiction, a general and categorical classification is made as “present” or “absent” addiction according to diagnostic criteria. Therefore, a dimensional evaluation of the problems related to substance use remains incomplete (Conway et al. 2010). Patients with alcohol and substance use disorders are people with very different problems (Ögel 2010). Therefore, treatment in alcohol and substance use disorders should be done by considering different dimensions of addiction (NIDA 2009). For example, the type of substance used by the person, the amount and duration of substance use are important factors in planning the treatment (Connors 1995). (Ogel, C 2012)
“Motivational interviewing is a directive and client-centered technique to help clients discover and analyze ambivalence and change behavior”(40). This interview technique is a targeted method that may work for people who are unwilling or undecided about treatment (18).
Motivational interviewing proposes different techniques to manage the client’s resistance and understand ambivalence. (Miller and Rollnick 2002). Although resistance is seen as the result of the interaction between the client and the therapist, it is also considered as the result of the client’s ambivalence. For example, the form of the therapist’s response to the client’s resistance to change is highly influenced by the magnitude of the resistance (Moyers and Rollnick 2002).
According to Miller and Stephen Rollnick, the founders of motivational interviewing, motivational interviewing is to reveal the invisible in the mind based on clinical trials. The aim is to reveal the behavior change for the desired result. Miller was invited to a lecture to talk about the treatment of alcohol use disorder, and there they talked and discussed with a group of young psychologists, which made Miller realize that what he was talking about was actually a different therapy technique and laid the foundations for motivational interviewing. (Miller, WR Rose, GS 2010)
In the motivational interview, the first phase of the treatment begins with a therapeutic attitude that puts the client in the center. The aim is to find the points where the client hesitates, to help them reach a solution and to create the desired change in behavior. Motivational interviewing has a wide variety of uses. (Uysal, H 2012). These areas are; addiction treatment, weight loss, education, anxiety disorder, marriage counseling, prevention of domestic violence, diabetes, cerebral palsy rehabilitation, depression, sexual behavior change, HIV/AIDS protection, PTSD. (Ogel, K 2009)
Motivational interviewing is a method that is frequently used in the field of addiction, that progresses in treatment and creates lasting effects. In the treatment of substance-alcohol addiction, people often hesitate to quit and start the cycle of use again. Motivational interviewing helps clients to understand the problems they are experiencing, helps to control this situation in a short time and makes a long-term contribution to the treatment. It can change the behavior of reuse. It is an effective method that is especially useful for people who are reluctant to quit.
There are some approaches and principles on which motivational interviewing is built: Ambivalence experienced in addiction treatment; It is a natural obstacle encountered in the healing process. People have natural motivations and values that can transcend this ambivalence. There is a collaborative relationship between the therapist and the client. For change to occur in the client, an empathetic, supportive and directive (dialectical) approach is needed. The contrast between the client’s current behavior and purpose should be highlighted. The therapist should support the client’s self-efficacy in healing and approach it from an optimistic point of view. Motivational interviewing offers solutions when a person decides to change because the focus is on the client and their problems. The client plays the role of the knower, and the therapist does not put forward ideas before the client and should remain neutral. (Alpaydın, N 2016)
Preparing the client for change is the product of a shared, collaborative relationship. In this process, the client may resist or deny some things from time to time. These resistance and denial behaviors are considered as feedback given to this therapist.
The cycle of change in addiction consists of five phases: Awareness, Decision making, Quitting, Continuation, and Restarting. In this process, change is not made in order to give the client insight, to give information, to gain skills. The most important issue is to resolve the ambivalence situation experienced by the client. Ambivalence, on the other hand, is the state of conflict that a person experiences about quitting or not quitting. While talking about ambivalence, both aspects of the problem are actually discussed, and this conversation also activates two-sided thoughts.
The most important thing in motivational interviewing is to listen to the client and reveal their desire for change. Helping and accompanying the client to use their own energy is important in this process. The questions asked should reveal how much the client wants change, what he wants to change, and his expectations during the healing process. “What do you want to do, what is your desire, why do you want to change, what is the importance of it for you, what do you believe you can do, what do you expect from me?” These questions are asked to get an idea about the client’s preparation for the process and the path to be followed is determined. The therapist does not try to persuade the client in a solution, does not make confrontation.
The first stage of the motivational interview in the recovery process from addiction is to create motivation for change in the client. Afterwards, open-ended questions should be asked, reflective listening, summarizing, acceptance and change should be discussed. In the first interview, clients may think that they may be criticized from time to time. In order to reduce this situation, it is necessary to discuss the role, expectations and goals of the therapist with the client in the first meeting. Then, in order to activate the client in the interview and to determine the topic to be discussed, the client is asked about the topic he/she wants to talk about. In this way, the subject to be discussed will be discovered and detailed. In the motivational interview, starting with issues such as diagnosis and diagnosis can cause problems or discussions, so these are not discussed. During the recovery period, it can be difficult for the client to make and maintain the decision to quit. In this process, the therapist should display a supportive and supportive attitude towards the client’s self-efficacy. It should be underlined that starting this treatment is a big step and the determination of the client should be emphasized. After collecting the information from the client, summarizing and reflecting is done from time to time to reveal the ambivalence. Reflection is shorter than summarizing and focuses on understanding and reflecting what the client is saying. The reflection method is applied to emphasize the positive aspects of the change process, to overcome the resistance and to make the client feel understood. In order to increase the collaborative relationship between the client and the therapist, the client’s story is detailed by asking open-ended questions. In fact, asking such questions motivates the client to share their feelings and thoughts more, and the client’s decision process is better questioned. It is important to dwell on (notice) ambivalence to help the client achieve balance in the decision-making process. This balance focuses on the client’s preferences and examines all aspects of change. While trying to establish this balance, the pros and cons of the current situation and change are discussed. ‘Land Balance’ can be used in this process. The land balance shows the pros and cons of the current situation and change with a diagram and provides a better understanding by writing.
In the motivational interview with the client, the importance of the quitting process to the client and the client’s self-confidence in this matter should be questioned. This questioning can be learned on a scale of 0-10. Materiality ‘How important is it to you to quit?’ If we make a scale of significance, and 0 ‘not at all important’ and 10 ‘very important’, what number would you consider appropriate?’ can be questioned.
For confidence and competence, ‘if we make a scale of 0 to 10 for your confidence in quitting, and 0 means I don’t trust at all and 10 shows very confident, which number would you consider appropriate?’ (Ögel,K.) Here, if the client gives a low score, he is asked why he gave this score for the degree of importance and he is expected to give at least 3 reasons. If the client gives a low score for confidence-efficacy, he is asked what he can do to increase this score. It may be questioned how the client wants his life to change in order to learn and work on his thoughts about the future or where he sees himself in ten years. There is a very important question that can be used here. ‘If you were 100 percent successful in making the change you want, what would be different? What would you like to happen five years from now?’ (Ogel, K.)
If the client has difficulties at this stage, their past periods, plans and the things they are most worried about can be questioned. In order for the client to look to the future more planned and confidently, their future goals should be discussed. How the behaviors affect the goals should be discussed and if there is a problem, it should be worked on. If there is a situation that will create a contrast between the target and the current behavior, the client must be made aware and resolved. The point to be considered while raising awareness to the client should be the resistance that the client can develop. It should not be discussed when dealing with this emerging resistance. Discussion can have a negative effect on the client’s stay in treatment. As soon as resistance arises, the therapist should consider this as a feedback to change method and change the strategy applied. When the client develops resistance; reflective listening, changing the focus, emphasizing one’s choice and control, therapeutic paradox methods can be used. The point that should not be forgotten at this stage is that resistance is a natural response and can be changed during the treatment process. The therapist tries to bring new perspectives to the client, but this change should not be compelling. The client must also want this change. The therapist should draw attention to the client’s wishes for change, but should not try to correct it.
In the second stage of the motivational interview, work should be done to strengthen the change, and this stage starts by talking and summarizing the change and problem from the beginning to the point reached. The change of clients does not happen immediately, this change takes place in an average of 3-6 months. The beginning of the change is understood in line with the words ‘I am ready, I believe, I guarantee, I will, I aim, I want, I am volunteer’ etc. from the client to the therapist. At this stage, the next steps, solution suggestions and change plan are discussed. Additionally, at this point, the therapist can provide advice or information to the client if necessary. In the second step, decreased resistance is observed and no rapid progress is made. First of all, the client should feel ready for the change plan and the degree of commitment should be evaluated. The change plan to be prepared is not a treatment plan and the goals are determined first. The goals set should be realistic and achievable. If unrealistic goals have been set, they should be discussed. Short-term goals should be set first, and the goals should grow as they are achieved. In other words, it is necessary to move towards the big goal with small steps. While preparing the change plan, the ideas of the client should be given importance, the unsuccessful experiences in the past should be accepted as a lesson and the client should be supported. The most important thing to consider at this point is the client’s self-efficacy.
It has been proven that motivational interviewing has a positive effect on people’s behavior change. The effectiveness of the interview is less dependent on the therapist’s experience and more dependent on the relationship of trust established between the therapist and the client. In order for this meeting to be more effective, the problem and risks should be clearly explained, the importance of change should be emphasized, and change should be advocated. At the point where advice should be given, the client’s opinion on this issue should be learned and acted upon. In addition, it should be spoken more slowly, the client should talk about behavior change, discovering new things, talk more from the therapist, ask for information and suggestions, but still the course of the interview should be under the control of the therapist.
In conclusion, motivational interviewing is a short-term, change-focused therapy technique that can be used simultaneously with many therapy methods. It is an evidence-based, reliable method. It is widely used in many fields thanks to its ease of learning and application.
The resistance in the sessions is an indicator of the patient’s ambivalence to change and therapy or the lack of motivation (Engle & Arkowitz, 2006). Motivational interviewing, which reduces resistance to change, has a particularly important place in facilitating the treatment process with existing experimentally proven treatments. Resistance in the first sessions has been found to be highly correlated with subsequent intersessional activities (such as homework). Therefore, it is thought that the high level of resistance shown in the first sessions of therapy is an indication that there will be problems in homework compliance in the next sessions. (Alpaydın, N 2016)