Behavioral Therapy versus Motivational Interviewing for Substance Abuse

The purpose of this note is to comment briefly on my personal experience with motivational interviewing for substance abuse (over-use) versus more of a behavior-oriented approach.  Motivational interviewing is a counseling technique developed by William Miller and Stephen Rollnick.  Essentially the client and the counselor develop a list setting forth the pros and cons of using a substance versus the pros and cons of quitting; then querying the client re the plausibility – desirability – feasibility of various change outcomes.  This is just a one-sentence summary, Miller and Rollnick have turned motivational interviewing into a business.  For a useful summary of techniques, see the 2008 article by Sobel & Sobel.

The problem with their formulation is that it requires a relatively sophisticated level of cognitive operations by the client.  In many cases the client may be unable to perform these if only because the client is enmeshed in a cycle of substance over-use, which has diminished the client’s capacity to perform the very operations the technique requires.  The client might even be under the active influence of the substance.  I have asked various experts in the field to clarify exactly how this works, however, none of them have been able to supply a satisfactory answer.

On the weekends I facilitate therapy groups at an inpatient psychiatric hospital.  There are three wards, one for pediatric/adolescents; Adult I; and Adult II.  Patients typically are admitted on a psychiatric hold written by law enforcement, a med/surg hospital ER psychiatrist or the county Department of Mental Health.  Patients with a psychotic disorder typically are found in Adult I; and persons who are depressed, in Adult II.  Prevalence of substance over-use is high in all of them.  I have been working in the Adult II ward.  In my experience patients in the pediatric/adolescent ward and persons in Adult I typically are refractory to any kind of cognitive intervention.  Patients in Adult II, however, typically are very smart.  The patient census comprises teachers, lawyers, accountants, even medical doctors.  They’ve hit some kind of a trough or low-point in their lives, as a result of which they’ve tried or threatened to harm themselves.  Their depression is not characterological; hopefully, six months from now they’ll be able to look back on their hospital experience as a pivot point for life change.  If there ever was a type of patient who should be amenable to motivational interviewing, this would be it.

Unfortunately, in my experience, they’re usually not.  One can’t talk a patient out of substance over-use, or create a binary set of circumstances (use versus not use) requiring a volitional decision by the patient – an act of will (or will-power) to quit.  One can elicit a complete and thoughtful list of pros and cons, with corollary advantages and disadvantages.  One can rank them hierarchically and articulate a persuasive case for change.  The facilitator can be completely empathetic and attuned to the patient.  But it still isn’t going to work, for the simple reason that the patient is overwhelmed by the stimulus supplied by the substance.  It is impossible for the patient to marshall sufficient will-power to stop over-using.

For this reason I’ve found that a behavioral approach is much more effective.  While still requiring some level of cognitive operations, they are much less complex and much easier for the patient to perform than those required by motivational interviewing.  Patients have no trouble understanding it and anecdotally report it is, or has the potential to be, much more helpful. 

Here’s how it goes.  Do you remember the story of Pavlov and his dogs?  Although you may have heard about it, you might not be completely familiar with how it works.  Ivan Pavlov was a Russian scientist who devised an experiment involving dogs and meat.  He noticed that when a dog sees meat, the dog’s natural, innate response is to salivate.  The meat is an unconditioned stimulus and salivating is an unconditioned response.  The reason why it’s called unconditioned is because it’s an innate or natural response to the situation or environment.  It’s not conscious; no motives or thoughts are involved (one might say conscious awareness is epiphenomenal, because all it does is go along for the ride on top of the behavior).  An unconditioned stimulus in turn is something that has a tendency to evoke an unconditioned response – make it more likely that it’ll occur – depending on factors like its frequency, intensity and duration.  What Pavlov did is to pair or associate the unconditioned stimulus with something completely different, like ringing a bell.  He’d show the dog the meat and ring the bell at the same time.  After a while the dog started salivating whenever it heard the bell – even in the absence of the meat.  The bell is a conditioned stimulus and salivating became a conditioned response. 

Another famous experiment, conducted by the psychologist John B. Watson, involved a young child identified as Little Albert.  He was shown a white mouse and, because it was cute and not threatening, he started to play with it.  Then, Watson started clanging a steel bar with a hammer whenever the mouse was brought into the room.  This naturally frightened Little Albert.  Watson then just brought the mouse into the room, without clanging the steel bar.  As you might have guessed, Little Albert now was afraid of the mouse.  Why?  He had been conditioned to associate it with the loud noise.  Pretty soon, Little Albert was afraid of anything that was white, even nice fluffy rabbits or a white blanket.  The feared stimulus became generalized to other ambiguous but analogous or adjacent situations.

With substance over-use, the unconditioned stimulus might be something like the sight or smell of the substance.  That in turn evokes an unconditioned response, which is physiological craving for the substance.  Motivational interviewing relies on the patient’s concept of what’s in their best interest to interfere with this connection.  Most persons who over-use substances, though, do so in specific contexts.  They might be partying with friends.  They might be sitting alone at home by themselves.  There are a lot of other possible examples.  The problematic situation becomes a conditioned stimulus and after a while, just being physically present in it is sufficient to promote desire to use the substance (at that point, a conditioned response). 

I’ve found, and patients report, that it’s much easier for a person over-using a substance simply to avoid desire-provoking scenarios like the two set forth above, than it is to decide unilaterally to stop using the substance.  While it still requires a volitional act, the amount of cognitive resources it takes simply to not go somewhere (or to engage in some other behavior, depending on the circumstances) is much less than the mental effort required in order to will oneself to quit.  Try it, you’ll see!