Addictive Behaviours Final Chapters 5-10

What is Motivational Interviewing (MI)?

A collaborative, person-centered counselling approach.

• Designed to elicit and strengthen a client's own motivation for change.

• Short-term therapy.

• Helps clients resolve ambivalence about substance use.

• Rather than telling clients why they should change, MI helps them discover their own reasons.

• Originally developed in the early 1980s for Alcohol Use Disorder and later expanded to smoking, medication adherence, exercise, diet, and many health behaviours.

• One of the strongest evidence-based counselling approaches in addiction treatment.

Why is Motivational Interviewing considered counterintuitive?

Most people naturally respond to someone with a problem by:

• giving advice

• persuading

• explaining consequences

• telling them what to do

• trying to "fix" them

MI deliberately avoids this because:

• people change more when motivation comes from themselves rather than someone else's advice.

• discovering personal reasons creates stronger commitment than being persuaded.

What are the goals of MI?

1. Increase intrinsic motivation

2. Lower resistance

3. Resolve ambivalence

These goals work together to increase the likelihood of lasting behaviour change.

What is intrinsic motivation?

Motivation that comes from inside the client.

Instead of changing because of:

• court orders

• family pressure

• guilt

• threats

• clinician advice

The client changes because:

• their own values

• goals

• hopes

• future

How does MI understand resistance?

Resistance is not viewed as a personality flaw or denial

What is ambivalence?

Ambivalence means holding two conflicting thoughts or feelings at the same time.

Ambivalence Example?

"I know I should stop drinking." AND "I don't want to stop."

What theories influenced Motivational Interviewing?

Person-Centered Therapy

Cognitive Behavioural Therapy

Stages of Change

Existential Therapy

Self-Determination Theory

What is the MI Spirit?

Four components:

1. Partnership (collaboration)

2. Acceptance

3. Compassion

4. Evocation

What does partnership mean in MI?

Counsellor and client work as equals

What does acceptance mean in MI?

Acceptance does NOT mean approving substance use

What is compassion in MI?

Compassion is an ethical commitment to:

• prioritize the client's wellbeing

• protect their interests

• genuinely care about them

What is evocation?

The defining feature of MI.

Instead of giving clients motivation, the clinician draws out motivation already inside them

What are the three communication styles used in counselling?

Directive

• tells

• advises

• prescribes

Following

• mostly listens

• little direction

Guiding

• balances listening with gentle direction

• hallmark of MI

What are the RULE principles?

R — Resist the righting reflex

• Don't immediately fix the client.

U — Understand motivations

• Motivation must come from the client.

L — Listen with empathy

E — Empower the client

What are the four MI therapeutic processes?

Engaging

Focusing

Evoking

Planning

What is Engaging?

The first stage of MI

Purpose:

• establish trust

• create rapport

• develop collaboration

• create psychological safety

What is Focusing?

Counsellor and client decide together:

• what problem to work on

• treatment priorities

• meaningful goals

• where to begin

What is Evoking?

Purpose: draw out the client's own reasons for changing.

Key idea: People believe their own arguments more than advice from others.

The clinician helps clients express:

• values

• goals

• motivation

• readiness

What is Planning?

Transforms motivation into action.

Planning answers:

• What will I do?

• When?

• How?

• What barriers will I face?

• How will I overcome them?

What does OARS stand for?

O — Open-ended questions

A — Affirmations

R — Reflective Listening

S — Summaries

Why are open-ended questions important?

They:

• encourage exploration

• help clients discover new insights

• allow clients to own the conversation

• strengthen motivation through self-expression

• reduce feelings of interrogation

Open-ended questions example?

Instead of: "Do you want to quit?"

Ask: "What are your thoughts about your drinking?"

What are affirmations?

Statements recognizing client strengths.

Simple affirmations

recognize behaviours or effort

Complex affirmations

recognize identity, values, or character

What is reflective listening?

Instead of asking another question, the counsellor reflects what the client said

Simple Reflection

paraphrases content

Complex Reflection

reflects underlying emotions

adds meaning

explores implied feelings

Why are summaries used?

organize thoughts

demonstrate active listening

allow corrections

increase client insight

transition between topics

close sessions

Recommended:

• one midway through the session

• one at the end

What is change talk?

Any statement supporting behaviour change.

• The more clients talk about changing, the more likely they are to actually change

What does DARN stand for?

Preparatory Change Talk

D — Desire

A — Ability

R — Reasons

N — Need

Represents thinking about change before commitment

What does CAT stand for?

Implementation Change Talk

C — Commitment

A — Activation

T — Taking Steps

Represents movement into actual behaviour change. Commitment statements ("I will") are the strongest predictors of future change

Why must DARN come before CAT?

Clients typically move from: Desire → Ability → Reasons → Need

before reaching: Commitment → Activation → Taking Steps.

Pushing commitment too early often increases resistance. MI follows the client's pace.

What is sustain talk?

Statements supporting continuation of current behaviour.

Examples:

• "Drinking helps me relax."

• "Everyone drinks."

• "It's not that bad."

How should MI respond to sustain talk?

Never argue

What is a double-sided reflection?

Reflects:

1. sustain talk

then

2. change talk

Ends on motivation for change.

Purpose: acknowledge ambivalence while gently emphasizing change

What is decisional balancing?

A structured exploration of:

• advantages of changing

• disadvantages of changing

• advantages of staying the same

• disadvantages of staying the same

Allows clients, not clinicians, to evaluate both options.

What is amplified reflection?

An advanced technique that slightly exaggerates sustain talk.

Purpose: encourage clients to correct the exaggeration themselves.

Must be used carefully because sarcasm can damage rapport

What is the Change Ruler?

A 0–10 scale measuring:

• importance of change

• confidence (self-efficacy)

The follow-up question is more important than the score itself

Why ask "Why a 5 instead of a 2?" (Change Ruler)

This encourages clients to explain: why change matters.

It produces change talk.

Asking: “Why not a 7?" usually produces sustain talk instead

What does FOCUS stand for?

F — First ask permission

O — Offer suggestions

C — Concise information

U — Use a menu of options

S — Solicit the client's thoughts

What is the Expert Trap?

The clinician assumes they know exactly what the client should do.

Results:

• too much advice

• too much talking

• poor understanding

• reduced collaboration

What is the Persuasion Trap?

Trying to convince clients with:

• facts

• logic

• arguments

Often causes clients to argue for staying the same, strengthening sustain talk

What is the Fixing Reflex?

The automatic urge to solve another person's problems.

Although natural, it often undermines MI because it reduces autonomy and client motivation

Signs a client is ready for change

more change talk

less sustain talk

imagining life after change

taking small behavioural steps

attending appointments

contacting treatment

skipping substance use

telling family members

researching treatment options

Characteristics of an effective change plan

Good change plans:

• are developed gradually across sessions

• contain specific behavioural goals

• include timelines

• identify barriers

• prepare coping strategies

• are measurable and realistic

Specific plans are much more successful than vague intentions

How is MI adapted for adolescents?

Effective for reducing alcohol use.

Adolescents value autonomy.

They often show high psychological reactance (resistance to authority).

Clinicians should avoid controlling approaches and respect independence.

How is MI adapted for older adults?

Integrate psychoeducation into MI.

Consider physical limitations and medical conditions.

Respect the perceived benefits of substance use (e.g., pain relief).

Collaboratively work toward safer, healthier behaviour rather than simply demanding abstinence.

What is the therapeutic alliance?

The working relationship between counsellor and client.

Includes trust, openness, cooperation, mutual respect, and collaboration.

One of the strongest predictors of successful treatment outcomes across psychotherapy

What is the difference between motivation and readiness?

Motivation: Wanting to change.

Readiness: Being prepared to act now.

Someone may strongly want change but still not be ready because of barriers (e.g., withdrawal fears, homelessness, transportation issues)

What is self-efficacy, and how is it assessed in MI?

Self-efficacy is a person's confidence that they can successfully make a change.

• Often measured using the confidence version of the Change Ruler (0–10).

• If importance is high but confidence is low, treatment should focus on building coping skills and confidence rather than increasing motivation.

Why shouldn't clinicians rush into planning?

Planning before motivation has developed usually leads to weak commitment and poor follow-through.

Effective change plans emerge gradually over multiple sessions after motivation has been strengthened.

What is the basic principle of Cognitive Behavioural Therapy (CBT)?

Proposes that events themselves do not directly cause emotions or behaviours

• Instead, a person's interpretation of those events influences how they think, feel, and behave

• Therefore, changing maladaptive thinking can reduce distress and unhealthy behaviours

Why can two people react differently to the same event according to CBT?

Because they interpret the event differently

• Their beliefs and thought patterns, not the event itself, determine their emotional and behavioural responses.

How does CBT explain substance use?

CBT views substance use as the result of distorted thinking, unhealthy beliefs, and maladaptive coping strategies rather than simply poor self-control

• Substance use is considered the final outcome of a predictable cognitive process

What are the primary goals of CBT in addiction treatment?

Identify harmful thought patterns

Challenge inaccurate beliefs

Replace distorted thinking with healthier alternatives

Reduce emotional distress

Teach effective coping strategies

Prevent relapse

How is the therapist's role different in CBT compared to many other therapies?

CBT is highly collaborative and active

• Rather than simply listening or giving advice, therapists help clients recognize thoughts, question assumptions, evaluate evidence, and develop healthier thinking patterns

Why is the therapeutic relationship still important in CBT?

Although CBT is structured and skills-based, research shows that a strong therapeutic alliance built on trust, collaboration, and safety is essential for successfully challenging deeply held beliefs

What are schemas?

Schemas are deeply rooted patterns of thinking and core beliefs developed through life experiences that shape how people interpret themselves, others, and the world

• Maladaptive schemas contribute to psychological distress and substance use

How do schemas contribute to addiction?

Negative schemas distort how people interpret experiences, making substances appear to be effective solutions for emotional pain or life problems

What are core beliefs?

Core beliefs are deep, often unconscious beliefs about oneself, other people, and the world that influence how every experience is interpreted.

How are core beliefs different from automatic thoughts?

Core beliefs are deeply ingrained, long-term beliefs, whereas automatic thoughts are rapid, situation-specific thoughts that arise from those core beliefs

How do core beliefs usually develop?

Through early childhood experiences, attachment relationships, trauma, criticism, rejection, neglect, love, and repeated life experiences

What are common negative core beliefs found in addiction?

About oneself:

• I am flawed.

• I am defective.

• I am weak.

• I am unlovable.

• I am incompetent.

About the world:

• People can't be trusted.

• The world is dangerous.

• Bad things always happen.

About substances:

• I need drugs to cope.

• I can't function without alcohol.

• I can't handle life sober.

Why are core beliefs difficult to change?

They are emotionally powerful, deeply ingrained, resistant to change, and have often been reinforced over many years

What is Schema Therapy?

A CBT-based approach specifically designed to identify and modify early maladaptive schemas and deeply rooted core beliefs

What are automatic thoughts?

Automatic thoughts are rapid, spontaneous thoughts that occur immediately in response to situations with little or no conscious effort

Why are automatic thoughts important in addiction?

They are often the first step in the chain leading to cravings and substance use because they trigger emotional reactions that increase the urge to use

What is an example of the automatic thought chain?

Stressful day → "I can't deal with this." → Anxiety → Craving → Substance use

What are cognitive distortions?

Systematic errors in thinking that bias how people process information and reinforce negative beliefs

What characteristics do cognitive distortions share?

Exaggerate negatives

Ignore positives

Expect worst-case scenarios

Reinforce existing negative beliefs

Bias thinking toward failure and rejection

What is overgeneralization?

Applying one negative event to all future situations (e.g., one relapse becomes "I'll never recover")

Why is overgeneralization harmful in addiction?

It increases hopelessness, reduces motivation, and raises relapse risk.

How does CBT challenge overgeneralization?

Therapists ask clients to examine evidence and recognize exceptions instead of assuming one event defines everything.

What is all-or-nothing (black-and-white) thinking?

Viewing situations in extreme categories, such as total success or complete failure, without recognizing middle ground

Why does all-or-nothing thinking contribute to relapse?

Small setbacks become viewed as total failures, increasing shame and making relapse more likely

How does CBT address all-or-nothing thinking?

By helping clients view behaviour on a continuum and recognize setbacks as learning opportunities rather than complete failures

What is magnification and minimization?

Magnification exaggerates mistakes or imperfections, while minimization dismisses successes or positive progress

Give an example of magnification and minimization

Magnification: "Everything is ruined."

Minimization: "My months of sobriety don't really count."

What is mind reading?

Assuming you know what other people are thinking, usually assuming negative judgments, without evidence

How can mind reading increase relapse risk?

Believing others are judging you increases shame, anxiety, avoidance, and cravings

How does CBT challenge mind reading?

Clients examine evidence, consider alternative explanations, and question whether they actually know what others think

According to CBT, what is the cognitive chain leading to substance use?

Core beliefs → Interpretation of situation → Emotional distress → Craving → Substance use

Why does CBT view substance use as logical?

Within the person's distorted belief system, using substances appears to be the most reasonable solution for coping with distress

What are current difficulties in the cognitive model?

Life stressors (e.g., grief, trauma, conflict, unemployment) that activate unhealthy thinking patterns and contribute to increased substance use

Why do therapists examine when life problems began?

To understand whether life events preceded increases in substance use and identify important triggers

What are vulnerable situations?

Internal or external circumstances that activate core beliefs and trigger distorted thinking

What sequence follows a vulnerable situation?

Vulnerable situation → Core belief activation → Cognitive distortions → Negative emotions → Craving → Substance use

What opportunities for intervention exist within the cognitive model?

Therapists can intervene by modifying core beliefs, changing interpretations, improving emotional regulation, or teaching craving-management skills before substance use occurs

What are permission-giving beliefs?

Thoughts that justify substance use (e.g., "I've had a terrible day, I deserve a drink.")

What are anticipatory beliefs?

Beliefs that substances will produce positive outcomes (e.g., "Alcohol will help me relax.")

Why are these beliefs targeted in CBT?

Increasing awareness of these automatic beliefs interrupts the cognitive process before substance use occurs

What is collaborative agenda setting?

Therapist and client jointly decide what topics will be addressed during the session

Why does every CBT session begin with a mood check?

To assess emotional state, recent substance use, relapse risk, crises, or significant life events that may require immediate attention

Why is reviewing homework essential in CBT?

Because lasting change occurs between sessions as clients practice new skills in everyday life

What occurs during the skill development portion of CBT sessions?

Clients learn and practice cognitive restructuring, coping skills, and problem-solving techniques

Why does every CBT session end with new homework?

Homework helps clients continue applying skills until the next session and promotes long-term behaviour change

What is Socratic questioning?

A collaborative questioning technique that helps clients evaluate beliefs and discover healthier conclusions themselves instead of being told what to think

Why is Socratic questioning effective?

Clients are more likely to change beliefs when they discover inaccuracies through guided questioning rather than being corrected directly.