Motivational Interviewing and Harm Reduction

by Tom Horvath, Ph.D., ABPP

sober business man seeing addiction therapist for motivational interviewingIn this article I compare these two important contemporary recovery concepts. From my perspective they are mostly similar, but have dramatically different rates of acceptance in the addiction treatment industry.

Motivational Interviewing (MI)

Motivational interviewing (MI) is a psychotherapeutic approach for promoting any healthy behavior change. MI was created for work with addiction, then extended to any behavior change about which someone is ambivalent. Ambivalence is a crucial aspect of MI. The person who is completely committed to change is actually changing, and not sitting in front of you discussing the possibility of it. MI accepts a person’s ambivalence, but works toward reducing ambivalence in favor of healthier behavior. One of the principal methods of MI is to engage the individual to think about and articulate reasons for change.

MI is a radically different approach to addiction treatment. MI offers no direct guidance or education. There may be little history taking or diagnostic assessment (although these components may occur in the broader context of treatment). There is no treatment plan or set of treatment goals specific to the individual. The general plan for every client is to identify and develop motivation for change, in order to move the individual in the direction of healthier behavior. MI assumes that individuals who act self-destructively are nevertheless underneath not self-destructive, but rather, just like everyone else, interested in being healthier and happier. Strikingly, MI is generally as effective as other addiction treatments such as CBT or 12-step facilitation, even though it is much shorter in length. In some studies the MI treatment lasts only one-third as long as the comparison treatment.

What is healthier behavior? In diagnosable addiction there is not much need to make fine distinctions between what is healthy or less healthy. Eating regular nutritious meals, getting regular sleep, exercising adequately, and not using (damaging) substances are simple concepts to understand. “Healthy” is generally synonymous with “long-term satisfaction.” Addiction is acting on short-term satisfaction. Health and recovery involve acting on long-term satisfactions.

Harm Reduction (HR)

Harm reduction (HR) is a public health approach that accepts client/patient goals as primary, even though these goals may be short-sighted, while still working to engage the individual in considering longer-term goals. Classic HR interventions include needle exchange programs (trade in your dirty needles for clean ones, to reduce your chance of infection), opiate replacement (use methadone or Suboxone so that you don’t have to stop opiates altogether, but can now use safer ones) and safe injection sites (shoot up in safer conditions for yourself and reduce problems for the public).

Individuals who accept HR assistance are willing to make some changes in their use or behavior (for the purpose of reducing harm or the risk of harm), but are not willing to abstain. If abstinence is the ultimate solution to addiction, then these individuals can be viewed as willing to go only a small distance in that direction. One of the main arguments in support of HR has been the suggestion that individuals with significant addiction may be able to approach abstinence only by degrees. If we do not give them a “ladder” to climb to abstinence one step at a time they are unlikely to jump (to that seemingly impossibly high perch) all at once.

HR makes use of the behavioral principle of “small steps” in the right direction. In cases of severe addiction the goal may be simply to keep someone alive long enough so that “recovery happens.” Dead individuals cannot recover. HR services also give someone an entry into services that is denied to someone who only has the options of abstinence-oriented treatment, or no treatment or assistance at all.

MI and HR compared

Both HR and MI view human beings as easily persuaded by short-term considerations (e.g., the desirability of getting high) at the expense of long-term considerations (e.g., doing well at school or work). Both approaches recognize that instructing someone not to act on short-term considerations might be helpful in the short-term, but probably won’t be helpful in the long term. On the contrary, by setting up too many rules and regulations, it is easy to drive people away. People ultimately do what they want to do. Both approaches are willing to engage the person in discussion to activate motivation for long-term satisfaction, while accepting whatever progress the individual makes in that direction. Both approaches support individuals deciding to pursue deeper change, to include abstinence and/or seeking additional treatment or services.

The fundamental differences appear to be that MI is a short-term effort conducted by sit-in-the-office therapists, while HR actively engages addicted individuals anywhere they might be found, possibly for long periods of time. HR can include all of MI (if there is opportunity to speak at length with the client), but HR also includes active helping as well as discussion. In HR oriented psychotherapy active helping might include engaging the individual in resolving problems that maintain addiction, thereby setting the stage for ending addiction.

Looking ahead for MI and HR

MI is widely accepted in US addiction treatment (judging by how many treatment facilities state they use it). HR would typically be controversial in the same facility. If the above analysis is accurate, the differences between MI and HR are not major. Why the difference in acceptance?

Perhaps some professionals do not understand how radically different MI is. If so, and they say they use MI, they are probably not true practitioners of it. On the other hand, there is no missing the in-your-face attitude of HR. If the practitioners who support MI do so because they don’t understand it well, I hope that when they do understand it, they will still support it (and practice it properly).

HR continues to build a substantial body of supportive research. I hope that in time HR will become the over-arching perspective for all addiction treatment and prevention, because it can incorporate everything else we do. With luck the acceptance of motivational interviewing is leading to the greater acceptance of harm reduction.