Can We All Stop Pretending That Motivational Interviewing Is Compatible With the 12 Steps?
The architects of Motivational Interviewing—chief among them William R. Miller—are curiously reluctant to admit publicly that their approach contradicts 12-step-based treatment. Why?
Motivational Interviewing (MI) is a psychological therapy developed for alcoholism and other addictions. It responds to the fact that no single technique is especially effective in resolving addiction or creating psychological change. Instead, people’s motivation determines their success in recovery—whichever technique or method they choose to pursue.
MI is a classic “client-centered” approach in which the client’s preferences, values and beliefs direct the course of treatment, and it has spread into every area of clinical and health care counseling. It was developed by William R. (“Bill”) Miller, now an emeritus professor at the University of New Mexico, where he previously headed the Center on Alcoholism, Substance Abuse, and Addictions (CASAA). Miller’s essential insights are that: (1) Treatment should focus on motivation, and (2) Motivation is summoned not by confrontation, but by its reverse: empathic interaction with a client that stimulates their desire to recover in their own chosen way.
This values-based, motivational approach was a basis for my most recent book, Recover!, which I wrote with Ilse Thompson. People don’t respond, Ilse and I maintain, when you instruct them on the “correct” behavior (typically meaning sobriety understood as abstinence). The instructional approach in general arouses people’s defenses. Instead, a would-be helper has to find—and operate from—the client’s own perspective. This process is about tapping into a person’s values. In the MI approach, people seek recovery when they find out who they are deep within, the self they really want to be.
Addiction is not a core identity around which to build your self-concept. It is—like any of the psychological issues and personal problems we all face—a surface characteristic. Our approach is consistent with that of MI in seeing addictive behaviors as correctable life difficulties that violate—rather than express—the person’s essential being.
So far so good. The trouble is, this enlightened, useful approach is all too often hampered by being employed in conjunction with another, entirely different approach—one to which MI is diametrically opposed in its fundamental precepts of defining and pursuing recovery. And few of us in the field dare to admit that this is a problem. Why? Because we’re talking about the ubiquitous 12 Steps.
MI directly contradicts the 12 Steps in theory and in practice in three essential ways:
(1) MI, unlike AA, avoids labeling the client. Instead of demanding a person declare themselves an alcoholic or addict, MI simply explores with the client his or her views of their problems.
(2) MI, unlike the 12 Steps, is not prescriptive. Instead of focusing on steps the person must follow to achieve sobriety, MI is about ways for helpers to assist people to reorient their thinking in the way that best suits them.
(3) MI, unlike AA and the 12 Steps, does not define sobriety as abstinence and recognizes and accepts harm reduction outcomes, as conceived by the client.
Since MI conflicts with the fundamentals of standard 12-step practices, you’d imagine that practitioners of these programs would be at each others’ throats!
Not at all. A détente has been reached—a dishonest détente that makes no sense on either side. It is now standard practice for traditional treatment programs around the US to promote their use of motivational interviewing. But how is this possible, when these programs demand that people label themselves alcoholics or addicts, that they follow the 12 Steps to the letter and that they accept abstinence as the only worthy goal?
An even more telling question may be why MI’s developers and proponents, most notably Miller himself, have avoided conflict with the dominant treatment philosophy in America.
I’ve known Bill Miller over several decades, beginning with our shared involvement in the issue of controlled-drinking therapy for alcoholics (which would now be included in “harm reduction” approaches to addiction). Bill was an early advocate of controlled-drinking therapy (CD). Like many others, he was confronted with the violently anti-CD reaction of Alcoholics Anonymous and abstinence-only advocates that occurred in the 1980s, by which all of us were burned. In retrospect, it was not Bill’s type of battle to back CD therapy, since his style is to avoid confrontation and oppositional stances.
With this background, despite knowing about him and his work in addiction for 30-plus years, I’m still unable to nail down Bill’s view of AA and the disease theory.
One of Bill’s major scientific contributions has been his and colleagues’ meta-analysis of alcoholism treatment outcomes. In this analysis, Miller et al. found that 12-step therapy and AA ranked 37th and 38th in effectiveness among 48 treatments they evaluated, despite AA and the 12 Steps’ overwhelming dominance in the US addiction treatment field. 1*
So one might think Bill wasn’t very positive towards AA. Yet he avoids criticizing the 12 Steps, and his writing about AA is open—even favorable—to it. 2*
His seminal book, Motivational Interviewing: Helping People Change (written/edited with Stephen Rollnick) is now in its third edition. In the first edition, Bill and Steve included tables contrasting the confrontational (read, 12-step-based) and the MI approaches. Writing separately with Bill White, Miller has shown that not a single study over four decades had found confrontation therapies to produce a positive result. 3*
But such comparisons between confrontation and MI were eliminated in subsequent editions of Motivational Interviewing.
Yet MI opposes labeling (as in “I am an alcoholic”), doesn’t demand a set of beliefs and prescribed steps, avoids negative attributions about the client’s behavior and doesn’t dictate goals, with moderation a legitimate option. Tables or no, everything about MI remains antithetical to the 12 Steps.
Many people experience AA and the 12 Steps as a guilt-inducing assault that—as Ilse and I describe—focuses on people’s “character defects” and opens these to other group members. Juliet Abram wrote about being an abuse victim who, in AA, was required to produce “negative self-inventories and listing one’s sins/defects on a daily basis.” We (Ilse Thompson, Juliet, I and others) find this process demoralizing, particularly for people who already have poor self-images.
In AA, the self is corrupt, unreliable, and must be denied. In MI, the self is the source for change. Ilse and I describe this goal as being “to embrace yourself as already worthy, whole, and wise.” Above all, we emphasize, addiction is not a core identity around which to build your self-concept. It is—like any of the psychological issues and personal problems we all face—a surface characteristic. Our approach is consistent with that of MI in seeing addictive behaviors as correctable life difficulties that violate—rather than express—the person’s essential being.
This crucial difference notwithstanding, Bill has seemingly chosen not to confront the often heavy-handed “tough-love” techniques employed in standard alcoholism treatment in the name of disease- and 12-step theology. In her 2013 book, Inside Rehab, Anne Fletcher noted that counselors in rehabs that claimed they used MI were rarely trained in the technique—and when push came to shove, “if a client resists 12-step meeting attendance, he might be suspended from the program,” or asked to leave altogether. Fletcher added, “My overriding sense was that multiple teachable moments were missed because of the pervasive focus on the 12 Steps.”
So I was surprised at a recent advance screening of an anti-12-step film for which I was interviewed, along with a number of other experts—including Bill. (The film’s name is still under embargo.) On camera, Bill—in his calm, rational manner—dismisses the disease approach as harmful, pointing out his treatment outcome research finding that the major determinant of relapse after alcohol treatment is the patient’s belief that alcoholism is a disease. Noting this syndrome as he does, publicly, would seemingly necessitate Bill’s being extremely antagonistic towards disease approaches like AA/NA and very explicit about these feelings in his work. But he isn’t.
My impression is that Bill, either due to personal style or for political and economic reasons, refuses to confront the AA and disease models that he and his work strongly oppose. Yet there is a cost to allowing non-empirically supported, ineffective methods to dominate the treatment landscape at the expense of what has been shown to work. As Fletcher quotes another non-disease model practitioner, Jeff Foote: “Almost every week, we hear unfortunate stories about more traditional, disease-model-based residential experiences.” Fletcher recounts many such experiences in Inside Rehab.
When I asked Bill for a blurb for Recover!, he said he would never endorse something that was anti-AA. And yet, when I criticized Nora Volkow and the National Institute on Drug Abuse’s disease model on Substance.com, he wrote approvingly to me, “It’s just so simplistically appealing that brain scans explain addiction. Your core, most telling point is that neuroscience has not produced a single useful tool for the diagnosis or treatment of addiction.”
Bill Miller is a seminal figure in the addiction field. But can he really have it both ways?
Stanton Peele has been empowering people around addiction since writing, with Archie Brodsky, Love and Addiction in 1975. He has developed the online Life Process Program. His new book (written with Ilse Thompson) is Recover! Stop Thinking Like an Addict with The PERFECT Program.
1* William R. Miller, Paula L. Wilbourne, and Jennifer E. Hettema, “What Works? A Summary of Alcohol Treatment Outcome Research,” in Reid K. Hester and William R. Miller, eds., Handbook of Alcoholism Treatment Approaches: Effective Alternatives, 3rd ed. (Boston: Allyn & Bacon, 2003), pp. 13–63.
2* Barbara S. McCrady and William R. Miller, Research on Alcoholics Anonymous: Opportunities and Alternatives. (Piscataway, NJ: Rutgers Center of Alcohol Studies, 1993).
3* William L. White and William R. Miller, “The Use of Confrontation in Addiction Treatment: History, Science and Time for Change,” Counselor 8(4):12–30, 2007.
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