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Stanton Peele Stanton Peele

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?

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Can you spot it? Photo via

Can you spot it? Photo via

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.


8 Comments

8 comments on “Can We All Stop Pretending That Motivational Interviewing Is Compatible With the 12 Steps?

    Mark Willenbring, MD

    For the most part I agree. However, I have three comments:
    1. MI is a treatment approach, AA is not. AA consists of volunteer support groups made up of peers supporting each other in recovery. Treatment of any kind consists of professional services for which a fee is charged. In my experience, use of MI in treatment can be consistent with a patient finding that a 12-step approach is helpful. Also, 12 step programs typically have as good as or better outcomes compared to other rehabs. The problem isn’t the approach, it’s the idea of rehab. With very few exceptions, evidence does not support intensive time limited treatment whether residential or OP compared to low intensity OP treatment.
    2. The likely reason that a predictor of relapse is believing that addiction is a disease is that the belief is more likely to occur among those with the most severe, refractory disorders.
    3. Neuroscience has given us many tools that are effective. For opioid addiction, methadone and buprenorphine, which are among the most powerful treatments in medicine. For alcohol, naltrexone and topiramate improve outcomes reliably. For smoking, bupropion and varenicline are both effective, the latter more so. In contrast, most psychotherapy research, including Bill’s, has failed to improve community outcomes.

      TheCleanSlateBlog

      I agree AA is definitely not “treatment” – but nor is most “treatment” for addiction deserving of a label that cashes in on the wonders of modern medicine. Personally, I think the entire notion of treating a non-medical condition (the repeated choice to use substances) is absurd. Treatment for the physical dangers of detoxification and other medical conditions created by heavy substance use? Definitely a good idea. Treatment for a choice? Bad idea.

      But all of that aside, AA should not be referred to as “treatment” – yet SAMHSA refers to it as treatment in NSDUH:

      “In 2009, among the 4.3 million persons aged 12 or older who received treatment for alcohol or illicit drug use in the past year, 2.5 million persons received treatment at a self-help group…” http://oas.samhsa.gov/NSDUH/2k9NSDUH/2k9Results.htm#7.2

      And the NIAAA NESARC papers refer to 12-step involvement as a form of treatment as well. That’s just two examples I’m able to quickly recall.

      But where do the rest of that 4.3 Million get their “treatment”? From formal treatment programs that push the 12-steps on people. According to N-SSATS 2009 (from SAMHSA) Twelve Step Facilitation is used in 78.8% of treatment programs. That’s just one specific 12-step centric counseling method used. The same report says that 98.6% of treatment programs use some undetermined form of Substance Abuse Counseling, and chances are those other forms of counseling are likely 12-step centric as well. http://wwwdasis.samhsa.gov/webt/state_data/US09.pdf

      For example, in NIDA’s document “Approaches To Substance Use Counseling, Of the 11 methods outlined in the book, only 2 do not specifically integrate, recommend, require, or encourage 12-step principles or meeting involvement (“Solution-Focused Brief Therapy” and “Motivational Enhancement Therapy.” http://archives.drugabuse.gov/ADAC/ADAC1.html

      Stanton has outlined some of the incompatibilities between MI and 12-step approaches. That AA isn’t treatment has little to do with his point. AA’s teachings are employed heavily in treatment, and meeting attendance is pushed hard. At the very least, you’ll get some nasty eye-rolls from counselors if you say you don’t want to be involved in AA, at worst you’ll be berated and humiliated (often in front of a group of your peers) for your arrogance and told that you’ll die without abstinence and AA – and you might even get kicked out of whatever program you’re attending.

      Stanton

      Mark, Your comment doesn’t answer the essential question in my post — why is everyone, including (especially) 12-step treatment groups, glomming onto MI?

    Dirk Hanson

    We’ve had a 150 years of psychotherapy for addiction, and Stanton doesn’t seem to notice that it almost never works.

    Patrick Dieter

    Where is the evidence showing that psych tx “almost never works?” In fact, it is almost never used without the shame and contamination of the 12 Steps. It is disingenuous to attempt any meaningful distinction between 12 step mtgs and 12 step facilitation. The way tx centers get away with it, is to claim that MI is used in th earliest first stage, then abandoned as if ambivalence has been removed at the very first sign of change talk, in favor of good old, deeply shaming 12 step tx. The term “alcoholic” is merely a euphemism for “original sin.”

  1. Shaun Shelly
    Shaun Shelly

    Forcing someone into any program and the ramming any doctrine down their throat is certainly contrary to the principles of MI. Certainly the rooms of NA/AA are not an MI type environment – it is directive and punitive. Having said that, I think that these fellowships can be useful for some, and our program certainly does not discourage membership, although we do caution against many of the concepts, which may be more harmful than helping.

    What is wrong, in my opinion, is the spurious co-opting of the 12-step programs into the so-called professional treatment setting. They have no place there. Once in the hands of someone labelled a “professional” and directed at a vulnerable patient the situation becomes iatrogenic. It is the very antithesis of the MI approach.

    On the psychotherapy thing, I think that we have seen that therapeutic relationship (sometimes with pharmacological assistance) is more important than modality of treatment in eliciting change. I know from our experience that CBT and lifeskills presented in groups with concurrent individual therapy seems to give the best results for our setting.

    Ken Ragge

    Personally, I was not at all surprised to see “two-hatter” therapists using MI to get people to commit to 12-Step treatment. Step groups are very much like ravenous rats. They will chew apart and swallow anything they can get their paws on and turn it into more of themselves.

    Years ago on the ADDICT-L list there was a friend of ardent 12-Step promoter and psychiatrist Floyd Garrett who was on the national licensing board for addiction treatment centers and owned one himself. In trying to explain how his treatment center didn’t just “use” the 12 Steps, he announced that his treatment center also used Rational Recovery with the Steps.

    Anyone who has read or is just familiarTrimpey’s “The Small Book, ” can understand just how ludicrous this man’s assertion was, regardless of what they think of Trimpey. It would be like inviting Satan to speak at an Easter church service.

    But that is the nature of the 12 Step monster.

    MI can be used to get people into treatment? Of course two-hatter mental health professionals and 12-Step treatment centers are going to use it. What does it matter to them that something good, something that uses a persons strengths to help them bring about behavior change is used to get them to relieve themselves of “the bondage of self”? Moreover, why in the world would someone promote something like MI without warnings about Stepdom?

    I remember years ago when I went back into “treatment” and one of the patients in my therapy group was about to be released. I remember thinking that the guy, if all he had was AA to go back to which was all he had to go back to in the shape he was in, still overwhelmed by his Vietnam experience 15 or 20 years later, would kill himself. A few days later, the patients were all called together to supposedly help us deal with this man’s suicide. His suicide immediately following 12-Step treatment used as proof of the need for the treatment and the Steps. “There but for the grace of God go I” unless, of course, I work harder to turn over my will and life to God and the group.

    Why doesn’t Miller make clear that MI is antithetical to 12 Steps? It might be that he simply lacks cajones.

    Bruce Gotts

    Very interesting.

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