An Interview with Annie Fahy, MSW on Motivational Interviewing
In this edition of the Wise Counsel Podcast, Dr. Van Nuys interviews Annie Fahy, MSW on the topic of Motivational Interviewing. Ms. Fahy is a colleague of Patt Denning, Ph.D. through the Harm Reduction Therapy Center of San Francisco, CA. Dr. Denning was the subject of a previous Wise Counsel Interview, concerned with Harm Reduction Psychotherapy.
After growing up in Connecticut, Ms. Fahy moved to Athens, Georgia where she spent her early career as a Labor and Delivery Nurse. After practicing nursing for many years, she found herself needing to make a job change, and ultimately settled up on working as a counselor in an addictions treatment center. The work of helping people struggling with addictions to establish a solid recovery was similar in many ways, she found, to the birth process, and she was able to draw upon strengths and skills she had developed in her prior career. To support her new counseling role, she went back to school earning a certificate in addictions counseling, and then an MSW from the University of Georgia at Athens. Thereafter, she left the employ of the addictions center and started a private practice, the "Recovery Cafe", also addressing addictions issues.
Fahy's early work with addicted persons was framed by the Minnesota or Hazelden Model common to most American treatment centers, which emphasizes that addictions are diseases and that the twelve step model of treatment due to Alcoholics Anonymous was a useful means of treatment. In looking around for additional ways she might serve her client base, she encountered the harm reduction paradigm and motivational interviewing. She was not impressed with motivational interviewing at first after reading the initial book on the subject by Drs. William Miller and Stephen Rollnick, and after taking an initial training course. What changed her mind was that she had the opportunity to train directly with Dr. Miller, the founder of Motivational Interviewing as a part of his EMMEE study run so as to help him better understand how to teach motivational interviewing to therapists. She submitted a tape of her work with a client to Dr. Miller and got to spend three days working with him, and the strengths of this therapeutic approach started to make sense to her. As she grew in her understanding of MI, she began to offer training programs in the approach to Georgia health care institutions and professional associations. She relocated from Georgia to California's Bay Area to work with Patt Denning, Ph.D. in 2008.
As presented by Ms. Fahy, Motivational Interviewing is a client centered set of psychotherapeutic strategies first developed by William Miller, Ph.D. (and then later developed by Miller and colleague Stephen Rollnick, Ph.D.). This therapy is applied by the interviewer to a client who is (usually) ambivalent about making a change to some maladaptive behavior they habitually engage in, such as drug use. The term 'client centered' is used here to denote the fact that motivational interviewing is a descendent of Carl Rogers' original humanistic Client Centered Psychotherapy from the 1950s and 60s. The strategies used in Rogers client centered psychotherapy, which include reflection, active listening, open ended questioning and summarizing are present in motivational interviewing. The two forms of therapy are distinguished less by technique and more by their different stances towards therapist directiveness. In classical client centered psychotherapy, the client sets the direction and goals for therapy, not the therapist. In contrast, motivational interviewing therapists are highly directive if only subtly so. They use conversational therapy techniques as first developed by Rogers to advance a therapeutic agenda of helping to clarify and crystallize a client's motivation to change. They are not coersive or insistent about it, however, in contrast to some addiction therapy approaches that stress confrontation. Motivational interviewers will back off of a line of questioning when clients offer resistance, only to return to the agenda again from a different direction. Client resistance may take a number of different forms, from expressions of negativity ("I can't", "I won't", "who cares"), to actual avoidance, to over-politeness (representing an escape from intimacy back into formality). Clients who are more ambivalent about committing to change will tend to offer more resistance to the idea of giving up cherished dysfunctional behaviors. As clients become less ambivalent about changing, they tend to become more willing to tolerate direct therapist feedback.
Motivational Interviewing has four key principles that guide its directional, and yet still very client centered practice. Motivational therapists work to support client's self-efficacy and self-esteem. They work to offer their clients a high degree of empathy and understanding. They do not try to push through client resistance, but rather acquiesce to such resistance. They maintain their directive approach not by directly pushing clients to talk about topics they don't want to explore, but instead by finding alternative ways to explore such sensitive areas. They work to help clients develop an increasingly clear sense of "discrepancy awareness", that is to say, to help them become increasingly aware of exactly what all the different aspects of their ambivalence are so that they can be made visible and thus potentially solvable.
As clients participate in motivational interviewing, they will typically exhibit a progression of "change talk". This is to say, as clients become increasingly aware of the nature of their ambivalence regarding an important decision they will typically use different language to describe their internal state. Early change talk takes the form of expression of desires or duties, ("I want to", "I need to"), middle change talk expresses awareness that there are good reasons why change is important, and a sense that change is possible ("I have reason to", "It's possible", "I know I can"). Late change talk involves an expression of commitment to the actual change process ("I will"). These varieties of change talk express a client's passage through stages of engagement with the change agenda: desire, ability, reasons, need and finally, commitment.
Motivational Interviewing has been the subject of much scientific study, much of which is supportive of the utility of using motivational interviewing with addicted populations. In the Project MATCH study, alcohol dependent men were offered one of three different therapeutic interventions: facilitated self-help (e.g., a twelve step program), a cognitive-behavioral therapy psychoeducational approach, and motivational interviewing. Four sessions of motivational interviewing were offered across 12 weeks, whereas the other interventions were offered weekly. The study ended with those men who had received motivational interviewing drinking significantly less than the other men who had received alternative interventions (but with none of the groups producing more complete sobriety than any other). If one is willing to give up the still commonly accepted definition of success with regard to addiction treatment that only complete sobriety is a good outcome, then motivational interviewing performed extremely well in this trial, producing a better treatment effect with less resources expended. Other studies have generally produced similar results, suggesting that motivational interviewing is a good method for helping people to create positive behavior change. The therapy works in part because it is not coersive or demanding of submission to a higher power or set of principles. Clients emerge from the process feeling understood; helped but not pushed. The approach is presently being applied to non-addiction-related behavior changes that people commonly feel ambivalent about, such as diet and exercise, diabetes care, sexually transmitted disease prevention, etc.
Ms. Fahy offers the following example of what motivational interviewing looks like in practice. A motivational interviewer working with someone who is ambivalent about their drinking might say to that person, "tell me about your drinking", which prompts the client to talk about various reasons why they might want to stop drinking. As the therapist becomes aware of these different reasons, he reflects them back to the client by summarizing their content, and then looks to see if the client is accepting or rejecting of that summary. "So", the interviewer might say, "you'd like to drink less because drinking is causing problems in your marriage". If the client feels understood, he might respond by saying, "Yes, that's right. I want to help save my marriage". This process of listening and reflecting is designed to help the client clarify wishes and goals, and to explore and map out their ambivalences and fears.
Motivational Interviewing appears to be a simple therapy to learn and to offer, but this is not actually the case. Ms. Fahy reports having encountered many inadequately trained therapists in her time as a trainer. Such therapists may not understand the full range of motivational techniques, and sometimes do not understand that it is important to stop providing motivational interviewing when the client has finally committed herself to change, and instead to switch to a form of therapy that will best facilitate the needed change. The EMMEE study (Evaluating Methods for Motivational Enhancement Education) showed that motivational interviewing cannot be learned from a textbook. Instead, extended practicum and direct supervision experiences are necessary before a therapist can hope to become skillful.
Links Relevant To This Podcast:
- Ms. Fahy currently works with the Harm Reduction Therapy Center in California, where she offers training in motivational interviewing
- Ms. Fahy recommends that people interested in Motivational Interviewing learn about MINT - the Motivational Interviewing Network of Trainers, of which she is a member.
- Lots of information on motivational interviewing research, application, trainings, etc. can be found at the www.motivationalinterview.org website.
- The classic book on Motivational Interviewing is Motivational Interviewing, Second Edition: Preparing People for Change, now in its second edition, by William Miller, Ph.D. and Stephen Rollnick, Ph.D. That early work focused on Motivational Interviewing as an intervention for addictions. A more recent work, Motivational Interviewing in Health Care: Helping Patients Change Behavior (Applications of Motivational Interviewing), explores the use of motivational interviewing in a behavioral health context. Similarly, Motivational Interviewing in the Treatment of Psychological Problems (Applications of Motivational Interviewing), explores the use of Motivational Interviewing as an intervention for addressing mental illness and mental health issues.
About Annie Fahy, MSW
Annie Fahy co-founded the Recovery Café a consulting counseling and training business in 2001. She is a graduate of the University of Georgia's Master's program in Social Work, though her counseling career began over 15 years earlier as a registered nurse in mental health and addiction settings. Annie designed and managed the Women's Services program, which provides intensive outpatient and residential addiction treatment services to women and their children. Since 2001 she has consulted and offered various training to a number of different entities. She is an experienced consultant and trainer for the Emory University School of Medicine Department of Family and Children's Services, Metro Atlanta Recovery Residences, the Department of Corrections and Pardons and Paroles, State Drug Court, Georgia Council for the Prevention of Child Abuse, Georgia Council For Substance Abuse and Georgia department of Children and Family Services and several Health organizations.
Annie is a behavior change specialist with expertise in substance abuse, high-risk lifestyle behaviors, harm reduction, trauma, compassion fatigue, and mind body disorders. Annie is an experienced trainer in Motivational Interviewing; an evidenced based interviewing method that motivates people toward health behavior change. She is affiliated with The MINT (Motivational Interviewing Network of Trainers); She was recently published in The Clinical Social Work concerning her work with Compassionate Fatigue. She is currently a Therapist/Trainer for The Harm Reduction Therapy Center in San Francisco and offers consultation and skill coaching in addition to formal training.
Great interview with depth - bill James - Dec 15th 2008
Annie Fahy's journey to MI was compelling to listen to. As I work to bring the empathic space and direction my staff need to apply MI to our Child Welfare casework, her metaphor about labor and delivery captured my attention.
Thank you for doing the broadcast.