Motivational Interviewing Role-Play Essay

Alcohol/Drug Abuse Counseling

Jeff Zimmerman
8/16/15

I'd like to explain to you a bit about a counseling method I've been studying,
then provide for you some excerpts of a recent role-playing exercise I did with a
fellow student which illustrates some of the principles of this counseling method. It's
called Motivational Interviewing (MI), and I'm quite excited about it. First, I'll explain
the method.
MI approaches counseling in a spirit of collaboration, evocation, and
autonomy.
In collaboration, the counselor respects the position of the client, and puts
forth effort to create a space in which the client may recognize desire to change,
and begin that change should they choose to.
By evocation we mean that the client possesses the resources and motivation
for change behavior, and the counselor facilitates a process of evoking the change
that the client desires.
And in the spirit of autonomy, the counselor places import upon both the
client's right to make their own decisions and the faith that the client possesses the
faculties to make decisions in their own best interest.
There are four general principles in MI; to express empathy, develop
discrepancy, roll with resistance, and support self-efficacy.
Empathetic counseling is based upon the work of Carl Rogers' client-centered
therapy, which will be mentioned later in the context of reflective listening. MI is
also a client-centered therapy, which put simply refers to the afore mentioned
values of collaboration and autonomy. Empathetic counseling styles believe that
acceptance facilitates change.
To develop discrepancy means that differences between the client's behavior
and values or goals are emphasized in order to draw the attention of the client. The
client's recognition of discrepancy opens up their awareness of the difference
between the present state of affairs and how the client would like things to be.
Change is then motivated by discrepancy.

Rolling with resistance refers to the natural occurrence of resistance in the

counselor-client relationship. MI believes that resistance should never be directly
opposed. In fact, resistance cannot exist without something or somebody to resist.
The counselor must take responsibility then for any resistance, and resistance to the
counselor is a sign for the counselor to change their approach. The client is never to
blame for resistance. The counselor is guided by the belief that the client possesses
all of their own solutions. It is the counselors position to evoke those solutions, but
never to impose them.
Self-efficacy refers to the client's belief that they can succeed in achieving
and maintaining the change they desire. Self-efficacy is a good predictor of the
outcome of treatment. The counselor's expectations of a person's likelihood to
change can also be a factor. The counselor cannot instill self-confidence, but the
counselor can support the development of the client's sense of self-efficacy.
Ultimately, all change must come from the client. For sustained change, the
decision to change and change behavior must be made by the client. The counselor
supports the client by believing that the client possesses the capability to change,
expressing that to them, and pointing out other areas of the client's life in which
they were successful at overcoming adversity.
MI conversations are guided by Carl Rogers' technique of reflective listening,
which, as mentioned earlier, is an important component in conveying empathy.
Reflective listening is essentially very simple, though, as I discovered, in practice
can be quite challenging and seem somewhat counterintuitive. The basic rules of
reflective listening are as follows; attempting to understand what the speaker has
said, then repeating that idea back to the speaker to determine if the listener
understands what was conveyed. In MI, reflective listening particularly involves
"listening for expressions of meaning, feeling, desire to change, and commitment to
change, making a hypothesis about that meaning, and repeating, paraphrasing or
reflecting back to the client this meaning."
In many ways, MI is similar to Carl Rogers' client-centered therapy. However,
whereas client-centered therapy is non-directive (the client chooses the direction of
therapy), MI is directive (the interviewer steers conversation according to the

principles of MI) because of its stated goal of facilitating change. MI's orientation
toward change is particularly beneficial in populations with addictions.
MI describes the process of change as a predictable series of stages, usually
in the following order; precontemplation, contemplation, preparation, action, and
maintenance. If relapse occurs, it is the final stage before starting the stages over
again, beginning with precontemplation. The counselor typically assesses the client
right away, formulating a hypothesis about the client's stage of change. By doing
this, the counselor can direct conversation appropriately for the client's current
state of affairs.
If the client is past precontemplation, the counselor may attempt to
understand the client as being in one of four profiles within a matrix of importance
and confidence by measures of low and high, which assess the client's readiness
and willingness to change. Whatever orientation the client has toward change, the
counselor focuses on building motivation for change.
In MI, the acronym OARS (Open questions, Affirming, Reflecting, and
Summarizing) refers to a method used in MI to build motivation for change.

Open questions elicit explanations from the client. It is important for

the client to share so that change talk can begin, and presenting open
questions elicits more sharing than a closed question. (A closed

question typically has 'yes' or 'no' as a natural response).

Affirmations are directly beneficial to the client as they communicate

the counselor's appreciation for the client.

Reflecting refers to the Carl Rogers style of reflective listening

mentioned earlier.
Summarizing is similar to reflective listening, but is a summary of a
larger body of different ideas presented by the client. Summaries help
bring together disparate threads of dialogue into a more cohesive
whole. Summaries also reinforce the client's statements and remind
the client that the counselor has been attentive.

There is much more to MI, but the basic process is one of developing
discrepancy and eliciting change talk. Next I will discuss the case of Sara, and

explain some of the techniques I used with her to develop discrepancy and elicit
change.

The case of Sara

Sara came to see me regarding marital problems. Our conversation opened
up some questions about her alcohol consumption and if her behavior is in line with
her values. (The role-play is not the interview in its whole state, but rather excerpts.
I will also attach the whole interview.)
J: "What brings you in today?"
S: "You know, Im not really sure, honestly. I guess it's mainly because my
husband and I are having some challenges. Weve been married for almost 20
years. I always joke if youve been married that long, of course you have
problems, but he and I are going through a really rocky patch right now, were
arguing a lot, we cant really seem to get along at all, really. And we made a
promise to ourselves that if we were ever in a situation where we were
considering breaking up or divorce that we would go to counseling first. I
guess thats pretty much why Im here."
J: "So you and your husband are not getting along, but it does sound like
youre wanting to work things out if thats possible."
So, my initial assessment of Sara is that she is in a contemplation stage
because she is in consideration of change. Indeed, she chose to be in my office,
which suggests some consideration of change. I also used summarizing change talk
in the final line. Of note, in summarizing it is often recommended that the counselor
use the conjunction 'and' instead of 'but'. However, using 'but' to differentiate
between conflict and change in a sentence, particularly if change talk follows the
'but', can have what is referred to as an eraser effect. "So you and your husband are
not getting along, but it does sound like youre wanting to work things out if thats
possible." The conflict is minimized while the desire to find a solution is highlighted.
J: "do you want to tell me about what kind of problems youre having? What
starts the fights, or what the fights are about?"
S: "Sure, I guess hes upset with me lately because Im not doing as much as I
was doing, like 4 or 5 years ago or whatever, where I was making dinner 4 or
5 nights a week, and I was doing the laundry every night and I was handling
the children and doing all the basics, and I guess lately Ive been like the

kids will feed themselves dinner, theyll do their own laundry, and thats
partly because theyre getting older and thats partly because I just really
dont want to do it sometimes. Thats kinda why he gets upset with me, thats
a piece of it I guess. Im not sure, I mean I guess if I really think about it it
might be, the kids will make their own dinner if when I come home from work
Ive had a bad day and decide to have a glass or two of wine. But I mean, I
dont really think thats the problem, I think the problem is so much more
than that, you know?"
J: "Well, first of all let me commend you for doing all of that hard work raising
the children for so many years."
I used the O of OARS, Open questions, to find out about the fights with her
husband. I actually asked two questions, neither of which could be responded to
with a simple yes or no answer.
I also used the A of OARS, Affirmation, to commend her for the effort she has
put into her family. I actually found this affirmation to be a bit blunt. In normal
conversation, especially with a stranger, it seems slightly out of turn to offer a
compliment like this. However, I also felt like the affirmation came from a genuine
place within me. Even if I normally wouldn't offer that in conversation with a
stranger, I can only imagine how much effort she has put forth for her family and I
believe she would benefit from acknowledgement.
J: "Mm hm. And you do feel that he, you mentioned your husband expresses
disappointment about you drinking as well? Can you tell me more about that?
"
S: "I guess when hes frustrated with me, often times itll be about something
I did when I was drinking, but I never really drank a lot. We got married super
young, and weve been together for a super long time, so I didnt do the
whole drinking thing when I was 21. I feel like Ive just jumped right to the
grown up drinking where you have a bad day at work and you come home
and you have a glass or two of wine, or you feel like drinking a screwdriver
with your dinner. I really dont think thats the only, I mean I dont really know
if thats the issue. I just dont know.

J: So hes uncomfortable with you consuming alcohol, because it is maybe

different from behavior you used to exhibit earlier in the marriage?"
S: "That a fair statement, thats fair."
J: "And hes uncomfortable with it. How do you feel about it? "
Again; open questions, followed by summarizing talk, then another open
question. It's worth noting that when I speak to Sara I try to frame questions and
statements in terms of 'you'; can you tell me more , how do you feel about it, etc.
It is also worth noting that MI recommends a general rule for interviewers of
roughly one question for every three statements made to the client. This helps
ensure the desired dynamic of reflective listening. Although in the role play with
Sara I reflected quite a bit, I found myself asking more questions than making
reflective statements at certain times during the role play.
S: "I mean, as someone who works hard and has kids and has to clean the
house and all that, I feel like I deserve it. I feel like, if I want to have a couple
glasses of wine when I come home, I deserve it, and Im an adult and I can
handle it. I dont really think that I should not be allowed to do it, Im a
grownup."
J: "So youre responsible enough to be able to drink without somebody
second guessing your choice. "

Here I assess Sara as fitting into the client profile of 'low importance, high
confidence', meaning that if she wished to change she believes that she would be
able to, but she has yet to be convinced that she should change. Because of this,
conversation with Sara should address the importance of change, if quitting drinking
is in her best interest. (If Sara were of a 'high importance, low confidence' client
profile, the counselor would be advised to converse more around self-efficacy and
supporting Sara's belief in her own capabilities to change.)
That being said, it is also important to honor Sara's autonomy, and I could
easily create resistance by seeming to advocate for changing her behavior in favor
of not drinking. In fact, at this point in the interview, I haven't been given any
reason believe that it's in her best interest to stop drinking. Because I want to be

very careful to show Sara that I respect her, I am comfortable reflecting back her
belief that she is responsible enough to drink without oversight.
J: "Mm hm. So what kind of things does he feel uncomfortable about, can you
tell me more about what his issue with drinking is that bothers him?"
S: "I guess he kind of, when we get into our huge knockdown drag out fights,
they are going to be the nights where Ive had a couple glasses of wine and
the kids have made their own dinner and Im just like, 'Whatever you want to
have, have, you know you to feed yourselves.' And when it starts thats kind
what its about, and hell just keep going on and on about you arent keeping
the house up, youre not being a good wife, were not spending time together.
It just kinda snowballs."
J: "How do you feel about that, do you feel like youre doing enough around
the house?"
S: "I can definitely do more, but theres that aspect of, 'Do I have to? Can my
kids pitch in and help, should he be helping more than he already does.' So I
guess I could, but I dont know that I should have to."
J: "Do you two have an agreement for shared responsibility in the home? And
what role do you play in that? "
S: "Well, he has always been way better at bathrooms than I have so he does
the bathrooms and I do the rest of the house. But, sometimes that can be a
lot more work, you know, bathrooms are gross and annoying, and I wasnt
good at them honestly, but Ive got the rest of the house. Weve got dogs so
you have to clean up dog fur all over the house. It just gets old after 20 years,
you know?"
J: "So you do share responsibility within the home?"
S: "We try. That has always been our agreement."
J: "And you have an agreement. Okay. So, how long have you been drinking?"

It is beginning to seem that Sara's consumption of alcohol is adversely

affecting her relationships. Here I began to develop discrepancy around her
responsibilities at home. I also wanted to develop discrepancy related to her values.
Since it was clear that her family is important to her, I wanted her to also explain

when and why she sometimes feels less importance upon being present with her
children.
S: "I never really get hung over so I dont really have consequences that way,
right? Its just something Ive realized for me is a good way to blow off steam
at the end of the day if Ive had a bad day."
J: "So theres some amount of pleasure and fun that you find in that."
S: "Oh, yea, totally. I laugh a lot normally, but when Im drunk its like I cant
stop laughing, and if everything is funny then life is so much better right?
(laughs) The things that make you cry, wont make you cry then."
J: "And you said you dont experience hangovers?"
S: "Nope, Ive not once had a hangover. Ill wake up like a little dehydrated,
but thats about it."
J: "And, so you dont feel like you have a lot of consequences though youre
here because youre feeling like the issue may be causing some problems
with your marriage which is important."
S: "Yea, thats fair definitely. Mentally I think that I dont have physical
consequences. I may have relationship or emotional consequences that could
be true."
J: "Some consequences in that area."
This was a bit of a tricky area. Sara was offering some explanations for
continuing with the status quo. Yet, as I pointed out, she was speaking with me at
least in part due to adverse outcomes of alcohol consumption. Sara is quite open to
admitting problematic aspects of her behavior. I couldn't help but wonder if in a real
interview would the client be so magnanimous about their own behavior? This last
excerpt seems like a point in the conversation where Sara could have put up some
resistance if she felt that I was invested in seeing outcomes which weren't in line
with her expressed desire.
J: "If you could imagine a scenario with your husband in which you two are
getting along, would it change anything about the nature of your alcohol
consumption, or his consumption? In an ideal scenario, what would that look
like and does it relate to alcohol or not?"

S:" I think that we could definitely get along better without it, if we both were
without it. I think it could be like one of those hurdles that if we took it away
our challenges might be more easily handled maybe? I dont know."
J: "So it may cause less tension in your relationship to have that element
removed"
S: "That sounds fair, definitely."
J: "And you also feel that its not something you want to give up?"
S: "I think about it and Ive done a lot of things in my life, I could probably do
it, but I dont really see why I should, you know? Just for me, taking him out of
the equation, I have to stop and think, is it really something I want to do, or is
it something that I just enjoy still, and what I want to do is continue enjoying
it?"
The "If you could imagine a scenario" line of questioning is an example of a
motivational technique called querying extremes. It involves asking the client to
imagine and describe the best case or worst case consequences. It is particularly
used when a client expresses little desire to change.
J: "Mm hm. So, being present with your children and making dinner with them
and doing those things you missed when you were a child and your mother
went back to work, is important to you to be present with your children."
S: "Definitely, thats VERY important."
J: "And also, although you dont feel like you have a problem with alcohol, or
consuming alcohol, theres actually a correlation between when you drink and
your presence with your children."
S: "Yea, and I mean, that would be a good reason to cut back, probably. Cause
Im thinking if I set a goal for myself to make dinner with them a couple
nights a week, I would have to really know in my mind that I cant drink at
that point. That piece of it makes me a little uncomfortable still, cause I really
enjoy the drinking so much. But the kids are such a huge motivation."
J: "Mm hm. So it sounds like theres maybe some conflict between doing
something that you enjoy doing that is pleasurable for you and yet thats
coming in conflict with some values that you have around being the type of
parent you really want to be."

S: "Yea, theres a definite conflict there. Its not, I dont really like to think
about it because conflict makes me uncomfortable in general, but thats
definitely a conflict, yea."
Here I continued to work at reflecting and trying to represent both sides of
Sara's ambivalence while also developing discrepancy. Examining both the positive
and negative aspects of her behavior is called decisional balance. There is a
possibility that simply through expressing both sides of her ambivalence Sara will
arrive at some clarity and motivation for change. Shortly after this excerpt I offered
Sara a decisional balance worksheet to work on at home and for us to discuss upon
her next visit.
In conclusion, my therapeutic strategies in the role play with Sara seemed to
be effective in developing discrepancy and eliciting change talk. I found the
technique of reflective listening required much more effort than I had suspected,
based on watching films of counselors practicing the technique.
I found myself very excited about MI after reading about MI and doing some role
play. What appeals to me most about MI is the client-centered orientation, the selfreflective approach of the counselor toward resistance in the client, and the
uniquely directive use of the traditionally non-directive reflective listening
technique. MI seems in line with my own values, and I look forward to doing more
research about this method and improving my reflective listening skills.