Mark Stanton

Motivational interviewing and the social context.

As Miller and Rose (September 2009) opened “the black box of treatment to examine linkages between processes of delivery and client outcomes” (p. 529) in motivational interviewing (MI), it is important that their model include factors from the social context that may explain conditions that enhance or diminish MI interventions. Aspects of the social context may serve as mediators or moderators of the relational (MI spirit) and technical (change talk) components in MI theory. In this comment, I suggest the addition of social influence to their theoretical model. Research indicates that significant others have an impact on client motivation, beginning as early as the decision to enter treatment and continuing throughout the change process (Smith & Meyers, 2004). Community reinforcement models use motivational enhancement techniques to teach significant others to change their own behaviors in order to effect change in the person with the problem (e.g., provide positive reinforcement for desired behaviors, discontinue positive reinforcement for problem behaviors, improve communication skills, and learn how to invite the person into therapy; Fernandez, Begley, & Marlatt, 2006; Stanton, 2009). Community reinforcement and family therapy (CRAFT) is one such model focused on bringing unmotivated substance abusers into treatment, and it has demonstrated greater success than confrontational interventions, engaging the substance abuser within as few as five sessions with the significant other (Miller, Meyers, & HillerSturmhofel, 1999). Behavioral couples therapy (Fals-Stewart, O’Farrell, Birchler, & Lam, 2009) argues for the inclusion of significant others in treatment, noting the reciprocal causality between issues such as substance abuse and couple dysfunction (sexual problems, intimate partner violence, significant psychological distress in family members, and relationship instability) and strong research support for couple intervention effectiveness. Although traditional MI often does not include the social context, MI has been adapted for couples therapy, and research indicates that inclusion of a significant other improves treatment retention and treatment outcomes (Burke, Vassilev, Kantchelov, & Zweben, 2002). Since Miller is a contributor to community reinforcement models, it is surprising that social factors are not included in the figure depicting the hypothesized relationship between process and outcome variables in MI (Miller & Rose, 2009, Figure 1, p. 530). Perhaps the intent was to focus solely on the specific factors related to session MI interventions, but it ignores the reality of the impact of the social surround on client readiness for MI and response to MI. For example, client readiness for MI may be impacted by the well-known demand–withdraw interaction between significant others and substance abusers in which frustrated significant others demand change and substance abusers defend themselves or pull away during a demand episode (Rohrbaugh, Shoham, Hofmann, & Tompson, 2002). Treatment that mimics this demand pattern is apt to result in poor retention of the substance-abusing client (Christensen, Eldridge, Catta-Preta, Lim, & Santagata, 2006). It is interesting to consider whether clients who have experienced such demand–withdraw interactions are more or less amenable to an MI intervention. Is MI effective because it differs from past or current social experiences of the client? Conceptual models of readiness for MI may benefit from consideration of this variable. Response to MI also requires recognition that an MI session is a small part of the client’s life during an entire week. Even a session that ideally implements MI will interact with social factors that may enhance, impede, or negate the impact of MI interventions. Burke et al. (2002) suggested that the positive effects of an MI session may be negated if the client returns home to a significant other who confronts him or her and demands change. In that case, preparatory change talk elicited in the MI session may recede or disappear under the pressure of demands at home, eroding client movement toward commitment. On the other hand, if the significant other were to receive training in MI concepts and techniques, similar to that provided to clinicians, it is possible that the significant other could participate in MI sessions, collaborate with the MI clinician, and extend the benefits of the MI session into the daily life of the client. The training must facilitate significant other empathy and inculcation of the MI spirit (the relational element), as well as the ability to use MI-consistent methods (the technical element). MI training for significant others is an element of the CRAFT model (Smith & Meyers, 2004), but such training needs refinement and research to determine the exact elements of training necessary to ensure its effectiveness on both relational and technical dimensions. Once the significant other is trained, MI sessions may be enhanced by the significant other’s involvement. For example, the significant other may help the clinician develop discrepancy by providing information unknown to the clinician about client goals or unwanted results of the problematic behavior. Later, the significant other may support client self-efficacy by making affirming comments in the session about client attempts at change (Stanton, 2009). Interaction at home may come to parallel MI sessions, incorporating MI concepts into the interpersonal relationship (Burke et al., 2002) and increasing the likelihood that change talk will result in progressively stronger commitment to change,