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How Does Motivational Interviewing Help SUD?


Motivational interviewing, also called contingency management (CM), carrot-and-stick, and the prize method is a treatment approach where people are rewarded for desired behavior. This approach is used in many drug treatment centers in Boston, though it in some circles, it is still a controversial practice for treating substance use disorder (SUD).

The concept behind motivational interviewing — that rewards reinforce positive behavior — is as old as management itself. However, operant conditioning, the framework with which motivational interviewing works, is fairly new, having been developed by famed psychologist and behaviorist B.F. Skinner in the first half of the 20th century.

The basic premise of all approaches based on operant conditioning is that positive and supportive actions tend to work better than punishment for creating desired behaviors. 

In the context of SUD treatment, it often means rewarding rehab program participants for desired behavior (such as attending therapy) as well as milestones and breakthroughs in their recovery. Using more general examples, it could be likened to giving children money for doing their chores or businesses giving top employees bonuses — even in cases where it could be argued that they should be working hard regardless. 

Operant conditioning has long been controversial because it brings up questions on free will — something that drug use often undermines. Nevertheless, multiple studies have shown it to be highly effective for treating substance use disorders, particularly methamphetamine use disorder, which has no effective medication-assisted treatments.

How does motivational interviewing work for keeping people clean?

The National Institute on Drug Abuse, in a statement regarding motivational interviewing, says, “Studies conducted in both methadone programs and psychosocial counseling treatment programs demonstrate that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs.”

The most common way motivational interviewing is done for SUD is by giving vouchers and prizes for recovering individuals that show negative results on their regular urine tests. Most often, the prizes and vouchers have a value between $1 and $100, depending on the situation.

Another way it is done is by rewarding recovering individuals for attending treatment sessions. In residential settings, where attendance is more or less involuntary, rewards or “carnival prizes” are sometimes given to the first ones to show up. More prizes can be given to those who are early several days in a row. 

In a sense, recovery is “game-ified” using much the same strategies businesses and other groups use to encourage repeat patronage. There are some conjectures as to why operant conditioning is effective for people with SUD, as they may already be primed for such behavior due to genetics or as a result of substance misuse changing the brain’s pathways. However, the true reason is still the subject of intense research.

How does it differ from standard cognitive-behavioral therapy?

Motivational interviewing is not therapy. Most clinicians would classify it as a type of intervention. Cognitive-behavioral therapy (CBT), on the other hand, is a true therapeutic approach where the therapist and patient work together to create lasting solutions to existing problems.

Motivational interviewing is also generally not enough to help a person achieve a full recovery. While it could give a recovering individual the push they need to attend detox or go to their methadone sessions, it still needs to be implemented within the context of another therapeutic approach, such as CBT.

In other words, while CBT can help a patient develop strategies for dealing with cravings and the core reasons of a SUD, motivational interviewing can only help with a patient’s motivation to attend treatment sessions.

Criticisms of motivational interviewing

As reported in the New York Times, motivational interviewing has received significant pushback from many involved in substance rehabilitation. This is even in the mounting face of evidence that the approach works. Critics of the approach often say that it is too expensive, or that the motives for recovery are artificial.

However, it’s now known that, similar to how many people are hooked on social media because of likes, the actual cash value of the prizes does not matter — up to a point

Even bonbons and candy bars have been successfully used in some pilot programs that employ the motivational interviewing approach. Even something as simple as coffee and donuts for everyone in the group when there’s perfect attendance has been shown to improve recovery motivation.

Furthermore, recovering individuals that undergo motivation interviewing also report more confidence and less shame about going through treatment. It also helps demonstrate to them that they can be successful if they’re sufficiently motivated.

Additionally, according to the National Institutes of Health, the longer a person undergoes motivational interviewing, the less important the prizes become. After some time, the prizes don’t matter anymore but the motivation to continue treatment stays.

Is motivational interviewing right for me?

While insufficient by itself, motivational interviewing has been shown by multiple studies to be effective at increasing attendance rates for therapy sessions and increasing the overall odds that individuals with SUD will have positive post-treatment outcomes. 

If you have tried different ways to get sober without lasting success, it may be worthwhile trying a treatment program that uses motivational interviewing in addition to other evidence-based approaches like CBT and medication-assisted therapy. 

If you need to find treatment centers that offer these services, our team at Boston Drug Treatment Centers is ready to help. Good luck, and be well!

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