Social Impact LIVE: Allen Zweben on Motivational Interviewing
Richard Hara is joined by guest Dr. Allen Zweben to discuss the second edition of Zweben’s book Treating Addiction as well as the School’s new skills lab in motivational interviewing.
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Richard Hara: Hello, I’m Richard Hara, and this is Social Impact LIVE, a weekly conversation with members of the Columbia School of Social Work community. I’m pleased to welcome to the program today Dr. Allen Zweben. Dr. Zweben is an expert in areas related to addiction medicine, particularly research on innovative assessment and treatment approaches for substance use problems. From 1975 to 1986 Dr. Zweben served as director of psychosocial intervention research at the Addiction Research Foundation, and as an associate professor at the University of Toronto. From 1986 to 2004 he served as professor and director of the Center for Addiction and Behavioral Health Research at the University of Wisconsin, Milwaukee. In 2005, Dr. Zweben returned to the Columbia School of Social Work, his doctoral alma mater, where he currently serves as a professor and as director of the Skills-Based Lab project, a new program that accelerates students’ instruction in key areas of social work practice with clients. Dr. Zweben, welcome to Social Impact LIVE.
Allen Zweben: Thank you.
Richard Hara: I know that you’re one of the co-authors of an essential reference work called Treating Addiction: A Guide for Professionals that’s recently come out in the new second edition. Before we go into the contents of this new edition, I’m going to ask you a question. But before that, I want to remind our readers — our viewers today that we’ll be finishing at 12:30. So, if you have questions, get them in early so that we can get to them for the last 10 minutes of the program, so thanks very much, okay. And now my question, how did you get into the work on treating addictions?
Allen Zweben: Well, I finished my doctoral program here in ‘77. And I — I was looking for some work, and actually, I was not that much interested. I had worked in addictions before. But Canada at that time was opening up new programs and was very sort of innovative. And they were advertising for a more of a public health approach. And they wanted social workers to become more involved in the field. The field often was dominated by people who are recovering. And they’ll — most of the practice wasn’t very evidence-based, it was more based on a more ideological model, which is nothing wrong with it, but it wasn’t really based on science. And the Addiction Research Foundation was a premier research organization and they had money from the fed, from the government to begin to look at evidence-based treatment. And so they invited me to become the director of the Psychosocial Intervention Research and head of social work to begin to develop evidence-based research, and that’s got my interest in that process. That’s where I started from.
Richard Hara: So, and is it at that point that you turned to motivational interviewing as an appropriate way to treat addictions?
Allen Zweben: That’s a good question. There was no such thing as motivational interviewing in 1975, and actually wasn’t even mentioning until about 1988, when we began doing some research. So, what we did have is that people were coming in and about 75% of the people didn’t stay more than four sessions. And nobody could really understand why people were dropping out, they didn’t — they weren’t showing up. And, so a lot of the burden was placed on these clients, they weren’t motivated, they weren’t interested. They really needed to be, to hit bottom first, which was a very pejorative way of dealing with people with addiction problems. So it was implicitly punitive. And so when I took over the Social Work Department I wasn’t satisfied that people were dropping out so much, and I said something we could do differently.
And at first, it was a lot of resistance to it, because the common belief was that these people were really not amenable to help unless they had really suffered and so on. So you had a weight somebody came in, and they dropped out and they said, well, he’s got to go out and experience pain and hardships and so on. And when he was desperate, he’ll come back to come into the program. Well, didn’t seem a very good way. I think it was very — felt it was very punitive that approach to do it. So I began to do some, what I call sort of pilot studies, I tried to find out by asking people about what they wanted from treatment. And I asked the therapists what they wanted for treatment. And most of the clients were asking for very brief intervention. They didn’t want to be attacked or be confronted. And most of the therapists had a different view. They felt that these patients really needed to be confronted with their problems, and they felt they should be in long- term treatment. So there was a disparity between what the therapist was seeing, and what the patient was experiencing.
And so I said to myself and someone in my group, why don’t we just try to do something different, and maybe try listening to what they’re doing, because it seems to me they were not so unmotivated, but they just didn’t agree with what they were getting and how they are being treated. So that reaction gave me some impetus to begin to do something different. And over that time I began to develop what I call some identified skills, and some of the skills are well known today, we didn’t call it that, we call it intensive listening. And other skill that we had was listening to self-motivational statements and today we call it change talk. And so we’re developing, actually, I saw a tape of mine in ’84 at the Addiction Research Foundation. I can’t look at myself anymore. But at ‘84, you’d see lot of those techniques that they call motivational interviewing being done today. And so, to make a long story short, that’s where I began this process of doing something differently. We called it in those days — actually there’s an article out, called “Facilitative Strategies,” and that’s in 1988. I met Bill Miller and that’s another story. That’s another story.
Richard Hara: So what you’re saying is that initially — well, it used to be that the actual treatment approach was creating problems for people in terms of sticking with treatment and so on. So you tried to remove that part of it, support clients in their autonomy and developing their own reasons to — to change and participate in treatment and so on. So, and now it sort of falls under this larger umbrella of motivational interviewing, and as part of the treatment for addiction. So in terms of the handbook, the first edition came out approximately when?
Allen Zweben: 2011.
Richard Hara: 2011, and here we are in 2019. You’ve got a second edition out now.
Allen Zweben: Yeah.
Richard Hara: So, I’m not sure if you want to tell me what’s changed in between editions.
Allen Zweben: Well, the difference is that we have five new chapters —
Richard Hara: Yeah, you’ve got five new chapters.
Allen Zweben: So we added some other interventions like mindfulness meditation, contingency management, and so on. So we added other chapter called “Stuff That Comes Up” that we did — we felt that there was something happening in treatment, people got to pay more attention to like people coming intoxicated and things like that. And so we took five new chapters, and we rewrote about — rewrote the rest of the chapters, 25 chapters, and also added a section on implementation. And so that in many ways it’s a rewritten book, it’s revised, but rewritten actually. The difference with this book is that over the last 5, 6 years, a lot more information came out about motivational interviewing, MI. And so we incorporated some of the latest data on MI, and basically MI in this book is kind of a foundation for everything we do. So we do contingency management, we do it with an MI foundation, we do medication development, we have an MI — read every chapter and it goes back to the engaging skills, compassionate skills, collaborative skills. But everything we do, it’s a much more kinder and gentler approach. And the last chapter actually says how the field has changed. It’s no longer moralistic, it’s a lot less punitive, and more forgiving, and more compassionate.
Richard Hara: And that’s been your experience over, what, how many decades of doing this kind of work?
Allen Zweben: Decades, yeah, don’t remind me of that. It’s been my experience that motivational interviewing offers a foundation for all practice. It’s a way of being with people and of listening to people and collaborating with people. And it’s a very compassionate approach. It’s collaborative. And it’s a way to — you can’t — and it builds on the relationship, which is a primary focus of all treatment. That relationship is so strong and so important. And the focus of that, and we do with the school here, as you know, you’ve been involved with some of this personally, as developing a collaborative relationship is essential for everything we do. And so you want — but also when people get an intervention they have to have, even if it’s medication, they still have a life to deal with. And the — and lives in MI many ways give some people skills to handle other things in their life, other family issues and children issues and so on. So it goes beyond just the addiction problem, but it’s something the skills to take away with you, that has some life strengthening perspective built into it.
Richard Hara: Yeah, yeah. So in my understanding, motivational interviewing is not so much a theoretical model, as it is a way to better communicate, right, with clients or as you are suggesting with — just with other people in your lives and in an empowering sort of way. Is that correct?
Allen Zweben: Yeah, it’s — it’s a — it has, you know, there’s some theory implicit in a sense of how you — people change and getting people to change —
Richard Hara: Okay.
Allen Zweben: — which is looking at some of the cost benefits of change, decision-making rules, and so on. But it’s very practical. And what’s most important about it is the way you teach it. It’s taught through an experiential model, it isn’t a didactic approach. So if you go to a motivational interviewing training program, you spend half the time having hands-on experience and listening skills, and reflecting skills and facilitating change skills. As you know, we’ve done that in the school. A lot of this has been done through our own program here in the school. So everything I’ve done, in a sense, in the MI with addiction has been brought over to other areas: weight loss, other issues around mental health problems, depression, and so on. And so it has great transitional — translational value for all kinds of treatment.
Richard Hara: Yeah. And I think that’s — that’s what’s so exciting about it, it’s the ability to extend it into so many different areas with so many different problems and populations, and so on and serving as a foundation, I think, for social workers and doing direct practice which is what you’re doing with this skills-based project, right, which I’ve been involved with as well. But do you want to talk about how that came to — come into being?
Allen Zweben: Well, for 14 and a half years, I was the senior associate dean at the School. And I would do these motivational labs sporadically. I used to call it my boutique labs and things like that. And then when I stepped down, I decided that why are we doing only for a few students or the 12 here and there, why don’t we do it for every students? And I felt it really shouldn’t come just from me, I could be training other people to make it more — give it a wide scope. So I ask the Interim Dean whether he would be willing to do this for all incoming students in the school, and so I developed a proposal. And at the proposal I demonstrated some of the value and some of the evidence for it, and how it could be useful in experiences. And so for the last year I’ve trained 31 instructors to do this, and we now have 285 students being, in the incoming students, going through the labs. And so the feedback I’m getting in terms of the program itself has been tremendous, because everybody seems to be benefiting. You know, one of the things you get in MI is the aha! approach like, oh my God, I can now talk to my grandmother, I haven’t talked to her in 20 years, or my kids are misbehaving, I shouldn’t be yelling and screaming at them, that maybe I can listen to what they’re saying and so on, and get this experience, especially from our students who haven’t had a lot of practice experience. But initially it came from the addiction field, and it got translated into many different areas of practice. And it’s been enormously — and now there has been 1300 studies in 50 countries. It’s, you know, it’s really become a phenomenal situation here.
Richard Hara: Yeah. And that’s been my experience as well working with students teaching the lab and really focusing on the experiential model, as you were saying, and kind of flipping the script around, so to speak. Often in trainings, we like to give the theory, we like to give the principles, etc., and examples on how to apply them. But in this training, in this — in this model, we sort of turn that around and — and design — well, you’ve designed exercises for trainees to experience for themselves what it’s like to have these kinds of conversations, right?
Allen Zweben: It’s been very helpful, particularly dealing with diversity issues and challenging dialogues and trying to connect with people of color and people of different backgrounds. And so MI has been shown actually that it’s a very culturally sensitive model because it’s so flexible and open and listening and supportive. And so it’s been tremendously — the feedback I’ve been getting from the instructors have been the same way, like we didn’t know that it could be so helpful with different processes. And the way you describe right now is your own way to it, you’ve adapted it to your own personality. One of the key things about it is that it helps with — even with addictions — it draws upon the client’s own resources. So when people do the MI they go, it’s pulled something out of me that I didn’t know I had or I didn’t realize how much compassion I have, or how skillful I am at listening. And it draws rather than imposing something that we think, we — it basically oriented to a drawing upon the person’s inner resources, and that’s been the feedback I’ve gotten from clients, addiction people, that they’ve been able to discover themselves and find the ways of having a life, processes that’s been very more meaningful to them. And the people that get training the same process, it draws — it — some — pulls something out of you, that you want to be a better person, you want to be a better human being, you want to improve your quality of life, we all have that. And what MI does is tries to drawn upon that so they can build on those inner resources.
Richard Hara: Yeah, yeah which — which it — which makes it sound very psychodynamic in a way, doesn’t it? I mean, you’re talking about people in sort of insight — developing insight and — you know?
Allen Zweben: No. It’s developing their own — trying to draw upon their own perspectives of who they are and what they are. We don’t interpret — interpret in many ways is almost patronizing and condescending, we’re feeling this way. We say, what are you doing? Where are you? What’s been helpful to you? What are you experiencing right now? So it really is — it’s — it may sound like interpretation, but basically, all the information comes from you, and I’m just drawing that out of you and helping you deal with it in a different way. But it’s not something we impose on somebody.
Richard Hara: Right, right. So — and you’re not, you know, sort of creating further resistance in the process, right?
Allen Zweben: Yeah, we don’t even use the word resistance. There’s a lot of words we don’t use in MI.
Richard Hara: Yeah, okay. We don’t want to use that word.
Allen Zweben: We talk about sustained talk, which is nothing’s happening and so on. We’re not blaming anybody for that, you know, we don’t call it, you know, substance abuse. We call it substance use. The person’s using too much. We don’t say they’re abusing, because it has a pejorative term to it.
Richard Hara: Words matter, so thank you. Let me turn to questions from our audience. Can you explain further how motivational interviewing specifically treats addiction?
Allen Zweben: It helps them to the process of engagement. A person who comes in may not be sure they have a problem. Usually they — often coming from some pressure from family and so on. So a person comes in and says, I don’t know if I have a problem or not, and so normal response was, what are you talking about? You know, you’ve been drinking 20 years. The MI approach is, well how do you see the issue? And get them to talk about — so they have to own their own responsibility rather than impose that. The other issue has to do with harm reduction, you want to use the term, but people — not everybody wants to change the way you want them to change. And MI says, well, what kind of changes do you really want to make? And for some people, and it’s understandable, they just prefer not to — what’s the word? Punish his family with their drinking so they decide that they may want to drink outside the house, rather have all the drinking in the house. And that’s another way to deal with it or having, you know, using needles that are sterilized. And so the whole harm reduction approach is very consistent with an MI approach because the client decides how they want to deal with it. And that becomes a step toward further change.
Richard Hara: Yeah, yeah. Okay, can MI prevent addiction once addictive behaviors are initially identified? Does it have a sort of preventive capacity or — yeah.
Allen Zweben: Well, the word preventive means if they already started they’re not preventing, but it can intervene —
Richard Hara: Okay.
Allen Zweben: — and facilitate some kind of change processes. And sometimes a person needs a number of things, not just the MI in itself. It’s not a panacea. For some people they may need some further help with medicine and so on. But the MI plays a role because how do they begin to understand that process, and what are the side effects? So MI listens to some of the issues that may be taking medication or say contingency management, you know, you have other issues they want to do. But how do you get people to engage with other treatments? So MI is a foundation, but it — in fact, some of the evidence says MI works even better with other models together, it has even more of an impact.
Richard Hara: Okay. Would motivational interviewing be appropriate in a group treatment of people with addictive behaviors?
Allen Zweben: Absolutely. MI becomes useful for families and I’ve done that with treatment. In many ways the people in the group become sort of MI people themselves, they begin list — using some of the same skills that you’re using. So often you teach the same skills that you use to group members and so on, it could be a family member that gives constructive feedback or good listening skills. So it can be translated to families, to groups, to communities, but the MI spirit, compassionate autonomy evoking change, is those skills go across all different networks and processes.
Richard Hara: Okay. Can the two of you demonstrate for us some of these MI techniques with Richard serving as the client?
Allen Zweben: Richard — Richard and I have done that before, so no problem.
Richard Hara: We’ve done this in our training.
Allen Zweben: I’m not sure we want to — we have — our time is — if you want to — I don’t know. How do you — what brings you here today?
Richard Hara: Well, I’ve been thinking about trying to take better care of myself more generally. And I guess that would mean sort of jogging or eating healthy and things like that.
Allen Zweben: So you’re concerned about your health?
Richard Hara: Yeah.
Allen Zweben: Seem pretty concerned.
Richard Hara: Getting at that age, yeah.
Allen Zweben: Yeah. Can you tell me a little bit more about what you have been doing to improve your health?
Richard Hara: Hm. That’s a good question. I’m trying to think if I’ve done anything positive lately. You know, it’s really hard for me to think of something —
Allen Zweben: It’s hard.
Richard Hara: Yeah, yeah, you know.
Allen Zweben: Think back.
Richard Hara: I guess try to go out and walk with my dog as much as possible.
Allen Zweben: Oh that’s good, yeah.
Richard Hara: So, yeah, in the morning.
Allen Zweben: So that’s a — that’s the beginning. You’ve done some of that already, that — that’s a beginning, that sounds good.
Richard Hara: Yeah.
Allen Zweben: Yeah. Is there other things you might consider doing that you might — that you’ve done in the past?
Richard Hara: Yeah, yeah. Well, you know, I used to be fairly active doing different sports, but it just seems like I don’t have time these days. And I’m afraid that, you know, at my age if I hurt something it’s never going to quite heal again, so yeah, you know, so —
Allen Zweben: So, your age is getting in a way of trying to do certain things.
Richard Hara: Right.
Allen Zweben: Yeah. It becomes — yeah.
Richard Hara: Yeah, yeah, yeah so, so yeah.
Allen Zweben: I can I can go on with this, I can ask him some more questions. It’s — what I just did was give him some open-ended questions, and he shared. And then he would say something and I reflect it back. And I gave him some affirmations I’m looking for, just give him some support that he should continue to — the idea is for him to engage with me to continue talking, to feel free, to feel safe, to feel I’m the person who wants to help him.
Richard Hara: Yeah.
Allen Zweben: But there’s — there’s actually some skills we could actually practice, we have exercises, like tell me 4 or 5 things you value about yourself. And then I can summarize that and give you a bouquet of affirmations.
Richard Hara: Mm-hmm. And the important thing I think is also when we’re doing this kind of exercises is what is it like to be on the receiving end? And I’m not — I don’t feel as if I’m — I’m sort of being interrogated, it’s allowing me to sort of go at my own pace when I struggled to come up with an answer there to your question. You are very good in — in sort of rephrasing and allowing me to just use my own creativity, right?
Allen Zweben: Right. You are a knowledgeable MI person.
Richard Hara: Okay.
Allen Zweben: I can say that.
Richard Hara: All right then, great. So hopefully that’s helpful to people who wanted to see a demonstration. Next question, which screening tool do you recommend for a quick screen to be included in a reproductive healthcare medical histories?
Allen Zweben: Yeah, I just finished chapter. Let me say a little bit about that. Maybe I am not answering the question directly. In MI you give the people bunch of instruments and — you know, and so on. Often, it’s probably not productive. It’s usually good to listen and to reflect because a person is busy filling out the forms. If we use any screening tools, it’s done — done afterwards, and that’s usually — but the screening tools, most of the stuff in the screening tools we can get through an MI interview like, you know, what’s happening with you? When did you take your last — you can do it in the process. The tool itself in many ways takes away interferes with the rapport-building process. So when the people get training by me, I say, what do you do in the first 10 minutes? They say, filling out a bunch of forms and so on. And the person sitting there — the person sitting there already knows the problem they have, what they need is somebody to listen and to reflect what they are feeling. And so for MI process, we’re not big on screening tools. Read the chapter on screening. I wrote the chapter with the screening tools. And really it says something like, maybe you should wait before you give out screening tools, and then get the relationship and use it in the process of maybe it could be helpful in that. I’m not going to be saying that you got to do screening tools.
Richard Hara: Right, right, as — as with a lot of life, timing is everything.
Allen Zweben: Yeah, it’s a rapport-building collaborative process, and the client already knows what the problems they have. You — they need you to feel that you are with them.
Richard Hara: Mm-hmm, okay. How do you work with shame in MI?
Allen Zweben: We’re not big on shame. Shame is really something, what do we call, MI-inconsistent. It’s — it’s –it’s keeping people, it’s not collaborative, it’s not supportive, in many ways it’s — it’s almost —
Richard Hara: If a client’s feeling ashamed. I mean —
Allen Zweben: Oh, I see what you mean.
Richard Hara: Yeah.
Allen Zweben: Client shame.
Richard Hara: Yeah.
Allen Zweben: Yeah, we try to reduce the shame by — by forgiveness, acceptance, understanding, joining with them coming alongside and say you’ve been going through this process and so on. So we have to reduce that shame so the person can feel free to evoke things they want to do with them. Shame usually is a way to keep people from doing this thing, it doesn’t build confidence, it doesn’t build self-efficacy, it doesn’t build support, it doesn’t build a relationship. So we have a list of things at MI we thinks that it’s helpful but working with shame is one of the things we try to reduce.
Richard Hara: So, but you would grant that it’s a fairly common problem with people coming for substance use disorder treatment or —
Allen Zweben: Well, it depends how you start out. You can elicit shame, if you talk to — ask certain kinds of questions say — who’s against you? But that’s not the — you don’t want to elicit shame, you want to elicit strength.
Richard Hara: Right, yeah, yeah. So if it does come up then — then you can go with it, explore and sort of support as needed, but it’s not necessarily something that you’re from the outset trying to identify and work with, okay.
Allen Zweben: Yeah, yeah. And also we have — we don’t shame clients ourselves.
Richard Hara: And we don’t yeah, yeah, it’s not helpful. How do we help someone who is addicted to suicidal ideation?
Allen Zweben: Well, MI is uniform in terms of the basic skills of listening, reflecting, and trying to elicit some person’s perspective on the problem a little — understand that where they’re coming from. But, in itself may not be the answer, but once you elicit all the issues and so on, you may need to use medication, you may if it’s needed. You may use other kinds of probe, MI is not a panacea.
Richard Hara: Okay.
Allen Zweben: It does — it’s facilitative and could be useful as independently, but it’s also could be used in conjunction with other models.
Richard Hara: Okay, all right. Let’s see, this is the last question. Thanks for the demo, that was helpful. If someone has bad habits wouldn’t be better to give them a program for how to change their habits? However long you talk to them, they won’t be able to come up with that kind of program. They may admit their problem, but have no clue about how to change their behavior. So, yeah I guess, sort of saying, you know, where are the solutions? And how, you know, if people haven’t been able to come up with those solutions in the past, how are they going to do it through MI?
Allen Zweben: Well, if they don’t come up with the solutions, we sometimes have an approach say, well, let me look at some of the other options. Clients need to feel it’s an option.
Richard Hara: Okay.
Allen Zweben: So if they don’t have an option, you may ask them, can I provide you with some options? And some options might be to — whatever that you think is appropriate for that particular problem. Could be some getting medication, could be — could be family therapy. But in itself, it isn’t saying, the burden is not completely — the burden is shared with us, it’s a shared decision making. And some things you may have ideas because you’re an expert, and the client may have ideas. And together you try to merge those ideas to have a consensus about what’s best for them.
Richard Hara: Mm-hmm. Well, it’s a conversation and it’s a collaboration.
Allen Zweben: Absolutely.
Richard Hara: Well, that concludes today’s episode. Thank you so much, Dr. Zweben, for joining us here today at Social Impact LIVE. We’ll be joined next week by CSSW faulty member Amy Werman and Shlomi Avni to discuss the effectiveness of wilderness therapy with at-risk youth. So, thanks to everyone for tuning in today, and looking forward to seeing you next week. Bye-bye now.