Treatment of antagonism: Motivational Interviewing

Treatment of antagonism: Motivational Interviewing

Treatment of antagonism: Motivational Interviewing 22 Megan Wrona, Brian Burke Department of Psychology, Fort Lewis College, Durango, CO, United Sta...

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Treatment of antagonism: Motivational Interviewing


Megan Wrona, Brian Burke Department of Psychology, Fort Lewis College, Durango, CO, United States

Case study Franklin (“Frank”) Jackson is a 46-year-old male who was referred to therapy by the Human Resources Department at the company that employs him. He initially presented with an imposing presence, with a tall, muscular build, a well-pressed suit and a tie, and a large brief case, which he forcefully placed directly between himself and the therapist. Frank reportedly has a history of negative, confrontational interactions with his colleagues and supervisors in his work as a regional sales manager for a manufacturing company. Whereas Frank can present as charming and engaging with his clients, ensuring that his sales numbers are regularly among the highest in the company, he has had increasing conflict with the employees he supervises as well as other regional sales managers. Frank’s confrontational style has typically been overlooked due to his high performance but a series of outbursts and threats over the past 6 months led to the current action plan. In his most recent outburst, Frank exploded during a staff meeting and shoved another manager before abruptly leaving the meeting, slamming the door behind him. As this was his third significant outburst, Frank’s employer has required at least 6 sessions of “anger management” with a therapist. When Frank initially came to therapy, he made his disinterest quite clear. He explained that he went to therapy as an adolescent after he was expelled from school. He also shared that he went to one couples therapy session at the request of his wife. He noted that both of these experiences were “worthless,” “stupid,” and “a complete waste of time.” He explained that he expects a similar outcome this time. Frank noted that he planned to be compliant with attendance to meet his employer’s requirement but denied having any problems that needed to be addressed so “this will be easy work for you.” He explained that he was only joking in the meeting and that everyone made a big deal out of absolutely nothing. Frank jokingly described psychology as a “sham of a profession” and provided mostly factual background information during the first session. Outside of work, Frank denied that any significant problematic issues exist. He has been married for 20 years and has two children, a 14-year-old son and 16-year-old daughter. However, in speaking with his wife with Frank’s permission, she painted a very different picture. She shared a history of significant marital issues that began to

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The Handbook of Antagonism

worsen when their children were born. Shortly after the birth of their son, she requested that Frank accompany her to couples therapy because the arguing between them had become so constant and unbearable. She acknowledged this was not helpful as Frank only attended one session with her and refused to return because of the “inadequacies” of the therapist. Since then, their relationship has continued to struggle and she perceives that problems have escalated. She shared that Frank is typically disengaged from the family, unless one of their children gets in trouble. When that occurs, he responds quickly and harshly. She noted that after particularly heavy periods of drinking, Frank often becomes physical with her. She denied significant physical altercations but acknowledged that he does shove her and grab her tightly when he is drunk. She generally responds to this with her own anger and threatens to leave him and/or kick him out of the house. Typically, after her anger reaches that tipping point, a large, heated argument ensues. Frank usually stops drinking for a few days after the argument and they reconcile. His wife admitted this is a poor pattern but described she has learned to cope with it because she does not expect that Frank will change as he has frequently blamed her for his high level of drinking and the conflict in their marriage.

Motivational Interviewing with antagonistic clients Motivational Interviewing (MI) is a client-centered yet directive counseling style designed to help people make behavioral changes (Miller & Rollnick, 1991, 2002, 2013). MI is a way of structuring conversations so that people enhance their internal motivation to make a specific change by themselves presenting arguments for why and how they will do so. Advances have been made toward “looking under the hood” of MI to understand the underlying mechanisms by which it affects behavior change (Miller & Rose, 2009). Notably, one theory of MI emphasizes two specific active components: a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and reinforcement of client change talk, or arguments that a client makes about a particular behavioral change (Miller & Rose, 2009). Another model of MI (Miller & Rollnick, 2013) puts forth four overlapping processes as follows: (1) engaging, wherein client and therapist establish a helpful working relationship; (2) focusing, the development of a specific direction or target behavior in the conversation about change; (3) evoking, eliciting change talk or the client’s own motivation for changing the behavior; and (4) planning, the phase in which client and therapist collaborate to form and commit to a concrete action plan to change the target behavior. Throughout this chapter, we employ these four processes of MI in the case of Frank above as we demonstrate how this model might approach the treatment of his antagonism. Hundreds of controlled research studies of MI have illustrated its efficacy for a wide variety of problems ranging from substance use (alcohol, marijuana, tobacco use) to reducing risky behaviors (unsafe sex, needle sharing) and increasing healthy behaviors (e.g., medication adherence, diet, and exercise; Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010). MI is significantly more effective than no treatment and at

Treatment of antagonism: Motivational Interviewing


least as effective as other viable treatments, with a dose effect such that more sessions tend to produce more behavioral change (Burke, Arkowitz, & Menchola, 2003), yet MI typically operates as a brief treatment with higher cost effectiveness than the alternatives (Lundahl & Burke, 2009). MI works for clients regardless of problem severity, age, or gender, with outcomes appearing durable up to 1 year posttreatment (Lundahl et al., 2010). Finally, MI is learnable by practitioners of diverse professions (Lundahl et al., 2013), optimally via a 9–16 h interactive workshop (Madson, Loignon, & Lane, 2009) followed by three or four feedback/coaching sessions over a 6-month period (Schwalbe, Oh, & Zweben, 2014). One of the largest psychotherapy outcome studies ever conducted, Project Match, involved MI. Clients were randomly assigned to one of three 12-week, manualguided, individual treatments for problem drinking: Cognitive Behavioral Coping Skills Therapy (CBT), Motivational Enhancement Therapy (MET, a modified version of MI), or Twelve-Step Facilitation Therapy (TSF). Two parallel but independent randomized clinical trials were conducted: One with 952 outpatients and another with 774 aftercare clients. Participants were monitored over 15 months including a 1-year posttreatment period for days abstinent and drinks per drinking day. Only two (of many) a priori contrasts demonstrated significant posttreatment attribute by treatment interactions, including the finding that outpatient clients who were high in anger and treated in MET had lower posttreatment drinking than those in CBT (Project MATCH Research Group, 1997). Thus an MI-based treatment showed specific value for problem drinkers high in antagonism. In fact, MI’s consistently demonstrated efficacy in the realm of substance use and related problems (Lundahl et al., 2010), which often involve clients high in anger or antagonism (Terracciano, L€ockenhoff, Crum, Bienvenu, & Costa, 2008) like the case of Frank outlined at the beginning of this chapter, suggest that it may be a promising initial approach to treat these types of clients. In fact, MI and MI-inspired treatments have been shown to be effective for people who are mandated to treatment even when the individual did not initially want to work on the change in the first place (i.e., LaChance, Feldstein Ewing, Bryan, & Hutchinson, 2009; Nirenberg, Baird, Longabaugh, & Mello, 2012). MI-inspired treatments (such as MET described previously) have been shown to be effective even within treatment for perpetrators of intimate partner violence, a population that is likely to be antagonistic within therapy and other interpersonal interactions (Woodin, 2015). We will discuss how MI may be implemented with an antagonistic client such as Frank through each of its four key overlapping phases/ processes.

Engaging: The relational foundation Like any successful therapy intervention, MI begins with the establishment of rapport and engagement within the therapeutic relationship. The establishment of a good therapeutic relationship and other common factors in psychotherapy cannot be underestimated and may account for more change than specific types or models of therapy, with estimates ranging from 30% to 70% (Imel & Wampold, 2008). Building a strong therapeutic relationship and engaging a client in MI is founded on the notion of


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expressing true empathy and compassion to help build a collaborative relationship in which a client can consider the possibility of changing their behavior (Miller & Arkowitz, 2015). In this dynamic, the therapist aims to position the client as the “expert” who holds the solutions to their own problems. A number of specific strategies used within this phase of treatment can be particularly helpful for individuals who exhibit resistance to treatment and may not want to change a problem behavior—both traits that are likely to be displayed by someone who is high on antagonism. MI, with its open style to exploring ambivalence, is well suited to help someone who is high on antagonism to consider making changes and engage in their therapy. Additionally, MI can be used by a therapist to help motivate a client before jumping into another treatment intervention such as CBT (see later chapters in this volume). To help build a strong, collaborative relationship, MI uses specific techniques to help foster the relationship. Whereas these techniques are used throughout the different phases of MI, they are especially important as the relationship is developing. The techniques, described with the acronym OARS, include open-ended questions, affirmations, reflection, and summarization. To begin with, open-ended questions are used to gather information and gain information about the client’s own perspective. By keeping questions open, the client begins to share what is most important for them rather than the therapist asking directly for specific information. The MI therapist follows the direction the client wishes to pursue and shapes open questions around that direction. Next, affirming statements are used to help identify strengths or progress, even very small bits of progress, that the client may not see themselves. Rather than giving vague positive praise (e.g., “Good job!”), affirmations in MI are clear, specific, and authentic (e.g., “Even though you haven’t stopped smoking yet, your persistence to succeed by trying to stop smoking again is evident” or “I appreciate you making time to be here, even though you aren’t sure that therapy will be helpful”). Affirmations aim to improve client self-efficacy and highlight positive growth. Reflections are critical to utilize during the engagement phase. Using reflections helps to develop trust that the therapist can understand the client and allows a client to feel heard, free of judgment. Reflections can range from repeating a particularly poignant word or phrase used by the client to recognizing and reflecting the emotional experiences that underlie what the client is sharing. With the latter reflections, therapists help the client identify feelings, ideas, or thoughts of which they might not yet be aware. Good reflections help deepen the client’s understanding of themselves and often move the session forward without using too many questions (Miller & Arkowitz, 2015). Finally, summarization is a skill that helps consolidate larger chunks of information or insight. With a summary, the therapist aims to provide an overview of what has been shared, including insights and feelings. Summaries serve a number of purposes including demonstrating that the therapist is listening and engaged, highlighting the value of what the client is sharing, and providing the client with time to reflect internally on the bigger picture. Additionally, summaries can help the therapist check for understanding and let the client correct any inaccuracies, as in the case of Frank excerpt that follows.

Treatment of antagonism: Motivational Interviewing


Therapist: Thanks for making the decision to meet with me today. I got the paperwork your boss sent regarding us meeting, which has some background information but certainly not the full picture of what is going on. What is your view of why you are here? [Open Ended Question] Frank: Let me start by being clear: I didn’t “make the decision” to be here, my boss did. She seems to think I need therapy for my “anger problems,” which I don’t have. Everything has been blown way out of proportion. Therapist: You really don’t want to be here and feel misunderstood by your boss. [Reflection] Frank: Absolutely. She totally misunderstood the situation and always sides with other employees over me. I am in the middle of a major sale and don’t have time for this right now. Can you tell me what I need to do to get this over with? Therapist: Well, it sounds like your boss wants you to attend at least six sessions here. Being here is not a priority for you, which I understand since you don’t see your anger as a problem and this is crunch time for you at work. You have many things you are juggling right now. However, you also made the time to be here today and didn’t ignore your boss’s request completely. [Summary] Frank: Yeah, sometimes it feels easier to just get things over with than fight them. I want to do whatever I can to check this box and move on to other more important things are work. Therapist: You are committed to your job and focused on your priorities at work. Coming here to meet a requirement, even if you don’t think it will be valuable, says a lot about what you are willing to do to be successful at your job. [Affirmation] Frank: Yeah, it is important to me to do the best I can at work. Therapist: Tell me about what that means, “to do the best I can?” [Open Ended Question]

Focusing: The strategic direction At some point, in order for therapy to be productive, it is essential to help the client develop a focus, a specific problem behavior that they wish to change. With clients high in antagonism such as Frank, however, they may come to view their problems as caused primarily by other people (i.e., externalize blame) and/or the unfair treatment they perceive from those around them. Frank believes his wife is oversensitive and his supervisees are “soft.” The pursuit of any change goal that the client does not currently espouse necessarily involves interventions designed to enable the client to adopt and accept the shared goal (Miller & Rollnick, 2013). This process may comprise the major part of the treatment in antagonism, that is, how to identify and work with the client on specific behavior changes that only they have the ability to make. Yalom’s (2017) 99% rule for responsibility assumption may be valuable in this regard. The notion is that, even if most (or 99%) of the negative events that happen to us are indeed someone else’s fault, psychotherapy can only target a client’s own behaviors. The goal therefore is to get the client to frame each of their frustrating issues with the outside world as behaviors that they may be able to change. For example, instead of believing that “people treat me badly,” the opportunity for change in


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that respect could be something like “I will react differently when I feel I am being wronged.” The following Frank’s session transcript illustrates this approach. Frank: My work is so frustrating—the people under me are lazy and unmotivated so all the pressure falls on me. Therapist: I can understand how challenging it can be to work with others who may not share your work ethic. [Reflective Listening] Frank: Yes, it certainly is. That’s why I get so mad sometimes. It’s their fault. Therapist: Maybe it is their fault. But, unfortunately, in our work together, we can only work on changing your behavior, not theirs. What might you be able to do differently in those frustrating situations? [99% rule—assuming responsibility by asking an Open Ended Question] Frank: I guess I could wait until the meeting is over before I get angry and yell at people. Therapist: Excellent idea—that might be something for us to work on together. [Affirmation and possible focus] Murphy (2008) provides another suitable strategy for focusing in MI. In his work with combat veterans (who also may be high on antagonistic traits), Murphy explains that they frequently have a general externalizing coping style that interferes with their ability to problem-solve and acknowledge their own role in the challenges that they face in life. Murphy’s suggestion is to give clients a Problem Identification Worksheet (2008, p. 81) on which they write down their possible problems in four separate columns: Problems I Definitely Have, Problems I Might Have, Problems Other People Told Me I Have, and Problems I Definitely Do Not Have. This list can be done collaboratively in session or by the client for homework between sessions and then utilized as a starting point for a focusing discussion as in the example of Frank as follows. Frank: I have that sheet you asked me to fill out for homework. Therapist: Great—let’s look at it together. Ah, I noticed your list of Problems I Definitely Have are mainly what you talked about earlier, that other people are hard to work and live with. [Using Murphy’s, 2008 strategy to find a behavioral focus; Summarization/Reflections] Frank: Yes. Therapist: And for Problems I Definitely Do Not Have, you wrote that you are neither an alcoholic nor an asshole. That’s good! Frank: Right. Therapist: So let’s examine what you put for Problems I Might Have and for Problems Other People Told Me I Have. You believe that you have overly high expectations at times and that you are judgmental. And other people tell you that you argue and yell too much, that you are rude or dismissive at times, and that you drink too much alcohol. What do you make of that? [Using the list as Feedback and ending with an Open Ended Question] Frank: Well, I don’t think I drink too much but it does make me angrier than I want to be sometimes… Therapist: Can you give me an example? [Eliciting more change talk regarding drinking by asking for elaboration via an Open Ended Question]

Treatment of antagonism: Motivational Interviewing


Another strategy that can be employed during the focusing phase of MI, especially if the client is unable or unwilling to generate a suitable problem list using Murphy’s (2008) approach, is to give the client honest feedback about what you as the therapist have observed in their behavior. This is optimally accomplished via what MI terms Elicit-Provide-Elicit (EPE; Miller & Rollnick, 2013, p. 139), in which the therapist first asks for permission to discuss a topic further or what the client knows about a topic before then providing tailored information or feedback and closing by asking the client what they think. This is what the use of EPE might look like with Frank if he had not come up with anything useful via Murphy’s (2008) list. Frank: I did not do the list you gave me for homework—it seemed pretty stupid. Therapist: That’s okay, Frank. But would it be alright if I gave you some feedback about what I have noticed about you in the time we have spent together so far? [Elicit #1: Asking Permission] Frank: Sure, I guess so. Therapist: You seem really strong and smart and I think we could do some really good work together. But you put me and our work down sometimes, like just before when you called the homework “stupid.” It gets in our way of what could be a valuable collaboration. What do you think about what I said? [Providing Feedback and then eliciting client’s understanding] Frank: You’re not the first person to tell me that. Therapist: Can you give me an example of where you heard the feedback before? [Eliciting more focusing talk by asking for elaboration]

Evoking: Preparing for change One of the keys to successful MI is recognizing how motivated a client is for change and, subsequently, tailoring interventions based on that level of motivation. Prochaska and DiClemente’s (1982) Transtheoretical Model of Change provides a guide for therapists to identify the level of motivation for change. The Transtheoretical Model includes six different phases of change: precontemplation, contemplation, preparation, action, maintenance, and relapse. In precontemplation, a client does not recognize that a problem exists and does not see any reasons to make changes. In contemplation, a client sees that a problem exists but remains ambivalent about whether they wish to change the problem behavior. Both precontemplation and contemplation are stages where the impact of MI can be particularly high. During the preparation phase, the client and therapist collaborate on planning to make the change and then implement the change during the action phase. Finally, because changing entrenched behaviors is very difficult, relapse is a stage many encounter as they fall back on previous patterns of behavior. Relapse does not mean failure and the goal of the MI therapist is to help a client return to the planned behavior change as quickly and easily as possible. MI can be optimally beneficial for clients in the precontemplation and contemplation stages of change. During these stages, the therapist still relies on OARS but open-ended questions are designed to elicit and evoke change talk more specifically. The goal is to help the client begin to explore their own motivation for change and


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how change might help them. To succeed in this, the therapist must be willing to entertain all options and goals, even if the therapist does not view the goals as positive in the long run. Often, antagonistic individuals may not initially see any reason to change and are likely to see many positives related to not changing a behavior. For example, if a client is trying to stop using substances, it is important for the therapist to validate that there are positives associated with using substances such as stress reduction or personal enjoyment. Using a decisional balance, in which a client explores the pros and cons of changing a behavior as well as the pros and cons of NOT changing that behavior, is one way to help clients identify possible reasons for change without ignoring the other side. Similarly, one might explore the pros and cons of changing antagonistic traits such as grandiosity (e.g., pros: people may like the client more; cons: people won’t know about accomplishments if one doesn’t inform others of them). Additionally, scaling questions help clients talk about a possible change while also helping to increase their own self-efficacy, motivation, and confidence. In these questions, the therapist asks the client to rate a concept (i.e., importance or confidence) on a scale of 0–10, where 0 is the lowest level (i.e., the change is not important at all) and 10 is the highest level (i.e., the change is as important as can be). Once the client provides a rating, the therapist then chooses a number below that rating and asks why the rating was not lower. For example, “why did you rate your importance of reducing your drinking as a 4 rather than a 2?” Whereas this might seem counterintuitive at first, this type of question invites the client to begin to argue for change, rather than the therapist (or other family members) suggesting why the change might be useful. When the therapist or others in the client’s life are telling the client why they must change, the natural tendency of the client (and most people!) is to defend what they are already doing and minimize the severity of the problem. Scaling questions help reverse this dynamic and highlight the client’s view on why the change might be helpful. Beyond scaling, MI therapists listen carefully for any indication of possible change talk and use specific questions or reflections to elicit more change talk. By highlighting the changes clients are already talking about, clients begin to notice more reasons within themselves to change. MI therapists want to support and affirm any movement toward the targeted behavior, even if the action is small. The therapist then strives to strengthen client motivation and move toward planning and action to make changes. In working with individuals who exhibit counterproductive levels of antagonism, identifying their role in making change is especially important as they tend to place blame on those around them rather than themselves and may be more likely to be ambivalent to changing. Here is how evoking and amplifying change talk went with Frank. Therapist: From what we have discussed so far, Frank, you have identified that those around you tend to think you argue and yell a lot and you shared that sometimes when you drink that anger intensifies. Would it be okay if we talked a little more about the connection you made between alcohol and anger? [Asking Permission] Frank: I guess so, but I’m not sure it is that related. Therapist: It may not be, but you noted that your anger worsens when you drink.

Treatment of antagonism: Motivational Interviewing


Frank: I guess that’s true—especially with my wife. She tells me that all the time. I have tried to drink less around her because she’s always nagging me about it. [Client identifying history of trying to change] Therapist: Sounds like she would like you to cut back. And that you have tried to minimize drinking around her, which demonstrates your commitment to her and is great way of trying to meet her halfway [Affirmation]. What made you decide to do that? [Open Ended Question, Evoking change talk] Frank: Well, I can see some of her reasons behind it and I don’t want her to leave me. Therapist: So, even though you don’t think it is a major problem, you have tried to reduce your drinking to help her and your relationship. On a scale of 0 to 10, how important is it to you personally to reduce your drinking? [Scaling question] Frank: Maybe, somewhere around 3. It’s not that big of a deal to me. Therapist: It definitely doesn’t seem like a high priority right now, compared to other things you are working on. But, I am curious. If it isn’t a priority at all, why did you chose 3 instead of a 1 or a 0? [Scaling follow-up question]. Frank: Well, I think, I guess there is some benefit. Therapist: Like what? [Evoking change talk about possible benefits] Frank: I wouldn’t have to listen to the nagging as much… And, maybe it would help reduce some fighting and lessen the chance of her wanting to separate. Therapist: What would it be like to have less fighting and nagging? [Evoking change talk] Evoking change talk can take many directions in MI as the therapist follows the client. Whereas the earlier transcript shows some possible questions to use, there are many other specific questions that could help Frank build motivation for change, including the following: “Regarding the importance of reducing drinking, what would it take to move from a 3 to a 5?” “What might you give up if you reduced your drinking? What might you gain?” “When you reduced your drinking around your wife before, what benefits did you notice for yourself?” “What made you successful the last time you worked on reducing your drinking?” “How do drinking and arguing with your wife fit with your overall goal of success in your life?”

Planning: The bridge to change In some cases, MI ends after evoking change talk and the plan is quite simply for the client to engage in other models of psychotherapeutic treatment, as the next three chapters in this book will discuss. In other words, MI may have a chief role to play as a prelude to other treatments. In fact, previous research found that MI’s efficacy was higher when it was employed as a first step to subsequent non-MI treatment (Burke et al., 2003). MI was initially designed to prepare clients for change in a small number of sessions, with further sessions using other models to follow if needed to help clients to initiate and maintain the change.


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Nevertheless, it may be fruitful to enter the planning stage with a client using MI if they are ready to do so, especially since work on volitional personality change suggests that specific plans for change are necessary for subsequent change (Hudson & Fraley, 2015). In order to know when it is time to begin crafting a change plan with your client, it is essential to look to them for cues. For instance, signs such as increased change talk, taking steps, and questions about change could all serve as harbingers of readiness to plan. To find out whether the client is ready to move into the planning phase, the therapist has two choices: Ask them directly (“What do you think about making a specific plan to change how you react in those meetings at work?”), or proceed as in Frank’s session as follows to explore a change plan as the session unfolds. Therapist: You have mentioned so many important things so far. [Affirmation] You’re not an alcoholic or, more importantly, an asshole. But you can be judgmental and yell at people on occasion, especially when you get angry, and you sometimes lose control when you drink too much. You know that you cannot change other people’s behavior that makes you frustrated with them, but you been wondering about changing the way you react, especially in office meetings. So where does all this leave you? [Summary and Key Question] Frank: I’m not sure. Maybe I could start by changing what I do when I get angry. Therapist: That sounds like a strong idea, Frank. How about if we discuss the details of what that change might look like? [Affirmation and Open Ended Question to move into planning] If Frank indicates that he is ready and willing to discuss a change plan, the therapist’s job is to maintain the spirit of MI, that is, not launching into advice-giving or telling the client how to change. Instead, an MI therapist would use OARS again (open-ended question, affirmations, reflections, and summaries) to help guide the client through a specific and realistic change plan. Therapist: What first steps could you take to reach your goal of reacting better when you get angry in work meetings? [Open Ended Question to begin a specific change plan] Frank: I suppose I could just wait until the meeting is over to get mad in private in my office. Therapist: Good idea. What other options could you try? [Open Ended Question to gather more change plan ideas before narrowing down] Frank: I don’t know. Therapist: I have another idea if you want to hear it. [EPE as in focusing phase above] Frank: Yes. Therapist: You could tell yourself that your coworkers are not making you mad on purpose. And take a deep breath. What do you think of that? [EPE; Note that this particular idea borrows from CBT, which is discussed at length in the next chapter in this volume] Frank: I could try that. [Next the therapist would help Frank narrow down to specific ideas that he wants to try, who could help with his plan, and when Frank will implement the plan. Then:]

Treatment of antagonism: Motivational Interviewing


Therapist: What might get in your way? [Troubleshooting the change plan] Frank: I’m not sure. But sometimes I get so angry in the moment that I feel like I am going to explode. Therapist: How would you deal with these obstacles? [Troubleshooting the change plan] The therapist would then summarize Frank’s change plan and ask a scaling question such as: “How committed are you on a scale of 0–10 to this plan, Frank?”

Conclusion Motivational Interviewing is a promising intervention for those who exhibit a high level of antagonistic traits. Whereas limited research has looked at MI’s efficacy with antagonism specifically, MI has already been shown to be effective for many individuals who may demonstrate antagonistic traits, such as individuals with substance use problems or those with a history of perpetrating violence. The style of MI can be especially useful as the therapist is nonconfrontational and explores a range of outcomes along with the client’s ambivalence related to changing or not changing their antagonistic behavior. This style may help to disarm individuals with high antagonism who may have previously felt pushed or trapped in to changing their behavior, which often results in disengagement or discontinuation of therapy. In doing so, MI serves to promote change in individuals who may be particularly antagonistic, difficult to engage, or resistant to change.

References Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: a meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71(5), 843–861. Imel, Z. E., & Wampold, B. E. (2008). Treatment and the science of common factors in psychotherapy. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (4th ed., pp. 249–266). Hoboken, NJ: John Wiley and Sons, Inc. Hudson, N. W., & Fraley, R. C. (2015). Volitional personality trait change: Can people choose to change their personality traits? Journal of Personality and Social Psychology, 109(3), 490–507. LaChance, H., Feldstein Ewing, S. W., Bryan, A. D., & Hutchinson, K. E. (2009). What makes group MET work? A randomized controlled trial of college student drinkers in mandated alcohol diversion. Psychology of Addictive Behaviors, 23(4), 598–612. 10.1037/a0016633. Lundahl, B. W., & Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: a practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232–1245. Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., & Burke, B. L. (2010). A meta-analysis of motivational interviewing: twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137–160.


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