It is important to be aware that the extent of such client behavior during treatment is powerfully affected
by the therapist's own style. Miller, Benefield and Tonigan (1993) found that when problem drinkers
were randomly assigned to two different therapist styles (given by the same therapists), one
confrontational-directive and one motivational-reflective, those in the former group showed twice as
much defensive behavior, but only half as many positive, self-motivational statements. Client defensive
responses were, in turn, predictive of less long-term change. Similarly, Patterson and Forgatch (1985)
had family therapists switch back and forth between these two styles within the same therapy session, and
demonstrated that clients’ defensive and uncooperative behavior went up and down markedly in response
to therapist behaviors. As in chess or martial arts, defensive behavior is the complementary response to
offensive strategies. The picture that emerges is one in which the therapist dramatically influences client
defensiveness, which in turn predicts the degree to which the client will change.
This is in contrast with the common view that defensive behavior arises from pernicious
personality characteristics that are part of the disorder. Historically, denial was regarded to be a trait of
alcoholism. In fact, extensive research has revealed few or no consistent personality characteristics among
people with alcohol abuse and dependence, and studies of defense mechanisms have found no different
pattern from the general population (Miller, 1985). In sum, people with alcohol problems do not, in
general, walk through the therapist's door already possessing abnormally high levels of denial or other
defensive styles. These important client behaviors are more a function of the interpersonal interactions
that occur during treatment.
An important goal in motivational interviewing, then, is to avoid evoking or exacerbating
defensive (counter-change) statements from the client. Said more bluntly, defensiveness or denial is not
so much a client problem, as a therapist skill issue. How you respond to defensive behavior is one of the
defining characteristics of motivational interviewing.
A first rule to go by is never meet counter-change statements head-on. Certain kinds of reactions
are likely to exacerbate defensiveness, backing the client further into a corner, and eliciting further
counter-change statements (Gordon, 1970; Miller et al., 1993). These therapist responses include:
Arguing, disagreeing, challenging
Judging, criticizing, blaming
Warning of negative consequences
Seeking to persuade with logic or evidence
Interpreting or analyzing the "reasons" for defensiveness
Confronting with authority
Sarcasm or incredulity
Even direct questions as to why the client is "resisting" (e.g., Why do you think that you don't have a
problem?) only serve to elicit from the client further defense of the counter-change position, and leave
you in the logical position of arguing for change. If you find yourself in the position of arguing with the
client to acknowledge a problem and the need for change, it's time to shift strategies.
Remember that you want the client to make self-motivational statements (ready, willing, and
able), and if you defend the need for change it may evoke the opposite. Here are several general
strategies for deflecting defensiveness within motivational interviewing (Miller & Rollnick, 1991):
Simple reflection. One good strategy is simply to reflect what the client is saying. This tends to
defuse or diffuse defensiveness, and sometimes has the effect of eliciting the opposite, balancing
Reflection with amplification. A modification is to reflect, but exaggerate or amplify what the
client is saying to the point where the client is likely to disavow it. There is a subtle balance here,
because overdoing an exaggeration can elicit hostility. There should be no hint of sarcasm or
irony in the therapist's words or tone of voice.
CLIENT: But I'm not an alcoholic, or anything like that.
THERAPIST: You don't want to be labeled
CLIENT: No. I don't think I have a drinking problem.
THERAPIST: So as far as you can see, there really haven't been any problems or harm
because of your drinking.
CLIENT: Well, I wouldn't say that.
THERAPIST: Oh! So you do think sometimes your drinking has caused problems, and
what you don't like is the idea of being called an alcoholic.
Double-Sided Reflection. The last therapist statement in this example is a double-sided reflection,
which is another way to respond to counter-change statements. If a client offers a defensive
statement, reflect it back with the other side (based on previous self-motivational statements in
the session). These have the quality of "On the one hand . . . . . and on the other hand . . . . ."
CLIENT: But I can't quit drinking. I mean, all of my friends drink!
THERAPIST: You can't imagine how you could not drink with your friends, and at the
same time you're worried about how alcohol is affecting you.
Shifting Focus. Another strategy is to defuse defensiveness by shifting attention away from the
touchy or problematic issue.
CLIENT: But I can't quit drinking. I mean, all of my friends drink!
THERAPIST: You're getting way ahead of things. I'm not making decisions for you
here, and I don't think you should get stuck on that concern right now. Let's just stay
with what we're doing here - going through your feedback - and later on we can think
together about what, if anything, you want to change and how you might handle it.
Siding with the Negative. Defensive responses can also be met by rolling with them rather than
opposing them. Taking up the negative side of the argument often will bring the client back to a
balanced or opposite perspective.
CLIENT: But I can't quit drinking. I mean, all of my friends drink!
THERAPIST: And it may very well be that when we're through, you'll decide that it's
worth it to keep on drinking as you have been. It may be too difficult for you to make a
change. That will be up to you.
Emphasizing Personal Control. The above example also illustrates another effective strategy in
responding to defensiveness: emphasizing that ultimately it is the client who decides whether or
not to change. This, of course, is the truth. No one can decide for the client. That fact that there
may be clear negative consequences of behavior (e.g., with a client for whom abstinence is a
condition of probation) does not alter this truth. Directly acknowledging that decision and choice
are in the client’s hands tends to defuse defensiveness, decreasing the need for the client to
continue to assert personal control.
2.5f. Reframing. Reframing is a strategy whereby the therapist invites the client to examine his
or her perceptions in a new light, or a reorganized form. New meaning is given to what has been said.
When a client is receiving feedback that confirms problematic drinking, a wife's reaction of "I knew it"
can be recast from "I'm right and I told you so" to "You've been so worried about him, and you care about
him very much." This is an example of reframing from what could be a negative interpretation to a more
The phenomenon of tolerance provides an excellent example for reframing in the other direction,
from positive to more negative (Miller & Rollnick, 1991). Clients will often admit to, even boast of being
able to "hold their liquor," to drink more than other people without looking or feeling as intoxicated. This
can be reframed (quite accurately) as a risk factor, the absence of a built-in warning system that tells the
person when they've had enough. Given high tolerance, the person continues to drink to high levels of
intoxication that can damage the body, but fails to realize it because he or she doesn't look or feel
intoxicated. Thus what seemed good news ("I can hold it") becomes bad news ("I lack a warning system
and am especially at risk").
Reframing can be used to encourage both client and SSO to deal with the drinking behavior. By
placing current problems in a more positive and optimistic frame, you can communicate that a problem is
solvable and changeable (Bergaman, 1985; Fisch, Weakland, & Segal,1982). Whenever possible, use the
client's own views, words, and perceptions as you develop a reframe.
CLIENT: I just like to have a few drinks on the weekend, after a hard week.
THERAPIST: You like to reward yourself on the weekend for getting through a difficult job, and
whether or not you drink it’s going to be important for you to have some way of kicking back and
letting go of the stress on the weekend. [This “agreement with a twist” - a reflection followed by
a reframe - sets the stage for exploring other ways of making the transition to a weekend.]
CLIENT: If I didn’t have a drink after I get home, I don’t know what I might say to my husband
or kids. It’s my way of letting off steam.
THERAPIST: You’ve tried hard not to burden your family by telling them your feelings, and so
you just carry all this around with you, and maybe alcohol helps you forget for awhile. [This
depicts the client as well-intentioned, and paves the way for improving communication.]
HUSBAND (to Therapist): That makes me nervous, wondering what she’s been holding back, but
I’m not very happy as it is, either.
THERAPIST: So it sounds like drinking has been one way for you to avoid conflict or tension in
your marriage. Your drinking kind of keeps the lid on, and in that way maybe it’s been a way
you’ve used to keep your marriage intact. Yet both of you seem uncomfortable with this now,
and it doesn’t seem to be doing what you want. [The implication is that the client cares about the
marriage and has been trying to keep it together, but needs to find more effective ways to do this.]
The general idea in reframing is to place the behavior in a new light, and to do so in a way that causes the
person to take action to change the problem. It invites the client to interpret experience in a new way.
Remember that the general tone in reframing is to suggest a new way of thinking about what is
happening. If you state it too strongly, it can come across as an authoritarian interpretation, which can
roadblock communication and increase defensiveness.
As illustrated above, it can be particularly effective to combine a reflection with a reframe, a
strategy called "agreement with a twist" (Miller & Rollnick, 1991). Initial reflection of a counter-change
statement, for example, has the effect of joining with the client's assertion, which is then melded with a
shift in meaning. This is often best done as a passing comment, without great emphasis:
CLIENT: But I really enjoy drinking, and nobody is going to make me quit!
THERAPIST: Alcohol is very important to you [reflection], maybe so important that you will be
willing to keep drinking no matter what it costs you [reframe]. What is it that you particularly
enjoy about alcohol [open question]?
2.5g. Summarizing. Finally, it is useful to summarize periodically during a session, and
particularly toward the end of a session. This amounts to a summary reflection that pulls together what
the client has said. It is especially useful to repeat and summarize the client's self-motivational
statements. Elements of reluctance or defensiveness may be included in the summary, to prevent a
negating reaction from the client, but particular emphasis is given to self-motivational themes, in order to
reinforce them. A summary serves the function of allowing the client to hear his or her own self-
motivational statements yet a third time, after the initial statement and your reflection of it. Here is an
example of how you might offer a summary to a client at the end of a first session:
Let me try to pull together what you've said today, and you can tell me if I've missed anything
important. I started out by asking you what you've noticed about your drinking, and you told me
several things. You said that your drinking has increased over the years, and you also notice that
you have a high tolerance for alcohol - when you drink a lot, you don't feel it as much as most
people do. You've also had some memory blackouts, which can be a worrisome sign. There have
been some problems and fights in the family that you think are related to your drinking. On the
feedback, you were surprised to learn that you are drinking more than 95% of the U.S. adult
population, and that your drinking must be getting you to fairly high blood alcohol levels even
though you're not feeling it. There were some signs that alcohol is starting to damage you
physically, and that you are becoming rather dependent on alcohol. That fits with your concern
that it might be tough for you to give up drinking. And I remember that you were worried that
you might be labeled as an alcoholic, and you don't like that idea. I appreciate how open you
have been to this feedback, though, and I can see you have some real concerns now about your
drinking. Is that a pretty good summary? Did I miss anything?
Along the way during a session, shorter "progress" summaries can be given. A "What else?" question
after a transitional summary can help to keep the process moving.
So thus far you've told me that you are concerned you may be damaging your health by drinking
too much, and that sometimes you may not be as good a parent to your children as you'd like
because of your drinking. What else concerns you?
2.6. Implementing Phase 1
The clinical methods just outlined are used throughout CBI, and particularly form the core of
Phase 1. This first phase of treatment begins with a period of open motivational interviewing, and then
proceeds into the more structured assessment feedback.
Breath Alcohol Screening. It is routine procedure in Project COMBINE to administer a breath
alcohol screen prior to each and every CBI session. The client’s BAC must be at or below 50 mg% (.050)
in order to proceed with a session. When a client’s BAC is above this level, the CBI session is
rescheduled. If the client’s BAC is above but near this level and descending, you have the option of
waiting until the BAC level reaches .050, or of rescheduling the session. Follow your center’s procedures
with regard to legal liability in releasing a client with an elevated BAC (e.g., to prevent the client from
driving while intoxicated). If the client has seen the MM clinician immediately prior to your CBI session
and was breath tested for the MM session, it is not necessary to repeat the breath test. Procedures for
coordinating this information are developed at each site.
2.6a. Getting Started with Motivational Interviewing. Begin your first meeting by greeting your
client, introducing yourself, and then briefly explaining what will be happening in the first session. With
the amount to be accomplished in the first session, it may take from 60-90 minutes. Here is an example
of how a structuring statement might sound:
We’re going to be talking for an hour or so today, maybe a little longer this first time, but usually
our sessions will be an hour or less. Today I want to take some time just to understand how you
see your situation, and particularly what has been happening with regard to your drinking. I’ll
ask you a few questions, but mostly I’m going to listen. A little later I’ll explain in more detail
what’s available to you during the rest of treatment, and I have just a few questionnaires I will
need you to complete today. Okay?
This is also the place to explain to your client the legal limits of confidentiality. With this done, proceed
directly into Phase 1. If the client asks a preliminary question, answer it, but don’t ask “Do you have any
questions?” at this point.
The open motivational interviewing phase starts quite simply, with an open question followed by
reflective listening. From your review of the client’s assessment information you will already have some
sense of the client’s situation, which may guide you in your choice of an opening question. In essence,
ask a broad question that invites the client to tell you about his or her drinking and current situation.
Tell me what you have been thinking about your drinking recently, and maybe how that compares
with what other people are telling you.
Obviously there are things that you have enjoyed about drinking, or ways it has been important to
you. What I’d like to ask you right now, though, is what drinking has cost you, what price you’ve
had to pay not only in money, but in your life more generally.
Once this process is underway, keep it going by using reflective listening, by asking for specific
examples, by asking "What else?", etc. If it bogs down, you can inquire about some general areas such
tolerance - does the client seem to be able to drink more than other people without showing as
memory - has the client had periods of not remembering what happened while drinking, or other
relationships - has drinking affected relationships with spouse, family, or friends? Who else has
been concerned about the client’s drinking, and what have their concerns been?
health - is the client aware of any areas in which alcohol has or may have harmed his/her health?
legal - have there been any arrests or other brushes with the law because of behavior while
financial - has drinking contributed to money problems?
Information from pretreatment assessment (to be used as feedback later) may also suggest some areas to
explore. Remember to ask few questions, and rely primarily on reflective listening. Keep in mind that
your goal is to elicit self-motivational statements, which can then be reinforced by reflection,
accumulated, and gathered together in summaries. If defensive behavior arises, use strategies outlined
above to respond to and defuse it.
If you encounter difficulties in eliciting client concerns, still another possible strategy is to take
up the negative side of the argument to evoke self-motivational statements. In this table-turning approach
(siding with the negative), you subtly take on the voice of the client's doubts and defenses, evoking from
the client the opposite side. Some examples:
You haven't convinced me yet that you are seriously concerned. You've come down here and
gone through several hours of assessment. Is that all you're concerned about?
I'll tell you one concern I have. This program is one that requires a fair amount of motivation
from people, and frankly I'm not sure from what you've told me so far that you're concerned
enough to carry through with it.
I'm not sure how much you are interested in changing, or even in taking a careful look at your
drinking. It sounds like you might be happier just going on as before.
And maybe it would be too difficult for you to quit drinking. Maybe no matter what happens, it's
worth it to you to be able to keep drinking.
If you use such statements, make them without any tone of sarcasm or irony.
Relatedly, a client may back down from a position if you state it more extremely, even in the
form of a question. For example:
So drinking is really important to you. Tell me about that.
What is it about drinking that you really need to hang onto, that you can't let go of?
In general, however, the best opening strategy for eliciting self-motivational statements is to ask for them
Tell me what concerns you about your drinking.
Tell me what it has cost you.
Tell me why you think you might need to make a change.
In listening to the client’s perceptions and concerns, offer interim summary reflections,
particularly reinforcing self-motivational statements. It can be useful to follow such interim summary
reflections with “What else?”
I’ve heard three things so far that concern you some about your drinking. One is that people are
starting to make comments to you about drinking too much. You also notice that you feel fairly
uncomfortable when you don’t have alcohol around. Then there is also this business of not
remembering things that have happened when you were drinking. That scares you a little. What
When it seems that you have elicited most of the client’s concerns, or when time is growing short
(e.g., after 30-40 minutes), draw together what your client has told you in a summary reflection as
described earlier. Offer a transitional summary statement such as:
Let me see if I have a good picture - at least a beginning picture - of where you are right now.
And let me know if I’ve missed something. You ....
Proceed to pull together the self-motivational statements and themes that you have heard, perhaps also
acknowledging the other side of the picture as well (the client’s reluctance, what the client likes about
drinking, etc.), but placing particular emphasis on the former. Then ask if your understanding is right, or
if you have missed something. Respond with reflective listening to anything more that the client offers,
and then provide another structuring statement:
What I want to do in the time we have left today, then, is three things. I’ll tell you a little about
what we’ll be doing in the next few sessions. As I mentioned earlier, I have a few questionnaires
for you to complete today, that will help us as we work together in the coming weeks. First,
though, I want to ask you whether there is someone who might be able to help and support you as
we work together . . .
2.6.b.1. Initiating Involvement of a Supportive Significant Other (SSO). One of the significant elements
of CBI is the active positive involvement of a supportive significant other (SSO) in the treatment
sessions. Previous research has shown that SSO involvement can help to improve treatment outcomes
(reference). The SSO is invited to attend the sessions to learn more about the individual’s alcohol
problems, offer constructive feedback about the treatment plans, provide ongoing support for sobriety and
in general, become a important motivator for change.
The SSO is not involved in sessions until phase I is completed so that the therapist has an
opportunity to develop rapport and understanding about the client’s current circumstances. SSO
involvement is introduced in the first and second sessions but involvement does not occur until the third
session, or later. The SSO selection process should be completed as early as possible in treatment if
clients are not opposed to the idea. However, in accordance with the CBI approach, SSO involvement
is encouraged and supported but not imposed upon the client. Clients need to be given the
opportunity to explore underlying ambivalence and uncertainty about SSO involvement before a decision
is made to involve the SSO. The first step is to utilize the following method for eliciting client concerns
about involving an SSO. Responding to client’s uncertainty and ambivalence with acceptance and respect
may help to minimize client resistance to involving SSOs in treatment. Remember to utilize a
motivational interviewing style when exploring SSO involvement.
Involving the SSO in treatment
sk open-ended questions
mploy reflective listening
rovide a definition of “support” and a clear rationale for involving an SSO
licit the client’s thoughts, reactions, and concerns
Begin by asking about social support in general, and support for abstinence in particular. Introduce
the idea of identifying someone from the client’s social network to engage in the treatment process. Pay
careful attention to the client’s verbal and non-verbal behavior in response to your open-ended questions
because this topic may elicit resistance or discouragement from some clients. Use motivational
interviewing strategies to elicit and explore your client’s thinking about having the SSO involved.
Emphasize the fact that the role of SSO is to build support for treatment and change. Be prepared to
provide a strong rationale for SSO involvement. In addition, be prepared to respond to some concerns that
clients may raise about SSO involvement. The table below may be helpful in thinking about some of the
most common client objections to SSO involvement.
Documents you may be interested
Documents you may be interested