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Motivational Interviewing in the Treatment
of Substance Use Disorders, Addictions,
and Eating Disorders
22
Therese K. Killeen, Stephanie E. Cassin, and Josie Geller
Abstract
Motivational interviewing is an evidence-based approach for helping clients
resolve ambivalence about change. An accumulation of research supports the
efficacy of motivational interviewing in engaging and retaining clients in treat-
ment across a variety of healthcare settings and with diverse populations. Core
components and proposed mechanism of action will be reviewed. This chapter
will further examine how motivational interviewing is used in the treatment of
addictive and eating disorders and explore research that has advanced the field
for these disorders, with implications for future study.
Keywords
Motivational interviewing • Substance use disorders • Eating disorders •
Comorbidity • Treatment
22.1 Introduction
Motivational interviewing (MI), an evidence-based client-centered approach aimed
at facilitating behavior change, has been used in the addiction field for over
25 years. The effectiveness of MI in changing the way clinicians approach addictive
disorders has permeated other healthcare areas that involve lifestyle change. MI is a
departure from the traditional confrontational approaches used in the treatment of
T.K. Killeen (*)
Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67
President Street, PO Box 250861, Charleston, SC, USA
e-mail: killeent@musc.edu
S.E. Cassin
Department of Psychology, Ryerson University, Toronto, ON, Canada
J. Geller
Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
T.D. Brewerton and A.B. Dennis (eds.), Eating Disorders,
Addictions and Substance Use Disorders, DOI 10.1007/978-3-642-45378-6_22,
#Springer-Verlag Berlin Heidelberg 2014
491
substance use disorders (SUD). Inherent in MI is maintaining a spirit that embraces
client autonomy and collaboration, which allows clients the freedom to more fully
explore their own behavior. Ambivalence is a normal process on the path to change,
and MI helps clients resolve ambivalence. MI empowers clients to make decisions
that are consistent with important life values and/or goals. Change is often consid-
ered when clients perceive a discrepancy between their current behavior and what
they value or what is important in life.
Client change talk, elicited by clinicians using evocative approaches and rein-
forcement, has been identified as an important predictor of behavior change
(Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003; Moyers et al., 2007). Prepara-
tory change talk often precedes a more robust type of change talk called
mobilizing talk in which commitment to take action is stated. Linguistic analysis
of MI session recordings has demonstrated that the active ingredient for behavior
change outcomes in MI is client change talk. Specifically, commitment talk, the
more robust form of change talk, is strongly associated with behavior change
(Amrhein et al., 2003). Within session mechanisms of change associated with client
behavior and clinician MI technique were explored in a meta-analysis of 19 studies.
Better outcomes were associated with client change talk/intention and client expe-
rience of discrepancy. Clinician MI-inconsistent behavior was related to worse
outcomes. Clinicians’ use of specific techniques such as a decisional balance
exercise showed the strongest association to better outcomes (Apodaca &
Longabaugh, 2009).
Clinicians use open-ended questions, affirmations, reflections, and summaries to
evoke change talk and explore goals/values that are important. Having the self-
efficacy to make major life changes is essential in order for change to occur.
Clinicians use MI to empower clients to increase confidence in their ability to
make behavior change. For example, a clinician may ask a client “what did you do
the last time you were successful in reducing your alcohol use (or other problem
behavior)?” Allowing clients the autonomy to make decisions is pertinent to both
SUD and eating disorders (ED) where clients experience a loss of control in so
many areas of their life. Now in its third edition, Motivational Interviewing:
Helping People Change, Miller and Rollnick (2012) have revised the practice of
MI in several areas as a result of ongoing empirical research.
22.1.1 Four Processes of MI
Miller and Rollnick (2012) introduce the four processes of MI in the third edition of
their book. These four processes provide more direction to the flow of the MI
conversation. In sequentially moving through these processes, clinicians are better
able to guide clients through a path toward change. The four sequential but
overlapping processes include engaging, focusing, evoking change, and planning
for change. MI was initially developed with phase 1 and phase 2 components. MI
principles and skills addressed client ambivalence about change (phase 1), with less
emphasis on moving the conversation to discussions about “how to” or exploring
492 T.K. Killeen et al.
options for change once clients were ready to change (phase 2). Thus, clinicians
move clients beyond resolution of ambivalence into more action-oriented conver-
sation with the flexibility to cycle back through processes with fluctuating ambiva-
lence and/or sustain talk. Establishing a trusting, therapeutic relationship through
engaging the client builds the foundation for future work and has been shown to
impact retention and substance use outcomes (Crits-Christoph, Gibbons, Hamilton,
Ring-Kurtz, & Gallop, 2011). Focusing the conversation on a mutually established
agenda often involves exploring and clarifying values/goals that may lead to
behavior change consideration. Evoking the client’s own motivation for change
is critical to MI. Clients, not clinicians, argue for change. Clinicians elicit change
talk through MI-specific skills and reinforce it when it does occur. Clinicians
determine the level of readiness for clients to move to more action-oriented
MI. There are several indicators of readiness such as envisioning what change
would be like or asking for help or information about change options. Planning for
change involves utilizing the same MI spirit and style as used in the other processes.
It is important that the clinician is in tune with the client and moves through these
processes at the client’s pace (Miller & Rollnick, 2012).
Clients demonstrating readiness to change are often ready to mobilize a plan of
action. There is a shift from preparatory to mobilizing language. Clinicians are
evoking and supporting client statements that express intentions and commitment.
Clinicians take care to approach change plans in a collaborative, respectful manner,
allowing clients the autonomy to decide what is in their best interest. The “righting
reflex” or the helpful desire on the part of the clinician to “fix” the problem is a
common urge that clinicians should be aware of and monitor. The skillful MI
clinician will exchange information and provide advice with permission in an
MI-consistent manner. It is not uncommon for the clinician to offer the client a
menu of options. Clients with SUD often feel out of control in their lives and having
choices can empower them. Change plans can be verbal or written, but often
specific goals need to be broken into small achievable steps so that patients may
experience early success. The MI change plan may also identify expected benefits
of change, barriers that may get in the way of change, and success criteria. It is
important that patients have the confidence and self-efficacy to implement the plan
(Miller & Rollnick, 2012).
22.2 MI Applied to Substance Use Disorders and Addictive
Disorders
22.2.1 Outcome Research
Motivational interviewing has been one of the most widely researched
interventions. To date, there have been several meta-analyses exploring the effec-
tiveness of MI across various health behaviors. The most recent meta-analysis of
MI effectiveness across a variety of problem behaviors showed that 50 % of studies
demonstrated small to moderate effect sizes and 25 % of studies demonstrated
22 Motivational Interviewing in the Treatment of Substance Use Disorders... 493
moderate to large effect sizes (Lundahl, Kunz, Brownell, Tollefson, & Burke,
2010). Importantly, this meta-analysis found that MI can produce at least equal
positive health behavior changes in comparison to strong psychosocial
interventions and can do so in a shorter length of delivery time. Thus, research
has demonstrated that MI is successful in motivating clients to change across a
variety of problem domains. In addition, the meta-analysis found that MI effects are
durable across time, MI can be delivered in various formats but may work best as a
prelude to further treatment, and a higher dosage of MI treatment time may produce
better outcomes. The use of a manual to deliver MI does not necessarily contribute
to effectiveness, and there may be certain populations such as socially excluded
individuals that fare better with MI approaches.
Adolescents are a vulnerable population with high rates of substance use, yet
treatment options remain limited and adolescents are difficult to engage and retain
in treatment. As such, a MI-consistent autonomous and collaborative approach is
more appealing for adolescents. In a review of 39 studies exploring mechanisms of
change for MI in adolescents with SUD, 67 % of the studies showed a positive
effect on substance use outcomes (Barnett, Sussman, Smith, Rohrbach, & Spruijt-
Metz, 2012). Differences in MI intervention designs made establishing specific
mechanisms for change in adolescent populations difficult. Specific MI adaptations
for adolescents include school-based interventions and the involvement of family
members. Studies in the review examined various forms of MI, including MI
implemented alone, added to other interventions such as CBT, delivered with
feedback, given following MD advice, and used as a booster to skill-based class-
room or social network interventions. Attitudinal (readiness/intention to change,
engagement in treatment, perceived risk) and behavioral (reduced dependence
criteria, drug refusal skills, self-monitoring) mechanisms for change were reported
in some studies. In two studies whereby process of change was measured, client
change talk and commitment were related to substance use outcomes (Baer et al.,
2008; Engle, Macgowan, Wagner, & Amrhein, 2010). Miller and Rose (2009)
proposed a hypothesized path relationship between MI and behavior change.
Clinicians using MI-consistent counseling style elicit preparatory (DARN: desire,
ability, reason, need) change talk followed by an increasingly stronger pattern of
commitment talk over the course of the session which is predictive of positive
change outcomes. Alternately, clinicians using a MI-inconsistent confronting style
elicit more sustain talk or resistance to change, which is predictive of poor
outcomes.
22.2.2 MI as a Stand-Alone Approach
MI can be implemented as a stand-alone approach, a preamble to another interven-
tion, an adjunct to another intervention, and delivered with feedback as is done in
motivational enhancement therapy (MET). MI is particularly useful in approaching
clients who are reluctant to change or complacent with the status quo. Studies have
explored the use of brief MI interventions in engaging clients in treatment and
494 T.K. Killeen et al.
improving retention. In one large National Institute of Drug Abuse (NIDA) Clinical
Trials Network (CTN) multisite study, 423 individuals presenting for treatment at
community substance abuse treatment programs were randomized to receive either
a standard intake assessment only or a standard intake assessment with 20 min of
MI techniques integrated into the intake session. Participants were followed for
retention in treatment and substance use outcomes. Those receiving the MI inter-
vention attended more treatment sessions and were more likely to be enrolled in
substance abuse treatment services at 1 month than those receiving the standard
intake assessment only (Carroll et al., 2006).
22.2.3 MI as an Adjunct or Prelude to Psychosocial Interventions
Given that MI is a style of communication that engages individuals in behavior
change, it is not surprising that MI has been integrated into other psychosocial
therapies to improve treatment engagement and outcomes. MI coupled with client
assessment feedback (motivational enhancement therapy—MET) and delivered in
three to four sessions provides clients with objective information that can help
guide decisions about change. In a large multisite community study, 461 substance
abuse treatment-seeking clients were randomized to receive either three individual
sessions of MET or three individual sessions of counseling as usual (CAU) in
addition to the regular group counseling offered at the perspective community
programs (Ball et al., 2007). In addition to employing MI spirit and style, MET
clients were given personalized feedback reports collected and summarized from
assessments they completed at study entry. Clinicians used MI skills to explore
ambivalence, develop discrepancies between current behavior and stated values,
elicit change talk, and collaboratively work a change plan. Clients participated in
the three sessions within the first 28 days of community treatment entry. Retention
and substance use outcomes were followed out to 16 weeks. Although both groups
reduced the number of days of primary substance use by the end of the study
intervention (4 weeks), those in the MET condition maintained this reduction into
the follow-up period, while those in the CAU returned to baseline levels of use
during this time (Ball et al., 2007).
A five-session motivational enhancement therapy plus cognitive behavioral
therapy (MET/CBT) intervention used in the Cannabis Youth Study included two
individual MET sessions focused on resolving ambivalence and increasing motiva-
tion, followed by three group sessions of cognitive behavioral coping skills
(Ramchand, Griffin, Suttorp, Harris, & Morral, 2011). Adolescents receiving the
MET/CBT intervention were followed out to 12 months and compared to outpatient
community treatment as usual (TAU) that was deemed “exemplary” by the Sub-
stance Abuse Mental Health Service Administration (SAMHSA) standards. At
12 months, greater reductions in substance use and illegal behaviors were observed
in the adolescents receiving MET/CBT than those in the TAU condition. These
results demonstrate that five sessions of MET/CBT delivered weekly can
22 Motivational Interviewing in the Treatment of Substance Use Disorders... 495
outperform community TAU that typically is longer in duration and involves more
treatment sessions.
A study targeting individuals with cocaine use disorders compared the addition
of one MET session followed by two CBT sessions (MET + CBT) to three sessions
of CBT delivered alone (McKee et al., 2007). Clinicians in the MET + CBT
condition were trained to also use an MI style when delivering the CBT component.
Participants were referred to community substance abuse treatment following the
interventions. Primary outcomes included changes in treatment motivation, treat-
ment satisfaction, and retention in standard community treatment. By the end of the
intervention, those receiving MET + CBT reported greater desire for abstinence and
greater expectation of success than those receiving CBT alone. While the propor-
tion of participants attending ongoing community treatment was similar across
groups, those in the MET + CBT attended significantly more treatment sessions
than the CBT alone group (5.66 vs. 1.57, respectively).
Motivational interviewing has also been successfully integrated with compli-
ance enhancement therapy (MI-CET) to increase retention and medication adher-
ence in pharmacotherapy studies. Sessions use MI techniques and personalized
feedback (i.e., alcohol use severity, lab results) coupled with medication
instructions and problem-solving discussions related to medication adherence. A
nine-session manual-guided MI-CET intervention delivered with the antidepres-
sant, citalopram, was evaluated for its impact on treatment adherence and retention
in 121 treatment-seeking adults with alcohol dependence (Heffner et al., 2010).
Compared with another CET without MI delivered as an adjunct to medication,
MI-CET participants had 20–30 % higher treatment completion rates. Thus, studies
clearly show the enhanced benefits of integrating MI into other therapy approaches.
22.2.3.1 Group MI
Substance abuse programs typically deliver treatment in a group format. Although
MI was originally designed for implementation in individual sessions, several
studies have explored its efficacy in group therapy. Female college drinkers
(N¼110) cited for campus alcohol violations attended one gender-specific motiva-
tional interviewing group session followed by 12 weeks of completing online
drinking dairies (LaBrie, Thompson, Huchting, Lac, & Buckley, 2007). The
sessions were 120 min and included personalized information regarding their
alcohol consumption patterns, normative feedback, gender differences in alcohol
effects, and discussions about participants’ reasons for drinking. Reductions in
alcohol consumption (29.9 %) and drinking consequences (35.9 %) from
pre-intervention to 3 months post-intervention were seen, with the most pronounced
effects in the heaviest drinking groups.
Another MI group intervention (GMI) was compared to an attention activity
control group (TAAC) in 101 inpatients with comorbid SUD and psychiatric
disorders (Santa Ana, Wulfert, & Nietert, 2007). Patients received two sessions
lasting 120 min and outcome measures collected at 1 and 3 months included
aftercare attendance and substance use. Patients in the GMI attended more aftercare
sessions than those in the TAAC group at 1 month (25.4 vs. 16.8, respectively) and
496 T.K. Killeen et al.
at 3 months (21.1 vs. 10.7, respectively). At 1 month, patients in the GMI group
reported significantly fewer days of illicit substance use and binge drinking, and
they consumed less alcohol than those in the TAAC group. These effects were
sustained for alcohol consumption and binge drinking at the 3-month follow-up.
More randomized controlled studies exploring the efficacy of group MI are needed
to advance the field and increase the potential for adoption in community programs
where the primary mode of treatment delivery is group therapy.
22.2.3.2 MI Delivered in Medical Settings
Only a small proportion of individuals who have problems with alcohol and illicit
drug use actually receive formal substance abuse treatment. Many of these
individuals are seen in emergency rooms or in primary care clinics when medical
problems associated with problematic use are encountered. One study using a state
trauma registry found that 21 % of injuries requiring hospitalizations were related to
substance use and the most severe injuries were substance related (Socie, Duffy, &
Erskine, 2012). Offering brief MI interventions targeting alcohol and drug use can
address substance use problems and also reduce healthcare utilization. Studies show
that using brief screening assessments in emergency department and primary care
clinics followed by a 15–20 min brief MI intervention can decrease alcohol and
drug use in patients presenting with modest problematic use and can identify and
refer those patients in most need of referral to substance abuse treatment programs
(Pilowsky & Wu, 2012; Saitz, 2005).
In one large study implemented across multiple medical treatment settings,
22.7 % of patients screened positive for problematic use to abuse/dependence of
alcohol or illicit substances (Madras et al., 2009). Sixteen percent received a brief
intervention, and another 7 % received referral to treatment. Brief interventions
included discussing the patient’s perspective of his or her substance use, providing
feedback from screening assessments compared with normative values, providing
recommended use guidelines (i.e., National Institute of Drug Abuse [NIDA], 2010),
and collaboratively developing a change plan. Several sites in this study used a brief
intervention referred to as FRAMES that employs an MI approach: feedback,
responsibility, advice, menu of options, empathy, and self-efficacy (Bien, Miller,
& Tonigan, 1993). In a random selection of the population that screened positive at
baseline, there were significant reductions in illicit drug use (67.7 %) and heavy
alcohol use (38.6 %) at the 6-month follow-up. In the more problematic group
referred to specialty substance abuse treatment, there were significant
improvements in other functional domains such as mental health, criminality,
unemployment, and housing instability. Clearly, implementing SBIRT (screening,
brief intervention, referral to treatment) interventions in emergency departments,
primary and specialty medical care settings can help to prevent risky alcohol/
substance use from becoming a significant medical concern and to refer patients
who are already experiencing medical complications to formal treatment (NIDA,
2010).
22 Motivational Interviewing in the Treatment of Substance Use Disorders... 497
22.2.4 MI and Behavioral Addictions
Motivational interviewing has also been implemented for pathologic gambling, a
DSM-5 substance-related and addictive disorder diagnostic category. A meta-
analysis of psychotherapy outcomes for gambling behavior included three motiva-
tional interviewing studies that demonstrated modest reductions in gambling fre-
quency and less financial loss as a result of gambling (Cowlishaw et al., 2012).
Petry, Weinstock, Morasco, and Ledgerwood (2009) conducted a randomized
control study comparing three interventions (brief advice, MET, or MET + CBT)
for problem gambling in college students. Although all interventions improved
problematic gambling behavior, at the 9-month follow-up, students receiving the
50-min session of MET wagered substantially less of their income than those
students receiving the other interventions. With the addition of pathologic gambling
to the addiction diagnostic category, more research exploring substance use treat-
ment approaches such as MI for pathologic gambling and perhaps other behavioral
addictions can be expected in the future.
22.2.5 Dissemination of MI
MI has been one of the most widely disseminated approaches in substance abuse
treatment programs over the last 10–20 years. In a recent survey administered to
over 1,400 clinicians in 345 private community substance abuse treatment
programs across the USA, over 80 % reported using MI in their practice (Bride,
Kintzle, Abraham, & Roman, 2012). Although MI has been adopted in many
substance abuse programs, the lack of supervision in MI is a challenge to the
field because it is necessary to maintain MI fidelity. In order to adequately imple-
ment MI, training involves intensive skill building workshops, post-workshop
experiential practice and role plays, and ongoing supervision and coaching guided
by fidelity ratings of taped sessions (Miller, Yahne, Moyers, Martinez, & Pirritano,
2004). Studies have shown that the best supervision model is to directly observe or
review taped sessions for clinician MI-consistent and MI-inconsistent style and
provide clinicians with feedback and coaching. Implementing MI with proficiency
has been shown to increase patient motivation and decrease resistance (Gibbons
et al., 2010; Martino, Ball, Nich, Frankforter, & Carroll, 2008; Miller et al., 2004).
In one large multisite community program study, a reduction in drug use during the
first 4 weeks of treatment was related to clinicians’ MI skill ratings (Martino et al.,
2008). The National Institute of Substance Abuse (NIDA) in conjunction with the
Substance Abuse and Mental Health Services Administration (SAMHSA) created a
MI supervision toolkit called Motivational Interviewing Assessment: Supervisory
Tools for Enhancing Proficiency (MIA:STEP) (Martino et al., 2006). This product
contains a tool for rating MI fidelity that can be used by supervisors to evaluate
clinicians’ use of MI, provide feedback, and coach clinicians to implement MI with
fidelity (Martino et al., 2006). Without supervision and coaching, clinicians are
more likely to experience therapy drift and fall below recommended proficiency
498 T.K. Killeen et al.
levels. Discrepancies between clinician self-report and supervisor/expert fidelity
ratings on MI style, MI-consistent, and MI-inconsistent proficiency ratings validate
the need for continued post-workshop supervision (Martino, Ball, Nich,
Frankforter, & Carroll, 2009). Clinician characteristics and organizational climate
have been shown to influence acquisition and retention of MI skills and adoption of
practice (Baer et al., 2009). The MIA-STEP toolkit ensures best practices for
delivering MI.
22.3 MI Applied to Eating Disorders
Individuals with eating disorders (ED), particularly those with binge-eating
symptoms, often describe their disorder as akin to an addiction (Cassin & von
Ranson, 2007). Many similarities have been noted between binge eating and SUD,
including preoccupation with thoughts about the substance (i.e., psychoactive
substance or food), cravings and repeated urges to consume the substance, mount-
ing tension until the substance is consumed, loss of control over the behavior,
consuming larger amounts than intended, feeling ashamed following use of the
substance, feeling unable to reduce or stop the behavior, and continuing to engage
in the behavior despite knowledge of adverse effects (Cassin & von Ranson, 2007;
Gold, Frost-Pineda, & Jacobs, 2003; Wilson, 1991).
Similar to SUD, ED symptoms are also reinforcing and fulfill important and
valued functions for the individual. For example, individuals with anorexia nervosa
(AN) report that their ED provides a sense of safety and protection, allows them to
feel in control, and makes them thinner and more attractive as a result of weight loss
(Serpell, Treasure, Teasdale, & Sullivan, 1999). In addition to these benefits,
individuals with bulimia nervosa (BN) also report that their ED allows them to
avoid or manage their emotions and to eat forbidden food without gaining weight
(Serpell & Treasure, 2002). Not surprisingly, given their ego-syntonic nature,
individuals often feel reluctant to engage in treatment and make changes to their
ED symptoms. However, individuals also acknowledge some costs associated with
their ED, including feeling that the ED has taken over their life (ironically, making
them feel more out of control), hindering relationships and career opportunities, and
damaging physical health (Serpell et al., 1999; Serpell & Treasure, 2002). MI is
designed to capitalize on this ambivalence and to enhance intrinsic motivation and
readiness for change.
Readiness for change is an important target for treatment because it has signifi-
cant implications for ED recovery. For example, longitudinal research
demonstrates that readiness for change predicts enrollment in intensive ED treat-
ment, completion of recovery-related activities, weight gain, treatment dropout, and
relapse following treatment (Bewell & Carter, 2008; Geller, Cockell, & Drab, 2001;
Geller, Drab-Hudson, Whisenhunt, & Srikameswaran, 2004; Rieger et al., 2000). It
is important to note that, in addition to fluctuating over time, readiness for change
also varies across specific ED symptoms. For example, an individual might feel
22 Motivational Interviewing in the Treatment of Substance Use Disorders... 499
ready to stop bingeing and purging, yet still feel pre-contemplative about reducing
dietary restriction (Geller et al., 2001).
22.3.1 Outcome Research
Empirical research examining the impact of MI on readiness for change and
psychosocial functioning in the ED has been accumulating over the past decade.
In the treatment of ED, MI has been used as both a stand-alone intervention
(in conjunction with a self-help manual) (Cassin, von Ranson, Heng, Brar, &
Wojtowicz, 2008; Dunn, Neighbors, & Larimer, 2006), and as a prelude or adjunct
to another treatment, such as outpatient cognitive behavioral therapy (Gowers &
Smyth, 2004; Katzman et al., 2010; Treasure et al., 1999) or intensive inpatient or
day patient ED treatment (Dean, Touyz, Rieger, & Thornton, 2008; Feld,
Woodside, Kaplan, Olmsted, & Carter, 2001; Geller, Brown, & Srikameswaran,
2011; George, Thornton, Touyz, Waller, & Beumont, 2004; Wade, Frayne,
Edwards, Robertson, & Gilchrist, 2009; Willinge, Touyz, & Thornton, 2010). A
recent systematic review of 10 studies concluded that MI holds promise in the
treatment of ED, particularly with respect to its impact on readiness for change
(Macdonald, Hibbs, Corfield, & Treasure, 2012). Although heterogeneity in study
design and methodology was noted as limiting comparison across studies, the bulk
of the evidence suggests that MI can be effective in increasing readiness for change
and improving eating pathology and psychosocial functioning (e.g., depression,
anxiety, self-esteem, quality of life).
22.3.2 MI as a Stand-Alone Treatment
Studies examining the impact of single-session, stand-alone MI interventions in
reducing binge eating have generated promising results. College students (N¼90)
with full or subthreshold BN or binge-eating disorder (BED) who were randomly
assigned to receive MET + self-help handbook reported increased readiness for
change compared to those who received a self-help handbook only (Dunn et al.,
2006). Although both groups decreased the frequency of their binge eating to a
similar extent, the MET group had higher binge abstinence rates at 4 months (24 %
vs. 9 %). In another study, women with BED (N¼108) recruited from the commu-
nity who were randomly assigned to receive MI + self-help handbook reported
greater improvements in binge eating, depression, self-esteem, and quality of life
over a 4-month follow-up period compared to those who received a self-help
handbook only (Cassin et al., 2008). In addition, the MI + self-help handbook
group reported higher binge abstinence rates (28 % vs. 11 %). Although research
on stand-alone MI interventions for EDs is still in its infancy, the studies conducted
to date suggest that MI can be effective in improving binge eating and psychosocial
functioning in non-treatment-seeking samples.
500 T.K. Killeen et al.
22.3.3 MI as a Prelude or Adjunct Treatment
Studies examining the application of MI in clinical ED samples have used MI as a
prelude to inpatient, day patient, or outpatient ED treatment with the aim of
increasing readiness for change and engagement in treatment or as an adjunct to
treatment with the aim of improving remission rates and preventing dropout.
22.3.3.1 Intensive Treatment
Individuals with AN and BN (N¼19) participating in a pilot study examining a
four-session group MI intervention as a prelude to a specialized ED treatment
reported improvements in readiness for change, depression, and self-esteem over
the course of treatment (Feld et al., 2001). Improvements were not reported in
eating pathology over the 6-week period; however, it is notable that 90 % of
participants enrolled in specialized ED treatment afterwards.
A more recent study examining the impact of a four-session group MI interven-
tion as an adjunct to treatment as usual in an inpatient sample (N¼42) reported that
MI did not improve eating pathology to a greater extent than treatment as usual;
however, the MI intervention fostered greater engagement in therapy and promoted
treatment continuation (Dean et al., 2008).
Another study examining the impact of a four-session MI intervention as an
adjunct to treatment as usual in an inpatient AN population (N¼47) reported that a
greater proportion of individuals in the MI group moved from “low” to “high”
readiness for change over the study period relative to the treatment-as-usual group,
whereas a greater proportion of the treatment-as-usual group dropped out from the
study (Wade et al., 2009). However, there were no significant group differences in
eating pathology among individuals who completed treatment.
A randomized controlled trial examined the efficacy of MI on readiness for
change, eating pathology, and psychosocial functioning in a mixed diagnosis (AN,
BN, EDNOS) tertiary care clinical population (N¼113) (Geller et al., 2011). In this
study, a smaller proportion of individuals in the MI group were rated as “highly
ambivalent” at 6-week and 3-month follow-up compared with those in the control
condition. However, both MI and control groups reported similar improvements in
eating pathology and depression. This latter finding might be attributed to two
sources of “MI contamination” in the control condition. First, all study participants
completed the readiness and motivation interview to assess readiness and motiva-
tion for change, which has several ingredients (e.g., curious, nonjudgmental inter-
viewer stance when discussing readiness) that are similar to a single-session MI
interventions. Second, the majority of participants in both groups were exposed to
additional treatment from care providers within an ED program that used an MI
stance during the study period (Geller et al., 2011).
22.3.3.2 Outpatient Treatment
Adolescents with AN (N¼42) who participated in a motivational assessment as
part of a pilot study reported improved motivation following the assessment, and
80 % enrolled in an outpatient CBT program (Gowers & Smyth, 2004). Moreover,
22 Motivational Interviewing in the Treatment of Substance Use Disorders... 501
individuals who reported greater motivation following the assessment gained
significantly more weight over a 6-week period.
A large randomized controlled trial examined the role of readiness for change in
treatment engagement and outcome in individuals with BN (Katzman et al., 2010;
Treasure et al., 1999). The first phase of treatment compared 4 sessions of either MI
or CBT in engaging patients in treatment and improving symptoms in women with
BN (N¼125) (Treasure et al., 1999). Despite a focus on motivation rather than
symptom reduction, MI was as effective as CBT in reducing the frequency of binge
eating, vomiting, and laxative abuse over the first 4 weeks of treatment. In terms of
clinically significant change, 53 % of individuals in the MI group showed improve-
ment in binge eating, 58 % in vomiting, and 27 % in laxative abuse. In a subsequent
two-stage randomized control trial, individuals with BN and EDNOS (N¼225)
were randomly assigned to receive 4 sessions of MI or CBT in phase 1 as a prelude
to 8 sessions of either individual or group CBT in phase 2 (Katzman et al., 2010).
All groups reported significant improvements in binge eating, vomiting, and laxa-
tive abuse, and they did not differ from one another. In addition, the groups did not
differ with respect to treatment completion/dropout.
Taken together, the body of literature suggests that MI holds promise in the
treatment of ED, particularly among individuals engaging in eating binges and/or
compensatory behaviors that are not sufficiently severe to require treatment at a
tertiary care facility. In individuals presenting for treatment at specialized inpatient
and day treatment programs, MI alone does not appear to have an immediate impact
on eating pathology. This finding is not surprising given that existing gold standard
evidence-based treatments for ED, such as CBT, typically require 20–40 sessions
depending on the client’s weight status (Fairburn, 2008). However, the empirical
research published to date does suggest that MI increases readiness for change and
promotes enrollment in, and engagement with, action-oriented treatment.
MI is increasingly being incorporated into evidence-based treatments for
ED. For example, treatments such as CBT and dialectical behavioral therapy
(DBT) have a client-centered focus and emphasize the importance of using a
collaborative stance throughout treatment. In addition, they both frequently make
use of specific MI techniques, such as using a decisional balance to explore
ambivalence regarding making and maintaining changes (e.g., reducing dietary
restriction or binge eating). The decisional balance can be used at the beginning
of treatment to increase clients’ readiness for change. In addition, it can be used
during the course of treatment if progress comes to a standstill (e.g., to explore
ambivalence about completing between-session homework assignments such as
food records) or if the client is contemplating dropping out of treatment (e.g., to
examine the benefits and costs of staying in treatment vs. dropping out from
treatment). Other ED treatments explicitly incorporate MI directly into the treat-
ment protocol. For example, a novel cognitive interpersonal treatment for AN, the
Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) uses MI techniques
to explore pro-anorexia beliefs and examine their potential role in the maintenance
of the ED.
502 T.K. Killeen et al.
22.4 Using MI in Comorbid ED and SUD
Individuals with an ED appear to be over four times more likely to develop a
comorbid SUD compared to the general population (Gadalla & Piran, 2007). The
specific rates of comorbidity vary depending on the type of ED symptoms and type
of substance. For example, rates of alcohol use disorders tend to be elevated in
individuals with bingeing symptoms and purging symptoms (Calero-Elvira et al.,
2009; Franko et al., 2005; Gadalla & Piran, 2007), whereas they do not tend to be
elevated in individuals with AN-restricting subtype (Franko et al., 2005). A poten-
tial reason for this pattern of comorbidity is that individuals with restricting AN
avoid alcohol due to its high caloric content, whereas alcohol reduces inhibitions
thereby increasing susceptibility to binge eating in individuals with AN-binge/
purge subtype, BN, and BED. Stimulant use disorders also tend to be elevated in
ED populations, and it has been postulated that individuals with ED might begin
taking stimulants to suppress appetite and promote weight loss (Nøkleby, 2012). As
mentioned previously, in addition to having elevated rates of comorbidity,
individuals with SUD and ED share many “addictive” features, such as feeling a
loss of control over the behavior and inability to reduce or stop the behavior despite
adverse physical and psychological effects (Cassin & von Ranson, 2007; Gold
et al., 2003; Wilson, 1991). Particularly relevant to the topic of MI, ambivalence
about recovery tends to be the norm among individuals with SUD and ED and can
pose a significant barrier in treatment if not addressed.
22.4.1 Limited Research
In light of the shared features and high rates of comorbidity, an integrated treatment
approach that concurrently addresses SUD and ED symptoms is recommended
(Harrop & Marlatt, 2010). Although MI has a large evidence base in the treatment
of SUD, and a growing evidence base in the treatment of ED, no empirical studies
have examined MI in the treatment of comorbid SUD and ED. Individuals with both
types of disorders are often characterized as ambivalent about change, difficult to
engage in treatment, and prone to relapse. Therefore, MI could be particularly
helpful given that it is intended to increase readiness for change and promote
engagement in treatment. Unfortunately, individuals who present for treatment
with comorbid SUD and ED are often excluded from research studies and clinical
services at specialty ED programs and addiction programs on the basis of their
coexisting disorders.
22.5 Future Directions
The clinical practice and empirical investigation of MI has grown exponentially
over the past decade. With respect to ED, many studies either lack a control
condition or have insufficient follow-up periods to determine the longer-term
22 Motivational Interviewing in the Treatment of Substance Use Disorders... 503
impact of the MI intervention. With these caveats in mind, the research conducted
to date suggests that MI has the potential to increase readiness for change and
improve eating pathology, particularly in individuals who binge eat and/or engage
in compensatory behaviors. Although MI has been shown to increase readiness for
change in individuals with AN, the studies conducted to date have reported rela-
tively little impact on eating pathology. However, with a few exceptions (Gowers &
Smyth, 2004), MI has been conducted primarily in a group format with individuals
with AN. It would be informative to examine the impact of individual MI on
readiness for change, dietary restriction, and weight restoration in individuals
with AN.
MI was originally intended for individuals not yet ready to take action, whereas
CBT is an action-oriented treatment intended for individuals ready to make
changes; however, this patient-treatment matching assumption has not yet been
examined empirically. Thus, this patient-treatment matching assumption (i.e., what
treatment works best for whom) would be a valuable avenue for future research.
When compared to other evidence-based treatments, such as CBT, MI has been
shown to exert similar effects on readiness for change and treatment outcome,
suggesting that MI may be used as an alternative to CBT in the preliminary stages
of treatment (Katzman et al., 2010; Treasure et al., 1999). When MI has been
delivered as a prelude to CBT, MI has typically consisted of a set number of
sessions (one to four sessions). Future research would benefit from empirically
examining when it is best to transition from the engagement to action-oriented (i.e.,
symptom reduction) phases of treatment. Finally, given that MI is increasingly
being incorporated into action-oriented evidence-based treatments, it would also be
informative to conduct dismantling studies to determine the effective components
of these integrated treatments.
Finally, given the elevated rates of comorbidity and shared features between ED
and SUD, it would certainly be a worthwhile endeavor to examine the effectiveness
of MI in individuals with comorbid disorders.
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