Motivational Interviewing With a Mandated-EAP Client
Ms. J., 29, is referred by her employee assistance program after a workplace incident in which she arrived late and argued with a supervisor. She reports drinking three to four glasses of wine four or five nights per week, usually after her child goes to bed. She says, 'I don't have a problem. My boss overreacted. Everyone drinks.' She is angry, arrives late, keeps her coat on, and says, 'You're just another person who's going to tell me to quit.' On importance of cutting down she rates 3/10; confidence 4/10. She denies any withdrawal symptoms, blackouts, or driving after drinking. She has not been told she must quit to keep her job, but she worries about her daughter. You have 25 minutes and this is the first session.
1. What would you do in the first 10 minutes, and how would you apply the MI spirit?
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First 10 minutes: engage and avoid the righting reflex. Say, 'You're here because work sent you, and you're not sure this is useful. I'm not going to tell you to quit or pretend I know what's best for you. I'd like to understand what happened and what you care about.' Ask permission: 'Would it be okay if we talked about your drinking, and you can tell me if I get it wrong?' Use open questions ('What happened at work from your view?'), affirmations ('You're here, even though you're angry. That says something'), reflections ('You feel singled out, and you don't see your drinking as the problem'), and summaries. Roll with sustain talk rather than arguing: 'You don't have a problem, and everyone drinks. That's your view.' Do not label her 'in denial,' lecture about liver damage, or imply she must quit to keep her job. The MI spirit is partnership, acceptance, compassion, and evocation. With 25 minutes, engagement is the intervention; an action plan now would be premature.
2. How would you respond to sustain talk and elicit change talk without confrontation?
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Respond to sustain talk with reflection, not correction. If she says, 'I don't have a problem,' reflect: 'You don't see your drinking as a problem, and you're angry that work made it one.' If she says, 'Everyone drinks,' reflect the function: 'It helps you unwind after your daughter goes to bed; it's the one part of the day that's yours.' Then look for change talk: 'What would make you consider cutting down, even a little?' and 'What worries you about the way things are now?' Evoke values: 'What kind of mom do you want to be?' Do not use the confrontation script ('You need to admit you're an alcoholic'). If she gives a reason for change, ask for elaboration: 'Tell me more about that.' Summarize both sides: 'On one hand, you don't think it's a problem and you resent being sent. On the other, you worry about your daughter and your job. Did I miss anything?' End with an autonomy-supportive question: 'What, if anything, would you want to do next?'
3. How would you use importance and confidence rulers, and what should you avoid?
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Use the rulers after engagement, not as a gimmick. Ask, 'On a 0-10, how important is cutting down, where 0 is not at all and 10 is the most important thing in your life?' She says 3. Ask, 'Why 3 and not 0?' This elicits her own reasons rather than yours. Then ask, 'What would move it to a 4?' For confidence: 'If you decided to cut down, how confident are you you could do it?' She says 4. Ask, 'Why 4 and not 2?' and 'What would help you feel more confident?' Reflect the change talk and summarize. Do not argue with the number or say 'Only 3?' Avoid premature advice, scare tactics, and making the plan contingent on accepting a label. Offer options only with permission: 'Would you like to hear what some people find helpful, or would you rather keep talking?' Given no withdrawal or driving risk, a wellness coach can focus on engagement and refer to a substance-use specialist if she wants or if risk emerges; know your scope.