Psychotherapy With group

00:00 CARLSON: Welcome to our program on addictions. 00:03 Today we'll be talking to William Miller about 00:06 Motivational interviewing. 00:08 Judy, what kind of a contribution has this approach 00:11 made to the field of addictions? 00:14 LEWIS: It's only revolutionized it, that's 00:16 all-I think because as counselors as therapists we're 00:20 accustomed to working with clients in a way that's 00:23 respectful, collaborative we're used to the idea of 00:27 working with clients to agree on what should be the goals 00:32 and the treatment plan. 00:33 And now I think, finally, people feel as though they 00:36 have permission and some backing to use these same 00:39 kinds of attitudes when they're working with 00:42 addictions clients. 00:43 And so many people just use this at the beginning- this 00:46 empathy, respect. 00:49 Dr. Miller's approach uses these conditions and focuses 00:52 on these conditions throughout the treatment process, and 00:55 really helps people move from this ambivalent state into the 01:00 state of really wanting to bring about self-change. 01:02 Yeah, exactly. 01:03 Let's bring out Dr. Miller, and learn about this approach. 01:05 Bill, welcome. 01:11 LEWIS: Hi. 01:13 Bill, could we start out getting a general overview of 01:18 your revolutionary approach? 01:21 MILLER: I don't know that it's revolutionary, but often, in 01:26 the addiction field, the model has been you need to put 01:28 something into the person, or change them, or convince them, 01:32 or confront them and this is more of a 01:34 drawing-out-of-the-person approach. 01:36 And you mentioned ambivalence just a moment ago-it's a place 01:41 where people get stuck. 01:42 They want to, they don't want to. 01:44 And they have trouble moving off that space. 01:46 This is a way of helping people to resolve that 01:49 ambivalence and move on toward behavior change. 01:53 It's both client-centered and directive, which is an odd 01:57 combination in some folks' minds but very interested in 02:01 the person's own perspective very concerned with how they 02:04 understand things and what they want with their lives. 02:07 And at the same time, it's not just following the person it's 02:10 moving the person along in the direction of change. 02:15 LEWIS: So you do have an idea about where you hope the 02:19 person will go? 02:21 MILLER: Yes, and that's the sense in which it's directive. 02:24 When you're sitting with a person who's using crack 02:26 cocaine, you do have an idea about where you'd like them to 02:29 go which is away from that direction. 02:31 That may or may not be where they are at the moment. 02:34 This approach starts with the person where they are but then 02:39 moves them in a direction of healthy change. 02:41 So you hope they'll move toward healthy change, but you 02:44 recognize that if you try to convince them to move in that 02:47 direction, it wouldn't be productive. 02:49 It may even do the opposite. 02:51 When a person is ambivalent, they have inside them both 02:55 arguments in a way-the argument toward health, the 02:58 argument toward continuing what they've been doing. 03:00 And if you as a counselor take the side of health you leave 03:04 the client the role of arguing against it. 03:06 And the client may indeed talk him- or herself into 03:09 continuing the behavior rather than changing. 03:12 And what we do is almost the opposite of that- is to draw 03:16 out of the person their own motivations for change, their 03:19 own desire for health, their own interest in doing 03:22 something different. 03:23 CARLSON: So there is an assumption that people really 03:26 do, at some level, want to be healthy. 03:29 MILLER: Absolutely, yeah-that that's inherent in the person 03:32 and that they have in them the resources to do that. 03:35 It draws on the person's inner resources rather than assuming 03:38 that I, as the therapist have the wisdom I need to give them 03:42 to fix them. 03:43 So it's very democratic in the fact of, given a choice, 03:47 people can find their own best way. 03:49 And that that's the natural way. 03:51 It's almost if we don't get in the way of changing, people 03:54 will move along naturally in that direction. 03:57 CARLSON: How do you conceptualize 03:58 the addiction process? 04:01 MILLER: It's an interesting one to put together with this 04:02 because addictions are fundamentally ambivalence. 04:06 What are they? 04:07 It's doing something that's pleasurable or in some way 04:10 reinforcing even though it's having adverse consequences. 04:14 And that's the diagnostic definition of what addictive 04:18 behavior is about, whether it's gambling or drug abuse or 04:21 whatever it is continuing to do something that's in one way 04:25 enjoyable and in another way destructive. 04:28 And people who are engaged in those behaviors know both of 04:32 those things. 04:32 It's not that they don't know there are negative 04:34 consequences to what they're doing. 04:35 They're ambivalent. 04:36 They're caught in this place of ''I want it and I don't 04:41 want it,'' and that's where they get stuck. 04:43 Traditional approaches that have been more confrontive 04:47 about addictions have assumed that part of addiction is 04:54 denial and that you need to confront that 04:57 and break it down. 04:58 So you're seeing the assumptions that we make about 05:01 addictions, I think, a little differently. 05:04 And that grew out of my own experience, really. 05:06 I started working in the addictions field without 05:08 knowing that that was the way you're supposed to do it, and 05:13 after a couple of years began hearing about this confrontive 05:16 model and I thought, ''Gee, that's not my experience with 05:18 the people I've been working with.'' Looked at the research 05:22 on personality and there really is no consistent 05:25 personality associated with addictive behaviors. 05:27 So people don't walk through the door with all the same 05:32 personality. 05:34 So if the clients in my office are all behaving the same way 05:37 it's not because they came through the door that way. 05:40 It's something about the interaction. 05:41 And so it focused me very much on motivation as something 05:45 that happens between two people as a kind of dance in 05:48 which two people engage. 05:50 LEWIS: So what you are saying is that something that the 05:53 counselor or therapist was doing was feeding into this 05:59 sense of the client being in denial. 06:02 MILLER: And the opposite is true, too. 06:04 I mean, I know how to behave as a therapist if l want my 06:07 client to be very resistant and denying and backing away 06:10 from change and that's to be very directive, very 06:14 confrontive, very teaching. 06:16 If you take a more client-centered approach and 06:19 listen reflectively you find that resistance goes down. 06:23 And there even has been research with counselors 06:25 changing their style every 12 minutes within a session and 06:28 you can see client denial going up and 06:30 down within a session. 06:31 So denial really isn't a client problem-it's a 06:34 therapist or an interaction problem. 06:36 CARLSON: Are there some principles or some guidelines 06:40 or steps that underlie your practice. 06:42 MILLER: Well, as a matter of fact, there are five of them. 06:45 And empathy is the first one that Steve Rollnick and I have 06:50 emphasized in that it's very important to do the very 06:54 things that Carl Rogers was talking about-to listen to 06:58 understand the person's perspective, to be interested 07:00 in how they see it and to try to get inside that. 07:03 And the skills of reflective listening are very 07:06 much a part of that. 07:07 So that's one of them. 07:08 So you have to express the empathy-you just can't be 07:10 there and be empathic. 07:12 It's got to be fed back some way? 07:14 It's not a feeling. 07:15 This is a behavior. 07:16 And it's something that you do. 07:19 And the skills of reflective listening that so many of 07:21 Rogers' students have talked about are exactly the thing 07:24 that one does there. 07:25 You must be good at that to do Motivational Interviewing 07:28 really can't do it without that reflective skill. 07:31 So that's one. 07:31 That's one. 07:32 And then developing discrepancy is the second one 07:35 where- What does that mean? 07:37 What you're hoping is that you'll develop in the client's 07:40 mind a growing discrepancy between where they are and 07:44 where they want to be. 07:45 So it's coming to understand what their hopes and goals and 07:48 desires are and then saying, ''How does that fit together 07:52 with crack use or with alcohol use'' So many clients really 07:58 think that they are where they want to be until they really 08:00 think about it and realize that there is a real 08:02 discrepancy? 08:03 Until they start talking about it. 08:05 What often happens is a client will think of one reason pro 08:08 and one reason con, and sort of stop thinking about it. 08:11 And this has the person follow the thoughts of, ''What is 08:15 this costing me and why would I want to change'' And it's 08:20 also as much going toward something as 08:21 going away from something. 08:23 Just stopping everything you can do with general anesthesia 08:27 but people are wanting to move toward something. 08:30 And so it's bringing to life the thing that the person 08:33 wants to move toward and then putting that together with 08:36 their current behavior and saying, ''How does that fit?' 08:39 It's goal directed. 08:40 It's very goal directed, and you're hoping that in the 08:42 client's mind, the discrepancy is growing. 08:44 And the more the client describes the difficulties and 08:48 describes what it's costing them to continue the addiction 08:52 and describing where they would rather be instead the 08:54 more that discrepancy begins to open up. 08:57 CARLSON: Okay. 08:57 What about the third one?

09:00 MILLER: Avoiding argument is a piece of that. 09:04 And I alluded to that earlier, that the one thing you don't 09:07 want to do in this approach is be in the position where 09:10 you're arguing for change and the client is 09:12 arguing against change. 09:14 It's a script that any counselor can write. 09:16 Been there, done that. 09:18 That's right. 09:19 You know how it goes, and you can write the client's lines 09:22 that are counterarguments. 09:23 So don't get yourself in that position of arguing with and 09:26 pushing against the client because it actually takes you 09:29 in the other direction. 09:31 MILLER: In the wrong direction, that's right. 09:33 CARLSON: And what's the final one? 09:36 MILLER: Well, there are two more, actually. 09:37 One is roll with resistance. 09:39 So rather than arguing or pushing against, when you meet 09:44 what we call resistance and I think actually it's not a good 09:46 term, I'd like to find a better way of talking about it 09:48 but when the client begins arguing against change, you 09:51 don't push against that. 09:53 You don't try to overwhelm it or come up with a brilliant 09:57 counterargument to it but roll with it in very much the 10:00 manner that Satir and Haley and other people have talked 10:03 about in family therapy, and to use the momentum of that to 10:07 then redirect the person in the direction of change. 10:11 And then the last of them is to support self-efficacy which 10:14 has a lot to do with optimism. 10:16 Because if you've developed a discrepancy and you've caused 10:19 the person to feel like they're in danger but they 10:23 don't see anything they can do about it, you really haven't 10:26 taken them anywhere. 10:27 You've just made them distressed. 10:29 So an important piece of it is that it's possible to change, 10:33 and to hold up that hope. 10:34 CARLSON: So that hope-it seems like that's a 10:36 real important element. 10:37 MILLER: It is. 10:38 So that's the five things that we've talked about that come 10:41 together to form Motivational Interviewing. 10:44 So you're hopeful, and ideally the client will be more 10:50 hopeful and have a greater sense of self-efficacy about 10:54 being able to resolve the issue. 10:57 You need to have the hope in you for the clients. 10:59 It's very contagious. 11:00 There's a wonderful experiment from 20 years ago in which 11:04 therapists were caused to be particularly optimistic about 11:07 certain clients, who, as it wound up, 11:10 were chosen at random. 11:12 And those clients for whom the therapists had particular hope 11:15 and belief got better at a much higher rate 11:18 than the rest did. 11:19 If we see in the client the possibility of getting better, 11:23 it's contagious, and it actually draws 11:26 it out of the person. 11:27 CARLSON: That would seem to be so important in this field. 11:29 It is. 11:30 So many of the people who come to us are down and out. 11:32 Yes. 11:33 We see them as down and out. 11:35 They need to borrow your hope for a while. 11:37 In a way, haven't we sometimes done the opposite of what we 11:41 need to do around self-efficacy? 11:42 MILLER: I think so often, working with addictions 11:45 clients, therapists will focus so much on the negative of the 11:51 problems that are part of the person's life that they move 11:57 the person away from a sense of self-efficacy 12:00 instead of toward it. 12:01 I think it's very useful to focus on the positive-on the 12:05 person's strengths on what they want in their life, on 12:09 the direction that they feel, on their future on what's been 12:13 good about their past. 12:15 The negative is true enough and most clients know it well 12:18 enough, that they don't need to be beaten with it. 12:20 MILLER: Yeah. 12:21 Now, the client in this approach is really in charge 12:24 of his or her treatment plan, finally with the therapist 12:29 being an expert consultant at helping with that, but then 12:33 the client is really in charge of deciding on what the 12:37 outcome of the interview should be, right? 12:40 Well, and of course, how could it be otherwise' We really 12:43 delude ourselves if we say, ''Well, you can't let a client 12:46 make choices.'' Who are we that we can't let 12:51 someone make choices? 12:52 In the end it is what the client decides to do that 12:55 makes the difference. 12:56 And this simply acknowledges and respects that fact. 12:59 CARLSON: Do you hope for abstinence as your goal? 13:01 Is that your outcome or the outcome that you hope for? 13:04 MILLER: Well, it's more important for some clients 13:07 than others, certainly. 13:07 There are good data on people for whom abstinence seems like 13:11 the way in which they're going to make it in the long run, 13:14 and that's information I share with people. 13:16 So given what I know about them, if they're hoping for a 13:20 non-abstinence goal and the data tells me they don't have 13:23 a very good chance of that, I'll share that information. 13:26 That doesn't mean that makes the decision for them. 13:28 And I'll work with them where they are and at least move in 13:31 the right direction. 13:32 The emphasis on harm reduction these days is wise I think-to 13:36 move to less dangerous drugs and less dangerous routes of 13:39 administration. 13:40 So even if they're not willing to go all the way to what I 13:42 would hope for them I'm willing to help them take 13:45 steps in that direction. 13:47 It's common for therapists and clients not to 13:50 have the same goal. 13:51 CARLSON: How does this approach work with clients who 13:54 come in with dual diagnosis they have a psychiatric 13:58 problem as well as an addiction problem? 14:02 MILLER: Well, most people with addictions 14:04 have multiple problems. 14:05 I don't personally care a lot for ''mentally ill'' 14:12 dual-diagnosis terms. 14:14 But when you're heavily involved with alcohol or crack 14:18 or heroin, you've got a ton of problems. 14:20 So it's never as simple as just treating the drug problem 14:23 itself which is one reason why I really encourage mental 14:26 health professionals to be involved in primary treatment 14:31 of addictions, because the very skills that you learn in 14:35 the process of becoming a health professional are 14:37 exactly what you need in the process of treating this. 14:40 This is not a special, secret club that you must be 14:43 initiated into. 14:45 The problems are very much interrelated and interwoven 14:48 with everything else in the person's life. 14:51 LEWIS: I once heard somebody who was working with both 14:53 mental health clients and addiction clients say that the 14:56 difference in how he approached them is if it was 15:00 any other client he assumed the client was telling the 15:02 truth until he learned he was lying but if it was an 15:05 addiction client he assumed he was lying until he made sure 15:09 he was telling the truth. 15:11 MILLER: Yeah, what's wrong with this picture' When you 15:14 look at the way addiction treatment was done 20 years 15:16 ago, at least, it was very harsh confrontational 15:20 therapy-hot seats and so forth. 15:21 We wouldn't do that to anybody else. 15:23 And that's not a part of the way in which you would treat 15:26 depression or battle with distress or anxiety disorders. 15:29 We've somehow reserved the very harsh treatment believing 15:32 that was necessary for this population and in fact if you 15:35 treat people like they're going to lie to you, they do. 15:37 Yeah. 15:38 And if you treat people as if they are trustworthy they tend 15:42 to be trustworthy. 15:43 It doesn't mean you're never lied to, but- 15:44 CARLSON: So you're bringing the person back into 15:46 treatment, aren't you? 15:47 Rather than just seeing them as this drunk. 15:50 LEWIS: See, I told you it was revolutionary. 15:54 MILLER: Of course. 15:57 LEWIS: What about when you're working with clients who might 16:01 benefit from participation in a 12-step group Alcoholics 16:05 Anonymous or one of the other self-help groups? 16:08 Are you able to integrate this approach with that work? 16:11 MILLER: Absolutely. 16:12 We've used Motivational Interviewing in programs where 16:17 the whole heart of the program was 12-step. 16:19 And one of the nice things about this respectful 16:21 client-centered approach is it seems to fit pretty well 16:25 whether your treatment orientation is 16:27 cognitive-behavioral or 12-step. 16:29 If you read the Big Book and the way in which Bill W. 16:33 talked about working with alcoholics it wasn't harsh and 16:36 confrontational. 16:37 It wasn't argumentative. 16:38 It was very respectful, very patient, very person centered. 16:43 So I find this entirely consistent with the 12-step 16:46 approach at least as it's understood in 16:48 the original writings. 16:50 CARLSON: One of the questions -- 16:52 This all sounds good but does it work? 16:55 Is there a research base for this model? 16:58 MILLER: Well, that's one of the things that's kept me 17:00 going in this area because I've been frankly very 17:03 surprised at how well this has worked. 17:06 There are about 20 controlled trials now, not just in 17:09 addictions there's some in diabetes management, 17:11 cardiovascular rehab, and so forth. 17:14 And 20 years ago l would never have believed that in a single 17:17 session which is the way this is usually done, you could see 17:21 such behavior change. 17:22 It boggles the mind. 17:24 But very consistently, we're finding both an additive 17:28 effect that is, when you put a session of Motivational 17:31 Interviewing at the beginning of a treatment program, you 17:33 get much better outcomes. 17:34 And you get much better participation in treatment 17:36 along the way. 17:37 Over time, too. 17:38 Over time. 17:39 And also as a freestanding approach, when you're just 17:42 doing Motivational Interviewing compared to 17:45 nothing- compared to no intervention you also get a 17:47 substantial behavior change. 17:49 So the studies have been predominantly positive. 17:52 There's only been one negative trial so far. 17:54 And the strength of that effect is just amazing to me. 18:01 CARLSON: In a couple minutes we're going to watch you work 18:04 with a young man named Mike. 18:06 Can you help our viewers just to focus on what it is that 18:13 they might be looking for in your work some of the 18:16 techniques or some of the strategies that 18:18 you might be using? 18:19 MILLER: Yeah. 18:20 Well, besides the principles that I talked about before the 18:25 way that one usually opens a session like this is with an 18:28 open question one that invites the person to tell you about 18:32 themselves. 18:33 And not just one of those, but a series of open questions. 18:36 I try not to ask closed-ended questions very often, but to 18:42 give a question where the client can move around a bit, 18:46 and then follow with reflective 18:48 listening, very much. 18:49 You and I were talking how easy he makes this look, so 18:52 it's important that the viewers know that there are 18:56 really strategies that you're using. 18:57 Oh, yes, and it does take a while to learn this. 19:01 Also, in what I'm reflecting and Rogers did this too 19:06 although he wasn't aware of it- I'm differentially 19:10 reflecting back the client's own statements that are moving 19:13 in the direction of change acknowledging the other side 19:16 as well, but helping the person move along. 19:21 There's acknowledgment of the person's freedom to choose, 19:25 and respect for that position. 19:28 But listening for the person's own motivation, for their own 19:33 goals, for their own desire to change and reflecting and 19:37 encouraging and moving that along as we go and providing 19:40 the encouragement and the hope that that can happen. 19:43 LEWIS: And this client was very ambivalent, wasn't he? 19:46 MILLER: Yeah, and that's not uncommon. 19:48 For some reason we pathologize that in the addiction field, 19:51 but ambivalence is very human and in fact is a normal part 19:55 of the change process-that when you go from not thinking 19:57 about change to beginning to think about it you must pass 19:59 through a period of ambivalence. 20:01 And it's just that that's where people get stuck. 20:04 And this is a particularly interesting case because he's 20:06 very aware of being there and very aware of how 20:10 uncomfortable it is to be at the ambivalent place and very 20:13 aware that he has to move one way or the other. 20:15 He has to move forward and resolve the ambivalence by 20:18 changing his behavior or move backwards and resolve the 20:22 ambivalence by shutting down and saying it 20:24 isn't really a problem. 20:25 Well, since ''I'm not sure'' are three of my favorite 20:28 ambivalent words l'm looking forward to watching this. 20:32 CARLSON: So let's watch your work with Mike. 20:33 MILLER: Okay. 20:35 MILLER: So, fill me in a little bit. 20:38 What is it that brings you here today? 20:40 MIKE: Well, actually I'm doing a favor for a friend of mine. 20:44 MILLER: Uh huh. 20:45 MIKE: And he told me about a study you guys were doing, and 20:47 so I figured I'd participate in it, and they told me you 20:50 were basically an addiction counselor, and he thought I 20:53 might be an interesting subject. 20:55 MILLER: Uh huh. 20:56 MIKE: Okay? 20:56 MILLER: Okay. 20:57 Well, tell me about where you are now with the addictions 21:00 that you?ve been? 21:01 MIKE: Well, what do you want to know in particular? 21:05 MILLER: Well, are you in recovery now, or 21:07 MIKE: No, I'm not. 21:08 MILLER: Okay. 21:08 Alright. 21:09 So what are the drugs or what it is you struggle with? 21:13 MIKE: Well, honestly cigarettes. 21:15 MILLER: Okay. 21:16 MIKE: That's the biggest. 21:17 MILLER: Okay. 21:17 MIKE: Alcohol to a degree, but I think I've had more of a 21:21 problem with that two or three years ago, you know, it seems 21:24 to have gone down to a degree and probably simply because of 21:29 the environment. 21:30 MILLER: So That's kind of settled down. 21:31 MIKE: Well, not all that much. 21:34 Okay, but enough, it's gone down simply because I'm 21:38 getting too old to do this stuff anymore if that make any 21:41 sense to you. 21:41 MILLER: It does. 21:42 You can't keep up with it anymore. 21:43 MIKE: I don't think I can. 21:44 I really don't think I can. 21:46 MILLER: And then the cigarettes are still a real 21:48 addiction for you? 21:50 MIKE: Yeah, I really do. 21:51 I think they are worse. 21:51 In the past I've done cocaine. 21:54 I've even done crack cocaine. 21:56 I've heard That's one of the most addictive drugs around. 21:58 Quite frankly, from my own personal experience, I don't 22:01 find it addictive at all. 22:02 MILLER: Yeah, it's interesting how it is different for 22:03 different people. 22:04 MIKE: Yeah. 22:04 MILLER: Yeah, but for you it's tobacco and alcohol. 22:07 MIKE: Yeah. 22:08 Yeah, and coffee. 22:09 MILLER: Yeah. 22:09 MIKE: I mean if we want to get that specific. 22:12 MILLER: How far do you want to go there' 22:13 MIKE: How do you want to go? 22:14 I got a lady That's supposedly addicted to Chapstick. 22:21 MILLER: It gets used for almost anything these days. 22:24 MIKE: Right. 22:24 MILLER: Yeah. 22:25 Well, how might you like things to be different? 22:27 I guess That's a good place to start. 22:31 MIKE: Well, basically, you know, I don't, 22:33 see That's my problem. 22:34 I don't think I'm really all that committed to making 22:36 things all that different because I'm not seeing that 22:38 much harmful benefit. 22:40 I was told that you are not able to slow down. 22:42 It's progressive. 22:43 You get worse and worse and worse and worse, and that just 22:45 doesn't seem to be the case with me. 22:47 Okay? 22:48 I think that there are certain things in my lifestyle that 22:50 just preclude me not using, okay? 22:52 MILLER: Right. 22:53 MIKE: And that, and smoking has become a problem because 22:56 I'm starting to play soccer, okay? 22:58 MILLER: So you can't breathe. 22:59 MIKE: So I can't breathe. 23:00 The kinds are younger and younger. 23:02 They are half my age, twice my size. 23:04 I'm having a problem with it. 23:05 MILLER: You are noticing it. 23:06 MIKE: Okay. 23:06 Yeah. 23:09 MILLER: So, I mean the message that you shouldn't use at all 23:11 is like somebody out there telling you that, but that 23:13 doesn't fit your experience. 23:15 MIKE: I don't know. 23:16 Use at all. 23:18 What does that mean? 23:19 What do you mean by that? 23:21 MILLER: Well, I guess maybe I misunderstood you. 23:22 I thought you were saying people tell you that you can't 23:27 use or shouldn't use or whatever. 23:29 MIKE: Oh yeah. 23:29 Yeah, they've told me that before, you know. 23:32 I've been through, I guess you know nothing about me do you? 23:36 MILLER: Nothing at all. 23:37 MIKE: Okay, I'm sorry about that. 23:38 I though at least they filled you in on some 23:40 MILLER: No, I asked not to be. 23:42 MIKE: Okay. 23:43 Well, no. 23:43 Alright, here's what happened. 23:44 I got a DUI a while back. 23:46 I think it was back in '93, and I had one prior to that in 23:49 '85 and went though some counseling. 23:52 It was mandatory, state-driven. 23:53 Basically you go through the counseling, and after you 23:58 successfully complete it, you are rehabbed. 24:01 Actually rehabbed. 24:03 MILLER: Right. 24:03 MIKE: Then you get your driving privileges back. 24:05 And I guess what I'm trying to say is that I've had some bad 24:07 experiences. 24:08 Not bad experiences with the counselors, but I found them 24:11 to be not less than professional but just very 24:16 rigid in their approach. 24:17 MILLER: Okay. 24:17 And that didn't work for you, that didn't fit. 24:20 MIKE: It didn't fit at the time, and at the time I don't 24:23 think I was really all that committed to quitting, and 24:26 then I was, but at another time, but the other time was 24:29 because I was earning $40 an hour, and I was working ten 24:33 hours a day five days a week, so guess what? 24:36 You're not supposed to be able to quit, you see. 24:39 That's what those counselors told me. 24:41 That was strange that I was, wasn't it? 24:43 So I mean, I guess what I'm saying is that I do probably 24:46 have a rather negative attitude about some of the 24:48 things I've been through as far as the 24:50 state program is concerned. 24:53 I don't know how I could explain that more, 24:55 or if you have any. 24:57 MILLER: Well, I think I've got it. 24:58 It sounds like your experience doesn't match what you were 25:01 being told. 25:02 MIKE: No. 25:03 MILLER: They are telling you this is how you are, and you 25:05 look at yourself and say, no. 25:07 MIKE: Yeah, That's not necessarily true. 25:09 And then there too you are supposed to say well I'm an 25:13 alcoholic and I've always had problems and I have to quit 25:16 and I can never drink again and this, that, 25:17 and everything else. 25:18 And you had to really say that, see. 25:20 Or else you weren't fitting in the role they 25:23 wanted you to play. 25:24 Without fitting in the role they wanted you to play you 25:27 could not get your license back. 25:28 So, you know, I played the game basically, and I went to 25:31 AA, and I also found that just to be a little bit on the, you 25:36 know, it didn't work for me. 25:37 It's bumper sticker therapy. 25:39 Fake it till you make it. 25:41 Wow, how profound. 25:43 Man, you guys are deep, you know. 25:46 MILLER: Alright. 25:47 MIKE: And you know, yes seriously, I've been there and 25:49 these guys didn't do anything all day, but they 25:52 didn't drink that day. 25:53 You know, I would rather, let's say, lift weights, maybe 25:57 build a patio, maybe program R base, and then drink instead 26:01 of just not drink and do nothing else. 26:03 I just, I found that you know, certain aspects of it I like, 26:10 but I think you have to have a deep seated religious belief 26:15 for it to work for you. 26:17 MILLER: Well, and it sounds like you want to have an 26:19 active life. 26:20 Not drinking is not doing something, it's doing nothing. 26:23 MIKE: Yeah, it's doing nothing. 26:24 MILLER: So, for you the question is what am 26:26 I going to be doing? 26:27 How do I spend my time' Playing soccer, and 26:30 MIKE: Yeah, That's good. 26:31 Actually I was thinking myself the way I can best quit 26:37 smoking is not by quitting smoking but playing soccer 26:40 three times a week. 26:41 Okay? 26:42 Now, I'm going for something, okay? 26:44 MILLER: That's right. 26:45 MIKE: And then all of a sudden I'm having a problem 26:46 breathing, okay? 26:48 So guess what? 26:49 You're gonna quit smoking. 26:50 You're not going to say I gotta quit smoking, you know. 26:53 But to me that doesn't work for me. 26:56 MILLER: It might even less than not work. 26:59 It might make it less likely. 27:01 MIKE: I think it's less likely. 27:02 I quit smoking before for about four months. 27:06 Then I blew out my knee, and you know, I went down to see 27:10 my brother, and boom, right back to it. 27:12 And you know, it's the same thing with drinking. 27:14 I think I was actually more, how shall I say, I seem to 27:20 have more of a craving when I was going through counseling. 27:24 MILLER: Right? 27:24 MIKE: Then when I wasn't, okay? 27:26 So, it's like okay, reverse effect. 27:28 Guys you really helped me a lot, you know. 27:31 MILLER: Well, I wonder if it isn't being told you can't or 27:34 like being in prison in a way. 27:36 MIKE: Yeah, it could be just immaturity on my part. 27:39 You know, if you tell me I can't do something, I'm going 27:40 to do something. 27:41 MILLER: Right. 27:42 MIKE: You know, maybe what they should say is you better 27:44 drink every day goddammit. 27:45 I want you to drink a fifth before noontime. 27:48 Then maybe I'd say "Screw you guys," you know. 27:51 I don't know. 27:51 Maybe there is something about my personality 27:54 that is like that. 27:55 So, you know, what shall I say? 27:58 One size doesn't fit all. 28:00 MILLER: Yeah, exactly. 28:02 MIKE: One size doesn't fit all. 28:03 MILLER: And for you what matters is having something 28:05 that you are going toward, not something you run away from. 28:08 MIKE: Right, right. 28:09 MILLER: And one of those things is soccer. 28:11 MIKE: Yeah. 28:11 MILLER: What else? 28:13 MIKE: Well, tennis. 28:14 How about backpacking. 28:16 You know, how about just waking up clear-headed. 28:19 MILLER: Yes, That's right. 28:21 MIKE: I mean, don't you think That's kind of... 28:23 MILLER: That's great. 28:23 MIKE: ...pleasurable, sometimes, you know? 28:26 MILLER: So just getting up in the morning and being able to 28:28 think clearly. 28:30 MIKE: Yeah but I'm telling you one thing right now. 28:32 You know, sometimes I won't drink four, five, six days. 28:35 If I smoke two packs of cigarettes, I 28:37 wake up with a hangover. 28:39 I thought it was the booze, but it isn't. 28:42 MILLER: Even without the booze. 28:43 MIKE: Oh, yeah. 28:44 It's carbon monoxide, man. 28:45 You got no oxygen in your system. 28:48 So. 28:48 I guess That's my real problem right now is the cigarettes. 28:54 MILLER: Uh huh. 28:55 MIKE: So. 28:55 MILLER: It sounds like you are not that worried 28:56 about alcohol really. 28:57 MIKE: No, it's bad, but it's not as bad. 28:59 MILLER: Not causing you problems 29:01 MIKE: Well, it is. 29:02 It will cause anyone problems. 29:04 MILLER: Hm, how so? 29:06 MIKE: Have a six-pack of beer, wake up, try 29:08 to program a computer. 29:09 MILLER: Okay. 29:10 MIKE: And so, have a six-pack of beer, wake up, find out how 29:13 alert you are for the first two hours of the day. 29:15 MILLER: Right. 29:16 MIKE: It's going to cause anyone problems. 29:18 You know, have a six-pack, have a twelve-pack, try to 29:21 play soccer the next day. 29:23 MILLER: Right. 29:23 MIKE: Okay. 29:23 It's 29:23 MILLER: It's amount and the after-effects of that. 29:27 MIKE: Right. 29:28 Right. 29:28 And I think my tolerance is up so high that it takes me too 29:31 much to get the same buzz, and unfortunately, the recovery, 29:37 it's getting to the point where it is just not worth it. 29:40 If I could get like a 12-pack high on three beers, then I 29:45 only have three ounces I've got to process. 29:47 If it's taking me 12 to get the same which I got three on, 29:51 now I got 12 to process you see. 29:53 MILLER: Yep. 29:54 MIKE: So we are at a balance point where we are getting 29:57 diminishing returns on ever expanding, how shall I say, 30:00 quantities. 30:02 MILLER: Like the slot machine doesn't 30:03 pay off so much anymore. 30:05 MIKE: Well, you know, it's addictions, so you're stupid, 30:07 so you keep on playing it, you know. 30:09 MILLER: It is amazing. 30:10 How long you keep going. 30:12 MIKE: Yeah. 30:13 MILLER: But you're, with alcohol, you are kind of 30:16 hitting a point where this isn't worth it anymore. 30:19 MIKE: Yeah, yeah. 30:20 But it is not because anybody is telling me from the 30:24 outside, because I'm being forced to do that. 30:27 It's just because I gotta wake up in the morning, and I know 30:32 how I feel. 30:33 Period, Okay? 30:34 And I think what has happened is before I used to drink all 30:39 the time, and I was always drinking. 30:42 And then I stopped and found out how good I felt, okay? 30:46 Now I have a compare and contrast whereas before I 30:49 never had a compare and contrast. 30:51 MILLER: Now you know. 30:51 MIKE: Now you know. 30:52 Now you know, hey wait, wasn't it a lot better when I was 30:54 clear headed then when I was, so, and to me then it does 30:59 become a problem because now at least you have something 31:01 you can you know, you can relate to. 31:04 You can say this is how I am without it. 31:06 This is how I am with it. 31:07 This is my performance without it. 31:08 This is my performance with it, you know. 31:11 MILLER: It's only when it's a problem for you, really, that 31:13 it matters. 31:13 MIKE: Right. 31:14 MILLER: If somebody else is telling you 31:16 MIKE: Yeah, it doesn't work. 31:18 MILLER: Or worse. 31:19 More likely you back away from it. 31:21 MIKE: Well, then why is the approach the opposite? 31:24 That's what I, I don't mean to be belligerent toward 31:27 addiction counseling, but I can't help but be. 31:29 Why, sometimes I wonder if these people didn't do more 31:33 bad than good 31:33 MILLER: It doesn't make any sense to me. 31:35 It's human nature to push against something when they 31:39 push against you. 31:40 MIKE: Well, I always heard in AA too, is the dumbest things 31:43 I ever heard. 31:44 Some of the comments I heard that were 31:46 just god awful stupid. 31:48 And these people were just complete idiots. 31:50 We alcoholics don't like to be told what to do. 31:54 I'm thinking wait. 31:55 We alcoholics. 31:56 What are you some special breed of people' No one likes 31:59 to be told what to do. 32:00 You know what, I really got tired of that kind of like 32:04 we're special because we have this disease or come feel 32:08 sorry for us because we have a disease. 32:10 And quite frankly, the more I read about alcoholism, no one 32:14 knows what the hell it is. 32:15 So I'm not going to say I am cause until there is a 32:18 definitive area that we can agree on, you know, I could 32:24 say alcohol dependent. 32:25 Now that makes sense. 32:25 It's a bit more clinical 32:26 MILLER: That you can understand. 32:28 MIKE: Yeah, That's understandable, but that's one 32:30 of the things I didn't like about AA is they 32:35 wore it like a badge. 32:37 It's nothing to be proud of, but it's nothing 32:40 to be ashamed of. 32:41 But you certainly don't do some reverse pride on it, and 32:44 you know, we're special because we're this. 32:47 We're different. 32:48 I didn't see any difference between those people and 32:50 normal people. 32:51 MILLER: It seems to work for some people, but that's not 32:53 going to help you. 32:54 MIKE: Well, who do you think it works for? 32:56 Apparently highly religious people who believe in higher 32:58 powers and miracles and some deity is going to come down 33:02 and save them anytime they have problems. 33:05 I'm not that type of person. 33:07 MILLER: That's not you. 33:09 And for you it has to be some reason that you see that 33:13 persuades you, okay, it's time. 33:16 MIKE: Yeah, a little bit. 33:18 MILLER: A little bit. 33:18 MIKE: A little bit more realistic, okay. 33:21 No nonsense, no bumper sticker stuff. 33:24 MILLER: And not being able to breathe on the soccer field is 33:26 no nonsense. 33:26 MIKE: I think that's kind of, I don't know if you can get 33:29 too much more guttural than that you know, and so that's 33:31 where it is. 33:33 MILLER: So, it's having something to pursue, having 33:35 something to live for really. 33:38 MIKE: Yeah, yeah. 33:39 That's it in a nutshell. 33:41 I've read a couple of books, and the one thing I really 33:44 enjoyed was the book Positive Addiction. 33:49 You know, having been a runner before, being cross-country, I 33:53 can see exactly how that worked. 33:54 Basically, this guy was saying what had happened is he was 33:58 under the suspicions that a lot of people running were 34:00 actually, had drinking problem and ran 34:03 themselves out of those. 34:04 Now I think that is actually true because after I run, I 34:10 have about this much desire to drink, and I have about that 34:13 much desire to smoke. 34:15 MILLER: Yeah. 34:16 MIKE: You got endomorphins, you feel good, you are alert. 34:19 MILLER: Yep, yep. 34:20 MIKE: Why would you want to pollute yourself, you know? 34:23 MILLER: Makes sense to me. 34:23 MIKE: So, That's my deal on that. 34:28 My read on who I am. 34:30 But am I committed? 34:31 No. 34:32 Total abstinence? 34:34 No. 34:34 Not at all. 34:35 MILLER: Oh, to total abstinence. 34:35 Okay. 34:36 Because I am hearing a lot of commitment in what you are 34:39 saying, that it's worth it to me to, in order to be able to 34:46 breathe on the soccer field... 34:47 MIKE: Right. 34:47 MILLER: ..to do something about cigarettes. 34:49 MIKE: Yeah. 34:49 MILLER: To quit smoking even. 34:50 MIKE: Yeah. 34:52 MILLER: So there I was hearing some commitment. 34:54 MIKE: Yeah, I think there is. 34:55 You see when I quit smoking, I quit drinking, too, you know. 34:58 MILLER: Is that right? 34:59 MIKE: Well, you have to. 35:00 Well, I mean at least I have to. 35:02 MILLER: Uh huh. 35:02 MIKE: Cause I can't like drink. 35:05 If I drink I'll have a cigarette. 35:07 MILLER: Okay, they are that tied together. 35:09 MIKE: Yeah. 35:09 MILLER: You do them together so many 35:11 MIKE: Well you 35:12 MILLER: tens of thousands of times. 35:13 MIKE: Yeah. 35:14 Well, even coffee. 35:15 You know coffee, cigarette, just association. 35:18 Yeah, I think like when you drink, you lose your judgment 35:21 and your willpower just goes down. 35:22 I don't know if you call it willpower. 35:23 I think its just judgment. 35:24 MILLER: Whatever it is. 35:25 MIKE: You are going ? "Oh a cigarette sure would taste 35:27 good now." Oh, yeah, okay. 35:28 MILLER: That happens with cocaine too. 35:32 I mean people, drinking is the most common reason why people 35:37 go back to using cocaine when they really wanted to stay 35:39 away from it. 35:40 MIKE: Oh, really? 35:40 MILLER: Yeah. 35:40 So That's exactly what you are talking about. 35:42 MIKE: There is such an association between the two? 35:45 MILLER: Well, whatever it is. 35:46 Or it just kind of dulls down your judgment. 35:49 MIKE: Yeah. 35:49 MILLER: Enough that you say, "Oh that would feel nice." 35:51 MIKE: Should I ask if you drink? 35:54 MILLER: I do. 35:54 Yes, I do. 35:55 MIKE: Well, you know how the judgment goes. 35:56 And let's face it, it goes. 35:58 It goes on everyone, you know. 36:00 They always say oh we alcoholics are different. 36:02 No, no, no, no. 36:03 You feed someone six beers and their judgment 36:06 is going to go down. 36:07 MILLER: It's going to have that effect. 36:08 MIKE: It's a physiological reaction to a toxic drug. 36:11 You know, let's face it. 36:12 MILLER: Yep. 36:13 MIKE: So, it is. 36:15 MILLER: So, you really would be talking about stopping 36:18 cigarettes and alcohol then. 36:20 MIKE: Well, yeah. 36:21 MILLER: In order to breathe. 36:21 MIKE: But I don't want to think about it. 36:23 Huh? 36:23 What's this? 36:24 MILLER: Oh. 36:24 MIKE: I don't want to think about that. 36:26 MILLER: Meaning you just want to do it and not think about 36:27 it, or you don't want to get serious? 36:28 MIKE: Well, I would rather do it and not think about it. 36:32 MILLER: Yep. 36:33 Not much point in thinking about it. 36:34 MIKE: Well, I mean, is there' 36:36 MILLER: No, no. 36:37 MIKE: Do I think about working out every day? 36:39 Do I think about brushing my teeth? 36:40 If I did I wouldn't want to brush my teeth. 36:42 I gotta brush my teeth tomorrow. 36:44 That's going to be pretty bad, you know that. 36:46 I gotta brush my teeth. 36:47 You know what I'm saying? 36:48 MILLER: I do. 36:48 MIKE: I think That's what happens when people do that, 36:52 and I see more procrastination because it is worse to think 36:55 about having to go to the gym and work out. 36:58 My god it's going to hurt and oh I'm going to do those curls 37:01 and my biceps are going to kill me and then I have to 37:04 wake up and brush my teeth. 37:06 I think that when you think about stuff like that, I think 37:09 it actually is more counterproductive than just 37:12 saying, oh screw it. 37:13 Just do it. 37:14 MILLER: Thinking about going to sleep. 37:16 MIKE: Yeah. 37:16 MILLER: As long as you are doing that you are not going 37:18 to be going to sleep. 37:18 MIKE: You're not going to sleep, no. 37:20 I hope that makes sense to you. 37:21 MILLER: Oh, it does. 37:22 No, it wasn't what I had meant by think about it, but I see 37:25 exactly what you mean, that if you are thinking about 37:29 something or like trying. 37:30 In other words if you are trying to do it, you 37:31 are not doing it. 37:32 You either do it or you don't do it. 37:34 But you don't try to do it. 37:36 You don't try to go to sleep. 37:37 You just go to sleep. 37:39 MIKE: You just go to sleep. 37:40 MILLER: So what would be great is if that was just natural. 37:43 You're not thinking about it. 37:45 It's just natural to do it. 37:46 MIKE: I mean, what do you think? 37:47 I'm thinking basically the thing I could best do it just 37:52 start running again and just start really 37:56 substituting habits. 37:57 I don't think, I think substitution of habit and 38:00 making habits so counterproductive or 38:03 contradictory I should say maybe which you just replace 38:09 one habit with another habit rather than just try to get 38:12 rid of one habit. 38:13 I think it kind of comes up to a vacuum state. 38:16 Now what do I do? 38:17 I got rid of this habit. 38:18 Now what do I replace it with? 38:19 You know, so 38:20 MILLER: Well, you are clearly telling me That's 38:22 what works for you. 38:23 That's what is going to do it. 38:24 MIKE: Well, That's what has done it in the past. 38:26 That's what's done it in the past. 38:28 Actually I got to join another soccer team. 38:30 I can play with even better people and that way I will 38:34 really get pissed off at myself, you know. 38:38 So. 38:39 MILLER: And That's what worked for you before' 38:42 MIKE: Mm hm. 38:42 MILLER: Good indication. 38:44 MIKE: Yeah. 38:44 Well, what hasn't worked for me is drug addiction 38:47 counselors, sorry to say. 38:49 MILLER: Yeah, yeah. 38:50 No your reaction to that was 38:52 MIKE: Well, you have to realize first off, most of the 38:55 people there, and I'm not trying to be apologist for 38:57 them, but in a way I am. 39:00 They were good people. 39:01 Most of the people there were forced to be there. 39:03 They weren't there on their own free will. 39:05 So, of course, they are going to be resistant. 39:09 And most of the people there, I mean you are basically, you 39:12 have to talk a certain way, behave a certain way, do 39:16 certain things so they think you are, 39:19 quote, whatever, rehabbed. 39:22 So you learn real quickly how to play the game. 39:24 What are you looking for? 39:25 Okay, what's this counselor looking for, or what's this 39:27 person want me to say? 39:28 Okay. 39:29 I'm supposed to feel this way about something because That's 39:31 the way she's been told that we define this addiction. 39:35 So what I'll do is I'll just play in her bullshit even 39:38 though it isn't true, and as long as I can do it in a 39:40 convincing way and fool her, boom, whappo, I got it, and I 39:43 got my license back. 39:44 And you know That's a game that I was playing the whole 39:47 time, and actually, I kind of lost respect for people 39:50 because they were so easy to fool. 39:52 All I did was I read the addiction counseling books. 39:55 I found out what they are looking for, what the traits 39:57 were 39:58 MILLER: Played the game. 39:58 MIKE: Played the game. 39:59 Found out, you know, what they wanted to hear. 40:02 And to me That's really counterproductive. 40:06 It, if anything, it's a waste of time, and it might even be 40:10 more harmful than it is helpful. 40:12 MILLER: It sounds like it was for you. 40:14 MIKE: Yeah. 40:15 Does anyone quit anything if they are not committed to it? 40:20 MILLER: My own sense is it's that internal reason that 40:22 really makes the difference. 40:23 When instead of there being somebody out there 40:26 MIKE: External. 40:27 MILLER: telling you, what's telling you is something 40:29 inside of you. 40:30 Your lungs or whatever it is. 40:31 MIKE: I think this time it's my body. 40:33 MILLER: Hey, yeah right. 40:35 MIKE: My brain is saying hey, I'm stupid, but your liver 40:38 doesn't like you too much. 40:40 Your lungs are a little pissed, you know? 40:42 MILLER: Yeah. 40:42 MIKE: So. 40:43 MILLER: So, what gets in the way of your 40:45 sticking with that? 40:46 What gets in the way of running? 40:48 MIKE: You know, I don't know. 40:49 I think it may be a fear of failure. 40:51 I really do. 40:53 Could be that. 40:54 Could be just the amount of effort. 40:56 Like I say it's been going down, going down, going down, 41:00 but I seem to really have a problem totally committing to 41:03 just okay this is the year man. 41:04 Let's do it. 41:05 MILLER: Yeah, well because it is pretty total. 41:08 I mean, that was what I was picking up earlier. 41:11 At least the way you are thinking about it. 41:13 It means stopping cigarettes and stopping drinking. 41:17 MIKE: Well, you know, it used to be a fear of withdrawal 41:18 with drinking, and when I quit I found out 41:21 MILLER: It's not a big deal. 41:22 MIKE: It's not. 41:23 And That's another thing. 41:25 Don't tell people about DT?s because quite frankly that 41:27 doesn't happen all that often. 41:29 MILLER: It's pretty rare. 41:30 MIKE: I mean, what do you get? 41:31 You get maybe higher energy level and That's it. 41:34 And you feel better, okay? 41:36 I mean, whoa, you are going to get DT?s, you are going to go 41:39 through withdrawal. 41:39 Oh, you are going to have to have doctor?s supervision. 41:41 By telling someone that you are just scaring 41:43 the fuck out of them. 41:44 You know? 41:45 Excuse my French, but that's what you do. 41:47 MILLER: That is something that happens to some people 41:48 but not very many. 41:49 MIKE: Yeah. 41:50 Yeah. 41:51 But I'm really worried about the smoking because I remember 41:53 last time I got just violent. 41:55 I mean I was bad to be around for five days. 41:57 I mean really bad. 41:59 I mean I was just blowing up on everything. 42:01 Every little thing I was just, everything was 42:04 just ticking me off. 42:05 And then after five days I was pretty cool, and after two 42:08 weeks I was real cool. 42:09 And I was kind of, yeah, but I'm thinking my god, what if a 42:13 client calls me up. 42:14 What am I going to do? 42:16 MILLER: Like five days in a mountain hut somewhere. 42:18 MIKE: Oh well, you think a kayak trip? 42:22 Just throw me for five days out in a kayak. 42:25 MILLER: That's a nice idea. 42:26 MIKE: No cigarettes, no booze. 42:28 MILLER: Yeah, the Grand Canyon or something. 42:29 MIKE: Well, you see, that would be very good. 42:31 MILLER: It would. 42:32 MIKE: I mean That's what I was thinking of doing. 42:34 MILLER: Something physical. 42:34 MIKE: Yeah. 42:35 Do something like that. 42:37 MILLER: You're committed. 42:39 MIKE: Backpacking. 42:39 100 miles from nowhere. 42:41 And maybe I could reward myself with a cigarette by the 42:45 time I get there. 42:46 By the time I get there it will be ten days and 42:48 I won't want one. 42:50 MILLER: Well, and the trip itself for you sounds like it 42:53 would be a reward. 42:53 MIKE: Oh yeah. 42:54 MILLER: Doing it would be fun. 42:55 MIKE: Yeah. 42:57 MILLER: So it might be a way to get 42:57 through those five days. 42:59 MIKE: Yeah. 43:00 Yeah, like I say, I'm, how shall I say? 43:05 I'm teetering on the edge where you know I've cut down, 43:10 I've cut down, I know how it feels to at least not drink 43:13 that much, but now I'm finding out, hey, it's not the 43:16 drinking That's giving me the hangover. 43:18 It's the cigarettes. 43:19 MILLER: Mm hm. 43:20 MIKE: And the drinking only compounds it because when I 43:22 drink I smoke like a son of a bitch. 43:24 And one of the things is I think I'm cutting down on my 43:26 drinking, not because I'm trying to cut down on my 43:28 drinking, but because I don't want to smoke that many 43:30 cigarettes which is weird, and you're not 43:32 supposed to be that way. 43:33 Not by the definition of drug addiction. 43:36 MILLER: Well, you are breaking all the rules. 43:37 MIKE: Yeah, I know. 43:38 But I mean, I wish they wouldn't tell me rules there. 43:41 If they are not sure, I don't want to hear them. 43:43 MILLER: Uh huh. 43:44 MIKE: You know, I mean it's like I think a lot of this 43:47 crap is self-fulfilling prophecy. 43:48 You have given people false information and they are 43:52 taking this false information to heart because these experts 43:55 in the field, so called experts, and it's really funny 43:57 how many different variations of the definition of 44:00 alcoholism we have. 44:02 All of them almost contradictory. 44:05 You get some poor slob That's going to say well so- and- so 44:08 says this, and they've been a leader in their field for the 44:11 last 20 years. 44:12 So, therefore, because they say this, I 44:16 have to be this way. 44:17 And instead of defining themselves as individuals, 44:20 they go into the stupid pattern or whatever type of 44:24 behavior that is supposed to be attached to them, and they 44:26 assume that behavior is theirs. 44:28 And that's why I don't like, it's not, it doesn't work. 44:32 And I don't think it ever will. 44:34 I mean, do you agree with me, or am I... 44:39 MILLER: Well, you know more about 44:40 you than I do, obviously. 44:41 MIKE: Well, That's the whole thing. 44:42 MILLER: I believe you. 44:43 MIKE: Yeah, but I mean how many people have you counseled 44:45 in your lifetime' I mean you?ve had to see certain 44:48 things works for certain people and certain things work 44:50 for other people, and it's not going to be one size fits all. 44:54 MILLER: No it isn't. 44:55 MIKE: It just, it's not there. 44:57 MILLER: I've worked with people who have done really 44:58 well in AA. 44:59 And I've worked with a lot of people who have said, "Ah, 45:01 it's not for me. 45:02 That's not my cup of tea." 45:03 MIKE: And I'm not trashing them. 45:04 I mean if it works for you, fine. 45:06 MILLER: There you go. 45:07 MIKE: If it works for you that's fine. 45:08 And I've seen it help a lot of people, and I know the type of 45:11 person it is going to work for. 45:12 It is not going to work for me. 45:14 MILLER: Now, tell me about this 45:14 teetering on the edge business. 45:17 MIKE: Don't know. 45:17 I think it's, like I said, I think it's fear of failure. 45:19 I think on my part it's a fear of failure, and it's also the 45:22 fear of withdrawal, especially from nicotine. 45:24 Because I know how I get. 45:28 MILLER: Mm hm. 45:30 MIKE: And I'm committed and then I'm not. 45:32 It's this ambivalent feeling. 45:33 MILLER: Yeah. 45:34 MIKE: And I can't seem to, you know, and 45:38 that's where I'm stuck. 45:39 That's where I'm stuck. 45:41 I'm stuck in that ambivalence which I guess is a 45:46 good thing in a way. 45:47 I mean, it's better than just being not committed at all. 45:49 MILLER: Well, That's exactly right. 45:50 It's a step forward. 45:51 MIKE: Yeah, it's a step forward, but it's still 45:53 MILLER: Becoming ambivalent is the first step toward change. 45:55 MIKE: Yeah, but let's face it, That's cognitive dissonance. 45:58 The ambivalence I really want to get over it, but I can't 46:01 seem to, I can't seem to just say okay, today's the day. 46:05 This is it. 46:06 MILLER: Right. 46:07 MIKE: So maybe, I don't know. 46:09 See I don't know even what to do, quite frankly 46:14 MILLER: Well, you mentioned a couple of things. 46:16 MIKE: Yeah, see I'm thinking I could cut down slowly. 46:19 See, look it, if I quit cigarettes, 46:23 drink is going to go. 46:24 It's going to have to go. 46:25 MILLER: Mmm hmm. 46:26 MIKE: Okay, so then That's it. 46:27 That's out. 46:27 Now that I know isn't that hard. 46:30 MILLER: Right. 46:30 You've done that. 46:31 MIKE: Yes, but the nicotine, ooooh, That's a scary thing 46:34 for me, man. 46:35 MILLER: And you've done that before also. 46:37 Yes? 46:38 MIKE: Playing. 46:39 Yeah, I was playing around. 46:40 I was playing two games a week. 46:42 MILLER: Okay. 46:44 MIKE: Now I would have to start running every day, an 46:47 hour a day five days a week. 46:49 I would have to gradually cut down, okay? 46:52 And then I would have to set a date, and I guess go on the 46:55 patch, and I would have to stay away from anyone that 46:59 wants to have a beer with me, because if I 47:02 have one beer, boom. 47:03 Right back to smoking. 47:04 Now I'm telling you what happened with smoking. 47:07 What was it, four months? 47:09 Whatever it was, blow out the knee. 47:11 As soon as I started again, now this is, as soon as I 47:14 started again, I was back up to two packs within a day. 47:19 MILLER: That's scary isn't it? 47:20 MIKE: Within a day. 47:21 It wasn't like this gradual, "Oh I'll just have one." It 47:25 was just like boom, and I was just right back in there, and 47:29 then I feel the lungs quit on me, yeah I 47:31 guess a fear of failure. 47:32 I don't know. 47:33 Maybe it was fear. 47:33 I don't know what it is. 47:34 Maybe it's fear of failure. 47:35 I don't know. 47:36 MILLER: How confident are you that you can do it? 47:38 MIKE: That's the problem. 47:39 I don't know. 47:40 MILLER: You're not sure. 47:41 MIKE: I'm not too sure. 47:42 I'm really not too sure. 47:45 MILLER: It's not so much the wanting to do it as, "I don't 47:48 know if I could if I make the decision." 47:49 MIKE: Right, right, right. 47:50 MILLER: Mm, okay. 47:52 MIKE: It's confidence probably. 47:54 MILLER: Well, and That's what would help. 47:55 Something that you could really be confident in. 47:59 Like the way you lit up when we talked about the Grand 48:02 Canyon or something. 48:03 Like I could get through five days that way. 48:05 I could do that. 48:07 MIKE: Am I supposed to spend maybe a year out there? 48:10 MILLER: No, I'm just using that example. 48:12 MIKE: Wait a second, if I made a lot of money, that would be 48:15 a good 48:16 MILLER: How long would it be' Well, the first five days you 48:18 said are the tough ones. 48:19 MIKE: Yeah, the first five are tough. 48:21 But really what it is, what basically what it really is 48:23 just not hanging around Chris because Chris will come over 48:26 and he'll want a beer. 48:27 I don't care if he has a beer, but if I have a beer, boom. 48:30 I'm going to light up. 48:30 I'm going to have to stay away from Bogden. 48:33 That's another guy on my soccer team. 48:35 It would have to be like really staying away from a lot 48:38 of people I know. 48:40 You know, maybe I'm just making excuses for myself. 48:42 I don't know. 48:43 I don't know. 48:43 But I would have to do that, and then I would really, I 48:48 would have to watch myself and not let myself talk to any 48:51 clients for five days. 48:52 Because I know how I get. 48:54 MILLER: Oh that five day period. 48:55 Yeah. 48:55 MIKE: Yeah, I don't know. 48:57 I don't know. 48:57 I'm still ambivalent. 48:59 MILLER: Well, that clearly is where you are. 49:01 And you are right that That's a normal 49:03 place people pass through. 49:04 You are saying, "Well let's get through," you know. 49:06 MIKE: I still want to 49:07 MILLER: It's an unpleasant place to be. 49:09 MIKE: Yeah. 49:09 MILLER: You either want to go back to not being able to 49:11 MIKE: Which is more comfortable. 49:12 Let's face it. 49:13 Which is more comfortable. 49:14 And I'll tell you that right now. 49:15 That's a hell of a lot more comfortable saying, "Ah, I'm 49:17 not going to quit smoking." That's more comfortable. 49:20 MILLER: Either side is more comfortable. 49:21 MIKE: Either side is more comfortable than the 49:22 ambivalence. 49:23 The ambivalence is the hell. 49:25 MILLER: It is. 49:25 MIKE: That's the hell. 49:26 Okay, cause well I know I shouldn't but I will and I 49:29 don't know if I should. 49:30 Here's what it is. 49:32 It's knowing that you are taking a carcinogen, a known 49:34 carcinogen, and you are putting it in your lungs. 49:36 You know that it's upping your blood pressure. 49:38 You know it is increasing your chance of lung cancer. 49:40 You know it's really screwing up your soccer. 49:42 It's that, it's doing that is pissing me off. 49:46 It's knowing that you are taking a poison, a poison 49:48 called alcohol. 49:49 You know the second drink your judgment is 49:51 going to go to hell. 49:53 And why am I doing this? 49:54 Let's just bang that head against that brick wall some 49:57 more too please. 49:59 And That's what pisses me off. 50:00 I mean if I was stupid, I could forgive myself for it. 50:04 If I define myself as an addict, you know, and I think 50:08 a lot of people do, then they can forgive themselves for it. 50:11 But that's, no. 50:14 MILLER: That is not a way out of you. 50:15 MIKE: No. 50:15 That out doesn't work. 50:17 That's a cop-out. 50:18 I mean, and see I wish I was stupid and I could just say, 50:24 didn't know any better. 50:25 MILLER: And you could sit back here and 50:27 MIKE: Yeah. 50:28 MILLER: be comfortable. 50:29 MIKE: Yeah, right. 50:30 MILLER: Now the place where you are is real uncomfortable. 50:33 MIKE: Yeah. 50:33 MILLER: And moving either way from it is more comfortable. 50:35 MIKE: Of course. 50:35 Of course. 50:36 Moving up or back. 50:39 MILLER: But staying in the ambivalence, because you are 50:40 conscious of it, you are conscious of taking in the 50:43 poison or the carcinogen or whatever it is 50:44 MIKE: That's the problem. 50:46 MILLER: Boy. 50:47 MIKE: That is, what are you doing this for? 50:50 You know, what are you doing this for? 50:52 And 50:53 MILLER: And That's the teetering then. "Which way am 50:55 I going to move off of this" 50:55 MIKE: Right. 50:56 MILLER: "because I don't want to stay here." 50:57 MIKE: And not only that. 50:58 You know the guys at soccer they always kill me. "Hey, you 51:03 smoking again" Oh yeah. 51:05 You're stupid, man? 51:06 So I got a little peer pressure going there. 51:08 MILLER: So they are not all pulling you into 51:10 drinking and smoking? 51:10 MIKE: Oh, no, no. 51:11 They wouldn't, well it all depends. 51:14 This is the Polish soccer team. 51:19 Most of these guys are right off the boat, okay? 51:21 And they do drink a lot, so 51:24 MILLER: They just give you a hard time about smoking? 51:25 MIKE: Right, and they don't smoke. 51:27 MILLER: Oh, okay. 51:28 MIKE: And I say, "Well listen, you know, hey, if you want me 51:31 to quit smoking, I'm going to have to quit drinking." "Oh no 51:34 you could." "No," I says, "I can't." It doesn't work that 51:37 way for me. 51:38 And then having never done it they don't know. 51:40 So I'm going to have to like, if I do this, I'm going to 51:43 have to stay away from them at least long enough to establish 51:46 some type of 51:47 MILLER: There you go. 51:49 People who make it through change usually do it, I mean 51:52 you've got it. 51:53 Usually do what you are saying which is for a while avoid the 51:58 valley of the shadow of death, you know. 52:00 I mean avoid the difficult place. 52:02 And then it gets more okay. you've got to not rush too 52:05 quick back in there, but it gets to be okay. 52:07 You don't then have to stay away 52:09 MIKE: Forever. 52:10 MILLER: Right. 52:10 So it's not forever and ever. 52:12 But for a while you are probably right. 52:13 MIKE: Yeah. 52:14 MILLER: Or, somehow, get them to, say, "Help me out guys." I 52:17 mean, if they won't do it, then you are right. 52:20 MIKE: No, it's not like they are bad guys. 52:22 They just don't know. 52:23 See, they're not 52:25 MILLER: Haven't done it. 52:26 MIKE: You know, they don't know. 52:29 I mean I think if you don't smoke, you don't smoke 52:34 cigarettes, you don't know. 52:35 You're not going to know. 52:37 And how could they possibly help it? 52:40 MILLER: Well, I only meant that if they could get it in 52:44 their heads that what you are saying is right 52:45 MIKE: Yeah, right. 52:46 MILLER: That if they want to help you stop smoking, they've 52:48 gotta also not encourage you to drink. 52:51 MIKE: Don't come over with the 12-pack and want something. 52:54 MILLER: Yeah. 52:55 MIKE: You know, come on. 52:56 MILLER: So if you could ask them to do that, help you out 52:58 that much, then 52:59 MIKE: They're guys. 52:59 They're guys. 53:00 MILLER: They won't 53:01 MIKE: These are guys, okay? 53:02 They're guys. 53:03 I'm single you see. 53:04 If I was married I could blame it on my wife. 53:06 In fact, I'm thinking of getting married, 53:09 well I'm just kidding. 53:10 But I'm thinking of a rent-a-wife situation. 53:13 See you rent a wife and you tell all your guy friends, 53:15 "Hey, I'm a married man. 53:17 My wife will kill me if you guys come over." Then you get 53:19 to get then the hell out of your place. 53:21 If you are a bachelor, they're trying to get away from their 53:23 wives, guess who they come over and hang around with? 53:25 You. 53:26 MILLER: Yep. 53:26 MIKE: And guess what. 53:27 That excuse doesn't work. 53:28 The only thing they understand is some bitchy lady with a 53:32 skirt, okay? 53:34 MILLER: That would work. 53:34 MIKE: And then you could clear them out of the place. 53:36 Otherwise, you can't clear them out, man. 53:38 See, then you have no excuse but to do what 53:41 they want to do. 53:41 MILLER: Yeah. 53:42 MIKE: That's the way guys are. 53:44 At least the guys I know are that way. 53:46 MILLER: So, you are right. 53:46 You would have to stay away from them for a while. 53:48 MIKE: Right. 53:48 Right. 53:49 I hope I'm not babbling here. 53:51 MILLER: No, no. 53:51 MIKE: I seem to be all over the place here. 53:53 MILLER: I mean you are giving me a real good 53:55 sense of who you are. 53:56 MIKE: Yeah. 53:56 MILLER: I mean I love to read a book to the end, and I'd 53:58 love to know which way you are going to go from this place. 54:00 MIKE: I would like to know myself. 54:01 I don't even know. 54:02 You know, I don't even know. 54:07 Like I say, I'm still at the ambivalent stage, and it's 54:11 getting to the point where I'm going to have to make 54:14 MILLER: It's too uncomfortable. 54:16 MIKE: Well, yeah. 54:16 But what do you want to go back? 54:18 I mean, where's back? 54:19 Where's back going to take you? 54:21 MILLER: Yeah. 54:22 You know. 54:23 MIKE: Yeah. 54:24 Yeah. 54:25 MILLER: But it's that "Can I do it?" obstacle. 54:27 MIKE: Well, that's, it's a confidence problems. 54:30 MILLER: So something that would 54:31 help you be more confident. 54:32 MIKE: Yeah, well, yeah, yeah. 54:36 MILLER: To be able to look at it and say, "I could do that. 54:39 I can see myself doing that." 54:41 MIKE: Well, yeah, but what's that going to do? 54:43 MILLER: I'm not sure. 54:45 MIKE: It's going to have to be internal if it's 54:46 going to work for me. 54:47 MILLER: Mm hm. 54:47 MIKE: It can't be anything external. 54:49 I can't deal with cheerleaders. 54:51 I can't deal with, Oh you can do, it you can do it. 54:56 Hey, come on. 54:56 I'm a little too old for that. 54:58 MILLER: There is certainly nobody pushing you. 55:00 MIKE: Well, you know, I'm going to have to figure out 55:02 that I can do it myself or just not going to 55:05 be able to get done. 55:06 And That's just, the long and the short of it is That's what 55:08 it's really going to take. 55:09 MILLER: That's the bottom line. 55:10 MIKE: Yeah. 55:10 I mean for a person like me, that is the bottom line. 55:13 And it has to be important enough. 55:16 But I think it is important enough now or else I wouldn't 55:19 be thinking about this in the first place. 55:20 MILLER: That's how it sounds. 55:23 MIKE: You know, as far as I'm concerned, I don't care if I 55:25 die tomorrow. 55:26 This is not about my health. 55:28 MILLER: Mm hm. 55:30 MIKE: Boy I can't stand, if I'm not the fastest guy out 55:33 there, I have an identity crisis, okay? 55:36 It's my arrogance, okay? 55:38 It's my conceit. 55:40 It's my pride, okay? 55:42 So I am using all the negative stuff you're never supposed to 55:45 have in AA to help me 55:47 MILLER: Challenge. 55:47 That's what will get you through. 55:51 Sheer cussedness. 55:52 MIKE: Yeah just sheer, you know, if anything, arrogance. 55:58 If anything, probably That's all it is. 56:00 And it really has nothing to do with health. 56:02 It really doesn't. 56:03 I mean I hate to admit it, but as far as longevity and life, 56:07 I don't really care about it. 56:09 High quality of life' Well, everyone dies. 56:11 Everyone makes such a big goddam deal out of it. 56:13 I'm so goddam tired of these people who, "Oh I eat these 56:16 healthy food, and I do this, and I know go out in the sun," 56:19 and yeah, yeah, you're 400 pounds overweight, 56:21 you don't work out. 56:22 You know, don't give me this live forever, but live what? 56:26 MILLER: We're all going to die anyhow. 56:27 MIKE: We're all going to die anyhow. 56:28 What are you going to do? 56:28 Just never go out in the sun? 56:30 MILLER: But while you are here, you want to be the best. 56:32 MIKE: Well, you know, it would kind of be nice to wake up, 56:34 you know, and feel healthy and be able to do 56:37 what you like to do. 56:38 MILLER: It is. 56:40 MIKE: Uh, well, yeah, if you could do what you like to do 56:42 forever, hey. 56:43 I would like to do that. 56:44 But I know That's not going to happen, and I accept that, and 56:47 to me it's not so much a longevity issue as it is a 56:51 quality of life issue. 56:52 And so That's the deal. 56:56 MILLER: You know the funny thing is it sounds to me like 56:57 you have made up your mind. 56:59 MIKE: Possibly. 57:00 MILLER: Maybe. 57:01 MIKE: Yeah. 57:01 I think I'm swaying. 57:03 MILLER: Leaning just a little. 57:04 MIKE: Swaying. 57:05 I hope it's not a pendulum, you know. 57:08 MILLER: I don't know though. 57:09 It's kind of back there. 57:10 MIKE: Yeah, back there is more comfortable. 57:11 At least it's known. 57:12 It's known. 57:13 See That's 57:14 MILLER: It's predictable. 57:14 MIKE: That's all it is. 57:15 It's known. 57:15 MILLER: It is predictable. 57:16 MIKE: That's all it is. 57:18 It's known. 57:21 Yeah, someone told me and it made a lot of sense. 57:23 Bang your head against a brick wall, you start to miss that 57:27 brick wall when you quit banging your head against it. 57:29 You know, I think That's what everything is. 57:33 Not just smoking, not just drinking, not just doing 57:35 whatever, cocaine or anything else, but everything else. 57:37 I think bad relationships are like that. 57:39 MILLER: Mmm, hmm. 57:41 MIKE: I think bad jobs are like that. 57:42 I think living in bad areas of town are like that. 57:45 I think, it's familiar. 57:47 Because it is familiar it is predictable. 57:49 MILLER: Right. 57:50 MIKE: You are comfortable with it. 57:51 It's not that terrible change, you know, 57:54 That's a scary thing. 57:56 And you know, maybe That's what it is. 57:57 So. 57:58 MILLER: What if you stopped smoking and drinking and you 58:00 still couldn't keep up with the young guys? 58:02 MIKE: Oh, I don't think that is going to be a problem. 58:04 MILLER: That's alright. 58:06 MIKE: I already can. 58:07 That's the thing. 58:10 It's just that you know I'm getting older, and this is not 58:14 going to last forever. 58:15 I put a lot in a bank account. 58:16 I had a scholarship, marathon scholarship, when I went to 58:20 college which I didn't take. 58:21 Ran a 4:32 mile, always been fast. 58:23 MILLER: Really. 58:24 MIKE: But I always had, the way I'm looking at it, I 58:26 always had a bank account, and I put a lot in that bank 58:28 account, that cardiovascular bank account. 58:30 Well, I've been drawing off that bank 58:31 account for a long time. 58:33 Now it's just about 58:35 MILLER: Balance is getting low. 58:36 MIKE: Balance is getting low. 58:37 So I have to kind of start filling it up again. 58:39 And 58:41 MILLER: That's a nice image. 58:42 MIKE: Well, I think That's exactly what's going on. 58:44 MILLER: That works. 58:46 MIKE: You can only do this stuff so long before you are 58:48 going to start feeling the effects. 58:49 I'm starting to feel the effects. 58:51 Maybe I always was but I was too stupid to realize it. 58:54 I'm not too sure. 58:55 MILLER: You don't want to go into debt. 58:57 MIKE: No. 58:57 I don't want to go into debt. 58:59 MILLER: Makes sense to me. 59:00 Well, I'd love to know how the story comes out. 59:02 I see that we are running out of the allotted time for this 59:05 filming session. 59:06 MIKE: Well, should we do a follow up? 59:08 MILLER: I'd like to know. 59:09 MIKE: You know, I tell you. 59:10 If I do this, it's not going to be for two to 59:13 three weeks, you know. 59:15 Everyone says, "Oh do it tomorrow." You know what? 59:18 No. 59:19 MILLER: You are going to set a date out there somewhere. 59:21 MIKE: Well, yeah. 59:22 MILLER: Not tomorrow. 59:23 MIKE: Not tomorrow. 59:24 Not tomorrow. 59:25 Not today, not right now. 59:27 I mean, you know, I'm just not going to do that you know. 59:32 It's going to be, here's what happens to me. 59:37 When I start doing shit That's contradictory to bad habits, 59:41 the bad habits start disappearing almost naturally. 59:45 And I start getting a roll. 59:47 MILLER: Beautiful. 59:47 MIKE: And then I start getting to the point where I want to 59:50 continue this good habit. 59:51 Bad habits, I'm not really thinking about. 59:52 They are starting to go away. 59:54 So I want to kind of like steamroll this turkey, and 59:57 then as soon as I got that steamroll thing going and I 01:00:01 got this thing on the run, it's okay baby, and now we're 01:00:05 going to get you. 01:00:06 Now you are vulnerable. 01:00:08 Now you're going to die. 01:00:09 That's 01:00:10 MILLER: That's the plan that works for you. 01:00:11 MIKE: Yeah. 01:00:13 MILLER: Good. 01:00:13 MIKE: Does that work for other people or am I strange' 01:00:16 MILLER: No, people are real different in terms of the way 01:00:19 they find, and it's kind of your personality and what 01:00:23 grabs you and what's the thing that finally tips 01:00:25 the seesaw for you. 01:00:26 MIKE: I was told, "That doesn't work." I was told, 01:00:29 "Well no, no. 01:00:29 One size fits all. 01:00:31 This is how we have to do this. 01:00:32 This is the only way we do it." You know, that's what I 01:00:34 was always told. 01:00:35 It made no sense to me, and I just really lost respect for, 01:00:39 you know, anyone in the industry because, do you have 01:00:43 any intuition? 01:00:44 Do you ever listen to your clients? 01:00:46 Have you ever thought that there could be something 01:00:48 called individuals out there? 01:00:50 Hey, bell shaped curve, guys. 01:00:52 Hey, you know what it is? 01:00:53 Guess what different IQ levels, 01:00:55 different personality traits. 01:00:57 Guess what. 01:00:57 MILLER: People know something about themselves. 01:00:58 MIKE: Yeah. 01:00:59 MILLER: Mmm hmm. 01:00:59 Yeah. 01:01:00 MIKE: So, but I never got that far. 01:01:02 Of course, like I said, it was state run. 01:01:04 It was a little bit different, so. 01:01:08 MILLER: Well, I wish you well. 01:01:09 I'd like to know how the story comes out. 01:01:14 CARLSON: Bill, was your work with Mike a good example of 01:01:16 Motivational Interviewing? 01:01:18 MILLER: It was, yeah. 01:01:19 He offered some unique challenges, I think, and gave 01:01:23 me a chance to really settle into the style, and I felt 01:01:27 pretty good about that interview. 01:01:29 How do you know in a case like that that you're not being 01:01:32 conned or you're not being deceived by someone' Well, you 01:01:35 don't, of course. 01:01:37 I tend to go with the person rather than 01:01:40 pushing against them. 01:01:42 And you get more honesty when you do that, as it turns out. 01:01:46 I wasn't particularly concerned about dishonesty in 01:01:49 this case but I often will acknowledge to the person that 01:01:52 they can deceive me if they choose and not much I can do 01:01:58 about that. 01:01:58 And that very acknowledgment somehow decreases the need and 01:02:04 desire to do that. 01:02:06 But l really liked this guy and it felt 01:02:09 very genuine to me. 01:02:10 He was talking exactly about where he is, in that stuck 01:02:14 place and in that contemplation stage of ''Do I 01:02:19 go forward or back now?'' 01:02:20 CARLSON: And he really liked you too. 01:02:22 After the session was over, I noticed he 01:02:25 didn't want to leave. 01:02:26 He wanted to keep talking with you. 01:02:28 MILLER: Yeah, we were chatting out in the hall. 01:02:30 And he wanted some ideas and things. 01:02:33 It seemed like he wanted some action steps, 01:02:36 where he might go next. 01:02:38 Yeah, and I think he'll be taking them. 01:02:40 CARLSON: Where would you go if you were to meet him again? 01:02:43 Where do you think the story's going to end? 01:02:47 MILLER: I think he's headed for making a change. 01:02:50 And the first thing I would do, of course, is check in on 01:02:54 where he is. 01:02:55 Sometimes people get the sense that once you've cracked this 01:02:59 motivation thing then you just get right to business and you 01:03:02 change them. 01:03:03 But the ambivalence continues throughout the process of 01:03:07 treatment and change, and so it may very well be that when 01:03:12 he comes back in, even if he may have gone a few days 01:03:16 without drinking or something, trying it out, he's still 01:03:19 going to remember the old days and have some ambivalence. 01:03:22 And so I would deal with that. 01:03:24 But I would start checking out whether he'd like some ideas 01:03:28 about other things to try. 01:03:30 This guy probably won't need them. 01:03:32 He's got lots of good ideas. 01:03:34 And usually the ideas that the client comes up with are 01:03:37 better than the ones I would come up with. 01:03:38 But if he wants suggestions, I could certainly make some. 01:03:41 I noticed, too, that there were several times when he was 01:03:46 convincing you that he needed to make a change-like he was 01:03:50 the one that said, ''Try drinking a six-pack and then 01:03:54 program a computer.'' He was the one that said, ''Well, if 01:03:59 I'm going to quit smoking I'm really going to have to 01:04:07 drinking, too.'' Right. 01:04:08 Now, is that something that's pretty typical? 01:04:11 LEWIS: Did you ask him something to put him in the 01:04:13 position of convincing you that he had a problem? 01:04:16 MILLER: Well, it's an interaction. 01:04:18 We're dancing together. 01:04:20 In fact, when we're looking at videotapes of therapists, one 01:04:24 of the scales we use is the dancing-wrestling scale. 01:04:27 Are these two people dancing with each other, or are they 01:04:29 wrestling with each other? 01:04:30 And we were dancing. 01:04:32 It had that sense of moving with him. 01:04:35 So I think I had something to do with the fact that we wound 01:04:39 up there and it certainly is where I want to be. 01:04:43 I want the person telling me about change rather than me 01:04:47 being the authority and telling them about change. 01:04:50 But that also has very much to do with his willingness in the 01:04:52 place he is to be ready to move. 01:04:55 So in a sense I just made it possible for him to move in 01:04:59 the direction that he was already headed anyhow. 01:05:02 You can't trick people into changing. 01:05:04 LEWIS: Although you did reflect or summarize positive 01:05:07 statements that he made statements that were oriented 01:05:11 toward change rather than against it. 01:05:14 I know there are a lot of places where he had ambivalent 01:05:18 statements that he made and the one that you picked up on 01:05:21 was the positive one. 01:05:23 MILLER: Right. 01:05:23 And that's a good example. 01:05:25 My role in that is to accentuate the positive. 01:05:30 But they're his words. 01:05:31 So he says it, and I reflect it. 01:05:35 He hears me say that he says it. 01:05:36 And I'll come back later, maybe, and summarize with it a 01:05:39 little bit too, or reflect it again. 01:05:42 But they're his words to begin with. 01:05:44 And it's that kind of process that seems to trigger change. 01:05:49 CARLSON: I like when he said, ''I can't change for at least 01:05:53 two or three weeks,'' which seemed to me to be quite 01:05:57 optimistic. 01:05:57 I would have been inclined, though, to say, ''Well, how 01:06:00 will that work? 01:06:00 How will you do that?'' And yet you resisted. 01:06:02 You kind of let back and let him just accept that fact. 01:06:07 ''You've got time in the future that you'll do this.'' 01:06:10 MILLER: Yeah. 01:06:10 It would be fine to say, ''Tell me what that will look 01:06:13 like,'' too, or, ''How would you do that?' 01:06:15 Nothing wrong with that. 01:06:16 I didn't know whether that would be pursuing too much, 01:06:19 because it seems like the more you pursue, the more they 01:06:21 distance, and when you stop pursuing they seem to move 01:06:24 toward you. 01:06:25 Well, the nice thing is that your clients 01:06:27 teach you this style. 01:06:28 That's where I learned it in the first place. 01:06:30 So if you're pursuing too much you find out right away. 01:06:35 You can judge whether you're doing the right thing by what 01:06:38 the client's doing. 01:06:39 You get immediate feedback. 01:06:41 So if the client is moving toward change, is talking 01:06:45 about how they might change or envisioning how it might be, 01:06:50 or the costs of the way it's been before you're doing fine. 01:06:53 All you have to do is agree. 01:06:54 You're on coast at that point. 01:06:56 But if you try something like that and the client suddenly 01:07:01 backs off, then it's, ''Oops I pushed a little too hard.'' 01:07:05 You can recover from that. 01:07:07 But you use the client, always and respect the client's 01:07:11 presence as the feedback for whether you're doing the right 01:07:14 thing or not. 01:07:16 CARLSON: Well, we have a studio audience who has lots 01:07:19 of questions. 01:07:20 So what we'd like to do now is take some specific questions 01:07:24 about the interview, and then in a little while we'll have 01:07:28 some general questions about the approach, Motivational 01:07:31 Interviewing. 01:07:34 AUDIENCE: You talked about dancing with your client 01:07:38 versus wrestling. 01:07:39 And it seems to me that your approach is more appropriate 01:07:43 to talkative, outgoing clients of this type. 01:07:47 What about if you had one who was wrestling, who was not as 01:07:51 talkative and who was quieter? 01:07:55 How would this approach fit? 01:07:58 Because I'm interested in goodness of fit, like more 01:08:00 research here. 01:08:02 And I'm wondering if you had someone who is 01:08:04 the opposite of dancing. 01:08:06 You obviously enjoyed yourself. 01:08:08 But if you had a wrestler, as most alcoholics are could you 01:08:15 just project a little bit how you would have 01:08:17 approached the client? 01:08:19 MILLER: Well, there are really two pieces- 01:08:21 AUDIENCE: And you would have to do this in the 01:08:22 abstract, I know that. 01:08:24 MILLER: Well, no. 01:08:25 There are two pieces. 01:08:27 One is, what if your client's less verbal? 01:08:28 I can talk about that in a bit. 01:08:30 But dancing and wrestling are interpersonal behaviors. 01:08:34 We could have been wrestling real easily. 01:08:38 There were lots of invitations to wrestle all through the 01:08:41 time, and all you would have to do is a little bit of 01:08:43 confronting, a little bit of pushing a little bit of 01:08:46 shaming or criticizing, and you'd have professional 01:08:49 wrestling on your hands. 01:08:50 It would be very dramatic. 01:08:51 So it's not that people come in wrestlers or dancers. 01:08:56 It's what you invite them to do with you. 01:09:01 So, sure, some people come through the door mandated by 01:09:05 the court, angry, defensive, but do they stay that way? 01:09:09 What happens over the course of the 01:09:11 session is in your hands. 01:09:13 So those aren't client personality traits. 01:09:16 Those are interactions of two people. 01:09:19 But the less verbal client, it's fine, really. 01:09:23 On another set of videotapes that I made, we had a very, 01:09:26 very nonverbal client. 01:09:28 And Rogers demonstrated the same thing-that even with a 01:09:32 client who's not talkative and not high on the verbosity 01:09:37 side, you can still stay with them and be very much a part 01:09:41 of their experience, reflect nonverbals, anticipate what it 01:09:48 might be that's going on and if you're wrong they tell you. 01:09:50 There's no penalty for missing here. 01:09:57 This sounds a little bit arrogant, but I really haven't 01:10:00 yet found a client with whom I couldn't do this. 01:10:03 Because it's not a trick. 01:10:05 It's not a technique. 01:10:07 It's a way of being with people. 01:10:08 And you offer that to the person, and you 01:10:10 see how they respond. 01:10:11 And how they respond is right. 01:10:13 The client's always right. 01:10:15 AUDIENCE: It's interesting that you mention Rogers. 01:10:19 How close is this approach to Rogers's approach? 01:10:22 Because as you said, Rogerian therapy indeed does a lot of 01:10:27 reflection, but for alcoholics, they require that 01:10:30 the alcoholic be in recovery for two years so they can 01:10:33 bring these things to the table that 01:10:36 this gentleman brought. 01:10:37 But how close are you to that? 01:10:40 MILLER: Very grounded in Rogers. 01:10:42 The work that Rogers did, we wouldn't be doing Motivational 01:10:46 Interviewing without that. 01:10:47 It's just fundamental to this approach. 01:10:50 The difference is the consciously 01:10:54 directive aspect of this. 01:10:56 Rogers described his approach as nondirective. 01:10:59 His students, Traux and Carkhuff, were able to 01:11:02 demonstrate that he was very contingently responding to 01:11:06 what clients were saying, and tending to reinforce and 01:11:09 emphasize the positive self-statements, and he wasn't 01:11:11 conscious of doing it. 01:11:13 And he was sort of surprised and shocked when they 01:11:16 demonstrated the operant contingencies 01:11:17 in what he was doing. 01:11:18 So in a way we're doing the same thing. 01:11:21 We're just trying to be very conscious and a little bit 01:11:23 strategic about it and to use reflection as a reinforcer for 01:11:30 the person's own momentum. 01:11:35 AUDIENCE: That leads into my question. 01:11:37 I loved the way, you call it, ''danced'' with him. 01:11:40 To me it was like tai chi, like one of the Eastern 01:11:45 martial arts, because you were so clear not to get engaged in 01:11:50 counterforce with him, and yet it was highly skillful. 01:11:54 But you mentioned before the interview about times that you 01:11:59 reflect and other times you lead. 01:12:01 And at least for me, the trick with this guy would be not to 01:12:04 lead at the wrong time or he would become 01:12:07 oppositional again. 01:12:09 Can you say any more about how you chose to encourage or 01:12:14 empower or lead in ways that wouldn't evoke the 01:12:19 oppositional? 01:12:20 I'm clear if it were oppositional you'd 01:12:22 know to back off. 01:12:25 MILLER: You see right away the person's response- they begin 01:12:27 moving in the other direction. 01:12:31 It's almost like interpretations in classic 01:12:34 psychotherapy, that you don't jump too far beyond where the 01:12:39 person is, but you go a little bit beyond 01:12:41 where the person is. 01:12:42 In this case, my suggesting of a five-day outback kind of 01:12:52 trip was consistent with what he'd been talking about, but 01:12:55 it was something new. 01:12:56 So it was a suggestion, an invitation 01:12:59 to think about this. 01:13:00 And he seemed to like it. 01:13:02 Later on, he said, ''Well, a year? 01:13:06 How long am I going to be out there''' So there I pushed a 01:13:09 little bit too hard. 01:13:10 But that was an example, I think, of understanding his 01:13:15 own perspective, where he is experientially, and making a 01:13:22 suggestion as a suggestion just to see if it's something 01:13:26 he's willing to pursue. 01:13:30 It's not, ''Okay, be quiet, now I know the answer and I'm 01:13:33 going to tell you what you should do.'' That will have a 01:13:36 very predictable result with this fellow and with, indeed, 01:13:40 many human beings- most human beings. 01:13:42 So it's just moving a little bit past, and doing it in the 01:13:45 context of the person's own values what's 01:13:49 important to him. 01:13:50 AUDIENCE: To make it concrete-you said something 01:13:56 about a cabin or outback, and he changed it to the river. 01:14:00 You followed the river. 01:14:02 MILLER: Absolutely. 01:14:02 Always follow the river. 01:14:05 AUDIENCE: Absolutely. 01:14:06 But it would have been tempting to me to say, ''Well 01:14:10 you've got two components you know. 01:14:12 One is to start doing more of a positive thing, like more 01:14:18 soccer whatever it is, more athletic stuff. 01:14:21 And the other is you need to be off alone for a period. 01:14:25 Can you plan more of that?'' You never asked that, and you 01:14:29 never pushed him to really get concrete in his plan. 01:14:34 MILLER: But he is planning. 01:14:36 If you listen toward the end of the tape, there's some of 01:14:40 what we call envisioning of thinking ahead to the time 01:14:43 when he has changed and how he deals with that. 01:14:46 So I don't need to tell him to plan. 01:14:48 He's doing it. 01:14:49 And I don't need him to write it down and 01:14:51 sign it as a contract. 01:14:52 It's happening. 01:14:53 One of the funny things about Motivational Interviewing is 01:14:55 it's not very dramatic. 01:14:59 Sometimes people weep during sessions but you don't have 01:15:02 these dramatic confessions and things in the session. 01:15:05 And if that's what you're looking for, a soap-opera kind 01:15:08 of response, it looks like not much 01:15:10 happened during the session. 01:15:11 And indeed, you sit and watch a session like this you say, 01:15:14 ''Well, did anything really happen?'' It's the data that 01:15:17 are persuasive-that when you do this 01:15:19 you really see changes. 01:15:20 Even though the person's not swearing they're going to do 01:15:23 something and laying out plans and signing contracts, they 01:15:27 actually do it. 01:15:27 And that's what matters to me not that they say they're 01:15:29 going to do it, but that they actually go ahead and change. 01:15:33 LEWIS: He did seem to me as though he was ready to wrestle 01:15:36 in the session when it first started that if you'd been 01:15:40 willing to wrestle with him, he was up for wrestling more 01:15:43 so than dancing. 01:15:43 MILLER: Oh, we'd have had a great time, you bet. 01:15:45 And it's what he expected. 01:15:47 This guy has had a lot of experience with addiction 01:15:49 counselors and he came in knowing what 01:15:51 was going to happen. 01:15:52 And it didn't happen. 01:15:57 AUDIENCE: I was more interested in, than anything 01:16:01 parallel between you and your client and we saw the client 01:16:06 and we heard you talking But what I would like to do is 01:16:10 sort of get inside you. 01:16:12 Like when you were making this point, ''freedom of choice,'' 01:16:16 what was your freedom of choice when you were in that 01:16:20 counseling relationship as a therapist? 01:16:28 When he said a couple times, ''fear of failure,'' any 01:16:34 beginning Rogerian counselor it would have been a focal 01:16:38 point-this man saying about himself, ''fear of failure.'' 01:16:43 But it seemed like you just went along with that. 01:16:47 But what was in you then, in relation to the fear of 01:16:52 failure, as the therapist? 01:16:56 And also any ambivalence in you regarding what are you 01:17:05 doing, taking this counseling relationship in what 01:17:09 direction, or anything in response to 01:17:14 his triggering you? 01:17:17 Did you have any struggle at all? 01:17:22 MILLER: Well, three questions again. 01:17:23 Yeah. 01:17:25 I had a couple reactions to ''fear of failure.'' My first 01:17:27 one was ''psychobabble'' -that this is a phrase he's picked 01:17:31 up somewhere or some counselor's given, or he read 01:17:33 it in some book. 01:17:34 So he wasn't connected to it. 01:17:36 It was an explanation, but he wasn't connected to it. 01:17:39 And yet I assumed he was telling me the truth and it 01:17:41 meant something. 01:17:42 And so my thought was, ''What does it really mean?'' And the 01:17:46 obvious thing to me that it meant was, ''I'm not sure I 01:17:48 can do this.'' So rather than going down the road of 01:17:52 exploring why he feels fear of failure and what his family 01:17:55 history is that would contribute to that and so 01:17:57 forth it really is an issue of confidence. 01:17:59 And if a person knows it's a problem, as he does, but isn't 01:18:04 sure how to do it or that he can do it, then that's the 01:18:08 place where you're stuck, and that is indeed 01:18:10 where this guy is stuck. 01:18:11 He needs something that he can believe in and say, ''Yeah, I 01:18:15 could do that,'' and then he will move forward with that. 01:18:18 I wasn't quite sure about the freedom of choice point except 01:18:23 that I can give you an example of it, which is toward the end 01:18:27 where we were talking about the ambivalent place and that 01:18:31 he can go forward or he can go back, but it's real 01:18:35 uncomfortable to stay where he is. 01:18:37 I didn't make a big deal out of it but that implicitly is, 01:18:41 ''You can choose to go back.'' And I somewhere reinforced 01:18:45 that and he said, ''Well, but why would you do that?'' So 01:18:49 he's again making the argument against that. 01:18:52 But it is imbued in the whole approach that of course the 01:18:56 person has freedom of choice about this, and they can 01:18:59 decide to continue doing what they've been doing. 01:19:01 They can decide to do more of it, they can change it, and it 01:19:04 really is in their hands. 01:19:07 And then what's going on with me? 01:19:09 I think that the ambivalence still is that I want to rush 01:19:14 in and fix it. 01:19:16 So it's a constant temptation for me to say, ''Ooh, ooh, I 01:19:20 know what you can do. 01:19:21 I can fix that for you.'' But I've learned enough from my 01:19:27 clients not to do that so often. 01:19:29 If they're asking, sure. 01:19:32 And I'll probably not give one idea, because when you give 01:19:36 one idea, then you know the client's line it's why it 01:19:39 won't work. 01:19:40 I tend to give several ideas and say, ''Which of these 01:19:43 sound like it might make sense for you?' I will ask 01:19:46 permission. 01:19:47 If I have an idea, I will ask permission and say, ''There is 01:19:53 one thing that occurs to me. 01:19:54 I don't know if it will make sense to you, but is it all 01:19:55 right if I tell you about that?'' And then, in that 01:20:00 respectful context, to say, ''This is just an idea. 01:20:04 I don't know if it works or not.'' And in 01:20:09 that way to do it. 01:20:09 But it's still a tremendous temptation to want to rescue, 01:20:14 to want to rush in with the answer. 01:20:16 And paradoxically, that doesn't answer it. 01:20:20 CARLSON: I feel a whole lot better knowing that that 01:20:21 doesn't go away for you, either. 01:20:23 It really helps me a lot. 01:20:26 MILLER: I'm still a fixer. 01:20:30 AUDIENCE: Speaking of paradoxes, I'd like to see you 01:20:32 talk a little bit about how you did not engage him as a 01:20:36 traditional chemical dependency counselor would. 01:20:40 When he started talking, he talked about the fact that he 01:20:42 used cocaine, he talked about the fact that he used alcohol, 01:20:45 he talked about the fact that he used cigarettes. 01:20:48 And he talked about the fact that he doesn't understand 01:20:51 this disease, and no one could give him a 01:20:54 definition of the disease. 01:20:55 And he tried to engage you several times in what his 01:20:59 previous experience had been with whoever his previous 01:21:04 provider was. 01:21:06 And I'd also like to see you talk about it in the fact that 01:21:09 you didn't address those issues, that you let those go. 01:21:13 Because I think a person more rooted in the traditional 01:21:17 training of a chemical dependency counselor or 01:21:19 therapist would have been, ''Look at what 01:21:21 you're telling me. 01:21:22 You're not telling me enough about the cocaine.'' He 01:21:25 mentioned it once. 01:21:26 You never even came back to it, I don't think, except for 01:21:28 one time when you talked about drinking and using cocaine. 01:21:31 And then he also talked about progression, and he didn't 01:21:35 think his disease was progressing and he wasn't even 01:21:39 sure he had a disease. 01:21:41 But then he talked about the fact that he went from one 01:21:44 cigarette or no cigarettes to two packs that day. 01:21:48 And you also let that go. 01:21:50 Or maybe you didn't. 01:21:52 But if you could frame that in terms of the paradox. 01:21:56 Because I think as traditional therapists who would be 01:22:00 looking to jump on those critical statements that he 01:22:04 made and I think that you sort of came around the back door 01:22:08 using the paradoxical approach. 01:22:11 MILLER: It's not paradoxical, really, but I'll come back to 01:22:15 that point. 01:22:15 I've never been a traditional addiction counselor so it's 01:22:19 not like I recovered from that. 01:22:20 I started out with Rogers, and sat with clients with 01:22:28 addiction problems and listened to them and talked to 01:22:30 them, and it was only some time later that I discovered I 01:22:34 wasn't doing it right. 01:22:35 I was supposed to be doing other things. 01:22:37 So I never operated that way. 01:22:40 And what you're talking about as traditional counseling is 01:22:44 changing pretty quickly. 01:22:46 I was surprised at the amount to which that still seems to 01:22:49 be occurring in this area, but it's a peculiarly American 01:22:53 phenomenon. 01:22:54 You don't find this in other cultures that much, and other 01:22:58 cultures look at this as, ''Really? 01:23:00 You do that? 01:23:01 That's very strange.'' But it's a different a model. 01:23:04 The model I think in what you're talking about is, 01:23:07 ''I've got to educate this person about the disease that 01:23:11 they have, and it has an inexorable progression to it, 01:23:15 and here's where they are in that progression. 01:23:17 And the most important thing is that they accept that they 01:23:20 have the disease and call themselves alcoholic or 01:23:24 whatever it is, and admit their helplessness to do 01:23:27 anything about it and accept help.'' And it fits into what 01:23:31 sociologists call the sick role, where you accept the 01:23:34 label, you confess that you can't do anything about it, 01:23:38 and you ask for someone else's help to do that. 01:23:40 So there's a long tradition to that role in societies, and 01:23:44 it's a role that we've used in this society to forgive people 01:23:49 for what's happened during their addictions and get 01:23:52 re-integrated into society. 01:23:54 And that's okay. 01:23:54 But the question is, does that really help people' And the 01:24:00 evidence as I read it, at least, indicates that being 01:24:02 willing to accept the label ''alcoholic'' is just 01:24:06 unrelated to outcomes. 01:24:07 You haven't gotten anywhere if you get the person to swear 01:24:11 that they're alcoholic. 01:24:12 Because there are lots of people who stop drinking and 01:24:16 change their drinking without ever taking that label into 01:24:19 themselves- and we all know there are lots of folks out 01:24:22 there who are very willing to say ''I'm an alcoholic'' who 01:24:24 are not doing well. 01:24:25 It's kind of unrelated. 01:24:27 So I'm not pushing for a label. 01:24:29 I'm not pushing for confession or acceptance. 01:24:32 Those just don't seem to be related to successful change. 01:24:37 LEWIS: Actually, avoiding labeling is an important part 01:24:41 of this, if I understand it correctly. 01:24:44 MILLER: In the sense that it's something that's easy to get 01:24:47 into an argument about. 01:24:48 It's easy for you to say, ''You have a diagnosis,'' and 01:24:50 the client says, ''No, I don't,'' and you try to 01:24:53 provide the proof and they give you the counterarguments, 01:24:55 and it's not productive. 01:24:57 If that were the crucial thing, if the made-for-TV 01:25:01 movies were right that it's being able to stand up in 01:25:04 front of people and say 'I'm an alcoholic'' that is the 01:25:07 healing moment-and there probably are people for whom 01:25:09 it is-then you would push hard to do that, but there just 01:25:13 isn't really any evidence that that's worth your time. 01:25:17 And you're much better, I think pulling from the client 01:25:20 their own desires, their own values, their own dreams and 01:25:25 where they're going and following those like the 01:25:27 river, rather than telling them what river they're 01:25:29 supposed to be in. 01:25:32 CARLSON: I'd like to revisit these five points that you 01:25:36 told us at the beginning and just to see 01:25:39 how they were covered. 01:25:40 The first was to express empathy. 01:25:43 I think that was clear. 01:25:46 MILLER: I think you'll see a lot of 01:25:47 reflections in the tape. 01:25:48 CARLSON: And then developing the discrepancy, and you were 01:25:52 doing that quite well at the end when you guys were almost 01:25:55 arguing-you for the addiction and he for the being free of 01:26:01 the addiction. 01:26:02 MILLER: Yes. 01:26:03 And you tend to see that increasing over the course of 01:26:05 a successful session. 01:26:07 And in fact, we have data to indicate that when you see 01:26:10 that, when you see the self-motivational statements 01:26:13 going up in the course of the session, behavior change tends 01:26:16 to follow from that. 01:26:17 So that discrepancy of his saying, ''It doesn't make 01:26:20 sense what I've been doing, and I would be so much better 01:26:23 if I made this change,'' are examples of that discrepancy 01:26:27 starting to open up for him. 01:26:29 CARLSON: And the third one-you could be Teflon Bill as you 01:26:33 avoided arguments. 01:26:35 He couldn't get you on anything. 01:26:37 You were the nonstick surface. 01:26:41 MILLER: Well, there just isn't any point in boxing. 01:26:44 It doesn't change behavior. 01:26:47 CARLSON: Then you rolled with resistance, like we talked 01:26:50 about before. 01:26:51 Can you talk some more about how you supported 01:26:53 self-efficacy- the self-effectiveness which is a 01:26:57 term Bandura coined? 01:26:58 MILLER: Yes. 01:27:01 Well, emphasizing that he did seem to have made a 01:27:05 decision was one. 01:27:07 Talking about the five-day river trip or whatever as, 01:27:11 ''This is something that you could see yourself doing that 01:27:15 would work for you.'' A number of times saying, ''This is 01:27:19 what works for you.'' And even more than that, when he comes 01:27:22 up with a strategy, reinforcing and agreeing with 01:27:26 that and saying, ''Yeah, it sounds like that would work 01:27:28 for you.'' So it wasn't as challenging with him. 01:27:32 He's got a lot of self-efficacy there but 01:27:36 somehow hadn't quite connected all of that yet to being able 01:27:39 to deal with smoking. 01:27:40 CARLSON: How it fits that problem, yeah. 01:27:41 LEWIS: And you go with the client's own 01:27:43 metaphors, I noticed. 01:27:44 Like with this client, he talked about the 01:27:47 cardiovascular savings account that he had, so 01:27:51 you went with that. 01:27:52 MILLER: That was great, I loved that. 01:27:54 And that's one thing that you want to know. 01:27:56 You want to know the imagery system of the person that 01:27:58 you're sitting with because that's the language in which 01:28:01 you can really speak to the person. 01:28:03 And sometimes the deepest reflections, and the 01:28:06 reflections that cause the most movement are those that 01:28:10 draw on the person's own occupation or imagery system. 01:28:14 And that was such a lovely metaphor, the savings account. 01:28:20 AUDIENCE: I think you have an advantage in the sense that 01:28:23 you just said you're not a recovering traditionalist. 01:28:27 So we're still teaching here some of these textbooks 01:28:32 written by these social scientists who promulgate the 01:28:36 preferred defense system of the alcoholic. 01:28:40 And that system is dominated by denial, so we have been 01:28:46 teaching, but I know Dr. Lewis has been encouraging us to 01:28:49 move toward motivational breakdown of 01:28:51 denial in the system. 01:28:57 Maybe I should just ask you, what do we do about the 01:29:00 preferred defense system of the alcoholic which has these 01:29:02 traditional entities such as denial and dichotomous 01:29:06 thinking and so on? 01:29:07 What do we do with that? 01:29:09 This is the question I think Tom was getting at. 01:29:12 What do we do with that from your approach? 01:29:15 I agree with you, I think we should shift our paradigms. 01:29:19 It's not paradoxical. 01:29:20 We should shift our paradigms for the 21st century. 01:29:23 So maybe you want to speak about that from the academic 01:29:26 standpoint. 01:29:27 MILLER: Well, I'll just speak about it from a personal 01:29:30 standpoint. 01:29:30 What I do is teach that the preferred defense mechanisms 01:29:34 of alcoholics don't exist. 01:29:37 AUDIENCE: You threw that through the window. 01:29:39 I figured that. 01:29:42 MILLER: And the books you're talking about probably aren't 01:29:44 written by social scientists, because there's not empirical 01:29:47 evidence that there's a consistent personality and 01:29:50 that, indeed, denial is any higher in alcoholics than it 01:29:53 is in other people. 01:29:54 I mean, alcoholics are as diverse as everybody else. 01:29:58 And it's an interesting question of how have we come 01:30:01 to believe, then, that that's so? 01:30:03 And if you behave in a consistently confrontational, 01:30:06 suspicious, aggressive, pushing fashion, people behave 01:30:14 in a denying resisting, oppositional way. 01:30:18 So if you do that constantly, every client is in denial. 01:30:22 And you just say, ''This is endemic to alcoholism. 01:30:25 Every client behaves this way.'' But they didn't come 01:30:29 through the door like that. 01:30:31 It's something that happens in the room. 01:30:33 Now, that' s radical. 01:30:35 Compared to traditional teachings in the United 01:30:38 States, that's radical. 01:30:39 But I really believe it's true. 01:30:41 AUDIENCE: I totally agree with you there, but we're not doing 01:30:43 it in treatment programs. 01:30:44 I have found that treatment programs in this state have 01:30:48 remained primitive as they were 25 years ago when I was 01:30:51 out there in the field. 01:30:53 They have not changed. 01:30:54 And people who lead these programs are primitive, and 01:30:57 still stay in that traditional mode. 01:31:00 So I'm encouraging what you're saying in the sense that, how 01:31:05 do we impact these treatment programs that are around this 01:31:10 state, or even in the culture of this country that are not 01:31:13 going anywhere. 01:31:14 LEWIS: Can I add to that question? 01:31:15 It seems as though maybe you're saying that even when 01:31:19 we talk about within the addictions profession, you're 01:31:23 having to learn to roll with the resistance as people try 01:31:29 to make some changes in how they see 01:31:32 addiction treatment going. 01:31:35 MILLER: Well, it's a different question-what's going to be 01:31:38 the best way to change the field and how do you deal with 01:31:40 people who are already in place and doing this? 01:31:45 Highest priority for me is that we not teach that 01:31:48 anymore, and that we start teaching the new people coming 01:31:51 into the field a different way of being with their clients. 01:31:53 So let's not promulgate any more of this stuff. 01:31:56 But changing counselor behavior is harder than 01:31:58 changing client behavior. 01:31:59 There's a tremendous investment. 01:32:02 And I always remember the story of the doctor who 01:32:05 discovered that if he washed his hands women didn't die in 01:32:09 childbirth from fever and just developed a tremendous passion 01:32:15 to tell other doctors this. 01:32:17 Couldn't get accepted, was eventually committed by his 01:32:20 colleagues to a mental institution. 01:32:22 It was just too hard to say, ''Because I didn't wash my 01:32:26 hands, hundreds of women have died.'' So it's such 01:32:32 dissonance to change your very model of thinking about 01:32:36 people, to say, ''Denial isn't out there in the client.'' 01:32:39 That's very tough. 01:32:41 So I want to put my time particularly into training the 01:32:46 next generation of counselors for this field so we don't 01:32:49 have more of the same. 01:32:52 CARLSON: We don't want you to be in a mental institution. 01:32:55 Be careful. 01:32:56 LEWIS: I think you do roll with the resistance. 01:32:59 MILLER: Well, of course that's what you do in teaching. 01:33:01 When I teach Motivational Interviewing to addictions 01:33:05 counselors, this is the only-well, no, doctors would 01:33:08 be the other one-where it comes up that you get a lot of 01:33:10 skepticism about whether this happens. 01:33:13 It's my job in teaching to show what I'm talking about 01:33:17 doing clinically. 01:33:18 It's my job to be respectful and to understand the person's 01:33:22 perspective and speak to that. 01:33:24 So in my teaching, I'm trying to do the same thing that I'm 01:33:27 encouraging trainees to do in counseling. 01:33:32 AUDIENCE: My question has some overlap with this. 01:33:35 I was wondering what your sense was of how Motivational 01:33:40 Interviewing has impacted treatment. 01:33:43 And also a little more specifically I'm assuming this 01:33:49 is implemented in substance abuse treatment programs at 01:33:54 University of New Mexico, but I'm curious about how that's 01:33:58 been implemented and how that's been worked with. 01:34:05 MILLER: It's interesting that this approach took much more 01:34:08 quickly in Europe and Australia and Britain than in 01:34:11 the United States, and now there's really substantial 01:34:15 increase in the United States in this approach. 01:34:17 And not just in the addiction field. 01:34:20 And I guess one of the things I hope will be a contribution 01:34:23 of my career is a humanizing of addiction treatment. 01:34:28 The manner in which people have been treated honestly has 01:34:36 been shameful. 01:34:37 And if that can change, if we can begin to treat people who 01:34:43 have addictive behaviors with the same respect and 01:34:45 compassion and joining that we do other kinds of physical and 01:34:50 mental problems, that's good. 01:34:53 And I think Motivational Interviewing teaches you that, 01:34:57 that if you practice it, even just start rudimentary trying 01:35:01 some parts of it, your clients teach you. 01:35:04 And I see that happening. 01:35:06 Treatment is very different in New Mexico than it is here. 01:35:09 We're a smaller state, but we have been teaching the new 01:35:15 generation of counselors for about 12 years now by 01:35:18 operating the state's principal training program for 01:35:23 counselors. 01:35:24 So this is fairly widespread there, and even to some extent 01:35:29 taken for granted. 01:35:30 I can no longer do controlled studies on Motivational 01:35:33 Interviewing at my own center because it's all through the 01:35:35 center and you can't have a control group. 01:35:40 And I think the change to professionalization of the 01:35:44 field, where treatment is now more often provided by people 01:35:47 who have been trained as mental health professionals, 01:35:51 has also helped because this is very natural to folks who 01:35:54 have been trained as counselors or psychologists or 01:35:56 social workers. 01:35:57 It was folks who were addiction counselors and that 01:36:01 was it, I think who had the hardest time with that kind of 01:36:04 paradigm change. 01:36:06 And it's kind of natural. 01:36:08 So it's happening and I feel very good about it, mainly for 01:36:13 our clients that they're being treated more humanely, more 01:36:17 respectfully. 01:36:20 AUDIENCE: There's been a concern expressed about the 01:36:24 fact that the teaching isn't really changing right now. 01:36:27 But another barrier, too, is the courts and their beliefs, 01:36:29 and what they consider as an addiction. 01:36:31 And then they're almost setting down treatment. 01:36:34 And then they send the addiction counselors an actual 01:36:38 goal of abstinence-this is what they're told, especially 01:36:42 with adolescents. 01:36:43 They're told, ''This is bad, this is wrong, you will go to 01:36:46 jail.'' So they come in with that approach and whatever our 01:36:50 beliefs are and where we want to work with them at what 01:36:53 stage they are they've been told their goal has to be 01:36:56 abstinence. 01:36:56 And it's in a very short time where they will go to jail. 01:36:59 Can Motivational Interviewing work with that population? 01:37:03 You can want to work with them but yet behind them there's 01:37:06 someone telling them, an external source saying, ''This 01:37:10 is what you need to do.'' How do you work within that 01:37:13 limitation? 01:37:15 MILLER: Actually, it works particularly well. 01:37:16 So the more defensive or resistant or reluctant the 01:37:23 population you're working with, the more beneficial this 01:37:26 is relative to charging into a change approach. 01:37:30 Half the clients that we see at our center are court 01:37:32 mandated, so it's very common. 01:37:35 The largest effect size that we've seen with Motivational 01:37:37 Interviewing has been with an adolescent population, 100 01:37:40 percent of whom were being brought into the program 01:37:43 against their will. 01:37:46 Because you're not an officer of the court. 01:37:52 You can and have to acknowledge the reality of it. 01:37:55 ''The court situation is, they say if you're not abstinent 01:37:59 within this time, you're going back to jail. 01:38:01 What do you want to do about that?'' And 01:38:04 work with the person. 01:38:05 You acknowledge-Glass sure knows this- you acknowledge 01:38:08 the reality of the situation and you also 01:38:11 work with the person. 01:38:12 Because the court's goal isn't necessarily the client's goal. 01:38:15 What's the client's goal? 01:38:17 And with adolescents and offenders, it's often, ''To 01:38:20 get the court off my back. 01:38:21 To be free.'' ''Well, how could you do that?' And work 01:38:26 with the person to move along to a plan that they will 01:38:30 accept, that also moves in the direction of doing what they 01:38:34 need to do in terms of the courts. 01:38:36 But it's still their choice. 01:38:38 We get the idea that because the court has said, ''You must 01:38:41 do this,'' the client doesn't have a choice. 01:38:43 But that's wrong. 01:38:44 They have a choice. 01:38:45 They can do it. 01:38:46 There are consequences of those choices. 01:38:48 You can talk about those, you can consider "what's likely to 01:38:51 happen if you do this and this, and which of those do 01:38:53 you want, and how do you want to proceed here". 01:38:55 But it certainly doesn't cause me to switch into an 01:38:59 authoritarian mode. 01:39:00 Usually by the time clients get to us, they've had quite a 01:39:03 lot of that already and if it were going to 01:39:06 help, it would have. 01:39:08 So I want to offer something different. 01:39:12 Well, we're getting near the end of our time and wanted to 01:39:16 know if you have any final comments or questions or 01:39:19 things you'd like to share with our audience that we 01:39:21 haven't touched on yet. 01:39:24 I think it's only to say that the skills that you learn and 01:39:29 practice in dealing with all other kinds of problems-the 01:39:34 things that you learn in training as a counselor social 01:39:37 worker, psychologist, or nurse- are the very things 01:39:41 that you use here. 01:39:42 And it's an exciting place to work. 01:39:45 There's been a tendency for health professionals and 01:39:48 mental health professionals to refer out-that as soon as you 01:39:52 run into an alcohol or drug problem, ''I can't treat this. 01:39:56 I need to send this person off to the specialist program.'' 01:39:59 And that's not right. 01:40:01 You have many of the skills that you need in order to be 01:40:05 able to be very helpful. 01:40:07 And the very kinds of things that you have to offer are the 01:40:10 kinds of things that people need who are struggling with 01:40:12 addictive behaviors-in part because they've got lots of 01:40:14 other problems that aren't going to go away necessarily 01:40:17 just because the substance abuse gets resolved. 01:40:20 So rather than just sending these people away some place, 01:40:24 work with them. 01:40:24 Now, there's some basic stuff you need to learn, to be sure. 01:40:28 But you have the things that you need in order to be able 01:40:32 to work compassionately and effectively with people with 01:40:36 addiction problems. 01:40:37 So use what you know. 01:40:39 Use your heart, use your compassion. 01:40:43 CARLSON: Well, this is a refreshing, 01:40:44 revolutionary approach. 01:40:46 It's very fortunate that you weren't trained as a 01:40:49 traditional addiction counselor and that you did not 01:40:52 have to go through that particular 01:40:53 recovery process yourself.

01:40:53 recovery process yourself. 01:40:56 I appreciate your helping us with ambivalence. 01:40:59 And I look in the preface of your book, and 01:41:01 you quote from Romans. 01:41:03 And you said, ''I do not understand my own actions, for 01:41:07 I do not do what I want but I do the very thing I hate.'' 01:41:11 And I think that's something we can all identify with along 01:41:15 with our clients and appreciate the humane way that 01:41:18 you help us to deal with that. 01:41:19 Thank you, Bill.