Motivational Interviewing for Veterans with PTSD and Addiction

Motivational interviewing (MI) is a therapeutic technique that may be part of a comprehensive treatment plan for Veterans struggling with addiction and post-traumatic stress disorder (PTSD).¹ Research shows that motivational interviewing techniques can provide numerous benefits, such as increasing treatment engagement and retention and reducing substance use.^2,3 If you or a Veteran you care about struggles, you can benefit from learning more about how MI can help you start the path to recovery.

What Is Motivational Interviewing (MI)?

Motivational interviewing emerged in the 1980s and stems from the person-centered counseling style originally developed by humanistic psychotherapist Carl Rogers.^4,5 

Today, MI is a goal-directed behavioral therapy designed to address a person’s resistance to change and increase their motivation to make desired changes in their lives.⁴ This is done with guidance from an MI therapist. In fact, the collaborative relationship between patient and therapist forms the cornerstone of MI.⁶ 

This patient-therapist alliance in MI involves four key elements, including:⁴

• Partnership. This active, empathic, and genuinely curious collaboration between therapist and client increases the likelihood that the patient will express concerns and drive the conversation.
• Acceptance. The therapist’s respect for and approval of the patient doesn’t mean the therapist agrees with everything the patient says but understands their perspective on things.
• Compassion. The therapist actively prioritizes the client’s needs and welfare.
• Evocation. The therapist explores and elicits the patient’s existing motivations, values, strengths, and resources.

Though MI can be used as a standalone treatment, it is commonly combined with other therapeutic techniques, such as cognitive-behavioral therapy (CBT), to treat a variety of conditions. In Veterans, specifically, MI has been shown to be effective in treating:^2,3

• Alcohol consumption in individuals with alcohol use disorder.
• A decline in drug use.
• Mental health disorders, including PTSD.

While research on motivational interviewing specifically for Veterans with co-occurring substance use disorder and PTSD is growing, it is still a developing area of study. However, clinical experience and research on the individual conditions, as well as co-occurring disorders in general, suggest that MI principles can be effectively integrated into treatment.⁷

What to Expect During a Session

As previously mentioned, the main goal of motivational interviewing is to foster a patient’s readiness and desire to make changes.⁶ 

During an MI session, therapists follow specific processes, including:⁶

• Engagement. Engagement sets the foundation for the therapist-patient relationship and establishes a mutually trusting and respectful partnership. 
• Focus. During this process, the patient’s needs and goals are identified, and an agenda is set to outline these goals for change.
• Evocation. This step utilizes core skills and motivational interviewing techniques to help the patient move towards a specific change objective. During this process, the therapist asks the patient to elaborate, provide examples, and reflect. At the same time, the therapist measures a patient’s confidence in their ability to successfully change their behaviors and meet their goals.
• Planning. This step develops the plan to help the patient make the necessary behavioral changes.

To accomplish the above, an MI therapist listens and interacts using the acronym OARS, meaning:⁶

• Open-ended questions. The therapist asks questions that cannot be answered with a simple yes or no.
• Affirmations. Using affirmations, the therapist shows genuine appreciation and positive regard for the client’s strengths. Perhaps the therapist praises the patient’s persistence in a situation or applauds their decision-making in another.
• Reflective listening. Reflections allow the patient to verify that what the therapist heard was what the patient intended. Skilled MI therapists may provide more reflections than questions during any given session.
• Summarization. The therapist sums up what the client said to ensure complete understanding.

Using Motivational Interviewing During Addiction Treatment

MI can be used to help Veterans identify and explore their desires, reasons, and need to change their substance use behaviors. It can empower a Veteran to change their behavior by helping them increase their awareness about the impact substance use has on their life, resolve their ambivalence about substance use, and increase their internal motivation to make lasting changes–more so than external factors.⁴

Research indicates that external motivators may pressure individuals with substance use disorders into treatment. Perhaps they feel pressure to get help from a spouse, employer, healthcare provider, family member, friend, or the child welfare or criminal justice system. These external motivators may be successful at getting individuals to stay in treatment, but it’s the internal motivators that will bring about significant, long-lasting change.⁴

Motivational approaches can help those with SUDs achieve better treatment outcomes, including:⁶

• Decrease alcohol and substance use.
• Improve treatment retention after detox.
• Improve retention in methadone maintenance programs.
• Increase engagement in HIV risk-reduction behaviors.

Individuals may receive MI as a standalone treatment or as a part of a treatment plan that involves other therapeutic interventions.⁴ When combined with other therapies, positive outcomes involving long-term behavior change, treatment retention, and abstinence can be even greater.⁶

PTSD Treatment & Motivational Interviewing

Limited research shows that motivational interviewing for Veterans with PTSD can help. One study found that war Veterans who screened positive for PTSD or another mental health problem and took part in trauma-informed telephone motivational interviewing sessions were more likely to begin mental health treatment and had greater retention when compared to a control group.⁸ However, for the treatment of PTSD, MI is not generally used as a standalone treatment but rather as a valuable tool to enhance the initiation of treatment and engagement in treatment.³ 

When combined with other evidence-based therapies, first-line treatments for PTSD–eye movement desensitization and reprocessing (EMDR), and various forms of trauma-focused CBT including prolonged exposure (PE), cognitive therapy for PTSD, and cognitive processing therapy (CPT)–MI can help a Veteran with PTSD overcome their uncertainty about their disorder and improve their internal motivation to change PTSD-related problematic behaviors, seek treatment, and participate in it.^3,8

Motivational Interviewing Success Rates & Effectiveness

The effectiveness of MI for SUD is generally supported by research, showing improvement in areas like reduced substance use and increased treatment retention when compared to no treatment.^4,6 When considering co-occurring substance use disorder and PTSD in Veterans, research on MI specifically for this population is still evolving and presents mixed findings regarding its direct impact on both conditions. However, it’s important to note that MI’s strength lies in its ability to enhance motivation and engagement in treatment. Therefore, even when direct effects on PTSD or substance use severity may vary, MI can be a valuable tool in helping Veterans initiate and actively participate in evidence-based therapies like trauma-focused CBT and EMDR, which are considered first-line treatments for PTSD and can indirectly contribute to better overall outcomes.^9,10

One systematic review showed that MI appears to be most effective for stopping or preventing unhealthy behaviors like binge drinking, reducing the quantity and frequency of drinking, smoking, and substance misuse.¹¹

Motivational enhancement therapy (MET) is a specific, focused adaptation of motivational interviewing principles often used in the treatment of substance use disorders and, as some research suggests, may also be beneficial for individuals with PTSD. MET typically involves a shorter duration of therapy with a more directive approach toward behavior change goals while still emphasizing the core MI principles of empathy, collaboration, and evocation.¹² 

Additionally, a systematic review concluded that treatments that include MET appear to have modest effects on treatment initiation and retention, but the impact on engagement in evidence-based treatments is unknown.⁸

There are limited studies on the effectiveness of the use of MI in the treatment of co-occurring SUD and PTSD, and those that do exist show mixed results on its effectiveness. One study found an MET intervention improved drinking outcomes (with an average reduction from 32 drinks per week at baseline to 16 by the 6-month follow-up), and people whose PTSD had resolved by the 3-month follow-up looked very similar in alcohol outcomes to participants who did not have PTSD at baseline.³ However, one study examining MI for PTSD and alcohol use found no statistically significant benefit for MI in terms of PTSD severity or alcohol use.⁸

As previously mentioned, MI may be more effective when combined with other interventions. Studies indicate that integrating MI strategies to address ambivalence and enhance motivation can help Veterans struggling with co-occurring substance use and mental health disorders, including PTSD, adhere to the CBT components of treatment–changing maladaptive behaviors, identifying and managing triggers for substance use, and practicing new behaviors to reinforce recovery goals.⁴

Is MI Covered by the VA as part of Veterans Benefits?

Addiction and mental health treatment are typically covered by the VA, provided that a Veteran is enrolled in the VA healthcare plan.¹³ However, certain services are covered even if a Veteran doesn’t qualify for VA benefits.¹⁴

You can contact your local VA center to determine your eligibility for VA benefits.¹⁴ Typically, Veterans who served in the active military, naval, or air service and didn’t receive a dishonorable discharge are eligible for benefits.¹⁵

Additionally, Veterans may also use other forms of healthcare coverage (such as private insurance plans, Medicare, Medicaid, or TRICARE), along with VA healthcare benefits to cover the cost of treatment for co-occurring disorders, including MI for SUD and PTSD.¹³ The best way to determine whether your plan will cover some or all of the cost of treatment is to contact the VA or verify your coverage with American Addiction Centers (AAC).

Our Veteran Team Can Help You Find Care

Effective addiction treatment and co-occurring disorder treatment look at the needs of the whole person and are individualized because what works for one person may not work for another.¹⁶

If you are a Veteran seeking treatment for co-occurring substance use and PTSD–or another mental health condition–and are interested in exploring MI as part of a comprehensive treatment plan, you should first reach out to your doctor, mental healthcare provider, or addiction care specialist, who can assess your situation and help you determine the best treatment plan for you. From there, you can look into programs that provide the appropriate level of care and offer services that meet your needs and goals. 

AAC treatment centers provide a complete continuum of care and offer co-occurring disorder treatment, evidence-based therapies, and a specialized treatment program for Veterans. 

Additionally, AAC has a primary mental health program available at River Oaks Treatment Center for Veterans (and other adults) who suffer from a mental health condition like PTSD but not addiction.

Don’t struggle alone. Call to connect with a member of AAC’s Veteran team. These compassionate and knowledgeable individuals are either Veterans themselves or have worked with Veterans for years and understand how to navigate the VA system. Share your story with them. They can answer your questions, explain your options, verify your insurance, and help you find your path to lasting recovery.

Additionally, if you’re not ready to talk, you can sign up for 24/7 text support to start the conversation today.