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William (Bill) Miller, Ph.D. - Guest
William (Bill) Miller, Ph.D. is the co-founder of Motivational Interviewing. He has taught at the University of New Mexico since 1976 as Emeritus Distinguished Professor of Psychology and Psychiatry, and since retired in 2006. In college, Bill Miller studied religion with the intent of becoming a pastoral minister. While also majoring in psychology, he decided to choose that path, understanding, however, that religion and psychology often interact in many ways. Bill has worked with cognitive behavior therapy in a humanistic way during his professional career, and began research at The University of New Mexico surrounding addiction, specifically alcoholism. He found that one of the biggest contributing factors to the success rate of the patient had to do with the levels of empathy rooted in the therapist. This discovery led him to his first sabbatical at an alcoholism clinic in Norway where he taught American students and his ideas for Motivational Interviewing blossomed. It wasn’t until his second sabbatical in Australia that he met Steve Rolnick, who Bill would go on to research and write about Motivational Interviewing alongside until the present. |
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W. Keith Sutton, Psy.D. - Host
Dr. Sutton has always had an interest in learning from multiple theoretical perspectives, and keeping up to date on innovations and integrations. He is interested in the development of ideas, and using research to show effectiveness in treatment and refine treatments. In 2009 he started the Institute for the Advancement of Psychotherapy, providing a one-way mirror training in family therapy with James Keim, LCSW. Next, he added a trainer and one-way mirror training in Cognitive Behavioral Therapy, and an additional trainer and mirror in Emotionally Focused Couples Therapy. The participants enjoyed analyzing cases, keeping each other up to date on research, and discussing what they were learning. This focus on integrating and evolving their approaches to helping children, adolescents, families, couples, and individuals lead to the Institute for the Advancement of Psychotherapy's training program for therapists, and its group practice of like-minded clinicians who were dedicated to learning, innovating, and advancing the field of psychotherapy. Our podcast, Therapy on the Cutting Edge, is an extension of this wish to learn, integrate, stay up to date, and share this passion for the advancement of the field with other practitioners. |
Keith Sutton, Psy.D. (00:24):
Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
In the institute, we have our licensed, experienced therapists, and for those in financial need, we have an associated nonprofit, Bay Area Community Counseling, where clients can work with associates, psych assistants, and licensed clinicians who are developing their abilities and expertise. Additionally, as part of our nonprofit, we also have the Family Institute of Berkeley, where we provide treatment, training, and one-way mirror trainings in family systems. To learn more about trainings, treatment, and employment opportunities, please go to sfiap.com and to support our nonprofit, you can go to sf-bacc.org to donate today to support access to therapy for those in financial need, as well as training in evidence-based treatment. BACC is a 501(c)(3) nonprofit, so all donations are tax deductible.
Keith Sutton, Psy.D. ( 02:20):
Today, I will be speaking with William (Bill) Miller, who is a psychologist and Emeritus Distinguished Professor of psychology and psychiatry at the University of New Mexico. He is the author of sixty-seven books, including four editions of Motivational Interviewing, Effective Psychotherapists: Clinical Skills That Improve Client Outcomes, Listening Well: The Art of Empathic Understanding, and On Second Thought: How Ambivalence Shapes Your Life. He had been teaching the skill of accurate empathy for over 50 years. Let's listen to the interview.
Keith Sutton, Psy.D. (02:51):
Hi, Bill. Welcome.
Bill Miller, Ph.D. (02:53):
Thank you very much.
Keith Sutton, Psy.D. (02:54):
Thanks so much for joining me today. I really appreciate it. So, gosh, I learned about motivational interviewing back when I was still a paraprofessional in my early twenties, and I just really enjoyed it. I've still got my book with all my highlights, and I didn't realize until much later on how foundational motivational interviewing was for my work. So I really love the approach. I teach some workshops in it, and I really see it as foundational. And I've recently, you know, gotten to check out the new addition of the book and also your book on effective psychotherapists, and I'm really kind of looking at what improves outcomes. I've also, you know, used the outcome rating scale and session rating scale based on the common factors research. And I was interviewing some time ago, Scott Miller, you know, about his work. And he said, you know, we-- the best thing you can do is get training on how to have a better relationship with your client. And he said, but we did research on that. And nobody would go to those workshops because they felt like, “Oh, I've already got such a good relationship.”
Bill Miller, Ph.D. (04:06):
I already do that.
Keith Sutton, Psy.D. (04:07):
What this is called is motivational interviewing. Motivational interviewing is a way to have a better alliance and really improve the outcome. So it's just a, yeah, it has such a great impact. It's so-- but one thing I'd like to jump into first before hearing about motivational interviewing and your work is how you get into doing the things that you're doing, kind of what was your evolution of thinking to get to the work you're doing?
Bill Miller, Ph.D. (04:34):
Gradually, of course. I mean, first of all, I started out intending to be a pastoral minister. So in college, I studied religion, which was much more complex than my childhood religion was, and I had majored in psychology and so I wound up kind of following the psychology path. Although I've always stood in the doorway between psychology and religion, I've passed things back and forth. So that’s been a part of my history too. In graduate school, before we ever laid hands on behavioral therapy and there was a behavioral program, we had a year's course in how to talk to clients, basically. And they went across campus to the counseling psychology program and hired a professor named Susan Gilmore, who was an academic grandchild of Carl Rogers.
Bill Miller, Ph.D. (05:28):
And she came and taught us a person-centered way of being with people. And I'm so grateful for that, that before we ever got into the techniques, this relational stuff really took hold. And so I've always done cognitive behavior therapy in a humanistic person-centered kind of way, and they fit perfectly well. So that was a good start for me, anyhow. Then, as I began doing research here at the University of New Mexico, we found that this is in behavioral treatment for people with alcohol problems. The biggest predictor of outcome was how empathic the therapist was. Accounted for two-thirds of the variance in the very behavioral outcome. So that was saying, there's something really important about the therapeutic relationship here, you're doing behavioral therapy. A very concrete behavior problem.
Bill Miller, Ph.D. (06:29):
And with that, I went off on my first sabbatical leave to Norway. And that's where motivational interviewing was literally evoked from me. And I had no idea of it when I went there, and I was role-playing with the therapists in this alcoholism clinic in Norway, and they said, Well, don't just talk to us. I mean, show us what you do then. And they were role-playing clients, they were finding it difficult, and essentially said, Oh, you know, okay, smart guy, what would you do with this? You know?
Keith Sutton, Psy.D. (07:01):
Sure. Stump the jump.
Bill Miller, Ph.D. (07:03):
Well, well, sure, and as I was demonstrating, they would stop me and interrupt me, which my American students didn't do, and ask very good questions. What are you thinking right now? You asked a question, but gosh, you could have asked many questions. Why that particular question?
Bill Miller, Ph.D. (07:24):
You're teaching this reflective listening. Okay. And you reflected something the client said, but how did you know what to reflect? Why did you reflect that rather than many other things the client is saying? And so they literally evoked from me some decision rules that I was using, if a show was not conscious, that had to do with having the client make the arguments for change, rather than me as the therapist. More complex than that, but basically that was the essence of it, which is precisely the opposite of what was being done in addiction treatment, in the seventies and eighties in the United States, at least. Authoritarian, sit down and shut up. You don't know anything. They wanna tell you what's wrong with you and what you need to do, which human beings don't respond to particularly well.
Keith Sutton, Psy.D. (08:19):
Yeah. Yeah. That confrontational style.
Bill Miller, Ph.D. (08:16):
Yeah. So, that was kind of how this got started. I mean, just many different kinds of things. I didn't meet Steve Rolnick until my second sabbatical in Australia, and we found each other in offices next door to each other.
Keith Sutton, Psy.D. (08:35):
Oh, great.
Bill Miller, Ph.D. (08:36):
And he said, You're the guy who wrote that paper on motivational interviewing? And I said, well, you read it! Thank you, I'm impressed. He said, I've been trying to teach this. And, you know, you need to write more about it. And so we did. We've been writing four editions of the text ever since.
Keith Sutton, Psy.D. (08:54):
Oh, wonderful. And I was reading your story in the effective psychotherapy book that you were talking about. I was surprised to hear that you were doing behavioral family therapy, which I didn't know about that background. I mean, I also do family therapy, and I'm familiar with Jerry Patterson's work. And you were saying that, once you were seeing him do it, can you speak to that a little bit? Because I thought that was really eye-opening.
Bill Miller, Ph.D. (09:23):
Well, that was another learning experience for me. I was trying to do behavioral family therapy supervised by one of Jerry's students. And I'm reading the books that Jerry wrote, and I'm trying to do the stuff that's in the books, you know, and that is pretty clear, but, you know, charts and graphs and so forth, and with parents. And it's just not working. And then they took us over to the Oregon Research Institute, where Jerry was. He had been in the psych department, but went over to a research Institute, and we watched him working with a family through a big one-way mirror. And as I said in my note in that book, he was doing all kinds of things in addition to what he wrote about. I mean, he was doing what he wrote.
Keith Sutton, Psy.D. (10:11):
Sure.
Bill Miller, Ph.D. (10:12):
But he was a warm, friendly, compassionate, interesting, funny guy. You know, I mean, you would do anything for this guy. And parents loved him. And, he was just joining up with them, and I said, Oh, that's how you do it. And I pulled on my person-centered training and began doing behavioral family therapy in that way, and started working. Again, it was a lesson for me in putting together techniques that were really heavily emphasized in the behavioral training.
Keith Sutton, Psy.D. (10:49):
Yeah.
Bill Miller, Ph.D. (10:50):
With how you are with clients, and if you aren't engaging and warm and empathic with clients, they generally won't do what your techniques do, you know? So that was another important aha for me, which I learned just from watching Jerry do one session.
Keith Sutton, Psy.D. (11:09):
Wow. Yeah, because you might have all those different techniques and there's great research around it, but if it's not within that kind of basis of that relationship and connection with the client, then it's not necessarily gonna go anywhere.
Bill Miller, Ph.D. (11:21):
Yeah. It's a both/and I think it matters what you do and it really matters how you do it. And, very often in clinical training, there's not much attention given to how you do this. At least in more behavioral programs and probably in other theoretical orientations as well. There's just emphasis on the technique that's consistent with the theory, neither teaching nor modeling of your presence with clients, how you are with clients.
Keith Sutton, Psy.D. (11:57):
Definitely. So one of the things that really strikes me about motivational interviewing, and I was actually, I, I learned motivational interviewing before I started working at a drug company now called outpatient program, which was very confrontative, and I was supposed to take over for a guy who was the hammer, and I am not the hammer. So it was very interesting having that juxtaposition.
Keith Sutton, Psy.D. (12:23):
But one of the things that I've really taken for motivational interviewing is just the profound respect for the other person and their way that they're deciding to live their life that we have, we are trying to have influence or help them or so on. But ultimately, it's really the only other person's choice about their life. And that idea of the spirit of motivational interviewing is, you know, just a great boundary respectful kind of basis, because you can't do motivational interviewing with the intent to get somebody to do what you want them to do. You have to have the intent that this person is gonna do whatever they're going to do, and I have to be okay with that, although I might be able to have some influence and help them along this path.
Bill Miller, Ph.D. (13:11):
Yeah. Well, Steve and I discovered that in, about 1993. So this is two years after our first book came out, and we were teaching people how to do motivational interviewing, and they were doing what we told them, and we were not happy. There was something wrong. And it was what you were talking about or trying to use these techniques on somebody to trick them into changing or manipulate them into changing, or is still, I'm in control as a therapist, you know? And that's the wrong spot, because ultimately it is the client who is in control. And, if you give up that control, you're giving up something you never had in the first place, 'cause it's always the client who decides whether, and how they will change , and so on. And so that's, that is a key piece of the spirit of me as well. You have to just know and accept that clients will get to decide what they're gonna do. That makes it more possible for them to change. And that's called Roger's insight. He said that when we feel unacceptable.
Keith Sutton, Psy.D. (14:23):
Mhm.
Bill Miller, Ph.D. (14:23):
We can't change it; it's paralyzing. And when we experience acceptance as we are, it becomes possible to change. Now that's weird writing. I don't know why we're made that way. But it really is true. When you convey acceptance as you are, then you make it possible for the person to choose to change and do something differently.
Keith Sutton, Psy.D. (14:49):
Rather than being bad for what you're doing or how you're doing it, or so on, kind of understanding or being validated or being seen for why it makes sense. And just having that acceptance almost allows the person to make peace with it or something to then move from there, rather than, I don't know. Avoiding it, or something like that. The shame is more about trying to get rid of it than moving forward with it or learning from it.
Bill Miller, Ph.D. (15:19):
And if you're, if you're trying to change somebody, they know that, and human beings back away from that. I received an interesting paper from an evolutionary psychologist in Australia, who asked, "I understand from an evolutionary perspective, why am I working so well?" It's because you start by saying you're in charge. There's, there's no, you know, no imagining that I'm gonna change you. I'm going to make decisions for you. You can't do that, you know? And when you signal that in the beginning, it just takes away the competitiveness or the tension in that, and people can relax and, oh, well, what do I want to do with my life? You know? Interesting stuff.
Keith Sutton, Psy.D. (16:09):
Well, I imagine also the effect on the therapist of potentially having less pressure or, you know, less burnout in, being able to let go of the feeling that they have to control or have to make somebody do something. Understanding that they can do as much as they can do on their side, and the client's gonna do what they can on their side, but not necessarily feeling all the, all the responsibility on their shoulders.
Bill Miller, Ph.D. (16:36):
Yeah. That's it. I mean, if I were doing research, I'm retired now, so I'm not. But I would be studying that. What is the effect on the clinician of learning motivational interviewing? And, through my whole career, I’ve heard all kinds of stories from people about, I was just on the edge of burnout, and then I found this, and it made my work much more rewarding. To save my life, people say, and they just go, " Wow. Incredible stuff. So it has an impact on the provider as well. And it is kind of relaxing, enjoying your work more, in relation to being relaxed with it. Which doesn't have to be with anything to do with being careless or not paying attention to what you're doing. Given what I know from my research, I've got to pay attention to what I'm saying or doing. Because I know it does influence outcomes, you know? And that's also knowing at the same time that I don't get to make the choices for people. They do. So these paradoxes are so much a part of the way you do motivational interviewing.
Keith Sutton, Psy.D. (17:41):
Yeah. And I imagine it gives patience, too, for the process.
Bill Miller, Ph.D. (17:44):
Oh, yes. Yeah. Which makes things go faster.
Keith Sutton, Psy.D. (17:48):
Paradoxically.
Bill Miller, Ph.D. (17:49):
I give, again, I got to know Monty Roberts, the original horse whisperer about 20 years ago, and I had been to the ranch. He kind of walked me through his method, but both of us saw in the other the same thing we're doing. And I said, “Damani, you're doing what I do. You do it with horses. That's incredible.” You know? “Wow.” He said, “Well, you're doing what I do. You're with alcoholics. That's amazing.” And, the similarities are there. It's about approaching, not pushing. I'm not trying to control you. When I co-authored a book on effective psychotherapists with Terry Moyers, we identified eight key characteristics of therapists who achieve better outcomes, regardless of the theoretical framework they work within. And when we finished it, I said to myself, you know, these look familiar.
Bill Miller, Ph.D. (18:41):
These eight characteristics, at least seven of them, have been characteristic of motivational learning from the very beginning. Is that what we've been doing? Have we been really teaching people how to be helpful? How to be a helper? How to work with people in a way that they'll let you in and listen to what you have to say? Because there's so much overlap. MI is not a theory. We don't have a theory of psychopathology. You know, it's a way of being with people.
Keith Sutton, Psy.D. (19:13):
I was gonna say a way of being.
Bill Miller, Ph.D. (19:15):
Whatever your school of psychotherapy or whatever your profession, it's a way of doing diabetes education. It's a way of doing classroom education. It's a way of doing primary care medicine. You know, it's the relational aspect of all these professions where we're trying to be helpful to people.
Keith Sutton, Psy.D. (19:35):
Definitely. And can you actually mention what those different, effective, I think you were saying there were seven, was that right?
Bill Miller, Ph.D. (19:43):
There were eight altogether.
Keith Sutton, Psy.D. (19:44):
Sorry. Eight. Yes.
Bill Miller, Ph.D. (19:46):
What is, well, the number one was accurate empathy. And we put it first in the book because it had the biggest effect. The overall effect on client outcomes was the largest. This involves reading 70 years of psychotherapy outcome research. And for such a long time. But what therapists seem to have are better outcomes, regardless of the techniques or their school of psychotherapy. What are they actually doing with clients? And that is related to better outcomes. Well, accurate empathy, certainly. Genuineness. Being yourself, auth, you know. Rather than putting on a mask and being an objective observer or a distant, mysterious guru or whatever. You're a real person there interacting with this person. That's associated with better outcomes as well.
Bill Miller, Ph.D. (20:42):
Positive regard. Language from Carl Rogers. And none of these things are just about feeling it inside yourself. If you're feeling empathetic for the person, it doesn't do them any good. Unless you express empathy, it's something you actually do with clients. Reflect on that, which helps both of you understand better. Well, the same thing with positive regard. It's not just something you're sitting there feeling. You're expressing positive regard. And in motivation, anything, we do that via affirmations, via noticing what people are doing well, and particularly noticing their strengths, noticing positive attributes, and commenting on those. Acceptance is another one. Accepting people as they are. That one's pretty straightforward. Hope. Now we know that the clients having hope is a good thing.
Keith Sutton, Psy.D. (20:42):
Yes.
Bill Miller, Ph.D. (21:41):
But turns out therapists having hope is also really important. And if you get to be kind of cynical, it'd probably be good to take some time off or get another line of work, because it's a self-fulfilling prophecy. Whatever you see as your client's likely outcome tends to happen in that direction. So, you know, that's interesting. Having clear goals and shared goals, which Scott Miller talks about, it's just a part of the therapeutic alliance, working alliance with people so that you both know where you're trying to go, and you agree about that. And it's the therapist's job to kind of keep things moving in that direction, you know? That's associated with better therapist outcomes, giving information and advice as one of the smaller effects, but it is a positive effect.
Bill Miller, Ph.D. (22:37):
And I think it's a small effect because it matters so much how you do it. There are ways you can give information and advice that drive people away and shut them down, and they don't wanna hear it. And there are ways of doing it that kinda lower the defenses, and people can listen to it and talk to you about it. So that's there. And what have I not mentioned, evocation? That's an interesting thing in various psychotherapies of things you're hoping that you will hear and see happen during your session. That to predict better outcomes. So the more the client does and says these kinds of things during sessions, the better the outcomes tend to be, and is strategically doing things as a therapist or counselor to evoke those kinds of responses during therapy. In a person-centered approach, the work of Eugene Lin, experiencing is exactly that. Experiencing is talking about yourself, first person, present tense. You, you're very much there. You're not talking in the abstract about yourself. You're not talking about the past, in a distancing kind of way. You're right there involved. And that is associated with better outcomes.
Bill Miller, Ph.D. (23:56):
How do you get those better outcomes in person-centered therapy? Accurate empathy, unconditional positive regard, genuineness, kind of the things that Rogers talked about in motivational interviewing are change talk. And in particular, the balance of change. Talk to sustained talk. And we've learned now that it is the ratio of those things that really predicts outcome. So the more you're evoking change talk, and the less you're evoking defensiveness and sustained talk, the better the outcomes are, you can see it in the session. So the client's giving you feedback. How are you doing right now? You know? Let's see if you do something, you get a chance to talk. That's the client saying, Good job. You know? You're on the right track. And if you say something, the client begins to back away and say, Well, I don't think it's that serious a problem. That's the client saying, Why don't you try something other than what you just did? You know?
Keith Sutton, Psy.D. (24:51):
Mhhhm
Bill Miller, Ph.D. (24:52):
Yes, try a little different response. And that's in the session shaping its immediate feedback. And so it's a way of getting better, too.
Keith Sutton, Psy.D. (25:00):
Yeah. And being attuned, it sounds like also with what you're getting back or how the client is responding or reacting to what you're saying.
Bill Miller, Ph.D. (25:09):
Absolutely. It's called responsiveness in the therapeutic literature.
Keith Sutton, Psy.D. (25:13):
Oh, great. And I wanna start off asking you a little bit about the accurate empathy, because I was, I was reading that, and I was struck by your referencing some of your early research and just how so significantly correlated the accurate empathy was with, some of the clients, therapists having, a hundred percent of the clients. Resolving their alcohol and follow up also, while, you know, the others were kind of in a bit of an average range or so on. There was a wide range, and even one that the lowest inaccurate empathy was actually seeing a deterioration that it was so correlated with, outcome Right. And follow up.
Bill Miller, Ph.D. (25:55):
And that, that's a finding with accurate empathy too, that therapists who are low in that actually have clients whose outcomes are worse than no treatment. So you're better off going home with a good book, really, than sitting down with a low-empathy therapist.
Keith Sutton, Psy.D. (26:09):
Yeah. I think that was a control group, right? Is that they actually just had a self-help book or something? Or was that
Bill Miller, Ph.D. (26:14):
Yeah. Well, yes, that was a control group in that study that you're talking about. And we had nine therapists, and the therapists on average had the same success rate as the self-help book, but five of them had a higher success rate. Three of them had a lower success rate, and one of them had exactly the same success rate. And so it could lead you to say, well, therapists are no different from self-help. And that's not true when you look at the graph. But how the person is doing, how much they're changing, depends on the therapist who's treating them. Right? Yes. For better or for worse, and Rogers and his colleagues knew that back in the sixties and seventies, you can behave in a way that makes clients worse.
Keith Sutton, Psy.D. (26:59):
Yeah. And I'm curious about that. Measuring accurate empathy. Because I know that you did some inner rate reliability, and I was doing, looking at some research articles, I saw there's the MI adherence kind of, scoring that was looking at more like whether it seemed like the therapist was interested in what the person was saying. And I don't know if there's any, I saw one article where they were actually looking at a kind of tone of voice and analyzing the kind of yes voice, but with the therapist and client. And the way I think about it often is that, you know, when our client feels like we understand, and when we understand, and we feel like our client feels like we understand, we get that kind of big head nod. The person's like, “yes, you're getting it.”
Keith Sutton, Psy.D. (27:45):
And then we can kind of move forward. But if we're, if they're not, if we're not kind of getting that, it's like the cue to the therapist to back up and come back around. But I've always thought that the determinant of accurate empathy is the client's reaction. And if they're like, actually feeling like you're getting it, or, and I was just curious in a research, like, how do you kind of measure that? And actually, we're doing a one-way mirror training where the trainers were talking about empathy, and she's like, well, how, how do you operationalize that? What does that mean? How does that behave? So that's why I was kind of digging into more in your books and some research around what that looks like, or how the therapist who's working on that?
Bill Miller, Ph.D. (28:27):
And I love those kinds of questions, you know, these things we aspire to. I wrote a book on loving kindness. So we're all kind of aspiring to that. What does it actually look like? How do you do that? You know? And the same thing with listening. I wrote a book for the general public called Listening Well, that is this kind of step-by-step learning, this way of listening to people. And it is very observable, very measurable, observers can agree to the extent to which it's happening, and that predicts outcomes. We've done both rating scales, which is the way Rogers and his students are measuring it. And we've also done behavior counts, number reflections to questions, and so forth. And in general, if the questions outnumber the reflections, that's not a good thing. You know, you wanna be listening more. And I, I tell people if you ask a question, you owe the person two reflections.
Keith Sutton, Psy.D. (29:24):
Oh. That's a nice way of putting it.
Bill Miller, Ph.D. (29:26):
Well, what's going on as you're reflecting is you're getting closer and closer to understanding what the person means, and so are they, together. And so that's why it's a dynamic process. It's not that you just make a guess and find out if you're right or not. You are making a guess when you form a reflection. And, I always teach people to do it as a statement, by the way, not to ask it as a question. not, not to say, you're angry with your mother, which is kind of threatening if you, if you hear it that way. And that sounds like you shouldn't, you shouldn't use the same words. You're angry with your mother, you know, as a, as a reflective statement. very comforting. And the person goes on and keeps talking to you about it. Well, there are a lot of artful things about that. But when you're doing that, well, you're, you and the client together are discovering more and more closely what it is the client's experiencing. What it is. They mean what? What's going on for them? And that's, of course, a value to the therapist, but it's also a direct value to the client as well.
Keith Sutton, Psy.D. (30:37):
Yeah. And sometimes I think about it, it's almost like a cultural anthropologist, like really being curious about each word the person's using, because what you're assuming they're meaning may be very different from what they are actually meaning. And being able to really understand when they're saying, you know, that you're really getting what they're saying, rather than just inserting your own kind of ideas about what that means.
Bill Miller, Ph.D. (31:05):
When clients speak, there's something they meant to begin with, then they put it into words. And it can go wrong at that point, 'cause we don't say what we mean necessarily. Then you have to hear the words accurately, which is more challenging for me as I age. And then, having heard the words, you have to figure out what they meant, you know? So your three steps are removed from the client's own experience, and usually, a first guess is wrong. And one of the training exercises that we do is to have people make a guess about what the speaker meant and ask it as a question, in fact, 'cause it's easier. You would say “Well, do you mean that?” And people are surprised how often they say, "Oh, I was just sure that was what it meant. But, no, it wasn't. Then you move into learning reflective skills and so forth, and being able to string reflectors together, and yeah. And like that. But it really is quite artful and at the same time, very behavioral. It's very measurable, very observable, and very related to client outcomes.
Keith Sutton, Psy.D. (32:04):
And when you're doing the actual, like, measurable, is it what the therapist is doing? Or are you measuring the client's reaction?
Bill Miller, Ph.D. (32:13):
We measure what the therapist is doing. And, Roger's group did an interesting study, actually, on whether the raters needed to hear what the client said in order to rate the accuracy of empathy. And they didn't, which is kind of surprising, you know. But, from the content of the reflection, you can kind of get a sense of how the person is, zeroing in on things. Mm. Now it's better to hear both. So we're sure. In our research, we usually code both therapists' and clients' responses. But you, you can do a pretty good job of getting a fix on how well the person does reflective listening just from their own responses.
Keith Sutton, Psy.D. (33:00):
Okay. Great. And you were mentioning the genuineness and authenticity. And I often find when I'm training, folks that are just, you know, working on their hours for licensure, that sometimes, I use that term, the mask, which I think, is a really good one. Because they come in acting like what they think a therapist is, rather than sometimes bringing themselves. So the client says, Oh, I lost my job. And then, you know, the intern says, How did that make you feel? Rather than…
Bill Miller, Ph.D. (33:27):
Exactly the question
Keith Sutton, Psy.D. (33:29):
I need rather than, and I say, you know, gosh, if your friend said “I lost [their job]”, you'd be like, “oh my gosh, what happened?” Like, you know, that there'd be more of a, and of course, in a boundaried way, but that you're more like having that reaction and being genuine, like, oh my gosh, what happened? And like, kind of matching that energy.
Bill Miller, Ph.D. (33:46):
And better still, to make a guess and reflect on what you think the person may be experiencing
Keith Sutton, Psy.D. (33:51):
Yeah.
Bill Miller, Ph.D. (33:52):
Not a big jump, just a small one, but nonetheless, staying a little bit ahead. I will continue the paragraph. So, instead of repeating what the person just said, you get skillful at saying what might be the next sentence. And if it's wrong, the client will tell you, that's not what we mean. But it moves it ahead so much better than staying close to what the person was saying. And that we call simple reflection, then. And if that's all you do, you just kind of go around in circles, or it doesn't seem to go anywhere. Doesn't have momentum.
Keith Sutton, Psy.D. (34:30):
And actually tell me about that part with the, I know you're saying not to have it as a question, although I know for myself, sometimes I feel uncomfortable saying like, oh, you're mad at your mother. You know? And so sometimes I will have that little inflection, you know, saying like, okay, so you're mad with your mother, kind of, I don't know, putting it often as a question, but I hear what you're saying is that you don't want it to necessarily sound as like a judgment of what That's right. But I also wanna be careful of not telling the person what their experience is, and kind of in a top-down kind of way.
Bill Miller, Ph.D. (35:07):
Yeah. Some of that is voice tone. It's a difference between, you're angry with your mother, and you are angry with your mother, you know? I mean, the latter is much more authoritarian. I know more about you than you do, and so on. So the music in the voice also matters, you know? But it's not, it's not clients who get uncomfortable with that. It is the listeners who say, I actually, I've taught them you're making a guess when you make a reflection.
Keith Sutton, Psy.D. (35:36):
Yes. Yes.
Bill Miller, Ph.D. (35:37):
And because, you know, you might be wrong. You are gonna want to be tentative and ask, you know, well, is this what you mean? You know? . But, that gets awkward quickly. And you, if you just inflect your voice up at the end, so you don't see anything wrong with what you did.
Keith Sutton, Psy.D. (35:55): . Yeah. That's, you hear it implying that there's some , that there's…
Bill Miller, Ph.D. (36:00): Exactly! It is not always intended. Sometimes it is. It's just a person's discomfort with, “I might be wrong about this”, but much better to say you don't say anything wrong with what you did.
Keith Sutton, Psy.D. (36:11):
Yeah. Interesting. Celia Ko did some research in a paper on centering the voice of the client. And one of the things that she talked about is some of the timidity was a piece that was helpful for some, but I hear what you're saying that that kind of that question mark or that kind of, you know, making sure that it's checking in with the client, their experience versus suggesting that they did the wrong thing. There's almost like that tonal difference there.
Bill Miller, Ph.D. (36:45):
The question does that, and questions also place a pressure? Again, this isn't necessarily conscious to the listener, but a question demands an answer. And there's a feeling of being interrogated that isn't there when you're making reflective statements. So it feels funny to the listener, but it works so much better than the person who's being listened to.
Keith Sutton, Psy.D. (37:08):
I find that when coaching parents, 'cause I almost teach them the motivational interviewing when they're drawing out their kids. And that sometimes if the parent just goes question after question, it's like an interior. And it, even though they might be curious and wanting to understand it may make the person feel kind of backed into a corner or something to that effect.
Keith Sutton, Psy.D. (37:29):
And I really liked what you're saying about the hope aspect too. Somebody I heard talked about, you know, our case conceptualization is only as good as it gives us hope for our clients.
Bill Miller, Ph.D. (37:40):
Yeah.
Keith Sutton, Psy.D. (37:41):
Because like you're talking with the therapist, if the therapist doesn't have hope, that's, that's very problematic.
Bill Miller, Ph.D. (37:47):
It is. Yeah. It's self-fulfilling. My next book is about hope, as a matter of fact.
Keith Sutton, Psy.D. (37:54):
Yeah.
Bill Miller, Ph.D. (37:55):
It comes out in August, and it's called Eight Ways to Hope.
Keith Sutton, Psy.D. (38:00):
Oh, say more about that. I was mentioning the loving and kind, which was making me think too, about kind of the eastern philosophy, kind of Buddhist concept about not having the attachment to the outcome. Which I think, oh, yes. Sometimes, you know, when I think about motivational interviewing, right. That the person may decide to continue doing heroin or whatever it might be, and that our attachment to the outcome, we have to kind of let go of that and create the space. And I was reading some of Pema Chodron's writing, and it sounded like she was talking about motivational interviewing. She was talking about getting frustrated with somebody. She was helping that relapse, and then realized, needing to let go. And that, you know, that she has to, you know, not, not take that on, and get frustrated with the person, 'cause that's not gonna be helpful, but really kind of letting go of the outcome of their process.
Bill Miller, Ph.D. (38:53):
We're not the only ones to discover these things. So you find threads of this all over the place.
Keith Sutton, Psy.D. (38:59):
Definitely. So, yeah. Tell me a little bit about the book that's up and coming about hope.
Bill Miller, Ph.D. (39:05):
Well, my editor said, you know, given what's happening in the world, I'd really like to have a book for the general public. And could you write one? I thought, I don't know. I don't wanna just write another book that says Hope is a good thing. But I did what I normally do, which is read voraciously everything I could find. Research-wise, and also books and commentary, and so forth. But there's a huge research literature on hope, which there wasn't when Carl Menninger was decrying the absence of any research on hope. Interesting how it's changed since then. So now there are hundreds to hundreds of studies. Well, we know a lot about hope, but the thing that struck me as I was reading was, this isn't just one thing, actually. There are a number of facets of it, or just kind of different pieces of it.
Bill Miller, Ph.D. (39:58):
And they all have to do with envisioning a better future. So that's kind of what's common to hope, but very different ways at it, you know? And I wound up with eight of them when I was done. I use the metaphor of a diamond, and yes, I mean, a diamond is solid, very solid stuff. And we give it to each other as a symbol of hope and so on. But also, as you turn it, it has different facets. And so it's, oh, look at it this way. That's kind of interesting, you know? And I had that experience. I was reading the Hope literature that, oh, yeah, this is, this is related, but a little bit different, you know? So some people find hope in statistics. What are my chances, doctor? You know? You wanna know, you know, with this surgery, what, what are the percentages of outcomes and so forth when you're making an investment, you wanna know something about the performance of the stock or whatever it is in the past. So that's the probability kind of hope.
Bill Miller, Ph.D. (41:07):
It's also hope without, it's not hope without desire. So wanting, just wanting, is a form of hope in itself. And I draw on like the Pygmalion story, or Pinocchio, where the person's passionate desire, to have a beautiful spouse or to have a child and so forth comes true. Well, there's a truth in that too. That desire itself is a powerful component. And in fact, you don't hope for something that you don't want. You have to want it, not to hope for it. And the other thing is, it has to seem at least possible.
Bill Miller, Ph.D. (41:48):
You don't hope for things that are, that you think are impossible. It's just, just so we don't invest in that. I said, you know, you might wish you could talk to Nelson Mandela or Cleopatra, but you don't hope to, you know.
Keith Sutton, Psy.D. (42:03):
Yes.
Bill Miller, Ph.D. (42:04):
So there's that possibility too, and seeing the possibility.
Keith Sutton, Psy.D. (42:10):
Mm.
Bill Miller, Ph.D. (42:11):
Like in people that you're mentoring in your students and your clients, you know? Seeing what's possible for them that they may not see, you know, is such a gift. I had professors who did that for me, who saw possibilities that I hadn't, hadn't even envisioned, and brought that out in me. One of them taught me to sing. I didn't know I could sing, and gave me a gift that's been with me my whole life, you know? So many possibilities. Another one, seeing that, it's there. And it could be, you know? So it's not seeing the world just as it is, which is the realist. But as it could be or ought to be. So it's just another aspect of it. And so there are, there are so many of these angles, so many aspects of the diamond that are fascinating. And that's the way I structured the book, just kind of walking through all these different ways of understanding hope. That is interrelated and yet different from each other. There's even hope, even hope against hope, you know, or hope beyond hope.
Keith Sutton, Psy.D. (43:23):
Yes. Yes.
Bill Miller, Ph.D. (43:24):
When, when all the other forms of hope are exhausted, there are people who still hope yes. Maybe, maybe beyond their own lifetime. Martin Luther King's last speech. I've seen the Promised land, I may not get there with you, and he didn't, you know? But we as a people will get there, you know, that kind of prophetic vision, you know? Very powerful.
Keith Sutton, Psy.D. (43:49):
Yeah. Makes me think of Viktor Frankl's Man’s Search for Meaning and, you know, the meaning leading to hope in the concentration camps in this way, and kind of actually leading to better survival rates and such.
Bill Miller, Ph.D. (44:08):
Yeah. Meaning is another one of the forms of hope that I talk about in Okay. And talk about Frankl.
Keith Sutton, Psy.D. (44:14):
Yeah. Yeah. Oh, great. You've been so prolific with so much great work for the general public as well as for therapists. I wanted to kind of pick your brain about, you know, I, I say something which might be too strong a statement, but I think it helps get a provocation from the people that I'm teaching. But I talk about what I, one of the things I learned from motivational interviewing is that resistance is due to the therapist. It's not something that's within the client. And oftentimes people are kind of taken aback by that, or are shocked. But that idea that, you know, resistance or I know in the second edition, you know, kind of shifted to splitting that up into discord and sustained talk versus each talk, but just that idea that that resistance is something that's evoked rather than something that the client is kind of bringing in. I, I, that's the way I kind of conceptualize it. Can you talk a little bit about that, that idea of…
Bill Miller, Ph.D. (45:12):
Resistance? Sure. Well, it's an interaction, and nobody stands alone on the beach and resists, so it's always an interaction between people. That means I'm involved in it, you know? I also have to consider the possibility that the person is reacting to something I'm doing. If they walk through the door angry, and I don't wanna be here, and, you know, this is on them, that's not, that's not on me. That's what happened to them before. But what happens after that is very much up to me. And, and if that, what we have called resistance, and I think it's an unfortunate term really. It either inherently blames the person for doing it or attributes it to pathology, you know? And neither of those is particularly healthy for the client, you know? And it sort of says in the, in your mind, “well, you, here I am doing my best work and you're resisting me.” You know? That's, so even the name, there's something wrong with a name. And that's why we tried to rehabilitate it into sustained talk.
Bill Miller, Ph.D. (46:20):
But the first two versions we talked about resistance. And then Terry Moyer, my colleague, said, “You know, most of the, what you guys are talking about as resistance examples you give are just part of the, of ambivalence, or just the person's system talk, saying, I don't feel like I want to do this. Or, you know, I don't think it'll work, and nothing abnormal about that at all.”
Keith Sutton, Psy.D. (46:44):
Yeah.
Keith Sutton, Psy.D. (46:47):
Well, even to speak to ambivalence for those who might not understand or know about motivational interviewing. The idea that we all have ambivalence. And, you know, the more the therapist takes one side of the ambivalence, the more they evoke the other side. So that sustains absolutely. It's not, it's…
Bill Miller, Ph.D. (47:04):
Reflective,
Keith Sutton, Psy.D. (47:05):
It's not pathological. But it is something that, within the context, can, there can be more or less of in the dynamic.
Bill Miller, Ph.D. (47:14):
I wrote a book on that too, called on, on second thought, oh, just got, I got interested in the phenomenon of ambivalence and did what I said, which was just read everything I could find on it. And it was fascinating. And I wind up thinking ambivalence is a virtue.
Keith Sutton, Psy.D. (47:30):
Hmm.
Bill Miller, Ph.D. (47:31):
Not a problem. Ambivalence is a virtue.
Keith Sutton, Psy.D. (47:34):
Yeah. Say more about that, because I'm remembering just reading recently in one of the books, say more about that, that ambivalent virtue.
Bill Miller, Ph.D. (47:43):
Well, it, I mean, what, what is ambivalence? You're considering different possibilities, and kind of weighing the pros and cons of them. So you're being thoughtful and reflective about it. But like, before acting ideally, you know, that's a good thing, and people who don't do that, who act impulsively without really reflecting much on the consequences of it. You just have unhappy outcomes in general. So at an individual level, I think that's a good thing. But if you think about democracy
Keith Sutton, Psy.D. (48:20):
Mm. Yeah.
Bill Miller, Ph.D. (48:21):
The basis of democracy is people disagreeing with each other and talking together and considering the possibilities and having to make a decision together. about how we're gonna go here. And to me that's a much healthier form of government than a dictatorship where somebody just does whatever they want to do. And so even at that social level, that ability, which is not totally uniquely human, but, you know, to take your time and really reflect on different possibilities and see different possible futures to project yourself more into the future. I think if I go down this road, I'm probably gonna go there. And if I go down this road, I might go down there and just spend some time weighing that, you know, it's not pathological. One of our personality traits is how comfortable we are with ambivalence. And some, some people are fine with it, you know, and they get uncomfortable when they reach the point where they have to make a decision, you know? But comfort with that, you know, it's okay. Just taking, taking your time, taking a look, is all right. So I'm more the, I make a decision and just get it over with kind of person.
Bill Miller, Ph.D. (49:42):
I married somebody who's much more reflective and thoughtful about it. When you're buying a house, it's a little better to be thoughtful and reflective about it. And consider you see the possibilities and so on. So, we help each other out as people in that way, too. A good committee is balanced in that way.
Keith Sutton, Psy.D. (50:02):
Well, it's interesting you're talking about the tolerance for ambivalence too, 'cause I think of, Lynn Lyons, a CBT therapist, talks about how anxiety wants certainty, and sometimes the more certainty the person wants, the more anxious they get. We can't truly get certainty. There's always gonna be, you know, other possibilities or so on. So yeah, that, and like you're saying too about maybe ambivalence, not necessarily being kind of wholly human, but that idea, like you're saying, of imagining possible futures, is kind of one of the aspects as humans that sets us apart of being able to look forward into the future at different possibilities. So that definitely makes sense, that ambivalence being such a big piece. So I, oftentimes, think that that idea of resistance is just a cue for the therapist that we might be missing something, right?
Keith Sutton, Psy.D. (50:56):
That we're, it's dragging our client along or so on. So we need to kind of circle back around, back ourselves up, and understand our clients. And I think, like you're saying with empathy being expressed that we may understand our client, but if our client doesn't feel like we understand them, or we haven't communicated in a way that they feel like we get it, then it's not, it's still not gonna go anywhere. Doesn't do any good. So the client has to feel that we understand to be able to be in alignment to then start moving forward again together. And I like how you described that in motivational interviewing. It's more of, it's, not directing, it's not following, but it's guiding that kind of collaborative walking.
Bill Miller, Ph.D. (51:43):
It's directional. There's a direction to it.
Keith Sutton, Psy.D. (51:45):
There is a direction.
Keith Sutton, Psy.D. (51:47):
Rather than directionless. So, such a wonderful piece. Any, any last things that we didn't cover or anything that you want to add in? I mean, there's so much to cover in such a short amount of time, and you've just been so prolific in your writing, and you've got so many wonderful books. Anything that we miss that you really want to add in here
Bill Miller, Ph.D. (52:13):
And not really. I mean we, I love talking about these things, and there's nothing I would rather have done. Then the career that I've had. It's just fascinating. I mean, another one that was my favorite study in terms of transformational changes, where people change dramatically in a matter of moments or hours at most. And I was thinking about that, shouldn't I, as a psychologist, be interested in that? You know? It doesn't often happen in therapy, you know, but these things just happen in everyday life. William James was writing about them. So I just get interested in these aspects of people and kind of dig in and then try to understand it, and also try to convey it in a way that people can understand what I'm saying, that's to say, in everyday language.
Keith Sutton, Psy.D. (53:11):
And is that an area you're digging into more of that transformational change?
Bill Miller, Ph.D. (53:16):
Nope. That's a study that and the editor wanted me to do a second edition, and they, I didn't really know how to do that. 'Cause it was, it was based on a whole series of interviews that we did, with people that had these kinds of experiences. I didn't want to retrace those steps. And the editor wanted me to write another chapter, which is how You Two Can Have a Quantum Change. And I said, “Uhhuh, sorry, I don't have that kind of magic, too.”
Keith Sutton, Psy.D. (53:44):
Yeah. I wish, wish we had that, that would be the magic wand.
Bill Miller, Ph.D. (53:48):
But, they do fascinate me. I just think I got to the place where it was clear to me it wasn't gonna go anywhere in psychology, but just created a lot of disinterest in the field.
Keith Sutton, Psy.D. (54:00):
Yes. Yes.
Bill Miller, Ph.D. (54:01):
And that was true from William James too. I mean, that there wasn't even a word for this kind of phenomenon, you know? So I did a study, it was my favorite study of my life. Kind of put out there what we found, and so maybe somebody else will take another step in another century.
Keith Sutton, Psy.D. (54:20):
Yes. Wonderful. Well, thank you so much. This is so great. And I just, really appreciate your contribution to the field and really, you know, taking these aspects of the Rogers' work and really moving it into kind of marrying it with some of that behavioral direction, and, and I think it's such a, a great, great piece in this influence on money, not just in the field of psychology, but in various fields. So I really appreciate all the great work that you've done. Thank you so much for taking the time.
Bill Miller, Ph.D. (54:54):
Thank you. Pleasure. Good conversation.
Keith Sutton, Psy.D. (54:57):
Great. Thanks a lot. Take care. Bye-Bye.
Bill Miller, Ph.D. (55:00)
Bye.
Keith Sutton, Psy.D. (55:03):
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Welcome to Therapy on the Cutting Edge, a podcast for therapists who want to be up to date on the latest advances in the field of psychotherapy. I'm your host, Dr. Keith Sutton, a psychologist in the San Francisco Bay Area, and the Director of the Institute for the Advancement of Psychotherapy. At the Institute for the Advancement of Psychotherapy, we provide training in evidence-based models, including Family Systems, Cognitive Behavioral Therapy, Emotionally Focused Couples Therapy, Eye Movement Desensitization and Reprocessing, Motivational Interviewing, and other approaches through live in-person and online trainings, on demand trainings, consultation groups, and one-way mirror trainings. We also have therapists throughout the Bay Area and California providing treatment through our six specialty centers, each grounded in an evidence-based approach, with our Lifespan Centers, Center for Children and Center for Adolescents, where all the therapists are working systemically; our Center for Couples, where all the therapists are using Emotionally Focused Couples Therapy; and our specialty issue centers, our Center for Anxiety, where all the therapists are using CBT and EMDR for trauma; and our center for ADHD and Oppositional & Conduct Disorder clinic, where we're integrating those four approaches.
Keith Sutton, Psy.D. (01:31):
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Keith Sutton, Psy.D. ( 02:20):
Today, I will be speaking with William (Bill) Miller, who is a psychologist and Emeritus Distinguished Professor of psychology and psychiatry at the University of New Mexico. He is the author of sixty-seven books, including four editions of Motivational Interviewing, Effective Psychotherapists: Clinical Skills That Improve Client Outcomes, Listening Well: The Art of Empathic Understanding, and On Second Thought: How Ambivalence Shapes Your Life. He had been teaching the skill of accurate empathy for over 50 years. Let's listen to the interview.
Keith Sutton, Psy.D. (02:51):
Hi, Bill. Welcome.
Bill Miller, Ph.D. (02:53):
Thank you very much.
Keith Sutton, Psy.D. (02:54):
Thanks so much for joining me today. I really appreciate it. So, gosh, I learned about motivational interviewing back when I was still a paraprofessional in my early twenties, and I just really enjoyed it. I've still got my book with all my highlights, and I didn't realize until much later on how foundational motivational interviewing was for my work. So I really love the approach. I teach some workshops in it, and I really see it as foundational. And I've recently, you know, gotten to check out the new addition of the book and also your book on effective psychotherapists, and I'm really kind of looking at what improves outcomes. I've also, you know, used the outcome rating scale and session rating scale based on the common factors research. And I was interviewing some time ago, Scott Miller, you know, about his work. And he said, you know, we-- the best thing you can do is get training on how to have a better relationship with your client. And he said, but we did research on that. And nobody would go to those workshops because they felt like, “Oh, I've already got such a good relationship.”
Bill Miller, Ph.D. (04:06):
I already do that.
Keith Sutton, Psy.D. (04:07):
What this is called is motivational interviewing. Motivational interviewing is a way to have a better alliance and really improve the outcome. So it's just a, yeah, it has such a great impact. It's so-- but one thing I'd like to jump into first before hearing about motivational interviewing and your work is how you get into doing the things that you're doing, kind of what was your evolution of thinking to get to the work you're doing?
Bill Miller, Ph.D. (04:34):
Gradually, of course. I mean, first of all, I started out intending to be a pastoral minister. So in college, I studied religion, which was much more complex than my childhood religion was, and I had majored in psychology and so I wound up kind of following the psychology path. Although I've always stood in the doorway between psychology and religion, I've passed things back and forth. So that’s been a part of my history too. In graduate school, before we ever laid hands on behavioral therapy and there was a behavioral program, we had a year's course in how to talk to clients, basically. And they went across campus to the counseling psychology program and hired a professor named Susan Gilmore, who was an academic grandchild of Carl Rogers.
Bill Miller, Ph.D. (05:28):
And she came and taught us a person-centered way of being with people. And I'm so grateful for that, that before we ever got into the techniques, this relational stuff really took hold. And so I've always done cognitive behavior therapy in a humanistic person-centered kind of way, and they fit perfectly well. So that was a good start for me, anyhow. Then, as I began doing research here at the University of New Mexico, we found that this is in behavioral treatment for people with alcohol problems. The biggest predictor of outcome was how empathic the therapist was. Accounted for two-thirds of the variance in the very behavioral outcome. So that was saying, there's something really important about the therapeutic relationship here, you're doing behavioral therapy. A very concrete behavior problem.
Bill Miller, Ph.D. (06:29):
And with that, I went off on my first sabbatical leave to Norway. And that's where motivational interviewing was literally evoked from me. And I had no idea of it when I went there, and I was role-playing with the therapists in this alcoholism clinic in Norway, and they said, Well, don't just talk to us. I mean, show us what you do then. And they were role-playing clients, they were finding it difficult, and essentially said, Oh, you know, okay, smart guy, what would you do with this? You know?
Keith Sutton, Psy.D. (07:01):
Sure. Stump the jump.
Bill Miller, Ph.D. (07:03):
Well, well, sure, and as I was demonstrating, they would stop me and interrupt me, which my American students didn't do, and ask very good questions. What are you thinking right now? You asked a question, but gosh, you could have asked many questions. Why that particular question?
Bill Miller, Ph.D. (07:24):
You're teaching this reflective listening. Okay. And you reflected something the client said, but how did you know what to reflect? Why did you reflect that rather than many other things the client is saying? And so they literally evoked from me some decision rules that I was using, if a show was not conscious, that had to do with having the client make the arguments for change, rather than me as the therapist. More complex than that, but basically that was the essence of it, which is precisely the opposite of what was being done in addiction treatment, in the seventies and eighties in the United States, at least. Authoritarian, sit down and shut up. You don't know anything. They wanna tell you what's wrong with you and what you need to do, which human beings don't respond to particularly well.
Keith Sutton, Psy.D. (08:19):
Yeah. Yeah. That confrontational style.
Bill Miller, Ph.D. (08:16):
Yeah. So, that was kind of how this got started. I mean, just many different kinds of things. I didn't meet Steve Rolnick until my second sabbatical in Australia, and we found each other in offices next door to each other.
Keith Sutton, Psy.D. (08:35):
Oh, great.
Bill Miller, Ph.D. (08:36):
And he said, You're the guy who wrote that paper on motivational interviewing? And I said, well, you read it! Thank you, I'm impressed. He said, I've been trying to teach this. And, you know, you need to write more about it. And so we did. We've been writing four editions of the text ever since.
Keith Sutton, Psy.D. (08:54):
Oh, wonderful. And I was reading your story in the effective psychotherapy book that you were talking about. I was surprised to hear that you were doing behavioral family therapy, which I didn't know about that background. I mean, I also do family therapy, and I'm familiar with Jerry Patterson's work. And you were saying that, once you were seeing him do it, can you speak to that a little bit? Because I thought that was really eye-opening.
Bill Miller, Ph.D. (09:23):
Well, that was another learning experience for me. I was trying to do behavioral family therapy supervised by one of Jerry's students. And I'm reading the books that Jerry wrote, and I'm trying to do the stuff that's in the books, you know, and that is pretty clear, but, you know, charts and graphs and so forth, and with parents. And it's just not working. And then they took us over to the Oregon Research Institute, where Jerry was. He had been in the psych department, but went over to a research Institute, and we watched him working with a family through a big one-way mirror. And as I said in my note in that book, he was doing all kinds of things in addition to what he wrote about. I mean, he was doing what he wrote.
Keith Sutton, Psy.D. (10:11):
Sure.
Bill Miller, Ph.D. (10:12):
But he was a warm, friendly, compassionate, interesting, funny guy. You know, I mean, you would do anything for this guy. And parents loved him. And, he was just joining up with them, and I said, Oh, that's how you do it. And I pulled on my person-centered training and began doing behavioral family therapy in that way, and started working. Again, it was a lesson for me in putting together techniques that were really heavily emphasized in the behavioral training.
Keith Sutton, Psy.D. (10:49):
Yeah.
Bill Miller, Ph.D. (10:50):
With how you are with clients, and if you aren't engaging and warm and empathic with clients, they generally won't do what your techniques do, you know? So that was another important aha for me, which I learned just from watching Jerry do one session.
Keith Sutton, Psy.D. (11:09):
Wow. Yeah, because you might have all those different techniques and there's great research around it, but if it's not within that kind of basis of that relationship and connection with the client, then it's not necessarily gonna go anywhere.
Bill Miller, Ph.D. (11:21):
Yeah. It's a both/and I think it matters what you do and it really matters how you do it. And, very often in clinical training, there's not much attention given to how you do this. At least in more behavioral programs and probably in other theoretical orientations as well. There's just emphasis on the technique that's consistent with the theory, neither teaching nor modeling of your presence with clients, how you are with clients.
Keith Sutton, Psy.D. (11:57):
Definitely. So one of the things that really strikes me about motivational interviewing, and I was actually, I, I learned motivational interviewing before I started working at a drug company now called outpatient program, which was very confrontative, and I was supposed to take over for a guy who was the hammer, and I am not the hammer. So it was very interesting having that juxtaposition.
Keith Sutton, Psy.D. (12:23):
But one of the things that I've really taken for motivational interviewing is just the profound respect for the other person and their way that they're deciding to live their life that we have, we are trying to have influence or help them or so on. But ultimately, it's really the only other person's choice about their life. And that idea of the spirit of motivational interviewing is, you know, just a great boundary respectful kind of basis, because you can't do motivational interviewing with the intent to get somebody to do what you want them to do. You have to have the intent that this person is gonna do whatever they're going to do, and I have to be okay with that, although I might be able to have some influence and help them along this path.
Bill Miller, Ph.D. (13:11):
Yeah. Well, Steve and I discovered that in, about 1993. So this is two years after our first book came out, and we were teaching people how to do motivational interviewing, and they were doing what we told them, and we were not happy. There was something wrong. And it was what you were talking about or trying to use these techniques on somebody to trick them into changing or manipulate them into changing, or is still, I'm in control as a therapist, you know? And that's the wrong spot, because ultimately it is the client who is in control. And, if you give up that control, you're giving up something you never had in the first place, 'cause it's always the client who decides whether, and how they will change , and so on. And so that's, that is a key piece of the spirit of me as well. You have to just know and accept that clients will get to decide what they're gonna do. That makes it more possible for them to change. And that's called Roger's insight. He said that when we feel unacceptable.
Keith Sutton, Psy.D. (14:23):
Mhm.
Bill Miller, Ph.D. (14:23):
We can't change it; it's paralyzing. And when we experience acceptance as we are, it becomes possible to change. Now that's weird writing. I don't know why we're made that way. But it really is true. When you convey acceptance as you are, then you make it possible for the person to choose to change and do something differently.
Keith Sutton, Psy.D. (14:49):
Rather than being bad for what you're doing or how you're doing it, or so on, kind of understanding or being validated or being seen for why it makes sense. And just having that acceptance almost allows the person to make peace with it or something to then move from there, rather than, I don't know. Avoiding it, or something like that. The shame is more about trying to get rid of it than moving forward with it or learning from it.
Bill Miller, Ph.D. (15:19):
And if you're, if you're trying to change somebody, they know that, and human beings back away from that. I received an interesting paper from an evolutionary psychologist in Australia, who asked, "I understand from an evolutionary perspective, why am I working so well?" It's because you start by saying you're in charge. There's, there's no, you know, no imagining that I'm gonna change you. I'm going to make decisions for you. You can't do that, you know? And when you signal that in the beginning, it just takes away the competitiveness or the tension in that, and people can relax and, oh, well, what do I want to do with my life? You know? Interesting stuff.
Keith Sutton, Psy.D. (16:09):
Well, I imagine also the effect on the therapist of potentially having less pressure or, you know, less burnout in, being able to let go of the feeling that they have to control or have to make somebody do something. Understanding that they can do as much as they can do on their side, and the client's gonna do what they can on their side, but not necessarily feeling all the, all the responsibility on their shoulders.
Bill Miller, Ph.D. (16:36):
Yeah. That's it. I mean, if I were doing research, I'm retired now, so I'm not. But I would be studying that. What is the effect on the clinician of learning motivational interviewing? And, through my whole career, I’ve heard all kinds of stories from people about, I was just on the edge of burnout, and then I found this, and it made my work much more rewarding. To save my life, people say, and they just go, " Wow. Incredible stuff. So it has an impact on the provider as well. And it is kind of relaxing, enjoying your work more, in relation to being relaxed with it. Which doesn't have to be with anything to do with being careless or not paying attention to what you're doing. Given what I know from my research, I've got to pay attention to what I'm saying or doing. Because I know it does influence outcomes, you know? And that's also knowing at the same time that I don't get to make the choices for people. They do. So these paradoxes are so much a part of the way you do motivational interviewing.
Keith Sutton, Psy.D. (17:41):
Yeah. And I imagine it gives patience, too, for the process.
Bill Miller, Ph.D. (17:44):
Oh, yes. Yeah. Which makes things go faster.
Keith Sutton, Psy.D. (17:48):
Paradoxically.
Bill Miller, Ph.D. (17:49):
I give, again, I got to know Monty Roberts, the original horse whisperer about 20 years ago, and I had been to the ranch. He kind of walked me through his method, but both of us saw in the other the same thing we're doing. And I said, “Damani, you're doing what I do. You do it with horses. That's incredible.” You know? “Wow.” He said, “Well, you're doing what I do. You're with alcoholics. That's amazing.” And, the similarities are there. It's about approaching, not pushing. I'm not trying to control you. When I co-authored a book on effective psychotherapists with Terry Moyers, we identified eight key characteristics of therapists who achieve better outcomes, regardless of the theoretical framework they work within. And when we finished it, I said to myself, you know, these look familiar.
Bill Miller, Ph.D. (18:41):
These eight characteristics, at least seven of them, have been characteristic of motivational learning from the very beginning. Is that what we've been doing? Have we been really teaching people how to be helpful? How to be a helper? How to work with people in a way that they'll let you in and listen to what you have to say? Because there's so much overlap. MI is not a theory. We don't have a theory of psychopathology. You know, it's a way of being with people.
Keith Sutton, Psy.D. (19:13):
I was gonna say a way of being.
Bill Miller, Ph.D. (19:15):
Whatever your school of psychotherapy or whatever your profession, it's a way of doing diabetes education. It's a way of doing classroom education. It's a way of doing primary care medicine. You know, it's the relational aspect of all these professions where we're trying to be helpful to people.
Keith Sutton, Psy.D. (19:35):
Definitely. And can you actually mention what those different, effective, I think you were saying there were seven, was that right?
Bill Miller, Ph.D. (19:43):
There were eight altogether.
Keith Sutton, Psy.D. (19:44):
Sorry. Eight. Yes.
Bill Miller, Ph.D. (19:46):
What is, well, the number one was accurate empathy. And we put it first in the book because it had the biggest effect. The overall effect on client outcomes was the largest. This involves reading 70 years of psychotherapy outcome research. And for such a long time. But what therapists seem to have are better outcomes, regardless of the techniques or their school of psychotherapy. What are they actually doing with clients? And that is related to better outcomes. Well, accurate empathy, certainly. Genuineness. Being yourself, auth, you know. Rather than putting on a mask and being an objective observer or a distant, mysterious guru or whatever. You're a real person there interacting with this person. That's associated with better outcomes as well.
Bill Miller, Ph.D. (20:42):
Positive regard. Language from Carl Rogers. And none of these things are just about feeling it inside yourself. If you're feeling empathetic for the person, it doesn't do them any good. Unless you express empathy, it's something you actually do with clients. Reflect on that, which helps both of you understand better. Well, the same thing with positive regard. It's not just something you're sitting there feeling. You're expressing positive regard. And in motivation, anything, we do that via affirmations, via noticing what people are doing well, and particularly noticing their strengths, noticing positive attributes, and commenting on those. Acceptance is another one. Accepting people as they are. That one's pretty straightforward. Hope. Now we know that the clients having hope is a good thing.
Keith Sutton, Psy.D. (20:42):
Yes.
Bill Miller, Ph.D. (21:41):
But turns out therapists having hope is also really important. And if you get to be kind of cynical, it'd probably be good to take some time off or get another line of work, because it's a self-fulfilling prophecy. Whatever you see as your client's likely outcome tends to happen in that direction. So, you know, that's interesting. Having clear goals and shared goals, which Scott Miller talks about, it's just a part of the therapeutic alliance, working alliance with people so that you both know where you're trying to go, and you agree about that. And it's the therapist's job to kind of keep things moving in that direction, you know? That's associated with better therapist outcomes, giving information and advice as one of the smaller effects, but it is a positive effect.
Bill Miller, Ph.D. (22:37):
And I think it's a small effect because it matters so much how you do it. There are ways you can give information and advice that drive people away and shut them down, and they don't wanna hear it. And there are ways of doing it that kinda lower the defenses, and people can listen to it and talk to you about it. So that's there. And what have I not mentioned, evocation? That's an interesting thing in various psychotherapies of things you're hoping that you will hear and see happen during your session. That to predict better outcomes. So the more the client does and says these kinds of things during sessions, the better the outcomes tend to be, and is strategically doing things as a therapist or counselor to evoke those kinds of responses during therapy. In a person-centered approach, the work of Eugene Lin, experiencing is exactly that. Experiencing is talking about yourself, first person, present tense. You, you're very much there. You're not talking in the abstract about yourself. You're not talking about the past, in a distancing kind of way. You're right there involved. And that is associated with better outcomes.
Bill Miller, Ph.D. (23:56):
How do you get those better outcomes in person-centered therapy? Accurate empathy, unconditional positive regard, genuineness, kind of the things that Rogers talked about in motivational interviewing are change talk. And in particular, the balance of change. Talk to sustained talk. And we've learned now that it is the ratio of those things that really predicts outcome. So the more you're evoking change talk, and the less you're evoking defensiveness and sustained talk, the better the outcomes are, you can see it in the session. So the client's giving you feedback. How are you doing right now? You know? Let's see if you do something, you get a chance to talk. That's the client saying, Good job. You know? You're on the right track. And if you say something, the client begins to back away and say, Well, I don't think it's that serious a problem. That's the client saying, Why don't you try something other than what you just did? You know?
Keith Sutton, Psy.D. (24:51):
Mhhhm
Bill Miller, Ph.D. (24:52):
Yes, try a little different response. And that's in the session shaping its immediate feedback. And so it's a way of getting better, too.
Keith Sutton, Psy.D. (25:00):
Yeah. And being attuned, it sounds like also with what you're getting back or how the client is responding or reacting to what you're saying.
Bill Miller, Ph.D. (25:09):
Absolutely. It's called responsiveness in the therapeutic literature.
Keith Sutton, Psy.D. (25:13):
Oh, great. And I wanna start off asking you a little bit about the accurate empathy, because I was, I was reading that, and I was struck by your referencing some of your early research and just how so significantly correlated the accurate empathy was with, some of the clients, therapists having, a hundred percent of the clients. Resolving their alcohol and follow up also, while, you know, the others were kind of in a bit of an average range or so on. There was a wide range, and even one that the lowest inaccurate empathy was actually seeing a deterioration that it was so correlated with, outcome Right. And follow up.
Bill Miller, Ph.D. (25:55):
And that, that's a finding with accurate empathy too, that therapists who are low in that actually have clients whose outcomes are worse than no treatment. So you're better off going home with a good book, really, than sitting down with a low-empathy therapist.
Keith Sutton, Psy.D. (26:09):
Yeah. I think that was a control group, right? Is that they actually just had a self-help book or something? Or was that
Bill Miller, Ph.D. (26:14):
Yeah. Well, yes, that was a control group in that study that you're talking about. And we had nine therapists, and the therapists on average had the same success rate as the self-help book, but five of them had a higher success rate. Three of them had a lower success rate, and one of them had exactly the same success rate. And so it could lead you to say, well, therapists are no different from self-help. And that's not true when you look at the graph. But how the person is doing, how much they're changing, depends on the therapist who's treating them. Right? Yes. For better or for worse, and Rogers and his colleagues knew that back in the sixties and seventies, you can behave in a way that makes clients worse.
Keith Sutton, Psy.D. (26:59):
Yeah. And I'm curious about that. Measuring accurate empathy. Because I know that you did some inner rate reliability, and I was doing, looking at some research articles, I saw there's the MI adherence kind of, scoring that was looking at more like whether it seemed like the therapist was interested in what the person was saying. And I don't know if there's any, I saw one article where they were actually looking at a kind of tone of voice and analyzing the kind of yes voice, but with the therapist and client. And the way I think about it often is that, you know, when our client feels like we understand, and when we understand, and we feel like our client feels like we understand, we get that kind of big head nod. The person's like, “yes, you're getting it.”
Keith Sutton, Psy.D. (27:45):
And then we can kind of move forward. But if we're, if they're not, if we're not kind of getting that, it's like the cue to the therapist to back up and come back around. But I've always thought that the determinant of accurate empathy is the client's reaction. And if they're like, actually feeling like you're getting it, or, and I was just curious in a research, like, how do you kind of measure that? And actually, we're doing a one-way mirror training where the trainers were talking about empathy, and she's like, well, how, how do you operationalize that? What does that mean? How does that behave? So that's why I was kind of digging into more in your books and some research around what that looks like, or how the therapist who's working on that?
Bill Miller, Ph.D. (28:27):
And I love those kinds of questions, you know, these things we aspire to. I wrote a book on loving kindness. So we're all kind of aspiring to that. What does it actually look like? How do you do that? You know? And the same thing with listening. I wrote a book for the general public called Listening Well, that is this kind of step-by-step learning, this way of listening to people. And it is very observable, very measurable, observers can agree to the extent to which it's happening, and that predicts outcomes. We've done both rating scales, which is the way Rogers and his students are measuring it. And we've also done behavior counts, number reflections to questions, and so forth. And in general, if the questions outnumber the reflections, that's not a good thing. You know, you wanna be listening more. And I, I tell people if you ask a question, you owe the person two reflections.
Keith Sutton, Psy.D. (29:24):
Oh. That's a nice way of putting it.
Bill Miller, Ph.D. (29:26):
Well, what's going on as you're reflecting is you're getting closer and closer to understanding what the person means, and so are they, together. And so that's why it's a dynamic process. It's not that you just make a guess and find out if you're right or not. You are making a guess when you form a reflection. And, I always teach people to do it as a statement, by the way, not to ask it as a question. not, not to say, you're angry with your mother, which is kind of threatening if you, if you hear it that way. And that sounds like you shouldn't, you shouldn't use the same words. You're angry with your mother, you know, as a, as a reflective statement. very comforting. And the person goes on and keeps talking to you about it. Well, there are a lot of artful things about that. But when you're doing that, well, you're, you and the client together are discovering more and more closely what it is the client's experiencing. What it is. They mean what? What's going on for them? And that's, of course, a value to the therapist, but it's also a direct value to the client as well.
Keith Sutton, Psy.D. (30:37):
Yeah. And sometimes I think about it, it's almost like a cultural anthropologist, like really being curious about each word the person's using, because what you're assuming they're meaning may be very different from what they are actually meaning. And being able to really understand when they're saying, you know, that you're really getting what they're saying, rather than just inserting your own kind of ideas about what that means.
Bill Miller, Ph.D. (31:05):
When clients speak, there's something they meant to begin with, then they put it into words. And it can go wrong at that point, 'cause we don't say what we mean necessarily. Then you have to hear the words accurately, which is more challenging for me as I age. And then, having heard the words, you have to figure out what they meant, you know? So your three steps are removed from the client's own experience, and usually, a first guess is wrong. And one of the training exercises that we do is to have people make a guess about what the speaker meant and ask it as a question, in fact, 'cause it's easier. You would say “Well, do you mean that?” And people are surprised how often they say, "Oh, I was just sure that was what it meant. But, no, it wasn't. Then you move into learning reflective skills and so forth, and being able to string reflectors together, and yeah. And like that. But it really is quite artful and at the same time, very behavioral. It's very measurable, very observable, and very related to client outcomes.
Keith Sutton, Psy.D. (32:04):
And when you're doing the actual, like, measurable, is it what the therapist is doing? Or are you measuring the client's reaction?
Bill Miller, Ph.D. (32:13):
We measure what the therapist is doing. And, Roger's group did an interesting study, actually, on whether the raters needed to hear what the client said in order to rate the accuracy of empathy. And they didn't, which is kind of surprising, you know. But, from the content of the reflection, you can kind of get a sense of how the person is, zeroing in on things. Mm. Now it's better to hear both. So we're sure. In our research, we usually code both therapists' and clients' responses. But you, you can do a pretty good job of getting a fix on how well the person does reflective listening just from their own responses.
Keith Sutton, Psy.D. (33:00):
Okay. Great. And you were mentioning the genuineness and authenticity. And I often find when I'm training, folks that are just, you know, working on their hours for licensure, that sometimes, I use that term, the mask, which I think, is a really good one. Because they come in acting like what they think a therapist is, rather than sometimes bringing themselves. So the client says, Oh, I lost my job. And then, you know, the intern says, How did that make you feel? Rather than…
Bill Miller, Ph.D. (33:27):
Exactly the question
Keith Sutton, Psy.D. (33:29):
I need rather than, and I say, you know, gosh, if your friend said “I lost [their job]”, you'd be like, “oh my gosh, what happened?” Like, you know, that there'd be more of a, and of course, in a boundaried way, but that you're more like having that reaction and being genuine, like, oh my gosh, what happened? And like, kind of matching that energy.
Bill Miller, Ph.D. (33:46):
And better still, to make a guess and reflect on what you think the person may be experiencing
Keith Sutton, Psy.D. (33:51):
Yeah.
Bill Miller, Ph.D. (33:52):
Not a big jump, just a small one, but nonetheless, staying a little bit ahead. I will continue the paragraph. So, instead of repeating what the person just said, you get skillful at saying what might be the next sentence. And if it's wrong, the client will tell you, that's not what we mean. But it moves it ahead so much better than staying close to what the person was saying. And that we call simple reflection, then. And if that's all you do, you just kind of go around in circles, or it doesn't seem to go anywhere. Doesn't have momentum.
Keith Sutton, Psy.D. (34:30):
And actually tell me about that part with the, I know you're saying not to have it as a question, although I know for myself, sometimes I feel uncomfortable saying like, oh, you're mad at your mother. You know? And so sometimes I will have that little inflection, you know, saying like, okay, so you're mad with your mother, kind of, I don't know, putting it often as a question, but I hear what you're saying is that you don't want it to necessarily sound as like a judgment of what That's right. But I also wanna be careful of not telling the person what their experience is, and kind of in a top-down kind of way.
Bill Miller, Ph.D. (35:07):
Yeah. Some of that is voice tone. It's a difference between, you're angry with your mother, and you are angry with your mother, you know? I mean, the latter is much more authoritarian. I know more about you than you do, and so on. So the music in the voice also matters, you know? But it's not, it's not clients who get uncomfortable with that. It is the listeners who say, I actually, I've taught them you're making a guess when you make a reflection.
Keith Sutton, Psy.D. (35:36):
Yes. Yes.
Bill Miller, Ph.D. (35:37):
And because, you know, you might be wrong. You are gonna want to be tentative and ask, you know, well, is this what you mean? You know? . But, that gets awkward quickly. And you, if you just inflect your voice up at the end, so you don't see anything wrong with what you did.
Keith Sutton, Psy.D. (35:55): . Yeah. That's, you hear it implying that there's some , that there's…
Bill Miller, Ph.D. (36:00): Exactly! It is not always intended. Sometimes it is. It's just a person's discomfort with, “I might be wrong about this”, but much better to say you don't say anything wrong with what you did.
Keith Sutton, Psy.D. (36:11):
Yeah. Interesting. Celia Ko did some research in a paper on centering the voice of the client. And one of the things that she talked about is some of the timidity was a piece that was helpful for some, but I hear what you're saying that that kind of that question mark or that kind of, you know, making sure that it's checking in with the client, their experience versus suggesting that they did the wrong thing. There's almost like that tonal difference there.
Bill Miller, Ph.D. (36:45):
The question does that, and questions also place a pressure? Again, this isn't necessarily conscious to the listener, but a question demands an answer. And there's a feeling of being interrogated that isn't there when you're making reflective statements. So it feels funny to the listener, but it works so much better than the person who's being listened to.
Keith Sutton, Psy.D. (37:08):
I find that when coaching parents, 'cause I almost teach them the motivational interviewing when they're drawing out their kids. And that sometimes if the parent just goes question after question, it's like an interior. And it, even though they might be curious and wanting to understand it may make the person feel kind of backed into a corner or something to that effect.
Keith Sutton, Psy.D. (37:29):
And I really liked what you're saying about the hope aspect too. Somebody I heard talked about, you know, our case conceptualization is only as good as it gives us hope for our clients.
Bill Miller, Ph.D. (37:40):
Yeah.
Keith Sutton, Psy.D. (37:41):
Because like you're talking with the therapist, if the therapist doesn't have hope, that's, that's very problematic.
Bill Miller, Ph.D. (37:47):
It is. Yeah. It's self-fulfilling. My next book is about hope, as a matter of fact.
Keith Sutton, Psy.D. (37:54):
Yeah.
Bill Miller, Ph.D. (37:55):
It comes out in August, and it's called Eight Ways to Hope.
Keith Sutton, Psy.D. (38:00):
Oh, say more about that. I was mentioning the loving and kind, which was making me think too, about kind of the eastern philosophy, kind of Buddhist concept about not having the attachment to the outcome. Which I think, oh, yes. Sometimes, you know, when I think about motivational interviewing, right. That the person may decide to continue doing heroin or whatever it might be, and that our attachment to the outcome, we have to kind of let go of that and create the space. And I was reading some of Pema Chodron's writing, and it sounded like she was talking about motivational interviewing. She was talking about getting frustrated with somebody. She was helping that relapse, and then realized, needing to let go. And that, you know, that she has to, you know, not, not take that on, and get frustrated with the person, 'cause that's not gonna be helpful, but really kind of letting go of the outcome of their process.
Bill Miller, Ph.D. (38:53):
We're not the only ones to discover these things. So you find threads of this all over the place.
Keith Sutton, Psy.D. (38:59):
Definitely. So, yeah. Tell me a little bit about the book that's up and coming about hope.
Bill Miller, Ph.D. (39:05):
Well, my editor said, you know, given what's happening in the world, I'd really like to have a book for the general public. And could you write one? I thought, I don't know. I don't wanna just write another book that says Hope is a good thing. But I did what I normally do, which is read voraciously everything I could find. Research-wise, and also books and commentary, and so forth. But there's a huge research literature on hope, which there wasn't when Carl Menninger was decrying the absence of any research on hope. Interesting how it's changed since then. So now there are hundreds to hundreds of studies. Well, we know a lot about hope, but the thing that struck me as I was reading was, this isn't just one thing, actually. There are a number of facets of it, or just kind of different pieces of it.
Bill Miller, Ph.D. (39:58):
And they all have to do with envisioning a better future. So that's kind of what's common to hope, but very different ways at it, you know? And I wound up with eight of them when I was done. I use the metaphor of a diamond, and yes, I mean, a diamond is solid, very solid stuff. And we give it to each other as a symbol of hope and so on. But also, as you turn it, it has different facets. And so it's, oh, look at it this way. That's kind of interesting, you know? And I had that experience. I was reading the Hope literature that, oh, yeah, this is, this is related, but a little bit different, you know? So some people find hope in statistics. What are my chances, doctor? You know? You wanna know, you know, with this surgery, what, what are the percentages of outcomes and so forth when you're making an investment, you wanna know something about the performance of the stock or whatever it is in the past. So that's the probability kind of hope.
Bill Miller, Ph.D. (41:07):
It's also hope without, it's not hope without desire. So wanting, just wanting, is a form of hope in itself. And I draw on like the Pygmalion story, or Pinocchio, where the person's passionate desire, to have a beautiful spouse or to have a child and so forth comes true. Well, there's a truth in that too. That desire itself is a powerful component. And in fact, you don't hope for something that you don't want. You have to want it, not to hope for it. And the other thing is, it has to seem at least possible.
Bill Miller, Ph.D. (41:48):
You don't hope for things that are, that you think are impossible. It's just, just so we don't invest in that. I said, you know, you might wish you could talk to Nelson Mandela or Cleopatra, but you don't hope to, you know.
Keith Sutton, Psy.D. (42:03):
Yes.
Bill Miller, Ph.D. (42:04):
So there's that possibility too, and seeing the possibility.
Keith Sutton, Psy.D. (42:10):
Mm.
Bill Miller, Ph.D. (42:11):
Like in people that you're mentoring in your students and your clients, you know? Seeing what's possible for them that they may not see, you know, is such a gift. I had professors who did that for me, who saw possibilities that I hadn't, hadn't even envisioned, and brought that out in me. One of them taught me to sing. I didn't know I could sing, and gave me a gift that's been with me my whole life, you know? So many possibilities. Another one, seeing that, it's there. And it could be, you know? So it's not seeing the world just as it is, which is the realist. But as it could be or ought to be. So it's just another aspect of it. And so there are, there are so many of these angles, so many aspects of the diamond that are fascinating. And that's the way I structured the book, just kind of walking through all these different ways of understanding hope. That is interrelated and yet different from each other. There's even hope, even hope against hope, you know, or hope beyond hope.
Keith Sutton, Psy.D. (43:23):
Yes. Yes.
Bill Miller, Ph.D. (43:24):
When, when all the other forms of hope are exhausted, there are people who still hope yes. Maybe, maybe beyond their own lifetime. Martin Luther King's last speech. I've seen the Promised land, I may not get there with you, and he didn't, you know? But we as a people will get there, you know, that kind of prophetic vision, you know? Very powerful.
Keith Sutton, Psy.D. (43:49):
Yeah. Makes me think of Viktor Frankl's Man’s Search for Meaning and, you know, the meaning leading to hope in the concentration camps in this way, and kind of actually leading to better survival rates and such.
Bill Miller, Ph.D. (44:08):
Yeah. Meaning is another one of the forms of hope that I talk about in Okay. And talk about Frankl.
Keith Sutton, Psy.D. (44:14):
Yeah. Yeah. Oh, great. You've been so prolific with so much great work for the general public as well as for therapists. I wanted to kind of pick your brain about, you know, I, I say something which might be too strong a statement, but I think it helps get a provocation from the people that I'm teaching. But I talk about what I, one of the things I learned from motivational interviewing is that resistance is due to the therapist. It's not something that's within the client. And oftentimes people are kind of taken aback by that, or are shocked. But that idea that, you know, resistance or I know in the second edition, you know, kind of shifted to splitting that up into discord and sustained talk versus each talk, but just that idea that that resistance is something that's evoked rather than something that the client is kind of bringing in. I, I, that's the way I kind of conceptualize it. Can you talk a little bit about that, that idea of…
Bill Miller, Ph.D. (45:12):
Resistance? Sure. Well, it's an interaction, and nobody stands alone on the beach and resists, so it's always an interaction between people. That means I'm involved in it, you know? I also have to consider the possibility that the person is reacting to something I'm doing. If they walk through the door angry, and I don't wanna be here, and, you know, this is on them, that's not, that's not on me. That's what happened to them before. But what happens after that is very much up to me. And, and if that, what we have called resistance, and I think it's an unfortunate term really. It either inherently blames the person for doing it or attributes it to pathology, you know? And neither of those is particularly healthy for the client, you know? And it sort of says in the, in your mind, “well, you, here I am doing my best work and you're resisting me.” You know? That's, so even the name, there's something wrong with a name. And that's why we tried to rehabilitate it into sustained talk.
Bill Miller, Ph.D. (46:20):
But the first two versions we talked about resistance. And then Terry Moyer, my colleague, said, “You know, most of the, what you guys are talking about as resistance examples you give are just part of the, of ambivalence, or just the person's system talk, saying, I don't feel like I want to do this. Or, you know, I don't think it'll work, and nothing abnormal about that at all.”
Keith Sutton, Psy.D. (46:44):
Yeah.
Keith Sutton, Psy.D. (46:47):
Well, even to speak to ambivalence for those who might not understand or know about motivational interviewing. The idea that we all have ambivalence. And, you know, the more the therapist takes one side of the ambivalence, the more they evoke the other side. So that sustains absolutely. It's not, it's…
Bill Miller, Ph.D. (47:04):
Reflective,
Keith Sutton, Psy.D. (47:05):
It's not pathological. But it is something that, within the context, can, there can be more or less of in the dynamic.
Bill Miller, Ph.D. (47:14):
I wrote a book on that too, called on, on second thought, oh, just got, I got interested in the phenomenon of ambivalence and did what I said, which was just read everything I could find on it. And it was fascinating. And I wind up thinking ambivalence is a virtue.
Keith Sutton, Psy.D. (47:30):
Hmm.
Bill Miller, Ph.D. (47:31):
Not a problem. Ambivalence is a virtue.
Keith Sutton, Psy.D. (47:34):
Yeah. Say more about that, because I'm remembering just reading recently in one of the books, say more about that, that ambivalent virtue.
Bill Miller, Ph.D. (47:43):
Well, it, I mean, what, what is ambivalence? You're considering different possibilities, and kind of weighing the pros and cons of them. So you're being thoughtful and reflective about it. But like, before acting ideally, you know, that's a good thing, and people who don't do that, who act impulsively without really reflecting much on the consequences of it. You just have unhappy outcomes in general. So at an individual level, I think that's a good thing. But if you think about democracy
Keith Sutton, Psy.D. (48:20):
Mm. Yeah.
Bill Miller, Ph.D. (48:21):
The basis of democracy is people disagreeing with each other and talking together and considering the possibilities and having to make a decision together. about how we're gonna go here. And to me that's a much healthier form of government than a dictatorship where somebody just does whatever they want to do. And so even at that social level, that ability, which is not totally uniquely human, but, you know, to take your time and really reflect on different possibilities and see different possible futures to project yourself more into the future. I think if I go down this road, I'm probably gonna go there. And if I go down this road, I might go down there and just spend some time weighing that, you know, it's not pathological. One of our personality traits is how comfortable we are with ambivalence. And some, some people are fine with it, you know, and they get uncomfortable when they reach the point where they have to make a decision, you know? But comfort with that, you know, it's okay. Just taking, taking your time, taking a look, is all right. So I'm more the, I make a decision and just get it over with kind of person.
Bill Miller, Ph.D. (49:42):
I married somebody who's much more reflective and thoughtful about it. When you're buying a house, it's a little better to be thoughtful and reflective about it. And consider you see the possibilities and so on. So, we help each other out as people in that way, too. A good committee is balanced in that way.
Keith Sutton, Psy.D. (50:02):
Well, it's interesting you're talking about the tolerance for ambivalence too, 'cause I think of, Lynn Lyons, a CBT therapist, talks about how anxiety wants certainty, and sometimes the more certainty the person wants, the more anxious they get. We can't truly get certainty. There's always gonna be, you know, other possibilities or so on. So yeah, that, and like you're saying too about maybe ambivalence, not necessarily being kind of wholly human, but that idea, like you're saying, of imagining possible futures, is kind of one of the aspects as humans that sets us apart of being able to look forward into the future at different possibilities. So that definitely makes sense, that ambivalence being such a big piece. So I, oftentimes, think that that idea of resistance is just a cue for the therapist that we might be missing something, right?
Keith Sutton, Psy.D. (50:56):
That we're, it's dragging our client along or so on. So we need to kind of circle back around, back ourselves up, and understand our clients. And I think, like you're saying with empathy being expressed that we may understand our client, but if our client doesn't feel like we understand them, or we haven't communicated in a way that they feel like we get it, then it's not, it's still not gonna go anywhere. Doesn't do any good. So the client has to feel that we understand to be able to be in alignment to then start moving forward again together. And I like how you described that in motivational interviewing. It's more of, it's, not directing, it's not following, but it's guiding that kind of collaborative walking.
Bill Miller, Ph.D. (51:43):
It's directional. There's a direction to it.
Keith Sutton, Psy.D. (51:45):
There is a direction.
Keith Sutton, Psy.D. (51:47):
Rather than directionless. So, such a wonderful piece. Any, any last things that we didn't cover or anything that you want to add in? I mean, there's so much to cover in such a short amount of time, and you've just been so prolific in your writing, and you've got so many wonderful books. Anything that we miss that you really want to add in here
Bill Miller, Ph.D. (52:13):
And not really. I mean we, I love talking about these things, and there's nothing I would rather have done. Then the career that I've had. It's just fascinating. I mean, another one that was my favorite study in terms of transformational changes, where people change dramatically in a matter of moments or hours at most. And I was thinking about that, shouldn't I, as a psychologist, be interested in that? You know? It doesn't often happen in therapy, you know, but these things just happen in everyday life. William James was writing about them. So I just get interested in these aspects of people and kind of dig in and then try to understand it, and also try to convey it in a way that people can understand what I'm saying, that's to say, in everyday language.
Keith Sutton, Psy.D. (53:11):
And is that an area you're digging into more of that transformational change?
Bill Miller, Ph.D. (53:16):
Nope. That's a study that and the editor wanted me to do a second edition, and they, I didn't really know how to do that. 'Cause it was, it was based on a whole series of interviews that we did, with people that had these kinds of experiences. I didn't want to retrace those steps. And the editor wanted me to write another chapter, which is how You Two Can Have a Quantum Change. And I said, “Uhhuh, sorry, I don't have that kind of magic, too.”
Keith Sutton, Psy.D. (53:44):
Yeah. I wish, wish we had that, that would be the magic wand.
Bill Miller, Ph.D. (53:48):
But, they do fascinate me. I just think I got to the place where it was clear to me it wasn't gonna go anywhere in psychology, but just created a lot of disinterest in the field.
Keith Sutton, Psy.D. (54:00):
Yes. Yes.
Bill Miller, Ph.D. (54:01):
And that was true from William James too. I mean, that there wasn't even a word for this kind of phenomenon, you know? So I did a study, it was my favorite study of my life. Kind of put out there what we found, and so maybe somebody else will take another step in another century.
Keith Sutton, Psy.D. (54:20):
Yes. Wonderful. Well, thank you so much. This is so great. And I just, really appreciate your contribution to the field and really, you know, taking these aspects of the Rogers' work and really moving it into kind of marrying it with some of that behavioral direction, and, and I think it's such a, a great, great piece in this influence on money, not just in the field of psychology, but in various fields. So I really appreciate all the great work that you've done. Thank you so much for taking the time.
Bill Miller, Ph.D. (54:54):
Thank you. Pleasure. Good conversation.
Keith Sutton, Psy.D. (54:57):
Great. Thanks a lot. Take care. Bye-Bye.
Bill Miller, Ph.D. (55:00)
Bye.
Keith Sutton, Psy.D. (55:03):
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