Clinical Reasoning for Difficult Clients

Motivational Interviewing



Brett Brasher

Mental Health Center of Dane County 625 West Washington

Madison, Wisconsin 53703

Telephone:(608) 280-2417

Fax: (608)280-2707


Mental Health Center of Dane County


It is not the failure to accept limitation but the acceptance of limitation that is at the heart of addiction. The only choice the alcoholic feels s/he has is the decision to continue using. The problem is not a failure to accept limitation but an inability to imagine a present and future without the problem. Even beyond this, recovery begins with the ability to conceive a present and a future focused on solutions. This expands the realms of possibility, breaking the chains of limitation, transforming problems into opportunities, and building the framework for contented sobriety. Some may call this belief in a brighter future faith, others may call it determining one’s own fate. Either way, the role of the therapist is to help the client construct a future when the problem no longer exists.

  • Brasher, B., Campbell T.C., Moen D. (1993) Solution oriented recovery. Journal of Systemic Therapies, 12, (3), pp. 1-15.
  • Watzlawick (1990)-- "The purpose of all therapy and the goal of all schools of therapy is therapeutic change...the traditional view, according to which the so-called patient suffers from insufficient reality adaptation and therefore needs help in order to gain insight into the "true" nature of things buried in his past, has become untenable." By contrast, constructivism suggests that the painful present consequences of a specific as-if fiction (which of course has its origin somewhere in the past) must be replaced by the effects of a different as-if fiction, which creates a more tolerable reality. Reality adaptation, in the sense of a better adaptation to a supposedly "real" reality, is replaced by a better adaptation of the fictional reality to the desired practical results." p.143.

    Watzlawick (1990)--"Self fulfilling prophecies seem to turn the basic laws of reality upside down. Imagined effect creates concrete cause; the future (not the past) determines the present; the prophecy of the event leads to the event of the prophecy." p.145.

  • Paul Watzlawick, Ph.D. 1990. Munchhausen’s Pigtail or Psychotherapy &

    Reality. New York: W.W. Norton & Co.




    All methods of therapy are based upon assumptions. How the therapist thinks about change is reflected in the style of therapy chosen. Changes in ways we explain a problem tends to result in a change in which we try to solve it.






    Interviewing to enhance a self- perception of competence. The clinical map is a guide. How you use it is the territory of a session. This is where the art comes in.

  • A) Socializing... Beginning the process of forming a relationship with a person rather than a chemical. General conversation to help the client feel comfortable and enhance a mutually cooperative relationship. Listen for client’s use of language, metaphors, and way of describing herself so that you may use this in adapting your own language to fit with the client’s. Ask about occupation, school, hobbies, and interests. This allows you to get information about resources, abilities, and strengths.

    B) Reason for meeting... It is important to get each person’s idea about the problem. Pay attention to the way the client describes the problem and use language that is consistent.

  • C) Chemical Experience...Understanding the relationship the person has with the chemical.
  • D) Signs of Change...Find out if there has been any change occurring before this first session. This is where you identify and explore exceptions.
  • How will you know when it is better?

  • E) Goal the desired solution, or keeping the new trend going.
  • Miracle Question..."If a miracle were to happen tonight while you were asleep and tomorrow morning you awoke to find that this problem were no longer a part of your life, what would be different? How would know that this miracle had taken place? How would other people be able to tell without you telling them?

    Video Description..."If I had two video tapes, one of you when you are standing up to the problem, and another when the problem is getting the best of you, what would I notice about the one where you are in charge? What would I notice that’s different about you in that video?" or "Let’s say that we have two videos of you, one is in the past when the problem was really getting in the way and the other is sometime in the near future when things are better. What’s most noticeable in the tape of you in the future that will tell us that things are better for you?"

    Questions which assume positive outcome..."Let’s make a leap of faith and say that our session ends up being helpful for you, how will you know?" or "You seem like an optimist, so let’s assume that you are able to beat this problem. What do you imagine will be different for you?"

    Questions that reinforce taking small steps..."What will be a small sign, something you’ll likely notice in the next week or so that will tell you that things are better for you?" or "What will be a small sign, something you’ll notice in the next week or so that will indicate to you there’s reason to be hopeful?"

    Follow up Questions..."Who else may see this?" or "What will you be doing instead?" or "What might you have to do to keep the miracle happening?" "How will this effect your life?"


    The goal here is to help the client develop a positive emotional orientation to the future.




    It is important for the therapist to know what they are being asked to do and who is doing the asking. Many clients come to therapy due to being required by outside forces. Accepting the client where s/he is helps set the stage for the development of mutually agreed upon goals.


  • Are you here to (satisfy, change, convince) someone else or to get something for you?

    Many times clients return to treatment after previously dropping out. The therapist can increase motivation by addressing the issues in a positive way. Although originally developed for telephone screening, these questions can also be used during the first interview after the client has returned to treatment.








  • Relative Influence Questions:
  • Relationship Issues:

    Goal Setting:

    Creating a New Reality:

    Miracle Question:


    People with dual diagnoses face multiple challenges. These people have both psychiatric and chemical abuse problems. The most devastating thing about mental illness is that it blocks the vision of self and locks it away.


    Treatment Issues

    Phases of the Mental Illness Experience

    Working with Voice Hearers

    Voice hearing is not an uncommon experience. Many people experience brief and occasional voices, particularly at times of bereavement, divorce and separation. The religious basis of our society is derived from the experience of voice hearers.



    Berg, I. & Miller, S. (1993). Working with the problem drinker: A solution focused approach. New York: W.W. Norton.

    Brasher, B., Campbell, T.C., Moen, D., (1993) Solution oriented recovery. Journal of Systemic Therapies, 12 (3), pp. 1-15.

    Campbell, T.C. & Brasher, B. (1994). The pause that refreshes: Opportunities, interventions and predictions in group therapy with cocaine addicts. Journal of Systemic Therapies, 13(2), pp.65-73.

    de Shazer, S., (1988). Clues: Investigating solutions in brief therapy. New York: W.W. Norton.

    de Shazer, S., (1984). The death of resistance, Family Process, 23, 79-93.

    de Shazer, S., (1985). Keys to solutions in brief therapy. New York: W. W. Norton.

    Dolan, Y. (1991). Resolving sexual abuse: Solution focused therapy and Ericksonian hypnosis for adult survivors. New York: W.W. Norton.

    Land, G. & Jarman, B. (1992). Breakpoint and beyond. Mastering the future today. Harper Business.

    Lipchik, E. (1988). Purposeful sequences for beginning the solution focused interview. In E. Lipchik (Ed.), Interviewing (pp. 105-117). Rockville, MD: Aspen.

    Miller, W.R., & Rollnick, S. (Eds.) (1991). Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press.

    O’Hanlon, B. & Wiener-Davis, M. (1989). In search of solutions: A new direction in psychotherapy. New York: W.W. Norton.

    White, M. & Epston, D. (1990). Narrative means to therapeutic ends. New York: W.W. Norton.