Recovery Discovery | Lab: AI + Motivational Interviewing

DeAnn and Craig discuss the potential of AI in therapy, specifically in the context of motivational interviewing (MI). They recap their previous experiment with a chatbot helping a character with alcohol consumption issues. Craig suggests using AI to practice MI, which DeAnn agrees on, given her recent research. DeAnn explains MI's principles, including empathy, rolling with resistance, and addressing ambivalence. They test the AI's MI skills, with DeAnn simulating a struggle with drinking. The AI demonstrates effective MI techniques, though it sometimes feels mechanical. They conclude that while AI can adapt to MI principles, there is more to explore surrounding the potential for cultural adaptations and effective development of a therapeutic alliance built over time.

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Music and Audio Production by Katie Hare.
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Transcript

DeAnn Knighton: 0:00

Oh, hello. This is DeAnn. Welcome back to recovery discovery. In our first episode of this series, Craig and I did a little experiment with a chat bot, helping a character I developed who was struggling with whether or not she may be drinking too much alcohol. You can go back and listen to that episode. Ultimately, the takeaways were that I was fairly surprised how well that chat bot did at moving the conversation in the right direction, following my lead, pivoting when needed. So Craig and I decided maybe it was time for another experiment, and to put our chat bot to the test again. Hey, Craig, hi, you're here. Are you? I'm good. So let's have you jump in here and talk to us a little bit about what we're thinking for this second iteration of our AI, I don't know, experiment, I guess we would call it.

Craig Knighton: 0:54

Well, the first thing is, I'm having that weird deja vu Time Machine experience you have in podcast land, where I just listened to our episode yesterday, even though we recorded it two or three weeks ago. So to me, it seems like it just happened again, because I got to hear it again. What I was thinking as I listened to it was that the first episode was about using AI as a way to learn, right, as a way to just explore a problem, try to understand if there is a problem. Is it real? Are the things I'm thinking are happening? Are they really happening? And should I do something? And if so, what might I consider, right? So your persona, your character was learning from the AI, I think from there, what makes sense, and this is a much harder problem, is to imagine AI being not just a source of information, but a little bit of a therapist, like a little bit of a helping me figure out How to change and maybe becoming an active participant in helping me change my behavior. So I know I've been learning about motivational interviewing from you, mostly, right? And I think that as a technique, it's interesting to explore whether or not an AI can use that technique if we just tell it to use that technique. I'm curious what will happen if we say, hey, use motivational interviewing to try to help me change my behavior. Maybe we get more specific than that, but that's the next experiment I'm interested in trying.

DeAnn Knighton: 2:41

I think this is perfect timing. I've done some deep diving into motivational interviewing over the last several months, so it fell into place that this would be a good thing to try. And what I think is really interesting about motivational interviewing, from a clinical standpoint, is that there is a really very direct coding process for effective mi so they can take an interview, plug it into this coding process to see how effective the interview was. Now I'm not going to say I'm going to be able to do that on the fly here as we go, I'm going to just be sort of looking for some of the main principles of motivational interviewing to see how the chat bot does, but that could be another experiment to try some time too, to actually do one of those interviews and then put it through the scrub test of motivational interviewing.

Craig Knighton: 3:31

So DeAnn, since you're kind of the resident expert on all of this, maybe you could tell us more about what you've learned about motivational interviewing, how it works, and kind of help people understand the structure and intent of motivational interviewing, and then we'll try it.

DeAnn Knighton: 3:50

I have a particular area of interest in my graduate program, I've been doing a lot of research on motivational interviewing. Motivational interviewing is a modality that is utilized quite a bit in the treatment of substance use disorder. It was an area I was interested in for a lot of reasons, one of which was because I had my own resistance and speculation, particularly because it felt like a form of persuasion that I didn't really feel comfortable in utilizing in a therapeutic approach. I also wanted to explore the idea of utilizing something like motivational interviewing when motivations are coming from extrinsic forces, such as in mandated treatment programs. And so I worked with a professor at Hazelden, Betty Ford, and we put together a 90 minute presentation on this topic. Don't worry, you're not going to hear all of that right now, but I did just want to hit on some highlights of what we reviewed in that particular presentation, so that you have an idea as we move into our little experiment of what to be on the lookout for and what some of the things that we'll be assessing after we do our experiment. It will be so DeAnn, let me tell you a story quickly about what I was taught as a young engineer about how to improve our sales process, and maybe you'll relate to this as someone who was in sales early in your career, but this was very early on. I was in my maybe mid 20s, and we brought a consultant in to help us learn how to sell better. And that consultant had a method that largely involved, like flipping the selling process, so that if somebody came to you and said, So, what do you do? What are you selling? Your answer would be along the lines of flipping that and reversing it by not answering the question, but by asking a question back to try to understand instead what you really need to know, which is, what problem are they trying to solve? Why would I start to talk about a solution before I even understand the problem they're solving. So what, what they would do is teach the sales people to never actually answer a question, but to always answer a question with a question of their own, to put the burden of speaking back on the person that they're selling to. And all of our engineering team thought this was incredibly manipulative. Like, okay, so you're never just going to answer any question we ask. You're going to answer every question with a question and and I'll never really end up understanding who you are, what you need and how to help you. And so that was the first thing. There was a lot of concern that this was like, not really ethical, or wrong somehow, especially wrong when it was being done with the intent to sell stuff, which to idealistic engineers, is kind of dirty anyway. But the second thing was that we all started realizing that the sales team was using that technique to manipulate us as an engineering organization and to try to get us to do the things that they that benefited them as an individual, like they had a quota they were trying to achieve. They really wanted to get an engineer to tackle a problem that would help them make a sale, and so they would use these same techniques to try to convince us to do things. And the first clue was, whenever you asked a question and was answered by a question, you knew that you were being manipulated. If you look at motivational interviewing at face value, it's easy to see why it can seem simply like a way of coercing someone into a particular way of thinking. And oh, maybe, you know, if it's it's something to help them stay sober, we can justify that as such a positive thing that the coercion makes sense. However, I want to clarify that motivational interviewing, the spirit of motivational interviewing, based on its creators, Miller and Rollnick, is rooted in a spirit of multi directional interaction with a client, and is not meant to be a tool to move anyone towards a therapist's particular goal or objective. Rather, what it is looking at is existing ambivalence that already exists in that client's experience that may be keeping them stuck or keeping them in a place of confusion about what they want and where they want to go, and typically speaking, ambivalence is rooted in a balance of what is referred to as equal parts change talk. Equal parts sustain talk. So just to give you an example of this that might be helpful is to think of it like if I were somebody who was struggling with how much I was drinking and maybe wanted to look into that further, and I was speaking with someone about it, and I was sharing that I just recently have had a few questionable experiences drinking the last few times where I woke up and wasn't really sure what had happened, and I found that kind of scary. I've been having a little more issue in managing how much I've been drinking. It seems that it's harder for me to keep track of what I'm drinking, and that there just feels like some discomfort for me related to that, however, I might also say in that same sentence that I am rooted in drinking culture. All of my friends and my family drink, and that's how I socialize, and it's really difficult for me to imagine not having drinking as a part of my life, and feels kind of impossible to consider not drinking. So within that statement, you heard kind of two contradictory thoughts. There's this concern about what's happening, yet also very quick to. To speak to the sustained talk that that is telling you that I'm not really ready yet to make a change based on some of those thought processes. So this is really common, especially if you're dealing with a maybe a little bit of denial around a particular topic, which can be common when we're looking at substance use disorder, and sometimes, even if we're saying this, we may not always hear ourselves and hear the ambivalence as we're speaking about it. And so in the role of counselor, the idea is to be able to highlight where that ambivalence exists, maybe help in terms of summarizing back or reflecting back to that individual, some of the things that they're sharing about the conflict they're experiencing with that

Craig Knighton: 10:47

now that we're going to try this experiment, I'm curious, what will you be looking for? What? What are the things that you will be waiting to see if it does because it's what you expect someone to do when they're using motivational nterviewing.

DeAnn Knighton: 11:01

The creators of MI Miller and Rollnick have focused this as an interactional multi directional flow. It should be more than just listening, but also not fully directive either. But this idea of multi directional, it shouldn't be. I know what you need, and I'm going to take you where I need you to go. You're looking at something right in the middle of that, in terms of what ideal utilization of motivational interviewing looks like. In summary, it is a person centered form of guiding to elicit strength and motivation of change. People have varying motivations for why they may want to change, but the foundational thing to be aware of when deciding to engage in the use of motivational interviewing is, as I mentioned, the presence of ambivalence. And likely ambivalence is represented by somewhat of a equal balance and sustain and change talk and perhaps effective motivational interviewing may help move in one direction or the other and help move someone towards action. I want to do a quick little sidebar on ambivalence as well. Its foundation comes from the root word, meaning both and then also to be strong, which I think was really cool and interesting. Because one of the ways I think that we sometimes think about ambivalence is that potentially, it's a weakness, right? It may represent a level of uncertainty that some people maybe are not always as excited to claim we like to appear potentially decisive that helps us maybe maintain our independence and make people feel comfortable that we've got things under control and that we know ourselves and so showing ambivalence can feel like a vulnerability that sometimes we're not always comfortable sharing. But what I love about that point is that it's actually something that could be reflected back to someone who is struggling with something is this idea that ambivalence is a form of strength, the ability to be able to look at something from more than one perspective, to weigh those options against each other, can be a really powerful tool. It represents maybe a mind that is more open to dialectical thinking, and the idea that two things can be true at the same time. And yeah, the shadow side of this being that we don't want to get stuck in ambivalence for too long. It could also be something that is delaying progress, delaying action, keeping us stuck. And so that can be a nice way to frame it up in terms of understanding its purpose, but also the need to want to talk through it and move through it, and maybe consider some of these areas where we're lingering maybe a little bit longer than we should, when we already maybe know what we want to do, but just aren't ready to take that step yet. So On another note, something that I'll be keeping an eye out for in our experiment is how the chat bot might react to resistance showing up in the process. Effective motivational interviewing skills would have a counselor utilizing neutrality to ensure that the client does not feel like they're being led or dragged into any particular direction. This includes overly supporting only one side of the equation and not not supporting the other side. People pick up on that, and so neutrality becomes incredibly important and ensuring that the spirit of MI is preserved. So we'll try and throw in some resistance into our example and see how that goes.

Craig Knighton: 14:41

Okay, are you ready to talk to chat? GPT, I am.

DeAnn Knighton: 14:45

Let's do this. You're on. Okay, hi. Are you there?

Chatbot: 14:49

Hey, I'm here.

DeAnn Knighton: 14:50

What's up? Oh, nice to talk with you.

Chatbot: 14:52

Nice to talk with you too. How's your day going so far?

DeAnn Knighton: 14:55

I'm pretty good. I would say it's spring in Salt Lake City.

Chatbot: 15:00

That's awesome. Spring in Salt Lake City must be beautiful. Are you enjoying the weather or getting into any fun activities?

DeAnn Knighton: 15:06

I like to do yard work, so I have been working in my yard. That

Chatbot: 15:10

sounds really rewarding. What kind of projects have you been working on in your yard?

DeAnn Knighton: 15:14

Oh, mostly just weed cleanup, nice.

Chatbot: 15:17

Clearing out leaves can make a huge difference. It must feel great to see everything looking neat and fresh. Are you planning to plant anything new this season? Yeah,

DeAnn Knighton: 15:26

actually, I think I am. I need to get some new soil, because there's a few spaces where I want to raise up the earth and do some planting. So that's next on the list, for sure.

Chatbot: 15:38

That sounds like a great plan, adding some fresh soil and raising up those areas will definitely help your new plants thrive. Do you already have some plants in mind, or are you still deciding what to put in?

DeAnn Knighton: 15:49

You know, I haven't really decided yet, but you know, this isn't actually the reason I'm here. Do you mind if I ask you something else? Of

Chatbot: 15:56

course, go right ahead. What's on your mind? Yeah,

DeAnn Knighton: 15:59

I was wondering, first of all, if you could tell me what you know about the approach of motivational interviewing to help someone move towards a behavior change.

Chatbot: 16:10

Sure, motivational interviewing is a counseling approach designed to help people find their own motivation to make positive changes. It's often used in areas like health, addiction and lifestyle changes. The key principles include expressing empathy, highlighting the differences between a person's goals and their current behaviors, rolling with resistance, rather than confronting it and supporting self efficacy. The idea is to help individuals resolve their ambivalence and empower them to take charge of their own change. It's a collaborative and person centered approach.

DeAnn Knighton: 16:45

Okay, cool. Sounds like you have a good handle on what it is I was I was wondering if you could help me with an issue that I'm dealing with, utilizing motivational interviewing. Absolutely

Chatbot: 16:58

I'd be happy to help. What kind of issue are you dealing with, and how would you like to apply motivational interviewing to it?

DeAnn Knighton: 17:04

Yeah, so currently I'm struggling a little bit with how much I am drinking. I've been drinking for most of my adult life, but the last couple of years, I've had a lot more stress, and I have found that I've had more situations of drinking more than I want to not keeping track as much about what I'm drinking, and it's starting to definitely give me some anxiety. I also had a couple of instances recently where I woke up the next day and didn't remember a lot of what had happened the night before, and it just left me not feeling good at all, and so I wanted to talk about that and see what you think.

Chatbot: 17:49

Thank you for sharing that with me. It sounds like you're recognizing that your drinking habits are causing some concerns and discomfort. A big part of motivational interviewing is exploring your own reasons for wanting to change, and building on those motivations, it might help to think about what's important to you and how reducing or changing your drinking could align with those values. What are some of the reasons you feel motivated to make a change, and what would a positive outcome look like for you? I would

DeAnn Knighton: 18:17

say I'm kind of sick of the amount of brain power it's taking up for me worrying about it, and that I feel like it might be contributing to my anxiety, but I really struggle with the idea of not drinking. It's a big part of my social life and my work culture and my home life, and I, you know, think about different options like moderating, but that just doesn't really feel realistic, and so I just I feel really torn and not sure where to go.

Chatbot: 18:50

It's understandable to feel torn, especially when drinking is intertwined with so many aspects of your life. Acknowledging how it's affecting your mental and emotional well being is a crucial step. One approach could be to set small, manageable goals that align with what you value most. For example, you might decide to start with reducing the number of drinks on certain days, or setting specific occasions where you'll drink less. This way, you can experiment and see what feels right without making an all or nothing commitment right away. How do you feel about trying a small step like that and seeing how it impacts your anxiety and overall well being?

DeAnn Knighton: 19:29

I don't know, you know, it's just I've tried that before, and I have a lot of friends who've tried that, and it just doesn't feel like there is any middle ground. Seems all or nothing to me.

Chatbot: 19:40

I get that it can definitely feel like an all or nothing situation, especially when moderation hasn't worked well in the past. In that case, it might be helpful to explore what a period of abstinence could look like, even if it's just for a short time, to see how it affects your anxiety and overall well being. You could also think about seeking. Support, whether from a counselor or a support group, to help navigate this change. Sometimes having that extra layer of accountability and understanding can make a big difference. How do you feel about trying a short break from drinking to see how you feel, or getting some outside support? Yeah,

DeAnn Knighton: 20:16

I don't know. I just don't know if I'm there. Yet that feels like a big step, and then I have to start telling people that I'm not drinking, and that just feels like it's opening up a whole thing I don't know that I'm ready for.

Chatbot: 20:28

I understand, and it's completely okay to feel that way. Taking a big step like that can be daunting, especially when it involves explaining your choices to others. Maybe a good starting point is to reflect on what a smaller, more private step could look like. You don't have to make any big announcements or drastic changes right away. Even just tracking your drinking more closely or setting a personal intention to cut back a little, could be a gentle way to start. You can take this at your own pace. What do you think about trying something small and personal first, without feeling pressure to make a big declaration.

DeAnn Knighton: 21:04

Yeah, I could give that some thought. I just kind of, I want to think on things for a little bit this. This was really helpful, though. Thank you.

Chatbot: 21:11

Of course, take your time. I'm glad we could talk it through a bit. If you ever want to chat more or need some support,I'm here.

DeAnn Knighton: 21:18

Okay, thank you. Have a good day.

Chatbot: 21:22

You're welcome. You have a great day too. Take care.

Craig Knighton: 21:27

So one thing I I would observe is, I think a little bit in how you prompted it, it was still educating instead of doing because the way you phrased the prompt, you didn't say use motivational interviewing. You asked it to tell you about how using motivational interviewing. I think it's sensitive enough that it took it a little while to get into the mode of actually just using mi instead of educating you about mi at the same time, right?

DeAnn Knighton: 22:01

But then I think it did. It got there. It got there. Yeah, I definitely was impressed. First of all, I liked the explanation of MI. I was like, Wow, that sounds really similar to just about everything we just talked about and hit on some of the same key things, like the ambivalence piece and the rolling with resistance. When he gave the explanation of what it was, and then as he started applying it, I do feel like he did the things like rolling with resistance that is an important part of motivational interviewing and demonstrating neutrality around what I was saying, even though I started the conversation saying, I don't know. I'm uncomfortable about this. But then, as he started saying things, fear started building up for me about like, I don't know, I don't know, right? And he rolled with that, I think, in a way that didn't feel like he was trying to force any direction, which is what motivational interviewing is supposed to be about. It's supposed to be about basically reflecting you back to yourself in some ways, and just helping you sort of hear yourself. And whether or not that means immediate action or helps with action down the road, it's just getting sort of that whole talk track outside of your head to someone who is going to help you think about it, but not in a way that's going to make you defensive or protective, right? Because it is a personal choice. And so as I think of that experience, I mean, I feel like there was a lot of adapting to what I was saying in effective ways and reflecting back what I was saying. Sometimes the reflecting back felt almost a little unnatural to me,

Craig Knighton: 23:41

yeah, almost mechanical, like saying the exact same words back to you that you just said, and that doesn't that's not how people would talk.

DeAnn Knighton: 23:49

Yes, right? So that would be, you know, maybe kind of one thing that pulled me out of it and made me kind of remember I'm talking to talking to a device. But otherwise, I felt like it applied the principles pretty well. What was your perspective as a functional introvert?

Craig Knighton: 24:10

I'm always impressed at its ability to maintain and keep a conversation moving, because I I can't do it small talk. I can't as a human, I can't do it, so I admire that a chat bot can do it better than I can. So I noticed that right I noticed that despite your resistance, it didn't ever seem to indicate that it didn't know what to do next, or give up, or it was going to keep trying right until you succumbed, or I said, I'm done.

DeAnn Knighton: 24:44

I'm done. Yeah, I don't want to talk about this anymore. But that was also true with the small talk at the beginning. I'm like, Oh, he is just going to keep going. We are not going to stop talking about my yard. And I have a feeling people are ready for us to move on. So there was a little bit of that where I'm like. Oh, yeah, clearly, I'm going to have to shut this down. So yeah, that is kind of an interesting consideration, but that in the scheme of like, what person centered therapy is meant to be, it goes with that theme to some degree, but that's not to say that in person centered therapy, as a therapist, you're not also doing some sort of, you know, directing of of places to go to conversation, right, right? You know, in the therapeutic process, what's something, what, what I feel like is some of the most valuable moments for people is that they built a connection with their therapist, and then throughout that, they are able and willing to accept insights from that person, because that person they they feel a familiarity, a comfort and a trust. And then when those insights come up in regards to, hey, this just happened, and somebody's able to sort of look at it objectively and piece it back that that it feels good to you, that you're like, Yeah, I believe that you that's interesting. That's something that's worth thinking about, right? And so that's, that's a skill where it develops over time in the relationship. And then the other piece would be, and my guess is, if I directed it on what to do, it would probably do pretty well, which is cultural adaptations for MI. So, you know, I'm guessing if I had told him, this is my culture, this is where I'm from now use motivational interviewing. It could be interesting to do a test if it would change. So maybe that could be one we could try sometime, where we do a side by side of the exact same but seeing if it would apply a cultural lens. It doesn't necessarily have to be motivational interviewing, but I think that could be really interesting.

Craig Knighton: 26:53

I know that what I've heard in interacting with other professionals is that that is part of the formula, whether it's therapy or counseling, or whatever process you're involved in finding if you can connect because of any commonality with that person. Maybe it's gender, maybe it's lived experience, maybe it's race, you, you name it, right? But these things do seem to matter to us, especially in our desire to both be understood and to want to satisfy them, right? So now, if you asked me to do something, how much would I want to do it? Because I want to satisfy you. Now that's not necessarily why you would use motivational interviewing. In fact, I should do it, because I have convinced myself that I want to do it, but I also think that's part of what humans do. We're social creatures. We want to please other people

DeAnn Knighton: 27:52

absolutely. And you know, it's really funny, I have a client recently who was telling me how she was working through something, and I've known her for a while. We've done a lot of sessions together, so we have a pretty good rapport. And she said, Oh yeah, I was, I emailed my sister and said my therapist mentioned that I should consider da, da, da. You know, I don't know it was like, the first time I had had somebody actually say that to me, where they were, like, I thought of your words while I was out in the world dealing with an issue. But then I also think it's interesting, right? Because it wasn't her owning it as something she thinks she should do. We do this thing where it's like, well, my therapist says I should try this, so maybe I should try it, right? So, yeah, it's interesting, for sure. I think that was really cool. It was like, definitely the kind of the next level of exploring what this technology can do, at least as it stands now,

Craig Knighton: 28:44

thanks for geeking out with me again.

DeAnn Knighton: 28:45

It was fun, my pleasure. I'll talk with you soon. Bye. Have a good day. Bye.