https://press.uchicago.edu/ucp/books/book/chicago/W/bo201564143.html

Ilana Gershon In what sense do you see the focus of your book, a therapeutic intervention called motivational interviewing (MI), as a distinctively American approach? 

Summerson Carr: I should begin by saying that many of my interlocutors in the world of MI will likely object to my characterization of the method as distinctively American. They would probably begin by pointing out MI’s significant international presence, with strongholds in the UK and Scandinavia as well as in the United States. They may then go on to remind me of the number of languages into which MI’s foundational textbook has been translated (28) and that approximately 40-45% of the membership of the Motivational Interviewing Network of Trainers (MINT) do not reside in the United States. These things are true, though they have very little bearing on my argument.  From the start, I take the “American” to be much more than a straightforward matter of national demographics; it is always also the ideological product of institutional and political history.  By way of this history, many American products, including therapies and counseling methods, travel over lands and seas. That they do so with apparent ease—as if unaided by labor, capital, and other geopolitical inequities—has rightly interested many other contemporary anthropologists.

MI’s American founder and lead developer, Dr. William Miller, recounts MI’s origin story by way of his own international travels.  According to him, through a series of serendipitous overseas encounters, he was gradually able to specify and articulate what he already knew deep inside: that is, a “spirit” of engagement that can be operationalized through a set of conversational techniques.  It is this combination of spirit and technique that Miller, his colleagues, and his many acolytes developed as MI over the last forty years. Furthermore, MI proponents in the United States commonly frame MI spirit as transcendent and MI techniques as if they are features of a universal language, allowing the method to “speak” to people regardless of where it is practiced. 

It is for all these reasons that I expect some significant pushback to my argument—developed over the course of the book—that MI draws on and manages historically-specific Anglo-American norms and values.  This includes translating paradigmatically American tropes of democratic governance into therapeutic exchange (Chapter One); MI’s adoption of rhetorical forms and formula that were developed by white colonial settlers since the establishment of the republic (Chapter Two); MI’s implicit grounding in American Protestant ideals, including its spirit of capital accumulation (Chapter Three); total quality management in production of MI’s “evidence-base,” (Chapter Four); and MI’s vernacularization of American Pragmatism (Chapter Five).  Less surprising is the way that MI, as a therapeutic intervention, draws on two school of American psychology—American behaviorism and the client-centered (or Rogerian) tradition—that had long been at philosophical odds and have organized the ways that psychotherapies have been trained and institutionalized in the United States. A throughline of the book is the remarkable way that MI seizes upon and defuses ideological differences, such as those that had so many U.S.-based psychologists at loggerheads for decades.  Accordingly, I suggest that in MI we also find a classically American way of managing difference.

Ilana Gershon: I see your two books, Scripting Addiction and Working the Difference as very much in dialogue with each other.  I am wondering if you could discuss how therapeutic practices shift when the therapist moves from viewing the client as in denial (as in Scripting Addiction) to being ambivalent.

Summerson Carr: As with your question above, it is hard to contain my response!  I cannot overstate how profound MI’s shift to ambivalence is, given that denial has long been the organizing concept of U.S. addiction treatment.  As I document in Scripting Addiction, the idea that addicts are the kind of people who cannot see and read their own inner states—aka, denial—means that traditional treatment entails engaging them in a clinically supervised regimen of inner reference. Practically speaking, this means that the typical clinical encounter is one in which the professional more-or-less explicitly relays that 1) they already see and know the “truth” that the addict denies and 2) that recovery will be measured by the client aligning their self-descriptions with the professional’s perspective.  Not surprisingly, this state-of-affairs commonly leads to therapeutic stand-offs and is frustrating for both parties.  It is also, arguably, violent, not just to the extent that it inherently grants the sovereign vision to the professional, but also because that professional is often the primary link to critical resources and services (housing, food, and so on).

Having documented these conundrums in my first book, and searching the field for alternatives as I was writing its conclusion, I became fascinated by MI, which began as a treatment for people labeled as problem drinkers (and has since spread to many other fields). You are right that MI replaces denial with “ambivalence,” which means both the client and the professional have more room to maneuver in searching ways to understand problem behavior.  After all, the “could be” or “sometimes seems” of ambivalence is far more capacious than the “it is” of denial.  Moreover, in MI, denial is understood as a difference between two people’s ways of looking at some problem—that is, the professional’s and the client’s—rather than a psychic attribute of the latter party.  As an epistemological shift, this radically re-grounds the question of an individual’s suffering and the practical means of resolving it.  More specifically, once interaction rather than interiority is taken as the grounds of therapeutic work, the professional becomes someone who can help conversationally rebuild what is taken to be real about a problem as well as a possible course of remedy. Mind you, this does not magically level the playing field, as I am careful to point out through the book.  I do think it feels a bit better and more constructive to those involved, perhaps especially the helping professional.  

Ilana Gershon: What does “paying it forward” mean for MINTIES, (what version of pay it forward do MINTIES adhere to), and how does it serve as a guide for behavior in contexts where people are often making calculations around boundaries?

Summerson Carr: Readers of Max Weber may remember that he identified Benjamin Franklin as personifying the ideological convergence of American Protestantism and American capitalism.  Interestingly, some say that Franklin was the one who coined the term, “paying it forward,” when asking a friend to whom he made a loan to lend the amount to another in need rather than return it.  The term paying it forward also has special resonance in Protestant communities in the United States, who define it as loving and giving to one’s proverbial neighbor, thereby mobilizing spirit.  Note that in both these definitions, “paying it forward” means extending oneself out of already established relationships of reciprocity into less predictable future interactions with unknown parties. This means that the logic of investment is primarily oriented not toward accumulation and but rather continual expansion.  This is very consistent with the work of MI proponents, particularly trainers, who devote themselves to disseminating MI and therefore, also, MI spirit for the good of others, whether proximate or still unknown.  In this sense, for MINTies, paying it forward means not observing boundaries, even considering them to be a dangerous conceit.  For them, to do otherwise would be to caricature an unknown audience, or think some are unworthy or unable to appreciate what they so value—that is, the spirit of MI.  Of course, disseminating MI, whether to doctors in China or the State of California’s corrections system, is also profitable.  But once that dissemination is understood as paying it forward, given the resonances of the term, any accumulation can be seen as a side effect of generosity and reinvestment. 

Ilana Gershon: In one of your chapters, you start discussing what an evidence-based practice means in bureaucratic terms, the answer clearly surprised you.   What was the surprise, and how do different MINTIES engage with this bureaucratic category?

Summerson Carr: Perhaps one should not be at all surprised that “evidence-based” is at least as much of a bureaucratic as a scientific qualification of a practice method. My student, Hannah Obertino Norwood, and I have also recently written about this in Social Science & Medicine—expanding select sections of Chapter Four’s discussion of MI science.  Hannah and I detail how the production of evidence-based practices centrally involves a wide range of extra-scientific actors—charitable foundations, public and private insurers, state and federal agencies, health and human service organizations—who work in tandem to register and legitimate certain programs and practices as “evidence-based.”  Once officially attached to a method like MI, the designation of “evidence-based” acts like a kind of passport; it green-lights the adoption of that method not just by various service agencies, but also by entire states in large part because it renders that method reimbursable.  The real surprise for me was how little “evidence” the designation of “evidence-based” requires.  As William Miller himself shared with me, a method can be registered as evidence-based based on a single study as long as that study is conducted in what officials consider the most epistemically virtuous way—that is, by way of a randomized controlled trial (RCT). What is more, that single study need not show that a method is effective in the sense of producing positive behavioral outcomes. Rather, the method must simply be shown to have an “observed effect” by way of an RCT, even if that effect is a negative one. Notably, while keenly aware of how important MI’s status as an evidence-based practice is to its spread, Miller was very forthcoming about this all in my conversations with him, saying that the main federal EBP registry for behavioral interventions at the time of his applications had “a very low bar.”  At the same time, he emphasized that this did nothing to diminish the spirited labor of MI researchers, who have produced almost 2,000 RCTs of MI over the last 30 years.  As for the MINTies who disseminate MI, there is a wide range of perspectives on the scientization of counseling methods, from true believers to those who think the whole EBP movement is a “whole bunch of crap” (to quote one of my interlocutors).  However, surely all US-based MINTies are aware that for MI (spirit) to successfully circulate, MI must also be recognized as scientific.  This is in part because, for decades, “evidence-based” has been practically synonymous with “reimbursable”—whether by private or public sources.  In this sense, and as I argue in the book, the EBP movement is as neo-Keynesian as it is neoliberal.     

Ilana Gershon: You talk about many of the paradoxes that practitioners eagerly say “Yes, and . . .” to in this book, but in reading this book, I was struck by yet another paradox which I wondered if you could address.  MI is a both a fairly standardized set of rules for conversational interaction that is closely monitored by auditors, at the same time that the training itself stresses a strong commitment and attention to the context, and presumes that the therapist is a perpetual apprentice, always learning and transforming.  I wonder if you could say a little about how standardization and localization/constant change interweave in MI practices.

Summerson Carr: Hmm…this is an interesting question.  First, I think we need to unravel what an “attention to context” means in the world of MI, which is quite different than how an anthropologist or sociologist might think of it.  Indeed, one is reminded of the shade many linguistic anthropologists have long thrown at conversation analysts.  Put simply, the MI-trained professional is supposed to be rigorously attuned to the context of each interview they conduct.  So, yes, there are a set of standards for how one conversationally engages, but if standard MI skills are not calibrated and applied relative to what a particular client says and does, the interview fails.  Or, to put it in my interlocutors’ terms, the professional practices MI skills without MI spirit.  As a conversational style, MI is a way of listening as well as speaking, which itself suggests a commitment to localization.

But easier said than done!  It is also a deceptively difficult method of rhetorical engagement and analysis, requiring a kind of pragmatic sensibility that I describe at length in Chapter Five. This is one reason that hundreds of US MINT members—including Miller—see themselves as perpetual apprentices.  Of course, lifelong apprentices are also especially reliable disseminators!  Furthermore, because the method is considered subject to decay without regular practice, there are many auditing tools that are focused on monitoring whether a practitioner’s MI skills and spirit are up to snuff.  But the question of managing the competing demands of standardization and localization is also a question about balancing research and practice. No doubt, standardization is especially important to MI as a contemporary scientific enterprise. Recall here the bureaucracy that MI proponents must navigate in order for the method to be officially registered and recognized evidence-based, which begins with the RCT.  Now consider how critical it is that the professionals enrolled in RCTs as research subjects who say they are doing MI are in fact doing MI whilst under study.  And while MINTies further removed from MI research sometimes grow weary of the latest updates to MI’s fidelity instruments, as they are regularly unveiled at annual conferences and professional get-togethers, I think most appreciate the utility of the various audits and quality controls in the work of spreading motivational interviewing. For MI to spread, after all, it must work the difference between research and practice as well as science and spirit. And, as you point out, this entails ironing out any felt disjuncture between standards and the pragmatics of local application.