CHCAOD511BSession six07/04/11

Motivational interviewing

“Motivational interviewing is a style of patient-centred counselling developed to facilitate change in health-related behaviours. The core principle of the approach is negotiation rather than conflict. In this article I review the historical development of motivational interviewing and give some of the theoretical underpinnings of the approach. I summarise the available evidence on its usefulness and discuss practical details of its implementation, using vignettes to illustrate particular techniques” (Treasure, J. 2004).

when a person feels that there is nothing that can be done about a serious health threat their defense mechanisms become active and they go into a state of denial to reduce the associated emotional arousal caused by them being aware of this threat.

Protection Motivation Theory

Empathy – Understanding the clients situation from their point of view.

Develop Discrepancy – Try to uncover inconsistencies in the information the client is giving to you. Support will require you to encourage the client to identify these discrepancies and clarify goal setting towards desired change.

Fundamental principles

Roll with Resistance – Clients sometimes will only provide you with part of the story, be selective in what they consider relevant, and give you half truths. As a support worker you can rephrase a client’s words to maintain their motivation. It may be appropriate to invite changes in perception and ideas. Don’t impose anything on the client. Examples of resistance may be:◦ Client not showing up at appointment◦ Arriving late◦ Refuses to answer questions◦ Plays word games◦ Arguing◦ Denying◦ Interrupting

Avoid Arguing – Fear and resistance will be the outcome of any direct arguing with clients.

Self-Efficacy – Clients need confidence in their own ability to make change. Workers can: ◦ Elicit hope for change ◦ Identify and recognize client strengths

Discuss client’s belief that change is possible

More about MI

Motivational interviewing is a collaborative, person-centered,evidence-based, guiding method of communication for enhancing and strengtheningintrinsic motivation for change.

First developed in early 1980’s to work with problematic alcohol use

Based on the understanding that signification people in one’s life can form the basis of motivation to change

Origins

Spirit of MI

Collaboration

Autonomy

Respect

Compassion

Was there a change agent (teacher, supervisor, counsellor, relative) who had a major positive influence on your life?

What were their characteristics? What are some characteristics you believe a

counsellor should have?

Consider...

creative and imaginative shows awareness by not imposing personal

concerns on a client has common sense and social intelligence shows respect for the client action orientated.

Jarvis, Tebbutt and Mattick (1995)

The ideal counsellor is..

Protection Motivation' theory, for example, proposes that people change a health risk behaviour when: (1) they perceive a serious and probable risk to their welfare, and(2) they perceive an available and efficaciouscourse of action by which their risk can be reduced

A review of PMT

MI Tools and techniques

Gorden (1990) listed 12 responses which block or inhibit two way conversations. He has called these roadblocks◦ Ordering, directing or commanding

Response: You need to stop drinking now. ◦ Warning or threatening

Response: If you don't stop using heroin you will be dead within six months.

◦ Giving advice, making suggestions, or providing solutions Response: The best thing you can do is tell your mother that...

Effective listening

◦ Persuading with logic, arguing or lecturing Response: You may think that but experts tell us differently.

◦ Moralising or preaching Response: You must realise that you can not be a good mother when you are drinking like this.

◦ Disagreeing, judging, criticisingResponse: No matter how strong the cravings are there is no excuse for stealing.

◦ Agreeing, approving or praising Response: It is very hard for you, your father had a drink problem so naturally you drink heavily.

Roadblocks

◦ Shaming, ridiculing or labelling Response: Your children are suffering as a result of your drinking. Why won't you stop

◦ Interpreting or analysing. Response: It seems to me that your wife is behaving like that to get a reaction from you.

◦ Reassuring, sympathising or consoling Response: Don't worry we will sort everything out

◦ Inappropriate questioning Response: This may be a question that is not relevant to the intervention and thereby limiting client willingness to respond.

Roadblocks cnt

Withdrawing, distracting, humoring or changing the subjectResponse: I think most of us drink in excess of the guidelines on occasions. Did you have any luck in finding a job?

Roadblocks cnt

Empathy Paraphrasing Reflecting Open ended questions

More tools & techniques

The client questions consistency between personal values and current behavior.

The counselor uses affirmations of the client's strengths and focuses on constructive efforts to change.

Carl Rogers “unconditional positive regard” Client in contemplation stage ready to start

developing discrepancy...in pre-contemplation need to continue developing awareness

Developing discrepancy

Good reflective statements incorporate meaning with elements of the change dilemma.

E.g. when the client says, "I do not think I have a drinking problem, but my wife does," the counselor responds with something like, "I understand you are not concerned about your drinking, but your wife is and this concerns you."

Reflective statements, therefore, are the mainstay of a positive therapeutic relationship, allowing resistance to be acknowledged and diffused.

Reflection

Begin with an opening/welcoming statement.

Focus on one aspect of ambivalence. Ask about the positive/benefits of the

client's substance use - ask the client to be specific, individualise the importance.

Ask about the less good things: ◦ be specific ◦ individualise using reflection and amplified

reflection ◦ probe to find out how the client feels (just

because something is less good does not mean the client sees it as a problem).

Checklist for MI interview

Summarise the positives and less positive aspects of behaviour - let the client hear the dilemma again.

Ask about life goals: ◦ how the client sees himself/herself in a year if

things work out well ◦ how he/she sees the future if he/she maintains

current behaviour.

Ask the client to describe his/her good qualities through the eyes of a partner of friend. Then ask how the client would describe himself/herself as a user.

Ask for a decision, but remember, people can be in contemplation for a long time. They may not be ready to change. They may want to discuss things further, or they may want to remain the same. If so, investigate harm reduction strategies. They may want to make changes but don't know where to start or they feel there are barriers they need to overcome. If so you would assist them with problem solving and goal setting.

MET is a development of the Transtheoretical Model of Change (TMC) (Prochaska et al., 1992), designed to help client’s build commitment and reach behavioral change◦ Lambie & Sias (n.d.)

Motivational enhancement therapy

MET has been thoroughly researched in the field of substance abuse with some research specific to adolescent substance abuse clients.

Clients with substance abuse issues and adolescents often share the stereotypical characteristics of being resistant, challenging, and narcissistic (Lambie, 2004).

MET

What changes would you most like to talk about?

What have you noticed about . . .? How important is it for you to change . . .? How confident do you feel about

changing . .? How do you see the benefits of . . .? How do you see the drawback of . . .? What will make the most sense to you? How might things be different if you . . .? In what way . . .? Where does this leave you now?

Top 10 useful questions