Definition of Motivational Interviewing, Exercises of Communication

Download Definition of Motivational Interviewing and more Exercises Communication in PDF only on Docsity!     A  Definition  of  Motivational  Interviewing   The  definition  of  Motivational  Interviewing  (MI)  has  evolved  and  been  refined  since  the  original   publications  on  its  utility  as  an  approach  to  behavior  change.  The  initial  description,  by  William   R.   Miller   in   1983,   developed   from   his   experience   in   the   treatment   of   problem   drinkers.     Through   clinical   experience   and   empirical   research,   the   fundamental   principles   and   methodologies   of  MI   have   been   applied   and   tested   in   various   settings   and   research   findings   have   demonstrated   its   efficacy.   MI   is   now   established   as   an   evidence-­‐based   practice   in   the   treatment  of  individuals  with  substance  use  disorders.       Motivational   Interviewing   focuses   on   exploring   and   resolving   ambivalence   and   centers   on   motivational   processes   within   the   individual   that   facilitate   change.   The  method   differs   from   more   “coercive”   or   externally-­‐driven   methods   for   motivating   change   as   it   does   not   impose   change  (that  may  be   inconsistent  with  the  person's  own  values,  beliefs  or  wishes);  but  rather     supports  change  in  a  manner  congruent  with  the  person's  own  values  and  concerns.       The  most  recent  definition  of  Motivational  Interviewing  (2009)  is:       “.  .  .    a  collaborative,  person-­‐centered  form  of  guiding  to  elicit   and  strengthen  motivation  for  change.”     The  Motivational  Interviewing  Approach   Motivational  Interviewing  is  grounded  in  a  respectful  stance  with  a  focus  on  building  rapport  in   the  initial  stages  of  the  counseling  relationship.      A  central  concept  of  MI   is  the  identification,   examination,  and  resolution  of  ambivalence  about  changing  behavior.   Ambivalence,  feeling  two  ways  about  behavior  change,  is  seen  as  a  natural  part  of  the  change   process.  The  skillful  MI  practitioner  is  attuned  to  client  ambivalence  and  “readiness  for  change”   and  thoughtfully  utilizes  techniques  and  strategies  that  are  responsive  to  the  client.       Recent  descriptions  of  Motivational  Interviewing  include  three  essential  elements:       1. MI  is  a  particular  kind  of  conversation  about  change  (counseling,  therapy,  consultation,   method  of  communication)   2. MI   is   collaborative   (person-­‐centered,   partnership,   honors   autonomy,   not   expert-­‐ recipient)   3. MI  is  evocative  (seeks  to  call  forth  the  person’s  own  motivation  and  commitment)     These  core  elements  are  included  in  three  increasingly  detailed  levels  of  definition:         Lay   person’s   definition   (What’s   it   for?):   Motivational   Interviewing   is   a   collaborative   conversation  to  strengthen  a  person’s  own  motivation  for  and  commitment  to  change.     A   pragmatic   practitioner’s   definition   (Why   would   I   use   it?):  Motivational   Interviewing   is   a   person-­‐centered  counseling  method  for  addressing  the  common  problem  of  ambivalence  about   change.         A   technical   therapeutic   definition   (How   does   it   work?):   Motivational   Interviewing   is   a   collaborative,   goal-­‐oriented   method   of   communication   with   particular   attention   to   the   language  of  change.    It  is  designed  to  strengthen  an  individual’s  motivation  for  and  movement   toward  a  specific  goal  by  eliciting  and  exploring  the  person’s  own  arguments  for  change.     The  “Spirit”  of  Motivational  Interviewing   MI   is  more   than   the  use  of  a   set  of   technical   interventions.   It   is   characterized  by  a  particular   “spirit”  or  clinical  “way  of  being”  which  is  the  context  or  interpersonal  relationship  within  which   the  techniques  are  employed.     The  spirit  of  MI   is  based  on  three  key  elements:  collaboration  between  the  therapist  and  the   client;  evoking  or  drawing  out  the  client‘s  ideas  about  change;  and  emphasizing  the  autonomy   of  the  client.     • Collaboration  (vs.  Confrontation)   Collaboration  is  a  partnership  between  the  therapist  and  the  client,  grounded  in  the  point   of  view  and  experiences  of  the  client.     This  contrasts  with  some  other  approaches  to  substance  use  disorders  treatment,  which  are   based   on   the   therapist   assuming   an   “expert”   role,   at   times   confronting   the   client   and   imposing   their   perspective   on   the   client’s   substance   use   behavior   and   the   appropriate   course  of  treatment  and  outcome.       Collaboration  builds   rapport  and   facilitates   trust   in   the  helping   relationship,  which  can  be   challenging   in   a   more   hierarchical   relationship.     This   does   not   mean   that   the   therapist   automatically  agrees  with  the  client  about   the  nature  of   the  problem  or   the  changes  that   may   be   most   appropriate.     Although   they   may   see   things   differently,   the   therapeutic   process  is  focused  on  mutual  understanding,  not  the  therapist  being  right.     • Evocation  (Drawing  Out,  Rather  Than  Imposing  Ideas)   The  MI  approach   is  one  of   the   therapist’s  drawing  out   the   individual's  own   thoughts   and   ideas,  rather  than  imposing  their  opinions  as  motivation  and  commitment  to  change  is  most   powerful  and  durable  when  it  comes  from  the  client.    No  matter  what  reasons  the  therapist   might  offer  to  convince  the  client  of  the  need  to  change  their  behavior  or  how  much  they   might   want   the   person   to   do   so,   lasting   change   is   more   likely   to   occur   when   the   client   discovers   their  own   reasons  and  determination   to  change.  The   therapist's   job   is   to   "draw   out"  the  person's  own  motivations  and  skills  for  change,  not  to  tell  them  what  to  do  or  why   they  should  do  it.     • Autonomy  (vs.  Authority)   Unlike   some   other   treatment  models   that   emphasize   the   clinician   as   an   authority   figure,   Motivational  Interviewing  recognizes  that  the  true  power  for  change  rests  within  the  client.   Ultimately,  it  is  up  to  the  individual  to  follow  through  with  making  changes  happen.  This  is   empowering   to   the   individual,   but   also   gives   them   responsibility   for   their   actions.   Counselors   reinforce   that   there   is   no   single   "right   way"   to   change   and   that   there   are       • Reflections   or   reflective   listening   is   perhaps   the   most   crucial   skill   in   Motivational   Interviewing.  It  has  two  primary  purposes.  First  is  to  bring  to  life  the  principle  of  Expressing   Empathy.   By   careful   listening   and   reflective   responses,   the   client   comes   to   feel   that   the   counselor   understands   the   issues   from   their   perspective.   Beyond   this,   strategic   use   reflective   listening   is   a   core   intervention   toward   guiding   the   client   toward   change,   supporting  the  goal-­‐directed  aspect  of  MI.    In  this  use  of  reflections,  the  therapist  guides  the   client  towards  resolving  ambivalence  by  a  focus  on  the  negative  aspects  of  the  status  quo   and   the   positives   of   making   change.   There   are   several   levels   of   reflection   ranging   from   simple   to   more   complex.   Different   types   of   reflections   are   skillfully   used   as   clients   demonstrate   different   levels   of   readiness   for   change.   For   example,   some   types   of   reflections  are  more  helpful  when  the  client  seems  resistant  and  others  more  appropriate   when  the  client  offers  statements  more  indicative  of  commitment  to  change.         • Summaries  are  a  special  type  of  reflection  where  the  therapist  recaps  what  has  occurred  in   all  or  part  of  a  counseling  session(s).  Summaries  communicate  interest,  understanding    and   call  attention  to  important  elements  of  the  discussion.  They  may  be  used  to  shift  attention   or  direction  and  prepare  the  client  to  “move  on.”  Summaries  can  highlight  both  sides  of  a   client’s   ambivalence   about   change   and   promote   the   development   of   discrepancy   by   strategically  selecting  what   information  should  be   included  and  what  can  be  minimized  or   excluded.       Change  Talk       Change  talk  is  defined  as  statements  by  the  client  revealing  consideration  of,  motivation  for,  or   commitment  to  change.  In  Motivational  Interviewing,  the  therapist  seeks  to  guide  the  client  to   expressions   of   change   talk   as   the   pathway   to   change.   Research   indicates   a   clear   correlation   between   client   statements   about   change   and   outcomes   -­‐   client-­‐reported   levels   of   success   in   changing   a   behavior.   The   more   someone   talks   about   change,   the   more   likely   they   are   to   change.    Different  types  of  change  talk  can  be  described  using  the  mnemonic  DARN-­‐CAT.       Preparatory  Change  Talk   Desire  (I  want  to  change)   Ability  (I  can  change)   Reason  (It’s  important  to  change)   Need  (I  should  change)             And  most  predictive  of  positive  outcome:       Implementing  Change  Talk   Commitment  (I  will  make  changes)   Activation  (I  am  ready,  prepared,  willing  to  change)     Taking  Steps  (I  am  taking  specific  actions  to  change)             Strategies  for  Evoking  Change  Talk     There   are   specific   therapeutic   strategies   that   are   likely   to   elicit   and   support   change   talk   in   Motivational  Interviewing:     1.     Ask  Evocative  Questions:  Ask  an  open  question,  the  answer  to  which  is  likely  to  be  change   talk.   2.     Explore   Decisional   Balance:  Ask   for   the   pros   and   cons   of   both   changing   and   staying   the   same.     3.   Good   Things/Not-­‐So-­‐Good   Things:   Ask   about   the   positives   and   negatives   of   the   target   behavior.   4.     Ask   for  Elaboration/Examples:  When  a  change   talk   theme  emerges,  ask   for  more  details.   “In  what  ways?”  “Tell  me  more?”  “What  does  that  look  like?”  “When  was  the  last  time  that   happened?”   5.     Look  Back:  Ask  about  a  time  before  the  target  behavior  emerged.  How  were  things  better,   different?   6.     Look   Forward:  Ask  what  may  happen   if   things   continue   as   they   are   (status   quo).   Try   the   miracle  question:  If  you  were  100%  successful  in  making  the  changes  you  want,  what  would   be  different?  How  would  you  like  your  life  to  be  five  years  from  now?   7.     Query   Extremes:  What   are   the   worst   things   that   might   happen   if   you   don’t   make   this   change?  What  are  the  best  things  that  might  happen  if  you  do  make  this  change?   8.     Use  Change  Rulers:  Ask:  “On  a  scale  from  1  to  10,  how  important  is  it  to  you  to  change  [the   specific  target  behavior]  where  1  is  not  at  all  important,  and  a  10  is  extremely  important?   Follow  up:  “And  why  are  you  at  ___and  not  _____  [a   lower  number  than  stated]?”  “What   might  happen  that  could  move  you  from  ___  to  [a  higher  number]?”     Alternatively,  you  could  also  ask  “How  confident  are  that  you  could  make  the  change  if  you   decided  to  do  it?”   9.     Explore  Goals  and  Values:  Ask  what  the  person’s  guiding  values  are.  What  do  they  want  in   life?  Using  a  values  card  sort  activity  can  be  helpful  here.  Ask  how  the  continuation  of  target   behavior  fits  in  with  the  person’s  goals  or  values.  Does  it  help  realize  an  important  goal  or   value,  interfere  with  it,  or  is  it  irrelevant?      10.   Come  Alongside:  Explicitly  side  with  the  negative  (status  quo)  side  of  ambivalence.     “Perhaps  _______is  so  important  to  you  that  you  won’t  give  it  up,  no  matter  what  the  cost.”               Sources     Amrhein,  P.  C.,  Miller,  W.  R.,  Yahne,  C.  E.,  Palmer,  M.,  &  Fulcher,  L.  (2003).  Client  commitment   language   during   motivational   interviewing   predicts   drug   use   outcomes.   Journal   of   Consulting  and  Clinical  Psychology,  71,  862-­‐878.     Center  for  Substance  Abuse  Treatment  (1999).  Enhancing  Motivation  for  Change  in  Substance   Abuse   Treatment.   Treatment   Improvement   Protocol   (TIP)   35.   Rockville,   MD:   Substance   Abuse  and  Mental  Health  Services  Administration,  Center  for  Substance  Abuse  Treatment.       Miller,  W.  R.,  Rollnick,  S.   (2002).  Motivational   Interviewing:  Preparing  People   for  Change.  2nd   Edition.    New  York:  Guilford  Press.     Miller,  W.R.  &  Rollnick,  S.  (2009).    Ten  things  that  Motivational  Interviewing  is  not.    Behavioural     and  Cognitive  Psychotherapy,  37,  129-­‐140.       Miller,  W.R.   &   Rollnick,   S.   (2010).  What’s   new   since  MI-­‐2?   Presentation   at   the   International   Conference   on   Motivational   Interviewing   (ICMI).   Stockholm,   June   6,   2010.   Accessed   at   http://www.fhi.se/Documents/ICMI/Dokumentation/June-­‐6/Miller-­‐and-­‐Rollnick-­‐june6-­‐pre-­‐ conference-­‐workshop.pdf     Miller,  W.R.  &  Rollnick,  S.  (2010).  What  makes  it  Motivational  Interviewing?  Presentation  at  the   International   Conference   on   Motivational   Interviewing   (ICMI).   Stockholm,   June   7,   2010.   Accessed   at   http://www.fhi.se/Documents/ICMI/Dokumentation/June-­‐7/Plenary/Miller-­‐ june7-­‐plenary.pdf.     Miller,   W.   R.,   Zweben,   A.,   DiClemente,   C.   C.,   &   Rychtarik,   R.   G.   (1992).     Motivational   Enhancement  Therapy  manual:  A  clinical   research  guide   for   therapists   treating   individuals   with   alcohol   abuse   and   dependence.     Rockville,  MD:   National   Institute   on   Alcohol   Abuse   and  Alcoholism.       Rollnick,   S.,   &   Miller,   W.R.   (1995).     What   is   motivational   interviewing?     Behavioural   and   Cognitive  Psychotherapy,  23,  325-­‐334.