motivationalinterviewing

Motivational Interviewing

"Helping People Change Problem Behaviors"

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Motivational interviewing is a client centered counseling approach that uses the client’s internal motivation to change by helping develop ambivalence about problem behaviors. This allows clients to reflect on and resolve some of the issues getting in the way of their progress in developing more effective strategies (Miller & Rollinick, 2002.) This approach draws on Prochaska and Diclemente’s model of change which posits that clients move through specific stages of change before taking action on problem behaviors (Prochaska, Norcross, and Diclemente, 1995).

Precontemplation ----> Contemplation -----> Preparation

-------> Action ------> Maintenance -----> Relapse Prevention

In the precontemplation stage, the person has no thought of changing, now or in the future (“It’s not my fault!”).

In the contemplation stage, the person is ‘thinking about’ changing, reflecting on the problem behavior and what its consequences are. Motivational Interviewing is a key strategy in engaging the person in the precontemplation and contemplation stages of change before they are committed to becoming a ‘client’.

The "Preparation" and "Action" stage are where change strategies can be usefully applied because the client is ready to make behavioral changes.

Why use this strategy?

This counseling strategy was initially developed to help motivate people with substance misuse problems to change without using confrontational techniques that appeared to create 'resistance' and often resulted in premature ternination. There are over 30 clinical trials that show the efficacy of motivational interviewing for problems associated with alcohol and drug use, weight and exercise related issues and engagement (Burke, Arkowitz & Menchola, 2003).

Whom to use it with?

Candidates for this treatment might be any of the following:

A person with a drug or alcohol problem.
A young adult who believes that their binge drinking is not a problem although they have had several legal encounters.
An adolescent who thinks smoking marijuana helps them deal with stress.
The “resistant” client.
The client who is not following a medication regimen.

When to use this procedure

Most clients who come into our office don’t believe that they have a problem or they feel that somebody else ‘is responsible’ for the problem. Starting to help the client change at this juncture is premature, because they are not ready for change. Efforts to confront the client with their problems at this stage often lead to disengagement and premature drop out. The first line of approach is to engage the person in reflecting about their problems in a non-judgmental way and helping them accept the usefulness of treatment. It is useful to think of motivational interviewing as a preliminary step in 'getting the client ready for treatment'.

How to use this procedure

Motivational Interviewing uses a number of strategies to increase the perceived discrepancy between what the person is doing right now and their goals and values. These techniques gently nudge the person towards the level of ambivalence about problem behaviors required to realize the need for change. (“I am not so sure that this is working for me”).

Some motivational interviewing strategies include:

Cost–Benefit Analysis: Exploring the pros and cons of engaging in the problem behavior.

Ask about disadvantages of continuing in the current situation.

What worries you about your parents not listening to you?

What difficulties are you having in relation to your pot smoking (or other drug/alcohol use)?

How has this stopped you from going to college/ getting a job?

- Ask the client about some the advantages of making a change.

What would you like to see changed in your life? How is that different from how things are today?

How do you see yourself six months from now- how will you want things to change?

If you had a magic wand, how would you change your current situation?

- List these next to each other so that the client can weigh the pros and cons and think about what they are doing.
- Encourage the client to actively generate advantages and disadvantages- this makes them more invested in the exercise.

Reflective Listening: This counseling strategy is particularly useful in presenting both sides of the argument to the client.

“You feel that it is better for you to quit smoking marijuana but right now that is difficult because that is the only way you know how to make friends and that is very important for you as a teenager.”

Emphasizing the power of personal choice and self-efficacy

The therapist should support the client in making their own decisions. It is important to leverage the client’s own experiences and values in their ability to change. Motivational Interviewing takes the view that clients are most likely to change when they view themselves as ‘in the driver’s seat’, making their own choices and acting without coercion in the direction of important values.It is important to make the client aware of their strengths and to use this to enhance their ability to change. people who feel powerless or hopeless are less likely to undertake change in behaviors.

Client: what if I told you that I feel like quitting all my medicine- you couldn't stop me."

Clinician: That's absolutely true- it is ultimately your choice. I cannot make that decision for you, that is your choice to make. Perhaps we could we discuss the pros and cons of your choice before you make a final decision. Even if you postponed your decision a bit, you would be free to change your mind tomorrow. Would there be any disadvantages to discussing this a bit?"

“Despite all the chaos in the family you were still able to stay in school and not drop out.”

“Coming here because your probation officer told you to must have been irritatingbut you still managed to make it. Now that you are here rather than wasting your time perhaps we could discuss if there is anything I could help you with”

Assessing the Client’s 'Readiness' to Change

Before starting therapy with the assumption that the person in your office is a client who wants to be helped, consider carefully assessing the client’s actual interest, motivation and readiness for change. A simple question like “How ready are you to make some changes in your behavior and thinking right now” with responses rated on a 0 (not ready) to 10 (ready) scale can be very helpful.

Handy Tips

Always use a collaborative approach.

If you find yourself arguing with the client step back and try to regain a perspective on their readiness.

If you find yourself being too active and ‘pushy’, this is a signal that you are working too hard.

Explore the situation with the client. Help them come up with the pro and cons of a behavior they would like to change.

With clients who are particularly reactive (always resisting direction or suggestion), it is sometimes useful to consider paradoxical instructions. For example, you may say “I don’t want you to do this more than once” instead of “I want you to do this once”.

Possible Pitfalls

Be careful not to start to ‘take sides’, become argumentative, pushy or too directive. Avoid falling into the trap of providing advice to the client about changing. This often backfires and makes the client defensive and resistant to change.

Key References

Burke, B.L., Arkowitz, H. & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of consulting and clinical psychology, 71 (5), 843-861

Miller, W.R. & Rollinick, S. (2002). Motivational Interviewing (2^nd Edition ) New York: Guilford Press.

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