Motivational Interviewing - Education for Mid-Level Providers

MI centers on exploring and resolving ambivalence and focuses on motivational processes in the individual in order to facilitate change. Its methodologies differs from externally-driven or more coercive techniques for motivating change since it does not compel change that goes beyond the individual's beliefs, values or wishes; but instead it supports change in a way that is consistent with the individuals values and beliefs. In 2009, the definition of MI was "a collaborative, client-centered type of guiding to educe and support motivation for change" (Miller &Rollnick).

MI is founded on a respectful approach with a focus on developing rapport in the early stages of the counseling relationship. A key principle of motivational interviewing is the identification, evaluation, and resolution of ambivalence regarding changing behavior. Ambivalence, which is feeling two ways regarding behavioral change, is viewed as a natural component of the change process. A skilled Motivational Interviewing practitioner is attuned to patient ambivalence and willingness for change and carefully uses methods and strategies that are responsive to the patient. The most current descriptions of MI comprise three important components:

• 1.Motivational Interviewing is a type of conversation about change that comprises counseling, therapy, consultation, and technique of change.
• 2.Motivational Interviewing is collaborative in that it is client-centered, partnership, respects autonomy, and not expert-recipient.
• 3.Motivational Interviewing is evocative in that it seeks to elicit the individual's own motivation and commitment.

The above components are incorporated in three increasingly comprehensive levels of definition. The first level is the layperson's definition. This defines MI as a collaborative conversation aimed at reinforcing an individual's own motivation for and commitment to change. The second level of definition is a pragmatic practitioner's definition, which centers on MI being a person-centered counseling technique for addressing the common problem of ambivalence regarding change. The third definition is the technical therapeutic definition, which about how MI works. According to this definition, MI is a collaborative, objective-oriented technique of communication with a specific attention to the language of change. MI is intended to reinforce an individual's motivation for and movement towards a particular objective by eliciting and exploring the individual's own arguments regarding change.

Motivational interviewing goes beyond the application of a set of methodological interventions. It is characterized by a specific "spirit" or clinical "way of existence" that is the setting or interpersonal relationship within which the methods are applied. The spirit of motivational interviewing is founded on three key components: collaboration between the therapist and the patient; evoking or eliciting the patient's concepts regarding change; and emphasizing the independence of the patient.

Collaboration is a partnership between the practitioner and the patient, based on the perspective and experiences of the patient. This is different from other approaches to substance abuse disorders that are founded on the practitioner assuming a "professional" role, at some points confronting the patient and forcing their point of view on the patient's behavior and the suitable approach to treatment and results. Collaboration is effective in developing rapport and facilitating trust in the helping relationship, which can be a problem in a hierarchical relationship. This does not imply that the practitioner automatically consents to the client regarding the problem and the changes that are suitable (Amrhein et al). Although both may view things differently, the process emphasizes mutual understanding and not the practitioner being right.

Evocation is about drawing out instead of imposing ideas. Motivational Interviewing approaches is about the practitioner's drawing out the client's personal thoughts and concepts instead of forcing their views since motivation and commitment to change is strong and long lasting when it comes from the patient. Irrespective of the explanations, the therapist gives to convince the client of the importance of behavioral change or how much they may want the client to change, durable change is prone to occur when the patient finds out their own reasons and resolve to change. The function of the therapist is to help in drawing out the client's motivations and skills for change and not to impose or tell what to do or why they should do it.

Unlike other therapeutic models that are founded on the clinician being the authority figure, MI is founded on the autonomy of the client. MI approaches is based on the recognition that true change power rests in the client. In the end, it is up to the person to follow through in ensuring that change takes place (Miller &Rollnick). This approach is empowers the individual and makes them responsible for their actions. Practitioners underpin that there is no one appropriate way to change, but there are different ways that change can take place. Clients are also encouraged to take a proactive role in creating options regarding how the desired change will be realized.

PRINCIPLES OF MI

In developing and bringing life to the components of Motivational Interviewing "style," there are four separate principles that direct the practice of Motivational Interviewing. A MI practitioner will hold true to these principles during the entire treatment process. The first principles is that of express empathy, which entails seeing the world from the client's perspective, feeling things as they do, thinking about thing just as the client thinks about them and sharing in the patient's experiences. Using this approach gives the foundation for clients to be heard and understood and by doing this the clients are likely to share their feelings openly and in depth. Expressing empathy depends on the client's experiencing the therapist as capable of seeing the world as they do.

The second principle is supporting self-efficacy. This is founded on the fact that Motivational Interviewing is a strengths-based approach that is founded on the belief that clients posses within themselves the abilities to change successfully. The belief by the client that change is possible is necessary in order to inspire hope in making the hard changes. It is possible that client had previously tried and failed in achieving or maintaining the desired change and this may have created doubt regarding their ability to change. In MI, therapists reinforce self-efficacy by stressing on past successes and emphasizing skills and strengths that the client already possesses.

The third principle is that of rolling with resistance. From an MI standpoint, resistance in therapy arises when the patient experiences conflict between their perspective of the problem or the solution and that of the therapist or when the patient experiences their liberty or independence being infringed on. These experiences are mainly caused by the client's ambivalence towards change. Therapists avoid eliciting resistance by avoiding confrontation with the client and when resistance arises, they focus on de-escalating the conflict and avoiding negative interaction. Statements and actions that show resistance are unchallenged during the initial stages of the counseling relationship. Rolling with resistance removes any struggle that may occur and the counseling session does not resemble an argument. By stressing on the need for the client to define the problem and create his or her own solutions, MI leaves nothing for the patient to resist. Through this approach, clients are invited to evaluate new perspectives and therapists are cautious not to enforce their way of thinking. A significant idea is that therapist's desist the "righting reflex," which is a propensity borne from concern, to ensure that the patient comprehends and agrees with the desire to change and to resolve the problem for the patient.

Developing discrepancy is the last principle of MI. Motivation for change results from a mismatch in an individual's perception of where they are and where they desire to be, and a MI practitioner works by developing this by aiding clients analyze the discrepancies between their present circumstances or behavior and their future objectives. When clients discover that their present behaviors are in conflict with their values or restrict the relaxation of self-identified objectives, they are likely to experience elevated motivation to make vital life changes. An MI practitioner must be cautious not to use strategies to develop discrepancy at the cost of the other principles, but should gradually aid patients to be aware of how their present behaviors may direct them away instead of towards their desired objectives.

MI TECHNIQUES AND STRATEGIES

MI practitioners utilize a set of skills in order to bring to life the "MI sprit," demonstrate the MI principles and direct the process toward evoking client change talk and commitment to change. OARS are micro-counseling skills, which is an acronym for open-ended questions, affirmations, reflections, and summaries. These are core therapist behaviors that are used to move the process forward and start a therapeutic coalition and evoke discussion about change. Shannon et al argues that open-ended questions cannot be easily replied with a yes or no or with answers with definite and limited information, but entails and in-depth and elaborate thinking regarding an issue. Open-ended questions allow the client to discover the reasons for and the likelihood of change, and also to create a forward momentum.
Affirmations are statements that identify patient strengths. They aid in developing rapport and in aiding the patient view themselves in a different and encouraging light. They also help the client to see that change is possible even after past failures. It entails reframing behaviors or concerns as proof of positive patient qualities. Affirmations are vital components in facilitating the motivational interviewing principle of enhancing self-efficacy.

Reflection is the most important skill in MI because it serves two main purposes. First, it brings to life the principle of expressing empathy. Through careful listening and reflective interactions, the patient feels that the therapist understands the problem from their viewpoint. Additionally, reflective listening is the main intervention for directing the patient toward positive change. According to Dart, this is achieved by directing the client towards resolving ambivalence by focusing on the negative features of the status quo and the positives of instituting change. The various levels of reflections raging from simple to intricate are used as clients exhibit different levels of readiness for change.

Summaries are a unique kind of reflections where the practitioner reviews what has happened in an entire or part of a counseling session. Summaries convey interest, comprehension and call attention to vital components of the discussion. They can be used to alter attention or course and prepare the patient to proceed. They are also useful in highlighting both sides of a patient's ambivalence regarding change and to promote the creation of discrepancy by selectively choosing what information to be included or minimized or excluded.

Change talk is another MI technique and statements by the patient disclosing contemplation of, inspiration for, or commitment to change. In MI, the practitioner seeks to direct the client to expressions of change talk as the passageway to change. Research studies show an apparent correlation between client responses about change and results. The more a person talks about change, the more probable they change. Various forms of change talk can be illustrated using the mnemonic DARN-CAT. DARN stand for desire, ability reason, and need, while CAT stands for commitment, activation and taking steps.

Eliciting change talk requires specific therapeutic strategies. Asking evocative questions that are open allows the client to give an answer that supports change talk. The second strategy is to explore decisional balance by asking the advantages and disadvantages of changing and maintain status quo. The third strategy is by asking both the positives and negatives of the target behavior. Fourthly, it is important for therapist to ask for examples by asking questions that give more details. The fifth strategy is to look back in order to understand how things were before the target behavior. The sixth strategy is to look forward by asking what may happen if changes are not instituted and what will be different if the change process is successful. According to Hettema et al, querying the extremes is the seventh strategy that entails asking the worst things that may happen if changes are not made and the best things if changes are successful. Exploring the objectives and vales of the clients, using change rulers such as a scale of 1 to 10 and coming alongside are additional strategies of evoking change talk.

HEALTH CARE TARGET GROUPS

MI evolved from the experiences of William Miller in treating individuals with a drinking problem. It is an effective strategy for treating alcohol-related problems. Several empirical studies that have been reviewed evaluated some form of alcohol used problem and have shown that MI is effective just like other treatments for drinking problems and is better than no treatment. When MI is compared with untreated samples, the difference in success rates is greater by 10 to 20 percent and when compared with existing treatments, the difference in success rate ranged from zero to 20 percent advantage for MI (Shannon et al). MI is also an effective treatment for marijuana dependence compared with no treatment. The success rate for marijuana dependence treatment using MI is about 15 percent. MI is also effective in tobacco cessation when compared with no treatment and its success rate ranges from five to about 17 percent. It is also effective in treating dependence on drugs such as heroine of cocaine compared to no treatment.

Although relatively few studies have examined the effectiveness of MI in lowering risky behaviors, there are evidence showing that MI is a promising approach in reducing behaviors such as sharing needles and engaging in unprotected sex. According to Lundahl & Burke, meta-analyses conducted showed some version of enhancing healthy behaviors such as better eating habits and increased exercise. MI has also showed promise in treating gambling addictions, eating disorders, increasing health habits such as healthy eating, emotional well-being, and parenting practices. Currently, MI is applied is psychiatry to manage poor treatment adherence in certain conditions such as psychosis, co-morbidity with substance abuse and in improving the general health of individuals with psychiatric disorders by stressing on the maladaptive components of their lifestyle.

Research supports the efficacy of motivational interviewing in eliciting behavioral change. Project MATCH remains one of the most comprehensive studies for alcohol treatment methods. It involved nine clinical locations in the United States. The MI-based treatment developed for project match was referred to as Motivational Enhancement Therapy (MET). It entailed four sessions offered at weeks 1, 2, 6, and 12. The only difference between met and MI is that it incorporated problem feedback. The initial two sessions included a drinker's check up that combined motivational interviewing with structured individual feedback of the client's evaluation outcomes leading to a personalized change plan intake. The next two sessions functioned as check-in visits to analyze progress, replenish motivation for change, and modify the change plan if necessary. MET was compared with cognitive-behavioral skills therapy and a 12-step facilitation therapy. Two outcome measures: percentage of day abstinent (PDA) and drinks per day (DOD) were generated from an interview-based evaluation instrument that utilized both drinking time estimation procedures and timeline follow-back methodology intake. Laboratory examinations were used to observe changes in alcohol use and substantiate the self-reported drinking measures. All therapists involved in the study were vigilantly trained and treatment sessions supervised by videotape.

Subjects in all treatment groups exhibited significant improvements on all drinking measures with no reliable variations between treatment groups. The only consistent and vigorous interaction effects found in this project, significant at 1- and 3- year follow-ups was that MET outperformed other treatments on both primary drinking result measures for clients with elevated anger. Project MATCH utilized a comprehensive set of result measures to evaluate depression, drinking consequences, % of days of paid work, and other life variables, which may be impacted by alcohol intake. All these measures exhibited improvements in approximately two thirds of the subjects, with no significant variations between treatment groups. Therefore, MET produced positive results on drinking and associated lifestyle variables with a clinically severe population and was effective like other empirically supported and considerably longer interventions. From the project, it is right to conclude that MI is an effective method to facilitate change in clients who might exhibit resistance to treatment. Additionally, MI is supported by more than two hundred clinical control trials across an assortment of target populations and behaviors.

References

Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L.. Client Commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 71, 862-­‐878.

Dart, M. A.. Motivational interviewing in nursing practice: Empowering the patient. Sudbury, Mass: Jones and Bartlett Publishers.

Hettema, J., Steele, J., & Miller, W.. Motivational Interviewing. Annual Review of Clinical Psychology, 91-111.

Lundahl, B & Burke, B.. The Effectiveness and Applicability of Motivational Interviewing: A Practice-Friendly Review of Four Meta-Analyses. Journal of Clinical Psychology: In Session, Vol. 65(11), 1232-1245.

Miller, W. R. and Rollnick, S.. Motivational Interviewing: Preparing People For Change. 2nd Edition. New York: Guilford Press.

Project MATCH Research Group.. Matching alcoholism treatments to client heterogeneity: Project MATCH post-treatment drinking outcomes. Journal of Studies on Alcohol, 58, 7-29.

Rollnick, S., Heather, N., & Bell, A.. Negotiating behavior change in medical settings: The development of brief motivational interviewing. Journal of Mental Health, 1, 25-37.

Shannon, S; Smith, V.J., Gregory, J.W.. A pilot study of motivational interviewing in adolescents with diabetes. Arch Dis Child 88. pp. 680-683.