Introducing the Concept
What is Motivational Interviewing? All I knew about it was that it was a new theory I had to learn; sit in a training venue at a place of employment; trying to wrap my mind around yet another way of working with people who had substance use disorders. That was the apparent emphasis at the time. Since that time I have seen this presented in workshops I have attended to stay current with my LCSW. I and my group partner, Chris Campbell, have the privilege of sharing just a bit about this counseling theory in the hopes that some of you all, along with us, will desire to take this theory and proceed with a client or two in the vocational rehabilitation process.
The application has been broadened to include a number of other disorders of human behavior including family dysfunction, criminal behavior and eating disorders, just to name some. Eating disorders are most troublesome to the parents of the children who have them.
"A metaphor that we use to convey the spirit of motivational interviewing when we are introducing the concepts to the parents is one of Aesop's fables. 'The sun and the wind were having a dispute as to who was the most powerful. They saw a man walking along and they challenged each other about which of them would be most successful at getting the man to remove his coat. The wind started first and blew up a huge gale; the coat flapped but the man only closed all his buttons and tightened up his belt. The sun tried next and shone brightly making the man sweat. He proceeded to take off his coat." (Motivational Interviewing for Eating Disorders
Dr Janet Treasure, Dr Ulrike Schmidt and Gill Todd, Eating Disorder South London & Maudsley NHS Trust)
Motivation defined is: "Probability of behavior change or movement toward a general goal can be extrinsic or intrinsic." (Louise A. Stanger, Ed.D, LCSW, Feb, 2008) An interview is a dialogue, discussion or conversation between or among people in a setting. This theoretical concept involves a personal, meaningful goal or behavior change and an action plan to achieve that goal. (Stanger, 2008) This can be any goal. Examples include losing weight, stopping behaviors such as smoking, drinking too much alcohol, using drugs, fighting, binge eating, starving, eating compulsively and whatever goal a person would choose. To change takes motivation. To motivate, that is the question!
Understanding motivation requires understanding the components of how people change. There are phases to change which have been ferreted out by those who study behaviors. According to Prochaska & DiClemente, there are six stages of change. First, there is Pre-contemplation, secondly, contemplation, thirdly; determination, fourthly, action, fifthly, maintenance and finally, relapse. (Louise Stanger, Ed. D. LCSW, Feb, 2008) During the pre-contemplation stage, the client is not thinking of changing anything. He believes there is no problem. The problem is with the other guy, or the spouse. The client may feel forced into treatment. The therapist's task is to raise doubt; increase the person's perception of risk and problems with his current behavior. In the contemplation stage, the client is considering change. He may not be totally convinced to do so. The therapist's task is to tip the balance; evoke a response to change by discussing the risk of not changing and strengthen the client's self efficacy for change of current behaviors. The determination stage is demonstrated by the client expressing a desire or wish for change of his behaviors. The therapist's tasks are to help the client to plan, specifically, to help the client determine the best course of action to take in seeking change. In the action stage, the client is actually trying to change. It is important to note he may experience setbacks. The therapist's tasks are to encourage action and help the client take steps toward change. Maintenance is characterized by the client's maintaining activity of change over time. Success is defined differently for each person. Desired change has existed for six months or more. The therapist's task is to strategize. Help the client identify and use strategies to prevent relapse. The sixth stage is relapse. The client engages in the undesired behavior after a period of time in the maintenance or action stage. The therapist's task is to re-start the process. Help the person renew the process of contemplation, determination and action without succumbing to demoralization. (Louise Stanger, Ed. D. LCSW, Feb., 2008) This whole process can be viewed as a cycle. The process is fluid, not static or linear. The counselor is directive and involved in the advice and planning process with the client. A definition of Motivational Interviewing is; "A directive client-centered counseling approach for eliciting behavior change by helping clients to explore and resolve ambivalence." (Rollnick & Miller, 1995)
Elements of MI Philosophy
There are several elements of the MI philosophy which have been gleaned from Motivational Interviewing Library Abstracts.
"Client resistance typically is a behavior evoked by environmental conditions." Resistance and denial are seen as responses to environmental cues, either by the therapist in the session, or by a spouse, a judge, or some other factor. The counselor deals with these negative emotions by not responding to their pull and by giving respectful, unconditional acceptance and pay attention to what the client does over the course of treatment rather than what the client says.
Motivation to change is not measured by the client's agreement, nor is lack of motivation defined by the disagreement of the client.
2. "The client/counselor relationship should be collaborative and friendly."
". . Client change is best enhanced through positive reinforcement." The counselor uses this environment to create a climate for change in the client. He can try new things, open up and not be put down for it. That will promote change behaviors in the client.
3. "Motivational Interviewing gives priority to resolving ambivalence."
Ambivalence is one of the keys to assisting clients to change. Traditional approaches to treating substance use disorders, according to Rollnick and Miller, are too action-oriented. The counselor pushes for change before the client is ready. This leads to premature termination of treatment. When the issues are not resolved, relapse may occur more quickly even after changes have been made.
4. "The counselor does not prescribe specific methods or techniques."
"MI counselors educate clients about the variety of therapeutic options available to them and, at times, the research support for particular options." (Abstract, MI Philosophy) Counselors are not to get too obsessed with choices the clients make, even when they may not be the counselor's idea of in their best interest. The client who takes responsibility for his choices usually has long-term success in the change he is making.
5. "Clients are responsible for their progress."
MI Counselors encourage clients to choose their behaviors, and in the same way, they encourage clients to take responsibility for their progress in treatment. The changes they make in their lives will most likely be long-term changes if they take responsibility for them.
6. "MI focuses on clients' sense of self-efficacy."
The MI approach increases the client's hope that the client can be empowered to do something about substance abuse problems. If they believe they cannot change, they will be more likely to use defense mechanisms such as denial or rationalization to avoid dealing with their pain. (The Motivational Interviewing Page)
Principles of MI
Four basic principles underlie this theoretical technique. The first of these is empathy. The client will be more likely to change his ways of thinking and behaving if he feels he is being heard and understood by the counselor. The Counselor's accurate understanding of the client and his experience facilitate changes. The second of these principles is Supporting Self-Efficacy. If the client can see that he has made other healthy changes in his life and others have shown him they can change and have changed, that empowers him to make changes in substance use. The third principle is to roll with Resistance. The MI Counselor uses the client's resistance to explore the client's views, not fight them. That takes the air out, so to speak and the client will be more willing to explore the views of the Counselor. There is no hierarchy for the client to fight when this principle is used. Counselors may introduce new perspectives, but not necessarily new ways of thinking to the client. The fourth principle is Develop Discrepancy. "Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be" (Miller, Zweben, DiClemente, & Rychtarik, 1992, p. 8) when clients perceive that their ways of behaving lead them away from, rather than to their desired goal, they will be more motivated to change. MI Counselors gently and gradually introduce this principle to clients, watching that they don't sacrifice the other principles on this one. (Miller, W. R., Zweben, A., DiClemente, C. C., & Rychtarik, R. G. (1992).
Strategies of MI
"The following includes some of the strategies used in motivational interviewing. This text is adapted and excerpted from Ingersoll, Wagner & Gharib (2000) and Rosengren & Wagner, (2001").
The Counselor begins by "Reviewing a Typical Day." The Counselor begins by building rapport and finding out how the client spent a typical day and how the using of substances fit into his life. Help the client tell the story of his day, focusing on feelings and behaviors. If the client is receptive, proceed with the next strategy.
This is the strategy of Looking Back. Help the client remember what life was like before he began using; before the problems with his job, family, relationships, legal issues, financial issues, came to bear on his life. What were his goals, aspirations, dreams and achievements like then? He may then comment, "I used to have it all," or something similar. The Counselor can then say, "Tell me more" and use OARS to navigate the rest of the session; assisting the client to see his history, how he began using substances and how he gradually continued to come to the place where he is, now.
Another strategy is "Good things, and less good things." The Counselor explores with the client the good things about substance use behaviors. It is important to see things from the client's point of view. When all the good things have been exhausted, and then explore the less good things about using. Avoid labeling behaviors as problems. Once this portion is explored, the Counselor can summarize the client's statements emphasize any "change talk" that emerged, then ask the client his thoughts.
This strategy is the Stages of Change. The Counselor may talk about something less threatening such as dieting, stopping smoking or spending money impulsively. When people change long-standing habits, they go through stages.
The first one is Pre-contemplation. The person is not thinking of any change at all. He may have thought about it, but did not believe he could do it. The next one is contemplation. Change thoughts are beginning to come into the person's mind. Just maybe, he has a chance to change. The third stage is preparation. The client is now beginning to prepare for changes to take place. The fourth stage is the action stage. The client is now taking steps to make the desired change. Old behaviors are being discarded and new ones are being tried. The client will often seek support from others around him during this stage. The fifth stage is maintenance or "holding" stage. The changes have been made and sustained for some period of time. The sixth stage is relapse. There are natural slips, lapses into the old patterns of behaviors and sometimes there is a period of relapse. That is normal. That will often happen before the change is permanent. There is good evidence that it is not a good idea to skip a stage of change. If the maintenance stage is not permanent, there may not have been enough time spent in the preparation stage.
Assessment and Feedback is another strategy which MI Counselors use. This assessment can be formal or informal. There are instruments which have been prepared to compile data on which the client may compare himself as in the beginning of treatment, the middle and the end. The Counselor is a conduit of information and the client ascribes meaning to the information.
Values Exploration is another strategy. A values focus can bring to bear the ideal values the client holds for himself vs. the actual behaviors in which he is involved. Sometimes clients don't believe they can achieve an ideal value set. What are the positive motivations behind the short-term behaviors which caused problems? What other behaviors can be put in their place to give that "rush" or "high" without the damage? Values cards can be helpful in moving this exercise along. "Topics discussed may include the meaning of the various values statements, evaluation of current consistency between values and behavior, perceived barriers to and opportunities for increasing value-behavior consistency, and personal evaluation of the extent to which the use of substances plays a role in achieving or preventing consistency." Value changes can be done in a very short time-frame.
Looking Forward as a strategy has the same idea as looking back. The client envisions two futures. One where old behaviors are continued and one in which new behaviors is put on. The client is the one who comments on the imaginings.
Exploring Importance and Confidence are two other areas which the counselor explores with the client. How important is the change to the client? Does the client believe he or she can make the needed change?
Decisional Balance is an exercise similar to good things, less good things, but its focus is on the future. The client is asked to discuss pros and cons of changing behaviors vs. pros and cons of not changing the behaviors.
Change Planning is a strategy in which the client carefully plans the changes he or she will make in the next 90 days, for example. There are forms which the client and Counselor complete conjointly.
Do it all in a moment or two. This final strategy has the use of the acronym FRAMES. Some treatment centers with little time and big problems attempt to use this approach. Most clinicians outside these centers do not have the formal materials with them to complete this kind of work. "Observe your clients. If during the session they are constantly arguing, disagreeing or ignoring you, then what you are doing is not working." If they don't complete homework between sessions, that may be ambivalence. If this continues, they may only be acquiescing. If clients quit, they may be giving up on the Counselor, not the behavior. They were not ready for change. The clients will let the counselor know how he is doing.
"Interaction Techniques
The basic approach to interactions in motivational interviewing is captured by the acronym OARS: (1) Open-ended questions, (2) Affirmations, (3) Reflective listening and (4) Summaries. The acronym is a nice image. It gives us power to move, yet it is not a powerboat. We don't zip from one place to another, yet with sustained effort OARS can take us a long way." (MI Interaction Techniques)
Open-ended questions are those which the client cannot answer with just one word or a few words. They cause a forward momentum which causes movement. Examples include: "What brings you here?" or "What makes you feel that it might be a time for a change?"
Affirmations are assertions of a client's strengths. The counselor's job is to find strengths where clients only see defeat. They are great for building rapport. They provide the warmth that a client needs to feel accepted. They have to be congruent and genuine to keep the rapport built.
Reflective listening is the key to this whole theoretical approach. Listen to the clients. They will let you know what has worked and what has not worked. This theory goes beyond the Rogerian approach in that the counselor has directives around "change talk" which the client brings to the session. Make reflections more than surface ones. Those which contain affective but unstated issues may work well. The client will let the counselor know when the counselor is not on track. It is recommended that a ratio of three reflections to one question keeps momentum going.
Summary is the last of these techniques. The counselor is to briefly summarize what the client has been saying. The counselor needs to do it often so as to keep on track with what the client is telling him. It can also be used to change directions. It contains an announcement, listing the basic elements, inviting correction and ending with an open-ended question. If ambivalence is present it should also be included in the summary. The goal for using OARS is forward motion of the client to changing behaviors. "Change talk involves statements or affective communications that indicate the client may be considering the possibility of change." (MI Interactional Techniques) There are four categories of "change talk". Milner and Rollnick have found. They are: "problem recognition, concern about the problem, commitment to change and belief that change is possible." Anything the client states which indicates any of these things can be used to move the client along to change.
Motivational Interviewing, after all, is a theoretical technique which takes skill and lends itself to the Rogerian theory, yet is directive in nature. It is very interesting that the responsibility is squarely in the client's power, with empathy and empowerment by the counselor to effect change in behaviors from destructive ones to constructive ones. Listening skills with which this course began are brought home to us, again, in this theory.
