Motivational Interviewing
By Kevin Patton
Motivational Interviewing is Useful for:
Those who seem stuck on the circle
Those who want to change but do not know what
Those who want to change but keep changing their mind
Those who know where they want to be but do not think they can do it/are worth it
Those who are not realistic about what they want/are setting goals too high deliberately
Cycle of Change (Prochaska & Diclemente)
Precontemplation (Not Thinking About It)
Clients neither acknowledge a problem or the need for any behavioral change.
The goal is to eventually increase the patient's awareness that the behavior in question merits attention.
Avoid actively trying to coerce the patient into acceptance of a problem.
The Four R's - Reluctance, Rebellion, Resignation, and Rationalization
Contemplation (Thinking About Change)
Clients are willing to consider the problem and the possibility of change.
Expressions of ambivalence often heard
A characteristic expression is "yes, but".
Open to information and decisional balance considerations.
Contemplation of change is not commitment to change.
Determination (Deciding to Change)
Clients offer a commitment to Action
Decide to stop problematic behavior
Decide to initiate positive behavior
Appear ready for and committed to action
Does not mean change is automatic
NOTE: Ambivalence about change may not be resolved
"Being adamant about change can be a sign of weak rather than strong determination. "
Barriers to success may play a role.
Action (Starting Off)
Implementing the plan'
Clients;
Often use therapy to make a public commitment to action. Seek external confirmation of the plan.
Seek support.
Gain greater self-efficacy.
Create artificial, external monitors of their activity.
Takes 3 - 6 months to complete this stage, but may vary with the problem:
Maintenance
New patterns of behavior take time to emerge and stabilize.
Threat of relapse or return to old patterns decreases in frequency and intensity.
Relapse
Relapse may be due to:
(1) strong, unexpected urges or temptations
(2) relaxing of their guard
(3) testing themselves
(4) commitment or self-efficacy erodes.
May seek treatment for support and reassurance.
Five General Principles for Workers
1. Express Empathy
2. Develop Discrepancy
3. Avoid Argumentation
4. Roll with Resistance
5. Support Self Efficacy
1.Express Empathy
An empathic style is one essential and defining characteristic of motivational interviewing. The skill of "accurate empathy," as described by Carl Rogers, has been shown to be predictive of success in treating problem drinkers. This style of empathic warmth and reflective listening is employed from the very beginning and throughout the process of motivational interviewing.
The attitude underlying this principle of empathy might be called "acceptance." Through skillful reflective listening, the worker seeks to understand the client's feelings and perspectives without judging, criticizing, or blaming. It is important to note here that acceptance is not the same thing as agreement or approval. It is possible to accept and understand a client's perspective but not to agree with it. Nor does an attitude of acceptance prohibit the worker from, differing with the client's views. The crucial attitude is a respectful listening to the client with a desire to understand his or her perspectives. Paradoxically, this kind of acceptance of people as they are seems to free them to change, whereas insistent nonacceptance ("You're not OK; you have to change") can have the effect of keeping people as they are. This attitude of acceptance and respect also builds a working therapeu¬tic alliance, and supports the client's self-esteem-an important condition for change (Miller, 1983).
An empathic worker seeks to respond to a client's perspectives as understandable, comprehensible, and (within the client's framework, at least) valid.
Ambivalence is accepted as a normal part of human experience and change, rather than seen as a pathological trait or pernicious defensive¬ness. Reluctance to give up a problem behavior is to be expected at the time of treatment; otherwise, the person would probably have changed before this point. The client is not seen as uniquely pathological or incapable. Rather, the client's situation is understood as one of being "stuck" through understandable psychological principles.
Principle 1: Express Empathy
Acceptance facilitates change
Skillful reflective listening is fundamental
Ambivalence is normal
2. Develop Discrepancy
We certainly do not mean that the general goal of motivational interviewing should be to have clients accept themselves as they are and stay that way. Neither do we advocate using reflective listening simply to follow clients wherever they happen to wander. A person who presents with a health-¬threatening drug habit can be motivated to change that habit. This certainly does involve, in at least one sense of the term, "confronting" the client with an unpleasant reality. The question is how best to accomplish this.
A second general principle of motivational interviewing is thus to create and amplify, in the client's mind, a discrepancy between present behavior and broader goals. In the original exposition of motivational interviewing, Miller (1983) described this as creating "cognitive dissonance," borrowing a concept introduced by Festinger (1957). A more general and, we believe, a better way to understand this process is simply as a discrepancy between where one is and where one wants to be. This can be triggered by an awareness of the costs of the present course of behavior.
When a behavior is seen as conflicting with important personal goals (such as one's health, success, family happiness, or positive self-image), change is likely to occur. Consider this example given by Premack (1970) of a man who dates his quitting [smoking] from a day on which he had gone to pick up his children at the city library. A thunderstorm greeted him as he arrived there; and at the same time a search of his pockets disclosed a familiar problem: he was out of cigarettes. Glancing back at the library, he caught a glimpse of his children stepping out in the rain, but he continued around the corner, certain that he could find a parking space, rush in, buy the cigarettes, and be back before the children got seriously wet. The view of himself as a father who would "actually leave the kids in the rain while he ran after cigarettes" was ... humiliating, and he quit smoking.
No one "confronted" this man. No one else may have known what a signif¬icant event was occurring in his life.
But in fact he was confronted by an unpleasant reality about himself, and it triggered a change. This kind of story-in which a life event changes one's perception of a habit-is common in the reports of people who have quit using alcohol, tobacco, or other drugs on their own. It is difficult, of course, for a therapist to arrange for such an event to occur. The principle, however, is one that is quite central to motivational interviewing. Motivation for change is created when people perceive a discrepancy between their present behavior and important per¬sonal goals.
Many people who seek consultation already perceive some discrepancy between where they are and where they want to be. Yet they are also ambivalent, caught in an approach-avoidance conflict. A goal of motiva¬tional interviewing is to develop discrepancy-to make use of it, increase it, and amplify it until it overrides attachment to the present behavior. The strategies of motivational interviewing seek to do this within the client, rather than relying primarily upon external motivators (e.g., pressure from the spouse, threat of unemployment, or court-imposed contingencies). This involves clarifying important goals for the client, and exploring the conse¬quences or potential consequences of his or her present behavior which conflict with those goals. When successfully done, motivational interviewing changes the client's perceptions (of discrepancy) without creating a feeling of being pressured or coerced.
The general approach is one that results in the client's presenting the reasons for change, rather than the counselor's doing so. People are often more persuaded by what they hear themselves say than by what other people tell them. When motivational interviewing is done well, it is not the worker but the client who gives voice to concerns (e.g., "This problem is more serious than I realized") and intentions to change (e.g., "I've got to do something about this").
Principle 2: Develop Discrepancy
Awareness of consequences is important.
A discrepancy between present behavior and important goals will motivate change.
The client should present the arguments for change.
3. Avoid Argumentation
A third important principle of motivational interviewing is that the coun¬selor avoids arguments and head-to-head confrontations. The least desira¬ble situation, from this viewpoint, is one in which the counselor is arguing that the client has a problem and needs to change, while the client is defending an opposite viewpoint.
Motivational interviewing is confrontational in its purpose: to increase awareness of problems and the need to do something about them. A casual observer of this counseling approach, however, would not be likely to label it as "confrontational." One experienced therapist called it "soft confrontation." It is this gently persuasive style that is a hallmark of motivational interviewing.
Direct argumentation tends to evoke reactance from people; that is, it results in their asserting their freedom to do as they please. The more you tell someone "You can't," the more likely she or he is to respond "I will."
Strongly defending a position (e.g., "You have a problem and you've got to change") is likely to elicit opposition and defensiveness from the client. As we have discussed in Part I, client resistance is strongly affected by how the worker responds, and resistance during treatment is predictive of failure to change. For these reasons, it is a general goal in motivational interviewing to avoid approaches that evoke client resistance. When resistance is encoun¬tered, the worker shifts strategies.
One place where arguments are quite likely to emerge, particularly in counseling addictive behaviors, is in regard to the applicability of a diagnos¬tic label. Some counselors place great importance on a client's willingness to "admit" to a label such as "alcoholic." (In fact, in most other problem areas there is usually little emphasis placed on a client's acceptance of a diagnostic label.) Trying to force a client to accept such a label can be counter-therapeu¬tic, however, and there is no evidence to suggest that recovery is promoted by persuading people to admit to a diagnostic label. Within Alcoholics Anonymous (AA), the emphasis has been more on self-recognition than on coerced admission. No doubt some people do find it an important turning point when they first accept their problem. The point here is that there is no particular reason why the worker should badger clients to accept a label, or exert great persuasive effort in this direction. Accusing clients of being "in denial" or "resistant" or "addicted" is more likely to increase their resistance than to instill motivation for change. We advocate starting with clients wherever they are, and altering their self¬-perceptions not by arguing about labels, but through substantially more effective means.
PRINCIPLE 3: AVOID ARGUMENTATION
Arguments are counterproductive.
Defending breeds defensiveness.
Resistance is a signal to change strategies. Labeling is unnecessary.
4. Roll with Resistance
If you don't argue, then what do you do? Jay Haley and other pioneers in the field of strategic family therapy have spoken of "psychological judo." They refer to the kinds of martial arts in which an attack is not met with direct opposition (as in boxing), but rather the attacker's own momentum is used to good advantage. It makes no difference what one throws at a master (or sifu) of this art. All blows fall on empty air, and the harder one attacks, the faster one falls into nothing. “Psychological tai chi ch’uan” is probably more accurate.
This is not to say that the sifu is passive. Not at all. He or she adds to the momentum-a little spin, a glance to the side, an extra tug. The fall is inevitable, but the sifu is in control of where the other person lands. Often it is not where the person intended to land, and there may be the surprise of "How did I get over here?"
Any analogy can be taken too far. Motivational interviewing is not like combat; it is not about winning and losing. The client is not an opponent to be defeated. Yet the illustration of rolling with resistance is useful. We experience, for example, how statements that a client offers can be turned or refrained slightly to create a new momentum toward change. 'The object in motion is not a body but a perception. The client starts by throwing out present perceptions, and finds (if the worker, the "sifu” is skillful) that they come down in a new place.
There is also an element of great respect for the client. What to do about a problem, if anything, is ultimately the client's decision. Reluctance and ambivalence are not opposed, but are acknowledged by the worker to be natural and understandable. The worker does not impose new views or goals. Rather, the client is invited to consider new information and is offered new perspectives. "Take what you want and leave the rest" is the permissive kind of advice that pervades this approach. It's an approach that is hard to fight against.
In motivational interviewing, the counselor also commonly turns a question or problem back to the client. It is not the therapist's job to generate all the solutions. Doing so, in fact, allows the client to dismiss each idea with "Yes, but . . " It is assumed that the client is a capable individual, with important insight and ideas for the solution of his or her own problems. Rolling with resistance, then, includes involving the client actively in the process of problem solving.
PRINCIPLE 4: ROLL WITH RESISTANCE
Momentum can be used to good advantage
Perceptions can be shifted.
New perspectives are invited but not imposed. The client is a valuable resource in finding solutions to problems
5. Support Self-Efficacy
A fifth important principle of motivational interviewing involves the con¬cept of "self-efficacy." This refers to a person's belief in his or her ability to carry out and succeed with a specific task. Self-efficacy is a key element in motivation for change and a good predictor of treatment outcome with addictive behaviors. A worker may follow the first four principles outlined above, and persuade a person that he or she has a serious problem. If, however, the person perceives no hope for change, then no effort will be made, and the worker’s efforts have been in vain.
Although the term "self-efficacy" is relatively recent, healers have long recognized that hope and faith are important elements of change. The worker’s own expectations about a client's chances for recovery can have a powerful impact on outcome. A general goal of' motivational interviewing is to increase the client's perceptions of his or her capability to cope with obstacles and to succeed in change.
In presenting the first principle-"Express empathy" - we have dis¬cussed the importance of supporting self-esteem, the person's general self-¬regard. Although self-efficacy can be influenced by general self-esteem, the former is much more specific. Essentially, self-efficacy means confidence in one's ability to cope with a specific task or challenge. A client may, for example, suffer from very low self-esteem, but nevertheless may be per¬suaded that it is possible and within his or her ability to change a particular problem.
"There are various messages that support self-efficacy. One is an empha¬sis on personal responsibility. The person not only can but must make the change, in the sense that no one else can do it for him or her. Motiva¬tional interviewing does not foster hope that the worker will change the client. "I will change you" is not the intended message. A more appropriate message is "If you wish, I will help you to change yourself." A client may also be encouraged by the success of others.
Contact with former clients as models can be helpful in this regard, but workers also use accounts of the numbers of people who have succeeded in changing, or specific success stories. Still another helpful fact is the number of differ¬ent approaches that are available and that have been shown to be helpful. Even a series of treatment failures need not be viewed as cause to abandon hope. It can be understood as this particular person's not yet having found the right approach. Given the range of different and promising treatment options, the chances of any given individ¬ual's finding something that works are quite good.
PRINCIPLE 5: SUPPORT SELF-EFFICACY
Belief in the possibility of change is an important motivator.
The client is responsible for choosing and carrying out personal change.
There is hope in the range of alternative approaches available.
Summary
These five broad principles bespeak a more general philosophy behind motivational interviewing. Each person possesses a powerful potential for change. Your task as a worker is to release that potential, to facilitate the natural change processes already inherent in the individual. In this approach, the client is treated with great respect, and as an ally rather than an opponent.
Motivational interviewing is about helping to free people from the ambivalence that entraps them, yielding repetitive cycles of self-¬defeating or self-destructive behavior. It is more than a set of techniques. It is a way of being with clients, which is probably quite different from how others may have treated them in the past. This way of being is not the whole story of change. There are many specific treatment strategies that can be quite helpful as people pursue the course of change.
Motivational inter¬viewing is intended to get the person unstuck, to start the change process happening. Once begun, change may occur rapidly with relatively little additional assistance or it may require a long span of direction and support.
Nuts and Bolts
REMOVING BARRIERS
Significant practical barriers sometimes impede change, e.g., childcare, travel distance, cost of treatment accessibility.
The more practical obstacles one can remove, the more likely it is that a client will participate.
It can be important, therefore, to explore, "What would stand in your way of your taking a first step?"
Removal of practical barriers can open the door for change.
The task is to assist client in practical problem solving.
EXTERNAL CONTINGENCIES
This in a way the opposite of approaches emphasized thus far, which seek to create internal motivation for change.
External contingencies can and do work. Problem drinkers brought into treatment by such external contingencies respond with about the same rate of success as those who are self¬-referred.
If an external contingency is to be used, one should ensure that it will be enforced.
Brief contingencies are likely to yield a rebound effect.
The contingency should be a firm and enduring one.
RECOGNISING CHANGE READINESS
Some changes in the client you might see...
Stops resisting and raising objections.
Asks few questions.
Appears more settled, resolved, unburdened and peaceful.
Makes self-motivational statements indicating a decision (or openness) to change. "I guess I need to do something about my..."
Begins to imagine how life might be after a change.
COMMUNICATING FREE CHOICE
Used during the commitment-strengthening process.
It's up to you what you do about this.
No one can decide this for you.
No one can change your (behaviour) for you. Only you can do it.
You can decide to go on just as you were or to change.
CONSEQUENCES OF ACTION AND INACTION
Ask the client to anticipate the result if they continue the behaviour as before.
Make a written list of possible negative and positive consequences.
Invite discussion of possible fears of changing.
Use reflection, summarizing, and reframing.
NEGOTIATING A CHANGE PLAN
The changes I want to make are...
The most important reasons I want to make these changes are...
The steps I plan to take in changing are..(specific, concrete, doable)
The ways other people can help me are...
I will know that my plan is working if...
Some things that could interfere with my plan are...
ASKING OF COMMITMENT
Are you ready to commit yourself to doing this?
Clarify what exactly the client plans to do.
Reinforce the likely benefits of change and the consequences of inaction.
Ask what concerns, fears, or doubts might interfere with carrying out the plan.
Ask what obstacles might be encountered and how they can be dealt with. Clarify the significant others role in helping.
Remind the client of your support.
Motivational Counseling Strategies
Reviewing a Typical Day
Here, the counsellor builds rapport while gathering information. The counsellor avoids a focus on "problem behaviours," focusing instead on how substance use fits in to the person's life. Rollnick et al. (1992) suggest starting with, "Can we spend the next 5-10 minutes going through a day from beginning to end. What happened, how did you feel, and where did your use of xxx fit in? Let's start at the beginning." (P. 30). Proceed to help the client tell a story of the day, focusing on feelings and behaviours. If the client is receptive, summarize, then move to the next strategy.
Looking Back
This strategy simply involves engaging in a conversation with the client about what life was like "before." Before substance use problems, before legal, work or relationship difficulties, etc. What does the client remember? What good memories, hopes, dreams or plans did the person once have? What successes, achievements did the person have? If the person's history is very negative, it may still be useful to explore "what it was like," not necessarily in an attempt to process or resolve issues from that time, but primarily to establish the situation that existed before substance problems.
These techniques can be spurred by a client comment such as, "I used to have it all" or "I wasn't always this way." This is a natural segue for a therapist comment and question, "So things have really changed. Tell me a little bit about what life was like back then." Then the therapist uses OARS to keep momentum going and to elicit how the problem behaviour fit into this circumstance and/or how it changed over time. For example, if drinking is the client issue, then, "So I'm wondering how your drinking fit in back then." Then later, the therapist might ask, "It sounds like your drinking changed over time. Tell me about that."
Then, you can explore how the client's path went from those previous dreams, plans successes or stressors into occasional, regular or chronic substance use. Again, the goal is not "insight" into deep psychological processes, just an establishment of some history to help "ground" the client as those with substance problems often seem caught in the "here and now" and sometimes seem to have lost a deep sense of self, of who they feel they are. The goal is for the client to obtain some perspective from the immediacy of his or her circumstance and to observe either how things have changed over time.
Good Things and Less Good Things
This strategy is simply to review what is "good" about substance use alongside a review of what is "not-so-good" about the use of substances. Steve Rollnick developed this phrasing for a particular purpose; namely, he wanted to avoid labelling a behaviour as a problem when the client was not using that language. Failure to do this may lead to arguments with clients where they state adamantly the behaviour is not a problem.
Conversely, clients are often willing to acknowledge that there are less good things about a behaviour. behaviour. The technique also provides the therapist an opportunity to explore what "positives" may be sustaining a behaviour. This is often a very fruitful inquiry and typically quite surprising to clients. They are often confronted with why they need to change a behaviour, but only rarely asked what benefits they are receiving. This often serves to reduce resistance and allows inquiry into the Less Good things to be more acceptable to the client. We start this technique with a prefacing comment, then follow with a question about the Good Things. We follow up until all the Good Things have been exhausted. We summarize, then ask about the Less Good Things.
These are then explored in more detail with requests made for examples of Less Good behaviour. For example, "You said that your use had affected your children. Tell me about a time that happened." Once this area is fully explored, we summarize, emphasize any change talk that emerged, and then ask the client what their take on this material might be. The most important part of this strategy is to avoid labelling things as a problem.
Some counsellors have begun using an alternate focus for the exploration of "good things and not-so-good things" - asking clients to talk about their experiences at AA or NA meetings and considering both "pros" of attending as well as "cons." The goal is to engage the client in sharing both likes and dislikes with the intention of reducing resistance or unhappiness about attending these meetings by "getting things out in the air." Often, people are more willing to accept the "good things" about meetings if their counsellor explores and gives respect to what clients see as the "not-so-good" things.
Discussing the Stages of Change
Below is an example of how a counsellor might talk with a client about the stages of change. After an explanation such as the one below (or something briefer!), the counsellor might ask the client to react to the explanation just given about the stages of change. The counsellor might ask the client to think about things they have changed in the past, and examples of when they were in the various stages of change during this process. If a client previously got stuck in a stage, ask the person to think about what methods they were using during that stage, if he or she can identify any. Write these down as well. Spend some time discussing the client's experiences with change, and consider focusing more on "less threatening" changes such as diet, adhering to medical advice, cigarette smoking, work habits, exercise, rather than on drug and alcohol abuse. This can reduce defensiveness about drug and alcohol in later sessions and help to teach how changing addictive behaviours is similar to making other changes.
One way a counsellor might introduce the topic:
In or out of treatment, people seem to pass through similar stages as they work on making changes. This goes for many kinds of changes. The same stages seem to apply to people who want to lose weight as they do to people who want to cut down or stop their drinking or drugging.
The first stage of change is called the "Pre-contemplation Stage". During this stage people are not thinking about making a change. This may be because they have never thought much about their situation or they have already thought things through and decided not to change their behaviour. Sometimes people may want to change, but not feel as if they could successfully make the change they desire. People in this stage might find it useful to get more information about their situation.
When people start thinking about their situation, they begin the second stage called the "Contemplation Stage." During this stage, people are "unsure" about what to do. There are both good and not-so-good things about their present situation. People in this stage also struggles with the good and not-so-good things that might come with change. During this stage people often both want change and yet want to stay the same at the same time. This can be a bit confusing for people as they feel torn between these options.
At some point, when people have been thinking through whether or not to change, they may come to feel that the reasons for change outweigh the reasons not to change. As this weight increases on the side of change, the person becomes more determined to do something. This is the beginning of the next stage, called the "Preparation Stage." During this stage, people begin thinking about how they can go about making the change they desire, making plans, and then taking some action toward stopping old behaviours and/or starting new, more productive behaviours. People often become more and more "ready" and committed to making changes.
During the next stage of change called the "Action Stage" people begin to implement their "change plans" and trying out new ways of being. Often, during this stage people let others know what's happening and look for support from them in making these changes.
Once people have succeeded in making and keeping some changes over a period of time they enter the "Maintenance Stage." During this stage, people try to sustain the changes that have been made and to prevent returning to their old ways. This is why this stage is also known as the "Holding Stage." Many times the person is able to keep up the changes made and then makes a permanent exit from the wheel (or spiral) of change. During this stage it is also common for people to have some "slips" or "lapses" where old habits return for a short time.
Sometimes people also have "relapses" which may last a longer period of time. When a person has a relapse, he or she typically returns to the precontemplation or contemplation stages. the person's task is to start around the wheel of change again rather than getting stuck. Keep in mind that relapses, slips, and lapses are normal as a person tries to change any long-standing habit. Often times people go around the wheel of change 3 or 4 (or more) times before permanent change takes hold.
There is some pretty good evidence that people shouldn't skip stages. Someone that jumps right into the action stage may not spend enough time preparing for change. The result is they have trouble in keeping the changes they've made. For this reason, it is important for you to know which stage you're in and what things you need to do to move to the next stage.
Assessment Feedback
Another strategy involves providing feedback to the client about their behaviour. This can be formalized, as in the Drinker's Check-up discussed below, or informal based on information elicited during the course of the intervention. Normative feedback can include information about levels of use, consequences of use or comparison to others. Standardized instruments like the ASI, SASSI, AUDIT or DrInC or InDUC provide ready resources for this type of feedback. The comparison can be to others or within themselves on scales. For example, a therapist could use the DrInC scales to convey where the client acknowledges experiencing problems and where they seem to be doing fine. An informal feedback opportunity that frequent arises is tolerance. Clients often point to their ability to "hold" alcohol as a sign there is not a problem. This statement allows the therapist to offer information about how tolerance operates, including the potential detrimental effects of circumventing this early warning system. Feedback can also be from locally used instruments or information gathered in the session. For example, in exploring HIV risk behaviour, on might elicit information about values, goals and sexual practices and then review with clients the information they shared, including any inconsistencies observed. They then explore together these inconsistencies. The most important point here is the therapist acts simply as a conduit for information. The client is given the job of ascribing meaning. An example of informal feedback might go like this:
Mary, would it be okay if I offered a little information to you based on what we've talked about so far? Correct me if I'm wrong about anything. To begin, it sounds like you've noticed an escalating pattern in your cocaine use. This is a source of some concern to you both because of your parents' history of substance misuse and because you've begun to drop away from your old friends. You're spending a lot more time recovering from the use and the financial drain has begun to create some issues with your husband. You've also noticed the high has changed and your using more to get to that place you want.
Finally, you are concerned about your relationship with your kids. You swore that you were going to be a better mom to your kids than your mom was to you, but now your not so sure how you've done with that. I'm wondering what you make of all this?
Values Exploration
A values focus can help a person define his or her "ideal self" by exploring those behavioural ideals to which the person resonates. Sometimes, individuals have forgotten about these values or have rejected them as naive or unachievable. Simply focusing on these ideals can help open a person detect actual behaviours inconsistent with the ideal.
A focus on values may stimulate motivation for change.
Focusing on discrepancies between ideal life conditions and actual conditions may induce a desire to "recalibrate" daily behaviours to be more congruent with deeply held beliefs. Awakened to a deeper sense of self and values, the person may become increasingly aware that the problematic behaviours meet certain short-term needs but do not lead to fulfilment of higher values or long-term satisfaction. Focusing on ideals can help decrease clients' defensiveness and increase desire for change by shifting the focus away from consideration of "bad" behaviours or lifestyle, toward a focus on a more deeply satisfying lifestyle that can be pursued and enjoyed. Clients may come to perceive that they do not necessarily have to purge valued aspects of their current self; instead they need to restrain certain tendencies in order to develop a deeper, more aware self and live with a greater sense of purpose (importance) and power (confidence).
Ambivalence about various possibilities can be viewed in part as the experiential result of multiple conflicting values. While ambivalence may be resolved from concluding that longer-term values (for example, stable job, good family and friend relationships, ownership of property) take precedence over short-term values (for example, fun, relief from stress or anxiety, excitement), there are other paths to its resolution. Sometimes, it is not so much a conflict between the long- and short-term values themselves but an issue that the strategies for fulfilling short-term values are precisely those strategies that prevent fulfilling the longer-term values. There are other ways to gain excitement other than using cocaine and living a fast lifestyle. By seeking with the client the positive motivations behind the problem behaviours, we can open the door to consideration of alternative behaviours that address short-term needs without unduly interfering with the pursuit of long-term goals.
In addition to a general discussion of the client's values, counsellors can use a set of values cards and have the client sort through the cards and order them in accordance with his or her priorities. Topics discussed may include the meaning of the various values statements, evaluation of current consistency between values and behaviour, perceived barriers to and opportunities for increasing value-behaviour consistency, and personal evaluation of the extent to which the use of substances plays a role in achieving or preventing consistency. Counsellors sometimes report that this technique increased the ease of practice as well as client engagement.
One study of individuals who have made "quantum" changes shows the dramatic shifts in values that individuals can undergo in a very brief timeframe.
Looking Forward
Looking Forward has a similar focus to Looking Back. It has the client envision two futures. The first is if they continue on the same path without any changes where they might be five or ten years from now. The second future is if - and the emphasis is on if - they decided to make a change in their behaviour, what that future might look like. The therapist's job is not argue one position or another, but rather just elicit the information and then ask the client to comment on these imaginings.
Exploring Importance and Confidence
A recent strategy developed by Rollnick and colleagues (Rollnick, Mason, & Butler, 1999) involves the dimensions of importance and confidence. This strategy essentially explores the client's impressions of how important is to make a change and how confident he or she is that he or she can succeed in changing. The therapist explores the client's impressions of what it is that makes the change important, how this change fits in with other aspects of his or her life, and what events may transpire to make this change seem more important than it currently does. The issues around a person's confidence in changing are explored in a similar way, and the therapist may guide the client to review past change attempts and determine how the therapist and significant others could help the person succeed in making a change.
Decisional Balance
The decisional balance exercise is a values exercise similar to good things/less good things, except with a focus on future behaviour. Counsellors ask clients to identify the anticipated "pros" and "cons" of changing a behaviour, then compare this with the pros and cons of not changing the behaviour. Once the pros and cons have been identified, counsellors may ask clients to consider which of these options best meet clients' ideals while also tending to their preferences for experiences. Counsellors may reflect that clients have the opportunity to create different lifestyles and to choose in part who they will become in the future through the course of action they choose.
As with a number of these strategies, this one can be done on paper as preparation for or a supplement to a conversational approach.
Change Planning
A change plan is a technique that can be quite helpful with clients that are ready to do this type of work. To avoid a premature focus on action plans, some have taken to calling these forms, "The Next 90 days." This form can then be used to record any number of actions including simply thinking more about an issue. This form typically includes just a few simple questions (Fill in), which the therapist and client fill in conjointly.
Do it All in a Moment or Two
One counsellor, Chris Dunn, has offered what he calls the 20-second MI intervention. Apparently, there are also colleagues at Kaiser-Permanente in Portland who are doing similar work. The basic premise is you have a very brief amount of time and a potentially thorny issue to solve. Chris simply clicks through an acronym-based model called FRAMES and leaves the client with the responsibility for making a choice. For example:
So, Bill you are in your third week of treatment and your feeling like you've accomplished everything you need to (FEEDBACK). My sense is you've begun exploring what's led to your drinking (FEEDBACK). I am concerned that you've not spent much time thinking about how you'll handle your home life (FEEDBACK). If you asked for my advice, I would recommend you stick with treatment a little longer and work on this area (ADVICE). However, there may be other ways to do this (MENU OF OPTIONS) and the choice is really yours to make (RESPONSIBILITY). I know you've been feeling antsy (EMPATHY) and I have faith that you can make a good decision (SELF-EFFICACY). What do you think?
Monitoring the effectiveness of your use of MI Strategies
Although formal research methods for client outcomes are a worthwhile goal, this is unlikely to be available for many clinicians. A much more practical method is available for practitioners: observe your clients. If during the session they are constantly arguing, disagreeing or ignoring you, then what you are doing is not working. It's a signal that you should shift methods. Even if you convince them of the folly of their ways, change is unlikely to be sustained under these circumstances. If clients agree to do something between sessions, then fail to do it, this does not necessarily mean there is a problem. It may simply be ambivalence. However, if it happens consistently, then you may be arguing for change and the client is simply acquiescing. It is time to focus on listening to your client. Finally, if your client's don't return for sessions, it may be a sign that they are giving up you rather than the problem behaviour. You may have pressed too hard for a change the client was not ready to make. Our advice: pay attention to your clients, they tell you one way or another how you are doing.
Motivational Interviewing and Other Ways of Listening
Confrontational (Gestalt)
Emphasis on user owning the issue for change to happen
Resistance seen as denial
User is therefore seen as incapable of making decisions
Motivational Interviewing
Ownership seen as irrelevant for change to occur – labels as not useful
Resistance is a part of the relationship
Client’s acceptance of the goals is seen as vital
Cognitive – Behavioural
Assumes the client is motivated
Teaches coping behaviours
Seeks to identify and modify certain cognitions
Motivational Interviewing
Employs specific strategies for motivating clients
Elicits coping strategies from the client
Explores and reflects client perceptions
Non Directive (Rogarian)
Allows the client to determine the content and direction of sessions
Avoids the worker giving advice and feedback
Empathetic reflection is used non contingently
Motivational Interviewing
Systematically directs the client towards motivation to change
Offers advice and feedback when appropriate
Empathetic reflection is used selectively to reinforce change
This article was posted by Kevin Patton
