Motivational Interviewing PDF

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Motivational Interviewing -

Theory, research, and practice

Is Motivation a “Thing”? • Analysis of natural language would suggest that we think of motivation as a thing which people have or don’t have, or have not enough or enough of, or the wrong “type” of • I don’t have any motivation today • He’s not got enough motivation to quite smoking • OR that it’s a quality of a person which can come and go or be persistent and static • I’m feeling very motivated this morning • She’s a very motivated person • This tricks us into conceptualising motivation as something “internal” to the person which somehow causes their behaviour

BUT “motivation” doesn’t explain anything about a person’s behaviour. • If they did X then they were motivated to do X. • If they didn’t do X then they weren’t motivated to do X. • Treating motivation as a quality of a person has unhelpful effects • We should wait until we FEEL motivated before acting • Healthcare professionals are responsible for “giving” someone motivation to change If someone lacks motivation to change, there is nothing to be done about it •

The Goal Theory of Current Concerns (Cox & Klinger, 2011)

An alternative model of “motivation” •

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Instead of focusing on whether or not someone achieves a certain internal “state”, think about the concepts we know empirically have a relationship to behaviour change Can we think about and talk about commitment to behaviour change WITHOUT talking about motivation?

Self-Control Theory (Rehm, 1977) •

Three requirements for self-motivated behaviour:

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Self-monitoring – Attending to our own behaviour and its consequences (can be biased to e.g. attend only to failure or negative consequences) Self-evaluation – Comparison of progress in relation to an internal standard (which may be biased/distorted) Self-reinforcement – Positive or negative feedback to the self A breakdown in any one of the three processes can impair motivation (and lead to depression)

Self-Discrepancy (Higgins, 1987) Evidence for the specificity of discrepancyaffect relations is mixed: Ozgul et al (2003) found no specific links and no effect of self-discrepancy beyond negative self-concept Watson et al (2016) found specific and longterm effects Models may also include the undesired self (ogilvie, 1987)

Cognitive Dissonance (Festinger, 1957): • •

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A state of discomfort cause by awareness of inconsistency between two beliefs of a belief and one’s behaviour, and which motivates people to reduce this discomfort. It is an emotional state, relating to the “self-conscious emotions” i.e. guilt, shame and pride. We are evolutionarily designed to reduce unpleasant emotional states and maximise pleasant ones. Reducing dissonance can be done by: • Ignoring/denying the discrepancy • Justifying the discrepancy • Minimising the discrepancy • Blaming the discomfort on something other than the discrepancy • Making a decision to alter the behaviour (Draycott and Dabbs (1998) for a review)

Self-Determination (Ryan and Deci, 2017) •

Basic Psychological Needs

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• Autonomy • Competence • Relatedness Internalising goals and values requires that all three needs are met Internal motivation to achieve goals is reduced to the extent that basic psychological needs are not met Persistence in effortful behaviour is impaired to the degree that motivation is not “internal”

Reactance (Brehm, 1966) -

Belief that one is capable of carrying out a particular behaviour if one chose. Distinct from the belief that the behaviour will produce a given outcome Low self-efficacy can be used as a justification, reducing dissonance and removing motivation to change. Self-efficacy is a variable phenomenon. People may have broad efficacy beliefs or efficacy beliefs only restricted to narrow situations They may believe they can only be efficacious with easy tasks or with easy and hard tasks.

Attributions and Expectancies •

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Locus of control(Rotter, 1954) • A stable tendency to attribute events and experiences to internal factors (e.g. effort, ability) or external factors (e.g. luck, powerful others). Locus of causality • A stable tendency to attribute the causes of one’s own behaviour to internal or external factors (deCharm, 1968)

Technical Definition of MI: “A collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” Miller’s Current Theory of MI •

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The resolution of ambivalence is promoted by accurate empathy (a la Rogerian counselling) And

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Resolution of ambivalence in a particular direction is influenced by the counselor’s differential reinforcement of client speech

Schematic Process of Motivational Interviewing

PROJECT MATCH 1993: •

Large multisite trial of several approaches to treatment of addiction: • 9 sites with 1,726 clients • Outcomes through 3 years of follow-up

Comparing Motivational Enhancement Therapy (4 sessions) with 12-step and CBT programmes (12 sessions) and assessing for whether matching clients to treatments improved outcomes • Similar outcomes for 4 sessions MET vs both 12-session programmes (Babor & Del Boca, 2003; Holder et al., 2000; Project MATCH Research Group, 1997, 1998a). • MET more cost-effective Effect size of MI doubled for clients from minority populations vs White/non-Hispanic (Hettema, Steele & Miller, 2005) Most “matching” variables had no effect, but MET more effective for “angry” clients •

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Current state of outcome research Lundhal et al (2010) meta-analysis - Some degree of effectiveness has been shown in substance misuse, reducing risky behaviours and increasing adherence to treatment - In general, MI is often as effective as more intensive treatments in “head to head” comparisons - The size of the MI effect is highly variable across studies – mostly small to medium effects which can endure for up to 12 months - MI may increase the efficacy of other treatments as adjunct - MI may be less effective if an explicit manual is followed - May be associated with adverse outcomes with clients who were already “ready for change” Frost et al (2018) review of reviews - No high-quality evidence in meta-analyses of outcome due to methodological flaws and poor quality of studies - MI appears effective for stopping unhealthy behaviour, less so for promoting healthy behaviour Current state of process research

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Magill et al (2014) meta-analysis

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Mi-consistent interventions lead to increased levels of change talk, but also of sustain talk Mi-inconsistent interventions lead to no improvement in change talk and increased levels of sustain talk Sustain talk predicts lack of change BUT change talk does NOT predict behaviour change Proportion of change to sustain talk predicts behaviour change

Predicting change •

As reported in Miller and Rose (2009) • Those with successful outcomes showed a steady increase in strength of expressed commitment to change over a session of MET • Those with unsuccessful outcomes also showed an increase in strength of commitment, but this dropped just before the end of the session • It was at this point that the MET manual required discussion of a change plan and asking about commitment to change

Research on Training Self-reported proficiency in MI is unrelated to coding of their skills by observers, and only the latter relates to treatment outcome (Miller & Mount, 2001; Martinez & Pirritano, 2004) • Only modest changes in practice and no difference in clients’ responses in session after brief MI workshops (Miller & Mount, 2000; Rubel, Sobell, & Miller, 2000) • Miller et al (2004) RCT of training approaches: progressive individual feedback and personal follow-up coaching. Clients of those who received either form of enhanced training showed higher levels of change and commitment talk. Miller and Rose (2009) Summary •

Current Practice of MI “The Rule of 4”

4 ASPECTS OF SPIRIT: 1. Partnership (MI is done “for” and “with” a person, never “to” the person) 2. Acceptance (having an unconditional positive regard, accurate empathy, autonomy support, affirmation) 3. Compassion (give priority to the person’s welfare and needs) 4. Evocation (“you have what you need, and together we will find it”) THE FOUR MI PROCESSES:

ENGAGING: •

Establishing a mutually trusting and respectful helping relationship • Avoiding early traps (e.g. premature focus, labelling, being the expert • Focusing on e.g. the clients’ goals, how important they are to them, offering hope • Using listening skills and avoiding “roadblocks to listening” • Reflection as the key skill • Exploring values and goals as the main focus, leading to exploration of discrepancies

FOCUSING: •

An ongoing process of seeking and maintaining direction • Three sources – the client, the setting and clinical expertise • The style of focusing is “guiding” – between directing and following • May need to start with and return to “agenda mapping”, especially if stuck, needing to change direction or needing to introduce topics which are being avoided. • Ethical issues arise where the client and therapist do not share the same treatment goals – should we influence them towards the goals we believe are “correct”? • Principles of nonmaleficence, beneficence, autonomy and justice • Avoid MI if you have a personal investment in the client’s change, especially if you also hold coercive power over them

EVOKING: •

Focus in on eliciting and amplifying change talk in order to encourage commitment • Awareness of “preparatory” and “mobilising” change talk • Awareness of “sustain talk” or resistance • Methods of evoking change talk

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Amplify change talk using MI skills Respond to sustain talk Need to focus on both issues of “importance” and “confidence”

PLANNING: •

Only when there is a balance of talk which favours change is the client ready to plan how to change • Don’t get ahead of the client’s readiness • If the client is raising the problems and you're providing the answers, you’re in the wrong chair. • Break down the plan into specifics • Continue to evoke and strengthen commitment talk • Can be useful to explicitly explore reluctance and doubt

THE FOUR MI PRINCIPLES:

Express Empathy Acceptance facilitates change. Skilful reflective listening is fundamental. Ambivalence is normal. Develop Discrepancy Awareness of consequences is important. A discrepancy between present behaviour and important goals will motivate change. The client should present the arguments for change.

Support Self-Efficacy Belief in the possibility of change is an important motivator The client is responsible for choosing and carrying out personal change The counsellor’s own belief in the person's ability to change becomes a self-fulfilling prophecy There is hope in the range of alternative approaches available

Roll with Resistance “Sustain talk” is natural and sometime inevitable Arguing, debating, challenging, persuading, etc. can all lead to more sustain talk Metaphor of dancing instead of wrestling

Four MI Skills: •

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Open questions • Remember, even a superficially “open” question can in fact be closed if the answer is directed by the question • Avoid “do you” and “don’t you” questions Affirmations • “Cheerleading” for your client • Focusing on their strengths, abilities and successes • Even if their only “success” is being willing to talk to you Reflections • The bedrock of MI • Statements which summarise your understanding of what your client means by what they have said. Summaries • An opportunity to show again your understanding • A way of structuring the conversation, pulling disparate threads together before perhaps changing topic

FOUR THINGS MI IS NOT: 1. Client centered counselling, or just being nice 2. A set of techniques 3. A panacea 4. A way of manipulating someone into doing what you want them to do 5. Not a method of persuasion

CHANGE TALK:

Techniques for eliciting change talk: - Evocative questions - Ask for elaboration - Query extremes - Looking forward or back - Importance and confidence ruklers - Opinions of trusted others - Discuss values, goals and self image - Sliding with the negative REFLECTION: • • • •

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A STATEMENT of your understanding of what the person means by what they’ve said. Repeating an element of what the speaker has said. Rephrasing what the speaker said, but substituting synonyms or slightly rephrasing what was offered. Paraphrasing, in which the listener infers the meaning in what was said and reflects this back in new words. This adds to and extends what was actually said and “reads between the lines” Reflection of feeling. Often regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimension through feeling statements, metaphor, etc.

Reflection Strategies for Handling Sustain Talk

STRATEGIC REPONSES FOR HANDLING SUSTAIN TALK: • Shifting Focus • If all else fails, change the topic. Do not allow sustain talk to continue • Positive Reframing • Invite the client to consider an alternative interpretation of their experiences • “It sounds like your partner is very worried for you” Agreement with a twist • Reflection or affirmation followed by a reframe • “You don’t get drunk when you drink. That’s not uncommon once the body has become tolerant to alcohol” • Emphasising Personal Choice and Control • “No one can force you to stop injecting. That is always going to be down to your own choice and no-one else’s” • Take the “one down” position • Siding with the Negative (“Therapeutic Paradox”) “You’ve got some really good reasons for continuing to take drugs, and not many reasons to stop. Maybe you need to be taking drugs for the forseeable future” •...