Today I am going to be discussing basic principles of one of my favorite approaches to supporting and motivating change: Motivational interviewing. I have noted benefits of motivational interviewing during my professional practice as well as my personal life with my loved ones. I have since, applied, researched and put in a deep thought about motivational interviewing.
We all want to support our loved ones through their journey in to making positive changes and we should do just that support. It is not our place to impose change on anyone unless they are presenting as a threat to themselves or society. We can, however, understand the trans theoretical stage of change a person is at, on a problem behaviour and use the motivational interviewing tools to motivate and support the people we love, wherever they fall on the stages of change ladder. As hard as it may be, we need understand that not every stage is the right stage to change and pushing change on an individual when they are not ready will only push them further away from desiring change.
The spirit of Motivational Interviewing
Motivational interviewing(MI) is based on four strategies and four principles. The O.A.R.S. (Open-ended questions, affirmation, reflective listening, summarizing) are the four strategies used during MI to provide a client centered counselling to the patient, client or a loved one. MI aims to open the floor for change by recognizing, reinforcing, eliciting and strengthening change talk. It creates a safe space to communicate possibility of change without trapping the individual into a committed plan. It lets the individual to put a foot in the door and peek into change at any moment. It encourages “rolling with resistance” and avoiding argumentation through this process. As flexible as this motivational tool is, it also allows space to develop a change plan, consolidate client commitment and there is an option to shift between MI and other methods.
GENERAL PRINCIPLES ofMI
There are four principles of MI which can be implemented for successful brief interventions. It uses a recovery coach style of intervention that is derived from the field of addictions counseling.
- EXPRESS EMPATHY
Expressing empathy is at the core of MI. It is a non-judgmental and accurate understanding of where the patient is in terms of wanting to change. It requires putting yourself in the shoes of the patient/client. MI is based on understanding that people will not change, unless you accept them for where they are at now. As an MI provider you go in with the intention of accepting that patient will not express intentions to change early and it might not be the right time for the patient to change. Empathy helps build trust and rapport which enhances patient/provider communication.
- DEVELOP DISCREPANCY
The second principle of MI is to work with the ambivalence that is already present within the patient in order to support the patient through his/her change. The goal is to create and amplify any discrepancy in the patient/client‟s mind between present and past behavior and future goals. It is about helping the patient look at the consequences of continuing a problem behavior or not adopting a new behavior (often, by looking at the pros of changing and the cons of remaining with the same behaviour). This is not about creating discrepancy in the patient by putting your own bias on the patient’s behaviour to ignite shame or guilt. The hope is that the patient/client will then be the one to present the argument for change and begin to realize the need for change.
- DECISIONAL BALANCE
In the decisional balance component of behaviour change, the key is to understand that ambivalence is a normal part of the process of change. It is about using “conflict” or discrepancy in goals vs. current behaviour to promote positive change. The process of using decisional balance by assessing pros and cons of the behaviour is especially useful in pre-contemplation and contemplation stages of change as a tool to increase motivation.
There are couple key rules while using decisional balance:
- AVOID ARGUMENTATION
MI differs from other approaches to behavior change in that it does not label patients/clients (IE. “non-compliant“). It understands that if the provider senses resistance, it is not that the client is non-compliant, but it is indicative that the strategy is not the right strategy for the patient and it is time to change strategies. This is an important principle behind the success of instilling motivation. Most people will not feel motivated to change if they feel they are not supported in their efforts and feel that they must defend their actions. Most of us are familiar with the fact that DEFENDING breeds DEFENSIVENESS.
- ROLL WITH RESISTANCE
Thus, if you are facing resistance, and different degrees of resistance are present in each change, the key is to let the resistance be expressed instead of trying to fight against it. Arguing in favour of change does not work as ultimately the power to change is in the individual and he/she needs to want it. The provider often simply reflects the patient/client’s questions and concerns back to them, so that they can further examine the possible alternatives. Thus, the patient/client becomes the source of possible answers, he/she does not feel defeated in sharing his/her concerns, and is able to take the risk to express feelings.
- SUPPORT SELF-EFFICACY
An important principle of MI requires the provider to support the patient/client’s belief in his/her ability to change. A way to show the client that he/she can change is to simply present the client with examples of positive change he/she implemented in the past or another aspect of his/her life. It is also equally important to emphasize the significance of taking responsibility. Finally, the patient/client should feel a strong support and a positive rapport with the provider, which furthers their sense of self-efficacy. Supporting self efficacy is especially useful in the Preparation, Action, and Maintenance, and post-relapse of change.
Match intervention to patient’s stage of change
It is important to recognize that not every client will be at the same stage of change. Each client presenting with a desire to change will need to be matched to the stage of change they are presenting with and the most appropriate intervention for this stage should be presented to the client.
According to trans theoretical model there are 5 stages of change:
In this stage assess the patient’s inner conviction and confidence. This is a stage where it is appropriate to present the patient with feedback such as measurement (lab results, monetary implications to their behaviour, etc.) and meaning of these measurements. If the client does not register any ambivalence and they are happy with their behaviour, simply provide them with support and let them know the resources available if they ever contemplate or are ready for change.
This is a stage of change that a client may present with and a number of MI tools can be used for motivating the client for change. Start with understanding that ambivalence is normal and supporting and accepting this ambivalence towards change may facilitate the change itself. In this stage, it is key to avoid argumentation and to roll with resistance. This is a stage where expressing empathy and providing methods to augment the patient’s discrepancy may prepare the patient for
change. The patient’s defence of the status quo tends to diminish the likelihood of change and confrontation causes the patient to defend the problem behavior. Thus, stay away from accepting or rejecting the status quo and understand the patient’s behaviour as an individual rather than labeling him/her under behaviors of individuals with the same behaviour. The goal is to help the PATIENT/CLIENT become the change agent.
If the client is in the preparation stage of change and is ready for change, it is time to provide the client with menu of choices and advice, only if the client want’s guidance. Support the client’s self efficacy in implementing and reinforcing the behavioral change. Let the patient understand that they are responsible for their behaviour alone and implement an action plan to reduce the risk of relapse.
During the maintenance stage make sure the client understands that any behaviour takes about two months to become a habit. Relapse is possible and it is common. Thus, it is important to establish relapse prevention and risk reduction plan. Make sure to reinforce behaviors that resulted in change and identify old behaviors that will compromise it. If relapse does occur, go back to identifying the new current stage of change and re-implementing the behaviour.
MI Strategies or O.A.R.S to use during Intervention
- Open-ended questions
Open ended questions are great tools to use, to open the floor or further elicit change talk as they demand more than one word responses. It’s the difference between, “Are you worried about this or tell me about your concerns about this?” to ” tell me more about this?”. These are some good open-ended question:
Help me understand your feelings/thoughts
Why is this a concern for you?
How do you see this affecting you?
What is this like for you?
These are statements that recognize the client’s strengths and efforts and acknowledges every behaviour, small or big, in the direction of positive change. These are some examples of affirmative statements:
I appreciate that you are willing to meet with me today.
You handled yourself really well in that situation.
If I were in your shoes, I don’t know if I could have managed nearly so well.
- Reflective Listening
Reflective listening leads to the ability to verbally mirror back to your clients what you understood them to say. The more you can effectively use reflective listening, the more you will see increase in client participation (i.e.So what I am hearing is …, I am right in saying…, You were thinking ….). Sometimes it is more important to reflect “negative responses” (such as anger or frustration) as clients might not even know that is what they are projecting.
Am I hearing anger (frustration) in your voice, I am getting the sense of being overwhelmed with the information I am giving you.
Another methods is to use a simple or an amplified reflection to respond to resistance.
An example of a simple reflection:
Client’s response: “If my wife would just get off my back I would do better.”
Practitioner’s Response: “It‟s really frustrating to have people lecture you.”
An example of a amplified reflection:
Client’s response: “My kids are always exaggerating my drinking.”
Practitioner’s Response:“You really don‟t have any problem with alcohol at all.”
Summarizing the client’s thoughts or feelings allows you to maintain control and direction of the interview. It is generally a good note to summarize even if all else fails.
These are examples of summarizing statements.
We‟ve talked about quite a bit today (state each piece discussed). Where do we go from here?
I am hearing you are not interested in our services right now? Help me understand how you would know when our services might be helpful to you?
MI is an accepting and humane approach that supports change
Use MI if you are in a profession that has interaction with changing human behaviour or to support change in a loved one. It is important to match the intervention of the MI to the client’s stage of change and implement many O.A.R.S strategies to facilitate change talk. The core of MI is represented by reflective listening and empathy. Research states that”Emphatic quotient‟ of practitioner predicts positive outcome as well as the ratio of reflective responses to direct questions. Next time, you want to motivate change rather than offering advice use empathy and reflective responses to support the behaviour change.
Miller, W. R., & Myers, T. B. Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions.