University of Worcester Institute of Health & Society Motivational Interviewing

Rationale Motivational interviewing was developed by William Miller & Steve Rollnick The 1st Edition of their book was published in 1991 and had a focus on ‘addictive’ behaviours What are some of the challenges of working with substance users?

MI was developed in response to working with client resistance in alcohol treatment in the late 1980’s It works in relatively ‘brief’ interventions It is a more helpful ‘stance’ in working with high levels of resistance in clients than a confrontational or coercive style

Conceptualising change Underpinning the approach is an understanding of change as a process Ambivalence – being in 2 minds about change Typically as the moment of change approaches we experience resistance. Can you think of a behaviour you have tried to change?

Transtheoretical Model of Change (Prochaska & DiClemente 1982) The transtheoretical model of change had proved a useful model for understanding the process that people go through in changing their behaviour.

Precontemplation Contemplation Action Maintenance Relapse

Groupwork Discuss with someone else how this model could be used to inform work With service users With social work students

What is it and where does it come from? “a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002: 25) A blend of different therapeutic approaches, inc. Person-Centred, Solution- Focused and cognitive-behavioural ideas/theories with a process model of change Emphasises empowerment and seeks to involve the service user in the work of changing their behaviour

Conceptualising motivation 3 distinct components Importance – the extent to which someone wants to change Confidence - the extent to which someone believes they have an ability to change Readiness – whether someone is ready to make a change How can this be used in practice?

To Change Behaviour we need to… Recognise the Advantages of Change “Things would be better if I did……” Feel we have the Self-Worth to make the change “I deserve better than this….” Believe in our own Ability “I can do this….” Have knowledge of Alternative Behaviours “What I’m going to do differently is…”

Intrinsic motivation Source of motivation to change is unique to everyone Aim to identify what it is and use this as the source of motivation to fuel the actions towards change

The approach Deficit v Strengths focus Encourages positive engagement Acknowledges and works with client resistance Is collaborative, not collusive Can help prevent worker burn-out by enabling you to work ‘smarter not harder’

Important Concepts in MI Helping Clients develop discrepancy; “the active ingredient underlying motivational interviewing’s efficacy” Originally developed from Festingers Cognitive Dissonance Theory (1957) ALSO… Internal v External motivations to change; Internal motivation is associated with greater long term change. Research shows people with low internal motivation have worse outcomes and people with higher levels of both internal and external motivation are better retained in services and have better outcomes. (Deci and Ryan, 1985, 1987, Curry et al 1991)

Micro-skills or ‘OARS’ MI is like a tree? Micro-skills or ‘OARS’ Principles ‘Spirit’

The ‘Spirit’ of MI Collaboration (not confrontation) – partnership approach Evocation (not education) – service users are experts Autonomy (not authority) – values and respects service users’ choices Are there therefore areas of practice which would conflict with these principles?

Principles of MI

1. Express empathy Acceptance is a re-requisite to starting the process of change Reflective listening is an essential response Expect to be met with ambivalence The SU should be seen as capable of changing

2. Develop discrepancy Awareness of the consequences of no change is important Awareness of any differences in what a SU wants or values and the current behaviours they display, e.g. “How do your current eating habits help or hinder you in losing weight?” The SU should put forward arguments for change

3. Avoid argument Arguments are counterproductive Defending breeds defensiveness What you pay attention to gets bigger - If you attempt to overcome resistance by arguing in favour of change this merely encourages the other person to take the polar opposite position of arguing against change and finding more and more reasons for why change is not possible

4. Roll with resistance Move on and try other strategies See it from the SU’s point of view

5. Support self efficacy SU will be motivated if they have a belief in the possibility of change A belief in their ability to succeed They are responsible for choosing how they will change

The Micro Skills or ‘OARS’ Ask Open Ended questions Affirm (statements of encouragement, e.g. “I appreciate your honesty” Doesn’t have to relate to the problem behaviour) Listen Reflectively Summarise …………….and Encourage and elicit Change-Talk

Affirmation examples “I saw you with your children, it’s clear you really care about your family” “Your frustration is understandable, you have been trying to work on this for some time” “It must have taken a lot of courage to come in here today knowing you haven’t met your goals.”

Scaling questions On a scale of 0 to10 how important is it for you to make this change? What does this number mean to you? Why are you at that number and not zero? What would need to happen for you to move to [higher number]? What can I do to help you move to [higher number]? The same process should be done with confidence

‘Raising’ Ambivalence – Decisional Balance Strategy Decisional balance worksheets can be used How does…….fit into your life? What do you like.. How does …work for you? Downsides etc etc…. If you’re still doing this/If nothing has changed in….weeks/months/years, what will life look like/what will be happening?

Eliciting negative consequences motivationally What difficulties have you had in relation to …? How might your …. Stop you doing what you want to do? In what ways do you think other people might be affected? What do you think will happen if you don’t make a change?

Looking back What were things like in your life before the (current behaviour)? Do you remember a time when things were going well for you? Tell me what was different about that time?

Looking forward How would you like for your life to be different? How do you envisage your life in 5 years? How has you current behaviour helped or hindered you in reaching this goal?

References Arnull, E (2014) Understanding substance misuse policy and practice. Northwich, Critical Publishing. Goodman, A (2009) Social work with drug and substance misusers 2nd Ed. Exeter, Learning Matters. Teater, B (2010) An introduction to applying social work theories and methods Maidenhead, OUP