Motivational interviewing (MI) is an evidence-based intervention that has been used to elicit intrinsic motivation to change behaviours. MI focuses on facilitating movement through Prochaska and DiClemente’s the transtheoretical model of change (TMM). TTM also known as The Stages of Change Model provides an understanding of behaviour change as an intentional process where the pros and cons of changing causes ambivalence. Ambivalence is a state of confliction where contradicting attitudes or feelings exist in an individual. These individuals feel stuck between wanting and not wanting to change. The transtheoretical model helps understand the processes individuals undergo when changing a problematic behaviour. This model involves progress through five stages of change: precontemplation, contemplation, preparation, action and maintenance. This model recognises that different people are in different stages of change and allows for an understanding of where people are in their behaviour and what interventions would be suitable.
Precontemplation – in this stage, an individual does not intend to take action in changing their behaviour. They are usually uninformed or unaware of that they have a problematic behaviour and usually tend to be defensive about it. individuals in the precontemplation stage are characterised as unmotivated and are not ready or interested in help.
Contemplation – Individuals in this stage will begin to recognise that their behaviour may be problematic. They weight the pros and cons of altering their behaviour. Contemplators tend to be ambivalent about the change as they are not sure how to change or feel as if they lack confidence to change. This ambivalence can cause the individual to feel stuck in this stage for a long time.
Preparation – In the preparation stage, people intend to take action and become less ambivalent about taking the next step. These individuals begin to realise that the cons overrule the pros and therefor believe that a change is necessary. These individuals typically have a plan of action, for example joining a gym, reducing the number of cigarettes.
Action- Is the stage where most individuals have made significant modifications in their lifestyles and intend on moving forward with that. they seem to be actively involved in taking steps in changing their problematic behaviour as they believe they have the willpower to change that behaviour.
Maintenance – In this stage the patient has sustained their behaviour change and is able to successfully avoid any temptations to return to their previous behaviour and be able to avoid relapse. Relapse is a factor in that takes place in the action or maintenance stages. It is a form of regression, where the individual returns to an earlier stage.
MI is an effective person-centred counselling method used to interact with patients to elicit behaviour change. It is used to “enhance motivation through the resolution of ambivalence”. MI is supported by five principles that accentuate a shared therapeutic communication where the autonomy of the patient is highly valued and the fundamental recourses for change are elicited by the healthcare professional. According to Hall et al. (2012) the healthcare professional in MI is considered a “facilitator rather than an expert, who adopts a no confrontational approach to guide the patient toward change”. The spirit of the MI is seen to be of one that is collaborative, evocative and honouring of the patient’s autonomy. Collaboration is where there is a partnership between the practitioner and the patient, where rapport and trust are built. The practitioner recognises the patient’s knowledge about themselves. Evocation is where the practitioner draws out the patient’s own motivation for change rather than evoking or encouraging their reasons for change. MI recognises that ultimately, the power for change rests with the client. By acknowledging the patient’s rights and freedom for change, the practitioner is therefore honouring the patient’s autonomy.
The practice of MI involves the use of certain skills. These skills assist in establishing a therapeutic relationship and building rapport while bringing the MI spirit to life. Open ended questions, Affirmations, Reflections, and Summaries, also known as OARS are the four core counselling techniques employed to build an effective therapeutic relationship and eliciting discussion about change. Asking Alistair Open ended questions can help create forward momentum used to allow the patient think about their thoughts and values about the possibility of change. For example, asking Alistair “can you tell me why you want to lose weight” and “can you tell me about the concerns you have about the effect of your weight”. Using affirmation with Alistair can help him feel that the change is possible even if he has been unsuccessful previously as it supports and strengthens the patient’s efforts for change. Affirmation can take the form of compliments or appreciation and understanding. For example, “I understand that it took a lot of courage for you to discuss your weight problem and I can appreciate that it must be difficult for you”. “So, you are beginning to worry about the impact of you being overweight on your knee” is an example of reflecting. Reflections or reflective listening plays a crucial role in MI, it brings to life the principle of empathy so that the patient can know that the practitioner understands the issues. It involves rephrasing what the patient has talked about and can be used to reinforce the desire for change. Lastly, summarising what has been said throughout the session demonstrates interest and understanding of the patient’s problems. Summarising ensures mutual understanding of all problems and can promote the development of discrepancies between the person’s current situation and future goals. For example, when talking to Alistair, “I would just like to check that I have understood everything so far. You are worried that your weight is the reason your knee has given in and you are worried what effects it has on your health. Is that correct?”.
There are four major principles that bring to life the elements of the MI and guide its practice. Expressing empathy involves placing oneself in the other person’s shoes and seeing the world through their eyes. This approach allows the patient to be heard and understood. As MI is an approach that believes patients have the power to change successfully, the practitioner can then be supporting self -efficacy. By promoting self-efficacy, the practitioner can help the individual improve their confidence that they are capable of change. Self-efficacy can be promoted by highlighting the patient’s strengths and highlighting all the times they have been successful in changing any aspect of their life. Moreover, resistance can occur in treatment when the patient’s views juxtapose those of the practitioner’s or when the patient feels like their freedom or autonomy is being invaded. This is usually based in the client’s ambivalence of change. Rolling with resistance involves approaching the resistance without judgment. MI then uses strategies such as “emphasising the individual’s choice to change or not (‘it’s up to you’), shifting the focus of the discussion or simply reframing what the person has said, in order to roll with resistance and prevent resistance from affecting engagement”. Finally, developing discrepancies between the patient’s current behaviour and future goals helps ‘tip the balance’ towards change. This can be done by exploring the pros and cons of change.
The central notion of MI is eliciting reasons for behaviour change, rather than informing them of reasons why they should change their behaviour. For example, with Alistair, through the case study, we can clearly identify that he is in the contemplation stage as he is beginning to recognise that his weight may be a problem that is affecting him as he is questioning if him being overweight is the reason that his knee gave in. one technique that can be used to aid Alastair is weighing up the pros and cons of change with Alistair and help him asking him open ended questions such as “what concerns do you have about the effect of your weight?” “What future goals or values will be impacted by your weight”.
Another useful strategy is to reframe any negative statements about the problem by re-expressing the statement with a positive connotation. This should increase Alistair’s commitment to change and therefore will proceed to the preparation stage. Helping Alistair progress from the preparation stage to the action stage will require creating a plan for him for change to get him prepared to act. Creating a solid plan provides the opportunity to consider any potential obstacles that may be faced throughout the change and therefore will make the patient prepared. Being prepared allows the person to be more eager to get started. Alistair may ask what he should be doing to change, one way to prompt him to make the suggestion is by asking “what do you think you will do to start losing weight”. Once the patient has made the plan, it will then guide them to the action stage. Having that rapport and trust between the practitioner and the patient that was built through the principles of MI allows the client to confide in you in what and how they are feeling about the change. For example, having that trustful, therapeutic relationship with Alistair will allow him to reveal any concerns he has. The practitioner can then be able to help resolve any barriers. This can decrease the rate of termination or relapse and will then lead the patient to the maintenance stage as it will stabilise change.
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