Motivational Interviewing. Practice Guide for Practitioners who Support People with Disability

Transcription

1 Motivational Interviewing Practice Guide for Practitioners who Support People with Disability

2 Document approval The Motivational Interviewing Practice Guide has been endorsed and approved by: Anna Edwards A/Executive Director Approved: 19 th August 2014 Document version control Distribution: Document name: Trim Reference: District Directors and Large Residential Centres Motivational Interviewing Practice Guide AT14/57207 Version: Version 1.0 This document replaces Policy link to <procedure/guidelines> Document status: Current File name: Motivational Interviewing Practice Guide Authoring unit: Clinical Innovation and Governance Date: August 2014 Next Review Date: August 2016 Motivational Interviewing Practice Guide

3 Table of contents 1 Introduction Introduction and purpose Common core standards Hyperlinks Copyright Disclaimer: Motivational interviewing What is motivational interviewing? Change Talk Sustain Talk and Discord Why motivational interviewing in disability services? The development of motivational interviewing Motivational Interviewing and FACS ADHC philosophies, values and beliefs What motivational interviewing is not It is not a way of tricking people into doing something they do not want to do It is not just person centred counselling It is not easy to learn and it is not what you are already doing MI is not a panacea Who does motivational interviewing help the most? Motivational interviewing and stages of change What is the evidence for motivational interviewing? Is there evidence supporting the use of motivational interviewing with people with impairments in cognitive functioning? Motivational interviewing and indigenous populations The practice of motivational interviewing? The SPIRIT of motivational interviewing The four processes of motivational interviewing Core micro skills in motivational interviewing OARS Decreasing practitioners behaviours inconsistent with motivational interviewing Agenda mapping, feedback and information exchange Adapting motivational interviewing for individuals with cognitive impairments The use of motivational interviewing when supporting people with disability who cannot have a conversation because of severe cognitive impairment How do people learn to do motivational interviewing? Learning motivational interviewing with FACS References Appendix 1 The definition of disability The definition of intellectual disability Appendix 2 Menu of Options Example Motivational Interviewing Practice Guide

4 1 Introduction 1.1 Introduction and purpose Welcome to the motivational interviewing practice guide. Motivational interviewing is a specialised person centred conversation that can help elicit and strengthen a person s internal motivation to change their behaviour. This resource was developed by Clinical Innovation and Governance (CIG), within Ageing, Disability and Home Care, Department of Family and Community Services, New South Wales, Australia (FACS ADHC). It has been developed to support the FACS ADHC psychology core standard Motivational Interviewing. The definition of disability as it is used here is the one provided in the FACS ADHC common core standard Philosophy, Values and Beliefs Practice Package and is reproduced for ease of reference at Appendix 1. Motivational Interviewing was chosen as a core standard for FACS ADHC psychologists in 2009 by the FACS ADHC psychology practice reference group in order to help psychologists engage people with disability in behaviour support work and help to increase positive outcomes for those people. It was also expected to assist FACS psychologists to engage and work collaboratively with those people in the person s wider circle of support whose engagement is required to help the person with a disability achieve his or her goals. A professional other than a psychologist may choose to complete this core standard and be appraised in the content area if there is adequate support, supervision, opportunity and relevance in developing these skills. Be mindful that the core standards should always be used in the context of the practitioner s scope of practice, their organisational policies and procedures, and their professional obligations. The work practice support person guiding participation in this core standard should have an extensive background in psychology and motivational interviewing. For the rest of this practice guide individuals with disability are referred to as person or people. Those individuals who provide support and other services and who are important to the welfare of the person, for example family members, support workers, case managers, service managers or other practitioners are referred to as important others. Motivational interviewing appears far easier to learn and sustain than it really is. It is not possible to achieve competence in motivational interviewing just by reading about it or by completing a brief workshop. Therefore, this practice guide does not set out to teach someone how to practice motivational interviewing. Instead, its purpose is to provide key information and an overview of the theory and practice of motivational interviewing. The aim is to Motivational Interviewing Practice Guide

5 provide enough information to help practitioners better appreciate how motivational interviewing might fit in with their work supporting a person and their important others. It is hoped this information will allow practitioners to make an informed decision about whether or not to pursue training in this evidence based therapeutic style. The practice guide outlines what motivational interviewing is and considers its possible role in assisting practitioners in their work providing behaviour support. It also looks at what motivational interviewing is not. It looks at who benefits most from a motivational interviewing approach and reviews some of the evidence supporting its use. It introduces the reader to the relational and technical aspects of motivational interviewing and provides some examples of how these apply to the work of a practitioner. It also considers how FACS practitioners can learn to practice motivational interviewing and discusses the FACS/ADHC programme that has helped to introduce interested FACS practitioners to motivational interviewing over the last five years. Finally, it sets out how FACS practitioners, who wish to, can obtain a certificate in Motivational Interviewing in Disability Services from Clinical Innovation and Governance. The main reference for motivational interviewing is the book Motivational Interviewing by William Miller and Stephen Rollnick. This is now in its third edition and is published in 2013 by the Guilford Press. Elaboration on key points in this practice guide can be found in this book as can further aspects of motivational interviewing that are not covered here for reasons of brevity. Also, Professors Miller and Rollnick have always stressed in their writings on motivational interviewing the importance for motivational interviewing practitioners to give back to the community more than they take. Thus, a lot of information and supportive material is available for free at the websites: and Practitioners interested in reading more about motivational interviewing are directed to each of these resources and to the research literature, which contains more than 1000 publications on motivational interviewing. Feedback on this practice guide is welcomed via the core standards address at CIGWebinars@facs.nsw.gov.au ensuring you include the title Motivational Interviewing in the subject line. 1.1 Common core standards This practice guide is designed to stand alone as a resource, but is also intended to be used with the associated motivational interviewing core standards program materials of Frequently Asked Questions and Motivational Interviewing Appraisal. It is enhanced when used with the four common core Motivational Interviewing Practice Guide

6 standards developed for across-discipline use. Information about related legislation, standards and guidelines are covered in the common core standard to guide the practitioner in their work in motivational interviewing. The four common core standards are: 1. Professional Supervision 2. The Working Alliance 3. Philosophy, Values and Beliefs 4. Service Delivery Approaches Professional Supervision The Professional Supervision core standard is designed to help derive the most benefit from professional supervision. It outlines clearly the nature and purpose of supervision and explains how supervision assists practitioners to meet the person's as well as organisational goals. The different roles of the manager and the professional supervisor are explained as is the need to involve line managers in the process of professional supervision. The importance of reflective practice is considered and an explanation of this key process is provided. Finally, the nature of the supervisory relationship is set out and a way to measure this crucial interpersonal process is recommended. The Working Alliance Research has shown that the strength of the working alliance predicts improvement and better outcomes. In fact studies indicate the strength of the alliance may sometimes be more important than the type of treatment practiced. This core standard looks at what the working alliance is, how it is assessed and how it can be strengthened. It considers its central role in intellectual disability, both with the person and their families, and also with support staff. Practitioners also learn a helpful way to measure the working alliance. Philosophies, Values and Beliefs. Over time there has been a shift in how disability is conceptualised and how services are provided. This core standard covers: the definition of disability philosophies and values that direct the disability service system, for example: o social model of disability o international Classification of Functioning, Disability and Health o United Nations' Convention on the Rights of Persons with Disabilities national and NSW Specific strategies, schemes, frameworks and position statements related legislation models of support, for example person and family centred approaches strengths based approach prevention and early intervention lifespan and futures planning Motivational Interviewing Practice Guide

7 community development consent, dignity in risk and safeguarding the application of evidence based practice functional goal setting, outcomes based practice and outcome measurement. Service Delivery Approaches This core standard covers the types of service delivery approaches currently available including: settings team work models service delivery options (e.g. direct and consultative) appropriate services to culturally and linguistically diverse and indigenous populations the development of documentation appropriate to the audience (accessible information) the principles and strategies of positive behaviour support the links between communication and behaviour for people with disability The common core standards include video footage of practitioners and family members discussing the relevance of the topic area to them. The common core standards also include practice guides and appraisals. The Frequently Asked Questions guide answers questions across all the core standards. All these resources can be found at: (you will need to register if this if your first time accessing the website. Register via this link above and choose your own log in data). 1.2 Hyperlinks Where documents or further information is available on the internet, hyperlinks have been provided. Hypertext is a system of storing text, and other computer files that allows direct links to related text and other data. This document is linked through hypertext in various sections to other documents and websites, known as hyperlinks. A Hyperlink is a word or group of words in this document that links to another document or website. To recognise and identify a hyperlink, the word/group of words will be in blue font and underlined. When the computer mouse s arrow is placed over the series of words, a box will appear, indicating that there is a link to another document. The dialogue box will indicate the location of the linked document and how to access the link. To activate the hyperlink press control [CTRL] and with the mouse click on the blue underlined word/s. Motivational Interviewing Practice Guide

8 Please advise Clinical Innovation and Governance if a link does not work, if the website, document or information is no longer valid, or if you would like to suggest any information or resources not currently within this document. 1.3 Copyright The content of this guide has been developed by drawing from a range of resources and people. The developers of this guide have endeavored to acknowledge the source of the information provided in this guide. The guide also has a number of hyperlinks to documents and internet sites. Please be mindful of copyright laws when accessing and utilising the information through hyperlinks. Some content on external websites is provided for your information only and may not be reproduced without the author s written consent. 1.4 Disclaimer: This resource was developed by the Clinical Innovation and Governance Directorate of Ageing, Disability and Home Care in the Department of Family and Community Services, New South Wales, Australia (FACS ). This practice guide has been developed to support practitioners who are working with people with a disability. It has been designed to promote consistent and efficient best practice. It forms part of the supporting resource material for the Core Standards Program developed by FACS ADHC. This resource has references to departmental guidelines, procedures and links, which may not be appropriate for practitioners working in other settings. Practitioners in other workplaces should be guided by the terms and conditions of their employment and current workplace. Access to this document to practitioners working outside of FACS has been provided in the interests of sharing resources. Reproduction of this document is subject to copyright and permission. Please refer to the website disclaimer for more details. The guide is not considered to be the sole source of information on this topic and as such practitioners should read this document in the context of one of many possible resources to assist them in their work. Whilst the information contained in this practice guide has been compiled and presented with all due care, FACS gives no assurance or warranty nor makes any representation as to the accuracy or completeness or legitimacy of its content. FACS does not accept any liability to any person for the information (or the use of such information), which is provided in this practice guide or incorporated into it by reference. Motivational Interviewing Practice Guide

9 2 Motivational interviewing 2.1 What is motivational interviewing? Motivational interviewing is a collaborative conversation between a practitioner and another person that can help to strengthen that person s own motivation and commitment to change a behaviour. In motivational interviewing a practitioner responds to the person they support in ways that enhances the person s internal motivation for change. In working with people with disability, these conversations can be about many things and might include deciding whether or not to take a medication as prescribed, whether or not to do more exercise, change a diet, drink less alcohol, do more physiotherapy, follow the suggestions of an occupational therapist, use a communication board, or learn relaxation skills to manage anxiety. Similarly, a practitioner might have a behaviour change conversation using motivational interviewing with important others. This might be about whether or not to use a positive behavioural approach to help support a relative with disability, to consider alternatives to punishment when disciplining a child, or to decide to negotiate with a person to have more time in their home alone without support workers A Guiding Style Conversations around behaviour change can exist on a continuum of styles ranging from direction through to following with a guiding style being in the middle. In direction a practitioner might suggest the best approach to a particular issue and make certain recommendations for others to follow. Common examples of directing are a psychologist providing direct support staff with positive behaviour support recommendations for working with behaviours of concern, for example aggression or withdrawal or encouraging a person who is obese to do more exercise to reduce the risk of diabetes. At the other end of the continuum is a following style where a psychologist may attempt to avoid instilling any unsolicited suggestions preferring instead to support whatever the person or important others propose as a preferred way forward. Examples might include accepting completely a person s decision to stay in bed for most of the day, or a parent s decision to smoke in front of his small children. In-between a directing and a following style is a guiding style. A guiding style is more concerned with working collaboratively with a person and important others on possible behaviour change. It can include elements of directing and giving information with a person s permission. It can also include aspects of following marked by good listening to a person s desires and a concerted effort to understand what it is the person will find most helpful. Examples of a guiding style can include listening to a person s goals for making new friends and discussing and agreeing ways to practice social skills that might help them achieve this. Another example might be taking the time to learn from support staff the best times for teaching a person who wants to learn new Motivational Interviewing Practice Guide

10 activities of daily living and integrating this with effective principles of teaching, for example shaping and chaining The Righting Reflex Using a guiding style helps a practitioner avoid using the righting reflex in behaviour change conversations. The righting reflex refers to the very natural impulse in psychologists to want to fix a person s problems. This is most evident when a person tells us about their difficulty and we want right away to offer helpful advice and suggestions about what we think will solve the problem. After all, psychologists are taught sometimes in lengthy university courses how to do just this. If a person has problem X then we offer solution Y. The difficulty with this approach is that it tends to really only be helpful with people who are ready to change and who are expressly asking for advice. In reality though most of the individuals a psychologist will work with are either ambivalent about changing a behaviour or have not really considered doing so at all. When a practitioner uses their righting reflex and offers solutions to a person who is not yet ready to change the natural tendency of the person is to give reasons that the solutions will not work. Unfortunately, this can lead to the practitioner thinking they just need to provide stronger or better solutions, which only leads to the person generating more reasons why these suggestions won t work. This phenomenon is called reactance. Reactance refers to the natural tendency of someone who is not yet ready to change to push back against attempts or suggestions to help make them change (Brehm and Brehm 1981). At its heart motivational interviewing is a conversation between two people that seeks to elicit a person s own intrinsic motivation for change. It is a therapeutic guiding style that views the work between a psychologist and a person considering behaviour change as a partnership. A guide can help a person to find the right path and can make suggestions about which way to go but ultimately the person must choose for himself or herself if they wish to go in that direction. Whilst a psychologist may have particular expertise in many areas such as positive behaviour support or other therapies for example cognitive behaviour therapy, dialectical behaviour therapy or mindfulness based practice, people they support and their important others have expertise too. They know themselves best. They know what is likely to be useful to them and how it might be most effective. They know what has worked in the past and what hasn t. They know what will fit in best with their lifestyle and their goals, desires and values. Motivational interviewing views an FACS practitioner and the person with whom they are working as each having their own areas of expertise to contribute to the partnership. By working collaboratively they can both help Motivational Interviewing Practice Guide

11 build a person s motivation to change behaviour in pursuit of that person s goals Change Talk In motivational interviewing there are two types of change talk, preparatory change talk and mobilising change talk. Preparatory change talk refers to statements a person makes that suggest he or she sees reasons for change and has confidence in his or her ability to change. This type of language is reflected in desire, ability, reason and need statements. Mobilising change talk is language used by a person that indicates they have decided to change a behaviour or that they are close to doing so. This is reflected most strongly in commitment language. Two other types of mobilising change talk are activation and taking steps. You will see that change talk varies in strength, with desire statements being weaker than need statements. The mnemonic used to remember change talk is DARN-CATS. Examples are provided in Table 1. Table 1 Examples of change talk Desire: This is any statement the person makes that reflects a desire to change behaviour in a particular direction, for example, It would be great if I did more exercise because I would feel better. Ability: This is any statement that indicates the person has a belief in their ability to carry out a behaviour for example, I m sure I could stop losing my temper if I really tried to. Reason: This is any statement a person makes that reflects a reason to change a behaviour, for example, If I can assist Joe to concentrate longer in class it will help him to learn. Need: This is any statement a person or an important other makes that reflects a need to change behaviour, for example If I don't stop losing my temper with the kids they will be taken into care and that would be terrible. Commitment: Commitment language is the language usually most strongly associated with behaviour change and is reflected in any statement that indicates a determination to change a behaviour, for example, I will start taking my medication as prescribed. Or, I am going to attend that parent training class. Activation: This language indicates movement in the direction of changing a behaviour but is just short of commitment language, for example, I m thinking about taking my medication as prescribed now. Or, I would consider attending a parent training class. Motivational Interviewing Practice Guide

12 Taking Steps: These statements show that the person has already taken action in the desired direction, for example, I got a dosette box from the GP to remind me when to take my medication. Or, I have found out the details of the next parent training class. Although this isn t commitment language and does not reflects a decision to change a specific behaviour it is clearly movement in that direction Sustain Talk and Discord The other side of change talk is sustain talk. Sustain talk refers to the statements a person makes that indicate a desire or intention to continue behaving as before. In motivational interviewing this type of language is responded to with empathy rather than with confrontation or attempts to persuade the person to change their mind. There is nothing inherently wrong with sustain talk. It simply indicates the person is less likely to change. Discord refers to statements a person makes that simply reflect a rupture or disharmony in the therapeutic relationship between the person and the practitioner. In motivational interviewing a number of ways to respond to sustain talk and discord are possible. These are not discussed in detail here for reasons of space. The interested reader is referred to chapter 15 in the book Motivational Interviewing Helping People Change 3 rd Edition (Miller and Rollnick 2013). It will suffice to say here that the guiding principle remains avoidance of confrontation coupled with a willingness to seek to understand the person s viewpoint. 2.2 Why motivational interviewing in disability services? Motivational interviewing was chosen as a psychology core standard by the FACS ADHC psychology practice reference group to help psychologists engage with people with disability and also with their important others. It can come as quite a surprise to psychologists to learn that many people in general psychotherapy drop out early from treatment. In fact, in psychotherapy the premature dropout rate for treatment is around 50% (Wierzbicki and Pekarik 1993). Similar high drop out rates have also been observed in family centred work in child behaviour support services (Pekarik and Stephenson 1988). It is a significant issue that needs to be addressed if we are to meet more fully the needs of people we seek to support. Motivational interviewing is an evidence based approach that can help increase engagement and retention in behaviour change efforts. Because it has been able to do this with individuals in many other clinical areas it is anticipated it has a role to do this people with disability too. Practitioners also have behaviour change conversations with many other people in addition to a person with disability. A psychologist might be Motivational Interviewing Practice Guide

13 discussing with a parent how best to discipline a child in ways other than physical punishment, discussing with a support worker in a group home ways to teach a person anger control strategies, working with an occupational therapist to use behavioural learning principles such as chaining and shaping to teach activities of daily living, or assisting a teacher to help a student pay attention longer in class. In all of these conversations there is also a role for motivational interviewing to help practitioners engage and work collaboratively with each of these people. It is not suggested that psychologists need to always use motivational interviewing in their work. Psychologists bring to their role a wide range of existing skills and strengths. Motivational interviewing is just one way of working collaboratively with a person. A psychologist is a professional who can make up his or her own mind as to where and when a motivational interviewing approach might be especially helpful. 2.3 The development of motivational interviewing The psychologist William Miller originally developed motivational interviewing for the treatment of alcohol disorders. In a recent paper in the journal The American psychologist Dr Miller and his colleague Dr Gary Rose describe the evolution of motivational interviewing over the last three decades (Miller and Rose 2009). In this paper they explain that early in his career Dr Miller noticed that if a practitioner was able to convey accurate empathy in the helping relationship it had a significant effect on a person s ability to change their behaviour afterwards. In a small clinical trial he trained nine practitioners in behavioural self control training and also in accurate empathy. Practitioner empathy in treatment was highly associated with a person s behaviour change up to 24 months after treatment. In fact it was more predictive of behaviour change than the type of therapy used. Dr. Miller went on to observe that if an empathic practitioner encouraged the person to talk about their own reasons or needs to change a behaviour and also their own ideas about how this might happen they were often more likely to go on to change. He also observed that when a practitioner tried to persuade a person to change, confronted the person with evidence that their behaviour was a problem, gave advice the person had not asked for, or warned the person about the consequences of their behaviour they were less likely to change. These observations led to him developing the therapeutic style he called motivational interviewing. A little later in 1989 whilst on sabbatical in Sydney Dr Miller met Stephen Rollnick a South African psychologist who was practicing in the United Kingdom (UK). Dr Rollnick explained that he had read Dr Miller s work and had been teaching the principles of motivational interviewing to UK practitioners. He too noted that practitioners found it a very helpful approach for working with people who struggled to change behaviour. This meeting led Motivational Interviewing Practice Guide

14 to Miller and Rollnick writing together the first edition of the book Motivational Interviewing (Miller and Rollnick 1991). Over the last 30 years the use of motivational interviewing has extended far beyond its original target group of people with alcohol problems. It is now used by practitioners working in adult mental health and psychiatry, vocational and rehabilitation services, forensic and probation services, child welfare and domestic abuse services, primary care, general medicine, dentistry, gambling and other addictions. It is an approach that appears to help practitioners working with people in many diverse areas who struggle to change behaviour. 2.4 Motivational Interviewing and FACS ADHC philosophies, values and beliefs FACS ADHC advocates for a person and family centred approach to support people with disability. As is made clear in the FACS ADHC Philosophies, Values and Beliefs Practice Package a person centred system places the person at the centre of decisions making about the support and services they use. This means listening to what the person wants, their dreams, hopes and wishes. It also means seeking to understand what it is the person does not want. When this is being done well the person is heard and supported to exercise choice and to direct their supports and service arrangements as they wish. In addition, FACS recognises the voices and the needs of important others who support people with disability. Often, it is parents and other family members who provide the majority of continuous support for individuals. Behaviour change efforts are usually most likely to be helpful and to succeed when family members and important others are listened to, included and actively involved in goal setting and decision making. Motivational interviewing fits well within the person centred approach advocated by FACS ADHC. As a strengths based person centred approach motivational interviewing has developed a philosophy and practice over 30 years that assists psychologists to listen better to people receiving psychology support. It place their wishes centre stage and evokes from people their own ideas and choices about what change might occur and how this might happen. It places the person s wishes and goals at the centre of support services. 3 What motivational interviewing is not Because motivational interviewing has been disseminated so rapidly and across so many different areas and populations over the years there is sometimes confusion about what motivational interviewing is and what it is not. Probably the most common misconception is that motivational interviewing is a powerful set of techniques that psychologists can use to trick a person into changing. To help clarify matters Miller and Rollnick recently wrote an article outlining 10 things that motivational interviewing is not. We cover here just a few of these that have particular relevance for this practice Motivational Interviewing Practice Guide

15 standard. The reader is referred to the original paper for a list of all 10 things (Miller and Rollnick 2009). 3.1 It is not a way of tricking people into doing something they do not want to do Motivational interviewing is not a set of tricks to persuade a person to do something they do not want to do. It is the opposite of this. At the heart of motivational interviewing is the desire to respect a person s autonomy, choice and welfare. Motivational interviewing does not instil motivation where none exists. Instead, a motivational interviewing practitioner helps evoke and strengthen motivation a person already has, or comes to have after thinking more deeply about an issue. It is a way of being with someone that helps the person enhance his or her own motivation for change in pursuit of his or her own desires and goals. 3.2 It is not just person centred counselling Although motivational interviewing shares many person centred counselling skills a motivational interviewing practitioner is also concerned with establishing in collaboration with a person a clear direction for behaviour change. In this way the motivational interviewing practitioner listens out for, and seeks to strengthen particular statements a person considering change might make that indicate motivation to change in this direction. As previously noted, in motivational interviewing this language is called change talk. When its occurrence increases it is thought to indicate increased internal motivation. Motivational interviewing practitioners learn how to respond in ways that strengthen this type of talk whilst responding in very different ways to reduce it s opposite, sustain talk. 3.3 It is not easy to learn and it is not what you are already doing Motivational interviewing is a deceptively difficult skill to learn. When watching a skilled practitioner doing motivational interviewing it can appear to be little more than a general conversation. However, it requires a grounding in key interpersonal skills that enhance the therapeutic relationship, an ability to respond to change talk using one set of principles and to sustain talk using an entirely different set of principles. In addition, an ability to design behaviour change plans collaboratively that are based on what is known about effective behaviour change planning is required. Like all complex skills learning motivational interviewing takes time. Although the evidence shows people can learn some of the skills in a two day Motivational Interviewing Practice Guide

16 interactive workshop using specialised exercises, ongoing expert feedback and coaching is often necessary to achieve beginner s proficiency. Because this is so, it is unlikely a practitioner with no training in this approach is doing motivational interviewing already although they may be excellent at some of the interpersonal counselling skills involved. How people learn motivational interviewing is considered more fully in Section MI is not a panacea Motivational interviewing is just one approach available to psychologists in their work in disability services. It is not suggested that this must always be used or is the only right way to engage and work collaboratively with people. It is simply one way that seems to be especially helpful for engaging a person in a collaborative person centred conversation about change and that can help build that person s motivation to change behaviour. Its greatest role will be in helping practitioners work with people who are ambivalent about a behaviour or lifestyle change, or who currently see no need to change a behaviour that may be detrimental to their well being or the well being of others. It is not an approach that a practitioner would use in every interaction with every person. If a person has become motivated to change and has a well formulated plan to do so then there may be little role for a motivational interviewing approach. 4 Who does motivational interviewing help the most? 4.1 Motivational interviewing and stages of change To understand better those for whom motivational interviewing is most helpful it is useful to consider briefly the stages of change theory. In a very influential model of how people change long standing behaviours, Prochaska and Di Clemente(1984) suggested that motivation to change is not an all or nothing phenomenon, i.e. either it is present or it isn t. Instead they suggest motivation often exists on a continuum and can fluctuate over years, weeks, days, or even in a conversation. In their stages of change model they suggested that people are typically at one of six stages when it comes to thinking about changing behaviour. These are pre-contemplation, contemplation, preparation, action, maintenance and relapse. Each of these stages is considered more fully below. A person who is in pre-contemplation is not even thinking about changing their behaviour or if they have thought about it they have no desire to change. They see no reason to do so and thus do not give it very much thought. A person in contemplation is in two minds about changing their behaviour, i.e. they are ambivalent. A part of them can see good reasons for changing and Motivational Interviewing Practice Guide

17 feels they might like to change but another part of them feels there are reasons for carrying on as before. A person in preparation has made up their mind to change and is taking active steps to get ready to do so. A person in action stage has changed their behaviour and is carrying out activities to help them continue to do so. In the maintenance stage this new behaviour has been successfully adopted for a prolonged period of time and less external support or strategies are required to keep it going now. The maintenance phase can continue for years. In the relapse phase the person has re-engaged in the old behaviour for whatever reason. The relapse phase is especially important to prepare people for as it is often a normal part of change and if the person interprets relapse as evidence that change is not possible they can go back into precontemplation or contemplation for weeks, months, or even years. Motivational interviewing is especially helpful for people in the precontemplation and contemplation stages of change. It is less relevant for people in preparation, action or maintenance as the person is already motivated to change their behaviour. However, even in these other stages motivational interviewing may still be used on occasion if a person becomes ambivalent again about changing their behaviour for whatever reason. 5 What is the evidence for motivational interviewing? Now with over 200 published clinical trials Miller and Rose (2009) note that motivational interviewing has been found to improve recruitment into treatment, retention in treatment, and treatment completion as well as improving follow-up attendance in areas as diverse as problem drinking, problem gambling, cardiovascular rehabilitation, diabetes management, dietary change, hypertension, illicit drug use, infection risk reduction, management of chronic mental disorders and substance use disorders in severe mental illness. Although not all studies have been favourable motivational interviewing does compare favourably to other evidence based treatments and significantly outperforms general advice giving. (Apodaca and Longabaugh 2009, and Rubak, Sandbaek, Lauritzen and Christensen 2005). Motivational Interviewing Practice Guide

18 5.1 Is there evidence supporting the use of motivational interviewing with people with impairments in cognitive functioning? There are randomised controlled trials of motivational interviewing being used in populations noted for the presence of cognitive impairment. For example motivational interviewing has been used extensively in addictions to help people with substance use disorders, (e.g Project MATCH 1993) in severe mental illness to assist reductions in substance use (e.g. Barrowclough, Haddock, Wykes et al 2010), and in acquired brain injury to benefit peoples mood after stroke (Watkins, Auton, Deans et al 2007). A large randomised controlled trial in brain injury combined phone based motivational interviewing with goal setting and problem solving, two areas particularly vulnerable to brain injury (Bell, Temkin, Esselman et al 2005). Assessment at one year discharge showed the treatment group reported better functional status and quality of well being. Also, in traumatic brain injury motivational interviewing plus cognitive behaviour therapy as a treatment for anxiety has proven helpful (Hsieh, Ponsford, Wong et al 2012). Smaller trials have shown benefit for treatment of substance misuse after brain injury (e.g. Bombardier and Rimele 1999). As yet there are no controlled clinical trials using motivational interviewing with individuals with intellectual disability. The evidence supporting its use in this population must be considered from a trans-diagnostic perspective i.e. looking at research with closely related populations such as that cited above where there is likely to be overlap and similarities in engagement and support issues. There is nothing to suggest that a person with an intellectual disability would respond any less favourably to a collaborative person centred approach with an empathic practitioner who seeks to elicit the person s reasons for, and ideas about change when such a conversation is possible. Even when a conversation is not possible a person with a disability is likely to respond more favourably to a practitioner who seeks to work in partnership, doing things with the person rather than to them, who respects the person s choice, and places the person s desires, wishes and welfare centre stage. As the severity of intellectual disability increases so too does the need for assistance from a person s wider circle of support. There is clear evidence that a motivational interviewing approach is helpful to families concerned with behaviour support. For example, in a randomised controlled trial, Nock and Kazdin (2005) used a brief motivational interviewing approach to enhance retention of parents in a parent management training programme. The programme aimed to help parents deal with their child s oppositional, aggressive, and antisocial behaviour. Drop out from such programmes can be as high as 50%, so the issue is not an insignificant one. The researchers reported that parents who received this brief intervention had greater treatment motivation, attended significantly more treatment sessions, and had greater adherence to treatment according to both parent and therapist reports. Motivational Interviewing Practice Guide

19 Although not dealing explicitly with children with intellectual disability the behavioural issues faced by these parents have much in common with the behavioural issues exhibited by individuals with intellectual disability in particular with impairments in executive functions. This is not surprising given that the frontal lobes and the seat of executive functions are significantly underdeveloped in children and adolescents leading to impulsive and poorly planned behaviours. It is likely that many obstacles to engagement with family members would be similar across these populations. 5.2 Motivational interviewing and indigenous populations Motivational interviewing appears to be especially helpful when recipients are from minority and indigenous populations. In the USA motivational interviewing has been particularly useful in some trials for native Americans as well as those from other minority backgrounds (e.g. Villaneuva, Tonigan, and Miller 2007, Winhusen et al 2008). 6 The practice of motivational interviewing? Motivational interviewing consists of two major components. One is the SPIRIT of motivational interviewing which refers to the overall relational aspect between the practitioner and the person receiving support. The second component is the four processes of motivational interviewing. The four processes are the stages of support typically followed by a motivational interviewing practitioner. Both the SPIRIT and the four processes of motivational interviewing are considered more fully below. 6.1 The SPIRIT of motivational interviewing The SPIRIT of Motivational Interviewing refers to the relational aspect of this guiding therapeutic style. SPIRIT is made up of the following four elements, partnership, acceptance, compassion and evocation. These are the core relational aspects that one expects to see evidence of in any motivational interviewing interaction and across all four processes of motivational interviewing. Each of the elements of SPIRIT is considered below. Partnership refers to the collaborative approach a motivational interviewing practitioner brings to their work. In true partnership both parties bring expertise to the relationship. Motivational interviewing is not something that is done to a person but rather it is a way of working with a person. As Miller and Rollnick make clear, People are the undisputed experts on themselves. No one has been with them longer or knows them better than they do themselves. (Miller and Rollnick 2013, page 15). In motivational interviewing the psychologist is not the expert on what the person needs. Psychologists have expertise in behaviour change approaches and psychological therapies. Thus, he or she has information that may be useful but ultimately it is the person who will decide what to use, and how and why they might use it. Motivational Interviewing Practice Guide

20 Acceptance refers to a radical acceptance of the person by the motivational interviewing practitioner. Stemming from the work of Carl Rogers, acceptance in motivational interviewing refers to the practitioner striving to see the inherent worth and potential in the person, and a belief in his or her ability to thrive when provided with the opportunity to do so. It includes accurate empathy exhibited by a deep attempt to listen to the person and to understand and see things as he or she does. This does not necessary mean agreeing with a person s viewpoint but it does mean working to understand how the person makes sense of their world. A practitioner uses accurate reflective listening to communicate accurate empathy. Two final parts of acceptance are autonomy support and affirmations. Autonomy support refers to a radical acceptance of the person s freedom to make their own decisions and choices. The opposite of this is to seek to impose on a person the will of others through demands or control. Even in those instances where a person does have limitations set on behaviour for example, not being able to play loud music at night in a small group home, how, or if they choose to accept this condition is ultimately their decision. In affirmations motivational interviewing practitioners seek to recognise and highlight genuine strengths in the person. For an example see Section 7 on core micro skills in motivational interviewing. Compassion refers to the motivational interviewing practitioner seeking to put the person s welfare first and the concerns of the person centre stage. Compassion is a recent addition to motivational interviewing and was added in recognition of the fact that a motivational interviewing approach might be used by a practitioner to try to evoke a decision by a person that is not in his or her best interests but is the interest of the practitioner. For example, a practitioner seeking to direct a recipient in the direction of agreeing to have a flatmate move in to a shared home or to take part in medical research when this is more in the interest of the practitioner than the person. When this occurs it is no longer motivational interviewing. Evocation refers to the practitioner seeking to evoke from the person their own ideas about why and how they might change a behaviour if they chose to do so. It is the opposite of a more traditional approach to support wherein a practitioner seeks to instil in the person ideas and suggestions through advice giving and advocacy for certain actions. Motivational interviewing is a particularly strength based approach to behaviour support as it focuses on a persons own strengths and wisdom about what may be helpful. Motivational interviewing practitioners might still give additional information but this is done within the overall SPIRIT of motivational interviewing. Thus, if advice is given it is with the permission of the person receiving this advice and is accompanied by an autonomy promoting message that makes clear that ultimately it will be the person s decision what they do with this information. Motivational interviewing practitioners offer their own support and knowledge as an option for the person to choose and use if they wish to. Giving Motivational Interviewing Practice Guide

21 information in a motivational interviewing style is considered more fully in Section The four processes of motivational interviewing In addition to the SPIRIT of motivational interviewing there are four processes of motivational interviewing. These are engaging, focusing, evoking, and planning. They reflect the processes a motivational interviewing practitioner will typically go through with a person thinking about, planning for, and finally engaging in behaviour change. Although set out linearly here, they can and do often overlap. It is not unusual for a person working on a behaviour change issue to decide after a while that they would prefer to work on a different behaviour instead. Alternatively, a person may start to think about work on changing the same behaviour but approaching the task in a different way. To make clearer the different aspects of the four processes they are each explored in more detail below. Engaging Any support provided by a practitioner is likely to be more successful if he or she has a good therapeutic relationship with the person receiving support. The link between a good therapeutic relationship and better outcomes in psychological practice has been well established in decades of research. Put simply, people are more likely to be helped by a practitioner that they like. A psychologist can be extremely knowledgeable about a large number of psychological supports and therapies but if he or she cannot engage with the person or their important others none of this will matter. Good engagement is at the centre of good psychology support. This affective bond forms one part of a strong working alliance. The other two parts are agreement on tasks and goals. For more information on the working alliance see the common core standard The Working Alliance at Core Standards In order to work in a motivational interviewing style practitioners are taught key micro-communication skills known to help engage a person in behaviour change conversations. These skills are covered more fully in Section 7. Equally important is training that helps the practitioner to identify and reduce common practitioner s behaviours that weaken engagement and lead to premature termination of support by a person. Both sets of skills are used throughout all four processes of motivational interviewing but are especially evident in the early engaging stage. Focusing In the focusing process the practitioner is concerned with reaching agreement with the person and/or their important others on what are to be the goals of psychological support. Psychologists have a wide range of skills that may be Motivational Interviewing Practice Guide