Miller And Rollnick Motivational Interviewing 2002 Pdf
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Motivational interviewing MI is a counseling approach developed in part by clinical psychologists William R.
- Jack, Joseph and Morton Mandel School of Applied Social Sciences
- Toward a theory of motivational interviewing.
- Motivational interviewing in community-based research: Experiences from the field
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Motivational Interviewing MI has been established as an effective psychotherapeutic treatment for problem drinking in clinical settings. Consequently, there is a growing interest in applying MI to facilitate change across other health behaviors, such as tobacco use, eating habits, and physical activity in a variety of community-based research settings. These extended applications pose new challenges regarding implementation and evaluation. For instance, investigators must consider how best to train intervention counselors; implement strategies for preserving the MI spirit, despite limited client contact time; incorporate adjunctive strategies that support brief MI sessions; and develop a plan for monitoring and evaluating MI treatment fidelity. This article highlights specific examples of how several behavior change research projects applied MI across a variety of settings and populations, provides lessons learned from our experience as a collaborative workgroup, and offers strategies for consideration in future community-based research.
Jack, Joseph and Morton Mandel School of Applied Social Sciences
Articles in the December issue discuss various health issues affecting school-aged children, including acne, eczema and growth disorders. Volume 41, No. One of the biggest challenges that primary care practitioners face is helping people change longstanding behaviours that pose significant health risks.
To explore current understanding regarding how and why people change, and the potential role of motivational interviewing in facilitating behaviour change in the general practice setting. Research into health related behaviour change highlights the importance of motivation, ambivalence and resistance. Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in others areas of health including smoking cessation, reducing sexual risk behaviours, improving adherence to treatment and medication and diabetes management.
When patients receive compelling advice to adopt a healthier lifestyle by cutting back or ceasing harmful behaviours eg. Importantly, an authoritative or paternalistic therapeutic style may in fact deter change by increasing resistance.
The Stages of Change model and motivational interviewing Prochaska and DiClemente 2 proposed readiness for change as a vital mediator of behavioural change. Their transtheoretical model of behaviour change the 'Stages of Change' describes readiness to change as a dynamic process, in which the pros and cons of changing generates ambivalence. Ambivalence is a conflicted state where opposing attitudes or feelings coexist in an individual; they are stuck between simultaneously wanting to change and not wanting to change.
Ambivalence is particularly evident in situations where there is conflict between an immediate reward and longer term adverse consequences eg. For example, the patient who presents with serious health problems as a result of heavy drinking, who shows genuine concern about the impact of alcohol on his health, and in spite of advice from his practitioner to cut back his drinking, continues to drink at harmful levels, embodies this phenomenon.
The Prochaska and DiClemente Stages of Change model 2 offers a conceptual framework for understanding the incremental processes that people pass through as they change a particular behaviour.
This change process is modelled in five parts as a progression from an initial precontemplative stage, where the individual is not considering change; to a contemplative stage, where the individual is actively ambivalent about change; to preparation, where the individual begins to plan and commit to change.
Successful progression through these stages leads to action, where the necessary steps to achieve change are undertaken. If successful, action leads to the final stage, maintenance, where the person works to maintain and sustain long term change. Motivational interviewing MI is an effective counselling method that enhances motivation through the resolution of ambivalence.
It grew out of the Prochaska and DiClemente model described above 2 and Miller and Rollnick's 1 work in the field of addiction medicine, which drew on the phrase 'ready, willing and able' to outline three critical components of motivation.
These were: 1. Using MI techniques, the practitioner can tailor motivational strategies to the individual's stage of change according to the Prochaska and DiClemente model Table 1. Recent meta-analyses show that MI is equivalent to or better than other treatments such as cognitive behavioural therapy CBT or pharmacotherapy, and superior to placebo and nontreatment controls for decreasing alcohol and drug use in adults 4—6 and adolescents.
In general practice, possible applications include:. Motivational interviewing is underpinned by a series of principles that emphasise a collaborative therapeutic relationship in which the autonomy of the patient is respected and the patient's intrinsic resources for change are elicited by the therapist.
Within MI, the therapist is viewed as a facilitator rather than expert, who adopts a nonconfrontational approach to guide the patient toward change. The overall spirit of MI has been described as collaborative, evocative and honouring of patient autonomy.
Although paradoxical, the MI approach is effective at engaging apparently 'unmotivated' individuals and when considered in the context of standard practice can be a powerful engagement strategy Case study, Table 2. A male patient, 52 years of age, who drinks heavily and has expressed the desire to reduce drinking, but continues to drink heavily.
It is easy to conclude that this patient lacks motivation, his judgment is impaired or he simply does not understand the effects of alcohol on his health.
These conclusions may naturally lead the practitioner to adopt a paternalistic therapeutic style and warn the patient of the risks to his health. In subsequent consultations, when these strategies don't work, it is easy to give up hope that he will change his drinking, characterise him as 'unmotivated' and drop the subject altogether. In MI, the opposite approach is taken, where the patient's motivation is targeted by the practitioner.
Using the spirit of MI, the practitioner avoids an authoritarian stance, and respects the autonomy of the patient by accepting he has the responsibility to change his drinking — or not. Motivational interviewing emphasises eliciting reasons for change from the patient, rather than advising them of the reasons why they should change their drinking. What concerns does he have about the effects of his drinking?
What future goals or personal values are impacted by his drinking? The apparent 'lack of motivation' evident in the patient would be constructed as 'unresolved ambivalence' within an MI framework. The practitioner would therefore work on understanding this ambivalence, by exploring the pros and cons of continuing to drink alcohol. They would then work on resolving this ambivalence, by connecting the things the patient cares about with motivation for change.
For example, drinking may impact the patient's values about being a loving partner and father or being healthy and strong. A discussion of how continuing to drink maintaining the status quo will impact his future goals to travel in retirement or have a good relationship with his children may be the focus. The practitioner would emphasise that the decision to change is 'up to him', however they would work with the patient to increase his confidence that he can change self efficacy.
The practical application of MI occurs in two phases: building motivation to change, and strengthening commitment to change. These basic counselling techniques assist in building rapport and establishing a therapeutic relationship that is consistent with the spirit of MI.
This involves goal setting and negotiating a 'change plan of action'. In the absence of a goal directed approach, the application of the strategies or spirit of MI can result in the maintenance of ambivalence, where patients and practitioners remain stuck. This trap can be avoided by employing strategies to elicit 'change talk'. Alternatively, if a practitioner is time poor, a quick method of drawing out 'change talk' is to use an 'importance ruler'.
Example: 'If you can think of a scale from zero to 10 of how important it is for you to lose weight. On this scale, zero is not important at all and 10 is extremely important. Where would you be on this scale?
This technique identifies the discrepancy for a patient between their current situation and where they would like to be. Highlighting this discrepancy is at the core of motivating people to change. This can be followed by asking the patient to elaborate further on this discrepancy and then succinctly summarising this discrepancy and reflecting it back to the patient. Next, it is important to build the patient's confidence in their ability to change.
This involves focusing on the patient's strengths and past experiences of success. Again, a 'confidence ruler' could be employed if a practitioner is time poor. Example: 'If you can think of a scale from zero to 10 of how confident you are that you can cut back the amount you are drinking.
On this scale, zero is not confident at all and 10 is extremely confident. Finally, decide on a 'change plan' together. This involves standard goal setting techniques, using the spirit of MI as the guiding principle and eliciting from the patient what they plan to do rather than instructing or advising. If a practitioner feels that the patient needs health advice at this point in order to set appropriate goals, it is customary to ask permission before giving advice as this honours the patient's autonomy.
Examples of key questions to build a 'change plan' include:. It is common for patients to ask for answers or 'quick fixes' during Phase II. In keeping with the spirit of MI, a simple phrase reminding the patient of their autonomy is useful, 'You are the expert on you, so I'm not sure I am the best person to judge what will work for you. But I can give you an idea of what the evidence shows us and what other people have done in your situation'.
In general practice, the particular difficulties associated with quick consultation times can present unique challenges in implementing MI. Miller and Rollnick 17 have attempted to simplify the practice of MI for health care settings by developing four guiding principles, represented by the acronym RULE:. The righting reflex describes the tendency of health professionals to advise patients about the right path for good health.
This can often have a paradoxical effect in practice, inadvertently reinforcing the argument to maintain the status quo.
Essentially, most people resist persuasion when they are ambivalent about change and will respond by recalling their reasons for maintaining the behaviour. Motivational interviewing in practice requires clinicians to suppress the initial righting reflex so that they can explore the patient's motivations for change.
It is the patient's own reasons for change, rather than the practitioner's, that will ultimately result in behaviour change. By approaching a patient's interests, concerns and values with curiosity and openly exploring the patient's motivations for change, the practitioner will begin to get a better understanding of the patient's motivations and potential barriers to change.
Effective listening skills are essential to understand what will motivate the patient, as well as the pros and cons of their situation. A general rule-of-thumb in MI is that equal amounts of time in a consultation should be spent listening and talking. Patient outcomes improve when they are an active collaborator in their treatment.
A truly collaborative therapeutic relationship is a powerful motivator. Patients benefit from this relationship the most when the practitioner also embodies hope that change is possible. If a practitioner has more time, four additional principles Table 5 can be applied within a longer therapeutic intervention. Barriers to implementing MI in general practice include time pressures, the professional development required in order to master MI, difficulty in adopting the spirit of MI when practitioners embody an expert role, patients' overwhelming desire for 'quick fix' options to health issues and the brevity of consultation times.
These barriers to implementing MI in primary care represent significant cons on a decisional balance. On the other hand, the pros for adopting an MI approach with patients who are resistant to change are compelling. While we are not advocating MI for all patient interactions in general practice, we invite practitioners to explore their own ambivalence toward adopting MI within their practice, and consider whether they are 'willing, ready and able'. Practitioners who undertake MI training will have an additional therapeutic tool to draw upon when encountering patient resistance to change and a proven method for dealing with a number of common presentations within general practice.
For further information and online motivational interviewing training opportunities visit www. To open click on the link, your computer or device will try and open the file using compatible software. To save the file right click or option-click the link and choose "Save As Follow the prompts to chose a location. These files will have "PDF" in brackets along with the filesize of the download. If you do not have it you can download Adobe Reader free of charge.
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If you don't have anything you can download the MS Word Viewer free of charge. Motivational interviewing techniques Facilitating behaviour change in the general practice setting. Cognitive behaviour therapy Incorporating therapy into general practice. Acceptance and commitment therapy Pathways for general practitioners.
Problem solving therapy Use and effectiveness in general practice. Early and tight glycaemic control The key to managing type 2 diabetes.
Toward a theory of motivational interviewing.
Articles in the December issue discuss various health issues affecting school-aged children, including acne, eczema and growth disorders. Volume 41, No. One of the biggest challenges that primary care practitioners face is helping people change longstanding behaviours that pose significant health risks. To explore current understanding regarding how and why people change, and the potential role of motivational interviewing in facilitating behaviour change in the general practice setting. Research into health related behaviour change highlights the importance of motivation, ambivalence and resistance. Recent meta-analyses show that motivational interviewing is effective for decreasing alcohol and drug use in adults and adolescents and evidence is accumulating in others areas of health including smoking cessation, reducing sexual risk behaviours, improving adherence to treatment and medication and diabetes management. When patients receive compelling advice to adopt a healthier lifestyle by cutting back or ceasing harmful behaviours eg.
A must-read for anyone interested in facilitating change with individuals, groups, organizations, and institutions. Miller and Rollnick explain how to work through ambivalence to facilitate change. They present detailed guidelines for using their approach and reflect upon the process of learning Motivational Interviewing MI. Chapters contributed by other leading experts address such special topics as MI and the stages-of-change, applications in medical, public health, and criminal-justice settings, and using the approach with groups, couples, and adolescents. Since the initial publication of this breakthrough work, MI has been used by countless clinicians. Theory and methods have evolved, reflecting new knowledge on the process of behavior change, a growing body of outcome research, and the development of new applications within and beyond the addictions field. Extensively rewritten, this revised and expanded second edition now brings MI practitioners and trainees fully up to date Source: www.
Interviewing in psychiatry I. Rollnick, Stephen, –. RCM56 William R. Miller, PhD, is Distinguished Professor of Psychology and Psychia-.
Motivational interviewing in community-based research: Experiences from the field