Practice Model: Motivational Interviewing

Risky behaviour issues, communication roadblocks, stages of change model, practice approach based on stages of change model


This page has three sections:

  1. Background Material that provides the context for the topic

  2. A suggested Practice Approach

  3. A list of Supporting Material / References

Feedback welcome!


Background Material


Sources:

Reasons why people might change as a matter of course:

  • Finding a new reference group to identify with that brings about a change in life focus

  • Finding or rediscovering a purpose in life

  • Experiencing dramatic or humiliating events

  • Maturing to accept different priorities, commitments and obligations

  • Developing new personal relationships, or salvaging existing relationships

  • Financial and/or legal problems

  • Health concerns, including concerns related to pregnancy

  • Work problems

  • Advice from friends and families

Communication roadblocks

People who engage in risky behaviours can experience a two-sided conflict between wanting and not wanting to engage in the behaviour. Communicating with them can be difficult. It is important to avoid the following ‘roadblocks’ to communication when speaking with them.

  1. Ordering, directing, commanding: 'Don't say that.'; 'You've got to face up to reality!'; and 'You have to do something about your drug use!'

  2. Warning or threatening: 'You're really asking for trouble!'; and 'If you go down that road you'll be sorry!'

  3. Giving advice, making suggestions, providing solutions: 'Have you thought about...?'; and 'What I would do is...' 'Why don't you...?'

  4. Persuading with logic, lecturing, arguing: 'The facts are...'; 'Statistics show...'; and 'Yes, but...'

  5. Moralising, preaching or telling someone what to do: 'You should go to rehab.'; 'The best thing you could do is get a job.'; and 'You really ought to...'

  6. Disagreeing, judging, criticising or blaming: 'It's your own fault.'; 'Don't you think you ought to think of others?'; and 'Surely there's more to do than smoke dope.'

  7. Agreeing, approving, praising: 'I think you're absolutely right.'; and 'That's how I would feel if I were you.'

  8. Shaming, ridiculing or labelling: 'That's a silly way to think.'; 'You really ought to be ashamed of yourself.'; and 'How could you do such a thing?'

  9. Interpreting or analysing: 'Do you know what the real problem is?'; and 'You don't really mean that.'

  10. Over questioning or probing: 'What makes you feel that way?'; and 'Why?'

  11. Reassuring, sympathising, consoling: 'Things aren't really that bad.'; 'Don't worry – you'll look back on this in a year and laugh.'; and 'Things will turn out OK, you'll see.'

  12. Withdrawing, distracting, humouring, changing the subject: 'Let's talk about that some other time.'; 'Oh, don't be so gloomy! Look on the bright side.'; and 'You think you've got problems! Let me tell you about ...'

The stages of change model

https://www1.health.gov.au/internet/publications/publishing.nsf/Content/drugtreat-pubs-front9-wk-toc~drugtreat-pubs-front9-wk-secb~drugtreat-pubs-front9-wk-secb-3~drugtreat-pubs-front9-wk-secb-3-3

The stages of change model, developed by Prochaska and DiClemente (among others) recognises that different people are in different stages of readiness for change. It is important not to assume that people are ready for or want to make an immediate or permanent behaviour change. By identifying a person's position in the change process, a worker can more appropriately match the intervention to the person's stage of readiness for change.


The diagram illustrates the stages-of-change model as an upward spiral process, involving progress through a series of stages until reaching the "lasting exit". Each loop of the spiral consists of the stages precontemplation, contemplation, preparation, action and maintenance.


The five stages of change

  1. Precontemplation People in this stage are not thinking seriously about changing and tend to defend their current behaviour patterns. The positives or benefits, of the behaviour outweigh any costs or adverse consequences so they are happy to continue the behaviour.

  2. Contemplation People in this stage are able to consider the possibility of quitting or reducing the behaviour but feel ambivalent about taking the next step. On the one hand the behaviour is enjoyable, exciting and a pleasurable activity. On the other hand, they are starting to experience some adverse consequences (which may include personal, psychological, physical, legal, social or family problems).

  3. Preparation Have usually made a recent attempt to change using behaviour in the last year. Sees the 'cons' of continuing as outweighing the 'pros' and they are less ambivalent about taking the next step. They are usually taking some small steps towards changing behaviour. They believe that change is necessary and that the time for change is imminent. Equally, some people at this stage decide not to do anything about their behaviour.

  4. Action (often 3 – 6 months) Actively involved in taking steps to change their using behaviour and making great steps towards significant change. Ambivalence is still very likely at this stage. May try several different techniques and are also at greatest risk of relapse.

  5. Maintenance Able to successfully avoid any temptations to return to using behaviour. Have learned to anticipate and handle temptations to use and are able to employ new ways of coping. Can have a temporary slip, but don't tend to see this as failure.

Relapse

Relapse is a factor in the action or maintenance stages. Many people who change their behaviour decide for a number of reasons to resume their old patterns of behaviour. Research clearly shows that relapse is the rule rather than the exception.


A lapse is a slip up with a quick return to action or maintenance whereas a relapse is a full-blown return to the original problem behaviour. Most people will experience relapse. Relapses can be important for learning and helping the person to become stronger in their resolve to change. Alternatively, relapses can be a trigger for giving up in the quest for change. The key to recovering from a relapse is to review the ‘quit’ attempt up to that point, identify personal strengths and weaknesses, and develop a plan to resolve those weaknesses to solve similar problems the next time they occur.


Practice Approach


Clinicians need to understand where consumers sit on the cycle of change and target interventions accordingly. The clinician is not responsible for change; the clinician is responsible for facilitating movement towards change.


At all times, when working with the stages of change model, it is important to use basic counselling skills including open-ended questions, reflective listening, summarising and confirming the person's views. The problem-solving and solution-focused practice models may be useful at points in the process, especially when discussing action.


Key principles include:

  • Expressing empathy: acceptance facilitates change; skilful reflection is fundamental; ambivalence is normal

  • Develop discrepancy: a discrepancy between present behaviour and important goals will motivate change

  • Support self-efficacy: the belief in the possibility of change is an important motivator; the person is responsible for choosing and carrying out personal change; the person should present arguments for change.

  • Avoid argument: arguments are counterproductive; defending breeds defensiveness; resistance is a signal to change strategies

  • Reframe resistance: new perspectives are invited but not imposed. Reflection can be used to reduce resistance and can also be employed as a way to work with, rather than against, the energy of resistance. Some examples are:

  • Simple acknowledgement of the person's disagreement, emotion or perception can permit further conversation rather than defensiveness.

  • Reflecting back what the person has said, exaggerating the point but with a quiet, understated tone. If successful, the person may back off a bit and might articulate the other side of the ambivalence.

  • Acknowledge what the person has said and include the other side of the issue, with the aim of increasing ambivalence.

The 10-point scale approach

One of the simplest tools for assessing readiness for change is to ask someone to indicate their response on a 10-point scale where 1 = not considering change, 4 = thinking about changing, and 7 = already changing.


Ask the person to mark on the scale how they currently feel about changing their behaviour. If dealing with drugs, it is likely that the person will feel differently about different drugs so it may be worth using the tool with each of the drugs they use. This approach can provide a framework for having a structured conversation with a young person about their drug use.


Not considering change

If their mark is on the left end of the line (roughly 1 to 3):

  • Goal for conversation: To encourage the person to think about the possibility of changing behaviour. People at this end of the scale can appear argumentative or in 'denial' and the natural tendency is to try to 'convince' them which usually provokes resistance and can be a roadblock to communication.

  • Some useful questions might be: 'What would have to happen for you to decide that your behaviour is a problem?' 'What warning signs might tell you to start thinking about changing? 'What things may happen if you continue to ...?' 'What have other people said about your behaviour?' 'How might your behaviour have stopped you from doing other things you want to do?' 'What are some of the hassles that your behaviour may have caused?'

Thinking about changing

If their mark is somewhere in the middle (roughly 3 to 6):

  • Goal for conversation: To encourage the person to examine the 'pros' and 'cons' of changing

  • Some useful questions might be: 'What are some of the reasons you might like to make a change to your behaviour?' 'What might be some of the advantages in not behaving as you do?' 'If we were to bump into each other on the street in six months, what do you think you would you like to tell me about your life at that point?'

Already changing

If your mark is on the right end of the line (roughly 7-10):

  • Goal for conversation: To encourage the person to explore factors that can support the decision to change.

  • Some useful questions will be: 'Pick one of the barriers to change and list some things that could help you overcome this barrier.' 'Pick one of those things that could help and decide to do it by ...... (write in a specific date).' 'If you've taken a serious step in making a change: What made you decide on that particular step?' What has worked in taking this step?' 'What helped it work?' What could help it work even better?' What else would help?' 'Can you break that helpful step down into smaller steps?' 'Pick one of those steps and decide to do it by ....... (write in a specific date).'

Once it is understood where a consumer sits in terms of motivation to change, the clinician can then employ strategies such as the following to assist clients to move towards effecting change (Diclemente & Prochaska, 1998).




Supporting Material

(available on request)

Working with Young People on AOD Issues (2004). This is the learner’s handbook for an online course offered by the Department of Health. Sections 3 onwards are particularly relevant to this topic. The link is https://web.archive.org.au/awa/20140804030158mp_/http://www.health.gov.au/internet/main/publishing.nsf/Content/9DB846C69B2FA8C4CA257BF0001E8C3B/$File/m9lw.pdf