In Focus

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Should Motivational Interviewing be a Foundational Skill for all Health Practitioners?

Posted by on Oct 1, 2017 in In Focus Articles | 0 comments

Using Motivational Interviewing (MI) enables clinicians to support and initiate behaviour change in the management and treatment of clients with chronic disease. Randomised control studies have demonstrated its particular usefulness in working with people struggling with HIV viral load, dental health, weight, sedentary behaviour and alcohol and tobacco use. MI has also been found to increase self confidence in clients to make changes to improve their health status (Van Buskirk & LoebachWetherell, 2014). Considering the current and estimated burden that chronic disease places on the healthcare system and the healthcare budget (World Health Organisation, 2013) is it now not time to consider MI as a foundational skill for all health care practitioners?

With clear evidence of MI’s efficaciousness, particularly in relation to chronic diseases, what is it that prevents this counseling style being taught and utilised to a high degree of proficiency for all health care practitioners? As Miller and Rollnick (2013) discuss, learning MI is an ongoing process that requires not only knowledge of the principles of MI, but also guided practice and feedback. Knowing about the theory of MI is fine, but being able to deliver MI effectively is even better.

Miller and Mount (2001) found that effective MI interventions decreased over time for practitioners who had only completed a one day training workshop. As well as training, developing a new skill such as MI takes time as well as supervision and coaching from more skilled colleagues. In a way it is similar to learning to drive a car. It usually takes several lessons and considerable practice to develop skills and build confidence before a learner is deemed ready to be tested for a drivers licence. And, of course, before getting behind the wheel a learner driver is required to demonstrate knowledge of the road rules.

Miller and Rollnick (2013), and the MI trainers at Veriti, are clear that introductory workshops are of benefit to people with little knowledge of or skill in MI. Beginning MI practitioners need to understand the philosophical beliefs inherent in the spirit of MI, what ambivalence might look and sound like, as well as how to engage with a client and view them as the expert in their own life. They need to observe MI in action which Veriti workshops achieve through examples from DVD recordings and live real life demonstrations (not role play), with participants in the classroom. From these demonstrations, participants experience the power of MI and can begin their own journey towards being an effective MI practitioner.

Integrating efficacious MI into practice also requires that organisations support their practitioners in using the skills effectively and with confidence. Miller and Rollnick (2013) recommend that organisations consider having on-site coaches or champions who not only provide supervision, coaching and support but also review the use of MI and identify practice gaps and lapses. To be able to effectively ‘grow’ an organisation’s use of high fidelity MI, practitioners need to be willing to have their client sessions reviewed, through tape recordings or observation, and to receive support when required.

So what needs to happen to make this proven intervention for assisting clients to change their behaviour, more readily utilised by health practitioners? Organisational support for staff attendance at follow-up and advanced MI courses, in addition to introductory MI training workshops, will certainly help consolidate skills and build confidence. A bigger and also desirable step would be including MI in undergraduate and postgraduate health courses. At a postgraduate level this would include ensuring practitioners working with clients with chronic disease are competent in using the skills as well as demonstrating the spirit of MI.

References

Miller, W. & Mount, K. A. (2001). A small study of training in motivational interviewing: Does one workshop change clinician and client behaviour? Behavioural and Cognitive Psychotherapy, 29, 457-471.
Miller, W. R. & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.
Van Buskirk, K.A. & LoebachWetherell, J. (2014).Motivational Interviewing Used in Primary Care A Systematic Review and Meta-analysis. Journal of Behavioral Medicine. Aug; 37(4): 768–780.

Motivational Interviewing with a client struggling with alcohol use

Posted by on Aug 30, 2017 in In Focus Articles | 0 comments

Motivational Interviewing (MI) – two styles of communication with a client struggling with alcohol use

Rick has been convicted of drink driving and has lost his licence for four months. Because Rick’s job involves driving to see clients his employer has stipulated he must seek counselling for his drinking behaviour. Rick arrives for his first session with his caseworker. The brief examples below show the traditional approach by a caseworker (CW) and a more Motivational Interviewing focused approach. Note some of the clear and the more subtle differences between the two approaches.

                      Traditional Communication            Motivational Interviewing Communication

CWThank you for coming here today. Can you tell me what brought you here?Thank you for coming here today. I imagine it may have been hard for you to keep this appointment?
CWCould you tell me about your drinking patterns? Do you drink everyday or do you tend to binge drink?What thoughts came up for you when today rolled around and you knew you had this appointment?
What made you decide to come?
CWWhen did you first start drinking? Have you ever stopped drinking?Can you tell me a bit about your relationship with alcohol? How did you and alcohol get to know each other?
CWHow has your drinking impacted on your life do you think?What have been some of the good things about your relationship with alcohol?
What are some of the less good things?
CWWhat are some of the possible consequences for you if you keep drinking?What are you thinking at the moment about your drinking?

Miller and Rollnick (2013) explain that helping conversations with clients lie along a continuum. The style used by the helper can be understood as directive at one end of the continuum and following at the other end. In the middle of the continuum lies the style known as guiding.

A directive style provides the client with advice, information and instruction. It has a place, for example, in explaining a medication regime or post-operative care requirements.

A following style also has a place in the helping style continuum. Sometimes clients just need to be heard, or to ‘get things off their chest’, and they may sometimes be best helped by just listening as they find their own path.

A guiding style can be explained by drawing on the analogy of hiring a local guide when visiting a foreign country (Miller and Rollnick, 2013). The best guides don’t just tell you what to do or follow you as you wander about. Instead they listen carefully to what you want to do and see, and offer their expertise if and when it is asked for. Guiding includes some use of the directive and following styles but focuses on collaborating with the client in a way that strengthens their motivation to change.

Look back again now at the examples above of traditional and Motivational Interviewing communication. What style of communication is reflected in each interaction? What do you think would make each interaction more or less helpful to Rick as he grapples with his drinking and desire to keep his job?

To learn more about Motivational Interviewing or attend our next MI workshop contact us at ebt@veriti.com.au

Reference

Miller, W. R. & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.

 

How Does Motivational Interviewing Work?

Posted by on Jun 4, 2017 in In Focus Articles | 0 comments

Motivational Interviewing (MI) is a well-known, accepted approach to helping people struggling with behaviour change. It has been proven effective in randomised control trials across a number of health care settings (Lundahl 2010). It is only recently, however, that scholars have begun to question exactly how Motivational Interviewing works and to suggest a causal theory (Madson et al, 2016).

Miller and Rose (2009) suggest there are two components critical to the effective practice of MI. The two components are the relational and technical skills of the MI practitioner.

In looking at the relational skills of the practitioner we might consider their ability to demonstrate the Spirit of Motivational Interviewing including the building of trust, collaboration with the client and non-judgemental recognition that the client is the expert in their own life. The Spirit also includes the practitioner listening and gaining an appreciation of the client’s beliefs, skills and abilities as well as their hopes for the future. Other relational behaviours and attitudes such as empathy and affirming the client’s attempts to manage their problem are critical to building the relationship and being able to assist the client to move toward change (Miller & Rollnick 2013).

The technical component is focussed on the practitioner’s effectiveness in guiding the client towards change talk and reducing sustain or status quo talk (previously called resistance). Sustain talk is the opposite of change talk in that the client is treading water rather than moving towards change.

Miller and Rollnick (2013) argue that ‘the more the client is engaged with sustain talk the further they are from moving towards change’. When people are not ready to make a change or feel pressured, shamed or coerced they often revert to sustain talk in order to defend themselves. For MI to work the practitioner needs to elicit change talk. Some of the ways this can be achieved include using evocative questioning, scaling for importance and confidence around change, and querying extremes such as ‘if you continue to do what you have been doing (or if you make the change) – where do you think you will be in 5 years’?

Research continues into how MI works, however, mastery of both the relational and technical components of MI appears to be essential for delivering effective help to clients.

To learn more about about Mi and Veriti’s MI workshops, send us an email to ebt@veriti.com.au or go to the Veriti Website.

References

Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20, 137-160. doi: 10.1177/1049731509347850

Madson, M.B., Schumacher, J.A., Baer, J.S., & Martino,S. (2016). Motivational Interviewing for Substance Use: Mapping Out the Next Generation of Research. Journal of Sustance Abuse Treatment , http:dx.doi.org/10.1016/j.jsat.2016.02.003

Miller, W. R., Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.

Miller, W.R., Rose, G.S. (2009). Toward a Theory of Motivational Interviewing. American Psychologist, 64,527-537.

Motivational Interviewing and the Transtheoretical Model of Behaviour Change – What’s the difference?

Posted by on Apr 29, 2017 in In Focus Articles | 0 comments

The concepts of Motivational Interviewing (MI) and the Transtheoretical Model of Behaviour Change (TTM) are often linked and connected in the literature (Miller & Rollnick, 2013). However, the idea that MI is based on the TTM is not correct (Miller & Rollnick, 2009). Miller and Rollnick describe MI and the TTM as ‘kissing cousins who never married’ (2013. p.35).

The Transtheoretical Model of Behaviour Change provides an understanding of what initiates behaviour change and how specifically, change may occur (Prochaska & DiClemente, 1984). Motivational Interviewing, on the other hand, is a specific counselling approach which optimises the individual’s drive for change.

The Transtheoretical Model of Behaviour Change shows us how, when we are supporting behaviour change in others, it is important to attempt to understand that person’s perspective. Understanding the TTM helps us assess where individuals are in terms of readiness for change. The main stages are:

Pre-contemplation – In the pre-contemplation phase individuals have no intention of changing behaviour and are often vocal in expressing this. For example, ‘smoking relaxes me and I have no intention of stopping’.

Contemplation – In the contemplation phase individuals may see reasons to leave things as they are, for example smoking is relaxing or going to the gym or exercising is too time consuming. These individuals feel stuck, as the disadvantages appear to outweigh the advantages of change. Further, contemplators may not know how to change and may lack confidence to change. Clients in the pre contemplation and contemplation phase often present as ambivalent and resistant to change.

Determination – In the determination phase individuals have the intention to change behaviour, and they develop action plans and attempt to overcome the blocks and barriers to change.

Action – in the action phase individuals put change plans into place.

Maintenance – maintenance is defined as a period where new behaviour is sustained for a number of months and may become a part of a permanent lifestyle change. Maintenance is hard and individuals may still struggle with cues to old behaviours. For example the person who has not smoked for 3 months goes to a party, has a drink and gets the urge to smoke a cigarette. The clinician’s role in this situation is to re-frame a slip-up not as failure but as an opportunity for better understanding, and to review managing high-risk situations.

Relapse – relapse is common and should be seen as part of an ongoing learning process. The reframing of relapse as a slip or a trip instils hope that this is just a bump in the road and that the individual can learn from this experience. The role of the clinician therefore is to normalise this phase, to encourage clients to learn from the experience and to identify the triggers to be avoided.

It is understandable that MI and the TTM have become somewhat confused as both were developed and promulgated at much the same time and both focus on behaviour. These days the TTM is often used in MI to help assess clients’ current level of readiness for behaviour change. The main focus in Motivational Interviewing is however on helping people by having the conversations that support and initiate behaviour change (Miller & Rollnick, 2013).

To see Veriti’s upcoming Introductory and Advanced Motivational Interviewing workshops click here or email us at ebt@veriti.com.au for more information.

References

Miller, W. R., & Rollnick, S. (2009). “Ten Things that Motivational Interviewing Is Not”. Behavioural and Cognitive Psychotherapy, 37, 129–140.
First published online 6 February, 2009. doi: 10.1017/S1352465809005128
Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.
Prochaska, J.O., & DiClemente, C.C. (1984). The transtheoretical approach: crossing traditional boundaries of therapy. Homeward, Il: Dow/Jones Irwin

Ambivalence and Motivational Interviewing (MI)

Posted by on Mar 20, 2017 in In Focus Articles | 0 comments

Ambivalence and Motivational Interviewing

During general introductions at Motivational Interviewing Training workshops it is not uncommon to hear participants at the start of the day say they want to learn “how to motivate” others. Generally, these “others” are individuals they are in a supportive or helping relationship with. As facilitators responding, it is important firstly to ask, “Is it possible to motivate another person?” and to recognize that motivation is neither present nor absent in an individual but is a constantly changing state or process within.

All people are motivated, but not always in the direction clinicians and helpers would like them to be. For example, some people are motivated to keep smoking (known as maintaining the status quo) and others are motivated to stop smoking and move towards behaviour change. Motivation is present in both examples, yet it is the direction of the motivation which is the important element as individuals usually feel both a push towards and a pull away from change (Miller & Rollnick, 2013).

The process of behaviour change involves resolving the push and pull of the change (Miller, 2012). Becoming ambivalent is the first step in developing motivation to change. Motivational Interviewing (MI) offers an alternative response to ambivalence, as it recognizes that ambivalence is normal, and it defines readiness to change as a dynamic and not a static factor (Miller, 2012).

Motivational Interviewing helps people explore ambivalence – what keeps the person doing what they do and what might move them towards wanting to make a change. It is a shift from the pre-contemplative stage of change, e.g. a client wanting to smoke, towards contemplation of change, e.g. a client thinking of quitting smoking (Prochaska & DiClemente, 1984). What clinicians and helpers evoke from clients therefore are arguments for both wanting to keep smoking – described as ‘sustain talk’ and arguments or reasons to stop smoking- described as ‘change talk’ (Miller & Rollnick, 2013).

Motivational Interviewing conversations assist clients to articulate this sense of being ‘of two minds’ (AIPC, 2015) by verbalizing the pros and cons of the behaviour change (Everett, Salamonson, Zecchin, & Davidson, 2009). This can be achieved by exploring the Good things/Less good things.

Good things

What are the good things about…? (name the behaviour under review).
What do you enjoy about…?
What would you miss about…?

Less good things

What about some of the less good things? What are some of the things you don’t like so much about…? (name the behaviour under review).
How do you feel about…? (explore the specifics the client has named as less good).
What are the things you wouldn’t miss about…? (explore the specifics the client has named).

Veriti conducts regular Introduction to Motivational Interviewing workshops, as well as Advanced Motivational Interviewing workshops. Veriti can also provide in house training for your organisation. Please go to the Veriti website for more information or contact us at ebt@veriti.com.au

References

Australian Institute of Professional Counselling. AIPC (2015). Principles and techniques of motivational interviewing.
http://www.aipc.net.au/articles/principles-and-techniques-of-motivational-interviewing/ Viewed 5 March 2017.
Everett, B., Salamonson, Y., Zecchin, R., & Davidson, P. M. (2009). Reframing the dilemma of poor attendance at cardiac rehabilitation: An exploration of ambivalence and the decisional balance.Journal of Clinical Nursing, 18, 1842-1849. doi: 10.1111/j.1365-2702.2008.02612.x
Miller, W. (2012). Motivational Interviewing: What It Is, How It Works, How To Learn It. A 2 Day workshop, 7 & 8 of November, Brisbane, Australia.
Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.
Prochaska, J.O., & DiClemente, C.C. (1984).The transtheoretical approach: crossing traditional boundaries of therapy. Homeward, Il: Dow/Jones Irwin.

The Power of Affirmation in Motivational Interviewing – Some thoughts & clues

Posted by on Jan 31, 2017 in In Focus Articles | 0 comments

What specifically is it in the Motivational Interviewing (MI) relationship that moves the client toward change? Recent research (Apodaca et al, 2015), examined therapist behaviours that elicit both change talk (client moving towards change) and sustain talk (client maintaining the status quo). Interestingly, the authors found that elements such as reflections and open questions increased the likelihood of both these client responses – sustain talk as well as change talk. The authors do not suggest that clinicians abandon the use of open questions and reflections as these skills are integral to the work of MI in facilitating open discussion about the clients hopes for the future and their ambivalence about change. They did, however, identify one element in MI that both increased change talk and reduced sustain talk. This was the use of affirmations.

So, what are affirmations? Affirming is about noticing and commenting on the positive aspects in a client. However, not all affirmations need to come from you as the clinician. Often the most powerful and helpful affirmations are those the client generates about themself. Carl Rogers (1967), who is often referred to as the ‘father of humanistic counselling,’ wrote about the power of unconditional positive regard for the client. This means valuing the person as doing their best to move forward in their lives constructively and respecting the person’s right to self-determination no matter what they choose to do. Miller and Rollnick (2013) identify affirmation as a key element in the Spirit of MI and in building and maintaining a therapeutic relationship with the client. The use of affirmations identifies client strengths and acknowledges the clients efforts in their struggles.

Are affirmations the same as praise? Not exactly. Praise often feels to the client as though the therapist is making a judgement about them and can be experienced as somewhat parental and patronising. Consider the difference between the praising response, ‘I am impressed you didn’t smoke for 3 days this week’ and the affirming one, ‘Wow, you didn’t smoke for 3 days this week – how did you manage that?’ Notice how the second response keeps the word ‘I’ (the therapist), out of the response, and instead invites the client to identify some of their specific strengths around their struggle with smoking. This response affirms the clients efforts.

Of course, the therapist must genuinely mean the affirmations they offer, and affirmations must be honest and communicate respect for the client. There is now growing evidence (Apodaca 2015, Critcher et al 2010, & Miller and Rollnick 2013), that using such affirmations in MI reduces defensiveness and facilitates change for the client.

Veriti conducts regular Introduction to Motivational Interviewing workshops and can also provide in-house training. Contact us at ebt@veriti.com, or click here for more information or to register for our next MI workshop on March 27, 2017.

References

Apodaca, T.R., Jackson, K.R., Borsari, B., Magill, M., Longabaugh, N., Mastroleo, & Barnett, P. Which individual therapist behaviors elicit client change talk and sustain talk in motivational interviewing?, Journal of Substance Abuse Treatment (2015), http://dx.doi.org/10.1016/j.jsat.2015.09.001
Critcher, C.R., Dunning, D., & Armor, D.A. (2010). When self affirmations reduce defensiveness: Timing is the key. Personality and Social Psychology Bulletin, 36(7), 947-959.
Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.
Rogers, C. R. (1965). Client-centered therapy. New York: Houghton Mifflin.

Treatment Adherence: Take as directed …

Posted by on Dec 16, 2016 in In Focus Articles | 0 comments

Contemporary healthcare and clinical research continually strive to find the cure or answer for illness and disease and methods of improving clinical outcomes. Clinicians armed with this clinical and research knowledge attempt to implement such findings in clinical practice. Often however, despite their knowledge, expertise, patience and good intent they find themselves having to argue, coerce or in some cases threaten clients to follow healthcare advice or treatment regimes.

The literature identifies “Health threatening behaviours [as] the commonest [sic] cause of premature illness in the developed world” (Rollnick et al., 2005). Some of the behaviour that we engage in is literally killing us and this message is now consistently communicated in health promotion, practice guidelines and Chronic Disease strategy (Bender, 2014; Queensland Government, 2010; WHO, 2001). The World Health Organisation specifically identifies poor dietary intake, inactivity and smoking as major factors in premature illness (WHO, 2003).

Chronic disease has been identified as the main cause of death and disability globally. The prevalence of chronic disease in Australia reflects that in other developed countries. Chronic diseases are the leading cause of illness, disability and death, accounting for 90% of deaths in Australia in 2011 and one third of Australians has at least one chronic illness. Chronic illnesses are also becoming more prevalent in developing countries. This is partially due to urbanisation, rising incomes and the increasing affordability of unhealthy food and lifestyle choices (AIHW, 2014).

Previously, in 2002, the World Health Report advised that by 2020 chronic illness was anticipated to contribute to 73% of all deaths and 60% of the worldwide burden of disease and, specifically, that 79% of these predicted deaths would occur in developing countries (BBC News Health, 3rd January, 2014; WHO, 2005). According to the World Health Organization health care systems are unable to address the burden of chronic disease, at least partially due to deficits within the health systems. Such deficits include a lack of clinician education and preparation, a lack of clinical and behavioural tools to support the clinician’s work, poor communication between clinicians and clients and gaps in the provision of care (WHO, 2003).

The literature further indicates that the rate, on average, of client adherence to treatment is only around 50% (Brown & Bussell, 2011; Desai, Mahajan, Sewlikar, & Pillai, 2014; Iuga & McGuire, 2014; Jordan & Osborne, 2007; Snowdon & Marland, 2012; WHO, 2003 & Zanni, 2012). The treatment adherence rate for acute illness is between 20 and 40% and the treatment adherence rate for chronic illness is between 30-60% (Jordan & Osborne, 2007). On average, therefore, around 50% of clients follow their treatment advice, while the other 50% do not.

Non-adherence costs money. In the United States, the costs incurred by individuals not following treatment direction or advice are between $100 and $300 billion dollars annually- which equates to 3-10% of total spending on health care in the US (Iuga & McGuire, 2014). European healthcare organisations spend US 159 billion per year to treat the often preventable heart disease, pulmonary disease and diabetes (KPMG, 2015) and in 2011-12 Australia spent $140.2 billion on health (AIHW, 2014).

Billions of dollars are spent annually on research and clinical trials to identify effective treatments for managing illness and disease (Haynes et al., 2008). However, the findings are based on the assumption that individuals will adhere to the treatment recommended. As clinicians we need to be aware of the multiple factors that may influence and derail treatment adherence and be ready to have a conversation about these with clients.

Click here for more information about or to register for Treatment Adherence, an online course developed by Veriti and hosted by Charles Bloe Training. This course is equivalent to two CPD points and explores the reasons for non-adherence as well as the implications for clients, clinicians and the health care system. To assist in addressing non-adherence, the course also introduces the theory of behaviour change as well as Motivational Interviewing skills. For organisations wishing to purchase group or block licences contact us at ebt@veriti.com.au

References

Australian Institute of Health and Welfare 2014 Australia’s health 2014. Australia’s health series no.14 . Cat. no. AUS 178. Canberra: AIHW.
BBC News Health (3rd January, 2014). Obesity quadruples to nearly one billion in developing world. http://www.bbc.com/news/health-25576400 viewed 30th August, 2015.
Bender, B., G. (2014). Can Health Care Organizations Improve Health Behaviour and Treatment Adherence?. Population Health Management. 17, (2). 71-78.doi: 10.1089/pop.2013.0045.
Brown, M., T., & J., K. Bussell. (2011). Medication Adherence: WHO Cares, Mayo Clin Proc. 86 (4):304-314, doi:10.4065/mcp.2010.0575
Desai, A., Mahajan, N., Sewlikar, S., & Pillai, R.(2014). Medication adherence: the critical step towards better patient outcome. International Journal of Basic & Clinical Pharmacology. 3, (5), 748-753.
Haynes, R. B., Ackloo, E., Sahota, N., McDonald, H.P., & Yao, X. (2008). Interventions for enhancing medication adherence (Review) This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library. (4), viewed 1ST September, 2013. http://www.thecochranelibrary.com
Iuga, A.O., & McGuire, M., J. (2014). Adherence and health care costs. Risk Management and Healthcare Policy. 7, 35-44.
Jordan, J. E., & Osborne, R. H. (2007). Chronic Disease Self- Management Programs: challenges ahead. MJA. 186(2), 84-86.
KPMG. (2015). Helping healthcare organisations unlock the value of big data. https://assets.kpmg.com/content/dam/kpmg/pdf/2015/04/unlocking-the-value-of-big-data.pdf viewed 29th August, 2015.
Queensland Government (2010). Chronic Disease Guidelines [3rd ed.]. Brisbane, Queensland.
Rollnick et al. (2005). Consultations about changing behaviour. BMJ, 331,961-3.
Snowdon, A., & Marland, G. (2012). No decision about me without me: concordance operationalised. Journal of Clinical Nursing. 22, 1353-1360.
World Health Organisation (2001). Chronic Diseases and Health Promotion. http://www.who.int/chp/about/integrated_cd/en/ viewed 30th August, 2015.
World Health Organization. (2003). Adherence to long-term therapies: evidence for action. WHO, Geneva.
WHO (2005). The impact of chronic disease in the United Kingdom. http://www.who.int/chp/chronic_disease_report/media/uk.pdf viewed 1st September, 2015.
Zanni, G., R. (2012).Medication adherence: Taking Special Measures. Pharmacy Times, http://www.pharmacytimes.com/publications/issue/2012/november2012/Medication-Adherence-Taking-Special-Measures,viewed 10th August, 2015.

Motivational Interviewing – It’s not about persuasion!

Posted by on Oct 26, 2016 in In Focus Articles | 0 comments

Contributed by Barb Bowler – Veriti Director

At Veriti Motivational Interviewing workshops we ask participants to choose something in their own life that they are currently working on changing, or thinking of changing, and that they are willing to share with other workshop participants. This issue then becomes their focus for the Motivational Interviewing activities throughout the day. Of course, we also discuss confidentiality and ensure that the group has a collective commitment to maintain it.

Most of us have experienced a ‘persuasion’ conversation about changing. It often goes a bit like this:

Client: “I need to loose 12 kilos to be at a healthy weight and I just feel stuck, it is so hard to stick to a diet.”
Helper: “I know how you feel, it can very demoralising.” “Have you tried meal replacement shakes-you can buy them at the chemist?” “I have a friend who lost heaps of weight that way.”

Client: “Yes, I did try that, but when I stopped using the shakes, I just put the weight back on again.”
Helper: “Well, I think the idea is that you just need to keep using them all the time and also get into regular exercise.” “Have you thought about joining a gym?”

Client: “I feel too big to go to a gym, I would just be too embarrassed.”
Helper: “I used a personal trainer for awhile, it really helped to keep me motivated, what about trying that?” “I could give you the name of the personal trainer I used”

Client: “Hmmm, I don’t know, it sounds like it would pretty expensive and I am trying to save for a house at the moment.”
Helper: “Well, what about Weight Watchers, lots of people find that works.”

Client: “Hmmm, I don’t know…..”

Have you ever had a conversation like this – either as the helper or as the person struggling with change? It’s well meaning, but generally not helpful for making changes.

In the Veriti Motivational Interviewing workshops, we show you a more effective approach. Using the spirit and skills of Motivational Interviewing, participants learn how to move away from offering suggestions and advice, and how instead to be more collaborative in their work. This involves using a number of strategies suggested by Miller and Rollnick (2013), such as curious questions, empathy, reflection and active listening to help the client talk about their struggle with change.

When the client’s own experience and self knowledge are evoked we generally find they can quite quickly identify what they are and are not willing to do around change. Curious questions about exceptions or times when the problem was not so great or was not an issue, are also a great tool to help clients identify strengths or abilities they have, but may have been overlooking.

These are just a couple of examples of Motivational Interviewing strategies. Come along to one of our workshops and learn more about effective ways to help people struggling with change.

Click here for information about our upcoming Motivational Interviewing workshop on 14 November 2016.

Contact us to find out more about Motivational Interviewing and how we can assist your organisation to support and empower your staff. Veriti is on twitter and we also welcome contact and your comments @Veritihealth.

References

Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.

Reflections on Undertaking Clinical Supervision Training

Posted by on Feb 11, 2016 in In Focus Articles | 0 comments

Contributed by Barb Bowler (Veriti Director)

What is it that makes a clinician begin to consider undertaking clinical supervision training?

For me, after an early discouraging experience of clinical supervision (see my earlier post), I began to receive really helpful supervision regarding my everyday clinical work. I trusted and liked my supervisor and I believe the feeling was mutual. Most of my sessions were about my clients, some were about another staff member with whom I worked, and occasionally I had a session about the system in which I worked.
I always left these sessions feeling that I had a way forward with the issue I had brought to the session. The ideas and plan I generated in the supervision session were usually helpful in moving an issue forward to some sort of resolution, although on a few occasions my plan didn’t work out at all.

Over time, as a supervisee, I came to realise that part of my supervisor’s skill in helping me, was asking relevant questions and making thoughtful observations. My supervisor also sometimes used their own experience of something similar to the situation with which I was struggling. Never was I told what or how to do something.

Eventually I took my thoughts regarding becoming a clinical supervisor to my supervision session. Some of the questions I remember my supervisor asking me at that session included ‘what makes you want to do it’, ‘how do you know you are ready’, ‘what do you know about the training’ and ‘what are your best hopes in taking this step’.

I remember also discussing my concerns about becoming a clinical supervisor – did I have the aptitude, experience, credibility among my peers and managers, and the ability to learn the skills needed to be effective in the role?

I still remember the anxiety I felt on that first morning when I met with my training group and our facilitators. I found it reassuring that we developed our own ‘code of conduct’ for the duration of the course. Our study of some of the dynamics involved in supervision, such as transference and parallel process, provided me with knowledge that I still draw upon in clinical supervision sessions today. However, the most valuable part of the training for me was the actual practice of clinical supervision in small groups. An experienced supervisor facilitated and provided supportive and comprehensive feedback as we undertook the role of clinical supervisor – what a rich vein of learning I had struck in this course!

Consideration of and knowledge about the supervisor’s ethical and legal responsibilities, debunking some of the myths around supervision and application of theory to practice were also valuable parts of the course. It was helpful for me to recognise the importance of having supervision of my supervision and it was (and still is) reassuring to be able to receive assistance to improve my practice of clinical supervision.

Are you considering training to be a clinical supervisor? Veriti is offering a four day course for beginning clinical supervisors (2 days in April and 2 days in June 2016). Click here to find out more.

A General Practice Example of Using Motivational Interviewing

Posted by on Jul 14, 2015 in In Focus Articles | 0 comments

Georgina* is a 35 year old mother of three young children. She has had asthma since childhood and frequent admissions to hospital for this, throughout her life. One of the struggles Georgina has is in continuing to take her medication when she is feeling well and not experiencing symptoms of asthma.

I work as a practice nurse in a busy urban practice and see Georgina and her family regularly for routine health care needs. Recently Georgina was admitted to hospital via ambulance when she became unwell at home with a severe asthma attack. Georgina’s GP has asked me to follow up with her regarding her medication adherence.

In previous conversations with Georgina around taking her preventive medications, I have emphasised the importance of taking her medications even when she is feeling well and Georgina has agreed to do this. However the usual pattern is that Georgina will take her meds for the first few weeks after our discussion but then begin to miss doses and finally stop taking them altogether. Then she will become unwell and the cycle begins over again.

I am determined that in this consultation I will attempt to try and understand better what forces are in play for Georgina regarding her using her preventive asthma medications . My understanding from interventions such as Motivational Interviewing (Miller & Rollnick, 2013), is that I need to listen more to the person and do less talking, education and advising, than perhaps I normally do.

The following table, illustrates in an abridged form both the approach I may have previously adopted and the more facilitative and alliance based motivational interviewing approach that I have learnt (Borrelli, Riekert, Weinstein, & Rathier, 2007; Lavoie et al., 2014).

What I may have said to Georgina prior to learning about Motivational InterviewingWhat I said with a focus on the principles of Motivational InterviewingWhat is the difference between the two approaches?
"Dr X asked me to talk to you about the need to take preventive meds for your asthma.""What would be the most helpful for you to talk about today around your asthma?Difference between the nurse setting the agenda and Georgina setting the agenda. However, the focus is still maintained on her asthma.
"Do you know that asthma not managed well can be very serious?""What do you know about asthma?"Difference between the nurse being the expert and in understanding what Georgina already knows about asthma.
"You need to develop a routine of taking your meds everyday"."Can you tell what it is like for you needing to take medication everyday?"Listening to Georgina and hearing about what she thinks and feels about the medication rather than the nurse telling her what to do.
"Why do you think you stop taking the meds when you know what is likely to happen?""What is most important about this for you?Rather than sounding confronting and critical, the nurse tries to understand what is most important for Georgina in relation to her asthma and taking medication.
"The medication will prevent you needing to go to hospital."What are some of the less good things about taking the medication?" {Write the responses down}
"What are some of the good things about taking it?" {Write these down}
Instead of assuming Georgina will respond to the logic of taking her medication regularly and avoiding hospitalisation, the nurse asks her to think about what the not so good and good things are around taking the meds.
"Do you think you now understand the importance of taking your medication everyday?""Looking at what you have written down, what are you thinking about this now?"Instead of the nurse attempting to hammer home the importance of regular medication, Georgina can see her own pros and cons list and reflect on this and what it means for her.

This session took around 30 minutes and I arranged to see Georgina again in a month. At this appointment Georgina reported she was feeling well and taking her medication more regularly with only two days when she missed it. The following is again an example of my possible pre and post motivational interviewing approach to this information.

What I may have said to Georgina prior to learning about Motivational InterviewingWhat I said with a focus on principles of Motivational InterviewingWhat is the difference between the two approaches?
"What happened for you to miss two days, we have talked about how important it is to take it every day?""Wow, so you have taken your meds for 28 out of 30 days - that's over a 90% success rate - how did you manage to do that?"Using positive affirmation for all the times she succeeded in taking her meds rather than focusing on the times she didn't. Georgina hears herself talk positively about her own self efficacy.

* Georgina is a fictional character but the example is based on real life characters and experiences.

Contact us to find out more about Motivational Interviewing and how we can assist your organisation to support and empower your staff. Veriti is now on twitter and we’d also welcome contact and your comments @Veritihealth.

References

Borrelli, B., Riekert, K. A., Weinstein, A., & Rathier, L. (2007). Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. The Journal of Allergy and Clinical Immunology, 120(5), 1023-1030.

Lavoie, K. L., Moullec, G., Lemiere, C., Blais, L., Labrecque, M., Beauchesne, M. F., et al. (2014). Efficacy of brief motivational interviewing to improve adherence to inhaled corticosteroids among adult asthmatics: results from a randomized controlled pilot feasibility trial. Patient Preference And Adherence, 8, 1555-1569.

Miller, W. R., & Rollnick, S. (2013). Motivational Interviewing: Helping people change (3rd ed.). New York: Guilford Press.

 

 

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