Motivational Interviewing (MI) Flashcards
What are low intensity treatments?
Compared to traditional treatment:
- Lower dose of the intervention
- Less contact with a therapist
- More self-direction of the client
- Modes of delivery: e.g. books, online, telephone
- Flexibility: time and pace
- Content is not necessarily different
The content of the intervention is not necessarily different
For a therapist this all requires a different way of working than in traditional face-to-face treatments
Cognitive Behavioural Therapy (CBT) is very suitable for Low Intensity Treatments because:
- Protocolised
- Short and to the point
- Practical (with assignments, in here and now)
This is certainly not the only treatment type suitable for low-intensity treatments
Why low-intensity-treatments?
Treatment Gap: Not many people seek and receive help for symptoms
- Lack of well-trained therapists
- Limited access to therapists
- High costs of treatment
- Stigma
Low-intensity treatments can make treatments accessible and affordable
Application of Low Intensity Treatments:
Highest need in common mental disorders such as anxiety and depression:
- Prevention
- Mild symptoms
But low intensity treatments have a much broader use
Organisation of care
Health care delivery:
- Freely available for the general population (e.g. self-help books, online treatments, mobile applications)
- Treatment (without or with minimal guidance)
- Addition to face-to-face treatment
- First step in a stepped care model
- Collaborative care
Organisation of care (Role of Therapist):
Therapist
- Different ways of communication dependent on the mode of delivery (email, telephone, chat)
- Role of the therapist is more coaching : motivation, education, monitoring, feedback
- Other background : (trained) nurses, GPs, BSc or MSc psychologists, lay person
- Basic knowledge of therapeutic techniques is key and supervision is important
Material (Low Intensity Treatments) characteristics:
Developing self-help material is a skill in its own right.
- Readable
- Unambiguous
- Engaging
- Appealing
- User-friendly
Are low intensity treatments effective?
- Yes, the treatments are effective when a therapist is involved
- The effects seem similar to face-to-face treatments
There is no convincing evidence that the following lead to higher effectiveness:
- Number of sessions
- More complex therapy
- Mode of delivery
- Therapist qualifications
what should be leading in Low Intensity Treatments?
Patient preference and expectations should be leading
Conclusion (Effectiveness of LIT)
- Minimal difference between face-to-face and guided self-help interventions (d=0.02 to the benefit of self-help)
- At 12 months follow-up there was no difference
- There was no difference in drop-out
So guided self-help and face-to-face treatments may be equally effective and implementation is a next step
What is motivational interviewing (MI)?
‘Directive, client centered, counseling style for eliciting behaviour change by helping clients to explore and resolve ambivalence’
The client is encouraged to take responsibility for the decisions that are made
Development of MI
- Comes from the field of addiction to motivate clients for behavioral change
- Aim is to increase treatment adherence (to the behavior change) and clinical outcomes
- Moved to other fields more recently such as lifestyle, psychological problems such as anxiety, depression, eating disorders
MI in practice
(1) Stand alone treatment (e.g. addiction)
(2) At the start of treatment (e.g. CBT)
(3) Integrated in the intake*
- More focus on MI when ambivalence or resistance is present
- Requires some flexibility of the interventions
Rationale (MI)
- Education is often not to sufficient to instigate behavior change
- From good intentions to behavior change is a big step
- Ambivalence towards ‘new’ behavior hinders implementation of intentions, i.e. wanting and not wanting to change whereas the reasons are incompatible
- This ambivalence is experienced as ‘uncomfortable’ and leads tot negative affect such as anxiety, avoidance, and procrastination
- MI helps to resolve this ambivalence by focusing on someone’s own motivation for change
What does MI involve?
MI Spirit
Therapist attitude is to create an open, receptive and affirmative, environment
- Collaboration (vs confrontation) characterised by encouragement
- Autonomy (vs authority): responsibility is with the client
- Compassion: prioritize the interest of the client and their perspective
- Evocation (vs education): drawing out the client’s idea’s about change; based on perceptions, values and aims that already exist
Communication skills: OARS
- Open questions: to encourage the client to think about what is going on
- Affirmation: positive reinforcement to build confidence
- Reflective listening: understanding what the client feels and reflect this to show understanding and empathy
- Summarize: Extensive reflection that can be used strategically to give direction (hopefully in the direction of change
Process
Evidence
Convincing evidence in the addiction field (also in combination with psychosis) (and lifestyle interventions) (d=0.28-0.40) compared to a non-active control group
Less evidence in the field of mental health
Methodological shortcomings
- More RCTs needed
- More research on working mechanism needed
Why MI in low intensity treatments?
- There is a lot of drop-out in low intensity treatments and many clients ae not committed to the treatment (e.g. homework)
- Ambivalence to behavior change plays an important role and increasing the intrinsic motivation can prevent this
- We know that confidence in the outcome and expectations about treatment are the most important predictors of outcome
- MI increases the intrinsic motivation by using the client’s own arguments
Disorders and Main Treatment Options
Balance scale: creating Discrepancy
Process: Engagement
Work on the therapeutic alliance where trust and mutual respect are key:
- welcome,
- feel at ease,
- understood,
- hopeful and,
- has the idea that you have a shared goal
What you DON’T do: questioning, give solutions, show authority
Process: Focus
Search direction: What are the worries, goals, priorities, problemthat a person wants help with?
The client is autonomous in determining the focus
Assessment, screening, providing information
Process: Evocation
Talk about change to explore the importance of
behaviour change and the confidence in the outcome
and to strengthen intentions to change
Change talk
‘Change talk’:
- Language that describes the discomfort of the current situation:
- ‘I can no longer stand to feel like this’
or the advantages of change‘It would be great to feel like my normal self again’
Intention to change
‘Commitment language’
‘Maybe I should do something about my low mood’
‘I really should do something about my low mood, I am sick of not doing anything during the day’
Rolling with resistance
Resistance: denial of the problem!
‘Rolling with resistance’: starting point is that behavior change is someone’s own decision, when you don’t want to change, fine!
This gives some space to explore the pro’s and con’s of change
To do: avoid argumentation, listen reflectively, develop discrancy
Balance scale: creating Discrepancy
Balance scale: Discrepancy (aim)
Aim: create discrepancy between current behaviour and the goals and values that someone has (this is the desired situation)
Balance scale provides insight in the pro’s and con’s of the current behaviour and the advantages of behaviour change
If current behaviour is opposing the goals and values you have (e.g. good health, happiness, intimacy, success, being a reliable person), is the succes of behaviour change bigger.
The client must give arguments for behaviour change, not the therapist.
Key is to create ambivalance and resolve it.
Readiness for change
When the client is convinced of the importance of change and has confidence in the outcome, he or she can move on to the next phase.
Readiness for change is assessed on a scale 1-10 re two aspects: importance and trust..
… followed by an exploration of the score: Why not 1?
Process: Planning
Goals must be SMART:
- Set goals
- Explore options for change
- Make a plan
- Make someone commit to the plan
Ask: how likely is it that someone will implement the
plan on a 0-10 scale
