Introduction and the Spirit of Motivational Interviewing

Motivational Interviewing has its origins in the United States in Bill Miller’s work in Substance Use Treatment, it has gained a great deal of popularity in a wide variety of settings over the past three decades.  It was originally offered as an intentional alternative to more confrontational approaches that were predominant in substance treatment models. Research and implementation efforts expanded to a variety of fields that necessitate behavioral change such as health behaviors, smoking cessation, and school truancy.

Motivational Interviewing incorporates four essential elements: 1) The Spirit of Motivational Interviewing, 2) Principles of Motivational Interviewing, 3) Change Talk, and 4) O-A-R-S.  We will start by taking a look at the Spirit of Motivational Interviewing, though each of these concepts will be expanded upon in much further detail throughout the course of this home study. We will be introduced to change talk and the micro-skills of O-A-R-S later in the course. 

 

Case Examples

Throughout this home-study there will be reference to several case examples.  Below are the case examples that will be used throughout the course, for your reference.

Case 1- Mr. A is a 45-year-old divorced Caucasian male client seeking Substance Use Treatment at a local outpatient treatment facility.  He was married for two years and does not have any children. He currently lives with his girlfriend, whom he has been dating for eight months.  He reports that he is experiencing conflict in his relationship, reporting that his girlfriend does not help pay any bills and works “very part-time”.  Robert has been working in the construction field off and on since graduating high school. He has worked with several construction agencies and work “has not been regular”, citing concerns with economy and with his health. Robert presents to today’s first session at the recommendation of his lawyer.  My lawyer said, “I will have to get into treatment eventually and it will look good if I get a jump on it.”  He explained that he is working with a lawyer after being charged with a second DUI earlier this year.  Robert reports that his first DUI was back “when I was a kid in the 1990s”.  Robert explained that “drinking has never affected me at work…. everyone I work with drinks.”  Robert explained that he drinks approximately 12-18 beers “throughout the course of the weekend.” He explained that ETOH use is “normally only at my place.” He explained that he does not typically drink outside of the home and the incident in which he was charged with a DUI “was a fluke”.  I was watching a baseball game at the bar with my buddies “and I drove home…it was only like three miles, but they had a checkpoint set up.”

 

Case 2- Mr. B is a 64-year-old African-American male client seeking assistance with smoking cessation.  Mr. B was referred to meet with a counselor in the smoking cessation clinic by his Primary Care Physician.  Mr. B is married with two children, and one grandchild.  He is very close with his family. Mr. B is smoking approximately ten cigarettes per day.  He has been smoking for approximately 45 years.  His doctor reports that he is not experiencing any acute medical concerns related to smoking, but he is concerned with increased difficulty with routine physical activity.  It was recommended to Mr. B by his Primary Care Physician several months ago that he attend the smoking cessation clinic, but it was not until one week ago when he decided to call and schedule an initial appointment.  Mr. B arrived to watch his grandson’s soccer game as he does each week, only to learn that the location had been changed.  The game was being held at the top of a large hill. After Mr. B had climbed nearly a quarter of the hill, he noticed that his breathing was becoming very heavy and it was increasingly difficult for him to catch his breath.  He realized that he would need to turn back and was unable to attend his grandson’s soccer game.  As Mr. B’s family is very important to him, this incident caused him to reconsider the recent referral made by his Primary Care Physician. Mr. B explains at the time of initial assessment that he stopped smoking for approximately 18 months when he was in his early 30s.  He explained that he became very ill and was hospitalized. During the hospitalization he was not able to smoke for several days.  He explained that after he left “it just kind of stuck” and he went 18 months without any use of tobacco products.  He explained that he returned to smoking after a particularly stressful period of time at work and has been smoking 10 cigarettes or more each day since that time.

 

Case 3 – Sierra is a 17-year-old Hispanic female presenting to a local outpatient behavioral health treatment center.  She presents to today’s initial session due to her mother’s concern with decreased academic performance, weight loss, and marijuana use. Sierra is talkative, bright, and anxious.  She does not deny using marijuana, but is not convinced that her use of marijuana is problematic.  She explained that she is more concerned with increase in anxiety over the past twelve months since she was involved in a serious automobile accident.  She describes a sharp increase in anxious symptoms, difficulty eating and sleeping, and distractibility.  She reports that soon after the accident she started to smoke marijuana socially with a few friends.  She explained that she immediately noticed that it helped her to feel less anxious, particularly prior to bedtime.

 

Case 4- Mr. Diamond is a 36-year-old Caucasian male preparing for discharge from a residential substance use treatment facility.  He entered treatment approximately one month ago, due to use of stimulants.  Mr. Diamond has been very active in treatment in the residential program, and has demonstrated a great deal of insight and growth.  He is a father of two young children, of whom he has an informal custody agreement arranged with their mother, with whom he separated from approximately three years ago.  He explains that his use of illicit substances created a great deal of strain in his relationship with significant other, at that time, and his children. He plans to return back to his full-time job with a local warehouse.  He works non-traditional hours and picks up as much overtime as possible to help support his children. 

 

The Spirit of Motivational Interviewing

The Spirit of Motivational Interviewing is best thought of as an attitude, a way of being with a person, not a collection of tricks or techniques. Motivational Interviewing is not a way to get people to do things they do not want to do. The spirit of Motivational Interviewing is the way of being with a client, empathically and intuitively. Motivational Interviewing without the Spirit is incomplete, much like lyrics without a tune or rhythm. The Spirit of Motivational Interviewing is a compilation of four distinct elements, partnership, acceptance, compassion, and evocation.

 

Partnership

 Partnership is in stark contrast with authoritarian approaches.  A true partnership assumes that a client presents to treatment with a great deal of proficiency.  After all, who knows more about their past treatment episodes, personality traits, support network, psychosocial factors than the individual does? 

There is extraordinary value in this knowledge and expertise.  The experienced Motivational Interviewer works collaboratively with the client to incorporate that client’s expertise in planning for and implementing behavioral changes. 

Clinicians bring expertise from their field; substance use, health behaviors, vocational rehabilitation, and others.  The clinician likely also has knowledge of relevant research, the agency’s programs and policies, and the interventions associated with evidence-based practice. Additionally, the clinician has been witness to other clients making behavioral changes similar to the one being sought by the client in front of us. 

In a collaborative, MI-spirited interaction, the therapist is tasked with making a concerted effort not to influence a client’s directed change when the clinician cannot in full confidence state that the change they're guiding them towards is undoubtedly in the client’s best interest. Equipoise, which is defined as a balance of forces or interests, speaks to the ethical guidance a clinician relies on when faced with situations such as whether a client is exploring ambivalence related to making a large purchase, having an abortion, or deciding whether or not to leave their significant other.   MI clinicians are asked to be compassionate in their use of MI, knowing that their interventions are evidenced to affect change. 

 

Acceptance

Acceptance is composed of four distinct individual elements: 1) absolute worth, 2) accurate empathy, 3) autonomy support, and 4) affirmation.  Absolute worth speaks to the importance of valuing the inherent worth of an individual. Absolute worth is in contrast with judgment, where conditions are placed on an individual’s worth.  Clinically, this judgment can be influenced by the practitioner’s world-view, limiting the value placed on one’s individuality and lived experience. 

Accurate empathy is not to be confused with sympathy.  The clinician who demonstrates accurate empathy does all they can to view the client’s world from that person’s eyes. The clinician might ask “What experiences has this client had that make their view of this matter different from mine?”   This is not only an attempt to ‘be in someone else’s shoes’ but rests on a belief that there is a value in the very action of doing so.   

Appreciation for the client’s absolute right and capacity for self-direction is autonomy support.  Respecting a client’s autonomy requires the clinician to let go of the power that never belonged to them in the first place. The goal of accurate empathy is to understand the client’s reality, by understanding their feelings, beliefs, values, and both the importance and confidence they possess and/or assign to a particular concern. 

Affirmation requires that the clinician acknowledge a client’s strengths, efforts, values, all while instilling hope.

 

Compassion

Compassion can be summarized as the intentional pursuit of a client’s best interests by a clinician.  It is possible to pursue the other three elements (Partnership, Acceptance, and Evocation) without the central focus being the client’s best interest, but not compassion.  Being compassionate as a clinician ensures that the trust bestowed upon the clinician through the Spirit of Motivational Interviewing is truly deserved.

 

Evocation

Underlying beliefs exist in many clinical intervention methods that a client lacks something, which is central to their presenting concern.  The clinician’s role is then to provide what is missing: knowledge, skills, or insights.  Motivational Interviewing is practiced from a place where it is assumed that the client is already in possession of what they need to make behavioral changes.  Clinicians practicing MI try to pull that ‘something’ out or evoke it rather than implanting or installing it.

 

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