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Motivational Interviewing Case Scenario

A 25-year-old female patient presented with withdrawal management from Ice, 2-3 points of intravenous use for ten years. She has a history of cannabis use of 0.5 gram since the age of fifteen to twenty years and is a smoker and she smokes 20-25 cigarettes per day. There is no past medical history. When the patient was twenty, she was diagnosed with anxiety during her teenage years and five years ago she was diagnosed with depression. It was planned that the patient will be admitted for ten days with long-term rehabilitative follow-up for twelve months in Windana. The patient was referred to the service by her mother, who also gave her the ultimatum that if she does not complete the detox program and the rehabilitation, she will not be welcomed in the home anymore and will lose all support including financial support. The patient would potentially be homeless if she chooses to self-discharge. She has also recently lost her license due to driving under the influence of the drug.

Therapeutic Intervention: Motivational Interviewing

In the literature, there are documentations which indicate that the practice of Motivational interviewing (MI) leads to a positive outcome on therapeutic alliance (Haugan et al., 2019). Motivational interviewing can be defined as a therapy that is the client-centred counselling technique which is to resolve a client’s uncertainty towards behaviour change, thus turning their intrinsic motivation into action (Gill et al., 2020; Rosengren, 2017). Motivational interviewing was an intervention which was initially developed in the area of substance abuse (Gill et al., 2020). Motivational interviewing is done in a collaborative style which strengthens the consumer's commitment and motivation to change. It is the style of counselling which is a person-centred that addresses the issue of ambivalence, the collaborative sessions are goal-directed with using the language of change, exploring consumer's reason for the change with the atmosphere of compassion and acceptance (Dickerson et al., 2018). There are three core skills for communication in motivational interviewing. First is informing: which is factual knowledge about treatment or diagnosis. Second, it is to ask: with open-ended questions to understand consumer’s perspective and problems. Third, is to have active listening: by giving a reflective statement to demonstrate our understanding (Gill et al., 2020).

The style of communication is extremely important as a part of motivational interviewing. The first style is the one in which the practitioner is listening and following the conversation without interjecting their agenda. This style enables the client to have faith in their knowledge, the practitioner is with the client and let the client work the problem out in their way. Another style of communication is the guiding style of communication where the practitioner is a good listener but also offers expertise when needed. From both the styles mentioned neither one is better than the other. It depends on the consumer; therefore it is up to the art and expertise of practitioner to use the appropriate style of communication according to the consumer’s need and situation, being flexible to change approach when needed (Gill et al., 2020). Motivational interviewing was found to decrease the desire for substance use and increase self-efficacy among Iranian woman with substance abuse (Oveisi et al., 2020). Motivational interviewing is effective in among clients with substance misuse is because often clients are ambivalent about the change of habit and often not sure if they do want to engage in psychotherapy either. The literature documents the use of motivational interviewing successfully in the reduction of substance abuse and alcohol consumption (Jiang et al., 2017; Sayegh et al., 2017; DiClemente et al., 2017; D'Amico et al., 2018).

Motivational interviewing can be explained as the meeting of minds and heart where the practitioner and consumer focus on the common goal and positive change (Sayegh et al., 2017). The practitioner would have a genuine curiosity about the consumer's world, their prioritization and their values instead of focusing on being rational and empirical (DiClemente et al., 2017). The acronym PACE stands for: partnership when practitioners say we are working together (Widder, 2017). Acceptance: valuing who the person is and respects their decision, this does not mean the practitioner approves of every behaviour but instead there is focus on accepting those and remains respectful (Widder, 2017). Compassion: caring about the consumer and wanting to understand them. Lastly, evocation with all the difficulty and obstacles that they face what makes them want to change (Widder, 2017).

Motivational interviewing is relatively more effective than the traditional approach is because practitioners are not imposing their opinion on an unhealthy behaviour and tell the consumer how it should be changed because it can undermine patient own expertise (D'Amico et al., 2018). It is not uncommon that practitioner and consumer see things differently, but the focus is on mutual understanding, moving away from practitioners being always right (Haugan et al., 2019). When practitioners tell the consumer to make a behaviour change, not only the consumer will not change but also can push the consumer to more unhealthy behaviour due to pressure placed on them when they are not ready. It is known that an individual is more likely to engage in behaviour change when they hear themselves articulate rather than be told to do something (Kelly & Barker, 2016).

Development of Skills

In the present case of the female patient before taking the motivational interviewing it was required that the development and betterment of the skills were done. As a part of the employment, it was made compulsory that as a part of education it was required of me to attend a two-day workshop. The workshop was for learning the crux of motivational learning and also to learn to apply the same in a simulated environment. After the workshop ended, I made it as my responsibility to make sure I learn more about motivational learning. To do that, I invested time for the self-development and research about motivational interviewing and this I achieved by the means of reading recent evidence available for the same. At the start of the employment after obtaining permission from the consumer as well as a nurse taking the session I had observed a few sessions to get hands-on experience on what is expected in these sessions. Working as a nurse full time I been able to put in practice what I learnt in theory. I often improve my skills by interacting with consumers and learn to adjust my approach accordingly. Bring their strength to deal with the issue in hand. Getting ideas from the person and then incorporation of these ideas in the practice this can be accomplished by affirmation of the client's ability and helping them in exploring their concerns.

Critical Analysis of The Intervention and Related Ethical Issues

One of the key challenges that can be seen with the incorporation of motivational interviewing is that it can be difficult to teach it to healthcare workers and the consistency of information thought. This can affect the effectiveness of the motivational interviewing that is being practised. There are various tools which have been created for the explanation and teaching of the concept of motivational interviewing. Motivational interviewing skill can be a complex tool (MISC) to be used and as result, it let to the development of more practical and simpler (MITI) which is more widely used (Gill et al., 2020). This leads to administrative burden as the gap that is present in the MITI or MISC when attempted to be closed leads to the formation of more tools (Gill et al., 2020). The authors developing the tools have reflected that the tools can only teach the basic concepts of motivational interviewing. As many tools are present, they cannot cover advanced skills and this could impair the learning outcome of trainees. Currently, available tools which might have more favourable standards are OnePass, MISTS, or BECCI. In the review conducted by Gill et al. (2020) show the diversity of different kinds of tools which can help in the identification of most appropriate to the needs.

It was suggested that all counsellors and people working in the area of substance abuse like healthcare professionals and others need to be trained in motivational interviewing, due to its importance, effectiveness and it is an added value for the client (Dickerson et al., 2018). To achieve this it can be made sure that the professionals involved are given minimal training and provision of the certificate which might be a requirement from the counsellors and workers in the field of substance abuse. Motivational interviewing moments allow the professionals to identify why a person might have difficulty in making change. This is one of the main reasons that motivational interviewing can be incorporated into any situations whether its therapy session for many other sessions to come or it can be an opportunity to explore things even in 10 minutes (Forman & Moyers, 2019; Rosengren, 2017).

The other challenge in this type of therapy is that unless the client is ready to be changed there is not much can be done in terms of behaviour change (Hayes, 2016). One of the core elements of motivation is to explore and determine where there the client want to get behaviour changed (Hardcastle et al., 2017). From the clinicians' point of view, it can be difficult for the clinician to stop oneself from pointing out why any behaviour might be unhealthy and is best to implement change (Dobson & Dobson, 2018). From the conversation with the patient, it was obvious that she was very much opposed to any type of authority figure, starting from her mother to health professional and police and legal system. She was also quite defensive and hard to engage initially, she probably thought clinician would be just another person who would tell her that she had to complete her stay otherwise she would face untoward consequences that she was made aware of. The patient approached saying she cannot do this anymore and the idea was just stupid and that she was at the centre because of her mother. It was informed to her that she is a voluntary inpatient and she can walk out at any stage. She was offered a one-on-one conversation where she explored herself about the need to change behaviour and that it was not necessarily all her mother’s idea.

Conclusion on Motivational Interviewing

The patient did benefit from motivational interviewing practice in the above scenario as she was able to identify reasons to why she wanted a change of habits, she realized she has a lot to offer and she was empowered to make the change. She was able to articulate her reasons to why she needed to complete the program. Use of MI is preferable because consumers often take apposing way when confronting them, and telling them to do things. It is seen that when things are explored by the client they are more acceptable rather than when it comes from any healthcare professional.

References for Motivational Interviewing

D'Amico, E. J., Parast, L., Shadel, W. G., Meredith, L. S., Seelam, R., & Stein, B. D. (2018). Brief motivational interviewing intervention to reduce alcohol and marijuana use for at-risk adolescents in primary care. Journal of Consulting and Clinical Psychology86(9), 775. https://doi.org/10.1037/ccp0000332

Dickerson, D., Moore, L. A., Rieckmann, T., Croy, C. D., Venner, K., Moghaddam, J., ... & Novins, D. K. (2018). Correlates of motivational interviewing use among substance use treatment programs serving American Indians/Alaska Natives. The Journal of Behavioral Health Services & Research45(1), 31-45. https://doi.org/10.1007/s11414-016-9549-0

DiClemente, C. C., Corno, C. M., Graydon, M. M., Wiprovnick, A. E., & Knoblach, D. J. (2017). Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychology of Addictive Behaviors31(8), 862. https://psycnet.apa.org/buy/2017-53537-001

Dobson, D. J., & Dobson, K. S. (2018). Avoidance in the clinic: Strategies to conceptualize and reduce avoidant thoughts, emotions, and behaviors with cognitive-behavioral therapy. Practice Innovations3(1), 32. https://doi.org/10.1037/pri0000061

Forman, D. P., & Moyers, T. B. (2019). With odds of a single session, motivational interviewing is a good bet. Psychotherapy, 56(1), 62–66. https://doi.org/10.1037/pst0000199

Gill, I., Oster, C., & Lawn, S. (2020). Assessing competence in health professionals’ use of motivational interviewing: A systematic review of training and supervision tools. Patient Education and Counseling103(3), 473-483. https://doi.org/10.1016/j.pec.2019.09.021

Hardcastle, S. J., Fortier, M., Blake, N., & Hagger, M. S. (2017). Identifying content-based and relational techniques to change behaviour in motivational interviewing. Health Psychology Review11(1), 1-16. https://doi.org/10.1080/17437199.2016.1190659

Haugan, P. S., Berge, M. C., Breiseth, V., Sund, E. R., & Hedlund, M. (2019). Does training in Motivational Interviewing affect the ability to build working alliance?–An intervention study. Society, Health & Vulnerability10(1), 1595365. https://doi.org/10.1080/20021518.2019.1595365

Hayes, S. C. (2016). Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies–republished article. Behavior Therapy47(6), 869-885. https://doi.org/10.1016/j.beth.2016.11.006

Jiang, S., Wu, L., & Gao, X. (2017). Beyond face-to-face individual counseling: A systematic review on alternative modes of motivational interviewing in substance abuse treatment and prevention. Addictive Behaviors73, 216-235. https://doi.org/10.1016/j.addbeh.2017.05.023

Kelly, M. P., & Barker, M. (2016). Why is changing health-related behaviour so difficult?. Public health136, 109-116. https://doi.org/10.1016/j.puhe.2016.03.030

Oveisi, S., Stein, L. A. R., Babaeepour, E., & Araban, M. (2020). The impact of motivational interviewing on relapse to substance use among women in Iran: A randomized clinical trial. BMC Psychiatry20, 1-7. https://doi.org/10.1186/s12888-020-02561-9

Rosengren, D. B. (2017). Building motivational interviewing skills: A practitioner workbook. Guilford publications.

Sayegh, C. S., Huey Jr, S. J., Zara, E. J., & Jhaveri, K. (2017). Follow-up treatment effects of contingency management and motivational interviewing on substance use: A meta-analysis. Psychology of Addictive Behaviors31(4), 403. https://doi.org/10.1037/adb0000277

Widder, R. (2017). Learning to use motivational interviewing effectively: Modules. The Journal of Continuing Education in Nursing48(7), 312-319. https://doi.org/10.3928/00220124-20170616-08

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