Critically analyse your practice of the Motivational Interviewing approach with specific reference to your classroom learning and work placement
On reflection I have learnt a great deal about the MI approach, putting the classroom learning into practice, then reviewing my performance on the DVD has been a fundamental part of my learning process. Although being familiar with many of the techniques, which are similar to skills I already possess, the actual approach was new to me.
In brief MI allows a normally client lead Person Centred Approach to have direction by allowing clients to recognise their ambivalence acknowledging that change is possible and cultivating their innate forces to make necessary changes that are acceptable to them. I have recognised that for myself I’m going to need to practice, review and hone my techniques & awareness with implementing this model.
It is emphasised with MI that the spirit of the approach is conceivably more important than techniques used . I feel the only real way to describe this phenomena is to acknowledge that the spirit would be how the therapist presents themselves & the way that he/she utilises the techniques. With MI it is the client’s responsibility to resolve their ambivalence finding intrinsic motivation to change problematic behaviours, not the therapists to impose or suggest change. The counselling approach is generally a soft, quiet eliciting style, which places importance on the working relationship being a partnership.
The extreme contrast to MI would be confrontational approaches, which may attempt to break a client’s denial through authoritative derogatory shaming approaches stripping away individuals defences and rebuilding their identities with societies or groups philosophies .
The therapeutic approach of a pure Person Centred counselling model essentially relies upon the three core conditions of Congruence, Empathy and Unconditional Positive regard these conditions contribute to the presence of the Counsellor influencing the relationship formed with the client.
With addiction treatment settings where time constraints are prevalent Motivational Interviewing can allow more structure & direction being applied to the normally client lead Person Centred Approach. By developing discrepancy between client beliefs and problematic behaviours direction can be achieved. According to “when discrepancy becomes large enough and change seems important, a search for possible methods for change is initiated” (p. 11).
I have already integrated some use of MI into my practice however, I’m aware at times my agencies policies and procedures are in conflict with the MI spirit. Recently, I have had to check my own incentives in using MI, making sure I’m not implementing it as a form of manipulation to move clients into adherence with agencies policies, which would blemish the spirit of the MI approach.
The compatibility of the MI approach in my place of work is questionable in some areas. Our treatment modality is a 12 step abstinent based approach, which immediately arises two conflicts with the MI spirit. Firstly, not all clients may wish total abstinence and those who do may wish to achieve it in some way that is not 12 step orientated. It is agency policy that all clients attend 12 step fellowship meetings every evening during their treatment duration.
In our treatment setting the MI approach has proven to be useful in several areas when clients initially arrive in treatment anxiety levels are high if not addressed can lead to dropout. Application of MI here can help the client focus on the influencing factors that motivated them to contemplate treatment in the first place. In addition, MI is acknowledged a beneficial approach to use with angry clients especially the principals of rolling with resistance and the expression of empathy .
Although the clients have attended our treatment facility for a variety of reasons, it is difficult to place them all in one bracket concerning the “stages of change” model. Taking into account their alcohol / drug use the vast majority would be in either contemplation or active change. Some clients may display signs of resistance to change around other areas of their life which may include being in a relationship with a partner who is still active in addictive behaviour. Many clients also have difficulty with assertiveness, which is going to be necessary to develop for them to help maintain addiction free lifestyles. It is a process of change for clients conversely many of these distinct essentials are met with varying degrees of resistance by individual clients.
The first example I’m going to use is a male client of 42 years of age who has been dependent upon substances for twenty years. He displays high levels of interest in the abstinent approach registering high using a Likert assessment tool to gauge his Willingness, Ability & Readiness regarding an abstinent way of life. With reference to his substance use, I would assess him to be in the action stage of Prochaska and DiCliemente “The stages of change” (see appendix A).
He has a partner who still is a substance user; he displays high levels of resistance to changing this area of his life and feels that he will be able to change her view on substance taking once he returns home after the completion of his treatment. I have been affirming the client consistently with the changes he has made to his behaviour whilst in treatment and with permission from him, pointing how his changes are in line with the 12 step abstinent based approach. What I’m trying to achieve is too reinforce his belief in himself about this particular approach. By doing this I feel that there are inconsistencies further developing between his two cognitions “I want to remain substance free, yet I want to go home to my partner who is a substance user.” As he is now beginning to question his own thinking, I can see that the cognitive dissonance is beginning to have an effect I’m hoping he will seek to alter the risky dissonant cognition by remaining in Bournemouth to attend aftercare.
A client we recently had at our facility who presented for cannabis use, and admitted his main motivation for being in treatment was to avoid going to prison displayed resistant behaviours towards the treatment modality. His resistance would manifest in ways of walking out of group therapy, getting up and walking around whilst clients were presenting personal assignments & generally showing no respect for what other clients were trying to achieve. The application of MI in this instance was quite difficult as a direct approach in line with agency policy and procedures needed to take place first. We had tried on several occasions not to take too much notice of the unacceptable behaviours he presented which could be considered rolling with resistance, however eventually had to enforce an ultimatum. In circumstances like this I found it very difficult almost impossible to remain in a totally pure orientated spirit of MI.
To say that I have mastered the “concepts & principles” of MI would be a significant over estimation. I have furthered my knowledge of the contributing elements of MI which included the “stages of change model”, the techniques used to work with ambivalence & resistance. Most importantly, I have learnt above all else MI is about allowing the client to be the expert and for me to be mindful of the type of language that I use. The spirit of MI I have no real problem with other than perhaps on occasions avoiding the “expert trap” generally I do present myself within the spirit of this model.
The application of this particular model I’m using at work in a tentative way, in other words I’m applying it in certain situations where perhaps I feel confident to use it. An example of this would be, when clients seem to be making rash decisions to leave treatment or are displaying ambivalence about an abstinent approach.
After reviewing the DVD it is clear to me that I lack confidence in the application of the MI approach. I do however feel though that practice and reviewing my practice can only help with me developing my implementation of this approach. I feel that I need to be more mindful of the language I use whilst working with clients. As it became apparent to me whilst reviewing the DVD that I can without realising fall into traps. An example of this would be at the end of the session I asked my client if I could give him something to take away. On reflection, I could have asked him how he felt he could assess his decision on getting a shed.
My future development is going to involve applying & reviewing my practice, what I have started to look for at my work setting in my own practice and that of my work colleagues is to identify what clearly is not MI.
Some observations I have acknowledged not only with this approach are the ethical conflicts that can arise between benevolence & autonomy . On reflection, the example I used earlier on in this assignment with a male client whose partner remains in active addiction. His autonomy was to return home after treatment completion my interest or benevolence is with the safety of the client. As a professional, I know it would be risky for him to return home to someone who remains actively taking illicit drugs. The question is do I then use MI as a way to manipulate the client? My answer is yes of course I do. Questionably is this really in the pure spirit of the approach?