These people are never going to get better,” says Paul. “Yes, they just do not listen and I just don’t know what to do with them anymore,” says Alan. “I no longer know what to try. They say one thing and then do something else,” adds Claude.
We introduced this conversation at the conclusion of previous article, entitled Motivational Interviewing and the Socratic Motivational Practice. There I explained how these comments were far from foreign to any of us, especially when it comes to working with challenging patients and clients, those with substance use disorder, and borderline personality disorder, and those involved in the criminal justice system. In that same article, I explained that I have had good success with the use of Motivational Interviewing (MI) but that I have also seen its limitations.
After all, the many randomized clinical control trials conducted (numbered more than two thousand), focusing on effectiveness of Motivational Interviewing have excluded patients and clients involved in the criminal justice system as well as those who are homeless. For those of us who serve in the public sector, these justice-involved and homeless individuals are the typical patients and clients we see on a daily basis.
Do they deserve a method that works for them? Do the clinicians who are called to work with them deserve some specific and tailored tools that will allow them to best serve this population, engage them and help them achieve recovery, while also maintaining self-care and preventing burnout?
I explained the answer to be the Socratic Motivational Practice, a modality that combines both the Socratic method and Motivational Interviewing. In the above referenced article, I gave a brief overview of MI. I explained that Motivational interviewing is defined as a counseling approach, originally started for working with those affected by alcoholism. Motivational Interviewing was described in 1983 by William Miller, who then teamed up with Stephen Rollnick in 1991 for an elaboration and development. The overall goal of Motivational Interviewing is to facilitate change by engaging the patient and client, using her or his intrinsic reason and desire for that change. As previously stated, Motivational Interviewing has been supported by over two thousand randomized clinical control trials, and the approach can be used both for the individual and in groups.
In this current article, I will elaborate more on Motivational Interviewing, looking at its eight main characteristics.
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Goal-oriented:
Focuses on a specific goal, be it to quit smoking, to cut down alcohol intake, or to abstain form cocaine or other substance use.
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Client-centered:
Borrowed from Carl Rogers, who came up with the person-centered approach, it is no longer about the clinician, but the patient, the client, or the individual becomes the focus.
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Focuses on ambivalence:
Ambivalence is everything and this is where change takes place. In fact, you want your patients and clients to be ambivalent; you therefore have something to work with. Ambivalence is everywhere.
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Non-judgmental:
Also borrowed from Carl Rogers, a fervent proponent of humanistic psychology, being non-judgmental is a sure way to help establish trust and a therapeutic relationship.
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Non-confrontational:
It used to be the norm to confront our patients and clients. After all, addiction was once thought of as a character flaw, and the solution, therefore, was to simply “straighten up.” “You just have to be hard on them. It’s about tough love,” Arlene, an addiction counselor once said. The use of MI started with patients and clients with alcohol use disorder, because frankly the confrontational model was failing at best. MI reminds us all to be non-confrontational.
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Non-adversarial:
Related to being non-confrontational, the spirit of Motivational Interviewing is all about being collaborative, and far from being adversarial. It takes us away from the righting reflex-where the clinician is always right, to a partnership and a real collaboration.
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Attempt to increase patient and client’s awareness of the problem:
Motivational Interviewing does appreciate that the patients and clients may not be aware of the problem, that they may be in pre-contemplation phase, and that it is the role of the therapist to help move them to the next phase.
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Exploration and resolution of ambivalence:
Yes, ambivalence is everywhere. We can all either make a case for change or remaining the same. As a result, exploring it instead of directing our patients and clients towards what we believe to be best will help effect change.
“I am the clinician. I just tell patients what they need to do. I hope I know what’s best for them,” says Amos, a fervent nurse, who is very dedicated to his patients and clients. “Amos,” I said, paused, and asked, “how has that been working for you?” “Well, they end up saying one thing and then just do whatever they want anyway,” he answered. “Should you then not try something different,” I asked.
Each time you feel the urge to tell your patients and clients what you think they should do, take a step back, and first ask them what they think. It is similar to the explanatory model followed by solution inquiry model that I often talk about. Each time you sense or believe that you really know more about your patients or clients, take one step back and ask them first. You have your own expertise and your patients and clients have theirs, and combining them will enhance your success rate, clinical outcomes, and likelihood of recovery.
References:
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Miller, W.R., Zweben, A., DiClemente, C.C., Rychtarik, R.G. (1992) Motivational Enhancement Therapy Manual. Washington, DC: National Institute on Alcohol Abuse and Alcoholism.
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Miller, W.R.; J. J. Onken, L. S., & Carroll, K. M. (Eds.) (2000). “Motivational Enhancement Therapy: Description of Counseling Approach”. National Institute on Drug Abuse: 89–93.
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Miller, W.R.; Rollnick, S. (2002). “Motivational Interviewing: Preparing People to Change”. Guilford press.
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Miller, W.R.; Zweben, A.; DiClemente, C.C.; Rychtarik, R.G. (1994). “Motivational Enhancement Therapy Manual”. Washington, DC: National Institute on Alcohol Abuse and Alcoholism.
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Shannon, S; Smith VJ; Gregory JW (2003). “A pilot study of motivational interviewing in adolescents with diabetes. Arch Dis Child”. 88: 680–683.