Appendix E: Motivational interviewing

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A useful tool in AOD client management is motivational interviewing (MI), irrespective of whether the client suffers co-occurring mental health conditions. MI can be beneficial for clients with comorbidity by increasing treatment motivation, adherence and behaviour change [528, 1162-1165], although it may not prove effective in all cases [1166]. A number of useful resources for MI are given in Appendix B, including Miller and Rollnick [389], Baker and Velleman [1167], and Clancy and Terry [296] from which this section draws upon.

MI is a directive, non-confrontational, client-centred counselling strategy aimed at increasing a person’s motivation to change. This strategy assumes equity in the client-AOD worker relationship and emphasises a client’s right to define his/her problems and choose his/her own solutions. It is, in this sense, a counselling style based on collaboration rather than confrontation, evocation rather than education and autonomy instead of authority, as opposed to a set of techniques [388].

Principles of MI include:

  • Avoid argumentation. Confrontation is unhelpful to change and is likely to increase resistance.
  • Express empathy, warmth, and genuineness in order to facilitate engagement and build rapport.
  • Support self-efficacy. Build confidence that change is possible.
  • Roll with resistance. Arguing, interrupting, negating and ignoring are signs a client is resistant to change.
  • Develop discrepancy. Generate inconsistency between how the client sees his/her current situation and how he/she would like it to be. This strategy is based on the notion that discomfort motivates change and internal inconsistency or ambivalence is a cause of human discomfort.

Thus MI aims to rouse feelings of ambivalence and discomfort surrounding current behaviour in order to motivate change. In the first two editions of MI, Miller and Rollnick conceptualised MI as having two phases: building motivation (Phase 1) and consolidating commitment (Phase 2). In the current (third) edition however, the sequential phases of MI have been relaxed, and reconceptualised as four overlapping processes (Figure 18, Table 50) [389]:

  • Engaging: the establishment of a meaningful connection and therapeutic relationship between the client and AOD worker, and is a prerequisite for everything that follows.
  • Focusing: the development and maintenance of a specific direction in conversation about change.
  • Evoking: the elicitation of the client’s own motivations for change, which has always been at the heart of MI. It can be achieved when there is a focus on a particular change and the client’s own ideas and feelings about how to achieve it are harnessed (i.e., the client talks themselves into changing).
  • Planning: involves developing commitment to change and formulating a specific plan of action. It is often the point where a client begins to talk about when and how to change, as opposed to whether and why.

Figure 18: Four processes of MI

Planning
Evoking
Focusing
Engaging

Source: Miller and Rollnick [389].

Table 50: Questions regarding each MI process

Engaging
  • How comfortable is the client talking with you?
  • How supportive/helpful are you being?
  • Does this feel like a supportive/collaborative partnership?
Focusing
  • What goals for change does the client really have?
  • Are you working together with a common purpose?
  • Does it feel like you’re moving together or in opposing directions?
Evoking
  • What are the client’s own reasons for change?
  • Is the reluctance about confidence or importance of change?
  • Are you pushing the client too far or too quickly in a particular direction?
Planning
  • What would be a reasonable next step towards change?
  • Are you remembering to evoke rather than prescribe a plan?
  • Are you offering advice or information with permission?

Source: Miller and Rollnick [389].