Motivational Interviewing

Transcription

1 MI Motivational Interviewing Jassin M. Jouria, MD INTRODUCTION Motivational interviewing (MI) is a method that promotes behavior change, and can be used in a multitude of environments and situations to foster growth and to help people to take on challenging situations. Motivational interviewing is a collaborative process that edifies the client and makes him or her responsible for personal choices. It is not necessarily a stand-alone type of therapy, but instead can be incorporated into treatments and routine care for clients with various health issues, including those with physical health problems, mental health issues, or substance abuse and addiction. MI has also successfully been used along with other forms of therapy to improve connection between the client and the provider and to alter the process at which the client makes changes in his or her life. Therapists can use motivational interviewing in a number of situations, yet it should always be recognized that no one could be forced to change. Although the goal of MI is not to directly change a person s behavior, it does guide the client toward making different choices that can foster change in his or her life. The concept of motivational interviewing began in the early 1980s with the publication of a book by William R. Miller, PhD, who focused his model of MI on working with people suffering from substance abuse and addiction. The book was titled Motivational Interviewing with Problem Drinkers and it was initially used among psychiatrists and other professionals who provided counseling services for people going through treatment for addiction [5]. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 1

2 Almost twenty years later, Miller and a colleague, Stephen Rollnick, published a second edition of the book. The second edition was geared, not only toward addiction professionals working in the field of psychotherapy, to any professional in the healthcare field who could utilize the principles and put the techniques of MI into practice with their clients [5]. Miller and Rollnick described motivational interviewing as a directive, clientcentered counseling style for eliciting behavior change by helping clients to restore and resolve ambivalence [5]. Ambivalence is a state in which a person is uncertain about which direction to take, if any. A person who feels ambivalent about his or her need for change or required treatments may approach the situation with a lack of motivation. The person may have such mixed feelings about the situation that making a decision can be paralyzing. When a therapeutic relationship starts, the client may be in various stages of ambivalence depending on the current situation. If he or she was recently diagnosed with an illness or disease, ambivalence may be paired with frustration or anger over the situation. Alternatively, the client may have known for quite some time that change is necessary but has been unwilling or unable to take steps to move forward. Motivational interviewing is more than just a set of techniques that can be implemented into conversations between healthcare providers and their clients. It recognizes several theories as a basis for its approach, including cognitive dissonance theory, which acknowledges that a person who acts against his or her beliefs will be motivated to either change behaviors or otherwise justify them; and self-perception theory, which is the idea that people conclude certain traits or ideas about themselves based on observing their own behaviors [33]. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 2

3 A basic premise exists in motivational interviewing that talk can be helpful for some situations, but without the motivation to change, talk, or simply telling a person to do something, will not get very far. The provider who is working with a client through motivational interviewing must recognize the level of motivation the client holds and must be willing to work through possible resistance to change in order to foster goal setting and to move forward [33]. Motivational interviewing can be used in many different types of specialties for helping clients to change. Although it may be considered a therapeutic approach that would traditionally be used in counseling or in sessions with a psychologist, motivational interviewing can actually be a part of some routine meetings or examinations for brief sessions. Motivational interviewing has been used successfully in implementing change in numerous situations, such as with drug or alcohol addiction, smoking cessation, vocational rehabilitation, criminal justice, pregnancy, and as a component of treatment for many different medical conditions [29]. Similarly, motivational interviewing is not simply designated for counselors or psychologists. It can be successfully implemented into appointments or interactions with various healthcare providers, including nursing staff, primary care physicians, nurse practitioners, or allied health professionals. There is some formal training available in developing the techniques associated with motivational interviewing, although learning the techniques and the process of MI is typically either integrated into formal education programs, or through stand-alone training opportunities, such as through workshops, conferences, or online educational programs. The Motivational Interviewing Network of Trainers (MINT) is a non-profit organization that was started by a group of MI practitioners who were originally trained by Miller and Rollnick in MI techniques. MINT promotes the ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 3

4 use of motivational interviewing, as well as continuing research and appropriate training of practitioners. The organization is composed of independent trainers and practitioners and can give details about specific educational opportunities for those who want to learn more about motivational interviewing and to put its methods into practice [30]. STAGES OF READINESS FOR CHANGE The ultimate goal of working through motivational interviewing is to move the client through the various stages of change, from being ambivalent or unmotivated to dealing with unhealthy behavior and making more positive choices [21]. The stages of readiness for change is actually a cycle of steps identified by James Prochaska, and each step requires various interventions to move the client on to the next step. The stages of change include: precontemplation, contemplation, preparation, action, maintenance, and termination [21, 22]. The precontemplation stage occurs before the client is even aware that a change needs to happen. Family members, friends, and significant others may easily recognize that the client has a problem or that change needs to happen but the client is often unaware. During this phase, the client is resistant to change because he or she does not understand its necessity. The client may even be aware that life is difficult or there are several aspects of life that demand attention that he or she cannot handle, but the concept of change is still foreign. The contemplation stage is when the client recognizes that a change needs to happen. It is often at this stage where motivational interviewing begins. Although the client may recognize the need for change, he or she may be so ambivalent about making the change or what steps to take that no change ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 4

5 occurs at all. Many people remain in the contemplation stage for years, always feeling that something needs to be done, but never taking steps to do anything. The preparation stage involves planning to make a change soon. People in this stage may still be ambivalent about what to do, but they are planning to try for a change. They may be uncertain that their plans are the best for solving their situation and so may still be somewhat ambivalent about making choices toward change. They often need to convince themselves that change is necessary and that their plans are the best method of working through the problem. The action stage involves taking the steps to overcome the problem. It is during this stage that the client does a lot of activity that demonstrates working toward the change, such as quitting smoking or exercising more. Others can see the client s work toward the change as well, which can be encouraging. This stage also requires the most energy to continue with changes, even if they are uncomfortable. The maintenance stage is the ongoing phase that may be life long for some people. This stage occurs after a person has done the work of making changes but then needs to continue to make efforts to maintain the results. For example, a person who has lost 50 pounds needs to maintain the weight loss by continuing with efforts that he or she implemented to lose the weight in the first place. If the person does not maintain the work, he/she may gain the weight back. The termination phase is one in which the initial issue is no longer a problem. Some people never reach this phase while working for change, as ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 5

6 the principles they developed and the work they completed must continue to be maintained and reinforced for the rest of their lives. For others, the termination phase results when the initial change or struggle is no longer a problem and they can move forward into other activities without continuously maintaining their previous efforts [22]. Key principles Motivational interviewing can be broken down into key principles, followed by significant processes that are used. Each process or principle is then supported by various therapeutic techniques. Each technique may serve to uphold or meet the goals of one or more principle or process throughout the interview. To start, motivational interviewing consists of four key principles that guide practice, which are empathy, discrepancy, rolling with resistance, and supporting self-efficacy [5]. Empathy Motivational interviewing is characterized by empathy on the part of the provider. Without empathy, no amount of discussion, sympathy, or understanding will stir the client toward change. The client needs empathy from the provider in order to feel as if he or she is not alone in the process and to feel that someone truly understands. Knowing that someone else has empathy can reduce feelings of isolation and can spur change. The goal of being empathic is to help the patient to feel that he or she can open up. The caregiver provides an open and non-judgmental attitude that conveys warmth. The provider s demeanor when engaging the client should express unconditional acceptance whereby the patient senses the provider s response to them to be: I know what you are going through; I care about what happens to you. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 6

7 The provider during motivational interviewing does not try to change the client s ambivalence or condemn the situation. Rather, ambivalence should be accepted as part of the process and the provider should expect that the client would have those feelings. If not, then the motivational interview would not otherwise be necessary. The provider should instead look at ambivalence on the part of the client as the reason for their time together and go forward from there. Discrepancy Discrepancy describes the state the client is currently in compared to the point at which he or she wants to be. The clinician works through the motivational interview to help the client see not only where he or she is currently, but to remind the client of their goals. The client must understand that these are two different states. The state where he or she currently is - one of ambivalence about a situation requiring change - is not the same as the state where he or she wants to be. If it were, the client would not be working through the motivational interview [6]. To best help the client develop discrepancy the clinician assists the client to see how far he or she has come in other areas of success. The clinician may point out other areas of change such as by saying to the client: remember when you used to struggle so much with this? Look where you are now and how much you have achieved in that area. It can be helpful for the client to know that he or she has overcome ambivalence or past challenges to reach goals in other areas and can know that it can be done in this area as well. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 7

8 It is important for the clinician to remember that the practice of developing discrepancy requires a non-judgmental attitude. The clinician should also remember to ask before giving advice, and to speak clearly and in a supportive tone. Clarifying those items that do not make sense may also be necessary and is often an ongoing part of the process to avoid misunderstanding. By utilizing these techniques, the client will be better able to have a clear direction and understand where he or she is at in a process of changing behavior versus where the client wants to be at the conclusion of the motivational interviewing process [6]. The provider incorporates these key principles throughout the process of the motivational interview. Instead of being a straightforward path, MI is a somewhat fluid method that uses these principles as a general direction. The provider may also use other processes as part of motivational interviewing that support the initial principles discussed. These processes are: engaging the client, promoting change by supporting self-focus, determining the client s motivation for change, and formulating a plan [6]. Roll with Resistance While working with clients through the process of change, there are bound to be times of resistance. When the provider discovers that the client is resistant to ideas, suggestions, or change overall, it is important to take it in stride and not create further tension; in other words, to roll with it. The provider should avoid responding in a manner that is harsh or critical, even if the client presents this type of demeanor. Often, the idea of change can be threatening and some people may respond negatively out of fear. Even if this is the response of the client, the provider ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 8

9 should work to remain calm and to continue with the relationship, providing the most support and direction possible through conversation. When the client starts to become upset or resistant to the MI process, it is a signal for the provider to slow down, avoid being forceful in any way, take a deep breath, and consider how their demeanor and delivery of information is presented to the client. The provider should consider his or her words, questions, and any types of non-verbal communication that could be threatening to the client and make adjustments as necessary. The provider should then determine how he or she can best present an empathic presence and show more understanding toward the client to prevent further resistance. It might be necessary for the provider to use some specific phrases during the interview that can clarify what the client is trying to say and to defuse the situation as necessary. For example, the provider could say: I hear what you are saying and I just want to make sure that I am understanding you correctly. That must be very difficult for you; I can t imagine how hard it is for you. It sounds as if you want to consider other options for dealing with what we are talking about. By responding differently, and not mirroring negative attitudes or behaviors, the provider prevents the conversation from unraveling and prevents the client from turning away from making changes because of feeling threatened or otherwise resisting the motivational interviewing process [6]. Support Self-Efficacy ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 9

10 Self-efficacy defines how a person feels about his or her abilities. It differs from self-esteem, which describes how a person feels about themself and their value as part of society. Instead, self-efficacy is the personal selfconfidence to perform a task or to take on a situation. A person may have a strong sense of self-efficacy in one area of life but be weak in another. For example, a client may be strong and confident at his job and may be quite successful as a leader at work; however, the client may also lack selfefficacy when struggling with alcohol use and may be ambivalent about change if they feel unable to overcome the struggle [11]. Although high levels of self-efficacy feelings may help a person to feel more confident in his or her pursuit of a goal or involvement with a certain activity, having self-efficacy does not necessarily guarantee that the person will succeed [11]. A provider may work with a client to help them feel more positive about personal abilities, but unless realistic goals and techniques for achieving those goals are introduced into the equation, the client may still not succeed when trying to change. Self-efficacy requires motivation and effort to be successful. A person s belief that he or she can accomplish a goal works as a powerful motivation toward change. Ultimately, it is the work of the client that facilitates change, and not the provider. The client s ability to make the change, rather than requiring assistance or having a provider do the work for them, further supports self-efficacy in the client because they know that the accomplishment was achieved specifically by and for them. The provider s role is to be confident in the client s ability to change and to empower the client by asking questions and directing the discussion. Engaging the client ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 10

11 The goal of expressing empathy is to build a relationship of trust between the provider and the client. Empathy involves accepting the client s state of ambivalence, even if the provider disagrees with the viewpoint. When the provider takes on a non-judgmental stance toward the client, he or she avoids being perceived as critical or otherwise condemning of the situation. This stance engages the client and supports the development of a trusting relationship. A client who is going through a crisis or other situation that requires motivational interviewing may already feel judged or criticized by others. Many people who are in need of change are also aware of that need, whether they can actually complete the change or not. For example, a client who needs to lose a significant amount of weight in order to establish a healthier lifestyle and to reduce the risk of developing certain health conditions is most likely aware of the need for weight loss. Often, when caregivers or the public judge or condemn others for their need for change, it only serves to further diminish the motivation for change while simultaneously causing negative feelings and disrupting self-esteem. Therefore, a non-judgmental, accepting attitude must be in place on the part of the caregiver before motivational interviewing even begins. Expressing empathy involves considering the thoughts and feelings of the other person by actually putting oneself into the place of the person. It differs from sympathy, in which subjective information may allow a provider to understand what a client is going through, but the provider can only acknowledge the other person s feelings as a method of providing comfort [7]. Sympathy is not wrong in itself, but empathy can actually break down potential barriers between the client and the provider by communicating comfort and building trust through understanding. A client who receives an ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 11

12 empathic response from a provider during a motivational interview may be willing to open up more if he or she perceives that some of the struggles involved are shared. Determining self-focus The focusing component of motivational interviewing involves setting up the direction in which the conversations will go. It often starts with an initial meeting in which the client and the provider meet to discuss their purposes for talking and to discuss initial thoughts, concerns, or priorities of the client. Through focusing, the provider takes the information given during the initial conversation and helps the client to find a direction for where the conversations will go [6]. It is important that the provider does not take complete direction with the interview by telling the client what he or she should do. Part of the goal of focusing is to allow the client to find his or her focus through the coaching involved with motivational interviewing, not to be told what to do. The provider should also avoid developing a premature focus in which he or she decides the direction of the interviews early on [6]. This can limit the potential for where the conversations could go and also impact how well the client is able to work toward change. If the provider decides on the focus for the client early on in the relationship, the client may be less likely to stay motivated or involved, particularly if he or she believes that the point of the relationship is only to work toward the clinician s goals, not the client s. To develop a focus for the interview process and the therapeutic relationship, the provider and the client should work together to decide what the goals of their time together should be. By collaborating on the focus, both the client and the provider have a vested interest in the relationship ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 12

13 because they have worked together to set their goals. Evoking change The heart of motivational interviewing, according to Community Care of North Carolina, is evoking change through the relationship between the provider and the client. Evoking change involves helping the client to determine his or her own amount of ambivalence toward the subject at hand and the amount of motivation that he or she has to make a change [6]. Evoking change first requires understanding what the client wants to change. This comes about through initial interviews, but may change through the course of the relationship. If the provider and the client have determined a focus for the MI, this will guide the provider toward where to direct their discussions to evoke change. After the focus of the discussion has been identified, the provider then helps the client to explore more reasons for change, barriers to change, and what systems should be in place to evoke change [6]. Before change can begin, the provider must also bring up and discuss the client s level of ambivalence. If the client is uncertain about changing or which direction to take in order to make the change, the ultimate goals and focus of the relationship may not go far if ambivalence is not addressed. The provider should ascertain the amount of uncertainty the client is experiencing by guiding the discussion. For instance, the provider may ask the client some questions to explore any ambivalent feelings and determine what might be keeping the client from taking a step in one direction or another. Change may be more likely to occur if the discussion focuses on past ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 13

14 successes for the client. This focus can help to improve confidence and feelings of self-esteem when a person knows that he or she has been successful when attempting a previous activity [6]. The provider might focus on the client s strengths at his or her job or in other relationships and use those strengths to apply to the current situation. For example, when considering a client who needs to lose a significant amount of weight, the provider might bring up that the client has been successful with committing to their duties at work and can stay focused on them. The client may bring up past success with completing projects or enduring through situations when circumstances were difficult. The provider can then use that information to empower the client toward his or her next goal of losing excess weight. By remembering personal successes, the client can bring that information to mind the next time he or she struggles with working toward a current goal. It should be noted that not all relationships developed through motivational interviewing evoke a complete change or result in change occurring at all. Some people, despite being willing to enter into the motivational interviewing situation and the therapeutic relationship, will be resistant to change. Making changes, regardless of the underlying need, can be scary and overwhelming and some people may ultimately decide that changing is not worth it. However, it is important for the provider that utilizes MI to understand that resistance to change does not have to be end of the relationship. Instead, it should be looked at as an opportunity for redirecting the focus of the relationship. The provider does not determine the path that the client takes. Rather, the provider helps the client along the path that he or she has chosen [5]. A final aspect of evoking change is preparing for the resources that will be ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 14

15 needed to support that change. Typically, a client does not make changes all on his or her own, and even with the help of a provider, long-term and permanent change is not carried out without the help and support of others. The client must learn about what resources are available and where to turn for continued support. As these ideas are mapped out, the motivational interview moves into the planning stage for how tasks will be completed in order to achieve the desired goals. Planning The planning phase of the interview comes after much of the discussion surrounding change has occurred, including discussion of the client s motivation and levels of ambivalence, his or her desire for permanent change, and level of commitment to the change. Additionally, the provider and the client have set goals for where to direct the interview in order to best plan for the final outcomes. Planning involves structuring how the process of the interview will take place. The client and the provider work together throughout the process and continuously re-evaluate how well the client is working toward set goals and ideas for change. This may involve setting smaller benchmarks during the process and providing little rewards along the way as the client makes changes [6]. Planning also involves accountability between the client and the provider. The client remains accountable toward the interviewer to keep him or her updated about the work completed toward ultimate goals, the achievement of smaller goals set along the way, and what resources have been utilized in the process. This accountability allows for evaluation of what is working in the process and what is not, and allows the provider and the client to work ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 15

16 together to make changes where necessary. Accountability is also required from the provider toward the client. The provider must follow through with his or her plans for coaching the client and commitment to the relationship. This involves keeping contact with the client, following up on unfinished business, and maintaining that side of the relationship to ensure that it will continue. MOTIVATIONAL INTERVIEWING TECHNIQUES Once the overall process of the motivational interview has been determined and the healthcare provider is aware of the need for empathy, finding a focus, evoking change in the client, and planning for resources, these processes are facilitated through the conversation. The provider can use a number of techniques to facilitate the interview, each with its own method of supporting the processes that make up the therapeutic relationship. Facilitating the process The motivational interview typically begins with a meeting between the client and the provider. Often, the first meeting is the first actual encounter with the client, and the provider does not have much information into his or her background. The provider may be aware of the need for the client s change because of circumstances understood in broad terms, but in order to understand the client s feelings of ambivalence as well as the greater details of the need for change, the provider and client must have initial meetings to discuss the client s background and contributing factors for the relationship. The initial encounter involves a getting to know you process in which the client provides background information about him- or herself. Even at the ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 16

17 beginning of the interviewing process, the provider must use techniques of therapeutic communication to gather information and to establish a basis for trust in the relationship. This involves active listening, avoidance of interruptions, and reflection on what the client has said [5]. Once the background discussion has taken place, the provider can move forward with the rest of the process of goal setting and evoking change by utilizing various therapeutic techniques that are inherent parts of the motivational interview. It is through these techniques that the client is able to open up and provide more information, learn to trust the provider, and work toward a mutual goal for the relationship. There are various techniques that make up the motivational interview and can be utilized effectively to support the different aspects of the relationship. OARS A technique that can be successfully used to engage the client, provide empathy, and promote communication is known as OARS, which stands for Open-Ended Questions Affirmations Reflection - Summaries. The process of using OARS in communication can be looked at in the same way as a reallife method of using oars in a rowboat. Wagner and Conners clarify the use of OARS this way: [OARS] give us power to move, yet it is not a powerboat. We don't zip from one place to another, yet with sustained effort OARS can take us a long way [8]. The provider uses open-ended questions to evoke more of a response than simply yes or no. Although closed questions are sometimes necessary or may be the only method of gaining some information, open-ended questions should be utilized to get the client to share more information [8]. Sometimes, by starting to talk with answering an open-ended question, the ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 17

18 client will continue to share much more. Open-ended questions are probing but should not be too intrusive for the client, which can result in an opposite effect. They demonstrate that the caregiver is curious about the client s situation and wants to hear more [6]. Examples of opening lines of open-ended questions that may be used in the interview include: Tell me more about What did you do after Can you explain more about How did you feel when Affirmations are the second section of the OARS mnemonic. Affirmations look for successes from the client and point out those areas of accomplishment. The provider must be genuine when providing affirmations, as false praise is completely different than a genuine affirmation and a client can usually understand when someone is not being authentic [5, 8]. If the client does recognize that the provider is not genuine in his or her words, a roadblock will quickly go up that is destructive to building trust and will keep the client from sharing any more information. Affirmations are words that are encouraging and optimistic; they are meant to help the client see progress being made. Examples of affirmations that could be included as parts of the interview are: I m glad that you want to talk about this. I think what you are doing would be very difficult, and you are putting a lot of work into it. You have made a lot of progress. ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 18

19 You controlled yourself well in that situation. The third component of OARS is reflective listening. This considers what the patient has said and repeats it back to him or her in slightly different language. The provider is reflecting on what the patient has said, while the patient is listening to his or her own words said in a different way. This helps both the provider and the patient. The provider uses reflection to fully understand what the client is saying so that none of the information will be misinterpreted. Reflection also helps the client to think about what he or she is saying, consider its truth or inconsistencies, and clarify ideas that might have been misunderstood. Reflection should be a regular part of the motivational interview, as one missed idea from one side or the other in the conversation can lead to a set of false assumptions and misinformation that must be corrected before the conversation can move on. Instead, regular reflection continues to provide clarification for statements in a manner that is not threatening. Examples of the openings of reflections that could be used in the interview include: What I hear you saying is It sounds as if you want to So, your concern is that You believe it is important to From your point of view, you Summaries are the final component of the OARS mnemonic. Summarizing takes the information the client has said and what has been discussed during the interview and puts it into one or two concise statements. This process has several purposes. It reinforces the idea that the provider is listening to the client and has heard what he or she has been talking about; it serves as ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 19

20 a type of reflection to help the client hear again what he or she has been saying and to think about it; it clarifies information from the part of the provider, and it provides a transition into the next segment, which could be closing the session or moving onto another topic [6]. A summary of the discussion can motivate the client because it supports the coaching provided by the provider. Summarizing also supports the focusing aspect of MI in that the client is able to see a few distinct areas in which to concentrate efforts, which can make the process seem less overwhelming and may give him or her a better idea of how to focus tasks later on. Examples of summarizing statements include: If we review what we have been discussing, I can see So, you believe that Am I correct? We have covered this information well by talking about Here are the points that I understand so far To summarize Informing or advice giving Providing information to the client and giving advice must be done very carefully to avoid taking over the direction of the conversation and telling the client what to do. There will be many times when clients are impressionable: if they are ambivalent about making a decision, they may want the provider to tell them what to do. This is an important scenario to avoid, as the client needs to process enough of the information in order to make his or her own decisions. Additionally, if the client makes a decision based on what he or she thinks the provider has said, there s a risk the client may later regret the ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 20

21 choice or may not be willing to stay with the outcomes and then feel angry or blame the provider for suggesting the wrong thing to do. By allowing the client to take their own direction and supporting them in decisions, the provider helps the client to feel empowered by their own choices and alleviates them of the role of being ambivalent to being more decisive and goal-oriented. Information and advice should be open and guiding, allowing the client to be the best expert for their own situation. The provider always asks permission before imparting advice or giving information about a situation, using statements or questions such as: Would it be all right if I shared with you I have seen this experience in the past. Can I tell you about it? Could I share with you what I have read about this? It may be helpful at the beginning of the relationship to determine what the client s best method of understanding information would be. Some people are visual learners and respond best to pictures or reading materials. Others are auditory learners, and can take in and better grasp the information that they hear. When the provider understands the various different types of learning methods, he/she can be better prepared to share information in a manner that has meaning for the client, such as by bringing reading materials that support the topic of the conversation [6]. Giving advice, even when it is permissible, is not simply telling the client what to do. Even if the client allows the advice, the provider should still never direct statements to the client to say such things as, if I were you, I would or you can fix this if you would Instead, the advice and the ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 21

22 information must be connected to the client s concerns and address those thoughts and feelings. A menu of options offers choices to the client so that he or she does not feel as if the advice or information given by the provider is the only choice for the client s behavior. Instead, providing a menu of options as part of the information still allows the client to choose the best step for him- or herself [6]. DARN CAT A helpful mnemonic that can be used to elicit change is remembering DARN CAT, which stands for Desire Ability Reason Need Commitment Activation - Taking steps. When a provider considers approaching the client with talk about change, he or she can think of the DARN CAT acronym as a reminder of how best to build motivation in the client. Desire means a statement or words that the client uses that indicates wanting to change. It is important to listen for desire statements, as the provider can remember these and use them to remind the client at a later time if he or she ever feels confused about their choices. Desire statements are the beginning of resolving ambivalence: if a patient has a desire for a change, he or she can at least understand the general direction in which to go. Desire statements include anything that signifies the client s wishes or needs: I need to get my life in order. I wish I could lose this weight to better care for my health. I want my blood pressure levels to be normal. The A of DARN signifies the client s ability to change, based on their beliefs that change can happen by working with the tools and guidance available ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 22

23 from the provider. The provider can better direct the client toward thinking about items and successes that will support his or her abilities. The provider might say: You were able to accomplish this before, is there something stopping you now? Why do you want to do this? The client also may also make statements that will signify that they have a growing belief in themselves. These might be positive phrases or comments that indicate that the provider has noticed the client has been thinking about the change made and has grown in believing in themself: I ve done this before; there is no reason why I can t do it again. If I can just.i think I can do it. I can make this change if I work at it. The R in DARN stands for reason and explores the reasons behind the change. The discussion may center on why it is important to change or the disadvantages of not making the change. Exploring the reasons behind the change also help to reduce ambivalence in the client because it provides a clearer direction of change for the client. The provider can ask questions to help the client better determine his or her need for change: Why do you think this change is important? What benefit do you see happening from this? The N in DARN CAT stands for need. This step is important for the client to better understand the true need for the change. Again, this step helps resolve some ambivalence when the client is able to see how the problem ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 23

24 affects his life and how making the change can improve the situation. Some people become so involved with their situations that they fail to see how destructive their lifestyles are. They may not be aware of the detrimental effects of their choices or be able to see how change could make things better. For example, a provider might work with a client with a history of substance abuse and who is working toward making changes in their behavior and relationships with their family. The client may be so engrossed with accessing and using drugs and alcohol that they do not understand the impact that their behavior has had on their spouse and children. The client may come to the situation feeling ambivalent about change or even unsure whether the change is worth the time and effort. Over time, by discussing the situation with the provider through motivational interviewing, setting goals, and taking steps toward change, the client may be more likely to see how much better life could be if he or she follows through with the changes. The client better understands how truly important it is for them to change. The client who starts to understand the need for change may make statements that indicate his or her level of comprehension: I didn t realize before how hurtful this all was. I need to change so I can spend more time with my family. I want to do things differently and try to mend my relationship with my spouse. The first part of the acronym, DARN, is devoted to promoting change for the client. Each of the letters in the word are focused on what the provider can do to guide the client toward change, as well as how the client can recognize ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 24

25 the importance of change and determine to make a difference. This is what is classified as change talk and is the focus of DARN. Alternatively, the CAT portion of the acronym consists of the second phase of mobilizing someone toward change. The C in CAT stands for commitment and signifies that the client is taking steps to commit to change. This step is important to acknowledge because verbalizing the commitment is the first step toward following through. If the client can speak his or her intent out loud, it may become clearer and may be easier to focus attention in the right direction. Examples of statements that indicate commitment on the part of the client include: I will quit, because... I plan to start I will finish The A of CAT stands for the activation of the stated commitment. Once a client commits to making a change, the provider and the client must work together to determine how to best go about making such a change. If the client is not equipped with the right tools for change, his or her words of commitment will be meaningless. Examples of phrases from the client that signify a readiness to activate the change include: I am ready for this. I am prepared to change by I will work at this through Finally, the T in CAT stands for taking steps, which are statements by the client that confirm the readiness to change. These statements demonstrate ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 25

26 the client s commitment to change because they come from the client instead of being directed by the practitioner. Because they are in the client s own words, the client has formed the suggestions for change into a meaningful and realistic statement that he or she can now put into practice, such as: I called my doctor to ask for a prescription for medication that will help me quit smoking. I really had a craving for earlier today, but I took a walk instead. The implementation of the steps of DARN, followed by CAT, help the client to understand the need for change and then take the important steps toward completing interventions to reach his or her goal. Throughout the process of working through the steps of the acronym, the provider should continually evaluate the progress being made and make changes when something doesn t work. If the client resists one of the steps, the provider should take a step back, clarify what is needed, and try to work through any gaps that have presented as part of the process. Elicit-provide-elicit Another method of helping the client to take charge of his or her decisions is the elicit-provide-elicit method. This idea serves to seek information from the client, provide advice that can be helpful and empowering, and then follow up with the success of the information. The elicit-provide-elicit method is directed by the provider but is actually a collaborative process between both the provider and the client. The first elicit establishes the client s expectations, beliefs, and goals of the interaction or the change that is required. The provider approaches the topic ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 26

27 with sensitivity and asks permission before giving advice or otherwise directing the client. The provider may open with a question or a statement, such as: Do you mind if we talk about Can I clarify something that you said about Would you like to discuss the subject of Can I share some related information about Each opening phrase is designed to ask or clarify what the client knows about the situation; it also asks permission for the provider to provide more direction on the topic. The second step is to provide information about the topic or to clarify something the client has brought up that still might be unclear. The provider may say: This could be why What we know is Others have worked through this by During the provide step, it is important to avoid using statements that include I or you; and, to remain neutral. This avoids coming across as judgmental or condemning in any way. After providing advice or direction, the provider once again elicits information from the client to determine how well he or she understands the information presented and to get a better feel for how the information will be used. The second step of eliciting involves more about the patient s feelings for the situation and how the information is interpreted. The provider may say: ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 27

28 What do you think of what we have talked about? Where can we go from here? How can I help you at this point? As with other interactions, it is important that the provider not tell the client what to do during the second elicit phase or give his or her opinion about the situation. Instead, it should be looked at as another opportunity to collaborate with the client by using known information to work toward results [5,10]. FRAMES Another guide used to solicit change is termed FRAMES, which stands for Feedback Responsibility Advice - Menu of options Empathy - Selfefficacy. Following the FRAMES model approach during the motivational interview can help the provider to remember the most important aspects of interaction to foster success for the client. Feedback involves the exchange of information between the provider and the client. The provider may ask for information from the client by asking open-ended questions and helping him or her to open up more with sharing. The provider may also give feedback as part of reflecting or summarizing the discussions and clarifying points. Alternatively, the provider may also offer feedback to the client in the form of thoughts or advice. An essential component of motivational interviewing is to always ask for permission before offering advice or feedback on the client s perspective. This practice respects the client s point of view and helps to address some of ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 28

29 the client s ambivalence about the topic [9]. The R of FRAMES stands for responsibility, which outlines some of the expectations for the interviews as well as the responsibilities for change. Ultimately, it is the client s role to take responsibility for making changes within him- or herself, however, the provider serves as a coach or director for assisting with changes. The provider and client work together to collaborate on the change process but the provider should direct the client as to his or her expectations for change that they have decided on together. It is not appropriate, nor is it possible, for the provider to take responsibility for the client s change; that responsibility must belong to the client. Many providers who work with clients during the motivational interview process are skilled and have knowledge of various psychological concepts and therapeutic techniques that would be helpful to share with others who need guidance for making changes in their lives. Giving advice can be very helpful for some clients, particularly when they have enough ambivalence about a topic of change that they are unable to make a decision about where to begin. Just as with offering feedback, it is essential that the provider ask for permission from the client before giving advice. This is a crucial element of communication, as unsolicited advice is often not helpful and could be misconstrued as looking to provide an automatic response, rather than searching together to find the right answers for the client s situation [9]. The menu of options refers to a list or group of choices given to the client for making decisions. When a client is ambivalent about making a decision, it can be easier when presented with more than one option of steps that could be taken toward the goal. For example, if a client is trying to lower his or her high blood pressure and is having difficulty adjusting to lifestyle changes, ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com ce4less.com 29