Motivational interviewing (MI) is a psychotherapeutic
method that was developed by William Miller and Stephen
Rollnick, originally described in 1983 (Miller, 1983). Miller
and Rollnick (2002) define MI as “a client-centered, directive
method for enhancing intrinsic motivation to change by
exploring and resolving ambivalence.” Its original application
was in substance abuse treatment with adults, where it was
developed in response to confrontational methods used in
this field during the 1970s and 1980s. Since then, it has been
used in many different areas, including “general medical care,
health promotion, social work and corrections” (Miller &
Rollnick, 2002, p. xiv)
– Explore your reactions to the readings and to what you have learned about Motivational Interviewing (MI). Explain how MI can be applied to clinical practice.
-Write one independent paragraph that includes a reference, explaining how Motivational Interviewing can be used by a psychiatric nurse practitioner to help a specific patient (for example, a drug addict or alcoholic patient that is non-complaining with his or her medications) and what considerations you need to be aware of to achieve success.
Responses will be checked by Turnitin for originality. It should be a minimum of 350 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). *Information about motivational interviewing is attached.
Issues in Mental Health Nursing, 32:436–440, 2011 Copyright © Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2011.565907
Motivational Interviewing: A Valuable Tool for the Psychiatric Advanced Practice Nurse
Abby Karzenowski, BSN, RN and Kathy Puskar, MN, MPH, DrPH, FAAN University of Pittsburgh, School of Nursing, Pittsburgh, Pennsylvania, USA
Motivational Interviewing (MI) is well known and respected by many health care professionals. Developed by Miller and Rollnick (2002), it is a way to promote behavior change from within and resolve ambivalence. MI is individualized and is most commonly used in the psychiatric setting; it is a valuable tool for the Psychi- atric Advanced Nurse Practice Nurse. There are many resources that talk about what MI is and the principles used to apply it. How- ever, there is little information about how to incorporate MI into a clinical case. This article provides a summary of articles related to MI and discusses two case studies using MI and why advanced practice nurses should use MI with their patients.
Motivational interviewing (MI) can be used by all health care professionals in any health care setting where a patient’s behav- ior affects the outcome. MI is a valuable tool for the Psychiatric Advanced Practice Nurse because it is useful in establishing the therapeutic alliance and assuming a non-judgmental position as a therapist. It was first described by Miller and Rollnick (2002) as a way to elicit behavior change by exploring and resolving ambivalence. The purpose of this article is to discuss MI, its use in two case studies, and its value for the psychiatric advanced practice nurse. Skills of MI include reflective listening, asking open ended questions, affirming, and summarizing. The ability to use MI as a tool to support and develop self-efficacy is an important issue in behavioral counseling. Motivational interviewing is defined as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002, PowerPoint Slide No. 2) and is a way of “combining elements of both style, warmth, empathy, and techniques, key questions and reflective listening” (W. R. Miller, 1996, p. 839).
The authors acknowledge Lindsay Starner for her editorial contri- butions to this manuscript.
Address correspondence to Kathy Puskar, School of Nursing, Uni- versity of Pittsburgh, 3500 Victoria Street, Room 415, Pittsburgh, PA 15261. E-mail: [email protected]
MI Definitions Bundy (2004) explains that the basis of MI comes from
the Transtheoretical Model of Change. The Transtheoretical Model of Change was developed by James O. Prochaska and his colleagues at the University of Rhode Island; the model posits that health behavior change involves progress through six stages of change (Prochaska & Velicer, 1997, p. 38). There are six stages of change: (1) pre-contemplation, where the per- son is not thinking about change at all, (2) contemplation, where the person is thinking about change, but has not made any plans, (3) planning, where the person has made plans to change, but has not started the plan yet, (4) action, where the person starts the plan, and (5) maintenance, and (6) ter- mination, where the person continues with the plan. Strate- gies to increase motivation in a person include giving advice, removing barriers, providing choice, decreasing desirability, practicing empathy, providing feedback, clarifying goals, and providing active helping. MI has five basic principles of change: expressing empathy, avoiding arguments, supporting self-efficacy, rolling with resistance, and developing discrep- ancy. There are eight steps of MI that promote the therapeutic process and they are: establishing rapport (a basis of trust is es- sential), setting the agenda (without an agenda the patient can at- tempt too much too quickly), assessing readiness to change (help identify barriers and supports for change), sharpening the focus (focus on what the patient wants to change), identifying ambiva- lence (show that there are reason for and against change the pa- tient can identify), eliciting self-motivating statements (promote the patient making positive statements and identify successes), handling resistance (use reflection to help with resistance) and shifting the focus (also helpful in handling resistance).
N. H. Miller (2010) identifies two phases to MI. “Phase one elicits change talk to promote intrinsic motivation for change” (N. H. Miller, 2010, p. 248). In phase one, the health care profes- sional helps the patient express his opinions using open-ended questions, reflective listening, affirmation, and summarization. Phase two focuses on strengthening the commitment to change once the person is motivated. Health care providers should
MOTIVATIONAL INTERVIEWING: A VALUABLE TOOL 437
encourage and listen for “change talk” where the patient is influ- enced by hearing themselves talk rather than by what someone else says. When a patient is closer to the preparation or ac- tion stage of change, coaching can be used. Coaching involves educating and assessing willingness, setting goals, assessing confidence, and following up. In the steps of coaching there are barriers and problems. Common barriers consist of misinforma- tion or lack of information, previous negative experiences with the change process, and lack of support. To problem solve these barriers, “[identify] the problem and reason for it, [select] the main reason and possible solutions, weighting the pros and cons of each solution, [select] one or two solutions to try, [attempt] that solution, and [repeat] the process if the initial solution is not successful” (N. H. Miller, 2010, p. 250).
Levensky, Forcehimes, O’Donohue, and Beitz (2007) intro- duce the five stages of the Transtheoretical Model of Change associated with MI and report that people will often relapse and move through the stages multiple times and in different orders before reaching the maintenance stage. It is important for health care professionals to work with patients at whatever stage of change the patient is at to promote collaboration and reduce resistance. There are three steps to provide information to pa- tients when using MI. First, the health care professional asks the patient what he already knows. Second, the health care pro- fessional asks permission to provide information to the patient. Third, the health care professional asks the patient to discuss his thoughts and reactions to the information given. The most common traps with unmotivated patients are the confrontation- denial trap, question-answer trap, expert trap, and premature focus trap.
MI Use Rubak, Sandbaek, Lauritzen, and Christensen (2005) talked
about ways MI is useful for the client who is reluctant or am- bivalent to change. MI strategies are persuasive and supportive rather than coercive and argumentative. This is to motivate the person to change from within. This study looked at 72 random- ized controlled trials. It showed that in 74% of the trials MI was effective and that the longer each individual session was the more effective MI was. Also, the more individual MI sessions a patient receives the better. “No studies showed motivational in- terviewing to be harmful or to have any kind of adverse effects” (Rubak et al., 2005, p. 308). MI can be used with patients with psychological or physiological disorders. Although the greater the length and number of sessions the better, it is shown that even 15-minute encounters can be beneficial. Rollnick, Butler, Kinnersley, Gregory, and Mash (2010) discuss how MI can be used in a wide range of health care settings and actually lead to a better relationship between the health care provider and patient. It also can save time by avoiding the typical lecture health care providers so often given patients. The goal of MI is to be an informed guide rather than a dictator. Engaging and collabo- rating with patients, emphasizing their autonomy, and eliciting
their motivation for change are ways to make sure the patient is responsible for their own change. This can be done by asking open-ended questions, listening to the patient to really under- stand what they are saying, and asking permission to provide information to the patient. Some additional useful strategies to use when engaging a patient with MI include having the patient choose one issue they want to work on, talking about the pros and cons of change, spending time where it is most needed, and making listening a priority.
Polcin (2006) focuses more on using MI for patients with ad- dictions by applying supportive and directive intervention. This helps the patient explore the actual or potential consequences of their actions. Directive intervention includes developing dis- crepancies and helping the patient realize that their substance use is inconsistent with their goals and values, exchanging feed- back (objective and nonjudgmental information or knowledge that the health care professional shares with the patient), en- gaging ambivalence by exploring pros and cons for using, and giving straightforward—yet reserved—advice for patients in the preparation or action phase. Polcin (2006) discusses MI issues related to avoiding confrontation, including the issue of a wan- dering session, which is when a session gets sidetracked and is not about the related problem. Polcin also discusses the avoid- ance of ambivalence and discrepancy (maintaining a balance between supportive statements and confrontation); weak or in- complete feedback, advice, and sharing of information; and a weak therapeutic alliance with a decrease in empathy, reflection, and affirmation. Using MI with special populations is discussed with mixed results noted. With criminal justice mandated clients, MI showed very little if any advantages. With women mandated by child welfare, MI had little added benefit. With those referred to their Employee Assistance Program (EAP), MI was found to be no more effective than standard treatment. In these special populations of mandated clients, the use of MI warrants further consideration and research.
Emmons and Rollnick (2001) discuss key principles of MI, including expressing empathy, developing discrepancy between patient goals and current problem behavior, avoiding arguing, rolling with resistance, and supporting self-efficacy for change. Technical aspects of MI include focusing on client-centered counseling, determining internal motivation using reflective lis- tening, and decreasing patient resistance. These strategies can help put the patient in the expert role. For health care profession- als in the community setting, it can be more difficult to imple- ment MI than for health care professionals in the inpatient psy- chiatric setting. Common issues in the community include time constraints and adapting a brief version of MI in the community setting. Strategies to help strengthen brief sessions include pro- viding additional materials, like printed pamphlets and video- tapes. In the community setting, it is difficult to find a balance between intervention and training. Ways to facilitate this include having researchers be familiar with the population being served, the setting, working with the target group, working with the prac- titioner group, and having a comprehensive evaluation process.
438 A. KARZENOWSKI AND K. PUSKAR
In summary, although there are many principles and theories to MI, generalized ideas are noted. These include being supportive of patients and helping them explore their behaviors. Most importantly, MI is patient focused and emphasizes what the patient needs. Based on the litera- ture, MI can be a useful tool to support client growth and change.
CASE STUDY #1 S.K. is a 21-year-old single Caucasian male in an intensive
outpatient treatment facility after completing a four-week stay at an inpatient psychiatric unit following a suicide attempt by overdose on Abilify. He received 12 weekly sessions of support- ive psychotherapy including MI. He was diagnosed with Bipolar II, Most Recent Episode Depressed, and Sedative/Hypnotic de- pendence. He is ambivalent about getting off prescription drugs, mainly Vicodin and Xanax. He also is ambivalent about taking an anti-depressant prescribed for him. The notes from his in- patient stay talk about the huge amount of resistance he has towards getting clean. He has many supports, including family and friends. He is well-educated, a college graduate who aspires to be a computer programmer. He has had multiple legal trou- bles, first as a teenager for dealing drugs in New York, then in his senior year of college for assault related to drugs. In the opening phase of treatment, MI was an extremely important and a valu- able tool especially since he was in the precontemplation stage of change. The first sessions were used to establish rapport, set the agenda, and assess his readiness for change. Express- ing empathy, avoiding arguments, and rolling with resistance was beneficial. The therapist acknowledged that S.K. believes that drugs help his depression and that he has little interest in quitting. Rolling with resistance seemed to help S.K. realize he would not be judged and lectured on his drug use but that he could talk about it openly and honestly. S.K. was initially very passive when talking about his drug use. He would respond to open-ended questions with short, blunt answers. It was helpful to use reflection when the therapist noticed him starting to shut down and lose interest. During the opening phase he also veri- fied what he might want to change. He was okay talking about his drug use, but refused to discuss his non-compliance with medications. He was reminded that not taking his medication is his decision as an adult and, as an adult, he would have to handle the consequences if any occur. After the opening phase of treatment, trust was established and S.K. started to open up a little more.
During the middle phase of treatment, S.K. was able to focus on his drug use. He was encouraged to use self-motivation and recognize his accomplishments. In one session, a scale of 0 to 10 was used to help identify his motivation to stop using drugs. With 10 being the most likely to use drugs and 0 being the least likely, S.K. was a 6. When he was asked why he wasn’t a 7 he identified his family as a support for keeping him clean. He enjoys going to his parents’ house, but he is not allowed over
if he is high, and his parents can tell if he has been using. He was then asked what was keeping him from being a 5 and he identified his social circle and lack of structured activities as barriers to his sobriety. Reflection was then used to review the pros and cons of using. He identified that the cons of using were more than the pros, especially since he has had legal problems due to his drug use. After realizing S.K. was comfortable, the therapist began to gently challenge his thinking. The therapist revisited the barriers to his drug use and challenged S.K. by asking for clarification that he has more interest in his social circle rather than his family since he continues to use drugs. He denied this. The therapist then supported his self-efficacy by telling him he is in counseling now and willing to accept help because he wants to change his behaviors. The therapist then had S.K. repeat that back in his own words.
At the terminal phase of treatment, S.K. continued using drugs, but the therapist was able to challenge him more. The therapist again used a 0–10 scale to assess his readiness for change and barriers for changing. His barriers were still his social circle and boredom, but he was agreeable to discussing different coping techniques and activities to help him remain clean, such as joining a team, spending time with family and different friends, and joining Narcotics Anonymous. S.K had progressed to the preparation stage of change at this point. He was receptive to the therapist, so giving advice was another intervention utilized. S.K. was told the physical problems that would occur if he continued to use drugs and that spending time with other people using drugs was not conducive to his recovery. He also was reminded of the legal consequences of his drug use, and that he was no longer in college so if he was caught dealing or in possession of drugs, he would face legal charges.
CASE STUDY #2 R.P. is a 16-year-old African American girl who was admitted
to the hospital related to manifestations of severe hypoglycemia. While she was in the hospital she was diagnosed with Type I Diabetes. Once her blood glucose levels were brought back up and stabilized, she stayed in the hospital for an additional three days, as per the protocol of the hospital. During those three days she and both of her parents, who were very supportive of their daughter, attended educational and counseling sessions with nurses, counselors, dieticians, and other clinicians discussing and learning about diabetes and what that meant in regards to necessary lifestyle adaptations and medical adherence.
Throughout the sessions on the three days R.P. remained in the hospital, she was agreeable and willing to go to the sessions and listen to what she was being told by the medical staff, but she made it quite clear to everyone, including her parents, that she was not interested in following the strict routine the nurses were proposing related to using insulin and adhering to a diet. R.P. repeatedly stressed that she was in high school, and she did not want to have to carry around syringes and medicine vials all day and then have to go to the bathroom a couple times a
MOTIVATIONAL INTERVIEWING: A VALUABLE TOOL 439
day to prick herself and give herself shots of insulin. She also was not fond of talks with the nutritionist who described to her how her diet would need to change and be tightly monitored and managed. All R.P. could think of was her weekly nights out with her girlfriends when they would go to the pizza shop and get pizza and sodas, and she quite adamantly expressed an unwillingness to give those nights up. She was ambivalent to making the necessary changes for proper diabetes management, which put her at risk for serious complications upon leaving the hospital. Therefore, arrangements were made for her to have 12 weekly psychotherapy counseling sessions with a therapist who would use MI techniques to help R.P. work through coping with her new diagnosis.
Following discharge from the hospital, R.P. met with her therapist on a weekly basis. In the first couple sessions, the therapist developed rapport with her client. The therapist gave R.P. time to openly share whatever her thoughts were about her diabetes diagnosis, and during that time the therapist actively listened without any suggestions or advice shared, and without any judgmental or challenging remarks. At this stage in the ther- apeutic relationship, the goal was to develop rapport so that the client would feel safe and comfortable sharing her feelings and struggles with someone who would openly listen, not condemn her frustrations, or argue with her about her unwillingness to change. The therapist empathetically acknowledged how diffi- cult a diagnosis of diabetes can be to cope with, especially as a young teenager.
After a couple sessions, R.P. became more and more willing to share her feelings with the therapist. From that point, the therapist could then move into the working phase of the thera- peutic relationship when she began to challenge some of R.P.’s ambivalence and encourage her to recognize where her resis- tance to change could be detrimental to her health and other life goals. The therapist encouraged R.P. to process and share both the pros and cons of resisting medical and nutritional guidelines and then had her consider how her other life goals might be affected by those pros and cons. As the therapist continued to openly and actively listen to and help the client work through these challenges, R.P. began to take more ownership of her thoughts and actions. As she showed increasing willingness to change, she and the therapist began to identify and develop other unique ways to work the management of diabetes into R.P.’s life without forcing her to compromise everything she loved as a teenager. The therapist’s use of MI techniques provided time and opportunity for R.P. to develop self-efficacy and recognize for herself why her attitudes needed to change and how she could most effectively make those necessary changes.
SUMMARY AND CONCLUSION Psychiatric clinical nurse specialists or nurse practitioners
can use MI in all aspects of their practice. Since many people who suffer from mental illness also have comorbid substance abuse/dependence problems, MI can be particularly helpful. Many times it is difficult to determine if a substance is causing
the mental illness. For example, if a patient is using cocaine, it may be difficult to determine cocaine abuse from mania. If someone is using LSD, they may have hallucinations, but not truly be psychotic. If substance abuse is not a factor, health care professionals can better treat the illness. Also, parts of an illness may not need to be treated when the substance is not being abused. If a person is having hallucinations when sober, it is much more clear they have actual psychotic symptoms and medication should be started. MI is also useful for medication compliance, which is another problem for people with mental illness. For advanced practice nurses not in the mental health field, MI can also be used for a wide range of health practices. It has been shown effective for weight loss, smoking cessation, medication compliance, dietary compliance, and establishing an exercise routine.
The American Psychiatric Nurses Association Stan- dard of Practice for Psychotherapy is 5F and reads, “The Psychiatric-Mental Health Advanced Practice Registered Nurse conducts individual, couple, group, and family psychotherapy using evidence-based psychotherapeutic frameworks and nurse-patient therapeutic relationships” (American Nurses Association, 2007, p. 42). The use of MI is a key element within the nurse’s scope of practice per the standards of practice as documented by the American Psychiatric Nursing Association.
MI is considered a valuable tool for the psychiatric advanced practice nurse. It has been proven to be successful in changing behavior and decreasing resistance in patients with many dif- ferent diagnoses. For psychiatric advanced practice nurses, the tools are knowledge and communication skills. Without stetho- scopes or blood pressure cuffs to provide concrete evidence to patients, psychiatric nurses must present patients with methods of therapy that have been proven to work. MI not only works, but has the evidence to back up its success.
Declaration of interest: The authors have no financial or personal relationships with any persons or organizations that would bias this manuscript.
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