Wednesday, February 13, 2013

Motivational Interviewing: A Client-Centered Approach (1 of 2)

What is motivational interviewing? Have you heard about this term and wondered what exactly it was referring to?

Today’s interview is with Kathleen Sciacca, a trainer and programmer for Motivational Interviewing, as well as a pioneer in the development of integrated treatment for co-occurring mental illness and substance disorders. Her integrated treatment programs and motivational interviewing trainings have been implemented across numerous states, communities and programs.

As per Kathleen, "Motivational Interviewing (MI) is grounded in Carl Rogers' “client-centered” counseling and “empathic reflective listening.” These are the pervasive elements of MI’s practice and spirit." Furthermore, this is an approach that is well-suited to facilitate change across a range of health behaviors.

And now, without further ado, Kathleen, could you please expand upon your initial comment about Motivation Interviewing?

The depth to which Rogers' client-centered approach can evoke a client’s intrinsic understanding and motivation to change is phenomenal.  As a communication style MI requires transitioning from traditional question answer advice giving “expert” grounded interventions to a set of five core interviewing skills that must be used as a comprehensive skill set.  

These are known as OARSOpen questions, Affirming responses, Reflective listening, Summarizing and the fifth is “evoking and reinforcingclient’ change talk -one of the research based elements of MI.  I repeatedly observed how this communication style works and I have maintained that Carl Rogers' empathic reflective listening is the most potent intervention in MI practice.  

Before deep-diving into MI, could you share with us a bit of your background? What led you into the field of mental health?

I started out on a very different unplanned path whereby I advanced in business, accounting and comptroller positions.  As I became more aware of myself and the world around me, I found the work lacked “meaning” and it was not the way I wanted to spend a good portion of my life. Inadvertently, I learned about psychotherapy and knew that was the work I wanted to do.  For me, it was work that could make a positive difference in people’s lives.  

When I returned to school to study psychology, I was 28 years old and a single parent with two children.  I worked full time and did my undergraduate and graduate work in the evenings for about eleven years. I was fortunate to find my first job in the field as the administrator for a group leading training institute.  This was the theme-centered group-leading model developed by Ruth C. Cohn, a pioneer and genius in her own right. 

This three-year training program covered numerous therapy models of its time during the 1970’s.  Much of the training was experiential and I gained a wealth of experience and a certificate as a group leadership trainer. Also, during my undergraduate years, I had an externship in a therapeutic community.  

During graduate school, I worked as a counselor in in a methadone maintenance program in the south Bronx of NYC. I provided individual and group treatment for clients who were addicted to heroine and a variety of other drugs and alcohol. Many of them had mental health issues and quite a few were Vietnam war veterans who had PTSD and addictions.  The term dual-diagnosis had not yet been uttered, but the clients certainly needed mental health treatment. I gained a wealth of experience and knowledge. This work became my foundation in the treatment of addictive disorders; it was accepted as my practicum towards the Ph.D.. 

Kathleen describes her background and MI in this video clip.

In the end, it was necessary for me to take time off from work to study for the comprehensive exams for the Ph.D.  During that time I applied for master’s level psychology positions with the New York State office of mental health. I was hired for a temporary position and assigned to work with clients who were severely, persistently mentally ill and in attendance in a day treatment program. 

It became apparent that many of these clients had long-standing drug and alcohol addictions that had gone untreated.  Many were treated as behavioral problems and terminated which led to incarceration and homelessness.  I had an innovative, caring supervisor who wanted to provide treatment for them. He approached me to address this since I had some experience in treating addictions.  Dual diagnosis as it became known, was relatively new to me as a concept, as well as to many others.

First, I tried to refer clients to substance abuse treatment, but each of them was rejected.  I became an advocate for their care and I developed group treatment interventions through trial and error.  Much of what happened after that was serendipitous. 

The NY State quality of care commission released an 18-month report detailing the neglect and downward spiral of the “multiply disabled.”  It is only fair to say that all of the states across the country neglected these clients as well.  By the time the commission learned about my work, I had replicated my integrated treatment programs across the six outpatient sites affiliated with the psychiatric hospital I worked for.  

This entailed not only a treatment approach, clinical materials and outcome measures, but also a training program for workforce development under very adverse circumstances.  The NYS commission visited a number of my programs and heralded them in their news outlets and invited me to present my work at their conference. 

The facility I worked for attained a grant for the MICAA training site for program and staff development New York state-wide.  I was appointed as the director and went on to implement integrated treatment programs throughout the NY State MH system and across systems to include substance abuse, criminal justice, homeless services and others.   

During this transition, I decided to forego what might have been about three years concentrating on my dissertation, and instead I focused on and pursued my work in the field of dual diagnosis.  That left me ABD (all but dissertation). This work ensued from 1984-1992; then due to extreme budget cuts, I was relocated to another facility and I voluntarily went to part time. By then I had become rather well-known in the field. I had some published work and outside assignments (with a lot of NY State scrutiny). Therefore, after I was laid off, it was a natural step for me to become self-employed. 

My career took a new path as a program developer, trainer, consultant, author.  I moved on to numerous statewide assignments across the country, as well as some international work. I designed a training/program implementation process that works and results in lasting dual diagnosis programs for people who have co-occurring disorders. 

What led you to specialize in motivational interviewing?

I learned about motivational interviewing (MI) from a trainee in my program implementation course who read the first book (1991) and noted the similarities between the dual diagnosis treatment approach (1984) and MI.

I eventually wrote an article "Removing Barriers" about the similarities in approach, the different skill sets in each model and the benefits of integrating these skills.

After studying MI, I formally became a trainer. I began teaching MI in more depth and integrating MI training into the dual diagnosis best practices model. Eventually, I began addressing providers, administrators, etc. from disciplines and fields outside of dual diagnosis.

My latest article "A New Language for Integrated Care" addresses the integration of behavioral health care and primary health care.

In 2009, I wrote the Motivational Interviewing Glossary and Facts Sheet because I found that many providers underestimated MI and believed they were practicing when they were not. I defined all of the terminology, each element, each core skill, the spirit of MI etc. to clarify that MI is a comprehensive communication style that requires all of its elements practiced.

I have stayed with teaching this approach because it yields results when practiced skillfully, and it applies to many kinds of behavior change both clinical and non-clinical; to behavioral health care and primary health care; and providers with varying degrees of clinical skills can utilize it. The presence or absence of provider clinical skills may be what distinguishes MI as therapeutic for some providers and clients and a counseling style for others.

Is Motivational Interviewing primarily used for working with clients who have addictions? Are their other mental health illnesses or concerns that lend themselves to use of this model?

Kathleen addresses this question, empathic listening and OARS in this clip.

Motivational interviewing began in the field of alcoholism and broadened out to various addictions. Over the years and at present, it is applied across numerous systems and behaviors.  Examples include: criminal justice interventions, primary health care – weight change, diabetes, HIV, cardiology and more; mental health; dual diagnosis; homeless services; educational settings and more.

Could you describe a case example in which you are applying some motivational interviewing techniques with a fictional client?

MI studies and training usually evolve around addressing “one” target behavior, for example HIV treatment compliance. In my own work, it is very clear that clients present with multiple target behaviors, symptoms and issues.

A case example might be a client who is on probation, who has addictive disorders and may also suffer from impulse control/anger management such as domestic violence.

MI now postulates that the approach be practiced within four areas or processes.  These areas and their sequence are not new to counseling or therapy; they provide somewhat of a road map for MI providers. They are engagement, focusing, evoking and planning.

Engagement is essential in all models.  MI applies Roger’s client-centered skills in this area.  Following the client, listening carefully and reflecting what is believed to be understood by the provider –empathic, reflective listening - in a non-judgmental, supportive manner; the provider follows the client including all feedback until the client agrees that he or she has been understood.  There is no assessment, evaluation or hidden agenda during the engagement process.

Roger’s evolved a client-centered approach that professes that the client is the main figure of importance.  Roger’s believed if the provider established a safe trusting environment for the client, the client would use that opportunity to communicate more deeply.  MI distinguishes itself from Roger’s work by postulating that there must be a “target behavior” or a change goal in order to be practicing MI.

The second process, “focusing,” begins to hone in on what target behavior will be addressed in the session.  This is done collaboratively: what is most important to the client? what is on the agenda of a provider? A doctor, for example, may want to discuss medication or other medical issues. Through collaboration, the client and the provider will agree to focus in on a target behavior –or perhaps more than one.

Once this is agreed upon, the “evoking” process begins. Here the provider works strategically or directionally to reinforce or elicit client’ “change talk.”  Change talk is a key element of MI.  It is elicited from the client, deepened by reflective listening and strengthened to the degree where it becomes “commitment” talk.  Commitment talk is the correlate to behavior change in this area of MI research.

In this example we have a client with a several interacting symptoms and behavioral issues.  Rather than advising the client as to what he or she should do about these – the provider engages the client by building rapport and conveying an empathic, genuine stance in relationship to the client’s perceptions, beliefs, opinions and respects the client’s autonomy.

If an agreeable target behavior comes into focus during the engagement process, the provider can readily segway and focus on that area, if not, the provider may proceed by finding out what the client views as important to discuss right now… It could be any one of the three, all three or something different.  The provider may also have areas to discuss and will present those to the client.

Together they will collaborate, agree upon what the focus will be.  This is known as “guiding.”  The provider will be directional in staying focused on the selected target and “evoke” or elicit and reinforce client’ change talk using a variety of strategies. Empathic reflective listening serves to deepen this exploration.

If they get as far as considering what the client may do in-between sessions, a plan will be designed collaboratively – or if the client is ready to make a full change in one or more of the areas a “change-plan” will be collaboratively worked out.

Let’s say the client and provider agree that the target behavior for a particular session is the client’s adjustment/success with probation and moving on to being free of the criminal justice system. The focus will be on this area and may include the client’s dislikes, adjustments, reasons to make changes, needs to make changes, etc.  These will be evoked/elicited rather than recommended:
Why does this person want to be free of the criminal justice system?
Why must this person complete this supervision successfully?
It is the client’s reasons that will lead to the motivation to do what is necessary to accomplish this.  Example: “I do not want my children to have a father who is in and out of prison, who is a criminal.”  A strong motivator that is latent with personal values.  “There is no excuse for me to hit my wife.”
“My children should never witness such a thing.”  Equally strong motivators that are value-laden.

Each area or target behavior will be approached from this perspective
How does the client view it?  What are the client’s reasons to change this?  
The drug problem may relate to both the criminal justice-related issues and the physical abuse.  These reasons and other reasons may suffice for changing one’s behavior.

MI is directional by attempting to elicit from the client the negative, impinging factors on the client’s life that may be associated with these symptoms or behaviors and the benefits of change as the client sees them.

The provider does not forego his or her expertise. The provider may make suggestions, provide education, participate in generating solutions, etc. But only when he or she has asked the client for permission to do so.  
“Would you like to know more about withdrawal from alcohol and how it might be made a bit easier?”  
If the client says yes the provider can educate and then follow by asking for feedback – “What do you think about that in your case?”

As I often put it, the role of the provider in MI has changed from what many of us have learned through traditional interventions – that it is our responsibility to “make people change,” a completely unrealistic stance; to the responsibility to make certain as best as possible that the client has had the opportunity to explore every aspect of the symptom, behavior, the impact on his or her life, the emotional underpinnings and more.

Therefore the client can make an informed, intrinsic decision about how he or she may want to proceed.  One element of MI is to respect the client’s autonomy, therefore it may turn out that the client decides not to change and the provider would accept the client’s decision.

Thanks so much, Kathleen, for providing us with this valuable introduction to motivational interviewing!

You may follow Kathleen on twitter at  @DualDiagCoOccur

What questions/comments come to your mind about motivational interviewing? 

Please see  Motivational Interviewing: A Client-Centered Approach (2 of 2)  in which Kathleen will be sharing with us what role Prochaska and DiClemente‘s Stages of Change Model plays in Motivational Interviewing, as well as additional MI pearls of wisdom :)

You May Also Enjoy These Links from Kathleen:
Dual Diagnosis
Motivational Interviewing Clips in Primary Health
Motivational Interviewing articles, fact sheets and more
Additional Motivational Interviewing articles
Motivational Interviewing Training Seminar


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