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Brief Motivational Interviewing

Brief Motivational Interviewing

The Menu of Strategies

The Menu of Strategies was initially developed as a brief motivational intervention for use with substance users in medical settings by Stephen Rollnick, Nick Heather and Alison Bell (Rollnick et al., 1992). It assumes that most people attend non-substance use specific support services with a low readiness to change their substance use, and therefore advice giving in the first instance would be of limited value and often met with resistance. The approach uses a menu of strategies matched to the degree of readiness to change of the substance user. Each strategy is designed to take 5-15 minutes to complete and can be used as stand-alone intervention. Whilst providing information is included as a strategy, it is designed as a patient-centred activity designed to empower people through maximising freedom of choice and should ideally be provided as a 'menu of options'.

Although initially conceived as a substance use intervention, the Menu of Strategies can easily be adapted to any situation supporting behavioural change. It is anticipated that the adapted Menu of Strategies described below will of most use to people such as social workers, youth workers, or those supporting individuals with complex and multiple needs.

 

Ambivalence

Ambivalence is having mixed feelings or contradictory ideas about something or someone.

Ambivalence is normal and is common in all forms of behavioural change, with the person both perceiving benefits to change and benefits to continuing as before. People often continue to commit crime, take drugs, or engage in antisocial behaviour because they are ambivalent about change.

The goal of Motivational Interviewing is explore ambivalence and encourage people to voice their own reasons for change. The practitioner does not argue in favour of change but assists and support the person that they are working with to do so.

 

Readiness for Change

The Menu of Strategies uses a linear continuum from ‘Not at all ready for change’ to those who are 'Very motivated to change' and need some external assistance and support to achieve this, with those who are most ambivalent in the middle. The aim of the Menu of Strategies is not necessarily to enable the desired change at that moment in time, but to help the person move towards behaviour change and bring forward in time the point at which this achieved.

The first task within the approach is to establish the degree of readiness to change within the individual and then to select the most appropriate strategy for their level of motivation. The practitioner does this by using some of the initial strategies such as ‘A typical day’ and ‘The good things and the less good things’ (see below).

The ‘strategies’ are different to the core motivational interviewing practitioner skills such as open-ended questions, affirmations, reflective listening and summarising (OARS). The ‘core skills’ are used all the time to support the different strategies implemented. The strategies described below are provided in order of readiness to change, moving down the strategies requires a greater degree of readiness. Getting ‘ahead’ of the client will often result in increased resistance and require the practitioner to revert to the use of a strategy earlier on in the list.

Hanson and El-Bassel (2004: 46) suggest that practitioners need to meet three essential objectives to effectively engage individuals and build ‘rapport’:
1. They must create a ‘safe space’ so that individuals can talk to them.
2. They must establish a collaborative partnership so that individuals will talk to them.
3. They must reach a preliminary agreement that a problem exists so that the individual has a reason to talk with them.

Effective use of the Menu of Strategies can help to achieve all three of these essential objectives.

 

The Menu of Strategies (adapted from Rollnick et al., 1992)

1. Opening strategy: Lifestyle, health, stressors, substance use
2. A typical day
3. The good things and the less good things
4. Providing information
5. The future and the present
6. Exploring concerns
7. Helping with decision-making

 

1. Opening strategy: Lifestyle, health, stressors, substance use

This strategy allows the practitioner to talk to the individual about general issues in the individual’s life. It may also be more focussed and concentrate on specific behaviours such as substance use, if necessary prompting with questions such as ‘where does your [use of drugs or alcohol / skipping school etc.] fit in?
The more positive the response the less ready for change the individual is likely to be. However, it often provides the practitioner with enhanced insight into the context and function of the behaviour in question

 

2. A typical day

This strategy enables the individual to talk about more general issues in a ‘safe’ way and assists the practitioner in assessing readiness for change. The practitioner does not make reference to problems or concerns. It is often a useful starting point for helping the practitioner to understand the context in which the individual's behaviour most commonly occurs. This strategy also enables the practitioner to identify triggers for the behaviour and also to elicit times that the behaviour does not occur.
The practitioner would usually start by asking “Can we spend 5 or 10 minutes talking about what a typical day is like for you”. The practitioner should use open-ended questions and reflection to explore behaviours, feelings and other relevant factors.

 

3. The good things and the less good things

This strategy allows the practitioner and the individual to explore particular behaviours and can be a good exercise in building rapport. It can be used as an alternative to 'A typical day' and can highlight initial ambivalence in individuals. It also provides insight into readiness to change. For example, a social worker might ask a looked after child who often went missing from home what was good about running away from home, and what was less good. The young person might say that being at home was boring and that there were too many rules, but that it upset their foster parents.

In individuals who appear willing to explore change in greater depth, a verbal or written cost benefit analysis can be conducted. A drug worker might ask "what would be the good things about continuing to use [named drug]" and "what would be the less good things?". This could then be followed up with "what would be the good things about stopping using [named drug] or using less?" and "what would be the less good things about stopping or using less?".

This strategy begins to help individuals explore their concerns, but at this stage the practitioner should avoid labelling or describing them as concerns or problems.

 

4. Providing information

Information should always be provided in a sensitive manner, and as part of the Brief Motivational Interviewing approach, practitioners should ask the individual whether they wish to provided with information first, and they should avoid giving direct advice. The best time to do this is when the individual appears interested and curious; asks for information; or the information realties to factors that they have raised in ‘change talk’. For example, if the individual said, “I would probably seek help if I knew where to go” then providing relevant information would be appropriate. Ensure that any information is balanced and factual and recognise that trying to frighten people into changing is rarely a successful strategy.

 

5. The future and the present

This strategy is only appropriate for use with individuals who are unhappy or dissatisfied in some way with their present position. The would be closer to the ‘change’ end of the readiness to change continuum. Focusing on the discrepancies between where the person is now and where they wish to be is a key concept in motivational interviewing approaches. A good opening question would be “How would you like things to be different in the future?”. This is seen as a more realistic approach than asking about their ideal future (as in Brief Solution-Focused Therapies) which may be unrealistic and unachievable.
Follow up questions can then be used such as “What is stopping you from doing these things?” that can lead onto more direct exploration of concerns around specific behaviours.

 

6. Exploring concerns

1. This is the most important of the strategies of all according to Rollnick et al. as it provides the framework for eliciting from the individual their reasons for their concerns about their behaviour. It can highlight ambivalence, and provides the practitioner to develop discrepancy in the individual. As it can only be used with individuals who have concerns it is not effective or appropriate with people who are not contemplating change.
An opening question might be “What concerns do you have about …?”. Explore the concern raised using open questions and reflect back to clarify and communicate to the individual that you are listening to them. Be supportive of individuals who find discrepancy uncomfortable.
It is important to explore concerns about changing as well as concerns about not changing.

 

7. Helping with decision making

This strategy follows on from ‘Exploring concerns’ and is used when concerns have been raised, ambivalence is identified and a desire to change has been expressed by the individual. Questions such as “How do you feel about this now?” are seen as more neutral than “What are you going to do about this now?”.
It is important at this stage not to ‘get ahead of the individual’, provide unwanted advice rather than allowing the individual to generate their own thoughts and opinions, and fall into the ‘expert problem-solver’ trap.
Rollnick et al. provide 8 suggested guidelines for helping with decision making:
• Do not rush individuals into decision making
• Present a menu of options for the future rather than a single course of action
• Describe what other people have done in similar situations
• Emphasise that the individual is expert on themselves and is the best judge of what is best for them
• Provide information in a neutral, non-judgmental and non-personal manner
• Failure to reach a decision to change is not a failed intervention (the ‘seeds of change’ may have been planted)
• Resolutions to change often break down and individuals should be reassured that they will not be judged if they return for further support in the future
• Commitment to change will fluctuate – expect this and empathise with individual’s predicament

 

References

HANSON, M. & EL-BASSEL, N. (2004). Motivating Substance-Abusing Clients through the Helping Process. In: STRAUSSNER, S. L. A. (ed.) (2004) Clinical Work with Substance-Abusing Clients. 2nd ed. (pp. 39-64). New York: Guilford Press.

ROLLNICK, S., HEATHER, N. AND BELL, A. (1992). Negotiating behaviour change in medical settings: The development of brief motivational interviewing, Journal of Mental Health, 1, pp. 25-37.

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