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Profile
Mr. Anthony Gatt is a counselling psychologist and member of the Maltese Psychological Association. He has worked in the drug and alcohol addiction field over the last five years. He trained as a psychologist in Canada and researched helpful and hindering events in the counselling process for outpatient drug addiction counselling. His work exposed him to MI and thereafter furthered his training in MI at the Justice Institute BC Canada.
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How many psychologists does it take to change a light bulb? Answer: Only one, but the light bulb has to want to change.
You may have heard this joke before without giving it much thought. If you dwell on it for a little while you will soon realise that it clearly captures the reality that in the counselling relationship it takes two to tango. A psychologists’ or a therapists’ efforts to help someone change are futile when the client is not ready to change. Some have come to label clients who seem to be stuck in their ways as “treatment resistant” clients: clients who complain bitterly about their lives, or perhaps have been ordered to treatment because of their addiction (substance, sexual, gambling) or delinquent behaviour has gotten them into serious legal trouble, and appear to be dedicated to the maintenance of the status quo, despite asserting the contrary.
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The helping professional who has encountered such individuals is aware of the challenging predicament he or she is faced with. The less motivation the client has to change certain behaviours, the more frustration both worker and client are likely to experience. Any caring professional knows the feeling of hopelessness and helplessness one experiences when embarking on a power struggle with someone who seems to be decided about not changing: A nurse trying to convince a lady suffering of diabetes unconcerned about her obesity, about the need to control her weight; a social worker trying to convince an indifferent parent about the harm in not sending their son or daughter to school; a youth worker trying to convince a teen who cares less about practicing safe sex, a psychologist working in the prisons trying to convince an inmate about the advantages of control his/her aggression; a counsellor trying to convince a client that there exist healthier ways to decreasing anxiety than illicit substances. All scenarios in which the helping professional runs the risk of hitting a brick wall if he/she is set on converting their client to healthier behaviours and/or beliefs.
Inability to effectively help a client deal with this lack of motivation issue has at times led to considerable blaming. On one end the therapist may experience feelings of inadequacy about his/her skills and question his/her contribution to the counselling relationship. On the other, the client may be blamed or labelled as a treatment resistant client or one who is suffering of an untreatable personality disorder.
In this article, it is my wish to draw the professional helpers’ attention to Motivational Interviewing (MI) - a useful conceptual framework and counselling approach that allows therapeutic relationships to stay on course and out of dead ends. Therapy is about change and MI builds on useful theories based on our current knowledge of motivation and change.
Developed by William Miller and Stephen Rollnick in the late 80s, MI aims at enhancing clients’ readiness for change. In the words of its own developers “Motivational Interviewing is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”. Originally developed as a tool in alcohol addiction counselling, this approach has been applied to address a wide range of other problem behaviours such as eating disorders, sexual obsessions, adolescent behavioural problems, and substance abuse. Throughout the last decade it has been heavily researched and validated as an evidence-based approach to address behaviours that are particularly resistant for change and individuals who are mandated to counselling or better known as involuntary clients. The approach has also recorded a rapidly growing application in general health care/medical settings such as compliance with treatment for diabetes and the prevention of sexually transmitted infections.
In its client-centredness, MI takes a non-punitive approach. Clients who experience ambivalence about change or have difficulty maintaining therapeutic gains are viewed as normal rather than resistant or relapsed. The authors of this model explain that people seeking treatment or ordered to treatment are in need of a therapeutic intervention that helps them to develop internal motivation, not another vehicle for pointing out how “bad” they are. MI encourages “change talk” and discourages power struggles and confrontation, which have at times been shown to be ineffective (if not harmful) therapeutic strategies.
Motivational Interviewing adopts the perspective that motivation to change is to be evoked in the client rather than imposed. It is the individual’s task (not the therapist’s) to articulate and resolve their own ambivalence. It is the therapists’ task to expect and recognize ambivalence, and to be directive in helping the client to examine and resolve their ambivalence.
Motivational Interviewing builds on the transtheoretical model of change whereby readiness for changes is viewed as the extent to which an individual has contemplated the necessity for change, and a decision balance between the pros and cons of change. A lack of motivation can therefore be viewed as a perceptual problem in which the individual sees no (or insufficient) need to change, whereas others (family friends or helping professionals) do perceive a problem and a need for change.
MI aims to alter how the client perceives, feels about and means to respond to the problematic behaviour. The therapist’s response to ambivalence is key to this. The ambivalence is resolved by focusing on the clients’ wants, beliefs, expectations, hopes and fears, with particular emphasis on inconsistencies between these and the problematic behaviour.
To achieve this Motivational interviewing approach is guided by four basic principles (a) expressing empathy, (b) developing discrepancy, (c) rolling with resistance, and (d) supporting self-efficacy (Miller & Rollnick, 2002).
Although expressing empathy is fundamental to virtually all psychotherapies, in motivational interviewing it takes the specific form of reflective listening (or accurate empathy) as described by Carl Rogers (1951). Underlying this principle of empathy is a client-centred attitude of acceptance, wherein client ambivalence or reluctance to change is viewed as a normal part of the human experience rather than as pathology. By not feeling under the gun the client is allowed the space to question his own thoughts and behaviours.
Developing discrepancy, is the second principle of motivational interviewing. A key goal in motivational interviewing is to increase the importance of change from the client's perspective. This is accomplished using specific types of questions, along with selective reflections, that direct the client toward the discrepancy between his or her problem behaviour and broader personal values.
Although motivational interviewing is intentionally directive, the therapist is careful not to explicitly advocate for change; it is the client who presents the reasons for change. Accordingly, when a client expresses resistance to change, it is a signal for the interviewer to respond differently. The third basic principle of motivational interviewing is not to oppose the client's resistance actively but rather to accept and flow with it.
Finally, a client's readiness for change is perceived to arise from the confidence the client has about successfully making the change. This confidence, often termed self-efficacy, is an essential element in motivation and a good predictor of treatment outcome (Bandura, 1982). The fourth guiding principle of motivational interviewing, therefore, is to enhance the client's confidence in his or her own capability to cope with obstacles and to succeed in changing.
Conclusion
Motivational interviewing is a relatively new and promising therapeutic approach that integrates the relationship-building principles of humanistic therapy with more active cognitive-behavioral strategies targeted to the client's stage of change. It has been defined as a client-centered yet directive method for enhancing intrinsic motivation to change by exploring and resolving client ambivalence.
Both at the time of its conception and even today Motivational Interviewing provides hope for working with individuals who were previously viewed as unmotivated or resistant, and therefore untreatable or at best difficult to treat.
References
• Bandura, A. (1982). Self-efficacy: Toward a unifying theory of behaviour change. Psychological Review, 84 191-215.
• Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press.
• Rogers, C. R. (1951). Client-centered therapy. Boston: Houghton-Mifflin.
Mr. Anthony Gatt is a counselling psychologist and member of the Maltese Psychological Association. He has worked in the drug and alcohol addiction field over the last five years. He trained as a psychologist in Canada and researched helpful and hindering events in the counselling process for outpatient drug addiction counselling. His work exposed him to MI and thereafter furthered his training in MI at the Justice Institute BC Canada.
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