Motivational Interviewing: User Friendly Advanced Applications for the Treatment of Sexual Compulsivity

J. Roland Fleck, EdDJan Parker, PhDNational University

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Transtheoretical Model (TTM)

Prochaska & DiClemente (1984) postulated the behavior change process as a sequence of five stages through which people advance as they create, modify or stop behaviors

Readiness for change gauge Interventions must match stage of change

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Precontemplation Stage

No recognition of a problem and no intention to change in the foreseeable future

Unaware, unwilling, unconcerned or too discouraged to change their behavior

Do not perceive behavior as creating adverse consequences or personal crisis

The essence of precontemplation is maintaining the status quo

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Contemplation Stage

Recognition of a problem and serious consideration about overcoming it

No commitment to take action or change Ambivalence about changing Weighing pros and cons of changing or not

changing Decisional balance evaluation process Recognizing where you want to go but not being

quite ready to do it

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Preparation Stage

Intention to change the behavior Initial formulation of a plan to act May have already taken some action toward

modifying the problem behavior Requires commitment to some type of action

plan Includes an evaluation of one’s perceived

capabilities (i.e., self-efficacy) for changing Pros for changing the behavior outweigh the

cons

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Action Stage

Plan is implemented to stop the old behavior pattern and engage in the new behavior

Requires major lifestyle changes requiring considerable commitment of time and energy

Path to actually creating a new pattern of behavior begins with this initial action

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Maintenance Stage

Behavior changes are continued and gains are consolidated and integrated

New behavior pattern becomes automatic and established

Risk of reverting back to the old behavior pattern is present

Return to problematic behavior at least once, reverting to a previous stage of change

The essence of maintenance is stabilizing behavior change and avoiding relapse

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Recurrence

Most people taking action to modify problem behavior do not succeed on their first attempt

Cycle through the stages of change on several occasions before achieving long-term successful behavior change

Visualize the stages of change model as a spiral rather than either a linear or circular progression

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Motivational Interviewing Miller & Rollnick (1991; 2002) developed an

interpersonal style that employs a series of principles to help people deal with addictive disorders and other problem behaviors

Assumption that the client has both the responsibility and capability to change

Role of the counselor is to create an environment that will increase and enhance the client’s motivation for and commitment to change

Helping clients resolve the ambivalence that prevents the realization of personal goals

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Definition of Motivational Interviewing

Motivational Interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. Compared to nondirective counseling, it is more focused and goal-oriented. The examination and resolution of ambivalence is its central purposes

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Four Assumptions Ambivalence about the problematic behavior (and

change) is normal and is a motivational obstacle to behavior change

Ambivalence in the client can be resolved by working with his/her intrinsic motivations and values

Alliance between therapist and client needs to be a collaborative partnership to which each contributes expertise

Change occurs through an empathic, supportive, but directive counseling style

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Four Principles

Used in applying the Motivational Interviewing approach to counseling and therapy

Four principles of Motivational Interviewing are considered far more important than any specific strategy or skill used in counseling and therapy

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Express Empathy

Foundation for facilitating change Respectful Understanding Communicate acceptance and understanding Use non-judgmental reflective listening Develop a collaborative relationship Not about agreeing, but trying to understand Possible to accept a person’s thoughts and

feelings without agreement and approval

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Develop Discrepancy

Clients are more likely to be persuaded by what they hear themselves say than by what a counselor or other person tells them

Create and amplify the discrepancy between the client’s present behavior and his/her broader life goals and values

Directive in moving the client toward a resolution of the ambivalence

Perceived discrepancy motivates change Client should always present the arguments for change

(i.e., change talk)

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Roll With Resistance

Resistance is not viewed as defiance Resistance is perceived as a sign that the client has a

different view of the situation Considers this ambivalence to be a normal part of the

change process Resistance is not directly confronted Resistance is turned and reframed to create a new

momentum toward change Counselor does not argue with the client Invites rather than imposes new perspectives Client is the primary resource in finding solutions

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Support Self-Efficacy Support self-efficacy by guiding the client toward a

belief in his/her own ability to successfully change Self-efficacy is a good predictor of treatment

outcome If the client does not perceive the ability to change,

the situation will appear hopeless and no effort will be made and the previous effort of the counselor will be of little use

Counselor needs to believe in the client’s capacity to change

Counselor’s belief in the client empowers the client

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Summary

“Motivational Interviewing honors and respects the individual’s autonomy to choose. It is a collaborative, not a prescriptive, approach, in which the counselor evokes the person’s own intrinsic motivation and resources for change. Implicit is the belief that such motivation and resourcefulness do lie within each individual and need to be evoked rather than imposed” (Miller & Rollnick, 2002, p. 41).

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Five Strategies of Motivational Interviewing

Miller and Rollnick describe five strategies that are effective in guiding clients through the five-stage continuum of change

First four strategies are derived largely from client-centered therapy, although they are used for a particular purpose—that of helping clients to explore their ambivalence and express reasons for change

Fifth strategy, eliciting self-motivational statements, is more directive and specific to Motivational Interviewing

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Ask Open-Ended QuestionsAffirmListen ReflectivelySummarize

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The acronym OARS is used to describe the four strategies of asking open-ended questions, affirming, reflective listening, and summarizing

This acronym presents an image that with sustained effort OARS can take us a long way

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Elicit Self-Motivational Statements (Change Talk) Rather than trying to persuade the client that

change is necessary, the counselor facilitates the client’s expressions of personal concerns and intentions and arguments for change

Counselor gives recognition to any type of self-motivational statements including:Problem RecognitionConcern about the ProblemCommitment to ChangeBelief that Change Is Possible

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Counselor can employ the four strategies described above (i.e., OARS) as well as various specific techniques including:Asking evocative questionsExploring pros and consAsking for elaborationUsing extremesLooking backLooking forwardExploring Goals

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Generic Concepts in User Friendly Terminology The following generic concepts are strategies

that are user friendly and consistent with the spirit of Motivational Interviewing:Use respectful understanding and begin where

the client is in order to engage him/herEducate the client about what to expect from

you in terms of services you can and cannot provide

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Broaden your concept of strength by focusing on the client’s unrecognized abilities and accomplishments in order to facilitate the development of self-efficacy

Help the client to identify family and friends who have been supportive in the past in order to explore obstacles that the client perceives to be preventing him/her from seeking support

Look for common ground with the client to allow the client to perceive you as an approachable person who can be trusted

Recognize the difference between rescuing/enabling and empowering

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Slow down the process in order to establish a collaborative set with the client. Each goal and each action step needs to be patiently and collaboratively developed between the client and the counselor

Help the client define what he/she wants to have happen from working with you

Explore a menu of options with the client emphasizing that the client does have choices and pointing out specifically where the choices exist

Help the client identify the next manageable step that he/she can realistically undertake in moving toward a particular goal

Conduct a thorough assessment and consider the assessment to be your first intervention

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Confrontation of Denial Approach to Sexual Compulsivity Treatment

Premature Advice and Head-on Confrontation

Frustration when the Client is Non-Compliant

Unresolved Countertransference

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Rescuing and Enabling Approach to Sexual Compulsivity Treatment

Premature Advice and Friendly Persuasion

Confrontation

Frustration when the Client is Non-Compliant

Unresolved Countertransference

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Stages of Change/Motivational Interviewing Approach to Treatment

Recognition of Client’s Stage along the Continuum of Change

Client-Centered Motivational Interviewing Strategies Tailored to the Client’s Stage of Change

Increases Potential for Engaging and Empowering the Client

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Non-Compliance Is Viewed as an Indication that the Therapist Needs to:Change Strategies

Collaboratively Review Obstacles

Collaboratively Re-Negotiate Goals