It is important to listen for and reinforce increases in five self-motivational areas:
1 self-esteem, for example how the person feels about themselves 2 concern, for example concern for change
3 competence, for example ability to change 4 knowledge of problems and strategies 5 desire for change.
When applying MI at an early stage of the therapeutic encounter, be careful to establish an atmosphere of trust and acceptance, allow the person to explore his/her problems, allow the person to do most of the talking, listen carefully and ask open-ended questions (see Chapter 1). In Box 11.2, we outline some ways in which you can develop skills in using MI in everyday therapeutic encounters.
Box 11.2 Developing skills in using MI in everyday therapeutic encounters
Explanatory questions
‘You say heroin helps you cope – tell me a little more. What does it help you cope with?’
(continued)
‘You say you have worries about using crack. Can you tell me what worries you?’
Reflections
Making a guess as to what the person means by reflecting it back to them for confirmation or clarity, ‘it sounds as if you are not certain about. . .’ Information is often coded; hear the words and understand the meaning.
Check out with the client if you are unsure, for example ‘can I just check that I have understood you correctly? You say that. . .’
Return the client’s reflection as a statement not a question, for example ‘so you’re more anxious when around certain friends than others. . .’ Avoid asking ‘why’ questions; why questions can give the impression that you are expressing moral disapproval. Instead of asking ‘why did you do that?’ say, ‘Tell me the reasons behind that action.’
The five principles of MI
There are five fundamental principles of MI:
1 expressing empathy 2 developing dissonance 3 avoiding arguments 4 rolling with resistance 5 supporting self-efficacy.
The following are examples of how to apply these principles in your work as a mental health nurse.
r Expressing empathy: Make statements that show you understand the impact of the client’s problems on their life, e.g. ‘That must have been traumatic for you.’
r Developing dissonance: When developing dissonance we recom- mend using an antecedent-behaviour-consequence approach (ABC). The ABC approach consists of:
r antecedent: identifying the immediate event that precedes a given behaviour
r behaviour: identifying how a person responds generally to a given behaviour
r consequence: identifying what occurs as a result of the given behaviour.
Phillips and Callaghan (2009) outline how this approach works in practice with a person using illicit substances. See below how the ABC approach is
used with Paul, who struggles to contain his aggressive impulses and whom you encounter while working on an acute inpatient ward.
r Avoiding arguments: Do not get into a war of attrition with the client.
r Rolling with resistance: If the client states that they do not want to work with your suggestions, ask them to identify actions they think might work and help them prioritize a list of what actions to take first.
r Supporting self-efficacy: Raise the client’s belief in their ability to help themselves by asking them to make a list of actions that have helped them successfully in the past, trying these actions again and, where successful, praising the client for their efforts.
Practice exercise
Paul was admitted to your ward three days ago. His behaviour since admission has been erratic, characterized by bouts of verbal and physical aggression towards staff and other patients, and moments where he is calm and affable. The following practice example shows you how to demonstrate skills in caring for Paul using the ABC approach to help him understand what his aggressive behaviour represents.
Antecedent Behaviour Consequence
Ask Paul to list immediate triggers for his aggression, e.g. feeling neglected, being bored.
For each of the triggers ask Paul to list how he generally responds to these triggers, e.g. he assaults staff and other patients.
Paul is restrained, and restrictions are imposed on his time out of the ward.
Using the ABC approach to help Paul manage his aggressive impulses to avoid the negative consequences, you may want to consider the following alternative.
Antecedent Behaviour Consequence
Paul identifies that he is feeling neglected and is bored.
Paul asks you for some therapeutic time to discuss how to deal with his feelings of neglect and boredom.
Paul gets 30 minutes of therapeutic time with you.
You agree that he can have time out from the ward to take a walk. He thus avoids being restrained and having restrictions placed upon him; i.e. his behaviour now has positive consequences.
(continued)
r It is important that you make clients aware of the possible consequences of contin- uing with the behaviour that they regard as problematic, for example for someone who misuses substances you can say: ‘Have you thought of what might happen if you continue to inject harmful drugs using needles shared with others?’
r Your role is to help the client highlight the discrepancy between what they want to achieve, and their current behaviour, for example ‘You say that it is your goal to avoid getting infected with HIV, yet you are still injecting drugs using needles that you share with other drug users and this is a major source of HIV infection.’
r You can also help the client note how changing their behaviour will help them achieve desired goals, for example ‘If you inhaled the heroin instead of injecting it, you will avoid the risk of HIV infection though this route.’
r It is crucial that you show change is possible, e.g. share your successes with previous clients, and that you instil hope by remaining positive about the client’s ability to change.