Week 5

Context

A wide range of therapies may be available in each area, but it is important to note that they are not suitable for all. The service user's wish to engage in any therapy is crucial. Service users will need a specialist assessment to take part in any therapeutic intervention – all are time-limited, and there is often a waiting list. Bear in mind that the relationship formed between the service user and the mental health professional is also part of the therapeutic process.

In this section we explore motivational Interviewing, a therapy that is beaming more widely used.

Content

Motivation

"The term motivation refers to factors that activate, direct, and sustain goal-directed behavior... Motives are the "whys" of behavior - the needs or wants that drive behavior and explain what we do. We don't actually observe a motive; rather, we infer that one exists based on the behavior we observe" (Nevid, 2013). There are three major components to motivation: activation, persistence, and intensity. Activation involves the decision to initiate a behaviour. Persistence is the continued effort toward a goal even though obstacles may exist. Finally, intensity can be seen in the concentration and vigor that goes into pursuing a goal. As might be expected, there are many theories about motivation, for example:

Incentive Theory of Motivation: The incentive theory suggests that people are motivated to do things because of external rewards. For example, you might be motivated to go to work each day for the monetary reward of being paid. Behavioural learning concepts such as association and reinforcement play an important role in this theory of motivation.

Drive Theory of Motivation: According to the drive theory of motivation, people are motivated to take certain actions in order to reduce the internal tension that is caused by unmet needs. For example, you might be motivated to drink a glass of water in order to reduce the internal state of thirst. This theory is useful in explaining behaviours that have a strong biological component, such as hunger or thirst. The problem with the drive theory of motivation is that these behaviours are not always motivated purely by physiological needs. For example, people often eat even when they are not really hungry.

Arousal Theory of Motivation: The arousal theory of motivation suggests that people take certain actions to either decrease or increase levels of arousal. When arousal levels get too low, for example, a person might watch an exciting movie or go for a jog. When arousal levels get too high, on the other hand, a person would probably look for ways to relax such as meditating or reading a book. According to this theory, we are motivated to maintain an optimal level of arousal, although this level can vary based on the inpidual or the situation.

Humanistic theories of motivation: These are based on the idea that people also have strong cognitive reasons to perform various actions. This is famously illustrated in Maslow's hierarchy of needs (see Self Awareness (Advanced)), which presents different motivations at different levels.

Approach/ Avoidance: Approach motivation may be defined as the energisation of behaviour by, or the direction of behaviour toward positive stimuli (objects, events, possibilities). Avoidance motivation may be defined as the energisation of behaviour by, or the direction of behaviour away from negative stimuli (objects, events, possibilities) (Elliott, 2006)

Motivational Interviewing

Motivational interviewing is a directive, client-centred counselling style for eliciting behaviour change by helping clients to explore and resolve ambivalence.Compared with non-directive counselling, it is more focused and goal-directed. The examination and resolution of ambivalence is its central purpose, and the counsellor is intentionally directive in pursuing this goal. Motivational Interviewing is a person-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Moyers & Rollnick 2002).

Motivation to change is elicited from the client, and not imposed from without. Other motivational approaches have emphasised coercion, persuasion, constructive confrontation, and the use of external contingencies (e.g., the threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies upon identifying and mobilising the client's intrinsic values and goals to stimulate behaviour change. In the following video, Dr Bill Matulich, a clinical psychologist in San Diego, California, explains both the background to, and the uses of, motivational interviewing (17 minutes).

Motivational Interviewing Framework

Stages of Change

Anyone trying to change their behaviour will go through a series of steps or stages. In motivational interviewing these stages are described as:

Pre-contemplation Stage – the person does not believe they have a problem or does not want to change. During pre-contemplation the disadvantages of change outweigh advantages. You may be concerned about some consequence of your client’s behaviour, but the client may accept this as okay for them.

Contemplation Stage - The person is beginning to evaluate their use and starts to think about change. The balance of costs and benefits begin to shift, although the client may appear not interested in change. ‘I should give up because of all the problems. But what am I going to do instead? I’ll miss it and my friends.’

Determination Stage (Readiness to change) - The person decides they do want to change. The balance has shifted. The client is preparing to take action and has confidence in their capacity to change. Change is seen as worthwhile. This is often a planning stage. Goal setting, identifying internal and external supports/resources and identifying strategies to support change can help.

Action Stage - The person changes by undertaking behaviours from the planning stage. The client is taking steps to change. Support and specific skill training can be provided. Review initial reasons that led to the decision to change.

Maintenance Stage - The person maintains their new behaviour. Changes in behaviour maintained for six months or more are usually associated with substantial improvements in the quality of life (e.g. housing, employment, relationships, physical and mental wellbeing). Without such changes, the effort to change may not seem worth it and relapse is more likely. Encourage clients to talk about the positive reasons for maintaining change to reinforce their decisions.

Relapse - The person returns to old behaviours or in the case of substance misuse it may be increased use

References and Further Reading

Elliot, AJ. (2006) The Hierarchical Model of Approach-Avoidance Motivation. Motivation and Emotion. 30:111–116

Miller, WR. and Rollnick, S. (2012) Motivational Interviewing:Helping People Change. Third Edition. New York: Guildford Press

Moyers, T. B. & Rollnick, S. (2002). A motivational interviewing perspective on resistance. Journal of Clinical Psychology: In Session. Volume 58(2), 185-193

Nevid, J. (2013). Psychology: Concepts and applications. Belmont, CA: Wadworth.