Reflection and Self-Assessment

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1st Jan 1970 Psychology Reference this

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I chose to do Motivational Interviewing (MI) on my client who has been referred to me because of driving under the influence of alcohol. A randomised control trial found out that drink driving offenders that received MI had lower rates of drink driving in the future as compared to those that received other counselling approaches (Stein et al., 2006). MI is “a client-centred directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002). The agenda I had in mind during the 5 minute video segment was to understand the client’s internal frame of reference and present concerns, and try to establish discrepancies between his behaviours and his goals in life.

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Initially I noticed, from client’s non verbal expression, that he was quite reluctant to participate in this counselling session. From here I could sense that clients is more or less at the pre-contemplation stage in the concept of “Stages of Change Model” (Miller & Heather, 1998) where client is happy with his current drinking behaviours and the positives outweigh the negatives. Clients at this stage of change will ignore or disbelieve that their behaviour is harmful (Rollnick, Heather, & Bell, 1992). Despite that, I kept reminding myself not to be judgemental and try to explore further into client’s concerns.

Immediately I “Express Empathy” which is the first of the four basic key principles in MI as describe by Miller and Rollnick (2002). At the beginning of the 5 minute video segment, I explained to the client that I understood where he was coming from and told client to treat this session as a casual conversation rather than a counselling session. The reason I did this was to allow client to be comfortable and open up, so I could experience what his feelings and thoughts were from his perspective without judgement or criticism, in other words, understanding the client’s internal frame of reference. Client replied with a short “I will try” answer. After client’s respond, I could see from his facial expression that he had changed from a “reluctant” look to a more “open” expression. This indicates that client is willing to take a step further and is less defensive towards the session. I was hoping for this response because the MI spirit of counselling state that it should consist of collaboration, evocation, and autonomy (Arkowitz, Westra, Miller, & Rollnick, 2008), therefore therapy should be a joint effort as opposed to one which I was in control, put differently “Client-Centred Approach”.

Throughout the 5 minute segment, I used skilful reflective listening, which is one of the four methods of MI (OARS): asking open questions; affirming; listen reflectively and summarising (Miller & Rollnick, 2002). Reflective listening allows me to express empathy as well as allowing me to check if I have interpreted his words correctly, instead of assuming. This is a style of empathic communication that should to be used throughout the process of MI as stated by Miller and Rollnick (2002), at the same time this would build up rapport between me and the client. The tone of my voice was genuine for the situation, there was no sarcasm or any form of speech which would make the client feel uncomfortable or increase resistant.

One of the strategies of MI which was used in the 5 minute segment was “The Good Things and The Less Good Things” (Rollnick et al., 1992) or the pros and cons technique which helps in building rapport, provides important information about the content, and enables an assessment of readiness to change to be made. I started off with asking client what were some of the “Good Things” he likes about his drinking habits. I used non-verbal actions like hand gesture in the expression of the question which helps me in controlling or regulate the flow of my speech as stated by Verderber and Verderber (2004). The question is also asked in an open manner, again is another method of MI (OARS) (Miller & Rollnick, 2002). This encourages my client to do the talking while I would listen reflectively. While client states the “Good Things” about his drinking behaviour, I maintained eye contact and non-verbal behaviours such as nodding of my head to express to client that I am listening to him in an emphatic manner. This pros and cons technique allows me to explore client’s ambivalence and decisional balance on the issue of his drinking habits.

On one occasion, I asked for elaboration on a specific occasion where he really enjoys drinking. Miller and Rollnick (2002) said elaboration on certain issues is particularly useful way to eliciting further change talk and helps to reinforce the motivational theme. But there was no change talk express by the client, instead client goes on and talks about the fun of his drinking session with his friends. After analysing critically, I noticed change talk would normally appear when discussing about the “Less Good Things” where I could “Develop Discrepancy” (second principle of MI) between what his present behaviour are and his broader goals and values as oppose to, when we were discussing the “Good Things”. Although, the client responses was not a change talk, I was not too surprise because we were still early into the session. In addition, elaboration on the “Good Things” helps me to understand more about the client from his perspective as well and building rapport and allowing client to speak his feelings out.

I notice that when we were discussing about the “Good Things”, client expressed persistency that what he did (drink driving) was the right thing to do. From this I could establish that client is at the pre-contemplation stages of change as I could see some form of resistant building up. Initially, I thought discussing about the “Good Things” would catch the client by surprise, because clients are often confronted with why they need to change behaviour, but are rarely ask what the benefits they are receiving from it (Rollnick et al., 1992). This often serves to reduce resistant and allow inquiry into the “Less Good Things” more acceptable to the client. Here I employed the third principle of MI, “Roll with Resistance” which I felt that I did a great job on. I stood on a neutral position and did not argue for change. Instead I acknowledge them to be natural and understandable. As stated by Arkowitz et al (2008), it can be a profound experience for clients to talk about the advantages of having the problem and to find the counsellor listening and responding compassionately without advocating for change. Evidence suggest treatment drop out is common where there is increase client resistance (Rollnick et al., 1992) and research has shown a decrease in client’s resistance is associated with long term change (Miller & Rollnick, 2002). On one hand, I had to control myself not to argue for change, and on the other hand, I nearly immersed myself too much into his frame of reference that I almost “Affirm” (method of MI, OARS) what the client had said. If I had affirmed his drinking behaviours with compliments I would have redirected the session into the wrong direction! From this experience, I learnt that affirmation should be best used when client has taken small steps towards the direction of change, and not on issues which encourage client to persist on their present behaviour. This is because MI is client-centred as well as directive method for enhancing intrinsic motivation to change.

Another method of MI is method is summarising (OARS). At the start of the 5 minute segment I perform a “transitional summary” (Miller & Rollnick, 2002) which marks a shift from one an introductory phase to a strategy phase. In addition, I also included a prefacing statement in that transitional summary that formally announces what is to follow next. This is done to create smoothness in the structure of the interview session. I think I did quite well in this, from the non-verbal cue expressed by the client, he seems to be more cooperative. Another summary I performed was at the ending of the 5 minute segment where I did a “collecting summary” (Miller & Rollnick, 2002) on the “Good Things”. I have to admit, I blunder with my words in performing this collective summary. After reviewing the video segment a number of times I noticed that I had stopped the client’s momentum in his flow of speech. I believe there could be more “Good Things” which the client has not mentioned. I was too focus on the structure of the pros and cons technique and was eager to jump into summarising the “Good Things” and move on to the “Less Good Things”. I believe I was quite nervous at the point in time. What I could have done better is to continue emphatic reflective listening or explore other concerns. For example I could say “You said you like drinking because you could get away from work or some problems, would you like to tell me more about it?” By doing this, I can get to know the reasons behind his drinking behaviour.

Another skill which I felt that I did poorly was the phrasing of “Is there anything else you would like to add on to the good things?” which is a close question (in that the literal answer is yes or no) and invited the client to answer “No”. I could have phrased it in a more open manner like “What else?” which invites continued exploration. Again, I need more practice in the structuring of my question to encourage more client speech.

Next I asked the client what were the “Less Good Things” about his drinking behaviours. Again, I slip out the word “obstacle” instead of the “Less Good Things”. It is important that I do not mention such strong words such as “disadvantages” or “problems”. As mention by Rollnick et al. (1992), it might create an impression to the client that I am trying to label his behaviour as a problem. That is the reason why this strategy is called the “Good Things and Less Good Things”.

Because client is in the pre-contemplation stage of change as ascertain earlier, client took a while to respond to the question of the “Less Good Things”. He hesitated for a couple of seconds and it was good that I remain my silence too. This silence is one of micro counselling skills which provided client time to think and allow them to proceed at their own pace (Franchino, 1986).

After the pause, client started to converse about the “Less Good Things” about his drinking behaviour. At this point in time, I did perform some good skills as well as some skills which I need more improvement on. Skills which I performed well are exploring client’s concerns. I took a step further in asking for elaboration into his areas for concerns for his drinking behaviour which again allow me to understand what his concerns were. However, I was not directive enough, I did not perform too well in amplifying the discrepancy between present behaviour and his or her broader goals or values. As stated by Miller and Rollnick (2002), “the goal of MI is to develop discrepancy “” to make use of it, increase it and amplify it until it overrides the inertia of the status quo”. What I could have done is to make the client be more aware of the discrepancy between his drinking behaviour and the trouble that he has caused when he was drunk. In doing so, it might be possible to elicit change talk.

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Another mistake I did was again stopping the client momentum of speech. While client was listing the “Less Good Thing”, I wanted him to pause so I could ask more elaboration. Therefore, I raise my hand up. My intention was to hint him to slow down, but I think it might interrupt his flow of speech. It really came naturally. I suppose, it might not have caused a major fault, but in the future, more work need to be done to control my actions as well.

The last principle of MI is “Support Self-Efficacy”, which I did not manage to perform is about the client’s responsibility for deciding and directing his or her own change (Miller & Rollnick, 2002). This, I believe will come naturally in the later stages of the counselling session. Overall, I would say more effort needs to be put into familiarising and practicing the MI style of counselling, because theory alone is just not practical enough.

References

Arkowitz, H., Westra, H., Miller, W., & Rollnick, S. (2008). Motivational Interviewing in the Treatment of Psychological Problems. New York: The Guilford Press.

Franchino, L. (1986). Basic counseling skill: A manual for trainers of bereavement counselors. Melbourne: Cruse Publishing.

Miller, W., & Heather, N. (1998). Treating Addictive Behaviors (2nd ed.). New York: Plenum Press.

Miller, W., & Rollnick, S. (2002). Motivational Interviewing (2nd ed.). New York: The Guilford Press.

Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behavior change in medical settings: The development of brief motivational interviewing. Journal of Mental Health , 1992(1), 25-37.

Stein, L., Colby, S., Barnett, N., Monti, P., Golembeske, C., & Lebeau-Craven, R. (2006). Effects of Motivational Interviewing for Incarcerated Adolescents on Driving Under the Influence after Release. The American Journal on Addictions, 15(1), 50-57.

Verderber, K., & Verderber, R. (2004). Inter-Act: Interpersonal Communication Concepts, Skills, and Contexts (10th ed.). New York: Oxford University Press.

I chose to do Motivational Interviewing (MI) on my client who has been referred to me because of driving under the influence of alcohol. A randomised control trial found out that drink driving offenders that received MI had lower rates of drink driving in the future as compared to those that received other counselling approaches (Stein et al., 2006). MI is “a client-centred directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (Miller & Rollnick, 2002). The agenda I had in mind during the 5 minute video segment was to understand the client’s internal frame of reference and present concerns, and try to establish discrepancies between his behaviours and his goals in life.

Initially I noticed, from client’s non verbal expression, that he was quite reluctant to participate in this counselling session. From here I could sense that clients is more or less at the pre-contemplation stage in the concept of “Stages of Change Model” (Miller & Heather, 1998) where client is happy with his current drinking behaviours and the positives outweigh the negatives. Clients at this stage of change will ignore or disbelieve that their behaviour is harmful (Rollnick, Heather, & Bell, 1992). Despite that, I kept reminding myself not to be judgemental and try to explore further into client’s concerns.

Immediately I “Express Empathy” which is the first of the four basic key principles in MI as describe by Miller and Rollnick (2002). At the beginning of the 5 minute video segment, I explained to the client that I understood where he was coming from and told client to treat this session as a casual conversation rather than a counselling session. The reason I did this was to allow client to be comfortable and open up, so I could experience what his feelings and thoughts were from his perspective without judgement or criticism, in other words, understanding the client’s internal frame of reference. Client replied with a short “I will try” answer. After client’s respond, I could see from his facial expression that he had changed from a “reluctant” look to a more “open” expression. This indicates that client is willing to take a step further and is less defensive towards the session. I was hoping for this response because the MI spirit of counselling state that it should consist of collaboration, evocation, and autonomy (Arkowitz, Westra, Miller, & Rollnick, 2008), therefore therapy should be a joint effort as opposed to one which I was in control, put differently “Client-Centred Approach”.

Throughout the 5 minute segment, I used skilful reflective listening, which is one of the four methods of MI (OARS): asking open questions; affirming; listen reflectively and summarising (Miller & Rollnick, 2002). Reflective listening allows me to express empathy as well as allowing me to check if I have interpreted his words correctly, instead of assuming. This is a style of empathic communication that should to be used throughout the process of MI as stated by Miller and Rollnick (2002), at the same time this would build up rapport between me and the client. The tone of my voice was genuine for the situation, there was no sarcasm or any form of speech which would make the client feel uncomfortable or increase resistant.

One of the strategies of MI which was used in the 5 minute segment was “The Good Things and The Less Good Things” (Rollnick et al., 1992) or the pros and cons technique which helps in building rapport, provides important information about the content, and enables an assessment of readiness to change to be made. I started off with asking client what were some of the “Good Things” he likes about his drinking habits. I used non-verbal actions like hand gesture in the expression of the question which helps me in controlling or regulate the flow of my speech as stated by Verderber and Verderber (2004). The question is also asked in an open manner, again is another method of MI (OARS) (Miller & Rollnick, 2002). This encourages my client to do the talking while I would listen reflectively. While client states the “Good Things” about his drinking behaviour, I maintained eye contact and non-verbal behaviours such as nodding of my head to express to client that I am listening to him in an emphatic manner. This pros and cons technique allows me to explore client’s ambivalence and decisional balance on the issue of his drinking habits.

On one occasion, I asked for elaboration on a specific occasion where he really enjoys drinking. Miller and Rollnick (2002) said elaboration on certain issues is particularly useful way to eliciting further change talk and helps to reinforce the motivational theme. But there was no change talk express by the client, instead client goes on and talks about the fun of his drinking session with his friends. After analysing critically, I noticed change talk would normally appear when discussing about the “Less Good Things” where I could “Develop Discrepancy” (second principle of MI) between what his present behaviour are and his broader goals and values as oppose to, when we were discussing the “Good Things”. Although, the client responses was not a change talk, I was not too surprise because we were still early into the session. In addition, elaboration on the “Good Things” helps me to understand more about the client from his perspective as well and building rapport and allowing client to speak his feelings out.

I notice that when we were discussing about the “Good Things”, client expressed persistency that what he did (drink driving) was the right thing to do. From this I could establish that client is at the pre-contemplation stages of change as I could see some form of resistant building up. Initially, I thought discussing about the “Good Things” would catch the client by surprise, because clients are often confronted with why they need to change behaviour, but are rarely ask what the benefits they are receiving from it (Rollnick et al., 1992). This often serves to reduce resistant and allow inquiry into the “Less Good Things” more acceptable to the client. Here I employed the third principle of MI, “Roll with Resistance” which I felt that I did a great job on. I stood on a neutral position and did not argue for change. Instead I acknowledge them to be natural and understandable. As stated by Arkowitz et al (2008), it can be a profound experience for clients to talk about the advantages of having the problem and to find the counsellor listening and responding compassionately without advocating for change. Evidence suggest treatment drop out is common where there is increase client resistance (Rollnick et al., 1992) and research has shown a decrease in client’s resistance is associated with long term change (Miller & Rollnick, 2002). On one hand, I had to control myself not to argue for change, and on the other hand, I nearly immersed myself too much into his frame of reference that I almost “Affirm” (method of MI, OARS) what the client had said. If I had affirmed his drinking behaviours with compliments I would have redirected the session into the wrong direction! From this experience, I learnt that affirmation should be best used when client has taken small steps towards the direction of change, and not on issues which encourage client to persist on their present behaviour. This is because MI is client-centred as well as directive method for enhancing intrinsic motivation to change.

Another method of MI is method is summarising (OARS). At the start of the 5 minute segment I perform a “transitional summary” (Miller & Rollnick, 2002) which marks a shift from one an introductory phase to a strategy phase. In addition, I also included a prefacing statement in that transitional summary that formally announces what is to follow next. This is done to create smoothness in the structure of the interview session. I think I did quite well in this, from the non-verbal cue expressed by the client, he seems to be more cooperative. Another summary I performed was at the ending of the 5 minute segment where I did a “collecting summary” (Miller & Rollnick, 2002) on the “Good Things”. I have to admit, I blunder with my words in performing this collective summary. After reviewing the video segment a number of times I noticed that I had stopped the client’s momentum in his flow of speech. I believe there could be more “Good Things” which the client has not mentioned. I was too focus on the structure of the pros and cons technique and was eager to jump into summarising the “Good Things” and move on to the “Less Good Things”. I believe I was quite nervous at the point in time. What I could have done better is to continue emphatic reflective listening or explore other concerns. For example I could say “You said you like drinking because you could get away from work or some problems, would you like to tell me more about it?” By doing this, I can get to know the reasons behind his drinking behaviour.

Another skill which I felt that I did poorly was the phrasing of “Is there anything else you would like to add on to the good things?” which is a close question (in that the literal answer is yes or no) and invited the client to answer “No”. I could have phrased it in a more open manner like “What else?” which invites continued exploration. Again, I need more practice in the structuring of my question to encourage more client speech.

Next I asked the client what were the “Less Good Things” about his drinking behaviours. Again, I slip out the word “obstacle” instead of the “Less Good Things”. It is important that I do not mention such strong words such as “disadvantages” or “problems”. As mention by Rollnick et al. (1992), it might create an impression to the client that I am trying to label his behaviour as a problem. That is the reason why this strategy is called the “Good Things and Less Good Things”.

Because client is in the pre-contemplation stage of change as ascertain earlier, client took a while to respond to the question of the “Less Good Things”. He hesitated for a couple of seconds and it was good that I remain my silence too. This silence is one of micro counselling skills which provided client time to think and allow them to proceed at their own pace (Franchino, 1986).

After the pause, client started to converse about the “Less Good Things” about his drinking behaviour. At this point in time, I did perform some good skills as well as some skills which I need more improvement on. Skills which I performed well are exploring client’s concerns. I took a step further in asking for elaboration into his areas for concerns for his drinking behaviour which again allow me to understand what his concerns were. However, I was not directive enough, I did not perform too well in amplifying the discrepancy between present behaviour and his or her broader goals or values. As stated by Miller and Rollnick (2002), “the goal of MI is to develop discrepancy “” to make use of it, increase it and amplify it until it overrides the inertia of the status quo”. What I could have done is to make the client be more aware of the discrepancy between his drinking behaviour and the trouble that he has caused when he was drunk. In doing so, it might be possible to elicit change talk.

Another mistake I did was again stopping the client momentum of speech. While client was listing the “Less Good Thing”, I wanted him to pause so I could ask more elaboration. Therefore, I raise my hand up. My intention was to hint him to slow down, but I think it might interrupt his flow of speech. It really came naturally. I suppose, it might not have caused a major fault, but in the future, more work need to be done to control my actions as well.

The last principle of MI is “Support Self-Efficacy”, which I did not manage to perform is about the client’s responsibility for deciding and directing his or her own change (Miller & Rollnick, 2002). This, I believe will come naturally in the later stages of the counselling session. Overall, I would say more effort needs to be put into familiarising and practicing the MI style of counselling, because theory alone is just not practical enough.

References

Arkowitz, H., Westra, H., Miller, W., & Rollnick, S. (2008). Motivational Interviewing in the Treatment of Psychological Problems. New York: The Guilford Press.

Franchino, L. (1986). Basic counseling skill: A manual for trainers of bereavement counselors. Melbourne: Cruse Publishing.

Miller, W., & Heather, N. (1998). Treating Addictive Behaviors (2nd ed.). New York: Plenum Press.

Miller, W., & Rollnick, S. (2002). Motivational Interviewing (2nd ed.). New York: The Guilford Press.

Rollnick, S., Heather, N., & Bell, A. (1992). Negotiating behavior change in medical settings: The development of brief motivational interviewing. Journal of Mental Health , 1992(1), 25-37.

Stein, L., Colby, S., Barnett, N., Monti, P., Golembeske, C., & Lebeau-Craven, R. (2006). Effects of Motivational Interviewing for Incarcerated Adolescents on Driving Under the Influence after Release. The American Journal on Addictions, 15(1), 50-57.

Verderber, K., & Verderber, R. (2004). Inter-Act: Interpersonal Communication Concepts, Skills, and Contexts (10th ed.). New York: Oxford University Press.

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