History of alcohol dependence

Full Answer Section

         

1. Understand Her Motivations (Empathy): Empathy is about active listening and accurately understanding Mary's internal frame of reference, including her feelings, perspectives, and values, without judgment. It means communicating acceptance and respect for her experience.
   • Application with Mary: Acknowledging the immense stress she's under: "It sounds like you're in an incredibly difficult situation right now, with a lot of pressure, especially with Kylie being with the local authority. That must be incredibly tough to navigate." Validating her ambivalence: "It makes sense that you feel conflicted – alcohol might offer some immediate relief, but it's also clear it's causing significant problems, especially with your daughter."
2. Listen to Her (Active Listening): This is the fundamental skill in MI. It involves deep listening to Mary's words, emotions, and unspoken cues, then reflecting back what is heard. This ensures understanding and demonstrates that she feels heard and valued.
   • Application with Mary: Using complex reflections like: "So, on one hand, you mentioned that a drink helps you relax after a stressful day, but on the other, the worry about Kylie and what happened at the nursery is really weighing on you." Or summarizing: "If I'm understanding correctly, you're here because your social worker and PCP suggested it, and a part of you sees this as a chance to make things right for Kylie, even though you're not sure if you can truly control your drinking."
3. Empower Her (Support Self-Efficacy): Self-efficacy is Mary's belief in her own ability to successfully make changes. The provider's role is to bolster this belief by highlighting her strengths, past successes (no matter how small), and her inherent capacity for change.
   • Application with Mary: Recognizing her strengths: "Mary, it took a huge amount of courage to refer yourself to counseling, especially with everything else going on. That really shows a strong desire to make a difference and take control." If she mentions past attempts to cut down, "You've tried to cut down before, and that shows a commitment to this. What did you learn from those attempts, even if they didn't stick?"

 

Detailed Overview of How the Interview May Progress

  The MI process typically unfolds through four overlapping phases or processes (Engaging, Focusing, Evoking, Planning):  

1. Engaging (Building Rapport and Establishing Trust)

 

• Goal: To establish a comfortable and collaborative working relationship with Mary, making her feel safe, understood, and respected.
• Provider Actions:
  • Warm Welcome & Non-Judgmental Stance: "Thank you for coming in today, Mary. I appreciate you taking this step to meet with me."
  • Open-ended Questions: "What brings you here to the counseling agency today?" or "What are your hopes for our time together?"
  • Affirmations: Acknowledge her agency and courage: "It took a lot of strength to reach out for help, especially with everything you're dealing with."
  • Reflective Listening: Reflecting her stated feelings and concerns: "It sounds like there's a lot of pressure from social services, and also a deep concern for Kylie's well-being."
• Expected Client Response: Mary might initially express frustration or resignation about her situation, possibly blaming external factors or expressing hopelessness. The goal here is for her to feel heard and for the conversation to feel like a collaboration, not an interrogation.

 

2. Focusing (Clarifying the Direction for Change)

 

• Goal: To help Mary identify and clarify a specific target for change that is meaningful to her. Given her context, it's clear the primary focus will be alcohol use, but how she frames it is important.
• Provider Actions:
  • Agenda Mapping: "You've mentioned concerns about your drinking, and also the situation with Kylie. Given everything on your plate right now, what feels most important to focus on in our conversations?" (This gives her autonomy).
  • Exploring Concerns: If she names alcohol, "Tell me more about your concerns regarding your alcohol use."
  • Connecting to Values: "How does your alcohol use fit, or not fit, with what you truly value in your life, especially as a mother?"
• Expected Client Response: Mary might express the conflict she feels. She might say things like, "I know I need to stop for Kylie, but it's the only way I cope," or "I just want things to go back to normal." The provider will gently guide the conversation towards her ambivalence about alcohol and its impact.

 

3. Evoking (Eliciting Motivations for Change)

 

• Goal: This is the heart of MI – to elicit Mary's own reasons, desires, abilities, and needs for change (known as Change Talk). This helps resolve her ambivalence by amplifying her own arguments for change.
• Provider Actions:
  • Decisional Balance: "What are some of the good things about drinking for you?" (Validate her perspective, e.g., "It helps you relax after a tough day.") "And what are some of the less good things about it, especially now with Kylie and social services involved?" (This helps to develop discrepancy between her current behavior and her goals/values).
  • Readiness Ruler: "On a scale of 0 to 10, where 0 is 'not at all ready' and 10 is 'very ready,' how ready are you to make a change in your drinking right now? And why are you at [specific number] rather than a lower one?" (This encourages her to articulate reasons for change).
  • Elaborating on Change Talk (DARN questions): If Mary says, "I want Kylie back," (Desire) the provider might ask, "Tell me more about what having Kylie back home would look like." If she says, "I need to stop drinking for Kylie's safety," (Need) the provider could ask, "What makes this a need for you right now?" If she mentions, "I could try going to an AA meeting," (Ability) "What steps would be involved in doing that?"
  • Looking Back/Forward: "Think back to a time when your drinking wasn't a problem, or was less of a problem. What was different then?" or "Imagine life five years from now if your drinking continued down this path. What might that look like? Now, imagine life five years from now if you successfully managed your drinking. What would that be like?"
• Expected Client Response: This phase will be characterized by increased "change talk" from Mary. She'll start to articulate more reasons, desires, needs, and abilities for changing her alcohol use, and less "sustain talk" (arguments for maintaining the status quo). She might show signs of distress as she confronts the discrepancy, but also hope as she considers alternatives.

 

4. Planning (Developing a Commitment to Change and a Plan)

 

• Goal: To help Mary commit to a specific plan for change, once her motivation is high. This is a collaborative process; the plan must come from her.
• This phase is only entered when sufficient change talk and a clear movement towards commitment are evident.
• Provider Actions:
  • Summarize Change Talk: "Mary, we've talked about how important Kylie is to you, your desire to be a stable mother for her, and the need to address your alcohol use to achieve that. You also mentioned some steps you could take, like looking into support groups."

Sample Answer

        Motivational Interviewing (MI) is a client-centered, guiding method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. For Mary, a 27-year-old with alcohol dependence whose child is in local authority care, MI offers a compassionate and effective approach to help her address her alcohol use. Her self-referral, despite ambivalence, is a crucial first step that MI can capitalize on.  

Discussing the Principles of Motivational Interviewing with Mary

  The spirit of MI is underpinned by four core principles (often remembered by the acronym RULE):

1. Resist the Righting Reflex: As a provider, it's natural to want to fix Mary's problems or tell her what she "should" do, especially given the severity of her situation with Kylie. However, MI emphasizes resisting this urge. Directly confronting Mary or dictating solutions will likely elicit resistance and push her further into ambivalence or defensiveness. Instead, the focus will be on understanding her perspective.