Understanding Motivational Interviewing in Recovery-Focused Nursing Practice: A Case Study Analysis
Question
Task: How does Motivational Interviewing contribute to recovery-focused nursing practice in addressing addiction and gambling, and what are the key challenges faced in this context?
Answer
Introduction
Addiction and gambling are complex and harmful human behavioural patterns that result in severe mental and physical health issues. In clinical mental health nursing practices, nurses are often involved in dealing with the addiction patients who are seeking therapy to get rid of their harmful behavioural practices (Gruber et al., 2021). I work in a community mental health care centre (ABC Mental Health Care), where I observe many of my colleagues dealing with different mental health patients mostly with addiction and gambling problems. I have noticed the co-existing problems that result in dealing with mental health patients and addiction patients being treated with the similar approaches but also facing specific challenges. I believe there is a need for more focus on the challenges and adopt specific approaches depending on the cases to avoid the co-existing problems.
Overall, this report involves discussion of various reasons behind addiction and gambling practices, MI as an effective approach to deal with the patients and discussion of specific case based approach to deal with a patient.
Reasons for using Alcohol, Substances or Gambling
Human nature exhibits different types of complex behaviours that are not always beneficial for them. These behaviours are harmful to the people in various different ways and most often, these types of behaviours arise from mental health issues. Some of these harmful behaviours include excessive alcohol consumption, substance abuse and gambling. Alcohol consumption and substance abuse generally start from the need for relaxation, temporary arousal and enjoyment and others whereas gambling starts from the wish to earn money without much effort (Hajcak, Klawohn & Meyer, 2019). However, once these addictions start getting stronger, they exponentially increase detrimental effects on the person’s mental and physical health in addition to increasing draining of personal wealth.
People addicted to alcohol, substances and gambling require lengthy help and support with rehab, medications, psychotherapy and others. However, before offering help to reduce the addiction problems gradually and developing new ways to do so, it is first important to understand where these issues arise from and why people get addicted so easily. These are further discussed as follows.
Social Interaction and Peer Pressure – One of the primary reasons behind alcohol and substance abuse as well as gambling is peer pressure and need for social interaction. There are many individuals who want to feel part of a group and start consuming alcohol, abusing substances and gambling along with the other peers of the group. This is mostly noted among young individuals studying in colleges or graduates who have just started working. While the need for more social interaction is one of the main reasons, peer pressure is another reason behind these issues. Often, in many cases, the patients have stated that they have been pressured by their friends or colleagues to try drinking alcohol or abuse substance or try a hand in gambling (Tackett et al., 2019).
After some repeated behaviour of taking part in these activities, they soon become habit and then addiction. The world is changing rapidly and so are the mentalities of people especially young adults and the adolescents. Now, more than ever, the need for acceptance and validation among different groups play important roles in determining the mental health of these people. In order to fulfill these requirements, these people become very vulnerable to alcohol addiction and substance abuse and they may feel compelled to do so to be accepted within the peers without thinking about the negative consequences of those practices.
Stress, Emotional Distress and Coping Mechanism – One of the most well documented and widely claimed reasons behind alcohol and substance abuse includes coping mechanism against emotional distress. A large majority of rehab patients as well as other known addicts have stated they have started drinking alcohol or abusing substance as a coping mechanism in order to get rid of great emotional stress, caused by other personal issues like relationships, work problems, financial issues and others, albeit for a temporary period of time (Wiklund et al., 2020). Initially, they do not take up alcohol or substance with the view to generate addiction but only for temporarily coping with the stress but as this practice increases in frequency, it slowly becomes deadly addiction.
Pleasure and Escapism – Some people often resort to alcohol, substances and gambling as means for pleasure. It is a commonly known practice of abusing alcohol and substances for recreation purposes – there are even some substances known as recreational drugs as they are extensively used for pleasure and recreational purposes. These practices often provide the person with great deal of relaxation, euphoria or pleasure for a short period of time and it does not take time to make these practices a habit and then addiction. Escapism is another excuse used by these people for taking up alcohol or substance abuse and gambling (Tackett et al., 2019). Patients have often stated that they wanted to escape their monotony of life and unfulfilled wishes and allure of these activities as means of pleasure attracted them to try these practices and before they knew, these practices became addiction for them. The patients have also often admitted that they did not think of the long term consequences before they started these practices and as result, there was no control or restraint over these practices before they became addictions.
Genetics – The final reason that is being discussed here is genetics. It is generally believed and proved through biological science that genetics often plays a role in determining some harmful characteristics of a person and alcohol addiction and gambling are included within them. It is believed that if a person’s parent(s) or other predecessors were involved in serious practices of addiction in alcohol, substances and gambling, then that person is also very likely to take up such practices and get addicted to them (Semmer & Frese, 2021). However, this is not always the case as it has been seen in many cases that the son of an addict has not taken up alcohol, substances or gambling throughout his life. Researchers believe this genetic problem is more of psychological that biological – forefathers involved in gambling and alcohol / substance addiction often encourage the younger generation to take up these practices rather than genetics working to induce similar characteristics.
There are also many other reasons why people resort to alcohol or substance abuse and gambling. Alcohol consumption, substance abuse and gambling are complex behaviours driven by a complex interplay of individual motivations and personal contexts that may vary from person to person. By examining the underlying reasons that compel individuals to resort to these harmful practices, valuable insights can be gained regarding the intricate nature of human behaviour that in turn can be utilised to provide help to those who want to get rid of addictions. Recognizing the diversity of motivations and personal contexts regarding these practices can help to develop more effective approaches to intervene, prevent and support for those affected by addictions.
Motivational Interviewing in Recovery Focused Practice
Motivational Interviewing is an approach of conversation that is used to strengthen a person’s motivation to change and move away from harmful practices like addiction. It is a client-centred and goal-oriented counselling approach that aims to explore and resolve ambivalence within the patients who are involved in addiction. The approach encourages behaviour change through collaborative and empathetic conversations i.e. it tries to strengthen the person’s will for a change from bad practices to good (Mezaour, 2022). In other words, this approach does not require taking specific actions on a person to change their practices but rather, it motivates the person to take actions themselves so that they can move away from addiction and other harmful practices. In the nursing practice involving addiction and mental health patients, Motivational Interviewing has gained a significant amount of prominence as a tool to treat the patients seeking help to get rid of addiction and other similar practices.
Motivational Interviewing (MI) is a patient-centred, goal-oriented counselling approach that aims to explore and resolve ambivalence within individuals, encouraging behaviour change through collaborative and empathetic conversations. In the context of nursing practice, particularly in the field of substance abuse and mental health, MI has gained prominence as an effective tool for facilitating recovery (Hajcak, Klawohn & Meyer, 2019). This essay critically analyzes the application of Motivational Interviewing in recovery-focused nursing practice, evaluating its strengths, limitations, and implications for patient outcomes.
In 1980s, William R. Miller and Stephen Rollnick developed the technique of Motivational Interviewing in order to create a method for addressing substance abuse reported by many patients (Gruber et al., 2021). Over time, the technique has evolved into a very popular approach applied in various healthcare practices including nursing. The approach of MI is based on the principles of collaboration, evocation, autonomy and empathy towards the patients seeking help to get rid of addiction of alcohol, substances and gambling. The main idea behind this approach is to evoke and strengthen the affected individual's motivation for change by exploring and resolving their ambivalence. The MI approach involves open-ended questions, reflective listening, affirmations and summarization based on which, the patient is motivated to move away from harmful practices.
Strengths of Motivational Interviewing
The main strength of MI is that it is a patient centric approach i.e. the approach often varies depending on the situation and condition of the patient. As a result, this approach is favourable to treat different types of patients and not just one. Moreover, within a collaborative and supportive environment, this approach helps the patients to become experts and motivates them to take actions themselves against harmful practices (Tackett et al., 2019). Hence, the patients are more encouraged to move away from addiction and gambling rather than waiting for someone else to provide them with medications and other support.
Ambivalence is known as one of the main obstacles to change behaviour of a person. This is mostly an issue among people struggling with mental health issues and addiction of alcohol / substances / gambling and lack decisiveness to change those behaviours (Semmer & Frese, 2021). MI helps to resolve this ambivalence among the patients by providing them with a structural framework that they can use for better and more resolute decision making.
In addition to providing the necessary help for the addiction patients, MI also benefits the nurses in terms of skill development. By going through MI procedure and helping the patients, the new nurses also develop very important communication skills that help them in their professional career dealing with different types of patients every day. Hence, other than helping the patients, MI also fosters a learning environment for the nurses who can constantly develop and grow their communication and psychotherapy skills through this approach.
Limitations of Motivational Interviewing
Although there are many benefits and uses of MI approach, there are also many limitations within this approach that makes it difficult to implement. The main limitation of this approach is that it is very time consuming and often has no specific time limit (Semmer & Frese, 2021). The goal cannot be achieved with 1 or 2 conversations as ambivalence is very hard to change and the overall behavioural change itself takes a long period of time – even months or years. Hence, despite the best efforts of help, it may take a long time to make the person change his behaviour.
Another major limitation of this approach is that it becomes failure if the patient is not ready for change. The success of approach depends significantly on the patient’s readiness to change i.e. if the patient is ready to change his behaviour towards addiction, the MI approach works faster and successfully but if the patient is not ready to change, then this approach may not achieve success at all (Hajcak, Klawohn & Meyer, 2019). In these cases, alternative approaches are considered including medications and other therapy approaches.
Successful MI sessions require high competency and skill sets of nurses in order to achieve success. Without these, MI may not achieve success as the nurses may not be competent or knowledgeable enough to conduct a MI session. Moreover, it is recommended that the nurses are kept within a constant learning environment including watching seniors conducting MI sessions on patients so that they can constantly develop and grow their communication and therapy skills. These skills help the nurses to conduct successful MI sessions.
Implications for Patient Outcomes
MI has demonstrated generally positive outcomes in terms of patient engagement and retention in clinical settings. Over the years, there have been various changes within the approach but the main goal has always been to actively involve patients in decision-making and acknowledging their autonomy and MI has been able to achieve that in maximum numbers of cases. MI has helped to develop a sense of ownership in the recovery process among the patients, potentially leading to improved adherence to treatment plans and commitment to change. The non-confrontational nature of the MI approach helps in reducing resistance from the patients commonly encountered in recovery settings as these patients are often much more receptive to exploring their motivations to get rid of addictions and other harmful behaviours (Semmer & Frese, 2021).
The patients then also actively work towards removing potential barriers to change, creating a motivational environment for collaboration with nurses in order receive the treatment / therapy that the patients require. However, it also must be remembered that while MI may initiate behavioural change among the patients, its impact on sustaining long-term recovery of the patients from addiction and harmful behaviour depends on various factors, including the severity of the issue, the presence of a support system and the availability of follow-up therapy and clinical help. All points considered, in a clinical setting, integration of MI into a comprehensive care plan is important for maximizing its effectiveness on the patients seeking help to get rid of addiction.
Motivational Interviewing has emerged as a very important and popular approach in recovery-focused nursing practice especially dealing with patients of gambling and addiction problems. MI is aligned with the principles of care and empowerment, which are completely patient-centric in nature. However, while it offers various benefits as discussed, including its patient-centric and motivational nature and effectiveness in ambivalence resolution among the patients, challenges such as time constraints and the dependency on patient readiness are also important factors that need to be taken into consideration while implementing or prescribing MI to a specific patient (Hajcak, Klawohn & Meyer, 2019). Other than the challenges, the application of MI in clinical nursing practice holds the potential to enhance patient engagement, reduce resistance to change and contribute to positive long-term behavioural change among the patients, provided that nurses receive adequate training and are competent and skilled enough to undertake MI sessions.
Working in Partnership for Change
In order to consider working in partnership with individuals facing co-existing problems and ambivalence about changing their alcohol or substance use, or problem gambling behaviour, it is very much essential that a person-centred approach is adopted as the characteristics and mental state may vary widely among different people. In order to go further into this discussion, the Trans-theoretical Model (TTM) of Change has been used as a model of reference and particular focus is put on the implementation of Motivational Interviewing (MI) to navigate ambivalence effectively.
The Trans-theoretical Model was first developed in 1983 by Prochaska and Di Clemente and this model states that behaviour change is a process that occurs through distinct stages: pre-contemplation, contemplation, preparation, action, maintenance and termination (Prochaska & Di Clemente, 1983).
Pre-contemplation Stage:
• Individuals in this stage are not considering change and are expected to be unaware of the need for change.
• The individuals may exhibit resistance to discussing or acknowledging the harmful behaviour.
• There is very high amount of ambivalence, with individuals holding conflicting feelings about the need for change from the harmful behaviour.
Contemplation Stage:
• Individuals in this stage identify the need for change but may feel ambivalent about taking action immediately
• Ambivalence manifests as a conflict between the desire for change and the resistance to the effort required to bring the change.
In this regard, it might be useful to mention that ambivalence in the conflicted nature of a human behaviour in which, the person cannot decide between whether to proceed with the effort to make the change or refrain from the change after considering the pros and cons of the change (Scott & Andrewes, 2021). Ambivalence often results in lack of decisiveness among the people and addiction patients having high degree of ambivalence are often most difficult to work with as they cannot decide whether they want or need a significant change in their behaviours.
Motivational Interviewing is a person-centered counseling approach that aims to boost and strengthen an individual's motivation for change from harmful behaviour like gambling and addiction. The spirit of MI is characterized by collaboration, evocation, autonomy and empathy between the nurse and the patient, which are discussed as follows.
Collaboration:
While working with a patient who is someone ambivalent about behaviour change, collaboration is required to acknowledge their expertise in their own life and fostering a partnership to bring changes in behaviour rather than implementing an authoritative relationship. An authoritative relationship will further increase the ambivalence of the individual and furthermore, the individual may not be interested in taking part of the MI sessions anymore.
Evocation:
The main aim of MI is to draw out the individual's own motivations and reasons for bringing changes – it is like the patient takes his own initiative and gives effort to bring the change himself rather than relying on others and the MI session just motivates the patient to do the same through asking open-ended questions and reflective listening to explore and understand the person's perspective.
Autonomy:
It is important to recognize and respect the individual's autonomy is crucial. Pressuring or imposing change in the patient is likely to be counterproductive for the cause.
Empathy:
It is very important in MI that an empathetic approach is utilised to understand the person's feelings and perspectives without unnecessary judgment (Hashemzadeh et al., 2019). It creates a safe space for the individual to express their ambivalence openly so that the person can be offered necessary help as required.
There are many different approaches that may or may not be helpful in different approaches and hence, the patients must be dealt with carefully with the right approach.
Some of the most helpful approaches are as follows.
Reflective Listening: While dealing with the patients, actively listening and reflecting back the person's thoughts and feelings regarding addiction and the need for change fosters a sense of being understood and the patient is less likely to resist change.
Open-Ended Questions: Open ended questions during the conversation encourage the individual to express their thoughts and motivations behind the addiction and need for change. These expressions provide a lot of insight into their ambivalence (Elezim et al., 2019).
Affirmations: Recognizing and affirming the individual's strengths and positive qualities can help the patient develop more motivation to put effort into making changes rather than resisting them.
Some of the least helpful approaches in most cases are as follows.Confrontation: If the patient is confronted directly with a strict approach, it may lead to defensiveness and resistance and this in turn will hinder understanding the nature of ambivalence within the patient.
Imposing Solutions: Forcing solutions without considering the individual's perspective can lead to negative outcomes and overall, it will fail the goal of MI in most of the cases.
Various research works (Scott & Andrewes, 2021; Wiklund et al., 2020) highlight the effectiveness of MI in resolving ambivalence and promoting behaviour change for patients suffering from alcohol addiction, substance abuse, gambling and other similar harmful practices. A study by Elezim et al. (2019) demonstrated that MI significantly increased the likelihood of individuals transitioning from harmful behaviour like addiction and gambling practices to getting rid of them as they are motivated to bring the changes themselves. In clinical practice, during a counselling session, a nurse might use MI techniques to determine the ambivalence of a patient regarding reduction of alcohol consumption.
Despite understanding the harmful nature of the amount of alcohol the person consumes, the nurse acknowledges the autonomy and choices of the individual so that the individual is more open to discuss the problem and find a solution within a supportive and collaborative environment. Working in partnership with individuals in the pre-contemplation and contemplation stages of the TTM requires a specific and careful approach that recognizes and respects ambivalence of the affected person (Scott & Andrewes, 2021). Motivational Interviewing approach, as discussed, can be a very effective framework for dealing with the patient’s ambivalence effectively. However, considering both the strengths and limitations of MI in different contexts, it is important that a critical approach is necessary so that the right aspects of the MI are utilised depending on the situations.
Conclusion
This entire report has examined the reasons for engaging in harmful behaviours like excessive alcohol consumption, substance abuse and gambling. The discussion in this report has also highlighted the range of various factors, ranging from social interaction and peer pressure to stress, emotional distress and genetic predispositions that have resulted in the individuals resorting to harmful practices like alcohol addiction and gambling. Based on these discussions, it has been mostly concluded that Motivational Interviewing (MI) is an effective approach for dealing with patients suffering from such harmful behaviour and seeking change from such behavioural patterns. Reflecting on this discussion made in this report, it becomes very much evident that the complexities of human behaviour especially involving harmful practices like gambling and addiction requires specific individual based approach rather than one common approach. Focusing on an individual rather than a group of individuals help to gather more specific data regarding behavioural patterns and thus different approaches can be adopted to deal with each individual patient. In terms of future practice, this report has identified the need for continuous learning and skill development among the nurses who are involved in the application of MI in various cases of dealing with addiction patients.
References
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