Motivational enhancement is a style of person-centred counselling developed to facilitate change in health-related behaviours. The core principle of the approach is negotiation rather than conflict. It aims to help people explore and resolve their ambivalence about behaviour change.

It combines warmth and empathy with focused reflective listening and the development of discrepancy between where the person is and where they would like to be. A core principle is that the person’s motivation to change is enhanced if there is a gentle process of negotiation in which the client, not the counsellor, explores the benefits and costs involved in change.

Another strong principle of this approach is that conflict is unhelpful and that a collaborative relationship is essential between counsellor and client, in order to tackle the problem together (Miller & Rollnick, 1991).

Motivational enhancement was initially used in the treatment of alcohol abuse where it was recognised that progress in treatment was limited by a person’s level of motivation to change (Miller & Rollnick, 1991). Similar difficulties with motivation and the ego-syntonic nature of the problem were recognised in eating disorders by Treasure & Ward (1997).

The approach was modified to help eating disorder sufferers move from the pre-contemplation or contemplation stages to an action stage where he or she was more likely to make behavioural changes.

Motivational enhancement helps change patterns of behaviour that have become habitual. It works in small doses to produce a large effect by reducing behaviours in the person that interfere with therapy. The 4 central principles of motivational enhancement are shown below.

1. Express empathy by using reflective listening to convey understanding of the person’s point of view and underlying drives
2. Develop the discrepancy between the person’s most deeply held values and their current behaviour (i.e. tease out ways in which current unhealthy behaviours conflict with the wish to ‘be good’)
3. Roll with resistance by responding with empathy and understanding rather than confrontation
4. Support self-efficacy by building the person’s belief that change is possible

(Miller & Rollnick, 1991)

Motivational enhancement has many applications since it is helpful for use in settings where there is resistance to change. The principles are simple but practical application is less easy, however once the overall skill is developed, it can be adapted to many situations.

Counsellors following the Transtheoretical Model of Change* might use motivational enhancement for people who are undecided about change (in the pre-contemplation and contemplation stages) and later shift to a more structured treatment approach such as cognitive–behavioural techniques once the person is committed to change.

*The Transtheoretical Model of Change has been the basis for developing effective interventions to promote change in health-related behaviours (Prochaska & DiClemente, 1983). The model is one of intentional change which uses a stage theory to illustrate how people modify a problem behaviour and acquire a new positive behaviour. It focuses on a person’s decision making processes and has previously been applied to a wide variety of problem health behaviours, such as smoking, exercise, alcohol abuse, medical compliance and stress management. (Velicer, Prochaska, Fava, Norman & Redding, 1998)

There needs to be room for flexibility to adjust for individual differences in the readiness to change and an empathic counsellor will know when to switch from a skills-based approach to a more motivational stance.

Treatment interventions often assume that people are ready for an immediate and permanent behaviour change. In contrast, the Transtheoretical Model makes no assumption about a person’s readiness for change. It recognises that different people will be at different stages and that appropriate interventions must be developed for everyone.

Treatment interventions often have high dropout rates as participants find a mismatch between the treatment program and their readiness. The Transtheoretical Model is designed to develop interventions that are matched to the specific needs of the individual.

Motivational enhancement highlights the importance of change by reflecting the discrepancy between the person’s current and ideal worlds and helps them to see themselves as others see them. It also bolsters confidence in making changes by reflecting a positive view of the person and belief in their ability to make behaviour change.

The counsellor reinforces commitment to change and supports small steps towards it. Rollnick & Miller (1995) defined specific behaviours used by counsellors that would lead to a stronger therapeutic alliance and a more effective outcome, summarised below.

The first four items explore the reasons the person sustains the behaviour and aim to create a shift in the balance of ‘pros’ and ‘cons’ towards the decision to change.

The last two items in the list cover the interpersonal aspects of the relationship. The counsellor provides warmth and optimism and takes a subordinate position, putting the person in a position of power and emphasising their autonomy and right to choose.

1. Understand the person’s frame of reference
2. Filter the person’s thoughts so that statements encouraging change are amplified and statements that reflect the status quo are dampened down
3. Elicit from the person statements that encourage change, such as expressions of problem recognition, intention to change and recognition of ability to change
4. Match the processes used in treatment to the stage of change; ensure treatment does not jump ahead of the person
5. Express acceptance
6. Affirm the person’s freedom of choice and self-direction

(The Key Skills of Effective Motivational Enhancement - Rollnick & Miller, 1995)

Instead of trying to ‘fix’ the person’s eating disorder by forceful instruction, counsellors need to use warmth and respect to show the person the value of change. Motivational counsellors need to suppress any inclination they might have to try to solve the client’s problems and instead remain flexible and able to provide an appropriate balance between acceptance and drive for change.

The process of change within motivational enhancement interventions has been studied in order to highlight the key strategies. Miller, Benefield & Tonigan (1993) found that a low level of resistance within the counselling session predicts change.

Resistance often arises in the presence of confrontation, so if the counsellor behaves in a way that minimises resistance, change follows. An increase in the rate of ‘self-motivational statements’ by the person, those that express interest in and intent to change, is positively associated with behaviour change.

References

1. Miller, W. R., Benefield, R. G., & Tonigan, J. S. (1993). Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461.
2. Miller, W. R., & Rollnick, S. (1991). Motivational interviewing: Preparing people for change. New York: Guilford Press.
3. Prochaska, J. Q., & Di Clemente, C. C. (1983). Stages and processes of self-change in smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology, 5, 390-395.
4. Rollnick, S., & Miller, W. R. (1995). What is motivational interviewing? Behavioural and Cognitive Psychotherapy, 23, 325-334.
5. Treasure, J. L., & Ward, A. (1997) Cognitive analytical therapy (CAT) in eating disorders. Clinical Psychology and Psychotherapy, 4, 62-71.
6. Velicer, W. F., Prochaska, J. O., Fava, J. L., Norman, G. J., & Redding, C. A. (1998). Smoking cessation and stress management: Applications of the Transtheoretical Model of Behaviour Change. Homeostasis, 38, 216-233.

Source: www.counsellingacademy.com.au

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There can be many reasons for children to be experiencing grief and loss. These may include; the death of a parent, pet, friend or grandparent, family separation or divorce, change of their living environment and exposure to traumatic events.

Children experience grief in their own unique way, while at the same time every child’s grief process will include: early grief, acute grief and subsiding grief. Each phase includes several components:

1. shock/denial
2. anger/blame
3. sadness/despair
4. understanding/acceptance

Sharing a child’s journey through the stages of grief can be very painful but children need to be encouraged to talk about their grief. Helping young people to make meaning of their loss is an important step for them to start building their world (Neimeyer, 2001). Children find it easier to cope with their feelings of loss when they are allowed to take part in the experience of grief and mourning (Despelder & Strickland, 1996).

In early grief it is common for the loss to be temporarily forgotten. Children may suppress their feelings in order to prevent, avoid, or reduce anxiety when feeling threatened. When there is a family loss or separation adults tend to rally around the adult involved, causing children to feel that their grief is not important.

The acute stage of grief has several components;

1. yearning
2. searching
3. dealing with sadness
4. anger
5. anxiety
6. guilt and shame
7. despair and disorganization

Each of these phases helps children recover from the loss, accept what has happened and move towards healing. Children need to know that their feelings and reactions are normal so that instead of trying to fight their feelings they can start to express them openly.

Yearning
In the yearning stage children feel that what has happened was not supposed to happen and that a different ending could be possible.

Searching
Searching behaviour can occur soon after a separation as part of normal grieving. When children realise that the person is not coming back they may begin to dress like, act like or take over the roles and responsibilities of that person. This phase ends when children accept that they have tried everything to bring the person back but nothing has changed.

Dealing with Sadness
As part of the healing process, children who are feeling sad may turn to adults for comfort or they may withdraw into a quiet space by themselves.

Anger
Grieving children who are struggling with a loss can be over sensitive resulting in outbursts of anger. Children may only hold on to their anger for so long before it comes out in an explosion (Berry, 2001). They may dislike and try to avoid gatherings where other children are having fun. Research by Bowlby (cited in Jarratt, 1982) shows that about one fourth to one third of children who have experienced a significant loss become overactive and aggressive towards their peers and adults.

Anxiety
After a loss, overly anxious children can become very suspicious and hostile viewing life as being full of threatening surprises with painful consequences that are out of their control. These children are often very anxious about personal safety, but only when someone else is in control.

Guilt and Shame
Children may experience intense guilt if they believe that their own impatience or jealousy caused the loss. Children tend to go into self-blame when no one talks to them about what led to the loss, reassuring them that it was not their fault. The more directly children are told about the loss, the less chance there is of them becoming confused, to deny the truth or to blame themselves.

Despair and Disorganization
Despair is one of the most difficult stages of the grief process. When children are in despair they may speak and move slower than they normally would, seem pessimistic causing them to have a lack of energy and motivation. They become disorganized which may cause them to become vague and unfocused.

Grieving children often become disorganized at home and daily responsibilities such as washing or brushing teeth may be neglected. They feel helpless and life seems to be meaningless and overwhelming.

Reorganization
Once the despair has been worked through and the experience of separation or loss is eventually mastered they can reorganize themselves and get on with life. The reality of the loss no longer has a profound impact on their outlook or self-esteem. Life and people become enjoyable and there is more focus on the present and the future rather than the past.

Children may change some or all of their friends and are usually drawn to those who have stood by, comforted and understood them. Some children are very wise and when they feel safe and loved, understood and supported they grieve and heal in there own way (Wismer, 2005).

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Obsessive compulsive disorder is a type of anxiety disorder primarily characterised by obsessions and compulsions. Obsessions are distressing, repetitive, intrusive thoughts or images that the person realises are irrational. Compulsions are repetitive behaviours that the person feels forced or compelled into doing in order to relieve the anxiety brought about by obsessions. In other words, compulsions are actions that are used to suppress the obsession and provide relief from distress and anxiety caused by the obsession (Barrow & Durand, 2009).

Typical obsessive thoughts include worry about being contaminated, fears of behaving improperly or thoughts of impending danger. The obsessions lead the person to perform a ritual or routine (compulsion) which typically involves such activities as hand washing, counting, repeating phrases or hoarding. This temporarily relieves the anxiety caused by the obsession as it neutralises the obsession, but is not a long-term solution. It is important for a person suffering from the disorder to recognize that the obsession is a result of their thoughts.

The compulsive behaviours are conducted with a goal of preventing distress or to prevent some dreaded situation.  Washing and cleaning behaviour is considered the most common compulsion and is experienced more by women (Andrews et al., 1996). This is characterised by a fear of contamination.

Checking behaviours are the second most common, used by sufferers as a ritual to prevent something bad from happening. Repeating behaviours including counting or touching certain objects or repeating certain words or numbers. Ordering is another compulsive behaviour, used to arrange objects according to a particular set of rules. Sufferers often have more than one form of ritual which may change over time.

The OCD thought pattern has been likened to superstitions: if X is done, Y won’t happen—in spite of how unlikely it may be that doing X will actually prevent Y. For example, the compulsion of turning lights on and off in a certain pattern may be used to alleviate the obsession that something bad is about to happen. Lights and other household items are common objects of obsession. Another example of this behaviour would be obsessing that a door is unlocked, which may lead to a compulsive constant checking and rechecking of the doors.

Common obsessions: Pathological doubt, contamination, aggressive impulses, need for symmetry, sexual obsessions.

Common compulsions: Checking, washing hands, praying, ordering/ arranging, mental Rituals (counting, praying), hoarding.

An Example of OCD - Howard Hughes in “The Aviator”

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Reactions to the news of sudden unemployment, whether through redundancy or dismissal, are as varied as the individuals affected. Emotional reactions can range from shock and disbelief to anger and resentment. Of course, there is no set template for how an individual will react to news of their job loss.

Reactions are dependant on an array of variables including, age, length of service, employment prospects, financial security, presence of dependants, personality and coping skills.

In order to work effectively with someone coping with unemployment, a counsellor needs to be clear about the unique impact the loss has had and is continuing to have on the individual. Nonetheless, theoretical models, outlining the stages of loss can provide a helpful framework from which more individualised approach can evolve. 

As a counselling professional, you are likely to be familiar with the well documented, Kubler-Ross (1969) model of stages of grief (see figure below).

These stages may not necessarily occur in order, however, the emotional wave that an individual experiences during grief is likely to share some features with the process as mapped above.

Sudden job loss, like any loss, will likely elicit a grief response. The extent of that response will be dependant on a variety of individual factors, as discussed above. Thus, we can expect in our clients a series of emotional reactions as they progress through the transition.

Birkel & Miller (1998) suggests that the emotional manifestations of job loss follow a similar pattern to the stages Kubler-Ross identified as typical of a grief response to death and dying. Birkel & Miller (1998) describe the emotional wave (or e-wave) of unemployment to illustrate the process.

The e-wave exemplifies the typical emotional cycle of someone experiencing unemployment. It is important to note, however, that individuals may not necessarily follow this pattern exactly.

“Here’s an overview of how the e-wave works. When you get the news that you’ve been terminated, this sudden change in your life pitches you into an ocean of emotion. As you tumble from wave to wave, you experience shock and denial, fear and panic, anger, bargaining, depression and temporary acceptance.

Just when you think you’ve reached the trough of the wave, you begin to climb up the crest of another wave. The cycle continues until you learn to positively channel, rather than avoid, your real feelings. Once you are able to front and manage your e-wave emotions, you can navigate your way through the stormy waters and, eventually, safely reach the shore.”                                        

(Birkel & Miller, 1998, p.35)

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The Australian Institute of Professional Counsellors (AIPC) is a private training organisation and was established in the early 1990s to meet the need for counsellor education in the vocational sector. It began as a small organisation in Brisbane and rapidly grew throughout the 90s.

AIPC is now a national private provider of professional counsellor education. The Institute’s primary course is the Diploma of Professional Counselling, which is a nationally recognised training program offered by distance education and online. This course was first officially accredited in 1995 when the Institute gained its Registered Training Organisation (RTO) status.

In 2007, the Institute added a Vocational Graduate Certificate in Counselling and Vocational Graduate Diploma of Counselling to its Scope of Registration and these courses commenced in 2008. Both courses include streams in Grief & Loss, Addictions and Family Therapy.

The Institute is also recognised as a non-university provider of higher education and has offered a Bachelor of Counselling since March 2008. In late 2008, the Institute added a variety of community services courses to its Scope of Registration and these courses are promoted and delivered under the Australian Institute of Community Services (AICS) trading name.

All Institute courses are approved for Austudy, Abstudy, Youth Allowance and Pensioner Education Supplement (PES) funding through Centrelink. The Institute’s Head Office is in the Brisbane suburb of Fortitude Valley, with Australian Student Support Centres located at: Sunshine Coast, Carina Brisbane, Gold Coast, Port Macquarie, Sydney, Melbourne, Adelaide and Perth.

The New Zealand agent is based in Auckland, whilst our UK wholly-owned subsidiary (College of Counselling UK) is based in London, United Kingdom.

The Institute’s ethos is heavily weighted towards providing a high quality training product and service standard to all students.

Our Mission

Genuine care and concern of our students is our highest mission. We pledge to provide an exceptional level of support to our students who will always enjoy the most practical and worthwhile external study program available.

The AIPC experience stands in our student’s minds as a place that brings enjoyment, fun and fulfilment to their daily lives.

Our Team

Our Educational Team includes over 60 team members accross Australia, providing support in a range of areas including: course development, student support, assessment marking, quality control, and more. We regularly publishe their profiles in our newsletters and via this Blog. You can meet some of them below:

1. Clive Jones (Education Manager)
2. Louise Whitehead (Project and Accreditation Manager)
3. Anda Davies (Associate Lecturer)
4. Pedro Gondim (Communications & Special Projects)

Community

Do you want to join the AIPC Community? Visit the following websites to subscribe to our ezine and follow our daily counselling tweets. Both services are provided at absolutely no cost:

www.aipc.net.au/ezine
twitter.com/counsellingnews

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