Motivational interviewing and the older population in psychiatry

Motivational interviewing is a psychological intervention that could potentially give clinical staff working with older people a way of tackling ambivalence and/or resistance to change in therapy. Although it has been shown to be effective in various spheres of mental health, we are unaware of any

Motivational interviewing is a psychological intervention that could potentially give clinical staff working with older people a way of tackling ambivalence and/or resistance to change in therapy. Although it has been shown to be effective in various spheres of mental health, we are unaware of any publications on its use in the older population. In this paper we discuss the main principles of this intervention and some adaptations necessary to meet the needs of older people (i.e. those over 65 years old). Patients require the capacity to understand and retain new information in order to make use of this intervention, which hence limits its use to those who retain good cognitive functioning. We would like to encourage the practice of motivational interviewing both as an intervention in its own right but also in preparation for patients requiring more specific therapies such as cognitivebehavioural therapy (CBT) or interpersonal psychotherapy.

Background
Motivational interviewing was first developed for use with individuals with substance use disorders by William R. Miller and Stephen Rollnick in 1991. Since then the technique has continued to develop and is now being used (albeit not in its pure form) for a variety of clinical problems and lifestyle changes. Research so far supports the efficacy of motivational interviewing techniques for alcohol problems and drug addiction, as well as for people with diabetes, hypertension, dual diagnosis, and bulimia (Burke et al, 2002). Although there are some technical considerations that may alter the practice of motivational interviewing with older people, as will be outlined in this paper, its basic principles remain the same: eliciting the patient's concerns, reflecting ambivalence and allowing the patient to develop a plan for change that best suits him or her.
Working with older people can be challenging and rewarding but at times also demoralising and demotivating, not least because this age can be associated with more losses than gains. Patients may have multiple problems and clinicians may unconsciously collude with the sense of hopelessness and helplessness that the patients might feel. More often than not patients are able to detect the presence or absence of optimism or pessimism in our interactions with them.
In old age services in the UK, like in most other mental health services, there is an increased emphasis on the use of psychological therapies (Welsh Assembly Government, 2005). The aim of this paper is primarily to raise awareness of a psychological technique that can be used by clinical staff, in the day-to-day management of older patients who are having psychological difficulties.

Psychological therapies and older people
Psychological treatments for individuals over the age of 50 years were thought to be ineffective in Freudian times and it was only in the late 1950s that this notion was challenged by Rechtschaffen, who provided a landmark review of psychotherapy with older adults (Rechtschaffen, 1959). He concluded that from a historical perspective, the trend for the use of psychotherapy with older people had been to use supportive approaches, in which the therapist played a more active role. This was based on the assumption that older people belonged to a stereotypical group of people with: 'increased dependency arising from realistically difficult circumstances; the immodifiability of external circumstances to which a neurosis may be an optimal adjustive mechanism; irreversible impairments of intellectual and learning ability; resistance (or lack of resistance) to critical selfexamination; the economics of therapeutic investment when life expectancy is shortened' (Rechtschaffen, 1959).
Rechtschaffen emphasised that there were individual differences in older people that the therapist ought to consider in deciding which approach was most feasible for which patient, and that there was no reason to discuss geriatric psychotherapy as distinct from any other psychotherapy unless there were distinctive features about it.
The older people that we refer to here are those who have experienced a diminution of their physical health and who, in addition or perhaps as a consequence, have become mentally ill, in particular anxious and/or depressed. Morbidity in older people is characterised by multiple pathology, non-specific presentation and a high incidence of complications of both disease and treatment (World Health Organization, 1991). Common themes when working with older adults include grieving for losses, fear of physical illness, disability and death, and guilt over past failures. Such themes tend to have a negative effect on self-efficacy. They can block the individual from moving on and hence will need to be addressed early on in therapy to establish the impact they are having on the person's confidence. Psychotropic medication in older patients, particularly those in poor physical health, is likely to be associated with more sideeffects; furthermore, it is common for patients to fear becoming dependent.

Why motivational interviewing?
Current literature and guidelines based on best available evidence (e.g. National Institute for Clinical Excellence, 2004a,b) encourage the use of CBT or interpersonal psychotherapy for some types of anxiety and/or depressive disorders. There is evidence for the efficacy of both these interventions in the older population. Both therapies require collaboration with the patient who, for a variety of reasons, is not always in the 'action phase' of the transtheoretical model of change as defined by Prochaska & DiClemente (1982). Up to two-thirds of patients entering treatment for mental health problems can, in fact, be classified as being at the 'pre-action' stage of change; that is, significantly ambivalent about change so as to preclude the active adoption of change-based strategies (Dozois et al, 2004). No stage of change studies have been carried out as yet for older people. However, the drop-out rates from therapies in general is very high. In one study based on therapy termination and persistence patterns in older patients in a community mental health centre, a surprisingly small percentage of the terminations were reported to be mutually agreed by patient and therapist (8.7%) and less than half of the patients (48.9%) attended twenty or more sessions (Mosher-Ashley, 1994).
Motivational interviewing is a patient-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence (Miller & Rollnick, 2002). It focuses on the person's present interests and difficulties and tries to resolve the ambivalence by eliciting and selectively reinforcing 'change talk', to move the person towards change. Hence change is thought to arise through its relevance to the person's own values and concerns (Miller & Rollnick, 2002). Motivational interviewing may be highly complimentary to CBT and interpersonal psychotherapy as it focuses on shifting ambivalent patients forward, increasing their probability of utilising the tools that such therapies provide and that are necessary for producing the change itself (Westra, 2004).

Principles of motivational interviewing
The four general principles as outlined by Miller & Rollnick are as follows: (a) express empathy; (b) develop discrepancy; (c) roll with resistance; and (d) support selfefficacy.

Express empathy
A client-centred and empathic counselling style is one of the defining characteristics of motivational interviewing. Miller & Rollnick regard the therapeutic skill of reflective listening, as described by Carl Rogers, to be the foundation on which clinical skilfulness in motivational interviewing is built. An empathic counsellor responds to a person's perspectives as understandable, comprehensible and valid within the person's own framework. Ambivalence is accepted as a normal part of human experience. Acceptance, however, is not the same as agreement or approval. It is possible to understand and accept a person's perspective while not agreeing with or endorsing it.

Develop discrepancy
A second general principle of motivational interviewing is to amplify a discrepancy between the present behaviour of patients and their broader goals and values. Many people who seek consultation already perceive significant discrepancy between what is happening and what they want to happen. Yet they are also ambivalent, caught in a conflict between the perceived benefits of the status quo and the costs of change. A goal of motivational interviewing is to develop discrepancy, to make use of it, increase it and amplify it until it overrides the ambivalence. Motivational interviewing seeks to accomplish this within the person, rather than relying on external motivators such as pressure from the spouse or family.

Roll with resistance
A common and undesirable situation is for a counsellor to be advocating change while the patient argues against it. Not only is the ambivalent person unlikely to be persuaded, but also they may in fact be forced in the opposite direction. Resistance needs to be quickly identified and reframed to create a new momentum for change. In motivational interviewing the counsellor turns a question or problem back to the person, emphasising that many of the insights and solutions are within the person's own grasp. Resistance is an interpersonal phenomenon and how the counsellor deals with it will influence whether it increases or diminishes. Support self-efficacy A fourth principle of motivational interviewing involves the concept of self-efficacy. This refers to a person's belief in their ability to carry out and succeed with a specific task. A counsellor may, by following the three principles outlined above, develop a person's belief that there is an important problem. However, if a person perceives no hope or possibility of change, then no effort will be made to bring this about. A general goal of motivational interviewing is to enhance the patient's confidence in their Bugelli & Crowther Motivational interviewing and older people in psychiatry special articles capability to cope with obstacles and to succeed in change. In this regard, a person may be encouraged by their own past successes in changing behaviour or by the success of others.

Modifying motivational interviewing for the older person
A number of physical, psychological, cognitive, social, developmental and environmental factors will have to be taken into consideration when applying any form of psychological therapy in the older population. A summary of the recommended modifications or adaptations of psychotherapy treatments in general for older people is given by Cook et al (2005). Such modifications also apply to motivational interviewing. In essence, therapy will require flexibility in planning, venue and collaboration. The goal should be clearly outlined and continually highlighted to reinforce the purpose and facilitate direction of treatment. Hospital visits, telephone calls or letters may be used to deliver therapy. Consultation and coordination with other healthcare providers is often necessary. It may be crucial to engage carers in certain aspects of treatment and the therapist may need to lead the older adult to conclusions more so than with younger adults. Therapists may have to proceed at a slower pace and use repetition and other strategies to aid the encoding and retention of information. In addition, as Cook et al (2005) rightly point out, many older adults hold negative stereotypes about mental health and psychological interventions that may result in reluctance to engage in therapy. Thus an additional adaptation may have to be orientation/socialisation into psychological therapy.

Conclusion
It is our opinion that motivational interviewing may be a useful intervention for those working with older people. So far, this technique has been proven to be beneficial for certain conditions in other age groups, both as a treatment option in its own right and as a prelude to other forms of treatment. However, it has not been described for use with older people. Clinical experience with this intervention in this age group is necessary in the first instance to help us identify more age-specific factors that would render motivational interviewing a useful tool in the older population. This could eventually be followed up by research to identify those for whom it is likely to be beneficial.

Declaration of interest
None.