MI is a collaborative, person-centred counselling method that helps people address ambivalent feelings or the natural resistance to change, and to find the internal motivation they need to change their behaviour. Ambivalence is a natural part of any change and we all have competing drivers in life. These often pull us in different directions for example someone thinking of suicide may be torn between wanting to live and wanting their pain to end. MI is designed to firstly identify and then to strengthen personal motivation and commitment, by eliciting and exploring a person’s own reasons for wanting to make changes. Miller and Rollnick, the developers of MI, define change conversations as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change”. (Miller & Rollnick, 2013)
Why do we use it?
Four distinct principles guide the practice of MI and we use the acronym R-U-L-E
Resist the ‘Righting Reflex’
Taking control and being the expert in somebody’s life has been proven not to be helpful. It dis-empowers, takes what limited control the person has away and often what we the “experts” think, do or suggest, does not help or work. Resistance to change is natural, whether the change is good or bad, our job is to sit with the person and their pain and let them find a way forward.
Understanding their motivations
It is their own reasons for change rather than ours that will ultimately result in behaviour change. Motivation for change occurs when people perceive a mismatch between “where they are and where they want to be”. We need to be curious to understand their current situation, talk with them about how suicide became an option, what their views, feelings and thoughts are and how they perceive their future. Together we need to understand and recognise their motivations for change and any barriers they see.
We need to listen with empathy, and empathy involves us seeing the person’s world as they see it. Thinking about things as the person thinks about them, feeling things as the person feels them, sharing in their experience. This approach builds rapport and trust and provides the basis for them to be heard and understood. They are then more likely to open up and share their experiences in depth. This approach often leads them to explore other possibilities, for example “suicide was an option, but maybe there is another way”.
People have the ability to control their own life and their own destiny. A person’s belief in themselves is needed to instill hope. You facilitate this by focusing on their previous successes and highlighting skills and strengths they have shown e.g. “When you went through some difficult times previously, you found an inner strength that helped you move forward”. This way you are not taking control but rather giving them the power to change their situation. We can’t trick somebody into choosing life over suicide but we can be a privileged witness to the ‘shift’ in their choices.
How do we use it?
Now lets look at the acronym O-A-R-S – these are core communication skills used to effectively build rapport and ensure we have a meaningful conversation.
OPEN ENDED QUESTIONS – are those that are not easily answered with a ‘yes’ or ‘no’ (these are closed questions). For example, “How do you feel?” vs “Do you feel sad?” Open ended questions invite the person to elaborate and think more deeply about their situation and this way you learn more about them. It’s probably your most powerful tool for learning about how suicide became an option for them, and what life stressors they are dealing with. AFFIRMATION – these assist in building connection and trust, and help the person find their strength and resilience again. For example, “You showed strength and determination when you decided to resign”. They often involve re-framing behaviours or concerns as evidence of positive traits and strengths. We recognise they are the experts in their own lives. We can’t trick somebody into choosing life over suicide or change their mind for them, but we can reconnect them to themselves and help them recognise that they are capable. REFLECTIVE LISTENING – To be a great listener all you have to do is listen to the content that is being shared as well as the feelings being expressed. So, if someone talks about the hopelessness of their situation you simply express empathy, then you repeat the feeling along with the content of what they just said. This allows the person to release the emotions that have kept them stuck and helps them to feel heard and acknowledged and go deeper. SUMMARISING – Reviewing what people say allows them to continuously move forward with the process of internal discovery and change. A Collective Summary reviews what has just been said, for example “So let’s go over what we have talked about so far”. A Linking Summary takes what is said at different times during the conversation and prompts the person to hear the discrepancies, for example “A while back you said you didn’t want your partner to know and yet you’ve just said you wanted to talk to them, where to from here?”. A Transitional Summary wraps up and puts a finishing touch on the conversation, for example “So, you will make that call today?”.
What strategies evoke change
There are specific strategies that are likely to elicit and support ‘change talk’ in Motivational Interviewing. It’s important that these are only used after the persons story is heard.
Ask Evocative Questions:Ask an open-ended question, the answer to which is likely to be talk about changing something.
Explore Decisional Balance: Ask for the pros and cons of both changing and staying the same.
Good Things/not So Good Things: Ask about the positives and negatives of the current options/thoughts/behaviours
Ask for Elaboration: When the discussion shifts to something futuristic, ask for more details. “In what way” “Tell me more” “What does that look like”
Look Back: Ask about a time when things were better/different.
Look Forward: Ask what happens if things continue as they are. Try the miracle question, “If things could be different, the way you want them to be, what would that look like?” “How would you like your life to be five years from now?”
Query Extremes: “What are the worst things that might happen if you go ahead with this?” “What are the best things?”
Use Change Rulers: “On a scale from 1 to 10, how confident are you that you could make some changes if you decide to?” ‘1’ not being so confident, ’10’ being extremely confident.
Use Goals and Values: “What do/did you want in life?” “How does this fit in with your goals about life and about yourself?”
Come Alongside: Explicitly side with the negative (status quo) side of ambivalence. “Perhaps suicide is so important to you that you can’t give up the idea of it, no matter what the cost”
RECOVERY ORIENTED PRACTICE
What is it?
The recovery movement began in the 1970’s as a civil rights movement aimed at restoring the human rights and full community inclusion of people with mental health issues. There are numerous definitions, but the ideology of recovery is based on hope, self-determination, self-management, empowerment and advocacy. Recovery is made possible by having a safe space to be ourselves and to find friends, family and peers who know and understand our experiences. It’s nurtured when our voices are heard, and we get to speak our stories of courage and resilience. Recovery is about hope.
We know that not all people who experience suicidal ideation have mental health concerns or illnesses, but we also know that they are experiencing incredible pain and the common language to define this space are the words hopeless, helpless, and worthless. A tunnel vision develops as the pain becomes consuming and when this happens, the only solution visible for them may be suicide.
Why do we use it in CALM?
If we place the CALM model of suicide intervention alongside the concept of recovery we can assist people to move a) from a passive, helpless space to an active sense of self; b) from hopelessness and despair to hope; c) from others control to personal control and responsibility; d) from feeling alone and worthless to embarking on a journey of self-discovery and meaning and e) from disconnectedness to connectedness, and starting with our conversation to living a meaningful and contributing life in a community of choice.
The reasons behind suicide behaviour are complex and whilst there are clear links between suicide and mental health conditions and or substance misuse, most people with a mental illness are not suicidal and not all people who suicide or have thoughts of suicide have a mental illness.
How do we use it in CALM?
By listening and caring. By ‘holding their hearts’ and being willing to feel their pain, and by recognising this is their journey and that they have a life’s worth of experiences and knowledge to draw upon. We accept it as a privilege being allowed into their lives and to walk alongside them, listening, acknowledging, and empowering them to develop options and find solutions. We don’t take on the role of expert but rather ensure that their voice is the most powerful and heard voice in the room.