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A language for integrated care

September 10, 2012
by By Kathleen Sciacca, MA
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How Motivational Interviewing and the Stages of Change can reshape delivery—and outcomes—for integrated care
Kathleen Sciacca, MA

Though the term “behavioral healthcare” (BHC) is defined to include mental health and addiction treatment, many clients also bring an array of integrated problems—legal, housing, physical health (HIV, Hepatitis C, diabetes, smoking, obesity, blood pressure, liver functions), and relationship problems. Typically, these problems are addressed by multiple providers across multiple sites and systems—if they are addressed at all. As a result, continuity of care is disrupted. Adding to this complexity is the fact that clients present across a spectrum of readiness to change in different areas of their symptoms and issues.

The partnering of behavioral and physical care parallels the development of integrated treatment for co-occurring mental illness and substance disorders in many ways. This new partnership aims at preventing detriment to clients as a result of parallel or sequential versus simultaneous and integrated treatment.

The physical healthcare model has evolved in large part without attention to behavioral change, though such change is now deemed necessary to improve client and provider outcomes. Treatment for Hepatitis C, for example, is frequently offered to clients with histories of addiction, but clients cannot receive it unless they are abstinent. Clients know that their past or present substance use will be a central topic of discussion and behavior change.

While many providers now recognize the value of partnering physical and behavioral health, few have yet focused on the communication style or interventions needed to address the array of behavioral changes and physical health issues, wherever the client is met across systems. This challenge must not be overlooked. Now is the opportunity to improve our communication approach and drive the necessary continuity. Here are five things that can be developed and accomplished by this effort:

•    A common language regarding client change or lack of change across providers, sites and systems, symptoms and issues..
•    A common client-provider communication style that facilitates the client’s discovery of his or her underlying motivation to change.
•    A common means of measuring and communicating incremental change that can be understood across providers and systems, enabling providers to match interventions with client’s stages of readiness to change.
•    A collaborative, empathic approach that respects each client’s autonomy, conveys client responsibility, and is directional in evoking the client’s side.
•    A set of common interventions for engagement that provide a safe, trusting environment in which each client can explore his or her thoughts, feelings, motivations, solutions and decisions.

Client-centered interventions effective across systems

One well-respected communication approach that has proven effective for various areas of behavior change is Carl Rogers’1 client-centered counseling. This client-centered approach highlights the importance and skill of empathic reflective listening: the ability to listen, to be present, and to reflect understanding of client thoughts and perceptions by reflecting them back to the client in a statement. Such listening conveys empathy and serves to deepen the client’s exploration. It often helps to lead the client to his or her intrinsic motivations, decisions, and solutions.

Rogers described this process: “… in most, if not all, individuals there exist growth forces, tendencies toward self-actualization, which may act as the sole motivation...” Eugene Gendlin2 explained: “Rogers eliminated all interpretation. Instead, he checked his understanding out loud, trying to grasp exactly what the patient wished to convey. When he did that, he discovered something: The patient would usually correct the first attempt. The second would be closer, but even so, the patient might refine it. Rogers would take in each correction until the patient indicated. "Yes, that's how it is. That's what I feel." Then there would be a characteristic silence. During such a silence, after something is fully received, the next thing comes in the client. Very often it is “something deeper.” Rogers discovered that a self-propelled process arises from inside. “Rogers renamed his ‘non-directive’ therapy ‘client-centered therapy.’” The person was the main figure of importance.

Client-centered Motivational Interviewing:

Client-centered communication, including empathic reflective listening, is the central skill and primary intervention in motivational interviewing (MI)3. The provider practices Rogers’ “non-directive” empathic reflective listening without imposing his or her values or preferences. The “spirit” of MI encompasses:

•    collaboration/partnership – respectful collaboration with the client’s side, opinions, feelings;
•    evoking - one works to evoke the clients ideas, perceptions, reasons to change;
•    autonomy/support - one evokes the client’s experience of choice and control, respects the client’s autonomy and decisions. Recently added are
•    compassion – Rogers professed “when people are able to understand one another’s needs, compassion is likely to be stimulated, and then people are often motivated to help one another get needs met…” and
•    acceptance – which is equal to Rogers' unconditional positive regard.

Dr. Carlo DiClemente maintains that a change in behavior requires daily intent, determination, persistence and focus. A client is unlikely to sustain this perseverance if he or she is ambivalent or unmotivated. Significant behavior changes require high motivation based on personal conviction about the value and importance of making the change.

The Practice of MI