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Psicología Online | Ciopa2001 | Actividades | 63 | Motivational otivational interview in the clinic of public health

Ciopa2001 / Actividades

Motivational otivational interview in the clinic of public health
Por: Gilberto Lucio Silva

Motivational otivational interview in the clinic of public health

 

Autor: Gilberto Lucio Silva

In the great majority of the psychologists who we have had chance to know, either in the scope of our attributions in the area, either through the display of their position of work in scientific meeting and/or specialized publications, it seems to exist a conception of that the motivation enters or must enter in the together doctor's office with the patient who demands psychological attendance. The understanding is pacific point of that the patient must arrive motivated for the therapeutic process since the beginning, even before to enter in contact with the professional who will go to take care of it.

This seems to evidence the existence of a problem in that it concerns to the model of treatment that is used as reference, which does not emphasize the capacity of psychologist to create conditions of motivation for the patient that looks aid in his practice. Even so motivation is admittedly essential in such a way to initiate the psychological treatment, as to keep the therapeutic bond, the continuity of the attendance.

It is not concern to manipulate the desire of the patient in order to convince him/her. to accept the treatment, nor to control the person in a way such that if becomes difficult to say no to an seducing invitation of the psychologist. Quite to the contrary, it is objective to create conditions so that the patient takes as possible the most clarified decision on the destination that will give to his/her order of aid.

Initial situation of minor motivation also can be found in private doctor's office, but it is perceive its bigger incidence in the attendance at jobs of public health, where we verify the presence of a patient who doesn't knows of the peculiarities of the process of psychological treatment. This it is addressed for professionals of other areas, mainly doctors, who identify in its problematic a emergency of pathological processes of psychical origin, for which the available pharmacopoeia will not provide the benefits desired in the case.

This patient already arrives distrustful and fearful at the doctor's office, finding that this "doctor of speaking" does not have to contribute in nothing for cure of him/her males, that it is certain that they are real estate, that is, material, physical, related to him/her physiological organism. Moreover, it is usual to find one additional impediment in the psychological attendance in public network, when it is come across with the reality of waiting list, feature of all the attendance offered to this level, in greater or minor degree.

Some features of the professional, however, seem to favor the permanence and the pursuing of the treatment, not allowing to develop the motivation in the relation that is established with the patient. These provide, moreover, to work better the direction of failure or success of the treatment, preventing, also, to always attribute the first one to the resistance's patient., and the second to the valorous psychologist that obtained to work that resistance, understood as being psychical characteristics of the patient in treatment.

Process that arrives to be similar to the verified one in the pedagogical boarding that understand the pupil as deposit of knowledge, and any feeds in the learning as responsibility of the patient that is not adjusted to the system that it deals with it. The psychotherapy also can be understood as a place of learning and change, new behaviors, new perceptions, new emotions.

The Initial Recognition: Constructing Motivation.

The capacity to understand the patient instead of imposing wisdom, is an obvious example, however not less important for the beginning of the work, of the therapeutic attitudes that effectively motivate the patient that needs psychological aid. This involves a regardful position of part of the professional, who propitiates the development of the motivation as part of the interaction and not as a aspect of personality waited in the patient.

This position is express since the beginning of the attendance, already in the interview of collection of data and presentation of the offered treatment, when the psychologist receives each subject in a personal mode and not within from a bureaucratic profile. Many times, it is in the first interview that all the future work to be carried through finds its possibility to reach one better performance. Even at the first contact it summarizes to a small parcel of real time, in general a period between fifteen and twenty minutes, it can mean very for the patient that looks psychological aid.

When the psychologist only collect few data and a telephone for contact, without presenting himself and his work, usually the patient doesn't come back, still convoked. This seems to define something as that an initial encouragement that creates an understanding loop, of affectionate listening in the environment typically neuter of the clinic of public health.

Ahead of this, some elements emerge in routine mode, in the carried through psychological interviews, seeming to be more effective in the direction of increase the therapeutic performance, and fortify the bond and the motivation of the patient.

One note of the psychologist, written almost always in the verse of the copy of the received guiding, where consist his name, schedule, telephone of the hospital, with the indication of the name of at least one employee to who can appeal to get information, gives to fold the possibilities of rollback of the patient when of the marking of its regular schedule in psychotherapy.

The capacity of the psychologist to provide feedback of personal information on the patient, instead of giving to generic information on the symptom or treatment, also can be detached. To leave of the speech of the patient, and to take off of it the doubt and conflict situations, help more to create motivation that to inquire from a previous script of initial interview.

Clearly to say the customer who will try to help it, recognizing, in the same act, seriousness for the patient of the presented facts, it appears as another motivational element of the work. Basic guidance on each problematic one, as for example, to present activities that can function as "crutch" (support) to prevent more damages to the patient, also serves to occasion positive effect in motivational terms.

The picture of "crutch", while dispensable element after the cicatrization of that he is broken, seems to be particularly efficient while it symbolizes the inherent desire to leave the problem. Therefore the patient who usual comes at the clinic keeps a basic ambivalence, almost always in a pre-conscientious level, between good and bad things related to his/her illness. It needs somebody to help him/her to decide what to want, facilitating the discovery of the cost/benefice relation of the illness and the change.

And even when secondary gains of the illness are especially recompensed, as when the patient receives greater attention from the next people when presenting the symptoms, these must be recognized for the psychologist while such, in the proper picture of a sick person who is temporarily plastered. The affirmation or confirmation, on the part of the psychologist, of whom this symtomatology picture is momentary, can open a communication channel between separate parts of the patient and he/she can start to see other possibilities of relationship.

Information given for the psychologist also generate a trend of bigger acceptance of the therapeutic work. The customer wants to receive something, a brochure, a booklet, one note of the professional, a guiding, a prompt for activity, an appreciation, for minim that are, of the symtomatology and the strategies that he/she uses or used in his/her fetching. And this can be carried through even in the initial contact, and fits to the psychologist's efforts to acquire and to keep informative features of this order.

If the psychologist delivers an informative bulletin, a brochure, a manual, that deals with the main problem of the patient (alcoholism, depression, conjugal crisis, anxiety, among others), in the interview of presentation of the job and collects of data, this represents a stimulation to motivate the patient. It is possible that during the period that precedes the ingression in the process, the patient needs to have a formal representative, something who gives a minimum form, a direction, to that he represents the sick aspect of its life.

About to the wait stack, we perceive that a maximum stated period exists to be obeyed so that the patient effectively waits the official notice of the psychologist, marking the schedule of beginning of the process. This stated period generally cannot exceed two months and way around ten weeks in order to make the patient to perceive that he/she is important, and that is welcome to the work. Bigger stated periods influence minus in the rollback of the patient to the treatment.

When perceiving a considerable number of people waiting vacant in the work, the psychologist must restrict the upgrade of new requests, in order to not cause damage to the initial investment of the patient, and the consequent damage that a abandon of the work will cause it, because of the delay in taking care of him/her demand.

It can always offer to alternatives, keeping the hand a stack of psychological attendance where the patient can find with bigger brevity a reception to his/her order. The proper ideal of efficiency of the work must be taken in account. An efficient and efficacious work does not match with the omnipotence of the everything and to all to take care of.

Encouraging Changes: aspects of the psychologist.

In general, the patient of the public hospital and maybe some patients of attendance in private doctor's office does not recognize of beginning the problem as being of order emotional, or which had the necessity of thinking better the moral dimension of life so that something that is not compatible in his/her self, because it can be integrated. He/she comes in a stage pre-contemplative that soon is followed by a negation attitude of that his/her starts to see indistinctly.

The choice of the path to follow depends on it to be able to reach a minimum determination, that prepares it to effect an attempt of change in route the output of the problem. It can, is certain, to come back to decay in the same initial picture, more the stages of contemplation of the problem, red tape to act in route the change and maintenance of new solutions, can become fulfilled in more satisfactory stated periods each time in that he concerns the overcoming of its problem, depending on the attitudes of the psychologist.

To demonstrate confidence in the result of the work always that possible, enthusiasm and optimism, at least hope, magnifies the probability of the patient to keep and to get success in the treatment. The encouragement of small changes can accomplish great progress, for example, in the depressive ideas, where the facts most current day to day of the patient, to wake up, to feed, to leave house to study or to work, and to see the people, are lived as true monsters that immobilize.

An element almost always disturbing in the handling is not the acceptance of the medication that the doctor indicated. Many times a light medication, when simple placebo, is not seen as more destructive that the proper illness, being considered one crazy's medication. The comment discloses that in the majority of the cases where the customer gives pursuing to the medical prompt, waiting the withdrawal of the medication under lapsing, bigger possibilities occur to get resulted positive in the together handling the psychologist. The factor confidence perhaps can in making them to understand this consequence of medicines. Confidence at the doctor, at the received aid, at the power that things has to cure.

The work with the imagination also shows important. What the patient assumes that it goes to happen in the course of him/her life, if to continue as it is or if to move, it can influence in its therapeutic progress. To work these ideas about him/herself and about the world seems to be a path more efficient than simply to try to eliminate the fear with rational explanations, or to collate the patient with the minus points of its behavior.

This last form to act of the psychologist, also, originates the phenomenon of "reatância", that it is mentioned to the fact of that an interrupted behavior can be reattached, restarted its momentary abandonment after. As the phenomenon of same name found in electric alternated circuits, a behavior that we tries to eliminate, becomes more attractive and most likely to come back to appear. If to try to take off something of somebody, this something seems to earn, suddenly, more importance and more resistance to the change.

The contribution of the psychologist can be accomplished while he develops doubts in each stage of the process, and if he puts the disposal of the patient to help him/her to choose it. This is always obtain that if he is in auto-effectiveness situation, or either, always that his auto-estimates is in high, what magnifies his confidence and reliability for the patient, and at least, his capacity of reflexive listening and empathic devolution of the contents brought for the customer.

The responsibility for the change must be left with the person, to the psychologist fits only and this is not little to warn for the change and the permanence in each situation that if presents. He can act, and almost always act, presenting strategies and alternatives to move, as one was stipulated menu of existences possibilities.

Strategies of Boarding and Aperture

The psychologist can use the confrontation yes, but less as style of whom I eat an objective for the customer, making it to be face the face with its painful truths, developing the discrepancy between its current behavior and the objective-target that it intends. This is made by the argument from the ratios presented for the customer to move. Some questions are pertinent, varying of case for case, to create discrepancy states, that to the end if disclose auto-motivations for the change:

  1. To evoke what it gives to pleasure/displeasure in the current behavior of life of the patient;
  2. To make to see both the sides of each question that brings;
  3. To elaborate with the experiences so that him/her speaks as it was of other times, that negative and positive aspects perceived;
  4. To place extremities, taking him/her to imagine what it could happen of worse in the brought situation;
  5. To look at life retrospectively, evaluating the current moment in function of personal history, the way he/she arrived here;
  6. To look at its life at the past, imagining what it will be able to come to be in the future;
  7. To explore objectives and values, what he/she would like to make and does not make;
  8. When to perceive resistance to the change, don't deny the same one, but to remain together it and to accept it.

It is important to observe, over all, that the resistance can express itself of many forms, fitting the psychologist identifies them better to be able to work with them. We have as examples, the resistance for:

  • Negation, when the patient disagrees openly, asks for excuses, does not assume guilt, affirms impunity, minimizes the problem, pessimism, does not accepting a conclusion, or ahead laziness of the change;
  • Interruption, when speaks of another thing, cuts the word of the psychologist;
  • Argument, for example, arguing with the psychologist;
  • attitude to ignore, not giving attention, not giving reply, not asking.

The therapist must take the sprouting of the resistance as sign of that it is necessary to change the strategies. Sometimes a simple invitation to the adoption of new perspectives, without imposition, makes the patient uses of a great armory of solutions that does not dare to pronounce, much less to use. Ahead of the diverse above described modalities of resistance, the psychologist can use some strategies that favor the aperture to the dialogue and the change.

To agree adding a small modification in that it was said, to affirm the strong points of the patient, his/her motivation to come, to hear in a reflexive way, and selectively summarize the affirmations auto-motivated of the patient, they are factors important to deal with the resistance in favor of the therapeutic work. They act for the alteration of the meaning of that it is said by the patient, making to see it that all question has, at least, two sides.

The psychologist also can use ample questions, moving away the patient from the immediate concern, what he finds in first plan, to extend the approach of the brought problems.

Finishing: Remaining Auto-Motivated

Before the fishing of the process it is important to revise the questions keys of the work, as if it is after the treatment. More important still is to negotiate a plan that has taken the patient to establish objectives, options that fix his/her participation in a continuous process of change.

We have evidenced that the factor most important in the referential of the patients is the change in system of value. They arrive with a system sufficient material, physicist, of understanding of life and emotional or moral problems. At the end of the process, a value system emerges where the relational and spiritual life are prioritized, at least in the processes efficient or evaluated more clearly as successful in such a way for the psychologist as for the patient.

A patient who does not carry through this change, usually to cross periods of relative improvement, soon to return to the previous problems. Not that it is a general rule, one result or cure conclusive and applied to all the patients. But we can speak of the positive result for the patients who effectively carry through this change of system of lived value. Change that becomes them more apt to remain motivated in all the aspects of its life. Specially in those of the relational world, the expectations ahead of the future and the evaluation of its path until the moment.

We would say, concluding, that the patient who effectively is right, seems us to be that one that leaves the doctor's office without finished everything, without to leave everything with the psychologist. He/she finishes the therapeutic process but continues in fetching, and better that everything, knowing that its fetching pre-definitively does not need or to be hindered precociously. At least to the level of the emotional and relational life, distance is a word that does not exist.

Internet: http://7mares.terravista.pt/gilbertolucio

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