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Introduction

Motivational interviewing (MI) is a client-centered approach used by healthcare providers to help transition individuals behaviors into more positive behavioral changes (Cucciare et al., 2011). Research shows that using MI with veterans will help improve outcomes and engagement in treatment (Murphy, Thompson, Murray, Rainey, & Uddo, 2008). There are a variety of behaviors veterans and service providers need or want to change and these behaviors include (Murphy, Rosen, Cameron, & Thompson, 2001):

• Increase employment
• Reduce substance abuse
• Decrease depression
• Decrease irritability
• Decrease sleep disturbances
• Decrease hypervigilance

Theory

Occupational therapists can use the transtheoretical model to guide someone in a self-directed process of change. Composed of six stages, the transtheoretical model includes: Precontemplation, contemplation, preparation, action, maintenance, and termination (Prochaska & Velicer, 1997). A therapist must identify which stage of the transtheoretical model the client is to mark that as the starting point in the journey to change. The stages of change are associated with certain intentions and actions related to changing behavior, necessary to move them along the stages, eventually to their desired goal (Finnell et al., 2011).

Evidence

Evidence mentions that the use of motivational interviewing and its uses such as techniques to help veterans explore ambivalence, personal reasons for change, and enhance self efficacy to work toward goals prove to be effective. Motivational interviewing pretreatment to war veterans with PTSD was associated with improved intrinsic motivation consistent with values related to veterans which in turn affected following sessions of therapy (Farber, 2015).  In addition, use of motivational interviewing served to enhance client engagement throughout the treatment process.

Case Study

Samuel is a 28-year old veteran of the army national guard. As a combat medic on patrol in Afghanistan his convoy encountered an improvised explosive device (IED). Due to this traumatic event Samuel experienced a TBI and now suffers from PTSD. Unfortunately, Samuel often gets easily frustrated and angry when dealing with people at work. His inability to maintain appropriate behaviors while engaging with coworkers and clients has caused work disruptions.  Samuel has participated in PTSD support groups at the local VA in the past but is currently not going because he is unable to control his emotions in the group setting.

Intervention Plan

Problem Statement

Samuel is unable to maintain a worker role due to his irritability and frustration when interacting with people at work.

Long Term Goals

1. Samuel will effectively demonstrate the use of his self-selected strategies during work scenarios with therapist by successfully completing 4 out of 5 interactions, without irritable outbursts, for work in 4 weeks.
2. Samuel will move from contemplation to maintenance related to finding positive behaviors to replace irritable behaviors with people for work in 4 weeks.

Short Term Goals

1. Samuel will identify 4 self-selected strategies to reduce irritability in order to complete successful interactions in the workplace for work in 2 weeks.
2. Samuel is able to participate in a work role play and identify 2 positive behaviors to use while engaging with people in 2 weeks to improve his worker role.
3. Samuel will move from contemplation to action related to changing his irritable behaviors while engaging with people at work in 2 weeks.

Intervention Format

Individual

Setting:

Samuel will meet the occupational therapist for individual sessions at the outpatient VA for 45 minutes 2x per week.

Supplies

None

Agenda

• Meet Samuel and build a partnership (5 min)
• Assess Samuel’s readiness to change (10 min)
• Engage in motivational interviewing to change interactions with people at work (25 min)
  • Potential open-ended questions
    • “Tell me about your workplace?”
    • “What causes people to irritate you?”
    • “How can you improve your interactions with people?”
  • Positive affirmations
    • “It sounds like you enjoy working there”
    • “You understand yourself quite well”
    • “You have a lot of experience to bring to the table”
  • Provide reflections
    • “You recognize that your military background has influenced your behavior”
    • “You identified that your past experiences have impacted your interactions but the ability to adapt is possible”
  • Provide a summary of the discussion (5 min)

Documentation

S: Client stated that he wants to continue to work but people are stupid. Client reported that civilians complain too much and do not realize the concept of real hardship.

O: Samuel engaged in a 45 minute session using the motivational interviewing technique focusing on improving his interactions with co-workers in the workplace. Client reported that is coworkers are afraid to talk to him now because he often gets frustrated and yells at them. Client stated that he doesn’t feel like they understand what he has been going through since he transitioned from military duty. Client portrayed anguish when mentioning his military experience. Client reported that he thinks he should improve his behavior so that he can keep working. Client affirmed that he recognizes that a change needs to be made. Client identified 2 techniques to use to control his behavioral response with his coworkers. With permission, the therapist gave the client information on incorporating his techniques.

A: Client presents with irritability when interacting with others which is making it hard to go back to work. The clients increased emotional arousal and negative feelings toward people could be linked to PTSD. Client appears to have insight and is demonstrating the willingness to change his behavior and interactions with people by identifying techniques to improve his behavioral response indicating that he has reached the preparation stage of the transtheoretical model of change. Client would benefit from continued motivational interviewing to reinforce his decision to change his behavior.

P: Continue with motivational interviewing approach to develop successful interactions in the workplace. Therapist will continue to assess the effectiveness of the treatment approach and modify as needed. Client to see OT 2x per week for 45 minutes each at the VA outpatient center.

References

Cucciare, M. A., Ketroser, N., Wilbourne, P., Midboe, A. M., Cronkite, R., Berg-Smith, S., &        Chardos, J. (2012). Teaching motivational interviewing to primary care staff in the  veterans health administration. Journal of General Internal Medicine, 27(8), 953-961.doi:http://dx.doi.org.ezproxy.fiu /10.1007/s11606-012-2016-6

Farber, T. (2015). The effect of a motivational interviewing pretreatment on CBT treatment of PTSD in veterans: A preliminary investigation (Order No. 10005015). Available from ProQuest Dissertations & Theses A&I; ProQuest Dissertations & Theses Global. (1765206796). Retrieved from http://ezproxy.fiu.edu/login?url=https://search-proquest-com.ezproxy.fiu.edu/docview/1765206796?accountid=10901

Finnell, D. S., Yow-Wu, B. W., Mary, A. J., Mary, A. M., Sessanna, L., & Lee, J. (2011). Applying the transtheoretical model to health care proxy completion. Med Decis Making, 31(2), 254-259. doi:10.1177/0272989X10379917

Murphy, R. T., Rosen, C. S., Cameron, R. P., & Thompson, K. E. (2002). Development of a group treatment for enhancing motivation to change PTSD symptoms.Cognitive and Behavioral Practice, 9(4), 308-316.doi:http://dx.doi.org.ezproxy.fiu.edu/10.1016/S1077-7229(02)80025-6

Murphy, R. T., Thompson, K. E., Murray, M., Rainey, Q., & Uddo, M. M. (2009). Effect of a        motivation enhancement intervention on veterans’ engagement in PTSD treatment.Psychological Services, 6(4), 264-278. http://dx.doi.org/10.1037/a0017577

Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change.        Am J Health Promot, 12(1), 38-48. doi:10.4278/0890-1171-12.1.38

Santa Ana, E. J., LaRowe, S. D., Armeson, K., Lamb, K. E., & Hartwell, K. (2016). Impact of group motivational interviewing on enhancing treatment engagement for homeless veterans with nicotine dependence and other substance use disorders: A pilot investigation. The American Journal on Addictions, 25(7), 533-541.doi:http://dx.doi.org.ezproxy.fiu.edu/10.1111/ajad.12426