2. Brain Injury Rehabilitation and Motivational Interviewing
Brain Injury Rehabilitation and Motivational Interviewing
Brain injury rehabilitation should include:
- development of a relationship with the client
- promotion of self-efficacy and
- the establishment of goals that are meaningful to the individual.
Motivational interviewing is an approach that designed to achieve these things.
Motivational interviewing is person centred, It is also consistent with SMARTEER gaol setting (see Module 13 Goals).
People with brain injury often experience lack of insight (poor self-awareness) which in turn can lead to lack of engagement with the rehabilitation process.
Andrew Medley and Theresa Powell have proposed Motivational Interviewing as an overarching therapeutic approach to promote engagement with clients and mutual understanding between clients and rehabilitation teams.
There is a need for more empirical evidence for the specific benefits of using Motivational Interviewing in brain injury rehabilitation, and gathering this evidence is problematic (nonetheless the framework is consistent with quality brain injury rehabilitation.
Evidence and discussion
Two articles provide a significant review and discussion of motivational interviewing and brain injury rehabilitation.
Motivational Interviewing to promote self-awareness and engagement in rehabilitation following acquired brain injury: A conceptual review
Andrew R. Medley and Theresa Powell School of Psychology, University of Birmingham, Edgbaston, Birmingham, UK
NEUROPSYCHOLOGICAL REHABILITATION
2010, 20 (4), 481–508
Summary
This conceptual review has explored the constructs of self-awareness and engagement in rehabilitation following ABI, revealing their multidimensionality and contingency upon a wide range of neurological, psychological and socio-environmental factors.
Rather than perpetually differentiating these domains of functioning, it is argued that optimal outcomes will arise from inclusive case formulations that acknowledge their profound overlap and interaction.
With some qualifications due to the need for more robust empirical evaluation, MI is proposed as an overarching therapeutic approach to promote therapeutic alliance and mutual understanding between clients and rehabilitation teams.
Specifically, the approach could add value in three main areas: firstly, by helping to create optimal conditions for holistic assessment and case formulation; secondly, by facilitating collaborative and realistic goal-setting based on improved awareness of deficits; and thirdly, by enhancing readiness for constructive engagement in a range of clinical rehabilitation interventions.
Converging evidence from the theoretical and empirical rehabilitation literature provides support for the potential of MI, and single case methodology should provide the most expedient way forward, elucidating specific relationships and hypotheses for definitive evaluation in larger-scale controlled trials. It is hoped that such avenues might precipitate a heightened focus on resiliency constructs and a more positive psychology of rehabilitation.
Motivational interviewing and acquired brain injury
Mark Holloway
SOCIAL CARE AND NEURODISABILITY
VOL. 3 NO. 3 2012, pp. 122-130
Conclusion
The evidence base for the effectiveness of MI with people with brain injuries is very small and not in any way conclusive. The systematic reviews and meta-analysis of MI that do exist are critical of its effectiveness even in non-brain injured populations. The number of studies in these analyses is small and comparisons made difficult by a lack of universal agreement of what constitutes an MI approach or even if there is such a thing. Presently there are too few brain injury specific papers to undertake a systematic review or meta-analysis undertaken of the effectiveness of MI within neuro-rehabilitation.
As the MI approach is based upon collaboration with the client, development of a therapeutic relationship, promotion of self-efficacy and the establishment of goals that are meaningful to the individual, it actually is not possible to withdraw these elements from neuro-rehabilitation, as they should form its very basis. In this sense, it is impossible to realistically evaluate the role of MI in brain injury rehabilitation. Therefore, the argument for MI becomes somewhat circular.
There are clearly methodological and ethical difficulties with assessing the impact of brain injury rehabilitation, an endeavour that would need to take place over decades to ascertain how opportunities and quality of life are impacted upon. As noted by Turner-Stokes (2005, 2008), randomised clinical trials are exceptionally and fundamentally difficult with this diverse cohort.
Medley and Powell’s (2010, p. 501) conclusion that MI is proposed as ‘‘an over-arching therapeutic approach to promote therapeutic alliance and mutual understanding between clients and rehabilitation teams’’ is well supported by their rationale that this approach will create the best chance for full and proper holistic assessment, will enable better and targeted goals to be established and will promote better engagement; supporting a person with a brain injury to be ‘‘rehabilitation ready’’. Their final conclusion that single case methodology could lead to larger scale controlled trials would appear wholly unsupported for all of the reasons, including methodological and ethical, that are related to the difficulties in holding these trials.
Evidence exists that neuro-rehabilitation can be effective. Evidence also exists that poor self-awareness limits engagement with neuro-rehabilitation and has a negative impact upon its outcome. Logic suggests that promotion of self-awareness promotes engagement with neuro-rehabilitation and that MI is a ‘‘tool’’ for doing this. There is, however, no evidence to date that it is MI that promotes this engagement within neuro-rehabilitation. Medley and Powell (2010) do not present any evidence that MI can be adapted to suit the needs of people with brain injuries nor do they examine why its core components are potentially unachievable for such clients. As the basic principles behind MI are congruent with holistic neuro-rehabilitation it seems impossible and unethical to separate these out. Therefore, gaining a high standard of evidence for or against the use of MI with people with brain injuries, is very difficult, if not impossible.
