Zoekresultaten

Motiverende gespreksvoering: actieve ingrediënten en verandermechanismen

AIM: To contribute to the knowledge and understanding of the active ingredients and mechanisms of change in Motivational Interviewing (MI), to enable MI-counsellors to optimise their MI-strategies in daily practice.METHOD: The body of this dissertation are two multiple case studies, one in 14 patients with schizophrenia receiving MI for medication adherence; another in 24 patients with a coronary artery disease receiving MI for smoking cessation.FINDINGS: We found that the active ingredients of MI consist of combinations of clinician factors and patient factors, mostly built up during longer interactions. ‘Arguing oneself into change’ was the most frequently observed mechanism of change.DISCUSSION AND CONCLUSION: Active ingredients in MI consist off combinations of factors contributed by the clinician and factors contributed by the patient. These factors can be employed in a person-centred MI-strategy to trigger a mechanism of change in the patient.This dissertation adds to the understanding of MI since it provides an explanation of how MI may work. It offers a general idea how counsellors can effectively execute MI. This ‘how-possibly’ explanation may be a building block in the development of a ‘how-actually’ explanation of the interactions leading to the active ingredients and mechanisms of change in MI.--De vraagstelling van het proefschrift is hoe MGv werkt: wat zijn de actieve ingrediënten en de verandermechanismen van motiverende gespreksvoering? De twee patiëntengroepen laten zien dat de actieve ingrediënten van MGv bestaan uit een wisselende combinatie van zorgverlener- en patiëntfactoren. Actieve ingrediënten ontstaan gedurende een langer lopende interactie tussen patiënt en professional.

Teacher Feedback during Active Learning

Feedback is one of the most powerful tools teachers can use to enhance student learning. In 2006, the Dutch Inspectorate of Education concluded from classroom observations that it is difficult for Dutch teachers to give their students good feedback in order to stimulate students' learning process and developmental progress. Similar problems were revealed in other school levels and countries, for example in secondary education and in Finland. Giving feedback during active learning may be even more troublesome for teachers. During active learning, students are working in small groups on different learning goals and undertake different learning activities at the same time. They need to achieve task-related goals as well as to develop the meta-cognitive knowledge and skills that are needed for active learning. Yet, teachers often seem unable to provide the feedback that is needed and they do not know how to support the development of meta-cognitive knowledge and skills.Therefore, this research project focused on ways to improve primary school teachers' feedback giving practices during active learning. The central research question is: How can primary school teachers learn to give optimal feedback to pupils during active learning? To answer this question, five studies have been conducted. In the first study, knowledge regarding teachers' feedback practices was gathered. A category system was developed based on the literature and empirical data. A total of 1465 teacher-student interactions of 32 teachers who practiced active learning in the domain of environmental studies in the sixth, seventh or eighth grade of 13 Dutch primary schools were videotaped and assessed using this system. Results showed that about half of the teacher-student interactions contained feedback. This feedback was usually focused on the tasks that were being performed by the students and on the ways in which these tasks were processed. Only 5% of the feedback was explicitly related to a learning goal. In their feedback, the teachers were directing (rather than facilitating) the learning processes. During active learning, however, feedback on meta-cognition and social learning is important. Feedback should be explicitly related to learning goals. In practice, these kinds of feedback appear to be scarce. In the second study, the problems these 32 primary school teachers perceive and the beliefs they hold regarding the provision of feedback were investigated. A writing task and an interview were conducted. It appeared that teachers believed that conditional teacher skills, especially time management, hindered them most from giving good feedback. The most widely held belief was that 'feedback should be positive'. Teachers also believed that it is important to adopt a facilitative way of giving feedback, but they found this difficult to implement. Only some teachers believed goal-directedness and a focus on student meta-cognition were important during active learning and teachers did not perceive problems regarding these aspects. In the third study, a professional development program (PDP) was developed, implemented and evaluated. The goals and content of the PDP were based on a review of the literature regarding feedback and active learning and on the results of the preceding studies. The design of the PDP was based on the extant literature regarding the features which are considered to be important for PDPs, including structural features, goal setting and characteristics of the professional development activities that are part of the program. Effects of this PDP on 16 primary schoolteachers' knowledge, beliefs, perceived problems and classroom behavior were examined via observations, a writing task and a questionnaire prior and twice after the program was implemented. Results showed that several aspects of feedback during active learning were improved, both in the short and in the long term. For example, teachers learned to believe that feedback must be goal-directed and that learning goals need to be communicated to students. In the classrooms, teachers related their feedback more often explicitly to the learning goals. In the fourth study, the extent to which teachers attributed the success of the PDP to each of the purposefully implemented features of the PDP was examined. The 16 teachers that participated in the PDP completed a questionnaire and four focus group interviews were conducted. Results indicated that teachers value most features quite highly; all features contributed to teachers' professional development according to the teachers themselves. The qualitative data was used to illustrate and specify the theoretical knowledge regarding the features that appeared to be effective in PDP's. Finally, in the fifth study, the learning process of two of the participating teachers was described in detail. Written reflections, as well as videotaped reflections during the video interaction training meetings were analyzed and related to the effects of the PDP on both teachers' knowledge, beliefs, perceived problems and classroom behavior during te course of the PDP. By relating the learning processes of these two teachers to the literature regarding professional development, we aimed for a rich understanding of the impact of the PDP on teachers' professional development.

Motivational interviewing

Selecting an optimal instrument to identify active ingredients of the motivational interviewing-process

OBJECTIVE: Motivational Interviewing (MI) can effectively stimulate motivation for health behavior change, but the active ingredients of MI are not well known. To help clinicians further stimulate motivation, they need to know the active ingredients of MI. A psychometrically sound instrument is required to identify those ingredients. The purpose of this study is to describe and evaluate the capability of existing instruments to reliably measure one or more potential active ingredients in the MI process between clients and MI-therapists.METHODS: We systematically searched MedLine, Embase, Cinahl, PsycInfo, Cochrane Central, specialised websites and reference lists of selected articles.RESULTS: We found 406 papers, 60 papers were retrieved for further evaluation, based on prespecified criteria. Seventeen instruments that were specifically designed to measure MI or aspects of MI were identified. Fifteen papers met all inclusion criteria, and reported on seven instruments that assess potential active ingredients of the interactive MI process. The capability of these instruments to measure potential active ingredients in detail and as a part of the interactive MI process varies considerably. Three of these instruments measure one or more potential active ingredients in a reliable and valid way.CONCLUSION: To identify the potential active ingredients in the interactive MI process, a combination of the SCOPE (which measures potential technical active ingredients) and the GROMIT or the global ratings of the MISC2 (to measure potential relational ingredients) seems favourable.

Active Ingredients and Mechanisms of Change in Motivational Interviewing for Medication Adherence. A Mixed Methods Study of Patient-Therapist Interaction in Patients With Schizophrenia

BackgroundTrials studying Motivational Interviewing (MI) to improve medication adherence in patients with schizophrenia showed mixed results. Moreover, it is unknown which active MI-ingredients are associated with mechanisms of change in patients with schizophrenia. To enhance the effect of MI for patients with schizophrenia, we studied MI's active ingredients and its working mechanisms.MethodsFirst, based on MI literature, we developed a model of potential active ingredients and mechanisms of change of MI in patients with schizophrenia. We used this model in a qualitative multiple case study to analyze the application of the active ingredients and the occurrence of mechanisms of change. We studied the cases of fourteen patients with schizophrenia who participated in a study on the effect of MI on medication adherence. Second, we used the Generalized Sequential Querier (GSEQ 5.1) to perform a sequential analysis of the MI-conversations aiming to assess the transitional probabilities between therapist use of MI-techniques and subsequent patient reactions in terms of change talk and sustain talk.ResultsWe found the therapist factor “a trusting relationship and empathy” important to enable sufficient depth in the conversation to allow for the opportunity of triggering mechanisms of change. The most important conversational techniques we observed that shape the hypothesized active ingredients are reflections and questions addressing medication adherent behavior or intentions, which approximately 70% of the time was followed by “patient change talk”. Surprisingly, sequential MI-consistent therapist behavior like “affirmation” and “emphasizing control” was only about 6% of the time followed by patient change talk. If the active ingredients were embedded in more comprehensive MI-strategies they had more impact on the mechanisms of change.ConclusionsMechanisms of change mostly occurred after an interaction of active ingredients contributed by both therapist and patient. Our model of active ingredients and mechanisms of change enabled us to see “MI at work” in the MI-sessions under study, and this model may help practitioners to shape their MI-strategies to a potentially more effective MI.

Active Ingredients and Mechanisms of Change in Motivational Interviewing for Smoking Cessation in Patients With Coronary Artery Disease: A Mixed Methods Study

Background: For patients with coronary artery disease (CAD), smoking is an important risk factor for the recurrence of a cardiovascular event. Motivational interviewing (MI) may increase the motivation of the smokers to stop smoking. Data on MI for smoking cessation in patients with CAD are limited, and the active ingredients and working mechanisms of MI in smoking cessation are largely unknown. Therefore, this study was designed to explore active ingredients and working mechanisms of MI for smoking cessation in smokers with CAD, shortly after a cardiovascular event.Methods: We conducted a qualitative multiple case study of 24 patients with CAD who participated in a randomized trial on lifestyle change. One hundred and nine audio-recorded MI sessions were coded with a combination of the sequential code for observing process exchanges (SCOPE) and the motivational interviewing skill code (MISC). The analysis of the cases consisted of three phases: single case analysis, cross-case analysis, and cross-case synthesis. In a quantitative sequential analysis, we calculated the transition probabilities between the use of MI techniques by the coaches and the subsequent patient statements concerning smoking cessation.Results: In 12 cases, we observed ingredients that appeared to activate the mechanisms of change. Active ingredients were compositions of behaviors of the coaches (e.g., supporting self-efficacy and supporting autonomy) and patient reactions (e.g., in-depth self-exploration and change talk), interacting over large parts of an MI session. The composition of active ingredients differed among cases, as the patient process and the MI-coaching strategy differed. Particularly, change talk and self-efficacy appeared to stimulate the mechanisms of change “arguing oneself into change” and “increasing self-efficacy/confidence.”Conclusion: Harnessing active ingredients that target the mechanisms of change “increasing self-efficacy” and “arguing oneself into change” is a good MI strategy for smoking cessation, because it addresses the ambivalence of a patient toward his/her ability to quit, while, after the actual cessation, maintaining the feeling of urgency to persist in not smoking in the patient.