Effecting Change through the Use of Motivational Interviewing

1. Effecting Change through the Use of Motivational Interviewing Thomas E. Freese, PhD Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs UCLA David Geffen School of Medicine, Dept. of Psychiatry www.psattc.org www.uclaisap.org

2. What is Motivational Interviewing? It is: A style of talking with people constructively about reducing their health risks and changing their behavior.

3. What is Motivational Interviewing? It is designed to: Enhance the client’s own motivation to change using strategies that are empathic and non-confrontational.

4. What is Motivational Interviewing? You can recognize it by observing: • The powerful behavioral strategies for helping clients convince themselves that they ought to change • The “spirit of MI” style in which it is delivered

5. How does MI differ from traditional counseling? 1. Patient and practitioner are equal partners in relationship (collaborative effort between two experts)

6. How does MI differ from traditional or typical medical counseling? • People are almost always ambivalent about change – ambivalence is normal • Lack of motivation can be viewed as unresolved ambivalence.

7. How does MI differ from traditional or typical medical counseling? • AMBIVALENCE is the key issue to be resolved for change to occur. • People are more likely to change when they hear their own discussion of their ambivalence. • This discussion is called “change talk” in MI. • Getting patients to engage in “change talk” is a critical element of the MI process. *Glovsky and Rose, 2008

8. How can MI be helpful for us in working with our consumers/patients? The successful MI therapist is able to inspire people to want to change Use of MI can help engage and retain consumers in treatment Using MI can help increase participation and involvement in treatment (thereby improving outcomes)

9. Definition of Motivation The probability that a person will enter into, continue, and comply with change-directed behavior

10. Motivational Interviewing A patient-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. directive method patient-centered exploring and resolving ambivalence

11. What’s the Best Way to Facilitate Change? Constructive behavior change comes from connecting with something valued, cherished and important Intrinsic motivation for change comes out of an accepting, empowering, safe atmosphere where the painful present can be challenged The Carrot

12. Where do I start? What you dodepends on where the consumer is in the process of changing The first step is to be able to identify where the consumer is coming from

13. Stages of ChangeProchaska & DiClemente Precontem- plation Contemplation Recurrence Preparation Maintenance Action

14. Helping People Change Motivational Interviewing is the process of helping people move through the stages of change

15. 1. Precontemplation Definition: Not yet considering change or is unwilling or unable to change. Primary Task: Raising Awareness 6. Recurrence Definition: Experienced a recurrence of the symptoms. Primary Task: Cope with consequences and determine what to do next 2. Contemplation Definition: Sees the possibility of change but is ambivalent and uncertain. Primary Task: Resolving ambivalence/ Helping to choose change Stages of Change:Primary Tasks 5. Maintenance Definition: Has achieved the goals and is working to maintain change. Primary Task: Develop new skills for maintaining recovery 3. Determination Definition: Committed to changing. Still considering what to do. Primary Task: Help identify appropriate change strategies 4. Action Definition: Taking steps toward change but hasn’t stabilized in the process. Primary Task: Help implement change strategies and learn to eliminate potential relapses

16. Precontemplation Stage Definition– Not yet considering change or is unwilling or unable to change Primary task– Raising Awareness

17. Some Ways to Raise Awareness in the Precontemplation Stage Offer factual information Explore the meaning of events that brought the person in and the results of previous efforts Explore pros and cons of targeted behaviors

18. Contemplation Stage In this stage the consumer sees the possibility of change but is ambivalent and uncertain about beginning the process Primary task– Resolving ambivalence and helping the consumer choose to make the change

19. Possible Ways to Help the Consumer in the Contemplation Stage Talk about the person’s sense of self-efficacy and expectations regarding what the change will entail Summarize self-motivational statements Continue exploration of pros and cons

20. Determination Stage In this stage the consumer is committed to changing but is still considering exactly what to do and how to do it Primary task– Help consumer identify appropriate change strategies

21. Possible Ways to Help the Consumer in the Determination Stage Offer a menu of options for change or treatment Help consumer identify pros and cons of various treatment or change options Identify and lower barriers to change Help person enlist social support Encourage person to publicly announce plans to change

22. Action Stage In this stage the consumer is taking steps toward change but hasn’t stabilized in the process Primary task– Help implement the change strategies and learn to limit or eliminate potential relapses

23. Possible Ways to Help the Consumer in the Action Stage Support a realistic view of change through small steps Help person identify high-risk situations and develop appropriate coping strategies Assist person in finding new reinforcers of positive change Help access family and social support

24. Maintenance Stage Definition– A stage in which the consumer has achieved the goals and is working to maintain them Primary task– consumer needs to develop new skills for maintaining recovery

25. Possible Ways to Help the Consumer in the Maintenance Stage Help consumer identify and try alternative behaviors (drug-free sources of pleasure) Maintain supportive contact Encourage person to develop escape plan Work to set new short and long term goals

26. Recurrence Definition– consumer has experienced a recurrence of the symptoms Primary task– Must cope with the consequences and determine what to do next

27. How to Help the Consumer Who Has Experienced a Recurrence Frame recurrence as a learningopportunity; recurrence does not equal failure! Explore possible behavioral, psychological, social antecedents to the recurrence/relapse Help person develop alternative coping strategies Explain Stages of Change and encourage him/her to stay in the process Maintain supportive contact

28. Building Motivation OARS(the microskills) • Open-ended questioning • Affirming • Reflective listening • Summarizing The goal is to elicit and reinforce self-motivational statements (Change Talk)

29. Open-Ended Questions Solicits information in a neutral way Helps person elaborate own view of the problem and brainstorm possible solutions Helps therapist avoid prejudgments Keeps communication moving forward Allows consumer to do most of the talking An open-ended question is one that requires more than a yes or no response

30. Affirmations Focused on achievements of individual Intended to: Support person’s persistence Encourage continued efforts Assist person in seeing positives Support individual’s proven strengths

31. Reflective Listening Key-Concepts Listen to both what the person says and to what the person means Check out assumptions Create an environment of empathy (nonjudgmental) You do not have to agree Be aware of intonation (statement, not question)

32. Types of Reflective Statements • 1. Simple Reflection (repeat) • Amplified Reflection (rephrasing and • paraphrasing) • Double-Sided Reflection (rephrasing, • paraphrasing and reflecting feeling) NIDA-SAMHSA Blending Initiative 33

33. Summarizing • Summaries capture both sides of the ambivalence (“You say that ___________ but you also mentioned that ________________.”) • They demonstrate the clinician has been listening carefully. • Summaries also prompt clarification and further elaboration from the person. • They prepare consumers to move forward.

34. Four Principles ofMotivational Interviewing 1. Express empathy 2. Develop discrepancy 3. Avoid argumentation 4. Support self-efficacy

35. Use the Microskills of MI to: Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal

36. Use the Microskills of MI to: Develop Discrepancy Discrepancy between present behaviors and important goals or values motivates change Awareness of consequences is important Goal is to have the PERSON present reasons for change

37. Weighing the Decisional Balance • Strategies for weighing the pros and cons… • “What do you like about drinking?” • “What do you see as the downside of drinking?” • “What Else?” • Summarize both pros and cons… • “On the one hand you said.., • and on the other you said….”

38. Importance/Confidence/Readiness Scale • On a scale of 1–10… • How important is it for you to change your drinking? • How confident are you that you can change your drinking? • How ready are you to change your drinking? • For each ask… • Why didn’t you give it a lower number? • What would it take to raise that number? 1 2 3 4 5 6 7 8 9 10

39. Decisional Balance

40. Use the Microskills of MI to: Avoid Argumentation Resistance is signal to change strategies Labeling is unnecessary Shift perceptions Peoples’ attitudes are shaped by their words, not yours

41. Support Self-Efficacy Belief that change is possible is an important motivator Person is responsible for choosing and carrying out actions to change There is hope in the range of alternative approaches available Use the Microskills of MI to:

42. Support Self-Efficacy Belief that change is possible is important motivator Person is responsible for choosing and carrying out actions to change There is hope in the range of alternative approaches available

43. Change Talk • Recognizing the problem • Expressing concern • Stating intention to change • Being optimistic about change

44. Change Talk • Dig for change talk… • I’d like to hear you opinions about… • What are some things that bother you about drinking? • What role do you think alcohol played in your injury? • How would you like your drinking to be 5 years from now?

45. Tools for Change Talk • Pros and Cons • Importance & Confidence Scales • Readiness Ruler

46. Signs of Readiness to Change • Fewer questions about the problems • More questions about change • Self-motivational statements • Resolve • Looking ahead • Experimenting with change

47. Types of Reflective Statements • 1. Simple Reflection (repeat) • Amplified Reflection (rephrasing and • paraphrasing) • Double-Sided Reflection (rephrasing, • paraphrasing and reflecting feeling) NIDA-SAMHSA Blending Initiative 50

48. Reflective Listening Exercise

49. Change Talk is Happening When the Consumer Makes Statements that Indicate: Recognition of a problem A concern about the problem Statements indicating an intention to change Expressions of optimism about change

50. Signs of Readiness to Change • Fewer questions about the problems • More questions about change • Self-motivational statements • Resolve • Looking ahead • Experimenting with change