Motivational Interviewing • Motivational Interviewing:a therapeutic style intended to help clinicians work with clients to address the client’s continuous fluctuation between opposing behaviors and thoughts.
Express EMPATHY through reflective listening. Develop discrepancy or inconsistencies between client goals and current behavior. Avoid argument and direct confrontation. Adjust to client’s resistance rather than opposing it directly. Support self-efficacy and optimism. Skills
Expressing Empathy • Acceptance facilitates change • Skillful reflective listening is fundamental to expressing empathy • Ambivalence is normal
Develop Discrepancy • Motivation for change is enhanced when clients perceive discrepancies between their current situation and their hopes for the future. • Developing awareness of consequences helps clients examine their behavior. • The client should present the arguments for change.
Four Types of Client Resistance • Arguing • The client contests the accuracy, expertise, or integrity of the clinician. • Interrupting • The client breaks in and interrupts the clinician in a defensive manner. • Denying • The client expresses unwillingness to recognize problems, cooperate, accept responsibility, or take advice. • Ignoring • The client shows evidence of ignoring and not following the clinician.
Responding to Resistance • Simple Reflection • Repeating the client's statement in a neutral form • Acknowledges and validates what the client has said and can elicit an opposite response. • Amplified Reflection • Reflect the client's statement in a more extreme way but without sarcasm. This can move the client toward positive change rather than resistance.
Responding to Resistance • Double Sided Reflection • Acknowledging what the client has said but also stating contrary things she has said in the past • Shifting Focus • Help the client shift focus away from obstacles and barriers • Offers an opportunity to affirm your client's personal choice regarding the conduct of his own life
Responding to Resistance • Agreement with a twist • Agree with the client, but with a slight twist or change of direction that propels the discussion forward. • Reframing • A good strategy to use when a client denies personal problems • Offer a new and positive interpretation of negative information provided by the client. • Reframing "acknowledges the validity of the client's raw observations, but offers a new meaning...for them"
Rolling With Resistance • Momentum can be used to good advantage. • Perceptions can be shifted. • New perspectives are invited but not imposed. • The client is a valuable resource in finding solutions to problems.
Siding With the Negative One more strategy for adapting to client resistance is to "side with the negative"--to take up the negative voice in the discussion. If your client is ambivalent, your taking the negative side of the argument evokes a "Yes, but..." from the client, who then expresses the other (positive) side.
Avoiding Arguments • Arguments are counterproductive. • Defending breeds defensiveness. • Resistance is a signal to change strategies. • Labeling is unnecessary.
Ask Open-Ended Questions Asking open-ended questions helps you understand your clients' point of view and elicits their feelings about a given topic or situation. Open-ended questions facilitate dialog; they cannot be answered with a single word or phrase and do not require any particular response.
Listen Reflectively Reflective listening is a way of checking rather than assuming that you know what is meant
Summarize Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on
Affirm When it is done sincerely, affirming your client supports and promotes self-efficacy.
Four types of Motivational Statements • Cognitive recognition of the problem (e.g., "I guess this is more serious than I thought.") • Affective expression of concern about the perceived problem (e.g., "I'm really worried about what is happening to me.") • A direct or implicit intention to change behavior (e.g., "I've got to do something about this.") • Optimism about one's ability to change (e.g., "I know that if I try, I can really do it.")
Behavioral/Cognitive-Behavioral Interventions • This is a broad range of interventions. • Strictly behavioral, e.g. contingency management • Extinction paradigms • Relapse prevention • Coping skills training • Purely cognitive approaches • All of these models have their basis in learning principles
Assumptions of these approaches • Human behavior is largely learned. • The same learning processes that create problem behaviors can be used to change them. • Behavior is largely determined by environmental and contextual factors • “Covert behaviors” such as thoughts and feelings can be changed using learning principles.
Assumptions 5. Actually engaging in new behaviors in the contexts in which they are to be performed is a critical part of behavior change. 6. Each client is unique and must be assessed as an individual in a particular context. 7. The cornerstone of adequate treatment is a thorough behavioral assessment.
Behavioral/CBTEtiology of Dependence • Operant factors play role in maintenance of abuse/dependence, through positive reinforcing aspects of the substance, plus avoidance of withdrawal symptoms (negative reinforcement). • Classical conditioning plays role in development of conditioned craving to triggers. • Cognitive factors, such as expectancies of substance effects, are important in maintaining dependence.
Behavioral/CBTEtiology of Dependence • As person responds to environmental, interpersonal, and intrapersonal challenges with substance use, continued use becomes an overused, overgeneralized, and maladaptive coping strategy. • By the time they seek treatment, person may have few other coping mechanisms left in their repertoire.
Behavioral/CBTAssessment • Behavioral and CBT approaches based on a thorough behavioral assessment, often using a functional analysis. • Early in treatment, functional analysis crucial in helping patient and clinician assess determinants of use, prioritize problems, set treatment goals, select type of interventions, monitor treatment progress.
Functional Analysis Trigger>>Thought>>>Feeling>>>Behavior>>>Consequence
Behavioral/CBTTreatment Goals • In behavioral approaches • Treatment goals are highly focused and depend on specific approach. • Example: cue exposure and extinction approaches work primarily on reducing reactivity to specific cues and may not affect other substance-related problems. • For instance, conditioned response to drug paraphernalia is extinguished, but what about that freeway exit sign that leads to the dealer’s house?
Behavioral/CBTTreatment Goals • In cognitive-behavioral approaches • Treatment goals tend to be broader than in strictly behavioral approaches. • May target improved social skills, reduced psychiatric symptoms, reduced social isolation, reentry into workforce, etc. in addition to reducing/stopping substance use.
Behavioral/CBTTreatment Goals Cognitive treatment approaches focus on: • identifying and modifying drug-related beliefs • reattribution of responsibility • thought-stopping • modifying black-and-white or catastrophic thinking
CBT Approaches CBT approaches: • Develop strategies for reducing availability and exposure to substance and related cues • Build motivation by discussing positive and negative consequences of continued use • Self-monitoring to identify high-risk situations and conduct functional analyses of use • Identification of seemingly irrelevant decisions which can culminate in high-risk situations • Confronting thoughts about using
CBT Approaches • Many CBT approaches expand to address: • Other problems that are seen to be functionally related to substance use • General problem-solving skills • Assertiveness training • Strategies for coping with negative affect • Awareness of anger and anger management • Coping with criticism • Increasing pleasant activities/relaxation time
Behavioral Interventions • Interventions have roots in work of Pavlov, Skinner, and Bandura. • Classical conditioning • Operant conditioning • Social learning/modeling
Behavioral Interventions • Cue exposure – develop hierarchy of cues that are triggers for use, then expose patient to them in lab or other controlled setting (very similar to systematic desensitization for anxiety disorders) where they do not have the option of using.
Behavioral Interventions • Operant techniques include application of positive incentives for desired behaviors (e.g. abstinence) and negative incentives for undesired behaviors. • One example is Contingency Management work by Steven Higgins and colleagues with cocaine abusers
Contingency Management Higgins Contingency Management approach 4 principles: • Drug use and abstinence must be swiftly and accurately detected; • Abstinence is positively reinforced; • Drug use results in loss of reinforcement; • Emphasis on development of reinforcers that compete with reinforcers of drug use.
Contingency Management • Urine specimens required 3x/week • Abstinence (measured by urinalysis) reinforced with a voucher system • Patients receive points redeemable for items consistent with a drug-free lifestyle, such as movie tickets, grocery vouchers, sporting goods (not cash, for obvious reasons!)
Contingency Management • To encourage longer periods of abstinence, value of points earned increases with each consecutive clean UA, and value of points is reset to original level after a relapse or no-show to treatment. • Often pts receive a bonus for every 3 consecutive clean urine samples. • Approach demonstrated to be very effective with cocaine users in studies throughout the 1990’s.
Effectiveness of contingency management: Cocaine abuseHiggins et al., 1991
Relapse PreventionOverview • Marlatt and Gordon (1985) develop and publish Relapse Prevention approach. • Would become one of the most widely used, adapted, and researched treatment approaches for broad range of disorders, including: eating disorders, sexual deviance, depression, schizophrenia, panic disorder, OCD, chronic pain, marital distress, social competence, and stuttering.
Relapse PreventionOverview Goals: • Prevent lapse or initial return to substance use (or whatever behavior is being addressed), so that a full-blown relapse (return to problematic use) is less likely. • Successful management of relapse episodes if they do occur, to prevent exacerbation or continuation of substance use.
Relapse PreventionOverview • Marlatt & Gordon’s approach originally designed as maintenance program for pts who had gone thru intensive treatment for substance use. • Goal was to extend and enhance therapeutic gains and reduce possibility of recycling back thru tx.
Relapse PreventionOverview • Does not view people who lapse back to substance use as tx failures who are victims of an underlying disease process. • Instead, views lapses as errors or temporary setbacks to be expected from someone learning new coping behaviors. • Viewed this way, lapses may provide valuable lessons in preventing future such episodes.
Relapse PreventionTheory • “To the extent that a substance is used to cope with unpleasant situations, experiences, or emotions, the behavior may be viewed as a learned maladaptive coping strategy.” • Strategy may be learned thru a combination of both classical and operant conditioning processes, which may not be under the individual’s control.
Relapse PreventionTheory • A substance’s predictable efficacy in providing temporary relief to an individual who has not developed alternative ways of handling unpleasant situations or emotions may foster continued reliance on the substance as a “primitive” coping mechanism. • May be a perceived lack of alternative coping strategies combined with low self-efficacy.
Relapse PreventionTheory of Treatment • Essentially a self-management approach • Model considers the individual (rather than a higher power or a group) to be the responsible agent of change. • Approach is empowering (consider in contrast the 12-Step approach with regard to power) and trains individuals to eventually act as their own therapists with regard to managing their addictive behaviors.
Relapse PreventionTreatment • Assess motivation, commitment, and self-efficacy for change. • Address ambivalence with a decision matrix exercise (cost-benefit analysis). Assesses costs/benefits of changing and of not changing. • Assess client’s self-image as a drinker or drug user.