Motivational Interviewing with Women

1. Motivational Interviewingwith Women Karen Ingersoll Ph.D. kareningersoll@gmail.com Virginia Summer Institute on Addiction Studies

2. Objectives: You will be able to: Identify 4 principles and 4 techniques of motivational interviewing Identify at least 2 areas of women�s health that could be addressed with motivational interviewing Try at least 2 motivational interviewing techniques with women considering changes in health behaviors

3. Workshop overview Review of research basis for MI and its principles Review of relevant MI and women�s addiction, health, and sexual health studies Practice of key MI techniques and strategies

4. Women�s Health Issues: Possible target behaviors Safer sex for STD/HIV primary prevention Safer sex to reduce STD/HIV transmission Contraception to prevent unwanted pregnancy or alcohol/drug/medication-exposed pregnancy Reducing smoking and drinking for self or for prenatal care Improving health behaviors in diabetes, heart disease, etc. Others?

5. Assumptions about motivation Motivation is a state of readiness to change It fluctuates naturally It can be influenced It can be strengthened Now I�ll discuss some of the specifics of a motivational interviewing-based intervention, and some details about how we adapted MI techniques within Project CHOICES. We begin from some well-researched assumptions about the nature of motivation. We know that the following four points are true: Now I�ll discuss some of the specifics of a motivational interviewing-based intervention, and some details about how we adapted MI techniques within Project CHOICES. We begin from some well-researched assumptions about the nature of motivation. We know that the following four points are true:

6. Handling Ambivalence Ambivalence is normal Exploring ambivalence increases the potential for change Motivation can fluctuate, and it�s related to the normative experience of ambivalence. Think for a moment about the last change you personally tried to make. Part of you wanted to change, yet another part wanted to remain the same. In counseling, we should explore both aspects of ambivalence, always beginning with the �don�t want to change� side. If as a counselor you respect the woman�s very good reasons for wanted to remain the same, she perceives that this part of her feeling is being protected, and she is then psychologically freed to explore the other side, the part of her that may want to change. In contrast, if the counselor brings up changing, attempts to persuade her to change, or endorses change, the woman will naturally protect the other side, and voice the reasons she doesn�t want to change. In a motivational approach, we always explore both aspects of the ambivalence.Motivation can fluctuate, and it�s related to the normative experience of ambivalence. Think for a moment about the last change you personally tried to make. Part of you wanted to change, yet another part wanted to remain the same. In counseling, we should explore both aspects of ambivalence, always beginning with the �don�t want to change� side. If as a counselor you respect the woman�s very good reasons for wanted to remain the same, she perceives that this part of her feeling is being protected, and she is then psychologically freed to explore the other side, the part of her that may want to change. In contrast, if the counselor brings up changing, attempts to persuade her to change, or endorses change, the woman will naturally protect the other side, and voice the reasons she doesn�t want to change. In a motivational approach, we always explore both aspects of the ambivalence.

7. Motivation and Counseling Persuasion and education alone don�t create behavior change Empathic interpersonal counseling styles increase willingness to consider change and avoid resistance We also know from social psychology that persuasion as a tactic, and education alone, are not enough to help people change habitual behavior. Rather, we use a counseling style in motivational interviewing that increases a woman�s readiness to consider change. We also know from social psychology that persuasion as a tactic, and education alone, are not enough to help people change habitual behavior. Rather, we use a counseling style in motivational interviewing that increases a woman�s readiness to consider change.

8. Motivational Interviewing Motivational Interviewing is a counseling style. Its goal is to explore and resolve ambivalence about changing behaviors MI creates and amplifies the discrepancy between personal goals and current behaviors. I�ve mentioned Motivational Interviewing, so let me be more specific. MI was developed by Miller and Rollnick in the early 90�s, building on 20 years of social and clinical psychology research that emphasized certain factors related to successfully making a planned change. MI is a counseling style�.I�ve mentioned Motivational Interviewing, so let me be more specific. MI was developed by Miller and Rollnick in the early 90�s, building on 20 years of social and clinical psychology research that emphasized certain factors related to successfully making a planned change. MI is a counseling style�.

9. A Woman Is Likely to Change When: Change is seen as important The woman is confident in her ability to make changes MI counselors know that in order to a woman to be motivated or ready for change, she must both believe that change is important, and feel confident that she can make the needed change.MI counselors know that in order to a woman to be motivated or ready for change, she must both believe that change is important, and feel confident that she can make the needed change.

10. Motivational Interviewing Originally developed for use with substance abusing populations in �80�s and �90�s (Miller & Rollnick, 1991) Has now been used with diverse populations Can be useful with any clients ambivalent about making a change, but it is only one approach Is a counseling style that draws from other types of psychotherapy Show book./Refer to article list Diverse pops such as medical patients as you may have heard discussed by Dr. Borges earlier: cardiac rehabilitiation, chronic pain, post-operative transplant issues, ALSO: eating disorders, weight management, smoking cessation, etc. Style is just one style: We recognize that it isn�t perfect an d that is a better fit for some counselors, clients, and researchers than others. Many of the principles may seem basic, take you back to some of the fundamentals of counseling. Sometimes as we get more sophisticated we don�t explicitly integrate those basics. MI revisits them over and over. Some of you may feel the style is familiar and similar to what you already do. It may reinforce your practices, help your organize your thinking about what you do, or provide additional techniques that fit into your own style. It is the way the components of MI are put together that makes it unique. AND WHY I THINK IT IS PARTICULARLY WELL SUITED FOR COUNSELING PSYCHOLOGY!Show book./Refer to article list Diverse pops such as medical patients as you may have heard discussed by Dr. Borges earlier: cardiac rehabilitiation, chronic pain, post-operative transplant issues, ALSO: eating disorders, weight management, smoking cessation, etc. Style is just one style: We recognize that it isn�t perfect an d that is a better fit for some counselors, clients, and researchers than others. Many of the principles may seem basic, take you back to some of the fundamentals of counseling. Sometimes as we get more sophisticated we don�t explicitly integrate those basics. MI revisits them over and over. Some of you may feel the style is familiar and similar to what you already do. It may reinforce your practices, help your organize your thinking about what you do, or provide additional techniques that fit into your own style. It is the way the components of MI are put together that makes it unique. AND WHY I THINK IT IS PARTICULARLY WELL SUITED FOR COUNSELING PSYCHOLOGY!

11. MI Characteristics Draws on Person-centered, Cognitive, and Reality therapies It�s compatible with the Stages of Change Considered a brief intervention approach It�s practical Found to be clinically useful, effective and efficient (Noonan & Moyers, 1997)

12. Express Empathy Develop Discrepancy Roll with Resistance Support Self-efficacy Motivational Interviewing Principles MI techniques stem from these 5 basic principles. First, express an empathic understanding and interest in the woman. Second, help her perceive a discrepancy between where she is and where she wants to be. Third, be approachable, flexible, and avoid arguing or persuading tactics. Fourth, if you perceive resistance, use this as a cue to change strategies and move in a more productive direction. Fifth, encourage optimism for change and support her when she makes statements of confidence in her ability to change. MI techniques stem from these 5 basic principles. First, express an empathic understanding and interest in the woman. Second, help her perceive a discrepancy between where she is and where she wants to be. Third, be approachable, flexible, and avoid arguing or persuading tactics. Fourth, if you perceive resistance, use this as a cue to change strategies and move in a more productive direction. Fifth, encourage optimism for change and support her when she makes statements of confidence in her ability to change.

13. Motivational Interviewing: Client-centered techniques Ask Open-ended questions Listen reflectively Affirm participation and honesty Summarize frequently Emphasize personal choice and control Here are some of the counseling techniques used in MI and in Project CHOICES that are fundamental, client-centered techniques. Here are some of the counseling techniques used in MI and in Project CHOICES that are fundamental, client-centered techniques.

14. Motivational Interviewing: Directive Techniques Elicit and Selectively reflect �change talk� Explore discrepancies between goals and behavior; envision a better future Assist in goal setting and taking steps These are the techniques that make MI a directive approach. For example,�.These are the techniques that make MI a directive approach. For example,�.

15. Studies of MI with Women:Target Behaviors Drinking during pregnancy Smoking during pregnancy Diabetes care Eating disordered behavior

26. Have there been studies of the impact of MI on sexual health issues?

27. HIV Risk Reduction Studies

32. Contraception Studies

33. Preventing alcohol-exposed pregnancy:  Project CHOICES Project CHOICES Intervention Research Group

34. The PROJECT CHOICES Intervention Research Group

36. Project CHOICES strategy Identify 6 settings with increased rates of women at risk for AEP Recruit non-treatment-seeking women at risk for AEP who were: fertile, having sex, not contracepting effectively, and drinking frequently or at binge levels Enroll them in an MI intervention

37. Why Motivational Interviewing? Good evidence of efficacy to reduce drinking Can enhance engagement into treatment/counseling Assumes low levels of readiness Recruiting a non-treatment seeking sample, similar to problem drinkers

38. CHOICES Intervention Components Used an MI intervention focused on risky drinking and ineffective contraception Over 8-14 weeks, women attended 4 counseling sessions and a session with a gynecologist All sessions were semi-structured and followed a treatment manual, and adhered to MI spirit We�re eagerly anticipating the results of the intervention. Since we�ve recently completed our 6 month followups, we have anecdotal evidence (not yet analyzed) that we should expect a positive impact from the study. So to summarize, we�..We�re eagerly anticipating the results of the intervention. Since we�ve recently completed our 6 month followups, we have anecdotal evidence (not yet analyzed) that we should expect a positive impact from the study. So to summarize, we�..

39. Assessment Overview demos, ob/gyn hx, MH, SA, drinking and contraception behaviors, attitudes and knowledge about FAS TLFB for both risk behaviors AUDIT TTM measures (stages and processes of change, self efficacy, etc.) Subset repeated at 3M and 6M follow-ups

40. Counseling Session 1 Orientation to study Informed consent Rapport building Assessment Provide fact sheets Make gyn appointment HW: Decisional balance for alcohol and contraception and self monitoring In her first session, In her first session,

41. Decisional Balance Exercise Pros Here�s a generic example of how you might draw a decisional balance for use in counseling. Here�s a generic example of how you might draw a decisional balance for use in counseling.

42. Counseling Session 2 Personalized Risk Feedback Debriefing of feedback Review self-monitoring log and decisional balance homework Initial goal setting In session 2, the woman receives feedback on a variety of measures she completed during the first session. She hears about how her drinking compares to national averages, how many calories she drank, and how much she spent on alcohol in the past year. She also learns about risks related to drinking at her level, and the risk of pregnancy and why she is at risk. In session 2, the woman receives feedback on a variety of measures she completed during the first session. She hears about how her drinking compares to national averages, how many calories she drank, and how much she spent on alcohol in the past year. She also learns about risks related to drinking at her level, and the risk of pregnancy and why she is at risk.

43. Here�s an example of a readiness ruler we use several times over the course of the sessions on which she can indicate her readiness to change one of the target behaviors.Here�s an example of a readiness ruler we use several times over the course of the sessions on which she can indicate her readiness to change one of the target behaviors.

44. Gyn Visit Contraception and ob/gyn history Contraception education and counseling Physical exam (if desired by woman) Provision of contraception After the second visit, she visits the gyn clinic practitioner associated with Project CHOICES. After the second visit, she visits the gyn clinic practitioner associated with Project CHOICES.

45. Counseling Session 3 Review self monitoring homework Debrief gyn visit experience Readiness rulers Decisional balance update Goal statement update: how well is it fitting? In session 3, she �..In session 3, she �..

46. Here�s an example of a tool we use in assisting the woman to think through her plans for change. Here�s an example of a tool we use in assisting the woman to think through her plans for change.

47. Counseling Session 4 Review prior sessions Develop final goal statement and change plan for alcohol and or contraception Discuss current decisional balance Discuss self-efficacy Schedule follow-up Certificate of completion In the last session, we�..In the last session, we�..

48. Eligibility Criteria for Intervention 18-44 years old Fertile Not contracepting effectively in past 3 months Drinking 8 drinks per week on average or 5 per occasion Available for 9 months Signed informed consent Now that you have a good understanding of the content of the Project CHOICES intervention, let me turn to some of the other aspects of the study design. Women were eligible for the study if they were:�Now that you have a good understanding of the content of the Project CHOICES intervention, let me turn to some of the other aspects of the study design. Women were eligible for the study if they were:�

50. Completion Rates Counseling Session 1 100.0% Counseling Session 2 92.0% Counseling Session 3 67.2% Counseling Session 4 58.7% Ob/Gyn Session 62.2% 3-Month Follow-Up 74.6% 6-Month Follow-Up 75.1%

51. Definition of �Not at Risk� Drinks = 7 drinks/week & no days = 5 drinks or Contracepts Effectively or Both

52. Evaluating Outcome Changing either behavior (or both) results in no risk for an alcohol-exposed pregnancy.

53. Pre-Intervention 100% At Risk 6 Month Follow-up 68.2% Not At Risk 31.8% At Risk

54. �Not At Risk� X Setting Setting % Not At Risk Jail 66.7% Treatment Center 57.1% Inner City Primary Care 57.1% Inner City Gyn 66.7% Media Recruits 79.5% County Primary Care 60.0%

55. Routes to Not at Risk (n=103 of 151 with 6 month follow up)

56. Project CHOICES Conclusions Findings Strongly Suggest the Intervention was Effective More Women Chose to Contracept than to Reduce Drinking Alcohol Problem Severity may Predict Outcome Stage 2 Efficacy Trial was Warranted Feasibility study published in PEDIATRICS Vol. 111 No. 5 May 2003

57. Project CHOICES Efficacy Study

58. Primary Research Questions Will a greater proportion of women reduce their risk of having an alcohol-exposed pregnancy after participating in the Information + Counseling group (IPC) than do those in the Information Only (IO) group? Which sociodemographic and behavioral variables mediate or moderate the effects of the intervention on high-risk behaviors?

60. Session I: Review Fact Sheet Advise Family Planning Visit Present Daily Journal Present Thinking Exercises Give Brochures - Gift Package

63. Session II: Personalized Feedback Review & Discuss the Daily Journal Discuss Family Planning Visit Review Thinking Exercise Complete Self-Evaluation Complete Goal Statement & Change Plan Discuss Temptation & Confidence Profiles

74. Session III: Discuss Family Planning Appointment Discuss Daily Journal Review & Update Thinking Exercises Review & Update Self-evaluation Exercise Revisit & Revise Goal Statements and Change Plans

76. Session IV: Recap Previous Sessions Review Goals & Change Plans Problem-solve, Reinforce Goals, Revisit Temptation and Confidence, Strengthen Commitment to Change Discuss Plans for Aftercare

77. Counselor Training: M.A. and Ph.D. Level with Counseling or Clinical Psychology Background On-site training in Motivational Interviewing Centralized training in Study Protocol Weekly Supervision �Pilot� clients

78. Intervention Quality Control: Audiotaped Sessions Session Checklists MI Rating Scale Supervisor Rating Scale Weekly Supervision

79. Consort Chart 416 allocated to receive information plus counseling (IPC) 125 lost to follow-up could not be located 291 included in anaylsis - 414 allocated to receive information only (IO) - 112 lost to follow-up could not be located - 302 included in analysis

80. Participant Characteristics Treatment (IPC) n = 416 Age Mean (SD) 29.8 (7.51) Median 28 Race Black/ not Hispanic 187 (45%) Marital Status Single 214 (51.4%) Education Grades 1-11 105 (25.2%) Grade 12 or GED 166 (39.9%) College 1+ years 144 (34.6%) Income < $20,000 235 (56.5%)

81. Additional Characteristics Treatment (IPC) n = 416 AUDIT Score Mean (SD) 17.81 (9.69) Median 16 DSM-IV criteria alcohol problems 303.90 alcohol dependence 230 (55.3%) 305.00 alcohol abuse 27 (6.5%) V71.09 no diagnosis 83 (20%) History of treatment for alcohol related problems 291 (70%)

82. Participant Behaviors Treatment (IPC) n = 416 Average number of drinks per week past 90 days Mean (SD) 35.59 (55.54) Median 18.04 Number of binge episodes past 3 months Mean (SD) 30.06 (28.71) Median 22 Average number of drinks per drinking day past 90 days Mean (SD) 7.96 (8.48) Median 5.34

83. Participant Behaviors Treatment (IPC) n = 416 Drug use in past 12 months 389 (93.5%) Current Smoker 316 (76%) Number of sexual partners in past 3 months Mean (SD) 7.61 (36.31) Median 2 Contraception use (past 3 months) Used contraception, but ineffectively 281 (67.5%) Used no contraception 134 (32.2%)

84. Participant Behaviors at 9 Months Follow-Up 69.1% of the intervention women reduced risk for an AEP Of the women who reduced their risk for AEP 32.8% used effective contraception only 19.9% reduced risk-drinking only 47.3% used both effective contraception and reduced risk drinking

85. Participant Behaviors at Follow-Up At the 3 month follow-up, 18% more women in the intervention group versus the control group. At the 6 month follow-up, 17% more women in the intervention group versus the control group. At the 9 month follow-up, 15% more women in the intervention group versus the control group.

86. Participant Behaviors at 9 Months Follow-Up The average number of binge-drinking episodes in the intervention group was reduced from 30.1 at baseline to 7.1 episodes at 9 months follow-up The median number of drinks per week at baseline was reduced from 36 drinks to 2.3 drinks at 9 months for intervention women At 9 months 57.9% of the intervention group reported no binge episodes versus 46.8% in the control group

87. Preventing Alcohol-Exposed Pregnancy in College Women

88. Sexual risks in college women College women fail to use contraception consistently. 38% of females reported alcohol facilitated their sexual opportunities.* Over 2,000 pregnancy tests are performed annually at VCU�s Student Health Center with several hundred visits for emergency contraception. VCU undergraduate survey, Spring 1999.

89. Mini epidemiological survey/screener Focus groups Randomized controlled trial Dual target: Women at risk can reduce drinking, increase contraception effectiveness, or both to reduce the risk of alcohol exposed pregnancy

90. Project Balance: reducing AEP risk among college women Funded by CDC/AAMC grant MM0044 Components: Epi survey, focus groups, and a randomized controlled trial

91. College women�s risks : Ineffective contraception odds are increased by: risk drinking (OR 1.7, 1.2-2.4) barrier vs. hormonal contraception (OR 2.9, 2.1-4.1) partner deciding on contraception (OR 3.8, 1.5-9.8) Ineffective/absent condom use odds are increased by: Risk drinking (OR 1.9, 1.3-2.8) Using condoms for STI prevention rather than contraception (OR 2.7, 1.5-5.0) Partner deciding on contraception (OR 2.6, .9-7.7)

92. Epi Survey N=2012 Female students aged 18-24, fertile 17 item survey administered in person, by phone or by self at student health center Anonymous and voluntary Demographics: Mean age = 20.4 years 69% White, 24% Black, 80% sexually active in past 90 days 9 seeking pregnancy/4 currently pregnant

93. College Women�s Risks in past 90 days 23% (n=457) drinking 8+/week 63% (n=1271) reporting a binge (5+) 80% (n=1603) reporting vaginal sex 18% (n=268) using contraception ineffectively 44% (n=878) ineffective/absent condom use 13% (n=261) at risk for pregnancy while drinking at risk levels 31% (N=618) at risk for STIs while drinking at risk levels

94. Focus Groups Findings Like malt liquor 1 drink = whatever size your cup is. Binge = �over your usual limit� regardless of how many drinks Moderate = Drinking to your tolerance rather than # of drinks Skepticism about, but widespread use of, BCPs. Condoms used more as backup or STD protection More concern about pregnancy than STD�s because �most STD�s can be treated.� Guy should supply condom

95. College Women Considerations Students don�t see behaviors as problematic Readiness for change might be low Intervention must address readiness for change and motivation Reality: Many would terminate pregnancy, so less AEPs carried to term. Goal is to prevent any negative consequence of drinking and having unprotected sex. Intractable binge drinking problem in this pop makes a dual intervention desirable. As a multisite team, we considered several important factors in designing the intervention.As a multisite team, we considered several important factors in designing the intervention.

96. Balance RCT Intervention Intervention used the Motivational Interviewing counseling style (Miller & Rollnick, 2002) Explore and resolve ambivalence about changing & increase perceived discrepancy between current behaviors and overall goals by providing feedback Counselor Strategies: express empathy; manage resistance without confrontation; support self efficacy Counselor Techniques (open-ended questioning; reflective listening; summarizing; affirming) Focused on dual behaviors � Alcohol Use and Contraceptive Behaviors Reduced to one session from 4 session Project CHOICES study

97. Balance RCT Components Informed Consent Give Assessment Battery --CORE Interview --FFI --OQ.45 --BSI Randomization CONTROL GROUP: give brochure, answer questions Schedule 1 and 4M Follow-ups INTERVENTION GROUP: TLFB Psycho-education Decisional Balance (pros and cons for both behaviors) Temptation and Confidence Scales BREAK (compute feedback) Provide feedback using MI Complete stage rulers (importance, confidence, readiness) Complete MY Plan Give info about optional GYN appt. Give SEQ Schedule 1 and 4M Follow-ups

98. Balance RCT Sample Baseline Characteristics (n=228) Intervention Information Age 1st contraception 16.2 16.3 # of partners/90 days 1.5 1.4 Age 1st drink 15.7 14.9 Most drinks/day 7.9 7.4 # of binges in 30 days 4.1 4.3 Ever had Pap 92% 84% Ever treated for STI 18% 18% Illicit drug use 82% 81% White 67% 73% Black/A.A. 17% 15% Asian/Pacific Isle 10% 5% no between groups differences

99. BALANCE Outcomes: 1M Follow-up (N=199) Intervention (94) Information(105) Drinks/week 9.5 11.4 # of Binges 2.9* 4.4 Most drinks/day 5.9* 7.1 Effective contraception 64%* 48% Not at risk for AEP 74%* 54% Being in control group increased odds of persistent AEP risk two-fold. Ingersoll et al.,(2005) Journal of Substance Abuse Treatment, 29, 173-180

100. BALANCE Outcomes: 4M Follow-up N=202 In past 3 months� Intervention(94) Information(105) Drinks/week 8.7 9.8 # of Binges (90 days) 6.5 7.7 Most drinks/day 6.0* 8.0 Effective contraception 68% 56%* Not at risk for AEP 75%* 62% Ceperich et al., under review Change in highest number of drinks from baseline is significantChange in highest number of drinks from baseline is significant

101. Balance RCT Conclusions High rate of risky drinking and unprotected sex in this sample of college women A one session motivational intervention targeting dual behaviors using brief follow-ups is feasible with college women. Women in both the intervention and control groups show decreased drinking and increased contraception at follow-ups (with significantly more in the intervention group). Differences between groups lessen at 4-month follow-up

102. Balance RCT Tips Preventing AEP may be less relevant for college women than preventing negative impact of drinking and engaging in unprotected sex Binge drinking is highly entrenched in college population. Most women motivated for and already (ineffectively) using contraception. May be easier to influence effectiveness of contraception than drinking Any decrease in very high rates of binge drinking is a success from a harm reduction perspective One session is feasible but boosters may be needed

103. EARLY: Preventing alcohol-exposed pregnancies in high risk community women Project Aim and Design Test single session interventions for their ability to prevent alcohol-exposed pregnancy in high risk women. Modified successful projects Choices and Balance to increase efficiency and portability CONDITIONS: 1. EARLY (counseling, FASD information, assessment) 2. Video Comparison (FASD information, assessment) 3. Assessment Control (assessment only) 258 women randomly assigned to one of three groups (86 per group) Follow-ups at 3 and 6 months

104. Eligibility for EARLY Woman between 18-44 years of age Sexually active with man in past 90 days Risky drinking = More than 7 standard drinks per week OR more than 3 drinks on one occasion in past 90 days Risky contraception = No contraception or inconsistent use of method Willing to be followed for 6 months Not currently in untreated Major Depressive Episode or untreated Opioid-dependent

105. EARLY Intervention Group Eligibility Screening Informed Consent and Enrollment Baseline Assessment Randomization One session intervention Schedule 3 and 6 M follow-ups

106. EARLY Intervention Group Single session, using MI spirit (evocation, collaboration, autonomy support and techniques (OARS) feedback comparing to women 18-44 drinks/week, drinks/day, binging, BAC $ Costs of drinking Pregnancy risk Efficacy of different contraception methods NOFAS 10 minute video 1 activity to explore ambivalence, readiness, tempting situations, or change planning. When needed, encourage a gyn visit

107. EARLY Video Group Eligibility Screening Informed Consent and Enrollment Baseline Assessment Randomization One session intervention ---NOFAS video and debriefing Schedule 3 and 6 M follow-ups

108. EARLY Control Group Eligibility Screening Informed Consent Enrollment Baseline Assessment Randomization Information Provision and Resource List Schedule 3 and 6 M follow-ups

109. EARLY Baseline Characteristics

110. EARLY Drinking Rulers

111. EARLY Contraception Rulers

112. EARLY Experience We�ve screened 237 women to get 30 enrolled participants; 12.7% eligibility rate to date Women report liking the intervention and the study experience Awaiting follow-up data; no comment on outcomes yet

113. Conclusion Single session interventions to reduce AEP risk are: Feasible Liked by women More practical Effective (Balance, for college women) Promising (EARLY, outcomes not yet known) Worthy of further testing Thanks to Balance team: Sally Brocksen, Danielle Hughes, Tawana Olds, and Mary Lewis, and EARLY team: Theresa Ly, Amy Fansler, Mike Karakashian, Stefania Fabbri, Corey Detrick, and Kim Penberthy

114. Role of Ambivalence Ambivalence is a normal component of psychological problems Acknowledge and protect the side that doesn�t want to change Explore pros and cons of change (decisional balance) Specifics are unique to each person--try not to assume Do NOT want to join with side that wants to change prematurely or will invoke REACTANCE. Natural tendency to support or protect the opposite viewpoint that exists within the person. MI assumes that people have the capacity to solve their own problems and come up with resourceful solutions�if we help remove the barriers. Research supports this. For example, empirical evidence that large groups of problem drinkers are successful eventually in changing drinking behaviors. ONLY 5% require formal treatment to do so. WE are not the change process---only a small piece.Do NOT want to join with side that wants to change prematurely or will invoke REACTANCE. Natural tendency to support or protect the opposite viewpoint that exists within the person. MI assumes that people have the capacity to solve their own problems and come up with resourceful solutions�if we help remove the barriers. Research supports this. For example, empirical evidence that large groups of problem drinkers are successful eventually in changing drinking behaviors. ONLY 5% require formal treatment to do so. WE are not the change process---only a small piece.

115. Ethel The Stages of Change

125. Three in a row exercise Imagine difficult client characteristics Seeing three in a row and bringing up behavior change: your reaction? What counselor actions could make it worse? What counselor actions could improve the scenario?

126. Persuasion exercise You are a counselor seeing clients at high risk for HIV transmission through risky sex. You have only 5 minutes to get your next client to change. Use as many of the following techniques as possible.

127. Persuasion techniques Order, direct, or command Warn or threaten Give advice, suggestions, or solutions Persuade with logic, argue, or lecture Moralize or preach Detach, humor, or withdraw Disagree, judge, blame, criticize Agree, approve, praise Shame, ridicule, label Interpret or analyze Reassure or sympathize Question or probe

128. Express Empathy Acceptance facilitates change Reflective listening helps the client feel understood Show acceptance that ambivalence is normal and change can be difficult

129. MI Strategies to build rapport: OARS Open-ended questions Affirmations Reflections simple, amplified, double-sided Summarize

130. Exercise: Thinking ReflectivelyTriads or quadsOne thing I like about myself is�.�Do you mean _________?�

131. Exercise: Forming Reflections Offer your hypothesis about the speaker�s meaning Put the guess into a STATEMENT Keep voice tone low at end 1. Demonstration �something I like about myself� 2. Practice �something I�m considering changing�

132. Video Example: Reflective Listening by Bill Miller

133. The 4 Principles of MI Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy

134. Develop Discrepancy Amplify cognitive dissonance Difference between where one is and where one wants to be Awareness of consequences is important Encourage client to present reasons for change--elicit change talk

135. Elicit the DARN-C Desire Ability Reasons Need Commitment to change

136. Using rulers to elicit DARN-C How important is it, on a scale of 0-10, for you to make this change now? 0 10

137. Using rulers to elicit DARN-C How confident are you, on a scale of 0-10, that you can make this change now? 0 10

138. Using rulers to elicit DARN-C How committed are you, on a scale of 0-10, to make this change now? 0 10

139. Explore the whys and hows to promote behavior change Importance Why Why should I? I want to, but�. What will I gain/lose? Confidence How? Efficacy expectations Will I be able to? What skills do I need? Red Importance Blue Confidence Although both are critical, you won�t get far if the patient�s concerns are blue and you�re focusing on red and vice versa. Accurate assessment of importance, confidence, and readiness is critical. Elicit difference between readiness and I/CRed Importance Blue Confidence Although both are critical, you won�t get far if the patient�s concerns are blue and you�re focusing on red and vice versa. Accurate assessment of importance, confidence, and readiness is critical. Elicit difference between readiness and I/C

141. Decisional Balance Exercise

142. Roll with Resistance Use momentum to your advantage Shift perceptions New perspectives are invited, not imposed Clients are valuable (best?) resource in finding solutions

143. Exercise: Batting Practice or Dodge Ball

144. Video example Managing overt resistance Feisty client, court-ordered, irritating What counseling techniques are used? What traps does the counselor avoid?

145. Support Self-Efficacy Instill or increase belief in possibility of change Client is responsible for choosing and carrying out change There a range of alternatives that can create change One�s belief in his or her ability to carry out and succeed with a specific task Both client and counselorOne�s belief in his or her ability to carry out and succeed with a specific task Both client and counselor

146. Exercise: Counseling DyadsExploring Previous Successes

147. Traps or Therapist Pitfalls Question-Answer Confrontation-Denial Expert Trap Labeling Trap Premature Focus Blaming Trap GOAL is to elicit from an ambivalent client the reasons for concern and the arguments for change!GOAL is to elicit from an ambivalent client the reasons for concern and the arguments for change!

148. Clinician traps example Cardiologist interview Post-MI patient Note the traps or countermotivational strategies used Note any MI-consistent interview behavior

149. Key Tasks in Consultations on Behavior Change

150. Contrast example: the MI way Same cardiac patient Note rapport building and agenda setting by clinician Which MI principles are being used? Which MI techniques do you notice?