Introduction to Motivational Interviewing Dr. CoCo Collins, MI Trainer

1. Introduction to Motivational InterviewingDr. CoCo Collins, MI Trainer 2011 Community Wellness Conference A New Game Plan for A Healthy Mississippi Biloxi, May 25, 2011

2. Contact: • drcococollins@gmail.com • 225-936-2959

3. Objectives:MI Basic Principles and Strategies • Spirit of MI • OARS - Open Ended Questions, Affirmation, Reflective Listening, and Summary Statements. • Motivational rulers and • looking for "change talk" using the DARN-CAT chart.

4. Why use MI? • It is one of the highest rated, evidence-based strategy to increase the likely hood that people will change (NREPP). • NREPP is a searchable online registry of more than 190 interventions supporting mental health promotion, substance abuse prevention, and mental health and substance abuse treatment. • http://nrepp.samhsa.gov/Search.aspx

5. What is MI primarily used for? • People who are not ready to change maladaptive behaviors.

6. Who founded MI? • Dr. William (Bill) Miller and later, Dr. Stephen Rollnick added to the depth of MI.

7. 5 Myths about Drug Addiction and Substance Abuse MYTH 1: Overcoming addiction is a simply a matter of willpower. You can stop using drugs if you really want to. Prolonged exposure to drugs alters the brain in ways that result in powerful cravings and a compulsion to use. These brain changes make it extremely difficult to quit by sheer force of will. MYTH 2: Addiction is a disease; there’s nothing you can do about it. Most experts agree that addiction is a brain disease, but that doesn’t mean you’re a helpless victim. The brain changes associated with addiction can be treated and reversed through therapy, medication, exercise, and other treatments. **MYTH 3: Addicts have to hit rock bottom before they can get better. Recovery can begin at any point in the addiction process—and the earlier, the better. The longer drug abuse continues, the stronger the addiction becomes and the harder it is to treat. Don’t wait to intervene until the addict has lost it all. **MYTH 4: You can’t force someone into treatment; they have to want help. Treatment doesn’t have to be voluntary to be successful. People who are pressured into treatment by their family, employer, or the legal system are just as likely to benefit as those who choose to enter treatment on their own. As they sober up and their thinking clears, many formerly resistant addicts decide they want to change. MYTH 5: Treatment didn’t work before, so there’s no point trying again; some cases are hopeless. Recovery from drug addiction is a long process that often involves setbacks. Relapse doesn’t mean that treatment has failed or that you’re a lost cause. Rather, it’s a signal to get back on track, either by going back to treatment or adjusting the treatment approach. http://www.helpguide.org/mental/drug_substance_abuse_addiction_signs_effects_treatment.htm

8. William Miller’s Explanation of MI: http://www.motivationalinterview.org/quick_links/about_mi.html

9. Definition of MI • Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence.

10. Compared with nondirective counseling, it is more focused and goal-directed. • The examination and resolution of ambivalence is its central purpose, and the counselor is intentionally directive in pursuing this goal. 

11. Joining up (example of the “Spirit of MI”) • http://www.youtube.com/watch?v=9Dx91mH2voo&feature=fvwrel

12. The Spirit of MI • Motivation to change is elicited from the client, and not imposed from without. • It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. • Direct persuasion is not an effective method for resolving ambivalence. • The counseling style is generally a quiet and eliciting one.

13. The Spirit of MI (cont.) • The counselor is directive in helping the client to examine and resolve ambivalence. • Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction. • The therapeutic relationship is more like a partnership or companionship than expert/recipient roles.

14. The goal in MI • Is to create forward momentum and to then harness that momentum to create change. • Reflective listening keeps that momentum moving forward. This is why Bill and Steve recommend a ratio of three reflections for every question asked. • Questions tend to cause a shift in momentum and can stop it entirely. Although there are times you will want to create a shift or stop momentum, most times you will want to keep it flowing.

15. READINESS RULER • HANDOUT

16. OARS • Open-ended questions, • Affirmations, • Reflective listening, and • Summaries.

17. Open Ended Questions: • "So what makes you feel that it might be time for a change?”

18. Affirmations: • are statements of recognition about client strengths. • "So you stayed sober for a week after treatment. How were you able to stay sober for that week?” • Use resistance as a source for affirmations. For example, "You didn't want to come today, but you did it anyway. I'm not sure, but it seems like that if you decide something is important enough, you are willing to put up with a lot just to do it."

19. Reflective listening (the key): • Remember this is a directive approach. • Unlike Rogerian therapists, you will actively guide the client towards certain materials. You will focus on their change talk and provide less attention to non-change talk. • For example, "You are not quite sure you are ready to make a change, but you are quite aware that your drug use has caused concerns in your relationships, effected your work and that your doctor is worried about your health."

20. Reflective listening (cont.) • Aratio of three reflections for every question asked. • 3:1

21. A simple reflection: • Client: But I can't quit drinking. I mean, all of my friends drink! • Counselor: Quitting drinking seems nearly impossible because you spend so much time with others who drink. • Client: Right, although maybe I should.

22. Amplified Reflections • Client: But I can't quit using. I mean, all of my friends use! • Counselor: Oh, I see. So you really couldn't quit using because then you'd be too different to fit in with your friends. • Client: Well, that would make me different from them, although they might not really care as long as I didn't try to get them to quit.

23. Double-sided Reflection: • Client: But I can't quit drinking. I mean, all of my friends drink! • Counselor: You can't imagine how you could not drink with your friends, and at the same time you're worried about how it's affecting you. • Client: Yes. I guess I have mixed feelings.

24. Summaries: • are a specialized form of reflective listening where you reflect back to the client what he or she has been telling you. • do them relatively frequently as too much information from the client can be unwieldy for the therapist to digest and feedback • if the interaction is going in an unproductive or problematic direction (e.g., reinforcing status quo talk, encountering resistance), the summary can be used to shift the focus of the intervention.

25. Summary example: • "Let me stop and summarize what we've just talked about. Your not sure that you want to be here today and you really only came because your partner insisted on it. At the same time, you've had some nagging thoughts of your own about what's been happening, including how much you've been using recently, the change in your physical health and your missed work. Did I miss anything? I'm wondering what you make of all those things."

26. Shifting Focus: • Client: But I can't quit drinking. I mean, all of my friends drink! • Counselor: You're getting way ahead of things here. I'm not talking about your quitting drinking here, and I don't think you should get stuck on that concern right now. Let's just stay with what we're doing here - talking through the issues - and later on we can worry about what, if anything, you want to do about it. • Client: Well I just wanted you to know.

27. BATTING PRACTICE OARS • Open-ended questions, • Affirmations, • Reflective listening, and • Summaries.

28. In simplest form, the implicit theory of MI proposes: MI will increase client change talk MI will diminish client resistance The extent to which clients verbally defend status quo (resistance) will be inversely related to behavior change The extent to which clients verbally argue for change (changetalk) will be directly related to behavior change

29. MI Increases Change Talk • Problem drinkers randomly assigned to MI (vs. confront/direct) showed 111% more change talk (Miller, Benefield & Tonigan, 1993) • Consistent with findings of within-subject clinical experiment (Patterson & Forgatch, 1985) • Psycholinguistic analysis of MI showed robust, atypical increases in change talk (Amrhein et al., 2003) SUPPORTED

30. MI Decreases Resistance • Problem drinkers randomly assigned to confront/direct showed 78% more resistance than those in MI. Counselor confront responses specifically predicted client level of resistance (Miller, Benefield & Tonigan, 1993) • Consistent with findings of within-subject clinical experiment (Patterson & Forgatch, 1985) • Psycholinguistic analysis of MI showed robust decreases in commitment to drug use during MI (Amrhein et al., 2003) • SUPPORTED

31. Client resistance predicts lack of change • Level of client resistance during counseling predicted absence of change in drinking (Miller, Benefield & Tonigan, 1993) • Verbal commitment to drug use during MI predicted continued drug use (Amrhein et al., 2003) • Resistance-poor outcome relationship replicated in several other studies • SUPPORTED

32. Change talk involves statements or affective communications that indicate the client may be considering the possibility of change. Four categories: • problem recognition, • concern about the problem, • commitment to change, and • belief that change is possible.

33. The Flow of Change Talk

34. Prochaska’s Stages of Change Theory& Appropriate Goals 1. Precontemplation- Increase awareness, raise doubt 2. Contemplation- Tip the balance toward change 3. Preparation- Select the best course of action 4. Action- Initiate change strategies 5. Maintenance- Learn relapse prevention strategies 6. Relapse- Get back on track with renewed commitment to change

35. Tasks and goals for each of the Stages of Change 1.PRECONTEMPLATION - The state in which there is little or no consideration of change of the current pattern of behavior in the foreseeable future. ￭ TASKS: Increase awareness of need for change and concern about the current pattern of behavior; envision possibility of change ￭ GOAL: Serious consideration of change for this behavior

36. Tasks and goals for each of the Stages of Change 2. CONTEMPLATION– The stage where the individual examines the current pattern of behavior and the potential for change in a risk – reward analysis. ￭ TASKS: Analysis of the pros and cons of the current behavior pattern and of the costs and benefits of change. Decision- making. ￭ GOAL: A considered evaluation that leads to a decision to change.

37. Tasks and goals for each of the Stages of Change 3. PREPARATION– The stage in which the individual makes a commitment to take action to change the behavior pattern and develops a plan and strategy for change. • TASKS: Increasing commitment and creating a change plan that is acceptable, accessible & effective. • GOAL: An action plan to be implemented in the near term.

38. Tasks and goals for each of the Stages of Change 4. ACTION– The stage in which the individual implements the plan and takes steps to change the current behavior pattern and to begin creating a new behavior pattern. ￭ TASKS: Implementing strategies for change; revising plan as needed; sustaining commitment in face of difficulties ￭ GOAL: Successful action to change current pattern. New pattern established for a significant period of time (3 to 6 months).

39. Tasks and goals for each of the Stages of Change 5. MAINTENANCE– The stage where the new behavior pattern is sustained for an extended period of time and is consolidated into the lifestyle of the individual. ￭ TASKS: Sustaining change over time and across a wide range of different situations. Avoiding slips and relapse back to the old pattern of behavior. ￭ GOAL: Long-term sustained change of the old pattern and establishment of a new pattern of behavior.

40. The 4 processes are somewhat linear ... • Engaging necessarily comes first • Focusing (identifying a change goal) is a prerequisite for Evoking • Planning is logically a later step Engage Focus Evoke Plan

41. DRUMMING FOR CHANGE TALK – DARN CAT • DESIRE to change (want, like, wish . . ) • ABILITY to change (can, could . . ) • REASONS to change (if . . then) • NEED to change (need, have to, got to . .) • COMMITMENT (intention, decision, promise) • ACTIVATION (willing, ready, preparing) • TAKING STEPS

42. Contact: • drcococollins@gmail.com • 225-936-2959

43. References American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised, 4th ed.). Washington, DC: American psychiatric Association. Brooks, F., McHenry, B., (2009). A Contemporary Approach to Substance Abuse and Addiction Counseling, American Counseling Association, Alexandria, VA. Hester, R. H. & Miller, W. R. (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (3rd ed.), 2003, Allyn & Bacon. http://coce.samhsa.gov/cod_resources/PDF/ChangeProcessesthatImproveTreatmentPractice10-04.pdf http://coce.samhsa.gov/cod_resources/PDF/Co-OccurringDisordersOverview10-04.pdf http://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf

44. References (cont.) http://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf http://www.helpguide.org/mental/drug_substance_abuse_addiction_signs_effects_treatment.htm Kelly, J., Magill, M., Stout, R. (2009). Addiction Research and Theory, 17, 236-259. Laudet, A. (2007). What does recovery mean to you? Lessons from the recovery experience for research and practice. Journal of Substance Abuse Treatment, 33, 243-256. Miller, William. (2010)r Looking Forward to MI-3. PowerPoint Presented to 2010 MINT Forum.m, San Diego Miller, P. & Miller, W. (2009). What should we be aiming for in the treatment of addiction? Society for the Study of Addiction, 104, 685-.686. Sannibale, C., Fucito, L., O’Connor, D., & Curry, K. (2005). Process evaluation of an out-patient detoxification service. Drug and Alcohol Review, 24, 475-481.