Motivational interviewing: developing basic skills

1. Motivational interviewing: developing basic skills Pathways to Housing PA Training Institute Matt Tice, LCSW Oksana Kaczmarczyk, LCSW, LCADC March 14, 2018

2. Matt Tice Oksana Kaczmarczyk MSW, LCSW, LCADC Rutgers University Over 9 years of clinical experience working with adults diagnosed with severe mental illness (SMI) and/or substance use D/O. Completed a training course in Cognitive Behavioral Therapy (CBT) through the Beck Institute and use CBT as the main treatment modality. • MSW, LCSW • University of Buffalo Matt Tice has worked his way through the ranks of Pathways to Housing PA, first as an Assistant Team Leader in 2012, then as a Team Leader, and then as Clinical Director in 2014.

3. WHAT IS MI “MI is more than a set of techniques…it is a way of being with people….and is designed to resolve motivational issues that inhibit positive change behavior…”

4. Motivation and Change • Motivation is fundamental to change • Motivation cannot be imposed, but can be promoted • Motivation has critical components: • Willingness • Readiness • Ability

5. Motivation and Change • Change occurs naturally • Change is a process not an event • Constructive behavior change arises when a person connects it with something of intrinsic value • Your own value and belief system will influence your client’s progress or lack there of towards change

6. Punitive responses inhibit change • Aggressive or punitive impositions of change aren’t effective • Confrontation produces increased Resistance • Labeling an individual as Resistant can increase denial • Forcing short term change is ineffective • “The Consequences” talk doesn’t work

7. The spirit of MI • MI • Collaboration. Partnership like relationship • Evocation. Motivation and resources for change are presumed to reside within the client • Autonomy. The counselor affirms the client’s right for self-direction • Non MI (Traditional) • Confrontation. Imposing acceptance of “reality” that the client cannot see • Education. The client is presumed to lack key knowledge, insight, and skills needed for change to occur. • Authority. The counselor tells the client what he or she must do

8. Principles of MI • Express empathy • Acceptance facilitates change • Reflective listening is fundamental • Ambivalence is normal • Develop discrepancy • The client not the counselor give reasons for change • Create and amplify discrepancy between current behaviors and person’s values and goals

9. Principles of MI • Roll with resistance • Avoid arguing for change • The client is a primary resource in finding solutions • Resistance is a signal to respond differently • Support self-efficacy • The person’s belief in the possibility of change is an important motivator • The client, not the counselor, is responsible for choosing and carrying out the change

10. Stages of Change and MI • Precontemplation • No consideration of change • Contemplation (MI the most effective here) • Examine current behavior and its risk-reward analysis • Ambivalence • Decision making • (DiClemente, 2003)

11. Stages of Change and MI • Preparation • Commitment to take action • A plan for change • Action • Implement the plan • Maintenance • New behavior/change is sustained • (DiClemente, 2003)

12. Stage of change • Precontemplation – explore their concerns • Question: “What are your thoughts about changing X behavior”? (this will help assess their stage of change) • Contemplation is the best place for MI • The goal is to move them to the next stage • Interventions have to match to the individual’s current stage

13. Pushing for change • Ambivalence • The Righting reflex-the innate desire to fix , advise, teach, or argue for the resolution of one’s ambivalence. • The harder the counselor argues for change, the stronger the client’s position for not changing

14. The Instinct of The Righting Reflex • “Why don’t you want to change?” • “How can you tell me that you don’t have a problem?” • “Why don’t you just sign up for treatment?” • “Why can’t you go to your appointments on your own?” • “What makes you think that you are not at risk?”

15. Eliciting “Change talk” • Developing discrepancy • Ambivalence makes change possible • As Discrepancy increases, ambivalence intensifies and then moves in the direction of change • When a behavior comes into conflict with a deeply held value, it is usually the behavior that changes

16. Eliciting “Change Talk” • Change talk –speech that reflects movement toward change • Resistance- movement away from change • Know how to recognize each • Know how to elicit change talk • Know the role you play in each

17. Building Motivation for Change • Elicit change talk • What would help you make this change? • Not “why wouldn’t you change?” • How might you go about it in order to succeed? • What three reasons do you have for making this change?

18. Eliciting “Change Talk” • Argument for change • Clients to argue for change • Less questions more reflections: • Reflective listening (taking a guess at what it is your client is saying and you deliver it back to the client) • Trying to put yourself in the client’s frame of mind and try to understand them • 2 reflections for every question that we ask • Person feels like they are being heard

19. Building Motivation for Change • Scaling questions (readiness ruler) • How important it is for you to change a particular behavior? • How confident are you that you can make this change? • Importance or confidence? • Importance has to be increased first before someone can work on the confidence

20. Scaling questions (readiness ruler) • 4 client profiles: • A: Low importance, low confidence • B: Low importance, high confidence • C: High importance, low confidence • D: High importance, high confidence

21. Building Motivation for Change • Follow up questions: • Why are you at a ___ not a 0 (why isn’t a lower number)? (this helps elicit change talk) • Don’t ask why one isn’t at a higher number because it doesn’t elicit a change talk • “What would it look like for you to go from___to a higher number?”(elicits change talk)

22. MI Methods • O-Open ended questions • A-Affirmation • R-Reflective listening • S-Summarizing

23. Open ended question • “Tell me what’s it like to live on the streets” • “What are your thoughts on getting an apartment?” • “What are some important reasons you may want to see the psychiatrist?” • “Tell me what challenges you encountered when you ended up homeless”

24. Affirmation • “Thank you for agreeing to meet with me today” • “I must say, if I were in your position, I don’t know if I would’ve managed to survive” • “You are very resourceful”

25. Reflective listening • Reflective listening (taking a guess at what it is your client is saying and you deliver it back to the client) • Trying to put yourself in the client’s frame of mind and try to understand them • 2 reflections for every question that we ask • Person feels like they are being heard • Double sided reflections: • On one hand I hear this side of the ambivalence, on the other hand I hear the other side of the ambivalence • Client in crisis (audience question)

26. What’s not Reflective Listening? • Ordering, directing, or commanding • Warning, threatening • Giving advise or providing solutions • Telling people what they should do; moralizing • Judging, criticizing or blaming • Shaming • Agreeing , approving, or praising

27. Summarize • Collecting summary • Summary +”What else?” • Encourage the person to keep going and draw together change talk • Linking summary • Connection to what was said earlier • Can help clarify person’s ambivalence • Transitional summary • Marks a shift from one focus to another

28. Questions for evoking change • Open ended questions to evoke change: • 1. Disadvantages of status quo • What worries you about your current situation • How has this stopped you from doing what you want in your life? • What do you think will happen if you don’t change anything?

29. Questions for Evoking Change • 2. Advantages of change • How would you like for things to be different? • What would your life look like 5 years from now? • What would be advantages of making this change? • 3. Optimism about change • What encourages you that you can change if you want to? • What do you think would work for you if you decided to change?

30. Questions for Evoking Change • 3. Optimism about change • What encourages you that you can change if you want to? • What do you think would work for you if you decided to change? • Who could offer you helpful support in making this change? • What strengths do you have to help you succeed?

31. Questions for Evoking Change • 4. Intention to change • How important is this to you? How much do you want to do this? • So what do you intend to do ? • What are you thinking about drinking at this point?

32. The Hierarchies Maslow’s Hierarchy of needs Hierarchy of personal values

33. Summary • MI facilitators lead conversational sessions that are collaborative, nonjudgmental, and focus on strengthening clients' own motivation and commitment to change. MI emphasizes client engagement (establishing a helpful relationship, understanding barriers and reasons to change), focusing (identifying change area, and setting an agenda), evocation (eliciting the client's motivation to change and building their self-efficacy), and planning (developing a commitment to change and formulating an action plan). • David et al (2018)

34. Case studies

35. John, is a 55 yo Caucasian male who’s been drinking alcohol since 13. He always said that alcohol was a part of his identity and could not live without using it. He tells you his health is important to him and that he wants to be involved in his daughter’s life. His doctor told him to stop drinking if he wanted to live longer than 5 years. His daughter told him that as long he is drinking, she wanted nothing to do with him. John states that lately, he has been thinking about quitting drinking, but he can’t imagine living without alcohol. • Stage of change-Contemplation • Non MI Dialogue of SW and John • J – “My daughter turned 29 yesterday and I couldn’t even go to see her. I am such a loser”. • SW- “Well, you know what you have to do if you wanna see her?” • J – “What’s that?” • SW – “Well, she told you million times that as long as you’re drinking, she’ll want nothing to do with you. Don’t you remember her saying that to you?”

36. John, is a 55 yo Caucasian male who’s been drinking alcohol since 13. He always said that alcohol was a part of his identity and could not live without using it. He tells you his health is important to him and that he wants to be involved in his daughter’s life. His doctor told him to stop drinking if he wanted to live longer than 5 years. His daughter told him that as long he is drinking, she wanted nothing to do with him. John states that lately, he has been thinking about quitting drinking, but he can’t imagine living without alcohol. • Non MI Dialogue (contd.) • J – “Yea, I remember what she told me. I tried not drinking yesterday, but I just couldn’t resist it”. • SW – “Maybe you didn’t try hard enough. I know when people really put their minds to do something, they can do it. Where there is a will, there is a way”. • J- “If it’s that easy for other people and I couldn’t even last half a day, something must be wrong with me. I am a loser, just like my mom told me I was”.

37. MI Dialogue • John, is a 55 yo Caucasian male who’s been drinking alcohol since 13. He always said that alcohol was a part of his identity and could not live without using it. He tells you his health is important to him and that he wants to be involved in his daughter’s life. His doctor told him to stop drinking if he wanted to live longer than 5 years. His daughter told him that as long he is drinking, she wanted nothing to do with him. John states that lately, he has been thinking about quitting drinking, but he can’t imagine living without alcohol. • J- “My daughter turned 29 yesterday and I couldn’t even go to see her. I am such a loser”. • SW- “It sounds like you are really upset that you didn’t get to see your daughter. What got in the way of you seeing her?” • J- “My drinking. I remember she told me I couldn’t see her if I was drinking. I really wanna see her, but I am not ready to give up alcohol”. • SW- “I see. On one hand I hear you say that your daughter is important to you, on the other hand I hear you say that you’re not ready to give up drinking”

38. John, is a 55 yo Caucasian male who’s been drinking alcohol since 13. He always said that alcohol was a part of his identity and could not live without using it. He tells you his health is important to him and that he wants to be involved in his daughter’s life. His doctor told him to stop drinking if he wanted to live longer than 5 years. His daughter told him that as long he is drinking, she wanted nothing to do with him. John states that lately, he has been thinking about quitting drinking, but he can’t imagine living without alcohol. • J – “You just can’t imagine…drinking has always been a part of me” • SW – “What would help you stop drinking?” • J – “My daughter is the biggest reason. I would see her regularly. And, I know that drinking is killing my liver. So, I would be in better shape without alcohol”. • SW – “If you were to decide to stop drinking, how confident you’d say you are that you could succeed at it. What number would you rate it on the confidence ruler?” • J – “ Hmmm, I am thinking 3”

39. Case Study 2 • Micheala had been engaged for years before she came in to housing 3 months ago. She more or less sees her apartment as a storage unit to drop off her ever increasing collection of things like books & other items, smoke cigarettes, and sleep at night. Her landlord complains to you regularly about the sanitation issues and smells coming from her apartment. She does not express any interest in reducing these behaviors. She has said she likes being in away from the cold and doesn’t like the threat of being hassled by cops or having her stuff stolen while on the street. • M– “That landlord better not get on my case any more. I don’t know why he’s got it out for me. • SW- “Wow, that sounds like its real stressful for you. It seems like the things he says bothers you.” • M- “Darn skippy it does. He doesn’t know what its like for a person like me. • SW- “I bet not. No one knows what it its like to be you. How have things been different for you since you’ve been in your apartment?” • M- “Well I don’t like people like you coming around all the time but at least I don’t have to move from place to place. • SW- “That makes sense. I appreciate you being honest with me about that.

40. Case Study 2 • Micheala had been engaged for years before she came in to housing 3 months ago. She more or less sees her apartment as a storage unit to drop off her ever increasing collection of things like books & other items, smoke cigarettes, and sleep at night. Her landlord complains to you regularly about the sanitation issues and smells coming from her apartment. She does not express any interest in reducing these behaviors. She has said she likes being in away from the cold and doesn’t like the threat of being hassled by cops or having her stuff stolen while on the street. • SW- “I’d love to work out a way to help you deal with the stress you talked about with your landlord but also have your own freedom. What do you think would be best to do first?” • M – “I don’t know. He complains about that way I keep my place but he doesn’t live here. I do. It should be up to me. I want to keep it how I want to keep it.” • SW- I get that. It bothers you when he’s saying what’s what. On one hand I, hear you say he should leave you be as it is, but on the other hand you are also saying you want to keep your place. How might these be at odds?”

41. Case Study 3 • Francis has been housed for 2 years and has recently had a probation violation for drug possession. He’d been steady maintaining his stated goals of sobriety up until recently when he’d let his cousin stay in his unit. The cousin brought a handful of issues related to his own addiction back into Francis’ life. On a recent home visit Francis tell you he wants help figuring out how to get his cousin out of his apartment and set some boundaries so he doesn’t get sent back to jail. • F- “I’ve got to figure this out. I can’t deal with the stress of all this. It’s too much.” • SW- “Man Francis, this is a lot to deal with. You seem to want to sort out next steps though. What do you think will be different if you could set up a plan?” • F- “I’d get the drugs out of my house for one! Plus I probably need to get some distance with me and my cousin which is tough ‘cause he’s always been there for me.”

42. Case Study 3 • Francis has been housed for 2 years and has recently had a probation violation for drug possession. He’d been steady maintaining his stated goals of sobriety up until recently when he’d let his cousin stay in his unit. The cousin brought a handful of issues related to his own addiction back into Francis’ life. On a recent home visit Francis tell you he wants help figuring out how to get his cousin out of his apartment and set some boundaries so he doesn’t get sent back to jail. • SW- “I hear that. Family and loyalty is important to you. At the same time so is staying out of jail and keeping your place. Do I have that right?” • F- “Yeah. I got to do it even if it sucks.” • SW- “It really is hard, but it’s a big deal for you to recognize what’s important for you and commit to it too. Where do you think you want to be in 5 years with your relationship with your cousin?” • F- “I’d love to set some distance now but be able to come back after some time. hopefully when we both get our lives together.” • SW – “Sounds like a great plan Francis. You’re really determined. Lets talk about how you want to make that work.”

44. Comments? Questions?

45. Kennedy D.P., Osilla C.K., Hunter S.B., Golinelli D., Hernandez E.M., and Tucker S.J. “A pilot test of a motivational interviewing social network intervention to reduce substance use among housing first residents” Journal of Substance Abuse Treatment, 2018-03-01, Volume 86, Pages 36-44. DiClemente C. C. (2006). Addiction and Change: how addictions develop and addicted people recover. New York, NY Miller W. R., & Rollnick S. (2002). Motivational Interviewing: preparing people for change. New York, NY.