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Theories of Change. Brentwood Hospital 4/23/14. Agenda. Intro: Getting this into Context Description of Motivational Interviewing Techniques: Eliciting change talk Identifying readiness to change I CAN summaries. Context. Where are we?. You are here. Substance Use Stats.
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Theories of Change Brentwood Hospital 4/23/14
Agenda • Intro: Getting this into Context • Description of Motivational Interviewing Techniques: • Eliciting change talk • Identifying readiness to change • I CAN summaries
Context Where are we? You are here.
Evolution of Treatment Approaches Old School Break’em down and Build’em up. Evidence Based Client-centered Cognitive-Behavioral Family Therapies Motivational Interviewing
Getting Motivated Overview of MI
Your Challenge is . . . • Lose weight • Eat healthy • Exercise • Stop smoking • Kick that heroin habit once and for all!
History of Motivational Approaches Transtheoretical Model of the Stages of Change Motivational Interviewing Mostly Application Miller & Rollnick • Mostly Theoretical • Prochaska & DiClemente
Stages of Change • Pre-contemplation • Contemplation • Preparation • Action • Maintenance Motivational Interviewing
MI Spirit • Evocation • Resist righting reflex • Understand motivation • Listen • Empower • Autonomy • Collaboration • MI Principles • Change Talk OARS • Open-ended Questions • Affirmation • Reflective Listening • Summaries • Help clients articulate reasons for change.
MI Spirit & Principles Resist righting reflex Understand motivation Listen Empower • Autonomy • Collaboration • Evocation
OARS Skills & Change Talk Eliciting change talk. • Open Questions • Affirmation • Reflective Listening • Summaries
What NOT to Do! • Convincing clients that they have a problem • Arguing for benefits of change • Telling clients how to change • Warning them of consequences of not changing
1 Practice Everything so Far Upset Client: They told me I have to make 90 AA meetings in 90 days! That is just not going to happen- I can’t even sit through one meeting. Response: Oh come on, its not that bad. Don’t you want to get better?
2 Another one Client: So my family has this “get together” and they all sit around and tell me how I am an alcoholic. Like none of them ever gets drunk. Response: If it looks like a duck and quacks like a duck its probably a duck. All those people can’t be wrong. You’re probably in denial, don’t you think?
Change Talk • Represents statements about change • Linked to a specific behavior or goal • Comes from the client • Refers to present situation
Continuum of Change • I wish things were different Desire • I know how to change Ability • It would be great if I changed Reason • I really need to change Need • I am going to change Commitment/Taking Steps
1 Evocative Questions • In what ways does this concern you? • How would you like things to be different? • How would things be better if you changed?
2 Elaboration • Tell me about a time you . . . (engaged in maladaptive behavior) • What does it look like when you . . . . • Tell me about a time before you . . .
3 Using Extremes Worst outcome vs. best outcome What concerns you the most? What is the worst that could happen? What do you hope for the most? What would a perfect outcome be?
4 Looking Back • Do you remember a time when things were going well? What has changed? • What did you want to do when you graduated from high school? • What is the difference between you now and you twenty years ago?
5 Looking Forward • If nothing changes, what do you see happening in 5 years? If you decide to change, what will it be like? • What are your hopes for the near future?
6 Exploring Goals Use value card sort • What are some things you regard as important? How does drinking fit in with that? • What sorts of things do you want to accomplish in your life? (Miller, Baca, Matthews, Wilbourne, 2001)
7 Use Feedback • Your scores on the MoCA (or MSE) indicate that you have moderate deficits in problem solving and memory. How does that fit with your own experience?
8 Readiness Rulers • On a scale of 1-10, how confident* are you – if you made a decision to change – that you could change, when 1=not at all confident and 10= extremely confident? • What led you to choose 6 rather than a 3? • What would it take to move from a 6 to a 7 or 8? * or important
Your Turn • Which of the previous techniques would work best (if at all) with your change challenge? • How do you feel when thinking about your challenge?
Which would you use? • Evocative Questions • Elaboration • Using Extremes • Looking Back/Forward • Exploring Goals • Use Feedback • Readiness Rulers
Signs of Readiness • Decreased resistance • Decreased discussion • Resolve • Change talk • Questions about change • Envisioning • Experimenting
1 Identifying Readiness So, what do other people say about this? I just can’t believe that people just cave in when they hear recommendations sending them to a halfway house. • Signs? • Your reasoning:
2 Identifying Readiness I agree it would be good to make some different choices that have less risk, but I also like to have fun with my friends. I have too much fun with them. • Signs? • Your reasoning:
3 Identifying Readiness You don't understand. These guys aren't going to take "No, thanks" for an answer. They're going to hound me. I've got to come back with something stronger. • Signs? • Your reasoning:
The ‘I CAN’ Strategy Indicate this is a summary, and include • Change talk, • Ambivalence, and then ask about the • Next step.
1 Ambivalence Strategies: ICAN “I still think weed is not as bad as people say, at least its not like cocaine. Maybe smoking has affected my grades, I don’t know. I’ve been thinking that maybe I should lay off for the rest of the semester or until I get my grades up. But weed really helps me relax and I need that."
2 Ambivalence Strategies: ICAN "I didn't like the way I felt on the Suboxone. There were just too many side effects. So, I stopped. But I think I need to do something. Nothing feels good. I'm always anxious. I can never get comfortable. I’m thinking that eventually I’ll start using again. That's where I'm at now.”
3 Ambivalence Strategies: ICAN “When I first got the DWI I figured the cop was just a jerk- I hadn’t even had that much to drink. And then I went to look at my car that was impounded and I thought- how did I survive that? The thing was completely smashed in. I know I need to stop drinking but I just don’t know if I need inpatient treatment. Maybe I can do this on my own."
Application to Other Areas • Medication adherence in mental health • Diabetes management • Eating disorders • Obsessive Compulsive Disorder • Suicidal Ideation
Discussion • Will you use this in your practice? Why or Why not? • What population do you think will benefit the most? The least? • If interested, what are your plans to learn more?
Resources • www.robinsteed.pbworks.com • www.motivationalinterview.org • Worksheets, training materials • http://www.integration.samhsa.gov/clinical-practice/motivational-interviewing • Full text articles, webinars, SAMHSA TIPs, training manuals • www.researchgate.net/publication/231081405_Motivational_Interviewing_and_the_Stages_of_Change/file/9fcfd50b5f8c5af70e.pdf#page=305 • Full text of Motivational interviewing: Preparing people for change (2nd ed.).
References • Miller, W.R., ’de Baca, J. C Matthews, D.B. Wilbourne, P.L (2001). Personal Values Card Sort, University of New Mexico. Available at http://www.motivationalinterviewing.org/content/personal-values-card-sort • Miller, W. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Full text available: www.researchgate.net/publication/231081405_Motivational_Interviewing_and_the_Stages_of_Change/file/9fcfd50b5f8c5af70e.pdf#page=305 • National Institute for Health and Clinical Excellence (NICE). Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Feb. 54 p. (Clinical guideline; no. 115). • Rosengren, D. (2009). Building motivational interviewing skills. New York: Guilford Press. • Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. (2011). Motivational interviewing for substance abuse. Cochrane Database of Systematic Reviews, Issue 5, Art. No.: CD008063. DOI: 10.1002/14651858.CD008063.pub2. • Substance Abuse and Mental Health Services Administration (2010). Getting started with evidence-based practices: Integrated treatment for co-occurring disorders. Evidence-Based Practice Series, Publication Id: SMA08-4367. • www.motivationalinterview.org