Learning Objectives

1. 1 In this session, you’ll begin to learn about motivational interviewing – an empathic, respectful philosophy and set of techniques for promoting behavior change. Although we’ll be talking about motivational interviewing as an approach to modifying substance use, it can be used for promoting a wide range of behaviors in many different professional and personal settings. I hope you’ll enjoy learning about it as much as I have.In this session, you’ll begin to learn about motivational interviewing – an empathic, respectful philosophy and set of techniques for promoting behavior change. Although we’ll be talking about motivational interviewing as an approach to modifying substance use, it can be used for promoting a wide range of behaviors in many different professional and personal settings. I hope you’ll enjoy learning about it as much as I have.

2. 2 Health Care Professionals will be able to: describe the transtheoretical model of behavior change and the principles of motivational interviewing cite evidence on the effectiveness of motivational interviewing start doing motivational interviewing in practice train others in the above Learning Objectives For these sessions, we’ll be focusing on Prochaska and DiClemente’s transtheoretical model of behavior change. This model speaks of stages of readiness to change, such as precontemplation and contemplation. How many of you have heard of this? How many of you have actually applied this model in practice? We’ll also be discussing principles of motivational interviewing as described by Dr. Bill Miller and colleagues. How many of you have actually used this model in practice? I’ll point out some of the evidence on the effectiveness of motivational interviewing as an approach to promoting behavior change. Finally, we’ll get down to you acquiring skills in motivational interviewing and thinking about training others to do so. For these sessions, we’ll be focusing on Prochaska and DiClemente’s transtheoretical model of behavior change. This model speaks of stages of readiness to change, such as precontemplation and contemplation. How many of you have heard of this? How many of you have actually applied this model in practice? We’ll also be discussing principles of motivational interviewing as described by Dr. Bill Miller and colleagues. How many of you have actually used this model in practice? I’ll point out some of the evidence on the effectiveness of motivational interviewing as an approach to promoting behavior change. Finally, we’ll get down to you acquiring skills in motivational interviewing and thinking about training others to do so.

3. 3 Our expectations vs. the reality of promoting behavior change The transtheoretical model of behavior change Assessing for stage of change Effectiveness of stage-based and motivational interventions In the first hour, we’ll do an introspective and discussion exercise on our feelings about trying to promote behavior change in our practice settings. Next we’ll focus on the transtheoretical model and talk about how to assess individuals for their stage of change. Then we’ll focus on some data on the effectiveness of motivational interventions.In the first hour, we’ll do an introspective and discussion exercise on our feelings about trying to promote behavior change in our practice settings. Next we’ll focus on the transtheoretical model and talk about how to assess individuals for their stage of change. Then we’ll focus on some data on the effectiveness of motivational interventions.

4. 4 What expectations do trainees have about promoting behavior change among patients/clients? To start off the introspective and discussion exercise, please tell me, “What expectations do novice health or social service professionals have about promoting behavior change in patients/clients? If you can remember, what were your expectations? (List these in front the room, then cover up if possible.)To start off the introspective and discussion exercise, please tell me, “What expectations do novice health or social service professionals have about promoting behavior change in patients/clients? If you can remember, what were your expectations? (List these in front the room, then cover up if possible.)

5. 5 Common Expectations ofNovice Clinicians “Knowledge is power”– Francis Bacon Sound advice will result inquick, easy, and lastingbehavior change Often not true Yes, most novice clinicians believe that simply bestowing our knowledge on patients and clients will elicit quick and lasting behavior change, as well as their deep appreciation.Yes, most novice clinicians believe that simply bestowing our knowledge on patients and clients will elicit quick and lasting behavior change, as well as their deep appreciation.

6. 6 How Does Behavior Change? Behavior A Behavior B This leads to the question, how does behavior change? If knowledge is insufficient to produce change, what else is necessary?This leads to the question, how does behavior change? If knowledge is insufficient to produce change, what else is necessary?

7. 7 What feelings do you experience when working with patients/clients to promote behavior change? Introspective Exercise #1(continued) Let’s put that question aside for a minute and answer a different one. What feelings do you experience when working with patients/clients to promote behavior change? (List these in front of room. Elicit discussion on a comparison of the responses to both questions. Point out that the difference between reality and expectations tends to cause stress and frustration.)Let’s put that question aside for a minute and answer a different one. What feelings do you experience when working with patients/clients to promote behavior change? (List these in front of room. Elicit discussion on a comparison of the responses to both questions. Point out that the difference between reality and expectations tends to cause stress and frustration.)

8. 8 Common Responses Some say: F u l f i l l m e n t The most common response is: - F R U S T R A T I O N - Although most of us have experience some success and fulfillment, the most common answer to this question is frustration.Although most of us have experience some success and fulfillment, the most common answer to this question is frustration.

9. 9 Think of a behavioryou have tried to change Introspective Exercise #1(continued) Now, let’s get back to that other question. To start to get insight into this, let’s take a look at our own behaviors. I’d like each of you to think of a behavior that you yourself have tried or are trying to change. It could be any behavior you’d like. Don’t worry, nobody will ask you about the behavior itself, but I want you to have a behavior in mind for some other questions I’m about to ask. Does anyone need more time?Now, let’s get back to that other question. To start to get insight into this, let’s take a look at our own behaviors. I’d like each of you to think of a behavior that you yourself have tried or are trying to change. It could be any behavior you’d like. Don’t worry, nobody will ask you about the behavior itself, but I want you to have a behavior in mind for some other questions I’m about to ask. Does anyone need more time?

10. 10 How much time elapsed between: the first time you engaged in the behavior, and the first time you recognized risk or negative consequences? Introspective Exercise #1(continued) With that behavior in mind: How much time elapsed between the first time you engaged in the behavior and the first time you recognized risks or negative consequences? (Repeat the question while showing the next slide.)With that behavior in mind: How much time elapsed between the first time you engaged in the behavior and the first time you recognized risks or negative consequences? (Repeat the question while showing the next slide.)

11. 11 How much time elapsed between the first time you engaged in the behavior and the first time you recognized risks or negative consequences? In your head, please choose one of these categories. I’ll call out each response, and I’ll ask everyone to raise your hands high when I call out your answer. As I poll the group, please look around to get a sense of how everyone is responding. Less than one month. Please raise your hands high…How much time elapsed between the first time you engaged in the behavior and the first time you recognized risks or negative consequences? In your head, please choose one of these categories. I’ll call out each response, and I’ll ask everyone to raise your hands high when I call out your answer. As I poll the group, please look around to get a sense of how everyone is responding. Less than one month. Please raise your hands high…

12. 12 Now, with the same behavior in mind, please think about your response to this question: How much time elapsed between the first time you recognized a risk or negative consequence and the first time you made an earnest attempt to change the behavior? (Repeat the question while showing the next slide.)Now, with the same behavior in mind, please think about your response to this question: How much time elapsed between the first time you recognized a risk or negative consequence and the first time you made an earnest attempt to change the behavior? (Repeat the question while showing the next slide.)

13. 13 How much time elapsed between the first time you recognized a risk or negative consequence and the first time you made an earnest attempt to change the behavior? Again, in your head, please choose one of these categories, and I’ll poll the group again …How much time elapsed between the first time you recognized a risk or negative consequence and the first time you made an earnest attempt to change the behavior? Again, in your head, please choose one of these categories, and I’ll poll the group again …

14. 14 Now, how many of you experience some success in changing your behavior? Great, congratulations. And how many of you experience at least some resumption of the undesired behavior?Now, how many of you experience some success in changing your behavior? Great, congratulations. And how many of you experience at least some resumption of the undesired behavior?

15. 15 Introspective Exercise #1(continued) What conclusions would you draw from the group’s responses? Elicit discussion from the group.Elicit discussion from the group.

16. 16 Common Conclusions Behavioral issues are common Change often takes a long time The pace of change is variable Knowledge is usually not sufficient to motivate change Relapse is the rule Most groups draw these conclusions.Most groups draw these conclusions.

17. 17 Common Conclusions(continued) Our expectations of patients/clients regarding behavior change are unrealistic Unrealistic expectations can lead to frustration and burn-out Now, how does our experience with behavior change compare to our expectations about promoting behavior change? Many of us still expect our patients and clients to change their behaviors in response to simple advice, when many of us did not change our behaviors even with knowledge of risks and consequences. Rather than blaming our patients and clients for our frustration, maybe we need to align our expectations more with reality. Behavior change is difficult. Behavior change takes time. We need to be patient. We cannot expect most of our patients and clients to quickly and permanently change their behaviors. When we approach our work with more realistic expectations, we will experience less failure and enjoy more just being there with our patients and clients.Now, how does our experience with behavior change compare to our expectations about promoting behavior change? Many of us still expect our patients and clients to change their behaviors in response to simple advice, when many of us did not change our behaviors even with knowledge of risks and consequences. Rather than blaming our patients and clients for our frustration, maybe we need to align our expectations more with reality. Behavior change is difficult. Behavior change takes time. We need to be patient. We cannot expect most of our patients and clients to quickly and permanently change their behaviors. When we approach our work with more realistic expectations, we will experience less failure and enjoy more just being there with our patients and clients.

18. 18 Benefits of Learning About the Transtheoretical Model & Motivational Interviewing More realistic expectations about patients’/clients’ behavior change Greater recognition of smaller accomplishments More success over time Less frustration and burn-out These are the benefits I’ve found in learning and applying the transtheoretical model and motivational interviewing - more realistic expectations, greater recognition of smaller accomplishments, more success over time, and much more enjoyment of this work.These are the benefits I’ve found in learning and applying the transtheoretical model and motivational interviewing - more realistic expectations, greater recognition of smaller accomplishments, more success over time, and much more enjoyment of this work.

19. 19 Transtheoretical Model ofBehavior Change All individuals progress through stages of change Movement may be forward or backward Movement may be cyclical So, now let’s talk more specifics about the transtheoretical model. This model postulates that individuals don’t just suddenly change their behaviors. Instead, we all go through stages of readiness to change. Movement through these stages may be forward, backward, or cyclical. So, now let’s talk more specifics about the transtheoretical model. This model postulates that individuals don’t just suddenly change their behaviors. Instead, we all go through stages of readiness to change. Movement through these stages may be forward, backward, or cyclical.

20. 20 Here is a diagram of the stages of readiness to change. Notice that the main path in the diagram is a clockwise circle, starting from precontemplation and coming around again through relapse. But there are also some paths backward, some short-cuts, and a way out of the circle. You’ll understand this better after we focus individually on each stage.Here is a diagram of the stages of readiness to change. Notice that the main path in the diagram is a clockwise circle, starting from precontemplation and coming around again through relapse. But there are also some paths backward, some short-cuts, and a way out of the circle. You’ll understand this better after we focus individually on each stage.

21. 21 Precontemplation Not considering change Actively opposed Haven’t considered it Goal: Move to contemplation Barriers: Knowledge of risks/consequences Self-efficacy Contentment First let’s look at precontemplation. This is where everyone starts. We are engaged in a particular behavior and we’re not even considering change. For people in this phase, the practitioner’s goal is just to get them to consider making a change. For each stage, there are barriers to getting to the next stage. Knowledge of risks or consequences is one barrier, though as we discovered when thinking about our own behavior change process, such knowledge is usually insufficient to elicit change. Another barrier is self-efficacy. I want to emphasize that self-efficacy and self-esteem may be related but are not the same. Self esteem is a general sense that one is a worthy individual. Self-efficacy is the belief that one can accomplish something if one tries. Lack of self-efficacy is often an important barrier to behavior change, especially for individuals who have tried to change and experienced relapses many times.First let’s look at precontemplation. This is where everyone starts. We are engaged in a particular behavior and we’re not even considering change. For people in this phase, the practitioner’s goal is just to get them to consider making a change. For each stage, there are barriers to getting to the next stage. Knowledge of risks or consequences is one barrier, though as we discovered when thinking about our own behavior change process, such knowledge is usually insufficient to elicit change. Another barrier is self-efficacy. I want to emphasize that self-efficacy and self-esteem may be related but are not the same. Self esteem is a general sense that one is a worthy individual. Self-efficacy is the belief that one can accomplish something if one tries. Lack of self-efficacy is often an important barrier to behavior change, especially for individuals who have tried to change and experienced relapses many times.

22. 22 People who start to get past these barriers may get to the stage of contemplation. In this stage there is ambivalence about changing. People are aware that there are advantages and disadvantages to continuing their substance use, and advantages and disadvantages to changing it. They are torn about what to do. They want to but don’t want to. The goal of practitioners for people in contemplation is to help them move toward a firm commitment to change their behavior. The barriers to this commitment are the same as those for precontemplation, plus there’s another that sometimes comes into play. Some people are generally indecisive and have a hard time making a decision to change just as they have a hard time making decisions about anything.People who start to get past these barriers may get to the stage of contemplation. In this stage there is ambivalence about changing. People are aware that there are advantages and disadvantages to continuing their substance use, and advantages and disadvantages to changing it. They are torn about what to do. They want to but don’t want to. The goal of practitioners for people in contemplation is to help them move toward a firm commitment to change their behavior. The barriers to this commitment are the same as those for precontemplation, plus there’s another that sometimes comes into play. Some people are generally indecisive and have a hard time making a decision to change just as they have a hard time making decisions about anything.

23. 23 This stage is known by two names: determination and preparation. People who get to this stage are determined to make a change. They have made a commitment to change their behavior within a relatively short period of time - arbitrarily, a month. The commitment must be firm. Statements like, “Maybe I’ll make a New Years resolution” don’t cut it. At this point, barriers to successful behavior change include a loss of commitment, a lack of knowledge about strategies to change behaviors, and a lack of a plan for change. The goals for practitioners are to help people strengthen their commitment to change and develop a plan.This stage is known by two names: determination and preparation. People who get to this stage are determined to make a change. They have made a commitment to change their behavior within a relatively short period of time - arbitrarily, a month. The commitment must be firm. Statements like, “Maybe I’ll make a New Years resolution” don’t cut it. At this point, barriers to successful behavior change include a loss of commitment, a lack of knowledge about strategies to change behaviors, and a lack of a plan for change. The goals for practitioners are to help people strengthen their commitment to change and develop a plan.

24. 24 In action, people have at least begun to make changes. This is the first stage in which we begin to see an actual change in behavior. In this stage, people can become disillusioned, or they can become overconfident. Practitioners work with people to help them optimize their plans for change.In action, people have at least begun to make changes. This is the first stage in which we begin to see an actual change in behavior. In this stage, people can become disillusioned, or they can become overconfident. Practitioners work with people to help them optimize their plans for change.

25. 25 In maintenance, there has been a durable behavior change – perhaps about six months or more. The behavior change is quite well learned. However, there is still risk for relapse. The goal in this stage is to help people build a stable lifestyle around their behavior change and help them attain the original goals that prompted their change. For example, consider an alcohol dependent individual who realizes that he is not going to be able to attract and hold on to the partner of his dreams. This person quits drinking to find a partner. If this person is in recovery for a long time and is still not meeting prospective partners, then relapse might become likely. Barriers to staying in maintenance are failure to attain these initial goals and major life stresses.In maintenance, there has been a durable behavior change – perhaps about six months or more. The behavior change is quite well learned. However, there is still risk for relapse. The goal in this stage is to help people build a stable lifestyle around their behavior change and help them attain the original goals that prompted their change. For example, consider an alcohol dependent individual who realizes that he is not going to be able to attract and hold on to the partner of his dreams. This person quits drinking to find a partner. If this person is in recovery for a long time and is still not meeting prospective partners, then relapse might become likely. Barriers to staying in maintenance are failure to attain these initial goals and major life stresses.

26. 26 Relapse is a non-trivial resumption of the undesired behavior. True to our own experiences with behavior change, relapse is considered a normal stage of the behavior change process. For practitioners, the goals are to identify relapse, help people reframe relapses from failures to opportunities to learn what will help more next time, and reassess the stage of readiness to change.Relapse is a non-trivial resumption of the undesired behavior. True to our own experiences with behavior change, relapse is considered a normal stage of the behavior change process. For practitioners, the goals are to identify relapse, help people reframe relapses from failures to opportunities to learn what will help more next time, and reassess the stage of readiness to change.

27. 27 Finally, there is termination. First I’ll emphasize that termination is not when the undesired behavior has stopped. This occurs in action. Termination occurs when the behavior change is so well learned and stable that relapse is highly unlikely. An example of termination would be a recovering cocaine addict who has ended relationships with all people he used with, gotten a new job, been in a steady relationship with an individual who has never used illicit drugs, never has cravings to use, and is repulsed by the thought of using again. Less than 20% of individuals who have ever smoked tobacco or had alcohol dependence ever progress to termination. Therefore, for most individuals with substance use disorders, we must view these disorders as chronic, requiring ongoing care perhaps for the rest of a person’s life. We expect relapses, and our goal is to reduce as much as we can the frequency, duration, and severity of the relapses – just as we do when treating cancer, heart attacks, strokes, diabetes, arthritis, depression, and schizophrenia.Finally, there is termination. First I’ll emphasize that termination is not when the undesired behavior has stopped. This occurs in action. Termination occurs when the behavior change is so well learned and stable that relapse is highly unlikely. An example of termination would be a recovering cocaine addict who has ended relationships with all people he used with, gotten a new job, been in a steady relationship with an individual who has never used illicit drugs, never has cravings to use, and is repulsed by the thought of using again. Less than 20% of individuals who have ever smoked tobacco or had alcohol dependence ever progress to termination. Therefore, for most individuals with substance use disorders, we must view these disorders as chronic, requiring ongoing care perhaps for the rest of a person’s life. We expect relapses, and our goal is to reduce as much as we can the frequency, duration, and severity of the relapses – just as we do when treating cancer, heart attacks, strokes, diabetes, arthritis, depression, and schizophrenia.

28. 28 Controversy: Stages of Change Stage of change measures lack reliability Stage of change measures are weak predictors of behavior change Stage of change is very dynamic and may be difficult to measure Many clinicians find that stage of change helps them tailor interventions Research is needed to determine whether stage-based interventions are more effective than others You may have heard that there is some controversy about the Transtheoretical Model. Although early research provided data that supported the validity of these stages, later research using sounder methods raised questions. Stage of change measures are limited in their reliability and validity. Furthermore, an individual’s stage of change is not a strong predictor of behavior change. However, another strain of research has shown that stage-based interventions are more effective than interventions that are not based on stages of change. One might conclude that stages of change may not be a useful concept in research because of their changeability, they are still a useful clinical concept in guiding interventions. So, are there any question about the transtheoretical model? You may have heard that there is some controversy about the Transtheoretical Model. Although early research provided data that supported the validity of these stages, later research using sounder methods raised questions. Stage of change measures are limited in their reliability and validity. Furthermore, an individual’s stage of change is not a strong predictor of behavior change. However, another strain of research has shown that stage-based interventions are more effective than interventions that are not based on stages of change. One might conclude that stages of change may not be a useful concept in research because of their changeability, they are still a useful clinical concept in guiding interventions. So, are there any question about the transtheoretical model?

29. 29 Assessing Stage of Change What question(s) would best assess stage of change? So, if we agree that stages of change are useful in guiding clinical interventions, how would be best determine an individual’s stage of change. What questions would we want to ask?So, if we agree that stages of change are useful in guiding clinical interventions, how would be best determine an individual’s stage of change. What questions would we want to ask?

30. 30 Assessing Stage of Change (continued) Criteria for assessment question: Accurate Non-leading Non-judgmental Respectful Before we come up with actual questions, let’s consider what would be desirable attributes of those questions. The questions should elicit accurate information. Therefore, the question should not be leading or judgmental, as such questions can influence the response. Also, questions should be respectful to engender a productive partnership. Any suggestions on precise questions to ask?Before we come up with actual questions, let’s consider what would be desirable attributes of those questions. The questions should elicit accurate information. Therefore, the question should not be leading or judgmental, as such questions can influence the response. Also, questions should be respectful to engender a productive partnership. Any suggestions on precise questions to ask?

31. 31 Assessing Stage of Change (continued) Sample initial questions: How do you feel about your [behavior]? What do you think about your [behavior]? How does [behavior] fit into your life? The best initial questions for assessing stage of change are open-ended questions. For example: How do you feel about your drinking? What do you think about your smoking? How does your drug use fit into your life?The best initial questions for assessing stage of change are open-ended questions. For example: How do you feel about your drinking? What do you think about your smoking? How does your drug use fit into your life?

32. 32 Sometimes the responses to these questions leave uncertainty, so a follow-up question is needed. Here are some possible follow-up questions that ask for clarification without being leading or judgmental.Sometimes the responses to these questions leave uncertainty, so a follow-up question is needed. Here are some possible follow-up questions that ask for clarification without being leading or judgmental.

33. 33 Assessing Stage of Change (continued) Ask initial question Listen carefully and assess If necessary, ask follow-up question and reassess So, the recipe for assessing stage of change is: ask an open-ended initial question, listen carefully, and ask a more close-ended but non-leading and non-judgmental question for clarification.So, the recipe for assessing stage of change is: ask an open-ended initial question, listen carefully, and ask a more close-ended but non-leading and non-judgmental question for clarification.

34. 34 Now I’m going to present a couple of examples of responses to open-ended questions on stage of change. I’d like you to vote on which stage of change fits the response. I’ll warn you that these questions are quite difficult - even a bit tricky. I think they are important, though, in getting across some important clinical nuances.Now I’m going to present a couple of examples of responses to open-ended questions on stage of change. I’d like you to vote on which stage of change fits the response. I’ll warn you that these questions are quite difficult - even a bit tricky. I think they are important, though, in getting across some important clinical nuances.

35. 35 Case 1 - What stage of change? Patient with alcoholic gastritis and labile hypertension Patient reports having 2 to 4 drinks on weekdays and 6 to 8 drinks on Fridays and Saturdays Clinician: What do you think about your drinking? Patient: Oh, I guess I’ve known for a long time – I really should cut down For the first case, imagine an individual whose drinking has caused stomach irritation and intermittently high blood pressure. He reports having 2 to 4 drinks on weekdays and 6 to 8 drinks on weekend days. You ask a nice, open-ended question about stage of change. The patient responds, “Oh, I guess I’ve know for a long time - I really should cut down. (Poll the audience.)For the first case, imagine an individual whose drinking has caused stomach irritation and intermittently high blood pressure. He reports having 2 to 4 drinks on weekdays and 6 to 8 drinks on weekend days. You ask a nice, open-ended question about stage of change. The patient responds, “Oh, I guess I’ve know for a long time - I really should cut down. (Poll the audience.)

36. 36 Case 1 - What stage of change? Patient: Oh, I guess I’ve known for a long time – I really should cut down … Possible stages are: Precontemplation - … but now’s not a good time. Contemplation - …but I’m torn. Determination - … and I will, starting tomorrow. Action - … and I started cutting down last weekend. Inquire about intention to change soon Actually, the best answer is no answer. We really cannot tell. The patient could be in any of the four stages of change. This case is important, because it illustrates that patients’ statements about what they SHOULD do are irrelevant. There are many things we SHOULD do that we don’t, but sometimes we do. What’s important in determining stage of change is not a sense of what one SHOULD do, but a sense of what one INTENDS to do. When someone says what they SHOULD do, we have to ask another question. For example, “So are you saying you’re going to cut down soon, or you’re not so sure?”Actually, the best answer is no answer. We really cannot tell. The patient could be in any of the four stages of change. This case is important, because it illustrates that patients’ statements about what they SHOULD do are irrelevant. There are many things we SHOULD do that we don’t, but sometimes we do. What’s important in determining stage of change is not a sense of what one SHOULD do, but a sense of what one INTENDS to do. When someone says what they SHOULD do, we have to ask another question. For example, “So are you saying you’re going to cut down soon, or you’re not so sure?”

37. 37 Case 2 - What stage of change? Alcohol-dependent patient with alcoholic cirrhosis, chronic pancreatitis, and frequent episodes of acute pancreatitis Clinician: How do you feel about your drinking lately? Patient: I haven’t had a thing to drink since leaving the hospital last week. The pain from my pancreas was awful. I’m never going to have more than a couple of beers again. This next case is also tricky but for different reasons. This is an alcohol dependent person with cirrhosis and chronic pancreatitis, whose drinking has led frequently to bouts of acute pancreatitits. In response to an open-ended question, the patient says, “I haven’t had a thing to drink since leaving the hospital last week. The pain from my pancreas was awful. I’m never going to have more than a couple of beers a day again.” What stage does this patient depict? (POLL THE AUDIENCE)This next case is also tricky but for different reasons. This is an alcohol dependent person with cirrhosis and chronic pancreatitis, whose drinking has led frequently to bouts of acute pancreatitits. In response to an open-ended question, the patient says, “I haven’t had a thing to drink since leaving the hospital last week. The pain from my pancreas was awful. I’m never going to have more than a couple of beers a day again.” What stage does this patient depict? (POLL THE AUDIENCE)

38. 38 Case 2 - What stage of change? Patient: I haven’t had a thing to drink since leaving the hospital last week, and I’m never again going to have more than two beers. Stage of change: Action about cutting down Precontemplation about quitting Individuals can be in different stages of change about different degrees of change The patient has avoided alcohol completely for a week. Since he has changed his behavior, he is clearly in action. However, does not intend to continue abstaining. Therefore he is in action about cutting down but in precontemplation about quitting. This case illustrates that individuals can be in different stages of change about different magnitudes of change.The patient has avoided alcohol completely for a week. Since he has changed his behavior, he is clearly in action. However, does not intend to continue abstaining. Therefore he is in action about cutting down but in precontemplation about quitting. This case illustrates that individuals can be in different stages of change about different magnitudes of change.

39. 39 Base expectations of behavior change on reality Assess stage of change initially with open-ended questions; use follow-up probe as needed Use intervention appropriate to stage Summary - Part 1 So far we’ve talked about the importance of adjusting our expectations so we’re more realistic about the difficulty and pace of behavior change. The stages of change model teaches us that change takes time and that relapse is to be expected. It’s fairly easy to assess an individual’s stage of change. Start with an open-ended question, and use a follow-up probe if necessary. Once we know an individual’s stage of change, we can tailor our counseling accordingly.So far we’ve talked about the importance of adjusting our expectations so we’re more realistic about the difficulty and pace of behavior change. The stages of change model teaches us that change takes time and that relapse is to be expected. It’s fairly easy to assess an individual’s stage of change. Start with an open-ended question, and use a follow-up probe if necessary. Once we know an individual’s stage of change, we can tailor our counseling accordingly.

40. 40 Objectives - Part 2 Describe the principles of MI Contrast MI to other styles Develop interviewing microskills that help counselors adhere to MI principles Review data on the effectiveness of MI In the next section, we’ll discuss the principles of motivational interviewing - principles that should guide our stage-based counseling. We’ll contrast motivational interviewing with more traditional alcohol counseling. Next we’ll review the scientific evidence on the effectiveness of motivational interviewing. Finally we’ll discuss some interviewing skills, or microskills, that can help you implement the principles of motivational interviewing.In the next section, we’ll discuss the principles of motivational interviewing - principles that should guide our stage-based counseling. We’ll contrast motivational interviewing with more traditional alcohol counseling. Next we’ll review the scientific evidence on the effectiveness of motivational interviewing. Finally we’ll discuss some interviewing skills, or microskills, that can help you implement the principles of motivational interviewing.

41. 41 Major References andAdditional Resources on Motivational Interviewing Miller WR & Rollnick S. Motivational Interviewing (second edition). New York: Guilford, 2002. SAMHSA/CSAT Treatment Improvement Protocol on Motivational Interviewing (#35)http://text.nlm.nih.gov www.motivationalinterview.org These are the major sources of the information I’ll be presenting on motivational interviewing. The first source is a book that is available at many bookstores and through online booksellers. The list price is $42. The second source is available for free online. “Motivational.org” is a website that contains a lot of information, links, and helpful references on motivational interviewing.These are the major sources of the information I’ll be presenting on motivational interviewing. The first source is a book that is available at many bookstores and through online booksellers. The list price is $42. The second source is available for free online. “Motivational.org” is a website that contains a lot of information, links, and helpful references on motivational interviewing.

42. 42 Introspective Exercise #2 About the behavior you used for Introspective Exercise #1: Think of individuals who helped you or tried to help you change your behavior Before we discuss the key principles of motivational interviewing, I’d like to ask for your participation in another exercise. Think back to the behavior you focused on for our last exercise – the behavior that you’ve tried to change. And now begin to think about the individuals who tried to help to change that behavior. These could have been professionals, family members, or friends.Before we discuss the key principles of motivational interviewing, I’d like to ask for your participation in another exercise. Think back to the behavior you focused on for our last exercise – the behavior that you’ve tried to change. And now begin to think about the individuals who tried to help to change that behavior. These could have been professionals, family members, or friends.

43. 43 Now, please focus on individuals who tried to help but actually were not helpful to you in changing your behavior. Please give me some adjectives that describe how these individuals came across to you? And, if you can, please give some specific examples of what they did that was not helpful. (Record these responses in front of the room, perhaps on a flip chart.)Now, please focus on individuals who tried to help but actually were not helpful to you in changing your behavior. Please give me some adjectives that describe how these individuals came across to you? And, if you can, please give some specific examples of what they did that was not helpful. (Record these responses in front of the room, perhaps on a flip chart.)

44. 44 Good. Now, please focus on the individuals who actually WERE helpful to you in changing your behavior. Again, please give me some adjectives that describe how these individuals came across to you? And, if you can, please give some specific examples of what they did that was helpful. (Record these in front of the room.)Good. Now, please focus on the individuals who actually WERE helpful to you in changing your behavior. Again, please give me some adjectives that describe how these individuals came across to you? And, if you can, please give some specific examples of what they did that was helpful. (Record these in front of the room.)

45. 45 MI: Theoretical Underpinnings Warmth, genuine empathy, and unconditional positive regard are necessary to foster therapeutic gain (Rogers, 1961) Ambivalence about decisions is resolved by conscious or unconscious weighing of pros and cons of change vs. not changing (Ajzen, 1980) Meet patients/clients where they are (Prochaska, 1983) Bill Miller and his colleagues emphasize that motivational interviewing draws many of its concepts from other sources. Carl Rogers was very influential in his views that counselor warmth, empathy, and positive regard are powerful tools in promoting therapeutic gain. Miller and his colleagues were also influenced by expectancy-value theories, which posit that decisions about behaviors involve a conscious or unconscious weighing of advantages and disadvantages of behavior. Prochaska and DiClemente’s Transtheoretical Model was instrumental in reinforcing the importance of meeting patients or clients where they’re at in helping them change behaviors.Bill Miller and his colleagues emphasize that motivational interviewing draws many of its concepts from other sources. Carl Rogers was very influential in his views that counselor warmth, empathy, and positive regard are powerful tools in promoting therapeutic gain. Miller and his colleagues were also influenced by expectancy-value theories, which posit that decisions about behaviors involve a conscious or unconscious weighing of advantages and disadvantages of behavior. Prochaska and DiClemente’s Transtheoretical Model was instrumental in reinforcing the importance of meeting patients or clients where they’re at in helping them change behaviors.

46. 46 Principles of MI Advice Barriers Choices Decrease desirability Many of your comments about what is and is not helpful illustrate the key principles of motivational interviewing. Fortunately, you can easily remember these principles because they start with the letters A through H. Now, we’ll talk about each principle, one at a time.Many of your comments about what is and is not helpful illustrate the key principles of motivational interviewing. Fortunately, you can easily remember these principles because they start with the letters A through H. Now, we’ll talk about each principle, one at a time.

47. 47 Principles of MI (continued) Advice Give advice only when individuals will be receptive Target advice to stage of change How do you feel when people give you advice that you didn’t want? (Elicit responses.) Yes. Giving advice that people don’t want is not only unhelpful, but can be destructive. So give advice only when you know that individuals will be receptive. Also, be sure to target any advice to the stage of change.How do you feel when people give you advice that you didn’t want? (Elicit responses.) Yes. Giving advice that people don’t want is not only unhelpful, but can be destructive. So give advice only when you know that individuals will be receptive. Also, be sure to target any advice to the stage of change.

48. 48 When we do motivational interviewing, we are often helping bring down the barriers to advancing to the next stage of change. One key barrier is self-efficacy, one’s sense that one can change one’s behavior if one really wants to. We can do this by reframing previous failures into partial successes. Consider an individual who tried several times but was unable to quit smoking marijuana. We can ask help this individual realize that these attempts were successful for a certain amount of time, that the individual brought important strengths to these attempts, and that future attempts might succeed with some slightly different strategies. Logistical barriers can hinder the process of behavior change. Such barriers include finances, transportation, and child care. Help individuals identify resources to overcome these barriers. When we do motivational interviewing, we are often helping bring down the barriers to advancing to the next stage of change. One key barrier is self-efficacy, one’s sense that one can change one’s behavior if one really wants to. We can do this by reframing previous failures into partial successes. Consider an individual who tried several times but was unable to quit smoking marijuana. We can ask help this individual realize that these attempts were successful for a certain amount of time, that the individual brought important strengths to these attempts, and that future attempts might succeed with some slightly different strategies. Logistical barriers can hinder the process of behavior change. Such barriers include finances, transportation, and child care. Help individuals identify resources to overcome these barriers.

49. 49 Providing choices is key. How many of you enjoy being told what to do? Not many. So instead of giving individuals one recommendation, give them a few, and ask them to choose. When individuals make a choice, they are more likely to follow through. Remember, it’s up to the individual to decide whether to change, how much to change – quitting versus cutting down, and how to change.Providing choices is key. How many of you enjoy being told what to do? Not many. So instead of giving individuals one recommendation, give them a few, and ask them to choose. When individuals make a choice, they are more likely to follow through. Remember, it’s up to the individual to decide whether to change, how much to change – quitting versus cutting down, and how to change.

50. 50 For individuals who have not yet committed to make a change, help decrease their perceptions of the desirability of the behavior. Acknowledge the positive aspects of the behavior, and then work with them to identify the less positive aspects and weigh the pluses and minuses. Also, help them identify other ways that they might attain the positives.For individuals who have not yet committed to make a change, help decrease their perceptions of the desirability of the behavior. Acknowledge the positive aspects of the behavior, and then work with them to identify the less positive aspects and weigh the pluses and minuses. Also, help them identify other ways that they might attain the positives.

51. 51 Conveying empathy is critical to effective motivational interviewing. Of course, the most effective empathy occurs when there is a deep understanding of the patient’s/client’s situation. Show that you accept and understand the patient’s/client’s views of the positives and negatives of the behavior and any dilemma about changing. Even many individuals in precontemplation understand that their behavior is hurting themselves or others, and they feel very bad about this. Uncovering and empathizing with these painful feelings can promote motivation to change.Conveying empathy is critical to effective motivational interviewing. Of course, the most effective empathy occurs when there is a deep understanding of the patient’s/client’s situation. Show that you accept and understand the patient’s/client’s views of the positives and negatives of the behavior and any dilemma about changing. Even many individuals in precontemplation understand that their behavior is hurting themselves or others, and they feel very bad about this. Uncovering and empathizing with these painful feelings can promote motivation to change.

52. 52 Feedback is important, as motivational to change is augmented by an understanding of the risks of consequences of the behavior. It’s not helpful to provide exhaustive lists of risks and consequences. Focus on those that will be most relevant to the individual. For example, many adolescent smokers are not be motivated by risks of cancer and heart disease, but they may desire better smelling breath and athletic performances.Feedback is important, as motivational to change is augmented by an understanding of the risks of consequences of the behavior. It’s not helpful to provide exhaustive lists of risks and consequences. Focus on those that will be most relevant to the individual. For example, many adolescent smokers are not be motivated by risks of cancer and heart disease, but they may desire better smelling breath and athletic performances.

53. 53 Principles of MI (continued) Discussion Question: What is the source of motivation to change behavior? Before we talk about the next principle, think for a second: where does motivational come from? Are some people born motivated, while others remain unmotivated? Does motivation just come and go unpredictably, like luck?Before we talk about the next principle, think for a second: where does motivational come from? Are some people born motivated, while others remain unmotivated? Does motivation just come and go unpredictably, like luck?

54. 54 Principles of MI (continued) Motivation comes from the discrepancy between: Current behavior Future goals Motivation comes from the discrepancy between one’s current behavior and future goals. When people realize that their current behaviors are not taking their lives in the directions they truly want to go, motivation to change results.Motivation comes from the discrepancy between one’s current behavior and future goals. When people realize that their current behaviors are not taking their lives in the directions they truly want to go, motivation to change results.

55. 55 So, help individuals take stock about the pros and cons of their current behavior and the pros and cons of changing their behavior in light of their goals for the future. For example, many individuals who engage in risky behavior actually do want to live to see their grandchildren grow up. Developing this discrepancy between behaviors and goals is very powerful.So, help individuals take stock about the pros and cons of their current behavior and the pros and cons of changing their behavior in light of their goals for the future. For example, many individuals who engage in risky behavior actually do want to live to see their grandchildren grow up. Developing this discrepancy between behaviors and goals is very powerful.

56. 56 Finally, active helping can be useful. Don’t take responsibility for the patient’s/client’s behavior change, but take some extra steps to let them know that you care. Make an extra phone call. Send a post card reminder. This helps reinforce for patients/clients that you think that their behavior change is important and worthy of your time and effort.Finally, active helping can be useful. Don’t take responsibility for the patient’s/client’s behavior change, but take some extra steps to let them know that you care. Make an extra phone call. Send a post card reminder. This helps reinforce for patients/clients that you think that their behavior change is important and worthy of your time and effort.

57. 57 So, let’s look back now at the results of our previous exercise. How do these principles compare to what you all feel has and hasn’t helped you?So, let’s look back now at the results of our previous exercise. How do these principles compare to what you all feel has and hasn’t helped you?

58. 58 Frameworks I want to emphasize at this point that motivational interviewing is not the only way to promote behavior change. A paternalistic, confrontational approach can be effective for some individuals. However, for other individuals, this approach elicits defensive and resistance. For some individuals, a blend of the two approaches may work best. Usually it’s best at least to start with a motivational approach, because a paternalistic approach can poison the empathic and respectful relationship required for a motivational approach.I want to emphasize at this point that motivational interviewing is not the only way to promote behavior change. A paternalistic, confrontational approach can be effective for some individuals. However, for other individuals, this approach elicits defensive and resistance. For some individuals, a blend of the two approaches may work best. Usually it’s best at least to start with a motivational approach, because a paternalistic approach can poison the empathic and respectful relationship required for a motivational approach.

59. 59 Application to Alcohol Treatment Conventional alcohol treatment Assumes readiness to change Uses confrontation and other aggressive strategies to promote readiness to change Aggressive confrontation often engenders more resistance Intrinsic motivational elicits more lasting behavior change than extrinsic motivation Motivational interviewing is bringing about a quiet revoluation in the field of alcohol treatment. Previously, conventional treatment assumed that clients were ready to change. If clients who resisted, aggressive techniques such as confrontation were used to attack resistance. Clearly this treatment has been and continues to be helpful for many individuals. However, research suggests that, for many people, these aggressive confrontational strategies can actually prompt many individuals to dig their heels in more and become MORE resistant - or to simply hide their true feelings and tell clinicians what they want to hear. Another advantage to motivational interviewing is that it can help many individuals find internal motivation, which is more effective that other sources of motivation, such as the desire to please other people. DECI, E.L., AND RYAN, RM. Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum Press, 1985. MILLER, W.R.; BENEFIELD, R.G.; AND TONIGAN, J.S. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology 61(3):455-461, 1993. Motivational interviewing is bringing about a quiet revoluation in the field of alcohol treatment. Previously, conventional treatment assumed that clients were ready to change. If clients who resisted, aggressive techniques such as confrontation were used to attack resistance. Clearly this treatment has been and continues to be helpful for many individuals. However, research suggests that, for many people, these aggressive confrontational strategies can actually prompt many individuals to dig their heels in more and become MORE resistant - or to simply hide their true feelings and tell clinicians what they want to hear. Another advantage to motivational interviewing is that it can help many individuals find internal motivation, which is more effective that other sources of motivation, such as the desire to please other people. DECI, E.L., AND RYAN, RM. Intrinsic Motivation and Self-Determination in Human Behavior. New York: Plenum Press, 1985. MILLER, W.R.; BENEFIELD, R.G.; AND TONIGAN, J.S. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology 61(3):455-461, 1993.

60. 60 Key MI Skills Open-ended questions Reflective listening Affirmations Summarize Elicit self-motivational statements Next we’re going to focus on some key interviewing microskills that can help implement motivational interviewing principles: open-ended questions, reflective listening, affirmations, summarizations, and eliciting self-motivational statements.Next we’re going to focus on some key interviewing microskills that can help implement motivational interviewing principles: open-ended questions, reflective listening, affirmations, summarizations, and eliciting self-motivational statements.

61. 61 Open-ended questions are useful because they call on patients to provide a breadth of information. These questions cannot be answered in just a few words. In these responses we can often recognize the patient’s/client’s goals and values.Open-ended questions are useful because they call on patients to provide a breadth of information. These questions cannot be answered in just a few words. In these responses we can often recognize the patient’s/client’s goals and values.

62. 62 Here’s an example of a close-ended question. This question is leading, as it may be difficult for a patient or client to say no and then to explain why. Can you suggest a more open-ended question?Here’s an example of a close-ended question. This question is leading, as it may be difficult for a patient or client to say no and then to explain why. Can you suggest a more open-ended question?

63. 63 A much better question would be: “How do you feel about your smoking?” This question communicates that you really want to understand the patient/client rather than just push for a decision.A much better question would be: “How do you feel about your smoking?” This question communicates that you really want to understand the patient/client rather than just push for a decision.

64. 64 Here is another close-ended question: “How much pot do you smoke?” The response would be very brief and would just provide one single bit of information. Can you suggest a more open-ended question?Here is another close-ended question: “How much pot do you smoke?” The response would be very brief and would just provide one single bit of information. Can you suggest a more open-ended question?

65. 65 A more open-ended question would be: “Would you please tell more about your pot smoking?” This question may elicit more information about the circumstances of use, the associated positive and negative aspects, and other important information. If not, you can follow-up with close-ended questions.A more open-ended question would be: “Would you please tell more about your pot smoking?” This question may elicit more information about the circumstances of use, the associated positive and negative aspects, and other important information. If not, you can follow-up with close-ended questions.

66. 66 Reflective listening is another key skill. Reflective listening merely mirrors what the patient/client says without adding any further meaning. Therefore, it is very non-threatening. It tends to elicit further comment, deepens the conversation, and helps patients/clients understand themselves better.Reflective listening is another key skill. Reflective listening merely mirrors what the patient/client says without adding any further meaning. Therefore, it is very non-threatening. It tends to elicit further comment, deepens the conversation, and helps patients/clients understand themselves better.

67. 67 Reflective Listening (continued) Reflective listening says: “I hear you.” “I’m accepting, not judging you.” “This is important.” “Please tell me more.” So, reflective listening says, “I hear you; I’m not judging you; this is important; please tell me more.”So, reflective listening says, “I hear you; I’m not judging you; this is important; please tell me more.”

68. 68 Reflective listening doesn’t direct, warn, advise, or persuade. It doesn’t label, interpret, or reassure. It should no content or emotional beyond what the patient/client just said.Reflective listening doesn’t direct, warn, advise, or persuade. It doesn’t label, interpret, or reassure. It should no content or emotional beyond what the patient/client just said.

69. 69 Let’s try it. A patient/client says, “My girlfriend gets really angry when I drink and pass out.” Can you suggest a response that would illustrate reflective listeningLet’s try it. A patient/client says, “My girlfriend gets really angry when I drink and pass out.” Can you suggest a response that would illustrate reflective listening

70. 70 One example would be, “She gets mad when you drink and fall asleep.” Yes, this simply restates and encourages the patient/client to say more.One example would be, “She gets mad when you drink and fall asleep.” Yes, this simply restates and encourages the patient/client to say more.

71. 71 Let’s try another one: “I’m not a pleasant drunk. I’ve really beaten people up badly.” This is a situation where the clinician is in danger of saying something that might come across as judgmental. A reflective response would be a perfect way to avoid this pitfall. Any suggestions?Let’s try another one: “I’m not a pleasant drunk. I’ve really beaten people up badly.” This is a situation where the clinician is in danger of saying something that might come across as judgmental. A reflective response would be a perfect way to avoid this pitfall. Any suggestions?

72. 72 One example would be: “You’ve hurt people when you’ve gotten drunk.” Yes, this statement carefully avoids passing judgment, encouraging the patient/client to say more.One example would be: “You’ve hurt people when you’ve gotten drunk.” Yes, this statement carefully avoids passing judgment, encouraging the patient/client to say more.

73. 73 Let’s try one more. “I know I should be drinking less.”Let’s try one more. “I know I should be drinking less.”

74. 74 A nice reflective response would be “You feel that drinking less would be a good idea.”A nice reflective response would be “You feel that drinking less would be a good idea.”

75. 75 Affirmations Support the patient/client Convey respect Convey understanding Encourage more progress Help clients/patients reveal less positive aspects of themselves Good. Now let’s move on to affirmations. Affirmations are helpful because they support the patient/client as you may be covering rather difficult material. Affirmations convey respect and understanding. They gently encourage more progress. Also, when patients/clients feel respected, they feel more free to reveal less positive information about themselves.Good. Now let’s move on to affirmations. Affirmations are helpful because they support the patient/client as you may be covering rather difficult material. Affirmations convey respect and understanding. They gently encourage more progress. Also, when patients/clients feel respected, they feel more free to reveal less positive information about themselves.

76. 76 Affirmations (continued) Examples? Many of you probably use affirmations quite frequently. Can anyone think of affirmations that you’ve used or affirmations that might be helpful to use?Many of you probably use affirmations quite frequently. Can anyone think of affirmations that you’ve used or affirmations that might be helpful to use?

77. 77 Affirmations (continued) “You are very courageous to be so revealing about this.” “You’ve accomplished a lot in a short time.” “I can understand why drinking feels so good to you.” Here are some examples. The first is for a patient/client who has revealed very sensitive information. The second conveys respect. The third conveys understanding. Can you see how affirmations can help strengthen the therapeutic relationship?Here are some examples. The first is for a patient/client who has revealed very sensitive information. The second conveys respect. The third conveys understanding. Can you see how affirmations can help strengthen the therapeutic relationship?

78. 78 Summarization “What you’ve said is important.” “I value what you say.” “Here are the salient points.” “Did I hear you correctly?” “We covered that well. Now let's talk about ...” The next microskill is summarization. This involves recounting back to the patient/client the essence of what you’ve heard over some time. It tells the patient/client: “What you said was important to me, and here’s what I heard; did I get that right? If so, great, let’s move on.”The next microskill is summarization. This involves recounting back to the patient/client the essence of what you’ve heard over some time. It tells the patient/client: “What you said was important to me, and here’s what I heard; did I get that right? If so, great, let’s move on.”

79. 79 Elicit Self-Motivational Statements Have patients/clients make their own arguments for change in 4 areas: Problem recognition Concern Intention to change Optimism Eliciting self-motivational statements is a critical skill for patients/clients who are not committed to change. Often experienced clinicians find themselves trying to figure out what to say to convince someone to change. Here the concept is that we help patients or clients make their OWN arguments in favor of change. The are four areas in which we can help elicit self-motivational statements.Eliciting self-motivational statements is a critical skill for patients/clients who are not committed to change. Often experienced clinicians find themselves trying to figure out what to say to convince someone to change. Here the concept is that we help patients or clients make their OWN arguments in favor of change. The are four areas in which we can help elicit self-motivational statements.

80. 80 The first area is problem recognition. What questions can we ask to help patients/clients identify some problems related to their substance use?The first area is problem recognition. What questions can we ask to help patients/clients identify some problems related to their substance use?

81. 81 Here are some examples: “How has your drinking created problems for you” and “How do you think you’ve been hurt by your drinking? These open-ended questions can be very helpful to use when taking a history or doing an assessment.Here are some examples: “How has your drinking created problems for you” and “How do you think you’ve been hurt by your drinking? These open-ended questions can be very helpful to use when taking a history or doing an assessment.

82. 82 Another area for eliciting self-motivational statements is the area of concerns. Can you think of any questions that would help patients/clients identify concerns?Another area for eliciting self-motivational statements is the area of concerns. Can you think of any questions that would help patients/clients identify concerns?

83. 83 Again, some open-ended questions can be helpful: “What worries do you have about your drinking?” and “What are you afraid might happen if your drinking continues?” Notice how the responses to these questions will be arguments for change.Again, some open-ended questions can be helpful: “What worries do you have about your drinking?” and “What are you afraid might happen if your drinking continues?” Notice how the responses to these questions will be arguments for change.

84. 84 The third area for eliciting self-motivational statements is intention to change. Do any questions come to mind that would help patients/clients identify reasons to change?The third area for eliciting self-motivational statements is intention to change. Do any questions come to mind that would help patients/clients identify reasons to change?

85. 85 Here are two: “What might be some advantages of changing your smoking?” and “What might be better for you if you gave up smoking?” Again, patients will make their own arguments for change.Here are two: “What might be some advantages of changing your smoking?” and “What might be better for you if you gave up smoking?” Again, patients will make their own arguments for change.

86. 86 Another helpful strategy is to ask the patient to rate their intention to change on a scale of 0-10 and why they didn’t respond with a lower number.Another helpful strategy is to ask the patient to rate their intention to change on a scale of 0-10 and why they didn’t respond with a lower number.

87. 87 The fourth and final area for eliciting self-motivational statements is optimism. What questions might help increase a patient’s/client’s optimism about being able to change?The fourth and final area for eliciting self-motivational statements is optimism. What questions might help increase a patient’s/client’s optimism about being able to change?

88. 88 Since low self-efficacy can be a barrier to change, here are two questions for eliciting self-motivational statements about optimism: “What difficult goals have you achieved in the past?” and “What might work for you if you did decide to change?”Since low self-efficacy can be a barrier to change, here are two questions for eliciting self-motivational statements about optimism: “What difficult goals have you achieved in the past?” and “What might work for you if you did decide to change?”

89. 89 Another way to elicit self-motivational statements on optimism is to ask individuals to rate their confidence in their ability to change. If they respond “7,” ask why they didn’t say “5” or “6.” Their responses will help uncover the strengths they can bring to their attempts at behavior change.Another way to elicit self-motivational statements on optimism is to ask individuals to rate their confidence in their ability to change. If they respond “7,” ask why they didn’t say “5” or “6.” Their responses will help uncover the strengths they can bring to their attempts at behavior change.

90. 90 “Layers” of MI So, now let’s review for a minute. We’ve talked about stages of readiness to change. Our goal is always to try to move someone to the next stage by addressing barriers. When we do this, we want to use motivational interviewing principles A through H. And to implement those principles, we often want to be using the microskills we just discussed. It’s quite challenging for new motivational interviewers to work on these three levels while engaging in active listening with patients or clients. However, with practice comes improvement and lots of fulfillment as clinnicians see patients and clients responding.So, now let’s review for a minute. We’ve talked about stages of readiness to change. Our goal is always to try to move someone to the next stage by addressing barriers. When we do this, we want to use motivational interviewing principles A through H. And to implement those principles, we often want to be using the microskills we just discussed. It’s quite challenging for new motivational interviewers to work on these three levels while engaging in active listening with patients or clients. However, with practice comes improvement and lots of fulfillment as clinnicians see patients and clients responding.

91. 91 Evidence on Effectiveness Project MATCH NIAAA-supported randomized controlled trial of: Twelve-step facilitation (TSF) therapy - 12 hr Cognitive-behavioral therapy (CBT) - 12 hr Motivational enhancement therapy (MET) - 4 hr Research Questions: Are demographic and clinical attributes associated with different outcomes of the various treatments? Should clients be matched to treatments? That brings up an important question. What do we really know about the effectiveness of motivational interviewing? First of all, we have evidence from Project MATCH, the largest randomized controlled trial ever performed on health behaviors. There were three arms. One group of patients received 12 hours of treatment using twelve-step group principles. The second group received 12 hours cognitive-behavioral therapy. The investigators could not ethically have a control group, so the third arm was set up as a minimal intervention, and motivational enhancement therapy was used. The chief aim of the trial was to determine whether certain demographic and clinical attributes were associated with more favorable responses to certain treatments. The purpose was to determine whether we should be matching certain patients to certain treatments.That brings up an important question. What do we really know about the effectiveness of motivational interviewing? First of all, we have evidence from Project MATCH, the largest randomized controlled trial ever performed on health behaviors. There were three arms. One group of patients received 12 hours of treatment using twelve-step group principles. The second group received 12 hours cognitive-behavioral therapy. The investigators could not ethically have a control group, so the third arm was set up as a minimal intervention, and motivational enhancement therapy was used. The chief aim of the trial was to determine whether certain demographic and clinical attributes were associated with more favorable responses to certain treatments. The purpose was to determine whether we should be matching certain patients to certain treatments.

92. 92 The results were very interesting. First of all, all three treatments were very effective. Secondly, there were very few and fairly minor matching effects. One result was that 4 hours of motivational interviewing yielded similar results to 12 hours of twelve-step facilitation therapy or 12 hours of cognitive-behavioral therapy. Now, we cannot conclude that MI is more powerful or more efficient than the other treatments, because the study was not set up to determine this. However, the study did demonstrate on a large scale that motivational interviewing is effective.The results were very interesting. First of all, all three treatments were very effective. Secondly, there were very few and fairly minor matching effects. One result was that 4 hours of motivational interviewing yielded similar results to 12 hours of twelve-step facilitation therapy or 12 hours of cognitive-behavioral therapy. Now, we cannot conclude that MI is more powerful or more efficient than the other treatments, because the study was not set up to determine this. However, the study did demonstrate on a large scale that motivational interviewing is effective.

93. 93 Adaptations of motivational interviewing - AMI More directive than “pure” MI May provide unrequested information on risks and consequences of unhealthy behaviors Effect sizes of AMI’s: For drug disorders: 0.56 (moderate) For alcohol use disorders: 0.25 to 0.53 (mild to moderate) No difference in effect with treatments of 20 weeks vs. 67 weeks Substance use decreased by 54% Evidence on Effectiveness (continued) In 2003, Burke and colleagues conducted a review of motivational interviewing interventions for alcohol and drug use disorders. Burke used the term “adaptation of motivational interviewing” to describe interventions that provided feedback on risks or consequences of substance use in a directive manner. They found that MI was effective for both. Interestingly, there seemed to be no consistent increase in effectiveness by lenthier interventions.In 2003, Burke and colleagues conducted a review of motivational interviewing interventions for alcohol and drug use disorders. Burke used the term “adaptation of motivational interviewing” to describe interventions that provided feedback on risks or consequences of substance use in a directive manner. They found that MI was effective for both. Interestingly, there seemed to be no consistent increase in effectiveness by lenthier interventions.

94. 94 Meta-Analysis of MI - 72 In early 2005, Hettema and colleagues published a larger meta-analysis of motivational interviewing. Their review included 72 studies with a variety of behavioral focuses and study designs.In early 2005, Hettema and colleagues published a larger meta-analysis of motivational interviewing. Their review included 72 studies with a variety of behavioral focuses and study designs.

95. 95 Settings Outpatient clinics (15) Inpatient facilities (11) Educational settings (6) Community organizations (5) G.P. offices (5) Prenatal clinics (3) Emergency rooms (2) Motivational interviewing was delivered in a variety of settings.Motivational interviewing was delivered in a variety of settings.

96. 96 MI Providers Paraprofessional / students - 8 Masters level - 6 Psychologists - 6 Nurses - 3 Physicians - 2 Dietician - 1 Mixed - 22 It was delivered by a variety of clinicians.It was delivered by a variety of clinicians.

97. 97 Quality of MI Delivered Being collaborative Client centered Nonjudgmental Building trust Reducing resistance Increasing readiness In each study they reviewed, they counted the number of features of motivational interviewing that were mentioned as being included in the intervention. On average, 3.6 of 12 features were included in each intervention.In each study they reviewed, they counted the number of features of motivational interviewing that were mentioned as being included in the intervention. On average, 3.6 of 12 features were included in each intervention.

98. 98 Dose/Quality Control of MI Mean dose = 2.2 hours (2 sessions) Mean training time = 10 hours Manual-guided - 74% Post-training supervision - 29% Fidelity checks - 26% Each intervention contained a mean of 2.2 hours of motivational interviewing. Clinicians had an average of 10 hours of training in MI. Most studies used manuals to guide counseling. Only about a fourth included post-training supervision of counselors, and a fourth conducted checks to determine whether counselors were delivering therapy as intended.Each intervention contained a mean of 2.2 hours of motivational interviewing. Clinicians had an average of 10 hours of training in MI. Most studies used manuals to guide counseling. Only about a fourth included post-training supervision of counselors, and a fourth conducted checks to determine whether counselors were delivering therapy as intended.

99. 99 Effect Sizes Behavior 3 mo. 12 mo. HIV risk behaviors .71 .53 Drug abuse .51 .29 Public health .51 .30 Gambling .44 .29 Treatment adherence .42 .72 Alcohol .41 .26 Diet/Exercise .14 .78 Smoking .04 .14 Here are the effect sizes they found by behavioral area. MI was particularly effective in changing HIV risk behavior, moderately effective in changing alcohol and drug use, gambling, and treatment adherence behavior, and only mildly effective with diet, exercise, and smoking.Here are the effect sizes they found by behavioral area. MI was particularly effective in changing HIV risk behavior, moderately effective in changing alcohol and drug use, gambling, and treatment adherence behavior, and only mildly effective with diet, exercise, and smoking.

100. 100 Conclusions Strongest and most enduring effect occurs when MI is added at beginning of other tx Improved retention, adherence, motivation Most effect occurs within 3 months and starts to decay by 12 months Effects are variable across sites and providers MI was most effective when it was used as a pre-treatment to help motivate retention in and adherence to other treatments. Like other treatments, some decay of effect occurs. This data can give us confidence that MI is effective for alcohol and drug use disorders when delivered in a variety of settings by a variety of providers.MI was most effective when it was used as a pre-treatment to help motivate retention in and adherence to other treatments. Like other treatments, some decay of effect occurs. This data can give us confidence that MI is effective for alcohol and drug use disorders when delivered in a variety of settings by a variety of providers.

101. 101 So, it’s now clear that MI is effective. To deliver MI, we follow principles A through H and use microskills to help patients and clients get past barriers to the next stage of change.So, it’s now clear that MI is effective. To deliver MI, we follow principles A through H and use microskills to help patients and clients get past barriers to the next stage of change.

102. 102 Objectives - Part 3 For clients/patients without commitment to change: In Parts 3 and 4, we will focus on how to apply motivational interviewing for patients with and without commitment to change. In Parts 3 and 4, we will focus on how to apply motivational interviewing for patients with and without commitment to change.

103. 103 First, let’s review. In what stages of change is there NO firm commitment to change?First, let’s review. In what stages of change is there NO firm commitment to change?

104. 104 Yes, there is no firm commitment to change in the stages of relapse, precontemplation, and contemplation. In other stages, there is firm commitment to change.Yes, there is no firm commitment to change in the stages of relapse, precontemplation, and contemplation. In other stages, there is firm commitment to change.

105. 105 Goals by Stage Relapse Precont Cont. Determ. Action Maint In stages where there is no firm commitment to change, the clinician’s goal is to build commitment. In stages where there is firm commitment to change, the clinician’s goal is to help patients or clients create, implement, and refine their plan for change to give them the best chance of durable change. In Part 3 of this educational module, we will focus on individuals who are not firmly committed to change.In stages where there is no firm commitment to change, the clinician’s goal is to build commitment. In stages where there is firm commitment to change, the clinician’s goal is to help patients or clients create, implement, and refine their plan for change to give them the best chance of durable change. In Part 3 of this educational module, we will focus on individuals who are not firmly committed to change.

106. 106 Barriers - Precontemplation Lack of knowledge Lack of self-efficacy Contentment Let’s review those barriers to moving individuals through those early stages of change where there is no firm commitment to change. In precontemplation, the barriers to moving to contemplation are a lack of knowledge about risks and consequences, a lack of self-efficacy (or confidence that one can change), and contentment. Remember, contentment is the sense that I know a behavior is harmful, and I could change if I wanted to, but I’m not going to worry about it for now.Let’s review those barriers to moving individuals through those early stages of change where there is no firm commitment to change. In precontemplation, the barriers to moving to contemplation are a lack of knowledge about risks and consequences, a lack of self-efficacy (or confidence that one can change), and contentment. Remember, contentment is the sense that I know a behavior is harmful, and I could change if I wanted to, but I’m not going to worry about it for now.

107. 107 The barriers of similar for progressing from contemplation to determination, plus there’s an additional possible barrier for some individuals of a general difficulty in making decisions.The barriers of similar for progressing from contemplation to determination, plus there’s an additional possible barrier for some individuals of a general difficulty in making decisions.

108. 108 Sequential Menu of Options for Addressing Lack of Knowledge Assess understanding of risks and consequences of the behavior, especially those that seem particularly relevant Establish receptivity to hearing another point of view Deliver the information Check for understanding Assess perception of relevance and implications To address a lack of knowledge, here are some suggested steps. We wouldn’t use every step for every patient. Consider some of these step as a tool to have in your tool chest for particular situations. The first step, assessing an individual’s understanding, is very helpful in most circumstances. When individuals already have knowledge, eliciting their knowledge helps you avoid telling them things that they already know. It’s also an opportunity to see if some of their knowledge might be incorrect. If an individual may have some misinformation, it is important to avoid an argument about it. Asking if they would be receptive to hearing another point of view can help avoid right vs. wrong arguments. After delivering the information, it can be helpful to ask someone to say repeat back what they heard as a check of our ability to convey the information clearly. A simple questions, “Does this seem relevant to you?” can help individuals search for ways that the new information might affect their decision to change.To address a lack of knowledge, here are some suggested steps. We wouldn’t use every step for every patient. Consider some of these step as a tool to have in your tool chest for particular situations. The first step, assessing an individual’s understanding, is very helpful in most circumstances. When individuals already have knowledge, eliciting their knowledge helps you avoid telling them things that they already know. It’s also an opportunity to see if some of their knowledge might be incorrect. If an individual may have some misinformation, it is important to avoid an argument about it. Asking if they would be receptive to hearing another point of view can help avoid right vs. wrong arguments. After delivering the information, it can be helpful to ask someone to say repeat back what they heard as a check of our ability to convey the information clearly. A simple questions, “Does this seem relevant to you?” can help individuals search for ways that the new information might affect their decision to change.

109. 109 Addressing Low Self-Efficacy For previous relapses Normalize repeated relapses Identify reasons for difficulty and reframe as learning experience For low self-esteem Assess for depression, eating disorders, abuse/violence, and family dysfunction Treat/refer as necessary Low self-efficacy often results from previous unsuccessful attempts to change. We can help first of all by affirming the difficulty of behavior change and the frequency of relapse. Often we can find ways to reframe failures as partial successes. For an individual who was able to change for 1 month, we can interpret that as an important accomplishment. Identifying precipitants for past relapses and strategies to address them can further bolster confidence. For some individuals, low self-efficacy can stem from low self-esteem, a more generalized sense of low self-worth. Often low self-esteem must be address before individuals will be able to succeed in making difficult behavior changes. Low self-efficacy often results from previous unsuccessful attempts to change. We can help first of all by affirming the difficulty of behavior change and the frequency of relapse. Often we can find ways to reframe failures as partial successes. For an individual who was able to change for 1 month, we can interpret that as an important accomplishment. Identifying precipitants for past relapses and strategies to address them can further bolster confidence. For some individuals, low self-efficacy can stem from low self-esteem, a more generalized sense of low self-worth. Often low self-esteem must be address before individuals will be able to succeed in making difficult behavior changes.

110. 110 Addressing Contentment Identify positive aspects of the behavior Identify "less positive" aspects of the behavior Explore short-term and long-term goals Identify how the behavior might help or hinder goal attainment Contentment, remember, is the sense that one should and could change but is still not interested. For individuals with contentment, first identify the positive aspects of the behavior. Keep asking until the individual cannot think of any more positive aspects. As the individuals responds, demonstrate acceptance, and avoid judgment. Once individuals are heard out about the positive aspects of a behavior, they are much more willing to take stock about the negative aspects. When asking about these, some individuals will bristle at words like “negative” and “problem,” so ask instead about “less positive” aspects of the behavior. Again, keep asking until the individual cannot think of any more less positive aspects of the behavior. Next, change the subject and ask the individual about goals. What’s most important, who’s most important in your life? What would you like to see happen in these realms? Inquire about physical health, mental health, relationships with family, relationships with friends, job, career, money, and legal issues. Help put individuals in touch with their dreams. Next, ask how the behavior fits in with these goals. Don’t be surprised if individuals are initially dumbfounded by this question, as many people haven’t thought about this before. Allow individuals time to think about this, even to wrestle with it. If individuals get stuck, have them think about each goal separately and analyze whether their behavior will help or hinder them in each goal. This is a critical process, because, remember, motivation comes from the discrepancy between current behaviors and future goals.Contentment, remember, is the sense that one should and could change but is still not interested. For individuals with contentment, first identify the positive aspects of the behavior. Keep asking until the individual cannot think of any more positive aspects. As the individuals responds, demonstrate acceptance, and avoid judgment. Once individuals are heard out about the positive aspects of a behavior, they are much more willing to take stock about the negative aspects. When asking about these, some individuals will bristle at words like “negative” and “problem,” so ask instead about “less positive” aspects of the behavior. Again, keep asking until the individual cannot think of any more less positive aspects of the behavior. Next, change the subject and ask the individual about goals. What’s most important, who’s most important in your life? What would you like to see happen in these realms? Inquire about physical health, mental health, relationships with family, relationships with friends, job, career, money, and legal issues. Help put individuals in touch with their dreams. Next, ask how the behavior fits in with these goals. Don’t be surprised if individuals are initially dumbfounded by this question, as many people haven’t thought about this before. Allow individuals time to think about this, even to wrestle with it. If individuals get stuck, have them think about each goal separately and analyze whether their behavior will help or hinder them in each goal. This is a critical process, because, remember, motivation comes from the discrepancy between current behaviors and future goals.

111. 111 For Ambivalence - DEARS Develop discrepancy - Compare positives and negatives of behavior, and positives and negatives of changing, in light of goals; elicit self-motivational statements Empathize with ambivalence and pain of engaging in behavior that hinders goals Avoid arguments - don't push for change, avoid labeling For individuals in contemplation, who, by definition, have ambivalence about change, help develop discrepancy between their behavior and their goals. Use double-sided reflections. For example: “On one hand you really like drinking after work, unwinding, relaxing, socializing with buddies, and getting a little buzz on. On the other hand, you really want better relationships at home, and you want to be a great parent.” Help deepen the individual’s sense of discomfort with this dilemma: “What is it like to enjoy going to the bar so much yet knowing that it interferes with you being the parent you want to be?” Elicit the individual’s pain about the dilemma and the losses associated with the behavior. As you do this, play the middle, or play both sides equally: “On one hand you’d like to get home earlier to be with your family; on the other hand, you really feel drawn to the bar. What is it like to be so torn about this?” Your goal is not to push the individual. Your goal is to elicit discomfort about the dilemma – enough discomfort that the individual will want to seek resolution. It’s very important that you not push the individual, because pushing can cause resistance and arguments. Also, be sure to avoid using labels that might be insulting. Using words like abuse, alcoholism, or addiction can engender arguments. Eventually some individuals may need to realize that they are alcoholics or addicts. However, many individuals will change without needing to embrace these labels, and these labels can be a barrier to change.For individuals in contemplation, who, by definition, have ambivalence about change, help develop discrepancy between their behavior and their goals. Use double-sided reflections. For example: “On one hand you really like drinking after work, unwinding, relaxing, socializing with buddies, and getting a little buzz on. On the other hand, you really want better relationships at home, and you want to be a great parent.” Help deepen the individual’s sense of discomfort with this dilemma: “What is it like to enjoy going to the bar so much yet knowing that it interferes with you being the parent you want to be?” Elicit the individual’s pain about the dilemma and the losses associated with the behavior. As you do this, play the middle, or play both sides equally: “On one hand you’d like to get home earlier to be with your family; on the other hand, you really feel drawn to the bar. What is it like to be so torn about this?” Your goal is not to push the individual. Your goal is to elicit discomfort about the dilemma – enough discomfort that the individual will want to seek resolution. It’s very important that you not push the individual, because pushing can cause resistance and arguments. Also, be sure to avoid using labels that might be insulting. Using words like abuse, alcoholism, or addiction can engender arguments. Eventually some individuals may need to realize that they are alcoholics or addicts. However, many individuals will change without needing to embrace these labels, and these labels can be a barrier to change.

112. 112 As you are performing motivational interviews, it’s important to keep your antennae out for resistance. When you sense resistance, avoid confronting it head on. Instead, change your approach. You can acknowledge that resistance to change or ambivalence is understandable. You can reframe statements to create new forward momentum. Or you can turn problems back to the patient or client.As you are performing motivational interviews, it’s important to keep your antennae out for resistance. When you sense resistance, avoid confronting it head on. Instead, change your approach. You can acknowledge that resistance to change or ambivalence is understandable. You can reframe statements to create new forward momentum. Or you can turn problems back to the patient or client.

113. 113 Role-Play Exercise Get in pairs or groups Assign patient/client and clinician roles Read scenarios Review feedback sheet Perform role play Clinician and patient/client comment What did the clinician do well What could have been done differently Lead learners in role play exercises. Distribute: Case scenarios of patients/clients in contemplation Skills lists to guide interviews and subsequent feedback -- MI Principles A through H -- MI Microskills -- DEARS Strategies Ask patients/clients NOT to play a particularly stubborn, resistant individual. Allow 5 to 10 minutes for the role play exercise. Afterward, allow 3 minutes for the learners share feedback initially in their pairs or groups.Lead learners in role play exercises. Distribute: Case scenarios of patients/clients in contemplation Skills lists to guide interviews and subsequent feedback -- MI Principles A through H -- MI Microskills -- DEARS Strategies Ask patients/clients NOT to play a particularly stubborn, resistant individual. Allow 5 to 10 minutes for the role play exercise. Afterward, allow 3 minutes for the learners share feedback initially in their pairs or groups.

114. 114 Debrief Role-Play Exercise Patients/Clients:What did your clinicians do well? Clinicians:What did you find challenging?How would you want to improve next time? Everyone:How did you see motivational interviewing working in your role play? (Lead the large group in discussing the role play exercises.)(Lead the large group in discussing the role play exercises.)

115. 115 So, hopefully you are now more comfortable in using MI skills for individuals who are NOT firmly committed to behavior change. We use microskills and apply MI principles A through H in helping individuals get past barriers to the next stage of change.So, hopefully you are now more comfortable in using MI skills for individuals who are NOT firmly committed to behavior change. We use microskills and apply MI principles A through H in helping individuals get past barriers to the next stage of change.

116. 116 In this part of the module, we will focus on patients/clients who are firmly committed to change.In this part of the module, we will focus on patients/clients who are firmly committed to change.

117. 117 These are patients in the stages of determination, action, and maintenance.These are patients in the stages of determination, action, and maintenance.

118. 118 We want to help individuals in determination create and implement a change plan. For individuals in action and maintenance, we want to help refine their plan to give them the best chance of durable behavior change.We want to help individuals in determination create and implement a change plan. For individuals in action and maintenance, we want to help refine their plan to give them the best chance of durable behavior change.

119. 119 As we do this, we want to avoid giving advice that individuals do not want. However, when they want advice, we want to provide it, leaving them free to accept, reject, or modify it. We want to help individuals around logistic and other barriers. We want to help individuals make their own choices about their plan, so it fits best with their goals, values, preferences, and constraints. We want to be empathic through the process. When necessary to reinforcement their commitment, we want to remind people about the undesirability of the behavior and their goals that are prompting their efforts to change. We want to be seen as an active helper, keeping primary responsibility for decisions and change with the patient. As we do this, we want to avoid giving advice that individuals do not want. However, when they want advice, we want to provide it, leaving them free to accept, reject, or modify it. We want to help individuals around logistic and other barriers. We want to help individuals make their own choices about their plan, so it fits best with their goals, values, preferences, and constraints. We want to be empathic through the process. When necessary to reinforcement their commitment, we want to remind people about the undesirability of the behavior and their goals that are prompting their efforts to change. We want to be seen as an active helper, keeping primary responsibility for decisions and change with the patient.

120. 120 Reinforce and strengthen commitment to change Continue: Reinforcing the potential benefits of change Bolstering self-efficacy for behavior change One set of goals is to continue reinforcing commitment and self-efficacy.One set of goals is to continue reinforcing commitment and self-efficacy.

121. 121 Help develop and refine a plan for change Identify what has and has not worked Identify internal and external triggers for the behavior Develop strategies to manage triggers Consider focus on social supports, self-reward, and environmental change Help foresee possible weaknesses in plan Then help individuals develop and refine a plan for change. First help them identify what has and has not worked for them in the past. Help them find ways to include and improve on previously helpful strategies for change. Identify internal and external triggers for the behavior. Internal triggers could include moods or, for women, times of the month. External triggers could include exposure to certain people, places, or events. Then ask individuals to brainstorm about options for avoiding or managing these triggers. Ask individuals to think of other ways of reinforcing behavior change. Who might want to support them or work with them on this? Options could include family members, friends, co-workers, various professionals, and treatment programs. What self-rewards might they set up for themselves? Options could include buying a nice piece of clothing or taking a special vacation. What changes in their environments would support their change and make relapse less likely? Options might include avoiding certain situations and discarding items that remind them of substance use. Then ask individuals what is the weakest part of the plan. What trigger or environmental cue will be most risky for them, and how could they bolster their plan about this? Then help individuals develop and refine a plan for change. First help them identify what has and has not worked for them in the past. Help them find ways to include and improve on previously helpful strategies for change. Identify internal and external triggers for the behavior. Internal triggers could include moods or, for women, times of the month. External triggers could include exposure to certain people, places, or events. Then ask individuals to brainstorm about options for avoiding or managing these triggers. Ask individuals to think of other ways of reinforcing behavior change. Who might want to support them or work with them on this? Options could include family members, friends, co-workers, various professionals, and treatment programs. What self-rewards might they set up for themselves? Options could include buying a nice piece of clothing or taking a special vacation. What changes in their environments would support their change and make relapse less likely? Options might include avoiding certain situations and discarding items that remind them of substance use. Then ask individuals what is the weakest part of the plan. What trigger or environmental cue will be most risky for them, and how could they bolster their plan about this?

122. 122 As you help individuals develop plans, help individuals identify options. Give advice or provide new ideas when individuals will be receptive. Help spell out choices that individuals need to make. For individuals at risk for making an unwise choice, express concern respectfully if they would be receptive. Regardless of your judgment about an individual’s choice, honor the decision and offer your partnership. Support any positive change. As you help individuals develop plans, help individuals identify options. Give advice or provide new ideas when individuals will be receptive. Help spell out choices that individuals need to make. For individuals at risk for making an unwise choice, express concern respectfully if they would be receptive. Regardless of your judgment about an individual’s choice, honor the decision and offer your partnership. Support any positive change.

123. 123 If the individual is receptive, suggest some other ways to strengthen plans for change. Suggest that the individual make promises to him or herself and track progress, perhaps with a diary or scoresheet. Suggest setting implementation dates for various aspects of the plan. Review to plan and suggest ways to maximize concreteness and specificity. For example, suggest setting specific limits rather than vague intentions to cut down.If the individual is receptive, suggest some other ways to strengthen plans for change. Suggest that the individual make promises to him or herself and track progress, perhaps with a diary or scoresheet. Suggest setting implementation dates for various aspects of the plan. Review to plan and suggest ways to maximize concreteness and specificity. For example, suggest setting specific limits rather than vague intentions to cut down.

124. 124 I’d like to make a few comments that pertain specifically to each stage. For individuals in determination, the emphasis is on creating a plan that capitalizes on past partial successes, which have been reframed as learning experiences. For individuals in action, the emphasis is on reviewing progress, identifying difficulties, and reinforcing the plan as needed.I’d like to make a few comments that pertain specifically to each stage. For individuals in determination, the emphasis is on creating a plan that capitalizes on past partial successes, which have been reframed as learning experiences. For individuals in action, the emphasis is on reviewing progress, identifying difficulties, and reinforcing the plan as needed.

125. 125 For individuals in maintenance, major losses and stresses are major causes of relapse. Help individuals develop contingency plans for such events. In addition, remember that individuals engaged in change are usually doing so to attain other goals. Help individuals continue making progress toward such goals. For example, consider an alcohol dependent individual who wants to quit drinking primarily to meet the future partner of his or her dreams. A major risk for relapse would be failures in relationships, so this goal should be tracked along with substance use and other elements of the individual’s plan for change.For individuals in maintenance, major losses and stresses are major causes of relapse. Help individuals develop contingency plans for such events. In addition, remember that individuals engaged in change are usually doing so to attain other goals. Help individuals continue making progress toward such goals. For example, consider an alcohol dependent individual who wants to quit drinking primarily to meet the future partner of his or her dreams. A major risk for relapse would be failures in relationships, so this goal should be tracked along with substance use and other elements of the individual’s plan for change.

126. 126 Lead learners in role play exercises. Distribute: Case scenarios of patients/clients in contemplation Skills lists to guide interviews and subsequent feedback -- MI Principles A through H -- MI Microskills -- DEARS Strategies Ask patients/clients NOT to play a particularly stubborn, resistant individual. Allow 5 to 10 minutes for the role play exercise. Afterward, allow 3 minutes for the learners share feedback initially in their pairs or groups.Lead learners in role play exercises. Distribute: Case scenarios of patients/clients in contemplation Skills lists to guide interviews and subsequent feedback -- MI Principles A through H -- MI Microskills -- DEARS Strategies Ask patients/clients NOT to play a particularly stubborn, resistant individual. Allow 5 to 10 minutes for the role play exercise. Afterward, allow 3 minutes for the learners share feedback initially in their pairs or groups.

127. 127 Debrief Role-Play Exercise Patients/Clients:What did practitioners do well? Clinicians:What did you find challenging?How would you want to improve next time? Everyone:How did you see motivational interviewing working in your role play? (Lead the large group in discussing the role play exericses.) (Lead the large group in discussing the role play exericses.)

128. 128 So, now you’ve seen how motivational interviewing strategies can be used to help individuals create and refine behavior change plans. Perhaps the most difficult part of this process is to support an individual who wishes to implement a change plan that seems to have little chance of success. Again, we can express concerns or ask questions about this, but our role is to support the patient in their efforts. If the change plan works, we can be glad to have been proved wrong. If not, we’re in an excellent position to help them consider what they might do next time to sustain behavior change for longer. So, now you’ve seen how motivational interviewing strategies can be used to help individuals create and refine behavior change plans. Perhaps the most difficult part of this process is to support an individual who wishes to implement a change plan that seems to have little chance of success. Again, we can express concerns or ask questions about this, but our role is to support the patient in their efforts. If the change plan works, we can be glad to have been proved wrong. If not, we’re in an excellent position to help them consider what they might do next time to sustain behavior change for longer.

129. 129 I hope you learned enough through this seminar to start using MI with patients and clients. Remember, beginning to do motivational interviewing is quite complex. For many clinicians, doing motivational interviewing often involves unlearning various other strategies we have become comfortable with over the years. When we do motivational interviewing, we’re essentially trying to do four things at once. So be patient with yourself. Expect to make mistakes. Learn from them. I strongly recommended that you buy Miller and Rollnick’s book and use it as a guide. For those who prefer more active learning, the motivationalinterview.org website lists workshops you can attend.I hope you learned enough through this seminar to start using MI with patients and clients. Remember, beginning to do motivational interviewing is quite complex. For many clinicians, doing motivational interviewing often involves unlearning various other strategies we have become comfortable with over the years. When we do motivational interviewing, we’re essentially trying to do four things at once. So be patient with yourself. Expect to make mistakes. Learn from them. I strongly recommended that you buy Miller and Rollnick’s book and use it as a guide. For those who prefer more active learning, the motivationalinterview.org website lists workshops you can attend.