MIA:STEP Toolkit Overview Jeanne L. Obert , MFT, MSM Executive Director Matrix Institute on Addictions

1. MIA:STEPToolkit OverviewJeanne L. Obert, MFT, MSMExecutive DirectorMatrix Institute on Addictions

2. What is an MI Assessment? • Use of client-centered MI style • MI strategies that can be integrated into the agency’s existing intake assessment process • Methods that can be used with diverse substance use problems • Skills for assisting clients in assessing their own substance use • Understanding the client’s perception and willingness to enter into a treatment process

3. MI strategies during 1st 20 min Agency Intake or Assessment MI strategies during last 20 min MI Assessment “Sandwich”

4. Development of the protocol • The NIDA Drug Abuse Treatment Clinical Trials Network designed the protocol • Designed as something that all outpatient community treatment providers could use • Researchers worked directly with MI experts and treatment providers on both development and implementation.

5. Profile of CTN study participants • Average age: 32 • Gender: 40% female • Race: 76% White • Marital Status: 21% married • Referral source: 32% referred by criminal justice system • Average years of education: 12 • Primary drug problem: alcohol (48%) followed by marijuana, cocaine, stimulants

6. Research findings 1. People receiving MI assessment completed more sessions in 4 weeks than those receiving standard intake.

7. Research findings 2. MI retained more people in treatment at the 4 week point than standard assessment.

8. Research findings 3.For alcohol users only, there was a more pronounced difference in treatment sessions attended at 4 weeks that was maintained at the 84 day follow-up. 5.1 3.3 Sessions Attended at 4 Weeks

9. Why another application of MI? • Positive outcomes depend on clients staying in treatment for adequate length of time • Adding MI at beginning of treatment increases client retention • The type of clinical supervision needed to maintain and improve MI skills is generally lacking

10. Implementing MI may require: • Focused clinical supervision • Audio taped MI Assessment sessions • Tape coding • Feedback, coaching and instruction for improving skills

11. Benefits of MI Assessment • It has a solid evidence-base • MI improves client engagement and retention • Using MIA:STEP: • Enhances clinical supervision • Builds counselor knowledge and proficiency in MI

12. Why consider this approach when staff are already trained in MI? • Most trained clinicians do not use MI appropriately, effectively or consistently • MI is more difficult than clinicians expect • The key to successful implementation of MI is supervisory feedback and coaching

13. MIA:STEP Toolkit includes everything you need to: • Introduce the idea of doing an MI assessment • Train counselors and supervisors • Provide ongoing supervision of MI • Train supervisors to use a simple tape rating system • Use an MI style of supervision

14. The costs of implementing MI Assessment • Time to learn and implement the protocol • Regular review and feedback on MI skills • Ongoing clinical supervision, including: - Training - Mentoring - Practice - Review of recorded interviews - Feedback - Development of learning plans • The cost of recorders and supplies

15. MIA:STEP Toolkit Overview • Briefing materials • Summary of the MI Assessment intervention • Results of the NIDA CTN Research • Teaching tools for enhancing and assessing MI skills • Interview rating guide and demonstration materials • Supervisor training curriculum

16. Motivational Interviewing Elicit behavior change Respect autonomy A patient-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. Tolerate patient ambivalence Explore consequences

17. Using MI with Co-occurring Disorders Taking Medications Staying Clean and Sober Participating in Dual Diagnosis Specialty Program

18. Stages of ChangeProchaska & DiClemente Precontemplation Contemplation Maintenance Preparation Action

19. Building Motivation Using the OARS • Open-ended questioning • Affirming • Reflective listening • Summarizing

20. Open-ended Questions • An open-ended question is one with more than a yes or no response • Helps person elaborate own view of the problem and brainstorm possible solutions

21. Affirmations • Focused on achievements of individual • Intended to: • Support person’s persistence • Encourage continued efforts • Assist person in seeing positives • Support individual’s proven strengths

22. Reflective Listening Key-concepts • Listen to both what the person says and to what the person means • Check out assumptions • Create an environment of empathy (nonjudgmental) • You do not have to agree • Be aware of intonation (statement, not question)

23. Levels of Reflection • Repeating – Repeating what was just said. • Rephrasing – Substituting a few words that may slightly change the emphasis. • Paraphrasing – Major restatement of what person said. Listener infers meaning of what was said. Can be thought of as continuing the thought. • Reflecting Feeling - Listener reflects not just the words, but the feeling or emotion underneath what the person is saying.

24. Types of Reflective Statements • 1. Simple Reflection (repeat) • Amplified Reflection (rephrasing and • paraphrasing) • Double-Sided Reflection (rephrasing, • paraphrasing and reflecting feeling)

25. Summarizing • Summaries capture both sides of the ambivalence • (You say that ___________ but you also mentioned that ________________.) • Summaries also prompt clarification and further elaboration from the person.

26. Four Principles ofMotivational Interviewing 1. Express empathy 2. Develop discrepancy 3. Avoid argumentation 4. Support self-efficacy

27. Express Empathy • Acceptance facilitates change • Skillful reflective listening is fundamental • Ambivalence is normal

28. Develop Discrepancy • Discrepancy between present drug use behaviors and important goals or values • Awareness of consequences is important (Use Pros and Cons) • Goal is to have the PERSON present reasons for change

29. Avoid Argumentation • Resistance is signal to change strategies • Labeling is unnecessary • Shift perceptions • Peoples’ attitudes shaped by their words, not yours

30. Support Self-Efficacy • Belief that change is possible is important motivator • Counselor’s expectations become self-fulfilling • Person is responsible for choosing and carrying out actions to change • There is hope in the range of alternative approaches available

31. Eliciting Change Talk • DARN C – Statements that indicate: • Desire to make a change • Ability to make change • Reasons for considering change • Need (emotional) to change

33. Exploring Ambivalence Use Decisional Balance Exercise • PRO’S • +’S • GOOD THINGS

34. Assessing Readiness to Change

35. Readiness Ruler (May be conducted on paper or verbally) Importance Ruler 1—----2—----3—----4—----5—----6—----7—----8—----9—----10 Very Important Not at all Important Confidence Ruler 1-------2-------3-------4-------5-------6-------7-------8-------9-------10 Not at all Confident Very Confident

36. Key Questions on Readiness Pull for Change Talk with some of the following questions: • “What do you think you will do?” • “What does this mean about your (habit)?” • What do you think has to change?” • “What are some of your options?” • “What’s the next step for you?” • “What would be some of the good things about • making a change?” • “Where does this leave you?”

37. Inventories to Assess Readiness

38. MI Supervisor Minimum Qualifications

39. Skills Assessed by Self and Supervisor

40. Skills Assessed by Self and Supervisor

41. Rating MI Adherence and Competence

42. Example of Skill SummaryOpen-Ended Questions Frequency and Extensiveness Higher if you ask questions that invite client conversation as opposed to asking only yes/no response questions. Skill Level Higher if: 1. Questions are relevant to the clinician-client conversation. 2. Questions encourage greater client exploration and recognition of problem areas and motivation for change, without appearing to be judgmental or leading to the client. 3. Inquiries are simple and direct, thereby increasing the chance that the client clearly understands what the clinician is asking. 4. Usually, several open-ended questions do not occur in close succession. Rather, high quality open-ended questions typicaly are interspersed with reflections and ample client conversation to avoid the creation of a question-answer trap between the clinician and the client. 5. You pause after each question to give the client time to respond.

43. Example of Skill SummaryOpen-Ended Questions (con’t) Skill Level Lower if: 1. Questions are poorly worded or timed to target an area not immediately relevant to the conversation and client concerns. 2. Questions often occur in close succession, giving the conversation a halting or mechanical tone. 3. Inquiries may compound several questions into one query making them harder for the client to understand and respond to. 4. Questions lead or steer the client. 5. Inquiries have a judgmental or sarcastic tone. 6. Pauses after each question are not sufficient to give the client time to contemplate and respond