Effecting Change through the Use of Motivational Interviewing

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Effecting Change through the Use of
Motivational Interviewing
Thomas E. Freese, PhD Pacific Southwest
Addiction Technology Transfer Center UCLA
Integrated Substance Abuse Programs UCLA David
Geffen School of Medicine, Dept. of
Psychiatry www.psattc.org www.uclaisap.org
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What are we talking about?
What does increasing motivation mean to you?
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Understanding How People Change Models

• Traditional approach
• Motivating for change

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Traditional approach (1)
The Stick

• Change is motivated by discomfort.
• If you can make people feel bad enough, they will
  change.
• People have to hit bottom to be ready for
  change
• Corollary People dont change if they havent
  suffered enough

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Traditional approach (2)
You better! Or else!
If the stick is big enough, there is no need for
a carrot.
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Traditional approach (3)

• The Traditional Approach often used a Directing
  Style of helping.

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Directing helping style

• Tell them its important.
• Show them how to do it.
• Explain it to them, id how life could be better
• Threaten them, instill fear.
• Give them short term goals.
• Make them a list.
• Constantly remind them.
• Tell them what you expect.

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Directing Style of Helping

• Might make sense if you believe that the client
  
• doesnt know what they need to know.
• does not know how to change.
• Is indifferent to consequences of problem.

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Directing Style of Helping

• With these assumptions, it makes sense to
• use your expertise and teach them knowledge.
• teach them skills for health promoting behavior.
• give them hell, or otherwise make them feel
  something strongly enough so they will change.

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Directing Style of Helping

• Given that you are caring, compassionate,
  well-intended, and that your advice is sound
• why does your directing helping style not work
  as well as you would hope?

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Guiding Style of Helping

• Respect their decisions.
• Have them to describe what is working.
• Ask them what their plan is.
• Find out whats important to them.
• Have them talk about their health and their
  goals.
• Have them list pros and cons.
• Ask what their goals are for Tx.

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Guiding Style of Helping

• Motivational Interviewing can be considered a
  specialized subset of a Guiding style.

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What is the problem?

• It is NOT that
• they dont want to see (denial)
• they dont care (no motivation)
• They are just in the early stages of change.

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What is Motivational Interviewing?

• It is
• A style of talking with people constructively
  about reducing their health risks and changing
  their behavior.

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What is Motivational Interviewing?

• It is designed to
• Enhance the clients own motivation to change
  using strategies that are empathic and
  non-confrontational.

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What is Motivational Interviewing?

• You can recognize it by observing
• The powerful behavioral strategies for helping
  clients convince themselves that they ought to
  change
• The spirit of MI style in which it is delivered

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MI Strategic goals

• Resolve ambivalence
• Avoid eliciting or strengthening resistance
• Elicit Change Talk from the client
• Enhance motivation and commitment for change
• Help the consumer move through the Stages of
  Change

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MI - The Spirit (1) Style

• Nonjudgmental and collaborative
• Based on consumer and clinician partnership
• Gently persuasive
• More supportive than argumentative
• Listens rather than tells
• Communicates respect and acceptance for consumers
  and their feelings

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MI - The Spirit (2) Style

• Explores consumers perceptions without labeling
  or correcting them
• No teaching, modeling, skill-training
• Resistance is seen as an interpersonal behavior
  pattern influenced by the clinicians behavior
• Resistance is met with reflection

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MI - The Spirit (3) Consumer

• Responsibility for change is left with the
  consumer
• Change arises from within rather than being
  imposed from without
• Emphasis on consumers personal choice for
  deciding future behavior
• Focus on eliciting the consumers own concerns

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MI - The Spirit (4) Clinician

• Implies a strong sense of purpose
• Seeks to create and amplify the consumers
  discrepancy in order to enhance motivation
• Elicits possible change strategies from the
  consumer
• Systematically directs consumer toward motivation
  for change

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Important considerations

• The clinicians counselling style is one of the
  most important aspects of motivational
  interviewing
• Use reflective listening and empathy
• Avoid confrontation
• Work as a team against the problem

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How does MI differ from traditional counseling?

• 1. Patient and practitioner are equal partners in
  relationship (collaborative effort between two
  experts)

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Reflection

• Bring to mind the person in your life who has
  meant the most to you. The person who has
• Provided support
• Helped resolve problems
• Made you feel better
• Helped to change your perspective

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Ambivalence is Normal
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Ambivalence is normal

• People are almost always ambivalent about change
  
• Lack of motivation can be viewed as unresolved
  ambivalence.

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How does MI differ from traditional or typical
medical counseling?

• AMBIVALENCE is the key issue to be
• resolved for change to occur.
• People are more likely to change when they hear
  their own discussion of their ambivalence.
• This discussion is called change talk
• in MI.
• Getting patients to engage in change talk is a
  critical element of the MI process.
• Glovsky and Rose, 2008

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How can MI be helpful for us in working with our
consumers/patients?

• The successful MI therapist is able to inspire
  people to want to change
• Use of MI can help engage and retain consumers in
  treatment
• Using MI can help increase participation and
  involvement in treatment (thereby improving
  outcomes)

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Definition of Motivation
The probability that a person will enter into,
continue, and comply with change-directed
behavior
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Reflection

• Think about the most difficult change that you
  had to make in your life.
• How much time did it take you to move from
  considering that change to actually taking action?

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Motivational Interviewing
A patient-centered directive method for
enhancing intrinsic motivation to change by
exploring and resolving ambivalence.
directive method
patient-centered
exploring and resolving ambivalence

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www.samhsa.gov Free
Bookstore
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Whats the Best Way to Facilitate Change?
The Carrot

• Constructive behavior change comes from
  connecting with something valued, cherished and
  important
• Intrinsic motivation for change comes out of an
  accepting, empowering, safe atmosphere where the
  painful present can be challenged

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Where do I start?

• What you do depends on where the consumer is in
  the process of changing
• The first step is to be able to identify where
  the consumer is coming from

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Stages of ChangeProchaska DiClemente
Precontem- plation
Contemplation
Recurrence
Preparation
Maintenance
Action
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Helping People Change

• Motivational Interviewing is the process of
  helping people move through the stages of change

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1. Precontemplation Definition Not yet
considering change or is unwilling or unable to
change. Primary Task Raising Awareness
6. Recurrence Definition Experienced a
recurrence of the symptoms. Primary Task Cope
with consequences and determine what to do next
2. Contemplation Definition Sees the
possibility of change but is ambivalent and
uncertain. Primary Task Resolving
ambivalence/ Helping to choose change
Stages of ChangePrimary Tasks
5. Maintenance Definition Has achieved the
goals and is working to maintain
change. Primary Task Develop new skills for
maintaining recovery
3. Determination Definition Committed to
changing. Still considering what to do. Primary
Task Help identify appropriate change strategies
4. Action Definition Taking steps toward
change but hasnt stabilized in the
process. Primary Task Help implement change
strategies and learn to eliminate potential
relapses
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Precontemplation Stage

• Definition
• Not yet considering change or is unwilling or
  unable to change
• Primary task
• Raising Awareness

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Some Ways to Raise Awareness in the
Precontemplation Stage

• Offer factual information
• Explore the meaning of events that brought the
  person in and the results of previous efforts
• Explore pros and cons of targeted behaviors

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Contemplation Stage

• In this stage the consumer sees the possibility
  of change but is ambivalent and uncertain about
  beginning the process
• Primary task
• Resolving ambivalence and helping the consumer
  choose to make the change

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Possible Ways to Help the Consumer in the
Contemplation Stage

• Talk about the persons sense of self-efficacy
  and expectations regarding what the change will
  entail
• Summarize self-motivational statements
• Continue exploration of pros and cons

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Determination Stage

• In this stage the consumer is committed to
  changing but is still considering exactly what to
  do and how to do it
• Primary task
• Help consumer identify appropriate change
  strategies

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Possible Ways to Help the Consumer in the
Determination Stage

• Offer a menu of options for change or treatment
• Help consumer identify pros and cons of various
  treatment or change options
• Identify and lower barriers to change
• Help person enlist social support
• Encourage person to publicly announce plans to
  change

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Action Stage

• In this stage the consumer is taking steps toward
  change but hasnt stabilized in the process
• Primary task
• Help implement the change strategies and learn
  to limit or eliminate potential relapses

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Possible Ways to Help the Consumer in the Action
Stage

• Support a realistic view of change through small
  steps
• Help person identify high-risk situations and
  develop appropriate coping strategies
• Assist person in finding new reinforcers of
  positive change
• Help access family and social support

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Maintenance Stage

• Definition
• A stage in which the consumer has achieved the
  goals and is working to maintain them
• Primary task
• consumer needs to develop new skills for
  maintaining recovery

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Possible Ways to Help the Consumer in the
Maintenance Stage

• Help consumer identify and try alternative
  behaviors (drug-free sources of pleasure)
• Maintain supportive contact
• Encourage person to develop escape plan
• Work to set new short and long term goals

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Recurrence

• Definition
• consumer has experienced a recurrence of the
  symptoms
• Primary task
• Must cope with the consequences and determine
  what to do next

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How to Help the Consumer Who Has Experienced a
Recurrence

• Frame recurrence as a learning opportunity
  recurrence does not equal failure!
• Explore possible behavioral, psychological,
  social antecedents to the recurrence/relapse
• Help person develop alternative coping strategies
• Explain Stages of Change and encourage him/her to
  stay in the process
• Maintain supportive contact

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EXERCISE 1 Using the Stages of Change Treatment
Matching Guide

• 37 year old client. Using opioids and alcohol.
• Comes to you for help because they have been
  arrested for DUI. He was place on probation
• Client says that he doesnt think that he has a
  problem. That using drinking calms him down and
  makes him feel better. Willing to address
  opioids
• Client states that he thinks that everyone should
  drink some.
• Clients says he is ready to stop everything right
  now to get probation officer off his back.

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Change Talk

• Recognizing the problem
• Expressing concern
• Stating intention to change
• Being optimistic about change

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Moving Toward Changethe DARN Steps
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Change Talk

• Dig for change talk
• Id like to hear you opinions about
• What are some things that bother you about
  drinking?
• What role do you think alcohol played in your
  injury?
• How would you like your drinking to be 5 years
  from now?

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Change Talk is Happening When the Consumer Makes
Statements that Indicate
Recognition of a problem A concern about the
problem Statements indicating an intention to
change Expressions of optimism about change
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Building Motivation OARS(the microskills)

• Open-ended questioning
• Affirming
• Reflective listening
• Summarizing

The goal is to elicit and reinforce
self-motivational statements (Change Talk)
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Open-Ended Questions
An open-ended question is one that requires more
than a yes or no response

• Solicits information in a neutral way
• Helps person elaborate own view of the problem
  and brainstorm possible solutions
• Helps therapist avoid prejudgments
• Keeps communication moving forward
• Allows consumer to do most of the talking

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Affirmations

• Focused on achievements of individual
• Intended to
• Support persons persistence
• Encourage continued efforts
• Assist person in seeing positives
• Support individuals proven strengths

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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)

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Types of Reflective Statements

• 1. Simple Reflection (repeat)
• Amplified Reflection (rephrasing and
• paraphrasing)
• Double-Sided Reflection (rephrasing,
• paraphrasing and reflecting feeling)

NIDA-SAMHSA Blending Initiative
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Types of Reflective Statements

• 1. Simple Reflection (repeat)
• Amplified Reflection (amplify/exaggerate the
  consumers point)
• Double-Sided Reflection (captures both sides of
  the ambivalence)

NIDA-SAMHSA Blending Initiative
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Simple Reflections

• Simple reflections stay very close to the
  speakers original meaning
• Client I dont know if I want to go to SAMHC or
  not.
• Staff Youre not really sure about going to
  SAMHC.
• Client It seems like being clean is getting
  easier.
• Staff Its not such a struggle to stay clean
  anymore.
• Client I cant wait to get my own place.
• Staff Moving out on your own is exciting.

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Practice

• Make a simple reflection
• Client I dont ever want to drink again.
• Client Some of the guys in the house are pretty
  cool.
• Client That Yvonna person who does our group is
  so awesome. Shes pretty much the most awesome
  person Ive ever met.

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Amplified Reflections

• Complex reflections not only repeat the speakers
  meaning, they shape it.
• Put words in peoples mouths
• Goal is always to get client to give more change
  talk.

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Making An Amplified Reflection

• listen to the client statement, then
• 1.) note your target behavior
• 2.) identify any change talk you
• heard
• 3.) reflect the change talk.
• Be creative if necessary!

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Example

• Client I dont want to go back to prison but
  this is way too hard.
• What is the target behavior? Staying in the
  program.
• What change talk did we hear? I dont want to
  go back to prison.
• Staff Youre struggling here, but you wont
  quit trying- prison is just not an option in your
  mind.
• Client ?

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Example

• Client Im not going to quit drinking. The
  drugs, fine, because I dont want to keep getting
  in trouble.
• What is the target behavior? Abstinence.
• What change talk did you hear? I dont want to
  keep getting in trouble.
• Staff Youre tired of being in trouble with the
  law. You want to put that behind you.
• Client ?

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Example

• Client Honestly, I think these meetings are
  stupid. Its just a bunch of people sitting
  around romanticizing drugs. I dont need to be
  doing that.
• What is the target behavior? attending support
  meetings
• What change talk did you hear? The client doesnt
  want to romanticize drug use.
• Staff You want real substance and support when
  you go to a meeting.
• Client ?

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Double Sided Refections

• So on the one hand you..but on the other you
  want..
• End on the change talk.
• I know I need to quit smoking for my health, but
  its so hard to stop.
• So on the one hand you are worried about
  withdrawal from nicotine, but on the other hand
  you dont want to die from smoking.

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Reflective Listening Exercise

• The Listener will using as many complex and
  double-sided reflections as possible. Remember
• note your target behavior
• find the emotion and/or the change talk
• reflect it- get creative.

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What if?

• What if the client doesnt say ANY change talk?
• Actions speak louder than words. Do the
  clients actions express any change talk? (Can
  you address any discrepancy between their words
  and their actions?)
• Client This program is worthless. I dont want
  anything to do with it.
• On the one hand, you dont really want to be
  here and you dont think it will help you at all.
  On the other hand, youre still sitting here in
  front of me. Im wondering how that adds up.
• Client ?

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What If, Cont

• No, I mean it What if the client gives you NO
  change talk? AT ALL?
• Try reflecting the resistance. Can you get even
  MORE resistant than the client?
• Client My PO wants me working and going to
  counseling and TASC. You guys want me going to
  all these meetings, making curfew, giving you all
  my money. My wife is always on my case. Im
  gonna have to get loaded just to deal with you
  all!
• Staff It would be impossible to deal with all
  these people sober. In fact, nobody could do
  it!
• Client ?

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What If, Cont

• Consider the possibility that you are not talking
  about the right issue

?
?
?
?
?
?
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SUD
MH
Pain
SUD
Family
Medical Issues
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• To avoid this

LET GO!!!
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SUD
SUD
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Summarizing

• Summaries capture both sides of the ambivalence
  (You say that ___________ but you also mentioned
  that ________________.)
• They demonstrate the clinician has been listening
  carefully.
• Summaries also prompt clarification and further
  elaboration from the person.
• They prepare consumers to move forward.

A summary is a series of reflections strung
together
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Four Principles ofMotivational Interviewing
1. Express empathy 2. Develop discrepancy 3. Avoi
d argumentation 4. Support self-efficacy
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Use the Microskills of MI to

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

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Empathic Listening

• Respect Client Autonomy.
• Respect Client Views.
• Look at Problem Together Client is not the
  problem.
• Reflect what client is experiencing.
• Genuinely care about your client.
• Empower Client to Take Control of Their Lives.
• Take care of your own crap!
• Get your own therapist if needed!
• Come to work with positive energy!

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Use the Microskills of MI to

• Develop Discrepancy
• Discrepancy between present behaviors and
  important goals or values motivates change
• Awareness of consequences is important
• Goal is to have the PERSON present reasons for
  change

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Weighing the Decisional Balance

• Strategies for weighing the pros and cons
• What do you like about drinking?
• What do you see as the downside of drinking?
• What Else?
• Summarize both pros and cons
• On the one hand you said..,
• and on the other you said.

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Importance/Confidence/Readiness Scale

• On a scale of 110
• How important is it for you to change your
  drinking?
• How confident are you that you can change your
  drinking?
• How ready are you to change your drinking?
• For each ask
• Why didnt you give it a lower number?
• What would it take to raise that number?

1 2 3 4 5 6 7
8 9 10
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The Decisional Balance
Avoid questions that inspire a yes/no answer.
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The Payoff for Asking the Questions

• These questions will lead to a working treatment
  plan
• Stage of change
• Benefits of use
• Consequences of use
• Willingness to work on these issues

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Use the Microskills of MI to

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

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Use the Microskills of MI to

• Support Self-Efficacy
• Belief that change is possible is an important
  motivator
• Person is responsible for choosing and carrying
  out actions to change
• There is hope in the range of alternative
  approaches available

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Support Self-Efficacy

• Belief that change is possible is important
  motivator
• Person is responsible for choosing and carrying
  out actions to change
• There is hope in the range of alternative
  approaches available

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Give them feedback and advice, but do it in a
motivational way

• The Feedback/Advice Sandwich

Ask Permission Give Feedback/Advice Ask for
Response
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When to Give Advice

• Does the consumer already know what I have to
  say?
• Have I elicited the consumers knowledge
  regarding this information?
• Is what Im about to say going to be helpful to
  the consumer (i.e., reduce resistance and/or
  increase change talk)

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Any time that you address substance use SEW it
up

• Summarize patients views (especially the pro)
• Encourage them to share their views
• What agreement was reached (repeat it)

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Possible Ways to Help the Patient in the
Determination Stage

• Offer a menu of options for change or treatment
• Help client identify pros and cons of various
  treatment or change options
• Identify and lower barriers to change
• Help person enlist social support
• Encourage person to publicly announce plans to
  change

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Let's Practice

• Focus on the clients definition of the problem

Give advise to change Explore options for
change Sew up the conversation
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How Do I Finish?

• Develop a Change Plan with the consumer by
• Offering a menu of change options
• Developing a behavior contract
• Lowering barriers to action
• Enlisting social support
• Educating the consumer about treatment

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You Are Using MI If You

• Talk less than your consumer does
• Offer one refection for every
  three questions
• Reflect with complex reflections more than half
  the time
• Ask mostly open-ended questions
• Avoid getting ahead of your consumers stage of
  readiness (warning, confronting, giving unwelcome
  advice, taking good side of the argument)

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Sample MI Interview Questions

• In looking over the good and not-so-good aspects
  of your alcohol/drug use, what do you notice?
• Which benefits seem most important to you?
• Which of the not-so-good things do you think
  cause the most problems for you?
• If we could come up with healthier ways for you
  to get these same benefits, do you think it might
  be easier for you to cut down on your
  alcohol/drug use?
• Which of the not-so-good things do you think
  affects your (MH dx) the most and might be the
  most important to try to reduce?
• On a scale of 0-10, how ready are you to start
  working on these things?

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Role Play of Motivational Interviewing Style

• While observing notice examples of when the
  microskills (O.A.R.S.) are being used.
• Were there any examples of Non-MI interventions?
• What stage of change do you think the client is
  in? Why?

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Strategies to Avoid
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What techniques should I avoid?

• Techniques to avoid when motivating clients
• Confrontation / denial
• Closed questions
• Clinician traps
• Roadblocks to reflective listening

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Clinician Traps

• Question-Answer Trap
• Confrontation-Denial Trap
• Expert Trap
• Labeling Trap
• Premature-Focus Trap
• Blaming Trap

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Roadblocks 1

• Ordering, directing, or commanding
• Warning or threatening
• Giving advice, making suggestions, providing
  solutions
• Persuading with logic, arguing, lecturing
• Moralising, preaching, telling them their duty
• Judging, criticising, disagreeing, blaming

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Roadblocks 2

• Agreeing, approving, praising
• Shaming, ridiculing, labeling, name-calling
• Interpreting, analysing
• Reassuring, sympathising, consoling
• Questioning, probing
• Withdrawing, distracting, humouring, changing the
  subject.

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Some questions to ask yourself when in
conversation with a client ...

• What am I doing?
• Where are we going, and whos deciding?
• What am I saying, and to what end?
• Am I actively listening?
• Are we dancing or wrestling?

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The 3 Chairs exercise

• Observe the activity and provide feedback.

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Concluding Thoughts

• Experiences and observations
• One thing I can take away from this training and
  use tomorrow is

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Thank You!!

• Thomas E Freese, PhD
• tfreese_at_mednet.ucla.edu
• For additional information on this or other
  training topics, visit
• www.psattc.org
• www.motivationalinterview.org
• www.uclaisap.org/dmhcod