Module II Screening and Assessment

1
Module V Motivational InterviewingAn
Evidence-Based, Patient-Centered Approach to
Addressing Risky, Problem, and Dependent Drinking
Project MAINSTREAM
November 2005
2
Learning Objectives

• 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

3
Objective Part 1

• 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

4
Introspective Exercise 1

• What expectations do trainees have about
  promoting behavior change among patients/clients?

5
Common Expectations ofNovice Clinicians

• Knowledge is power Francis Bacon
• Sound advice will result inquick, easy, and
  lastingbehavior change
• Often not true

6
How Does Behavior Change?

• Behavior A Behavior B

7
Introspective Exercise 1(continued)

• What feelings do you experience when working with
  patients/clients to promote behavior change?

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 -

9
Introspective Exercise 1(continued)

• Think of a behavioryou have tried to change

10
Introspective Exercise 1(continued)

• How much time elapsed between
• the first time you engaged in the behavior, and
• the first time you recognized risk or negative
  consequences?

11
Introspective Exercise 1- Response choices -

• lt 1 mo.
• 1 to 3 mo.
• 4 to 6 mo.
• 7 to 12 mo.

• 13 mo. to 2 yr.
• 3 to 5 yr.
• gt 5 yr.

12
Introspective Exercise 1(continued)

• How much time elapsed between
• the first time you recognized risks or negative
  consequences, and
• the first time you made an earnest attempt to
  change the behavior?

13
Introspective Exercise 1- Response choices -

• lt 1 mo.
• 1 to 3 mo.
• 4 to 6 mo.
• 7 to 12 mo.

• 13 mo. to 2 yr.
• 3 to 5 yr.
• gt 5 yr.

14
Introspective Exercise 1(continued)

• Did you ever experience some success in changing
  your behavior?
• Did you ever experience a resumption of or
  increase in the undesired behavior after
  experiencing some success?

15
Introspective Exercise 1(continued)

• What conclusions would you draw from the groups
  responses?

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

17
Common Conclusions(continued)

• Our expectations of patients/clients regarding
  behavior change are unrealistic
• Unrealistic expectations can lead to frustration
  and burn-out

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

19
Transtheoretical Model ofBehavior Change

• All individuals progress through stages of change
• Movement may be forward or backward
• Movement may be cyclical

20
Transtheoretical Model
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Action
SynonymsDetermination PreparationTermination
Exit
Termination
21
Precontemplation

• Not considering change
• Actively opposed
• Havent considered it
• Goal Move to contemplation
• Barriers
• Knowledge of risks/consequences
• Self-efficacy
• Contentment

22
Contemplation

• Considering change - ambivalent
• Goal Move to determination
• Barriers
• Knowledge of risks/consequences
• Self-efficacy
• Contentment
• Indecisiveness

23
Determination/Preparation

• Committed to change within 1 mo.
• Goal Move to action, design plan
• Barriers
• Loss of commitment
• Knowledge of options
• Making decisions about plans for change

24
Action

• Has begun to change behavior
• Goals
• Optimize plans
• Maintain changes
• Barriers
• Failure and disillusionment
• Overconfidence

25
Maintenance

• Behavior change is well-learned typically for 6
  months
• Goal Stable, new lifestyle attainment of
  original goals
• Barriers
• Major losses and stresses
• Failure to attain original goals

26
Relapse

• Resumption of undesired behavior
• Relapse is a normal, expected stage of behavior
  change
• Goals
• Identify relapse
• Reframe as opportunity to learn
• Restage

27
Termination/Exit

• Relapse is highly unlikely
• Stable, healthy lifestyle
• Precontemplation and no temptation about
  returning to behavior

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

(Institute of Medicine, Health and Behavior, 2001)
29
Assessing Stage of Change

• What question(s) would best assess stage of
  change?

30
Assessing Stage of Change (continued)

• Criteria for assessment question
• Accurate
• Non-leading
• Non-judgmental
• Respectful

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?

32
Assessing Stage of Change (continued)

• Sample follow-up questions
• So, are you saying that youre thinking of
  changing soon, or not really?
• Im confused. Are you saying that youre ready
  to change, or is this a bad time?

33
Assessing Stage of Change (continued)

• Ask initial question
• Listen carefully and assess
• If necessary, ask follow-up question and reassess

34
Assessing Stage of Change (continued)

• Ask initial question
• Listen carefully and assess
• If necessary, ask follow-up question and reassess.

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 Ive known for a long time
  I really should cut down

Precontemplation Action Contemplation Maintenance
Determination Relapse
36
Case 1 - What stage of change?

• Patient Oh, I guess Ive known for a long time
  I really should cut down
• Possible stages are
• Precontemplation - but nows not a good time.
• Contemplation - but Im torn.
• Determination - and I will, starting tomorrow.
• Action - and I started cutting down last
  weekend.
• Inquire about intention to change soon

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 havent had a thing to drink since
  leaving the hospital last week. The pain from
  my pancreas was awful. Im never going to have
  more than a couple of beers again.

Precontemplation Action Contemplation Maintenance
Determination Relapse
38
Case 2 - What stage of change?

• Patient I havent had a thing to drink since
  leaving the hospital last week, and Im 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

39
Summary - Part 1

• 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

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

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.ni
  h.gov
• www.motivationalinterview.org

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

43
Introspective Exercise 2 (continued)
For individuals whowere not helpful How did
they come across? What did they do thatwas not
helpful?
44
Introspective Exercise 2 (continued)
For individuals who were helpful How did they
come across? What did they do thatwas not
helpful?
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)

46
Principles of MI

• Advice
• Barriers
• Choices
• Decrease desirability

• Empathy
• Feedback
• Goals
• Helping

47
Principles of MI (continued)

• Advice
• Give advice only when individuals will be
  receptive
• Target advice to stage of change

48
Principles of MI (continued)

• Reduce Barriers
• Bolster self-efficacy
• Address logistical barriers

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Principles of MI (continued)

• Provide Choices
• Its the individuals choice
• Whether to change
• How to change

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Principles of MI (continued)

• Decrease Desirability
• Help individuals
• Decrease their perceptions off the desirability
  of the behavior
• Identify other behaviors to replace the positives

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Principles of MI (continued)

• Empathy
• Develop and communicate an understanding of the
  individuals situation and feelings around the
  behavior
• Uncover pain around the behavior

52
Principles of MI (continued)

• Feedback
• Help the individual identify and understand
  relevant
• Risks of the behavior
• Negative consequences of the behavior

53
Principles of MI (continued)

• Discussion Question
• What is the source of motivation to change
  behavior?

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Principles of MI (continued)

• Motivation comes from the discrepancy between
• Current behavior
• Future goals

55
Principles of MI (continued)

• Goals
• Help individuals weigh
• the pros and cons of their behavior
• the pros and cons of changing their behavior
• in light of their goals for the future

56
Principles of MI (continued)
Active Helping Without assuming responsibility
for behavioral change, extend yourself and show
you care
57
Principles of MI (continued)
Discussion Question How do the principles of MI
compare to what youve found helpful and not
helpful in promoting behavior change?
58
Frameworks
MotivationalPatient-Centered Partnership
ConfrontationalProvider-Centered Paternalism
Have multiple tools in your tool chest Easier
Motivational ConfrontationalHarder
Confrontational Motivational
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

(Miller, 1993 Deci Ryan, 1985)
60
Key MI Skills

• Open-ended questions
• Reflective listening
• Affirmations
• Summarize
• Elicit self-motivational statements

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Open-Ended Questions

• Probe widely for information
• Help uncover the pt/clients priorities and
  values
• Avoid socially desirable responses
• Draw people out

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Open-Ended Questions (continued)
Example 1 Would you like to quit smoking? A
more open-ended question?
63
Open-Ended Questions (continued)
Example 1 Would you like to quit
smoking? How do you feelabout your smoking?
64
Open-Ended Questions (continued)
Example 2 How much pot do you smoke? A more
open-ended question?
65
Open-Ended Questions (continued)
Example 2 How much pot do you smoke? Would
you please tell me more about your pot smoking?
66
Reflective Listening

• A critical MI skill
• Mirrors what pt/client says
• Is non-threatening
• Deepens the conversation
• Helps patients/clients understand themselves

67
Reflective Listening (continued)

• Reflective listening says
• I hear you.
• Im accepting, not judging you.
• This is important.
• Please tell me more.

68
Reflective Listening (continued)
Reflective listening is NOT

• Directing
• Warning
• Advising
• Persuading
• Moralizing
• Agreeing

• Disagreeing
• Labeling
• Interpreting
• Reassuring
• Questioning
• Withdrawing

69
Reflective Listening (continued)
Example 1 My girlfriend gets really angry when
I drink and pass out. Reflective response?
70
Reflective Listening (continued)
Example 1 My girlfriend gets really angry when
I get drunk and pass out. She gets mad when
youdrink and fall asleep.
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Reflective Listening (continued)
Example 2 Im not a pleasant drunk.Ive
beaten people up badly. Reflective response?
72
Reflective Listening (continued)
Example 2 Im not a pleasant drunk.Ive
beaten people up badly. Youve hurt people
whenyouve been drunk.
73
Reflective Listening (continued)
Example 3 I know I shouldbe drinking
less. Reflective response?
74
Reflective Listening (continued)
Example 3 I know I shouldbe drinking
less. You feel that drinking lesswould be a
good idea.
75
Affirmations

• Support the patient/client
• Convey respect
• Convey understanding
• Encourage more progress
• Help clients/patients reveal less positive
  aspects of themselves

76
Affirmations (continued)

• Examples?

77
Affirmations (continued)

• You are very courageous to be so revealing about
  this.
• Youve accomplished a lot in a short time.
• I can understand why drinking feels so good to
  you.

78
Summarization

• What youve 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 ...

79
Elicit Self-Motivational Statements

• Have patients/clients make their own arguments
  for change in 4 areas
• Problem recognition
• Concern
• Intention to change
• Optimism

80
Elicit Self-Motivational Statements (continued)
Problem recognition Examples of questions to
elicitself-motivational statements?
81
Elicit Self-Motivational Statements (continued)
Problem recognition How has behavior made
problems for you? How do you think youve been
hurt by behavior?
82
Elicit Self-Motivational Statements (continued)
Concern Examples of questions to
elicitself-motivational statements?
83
Elicit Self-Motivational Statements (continued)
Concern What worries do you haveabout your
behavior? What are you afraid might happen if
things continue as they are?
84
Elicit Self-Motivational Statements (continued)
Intention to Change Examples of questions to
elicitself-motivational statements?
85
Elicit Self-Motivational Statements (continued)
Intention to Change What might be some
advantages ofchanging your behavior? What
might be better for you if you did change your
behavior?
86
Elicit Self-Motivational Statements (continued)
Intention to Change On a scale of 0 to 10, how
important is it for you to change your
behavior? Why didn't you say 1 or 2 points
lower?
87
Elicit Self-Motivational Statements (continued)
Optimism Examples of questions to
elicitself-motivational statements?
88
Elicit Self-Motivational Statements (continued)
Optimism What difficult goals have youachieved
in the past? What might work for you if youdid
decided to change?
89
Elicit Self-Motivational Statements (continued)
Optimism On a 0 to 10 scale, how confident are
you that you could change? Why didn't you say 1
or 2 points lower?
90
Layers of MI
Engage in Active Listening with the Patient/Client
Use Microskills
Implement MI Principles
Address Barriers tothe Next Stage of Change
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?

(Project MATCH Research Group. J Stud Alc
1997587-29)
92
Evidence on Effectiveness (continued)

• Project MATCH - Results
• All three treatments were effective
• Matching effects were few and fairly minor
• Four hours of MET were as effective as twelve
  hours of TSF or CBT
• Caution Study was not designed to assess
  differential efficiency of treatments
• Study does suggest effectiveness of MET

(Project MATCH Research Group. J Stud Alc
1997587-29)
93
Evidence on Effectiveness (continued)

• Adaptations of motivational interviewing - AMI
• More directive than pure MI
• May provide unrequested information on risks and
  consequences of unhealthy behaviors
• Effect sizes of AMIs
• 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

(Burke BL et al. J Consult Clin Psychol, 2003)
94
Meta-Analysis of MI - 72

• 72 studies considered
• Alcohol - 31
• Illicit drugs - 14
• Smoking - 6
• HIV risk - 5
• Treatment adherence - 5
• Water purification - 4
• Diet/exercise - 4
• Gambling - 1
• Eating Disorder - 1
• Relationship - 1

• 72 studies considered
• MI vs. other tx - 25
• MI vs. usual tx - 6
• MI vs. no tx/placebo - 21
• MI other tx - 7
• MI usual tx - 5
• Mixed designs - 6
• Within-group only - 2

(Hettema et al., Annual Rev Clin Psych, 2005)
95
Settings

• Outpatient clinics (15)
• Inpatient facilities (11)
• Educational settings (6)
• Community organizations (5)
• G.P. offices (5)
• Prenatal clinics (3)
• Emergency rooms (2)

• Halfway house (2)
• EAP
• Telephone (3)
• In home (1)
• Jail (1)
• Mixed (7)
• Unspecified (8)

(Hettema et al., Annual Rev Clin Psych, 2005)
96
MI Providers

• Paraprofessional / students - 8
• Masters level - 6
• Psychologists - 6
• Nurses - 3
• Physicians - 2
• Dietician - 1
• Mixed - 22

(Hettema et al., Annual Rev Clin Psych, 2005)
97
Quality of MI Delivered
Mean characteristics per study 3.6

• Being collaborative
• Client centered
• Nonjudgmental
• Building trust
• Reducing resistance
• Increasing readiness

• Increasing self-efficacy
• Reflective listening
• Increasing discrepancy
• Eliciting change talk
• Exploring ambivalence
• Expressing empathy

(Hettema et al., Annual Rev Clin Psych, 2005)
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

(Hettema et al., Annual Rev Clin Psych, 2005)
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

(Hettema et al., Annual Rev Clin Psych, 2005)
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

(Hettema et al, Annual Rev Clin Psych, 2005)
101
Summary - Part 2

• Motivational interviewing works
• Follow principles A to H
• Use microskills
• Help address barriers to progressing to the next
  stage of change

102
Objectives - Part 3

• For clients/patients without
• commitment to change

• Review barriers
• Employ MI principles and skills to promote
  progress

103
In which stages is there- no firm commitment to
change?- firm commitment to change?
104
NO FIRM COMITMENT TO CHANGE
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Action
FIRM COMMITMENT TO CHANGE
Termination
105
Goals by Stage

Build commitmentto change

• Relapse
• Precont
• Cont.
• Determ.
• Action
• Maint

Create, implement, andrefine plan for change
106
Barriers - Precontemplation

• Lack of knowledge
• Lack of self-efficacy
• Contentment

107
Barriers - Contemplation

• Lack of knowledge
• Lack of self-efficacy
• Contentment
• Chronic indecision

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

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

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

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

112
For Ambivalence - DEARS (continued)

• Roll with Resistance
• Change strategies in response to resistance
• Acknowledge reluctance and ambivalence as
  understandable
• Reframe statements to create new momentum
• Engage pt/client in problem solving
• Support Self-efficacy
• Bolster responsibility and ability to succeed
• Foster hope with menus of options

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

114
Debrief Role-Play Exercise

• Patients/ClientsWhat did your clinicians do
  well?
• CliniciansWhat did you find challenging?How
  would you want to improve next time?
• EveryoneHow did you see motivational
  interviewing working in your role play?

115
Summary - Part 3

• Use MI skills to
• Provide information
• Bolster self-efficacy
• Develop discrepancy between current behaviors and
  future goals
• Elicit self-motivational statements
• Practice!

116
Objectives - Part 4
For clients/patients with commitment to change

• Review barriers
• Employ MI principles and skills to promote
  progress

117
NO FIRM COMITMENT TO CHANGE
Precontemplation
Relapse
Contemplation
Maintenance
Determination
Action
FIRM COMMITMENT TO CHANGE
Termination
118
Goals by Stage

Relapse Precont Cont. Determ. Action Maint
Build commitmentto change

Create, implement, andrefine plan for change
119
Principles of MI

• Advice
• Barriers
• Choices
• Decrease desirability

• Empathy
• Feedback
• Goals
• Helping

120
Reinforce and strengthen commitment to change

• Continue
• Reinforcing the potential benefits of change
• Bolstering self-efficacy for behavior change

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

122
Help develop and refine a plan for change
(continued)

• In developing and refining plans
• Help identify options
• Present menus of options
• Honor the patient's/client's decisions
• Make statements of partnership

123
Help develop and refine a plan for change
(continued)

• Suggest that the patient/client make promises and
  track implementation
• Set an implementation date
• Review the plan, maximizing concreteness and
  specificity, as the pt/client agrees
• Suggest making a contingency plan
• Arrange follow-up

124
Help develop and refine a plan for change
(continued)

• Determination
• Review previous attempts reframe as learning
  experience
• Action
• Review recent progress and difficulties

125
Help develop and refine a plan for change
(continued)

• Maintenance
• Foresee and plan for major stressors
• Track progress and plan toward the goals that
  prompted behavior change

126
Role-Play Exercise

• Get in pairs or groups
• Assign patient/client and practitioner
• Read scenarios
• Review feedback sheet
• Perform role play
• Patient/client gives feedback - what was done
  well what could be done differently

127
Debrief Role-Play Exercise

• Patients/ClientsWhat did practitioners do well?
• CliniciansWhat did you find challenging?How
  would you want to improve next time?
• EveryoneHow did you see motivational
  interviewing working in your role play?

128
Summary - Part 4

• For determination, action, maintenance
• Reinforce/strengthen commitment
• Help develop/refine plan for change
• For maintenance, focus on the goals that prompted
  behavior change
• Practice!

129
Layers of MI
Engage in Active Listening with the Patient/Client
Use Microskills
Implement MI Principles
Address Barriers tothe Next Stage of Change