Motivational Interviewing Therese Killeen PhD
Overlap in Treatment and Legal Systems • About 50 to 60% of substance abuse clients are legally mandated to substance abuse treatment • High rate of substance abuse in offenders • High rate of recidivism in both populations • Problems are complex • Drug courts allow for collaboration with the treatment and legal system
Commonalities in Client Characteristics • Angry • Frightened about what might happen • Reluctant to examine abusive/illegal behavior • Unwilling to relinquish their only sense of control • Difficulty accepting responsibility for their behavior
Goals for rehabilitation • Increase effectiveness of interactions with clients/offenders • Improve the climate of the criminal justice system/ addiction treatment • Reduce Recidivism • Help clients/offenders commit to or even consider change • Help engage and remain in treatment • Build supportive relationships
Motivational Interviewing A client-centered goal directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence
Motivational Interviewing in Special Populations/Settings • Substance Use Disorders/Dual Disorders • Medical/Public Health Settings • Criminal Justice • Adolescents • Couples • Group Settings
Outcome Effects Attributed to: • Therapist effects – who delivers treatment and how • Process effects – what happens between clients and therapists • Laws of learning – principles of behavior and change Mesa Grande Review, W. Miller
AMBIVALENCE • …a state of mind in which a person has coexisting but conflicting feelings, thoughts, and actions about something • The “I do but I don’t” dilemma Status ambivalence change Quo movement
Basic Assumptions about the Nature of Motivation • Motivation is a key to change • Motivation is Multidimensional • Motivational is dynamic and fluctuating • Motivational is influenced by social interactions • Motivation can be modified • Motivation can be influenced by clinician style
Motivation Changes are more lasting when autonomously /intrinsically versus extrinsically motivated no external intrinsic motivation motivation /pressure motivation
Recurrence Action Maintenance Preparation Contemplation Precontemplation Stages of Change
How Many Patients Are Ready? Action Prep Precon Contemplation
Matching Interventions to Client Stage of Change • Precontemplation stage - must raise their awareness before they can consider change; • Contemplation stage - require help resolving their ambivalence and choosing positive change over their current situation; • Preparation stage - need help identifying potential change strategies and choosing the most appropriate one for their circumstances;
Continued - • Action stage - need help implementing and complying with the change strategies and learning how to prevent or limit relapse; • Maintenance stage - may have to develop new skills for maintaining recovery /behavior change • Recurrence stage - need help recovering quickly and resuming the change process.
Flexible Pacing • The concept of pacing requires that clinicians meet their clients at the clients’ levels and use as much or as little time as is necessary to accomplish the essential tasks of each stage of change.
Critical to MIChange most likely to occur if client experiences a discrepancy between values/goals and current behavior.
Readiness to Change • Less ready the client is to change, the more important it is to do MI • Clients may vacillate between and during sessions • Moving into action strategy prematurely may adversely affect outcome • Could be countertherapeutic to continue with MI when client is clearly ready for behavior change
Spirit of MI • Collaboration • Evocation • Autonomy
Collaboration Dancing Wrestling
High Spirit Evocation • Elicits the client’s ideas about change. • “Curious and patient” • Stay focused on whatever behavior change the client is willing to do.
Being Supportive of High Autonomy • Accept that the clients may not choose to change. • Are invested in behavior change but don’t push it, in order to maintain therapeutic alliance. • Reinforce that ultimately any behavior change is within the realm of the client.
How is “Spirit” different from other counseling characteristics? • Not sympathy or being soft • No emphasis on expertise (on the part of the counselor) • Education of client not considered effective (not to be confused with exchanging information) • Does not focus on skill-building • Does not analyze unconscious motivations
Fundamental Principles • Express Empathy • Develop Discrepancy • Roll with Resistance • Support Self-efficacy
MI MICRO-SKILLSOARS • Open-ended Questions • Affirmation • ReflectiveListening • Summary
OPEN-ENDED QUESTIONS • An open-ended question is one where there is more than a yes or no response “Do you realize the number of charges against you?” versus “ What is your understanding of the charges you have against you?”
AFFIRMATIONS • Client Focused • Building Rapport • Recognizing and reinforcing Client Strength and Effort • Aimed at • Supporting Client’s Involvement • Encouraging Continued Attendance • Assisting Client to see the Positives
Affirmation Examples • That was quite an accomplishment. • You have really done well this week. • Congratulations, you stuck to your plan. • You are really putting a lot of effort into this. • It took a lot to come in today, but you made it. • You really handled that situation well.
Reflective Listening • “Statements” that lets the client know you are listening • Reasonable guess as to the meaning of what was said • Checking out your assumption with the client
REFLECTIVE LISTENINGFine tuning • Level One:Repeat • Level Two:Rephrase • Level Three: Paraphrase • Reflect Feelings • Summary • Metaphors, Similes • Continue the sentence/paragraph
Client: I work hard all day, and deserve some time to myself. Marijuana helps me wind down. Clinician: Marijuana helps you settle down after a stressful day at work. Simplereflection
Client: “I got charged for distribution of marijuana. One of my friends turned me in so that he would get a lesser charge.” Clinician: “I imagine you are pretty angry that you friend did this to you.”
SUMMARIZING • Special form of reflection • Counselor chooses what to include and emphasize • Include client’s concerns about change, problem recognition, optimism about change, ambivalence about change • Restatement of any change talk about intention to change, and confidence in his or her ability to change • Let client know you are listening
“You have been charged with a DUI and you really don’t want to lose your driver’s license. Your lawyer has recommended that you enter this treatment program. While you don’t think it is necessary because you don’t feel you have a problem with alcohol, you plan on completing this program because you do not want to have this charge on your record. In addition, you are thinking that maybe getting into this program may also improve the situation at home.”
MI Clinician Goals • Talk less than your client • Most common response - reflection • Reflect twice for each question • Complex reflections (paraphrase and summarize) over half the time • Use open questions • Avoid getting ahead of client’s readiness level
Change Talk • Disadvantage of the status quo • Advantage of change • Optimism about change • Intention to change
EVOCATIVE OPEN QUESTIONS Desire: "What do you want to do about this behavior?" Ability: "What makes you believe you can do this?" Reason/Need: "Why would you want to make this change?" Commitment: "So what are you willing to do now.” Exploring reasons against change. For example, "What keeps you from making this change"
Change most likely to occur if client experiences a discrepancy between values/goals and current behavior.
Evocative questions Explore decisional balance Elaboration Examples Look back Look forward Query extremes Explore goals and values Come alongside Evoking Change Talk Strategies
Evocative Questions • “How might you go about making this change?” • “What would be a good first step?” • “What obstacles do you foresee and how might you deal with them?” • What gives you the confidence that you can do this?”
Elaboration • “Tell me more about that.” • “What about the last time that happened?” • “Give me an example?” • “What else?”
Developing Discrepancies • Use of summaries • Differences between stated goals and actual behavior • Tip the Balance by making a decision to change • Use of pros and cons exercise “So you say that you need to save money to move but on the other hand you find yourself spending $100 a week buying MJ… What do you make out of this?” “How does your drinking fit in with your having a happy family and good job?”
Exploring pros and cons – Developing Discrepancies • “What are the good things about your drinking?” • “What are the not so good things?”
Readiness Ruler: Eliciting Change Talk • 0 1 2 3 4 5 6 7 8 9 10 • Not at allExtremely • How important is it to you to change this? • How confident are you that you can change this?
Evoking Change talk • Why are you at a 5 and not a 1 or 2 ? • What would need to happen to take it from a 5 to say a 7 or 8?
Imagine extremes • “What is the worst that can happen if you continued?” • What do you think would have to happen to make you decide to tell yourself, “ok that’s enough?”
Looking Forward • “What would you like your life to be like in 2 years?” • “How does what you are doing now make that difficult?” • “What would it be like if you continue with the way things are now?” • Suppose things don’t change, how do think your life will look?”
Looking Back • “When was the last time things were going well for you and what was it like for you?” • “What do you think could have prevented this setback? • “Before you used , what was your life like?” • “As you step back and look at all this, what do you make of it?”
CLIENT RESISTANCE Involves feelings-actions-behaviors of an interpersonal nature where there is a lack of collaboration
Arguing Discounting Disagreeing Hostility Blaming De - focus Defensive Pessimism Passivity Body language Identifying resistance
What is resistance? • Interpersonal behavior • Information • Clinician influences resistance: How you respond matters? • Not a client problem, but a clinician skill issue • Cue to change direction/back off