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
What are we talking about? What does “increasing motivation” mean to you?
Understanding How People Change: Models Traditional approach Motivating for change
Traditional approach (1) • 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 don’t change if they haven’t suffered enough The Stick
Traditional approach (2) You better! Or else! If the stick is big enough, there is no need for a carrot.
Traditional approach (3) The Traditional Approach often used a Directing Style of helping.
Directing helping style • Tell them it’s 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.
Directing Style of Helping • Might make sense if you believe that the client : • doesn’t know what they need to know. • does not know how to change. • Is indifferent to consequences of problem.
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.
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?
Guiding Style of Helping • Respect their decisions. • Have them to describe what is working. • Ask them what their plan is. • Find out what’s 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.
Guiding Style of Helping • Motivational Interviewing can be considered a specialized subset of a Guiding style.
What is the problem? It is NOT that… • they don’t want to see (denial) • they don’t care (no motivation) They are just in the early stages of change.
What is Motivational Interviewing? It is: A style of talking with people constructively about reducing their health risks and changing their behavior.
What is Motivational Interviewing? It is designed to: Enhance the client’s own motivation to change using strategies that are empathic and non-confrontational.
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
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
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
MI - The Spirit (2) : Style • Explores consumer’s perceptions without labeling or correcting them • No teaching, modeling, skill-training • Resistance is seen as an interpersonal behavior pattern influenced by the clinician’s behavior • Resistance is met with reflection
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 consumer’s personal choice for deciding future behavior • Focus on eliciting the consumer’s own concerns
MI - The Spirit (4) : Clinician • Implies a strong sense of purpose • Seeks to create and amplify the consumer’s discrepancy in order to enhance motivation • Elicits possible change strategies from the consumer • Systematically directs consumer toward motivation for change
Important considerations The clinician’s 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”
How does MI differ from traditional counseling? 1. Patient and practitioner are equal partners in relationship (collaborative effort between two experts)
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 Reflection
Ambivalence is normal • People are almost always ambivalent about change – • Lack of motivation can be viewed as unresolved ambivalence.
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
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)
Definition of Motivation The probability that a person will enter into, continue, and comply with change-directed behavior
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? Reflection
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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What’s the Best Way to Facilitate Change? 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 The Carrot
Where do I start? What you dodepends 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
Stages of ChangeProchaska & DiClemente Precontem- plation Contemplation Recurrence Preparation Maintenance Action
Helping People Change Motivational Interviewing is the process of helping people move through the stages of change
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 Change:Primary 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 hasn’t stabilized in the process. Primary Task: Help implement change strategies and learn to eliminate potential relapses
Precontemplation Stage Definition– Not yet considering change or is unwilling or unable to change Primary task– Raising Awareness
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
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
Possible Ways to Help the Consumer in the Contemplation Stage Talk about the person’s sense of self-efficacy and expectations regarding what the change will entail Summarize self-motivational statements Continue exploration of pros and cons
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
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
Action Stage In this stage the consumer is taking steps toward change but hasn’t stabilized in the process Primary task– Help implement the change strategies and learn to limit or eliminate potential relapses
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
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
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
Recurrence Definition– consumer has experienced a recurrence of the symptoms Primary task– Must cope with the consequences and determine what to do next
How to Help the Consumer Who Has Experienced a Recurrence Frame recurrence as a learningopportunity; 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
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 doesn’t 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.