Effecting Change through the Use of Motivational Interviewing

Effecting Change through the Use of

Motivational Interviewing

Thomas E. Freese, PhD

Pacific Southwest Addiction Technology Transfer CenterUCLA Integrated Substance Abuse Programs

UCLA David Geffen School of Medicine, Dept. of Psychiatry

www.psattc.orgwww.uclaisap.org

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

How does MI differ from traditional counseling?

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

How does MI differ from traditional or typical medical counseling?

• People are almost always ambivalent about change – ambivalence is normal

• 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

A patient-centered directive method for enhancing intrinsic motivation to change by

exploring and resolving ambivalence.

directive method patient-centered

exploring and resolving ambivalence

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 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

Stages of ChangeProchaska & DiClemente

Helping People Change

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

Stages of Change:Primary Tasks

1. PrecontemplationDefinition:

Not yet considering change or is unwilling or unable to change.

Primary Task:Raising Awareness 2. Contemplation

Definition: Sees the possibility of change but

is ambivalent and uncertain.

Primary Task:Resolving ambivalence/

Helping to choose change

3. DeterminationDefinition:

Committed to changing.Still considering what to do.

Primary Task:Help identify appropriate

change strategies4. ActionDefinition:

Taking steps toward change but hasn’t stabilized in the process.

Primary Task:Help implement change strategies

and learn to eliminate potential relapses

5. MaintenanceDefinition:

Has achieved the goals and is working to maintain change.

Primary Task:Develop new skills for maintaining recovery

6. RecurrenceDefinition:

Experienced a recurrence of the symptoms.

Primary Task:Cope with consequences and

determine what to do next

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 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

• Open-ended questioning

• Affirming

• Reflective listening

• Summarizing

Building Motivation OARS(the microskills)

The goal is to elicit and reinforce

self-motivational statements (Change Talk)

The goal is to elicit and reinforce

self-motivational statements (Change Talk)

Open-Ended Questions

• 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

An open-ended question is one that requires more than a yes or no response

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

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)

NIDA-SAMHSA Blending Initiative 33

1. Simple Reflection (repeat)

2. Amplified Reflection (rephrasing andparaphrasing)

3. Double-Sided Reflection (rephrasing,paraphrasing and reflecting feeling)

Types of Reflective Statements

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.

Four Principles ofMotivational Interviewing

1. Express empathy

2. Develop discrepancy

3. Avoid argumentation

4. Support self-efficacy

Use the Microskills of MI to:

Express Empathy

• Acceptance facilitates change

• Skillful reflective listening is fundamental

• Ambivalence is normal

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

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….”

Importance/Confidence/Readiness Scale

On a scale of 1–10… • 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 didn’t you give it a lower number?

• What would it take to raise that number?

1 2 3 4 5 6 7 8 9 10

Decisional Balance

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

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

Use the Microskills of MI to:

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

Change Talk

•Recognizing the problem

•Expressing concern

•Stating intention to change

•Being optimistic about change

Change Talk

Dig for change talk…•I’d 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?

Tools for Change Talk

• Pros and Cons• Importance & Confidence Scales

• Readiness Ruler

Signs of Readiness to Change

• Fewer questions about the problems

• More questions about change

• Self-motivational statements

• Resolve

• Looking ahead

• Experimenting with change

NIDA-SAMHSA Blending Initiative 50

1. Simple Reflection (repeat)

2. Amplified Reflection (rephrasing andparaphrasing)

3. Double-Sided Reflection (rephrasing,paraphrasing and reflecting feeling)

Types of Reflective Statements

Reflective Listening Exercise

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

• Fewer questions about the problems

• More questions about change

• Self-motivational statements

• Resolve

• Looking ahead

• Experimenting with change

Signs of Readiness to Change

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

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 consumer’s

stage of readiness (warning, confronting, giving unwelcome advice, taking “good” side of the argument)

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?

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?

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

For more information, contact:

Thomas E. Freese, PhDtfreese@mednet.ucla.edu

Beth Rutkowski, MPHbrutkowski@mednet.ucla.edu

www.psattc.orgwww.uclaisap.org