Motivational Interaction Michael Dean & Associates Addictions Ontario May 30th, 2011

Motivational InteractionMotivational Interaction

Michael Dean & AssociatesMichael Dean & Associates

Addictions OntarioAddictions Ontario

May 30th, 2011May 30th, 2011

Learning ObjectivesLearning Objectives

Increase understanding of the technical Increase understanding of the technical components of MIcomponents of MI

Gain increased awareness as to the application Gain increased awareness as to the application of MIof MI

Obtain an overview of the day long training Obtain an overview of the day long training session for Motivational Interactionsession for Motivational Interaction

Identify components of MI you are already Identify components of MI you are already using in your workusing in your work


Motivational InterviewingMotivational Interviewing

What is it?What is it? A directive, client centred counselling style for A directive, client centred counselling style for

eliciting behaviour change by helping clients eliciting behaviour change by helping clients to explore and resolve ambivalence.to explore and resolve ambivalence.

The ‘spirit’ of MI : “a way of being with the The ‘spirit’ of MI : “a way of being with the client”…Bill Millerclient”…Bill Miller


What is Motivational InteractionWhat is Motivational Interaction

Based on principles of Motivational Based on principles of Motivational Interviewing PLUSInterviewing PLUS

Incorporates some principles of Solution Incorporates some principles of Solution Focused Brief TherapyFocused Brief Therapy

A way to work with short episodes of client A way to work with short episodes of client engagementengagement


WHY Motivational Interaction?WHY Motivational Interaction?

As stated re: short episodes of engagementAs stated re: short episodes of engagement Traditional MI can be intimidating as it was Traditional MI can be intimidating as it was

intended for a process of “interviewing”intended for a process of “interviewing” Literature supports some brief interventions as Literature supports some brief interventions as

being effective as some longer episodes of being effective as some longer episodes of carecare

You are already doing some of it…lets label it.You are already doing some of it…lets label it.


Some supportive literatureSome supportive literature Single-Session Motivational Interviewing for Drug Detoxification Inpatients: Effects on Single-Session Motivational Interviewing for Drug Detoxification Inpatients: Effects on

Self-Efficacy, Stages of Change and Substance UseSelf-Efficacy, Stages of Change and Substance Use

ANNE H. BERMAN,LARS FORSBERG, NATALIE DURBEEJ, HA° KAN KA¨ LLME´N, ANNE H. BERMAN,LARS FORSBERG, NATALIE DURBEEJ, HA° KAN KA¨ LLME´N, AND ULRIC HERMANSSON. Substance Use & Misuse, 45:384–402. AND ULRIC HERMANSSON. Substance Use & Misuse, 45:384–402. 20102010

SOLUTION-FOCUSED GROUP THERAPY FOR LEVEL 1 SUBSTANCE ABUSERS: Sara SOLUTION-FOCUSED GROUP THERAPY FOR LEVEL 1 SUBSTANCE ABUSERS: Sara A. Smock, Virginia Polytechnic Institute and State University; Terry S. Trepper and Joseph L. A. Smock, Virginia Polytechnic Institute and State University; Terry S. Trepper and Joseph L. Wetchler, Purdue University Calumet; Eric E. McCollum, Virginia Polytechnic Institute and Wetchler, Purdue University Calumet; Eric E. McCollum, Virginia Polytechnic Institute and State UniversityRose , Ray and Kent Pierce, Purdue University Calumet.State UniversityRose , Ray and Kent Pierce, Purdue University Calumet.

BRIEF INTERVENTION FOR SUBSTANCE USE:, A MANUAL FOR USE IN PRIMARY BRIEF INTERVENTION FOR SUBSTANCE USE:, A MANUAL FOR USE IN PRIMARY CARE, World Health Organization, Department of Mental Health & Substance Dependence CARE, World Health Organization, Department of Mental Health & Substance Dependence


PracticalityPracticality

Traditional MI focuses on clients willingness Traditional MI focuses on clients willingness to change ( once change talk is occurring)to change ( once change talk is occurring)

Brief Solution Focused therapy focuses on the Brief Solution Focused therapy focuses on the positive behaviors/decisions client is positive behaviors/decisions client is demonstratingdemonstrating

We need to identify those opportunities to We need to identify those opportunities to apply principles of MI………….apply principles of MI………….


ApplicationApplication

AddictionsAddictions AnxietyAnxiety PTSDPTSD Obsessive CompulsiveObsessive Compulsive SuicidalitySuicidality General health issuesGeneral health issues

Problem gamblingProblem gambling Medication adherenceMedication adherence Concurrent DisordersConcurrent Disorders DepressionDepression Eating disordersEating disorders


MotivationMotivation

““The most prevalent common-sense view of The most prevalent common-sense view of motivation is that people do things because motivation is that people do things because they perceive them as being better in some they perceive them as being better in some way than not doing them” way than not doing them” (West, 1989)(West, 1989)

““Motivation is the sum of the factors that Motivation is the sum of the factors that influence an individual to behave in a certain influence an individual to behave in a certain way” way” (Saunders, 1994)(Saunders, 1994)

““People only change when the pain of change People only change when the pain of change is less then the pain of staying the same” is less then the pain of staying the same” (Saunders (Saunders law of behaviour change)law of behaviour change)


Hand in HandHand in Hand

In order to elicit change behaviour we need to In order to elicit change behaviour we need to determine the starting point.determine the starting point.

Where is the client in regard to Where is the client in regard to willingness/readiness to change?willingness/readiness to change?

We can’t start talking of change until we know We can’t start talking of change until we know what change is required.what change is required.

To address the above we need a tool…a To address the above we need a tool…a process…….process…….


Need to know where client is in Need to know where client is in Change ProcessChange Process


Goals & Key Areas of MIGoals & Key Areas of MI The overall goal of MI is to explore and resolve clients’ The overall goal of MI is to explore and resolve clients’

ambivalence in order to enhance their motivation to ambivalence in order to enhance their motivation to changechange

Successful resolution of said ambivalence will occurSuccessful resolution of said ambivalence will occur by facilitating client statements that reflect:by facilitating client statements that reflect: Self-Esteem – their belief that they are “OK” (this must Self-Esteem – their belief that they are “OK” (this must

happen so they feel powerful enough to change)happen so they feel powerful enough to change) Concern – concern about their behavioursConcern – concern about their behaviours Competence – their ability to make changesCompetence – their ability to make changes Knowledge of Problem – recognize their problem Knowledge of Problem – recognize their problem

behaviour's)behaviour's) Knowledge of Strategies – reflect on strategies for changeKnowledge of Strategies – reflect on strategies for change Desire to Change – reflect a desire for things to be Desire to Change – reflect a desire for things to be

differentdifferent


Brief InterventionsBrief Interventions

Hallway conversationHallway conversation In residential settings while performing In residential settings while performing

residential related taskresidential related task Pre and Post dialogue for other sessions e.g.. Pre and Post dialogue for other sessions e.g..

patient in to set broken arm or pick up patient in to set broken arm or pick up workfare fundsworkfare funds


The FRAMES AcronymThe FRAMES Acronym

FeedbackFeedback ResponsibilityResponsibility AdviceAdvice MenuMenu EmpathyEmpathy Self-efficacySelf-efficacy


F, R, & AF, R, & A

Feedback – through structure, clients areFeedback – through structure, clients are encouraged to reflect on their lives, theirencouraged to reflect on their lives, their choices, and their behaviourschoices, and their behaviours Responsibility – all responsibility forResponsibility – all responsibility for change lies on the clientchange lies on the client Advice – counsellor takes an active roleAdvice – counsellor takes an active role and gives advice that is clear, simple, andand gives advice that is clear, simple, and non-authoritativenon-authoritative


M, E, & SM, E, & S

Menu – clients are given a menu ofMenu – clients are given a menu of

treatment choices (increases ownership)treatment choices (increases ownership) Empathy – the active ability to understand,Empathy – the active ability to understand,

and reflect that understanding, to the clientand reflect that understanding, to the client

(can include confrontation and challenge)(can include confrontation and challenge) Self-efficacy – the clients’ belief that theySelf-efficacy – the clients’ belief that they

have the ability to succeedhave the ability to succeed


Helping Tasks to Support FRAMESHelping Tasks to Support FRAMES

Be empathic – expressing warmth,Be empathic – expressing warmth, acceptance, and a non-judgmental attitudeacceptance, and a non-judgmental attitude Point out discrepancies – between clients’Point out discrepancies – between clients’ present behaviour and their long-term goalspresent behaviour and their long-term goals Avoid arguments – confrontation leads toAvoid arguments – confrontation leads to resistance, refer back to responsibilityresistance, refer back to responsibility Roll with resistance – change strategies, allowRoll with resistance – change strategies, allow client to find their own solutionsclient to find their own solutions Support self-efficacy – the most importantSupport self-efficacy – the most important aspect of MIaspect of MI


Motivational StrategiesMotivational Strategies

Ask open ended questionsAsk open ended questions Listen reflectivelyListen reflectively AffirmAffirm SummarizeSummarize Elicit self-motivational (or change ) statementsElicit self-motivational (or change ) statements Use Visual cues and aids ( once again…we do Use Visual cues and aids ( once again…we do

this already. Lets put it into the context of this already. Lets put it into the context of motivation)motivation)


Visual AidVisual Aid


Open Ended questions?Open Ended questions?

What brings you to the office today?What brings you to the office today? What can we help you with?What can we help you with? What have you been doing in your recovery What have you been doing in your recovery

since we last met?since we last met? How did your recent interaction with your How did your recent interaction with your

employer go? employer go? WE DON’T NEED STRUCTURED WE DON’T NEED STRUCTURED

INTERVIEWS TO STATE THE ABOVEINTERVIEWS TO STATE THE ABOVE


Affirmation?Affirmation?

That is great, seems like you are making That is great, seems like you are making progressprogress

That was a big step for youThat was a big step for you You stated that very wellYou stated that very well WE DON’T NEED STRUCTURED WE DON’T NEED STRUCTURED



Summarize?Summarize?

What I am hearing you say is…What I am hearing you say is… You have done A, B and C and what like to do You have done A, B and C and what like to do

DD Can I clarify what I think you want to doCan I clarify what I think you want to do WE DON’T NEED STRUCTURED WE DON’T NEED STRUCTURED



Elicit Self Motivational (change ) Elicit Self Motivational (change ) statements?statements?

Recognizing a problem exist ( example?)Recognizing a problem exist ( example?) Articulating concerns ( example?)Articulating concerns ( example?)

Expressing and intention to changeExpressing and intention to change

( example?)( example?)

Showing optimism ( example?)Showing optimism ( example?)


Change TalkChange TalkDARN-CDARN-C

DesireDesire AbilityAbility ReasonsReasons NeedNeed

AndAnd Commitment ( taking steps)Commitment ( taking steps)


OARSOARS

OOpen Endedpen Ended AAffirmationffirmation RReflective listeningeflective listening SSummarizingummarizing


Deploy DiscrepancyDeploy Discrepancy

Possible questions include:Possible questions include: ““How does your (drug use) fit in with your goals?”How does your (drug use) fit in with your goals?” ““How does the you ‘as a drug user’ fit in with theHow does the you ‘as a drug user’ fit in with the ‘ ‘you as… (their goals or positive self)’?”you as… (their goals or positive self)’?” ““Is there anything about your drug use you need toIs there anything about your drug use you need to change to get the things you want?”change to get the things you want?” ““How would things be in a year if you stayed theHow would things be in a year if you stayed the same?”same?”Give praise & support self-efficacyGive praise & support self-efficacy ““You recognize that things have to change for youYou recognize that things have to change for you to attain your goals…”to attain your goals…”


Ask for a DecisionAsk for a Decision Restate the client’s dilemma or ambivalenceRestate the client’s dilemma or ambivalencePossible questions/comments include:Possible questions/comments include: ““You were saying that your were trying to decideYou were saying that your were trying to decide whether to continue or cut down...”whether to continue or cut down...” ““After this discussion, are you more clear aboutAfter this discussion, are you more clear about what you would like to do?”what you would like to do?” ““So have you made a decision?”So have you made a decision?”Give praise & support self-efficacyGive praise & support self-efficacy ““Congratulations, you’ve made an importantCongratulations, you’ve made an important decision today. How do you feel about that?”decision today. How do you feel about that?”


Set a Short-Term GoalSet a Short-Term Goal

Possible questions include:Possible questions include: ““What will be your next (first) step now?”What will be your next (first) step now?” ““What will you do in the next one or two days (week)?”What will you do in the next one or two days (week)?” ““Have you already been doing things to achieve this?Have you already been doing things to achieve this? Can you do more of this?”Can you do more of this?” ““Who will be helping you on this?”Who will be helping you on this?” ““On a scale of 1-10 how confident are you that you will do On a scale of 1-10 how confident are you that you will do

this next step?”this next step?”Give praise & support self-efficacyGive praise & support self-efficacy “ “That sounds like a meaningful goal. What will you needThat sounds like a meaningful goal. What will you need to make sure you achieve it?”to make sure you achieve it?”


Practice Case Practice Case

Youth not wanting to consider usage of Youth not wanting to consider usage of cannabis as a problemcannabis as a problem


CASE : Client backgroundCASE : Client background

You are 26 yr old youth who has been using You are 26 yr old youth who has been using cannabis (in all forms) for 12 years. You cannabis (in all forms) for 12 years. You dropped out of school early, have not held dropped out of school early, have not held regular employment…..your parents are now regular employment…..your parents are now wanting you to leave their house. You are wanting you to leave their house. You are denying that cannabis is the root to your denying that cannabis is the root to your problems.problems.


Case : Clinician backgroundCase : Clinician background

You are a case manager in the out patient MH services. You are a case manager in the out patient MH services. This client ( 28 yr old male) was referred to you by This client ( 28 yr old male) was referred to you by the crisis team, as the client presented two weekends the crisis team, as the client presented two weekends in a row at ER and ended up in CRISIS, the client in a row at ER and ended up in CRISIS, the client demonstrated signs of cannabis psychosis demonstrated signs of cannabis psychosis (schizophrenia type behaviors, denying drug use), (schizophrenia type behaviors, denying drug use), though a joint was found on person in both episodes. though a joint was found on person in both episodes. He is denying that Cannabis is a problem. He dropped He is denying that Cannabis is a problem. He dropped out of school early and is not very employable. His out of school early and is not very employable. His parents want him out of the house. parents want him out of the house. Your goal is to at Your goal is to at least have him admit some problem useleast have him admit some problem use..


Next StepsNext Steps

Practice, practice, practicePractice, practice, practice Other?Other? BOOK training sessionBOOK training session


Thank YouThank You


ResourcesResources Motivational interviewing In the Treatment of Motivational interviewing In the Treatment of

Psychological problems. ED Miller W. Arkowitz, H. Psychological problems. ED Miller W. Arkowitz, H. Westra, H. Rollnick, S., Guilford Press, New York Westra, H. Rollnick, S., Guilford Press, New York NY. 2008NY. 2008

Motivational Interviewing In Health Care.Rolnick,S. Motivational Interviewing In Health Care.Rolnick,S. Miller, W. Butler, C., Guilford Press, New York NY. Miller, W. Butler, C., Guilford Press, New York NY. 20082008

Motivational interviewing: Preparing people for Motivational interviewing: Preparing people for change. Rolnick,S. Miller, W., Guilford Press, New change. Rolnick,S. Miller, W., Guilford Press, New York NY. 2002York NY. 2002

Addiction and Change; how addictions develop and Addiction and Change; how addictions develop and addicted people recover. DiClemente, C.,addicted people recover. DiClemente, C.,

Guilford Press, New York NY. 2003Guilford Press, New York NY. 2003


Documents

Motivational Interaction Michael Dean & Associates Addictions Ontario May 30th, 2011