Theories of Change

Brentwood Hospital4/23/14

Agenda• Intro: Getting this into Context• Description of Motivational Interviewing

Techniques:1. Eliciting change talk2. Identifying readiness to change3. I CAN summaries

ContextWhere are we?

You are here.

Substance Use Stats

Evolution of Treatment Approaches

Old SchoolBreak’em down and

Build’em up.

Evidence BasedClient-centered

Cognitive-BehavioralFamily Therapies

Motivational Interviewing

Getting MotivatedOverview of MI

Your Challenge is . . . • Lose weight• Eat healthy• Exercise• Stop smoking• Kick that heroin habit once and for all!

History of Motivational ApproachesTranstheoretical

Model of the Stages of Change

• Mostly Theoretical • Prochaska &

DiClemente

Motivational Interviewing

• Mostly Application• Miller & Rollnick

Stages of Change

• Pre-contemplation• Contemplation• Preparation• Action•Maintenance

Motivational Interviewing

Evocation MI Spirit

Change Talk

MI Principl

es

AutonomyCollaboration

Resist righting reflexUnderstand motivationListenEmpower

Open-ended QuestionsAffirmationReflective ListeningSummaries

Help clients articulate reasons for change.

OARS

MI Spirit & Principles

Resist righting reflexUnderstand motivationListenEmpower

AutonomyCollaborationEvocation

OARS Skills & Change Talk

Eliciting change talk.

Open QuestionsAffirmationReflective ListeningSummaries

http://vimeo.com/66753575

What NOT to Do!• Convincing clients that they have a problem• Arguing for benefits of change• Telling clients how to change• Warning them of consequences of not

changing

Practice Everything so FarUpset Client: They told me I have to make 90 AA meetings in 90 days! That is just not going to happen- I can’t even sit through one meeting.Response: Oh come on, its not that bad. Don’t you want to get better?

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Another oneClient: So my family has this “get together” and they all sit around and tell me how I am an alcoholic. Like none of them ever gets drunk.Response: If it looks like a duck and quacks like a duck its probably a duck. All those people can’t be wrong. You’re probably in denial, don’t you think?

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Eliciting Change Talk

Change Talk• Represents statements about change• Linked to a specific behavior or goal• Comes from the client• Refers to present situation

Continuum of Change• I wish things were different Desire• I know how to change Ability• It would be great if I changed Reason• I really need to change Need• I am going to change

Commitment/Taking Steps

Evocative Questions• In what ways does this concern you?• How would you like things to be different?• How would things be better if you changed?

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Elaboration• Tell me about a time you . . . (engaged in

maladaptive behavior)• What does it look like when you . . . . • Tell me about a time before you . . .

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Using ExtremesWorst outcome vs. best outcome

What concerns you the most?What is the worst that could happen?What do you hope for the most?What would a perfect outcome be?

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Looking Back• Do you remember a time when things were going

well? What has changed?• What did you want to do when you graduated from

high school?• What is the difference between you now and you

twenty years ago?

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Looking Forward• If nothing changes, what do you see happening in

5 years? If you decide to change, what will it be like?• What are your hopes for the near future?

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Exploring GoalsUse value card sort

• What are some things you regard as important? How does drinking fit in with that?• What sorts of things do you want to accomplish in

your life?

(Miller, Baca, Matthews, Wilbourne, 2001)

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Use Feedback• Your scores on the MoCA (or MSE) indicate that

you have moderate deficits in problem solving and memory. How does that fit with your own experience?

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Readiness Rulers• On a scale of 1-10, how confident* are you – if you

made a decision to change – that you could change, when 1=not at all confident and 10= extremely confident?• What led you to choose 6 rather than a 3?• What would it take to move from a 6 to a 7 or 8?

* or important

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Your Turn• Which of the previous techniques would

work best (if at all) with your change challenge?• How do you feel when thinking about your

challenge?

Which would you use?• Evocative Questions• Elaboration• Using Extremes• Looking

Back/Forward

• Exploring Goals• Use Feedback• Readiness Rulers

Identifying Readiness

Signs of Readiness• Decreased resistance• Decreased

discussion• Resolve• Change talk

• Questions about change• Envisioning• Experimenting

Identifying ReadinessSo, what do other people say about this? I just can’t believe that people just cave in when they hear recommendations sending them to a halfway house. • Signs?• Your reasoning:

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Identifying ReadinessI agree it would be good to make some different choices that have less risk, but I also like to have fun with my friends. I have too much fun with them. • Signs?• Your reasoning:

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Identifying ReadinessYou don't understand. These guys aren't going to take "No, thanks" for an answer. They're going to hound me. I've got to come back with something stronger. • Signs?• Your reasoning:

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Dealing with Ambivalence

The ‘I CAN’ StrategyIndicate this is a summary, and include • Change talk, • Ambivalence, and then ask about the • Next step.

Ambivalence Strategies: ICAN“I still think weed is not as bad as people say, at least its not like cocaine. Maybe smoking has affected my grades, I don’t know. I’ve been thinking that maybe I should lay off for the rest of the semester or until I get my grades up. But weed really helps me relax and I need that."

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Ambivalence Strategies: ICAN"I didn't like the way I felt on the Suboxone. There were just too many side effects. So, I stopped. But I think I need to do something. Nothing feels good. I'm always anxious. I can never get comfortable. I’m thinking that eventually I’ll start using again. That's where I'm at now.”

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Ambivalence Strategies: ICAN“When I first got the DWI I figured the cop was just a jerk- I hadn’t even had that much to drink. And then I went to look at my car that was impounded and I thought- how did I survive that? The thing was completely smashed in. I know I need to stop drinking but I just don’t know if I need inpatient treatment. Maybe I can do this on my own."

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Continuing on as Before Making a ChangeBenefits Costs Costs Benefits

Helps me relax

Feel like I fit in

Don’t worry about the bills

Love the buzz I get

Legal Trouble  Can’ see my

kids – wife won’t let me

 Paying for my attorney and court costs

 People don’t trust me

Won’t have a way to relax

 What about my friends?

 Life will be boring

Family would trust me again

 Marriage would go better

 Better at my job

More Money  Get off

probation sooner

The Decision Matrix

Application to Other Areas• Medication adherence in mental health• Diabetes management• Eating disorders• Obsessive Compulsive Disorder• Suicidal Ideation

Discussion• Will you use this in your practice? Why or

Why not?• What population do you think will benefit the

most? The least?• If interested, what are your plans to learn

more?

Resources1. www.robinsteed.pbworks.com2. www.motivationalinterview.org• Worksheets, training materials

3. http://www.integration.samhsa.gov/clinical-practice/motivational-interviewing• Full text articles, webinars, SAMHSA TIPs, training manuals

4. www.researchgate.net/publication/231081405_Motivational_Interviewing_and_the_Stages_of_Change/file/9fcfd50b5f8c5af70e.pdf#page=305• Full text of Motivational interviewing: Preparing people for

change (2nd ed.).

References• Miller, W.R., ’de Baca, J. C Matthews, D.B. Wilbourne, P.L (2001). Personal Values Card Sort, University of

New Mexico. Available at http://www.motivationalinterviewing.org/content/personal-values-card-sort• Miller, W. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New

York: Guilford Press. Full text available: www.researchgate.net/publication/231081405_Motivational_Interviewing_and_the_Stages_of_Change/file/9fcfd50b5f8c5af70e.pdf#page=305

• National Institute for Health and Clinical Excellence (NICE). Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Feb. 54 p. (Clinical guideline; no. 115). 

• Rosengren, D. (2009). Building motivational interviewing skills. New York: Guilford Press.• Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. (2011). Motivational

interviewing for substance abuse. Cochrane Database of Systematic Reviews, Issue 5, Art. No.: CD008063. DOI: 10.1002/14651858.CD008063.pub2.

• Substance Abuse and Mental Health Services Administration (2010). Getting started with evidence-based practices: Integrated treatment for co-occurring disorders. Evidence-Based Practice Series, Publication Id: SMA08-4367.

• www.motivationalinterview.org