CHAPTER 5 Motivational Interviewing Substance Abuse and Addiction

CHAPTER 5: Motivational Interviewing Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory First Edition Todd F. Lewis Developed by Katie A. Wachtel, University of North Carolina at Greensboro

Introduction • Defined as a collaborative, person-centered, form of guiding to elicit and strengthen motivation to change • Born out of the substance abuse field and is becoming more accepted amongst other clinical issues • The goals of this chapter are to share the history and goals of MI, discuss theoretical influences on MI, and to outline how to use MI with substance abuse clients Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -2

History of MI • Created Rollnick in early 1980’s by William R. Miller and Stephen • Started in response to then current beliefs about substance abuse counseling that stated: Substance abusers are defective and must be “fixed” Substance abusers offer nothing in counseling Use of confrontation is necessary to break down denial Clients must admit to being addicts before they can change • These beliefs increased client resistance Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -3

Goals of MI • Increase behavior intrinsic motivation to change a • Help lower resistance during counseling • Help clients resolve ambivalence Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -4

Influences on MI • Client-centered counseling MI is considered a gentle, persuasive style, but can differ from client-centered counseling in that it has a directive quality as well • Transtheoretical model of change The stages of change (precontemplation, preparation, action, maintenance) provides a model for how to implement MI techniques • It is important to note that MI is not the same as either theory; but rather, it uses each theory to inform it’s techniques and principles Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -5

MI Spirit • The foundation of MI • Adherence to MI spirit requires Collaboration Evocation Client autonomy Compassion • Techniques and principles of MI must be implemented in a way that highlights the MI spirit • Consistent with a guiding communication style Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -6

Principles of MI Avoiding argumentation Arguments are counterproductive and increase resistance Rolling with resistance Understanding and accepting clients’ resistance increasing feelings of respect in the counseling relationship Expressing empathy Clients can identify their own reasons for change when they feel unconditionally accepted in the counseling relationship Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -7

Principles of MI Continued Developing discrepancy In order for change to take place, it is helpful for clients to experience a discrepancy between their goals and the problematic behavior Supporting self-efficacy Enhance clients’ perceptions of their ability to change Remember: RULE Resisting the righting reflex Understanding the client’s own motivations Listen with empathy Empower client Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -8

The Four Key Processes of MI Engaging Establishing a solid, collaborative relationship with the client Focusing Help clients find direction in terms of what they want Evoking Explore client ambivalence Planning Strengthening commitment and developing a collaborative plan to move ahead Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -9

Increasing Importance The more important change is perceived to be by the client, the more effort they will put in to working toward change Techniques to facilitate increasing importance Reflective listening OARS: open-ended questions, affirmations, reflections, and summary Develop discrepancies Ruler exercise Roll with Resistance Worst-case/best-case outcomes Find out what is important and negotiate for change Explore importance of events that instigated counseling Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -10

Resolving Ambivalence • MI considers ambivalence to be normal. • One goal of MI is to decrease ambivalence so clients do not feel stuck between feelings (giving up substances vs. continuing to use substances) • Eliciting change talk MI highlights clients’ natural statements about making changes and reinforcing them in order to decrease ambivalence Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -11

Resolving Ambivalence Continued Methods for eliciting change talk DARN: desire to change, ability to change, reasons to change, need for change Commitment language Taking steps Problem recognition Expression of concern Intention to change Optimism Handling resistance Low resistance in the counseling environment is necessary to Substance resolving ambivalence Abuse and Addiction Treatment: Practical Application of Lewis. Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -12

Resolving Ambivalence Strategies for handling resistance Reflective responses Strategic responses Strategies to resolve ambivalence OARS Clarify target behavior Importance ruler exercise Explore both sides of ambivalence Decisional Balance (pro/con exploration) Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -13

Enhancing Confidence • Clients may place high importance on changing behaviors but have difficulty making changes because they lack confidence • Strategies for building confidence Open-ended questions focused on ability and strengths Ruler exercise focused on confidence Personal supports Past successes at changing a behavior Offering information and advice-MI consistent Hypothetical change, envisioning change, anticipating barriers Explore barriers to change Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -14

Strengthening Commitment • Clients are ready for change when they express a lot of change talk and are high on importance, confidence and readiness. • Clinicians assist in developing a plan and encouraging action • It is importance for clinicians to be sure the client is ready for change rather than pushing for change (collaboration) • Change plans should be specific, include awareness of barriers and plans to overcome barriers, include personal supports and time frames Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -15

MI in the Treatment of Diverse Populations • The basic tenets of MI seem to be well suited for work with diverse populations; however, little research has been done to support this • MI has gained support worldwide and is used with a variety of client populations • Most research supports MI as effective with diverse populations, but more research is needed Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -16

Running Case Study: Michael • Michael is high on importance related to his drinking, but continues to feel strong ambivalence about stopping • Clinician uses affirmations while setting the agenda. He uses open questions, affirming, reflecting, summarizing, the ruler exercise, pro/con exploration, best-case/worstcase outcomes, and emphasizing change talk throughout the session in order to resolve ambivalence and enhance client confidence. • Client plan and clinician collaboratively developed an action • Michael remained non-defensive and demonstrated little resistance Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -17

Strengths, Limitations, and Ethical Issues of MI Strengths Applicable with diverse populations Respectful and strength-based Applicable across a wide range of behavior problems Places greater responsibility on clinician when resistance is high Offers skills for “difficult” clients Empirically supported Can be integrated into other approaches to substance abuse treatment Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -18

Strengths, Limitations, and Ethical Issues of MI Continued Limitations Some situations may warrant education, advice, and direction Little is known about when MI is most and least effective More research is needed on use with diverse populations Ethical issues Some concern about manipulation Can be unethical if the clinician has bias about the needs of the client, has influence over the client, or is personally invested in the outcome of the client Lewis. Substance Abuse and Addiction Treatment: Practical Application of Counseling Theory, First Edition. © 2014 by Pearson Education, Inc. All Rights Reserved 5 -19