Effecting Change through the Use of Motivational Interviewing

Effecting Change through the Use of Motivational Interviewing Sherry Larkins, Ph. D Joy Chudzynski, Psy. D 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 “motivation” mean to you?

Understanding How People Change: Models Traditional approach Motivating for change

Traditional approach The Stick • • 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

Traditional approach You better! Or else! If the stick is big enough, there is no need for a carrot.

Traditional approach 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.

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.

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: 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: 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

How does MI differ from traditional counseling? 1. Patient and practitioner are equal partners in relationship (collaborative effort between two experts)

REFLECTION 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

Ambivalence is Normal

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

REFLECTION 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?

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What’s the Best Way to Facilitate Change? The Carrot • 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

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 Change Prochaska & Di. Clemente

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. 6. Recurrence Definition: Primary Task: Raising Awareness 2. Contemplation Definition: Experienced a recurrence of the symptoms. Sees the possibility of change but is ambivalent and uncertain. Primary Task: Cope with consequences and determine what to do next 5. Maintenance Resolving ambivalence/ Helping to choose change Stages of Change: Primary Tasks Definition: 3. Determination Definition: Has achieved the goals and is working to maintain change. Committed to changing. Still considering what to do. Primary Task: Develop new skills for maintaining recovery 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 Help identify appropriate change strategies

EXERCISE 1: Use the Stages of Change Treatment Matching Guide • Angelica is a 42 -year old mother to a son in middle school. Over the past 10 years, she has worked in various childcare settings as a teacher’s assistant. She sustained a fall while at work, for which she was prescribed pain medications, and was put on short-term disability as the injury healed. She returned to work and was laid-off 6 months later. This was two years ago; she has not worked since. • At her last appointment, she informed the doctor that she was feeling very depressed about not working, but that she was still in a lot of pain from her work-related injury. She asked for more pain medications and claimed she was not ready to go back to work. She reported that she has had trouble sleeping at times because she feels like she is “racing. ” • The doctor asks you to assess Angelica to determine if any mental health and/or substance use services might be warranted.

Change Talk • Recognizing the problem • Expressing concern • Stating intention to change • Being optimistic about change

Moving Toward Change: the DARN Steps Reason Ability Desire Need Commitment

Moving Toward Change: the DARN Steps • Desire – What would one enjoy doing/not doing • Ability – What one is able/unable to do • Reason – Reasons for doing/not doing behavior • Need – What one needs or doesn’t need to do (should, must, ought) • Commitment – what one intends/doesn’t intend to do

Change Talk Dig for change talk… • I’d like to hear you opinions about… • What might you enjoy about… • If you decided to…. how would you do it? • What are some things that bother you about using? • What role do you think alcohol played in your injury? • How would you like your drinking/using to be 5 years from now?

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

Drumming For Change I love to smoke my weed. I’m happy with living on the streets. I ain’t going to do anything different I just want to wake up sober in the morning. I need to do something to get my energy back. I mostly forgot to call my probation officer. Mostly I just don’t see any benefits to getting my high school degree. There’s no way I want to be on insulin. I broke down and went to a bar on Tuesday. I need to get high to feel right. I’m killing myself. I’ve been kinda forgetting to take my anti-depressants. I don’t’ see how drinking 4 or 5 beers a night is a problem. If I lose this job, my girlfriend is definitely going to leave me. I just don’t see how coming here is helping. I can’t keep having those one-nighters. My kids are the most important thing to

Building Motivation OARS (the microskills) • Open-ended questioning • Affirming • Reflective listening • Summarizing The goal is to elicit and reinforce self-motivational statements (Change Talk)

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

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)

Types of Reflective Statements 1. Simple Reflection (repeat) 2. Amplified Reflection (amplify/exaggerate the consumer’s point) 3. Double-Sided Reflection (captures both sides of the ambivalence) NIDA-SAMHSA Blending Initiative

Reflections • Questions to guide you: – What has s/he said? – What does s/he mean? – How does s/he feel about this? – How does this affect how s/he thinks? – How does this affect how s/he feels about herself or her world?

Simple Reflections • Simple reflections: stay very close to the speaker’s original words and meaning: • Client: Everybody out there is trying to mess with my head. Clinician: ? ? • Client: Usually when I get depressed, I just try to stay busy, and it eventually goes away. But this time…. . I can’t seem to shake it. Clinician: ? ?

Amplified Reflections • Amplified reflections not only repeat the speaker’s meaning, they shape it. • “Put words in peoples’ mouths” • Goal is always to get client to give more change talk. • Give them back the emotions underlying their statement.

Amplified Reflection: Example Client: I don’t want to go back to prison but this is way too hard. Clinician: You’re struggling here, but you won’t quit trying- prison is just not an option in your mind. Client: Nobody at the clinic wants to help me. They can’t even speak my language. Clinician: ? ?

Amplified Reflection: Example • Client: I keep thinking I should get this checked out at the clinic, but I just never seem to make it there. • Clinician: ? ? ? • Client: You know if my mom would just back off, this situation would be a whole lot less tense and then these things wouldn't happen. • Clinician: ? ? ?

Double Sided Refections • So on the one hand you…. . but on the other you want……. . • End on the change talk. Client: I know it might not be good for me, but it is the only thing that helps me sleep. Client: On the one hand using seems to help you sleep, but on the other hand you are worried about how it is affecting your health.

Double Sided Reflection: Example Client: I’m trying to get a job, but I’ve got to look out for my kids. Clinician: ? ? ? Client: That shelter is the last place in the world I’d ever want to stay, but being on the street is no good. Clinician: ? ? ? Client: Man, I feel like crap today. I went to a friend’s party this weekend, it was a lot of fun and well, you know, I got trashed. Clinician: ? ? ?

Case Example Working with a non-communicative client

Reflective Listening Exercise Talk about a personal change you are making. Listener will only respond with reflections. Not Questions. The Listener will use as many complex and doublesided reflections as possible.

What if…? • What if the client doesn’t say ANY change talk? • “Actions speak louder than words. ” Do the client’s actions express any change talk? (Can you address any discrepancy between their words and their actions? ) – Client: “This program is worthless. I don’t want anything to do with it. ” – “On the one hand, you don’t really want to be here and you don’t think it will help you at all. On the other hand, you’re still sitting here in front of me. I’m wondering how that adds up. ” – Client: ?

What If, Con’t • No, I mean it: What if the client gives you NO change talk? AT ALL? • Try reflecting the resistance. Can you get even MORE resistant than the client? Client: My PO wants me working and going to counseling. You guys want me going to all these meetings, making curfew, giving you all my money. My wife is always on my case. I’m gonna have to get loaded just to deal with you all!” Clinician: It would be impossible to deal with all these people sober. In fact, nobody could do it!

What If, Con’t • Consider the possibility that you are not talking about the right issue… ? ? ?

SUD MH Pain Family Medical Issues SUD

To avoid this… LET GO!!!

SUD Hypertension Diabetes Cancer SUD

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. A summary is a series of reflections strung together

Four Principles of Motivational 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

Empathic Listening • Respect Client Autonomy. • Respect Client Views. • Look at Problem Together – Client is not the problem. • Reflect what client is experiencing. • Genuinely care about your client. • Empower Client to Take Control of Their Lives.

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

THE DECISIONAL BALANCE The good things about ______ The notso-good things about ____ The not-sogood things about changing The good things about changing Avoid questions that inspire a yes/no answer.

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

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

An example of rolling with resistance

Use the Microskills of MI to: 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

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

MI Skills Exercise • Angelica is a 42 -year old mother to a son in middle school. Over the past 10 years, she has worked in various childcare settings as a teacher’s assistant. She sustained a fall while at work, for which she was prescribed pain medications, and was put on short-term disability as the injury healed. She returned to work and was laid-off 6 months later. This was two years ago; she has not worked since. • At her last appointment, she informed the doctor that she was feeling very depressed about not working, but that she was still in a lot of pain from her work-related injury. She asked for more pain medications and claimed she was not ready to go back to work. She reported that she has had trouble sleeping at times because she feels like she is “racing. ” • The doctor asks you to assess Angelica to determine if any mental health and/or substance use services might be warranted.

MI Skills Exercise • In groups of 3 (clinician, client, observer), begin a discussion with Angelica to enhance her readiness for change concerning substance use issues. • Use Decisional Balance, Readiness/Confidence/Importance Rulers, Open-ended questions, Amplified Reflections • Observer: Listen for change talk and note when you hear Desire, Ability, Reason, Need, Commitment (DARN C)

GIVE THEM FEEDBACK AND ADVICE, BUT DO IT IN A MOTIVATIONAL WAY The Feedback/Advice Sandwich Ask Permission Give Feedback/Advice Ask for Response

When to Give Advice • Does the consumer already know what I have to say? • Have I elicited the consumer’s knowledge regarding this information? • Is what I’m about to say going to be helpful to the consumer (i. e. , reduce resistance and/or increase change talk)

ANY TIME THAT YOU ADDRESS SUBSTANCE USE… “SEW” IT UP • • • Summarize patients views (especially the pro) Encourage them to share their views What agreement was reached (repeat it)

Possible Ways to Help the Patient in the Determination Stage • Offer a menu of options for change or treatment • Help client 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 95

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 Anthony Jackson is a 67 -year old living alone in an apartment in a mixed-age housing project. For the past month he has been seen by a visiting nurse from your agency. The nurse was assigned upon his discharge from the hospital where he spent 4 days. He had a fall in the middle of the night prior to the hospitalization, was a bit confused on admission, and was also diagnosed of anemia in the hospital. The nurse noted the smell of alcohol during two of his visits, but Mr. Jackson did not ever appear intoxicated. l When the nurse asked him about his drinking, he said, “Oh, I don’t drink very much, really. I just seem so tired all the time and a little drink now and then makes me feel better. ” He has complained about feeling a bit “blue” and his difficulty sleeping at night. He was prescribed medication for sleep 6 months ago. l A caseworker is assigned to his case and visits two times/week. In addition, he has one friend who visits almost every day. Not counting his stay in the hospital, he has been confined to his apartment for the last two months. l The nurse asked you to see Mr. Jackson to assess his mental health needs, address his alcohol problems, and determine what additional services are needed. l

Role Play of Motivational Interviewing Style • While observing notice examples of when the microskills (O. A. R. S. ) are being used. – Open-ended Questions – Affirmations – Reflective Statements (amplified, double-sided) – Summarizing • Note when clinicians uses tools to dig for change: – Decisional Balance – Rulers

Video: A Motivational Interview • While observing notice examples of when the microskills (O. A. R. S. ) are being used. – Open-ended Questions – Affirmations – Reflective Statements (amplified, double-sided) – Summarizing • Note when clinicians uses tools to dig for change: – Decisional Balance – Rulers

Strategies to Avoid

What techniques should I avoid? Techniques to avoid when motivating clients: • Confrontation / denial • Closed questions • Clinician traps • Roadblocks to reflective listening

Clinician Traps • • • Question-Answer Trap Confrontation-Denial Trap Expert Trap Labeling Trap Premature-Focus Trap Blaming Trap

Roadblocks 1 • • • Ordering, directing, or commanding Warning or threatening Giving advice, making suggestions, providing solutions Persuading with logic, arguing, lecturing Moralizing, preaching, telling them their duty Judging, criticizing, disagreeing, blaming

Roadblocks 2 • • • Agreeing, approving, praising Shaming, ridiculing, labeling, name-calling Interpreting, analyzing Reassuring, sympathizing, consoling Questioning, probing Withdrawing, distracting, humoring, changing the subject.

Some questions to ask yourself when in conversation with a client. . . • • • What am I doing? Where are we going, and who’s deciding? What am I saying, and to what end? Am I actively listening? Are we dancing or wrestling?

The 3 Chairs exercise Observe the activity and provide feedback.

Concluding Thoughts • Experiences and observations • One thing I can take away from this training and use tomorrow is…

THANK YOU!! Sherry Larkins, Ph. D (larkins@ucla. edu) Joy Chudzynski, Psy. D (joychud@ucla. edu ) For additional information on this or other training topics, visit: www. psattc. org www. motivationalinterview. org www. uclaisap. org/dmhcod