1. Motivational Interviewing
Mary Marden Velasquez, Ph.D.
Associate Dean for Research
Director, Center for Social Work Research
Director, Health Behavior Research and Training Institute
The University of Texas at Austin
Kirk von Sternberg, Ph.D.
Associate Director, Health Behavior Research and Training Institute
School of Social Work

2. Health Behavior Research and Training Institute
Specializes in the development and implementation of interventions using the Transtheoretical Model (TTM) and Motivational Interviewing (MI) and in the training and supervision of providers in the field who address behavior change on the front lines.
Our intervention research has targeted HIV and safer sexual practices, prenatal health, alcohol, cocaine, smoking, STI testing, and fetal alcohol spectrum disorder. The HBRT Institute has a history of providing training, supervision, and “coaching” on the TTM, MI, and evidence-based intervention and prevention approaches, with a recent emphasis on teaching health care providers to use brief motivational interventions in medical settings. Collaborators include state, federal, and international governmental agencies.

3. HBRT: A Brief History University of Houston- Department of Psychology
University of Texas Medical School at Houston- Department of Family and Community Medicine
Director of Research
University of Texas Health Science Center at Houston School of Public Health (cross appt)
University of Texas-Austin School of Social Work
Professor, Associate Dean for Research
Center for Social Work Research
Director
Health Behavior Research and Training Institute

4. University of Texas Medical School at Houston
Stages of Change
MAINTENANCE
ACTION
PREPARATION
CONTEMPLATION
RELAPSE
&
RECYCLE
PRECONTEMPLATION
University of Texas Medical School at Houston

6. Motivational Interviewing
Motivational Interviewing is a
directive, client-centered
counseling style that
enhances motivation
for change by
helping the client
clarify and resolve ambivalence
about
behavior change.
The
Goal
of Motivational Interviewing is to
create
and
amplify discrepancy
between present behavior and broader
goals.
Create cognitive dissonance between
where one is
and where one
wants to be

7. The Transtheoretical Model
Offers an integrative framework for understanding, measuring, and intervening in patients’ health behaviors
Clinicians assess clients’ readiness to change and enhance motivation through a series of techniques, depending on the clients’ stage of readiness

8. Why Motivational Interviewing?
Evidence-based >120 clinical trials
Relatively brief
Specifiable
Grounded in testable theory
With specifiable mechanisms of action
Generalizable across problem areas
Complementary to other treatment methods
Verifiable – Is it being delivered properly?
Can be delivered by non-specialists

9. What do we know?
MI triggers reliable aggregate change across a range of target problems, settings, and providers

10. Motivational Interviewing Assumptions – I
Motivation is a state of readiness to change,
which may fluctuate from one time or situation
to another. This state can be influenced.
Motivation for change does not reside
solely within the client.
The counselor’s style is a powerful determinant
of client resistance and change. An empathic
style is more likely to bring out self-motivational
responses and less resistance from the client

11. Motivational Interviewing Assumptions – II
People struggling with behavioral problems
often have fluctuating and conflicting motivations
for change, also known as ambivalence.
Ambivalence is a normal part of considering and
making change and is NOT pathological
Each person has powerful potential for change.
The task of the counselor is to release that potential
and facilitate the natural change process that is
already inherent in the individual.

12. Stages of Change Precontemplation- Not ready to change
Contemplation- Thinking about changing
Preparation- Preparing to change
Action- Actively changing
Maintenance- Continuing to support the change
Relapse- Slipping back to the previous behavior

13. Stages of Change ACTION MAINTENANCE PREPARATION CONTEMPLATION
RELAPSE
&
RECYCLE
PRECONTEMPLATION

14. Working with Clients Who are Not Ready to Change

15. Components of MI Spirit
A = Autonomy
C = Collaboration
E = Evocation
11:20-11:25 (5)
Autonomy = responsibility for change is left with the client. The counselor affirms the client’s right and capacity for self-direction and facilitates informed choice.
Collaboration = Exploration & support are key ingredients of the relationship. The counseling style involves a partnership that honors the client’s expertise and perspectives. The counselor provides an atmosphere that is conducive rather than coercive to change.
Evocation = The counselor does not impart wisdom, but rather elicits it from within and draws it out from the person. The resources and motivation for change are presumed to reside within the client. Intrinsic motivation for change is enhanced buy drawing on the client’s own perceptions, goals and values.

16. Autonomy – Responsibility for change is left with the client, hence there is respect for the individual’s autonomy. The clients are always free to take our advice or not. When motivational interviewing is done properly, it is the client rather than the counselor who presents the arguments for change.

17. Underlying the Spirit of Motivational Interviewing
is:
Collaboration - In motivational interviewing, the counselor does not assume an authoritarian role. The counselor seeks to create a positive atmosphere that is conducive to change.
Evocation - Consistent with a collaborative role, the counselor’s tone is not one of imparting things, such as wisdom or insight, but rather eliciting – finding these things within and drawing them out from the person.

18. Using OARS Micro-skills
Eliciting Change Talk
The idea in MI is to have the client present arguments for both sides in making changes. It is the interviewer’s task to facilitate the client’s expression of such change talk. This is a process of shared decision-making, not an attempt to manipulate or sculpt the client’s will.

19. Eliciting Change Talk D = Desire for change A = Ability to change
R = Reasons for change
N = Need for Change
C = Commitment to Change

20. The Flow of Change Talk MI Desire Ability Reasons Need Commitment

21. Therapists Influence Client Motivation
Expectations influence outcomes
Differences in drop-out rates
Differences in outcome rates
Simple actions decrease drop-out
Empathic therapists have better outcomes

22. Qualities of a Good Motivational Counselor
Respect for individual differences
Tolerance for disagreement and ambivalence
Patience with gradual approximations
Genuine caring and interest in
clients served

23. MI - Like Dancing
Not Wrestling

24. Eight Stages in Learning MI
1. The spirit of MI
2. OARS – Client-centered counseling skills
3. Recognizing and reinforcing change talk
4. Eliciting and strengthening change talk
5. Rolling with resistance
6. Developing a change plan
7. Consolidating client commitment
8. Shifting flexibly between MI and other methods
Miller, W. R., & Moyers, T. B. (in press). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions.

25. Importance Ruler How important is it to you to quit smoking
Importance Ruler How important is it to you to quit smoking? If 0 was “not important,” and 10 was “very important,” what number would you give yourself ?

26. Exploring Importance
Why are you at x and not y? Or, how did you get from x to y? (always start with the higher number)
What would have to happen for it to become much more important for you to change?
What would have to happen before you seriously considered changing?

27. Why have you given yourself such a high score on importance?
What would need to happen for your importance score to move up from x to y?
What stops you moving up from x to y?

28. What are the good things about your tobacco use?
What are some of the less good things?
What concerns do you have about your tobacco use?
If you were to change, what would it be like?
Where does this leave you now?
Use this when you want to ask about change in a neutral way)

29. Confidence Ruler If you decided right now to quit smoking , how confident do you feel about succeeding with this?   If 0 was ‘not confident’ and 10 was ‘very confident’, what number would you give yourself?

31. The Health Behavior Research and Training Institute
Motivational Interviewing Training and Coaching

32. Training
The HBRT Institute specializes in the training and supervision or coaching of providers in the field who address behavior change on the front lines.
The organizations HBRT has worked with include:
NIH (NIAAA, NIDA, NHLBI, NIAID) and CDC
SAMHSA/TDSHS
Harris County Hospital District
Family Medicine Residency programs in Georgia and Texas
ATC-MHMR
CPS/Children and Families
Federal Bureau of Prisons
And many others

33. Training Our challenge at the HBRT Institute is to:
Meet the specific training and supervision needs of our community providers
Help ensure sustained treatment fidelity
Facilitate wide-spread dissemination of evidence-based practices
Our system of training & coaching:
Is targeted to the individual needs of the community providers
Is practical and efficient.
Maximizes the productivity of the expert Institute Coaches
Bridges geographical and time barriers between the expert Coaches and professionals being trained
Utilizes available technologies (i.e. secure, personal website) for training & coaching

34. Implementing Evidence-Based Brief MI Intervention
InSight
The InSight SBIRT model was implemented in eight Harris County Hospital District (HCHD) locations, including emergency departments, community clinics, and school-based clinics.
The role of HBRT included the development of the Specialist training as well as ongoing coaching to insure the treatment fidelity and sustainability in community medical settings.

35. Evidence-Based SBIRT Intervention
Project providers are trained to use a brief version of Motivational Interviewing (MI) tailored to the medical setting.
“Brief Interventions” (BI), consisting of one to five short motivational sessions
“Brief Treatment” (BT), one to twelve MI sessions, to promote reduction and/or cessation of substance use. Sessions are adapted from a substance abuse treatment manual based on the Transtheoretical Model’s stages and processes of change (Velasquez, Maurer, Crouch & DiClemente, 2001)

36. Comprehensive Training System for Specialists
Motivational Interviewing training
InSight Specialists (social workers, nurses, master’s level counselors, licensed chemical dependency counselors) received a series of training workshops
Standardized Patient training
initial and booster trainings
Quarterly in-service trainings
Effectiveness must be demonstrated
Need ability to replicate with fidelity—monitoring process

37. Treatment Fidelity - Coaching
On-going support from highly skilled MI “Coaches.”
Sessions are digitally recorded
Coaches meet with Specialists monthly to:
discuss cases,
practice using role-plays,
provide feedback from audiotape review
The Specialists proficiency with MI skills is evaluated quarterly by the Coaching team using the “Motivational Interviewing Treatment Integrity Skill Coding System (MITI).”

38. Coaches’ Quarterly Report Date _____________
Specialist __________________________ Coach ________________________
Session Checklist Average __________
MI Spirit Average __________
MI Empathy Average __________
Average of MITI Behavior Counts
Ratio of Reflections to Questions
(1:1 minimal competence) __________
% Open Questions of all Questions
(50% minimal competence) __________
[OQ/{OQ+CQ}]
% MI Adherent
(90% MI-A minimal competence) __________
[MiA/ (MiA+MiNa)]
5. MI Scale Average __________
Overall Rating (circle one):
Red-lined Needs Improvement Acceptable Proficient
Comments:
Number of Tapes Turned in ________ Number of tapes used for ratings ________
Number of Taping Agreement Forms: Agreed ______ Declined ______ Total ______

39. Sustaining the Coaching Model
Peer Specialist Coach
Coaching of Specialists is conducted by the on-site peer Specialist Coaches
Specialist Coaches receive ongoing support from Institute Coaches through:
Web-based tape review
Monthly consults
Booster Workshops

40. Sustaining the Coaching
Each New Specialist and Specialist Coach has a private secure web-site, shared only with their assigned Institute Coach, for session tape review and feedback.

41. Tailored Training and Coaching Models
Counseling Front-Line Professionals:
Initial training – MI Principles, Skills Training, Role Plays
Standardized Patient Training – Practicing the principles and the skills
Coaching – On-going coaching and feedback
Follow-up training – Checking progress and training on advanced MI strategies
Non-clinical staff
Initial training – MI Principles
Peer Coaches
Initial training – advanced strategies, session coding and feedback training

42. Conclusions
Comprehensive training and monitoring procedures are required to sustain the integrity of an MI intervention.
The wide-spread transfer of a research-based brief MI intervention into a number of varied settings is feasible.
The training and coaching model can be adapted to any number of settings and behaviors
Professionals in medical and other community settings can influence patient outcomes, resulting in significant health behavior change and corresponding cost-savings.