1. Motivational Interviewing Therese Killeen PhD

2. Overlap in Treatment and Legal Systems About 50 to 60% of substance abuse clients are legally mandated to substance abuse treatment About 50 to 60% of substance abuse clients are legally mandated to substance abuse treatment High rate of substance abuse in offenders High rate of substance abuse in offenders High rate of recidivism in both populations High rate of recidivism in both populations Problems are complex Problems are complex Drug courts allow for collaboration with the treatment and legal system Drug courts allow for collaboration with the treatment and legal system

3. Commonalities in Client Characteristics Angry Angry Frightened about what might happen Frightened about what might happen Reluctant to examine abusive/illegal behavior Reluctant to examine abusive/illegal behavior Unwilling to relinquish their only sense of control Unwilling to relinquish their only sense of control Difficulty accepting responsibility for their behavior Difficulty accepting responsibility for their behavior

4. Goals for rehabilitation Increase effectiveness of interactions with clients/offenders Increase effectiveness of interactions with clients/offenders Improve the climate of the criminal justice system/ addiction treatment Improve the climate of the criminal justice system/ addiction treatment Reduce Recidivism Reduce Recidivism Help clients/offenders commit to or even consider change Help clients/offenders commit to or even consider change Help engage and remain in treatment Help engage and remain in treatment Build supportive relationships Build supportive relationships

5. Motivational Interviewing A client-centered goal directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence

6. Motivational Interviewing in Special Populations/Settings Substance Use Disorders/Dual Disorders Substance Use Disorders/Dual Disorders Medical/Public Health Settings Medical/Public Health Settings Criminal Justice Criminal Justice Adolescents Adolescents Couples Couples Group Settings Group Settings

7. Outcome Effects Attributed to: Therapist effects – who delivers treatment and how Therapist effects – who delivers treatment and how Process effects – what happens between clients and therapists Process effects – what happens between clients and therapists Laws of learning – principles of behavior and change Laws of learning – principles of behavior and change Mesa Grande Review, W. Miller

8. AMBIVALENCE …a state of mind in which a person has coexisting but conflicting feelings, thoughts, and actions about something …a state of mind in which a person has coexisting but conflicting feelings, thoughts, and actions about something The “I do but I don’t” dilemma The “I do but I don’t” dilemma Status ambivalence change Quo movement

9. Basic Assumptions about the Nature of Motivation Motivation is a key to change Motivation is a key to change Motivation is Multidimensional Motivation is Multidimensional Motivational is dynamic and fluctuating Motivational is dynamic and fluctuating Motivational is influenced by social interactions Motivational is influenced by social interactions Motivation can be modified Motivation can be modified Motivation can be influenced by clinician style Motivation can be influenced by clinician style

10. Motivation Changes are more lasting when autonomously /intrinsically versus extrinsically motivated no external intrinsic motivation motivation /pressure motivation

11. RecurrenceMaintenance Action Preparation Contemplation Precontemplation Stages of Change

12. How Many Patients Are Ready? Prep Contemplation Precon Action

13. Matching Interventions to Client Stage of Change Precontemplation stage - must raise their awareness before they can consider change; Precontemplation stage - must raise their awareness before they can consider change; Contemplation stage - require help resolving their ambivalence and choosing positive change over their current situation; Contemplation stage - require help resolving their ambivalence and choosing positive change over their current situation; Preparation stage - need help identifying potential change strategies and choosing the most appropriate one for their circumstances; Preparation stage - need help identifying potential change strategies and choosing the most appropriate one for their circumstances;

14. Continued - Action stage - need help implementing and complying with the change strategies and learning how to prevent or limit relapse; Action stage - need help implementing and complying with the change strategies and learning how to prevent or limit relapse; Maintenance stage - may have to develop new skills for maintaining recovery /behavior change Maintenance stage - may have to develop new skills for maintaining recovery /behavior change Recurrence stage - need help recovering quickly and resuming the change process. Recurrence stage - need help recovering quickly and resuming the change process.

15. Flexible Pacing The concept of pacing requires that clinicians meet their clients at the clients’ levels and use as much or as little time as is necessary to accomplish the essential tasks of each stage of change. The concept of pacing requires that clinicians meet their clients at the clients’ levels and use as much or as little time as is necessary to accomplish the essential tasks of each stage of change.

16. Critical to MI Change most likely to occur if client experiences a discrepancy between values/goals and current behavior.

17. Readiness to Change Less ready the client is to change, the more important it is to do MI Less ready the client is to change, the more important it is to do MI Clients may vacillate between and during sessions Clients may vacillate between and during sessions Moving into action strategy prematurely may adversely affect outcome Moving into action strategy prematurely may adversely affect outcome Could be countertherapeutic to continue with MI when client is clearly ready for behavior change Could be countertherapeutic to continue with MI when client is clearly ready for behavior change

18. Spirit of MI Collaboration Collaboration Evocation Evocation Autonomy Autonomy

19. Dancing Wrestling Collaboration

20. High Spirit Evocation Elicits the client’s ideas about change. Elicits the client’s ideas about change. “Curious and patient” “Curious and patient” Stay focused on whatever behavior change the client is willing to do. Stay focused on whatever behavior change the client is willing to do.

21. Being Supportive of High Autonomy Accept that the clients may not choose to change. Accept that the clients may not choose to change. Are invested in behavior change but don’t push it, in order to maintain therapeutic alliance. Are invested in behavior change but don’t push it, in order to maintain therapeutic alliance. Reinforce that ultimately any behavior change is within the realm of the client. Reinforce that ultimately any behavior change is within the realm of the client.

22. How is “Spirit” different from other counseling characteristics? Not sympathy or being soft Not sympathy or being soft No emphasis on expertise (on the part of the counselor) No emphasis on expertise (on the part of the counselor) Education of client not considered effective (not to be confused with exchanging information) Education of client not considered effective (not to be confused with exchanging information) Does not focus on skill-building Does not focus on skill-building Does not analyze unconscious motivations Does not analyze unconscious motivations

23.  Express Empathy  Develop Discrepancy  Roll with Resistance  Support Self-efficacy

24. MI MICRO-SKILLS OARS  Open-ended Questions  Affirmation  Reflective Listening  Summary

25. OPEN-ENDED QUESTIONS An open-ended question is one where there is more than a yes or no response An open-ended question is one where there is more than a yes or no response “Do you realize the number of charges against you?” versus “ What is your understanding of the charges you have against you?”

26. AFFIRMATIONS Client Focused Client Focused Building Rapport Building Rapport Recognizing and reinforcing Client Strength and Effort Recognizing and reinforcing Client Strength and Effort Aimed at Aimed at –Supporting Client’s Involvement –Encouraging Continued Attendance –Assisting Client to see the Positives

27. Affirmation Examples That was quite an accomplishment. That was quite an accomplishment. You have really done well this week. You have really done well this week. Congratulations, you stuck to your plan. Congratulations, you stuck to your plan. You are really putting a lot of effort into this. You are really putting a lot of effort into this. It took a lot to come in today, but you made it. It took a lot to come in today, but you made it. You really handled that situation well. You really handled that situation well.

28. Reflective Listening “Statements” that lets the client know you are listening “Statements” that lets the client know you are listening Reasonable guess as to the meaning of what was said Reasonable guess as to the meaning of what was said Checking out your assumption with the client Checking out your assumption with the client

29. REFLECTIVE LISTENING Fine tuning REFLECTIVE LISTENING Fine tuning  Level One: Repeat  Level Two: Rephrase  Level Three: Paraphrase  Reflect Feelings  Summary  Metaphors, Similes  Continue the sentence/paragraph

30. Client: I work hard all day, and deserve some time to myself. Marijuana helps me wind down. Clinician: Marijuana helps you settle down after a stressful day at work. Simple reflection

31. Client: “I got charged for distribution of marijuana. One of my friends turned me in so that he would get a lesser charge.” Clinician: “I imagine you are pretty angry that you friend did this to you.”

32. SUMMARIZING Special form of reflection Special form of reflection Counselor chooses what to include and emphasize Counselor chooses what to include and emphasize Include client’s concerns about change, problem recognition, optimism about change, ambivalence about change Include client’s concerns about change, problem recognition, optimism about change, ambivalence about change Restatement of any change talk about intention to change, and confidence in his or her ability to change Restatement of any change talk about intention to change, and confidence in his or her ability to change Let client know you are listening Let client know you are listening

33. “You have been charged with a DUI and you really don’t want to lose your driver’s license. Your lawyer has recommended that you enter this treatment program. While you don’t think it is necessary because you don’t feel you have a problem with alcohol, you plan on completing this program because you do not want to have this charge on your record. In addition, you are thinking that maybe getting into this program may also improve the situation at home.”

34. MI Clinician Goals Talk less than your client Talk less than your client Most common response - reflection Most common response - reflection Reflect twice for each question Reflect twice for each question Complex reflections (paraphrase and summarize) over half the time Complex reflections (paraphrase and summarize) over half the time Use open questions Use open questions Avoid getting ahead of client’s readiness level Avoid getting ahead of client’s readiness level

35. Change Talk Disadvantage of the status quo Disadvantage of the status quo Advantage of change Advantage of change Optimism about change Optimism about change Intention to change Intention to change

36. EVOCATIVE OPEN QUESTIONS Desire: "What do you want to do about this behavior?" Ability: "What makes you believe you can do this?" Reason/Need: "Why would you want to make this change?" Commitment: "So what are you willing to do now.” Exploring reasons against change. For example, "What keeps you from making this change"

37. Change most likely to occur if client experiences a discrepancy between values/goals and current behavior.

38. Evoking Change Talk Strategies Evocative questions Evocative questions Explore decisional balance Explore decisional balance Elaboration Elaboration Examples Examples Look back Look back Look forward Query extremes Explore goals and values Come alongside

39. Evocative Questions “How might you go about making this change?” “How might you go about making this change?” “What would be a good first step?” “What would be a good first step?” “What obstacles do you foresee and how might you deal with them?” “What obstacles do you foresee and how might you deal with them?” What gives you the confidence that you can do this?” What gives you the confidence that you can do this?”

40. Elaboration “Tell me more about that.” “Tell me more about that.” “What about the last time that happened?” “What about the last time that happened?” “Give me an example?” “Give me an example?” “What else?” “What else?”

41. Developing Discrepancies Use of summaries Use of summaries Differences between stated goals and actual behavior Differences between stated goals and actual behavior Tip the Balance by making a decision to change Tip the Balance by making a decision to change Use of pros and cons exercise Use of pros and cons exercise “So you say that you need to save money to move but on the other hand you find yourself spending $100 a week buying MJ… What do you make out of this?” “How does your drinking fit in with your having a happy family and good job?”

42. Exploring pros and cons – Developing Discrepancies “What are the good things about your drinking?” “What are the good things about your drinking?” “What are the not so good things?” “What are the not so good things?”

43. Readiness Ruler: Eliciting Change Talk 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Not at allExtremely Not at allExtremely How important is it to you to change this? How important is it to you to change this? How confident are you that you can change this? How confident are you that you can change this?

44. Evoking Change talk Why are you at a 5 and not a 1 or 2 ? Why are you at a 5 and not a 1 or 2 ? What would need to happen to take it from a 5 to say a 7 or 8? What would need to happen to take it from a 5 to say a 7 or 8?

45. Imagine extremes “What is the worst that can happen if you continued?” “What is the worst that can happen if you continued?” What do you think would have to happen to make you decide to tell yourself, “ok that’s enough?” What do you think would have to happen to make you decide to tell yourself, “ok that’s enough?”

46. Looking Forward “What would you like your life to be like in 2 years?” “What would you like your life to be like in 2 years?” –“How does what you are doing now make that difficult?” “What would it be like if you continue with the way things are now?” “What would it be like if you continue with the way things are now?” Suppose things don’t change, how do think your life will look?” Suppose things don’t change, how do think your life will look?”

47. Looking Back “When was the last time things were going well for you and what was it like for you?” “When was the last time things were going well for you and what was it like for you?” “What do you think could have prevented this setback? “What do you think could have prevented this setback? “Before you used, what was your life like?” “Before you used, what was your life like?” “As you step back and look at all this, what do you make of it?” “As you step back and look at all this, what do you make of it?”

48. Involves feelings-actions- behaviors of an interpersonal nature where there is a lack of collaboration

49. Identifying resistance Arguing Arguing Discounting Discounting Disagreeing Disagreeing Hostility Hostility Blaming Blaming De - focus Defensive Pessimism Passivity Body language

50. What is resistance? Interpersonal behavior Interpersonal behavior Information Information Clinician influences resistance: How you respond matters? Clinician influences resistance: How you respond matters? Not a client problem, but a clinician skill issue Not a client problem, but a clinician skill issue Cue to change direction/back off Cue to change direction/back off

51. Responses to Resistance Shifting focus Shifting focus Reframing Reframing Agreeing with a twist Agreeing with a twist Emphasize personal choice and control Emphasize personal choice and control Coming alongside Coming alongside

52. Agreement with a twist Initial agreement but with a slight change of direction Initial agreement but with a slight change of direction Example: You’ve got a good point there. All this nagging and blaming is not helpful. This is a problem that involves the whole family.

53. Emphasizing Personal Choice and Control “It is entirely up to you. This is really your decision. No one can make that decision for you.” “It is entirely up to you. This is really your decision. No one can make that decision for you.” “If you decide that you do not want to change, then that is your decision.” “If you decide that you do not want to change, then that is your decision.”

54. Reframing Acknowledge what client has said but offer a different perspective Acknowledge what client has said but offer a different perspective Example: “I wonder if all that complaining your wife does is her way of showing her concern.” Focus on how long the client stayed in treatment the last time rather than the fact that he/she did not complete.

55. Coming alongside Taking the side of no change as a way to foster the clients ambivalence and elicit change talk. Taking the side of no change as a way to foster the clients ambivalence and elicit change talk.

56. Shifting focus Going around the resistance – taking a detour Going around the resistance – taking a detour Example – Maybe we are getting ahead of ourselves here. I am worried, as you are, about some of the things that are going on in your life right now. Tell me more about……

57. Information exchange versus information giving

58. Information Giving –A one-way process –Combine facts with interpretation & persuasion –Decide what to assess & what information to provide –Reinforce passivity in patient –Ask lots of closed questions

59. Information Exchange Elicit needs & knowledge Elicit needs & knowledge –“What would you most like to know about.?” –“How much do you know about...?” Ask permission to provide information Ask permission to provide information –Keep to information, away from personal interpretation –Some clients say that it helps to….. –This may or may not help but ….. –You may or may not agree ….. Elicit client’s interpretation Elicit client’s interpretation –“What do you make of that...?” –“What does this mean for your future...?”

60. Summary Stay in the “spirit of MI” Stay in the “spirit of MI” Use OARS skills Use OARS skills Identify and reinforce change talk Identify and reinforce change talk Identify and roll with resistance Identify and roll with resistance Do not get ahead of client’s stage of change Do not get ahead of client’s stage of change motivationalinterviewing.org

61. Eight Stages of Learning MI Overall MI Spirit Overall MI Spirit OARS Skills OARS Skills Recognizing change talk and resistance Recognizing change talk and resistance Eliciting/strengthening change talk Eliciting/strengthening change talk Rolling with Resistance Rolling with Resistance Developing change plan Consolidating commitment Transition and blending (with other approaches)