1. Effecting Change through the use of Motivational Interviewing Jeanne L. Obert, MFT, MSM Executive Director, Matrix Institute UCLA Integrated Substance Abuse Programs

2. One Way of Thinking Change is motivated by discomfort. If you can make people feel bad enough, they will change. People have to “hit bottom” to be ready Corollary: People don’t change because they haven’t suffered enough The Stick

3. Assumptions in working with people who clearly need to change If the stick is big enough. There is no need for a carrot. You better ____ or ________!

4. Assumptions in working with people who clearly need to change People change only when they have to. If the consequences are negative enough, people will change to avoid them.

6. Motivational Interviewing, 2 nd Edition. Miller and Rollnick We can’t help wondering, why don’t people change? You would think: that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication

7. You would think….. that hangovers, damaged relationships, an auto crash, and memory blackouts would be enough to convince a person to stop drinking

8. You would think….. that the very real threats of blindness, amputations and other complications from diabetes would be enough to motivate weight loss and glycemic control

9. You would think….. that time spent in the dehumanizing privations of prison would dissuade people from re-offending

10. AND YET Addictive behaviors persist despite overwhelming evidence of their destructiveness.

11. What has occurred The field of addictions has provided a natural arena to study the process of change. What causes change to occur? How does the process unfold? Is it possible to “push the river”? What is the best way to do that?

12. Another Way of Thinking People are ambivalent about change AMBIVALENCE is the key issue to be resolved for change to occur. Lack of motivation can be viewed as unresolved ambivalence. The Carrot

13. Increasing the negative consequences (using the stick) does not always decrease the attractiveness of the behavior. It can sometimes exacerbate it rather than diminish it. Ambivalent people may not respond in predictable ways.

14. The Theory of Psychological Reactance (one possible explanation) This theory predicts an increase in the rate and attractiveness of a behavior IF the person perceives a challenge or infringement to his or her personal freedom.

15. What facilitates change 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 The Carrot

16. The Process of Change Positive change often occurs without formal treatment. Treatment can be viewed as facilitating what is a natural process of change.

17. Most Change Happens Early A little counseling can lead to significant change. Dozens of studies from many different countries document the effectiveness of brief interventions for many problems.

18. Perceived Efficacy People who believe that they are likely to change do so. People whose counselors believe that they are likely to change do so. Those who are told that they are not expected to improve or who do not believe they will improve indeed do not. Beliefs about possibility of change become self-fulfilling prophecies. (Waiting list effects in control groups.)

19. Beyond the Initial Session in Drug Abuse Treatment What factors influence whether a patient stays in treatment and does well following treatment? Factor that seems to make the biggest difference is the professional to whom the patient is assigned.

20. Back to Where we Started Ideal atmosphere for change within the therapeutic relationship (Carl Rogers, 1959) Accurate empathy* Non-possessive warmth Genuineness

21. Some things we’ve learned Caregiver empathy can be a significant determinant of person’s response to treatment. Directive, confrontational counseling styles increase patient/client resistance. Empathic counseling styles facilitate change.

22. More things we’ve learned Level of MOTIVATION is often a good predictor of outcome. MOTIVATION can be influenced by naturally occurring factors and by specific interventions.

23. What Causes a Person to be Judged “Motivated” The person agrees with us Is willing to comply with our recommendations and treatment prescriptions States desire for help Shows distress, acknowledges helplessness Has a successful outcome

24. Definition of Motivation The probability that a person will enter into, continue, and comply with change-directed behavior

25. A patient-centered directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.

26. Stages of Change Prochaska & DiClemente

27. What Research Tells Us about Patients with C-O Disorders Patients are often demoralized and unwilling to consider alcohol and drug abstinence (or manage their dual disorders ) due to: Severe and disabling symptoms Frequent failed treatment episodes Poor functional adjustments

28. What Research Tells Us about Patients with C-O Disorders Extensive literature references the low motivation for change in this population Emphasis has been on primary importance of engagement and motivational enhancement strategies

29. Treatment Enhancements for C-O Disordered Patients  Necessary because: These patients are notorious for treatment noncompliance Noncompliance can lead to adverse consequences such as poor outcomes, violent behavior, increased rates of re- hospitalization and utilization of emergency services and jails

30. A Three Part Process Staying Clean and Sober Taking Medications Participating in Dual Diagnosis Specialty Program

31. Precontemplation Stage Not yet considering change or is unwilling or unable to change Offer factual information. Explore the meaning of events that brought the person in and the results of previous efforts Explore pros and cons of targeted behaviors

32. Contemplation Stage Sees possibility of change but is ambivalent and uncertain Talk about the person’s sense of self- efficacy and expectations regarding what the change will entail. Summarize self-motivational statements. Continue exploration of pros and cons.

33. Determination Stage Committed to making change but is still considering what to do. Offer a menu of options for change or treatment Negotiate a change (treatment) plan and behavior contract

34. Determination Stage Committed to making change but is still considering what to do. Identify and lower barriers to change Help person enlist social support Encourage person to publicly announce plans to change

35. Action Stage Taking steps to change but hasn’t reached a stable state Support a realistic view of change through small steps. Help person identify high-risk situations and develop appropriate coping strategies.

36. Action Stage Taking steps to change but hasn’t reached a stable state Assist person in finding new reinforcers of positive change. Help access family and social support.

37. Maintenance Stage Has achieved goals and is working to maintain them. Help person identify and try alternative behaviors (drug-free sources of pleasure) Maintain supportive contact

38. Maintenance Stage Has achieved goals and is working to maintain them. Encourage person to develop “fire- escape” plan Work to set new short and long term goals.

39. Recurrence Has experienced a recurrence of symptoms and must cope with CONSEQUENCES and DECIDE WHAT TO DO NEXT Explore with person the meaning and reality of recurrence as a learning opportunity. Explain Stages of Change and encourage him/her to stay in the process.

40. Recurrence Has experienced a recurrence of symptoms and must cope with CONSEQUENCES and DECIDE WHAT TO DO NEXT Help person find alternative coping strategies. Maintain supportive contact.

41. Four Principles of Motivational Interviewing 1. Express empathy 2.Develop discrepancy 3.Avoid argumentation 4.Support self-efficacy

42. 1.Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal

43. Motivational Interviewing Intervention Elicit Pros and Cons of Target Behavior

44. 2.Develop Discrepancy Ready, Willing and Able 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

45. Motivational Interviewing Intervention Facilitate discussion of lifestyle satisfaction (compared to that once envisioned)

46. 3. Avoid Argumentation Resistance is signal to change strategies Labeling is unnecessary Shift perceptions Peoples’ attitudes shaped by their words, not yours

47. Motivational Interviewing Interventions Elicit individual’s stated concerns (rather than stating yours) Emphasize and reflect areas of greatest concern and discrepancy

48. 4.Support Self-Efficacy Ready, Willing and Able 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

49. Motivational Interviewing Intervention Elicit and support realistic intended behavior change

50. Building Motivation OARS Open-ended questioning Affirming Reflective listening Summarizing

51. Open-ended Questions An open-ended question is one with more than a yes or no response Helps person elaborate own view of the problem and brainstorm possible solutions

52. 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

53. 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)

54. SUMMARIZING  Summaries capture both sides of the ambivalence (You say that ___________ but you also mentioned that ________________.)  Summaries also prompt clarification and further elaboration from the person.

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

56. Providing Feedback Elicit (ask for permission) Give feedback or advice Elicit again (the person’s view of how the advice will work for him/her)

57. Signs of Readiness to Change Less resistance Fewer questions about the problems More questions about change Self-motivational statements Resolve Looking ahead Experimenting with change

58. You are using MI if you: Talk less than your client does On average, reflect twice for each question Reflect with complex reflections more than half the time Ask mostly open ended questions Avoid getting ahead of your client’s stage of readiness (warning, confronting, giving unwelcome advice, taking “good” side of the argument

59. JLObert@matrixinstitute.org www.matrixinstitute.org www. uclaisap.org http://motivationalinterview.org Enhancing Motivation for Change in Substance Abuse Treatment TIP 35 JLObert@matrixinstitute.org www.matrixinstitute.org www. uclaisap.org http://motivationalinterview.org Enhancing Motivation for Change in Substance Abuse Treatment TIP 35 http://motivationalinterview.org JLObert@matrixinstitute.org www.matrixinstitute.org www. uclaisap.org http://motivationalinterview.org Enhancing Motivation for Change in Substance Abuse Treatment TIP 35 JLObert@matrixinstitute.org www.matrixinstitute.org www. uclaisap.org http://motivationalinterview.org Enhancing Motivation for Change in Substance Abuse Treatment TIP 35 http://motivationalinterview.org