integrated behavioral health interventions for substance use core components of motivational interviewing Week 3

core MI components relational partnership empathy technical cultivating change talk softening sustain talk

D – Desire A – Ability N – Needs C – Commitment R – Reasons Steps DANCR Steps D – Desire A – Ability N – Needs C – Commitment R – Reasons Steps mobilizing change talk

core components of MI O-open-ended questions A-affirmations R-reflections S-summaries

open vs. closed questions closed questions = those that can be answered “yes,” “no,” or in a few words Ex: How much do you drink each night? Ex: What is your drug of choice? Ex: How old are you? open questions = those that pull for a longer answer Ex: Tell me about your evening routine. Ex: What is your family like? Ex: Tell me about your drinking.

leave the person waiting for the next question the impact of closed-ended questions leave the person waiting for the next question feel more like an interrogation don’t expand the conversation if you don’t ask the right question, you might miss something

affirmations praising or affirming the person support autonomy & empathy build the therapeutic relationship examples: “You’ve been working really hard to cut back.” “I realize it was challenging to get here; I respect that you are dedicated to following through on your obligations.” “You feel like you have a ways to go, but you’ve come a long way thus far.”

simple reflections - defined responding to resistance with non-resistance acknowledge and validate emphasize change talk encourage more change talk - person opens up enhance collaboration, trust, and rapport clarifies points of confusion

simple reflections (cont’d) Patient says: “My wife says she’s going to leave me if I don’t quit drinking.” DBH says: “If you don’t make some changes you may lose your family.”

complex reflections

complex reflections Patient says: “I’ve been smoking for a long time.” DBH says: “It’s become a part of who you are now, but you don’t want it to be.”

complex reflections Patient says: “I guess I’ve thought about whether or not my drinking is hurting my efforts to get control of my diabetes.” DBH says: “You’re starting to think this could be the missing link.”

double-sided reflections to explore ambivalence “So on the one hand you...but on the other you want…” work off of previously supplied information end on the change talk

double-sided reflections Patient says: “I know I need to quit smoking for my health, but it’s so hard to stop.” DBH says: “So on the one hand you are worried about withdrawal from nicotine, but on the other hand you don’t want to die from smoking.”

ruined reflections ruined reflections meant to be a reflection, however, inflection at end sounds like question example: “You’re seeing that your drinking is having some real consequences now, right?”

empathy Putting yourself in the patient’s “shoes” through reflective listening.

We want twice as many reflections as questions in an MI style

We want half of our reflections to be complex versus simple reflections

summaries & key questions summarize key points (snippets of change talk) from the conversation (this is akin to a long reflection) use the summary to direct the session toward the change goal or transition end with a key question (open) that evokes change talk and moves the person into a planning phase example: “So you started out just kind of drinking in the evenings to relax, after a stressful day at work. As your work stress started to increase you found yourself drinking a little more than you’d planned each night. Now you have some mornings where you’re a little hungover in the mornings and your co-workers are starting to take notice. I’m curious…what are some other ways you’ve managed work stress in the past?”

providing information how to provide information in an MI-consistent fashion: Elicit: ask permission to provide the information e.g.: “There’s something I’ve seen that seems to work for some of my patients. Is that something you’d like to hear about?” Provide: provide the information Elicit: elicit their response to the information e.g.: “Is that something you think might work for you? (or) How does that fit for you? (or) What do you make of that?”

4 strategies for decreasing sustain talk ask about extreme situations: “What if this problem continued on the current trajectory? What would things look like a few years from now?” 2) inquire about the past “How have you been successful making changes in the past? Can you think of something challenging you’ve overcome in the past?” 3) ask about the future “If you quit drinking, what do you think your life would look like 3 years from now?” 4) bring their values into the conversation