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 velasquez@mail.utexas.edu Kirk von Sternberg, Ph.D. Associate Director, Health Behavior Research and Training Institute School of Social Work vonsternberg@mail.utexas.edu

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.

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

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

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

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

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

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

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

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.

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

Stages of Change ACTION MAINTENANCE PREPARATION CONTEMPLATION RELAPSE & RECYCLE PRECONTEMPLATION

Working with Clients Who are Not Ready to Change

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.

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.

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.

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.

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

The Flow of Change Talk MI Desire Ability Reasons Need Commitment

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

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

MI - Like Dancing Not Wrestling

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.

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 ? 0 10

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?

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?

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)

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? 0 10

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

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

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

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.

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)

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

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).”

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 0 1 2 3 4 5 6 7 Comments: Number of Tapes Turned in ________ Number of tapes used for ratings ________ Number of Taping Agreement Forms: Agreed ______ Declined ______ Total ______

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

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.

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

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.