2.  Use of client-centered MI style  MI strategies that can be integrated into the agency’s existing intake assessment process  Methods that can be used with diverse substance use problems  Skills for assisting clients in assessing their own substance use  Understanding the client’s perception and willingness to enter into a treatment process NIDA-SAMHSA Blending Initiative2

3. 3 MI strategies during 1 st 20 min MI strategies during last 20 min MI strategies during last 20 min Agency Intake or Assessment

4.  The NIDA Drug Abuse Treatment Clinical Trials Network designed the protocol  Designed as something that all outpatient community treatment providers could use  Researchers worked directly with MI experts and treatment providers on both development and implementation. NIDA-SAMHSA Blending Initiative4

5.  Average age: 32  Gender: 40% female  Race: 76% White  Marital Status: 21% married  Referral source: 32% referred by criminal justice system  Average years of education: 12  Primary drug problem: alcohol (48%) followed by marijuana, cocaine, stimulants NIDA-SAMHSA Blending Initiative5

6. 6 1. People receiving MI assessment completed more sessions in 4 weeks than those receiving standard intake.

7. NIDA-SAMHSA Blending Initiative7 2. MI retained more people in treatment at the 4 week point than standard assessment.

8. NIDA-SAMHSA Blending Initiative8 Research findings 3. For alcohol users only, there was a more pronounced difference in treatment sessions attended at 4 weeks that was maintained at the 84 day follow-up. Sessions Attended at 4 Weeks 5.1 3.3

9.  Positive outcomes depend on clients staying in treatment for adequate length of time  Adding MI at beginning of treatment increases client retention  The type of clinical supervision needed to maintain and improve MI skills is generally lacking NIDA-SAMHSA Blending Initiative9

10.  Focused clinical supervision  Audio taped MI Assessment sessions  Tape coding  Feedback, coaching and instruction for improving skills NIDA-SAMHSA Blending Initiative10

11.  It has a solid evidence-base  MI improves client engagement and retention  Using MIA:STEP:  Enhances clinical supervision  Builds counselor knowledge and proficiency in MI NIDA-SAMHSA Blending Initiative11

12.  Most trained clinicians do not use MI appropriately, effectively or consistently  MI is more difficult than clinicians expect  The key to successful implementation of MI is supervisory feedback and coaching NIDA-SAMHSA Blending Initiative12

13.  Introduce the idea of doing an MI assessment  Train counselors and supervisors  Provide ongoing supervision of MI  Train supervisors to use a simple tape rating system  Use an MI style of supervision NIDA-SAMHSA Blending Initiative13

14.  Time to learn and implement the protocol  Regular review and feedback on MI skills  Ongoing clinical supervision, including: - Training- Mentoring - Practice- Review of recorded interviews - Feedback- Development of learning plans  The cost of recorders and supplies NIDA-SAMHSA Blending Initiative14

15. 1. Briefing materials 2. Summary of the MI Assessment intervention 3. Results of the NIDA CTN Research 4. Teaching tools for enhancing and assessing MI skills 5. Interview rating guide and demonstration materials 6. Supervisor training curriculum NIDA-SAMHSA Blending Initiative15

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

17. Staying Clean and Sober Taking Medications Participating in Dual Diagnosis Specialty Program

19. Open-ended questioning Affirming Reflective listening Summarizing

20.  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

21.  Focused on achievements of individual  Intended to:  Support person’s persistence  Encourage continued efforts  Assist person in seeing positives  Support individual’s proven strengths

22. 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)

23.  Repeating – Repeating what was just said.  Rephrasing – Substituting a few words that may slightly change the emphasis.  Paraphrasing – Major restatement of what person said. Listener infers meaning of what was said. Can be thought of as continuing the thought.  Reflecting Feeling - Listener reflects not just the words, but the feeling or emotion underneath what the person is saying.

24. NIDA-SAMHSA Blending Initiative24 1. Simple Reflection (repeat) 2.Amplified Reflection (rephrasing and paraphrasing) 3.Double-Sided Reflection (rephrasing, paraphrasing and reflecting feeling)

25.  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.

26. 1. Express empathy 2.Develop discrepancy 3.Avoid argumentation 4.Support self-efficacy

27.  Acceptance facilitates change  Skillful reflective listening is fundamental  Ambivalence is normal

28.  Discrepancy between present drug use behaviors and important goals or values  Awareness of consequences is important (Use Pros and Cons)  Goal is to have the PERSON present reasons for change

29.  Resistance is signal to change strategies  Labeling is unnecessary  Shift perceptions  Peoples’ attitudes shaped by their words, not yours

30.  Belief that change is possible is important motivator  Counselor’s expectations become self-fulfilling  Person is responsible for choosing and carrying out actions to change  There is hope in the range of alternative approaches available

31.  DARN C – Statements that indicate:  D esire to make a change  A bility to make change  R easons for considering change  N eed (emotional) to change

32. NIDA-SAMHSA Blending Initiative32 Exercises for Eliciting Change Talk

33. PRO’S +’S GOOD THINGS Use Decisional Balance Exercise

34. NIDA-SAMHSA Blending Initiative34 Readiness for change involves both Importance and Confidence Readiness can be assessed through Basic Scaling Ruler Clinical Interview Inventories to Assess Readiness

35. NIDA-SAMHSA Blending Initiative35 1-------2-------3-------4-------5-------6-------7-------8-------9-------10 Importance Ruler Confidence Ruler 1—----2—----3—----4—----5—----6—----7—----8—----9—----10 Not at all Important Very Important Not at all Confident Very Confident (May be conducted on paper or verbally)

36. NIDA-SAMHSA Blending Initiative36 Pull for Change Talk with some of the following questions:  “What do you think you will do?”  “What does this mean about your (habit)?”  What do you think has to change?”  “What are some of your options?”  “What’s the next step for you?”  “What would be some of the good things about making a change?”  “Where does this leave you?”

37. NIDA-SAMHSA Blending Initiative37 URICA – University of Rhode Island Change Assessment Scale (SOC) (McCo9nnaughy, et al., 1989) SOCRATES – Stage of Change Readiness and Treatment Eagerness Scale (Miller & Tonigan, 1996) Mentioned in MIA- STEP Toolkit Alcohol Effects Questionnaire (AEQ). Alcohol Use Disorders Identification Test (AUDIT) Alcohol Expectancy Questionnaire all @ http://silk.nih.gov/silk/niaaa1/publication/instable.htm In Public Domain Alcohol and Drug Consequences Questionnaire (Cunninghom) Brief Situational Confidence Questionnaire (Sobel) Personal Feedback Report (Project Match, NiAAA) Readiness to Change Questionnaire (RCQ – TV) (Heather) Situational Confidence Questionnaire (SCQ-39) – Addiction Research Foundation Others listed in Appendix C of TIP 35

38. NIDA-SAMHSA Blending Initiative38 Complete a 15 hour MI skill-building workshop conducted by a MINT (Motivation Interviewing Network of Trainers) Trainer Have an interest in becoming a MI Supervisor Be in position with authority to supervise other staff members

39. NIDA-SAMHSA Blending Initiative39 MI Style and Spirit Fostering a Collaborative Atmosphere Open-ended Questions Affirmations Reflective Statements

40. NIDA-SAMHSA Blending Initiative40 Motivation to Change Developing Discrepancies Pros, Cons and Ambivalence Client-Centered Problem Discussion and Feedback Change Planning

41. NIDA-SAMHSA Blending Initiative41 Frequency and Extensiveness From 1 (not at all) to 7 (extensively) Skill Level From 9 (no at all) to 7 (excellent)

42. NIDA-SAMHSA Blending Initiative42 Frequency and Extensiveness Higher if you ask questions that invite client conversation as opposed to asking only yes/no response questions. Skill Level Higher if: 1. Questions are relevant to the clinician-client conversation. 2. Questions encourage greater client exploration and recognition of problem areas and motivation for change, without appearing to be judgmental or leading to the client. 3. Inquiries are simple and direct, thereby increasing the chance that the client clearly understands what the clinician is asking. 4. Usually, several open-ended questions do not occur in close succession. Rather, high quality open-ended questions typicaly are interspersed with reflections and ample client conversation to avoid the creation of a question- answer trap between the clinician and the client. 5. You pause after each question to give the client time to respond.

43. NIDA-SAMHSA Blending Initiative43 Skill Level Lower if: 1. Questions are poorly worded or timed to target an area not immediately relevant to the conversation and client concerns. 2. Questions often occur in close succession, giving the conversation a halting or mechanical tone. 3. Inquiries may compound several questions into one query making them harder for the client to understand and respond to. 4. Questions lead or steer the client. 5. Inquiries have a judgmental or sarcastic tone. 6. Pauses after each question are not sufficient to give the client time to contemplate and respond