Workshop on Motivational Interviewing and Substance Use Andrew Hamid and Allen Zweben Alumni Conference Columbia University School of Social Work April 27, 2018

Historical View of Motivation and Addiction Static “TRAIT” or disposition that a person either has or does not have (eg. addictive personality) Reflected in the degree to which client agrees with perspective of the counselor Agreement on goals of treatment

Contemporary View of Motivation and Addiction “STATE” (rather than trait) determined by multiple factors dynamic and fluctuating influenced by social interactions can be modified influenced by clinician style

Other Changes in Addiction Field Shift from simplistic models of addiction to “Bio-psycho-social” perspective Focus on client competencies and strengths Individualized and client centered treatment Shift away from labeling Use of empathy, not authority and power

E. Kurtz Not-God: A History of Alcoholics Anonymous -- Bill W, 1955, quoted in E. Kurtz Not-God: A History of Alcoholics Anonymous “We found that…drinkers would not take pressure in any form, excepting from John Barleycorn [alcohol] himself. They always had to be led, not pushed….We found we had to make haste slowly.”

Overview Motivation is a key to change. Motivation is multidimensional. Motivation is dynamic and fluctuating. Motivation is influenced by social interactions. Motivation can be modified. Motivation is influenced by the clinician's style. The clinician's task is to elicit and enhance motivation.

Slap hands on thighs when you hear change statements “I went for a walk when I got upset the other day.” “I’ve thought about smoking less, but I’ve been so upset lately.” “If I stop using I’ll be able to stay alive.” “I only drink as much as my girlfriend does when we are out.”

“I’d be unbearable to my family if I didn’t have a drink.” “If I stop drinking after work, I’ll have time and energy to do what I really want and enjoy.” “I’ve cut down on the number of days I drink.” “I’m staying away from places where I used to use drugs

“I can’t go on like this.” “I can quit when I want to.” “I need to get to see someone about this problem right away.” “I’m okay just the way I am.” “I can’t cope with my mother and ex-wife arguing.”

What is your understanding about motivation?

Motivation is on a continuum – different levels of readiness to change. There may be an acceptance of the problem but not the solution Explain

AMBIVALENCE!!

EXERCISE Choose a partner Determine who is counselor and who is client Client discusses something in his/her life that needs changing Counselor: Assess level of READINESS TO CHANGE on a scale of 1-10 (10 being highest - fully committed to 1 – no commitment at all) but do not let client know

To be discussed in the group. Counselor gives the client the rating and offers an explanation for the decision Client agrees or disagrees and explains

What are the processes and strategies that can be used to address the different levels of readiness to change?

MI Spirit Focus on client’s concerns Arguments for change are elicited from client Direction persuasion and confrontation are avoided Therapeutic relationship is partnership Express empathy through reflective listening

MI Spirit Create an atmosphere conducive of change Answers and resources lie within client Skillful reflective listening clarifies and amplifies the client’s experience / meaning Client choice

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

Using reflection strategically Not a passive process but highly selective Direction (to draw attention) Reinforcement (to strengthen, build up) Exaggeration (to elicit correction from client) Increase awareness (linking together disconnected pieces of information)

EXERCISE – Reflective Listening Dyads - Choose a counselor and client Client talks about a concern Therapist provides a response indicating an empathic understanding of the problem Client responds positively or negatively If negative, therapist continues until receives a positive response

MI General Principles The clinician practices motivational interviewing with the following general principles in mind: Express empathy through reflective listening Avoid argument and direct confrontation Adjust to client resistance (sustain talk) rather than opposing it via reflective listening Support self-efficacy (confidence) and optimism.

Basic Motivational Strategies Ask open ended questions Affirm Listen reflectively and summarize Elicit change talk – “What do you want to do? Options? Say more

Building Motivation for Change Engage the client Explore the chain of events Discover the client’s beliefs Build rapport

Establish Rapport Explore the chain of events that lead to help seeking via open-end questions What brought you here today? What happened that you are seeking treatment Explore the client’s view of the problem(s) How do you see your drinking? What do you like about cocaine? What are your concerns?

Overriding Issues Importance and Confidence

Responding to “sustain talk” Determine what is being communicated in the “sustain-talk” Identify the “positives” Respond with an affirmation or reflection Follow with a question

Responding to ‘sustain-talk” “I don’t see what I have to be here; this is a waste of my time” “I can quit anytime” “I thought wine was supposed to be good for your health” “I don’t drink first thing in the morning” “Everyone deserves a vice”

Responding to “Sustain talk” “It’s legal in Colorado” “I can quit on my own” “Everyone else drinks like me” “AA is for drunks and losers” “Cannabis is natural; it’s a herb” “You just try to make everyone out to be an alcoholic; that’s how you stay in business”