Presented by Brett Engle, PhD, LCSW www.motivationalinterviewing.org in SBIRT Presented by Brett Engle, PhD, LCSW www.motivationalinterviewing.org

Overview Rationale and evidence-base Target behaviors/change goals Spirit of MI Collaboration, acceptance, evocation Processes of MI and application Engaging, focusing, evoking, and planning Techniques of MI OARS Exchanging information using elicit-provide-elicit DARN-CAT change and sustain talk

Rationale for MI Brief and cost effective (Dennis et al., 2004) Versatile-intensity/duration, professions, combined treatments, settings (Lundahl et al., in press; Miller & Rose, 2009) Humanistic-facilitates relationships, rapport and disclosure (Miller & Rose, 2009) Consistent with SW ethics and values (Hohman, 2012) May be more effective with minorities (Hettema, Steele, & Miller, 2005) Established training tools and practices (Moyers et al., 2005; Madson & Lane, 2008)

Evidence-Base for MI About 200 clinical trials and 1000 peer reviewed articles involving MI (Miller & Rose, 2009) Average dose: 2 sessions/2 hours Effect size is often maintained or even increases through 1 year follow up when MI is added to beginning of treatment (Miller, 2005)

Evidence-Base for MI: Target Behaviors/Outcomes More likely to enter, stay in and complete treatment Participate in follow-up visits Adhere to glucose monitoring and improve glycemic control Increase exercise and fruit and vegetable intake Reduce stress and sodium intake Keep food diaries Weight loss http://www.nytimes.com/2010/10/26/health/26weight.html?_r=1&src=dayp Reduce unprotected sex and needle sharing Improve medication adherence Decrease alcohol and illicit drug use Quit smoking Fewer subsequent injuries and hospitalizations Rollnick, Miller, & Butler (2008)

MI Spirit Collaboration/Partnership Acceptance Compassion Evocation

Collaboration Interviewer functions as a partner or companion, collaborating with the client’s own expertise Dancing versus wrestling Avoiding the “expert trap” Non-judgmental Active collaborative conversation Joint decision-making process

Acceptance Absolute worth Affirmation Accurate empathy Autonomy support

Absolute Worth Unconditional positive regard (Rogers) Dignity and worth of the person (NASW Code of Ethics)

Affirmation Seek and acknowledge strengths, including change talk, resources, and values Building blocks

Accurate Empathy “to sense the person’s inner world of private personal meanings…” (Rogers, 1989, pp. 92-93) Anticipating Experiencing Communicating

Autonomy Support Responsibility : Resistance trade off People can and will make own decision Paradoxical nature of behavior change Support both self-determination and self-efficacy Detachment from outcomes

Compassion To benevolently seek and value the well-being of others To give priority to the person’s needs Never exploit Not necessarily to “suffer with.”

Evocation Elicit and activate person’s own resources, rationale and motivation for behavior change The person’s side of ambivalence that favors change Includes their goals, values, and aspirations that relate to target behavior

Four Processes/Methods and Flow of MI Engaging Focusing Evoking Planning

Engaging Meet where patient is Discord and sustain talk be prevalent Empathize Establish trust and rapport Verbally and non-verbally

Focusing Focus and structure conversation on an identified target behavior Redirect discourse toward target behavior when necessary Discuss possible change rather than history

Evoking Patient’s own ideas about change Change talk side of ambivalence

Planning Decision making Action steps and target behaviors prioritized Implementation intentions (Gollwitzer)

Techniques: OARS Open questions Affirmations Reflections: Simple and complex Summaries

Technique: Exchanging Information Elicit-Provide-Elicit Ask permission Clarify information needs and gaps “May I ask what you already know about…” Provide Prioritize Support autonomy Don’t prescribe the person’s response Ask for person’s interpretation, understanding, or response

Preparatory Change (and Sustain) Talk Four Kinds DARN DESIRE to change (want, like, wish . . ) ABILITY to change (can, could . . ) REASONS to change (if . . then) NEED to change (need, have to, got to . .)

Mobilizing Change (and Sustain) Talk reflects resolution of ambivalence COMMITMENT (intention, decision) ACTIVATION (ready, prepared, willing) TAKING STEPS

Commitment-Behavior Change Model in Groups: Participant Desire, Ability, Reasons, and Need (DARN) change talk mediate Commitment Language, which in turn mediates their impact on health behavior. Desire Ability (Self-efficacy) Reasons Need Commitment Activation Taking Steps Health behavior From “How Does Motivational Interviewing Work? What Client Talk Reveals,” by P. C. Amrhein, 2004, Journal of Cognitive Psychotherapy: An International Quarterly, 18, 4, p. 331. Copyright 2004 by the Springer Publishing Company. Adapted with permission.

Supplemental Slides

12 Tasks in Learning MI 1. Understanding the spirit of MI 2. Developing skill and comfort with reflective listening and the client-centered OARS skills 3. Identifying change goals/target behaviors 4. Giving information in an MI adherent manner 5. Recognizing change and sustain talk 6. Evoking and reinforcing change talk 7. Responding to, reinforcing, and strengthening change talk 8. Responding to sustain talk and discord so as to not amplify it 9. Developing hope and confidence 10. Timing and negotiating a change plan 11. Strengthening commitment 12. Flexibly integrating MI with other skills and practices (Miller & Moyers, 2006; Miller & Rollnick, 2013)

Discord Interpersonal behavior that reflects dissonance in the working relationship: Arguing, interrupting, discounting, or ignoring

Motivational Interviewing Defined Lay Definition: A collaborative conversation style for strengthening a person’s own motivation and commitment to change Used in many contexts by many different professional or paraprofessional people

Motivational Interviewing Defined Clinical Definition: A person-centered counseling style for addressing the common problem of ambivalence about change Why should I as a clinician learn MI? How would I use it?

Motivational Interviewing Defined Technical Definition: A collaborative, goal-oriented style of communication with particular attention to the language of change, designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion How does it work?

Continuum of Communication Styles Directing Guiding Following

Directing Parameters of the working relationship Exceptions to confidentiality The nonnegotiables Providing information

Following Understanding and taking an interest in the other person Being curious and showing respect Super listening

Guiding Focus and structure conversation on an identified target behavior Redirect discourse toward target behavior when necessary Discuss possible change rather than history Elicit/emphasize/reinforce change talk

What Good Listening Is Not * (Roadblocks: Thomas Gordon) Asking questions Agreeing, approving, or praising Advising, suggesting, providing solutions Arguing, persuading with logic, lecturing Analyzing or interpreting Assuring, sympathizing, or consoling

What Good Listening is Not (Roadblocks, from Thomas Gordon) Ordering, directing, or commanding Warning, cautioning, or threatening Moralizing, telling what they “should” do Disagreeing, judging, criticizing, or blaming Shaming, ridiculing, or labeling Withdrawing, distracting, humoring, or changing the subject

Hypothesized Relationship Among Process and Outcome Variables in MI Therapist Empathy & MI Spirit Client Preparatory Change Talk & Diminished Resistance Training in MI Behavior Change Therapist Use of MI-Consistent Methods Commitment to Behavior Change From Miller and Rose (2009) Toward a Theory of Motivational Interviewing., 64, p. 527-537. American Psychologist

Ten Things that MI is Not (Miller & Rollnick, 2008) 1. Based on the transtheoretical model of change 2. A way of tricking people into doing what you want them to do 3. A specific technique (MI is a counseling method; no specific technique is essential) 4. Decisional balance, equally exploring pros and cons of change 5. Assessment feedback 6. A form of cognitive-behavior therapy 7. Just client-centered therapy 8. Easy to learn 9. What you were already doing 10. A panacea for every clinical challenge

Evidence-Base for MI: Effects across Samples 25% no effect 50% small but meaningful effect 25% moderate to strong effect Average MI intervention: 99 minutes (Lundahl et al., in press) Brief MI in health care: 5-15 minutes (Martino et al., 2007)

Reflections * Forming Reflections Are statements rather than questions Make a guess about the client’s meaning (rather than asking) Yield more information and better understanding Often a question can be turned into a reflection

Forming Reflections X X X X A reflection states an hypothesis, makes a guess about what the person means Form a statement, not a question Think of your question: Do you mean that you . . . ? Cut the question words Do you mean that You . . Inflect your voice down at the end There’s no penalty for missing In general, a reflection should not be longer than the client’s statement. X X X X

Giving Information/Educating 59 Collaboration: Giving Information/Educating Neutral language “Folks have found…” “Others have benefited from…” “Doctors recommend…” Conditional words “Might consider” vs. “ought to,” “should” Avoid the “I” and “Y” words “I think…” “You should…” Gary S. Rose, Ph.D. grosephd@erols.com