Theories of Change Brentwood Hospital 4/23/14

Agenda Intro: Getting this into Context Description of Motivational Interviewing Techniques: Eliciting change talk Identifying readiness to change I CAN summaries

Context Where are we? You are here.

Substance Use Stats 1) 17.6 million (1 in 12 adults) have an alcohol disorder 48 million (12 years old +) misuse prescription drugs – 20% of population 23.2 million needed treatment for drug or alcohol use- 9.4 % of us population But only 2.4 million got treatment (10% of those need) NIH

Evolution of Treatment Approaches Old School Break’em down and Build’em up. Evidence Based Client-centered Cognitive-Behavioral Family Therapies Motivational Interviewing . Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. SAMSHA recommends Cochrane says yeah, sorta NICE and WHO recommends National Institute for Health and Clinical Excellence (NICE). Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Feb. 54 p. (Clinical guideline; no. 115). 

Getting Motivated Overview of MI

Your Challenge is . . . Lose weight Eat healthy Exercise Stop smoking Kick that heroin habit once and for all! Write down a behavior that you’ve tried to stop or start. As I go through this ask yourself how you would react to the principles and techniques

History of Motivational Approaches Motivational Interviewing Transtheoretical Model of the Stages of Change Mostly Theoretical Prochaska & DiClemente Mostly Application Miller & Rollnick Both have been called Motivation Enhancement Therapy

Stages of Change Pre-contemplation Contemplation Preparation Action Maintenance Motivational Interviewing Pre: unwilling, unable, resistant Cont: recognizes need, but ambivalent Prep: committed to change but is thinking about how Action: making changes Maint: working to keep gains

MI Spirit MI Principles Change Talk OARS Resist righting reflex Evocation MI Spirit Change Talk Autonomy Collaboration Resist righting reflex Understand motivation Listen Empower MI Principles OARS Open-ended Questions Affirmation Reflective Listening Summaries Philosophy > Principles > Skills > Techniques Help clients articulate reasons for change.

MI Spirit & Principles Resist righting reflex Understand motivation Listen Empower Autonomy Collaboration Evocation The spirit of respecting the clients right to make their own decisions, wanting to work with them by asking questions to draw out their opinion informs the principles Ev-oh-kay-tion

OARS Skills & Change Talk Open Questions Affirmation Reflective Listening Summaries Eliciting change talk.

What NOT to Do! Convincing clients that they have a problem Arguing for benefits of change Telling clients how to change Warning them of consequences of not changing Think of your change challenge- how would you react to these? Would it work?

Practice Everything so Far 1 Practice Everything so Far Upset Client: They told me I have to make 90 AA meetings in 90 days! That is just not going to happen- I can’t even sit through one meeting. Response: Oh come on, its not that bad. Don’t you want to get better?

2 Another one Client: So my family has this “get together” and they all sit around and tell me how I am an alcoholic. Like none of them ever gets drunk. Response: If it looks like a duck and quacks like a duck its probably a duck. All those people can’t be wrong. You’re probably in denial, don’t you think?

Eliciting Change Talk

Change Talk Represents statements about change Linked to a specific behavior or goal Comes from the client Refers to present situation

Continuum of Change I wish things were different Desire I know how to change Ability It would be great if I changed Reason I really need to change Need I am going to change Commitment/Taking Steps

Evocative Questions 1 In what ways does this concern you? How would you like things to be different? How would things be better if you changed?

2 Elaboration Tell me about a time you . . . (engaged in maladaptive behavior) What does it look like when you . . . . Tell me about a time before you . . .

3 Using Extremes Worst outcome vs. best outcome What concerns you the most? What is the worst that could happen? What do you hope for the most? What would a perfect outcome be?

4 Looking Back Do you remember a time when things were going well? What has changed? What did you want to do when you graduated from high school? What is the difference between you now and you twenty years ago?

5 Looking Forward If nothing changes, what do you see happening in 5 years? If you decide to change, what will it be like? What are your hopes for the near future?

6 Exploring Goals Use value card sort What are some things you regard as important? How does drinking fit in with that? What sorts of things do you want to accomplish in your life? (Miller, Baca, Matthews, Wilbourne, 2001)

7 Use Feedback Your scores on the MoCA (or MSE) indicate that you have moderate deficits in problem solving and memory. How does that fit with your own experience?

8 Readiness Rulers On a scale of 1-10, how confident* are you – if you made a decision to change – that you could change, when 1=not at all confident and 10= extremely confident? What led you to choose 6 rather than a 3? What would it take to move from a 6 to a 7 or 8? * or important

Your Turn Which of the previous techniques would work best (if at all) with your change challenge? How do you feel when thinking about your challenge?

Which would you use? Evocative Questions Elaboration Using Extremes Looking Back/Forward Exploring Goals Use Feedback Readiness Rulers

Identifying Readiness

Signs of Readiness Decreased resistance Decreased discussion Resolve Change talk Questions about change Envisioning Experimenting Decreased resistance. The wind seems to have gone out of the sails of resistance. Dissonance in the counseling relationship diminishes, and resistance decreases.   Decreased discussion about the problem. The client seems to have talked enough about the area of concern. If the client has been asking questions about the problem area, these stop. There is a feeling of at least partial completion, of or for waiting to take the next step. Resolve. The client appears to have reached some resolution and may seem more peaceful, relaxed, calm, unburdened, or settled. This can also have a tone of loss, or resignation. Change talk. When resistance is reduced, change talk increases, and clients make direct statements about a desire to change, the ability to change, the reasons or benefits of change, and the need to change (the disadvantages of the status quo). They may also make statements of intention to change. Questions about change. Clients may begin to ask what they could do about the problem, how people change once they decide to, and the like. Envisioning. The client talks about how life might be after a change. This can be mistaken for resistance; that is, looking ahead to change often causes a person to anticipate difficulties if a change were made. Of course, the client may also envision positive outcomes of change. Experimenting. The client may have begun experimenting with possible change actions since the last session.

Identifying Readiness 1 Identifying Readiness So, what do other people say about this? I just can’t believe that people just cave in when they hear recommendations sending them to a halfway house. Signs? Your reasoning:

Identifying Readiness 2 Identifying Readiness I agree it would be good to make some different choices that have less risk, but I also like to have fun with my friends. I have too much fun with them. Signs? Your reasoning:

Identifying Readiness 3 Identifying Readiness You don't understand. These guys aren't going to take "No, thanks" for an answer. They're going to hound me. I've got to come back with something stronger. Signs? Your reasoning:

Dealing with Ambivalence

The ‘I CAN’ Strategy Indicate this is a summary, and include Change talk, Ambivalence, and then ask about the Next step. Elements Miller and Rollnick (2002) suggest: A statement indicating that you are pulling together what the client has said. A summary of the client's perceptions of the issue, including any reasons or need for change noted by the client. A summary of the client's ambivalence, including the benefits of the status quo. Objective evidence relevant to the importance of change. A restatement of desire, ability, and commitment to change. Your assessment of the client's situation, especially when it matches the client's concern.

Ambivalence Strategies: ICAN 1 Ambivalence Strategies: ICAN “I still think weed is not as bad as people say, at least its not like cocaine. Maybe smoking has affected my grades, I don’t know. I’ve been thinking that maybe I should lay off for the rest of the semester or until I get my grades up. But weed really helps me relax and I need that." So I’m hearing you say that weed really helps you relax but that it has been affecting your grades. So do you think you’d like to do next?

Ambivalence Strategies: ICAN 2 Ambivalence Strategies: ICAN "I didn't like the way I felt on the Suboxone. There were just too many side effects. So, I stopped. But I think I need to do something. Nothing feels good. I'm always anxious. I can never get comfortable. I’m thinking that eventually I’ll start using again. That's where I'm at now.”

Ambivalence Strategies: ICAN 3 Ambivalence Strategies: ICAN “When I first got the DWI I figured the cop was just a jerk- I hadn’t even had that much to drink. And then I went to look at my car that was impounded and I thought- how did I survive that? The thing was completely smashed in. I know I need to stop drinking but I just don’t know if I need inpatient treatment. Maybe I can do this on my own."

Continuing on as Before The Decision Matrix Continuing on as Before Making a Change Benefits Costs Helps me relax Feel like I fit in Don’t worry about the bills Love the buzz I get Legal Trouble  Can’ see my kids – wife won’t let me  Paying for my attorney and court costs  People don’t trust me Won’t have a way to relax  What about my friends?  Life will be boring Family would trust me again  Marriage would go better  Better at my job More Money  Get off probation sooner Now see if you can complete this matrix on your own challenge

Application to Other Areas Medication adherence in mental health Diabetes management Eating disorders Obsessive Compulsive Disorder Suicidal Ideation

Discussion Will you use this in your practice? Why or Why not? What population do you think will benefit the most? The least? If interested, what are your plans to learn more?

Resources www.robinsteed.pbworks.com www.motivationalinterview.org Worksheets, training materials http://www.integration.samhsa.gov/clinical-practice/motivational-interviewing Full text articles, webinars, SAMHSA TIPs, training manuals www.researchgate.net/publication/231081405_Motivational_Interviewing_and _the_Stages_of_Change/file/9fcfd50b5f8c5af70e.pdf#page=305 Full text of Motivational interviewing: Preparing people for change (2nd ed.).

References Miller, W.R., ’de Baca, J. C Matthews, D.B. Wilbourne, P.L (2001). Personal Values Card Sort, University of New Mexico. Available at http://www.motivationalinterviewing.org/content/personal-values-card-sort Miller, W. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New York: Guilford Press. Full text available: www.researchgate.net/publication/231081405_Motivational_Interviewing_and_the_Stages_of_Change/file/9fcfd 50b5f8c5af70e.pdf#page=305 National Institute for Health and Clinical Excellence (NICE). Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Feb. 54 p. (Clinical guideline; no. 115).  Rosengren, D. (2009). Building motivational interviewing skills. New York: Guilford Press. Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. (2011). Motivational interviewing for substance abuse. Cochrane Database of Systematic Reviews, Issue 5, Art. No.: CD008063. DOI: 10.1002/14651858.CD008063.pub2. Substance Abuse and Mental Health Services Administration (2010). Getting started with evidence-based practices: Integrated treatment for co-occurring disorders. Evidence-Based Practice Series, Publication Id: SMA08-4367. www.motivationalinterview.org