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

3. 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

4. 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

5. 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

6. 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.”

7. 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.

8. 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.”

9. “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

10. “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.”

11. What is your understanding about motivation?

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

13. AMBIVALENCE!!

14. 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

15. 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

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

17. 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

18. 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

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

20. 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)

21. 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

22. 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.

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

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

25. 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?

26. Overriding Issues
Importance and Confidence

27. 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

28. 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”

29. 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”