1. Motivational Interviewing in Action: Live Demonstration with Scott Caldwell, MA CSAC, member of the Motivational Interviewing Network of Trainers Wisconsin Public Psychiatry Network Teleconference January 5, 2012

2. 2 Outline for this teleconference: I.What is MI II.Demonstration with observer coding III.Debrief

3. 3 Motivational Interviewing Source: Miller & Rollnick (2002) First developed in 1983, MI is a collaborative and person- centered way of being with people. It involves a goal- oriented conversation about a particular behavior and draws upon a person’s own reasons and motivations for positive behavior change.

4. 4 One contribution of MI has been a change in thinking, a realization that enhancing motivation for change is an important part of the therapist’s job. Rather than waiting for sufficient suffering to render the person “ready” for treatment, or dismissing clients because they are “resistant to treatment,” it is possible to evoke motivation for change. That makes it possible to treat a broader ranger of people and to do so earlier than might otherwise occur. This is a point of view that is sorely needed in the field of mental health. (p. 327) Source: Arkowitz, Miller, Westra, & Rollnick (2008)

5. 5 What MI is NOT A technique or bag of tricks Just client-centered therapy Stages of Change Problem solving A panacea for tough clinical difficulties Easy to learn Source: Miller & Rollnick (2009)

6. 6 What is MI? 1.Clinician Spirit 2.Person-centered, empathetic listening 3.Target behavior 4.Attending to client Change Talk 5.OARS Skills

7. 7 1. Clinician Spirit (a way of being with people) Collaboration – developing a partnership that honors client knowledge, expertise, and experience; power sharing Evocation – resources and motivation for change reside in the client; motivation is enhanced by eliciting client ideas, goals, values Support autonomy – respect for client right to make informed choices; client is in charge and thus responsible for outcome; emphasis on client choice, control

8. 8 2. Empathetic listening Counselor accurate empathy is the single best predictor of behavior change Good reflective listening looks easy, but it’s a complex skill Involves careful listening with the goal of understanding the client’s meaning Make a guess about the meaning, then offer guess as a statement (not a question) Levels of Reflection: Simple, Complex

9. 9 Client statementReflection I can’t stand the side effects from this medication. You can’t tolerate it. I keep trying to feel better, but nothing seems to work. You’re staying hopeful. If I could just get out of bed in the morning, that would be a good start. Like the sunrise, getting up every day.

10. 10 3. Target behavior Drinking Drug use Mental health Family Showing up to group Medication adherence Self-harm Agenda Setting Fun

11. 11 4. Client Change Talk Any client speech around a target behavior which favors movement in the direction of change Types of change talk (DARN-C)

12. 12 DARN-C: DESIRE to change (want, like, wish) ABILITY to change (can, could) REASON to change (if… then) NEED to change (need, have to, got to) COMMITMENT to change (I will, I’m ready I’m going to)

13. 13 4. Client Change Talk Any client speech around the target behavior which favors movement in the direction of change Types of Change Talk (DARN-C) The skillful MI practitioner: 1) recognizes 2) proactively evokes, and 3) differentially responds to Change Talk

14. 14 5. Directive use of OARS Skills Open questions: elicit client change talk Affirmation: affirm change efforts Reflection: reinforce change talk Summarizing: collect client change talk statements (flowers); offer back in a summary (bouquet)

15. 15 Demonstration w/ observer coding HANDOUTS Observer Sheet MI Spirit Ratings Key MI Skills Count Description

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19. 19 Benchmarks of basic MI proficiency: Spirit global ratings ave. (1 - 5).........3.5 % Open questions of total questions..... 50% % of Complex reflections of total reflections40% Ratio of Reflections to Questions........ 1:1 MI Adherent behaviors................ 90% MI Non-adherent behaviors............ ≤10% Source: Moyers et al. (2009, p. 27)

20. How MI works: Path model MI Spirit OARS Change talk: Desire Ability Reasons Need Commitment Behavior Change Source: Miller & Rose (2009)

21. Client predictors: MI Spirit OARS Change talk: D A R N Commitment Behavior Change Source: Amrhein et al. (2003); Moyers et al. (2007) Variables that do not predict outcome: Clinical severity Voluntary vs. involuntary Socio-demographics Age, gender

22. Therapist predictors: MI Spirit OARS Change talk: Desire Ability Reasons Need Commitment Behavior Change Source: Gaume et al. (2008); Glynn & Moyers (2010); Moyers, Miller, & Hendrickson (2005) High levels of Spirit and Skills

23. 23 When MI is particularly useful… At the beginning of services With people who are uninterested or ambivalent about change With people who present as angry, resistant, or defiant Cross-culturally Integrated with other evidence- based treatments

24. 24 How do clinicians learn MI? Stay tuned… next MH Teleconference on January 19, 2012 “Advancing Practice in MI”

25. Thank you. Scott.Caldwell@wisconsin.gov

26. Presentation References Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L. (2003). Client commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology, 71, 862-878. Arkowitz, H., & Miller, W. R. (2008). Learning, applying, and extending motivational interviewing. In H. Arkowitz, H. A. Westra, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (pp. 1-25). New York: The Guilford Press. Arkowitz, H., Miller, W. R., Westra, H., & Rollnick, S. (2008). Conclusions and future directions. In H. Arkowitz, H. A. Westra, W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing in the treatment of psychological problems (pp. 324-342). New York: The Guilford Press. Gaume, J., Gmel, G., Faouzi, M., & Daeppen, J. B. (2008). Counselor skill influences outcomes of brief motivational interventions. Journal of Substance Abuse Treatment, 37, 151-159. Glynn, L. H., & Moyers, T. B. (2010). Chasing change talk: The clinician’s role in evoking client language about change. Journal of Substance Abuse Treatment, 39, 65-70. Moyers, T. B., Martin, T., Christopher, P. J., Houck, J. M., Tonigan, J. S., & Amrhein, P. C. (2007). Client language as a mediator of motivation efficacy: Where is the evidence? Alcoholism: Clinical and Experimental Research, 31(S3), 40S-47S.

27. Presentation References (cont.) Moyers, T. B., Martin, T., Manuel, J. K., Miller, W. R., & Ernst D. (2009). Revised global scales: Motivational Interviewing Treatment Integrity 3.1 (MITI 3.1). University of New Mexico: Center on Alcoholism, Substance Abuse and Addictions. Accessed from http://casaa.unm. edu/download/MITI3_1.pdf Moyers, T. B., Miller, W. R., & Hendrickson, S. M. (2005). How does motivational interviewing work? Therapist interpersonal skill predicts client involvement within motivational interviewing sessions. Journal of Consulting and Clinical Psychology, 73, 590-598. Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2 nd edition). New York: The Guilford Press. Miller, W. R., & Rollnick, S. (2009). Ten things that motivational interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129-140. Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527-537.