Presented byPresented by

Brett Engle, PhD, LCSWBrett Engle, PhD, LCSW

www.motivationalinterviewing.orgwww.motivationalinterviewing.org

Motivational Interviewing in SBIRT

• 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 MIRationale 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 MIEvidence-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: Evidence-Base for MI: Target Behaviors/OutcomesTarget 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)

• Collaboration/Partnership

• Acceptance

• Compassion

• Evocation

• 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

• Absolute worth

• Affirmation

• Accurate empathy

• Autonomy support

• Unconditional positive regard (Rogers)

• Dignity and worth of the person (NASW Code of

Ethics)

• Seek and acknowledge strengths, including change talk, resources, and values

• Building blocks

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

• Anticipating

• Experiencing

• Communicating

• 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

• 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.”

• 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

• Engaging

• Focusing

• Evoking

• Planning

• Meet where patient is

• Discord and sustain talk be prevalent

• Empathize

• Establish trust and rapport

• Verbally and non-verbally

• Focus and structure conversation on an identified target behavior

• Redirect discourse toward target behavior when necessary

• Discuss possible change rather than history

• Patient’s own ideas about change

• Change talk side of ambivalence

• Decision making

• Action steps and target behaviors prioritized

• Implementation intentions (Gollwitzer)

• Open questions

• Affirmations

• Reflections: Simple and complex

• Summaries

• 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

• Elicit– Ask for person’s interpretation, understanding, or response

PreparatoryPreparatory Change Change (and Sustain) Talk(and Sustain) Talk

Four KindsFour 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 . .)

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MobilizingMobilizing Change Change (and Sustain) Talk(and Sustain) Talk

reflects resolution of ambivalencereflects resolution of ambivalence

• COMMITMENT (intention, decision)

• ACTIVATION (ready, prepared, willing)

• TAKING STEPS

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Desire

Ability (Self-efficacy)

Reasons

Need

CommitmentActivationTaking Steps

Health behavior

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.

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 SlidesSupplemental Slides

12 Tasks in Learning MI12 Tasks in Learning MI

1. Understanding the spirit of MI2. Developing skill and comfort with reflective listening and the

client-centered OARS skills3. Identifying change goals/target behaviors4. Giving information in an MI adherent manner5. Recognizing change and sustain talk6. Evoking and reinforcing change talk7. Responding to, reinforcing, and strengthening change talk8. Responding to sustain talk and discord so as to not amplify it9. Developing hope and confidence 10. Timing and negotiating a change plan11. Strengthening commitment12. Flexibly integrating MI with other skills and practices

(Miller & Moyers, 2006; Miller & Rollnick, 2013)

DiscordDiscord

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

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• 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

• 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?

• 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?

Directing Guiding Following

• Parameters of the working relationship

• Exceptions to confidentiality

• The nonnegotiables

• Providing information

• Understanding and taking an interest in the other person

• Being curious and showing respect

• Super listening

• 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 What Good Listening Is Not Not ** (Roadblocks: Thomas Gordon)(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

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What Good Listening is What Good Listening is NotNot(Roadblocks, from Thomas Gordon)(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

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Hypothesized Relationship Among Hypothesized Relationship Among Process and Outcome Variables in MIProcess and Outcome Variables in MI

Behavior Change

Commitment to Behavior Change

Client Preparatory Change Talk & Diminished Resistance

Therapist Empathy & MI Spirit

Therapist Use of MI-Consistent Methods

Training in MI

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 change2. A way of tricking people into doing what you want them to do3. A specific technique (MI is a counseling method; no specific technique is essential)4. Decisional balance, equally exploring pros and cons of change5. Assessment feedback6. A form of cognitive-behavior therapy7. Just client-centered therapy8. Easy to learn9. What you were already doing10. A panacea for every clinical challenge

Evidence-Base for MI:Evidence-Base for MI:Effects across SamplesEffects 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)

(Lundahl et al., in press)

Reflections 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

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Forming ReflectionsForming Reflections

• 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

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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