Effecting Change through the use of Motivational Interviewing

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Effecting Change through the use of
Motivational Interviewing

• Jeanne L. Obert, MFT, MSM
• Executive Director, Matrix Institute
• UCLA Integrated Substance Abuse Programs

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One Way of Thinking
The Stick

• Change is motivated by discomfort.
• If you can make people feel bad enough, they will
  change.
• People have to hit bottom to be ready
• Corollary People dont change because they
  havent suffered enough

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Assumptions in working with people who clearly
need to change
You better ____ or ________!
If the stick is big enough. There is no need for
a carrot.
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Assumptions in working with people who clearly
need to change

• People change only when they have to.
• If the consequences are negative enough,
• people will change to avoid them.

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BUT DO THEY ALWAYS ?
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Motivational Interviewing, 2nd Edition. Miller
and Rollnick

• We cant help wondering, why dont people change?
  You would think
• that having had a heart attack would be enough to
  persuade a man to quit smoking, change his diet,
  exercise more, and take his medication

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You would think..

• that hangovers, damaged relationships, an auto
  crash, and memory blackouts would be enough to
  convince a person
• to stop drinking

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You would think..

• that the very real threats of blindness,
  amputations and other complications from diabetes
  would be enough to motivate weight loss and
  glycemic control

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You would think..

• that time spent in the dehumanizing privations of
  prison would dissuade people from re-offending

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AND YET

• Addictive behaviors persist despite overwhelming
  evidence of their destructiveness.

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What has occurred

• The field of addictions has provided a natural
  arena to study the process of change.
• What causes change to occur?
• How does the process unfold?
• Is it possible to push the river?
• What is the best way to do that?

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Another Way of Thinking
The Carrot

• People are ambivalent about change
• AMBIVALENCE is the key issue to be resolved
  for change to occur.
• Lack of motivation can be viewed as
• unresolved ambivalence.

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Ambivalent people may not respond in predictable
ways.

• Increasing the negative consequences (using the
  stick) does not always decrease the
  attractiveness of the behavior.
• It can sometimes exacerbate it rather than
  diminish it.

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The Theory of Psychological Reactance(one
possible explanation)

• This theory predicts an increase in the rate and
  attractiveness of a behavior IF the person
  perceives a challenge or infringement to his or
  her personal freedom.

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What facilitates change
The Carrot

• Constructive behavior change comes from
  connecting with something valued, cherished and
  important
• Intrinsic motivation for change comes out of an
  accepting, empowering, safe atmosphere where the
  painful present can be challenged

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The Process of Change

• Positive change often occurs without formal
  treatment.
• Treatment can be viewed as facilitating what is a
  natural process of change.

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Most Change Happens Early

• A little counseling can lead to significant
  change.
• Dozens of studies from many different countries
  document the effectiveness of brief interventions
  for many problems.

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Perceived Efficacy

• People who believe that they are likely to change
  do so. People whose counselors believe that they
  are likely to change do so. Those who are told
  that they are not expected to improve or who do
  not believe they will improve indeed do not.
• Beliefs about possibility of change become
  self-fulfilling prophecies. (Waiting list
  effects in control groups.)

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Beyond the Initial Sessionin Drug Abuse Treatment

• What factors influence whether
• a patient stays in treatment and
• does well following treatment?
• Factor that seems to make the biggest difference
  is the professional to whom the patient is
  assigned.

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Back to Where we Started

• Ideal atmosphere for change within the
  therapeutic relationship (Carl Rogers, 1959)
• Accurate empathy
• Non-possessive warmth
• Genuineness

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Some things weve learned

• Caregiver empathy can be a significant
  determinant of persons response to treatment.
• Directive, confrontational counseling
• styles increase patient/client resistance.
• Empathic counseling styles facilitate change.

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More things weve learned

• Level of MOTIVATION is often a good predictor of
  outcome.
• MOTIVATION can be influenced by naturally
  occurring factors and by specific interventions.

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What Causes a Person to be Judged Motivated

• The person agrees with us
• Is willing to comply with our recommendations
  and treatment prescriptions
• States desire for help
• Shows distress, acknowledges helplessness
• Has a successful outcome

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Definition of Motivation
The probability that a person will enter into,
continue, and comply with change-directed
behavior
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Motivational Interviewing
Elicit behavior change
Respect autonomy
A patient-centered directive method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence.

Tolerate patient ambivalence
Explore consequences
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Stages of ChangeProchaska DiClemente
Precontemplation
Contemplation
Maintenance
Preparation
Action
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What Research Tells Usabout Patients with C-O
Disorders

• Patients are often demoralized and unwilling
  to consider alcohol and drug abstinence (or
  manage their dual disorders ) due to
• Severe and disabling symptoms
• Frequent failed treatment episodes
• Poor functional adjustments

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What Research Tells Usabout Patients with C-O
Disorders

• Extensive literature references the low
  motivation for change in this population
• Emphasis has been on primary importance of
  engagement and motivational enhancement strategies

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Treatment Enhancements for C-ODisordered Patients

• Necessary because
• These patients are notorious for treatment
  noncompliance
• Noncompliance can lead to adverse consequences
  such as poor outcomes, violent behavior,
  increased rates of re-hospitalization and
  utilization of emergency services and jails

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A Three Part Process
Taking Medications
Staying Clean and Sober
Participating in Dual Diagnosis Specialty Program
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Precontemplation StageNot yet considering change
or is unwilling or unable to change

• Offer factual information.
• Explore the meaning of events that brought the
  person in and the results of previous efforts
• Explore pros and cons of targeted behaviors

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Contemplation StageSees possibility of change
but is ambivalent and uncertain

• Talk about the persons sense of self-efficacy
  and expectations regarding what the change will
  entail.
• Summarize self-motivational statements.
• Continue exploration of pros and cons.

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Determination StageCommitted to making change
but is still considering what to do.

• Offer a menu of options for change or treatment
• Negotiate a change (treatment) plan and behavior
  contract

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Determination StageCommitted to making change
but is still considering what to do.

• Identify and lower barriers to change
• Help person enlist social support
• Encourage person to publicly announce plans to
  change

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Action StageTaking steps to change but hasnt
reached a stable state

• Support a realistic view of change through small
  steps.
• Help person identify high-risk situations and
  develop appropriate coping strategies.

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Action StageTaking steps to change but hasnt
reached a stable state

• Assist person in finding new reinforcers of
  positive change.
• Help access family and social support.

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Maintenance StageHas achieved goals and is
working to maintain them.

• Help person identify and try alternative
  behaviors (drug-free sources of pleasure)
• Maintain supportive contact

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Maintenance StageHas achieved goals and is
working to maintain them.

• Encourage person to develop fire-escape plan
• Work to set new short and long term goals.

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RecurrenceHas experienced a recurrence of
symptoms and must cope with CONSEQUENCES and
DECIDE WHAT TO DO NEXT

• Explore with person the meaning and reality of
  recurrence as a learning opportunity.
• Explain Stages of Change and encourage him/her to
  stay in the process.

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RecurrenceHas experienced a recurrence of
symptoms and must cope with CONSEQUENCES and
DECIDE WHAT TO DO NEXT

• Help person find alternative coping strategies.
• Maintain supportive contact.

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Four Principles ofMotivational Interviewing
1. Express empathy 2. Develop discrepancy 3. Avoi
d argumentation 4. Support self-efficacy
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Express Empathy

• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Ambivalence is normal

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Motivational InterviewingIntervention
Elicit Pros and Cons of Target Behavior
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Develop DiscrepancyReady, Willing and Able

• Discrepancy between present behaviors and
  important goals or values motivates change
• Awareness of consequences is important
• Goal is to have the PERSON present reasons for
  change

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Motivational InterviewingIntervention
Facilitate discussion of lifestyle satisfaction
(compared to that once envisioned)
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3. Avoid Argumentation

• Resistance is signal to change strategies
• Labeling is unnecessary
• Shift perceptions
• Peoples attitudes shaped by their words, not
  yours

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Motivational InterviewingInterventions
Elicit individuals stated concerns (rather than
stating yours) Emphasize and reflect areas of
greatest concern and discrepancy
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Support Self-EfficacyReady, Willing and Able

• Belief that change is possible is important
  motivator
• Person is responsible for choosing and carrying
  out actions to change
• There is hope in the range of alternative
  approaches available

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Motivational InterviewingIntervention
Elicit and support realistic intended behavior
change
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Building MotivationOARS

• Open-ended questioning
• Affirming
• Reflective listening
• Summarizing

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Open-ended Questions

• An open-ended question is one with more than a
  yes or no response
• Helps person elaborate own view of the problem
  and brainstorm possible solutions

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Affirmations

• Focused on achievements of individual
• Intended to
• Support persons persistence
• Encourage continued efforts
• Assist person in seeing positives
• Support individuals proven strengths

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Reflective Listening Key-concepts

• Listen to both what the person says and to what
  the person means
• Check out assumptions
• Create an environment of empathy (nonjudgmental)
• You do not have to agree
• Be aware of intonation (statement, not question)

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SUMMARIZING

• Summaries capture both sides of the ambivalence
• (You say that ___________ but you also
  mentioned that ________________.)
• Summaries also prompt clarification and further
  elaboration from the person.

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Change Talk

• Recognizing the problem
• Expressing concern
• Stating intention to change
• Being optimistic about change

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Providing Feedback

• Elicit (ask for permission)
• Give feedback or advice
• Elicit again (the persons view of how the advice
  will work for him/her)

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Signs of Readiness to Change

• Less resistance
• Fewer questions about the
  problems
• More questions about change
• Self-motivational statements
• Resolve
• Looking ahead
• Experimenting with change

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You are using MI if you

• Talk less than your client does
• On average, reflect twice for each question
• Reflect with complex reflections more than half
  the time
• Ask mostly open ended questions
• Avoid getting ahead of your clients stage of
  readiness (warning, confronting, giving unwelcome
  advice, taking good side of the argument

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JLObert_at_matrixinstitute.org
www.matrixinstitute.org www. uclaisap.orghttp/
/motivationalinterview.orgEnhancing Motivation
for Change in Substance Abuse TreatmentTIP 35