Motivational Interviewing An Evidence-Based Tool for Drug Court

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Motivational InterviewingAn Evidence-Based
Tool for Drug Court

• Joe Lunievicz, BA, RYT
• Director Training Institute, NDRI, Inc.
• Executive Director, NDRI-USA, Inc.

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Agenda

• What is it?
• Evidence Base
• Techniques Used
• Practice

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Exercise in Pairs

• Write down on paper
• What are three things you value in life?
• What is one five-year goal you have?
• Discuss with your partner

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What Motivates your participants to move towards
graduation?What are their goals?What do they
value?How does present behavior get in the way?
Participants?
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Motivational Interviewing

• A directive, client-centered counseling style
  for eliciting behavior change by helping clients
  to explore and resolve ambivalence. It is a
  style of helping that uses a set of specific
  strategies.

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Motivational Interviewing (Cont.)

• Motivation- or presumed lack of it- is not
  viewed as a personality problem or character
  trait, but as a state of readiness for change
  that can be influenced by a helping relationship.
• Rollnick Miller, 1995

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After 30 years of Research Bill Miller Steve
Rollnick - Stockholm, June 2010 Presentation

• 200 randomized clinical trials Evidence Base
• 10 multisite clinical trails Evidence Base
• 1000 publications
• Dozens of books and videotapes MI 2 in 2002
• Several coding systems for quality assurance
• MIA-STEP to support MI supervisors
• Research on MI Training

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Evidence Base with

• 100,000 individuals
• Alcohol, crime, drugs, family/relationships,
  social functioning, trauma/injuries,
  treatment/recovery
• Age 18-25, 26-55, 55
• Male, female
• Caucasian, Asian, Black or African American,
  Hispanic or Latino
• Outpatient, school, community settings
• Urban, suburban

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Motivational Interviewing

• Is a brief intervention
• Developed to work with unmotivated drinkers
• Based on work by Rollnick and Miller 1991
• Useful for clients who are reluctant to change
  (ambivalence - contemplators)
• Draws on client-centered therapy, cognitive
  therapy change therapy
• Is non-confrontational
• Uses specific strategies/skills

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MI Basic Principles

• Expressing Empathy
• Developing Discrepancy
• Rolling with Resistance
• Supporting Self-Efficacy

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MI helps the client

• Enhance intrinsic motivational change
• Recognize the need to do something about the
  potential problem
• Resolve ambivalence
• Decide to change

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The Counselor

• Does not assume an authoritarian position
• Avoids conveying the message I have the answers
• Treats the client as an adult capable of making
  responsible decisions
• Treats the client as the expert on his or her
  own experience

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The Counselor Does Not

• Argue with client
• Impose a diagnostic label on client
• Tell client what they must do
• Seek to break down denial by direct
  confrontation
• Imply clients powerlessness

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Why use MI in Drug Court?

• Better Engagement
• More Information
• Better Assessments
• More Relevant Recommendations
• More Successful Outcomes

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MI Intervention vs. MI techniques

• Full intervention
• Or
• Individual techniques that make up the
  intervention

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Example Motivational Enhancement Therapy - NIDA

• Alcoholics, outpatient tx
• 7-8 hour assessment
• 4 sessions
• 12, structured feedback, future plans
  motivation for change
• 34, reinforce progress, encourage reassessment
  provide objective assessment of progress
• Significant other involved in session 1 or 2
• Breath alcohol readings
• 90 day timeframe

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MINT blog post Old

• Are you a smoker?
• Well, sort of, yes.
• How much do you smoke each day?
• A pack or two.
• The way youre coughing, I have to tell you, its
  going to get worse if you continue.
• Yes, I know but you see it helps with the stress.
  If you knew what I go through with the truck and
  long hauls. Its enough just to get through the
  day.
• But if you carry on like this you might lose even
  more time at work.
• Yeah. Im cutting back, you see.
• Well weve got some good aids to quitting if you
  are interested?
• Yes, thanks, sure. Ill give it some thought.

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MINT blog post New

• Would you mind if we talked about your smoking?
• Well, ok.
• How do you really feel about it?
• Im trying to cut back, but I cant say its easy
  with my job. You know its stressful driving a
  truck.
• Its not easy for you, yet youd like to smoke
  less.
• Oh, if I could, definitely. I know its not good
  for my lungs or this cough for a start.
• You can feel the effect for yourself and its not
  pleasant
• Thats right. But its such a stress reliever its
  hard to let go.
• Its difficult to imagine being without smoking.
• Yes, thats exactly right. You got me.
• I dont want to give you a lecture or hassle you
  about this, but Im wondering what would be
  helpful for you?
• I just dont know.
• Tell me. Deep down. How important is this for you
  right now?
• I feel sick and Im tired and this smoking wears
  me down.

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Paraphrasing/Reflection

• Pairs
• Cant respond until you have paraphrased
  accurately.
• Argue your point.

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MI Strategies

• OARS
• Open Ended Questions
• Affirming
• Reflection
• Summarizing

• Balance sheet
• Stages of change
• Using the importance Ruler
• Exploring goals and values
• Elicit Change Talk

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Questioning SkillsEffective vs. Ineffective
Questions

• Ineffective
• Too many questions
• Accusatory questions Why?
• Multiple questions
• Explanatory questions
• Closed questions

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Questioning SkillsEffective vs. Ineffective
Questions

• Effective
• Have specific objectives in mind
• State background for question
• Use language of the client
• Check out whether client is understanding
• Ask openly Who, What, When, Where How
• Use open-ended questions
• Paraphrase Reflect Summarize

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Open Ended Questions

• Who, what, where, when
• Tell me about
• How did you
• Redirect Now tell me about

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Open-ended Examples

• What worries you about your current situation?
• Tell me about difficulties have you had with your
  drug use?
• What do you think will happen if you dont
  change?
• How has your anger interfered with your life?
• What would your life be like 5 years from now?

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Affirm (but dont flatter)

• Strengths based technique
• Verbally supports or validates a participants
  thoughts, emotions, or actions
• Demonstrates Appreciation, Understanding,
  Support
• When you see a strength, notice it

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Affirmation Example

• 1. Participant arrives on time for his case
  management appointment.
• Youre punctual. That will be a big help in this
  program.
• 2. Participant I dont want to do anything more
  than I need to. I just want to finish the program
  and get on with my life.
• Determination is a good characteristic to have
  in treatment. It will help to keep you focused.

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Reflective Listening

• Rationale
• Conveys willingness to try to understand
• Serves as a perception check
• Clarifies feelings
• Leads to more exploration
• Demonstrates empathy

• Common Errors
• Not listening closely
• Limited feeling vocabulary
• Monotone vocal qualities
• Premature focus on problem solving

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Reflection

• Expressing Empathy
• So, what I hear you saying is
• Reflecting Conflict
• On the one handbut on the other hand
• So what youre saying isbut you are not able
  to
• Rolling with resistance
• You dont have to do anything you dont want
  to.

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Summarizing

• The set-up statement
• Let me see if I understand correctly
• Reflection, Reflection, Reflection
• Open ended Question
• What did I miss?
• What other concerns do you have?

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Practice Speaker

• Something about yourself that you
• Want to change
• Need to change
• Should change
• Have been thinking about changing
• but you havent changed yet.

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Practice Listener

• Listen carefully
• Ask these 4 questions
• Why would you want to make this change?
• How might you go about it in order to succeed?
• What are the three best reasons for you to do it?
• On a scale from 0 to 10, how important would you
  say that it is for you to make this change?
• Why are you a (?) and not a zero?
• Give a short summary/reflection of the speakers
  motivations for change.
• Ask So what do you think youll do? and just
  listen with interest.

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Resources

• NREPP SMAHSAs National Registry of
  Evidence-based programs and practices
• MI Bill Miller email wrmiller_at_unm.edu
• MI http//www.motivationalinterviewing.org