Alison Bell Medicine in Addictions Conference

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1 Alison Bell Medicine in Addictions Conference 2013

2 Motivational Interviewing

3 Are we Dancing or Wrestling?

4 Definition of Motivational Interviewing Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is 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.

5 A Useful Point to Note: Some Things Work for Some People Some of the Time in Some Situations on Some Days

6 Motivational Interviewing Evidence Extensive evidence of effectiveness of motivational interviewing including: Alcohol and drug treatment HIV risk reduction Mental health; comorbidity Medication adherence Health behaviour change See website: motivationalinterview.org

7 Exercise # 1 Work with one other person One will be the speaker One will be a helper Switch roles when I tell you to reverse

8 Speaker s Topic Something about yourself that you: Want to change Need to change Should change Have been thinking about changing But you haven t changed yet

9 Helper s Task Find out what the person wants to change Explain why the person should make this change Give at least 3 specific benefits that would result from making the change Tell the person how they could make the change Emphasise how important it is to change Persuade the person to do it If you meet with resistance repeat the above! (PS: this is NOT motivational interviewing)

10 Persuasion: What goes wrong?

11 Conflicting thoughts and feelings towards someone or something Ambivalence

12 The Righting Reflex Usually comes from the heart, good intentions, the desire to fix things But Often leads to resistance, polarising of positions

13 When Worlds Collide Righting Reflex: persuader has all the good lines Ambivalent person has all the yes, but arguments Problem is I learn what I believe as I hear myself speak

14 Initial Aim Minimise the language of defence and maximise the language of possibility and change

15 A Continuum of Styles

16 Exercise # 2 Speaker: Same Topic Something about yourself that you: Want to change Need to change Should change Have been thinking about changing But you haven t changed yet

17 Listener Role Exercise # 2 Listen carefully with a goal of understanding the dilemma Give no advice Use reflection or silence Give a short summary of the speaker s motivation for change Ask: So what do you think you will do?

18 Fundamental Processes 1. Engaging 2. Focusing 3. Evoking 4. Planning

19 4 Processes Somewhat Linear Engaging necessarily comes first Focusing (identifying a change goal) is a pre-requisite for Evoking Planning is logically a later step

20 NB Engaging skills used throughout MI Focusing is not a one-time event; refocusing is needed, and focus may change Evoking can begin early Testing the water on planning may indicate a need for more of the above

21 Empathy Research in addiction context shows counsellors who show high levels of empathic skills have clients who are: Less resistant More likely to stay in treatment More likely to change Less likely to relapse Single best predictor of higher success rate

22 MI Framework Spirit: Principles Microskills: OARS Change Talk: DARN Commitment Talk: CATs

23 Motivational Interviewing Spirit Autonomy/Acceptance (Guiding not leading) Collaboration (Dancing not Wrestling) Evocation (Elicit change talk) Compassion

24 Elicit Change Talk Directive element of motivational interviewing Ask evocative questions Use importance and confidence questions/rulers Looking back or looking forward Exploring values Exploring pros and cons of change and staying same (NB: focus on pros of change and cons of staying same)

25 Preparatory Change Talk Desire (want, like, wish ) Ability (can, could ) Reason (if then) Need (need, have to, got to )

26 Motivational Interviewing: Commitment Commitment (intention, decision, promise) Activation (willing, ready, preparing) Taking Steps

27 Evoking Change Talk Change talk is any speech that favours movement in direction of change (as opposed to sustain or resistance talk) Recognise change talk Evoke change talk Respond to change talk

28 Getting Moving - OARS Ask Open Questions Affirm Listen Reflectively Simple Amplified Double-sided Summarise

29 Guidelines with Questions Open the door, encourage client to talk Try to avoid 3 questions in a row Offer 2 reflections per question asked Think engagement rather than fact finding as initial task

30 Desire Want, Wish, Like How would you like for things to be different? What are you looking for from this program? How do you want your life to be different a year from now? What do you wish for?

31 Ability Can, Could, Able If you did decide to change, how could you do it? What do you think you might be able to do? How confident are you that you could... if you made up your mind? How likely are you to be able to...?

32 Reasons Specific reasons why. If... then... What are some of the reasons for making a change to your drinking? What s the downside of how things are now? What would make it worth your while to reduce your cannabis use? What might be the three best reasons for quitting smoking?

33 Need Express an urgency for change What needs to happen? How important is it for you to make a change to...? How serious or urgent does this feel to you?

34 Importance Ruler On a scale of 1-10, how important is it for you to make a change? Not at all important Extremely Important Why are you at a... and not 0 (or a lower number)? What would need to happen for the number to be higher?

35 Affirmations Include Commenting positively on an attribute It takes a lot of strength to talk about change A statement of appreciation I appreciate your making the effort to come here today A compliment I like the way you have thought this through An expression of hope, caring or support I can see this is a difficult decision for you and I appreciate how honest you are being

36 Summarise Collect material that has been offered So far you ve told me Link content with something discussed earlier That sounds a bit like what you told me about feeling lonely sometimes Transition to a new task Let me summarise what you ve told me so far and see if I have missed something important.

37 Fundamental Principle - Focusing 1. Engaging relational foundation 2. Focusing strategic direction Possible sources of focus: client context clinician

38 Focusing Scenarios Clear direction proceed to evoking Several options agenda mapping Unclear direction formulation Outcome of focusing may be: Single goal Set of goals prioritised Set of changes towards longer term goal

39 Affirmations Appreciate a strength or positive action Should be true and genuine Express positive regard and caring Strengthen working alliance Diminish defensiveness

40 Other Evoking Strategies Looking Back Looking Forward Exploring Goals and Values Querying Extremes Decisional balance (with a focus on negatives of status quo and positives of change)

41 Responding to Change Talk All EARS Elaborating give me an example, in what ways, Affirming commenting positively on the person s statement Reflecting - continuing Summarising collecting change statements

42 Eliciting and Strengthening Confidence Talk Evocative questions (scale 1 10) Reviewing past successes Personal strengths and supports Brainstorming options Agenda mapping Hypothetical change imagine

43 Recognising Readiness Diminished sustain talk Resolve Increased change talk Questions about change Envisioning Taking steps

44 Planning Process Time for planning process when: Sufficient engagement Clear shared goal Sufficient client motivation for the change Test the water

45 Giving Information and Advice Best if person asks for it first (beware of Advice tennis match!) Get permission Qualify honour autonomy Ask provide ask Offer several suggestions

46 Mobilising Change Talk Reflects resolution of ambivalence Predicts actual change Commitment (intention, decision, promise) Activation (willing, ready, preparing) Taking Steps Remember cats don t come until they are good and ready!

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