Director Health Behavior Research and Training Institute
The University of Texas at Austin
Kirk von Sternberg Ph.D.
Associate Director Health Behavior Research and Training Institute
School of Social Work
The University of Texas at Austin
2 Health Behavior Research and Training Institute
Specializes in the development and implementation of interventions using the Transtheoretical Model (TTM) and Motivational Interviewing (MI) and in the training and supervision of providers in the field who address behavior change on the front lines.
Our intervention research has targeted HIV and safer sexual practices prenatal health alcohol cocaine smoking STI testing and fetal alcohol spectrum disorder. The HBRT Institute has a history of providing training supervision and coaching on the TTM MI and evidence-based intervention and prevention approaches with a recent emphasis on teaching health care providers to use brief motivational interventions in medical settings. Collaborators include state federal and international governmental agencies.
HBRT A Brief History
University of Houston- Department of Psychology
University of Texas Medical School at Houston- Department of Family and Community Medicine
Director of Research
University of Texas Health Science Center at Houston School of Public Health (cross appt)
University of Texas-Austin School of Social Work
Professor Associate Dean for Research
Center for Social Work Research
Health Behavior Research and Training Institute
4 Stages of Change University of Texas Medical School at Houston 5 (No Transcript) 6 Motivational Interviewing Motivational Interviewing is a directive client-centered counseling style that enhances motivation for change by helping the client clarify and resolve ambivalence about behavior change. The Goal of Motivational Interviewing is to create and amplify discrepancy
between present behavior and broader goals. Create cognitive dissonance between where one is and where one wants to be 7 The Transtheoretical Model
Offers an integrative framework for understanding measuring and intervening in patients health behaviors
Clinicians assess clients readiness to change and enhance motivation through a series of techniques depending on the clients stage of readiness
8 Why Motivational Interviewing
Evidence-based gt120 clinical trials
Grounded in testable theory
With specifiable mechanisms of action
Generalizable across problem areas
Complementary to other treatment methods
Verifiable Is it being delivered properly
Can be delivered by non-specialists
9 What do we know
MI triggers reliable aggregate change across a range of target problems settings and providers
10 Motivational Interviewing Assumptions I
Motivation is a state of readiness to change
which may fluctuate from one time or situation
to another. This state can be influenced.
Motivation for change does not reside
solely within the client.
The counselors style is a powerful determinant
of client resistance and change. An empathic
style is more likely to bring out self-motivational
responses and less resistance from the client
11 Motivational Interviewing Assumptions II
People struggling with behavioral problems
often have fluctuating and conflicting motivations
for change also known as ambivalence.
Ambivalence is a normal part of considering and
making change and is NOT pathological
Each person has powerful potential for change.
The task of the counselor is to release that potential
and facilitate the natural change process that is
already inherent in the individual.
12 Stages of Change
Precontemplation- Not ready to change
Contemplation- Thinking about changing
Preparation- Preparing to change
Action- Actively changing
Maintenance- Continuing to support the change
Relapse- Slipping back to the previous behavior
13 Stages of Change 14 Working with Clients Who are Not Ready to Change 15 Components of MI Spirit
Autonomy Responsibility for change is left with the client hence there is respect for the individuals autonomy. The clients are always free to take our advice or not. When motivational interviewing is done properly it is the client rather than the counselor who presents the arguments for change.
Underlying the Spirit of Motivational Interviewing
Collaboration - In motivational interviewing the counselor does not assume an authoritarian role. The counselor seeks to create a positive atmosphere that is conducive to change.
Evocation - Consistent with a collaborative role the counselors tone is not one of imparting things such as wisdom or insight but rather eliciting finding these things within and drawing them out from the person.
18 Using OARS Micro-skills
Eliciting Change Talk
The idea in MI is to have the client present arguments for both sides in making changes. It is the interviewers task to facilitate the clients expression of such change talk. This is a process of shared decision-making not an attempt to manipulate or sculpt the clients will.
19 Eliciting Change Talk
D Desire for change
A Ability to change
R Reasons for change
N Need for Change
C Commitment to Change
20 The Flow of Change Talk MI Desire Ability Reasons Need Commitment Change 21 Therapists Influence Client Motivation
Expectations influence outcomes
Differences in drop-out rates
Differences in outcome rates
Simple actions decrease drop-out
Empathic therapists have better outcomes
22 Qualities of a Good Motivational Counselor
Respect for individual differences
Tolerance for disagreement and ambivalence
Patience with gradual approximations
Genuine caring and interest in
23 MI - Like Dancing
24 Eight Stages in Learning MI
1. The spirit of MI
2. OARS Client-centered counseling skills
3. Recognizing and reinforcing change talk
4. Eliciting and strengthening change talk
5. Rolling with resistance
6. Developing a change plan
7. Consolidating client commitment
8. Shifting flexibly between MI and other methods
Miller W. R. Moyers T. B. (in press). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions.
25 Importance RulerHow important is it to you to quit smokingIf 0 was not important and 10 was very important what number would you give yourself
26 Exploring Importance
Why are you at x and not y Or how did you get from x to y (always start with the higher number)
What would have to happen for it to become much more important for you to change
What would have to happen before you seriously considered changing
Why have you given yourself such a high score on importance
What would need to happen for your importance score to move up from x to y
What stops you moving up from x to y
What are the good things about your tobacco use
What are some of the less good things
What concerns do you have about your tobacco use
If you were to change what would it be like
Where does this leave you now
Use this when you want to ask about change in a neutral way)
29 Confidence RulerIf you decided right now to quit smoking how confident do you feel about succeeding with this If 0 was not confident and 10 was very confident what number would you give yourself
30 (No Transcript) 31 The Health Behavior Research and Training Institute
Motivational Interviewing Training and Coaching
The HBRT Institute specializes in the training and supervision or coaching of providers in the field who address behavior change on the front lines.
The organizations HBRT has worked with include
NIH (NIAAA NIDA NHLBI NIAID) and CDC
Harris County Hospital District
Family Medicine Residency programs in Georgia and Texas
CPS/Children and Families
Federal Bureau of Prisons
And many others
Our challenge at the HBRT Institute is to
Meet the specific training and supervision needs of our community providers
Help ensure sustained treatment fidelity
Facilitate wide-spread dissemination of evidence-based practices
Our system of training coaching
Is targeted to the individual needs of the community providers
Is practical and efficient.
Maximizes the productivity of the expert Institute Coaches
Bridges geographical and time barriers between the expert Coaches and professionals being trained
Utilizes available technologies (i.e. secure personal website) for training coaching
34 Implementing Evidence-Based Brief MI Intervention
The InSight SBIRT model was implemented in eight Harris County Hospital District (HCHD) locations including emergency departments community clinics and school-based clinics.
The role of HBRT included the development of the Specialist training as well as ongoing coaching to insure the treatment fidelity and sustainability in community medical settings.
35 Evidence-Based SBIRT Intervention
Project providers are trained to use a brief version of Motivational Interviewing (MI) tailored to the medical setting.
Brief Interventions (BI) consisting of one to five short motivational sessions
Brief Treatment (BT) one to twelve MI sessions to promote reduction and/or cessation of substance use. Sessions are adapted from a substance abuse treatment manual based on the Transtheoretical Models stages and processes of change (Velasquez Maurer Crouch DiClemente 2001)
36 Comprehensive Training System for Specialists
Motivational Interviewing training
InSight Specialists (social workers nurses masters level counselors licensed chemical dependency counselors) received a series of training workshops
Standardized Patient training
initial and booster trainings
Quarterly in-service trainings
37 Treatment Fidelity - Coaching
On-going support from highly skilled MI Coaches.
Sessions are digitally recorded
Coaches meet with Specialists monthly to
practice using role-plays
provide feedback from audiotape review
The Specialists proficiency with MI skills is evaluated quarterly by the Coaching team using the Motivational Interviewing Treatment Integrity Skill Coding System (MITI).
Coaching of Specialists is conducted by the on-site peer Specialist Coaches
Specialist Coaches receive ongoing support from Institute Coaches through
Web-based tape review
40 Sustaining the Coaching
Each New Specialist and Specialist Coach has a private secure web-site shared only with their assigned Institute Coach for session tape review and feedback.
41 Tailored Training and Coaching Models
Counseling Front-Line Professionals
Initial training MI Principles Skills Training Role Plays
Standardized Patient Training Practicing the principles and the skills
Coaching On-going coaching and feedback
Follow-up training Checking progress and training on advanced MI strategies
Initial training MI Principles
Initial training advanced strategies session coding and feedback training
Comprehensive training and monitoring procedures are required to sustain the integrity of an MI intervention.
The wide-spread transfer of a research-based brief MI intervention into a number of varied settings is feasible.
The training and coaching model can be adapted to any number of settings and behaviors
Professionals in medical and other community settings can influence patient outcomes resulting in significant health behavior change and corresponding cost-savings.
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