Motivational Interviewing

1
Motivational Interviewing

• Mary Marden Velasquez Ph.D.
• Associate Dean for Research
• Director Center for Social Work Research
• Director Health Behavior Research and Training
  Institute
• The University of Texas at Austin
• velasquez_at_mail.utexas.edu
• Kirk von Sternberg Ph.D.
• Associate Director Health Behavior Research and
  Training Institute
• School of Social Work
• The University of Texas at Austin
• vonsternberg_at_mail.utexas.edu

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.

3

• 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
• Director
• Health Behavior Research and Training Institute
• Director

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
• Relatively brief
• Specifiable
• 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

• A Autonomy
• C Collaboration
• E Evocation

16

• 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.

17

• Underlying the Spirit of Motivational
  Interviewing
• is
• 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
• clients served

23
MI - Like Dancing

• Not Wrestling

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

• 0 10

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

27

• 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

28

• 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

• 0
  10

30
(No Transcript)
31
The Health Behavior Research and Training
Institute

• Motivational Interviewing Training and Coaching

32
Training

• 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
• SAMHSA/TDSHS
• Harris County Hospital District
• Family Medicine Residency programs in Georgia and
  Texas
• ATC-MHMR
• CPS/Children and Families
• Federal Bureau of Prisons
• And many others

33
Training

• 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

• InSight
• 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

• Coaching
• On-going support from highly skilled MI
  Coaches.
• Sessions are digitally recorded
• Coaches meet with Specialists monthly to
• discuss cases
• 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).

38

• Coaches Quarterly Report Date _____________
• Specialist __________________________ Coach
  ________________________
• Session Checklist Average __________
• MI Spirit Average __________
• MI Empathy Average __________
• Average of MITI Behavior Counts
• Ratio of Reflections to Questions
• (11 minimal competence) __________
• Open Questions of all Questions
• (50 minimal competence) __________
• OQ/OQCQ
• MI Adherent
• (90 MI-A minimal competence) __________
• MiA/ (MiAMiNa)

39
Sustaining the Coaching Model

• Peer Specialist Coach
• 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
• Monthly consults
• Booster Workshops

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
• Non-clinical staff
• Initial training MI Principles
• Peer Coaches
• Initial training advanced strategies session
  coding and feedback training

42
Conclusions

• 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.