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Motivational Interviewing Richard Rawson, Ph.D. Pacific

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Title: Motivational Interviewing Richard Rawson, Ph.D. Pacific


1
Motivational Interviewing
  • Richard Rawson, Ph.D.
  • Pacific Southwest ATTC
  • UCLA Integrated Substance Abuse Programs
  • 2008

2
Traditional approach (1)
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 for
    change
  • Corollary People dont change if they havent
    suffered enough

3
Traditional approach (2)
You better! Or else!
If the stick is big enough, there is no need for
a carrot.
4
Traditional approach (3)
  • Someone who continues to use is
  • in denial.
  • The best way to break through the
  • denial is direct confrontation.

5
Another approach Motivating (1)
  • People are ambivalent about change
  • People continue their drug use because of their
    ambivalence

The carrot
6
Another approach Motivating (1)
  • Motivation for change can be fostered by an
    accepting, empowering, and safe atmosphere

The carrot
7
Ambivalence
  • Ambivalence Feeling two ways about something.
  • All change contains an element of ambivalence.
  • Resolving ambivalence in the direction of change
    is a key element of motivational interviewing

8
Why dont people change?

9
What is the problem?
  • It is NOT that
  • they dont want to see (denial)
  • they dont care (no motivation)
  • They are just early in the stages of change
  • Addiction is a brain disease that disables the
    brain from functioning normally in areas such as
    motivation, attention, perception, memory,
    planning, etc.

10
Activity 1 Reflection
  • Take some time to think about the most difficult
    change that you had to make in your live.
  • How much time did it take you to move from
    considering that change to actually taking
    action.

11
Stages of Change
  • Recognizing the need to change and understanding
    how to change doesnt happen all at once. It
    usually takes time and patience.
  • People often go through a series of stages as
    they begin to recognise that they have a problem.

12
Helping people change (1)
  • Helping people change involves increasing their
    awareness of their need to change and helping
    them to start moving through the stages of
    change.
  • Start where the client is
  • Positive approaches are more effective than
    confrontation particularly in an outpatient
    setting.

13
Helping people change (2)
  • Motivational interviewing is the process of
    helping people moving through the stages of
    change.

14
First Stage Pre-contemplation
  • People at this stage
  • Are unaware of any problem related to their drug
    use
  • Are unconcerned about their drug-use
  • Ignore anyone elses belief that they are doing
    something harmful

15
Second Stage Contemplation
  • People at this stage are considering whether or
    not to change
  • They enjoy using drugs, but
  • They are sometimes worried about the increasing
    difficulties the use is causing.
  • They are constantly debating with themselves
    whether or not they have a problem.

16
Third Stage Determination/preparation
?
  • People at this stage aredeciding how they
    aregoing to change
  • May be ready to change their
  • behaviour
  • Getting ready to make the change
  • It may take a long time to move to the next stage
    (action).

17
Fourth Stage Action
  • People at this stage
  • Have begun the process of changing
  • Need help identifying realistic steps, high-risk
    situations, and new coping strategies

18
Fifth Stage Maintenance
  • People in this stage
  • Have made a change and
  • Are working on maintaining the change

19
Relapse
  • People at this stage have reinitiated the
    identified behaviour.
  • People usually make several attempts to quit
    before being successful.
  • The process of changing is rarely the same in
    subsequent attempts. Each attempt incorporates
    new information gained from the previous
    attempts.

20
Relapse
  • Someone who has relapsed
  • is NOT a failure!
  • Relapse is part of the recovery process.

21
Principles of Motivational Interviewing
22
Principles of Motivational Interviewing
  • Motivational interviewing is founded on 4 basic
    principles
  • Express empathy
  • Develop discrepancy
  • Roll with resistance
  • Support self-efficacy

23
Principle 1 Express empathy
  • The crucial attitude is one of acceptance
  • Skilful reflective listening is fundamental to
    the clients feeling understood and cared about.
  • Client ambivalence is normal the clinician
    should demonstrate an understanding of the
    clients perspective
  • Labelling is unnecessary

24
Example of expressing empathy
I am so tired that I cannot even sleep So I
drink some wine.
You drink wine to help you sleep.
When I wake upI am too late for work
already Yesterday my boss fired me.
So you are concerned about not having a job.
...but I do not have a drinking problem!
25
Principle 2 Develop discrepancy
  • Clarify important goals for the client
  • Explore the consequences or potential
    consequences of the clients current behaviours.
  • Create and amplify in the clients mind a
    discrepancy between current behaviour and life
    goals

26
Example of developing discrepancy
I only enjoy having some drinks with my
friendsthats all. Drinking helps me relax and
have funI think that I deserve that for a change
So drinking has some good things for youNow tell
me about the not-so-good things you have
experienced because of drinking.
Wellas I said, I lost my job because of my
drinking problemand I often feel sick.
27
Principle 3 Roll with resistance
  • Avoid resistance
  • If it arises, stop and find another way to
    proceed
  • Avoid confrontation
  • Shift perceptions
  • Invite, but do not impose, new perspectives
  • Value the client as a resource for finding
    solutions to problems

28
Example of NOT rolling with resistance
I do not want to stop drinkingas I said, I do
not have a drinking problemI want to drink when
I feel like it.
But, Anna, I think it is clear that drinking has
caused you problems.
You do not have the right to judge me. You dont
understand me.
29
Example of rolling with resistance
I do not want to stop drinkingas I said, I do
not have a drinking problemI want to drink when
I feel like it.
You do have a drinking problem
Others may think you have a problem, but you
dont.
Thats right, my mother thinks that I have a
problem, but shes wrong.
30
Principle 4 Support self-efficacy
  • Belief in the ability to change (self-efficacy)
    is an important motivator
  • The client is responsible for choosing and
    carrying out personal change
  • There is hope in the range of alternative
    approaches available

31
Example of supporting self-efficacy
I am wondering if you can help me. I have failed
many times.
Anna, I dont think you have failed because you
are still here, hoping things can be better. As
long as you are willing to stay in the process, I
will support you. You have been successful before
and you will be again.
I hope things will be better this time. Im
willing to give it a try.
32
OARS
  • The OARS are the skills that can be used by
    interviewers to help move clients through the
    process of change.
  • Open-ended questions
  • Affirmation
  • Reflective listening
  • Summarising

33
OARS Open-ended questions
Close Versus Open-ended questions
  • Are there good things about using? vs.
  • What are the good things about your substance
    use?
  • Are there bad things about using? vs.
  • Tell me about the not-so-good things about
    using
  • Do you have concerns about your substance use?
    vs.
  • You seem to have some concerns about your
    substance use. Tell me more about them.
  • Do you worry a lot about using substances? vs.
  • What most concerns you about that?

34
OARS Affirmation
  • Thanks for coming today.
  • I appreciate that you are willing to talk to me
    about your substance use.
  • You are obviously a resourceful person to have
    coped with those difficulties.
  • Thats a good idea.
  • Its hard to talk about....I really appreciate
    your keeping on with this.

35
OARS Reflective listening
  • Reflective listening is used to
  • Check out whether you really understood the
    client
  • Highlight the clients ambivalence about their
    substance use
  • Steer the client towards a greater recognition of
    her or his problems and concerns, and
  • Reinforce statements indicating that the client
    is thinking about change.

36
OARS Summarize
  • Summarizing is an important way of gathering
    together what has already been said, making sure
    you understood the client correctly, and
    preparing the client to move on. Summarising is
    putting together a group of reflections.

37
Motivational Interviewing
  • Eliciting Change Talk

38
OARS What is change talk?
  • Change talk An indication that you are
    successfully using motivational interviewing.
  • If you are using MI successfully you will hear
    statements that indicate the client
  • Recognises the disadvantages of staying the same
  • Recognises the advantages of change
  • Expresses optimism about change
  • Expresses the intention to change

39
Helping to elicit change talk (1)
  • Ask the client to clarify their statements or
    elaborate
  • Describe the last time this happened,
  • Give me an example of that, or Tell me more
    about that.

40
Helping to elicit change talk (2)
  • Ask the client to imagine the worst consequences
    of not changing and the best consequences of
    changing.

41
Helping to elicit change talk (3)
  • Explore the clients goals and values to identify
    discrepancies between the clients values and
    their current substance use.
  • What are the most important things in your
    life?

42
Contingency Management
  • also known as
  • Motivational Incentives

43
The Problem Allure of Immediate Drug
Reinforcement
44
Abstinence
Continued Use
Ambivalence
45
Solution Methods to Enhance Motivation for
Abstinence
  • Natural aversive consequences (hitting
    bottom)
  • Feedback re problems/consequences -
    Confrontation - Motivational Enhancement Therapy
  • Positive reinforcement for behavior change

46
Part 1 Behavior can be modified by
Rewards
Punishments
47
Rewards to shape behavior in everyday life.
  • Child rearing
  • Praise, money, food
  • Education
  • Grades and honors
  • Business and work settings
  • Bonuses and promotions
  • Criminal justice
  • Early release for good behavior

48
Examples of Punishers
  • Child rearing
  • Time out, grounding
  • Education
  • Bad grades, detention, suspension
  • Business and work settings
  • Demotions
  • Criminal justice
  • Fines, tickets, jail

49
Rewards versus Punishments
  • Both can change behavior..
  • But most people prefer rewards.

50
Punishments
  • Do no teach what to do only what not to do.
  • Promote harsh and demeaning atmosphere.
  • May also do harm (e.g. promote aggression).
  • In criminal just settings, punishers often do not
    occur immediately after the inappropriate
    behavior.
  • Often the inappropriate behavior occurs multiple
    times prior to the punishment. Punishment, when
    delivered inconsistently, can actually encourage
    inappropriate behaviors.

51
Rewards
  •  Teach new behaviors and promote growth
  • Promote self-esteem and self-confidence
  • Promote positive atmosphere communication

52
Incentives in Health Care
  • Mammography screening
  • Child immunization

53
BREAST CANCER Mammography Screening
Recommendation for Women Ages 50 and older
ANNUAL MAMMOGRAM With physician
advice alone, few women receive an annual
mammogram (Stoner et al., 1998)
54
Mammogram Compliance
Rate of Compliance
Rates of mammogram screening were 2.5 times
higher for the incentive as compared to the
control women. (Stoner et al., 1998)
55
Childhood
Immunizations
56
Immunization Rates
Rate
Rates increased when WIC food vouchers were given
to those who had their children immunized.
(Hoekstra et al., 1998)
57
Incentives in Substance Abuse Treatment
AA
AA
58
Incentives in Drug Abuse Treatment
  • Positive Negative
  • - award ceremonies - extra therapy
  • - certificates key chains - time
    restriction
  • - status/recognition - dismissal
  • - take-homes in methadone - probation,
    referral to judge

59
By increasing rewards in substance abuse
treatment.
we may be able to enhance outcomes.
60
How Incentives Could Work For You
Patient attends treatment, Gives negative samples
Give Incentive
More patients
  • attend treatment
  • stay clean
  • stay out of jail!

61
ContingencyManagement
  • Making abstinence a more
  • attractive option through
  • positive reinforcement of
  • behavior change

62
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63
It is the CONTINGENCY that matters.
BEHAVIOR
REWARD
Giving things away for free does NOT change
behavior
64
Later Studies Motivational Incentives with
Monetary Rewards
Research has shown that monetary incentives can
Increase treatment retention
 Decrease drug use during treatment
65
Motivational Incentives Research with Vouchers
  • Vouchers earned for achieving therapeutic goals
  • e.g. cocaine-free urines
  • Vouchers are worth money
  • Vouchers are exchanged for
  • retail items (e.g. clothing, sports equipment)
  • services (e.g. rent bill payments)

66
Research on Motivational Incentives
Cocaine Alcohol Marijuana
67
Motivational Incentives
Research studies have tested incentives
for ability to improve drug abuse treatment
outcomes and shown they work
68
Addressing the Cost Barrier
  • Society cant afford this
  • Our program cant afford this

69
Steps to designing a contingency management
intervention
  • 1. Pick a behavior you want to change
  • 2. Pick a reinforcer
  • 3. Design a monitoring and reinforcing schedule
    and decide upon a time frame for re-assessment
  • 4. Ensure consistent application of procedure

70
Implementation Guidelines
  • Typically, it is recommended that the contingency
    management component of therapy be carried out in
    the first 5 minutes of the session, so therapy
    can proceed after the reward has been given (if
    achieved)
  • Maintain a positive attitude, be encouraging, and
    remain non-confrontational
  • Praise consumers for keeping their appointments
    (even when they are late or drug tests are
    positive)

71
Discontinuation of Contingency Management
Procedures
  • Providing incentives indefinitely can be
    expensive and the benefits of contingency
    management may decrease over time
  • Most contingency management programs offer
    incentives for at least 3 months
  • At the end of the contingency management
    treatment, the reinforcement scheduled should be
    tapered off or eliminated entirely
  • Little research is available to provide support
    for which method is optimal

72
Suggestions for the Discontinuation of
Contingency Management Procedures
  • Consumers should be informed about how long the
    incentives will last
  • During the final 1-2 weeks speak with the
    consumer about how they feel about maintaining
    the behavior after the incentives end
  • At this point the consumer can be reminded of
    their progress throughout the course of treatment
  • Providing a certificate of completion is a
    popular approach when incentives are discontinued

73
  • The End
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