Motivational Interviewing (MI) in Dual Diagnosis Populations. Disclosures & Research Grants. Introduction. Research. Practice

Transcription

1 Motivational Interviewing (MI) in Dual Diagnosis Populations Antoine Douaihy, MD Professor of Psychiatry & Medicine University of Pittsburgh School of Medicine Member of the Motivational Interviewing Network of Trainers April 21 st, 2017 Disclosures & Research Grants NIDA NIMH NIAAA HRSA SAMSHA Alkermes Royalties for 2 academic books published by OUP and one book published by PESI Publishing & Media Introduction A Show of Hands: How familiar are you with MI? o 1. No familiarity o 2. Brief surface-level introduction o 3. Intensive training over multiple days o 4. Intensive training(s) and broad familiarity with periodic use o 5. Extensive familiarity: Use it often; Maybe even train others Research Practice

2 ??! Definitions & Concepts Context of addiction treatment-roughly half of the population with have another psychiatric disorders In mental health services-substance use disorders are the second most common diagnosis in the general population-& the most frequent cooccurring disorder among people with serious psychiatric illness Expectation not an exception The good news is: effective treatment of substance use can improve the course of co-occurring disorders Which comes first???? Why Integrated Treatment? A high rate of co-occurrence, or comorbidity, between substance use disorders and psychiatric illness Comorbidity affects the course and prognosis of both the individuals psychiatric illness and substance use Individuals experience poorer outcomes than those with only a psychiatric illness or substance use Higher service utilization and increased service costs Traditional practice of treating co-occurring disorders as separate conditions in a parallel or sequential fashion is largely ineffective We have identified integrated best and evidence-based practices that result in improved outcomes for these individuals Motivational Interviewing is one of these practices Integrated Care Historical Background MI Abstinence from Drugs & Alcohol MI Engagement in Treatment, Mutual Support Groups & Medical Care Accidental and atheoretical development of MI William R. Miller, PhD Later with Steve Rollnick o Wrote first MI article in 1983 o Began work in the field of alcohol and substance use MI Adherence to Medications

3 Confrontation vs. Empathy Miller, Benefield, & Tonigan (1993) reported drinking outcomes at 12 months were strongly predicted by counselor style: the more the counselor confronted, the more the client drank Random assignment to counseling styles also strongly predicted the degree of client resistance (higher with confrontation) Expressed motivation for change (higher with MI) Confrontation vs. Empathy It matters what the counselor does Counselor s empathy predicts client change Confrontation undermines change Given a brief intervention, clients went ahead and changed on their won without any treatment Definitions & Key Concepts Definitions & Key Concepts Self-Perception Theory o "Individuals come to know their own attitudes, emotions and internal states by inferring them from observations of their own behavior and circumstances in which they occur (Bem, 1972) Reactance Theory o The natural human tendency to reassert one s freedom when it appears to be threatened. even if it hurts them. o Or The more somebody verbalizes a position (either positive or negative), the more s/he will commit to it. Definitions & Key Concepts Direction Languages Deceptive Simplicity o Many MI concepts appear easy at first glance, but take practice to master and perform intentionally Directing as a clinician behavior Direction as goal-orientation Directional rather than directive as a description of MI

4 A Continuum of Coaching Styles Directing <=> Guiding <=> Following A Continuum of Coaching Styles Directing <=> Guiding <=> Following Behavior therapy Cognitive therapy Dr. Phil????? Motivational interviewing Solution focused therapy Psychodynamic psychotherapy Ambivalence Ambivalence means that 2 sides of change exist. We want patients to advocate for the side of positive change. o Things to watch for: The Righting Reflex Self-Reactance Theory Staff: Smoking costs so much. You can t afford it. Patient: Sure I can. I can buy a cheaper brand. I could also skip one AA meeting per week and buy a pack with the saved bus fare. Staff: Smoking causes cancer. It will kill you! Patient: I don t think so. My Grandfather lived 90 years and smoked every day! Act like you have 30 minutes with a patient and it will take all day. Act like you have all day with a client and it will take 30 minutes. o We want to fish WITH patients, not be relied upon by them. Walking with others and guiding them instead of fixing their problems for them shows that we believe in their ability to be autonomous and resourceful. Impact of the Righting Reflex (Slide courtesy of Dr Bill Miller) Invalidated Resist Withdraw Not respected Arguing Disengaged Not understood Discounting Disliking Not heard Defensive Inattentive Angry Oppositional Passive Ashamed Denying Avoid/leave Uncomfortable Delaying Not return Unable to changejustifying Impact of a Listen/Evoke/Empathic Style: MI (Slide courtesy of Dr Bill Miller) Affirmed Accept Approach Understood Open Talk more Accepted Undefensive Liking Respected Interested Engaged Heard Cooperative Activated Comfortable/safe Listening Come back Empowered Hopeful/Able to change

5 The Underlying Spirit of MI The Spirit of MI Collaboration Evocation Autonomy Acceptance Compassion VS. Confrontation Education Authority Elements of MI 1. MI is a particular kind of conversation about change 2. MI is collaborative 3. MI is evocative Layperson s Practitioner's Technical MI (3 rd Edition) MI is a collaborative conversation style for strengthening a person s own motivation and commitment to change. (What it is for?) MI is a person centered counseling style for addressing the common problem of ambivalence about change. Why would I use it?) MI is a collaborative, goal oriented style of communication with particular emphasis to the language of change. It is designed to strengthen personal motivation for and commitment to a specific behavior by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion. (How does it work?) 4 Fundamental Processes in MI Four Fundamental Processes in MI 1. Engaging The Relational Foundation Person-centered style Listening understanding dilemma and values OARS (Open questions; Affirmations; Reflections & Summaries) core skills

6 4 Fundamental Processes in MI 1. Engaging The Relational Foundation 2. Focusing Strategic Centering (a change goal) Agenda mapping Finding a focus Information and advice Finding a Focus What is the focus, the change goal for MI? Most often, it is from the patient s agenda Sometimes prescribed by the context What if you have your own goal(s) that the patient does not currently share? Equipoise Equipoise is not a therapist attribute (like equanimity: composure, balance, emotional stability) Equipoise is the conscious clinical decision to try not to influence a patient s direction of choice or change Practitioner s Aspiration Should I proceed strategically to favor the resolution of the patient s ambivalence in a particular direction? or Do I want to maintain equipoise/ neutrality and not intentionally or inadvertently steer the person in one particular direction? MI was originally developed for the former situation Engaging and Focusing Identification of Change Goal Aspiration A conscious choice Equipoise Evoking Planning? 4 Fundamental Processes in MI 1. Engaging The Relational Foundation 2. Focusing Strategic Centering 3. Evoking The Transition to MI Selective eliciting Selective responding Selective summaries Both choices involve equanimity, collaboration and autonomy

7 Change Talk Change Talk vs. Sustain Talk A guiding premise of MI is to have the patient, rather than the practitioner voice the argument for change Change talk refers to patient s statements that indicate an inclination or reason for change As a person argues on behalf of one position, they become more committed to it The more a person talks about change in the course of a conversation, the more likely change is to occur Counsel in a reflective, supportive manner, and discord goes down while change talk increases Change talk: any patient speech which favors movement in the direction of change on a particular behavior Shows up as natural language Several types Sustain talk: maintaining status quo Types of Change Talk DARN Desire to change (want, wish, hope) Ability to change (can, could) Reason to change (if then) Desire Ability Reasons Flow of Change Talk Commitment Activation Taking Steps Change Need to change (have to, got to) Mobilizing Change Talk: CAT Commitment to change (I will, I m going to) Need (DARN) (CAT) Activation (I m preparing, I m ready) Taking steps Relative Strengths of Commitment Language (1) Weakest I hope to I will try I think I will I suppose I will I imagine I will I suspect I will I will consider I guess I will I will see (about) (2) Weak I favor I believe I accept I aim I aspire I am inclined I anticipate I predict I presume (3) Moderate I look forward to I consent to plan to I resolve to I expect to I concede to I declare my intention to I dedicate myself (4) Stronger I am devoted to I pledge to I agree to I am prepared to I intend to I am ready to (5) Strongest I guarantee I will I promise I vow I shall I give my word I assure I know I will In MI, the practitioner s task is to: a. Recognizechangetalk b. Proactively elicit it, and c. Strategically respond to it.

8 OARS Skills Open question Affirmation Reflective Listening (Heart of MI!!!!) Summary Reflective Listening A testing of hypothesis at what the patient means by what they just said Is always in the form of a statement never a question It can be simple or complex o Complex reflections add meaning or emphasis to what has just been said o Complex reflections moves the exploration process forward It is collaborative/non-authoritarian; it is a not an interpretation It is reinforced by patient s response It is never critical, judgmental, or confrontational It can be directive (selective) but never directs by giving advice/suggestions without permission. 43 Selective Reflective Listening Reflective listening is not a passive process It can be quite directive Practitioner determines what to reflect in order to emphasize or deemphasize certain aspects of what the person is saying For example, change talk is preferentially reflected so that people hear their own statements of change at least twice Miller & Rollnick (2013,p. 400) Benchmarks of Practice Basic Competency Proficiency Spirit rating (1 5) ave %Open questions of total 50% 70% Questions % Complex reflections of total 40% 50% Reflections Ratio of Reflection to Question %MI Adherent behaviors 90% 98% %MI Non adherent behaviors 10% 2% The concept formerly known as resistance Sustain Talk + Discord = Resistance Sustain Talk is about the target behavior. Discord is about the relationship. Both are signals to respond differently and are highly responsive to the relationship. 4 Fundamental Processes in MI 1. Engaging The Relational Foundation 2. Focusing Strategic Centering 3. Evoking The Transition to MI 4. Planning The Bridge to Change Negotiating a change plan Consolidating commitment 35

9 Skeptical? Evidence Base of MI Over 1,300 publications Over 250 randomized clinical trials Several meta analyses Effective across a range of populations, settings, and behaviors Culturally relevant Lundahl et al., Meta analysis of 119 studies: 50% some behavior change and 25% moderate or strong behavior change Number of MI studies by year 160 n = 150 Obesity Dental Asthma Violence Family Health Prom n=93 Psychiatric Diabetes Cardiac HIV 60 n=54 Smoking/Tob Adh/Retention n=36 Eating Dis Offenders Gambling n=6 Dual Dx 0 AOD Important Findings With training, MI can be delivered effectively by health care practitioners; professional role does NOT appear to affect its efficacy MI achieves it effects in ONE to FOUR sessions Requires a minimum dose of about 20 minutes. More sessions Greater efficacy Rubak et al., 2005 Skills & Strategies Open Questions Processes Engaging Spirit Motivational Interviewing Reflections Affirmations Summaries Focusing Evoking Partnership Acceptance Compassion Planning Eliciting & Responding To Change Talk Evocation Miller and Rollnick, 2013 Learning MI Insights from MI training Research MI is simple, but not easy to learn Self perceived practice doesn t correlate with actual practice One shot workshops are a good start, but do not promote even basic MI proficiency Educational attainment, degree, or experience doesn t correlate with competent MI practice You don t have to be a specialist to effectively promote behavior change Evocative Questions What is your approach to utilizing evidence-based practices in dual diagnosis populations and particularly MI? How coherent is it? What research supports it? Are you practicing evidence-based therapy or deliberately practicing evidence-based therapy? Are you receiving supervision for your practices? How are our attitudes about patients affecting the treatment of their substance use and psychiatric disorders?

10 Further Resources