Motivational Interviewing: Clinical Updates within Substance Abuse Treatment TARA DEWITT, PHD

Motivational Interviewing: Clinical Updates within Substance Abuse Treatment TARA DEWITT, PHD

Learning Objectives Updates within MI-3 Appreciate the Spirit of Motivational Interviewing: including awareness of equipoise and compassion Expand MI toolkit to more readily navigate discord and bring forward change talk and ambivalence

MI Definition and History Things do not change: We change. (20 minutes) - Henry David Thoreau

Technical Definition MI 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 Miller & Rollnick, 2013

The Spirit of MI Spirit of MI 5

The Underlying Spirit of MI Collaboration Compassion MI Spirit Acceptance Evocation

Acceptance Absolute Worth Affirmation Autonomy Accurate Empathy

Autonomy Support Overt recognition of the client s right and capacity for self-direction

Assumptions MI Inconsistent I am the expert on why & how patients should change I collect info about problems I correct gaps in knowledge I just need to tell them clearly what to do MI Consistent I have some expertise, & patients are the experts on themselves I find out what info the patient wants & needs I match info to patient needs & strengths Advice that champions patient needs & autonomy can be helpful

MI SPIRIT: EVOCATION

MI Spirit: Compassion The work is in the best interest of the client.

Your 11am: A 61 year old, African American male with a history of incarceration for petty larceny and selling drugs is currently using cocaine. He was referred to a vocational program to receive his CDL license but was asked to leave following a dispute with his instructor. Pt is currently supporting himself on disability payments and utilizing cocaine on a regular basis.

Your 11am: A 61 year old, African American male with an extensive history of childhood physical and emotional abuse sustained at the hands of his father. Pt was recently racially targeted at a local convenience store and served 2 years and 8 months in prison, for reportedly stealing candy. Pt reports that he wants to receive vocational training so he can get work. Pt is currently using cocaine and supporting himself on disability.

Engagement and Empathy Which client are you more looking forward to seeing? Which client do you feel more empathy for? Which client do you anticipate a better treatment outcome?

Compassion Requires Knowing When to Maintain Neutrality Neutrality (equipoise) is not a therapist attribute (like equanimity, composure, balance, emotional stability) It is a conscious clinical decision to try not to influence a client s direction of choice or change. Consider the difference between therapy and car sales. It can be about: A change goal and/or The means to reach a change goal

Four Process of MI Planning Bridge to change Evoking Transition to MI Focusing Strategic Centering Engaging Relational Foundation

Four processes 1. Engaging is the process of establishing a helpful connection & working relationship 2. Focusing is the process by which we develop & maintain a specific direction in the conversation about change 3. Evoking involves eliciting the clients own motivations about change & lies at the heart of MI 4. Planning encompasses both developing a commitment to change & formulating a concrete plan of action

Foundational Skills of MI Open-ended questions Affirmation Reflection Summary

Basic MI Skills (OARS) Open-ended questions: understanding, agenda setting, eliciting change talk Affirmation: recognition of efforts; recognition of strengths- tied directly to target behavior Reflection: understanding, empathy, eliciting more, reinforcing change talk Summary: understanding, eliciting more, reinforcing change talk, transition to planning

The Spirit of MI is to appreciate Ambivalence.

Tenets of MI: Ambivalence If you argue for one side, an ambivalent person is likely to defend the other side As a person defends the status quo, the likelihood of change decreases Resist the "righting reflex Instead, focus on eliciting change talk: self-expressed language that is an argument for change

Change Talk Specific to MI Self -expressed speech that favors movement in the direction of change Opposite is sustain talk - Speech that favors things staying the same-status quo Expresses client s desires, ability, reasons, & need to change Conveys optimism about making change & the benefits of succeeding States willingness & intention to change Specific to a target behavior or set of target behaviors

Recognizing Change Talk Desire: I want to Ability: I think I can Reasons: I am going to lose my job. Need: I need to Commitment: I am going to Activating: I am willing to Taking steps: I have already

EARS: Responding to Change Talk E is for elaborate; Tell me more ; seek details, examples, meaning, connection with values & goals A is for affirm; R is for reflect S is for summarize; change talk provides the flowers in the bouquet

Strategies for Eliciting Change Talk Ruler for importance, confidence, readiness Querying extremes Hypothetical questions Looking forward Goals and values

Recognizing Readiness for Planning + + + + + + Increased Change Talk Decreased Sustain Talk and Discord Resolve: less discussion of the problem, sighs, tears, a quietude Questions about change Envisioning Taking steps

Testing the waters Testing the Water Summarize & Key Questions 27

Offer a Bouquet of Change Talk & Test the Water Offer a bouquet of Change Talk & Test the water: Although there are things that worry you about going into treatment for you substance use, you are recognizing that it is causing problems at obtaining a job. Financial independence is important to you as well as the opportunity to learn new skills. And you are not sure how to manage the cravings on your own. Where does this leave you?

MI 3 Dancing with Discord MI 2 Rolling with ResistanceS

Deconstructing Resistance Resistance (MI2) Sustain Talk Discord (MI3)

Discord: It is about you + + + Symptom of relationship/ disengagement How we respond to sustain talk is often the culprit Righting reflex

Signs of Discord Defending Squaring Off Interrupting Disengagement Arguing

Dancing with Discord Specific strategies Reflect, reflect, reflect Emphasize autonomy Apologize Affirm

Resources Video clips: Brene Brown on Empathy on Utube The Rounder with Dr. Terri Moyers on Utube Join up video with Monty Roberts on Utube Coding: MITI 4.2 https://casaa.unm.edu/download/miti4_2.pdf Tools for use with clients: Value Card Sort: http://www.motivationalinterviewing.org/sites/default/files/valuescardsort_0.pdf

Questions? For additional information contact: Dr. Tara DeWitt drtaradewitt@gmail.com

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Upcoming Event Addressing the Mental Health Needs of Children with Incarcerated Parents June 27, 2018 12-1pm Visit http://ctacny.org for more information