use of client-centered mi style mi strategies that can be integrated into the agency’s existing...

MIA:STEPToolkit Overview

Jeanne L. Obert, MFT, MSMExecutive DirectorMatrix Institute on Addictions

What is an MI Assessment?

Use of client-centered MI style MI strategies that can be integrated into

the agency’s existing intake assessment process

Methods that can be used with diverse substance use problems

Skills for assisting clients in assessing their own substance use

Understanding the client’s perception and willingness to enter into a treatment processNIDA-SAMHSA Blending

Initiative 2

MI Assessment “Sandwich”

NIDA-SAMHSA Blending Initiative 3

MI strategies during 1st 20 min

MI strategies during last 20 min

Agency Intake or Assessment

Development of the protocol

The NIDA Drug Abuse Treatment Clinical Trials Network designed the protocol

Designed as something that all outpatient community treatment providers could use

Researchers worked directly with MI experts and treatment providers on both development and implementation.


Profile of CTN study participants

Average age: 32 Gender: 40% female Race: 76% White Marital Status: 21% married Referral source: 32% referred by

criminal justice system Average years of education: 12 Primary drug problem: alcohol (48%)

followed by marijuana, cocaine, stimulants


Research findings

5.02

4.03

00.5

11.5

22.5

33.5

44.5

5

Number of sessions/ 28

days

Treatment condition

MIStandard treatment


1. People receiving MI assessment completed more sessions in 4 weeks than those receiving standard intake.

Research findings


2. MI retained more people in treatment at the 4 week point than standard assessment.


Research findings

3. For alcohol users only, there was a more pronounced difference in treatment sessions attended at 4 weeks that was maintained at the 84 day follow-up.

Sessions Attended at 4 Weeks

5.1

3.3

Why another application of MI?

Positive outcomes depend on clients staying in treatment for adequate length of time

Adding MI at beginning of treatment increases client retention

The type of clinical supervision needed to maintain and improve MI skills is generally lacking


Implementing MI may require:

Focused clinical supervisionAudio taped MI Assessment

sessions Tape coding Feedback, coaching and

instruction for improving skills


Benefits of MI Assessment

It has a solid evidence-baseMI improves client engagement

and retentionUsing MIA:STEP:

Enhances clinical supervision Builds counselor knowledge and

proficiency in MI


Why consider this approach when staff are already trained in MI?

Most trained clinicians do not use MI appropriately, effectively or consistently

MI is more difficult than clinicians expect

The key to successful implementation of MI is supervisory feedback and coaching


MIA:STEP Toolkit includes everything you need to:

Introduce the idea of doing an MI assessment

Train counselors and supervisorsProvide ongoing supervision of

MITrain supervisors to use a simple

tape rating systemUse an MI style of supervision


The costs of implementing MI Assessment

Time to learn and implement the protocol

Regular review and feedback on MI skills

Ongoing clinical supervision, including:

- Training - Mentoring - Practice - Review of recorded interviews- Feedback - Development of learning plans

The cost of recorders and supplies


MIA:STEP Toolkit Overview

1. Briefing materials2. Summary of the MI Assessment

intervention3. Results of the NIDA CTN Research4. Teaching tools for enhancing and

assessing MI skills5. Interview rating guide and

demonstration materials6. Supervisor training curriculum


A patient-centered directive method for enhancing intrinsic motivation to change by

exploring and resolving ambivalence.

Using MI with Co-occurring Disorders

Staying Clean and Sober

Taking Medications

Participating in Dual DiagnosisSpecialty Program

Stages of ChangeProchaska & DiClemente

Building Motivation Using the OARS

•Open-ended questioning

•Affirming

•Reflective listening

•Summarizing

Open-ended Questions

An open-ended question is one with more than a yes or no response

Helps person elaborate own view of the problem and brainstorm possible solutions

Affirmations

Focused on achievements of individual

Intended to: Support person’s persistence Encourage continued efforts Assist person in seeing positives Support individual’s proven

strengths

Reflective Listening Key-concepts

Listen to both what the person says and to what the person means

Check out assumptionsCreate an environment of empathy

(nonjudgmental)You do not have to agreeBe aware of intonation (statement,

not question)

Levels of Reflection Repeating – Repeating what was just said. Rephrasing – Substituting a few words

that may slightly change the emphasis. Paraphrasing – Major restatement of what

person said. Listener infers meaning of what was said. Can be thought of as continuing the thought.

Reflecting Feeling - Listener reflects not just the words, but the feeling or emotion underneath what the person is saying.

Types of Reflective Statements


1. Simple Reflection (repeat)

2. Amplified Reflection (rephrasing andparaphrasing)

3. Double-Sided Reflection (rephrasing,paraphrasing and reflecting feeling)

Summarizing

Summaries capture both sides of the ambivalence

(You say that ___________ but you also mentioned that ________________.)

Summaries also prompt clarification and further elaboration from the person.

Four Principles ofMotivational Interviewing

1. Express empathy

2. Develop discrepancy

3. Avoid argumentation

4. Support self-efficacy

Express Empathy

Acceptance facilitates change

Skillful reflective listening is

fundamental

Ambivalence is normal

Develop Discrepancy

Discrepancy between present drug use

behaviors and important goals or

values

Awareness of consequences is important (Use Pros and Cons)

Goal is to have the PERSON present reasons

for change

Avoid Argumentation

Resistance is signal to change strategies

Labeling is unnecessary

Shift perceptions

Peoples’ attitudes shaped by their words,

not yours

Support Self-Efficacy

Belief that change is possible is important motivator

Counselor’s expectations becomeself-fulfilling

Person is responsible for choosing and carrying out actions to change

There is hope in the range of alternative approaches available

Eliciting Change Talk

DARN C – Statements that indicate:

Desire to make a change

Ability to make change

Reasons for considering change

Need (emotional) to change


Exercises for

Eliciting Change

Talk

Exploring Ambivalence

Both Sides of the Ambivalence

CON’S

--’S

NOT SO GOOD

THINGS

PRO’S

+’S

GOOD THINGS

No Change

Change

Use Decisional Balance Exercise

Assessing Readiness to Change


Readiness for change involves both Importance and Confidence

Readiness can be assessed through

Basic Scaling Ruler

ClinicalInterview

Inventories to Assess Readiness

Readiness Ruler


1-------2-------3-------4-------5-------6-------7-------8-------9-------10

Importance Ruler

Confidence Ruler

1—----2—----3—----4—----5—----6—----7—----8—----9—----10

Not at allImportant

Very Important

Not at allConfident

VeryConfident

(May be conducted on paper or verbally)

Key Questions on Readiness


Pull for Change Talk with some of the following questions:

“What do you think you will do?”

“What does this mean about your (habit)?”

What do you think has to change?”

“What are some of your options?”

“What’s the next step for you?”

“What would be some of the good things about

making a change?”

“Where does this leave you?”

Inventories to Assess Readiness


•URICA – University of Rhode Island Change Assessment Scale (SOC) (McCo9nnaughy, et al., 1989)•SOCRATES – Stage of Change Readiness and Treatment Eagerness Scale (Miller & Tonigan, 1996)

Mentioned in MIA-STEP Toolkit

•Alcohol Effects Questionnaire (AEQ). •Alcohol Use Disorders Identification Test (AUDIT)•Alcohol Expectancy Questionnaire all @ http://silk.nih.gov/silk/niaaa1/publication/instable.htm

In Public Domain

•Alcohol and Drug Consequences Questionnaire (Cunninghom)•Brief Situational Confidence Questionnaire (Sobel)•Personal Feedback Report (Project Match, NiAAA)•Readiness to Change Questionnaire (RCQ – TV) (Heather)•Situational Confidence Questionnaire (SCQ-39) – Addiction Research Foundation

Others listed in Appendix C of TIP

35

MI Supervisor Minimum Qualifications


Complete a 15 hour MI skill-building workshop conducted by a MINT (Motivation Interviewing Network of Trainers) Trainer

Have an interest in becoming a MI Supervisor

Be in position with authority to supervise other staff members

Skills Assessed by Self and Supervisor


MI Style and Spirit

Fostering a Collaborative Atmosphere

Open-ended Questions Affirmations

Reflective Statements

Skills Assessed by Self and Supervisor


Motivation to Change

Developing Discrepancies

Pros, Cons and Ambivalence

Client-Centered Problem Discussion

and Feedback

Change Planning

Rating MI Adherence and Competence


Frequency and Extensiveness

• From 1 (not at all) to 7 (extensively)

Skill Level

• From 9 (no at all) to 7 (excellent)

Example of Skill SummaryOpen-Ended Questions


Frequency and Extensiveness Higher if you ask questions that invite client conversation as opposed to asking only yes/no response questions.

Skill Level Higher if: 1. Questions are relevant to the clinician-client conversation. 2. Questions encourage greater client exploration and recognition of problem areas and motivation for change, without appearing to be judgmental or leading to the client. 3. Inquiries are simple and direct, thereby increasing the chance that the client clearly understands what the clinician is asking. 4. Usually, several open-ended questions do not occur in close succession.

Rather, high quality open-ended questions typicaly are interspersed with reflections and ample client conversation to avoid the creation of a question-answer trap between the clinician and the client.

5. You pause after each question to give the client time to respond.

Example of Skill SummaryOpen-Ended Questions (con’t)


Skill Level Lower if: 1. Questions are poorly worded or timed to target an area not immediately relevant to the conversation and client concerns.

2. Questions often occur in close succession, giving the conversation a halting or mechanical tone.

3. Inquiries may compound several questions into one query making them harder for the client to understand and respond to.

4. Questions lead or steer the client.

5. Inquiries have a judgmental or sarcastic tone.

6. Pauses after each question are not sufficient to give the client time to contemplate and respond

use of client-centered mi style mi strategies that can be integrated into the agency’s existing...

Documents

mi experts

assessment slide

mi assessment intervention

mi assessment train

solid evidencebase mi

treatment sessions

nida ctn research

use of client