+Motivational InterviewingAn Evidence-Based Tool for Drug Court

Joe Lunievicz, BA, RYTDirector Training Institute, NDRI, Inc.

Executive Director, NDRI-USA, Inc.

+Agenda

• What is it?• Evidence Base• Techniques Used• Practice

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Exercise in PairsWrite down on paper:•What are three things you value in life?

•What is one five-year goal you have?

Discuss with your partner

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What Motivates your participants to move towards graduation?

What are their goals?

What do they value?

How does present behavior get in the way?

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Participants?

+Motivational InterviewingA directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence. It is a style of helping that uses a set of specific strategies.

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+Motivational Interviewing (Cont.)Motivation- or presumed lack of it- is not viewed as a personality problem or character trait, but as a state of readiness for change that can be influenced by a helping relationship.

Rollnick & Miller, 1995

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+ After 30 years of Research … Bill Miller & Steve Rollnick - Stockholm, June 2010 Presentation

200+ randomized clinical trials – Evidence Base 10 multisite clinical trails – Evidence Base 1000+ publications Dozens of books and videotapes – MI 2 in 2002 Several coding systems for quality assurance MIA-STEP to support MI supervisors Research on MI Training

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+ Evidence Base with… 100,000 + individuals Alcohol, crime, drugs, family/relationships, social

functioning, trauma/injuries, treatment/recovery Age 18-25, 26-55, 55+ Male, female Caucasian, Asian, Black or African American, Hispanic

or Latino Outpatient, school, community settings Urban, suburban

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Motivational Interviewing

Is a brief intervention Developed to work with “unmotivated drinkers” Based on work by Rollnick and Miller 1991 Useful for clients who are reluctant to change

(ambivalence - contemplators) Draws on client-centered therapy, cognitive

therapy & change therapy Is non-confrontational Uses specific strategies/skills

+ MI Basic Principles Expressing Empathy Developing Discrepancy Rolling with Resistance Supporting Self-Efficacy

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MI helps the client…

Enhance intrinsic motivational change

Recognize the need to do something about the potential problem

Resolve ambivalence

Decide to change

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The Counselor…

Does not assume an authoritarian position Avoids conveying the message “I have the

answers”

Treats the client as an adult capable of making responsible decisions

Treats the client as the “expert” on his or her own experience

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The Counselor Does Not…

Argue with client

Impose a diagnostic label on client

Tell client what they “must” do

Seek to “break down” denial by direct confrontation

Imply clients’ powerlessness

+Why use MI in Drug Court?Better EngagementMore InformationBetter AssessmentsMore Relevant RecommendationsMore Successful Outcomes

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+MI Intervention vs. MI techniques Full intervention

Or

Individual techniques that make up the intervention

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Example: Motivational Enhancement Therapy - NIDA

Alcoholics, outpatient tx 7-8 hour assessment 4 sessions

1&2, structured feedback, future plans & motivation for change

3&4, reinforce progress, encourage reassessment & provide objective assessment of progress

Significant other involved in session 1 & or 2 Breath alcohol readings 90 day timeframe

+MINT blog post – “Old” Are you a smoker?

Well, sort of, yes.

How much do you smoke each day? A pack or two.

The way you’re coughing, I have to tell you, it’s going to get worse if you continue. Yes, I know but you see it helps with the stress. If you knew what I go

through with the truck and long hauls. It’s enough just to get through the day.

But if you carry on like this you might lose even more time at work. Yeah. I’m cutting back, you see.

Well we’ve got some good aids to quitting if you are interested? Yes, thanks, sure. I’ll give it some thought.

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+MINT blog post – “New” Would you mind if we talked about your smoking?

Well, ok.

How do you really feel about it? I’m trying to cut back, but I can’t say its easy with my job. You know its stressful driving a truck.

Its not easy for you, yet you’d like to smoke less. Oh, if I could, definitely. I know it’s not good for my lungs or this cough for a start.

You can feel the effect for yourself and its not pleasant That’s right. But its such a stress reliever its hard to let go.

It’s difficult to imagine being without smoking. Yes, that’s exactly right. You got me.

I don’t want to give you a lecture or hassle you about this, but I’m wondering what would be helpful for you? I just don’t know.

Tell me. Deep down. How important is this for you right now? I feel sick and I’m tired and this smoking wears me down.

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+Paraphrasing/ReflectionPairs

Can’t respond until you have paraphrased accurately.

Argue your point.

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+MI Strategies

OARS Open Ended

Questions Affirming Reflection Summarizing

Balance sheet Stages of change Using the

importance Ruler Exploring goals and

values Elicit Change Talk

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+Questioning SkillsEffective vs. Ineffective Questions Ineffective

Too many questions Accusatory questions: Why? Multiple questions Explanatory questions Closed questions

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+ Questioning SkillsEffective vs. Ineffective Questions EffectiveHave specific objectives in mindState background for questionUse language of the clientCheck out whether client is understandingAsk openly: Who, What, When, Where & How

Use open-ended questionsParaphrase; Reflect; Summarize

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+Open Ended Questions

Who, what, where, whenTell me about…How did you…Redirect: Now tell me about…

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+Open-ended Examples:

What worries you about your current situation? Tell me about difficulties have you had with

your drug use? What do you think will happen if you don’t

change? How has your anger interfered with your life? What would your life be like 5 years from now?

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+Affirm (but don’t flatter)Strengths based techniqueVerbally supports or validates a

participant’s thoughts, emotions, or actions

Demonstrates: Appreciation, Understanding, Support

When you see a strength, notice it

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+ Affirmation Example:

1. Participant arrives on time for his case management appointment.“You’re punctual. That will be a big help in this program.”2. Participant: “I don’t want to do anything more than I need to. I just want to finish the program and get on with my life.”“Determination is a good characteristic to have in treatment. It will help to keep you focused.”

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+ Reflective Listening Rationale

Conveys willingness to try to understand

Serves as a perception check

Clarifies feelings Leads to more exploration

Demonstrates empathy

Common Errors Not listening

closely Limited feeling

vocabulary Monotone vocal

qualities Premature focus on

problem solving

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+ReflectionExpressing Empathy:“So, what I hear you saying is…”Reflecting Conflict:“On the one hand…but on the other hand…”“So what you’re saying is…but you are not able to…”Rolling with resistance:“You don’t have to do anything you don’t want to.”

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+SummarizingThe set-up statement

Let me see if I understand correctly…Reflection, Reflection, ReflectionOpen ended Question

What did I miss?What other concerns do you have?

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+Practice: Speaker• Something about

yourself that you• Want to change• Need to change• Should change• Have been thinking

about changing• … but you haven’t

changed yet.

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Practice: Listener• Listen carefully• Ask these 4 questions:

• Why would you want to make this change?• How might you go about it in order to

succeed?• What are the three best reasons for you to do

it?• On a scale from 0 to 10, how important would

you say that it is for you to make this change?• Why are you a (?) and not a zero?

• Give a short summary/reflection of the speaker’s motivations for change.

• Ask: “So what do you think you’ll do?” and just listen with interest.

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+ Resources:

NREPP SMAHSA’s National Registry of Evidence-based programs and practices

MI – Bill Miller email wrmiller@unm.edu

MI – http://www.motivationalinterviewing.org

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