motivational interviewing: clinical updates within … tara_mi...2018/06/13  · updates within mi-3...

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

• 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

Learning Objectives

MI Definition and History

‣(20 minutes)

Things do not change: We change. - Henry David Thoreau

“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”

Technical Definition

Miller & Rollnick, 2013

5

The Spirit of MI Spirit of MI

Collaboration

Acceptance

Evocation

Compassion MI Spirit

The Underlying Spirit of MI

Acceptance

Absolute Worth

Affirmation Autonomy

Accurate Empathy

Autonomy Support

Overt recognition of the

client’s right and capacity for

self-direction

Assumptions ‣ MI Inconsistent ‣ 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

‣ 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 SPIRIT: EVOCATION

The work is in the best interest of the client.

MI Spirit: Compassion

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?

‣ 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

Compassion Requires Knowing When to Maintain Neutrality

Engaging – Relational Foundation

Focusing – Strategic Centering

Evoking – Transition to MI

Planning – Bridge to change

Four Process of MI

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

Four processes

‣Open-ended questions

‣Affirmation

‣Reflection

‣Summary

Foundational Skills of MI

‣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

Basic MI Skills (OARS)

The Spirit of MI

appreciate Ambivalence.

is to

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

‣ 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

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…

Recognizing 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

EARS: Responding to Change Talk

‣Ruler for importance, confidence, readiness

‣Querying extremes ‣Hypothetical questions ‣Looking forward ‣Goals and values

Strategies for Eliciting Change Talk

₊ Increased Change Talk ₊ Decreased Sustain Talk and

Discord ₊ Resolve: less discussion of the

problem, sighs, tears, a quietude ₊ Questions about change ₊ Envisioning ₊ Taking steps

Recognizing Readiness for Planning

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Testing the waters Testing the Water Summarize & Key Questions

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?”

Offer a Bouquet of Change Talk & Test the Water

MI 3 Dancing with Discord

MI 2 Rolling with ResistanceS

Deconstructing Resistance

Resistance (MI2)

Sustain Talk Discord

(MI3)

⁺ Symptom of relationship/ disengagement

⁺ How we respond to sustain talk is often the culprit

⁺ Righting reflex

Discord: It is about you

Signs of Discord ‣Defending

‣Squaring Off

‣Interrupting

‣Disengagement

‣Arguing

‣Reflect, reflect, reflect ‣Emphasize autonomy ‣Apologize ‣Affirm

Dancing with Discord

Specific strategies

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

Thank You For

Joining Us!

Upcoming Event Addressing the Mental Health Needs of Children with

Incarcerated Parents June 27, 2018 | 12-1pm

Visit http://ctacny.org for more information