Motivational Interviewing

Richard Rawson, Ph.D.Pacific Southwest ATTC

UCLA Integrated Substance Abuse Programs2008

Traditional approach (1)

• Change is motivated by discomfort.• If you can make people feel bad enough, they

will change.• People have to “hit bottom” to be ready for

change• Corollary: People don’t change if they haven’t

suffered enough

The Stick

Traditional approach (2)

If the stick is big enough,

there is no need for a carrot.

You better!Or else!

Traditional approach (3)

Someone who continues to use is “in denial.”

The best way to “break through” the denial is direct confrontation.

Another approach: Motivating (1)

• People are ambivalent about change

• People continue their drug use because of their ambivalence

The carrot

Another approach: Motivating (1)

• Motivation for change can be fostered by an accepting, empowering, and safe atmosphere

The carrot

Ambivalence

Ambivalence: Feeling two ways about something.

– All change contains an element of ambivalence.

– Resolving ambivalence in the direction of change is a key element of motivational interviewing

Why don’t people change?

What is the problem?

It is NOT that…• they don’t want to see (denial)• they don’t care (no motivation)

They are just early in the stages of change

Addiction is a brain disease that disables the brain from functioning normally in areas such as motivation, attention, perception, memory, planning, etc.

Activity 1: ReflectionTake some time to think about the most

difficult change that you had to make in your live.

How much time did it take you to move from considering that change to actually taking action.

Stages of ChangeRecognizing the need to change and

understanding how to change doesn’t happen all at once. It usually takes time and patience.

People often go through a series of “stages” as they begin to recognise that they have a problem.

Helping people change (1)

Helping people change involves increasing their awareness of their need to change and helping them to start moving through the stages of change.

– Start “where the client is” – Positive approaches are more effective than

confrontation – particularly in an outpatient setting.

Helping people change (2)

Motivational interviewing is the process of helping people moving through the stages of change.

First Stage: Pre-contemplation

People at this stage:

• Are unaware of any problem related to their drug use

• Are unconcerned about their drug-use

• Ignore anyone else’s belief that they are doing something harmful

Second Stage: ContemplationPeople at this stage are considering whether or

not to change:

• They enjoy using drugs, but

• They are sometimes worried about the increasing difficulties the use is causing.

• They are constantly debating with themselves whether or not they have a problem.

Third Stage: Determination/preparation

People at this stage aredeciding how they aregoing to change

• May be ready to change their

behaviour

• Getting ready to make the change

It may take a long time to move to the next stage (action).

?

Fourth Stage: Action

People at this stage:

• Have begun the process of changing

• Need help identifying realistic steps, high-risk situations, and new coping strategies

Fifth Stage: MaintenancePeople in this stage:

– Have made a change and

– Are working on maintaining the change

RelapsePeople at this stage have reinitiated the

identified behaviour.

• People usually make several attempts to quit before being successful.

• The process of changing is rarely the same in subsequent attempts. Each attempt incorporates new information gained from the previous attempts.

RelapseSomeone who has relapsed

is NOT a failure!

Relapse is part of the recovery process.

Principles of Motivational Interviewing

Principles of Motivational Interviewing

Motivational interviewing is founded on 4 basic principles:

– Express empathy

– Develop discrepancy

– Roll with resistance

– Support self-efficacy

Principle 1: Express empathy

• The crucial attitude is one of acceptance

• Skilful reflective listening is fundamental to the client’s feeling understood and cared about.

• Client ambivalence is normal; the clinician should demonstrate an understanding of the client’s perspective

• Labelling is unnecessary

Example of expressing empathy

I am so tired that I cannot even sleep…

So I drink some wine.You drink

wine to help you sleep.

…When I wake up…I am too late for work already…

Yesterday my boss fired me.

So you are concerned about not

having a job.

...but I do not have a drinking problem!

Principle 2: Develop discrepancy

• Clarify important goals for the client

• Explore the consequences or potential consequences of the client’s current behaviours.

• Create and amplify in the client’s mind a discrepancy between current behaviour and life goals

Example of developing discrepancy

Well…as I said, I lost my job

because of my drinking problem…

and I often feel sick.

I only enjoy having some drinks with my friends…that’s all. Drinking helps me relax and have fun…I think that I deserve that for a change…

So drinking has some good things for you…Now tell me about the not-so-good things you have experienced because of drinking.

Principle 3: Roll with resistance

• Avoid resistance

• If it arises, stop and find another way to proceed

• Avoid confrontation

• Shift perceptions

• Invite, but do not impose, new perspectives

• Value the client as a resource for finding solutions to problems

Example of NOT rolling with resistance

You do not have the right to judge

me. You don’t understand me.

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

But, Anna, I think it is clear that drinking has caused you problems.

Example of rolling with resistance

That’s right, my mother thinks that I have a problem, but

she’s wrong.

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

You do have a drinking problem

Others may think you have a

problem, but you don’t.

Principle 4: Support self-efficacy

• Belief in the ability to change (self-efficacy) is an important motivator

• The client is responsible for choosing and carrying out personal change

• There is hope in the range of alternative approaches available

Example of supporting self-efficacy

I hope things will be better this

time. I’m willing to give it a try.

I am wondering if you can help me. I have failed many

times.

Anna, I don’t think you have failed because you

are still here, hoping things can be better. As long as you are willing to stay in the process, I will support you. You have been successful before and you will be again.

OARS

The OARS are the skills that can be used by interviewers to help move clients through the process of change.

Open-ended questions

Affirmation

Reflective listening

Summarising

OARS: Open-ended questions

• “Are there good things about using?” vs.

–“What are the good things about your substance use?”

• “Are there bad things about using?” vs.

–“Tell me about the not-so-good things about using”

• “Do you have concerns about your substance use?” vs.

–“You seem to have some concerns about your substance use. Tell me more about them.”

• “Do you worry a lot about using substances?” vs.

–“What most concerns you about that?”

Close Versus Open-ended questions:

OARS: Affirmation• “Thanks for coming today.”

• “I appreciate that you are willing to talk to me about your substance use.”

• “You are obviously a resourceful person to have coped with those difficulties.”

• “That’s a good idea.”

• “It’s hard to talk about....I really appreciate your keeping on with this.”

OARS: Reflective listening

Reflective listening is used to:

• Check out whether you really understood the client

• Highlight the client’s ambivalence about their substance use

• Steer the client towards a greater recognition of her or his problems and concerns, and

• Reinforce statements indicating that the client is thinking about change.

OARS: Summarize

Summarizing is an important way of gathering together what has already been said, making sure you understood the client correctly, and preparing the client to move on. Summarising is putting together a group of reflections.

Motivational Interviewing

Eliciting Change Talk

OARS: What is “change talk”?

Change talk: An indication that you are successfully using motivational interviewing.

If you are using MI successfully you will hear statements that indicate the client:

1. Recognises the disadvantages of staying the same

2. Recognises the advantages of change

3. Expresses optimism about change

4. Expresses the intention to change

Helping to elicit “change talk” (1)

Ask the client to clarify their statements or elaborate: – “Describe the last time this happened,”

– “Give me an example of that,” or “Tell me more about that.”

Helping to elicit “change talk” (2)

Ask the client to imagine the worst consequences of not changing and the best consequences of changing.

Helping to elicit “change talk” (3)

Explore the client’s goals and values to identify discrepancies between the client’s values and their current substance use. – “What are the most important things in

your life?”

Contingency Management

…also known as

Motivational Incentives

The Problem: Allure of Immediate Drug Reinforcement

AmbivalenceAmbivalence

Solution: Methods to Enhance Motivation for

Abstinence

• Natural aversive consequences (“hitting bottom”)

• Feedback re problems/consequences- Confrontation- Motivational Enhancement Therapy

• Positive reinforcement for behavior change

Part 1:Part 1:Behavior can be modified by:Behavior can be modified by:

PunishmentsPunishmentsRewardsRewards

Rewards to shape behavior in Rewards to shape behavior in everyday life…….everyday life…….

• Child rearingChild rearing• Praise, money, foodPraise, money, food

• EducationEducation • Grades and honorsGrades and honors

• Business and work settingsBusiness and work settings• Bonuses and promotions Bonuses and promotions

• Criminal justiceCriminal justice• Early release for good behavior Early release for good behavior

Examples of PunishersExamples of Punishers•Child rearingChild rearing

•Time out, groundingTime out, grounding

•EducationEducation

•Bad grades, detention, Bad grades, detention, suspensionsuspension

•Business and work Business and work settingssettings

•Demotions Demotions

•Criminal justiceCriminal justice

•Fines, tickets, jailFines, tickets, jail

Rewards Rewards versus versus

PunishmentsPunishments

Both can change Both can change behavior…..behavior…..

But most people But most people prefer rewards.prefer rewards.

PunishmentsPunishments

• Do no teach what to do; only what not to do.• Promote harsh and demeaning atmosphere.• May also do harm (e.g. promote aggression).• In criminal just settings, punishers often do not occur

immediately after the inappropriate behavior.• Often the inappropriate behavior occurs multiple times

prior to the punishment. Punishment, when delivered inconsistently, can actually encourage inappropriate behaviors.

RewardsRewards

• • Teach new behaviors and Teach new behaviors and promote growthpromote growth

• • Promote self-esteem and self-Promote self-esteem and self-confidenceconfidence

• Promote positive atmosphere & Promote positive atmosphere & communicationcommunication

Incentives in Health Care Incentives in Health Care

• Mammography Mammography screeningscreening

• Child immunizationChild immunization

BREAST CANCERBREAST CANCERMammography ScreeningMammography Screening

Recommendation for Women Ages 50 and older:Recommendation for Women Ages 50 and older:

ANNUAL MAMMOGRAMANNUAL MAMMOGRAM

With physician advice alone, few women receive With physician advice alone, few women receive an annual mammogram an annual mammogram (Stoner et al., 1998)(Stoner et al., 1998)

Mammogram ComplianceMammogram Compliance

0%

20%

40%

60%

Incentive No Incentive

Rat

e of

Com

pli

ance

Rat

e of

Com

pli

ance

Rates of mammogram screening were 2.5 times higher for the Rates of mammogram screening were 2.5 times higher for the incentive as compared to the control women. incentive as compared to the control women. (Stoner et al., 1998)(Stoner et al., 1998)

ChildhoodImmunizations

In 1989-91, immunization rateswere as low as 23% for two-yearolds in the Chicago area.

Immunization Rates

0%

20%

40%

60%

80%

100%

Voucher Control

Rat

e

Rates increased when WIC food vouchers were given to those who had their children immunized. (Hoekstra et al., 1998)

Incentives in Incentives in Substance Abuse TreatmentSubstance Abuse Treatment

AA

AA

AA

Incentives in Incentives in Drug Abuse TreatmentDrug Abuse Treatment

PositivePositive NegativeNegative- award ceremonies- award ceremonies - extra therapy - extra therapy

- certificates; key chains- certificates; key chains - time restriction - time restriction

- status/recognition- status/recognition - dismissal - dismissal

- - take-homes in methadone - probation, referral take-homes in methadone - probation, referral to judge to judge

By increasing rewards in By increasing rewards in substance abuse treatment….substance abuse treatment….

we may be able we may be able to enhanceto enhanceoutcomes.outcomes.

More patientsMore patients• attend treatmentattend treatment

• stay cleanstay clean

Patient attendsPatient attendstreatment,treatment,

Gives negative samplesGives negative samples

Give IncentiveGive Incentive

How Incentives How Incentives Could Work For YouCould Work For You

•stay out of jail!stay out of jail!

ContingencyContingencyManagementManagement

Making abstinence a more Making abstinence a more

attractive option through attractive option through

positive reinforcement of positive reinforcement of

behavior changebehavior change

It is theIt is the CONTINGENCYCONTINGENCY

that matters……….that matters……….

BEHAVIORBEHAVIOR REWARDREWARD

Giving things away for free Giving things away for free does NOT change behaviordoes NOT change behavior

Later Studies: Motivational Incentives with Monetary

Rewards

Research has shown that monetary incentives can : • Increase treatment retention • Decrease drug use during treatment

Motivational Incentives Research with Vouchers

• Vouchers earned for achieving therapeutic goals– e.g. cocaine-free urines

• Vouchers are worth money• Vouchers are exchanged for

– retail items (e.g. clothing, sports equipment)– services (e.g. rent; bill payments)

Research on Motivational Incentives

Cocaine Alcohol Marijuana

Motivational IncentivesMotivational Incentives

Research studies haveResearch studies havetested incentives fortested incentives forability to improve ability to improve drug abusedrug abusetreatment outcomes treatment outcomes and shown they workand shown they work

Addressing the Cost Barrier

• Society can’t afford this

• Our program can’t afford this

Steps to designing a contingency management intervention

• 1. Pick a behavior you want to change• 2. Pick a reinforcer• 3. Design a monitoring and reinforcing

schedule and decide upon a time frame for re-assessment

• 4. Ensure consistent application of procedure

Implementation Guidelines• Typically, it is recommended that the contingency

management component of therapy be carried out in the first 5 minutes of the session, so therapy can proceed after the reward has been given (if achieved)

• Maintain a positive attitude, be encouraging, and remain non-confrontational

• Praise consumers for keeping their appointments (even when they are late or drug tests are positive)

Discontinuation of Contingency Management

Procedures• Providing incentives indefinitely can be

expensive and the benefits of contingency management may decrease over time

• Most contingency management programs offer incentives for at least 3 months

• At the end of the contingency management treatment, the reinforcement scheduled should be tapered off or eliminated entirely

• Little research is available to provide support for which method is optimal

Suggestions for the Discontinuation of

Contingency Management Procedures

• Consumers should be informed about how long the incentives will last

• During the final 1-2 weeks speak with the consumer about how they feel about maintaining the behavior after the incentives end

• At this point the consumer can be reminded of their progress throughout the course of treatment

• Providing a certificate of completion is a popular approach when incentives are discontinued

The End