Use of client-centered MI style MI strategies that can be integrated into the agency’s existing...
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Transcript of 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”
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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.
NIDA-SAMHSA Blending Initiative 4
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
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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
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1. People receiving MI assessment completed more sessions in 4 weeks than those receiving standard intake.
Research findings
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2. MI retained more people in treatment at the 4 week point than standard assessment.
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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
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Implementing MI may require:
Focused clinical supervisionAudio taped MI Assessment
sessions Tape coding Feedback, coaching and
instruction for improving skills
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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
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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
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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
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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
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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
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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
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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
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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
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Readiness for change involves both Importance and Confidence
Readiness can be assessed through
Basic Scaling Ruler
ClinicalInterview
Inventories to Assess Readiness
Readiness Ruler
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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
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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
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•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
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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
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MI Style and Spirit
Fostering a Collaborative Atmosphere
Open-ended Questions Affirmations
Reflective Statements
Skills Assessed by Self and Supervisor
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Motivation to Change
Developing Discrepancies
Pros, Cons and Ambivalence
Client-Centered Problem Discussion
and Feedback
Change Planning
Rating MI Adherence and Competence
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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
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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)
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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