Motivational Interviewing Introduction

Amy Shanahan, MS, CADCDirector of Clinical Care ServicesWestern Psychiatric Institute & Clinic of UPMCshanahana@upmc.edu

Jeff Geibel, PhDSenior Program DirectorAddiction Medicine ServiceDual Diagnosis ProgramWestern Psychiatric Institute & Clinic of UPMC geibelsj@upmc.edu

Motivational Interviewing

Historical Background

• William R. Miller, PhD–Steve Rollnicko Wrote first MI article in 1983o Collaborated and wrote the first MI book

• Influenced by Carl Rogers person-centered counselingo Congruence – genuineness & honestyo Empathy – feeling what the person is feelingo Respect – acceptance and unconditional positive regard

MI Studies160 Obesity

Dentaln = 150

120

140 Asthma Violence Family

100Health Prom Psychiatric Diabetes Cardiac HIVSmoking/TobAdh/Retention Eating Disorders Offenders Gambling Dual Dx

n = 93

60

80

n = 54

20

40

n = 6

n = 36

01988‐94 1995‐99 2000‐02 2003‐06 2007‐09

AOD

Important Findings• MI can be delivered effectively by health care

practitioners; professional role does NOT appear to affect its efficacy

• MI achieves it effects in ONE to FOUR sessions• Requires a “minimum dose” of about 20 minutes.• More sessions = Greater efficacy• Feedback and coaching + MI workshop = significant

improvement in clients’ responses.

Confrontation vs. Empathy• Miller, Benefield, & Tonigan (1993) reported drinking

outcomes at 12 months were strongly predicted by counselor style: o The more the counselor confronted, the more the client drank o Random assignment to counseling styles also strongly predicted the degree of

client “resistance” (higher with confrontation) o Expressed motivation for change (higher with MI)

Confrontation vs. Empathy• It matters what the clinician does• Confrontation undermines change• Given a brief motivational intervention, clients went

ahead and changed on their own without any treatment

• Clinician’s empathy predicts client change

MI Spirit• Partnership/Collaboration• Acceptance• Compassion • Evocation

- confrontation - authority- self-interest- education

OARS SkillsOpen-ended questionsAffirmation Reflective Listening (Heart of MI!!!!) Summary

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Open-Ended Questions• Are you doing OK?

o What has been good in your day so far?o Where would you like to start today?

• Are you married?o Tell me about the important relationships in your life?o What does your home situation look like?

• How much do you exercise on a typical occasion?o What does a typical exercise session look like for you?o Tell me about the physical activities you enjoy the most?

• Did you have a good day?o What did you talk about at lunch today?o What is something interesting or funny that happened today?

Affirmations• A person you see is here for the 3rd time this year. He continues to use

substances despite his efforts to cut down; one time completing detoxification treatment. While on the unit he has been swearing, disrespectful to some staff and keeps asking to go home.

1. Strengths: 1. He has made attempts to cut down several times.2. Despite potential embarrassment, he is here and accepting some medical

attention.

2. Affirmation:1. You are courageous and have taken some steps to consider changing.2. You are strong minded and know what you need to do.

Roadblocks to Listening• Praising

• Shaming

• Interpreting/analyzing

• Reassuring/consoling

• Questioning/Probing

• Distracting/changing the subject

• Directing

• Warning/threatening

• Giving advice

• Lecturing/arguing

• Preaching

• Judging

Handout – “Roadblocks worksheet”

Active Listening

Reflections• Simple Repeating (repeats an element of what the client said)

o Rephrasing (uses new words)

• Complex o Paraphrasing (makes a guess to unspoken meaning)o Reflection of feeling (a paraphrase that emphasizes the emotion through feeling

statements)o Metaphors and similes (Kind of like…; It’s as though…)o Double-sidedo Amplifiedo Continuing the sentence/paragraph

Reflections• I’m not sure I’ll be able to fit going to treatment appointments with my

busy schedule.

1. What is your first reaction to this statement?2. Using the SPIRIT of MI, provide a simple reflective statement in

response.

Practice Reflections• “I’m not sure I’ll be able to fit going to treatment

appointments in with my busy schedule.”

Provide an example of a complex reflection.o What might this person really be saying? o What might be the underlying feeling?o Example of a metaphor?o Might this person feel two ways about this? What double-sided reflection might you

consider?o Amplified?o Continuing the paragraph?

Summaries• Longer reflections that capture what the person is

sharing and can be used to:o Summarize key points.o Shift back to the topic.o End a session.

Example: Over the past year you’ve made attempts to change your substance use patterns, are here because of health complications and you are wondering how you might be able to juggle treatment so you don’t have to come back here again.

MI in Summary• MI is a Collaborative Conversation that,• Respects autonomy,• Focuses on ambivalence and,• Involves a “Spirit” and,• Tools to engage people in a discussion about

change.• OARS are the tools we can use.