Motivational InterviewingMotivational Interviewing

Mary Marden Velasquez, Ph.D.Mary Marden Velasquez, Ph.D.Associate Dean for ResearchAssociate Dean for Research

Director, Center for Social Work ResearchDirector, Center for Social Work ResearchDirector, Health Behavior Research and Training InstituteDirector, Health Behavior Research and Training Institute

The University of Texas at AustinThe University of Texas at Austinvelasquez@mail.utexas.eduvelasquez@mail.utexas.edu

Kirk von Sternberg, Ph.D.Kirk von Sternberg, Ph.D.Associate Director, Health Behavior Research and Training InstituteAssociate Director, Health Behavior Research and Training Institute

School of Social WorkSchool of Social WorkThe University of Texas at AustinThe University of Texas at Austinvonsternberg@mail.utexas.eduvonsternberg@mail.utexas.edu

Health Behavior Research Health Behavior Research and Training Instituteand Training Institute

Specializes in the development and implementation of Specializes in the development and implementation of interventions using the Transtheoretical Model (TTM) and interventions using the Transtheoretical Model (TTM) and Motivational Interviewing (MI) and in the training and Motivational Interviewing (MI) and in the training and supervision of providers in the field who address behavior supervision of providers in the field who address behavior change on the front lines.change on the front lines.

Our intervention research has targeted HIV and safer Our intervention research has targeted HIV and safer sexual practices, prenatal health, alcohol, cocaine, sexual practices, prenatal health, alcohol, cocaine, smoking, STI testing, and fetal alcohol spectrum disorder. smoking, STI testing, and fetal alcohol spectrum disorder. The HBRT Institute has a history of providing training, The HBRT Institute has a history of providing training, supervision, and “coaching” on the TTM, MI, and supervision, and “coaching” on the TTM, MI, and evidence-based intervention and prevention approaches, evidence-based intervention and prevention approaches, with a recent emphasis on teaching health care providers with a recent emphasis on teaching health care providers to use brief motivational interventions in medical settings. to use brief motivational interventions in medical settings. Collaborators include state, federal, and international Collaborators include state, federal, and international governmental agencies.governmental agencies.

HBRT: A Brief HistoryHBRT: A Brief History

University of Houston- Department of PsychologyUniversity of Houston- Department of Psychology

University of Texas Medical School at Houston- Department of University of Texas Medical School at Houston- Department of Family and Community MedicineFamily and Community MedicineDirector of ResearchDirector of Research

University of Texas Health Science Center at Houston School of University of Texas Health Science Center at Houston School of Public Health (cross appt)Public Health (cross appt)

University of Texas-Austin School of Social WorkUniversity of Texas-Austin School of Social WorkProfessor, Associate Dean for ResearchProfessor, Associate Dean for Research

Center for Social Work ResearchCenter for Social Work ResearchDirectorDirector

Health Behavior Research and Training InstituteHealth Behavior Research and Training InstituteDirectorDirector

Stages of

Change

University of Texas Medical School at

Houston

Motivational InterviewingMotivational Interviewing

Motivational Interviewing is a directive, client-centeredcounseling style that enhances motivation for change byhelping the client clarify and resolve ambivalence aboutbehavior change.

The Goal of Motivational Interviewing is to create andamplify discrepancy between present behavior and broadergoals.

Create cognitive dissonance between

where one is and where one

wants to be

The Transtheoretical ModelThe Transtheoretical Model

Offers an integrative framework for Offers an integrative framework for understanding, measuring, and understanding, measuring, and intervening in patients’ health behaviorsintervening in patients’ health behaviors

Clinicians assess clients’ readiness to Clinicians assess clients’ readiness to change and enhance motivation through change and enhance motivation through a series of techniques, depending on the a series of techniques, depending on the clients’ stage of readinessclients’ stage of readiness

Why Motivational Interviewing?Why Motivational Interviewing?

Evidence-based >120 clinical trialsEvidence-based >120 clinical trials Relatively briefRelatively brief SpecifiableSpecifiable Grounded in testable theoryGrounded in testable theory With specifiable mechanisms of actionWith specifiable mechanisms of action Generalizable across problem areasGeneralizable across problem areas Complementary to other treatment methodsComplementary to other treatment methods Verifiable – Is it being delivered properly?Verifiable – Is it being delivered properly? Can be delivered by non-specialistsCan be delivered by non-specialists

What do we know?

•MI triggers reliable aggregate change across a range of target problems,

settings, and providers

Motivational Interviewing Assumptions – I

Motivation is a state of readiness to change, which may fluctuate from one time or situation to another. This state can be influenced.

Motivation for change does not reside solely within the client.

The counselor’s style is a powerful determinant of client resistance and change. An empathic style is more likely to bring out self-motivational responses and less resistance from the client

Motivational Interviewing Assumptions – II

People struggling with behavioral problems often have fluctuating and conflicting motivations for change, also known as ambivalence. Ambivalence is a normal part of considering and making change and is NOT pathological

Each person has powerful potential for change. The task of the counselor is to release that potential and facilitate the natural change process that is already inherent in the individual.

Stages of ChangeStages of Change

PrecontemplationPrecontemplation- - Not ready to changeNot ready to change ContemplationContemplation- - Thinking about changingThinking about changing Preparation-Preparation- Preparing to changePreparing to change Action- Action- Actively changingActively changing Maintenance- Maintenance- Continuing to support theContinuing to support the

changechange Relapse-Relapse- Slipping back to the previous Slipping back to the previous

behaviorbehavior

Stages of Change

Working with Clients Working with Clients Who are Not Ready to Who are Not Ready to ChangeChange

Components of MI Components of MI SpiritSpirit

AA = = AutonomyAutonomy

CC = Collaboration = Collaboration

EE = Evocation = Evocation

AutonomyAutonomy – Responsibility for change is – Responsibility for change is left with the client, hence there is left with the client, hence there is respect for the individual’s autonomy. respect for the individual’s autonomy. The clients are always free to take our The clients are always free to take our advice or not. When motivational advice or not. When motivational interviewing is done properly, it is the interviewing is done properly, it is the client rather than the counselor who client rather than the counselor who presents the arguments for change.presents the arguments for change.

Underlying the Underlying the Spirit of Motivational Spirit of Motivational InterviewingInterviewing

is: is:

CollaborationCollaboration - In motivational interviewing, - In motivational interviewing, the counselor does not assume an the counselor does not assume an authoritarian role. The counselor seeks to authoritarian role. The counselor seeks to create a positive atmosphere that is create a positive atmosphere that is conducive to change.conducive to change.

Evocation Evocation -- Consistent with a collaborative Consistent with a collaborative role, the counselor’s tone is not one of role, the counselor’s tone is not one of imparting things, such as wisdom or insight, imparting things, such as wisdom or insight, but rather but rather elicitingeliciting – finding these things – finding these things within and drawing them out from the person. within and drawing them out from the person.

Using OARS Micro-Using OARS Micro-skillsskills

Eliciting Change TalkEliciting Change Talk The idea in MI is to have the client The idea in MI is to have the client

present arguments for both sides in present arguments for both sides in making changes. It is the making changes. It is the interviewer’s task to facilitate the interviewer’s task to facilitate the client’s expression of such change client’s expression of such change talk. This is a process of shared talk. This is a process of shared decision-making, not an attempt to decision-making, not an attempt to manipulate or sculpt the client’s will. manipulate or sculpt the client’s will.

Eliciting Change TalkEliciting Change Talk

DD = Desire for change= Desire for change

AA = Ability to change= Ability to change

RR = = Reasons for changeReasons for change

NN = = Need for ChangeNeed for Change

CC = = Commitment to ChangeCommitment to Change

The Flow of Change TalkThe Flow of Change Talk

Desire Desire

Ability Ability

Reasons Reasons

Need Need

Commitment Commitment

ChangeChange

MI

Therapists Influence Client Therapists Influence Client MotivationMotivation

Expectations influence outcomesExpectations influence outcomes Differences in drop-out ratesDifferences in drop-out rates Differences in outcome ratesDifferences in outcome rates Simple actions decrease drop-Simple actions decrease drop-

outout Empathic therapists have better Empathic therapists have better

outcomesoutcomes

Qualities of a Good Motivational Qualities of a Good Motivational CounselorCounselor

Respect for individual Respect for individual differencesdifferences

Tolerance for disagreement Tolerance for disagreement and ambivalenceand ambivalence

Patience with gradual Patience with gradual approximationsapproximations

Genuine caring and interest in Genuine caring and interest in clients servedclients served

MI - Like DancingMI - Like Dancing

Not WrestlingNot Wrestling

Eight Stages in Learning Eight Stages in Learning MIMI

1.1. The spirit of MIThe spirit of MI2.2. OARS – Client-centered counseling skillsOARS – Client-centered counseling skills3.3. Recognizing and reinforcing change talkRecognizing and reinforcing change talk4. Eliciting and strengthening change talk4. Eliciting and strengthening change talk5.5. Rolling with resistanceRolling with resistance6.6. Developing a change planDeveloping a change plan7.7. Consolidating client commitmentConsolidating client commitment8.8. Shifting flexibly between MI and other methodsShifting flexibly between MI and other methods

Miller, W. R., & Moyers, T. B. (in press). Eight stages in learning Miller, W. R., & Moyers, T. B. (in press). Eight stages in learning motivational interviewing. motivational interviewing. Journal of Teaching in the AddictionsJournal of Teaching in the Addictions..

00 10 10

Importance RulerImportance Ruler

How important is it to you to quit smoking?How important is it to you to quit smoking?

If 0 was “not important,” and 10 was “very important,” If 0 was “not important,” and 10 was “very important,” what number would you give yourselfwhat number would you give yourself ??

Exploring ImportanceExploring Importance

Why are you at x and not y? Or, how Why are you at x and not y? Or, how did you get from x to y? (always did you get from x to y? (always start with the higher number) start with the higher number)

What would have to happen for it to What would have to happen for it to become much more important for become much more important for you to change?you to change?

What would have to happen before What would have to happen before you seriously considered changing?you seriously considered changing?

Why have you given yourself such a Why have you given yourself such a high score on importance?high score on importance?

What would need to happen for What would need to happen for your importance score to move up your importance score to move up from x to y?from x to y?

What stops you moving up from x What stops you moving up from x to y?to y?

What are the good things about your What are the good things about your tobacco use? tobacco use?

What are some of the less good things?What are some of the less good things?

What concerns do you have about your What concerns do you have about your tobacco use? tobacco use?

If you were to change, what would it be If you were to change, what would it be like?like?

Where does this leave you now?Where does this leave you now?– Use this when you want to ask about change in a Use this when you want to ask about change in a

neutral way)neutral way)

Confidence RulerConfidence Ruler

If you decided right now to quit smoking , how confident If you decided right now to quit smoking , how confident do you feel about succeeding with thisdo you feel about succeeding with this? ?   If 0 was ‘not confident’ and 10 was ‘very confident’, what number If 0 was ‘not confident’ and 10 was ‘very confident’, what number would you give yourself?would you give yourself?

00 10 10

The Health Behavior Research The Health Behavior Research and Training Instituteand Training Institute

Motivational Interviewing Training and Motivational Interviewing Training and CoachingCoaching

TrainingTraining

The HBRT Institute specializes in the training and The HBRT Institute specializes in the training and supervision or coaching of providers in the field supervision or coaching of providers in the field who address behavior change on the front lines. who address behavior change on the front lines.

The organizations HBRT has worked with include:The organizations HBRT has worked with include:– NIH (NIAAA, NIDA, NHLBI, NIAID) and CDCNIH (NIAAA, NIDA, NHLBI, NIAID) and CDC– SAMHSA/TDSHS SAMHSA/TDSHS – Harris County Hospital District Harris County Hospital District – Family Medicine Residency programs in Georgia and Family Medicine Residency programs in Georgia and

Texas Texas – ATC-MHMR ATC-MHMR – CPS/Children and Families CPS/Children and Families – Federal Bureau of PrisonsFederal Bureau of Prisons– And many others And many others

TrainingTraining

Our challenge at the HBRT Institute is to:Our challenge at the HBRT Institute is to:– Meet the specific training and supervision needs of our Meet the specific training and supervision needs of our

community providerscommunity providers– Help ensure sustained treatment fidelityHelp ensure sustained treatment fidelity– Facilitate wide-spread disseminationFacilitate wide-spread dissemination of evidence-based of evidence-based

practices practices

Our system of training & coaching:– Is targeted to the individual needs of the community

providers – Is practical and efficient. – Maximizes the productivity of the expert Institute Coaches– Bridges geographical and time barriers between the expert

Coaches and professionals being trained– Utilizes available technologies (i.e. secure, personal

website) for training & coaching

Implementing Evidence-Implementing Evidence-Based Brief MI InterventionBased Brief MI Intervention

InSightInSight

The InSight SBIRT model was implemented in The InSight SBIRT model was implemented in eight Harris County Hospital District (HCHD) eight Harris County Hospital District (HCHD) locations, including emergency departments, locations, including emergency departments, community clinics, and school-based clinics. community clinics, and school-based clinics.

The role of HBRT included the development of The role of HBRT included the development of the Specialist training as well as ongoing the Specialist training as well as ongoing coaching to insure the treatment fidelity and coaching to insure the treatment fidelity and sustainability in community medical settings.sustainability in community medical settings.

Evidence-Based SBIRT Evidence-Based SBIRT InterventionIntervention

Project providers are trained to use a brief Project providers are trained to use a brief version of Motivational Interviewing (MI) version of Motivational Interviewing (MI) tailored to the medical setting. tailored to the medical setting.

““Brief InterventionsBrief Interventions” (BI), consisting of one to ” (BI), consisting of one to five short motivational sessionsfive short motivational sessions

““Brief TreatmentBrief Treatment” (BT), one to twelve MI ” (BT), one to twelve MI sessions, to promote reduction and/or sessions, to promote reduction and/or cessation of substance use. Sessions are cessation of substance use. Sessions are adapted from a substance abuse treatment adapted from a substance abuse treatment manual based on the Transtheoretical Model’s manual based on the Transtheoretical Model’s stages and processes of change stages and processes of change (Velasquez, (Velasquez, Maurer, Crouch & DiClemente, 2001)Maurer, Crouch & DiClemente, 2001)

Comprehensive Training Comprehensive Training System for SpecialistsSystem for Specialists

Motivational Interviewing trainingMotivational Interviewing training– InSight Specialists (social workers, InSight Specialists (social workers,

nurses, master’s level counselors, nurses, master’s level counselors, licensed chemical dependency licensed chemical dependency counselors) received a series of training counselors) received a series of training workshopsworkshops

Standardized Patient training Standardized Patient training – initial and booster trainingsinitial and booster trainings

Quarterly in-service trainingsQuarterly in-service trainings

Treatment Fidelity - Treatment Fidelity - CoachingCoaching

CoachingCoaching• On-going support from highly skilled MI On-going support from highly skilled MI

“Coaches.” “Coaches.” • Sessions are digitally recorded Sessions are digitally recorded • Coaches meet with Specialists monthly to:Coaches meet with Specialists monthly to:

• discuss cases, discuss cases, • practice using role-plays, practice using role-plays, • provide feedback from audiotape reviewprovide feedback from audiotape review

• The Specialists proficiency with MI skills is The Specialists proficiency with MI skills is evaluated quarterly by the Coaching team evaluated quarterly by the Coaching team using the “Motivational Interviewing Treatment using the “Motivational Interviewing Treatment Integrity Skill Coding System (MITI).” Integrity Skill Coding System (MITI).”

Coaches’ Quarterly Report Date _____________Specialist __________________________ Coach ________________________

1. Session Checklist Average __________2. MI Spirit Average __________3. MI Empathy Average __________4. Average of MITI Behavior Counts

Ratio of Reflections to Questions(1:1 minimal competence) __________

% Open Questions of all Questions(50% minimal competence) __________

[OQ/{OQ+CQ}]

% MI Adherent(90% MI-A minimal competence) __________

[MiA/ (MiA+MiNa)]

5. MI Scale Average __________Overall Rating (circle one): Red-lined Needs Improvement Acceptable Proficient

0 1 2 3 4 5 6 7Comments:Number of Tapes Turned in ________ Number of tapes used for ratings

________Number of Taping Agreement Forms: Agreed ______ Declined ______ Total

______

Sustaining the Coaching ModelSustaining the Coaching Model

Peer Specialist CoachPeer Specialist Coach

Coaching of Specialists is conducted by the on-site peer Specialist Coaches

Specialist Coaches receive ongoing support from Institute Coaches through:

1. Web-based tape review2. Monthly consults3. Booster Workshops

Sustaining the CoachingSustaining the Coaching

Each New Specialist and Specialist Coach has a private secure web-site, shared only with their assigned Institute Coach, for session tape review and feedback.

Tailored Training and Coaching Models

1. Counseling Front-Line Professionals:• Initial training – MI Principles, Skills Training, Role

Plays• Standardized Patient Training – Practicing the

principles and the skills• Coaching – On-going coaching and feedback • Follow-up training – Checking progress and

training on advanced MI strategies

2. Non-clinical staff• Initial training – MI Principles Initial training – MI Principles

3.3. Peer CoachesPeer Coaches• Initial training – advanced strategies, session Initial training – advanced strategies, session

coding and feedback training coding and feedback training

Conclusions

1. Comprehensive training and monitoring procedures are required to sustain the integrity of an MI intervention.

2. The wide-spread transfer of a research-based brief MI intervention into a number of varied settings is feasible.

3.3. The training and coaching model can be adapted to The training and coaching model can be adapted to any number of settings and behaviorsany number of settings and behaviors

4.4. Professionals in medical and other community Professionals in medical and other community settings can influence patient outcomes, resulting in settings can influence patient outcomes, resulting in significant health behavior change and significant health behavior change and corresponding cost-savings.corresponding cost-savings.