Theories of Change Brentwood Hospital 4/23/14
Feb 22, 2016
Theories of Change
Brentwood Hospital4/23/14
Agenda• Intro: Getting this into Context• Description of Motivational Interviewing
Techniques:1. Eliciting change talk2. Identifying readiness to change3. I CAN summaries
ContextWhere are we?
You are here.
Substance Use Stats
Evolution of Treatment Approaches
Old SchoolBreak’em down and
Build’em up.
Evidence BasedClient-centered
Cognitive-BehavioralFamily Therapies
Motivational Interviewing
Getting MotivatedOverview of MI
Your Challenge is . . . • Lose weight• Eat healthy• Exercise• Stop smoking• Kick that heroin habit once and for all!
History of Motivational ApproachesTranstheoretical
Model of the Stages of Change
• Mostly Theoretical • Prochaska &
DiClemente
Motivational Interviewing
• Mostly Application• Miller & Rollnick
Stages of Change
• Pre-contemplation• Contemplation• Preparation• Action•Maintenance
Motivational Interviewing
Evocation MI Spirit
Change Talk
MI Principl
es
AutonomyCollaboration
Resist righting reflexUnderstand motivationListenEmpower
Open-ended QuestionsAffirmationReflective ListeningSummaries
Help clients articulate reasons for change.
OARS
MI Spirit & Principles
Resist righting reflexUnderstand motivationListenEmpower
AutonomyCollaborationEvocation
OARS Skills & Change Talk
Eliciting change talk.
Open QuestionsAffirmationReflective ListeningSummaries
What NOT to Do!• Convincing clients that they have a problem• Arguing for benefits of change• Telling clients how to change• Warning them of consequences of not
changing
Practice Everything so FarUpset Client: They told me I have to make 90 AA meetings in 90 days! That is just not going to happen- I can’t even sit through one meeting.Response: Oh come on, its not that bad. Don’t you want to get better?
1
Another oneClient: So my family has this “get together” and they all sit around and tell me how I am an alcoholic. Like none of them ever gets drunk.Response: If it looks like a duck and quacks like a duck its probably a duck. All those people can’t be wrong. You’re probably in denial, don’t you think?
2
Eliciting Change Talk
Change Talk• Represents statements about change• Linked to a specific behavior or goal• Comes from the client• Refers to present situation
Continuum of Change• I wish things were different Desire• I know how to change Ability• It would be great if I changed Reason• I really need to change Need• I am going to change
Commitment/Taking Steps
Evocative Questions• In what ways does this concern you?• How would you like things to be different?• How would things be better if you changed?
1
Elaboration• Tell me about a time you . . . (engaged in
maladaptive behavior)• What does it look like when you . . . . • Tell me about a time before you . . .
2
Using ExtremesWorst outcome vs. best outcome
What concerns you the most?What is the worst that could happen?What do you hope for the most?What would a perfect outcome be?
3
Looking Back• Do you remember a time when things were going
well? What has changed?• What did you want to do when you graduated from
high school?• What is the difference between you now and you
twenty years ago?
4
Looking Forward• If nothing changes, what do you see happening in
5 years? If you decide to change, what will it be like?• What are your hopes for the near future?
5
Exploring GoalsUse value card sort
• What are some things you regard as important? How does drinking fit in with that?• What sorts of things do you want to accomplish in
your life?
(Miller, Baca, Matthews, Wilbourne, 2001)
6
Use Feedback• Your scores on the MoCA (or MSE) indicate that
you have moderate deficits in problem solving and memory. How does that fit with your own experience?
7
Readiness Rulers• On a scale of 1-10, how confident* are you – if you
made a decision to change – that you could change, when 1=not at all confident and 10= extremely confident?• What led you to choose 6 rather than a 3?• What would it take to move from a 6 to a 7 or 8?
* or important
8
Your Turn• Which of the previous techniques would
work best (if at all) with your change challenge?• How do you feel when thinking about your
challenge?
Which would you use?• Evocative Questions• Elaboration• Using Extremes• Looking
Back/Forward
• Exploring Goals• Use Feedback• Readiness Rulers
Identifying Readiness
Signs of Readiness• Decreased resistance• Decreased
discussion• Resolve• Change talk
• Questions about change• Envisioning• Experimenting
Identifying ReadinessSo, what do other people say about this? I just can’t believe that people just cave in when they hear recommendations sending them to a halfway house. • Signs?• Your reasoning:
1
Identifying ReadinessI agree it would be good to make some different choices that have less risk, but I also like to have fun with my friends. I have too much fun with them. • Signs?• Your reasoning:
2
Identifying ReadinessYou don't understand. These guys aren't going to take "No, thanks" for an answer. They're going to hound me. I've got to come back with something stronger. • Signs?• Your reasoning:
3
Dealing with Ambivalence
The ‘I CAN’ StrategyIndicate this is a summary, and include • Change talk, • Ambivalence, and then ask about the • Next step.
Ambivalence Strategies: ICAN“I still think weed is not as bad as people say, at least its not like cocaine. Maybe smoking has affected my grades, I don’t know. I’ve been thinking that maybe I should lay off for the rest of the semester or until I get my grades up. But weed really helps me relax and I need that."
1
Ambivalence Strategies: ICAN"I didn't like the way I felt on the Suboxone. There were just too many side effects. So, I stopped. But I think I need to do something. Nothing feels good. I'm always anxious. I can never get comfortable. I’m thinking that eventually I’ll start using again. That's where I'm at now.”
2
Ambivalence Strategies: ICAN“When I first got the DWI I figured the cop was just a jerk- I hadn’t even had that much to drink. And then I went to look at my car that was impounded and I thought- how did I survive that? The thing was completely smashed in. I know I need to stop drinking but I just don’t know if I need inpatient treatment. Maybe I can do this on my own."
3
Continuing on as Before Making a ChangeBenefits Costs Costs Benefits
Helps me relax
Feel like I fit in
Don’t worry about the bills
Love the buzz I get
Legal Trouble Can’ see my
kids – wife won’t let me
Paying for my attorney and court costs
People don’t trust me
Won’t have a way to relax
What about my friends?
Life will be boring
Family would trust me again
Marriage would go better
Better at my job
More Money Get off
probation sooner
The Decision Matrix
Application to Other Areas• Medication adherence in mental health• Diabetes management• Eating disorders• Obsessive Compulsive Disorder• Suicidal Ideation
Discussion• Will you use this in your practice? Why or
Why not?• What population do you think will benefit the
most? The least?• If interested, what are your plans to learn
more?
Resources1. www.robinsteed.pbworks.com2. www.motivationalinterview.org• Worksheets, training materials
3. http://www.integration.samhsa.gov/clinical-practice/motivational-interviewing• Full text articles, webinars, SAMHSA TIPs, training manuals
4. www.researchgate.net/publication/231081405_Motivational_Interviewing_and_the_Stages_of_Change/file/9fcfd50b5f8c5af70e.pdf#page=305• Full text of Motivational interviewing: Preparing people for
change (2nd ed.).
References• Miller, W.R., ’de Baca, J. C Matthews, D.B. Wilbourne, P.L (2001). Personal Values Card Sort, University of
New Mexico. Available at http://www.motivationalinterviewing.org/content/personal-values-card-sort• Miller, W. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New
York: Guilford Press. Full text available: www.researchgate.net/publication/231081405_Motivational_Interviewing_and_the_Stages_of_Change/file/9fcfd50b5f8c5af70e.pdf#page=305
• National Institute for Health and Clinical Excellence (NICE). Alcohol-use disorders. Diagnosis, assessment and management of harmful drinking and alcohol dependence. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Feb. 54 p. (Clinical guideline; no. 115).
• Rosengren, D. (2009). Building motivational interviewing skills. New York: Guilford Press.• Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. (2011). Motivational
interviewing for substance abuse. Cochrane Database of Systematic Reviews, Issue 5, Art. No.: CD008063. DOI: 10.1002/14651858.CD008063.pub2.
• Substance Abuse and Mental Health Services Administration (2010). Getting started with evidence-based practices: Integrated treatment for co-occurring disorders. Evidence-Based Practice Series, Publication Id: SMA08-4367.
• www.motivationalinterview.org