Effecting Change
through the Use of
Motivational Interviewing
Thomas E. Freese, PhD
Pacific Southwest Addiction Technology Transfer Center
UCLA Integrated Substance Abuse Programs
UCLA David Geffen School of Medicine, Dept. of Psychiatry
www.psattc.org
www.uclaisap.org
Has anyone seen
my motivation?
What is
Motivation?
I think I lost it
somewhere
between here
and who cares!
Traditional approach
Motivating for change
UNDERSTANDING HOW
PEOPLE CHANGE: MODELS
Directing Style of Helping
•
•
•
•
•
•
•
•
Tell them it’s important
Show them how to do it
Explain it to them, how life could be better
Threaten them, instill fear
Give them short term goals
Make them a list
Constantly remind them
Tell them what you expect
A Different Approach:
The Guiding Style
Guiding Style of Helping
•
•
•
•
•
Respect their decisions
Have them to describe what is working
Ask them about their plan
Find out what’s important to them
Have them talk about their health and their
goals
•  Ask what their goals are for treatment
Guiding Style of Helping
•  Motivational Interviewing can be considered
a specialized subset of a Guiding style.
•  How does MI work to facilitate change?
–  Reduces resistance
–  Raises discrepancy
–  Elicits change talk
What is Motivational
Interviewing?
Developed by William Miller (U New Mexico), Stephen Rollnick (Cardiff University School of Medicine), and colleagues over the past three decades. Miller and Rollnick (2012, p. 29) define MI as: “a collaboraNve, goal-­‐oriented style of communicaNon with parNcular aPenNon to the language of change. It is designed to strengthen personal moNvaNon for and commitment to a specific goal by eliciNng and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” Everyone is
doing it!
In Combination
with Other EBT
Mental Health
Couples Treatment
Parents and Families
Eating Disorders
Adolescents/Young Adults
Medication Adherence
Criminal Justice/Probation
HIV-risk Behaviors
Treatment Engagement and Retention
Diet & Exercise (diabetic, hypertension)
Dual Diagnosis (psychosis, depression, anxiety)
Alcohol/Drug (cannabis, cocaine, heroin, nicotine)
Data on MI for SUD and Other Behaviors:
A meta analysis of 30 studies
0.7
Effect Size
0.6
0.5
0.4
0.3
0.2
0.1
0
Alcohol (BAC
Smoking
Cessation
Drug
Addiction
HIV-Risk
Behavior
Diet and
Exercise
Problem Area
Burke, B.L., Arkowitz, H., & Menchola, M. (2003). Journal of Consulting
MI in Medical Care Settings:
A Meta analysis of 48 studies with 9,681 participants
•  Overall a moderate advantage over
–  Waitlist (7 studies)
–  Information only (16 studies)
–  Treatment as usual (28 studies)
•  MI most promising for:
–  HIV viral load
–  dental outcomes
–  death rate
–  body weight
–  alcohol and tobacco use
–  sedentary behavior,
–  self-monitoring
–  confidence in change
•  MI less effective for:
–  eating disorder
–  self-care behaviors
–  some medical outcomes
(e.g., heart rate)
Lundahl BW, et al., (2010). Research on Social Work Practice, 20, 137-160.
The Underlying Spirit of MI
Partnership
Compassion
MI
Spirit
Evocation
Acceptance
Four Processes of MI
Planning
Evoking
Focusing
Engaging
Can it be MI without . . .
• Engaging?
• Focusing?
• Evoking?
• Planning?
NO
NO
NO
YES
Roadblocks to Communication
Roadblocks to
Communication
- Ordering, directing
- Excessive reassuring,
- Warning or threatening
sympathizing, consoling
- Giving advice
- Questioning or probing
- Persuading, arguing,
excessively
lecturing
- Withdrawing,
- Moralizing, preaching, telling
distracting, humoring
clients what they “should”
do
- Cultural/Racial
- Disagreeing, judging,
roadblocks
blaming
- Organizational
- Praising prematurely or in
roadblocks
excess
- Shaming, ridiculing, labeling - Gender/Age roadblocks
Engagement:
Beware of Traps!
•  Assessment Trap
–  If I just ask enough questions, I’ll know what
to tell the client to do
•  Premature Focus Trap
–  Your idea of the problem and the client’s idea
is different
•  Expert Trap
–  I’m in control and I have the answer
Engagement:
More Traps!
•  Labeling Trap
–  “You’re an alcoholic.” “You have a drug
problem.” “You’re an addict.”
•  Blaming Trap
–  Who’s a fault for the problem? Who is to blame?
•  Chat Trap
–  Small talk without direction to the conversation
The Concept of
Ambivalence
•  Ambivalence is normal
•  Clients usually enter
treatment with fluctuating
and conflicting motivations
•  They “want to change and
don’t want to change”
•  “Working with ambivalence
is working with the heart of
the problem”
“People are better persuaded
by the reasons they themselves
discovered than those that
come into the minds of others”
Blaise Pascal
The Interview
Summarize
and Ask
Key
Question
Plan
Evoke
Focus
Engage
Core Skills
•
•
•
•
O pen-Ended Questions
A ffirmations
R eflective Listening
S ummarizing
Open-Ended Questions
§  Are difficult to answer with brief replies or
simple “yes” or “no” answers.
§  Contain an element of surprise; you don’t
really know what the patient will say.
§  Are conversational door-openers that
encourage the patient to talk.
§  Is this an open-ended or closed-ended
question?
Open and Closed
Questions Quiz
1. Don’t you think your drinking is part of
the problem?
C
2. Tell me about when you were able to
quit smoking?
O
3. How is it going with managing your pain
meds?
O
4. Do you know you might die if you don’t
stop using?
C
5. What do you want to do about your
drinking?
O
6.  Can you tell me about what you know
about your heart condition?
C
Converting Closed Questions
1.  Do you think your drug use is a
problem?
2.  Do you have any health problems
related to your drinking?
3.  Have you considered getting some
professional help?
4.  Are you worried about dying?
5.  Would there be any benefits to not
smoking marijuana?
The Communication Cycle
1.  What the
client
means.
2.  What the
client
actually
says.
Accurate
Empathy
1=4
4.  What the
clinician says
he or she
heard.
3.  What the
clinician
hears.
Levels of Reflection
Simple
Exactly repeating one or more aspects of what is
said or changing one or more of the words used in a
statement (no meaning is added)
Complex
Reflecting the inferred meaning of a statement or
paraphrasing that focuses on the emotional aspect
of the statement (meaning is added on to what was
said)
Reflective Listening
Making your best guess about what a paNent means. What does the client
mean?
I should
stop using
it.
Tell me
about your
marijuana
use.
What does this client mean?
I know I
shouldn’t have.
He just came by
and I couldn’t
turn him away.
What made
you decide
to see him?
What does the patient
mean?
What about it?
What difference
does it make?
How are
things going
with the
medication?
Forming Reflective
Statements
If you find it helpful, start your
reflections with the following:
“It sounds like you…”
“You’re feeling…”
“It seems that you…”
“So you…”
What is the focus?
Psychiatric
Alcohol
Use
Illness
Medical
Issues
Housing
HIV Risk
Drug Use
Treatment
Adherence
Medication
Adherence
Agenda Mapping
Alcohol Use Psychiatric Illness Treatment Adherence Medical Issues Drug Use HIV Risk Behavior MedicaNon Adherence Housing The MI Hill
Pre-Contemplation
Contemplation
Preparation
Action
Recognizing Resistance
Resistance is when patients :
•  argue
•  interrupt
•  fail to link (problems to use)
•  ignore problems
•  fail to engage or follow through
Where does resistance start?
Rolling with Resistance
To reduce resistance:
•  Shift the focus
•  Reframe
•  Emphasize personal choice and control
•  Stop providing solutions
•  Talk about something else
CONDUCTING A BRIEF
INTERVENTION
FLO: THE 3 TASKS OF A BI
L
O
Feedback
Listen & Understand
Options Explored
W
Warn
F
Avoid Warnings!
(that’s it) 4
HOW DOES IT ALL FIT
TOGETHER?
Feedback Se*ng the stage Tell screening results Explore pros & cons Listen & understand Explain importance Assess readiness to change Discuss change op>ons Op>ons explored Follow up THE 3 TASKS OF A BI
F
L
O
Feedback
Listen & Understand
Options Explored
THE 1ST TASK: FEEDBACK
The Feedback Sandwich
Ask Permission
Give Feedback
Ask for Response
THE 1ST TASK: FEEDBACK
What you need to cover:
1. Range of scores and context
2. Substance use norms in
population
3. Screening results
4. Interpretation of results (e.g.,
risk level)
5. Patient feedback about results
THE 1ST TASK: FEEDBACK
What do you say? 1. Range of score and context -­‐ Scores on the AUDIT range from 0-­‐40. 2. Norms – Most people who are social drinkers score less than 8. 3. Results -­‐ Your score was 18 on the alcohol screen. 4. InterpretaNon of results -­‐ 18 puts you in the moderate-­‐
to-­‐high risk range. At this level of use, you are at significant risk for having or developing a variety of health issues. 5. PaNent reacNon/feedback -­‐ What do you make of this? The 1st Task: Feedback
Finding the conversation…
•  Ask the patient about their concerns
•  Provide non-judgmental feedback/information
•  Watch for signs of discomfort with status quo or
interest or ability to change
•  Always ask this question: “What role, if any, do
you think alcohol played in your (getting
injured)?
•  Let the patient decide.
•  Just asking the question is helpful.
SUD
Medical
Housing
Family
Mental
Health
SUD
O
L
F
Options Explored
Feedback
Listen & Understand
5
THE 2ND TASK:
LISTEN & UNDERSTAND
Tools for Change Talk
• Pros and Cons
• Importance/Readiness Ruler
DIGGING FOR CHANGE:
THE DECISIONAL BALANCE
The good
things
about
______
The notso-good
things
about ____
The not-sogood things
about
changing
The good
things
about
changing
Avoid questions that call for a yes/no answer.
THE 2ND TASK:
LISTEN & UNDERSTAND
Listen for the Change Talk
•  Maybe drinking did play a role in what happened.
•  If I wasn’t drinking this would never have
happened.
•  Using is not really much fun anymore.
•  I can’t afford to be in this mess again.
•  The last thing I want to do is hurt someone else.
•  I know I can quit because I’ve stopped before.
Summarize, so they hear it twice!
THE 2ND TASK:
LISTEN & UNDERSTAND
Weighing the Pros and Cons
not so
good
good
Summarize Both Pros and Cons
“On the one hand you said..,
and on the other you said….”
THE 2ND TASK:
LISTEN & UNDERSTAND
Importance/Confidence/Readiness
On a scale of 1–10…
•  How important is it for you to change your drinking?
•  How confident are you that you can change your
drinking?
•  How ready are you to change your drinking?
For each ask:
•  Why didn’t you give it a lower number?
•  What would it take to raise that number?
1
2
3
4
5
6
7
8
9
10
The Payoff for Asking the
Questions…
•  These questions will lead to a working
treatment plan
–  Stage of change
–  Benefits of use
–  Consequences of use
–  Willingness to work on these issues
5
O
Listen & Understand
Options Explored
Feedback
L
F
THE 3RD TASK:
OPTIONS FOR CHANGE
What now?
•  What do you think you will do?
•  What changes are you thinking
about making?
•  What do you see as your options?
•  Where do we go from here?
•  What happens next?
THE 3RD TASK:
OPTIONS FOR CHANGE
Offer a Menu of Options
•  Manage drinking/use
(cut down to low-risk limits)
•  Eliminate your drinking/drug use
(quit)
•  Never drink and drive
(reduce harm)
•  Utterly nothing
(no change)
•  Seek help
(refer to treatment)
THE 3RD TASK:
OPTIONS FOR CHANGE
•
•
•
•
•
During MENUS, explore previous
strengths, resources, and successes
Have you stopped drinking/using drugs
before?
What personal strengths allowed you to
do it?
Who helped you and what did you do?
Have you made other kinds of changes
successfully in the past?
How did you accomplish these things?
THE 3RD TASK:
OPTIONS FOR CHANGE
Closing the Conversation (“SEW”)
•
Summarize patient’s views
•
What agreement was reached
(especially the pro)
•  Encourage them to share their views
(repeat it)
ENCOURAGE FOLLOWUP VISITS
At follow-up visit:
•  Inquire about use
•  Review goals and progress
•  Reinforce and motivate
•  Review tips for progress
Referral to Treatment
for Patients at Risk for
Substance Dependence
REFERRAL TO TREATMENT
•  Approximately 5% of patients screened will
require referral to substance use evaluation
and treatment.
•  A patient may be appropriate for referral
when:
•  Assessment of the patient’s responses to the
screening reveals serious medical, social, legal, or
interpersonal consequences associated with their
substance use.
These high risk patients will receive a brief
intervention followed by referral.
“WARM HAND-OFF”
APPROACH TO REFERRALS
•  Describe treatment options to patients based on
available services
•  Develop relationships between health centers,
who do screening, and local treatment centers
•  Facilitate hand-off by:
•
Calling to make appointment for patient/student
•
Providing directions and clinic hours to patient/student
•
Coordinating transportation when needed
PRACTICE FLO – DIVE
RIGHT IN!
•  Try screening and giving feedback only
•  After several practices with F add in L & O
•  Post your questions and share your
experiences on The World of SBIRT blog
6
MEDI-CAL SBIRT IMPLEMENTATION
REIMBURSEMENT
The following SBIRT services are covered:
1.  Screening
•
•
•
•
•
Must use a Medi-Cal approved screening instrument
(AUDIT, AUDIT-C)
Limited to one unit per recipient per year, by any
provider working under an SBIRT-trained supervisor
A prescreen or brief screen is not reimbursable
Bill under HCPCS code H0049; $24
SBIRT may be provided on same date of service as
other E/M procedures
MEDI-CAL SBIRT IMPLEMENTATION
REIMBURSEMENT
2. Brief intervention
•  May be provided on the same date of service as
the screening, or on subsequent dates
•  Limited to three sessions per patient per year,
provided by any SBIRT-trained provider
•  Sessions may be combined in 1 or 2 visits, or be
administered at 3 separate visits
•  Bill under HCPCS code H0050; $48
MEDI-CAL SBIRT IMPLEMENTATION
REIMBURSEMENT
3. Rural Health Clinics (RHCs) and Federally
Qualified Health Centers (FQHCs):
•  SBIRT costs are included in the all-inclusive
prospective payment systems (PPS) rate
•  SBIRT services that meet the definition of an
FQHC/RHC visit, as defined in the Rural Health
Clinics (RHCs) and Federally Qualified Health
Centers (FQHCs) section of the Part 2 – Medi-Cal
Billing and Policy manual, are billable
SBIRT IMPLEMENTATION
COMMERCIAL PAYERS
•  Commercial insurance plans currently not
required to cover annual SBIRT screening but
some do
•  As with most healthcare procedures, they may
all eventually follow the CMS lead
•  Billed as:
•  CPT code 99408 (alcohol/other substance
screening & brief intervention, 15-30 minutes)
•  CPT code 99409 (alcohol/other substance
screening & brief intervention, > than 30 minutes)
SBIRT IMPLEMENTATION
MEDICARE
•  Medicare covers SBIRT provided in outpatient offices/
clinics when medically necessary
•  In other words, you can use with your Medicare pts
•  Annual screenings not currently mandated
•  May be provided by:
•
•
•
•
•
•
Physician
Clinical psychologist
LCSW
Nurse Practitioner (NP)
Physician Assistant (PA)
Clinical Nurse Specialist (CNS)
SBIRT IMPLEMENTATION
MEDICARE
•  Billed as:
•  HCPCS code G0396 (alcohol/other substance
screening & brief intervention, 15-30 minutes)
•  HCPCS code G0397 (alcohol/other substance
screening & brief intervention, > than 30
minutes
•  As of Jan 2013, SBIRT included within Telehealth
Services
STRATEGIES FOR
IMPLEMENTATION
•  Study and Learn
—  Study the SBIRT models and guidelines
—  Consider how to apply best in your setting
—  Determine availability of behavioral health
services for referral and treatment
Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider
Conference, August 7, 2012
STRATEGIES FOR
IMPLEMENTATION
•  Decide
—  Choose the best screening method for
you
—  Annually
—  What screening tool to use
—  Who will administer
—  Indications for screening (everyone, age
groups, certain diagnoses)
Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider
Conference, August 7, 2012
STRATEGIES FOR
IMPLEMENTATION
•  Prepare
—  Select a “champion” for the effort
—  Train clinicians and staff on their specific
responsibilities
—  Put copies of screener, guidelines, etc. in
exam rooms
—  Determine a record-keeping system (EHR’s?)
Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider
Conference, August 7, 2012
STRATEGIES FOR
IMPLEMENTATION
•  Reinforce
—  Remind staff regularly
—  Collect success stories to encourage
ongoing implementation/support
—  Accept feedback from staff and patients
and adapt as you go
Source: Amy Brom, SBIRT presentation conducted at Northern CAIRS Provider
Conference, August 7, 2012
FOR ASSISTANCE ON
IMPLEMENTATION
SAMHSA TAP (Technical Assistance
Publication Series) #33: Systems-Level
Implementation of Screening, Brief Intervention,
and Referral to Treatment (SBIRT)
Available for download at:
http://store.samhsa.gov/product/TAP-33-Systems-LevelImplementation-of-Screening-Brief-Intervention-andReferral-to-Treatment-SBIRT-/SMA13-4741
Excellent example of step-by-step SBIRT
procedure:
A Nurse-Delivered Brief Motivational Intervention
for Women Who Screen Positive for Tobacco,
Alcohol, or Drug Use
Available for download at:
http://www.mirecc.va.gov/apps/
activities/products/productDetail.asp?
id=146
Useful Books
Miller, W.R., & Rollnick, S. (2012). Motivational
Interviewing: Helping People Change 3rd edition
(New York, Guilford Press).
Rollnick S., Miller, R. W., & Butler, C. C. (2008). Motivational
Interviewing in Health Care: Helping Patients Change
Behavior. Guilford Press, New York.
Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2008).
Motivational Interviewing in the Treatment of Psychological
Problems. Guilford Press, New York.
Rosengren, D. B. (2009). Building Motivational Interviewing
Skills: A Practitioner Workbook. Guilford Press, New York.
Naar-King, S., & Suarez, M. (2011). Motivational Interviewing
with Adolescents and Young Adults. Guilford Press, New York.
Wagner, C., & Ingersoll, K. (2013). Motivational Interviewing
in Groups. New York: Guilford Press.
Useful References
Burke, B.L., Arkowitz, H., & Menchola, M. (2003). The efficacy
motivational interviewing: A meta-analysis of controlled
trials. Journal of Consulting and Clinical Psychology, 71,
843-861.
Hettema, J., Steele, J., & Miller, W.R. (2005). Motivational
interviewing. Annual Reviews of Clinical Psychology, 1,
91-111.
Miller, W.R., & Rose, G.S. (2009). Toward a theory of
motivational interviewing. American Psychologist, 64,
527-537.
Lundahl BW, Kunz C, Brownell C., Tollefson D, and Burke B.
(2010). Meta-analysis of motivational interviewing: Twenty
Five years of empirical studies. Research on Social Work
Practice, 20, 137-160.
Smedslund, G., Berg, R.C., Hammerstrom, K.T., Steiro, A.,
Leiknes, K.A., Dahl, H.M., & Karlsen, K. (2011). Motivational
interviewing for substance abuse. Cochrane Database of
Systematic Reviews, Issue 5. Art. No.: CD008603.
Useful Websites
•  www.motivationalinterviewing.org
•  www.casaa.unm.edu
•  www.guilford.com/p/miller2
THANK YOU!!
Thomas E Freese, PhD
tfreese@mednet.ucla.edu
For additional information
on this or other training topics, visit:
www.psattc.org
www.uclaisap.org/dmhcod