Tip 35: Motivational Interviewing with Patients with Substance Abuse Issues

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Tip 35: Motivational Interviewing with Patients with Substance Abuse Issues - Presentation Transcript

  1. Enhancing Motivation for Change in Substance Abuse Treatment Based on TIP 35 Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  2. Overview
    • Introduction
    • ‘ FRAMES' and Other Approaches
    • Stages of Change
    • Precontemplation
    • Contemplation
    • Preparation
    • Action
    • Maintenance
    • Integrating Motivational Approaches
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  3. Motivation
    • Motivation is a key to change
    • Motivation is multidimensional
    • Motivation is dynamic and fluctuating
    • Motivation is influenced by social interactions
    • Motivation can be modified
    • Motivation is influenced by clinician's style
    • The clinician's task is to elicit and enhance motivation
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  4. Why enhance motivation?
    • Inspiring motivation to change
    • Preparing clients to enter treatment
    • Engaging and retaining clients in treatment
    • Increasing participation and involvement
    • Improving treatment outcomes
    • Encouraging a rapid return to treatment if symptoms recur
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  5. Desirable attributes for the counselor
    • Nonpossessive warmth
    • Friendliness
    • Genuineness
    • Respect
    • Affirmation
    • Empathy
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  6. Help Increase Motivation
    • Focusing on client strengths
    • Using empathy more than authority
    • Recognizing co-occurring disorders
    • Employ client centered treatment
    • Respecting the client's autonomy
        • For more detailed information, see TIP 35, pp. xvi–1.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  7. Elements Of Current Motivational Approaches
    • The FRAMES approach
    • Decisional balance exercises
    • Discrepancies between personal goals and current behavior
    • Flexible pacing
    • Personal contact with clients in treatment
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  8. FRAMES
    • Feedback regarding personal risk or impairment
    • Responsibility for change is placed squarely and explicitly on the client
    • Advice is clearly given to the client by the clinician in a nonjudgmental manner.
    • Menus of self-directed change options and treatment alternatives are offered to the client.
    • Emphatic counseling
    • Self-efficacy is engendered in the client to encourage change.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  9. Decisional Balance
    • Individuals naturally explore the pros and cons of any major life choices
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  10. Discrepancies Between Goals and Current Behavior
    • Help clients recognize a discrepancy or gap between their future goals and their current behavior.
    • The clinician might clarify this discrepancy by asking, "How does drinking fit in with having a family and a stable job?"
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  11. Flexible Pacing and Personal Contact
    • Pacing
      • meet clients at their levels
      • use as much time as necessary with the essential tasks of each stage of change.
    • Personal Contact: letters or telephone calls
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  12. Precontemplation
    • The client is unaware, unable, or unwilling to change.
      • Counselor can
        • Establish rapport
        • Raise doubts about patterns of use
        • Give info on risks, pros and cons of use
    • The client is likely to be wary of the counselor and of treatment.
      • Counselor
        • Should not rub the client the wrong way
        • Should try to keep the interview informal.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  13. Goals/Actions
    • Explore the meaning of events that brought the client to treatment or the results of previous treatments.
    • Elicit the client's perceptions of the problem.
    • Offer factual information about the risks
    • Provide personalized feedback about assessment
    • Explore the pros and cons of substance use.
    • Help a significant other intervene.
    • Examine discrepancies between the client's and others‘ perceptions of the problem behavior.
    • Express concern and keep the door open.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
    • Many clients are ambivalent about change.
    • Ambivalence is expressed in several ways.
      • Argue: challenge or discount statements
      • Interrupt: take over or cut off conversation
      • Deny: blame, disagree, excuse, minimize
      • Ignore: not respond, not pay attention
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  14. Ways to Respond
    • Simple: Rephrase the client statement, neutrally.
    • Amplified: Exaggerate statement without sarcasm.
    • Double-sided reflection: Acknowledge statement, but use contradictory information client reported earlier.
    • Agreement with a twist: Agree, but change direction.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  15. Contemplation
    • The client is ambivalent or uncertain, considering the possibility of change.
      • Counselor can
        • Discuss and weigh pros/cons of using
        • Emphasize client's free choice and responsibility
        • Elicit self-motivational statements
    • At this stage, the client usually meets the counselor halfway, and is willing to look at the "cons" of using.
    • Reassure the client that no one can force him to change.
    • Ask questions that prompt motivation.
      • For example, "When you want to keep up your motivation for doing something, what are some of the things you say to yourself?"
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  16. Goals/Actions
    • Help the client recognize the problem
    • Help the client acknowledge concern
    • Help the client generate intention to change:
    • Help the client develop optimism
    • Convey feedback
    • Help clients see a difference
    • Show curiosity about client strengths. Explore how those skills and competencies may be negated by drinking
    • Reframe negative statements.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  17. Highlight Reasons for Change
    • Summarize concerns
    • Explore specific pros and cons
    • Allow client to explain benefits
    • Assure client conflicting feelings are normal
    • Review feedback from assessment
    • Find out what client expects from treatment
    • Provide info
    • Help client connect core values to committing to treatment
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  18. Strengthen the client's personal choices.
    • Nudge the client to make positive choices.
    • "No one can decide this for you. You can choose."
    • Help the client set goals and take steps.
    • Provide feedback.
    • Remind client of "triggers," including negative emotions (anger), social pressures (peers), physical concerns (headache) and extended withdrawal symptoms (craving).
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  19. Reinforce the client's commitment
    • What do you think has to change?
    • What are you going to do?
    • How are you going to do it?
    • What are some benefits of making a change?
    • How would you like things to turn out, ideally?
        • For more detailed information, see TIP 35, pp. 54–92.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  20. Preparation
    • The client asks questions, indicates willingness and considers options to make specific changes.
    • Explore treatment expectancies and the client's role.
    • Elicit from the client what has worked in the past either for him or others whom he knows.
    • At this stage, the client shifts from "thinking about it" to "planning first steps."
    • Counselor guides the steps by offering help but not yanking the client forward.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  21. Helps The Client To Get Ready
    • Negotiating a plan
    • Offering a menu of options
    • Developing a behavior contract
    • Identifying and lowering barriers
    • Enlisting social support
    • With permission offer advice
    • Assist the client to negotiate finances, child care, work, transportation, or other potential barriers.
    • Have the client publicly announce plans
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  22. Client Indicates Readiness
    • Stops arguing, interrupting, denying
    • No longer asks questions about the problem,
    • but more about how to change
    • Appears calm, peaceful
    • States openness to change ("I have to do something")
    • Expresses optimism ("I can beat this")
    • Talks about how life will be after the change
    • Experiments between sessions
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  23. Barriers
    • Ask what has gone wrong in the past
    • Find out if clients anticipate problems
    • Provide all necessary information
    • Sources of barriers may include
      • Family relations
      • Health problems
      • Depression or other negative feelings
      • Bureaucracy: Waiting lists, paperwork, legal
      • Finances
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  24. Action
    • The client takes steps toward change, but is still unstable.
      • Counselor can
        • Negotiate action plan
        • Acknowledge difficulties and support attempts
        • Identify risky situations and coping strategies
        • Help client find new reinforcers
        • Support perseverance ("Sticking to the plan")
    • In this stage, clients are receptive to the full range of counselor techniques, but motivation can wax and wane
    • If relapse occurs, the counselor "backs up" and applies techniques from an earlier stage.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  25. Goals/Actions
    • Engage the client in treatment and reinforce the importance of remaining in recovery.
    • Support a view of change through small steps.
    • Acknowledge difficulties for the client in early stages of change.
    • Help the client identify high-risk situations and develop appropriate coping strategies
    • Assist the client in finding reinforcers
    • Help the client assess levels of social support.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  26. Explore Expectations
    • Explore past experiences, hopes, and fears regarding
      • Confrontation, judgment
      • Costs; in money; in changed behavior.
      • Family involvement; shame, guilt.
      • Medications; will have to withdraw from or take
      • Rules; too strict, no "wiggle room."
      • Understanding
    • Immunize against difficulties
    • Resolve barriers to treatment
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  27. Increase motivations
    • Help the client to see the value of both internal and external motivating factors
    • Suggest to the client that external coercions are compatible with the client's best interests
    • Support signs of internal motivation
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  28. Examine and interpret noncompliant behavior
    • Noncompliant behavior is a thinly veiled expression of dissatisfaction with treatment or the therapeutic process.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  29. Maintenance
    • Client has met initial goals, made changes in lifestyle and now practices coping strategies.
      • Counselor can
        • Support and affirm changes
        • Rehearse new coping strategies
        • Review goals
        • Keep in contact
    • In this stage, clients "keep on keeping on."
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  30. Cont…
    • The counselor reminds the client about new tools to maintain and reinforce recovery, such as
      • Action plan
      • Awareness of risky situations
      • Coping strategies for each situation
      • Participation in 12-Step programs
      • Pursuit of hobbies and cultural activities
      • Volunteer opportunities
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  31. Goals/Actions
    • Help the client identify and sample drug-free sources of pleasure (i.e., new reinforcers).
    • Support lifestyle changes.
    • Affirm the client's resolve and self-efficacy.
    • Help the client practice/use coping strategies
    • Maintain supportive contact
    • Develop a "fire escape" plan if the client resumes substance use.
    • Review long-term goals with the client.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  32. Form a Plan.
    • Identify triggers
    • Identify effect/benefits of using in response to the trigger
    • Identify appropriate coping response
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  33. Developing Reinforcers
    • Competing
    • Contingent (If/Then)
    • Community (natural consequences)
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  34. Recurrence
    • Help the client reenter the change cycle and commend any willingness to reconsider positive change.
    • Explore the meaning and reality of the recurrence as a learning opportunity.
    • Assist the client in finding alternative coping strategies.
    • Maintain supportive contact.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  35. Other Tools
    • Consciousness raising increases information about the problem.
    • Self-reevaluation involves assessing how one feels and thinks about oneself with respect to problem behaviors.
    • Self-liberation means choosing and committing to act or believing in ability to change.
    • Counterconditioning involves substituting coping alternatives
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  36. Cont…
    • Stimulus control means avoiding or countering stimuli that elicit problem behaviors.
    • Reinforcement management is being rewarded for making changes.
    • Helping relationships are created by being open and trusting about problems with caring people
    • Emotional arousal and dramatic relief involve experiencing and expressing feelings about one's problems and solutions
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  37. Cont…
    • Environmental reevaluation is the process of assessing how one's problems affect the personal and physical environment.
    • Social liberation involves increasing alternatives for nonproblematic behavior.
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  38. Applications of Motivational Approaches
    • A means of rapid engagement in the general medical setting to facilitate referral to treatment
    • A first session to increase the likelihood that a client will return and to deliver a useful service if the client does not return
    • An empowering brief consultation when a client is placed on a waiting list, rather than telling a client just to wait for treatment
    • A preparation for treatment to increase retention and participation
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
    • A help to clients coerced into treatment to move beyond initial feelings of anger and resentment
    • A means to overcome client defensiveness and resistance
    • A stand-alone intervention in settings where there is only brief contact
    • A counseling style used through the process of change
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  39. Other Things to Remember
    • Often there is a relatively short period of time to make a beneficial impact on the client
    • The average length of stay in substance abuse treatment is very short
    • If clinicians do not make an impact in the first session or two with clients, they may not be able to make an impact at all
    • Make the best use of the first contact
    • It is usually a mistake to start a session with filling out forms
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
  40. Summary
    • There are different goals and tools for each stage of change
    • Even one session can make a positive impact on a client
    • Lasting change takes time and effort
    • All clients have the ability to learn to make positive choices and changes
    Copyright AllCEUs.com A subsidiary of CDS Ventures, LLC
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