MASBIRT TTA Conference: SBIRT: Talking to 12/5/2014 patients about their alcohol and other drug use Motivational Interviewing (MI) Skills to Enhance Agenda Ag enda Motivation To Change I. Overview of MI: the Spirit of MI II. Essential MI Skills: OARS III. Brief Negotiated Interview (BNI) Algorithm IV. BNI in Action: Video and practice V. Wrap ‐ up: Q&A Thanks to: Ed Bernstein, MD, BNI ‐ ART Institute, BU School of Public Health & Boston Medical Center Suzanne Mitchell, MD, MS Boston University School of Medicine Bl Blaise aise Pa Pascal re reminds us… us… MI De MI Demons monstration in in the the ER ER “People are generally better persuaded • How we can talk about alcohol/drug use quickly & effectively by the reasons which they have themselves http://www.bu.edu/bniart/sbirt ‐ in ‐ health ‐ care/sbirt ‐ educational ‐ materials/sbirt ‐ videos/ discovered than by those which have come in to the mind of others.” Motivational In Mo Interv rvie iewing (M (MI) I) Authenticity Authen ticity is is Im Important • Client ‐ centered • Goal ‐ directed (behavior change) “Of course I’m listening… • Helps resolve ambivalence Don’t you see me making eye contact, striking an open posture, leaning A ‐ C ‐ E towards you and nodding empathetically?” • affirms client’s Autonomy • Collaboration between pt & practitioner • Elicits client’s intrinsic motivation & reasons for change Miller & Rollnick, 2002. 1
MASBIRT TTA Conference: SBIRT: Talking to 12/5/2014 patients about their alcohol and other drug use Mo Motivational In Interv rvie iewing (M (MI) I) Motivational In Mo Interv rvie iewing (M (MI) I) Mo Motivati tiona onal In Interv rviewing • assumes motivation is fluid and can be Motivational Interviewing was developed from the influenced in the context of a relationship rather simple notion that the way clients are spoken to about changing addictive behavior • Principle task: to guide conversation towards affects their willingness to talk freely about why eliciting motivation for change and how they might change. • Goal: to influence change in the direction of health Stephen Rollnick, PhD Addiction 2001; 96:1769 ‐ 70. A Fe Few MI MI Pr Principles Five Gener Fi General Pr Principles of of MI MI � Ambivalence is normal to the change process 1. Express empathy 2. Resolve ambivalence � Asking permission can decrease defensiveness and increase patients being more open 3. Avoid arguments 4. Support self ‐ efficacy � The patient is the active decision ‐ maker 5. Roll with resistance � Reflective listening is key to helping a patient consider change Mo Motivational In Interv rvie iewing (M (MI) I) ...... NOT 2
MASBIRT TTA Conference: SBIRT: Talking to 12/5/2014 patients about their alcohol and other drug use Open Ques Open Questions tions The The Skills Skills: “OA “OARS” OPEN CLOSED O = open ‐ ended questions • Are you worried about • What worries you most about A = affirm your current situation? your current situation? R = reflection • What changes have you noticed? • Have you noticed S = summarize • How so? changes? • How important is your health to • Do you care you? about your health? Affirm Af rmations ns Refle flections � Statements and gestures that recognize strengths and The process of reflective listening involves acknowledge behaviors that lead in the direction of hearing what the client says and positive change � simple reflection : e ither repeating or • I am really impressed with the way you…. paraphrasing back to the client or… • That’s great how you’ve reached your goal of cutting back on your drug use. � complex reflection : reflecting the feeling you • Using protection shows that you have real respect for believe is behind what the client says. yourself and your partners. • Be genuine and specific • Only say it when you really mean it. Ty Types of Ty Types of of Refle of Re flections Reflections Reflective Li Re Listening ening Ex Exer ercise cise • Divide into pairs. One person starts as the Speaker; the other as the “I have been to treatment six times. Nothing is going to work for Listener/reflector. Switch roles after completing the exercise. me. I just can’t stop drinking.” • Speaker : Choose a statement about yourself ‐ o I don’t like conflict ….or o I have a sense of humor ….or • Simple Reflection : o I let things bother me more than they should ….or • “You’ve been to treatment before and it hasn’t worked.” o I am loyal …or o One thing I like about myself is that I…” (not on handout) • Listener offers a reflection of what the speaker might mean • Complex Reflection : • Speaker tells the Listener whether the reflection is accurate after each reflection • “You’ve tried to quit drinking in the past and it hasn’t worked. You’re wondering if it’s going to be different this time.” • After the Listener/Reflector has offered 4 ‐ 5 reflections, switch roles. New Speaker chooses a different statement. 3
MASBIRT TTA Conference: SBIRT: Talking to 12/5/2014 patients about their alcohol and other drug use Doubl Double ‐ si sided ded Re Reflection Practice: Pr “I’m not sure what I’ll do. I really like Captures both sides of the ambivalence (…AND…) drinking, but it’s becoming a hassle now.” “On one hand, you think everyone is over reacting and on the other hand you can understand why your family is so upset.” MI skill – Double Sided Reflection Re Reflecting Summariz Summ arize: e: Re Reflecting • Hypothesize with client: • I’ve been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work “ Let’s see if I have this right…” “Here’s what I heard. Tell me if I missed anything…” other than having a couple of drinks. “Anything you want to add or change?” • In spite of the lack of success, you keep looking for ways to feel better • Highlight statements indicating motivation to besides drinking. change • You’ve been feeling down • Accomplishes 2 goals: • Drinking works in the short term • Communicates to patient that you are genuinely • You’d be happy to find something other than drinking to work . interested in what s/he is saying • Gives yourself a chance to get the facts straight! The Art of Active Listening. (2005). National Aging Information & Referral Support Center, Washington D.C. Activity Activity: Re Reflection Brief Ne Bri Nego goti tiated ated In Interview Client Voice and Choice • Take some time to think about a A collaborative conversation about health promotion difficult change that you had to make (Shared agenda) in your life. • Clients as experts in their lives • How much time did it take you to move from considering that change to • Listening, not telling actually taking action. • Practicing silence • Active listening skills 4
MASBIRT TTA Conference: SBIRT: Talking to 12/5/2014 patients about their alcohol and other drug use Br Brie ief Negotia Negotiated ed In Interv rview (B (BNI) Acti Active Li Listening ening Str Strategies gies Al Algorith gorithm: 5 St Step eps Silence 1. Build Rapport Allow for comfortable silences to give person time to think and • talk 2. Pros & Cons • Slows conversation; no one feels rushed 3. Feedback/Information Body language cues 4. Readiness Ruler / Confidence Ruler • Eye contact, head nodding, empathic facial expressions • Body opened (no crossed arms), turned towards person 5. Action Plan The Art of Active Listening. (2005). National Aging Information & Referral Support Center, Washington D.C. Step St ep 1: 1: Build ild Rapport Rapport Step St ep 1: 1: Pr Pros & Cons Cons St Step ep 2: 2: Pro Pros & Cons Cons Ask permission Would you mind taking a few minutes to Pros Help me understand through your talk about your [X] use? • “ good things” eyes the good things about using Before we go further, I’d like to learn a • “things it does for you” [X]? little more about you. • “things you like about it” What are some of the not so good Day in the life Cons things about using [X]? What is a typical day like for you? • “ not so good things” • “things you don’t like as much” • “the downsides, or drawbacks” So, on the one hand you said [PROS], and on the other hand Substance use Where does your [X] use fit in? [CONS]. Summary Step St ep 4: 4: Readi adiness/Im ess/Import portance ance Rul Ruler Step St ep 3: 3: Feedback eedback & In Informatio ion Step St ep 3: 3: Feedback edback & In Information Given what you mentioned, on a 1 ‐ 10 scale, with one being not ready/important at all Ruler Ask permission I have some information on [X] use—would and 10 being completely ready/important to you mind if I shared it with you? make any change about your use of X, where would you put yourself? We know that drinking / using… Provide information [insert alcohol / drug information here] …can put you at risk for illness and injury. You marked ___. That’s great. Affirmation That means you’re ___% ready to make a • Reinforce positives It can also cause health problems like… change. [insert relevant health issues here]. Why did you choose that number and not a lower number, like a 1 or 2? Lower number Ask for thoughts What are your thoughts on that? What would it take to go from 4 to 7? 5
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