The Motivational Interviewing Treatment Integrity (MITI) Code Instructor: Sue EckMaahs, EckMaahs & Associates, LLC; St. Paul, Minnesota Co-developers of the MITI 3.1.1 � Tim Martin � Jennifer Knapp Manual � William Miller � Denise Ernst (MITI 3.0) � Coders who really know what they are doing: Paulette Christopher, Sean Tollison, Lisa LeHigh Wanted !! � Quick and dirty rating system for MI � Must be able to generate simple ratings indicating therapist competence � Must be suitable for research as well as frontline clinical settings � Ability to use as a self-rating tool desirable � No long winded instruments need apply 1
Why use the MITI coding in supervision and training? � Shows us whether the helper is utilizing MI skills. � Allows us to provide feedback that is structured and meant to “shape” MI Spirit, Empathy as well as skills. MITI Limitations � Doesn’t measure change talk and practitioner responses to it. We need to attend to this as part of our coaching. CODING 2
Coding tapes � Audio tapes are used, randomly picking a 20 minute segment. � Coders need to know the target behavior of the intervention. � Two passes are often done to help codes become better coders. � Practice, practice, practice. Group coding � Is useful because it allows everyone to discuss behavior counts. � Always, always use your manual! � Discussion is encouraged, and often times, you get to change your mind! � Don’t over think it! ☺ What are we Coding? 1. Global Measures (Overall Spirit & Guiding) � Evocation � Collaboration � Support for Autonomy � Direction � Empathy 2. Behavior Counts (Micro-Skills) 3
The Behaviour Counts “It has been an axiom of mine that the little things are infinitely the most important.” ~ Sherlock Holmes (A. Conan Doyle) Behaviour Counts Measure… 1) Giving Information 2) MI Adherent 3) MI Non-Adherent 4) Question Open a. Closed b. 5) Reflection Simple a. Complex b. Parsing Interviewer Speech… � An “utterance” is defined as a complete thought. � There can be more than one utterance in a sentence. Each gets it’s own code (EX: Reflect, Confront, Question). � This is called a “volley”. 4
How would you parse this? “Well, let me ask you this: since you’ve been forced to code here and since you’re feeling like everyone’s kind of pecking on you like a crow, there’s a bunch of crows flying around pecking on you about this thing about you drinking, what would you like to do with the time you spend there? What would be helpful to you?” Answer: “Well, let me ask you this: since you’ve been forced to code here and since you’re feeling like everyone’s kind of pecking on you like a crow, there’s a bunch of crows flying around pecking on you about this thing about you drinking, what would you like to do with the time you spend there? What would be helpful to you?” Utterance # 1: Reflection Utterance # 2: Open Question How would you parse this? “What you say is absolutely true, that it is up to you. No one makes that choice for you. No one can make that choice for you. Even if your wife wanted to decide for you, or your employer wanted to decide for you, or I wanted to decide for you; nobody can. It’s really completely your own choice. And what I hear you struggling with is, “what do I want?” Is it time for me to change things? Is this drug test a wake-up call?” 5
Answer: “What you say is absolutely true, that it is up to you. No one makes that choice for you. No one can make that choice for you. Even if your wife wanted to decide for you, or your employer wanted to decide for you, or I wanted to decide for you; nobody can. It’s really completely your own choice. And what I hear you struggling with is, “what do I want?” Is it time for me to change things? Is this drug test a wake-up call?” Utterance # 1: MiA (Autonomy) Utterance # 2: Reflection LET’S PRACTICE! Giving Information This category is used when the interviewer gives information, educates, gives an opinion without advising, or provides feedback. Coders need not distinguish among types of giving information. 6
Examples of Giving Information � Providing feedback from assessment instruments/tests. � Providing feedback about the client that is not already available (i.e. collateral source). � Explaining ideas or concepts relevant to the intervention. � Education about a topic. Differentiating MiNA from Giving Information… Giving Information should not be coded when the person is actually giving advice, warning, confronting, or directing. EXAMPLES pg 19: � You indicated that you usually drink 18 standard drinks per week. This far exceeds social drinking. (MI Non Adherent: Confront) � Keep track of your cravings, using this log, and bring it back next week to review with me. (MI Non-Adherent: Direct) Closed Question This behavior code is used when the interviewer asks the client a question that can be answered with a “yes” or “no” response OR specifies a very restricted range (i.e., How long…, How many.., who is… ?”). 7
Closed Questions Usually sound like: � Do you… � Did you… � Will you… � Were you… � Have you… � Etc. Also code as Closed Question if… � The question is intended to be open, but begins with a stem word such as can, could, did, would, should, are, will have: � Can you tell me more? � Could you explain that? � Do you want to tell me more about that? � Will you explain that? Open Question An open question is coded when the interviewer asks a question that allows a wide range of possible answers. It may seek info, invite client perspective, or encourage self-exploration. It allows the option of surprise for the questioner. 8
Open Questions… � “What brings you into today?” � “What can you tell me about that?” � “Tell me more about that…” (coded as open) � “In what ways….?” � “What have you noticed…?” � “What concerns you about….?” Stacked Questions… � An open question followed by “for example” closed question is coded as ONE open question (EX, pg 20) � More than one question in an utterance gets only ONE CODE. Open question trumps the closed. Questions trying to be reflections… …are coded as QUESTIONS (either open or closed). 9
LET’S PRACTICE PARSING! Reflection This category is meant to capture reflective listening statements made by the practitioner in response to client statements. May introduce new meaning or material, but essentially captures and returns to the client something they have said. Simple Reflections… Simple reflections add little or no meaning (or emphasis) to what clients have said. They may mark very important or intense client emotions, but do not go far beyond the client’s original intent in the statement. Summaries may be coded as simple reflections if they do not add additional points or direction. 10
Complex Reflections… Complex reflections typically add substantial meaning or emphasis to what the client had said. They serve the purpose of conveying a deeper or more complex picture of what the client had said. May add subtle or very obvious content to the client’s words, or they may combine statements from the client to form summaries that are complex in nature. Some things that can make a reflection complex… � Adding content or adding on (interpretation or feeling) � Metaphor or Simile (“picture language”) � Amplification (stronger or weaker ) � Double-Sided (reflect two sides of clients’ viewpoint) � Reframing (put situation in a different light) � Verbalization of unexpressed emotion � Emphasize one side (for particular effect) Decision Rule: If you cannot tell if it is simple or complex, it defaults to SIMPLE! 11
Series of Reflections… When a practitioner offers a series of simple and complex reflections in one utterance, only the COMPLEX reflection is coded. EXAMPLE: Simple Reflection + MI Adherent Statement + Complex Reflection CODE = MI Adherent, Complex Reflection Reflection and Question in Sequence… Sometimes practitioner begins with a reflection, but adds a question to “check” the reliability (either open or closed). CODE BOTH ELEMENTS. EXAMPLE: So you don’t ever want to use heroin again. Is that right? (CODE: Reflection, Closed Question) Reflections Turned into Questions… ...are coded as Questions! � EXAMPLE: So this has been a very long week for you? (CODE: Closed Question) This would be a reflection without the upward inflection at the end. 12
MI Adherent This category is used to capture particular behaviors that are consistent with a motivational interviewing approach. We only code MI Adherent for those utterances that fit the following 4 categories…. Asking for Permission before giving advice or information � OR asking what the client already knows or has been told about a topic before giving advice or information. � Indirect forms of permission are also coded, such as when the practitioner invites the client to disregard the advice if desired. � NOTE: Permission is implied if the client has asked for the information. Affirming the client � Saying something positive or complimentary. � Commenting on client’s strengths, abilities or efforts IN ANY AREA (not simply in relation to the target behavior). 13
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