Wanted !! Quick and dirty rating system for MI Must be able to - - PDF document

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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

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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

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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)

4 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

a.

Open

b.

Closed 5) Reflection

a.

Simple

b.

Complex

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”.

5 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

• wn 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?”

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Utterance # 1: MiA (Autonomy) Utterance # 2: Reflection

Answer:

“What you say is absolutely true, that it is up to you. No

• ne 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?”

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.

7 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… ?”).

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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.

9 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).

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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.

11 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!

12 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.

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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).

14 Emphasizing the client’s control

Freedom of choice Autonomy Ability to decide

Supporting the client

Using statements of compassion or

sympathy.

Note: No differentiating codes are assigned to MI Adherent behaviors. The rater merely identifies them as belonging to this category and codes them as MiA.

Decision Rule: The MI Adherent code takes precedence when the utterance clearly falls into the MI Adherent category. When in doubt, an alternative code (for example, Open Question or Reflection) should be given.

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MI Non-Adherent

This category is used to capture those interviewer that are inconsistent with a motivational interviewing

• approach. We only code MI Non-Adherent for those

utterances that fit into the following 3 categories….

Advising Without Permission by…

Making suggestions Offering solutions Language often includes words such as:

should, why don’t you, consider, try, suggest, advise, how about if you.., you could…, what about if you…, etc.

Confronting

Directly or indirectly disagreeing with client. Arguing Shaming Blaming Correcting Labeling Moralizing Ridiculing Questioning their honesty

VOICE TONE COUNTS HERE, EVEN IF THE CONTENT SEEMS OK! There is often a quality of uneven power sharing along with disapproval or negativity.

16 Directing the client by…

Giving orders Commands Imperatives Mandates

Decision Rule: The MI Non-Adherent code takes precedence when the utterance clearly falls into the MI Non-Adherent category. When in doubt, an alternative code (for example, Open Question or Reflection) should be given.

Some things are left “uncoded”

Self-disclosure – “I gave up drinking 6 years

ago” (per authors, there is a mistake in coding manual – cross it out on page 18.)

Structuring – “We are here today to…”, “Now

we’ll talk about…”

Greetings & Opening and closing statements

that serve as formalities – “I hope you have a nice week.” or “Thank you for coming in today.” (VS… I really appreciate you coming in.. I know this is difficult).

17 More things left “uncoded”

Facilitative Statements – EX “OK. Alright,

good” or “Great” when used as a way of facilitating or transitioning the conversation (VS when tied to a client behavior).

Previous Session Content – “Last week you

mentioned…”

Incomplete Thoughts – “We are here today

to…”, “Now we’ll talk about…”

Off-topic material – “It’s a bit cold in here”,

LET’S PRACTICE!

The Global Ratings

Evocation Collaboration Autonomy/Support Direction Empathy

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Evocation

Measures the extent to which the practitioner conveys an understanding that motivation for change, and the ability to move toward that change reside mostly within the client.

Practitioners High in Evocation…

Are curious about clients’ unique ideas about

why change may or may not be good for them.

Actively seek to explore client’s ideas about

change, even when the client does not offer them outright.

May provide information, but don’t rely on it as

a means of “helping” the client to change.

Understand the value of hearing the client’s

• wn language in favor of change and actively

create opportunities for that language to occur.

Practitioners Low in Evocation…

Have only superficial interest in the clients’

ambivalence or reasons for change & miss

• pportunities to explore these reasons in detail.

May make assumptions about client’s intent to

change or not to change.

May rely on persistent fact-gathering or

information-giving and convey distrust of the clients’ own knowledge about the problem.

Are likely to provide the client reasons to

change rather than elicit them.

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Collaboration

Measures the extent to which the practitioner behaves as if the interview is occurring between two equal partners, both having knowledge that might be useful.

Practitioners High in Collaboration…

Work cooperatively with the client toward the

goals of the interview.

Do not rely on dominance, expertise or

authority to achieve progress.

Are curious about client ideas and are willing to

be influenced by them.

Can hold the reins on their own expertise,

using it strategically and not before the client is ready to receive it.

Practitioners Low in Collaboration…

Do not work towards a mutual understanding during the

session.

Rely on their own authority and expertise for progress

and do not appear to value the client’s knowledge.

Are often ahead of their clients in prescribing both the

need for change and the means to achieve it.

May appear to be “wrestling”, rather than dancing with

the client.

May be dismissive or passive, not making a genuine

contribution to the interaction.

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Autonomy/Support

Conveys the extent to which the practitioner supports and actively fosters client perception

• f choice as opposed to trying to control the

client’s behavior or choices.

Practitioners High in Autonomy/Support…

Ensure, either directly or implicitly, that the

topic of choice and control is raised.

View the client as having the potential to

move in the direction of health.

Work to help the client recognize choices. May explicitly acknowledge the client has the

choice to change or maintain the status quo.

May express an optimism about the client’s

ability to change.

Practitioners Low in Autonomy/Support…

View the client as incapable of moving in the direction of

health without practitioner input.

May assume the client will change his/her behavior in

the direction the practitioner thinks best.

May tell the client s/he has no choice or imply that

external consequences (arrest, etc.) have removed choice.

May be sarcastic, or cynical about the client’s ability to

change.

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Collaboration Autonomy Support Evocation MI Spirit

Elements of MI Spirit Measured in MITI 3.1.1

Direction

Measures the degree to which the practitioner maintains appropriate focus on a specific target behavior or concerns directly tied to it. Not a good measure of MI in and of itself (i.e., one can be high in direction, low in spirit.)

Practitioners High in Direction…

Exert substantial influence concerning the topic and

movement of the session.

Are transparent in their focus on a target behavior or

referral question.

Make consistent efforts to return to the target behavior

when conversation wanders.

May exert direction by seletively reinforcing client

discussions toward the possibility of change.

Keep the focus on present thoughts about change and

not drifting into history of the problem.

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Target behavior not clear or transparent. May

not appear to explore any particular behavior change on the part of the client.

Do not take opportunities to bring change into

the discussion.

May accept excessive focus on historical topics

• r theoretical explanations that divert attention

from changing a current behavior.

Appear to lack a compass to help them move

toward a specific, desirable end.

Empathy

Measures the extent to which the practitioner understands or makes an effort to grasp the client’s own unique perspective and feelings. Not to be confused with warmth or advocacy.

Practitioners High in Empathy…

Approach the session as an opportunity to learn

about the client.

Are curious and spend time exploring the client’s

• pinions and ideas, especially about the target

behavior.

Show an active interest in understanding what

the client is saying, beyond just what is explicitly stated.

May accurately follow or perceive a complex

story or statement or probe gently to gain clarity.

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Practitioners Low in Empathy…

Show indifference or active dismissal of the client’s

perspective and experiences.

May probe for factual information to pursue their own

agenda or “build a case” for their point of view.

Show little effort to gain a deeper understanding of

complex events and feelings.

May ask questions that reflect shallowness or

impatience.

Might express hostility toward the client’s viewpoint or

directly blame the client for negative outcomes.

Uses of the MITI

Evaluating practitioner competence in clinical

trials

MI Skill coaching Self-assessment for students of MI Evaluating success of teaching MI Screening tool for hiring More cost-effective than MISC, but cannot be

used to evaluate therapy process

Overlap between supervision and treatment integrity

MITI can be used for supervision and

coaching (objectivity not required)

MITI can be used to evaluate

treatment/program integrity (objectivity required)

MITI cannot be used for BOTH

treatment/program integrity and supervision by the same person in a single project

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Fogel (“…the rebellious supervisor”)

“My whole purpose in supervision/coaching has been to create such a safe environment that the trainee can function in his/her own style and feel cherished enough to ask for help when the going gets rough. We can then reflect, explore options, and discover together the process which feels suited to the trainee’s present psychic state and skills”

Resources and Help…

Sue EckMaahs

Work: 651/489-1122 Cell: 651/303-1166 seckmaahs@eckmaahs.com

Resources: www.motivationalinterview.com

www.casaa.unm.edu (MITI materials and data)

Motivation Interviewing: Preparing People for

Change, 2nd Edition. (Miller and Rollnick), The Guilford Press, 2002.