I'm Dr. Amy Cohen, Program Director for SMI Advisor and a Clinical Psychologist. I'm pleased that you're joining us for today's SMI Advisor webinar, Using Motivational Interviewing with Serious Mental Illness to Address Medication Nonadherence, Create Change, and Enhance Stability. As my advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. And now I'd like to introduce you to the faculty for today's webinar, Christopher Link. Mr. Christopher Link is a member of the Motivational Interviewing Network of Trainers and is focused and specialized in the practice and art of providing trainings in motivational interviewing across a range of organizational settings over the last 13 years. While at the Department of Veterans Affairs, Mr. Link was a regional trainer for VISN 12, which is the VA Greater Lakes Healthcare System. Currently, Mr. Link teaches at the University of Chicago School of Social Work, Social Service Administration. There he teaches MI and clinical research courses. Additionally, he has over seven years of experience working with the population with serious mental illness, including a community-based transitional living program and a psychosocial residential rehabilitation program at the VA. Chris, thank you for leading today's webinar. Thank you, Amy. So I just want to announce I have no disclosures, no financial relationships or commercial interests or conflicts of interest to this report. So for today, our learning objectives, my aim is to help you kind of understand, explain medication nonadherence through the MI, so motivational interviewing. Whenever I talk about motivational interviewing, I'm just going to refer to it as MI. The specific lens of MI of ambivalence regarding motivation to not take psychotropic medications as prescribed, also to summarize adaptations of MI to effectively work with consumers experiencing positive and or negative symptoms, which are often associated with severe mental illness as MI. And then finally, to describe the use of value card sorting within the context of an MI session and how that can assist in the evocation of change talk and enhance stability. So I want to start with the definition of nonadherence. This is an important point, and I'm going to try to tie everything I do into MI, and it's going to kind of grow and develop on itself. Also, later, referring to slides that we covered at the beginning and how MI relates to them. So just so we have our definitions to understanding rights correctly, compliance and adherence are terms relating to suboptimal taking of medication by patients, so suboptimal, not as prescribed, somehow not as prescribed by the prescribing physician. So often the terms, these are terms a lot of times providers have heard, especially if they've been practicing for a while, compliance or adherence, they're often used interchangeably. But what's really interesting is they indicate a different view on the relationship between the patient, the healthcare professional, and the collection of medication from pharmacy to the proper intake. So compliance, that's a term often kind of used throughout history, is the extent to which the patient follows recommendations of the prescriber. And so this definition has a power dynamic within it. So as a negative connotation, the patients are subservient to prescribers. We're going to come back to this and talk about this, because within MI, within a spirit of MI, collaboration is something that's really important. It's considered a core element of MI, and you want to minimize that hierarchy. And so adherence, on the other hand, refers to the extent that medication intake corresponds to the recommendations of the healthcare provider. So that's why we're talking about medication non-adherence or adherence. And so since the problem isn't typically medication adherence, that's why we're looking at MI and the behavior issue of non-adherence. So there's different types of medication non-adherence. We have intentional and unintentional. So intentional, looking at the left side of the screen, tends to be active, looking at kind of the pros and cons, that's rational decision-making process. So this might be, for example, there's a lot of ways this could look. This could be the person who, when they are reading on Google and looking at, like, these are medication side effects. These are all the things that could go wrong. Again, all important things, especially in our digital age, very much a fact of when somebody is being prescribed medications, they look at regardless of socioeconomic circumstances often. So looking at possible concerns or side effects or disadvantages. Another thing is, again, medications have certain stigmas related to them, especially medications often associated with SMI. There's many types of stigmas, and that's an important factor, which we will talk about with some of the kind of cultural phenomena associated with medication non-adherence. So then also, so in the intentional type of medication non-adherence, this is where communication to the provider. Typically, it could be the provider, somebody working with a client, it could be the person prescribing the medications that's essential to address this type of non-adherence, because this is the active pros and cons, rational decision-making. So this person has this kind of active interest and concern, and so communication addressing these types of questions is an essential way to intervene. On the other kind of side of the coin, we have unintentional. So it could be passive, unplanned behavior, less associated with beliefs or intentional non-adherence, so not intentional. It could be they forgot. For example, one example, somebody maybe who's concurrently has a diagnosis of a severe mental illness and is using cannabis. Maybe the cannabis is affecting their memory. This is just one example, and they're forgetting to take their medications because their memory is impaired. So that could apply to a whole range of substances, but it could just be forgetting. Maybe they don't have their medication box set up. Maybe they're not using a medication box. It could also be a forgetfulness or not knowing how to use medications, a lack of understanding. Also thinking about older populations, this could be an issue too. I see this. I've seen this too, where an older person just doesn't understand how medication works. You explain it and they forget. So here, the intervention should address simplification, a regimen, reminders, and support. These things are important to be aware of at the beginning, because when we get more into how to use MI to work with medication non-adherence, this will help us think about what could be going on that's figuring into non-adherence, and then it helps us understand the ambivalence too, like what are some of the factors? To address a more meta and global issue related to culture and medication non-adherence, there's a study by Sheehan, Kennedy, and Stupenz. The article describes a lot of stuff, and it boils down into this chart. It's way beyond the scope to describe this whole chart, but the essential things I want you to understand is what's really interesting. As you can see, the dark arrows relate specifically to positive association. One thing that stood out that's really relevant to our discussion today is control of illness. You can see control of illness, I'm going to pull my mouse over here, control of illness related to personal and treatment, and how that relates to medication adherence. Control of illness, the more control the person thinks they have related to their illness, the less anxiety they have related to it. The less control they feel they have, the more ineffective their behaviors will be, and their cognitive and emotional changes will be. They'll have more behaviors that could be contributing to non-adherence, possibly more cognitive issues related to possibly even why they feel like they're less effective in controlling it, and more possibly negative or dysphoric emotional aspects. Greater control, less anxiety, lower avoidance even, and it's a denial, but with an MI, I'm not going to use that term, and I can go back until when we start talking about MI and what the foundation of it is. We're going to talk about avoidance more. Control of medication is a really important point, and I think with the spirit of MI, we're going to talk about autonomy. That's going to be a really important thing to point out too when you're talking about medication adherence. Autonomy is going to come in. The other thing I want to mention here is oftentimes when somebody comes in, at some point when they're diagnosed, they're going to think about, they might take on the narrative of the perspective of the provider about the illness when somebody is first diagnosed. Of course, then they're also going to have their own understanding, their personal experience based on how to interpret the symptoms. There's often a collision in the sense of the perspective of the provider versus the client's personal experience of the symptoms. Of course, cultural beliefs, religious beliefs, self-efficacy, knowledge of illness, all these things come into this. This chart contains a lot, but thinking about those two points, control of the illness and perspective of the provider versus how that might clash with personal experience. Some of the factors in here are considered modifiable versus non-modifiable. Modifiable factors, and those are the things that we can control for, are patient trust. Patient trust with the provider and communication. That is really specific to what we're talking about with MI. We can teach you and you can learn skills to increase how to express and increase trust and to better communicate with using MI. Then some other ways that cultural issues can be addressed in terms of intervention to make medication adherence decrease, so medication adherence to increase, is there some recommendations from McQuaid and Lander. Again, individually deliver patient and provider interventions with cultural adaptations appropriate. A lot of times, considering a cost, considering the symptoms, considering medication beliefs like we just talked about, unintentional, intentional, and providing cultural competence or cultural humility training to providers. This will decrease perceived discrimination may be reduced. Medication beliefs may be understood more by the provider. Complementary alternative medications are more likely to be discussed. Again, tapping into the client's belief system. Again, when we get into MI, it's about evoking the client's own reasons about how they might find get on board to taking medications more as prescribed. Implicit bias training. Again, if you think about some of the research that's come out about Caucasian providers when wanting to address somebody coming in who's African-American who has sickle cell anemia and pain medications, how implicit bias training can help mediate some of those negative consequences. Then absolutely considering language concordant services through interpreters, making sure you have somebody there who speaks the same language. If the provider doesn't, having somebody there who's from that culture, that makes a big effect. It makes a big effect in establishing trust in the patient, the client understanding that the therapist knows where you're coming from. Severe mental illness, serious mental illness. Again, typically it's been associated with schizophrenia, schizophrenia spectrum disorders, schizophrenic disorders, bipolar disorder, bipolar disorder with psychotic features, major depressive disorder with psychotic features. Again, but any of these mental illnesses have the potential to produce impairment, interfere with quality of life, or qualify as serious according to the federal usage of the term. This is what we're looking at developing as we go through this slideshow to cater MI to how to use MI with this population. Some of the relevance of this, estimates of non-adherence with SMI population. It's huge. Globally, 450 million people affected by psychiatric disorders, major depressive disorder. Again, you can see that the numbers here are 350 million, bipolar disorder, 60 million, schizophrenia, 21 million. So poor medication adherence estimates approximate $6 trillion by 2030. And then looking at some of the rates of adherence of schizophrenia for people who are diagnosed with some form of schizophrenia and spectrum disorder, 50, 60% non-adherence. Major depressive disorder, 50% haven't taken half the prescribed dose in the first three months. And thinking about the effect that has on the course of their illness, and then also like their perceived efficacy on how the medication helps. That's a whole other part. And bipolar disorder, 35% non-adherence. So bipolar disorder, last one, non-adherence rates range between 35% to 65% in the first year. So again, this is a very, very relevant, very, very real issue that it's absolutely essential to address since this is often the first line of kind of treatment with severe mental illness. So kind of going back, Senigan talks about some kind of more aspects of intentional, unintentional medication non-adherence behaviors. Again, thinking about this and how this looks concretely. Failing to initially fill or refill a prescription. Thinking about, so get the prescription. Prescriptions nowadays, at least are probably sent straight to the pharmacy. It's kind of rare somebody's given a piece of paper. That used to be another barrier along the way. But now, but in terms of picking it up and do they have a ride, all these different things. So in a sense, it's non-adherence isn't something to blame the client in. Isn't necessarily a trait of the client. There's something wrong with them. There's a whole range of issues involved. And I'll kind of tie that back into MI at some point later, how it's not about blaming the client. Something's characteristically wrong with them. It's looking at barriers that are modifiable. So, or discontinuing medication before completing the course of therapy. So if we think of something very kind of just very non-stigmatizing. When people take antibiotics, I don't actually know what the numbers are, but I've heard oftentimes how few people complete the full course of antibiotics when they're given a prescription. And how that affects the effectiveness of taking it. So, discontinuing a medication before completing the course of therapy with a severe mental illness. Or taking more or less. So it's not always taking less of the medication. It could be taking more. And then what effect that's having. Are they having more side effects? And then whatever types of medications are on or taking the dose at the wrong time. Certain medications, I'm not a prescriber, but certain medications are meant to be taken at a certain time. Maybe some cause drowsiness. Maybe some help make more sense to take those during, before you go to bed. All the person's taking it during the day and then they're tired. So it makes me tired. So again, understanding all these things. And so we can see how am I eventually having that level of engagement and trust. We're going to find out more of what's going on. And then it's going to establish trust and communication. And you're going to be able to be more effective and less frustrated with helping people who are experiencing severe mental illness and struggling. Okay. So some of the effects of non-adherence with SMI. So kind of some of the ones of common sense. Increase their level of the outcome of the illness, complications, possibly leading to rehospitalization. Of course, kind of doing less well, poor outcomes in their personal lives and their social lives. Relapse of symptoms. Again, very common people with severe mental illness, they start taking the medications, they start getting better. Then it's like, oh my gosh, I feel so much better. Maybe that wasn't really me. Maybe that wasn't really going on. And then thinking they can stop taking their symptoms, their medications, and then the symptoms come up and then it leads to rehospitalization or them getting worse. Very common. Reduce effectiveness of subsequent treatment. And then again, it's in a sense wastage of the limited healthcare resources, especially right now. And that's something I'm going to try to intertwine within our discussion of this today is kind of treatment right now in the time of COVID. I'm going to kind of bring some things up in terms of like healthcare system is extremely taxed and it's more difficult in some ways too. Easier in some ways because we have digital technology. In some ways though that providers are being asked to do more than they've ever done. Increased substance use. Again, substances play an interesting role in multiple ways with medications and severe mental illness, poor quality of life, and increased suicidality. So some factors, and this is kind of what I touched on before, not seeing medication non-adherence as a trait that is something that is non-modifiable, that it's some character flaw in the person. Because I think it can be frustrating when the provider, you're seeing somebody and you're trying to help them and they're constantly, there's a problem about medication. They're not taking it or they're frustrated. They don't want to take it. This leaves a lot of frustration. So there's factors involved, lower level of education, younger age, cognitive impairment. You can see how that could lead to all types of confusion about either effectiveness of communication and treatment, or possibly understanding how to take the medications. High intensity of delusional symptoms, suspiciousness, again, not wanting to take medications because not sure what it is. Substance use independence. Again, how that could affect possibly more chaotic lifestyle, not taking medication. Minority ethnicity. That would be a whole topic possibly in itself to talk about with related to medication adherence and how that ties into culture too. Cultural beliefs and how that ties into kind of thoughts about power and control, thoughts of medication, especially who is the provider, is the provider of that same culture or not. Again, other things that go with it, poor insight, poor therapeutic alliance, that's modifiable. That's something that therapists can work on and change. Lower socioeconomic status, is that medication something available? What is their healthcare like? What are the barriers, treatment? Bad experiences with admission, bad experiences with providers where the communication didn't go well and they don't have trust. They have mistrust already developed. And then again, just going to touch over some of these things. There's potentially involved in adherence. Some of these kind of we've touched on already. So with bipolar and schizophrenia, psychotic symptoms for both bipolar, high severity depressive episodes, rapid cycling, highly effective morbidity, comorbidity with anxiety or obsessive compulsive disorder, weight gain, adverse effects, cognitive effects, longer duration of episodes, suicide attempts, schizophrenia again, psychotic symptoms. High severity depression at baseline, early dysphoric response, a short illness duration. So maybe it was just a short, brief psychotic episode. And then so maybe again, not seem to need to take the medications again. So we have different types of side effects correlated with typically antipsychotics, poor response or tolerance to treatment, taking medications that cause side effects that just medication after medication and working with people who they had kind of some rare, unusual kind of reaction and this kind of had a kind of change and changes. So they don't want to continue with them or just early treatment discontinuation rate, hostility to treatment. These are some factors involved, just reviewing some factors. So now we're looking at some moving into the phase where we're looking at some, a literature review of the effectiveness of MI with addressing medication on adherence. And so it's interesting. We'll kind of start. So the way we start is kind of like a little bit discouraging, but we'll end with encouraging. So there was this kind of really important study that came out by Dreymalski and Campbell and they reviewed the literature of PubMed and PsychInfo from 1965 to 2006. And they found only five empirical studies. And then the two studies they found increased in the antipsychotic adherence following MI. Three found no change. The very few, the conclusions they came up with is there's no reliable research on MI and medication adherence for patients with schizophrenia before 2006. That was surprising and not surprising that when you dig into the literature, you often find things like this, that I was honestly surprised how, in some ways, so how little I found. But again, as we go on, we're going to find, we're going to end up with some really good stuff here in terms of what some current research is being done. So the research on the use of MI to increase medication adherence among patients diagnosed with schizophrenia was extremely limited. Every study reviewed was a combination of cognitive behavioral therapy and MI. There were no studies of MI as a standalone limited ability, so it was a limited ability to draw conclusions. And it was apparent a lack of clinical experience and training in MI and provisions to ensure fidelity as design flaws of studies. And that's a common thing too. So in the studies, the people designed, trained to deliver the therapy had what would be considered maybe novice or beginner level experience with MI. And some of the later studies even admitted, which were really robust, we'll see, as even the amount of training they had is still so much more than I have seen. And so that, this is kind of a very kind of, this is a theme throughout the research. We keep moving on. So Barkov, 2013. So confirming the effectiveness of MI to improve medication adherence with hospitalization rates in multi-episode schizophrenia in schizoaffective patients. So it was a randomized control study. So we have a high level quality study of a sample size 114. Subject experienced a psychotic relapse due to medication non-adherence in the past year. That was one of the criteria for being in it. And MI or health education over five to eight sessions, so the two possible courses of treatment results. MI did not improve medication non-adherence, nor were there significant differences in hospitalization rates. So again, so kind of surprising study. And this wasn't that long ago. MI did reduce hospitalization rates for female patients, non-cannabis users, younger patients, and with shorter illness duration. So these are the findings. Again, not exactly some findings, but not something to grasp onto again. So looking for, hoping to find more, moving on. And so here we get to another one, Palico, 2014, a systematic review of meta-analysis. So looking at 17 randomized control style, randomized control studies. So MI improves medication adherence at differential exposure times and counselor's levels of educations. So again, we're looking at how much exposure did the client have to MI and how much MI experience and ability did the counselor have. However, the evaluation of MI characteristics associated with success had inconsistent results. So some of the characteristics were MI delivery mode, how was it delivered, fidelity, fidelity of face feedback, again, learning MI, that's something I'd like to say more about later at the end. The background of the counselors and exposure time. So these were all questions that they looked at kind of variables. What they did is find improves self-reported objective measures of adherence to chronic medication at different lengths of exposure. Current evidence does not allow, unfortunately, consistent predictions of success. Larger studies needed to assess different delivery modes, fidelity assessment and feedback among diverse populations. So not surprising, more diverse populations, more fidelity assessments and feedback for determining kind of practitioner's level and skill and more studies. So the most interesting research I came across was by this group of, I think they're out of a Nordic country, Scandinavian country, Dabur et al. And it was a quality study of patient process in MI. And qualitative multiple case study of MI sessions analyzing interaction process affecting motivation of patients with schizophrenia. So looking at the quality of multiple case studies, analyzing the interaction. So now we're looking at some of those types of studies or types of fidelity measurements that they can use to analyze both what the patient said and the client said and analyze and really tease out what's happening in the MI session. This is something that's really only used in MI process research. Terry Moyer's done a whole bunch of research with us. So it's kind of the, it's not something usually practitioners receive feedback on, but it's used to evaluate the quality of MI and trying to really understand what works. So 14 cases, so not a huge sample size, but what they did was pretty amazing. So 66 audio recorded MI sessions made four different conditions, again, not ambivalent motivation and medication adherence, not ambivalent motivation for medication adherence, ambivalent solve, motivated for medication adherence, ambivalent not solved. There are three successful factors. This is what's really important we're finding out here is a trusting relationship in some sense, not a surprise, regardless of the therapeutic technique. Time and time again, we find that a trusting relationship is the most important thing when providing therapy. And this has to do in some ways, not just with MI, but I think MI really lays out clearly the components to have a trusting relationship. And we'll talk about how it does that in a bit. The therapist's ability to adapt MI strategy to the process. So here, it's not just knowing MI, but how did the therapist use MI, MI kind of strategy or MI kind of as a therapy? How did they use it to address the process? So there's using motivational interviewing with just any behavior change. It could be using MI with somebody in a smoking cessation clinic. And then there's using MI perhaps with somebody with severe mental illness, somebody with maybe somewhat significant positive symptoms or maybe somewhat significant negative symptoms. That's a whole nother level. When you're hearing disorganized speech, when you're having a lot of poverty of thought, poverty of speech, that's much different. And so I think what they're getting at is kind of some of the things is the quality and the training of the provider and understanding some things we're going to talk about can really make a big difference in being successful using MI with this population. And then relating patient values to long-term medication adherence. So the conclusion, success of an MI intervention for medication adherence can be explained by well-defined factors that therapists should consider when using MI. So another study, again, I'm really intrigued by this offer, and these are really current studies coming out. So this is the most exciting thing that I kind of discovered when preparing for this webinar. So active ingredients, title, active ingredients and mechanisms for change and motivational intervening for medication adherence in mixed methods study of patient-therapist interaction in patients with schizophrenia. So 14 case studies that they performed general sequential querier of MI sessions, that's just a type of analysis, it's not even specific to MI, to assess transitional probabilities between MI techniques and patients' reactions in terms of change talk and sustained talk. So using a method to analyze the sequential order of MI techniques of what the therapist would do in MI to see what was most effective. This is really exciting, I thought it was. So this has developed a model of potential active ingredients and mechanisms of change in MI in patients with schizophrenia. And so the results kind of similar to before is therapist factors of a trusting relationship and empathy, a trusting relationship and empathy. So not some trick, not something super fancy, but a trusting relationship and empathy are essential, they're core ingredients to enable a succinct depth of conversation to allow the triggering mechanisms of change, that they allow a succinct depth of conversation to allow the triggering mechanisms of change. And so they looked at like a whole bunch of kind of components of MI, and like emphasizing autonomy, seeking collaboration, these are very specific MI skills that come out of a certain coding instrument called the MITEI. But they found that it wasn't even that sequence, it was 70% of the time, it was reflections, complex reflections and questions, addressing medication adherence, follow change talk. So it comes down to basic ingredients, complex reflections and often evocative open-ended questions addressing medication adherence, following change talk, that that was what is effective and combining that with the other results, with getting at values, trusting relationship and then now we're moving into, this is what MI is good at, this is what MI is designed for. So all this talk about MI, I often find sometimes when I give a presentation, I talk a whole bunch about MI, but then it's like, oh, I forgot to give a definition. So let's take a look at two definitions. And again, MI is something that most people have heard about, I have devoted the last nine years of my life to it, like almost wholeheartedly, it's my passion. So just kind of again, kind of looking at some components of this. The lay person's definition, so if you're just describing this to somebody, motivational interviewing is a collaborative conversation style for strengthening a person's own motivation and commitment to change. Technical definition, MI is a collaborative goal-oriented style of communication with particular attention to the language of change, is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring a person's own reasons for change within an atmosphere of acceptance and compassion. So these are the definitions out of the last publication of kind of the main book on motivational interviewing by Mill and Rolnick in 2013. Just to have the definition set out explicitly before we move into now the MI section of this presentation. And so I see is there's four main components of MI. There's a four processes of MI, which kind of became clarified and elucidated in the 2013 version, the third edition of motivational interviewing, there's three editions. We'll talk slightly about that. The spirit of motivational interviewing, which most people have heard about that was present in I think the second edition. And then kind of what we do with MI, the spirit of MI is kind of the ethos, the ors of MI is kind of what we're doing. We're basically asking questions or giving statements. And the I is for information. And that was something that was added by Rosengren on a book about how to use skills with MI. And then the other important thing I would talk about because with MI, it's all about change, talk, and sustain talk. And I'm going to say a lot more about that because that has to do with ambivalence. So this is kind of how I would describe when I'm teaching classes or giving presentations or trainings, the four components that are important to think about with MI. And so kind of just presented a different way. In the spirit of MI, we have partnership. This is just an overview. We have acceptance. We have evocation. And we have compassion. Together, that intersection of all those and that Venn diagram is the spirit of MI. Then we have engaging, focusing, evoking, and planning. That is the four processes. That could be new to some of you if you haven't been maybe learned about MI since 2013. That's something different. So it's the spirit of MI. It's engaging and focusing. And then it's plus the target behavior, which I'll say more about, which is the patient's dilemma or it's their ambivalence. And that's conceptualized as change, talk, or sustained talk. Understanding this is key to using MI. So that's kind of MI laid out in a nutshell. And so the four processes. This is important to think about. A lot of times, people think about the trans-theoretical model of change that kind of where you have pre-contemplation, contemplation. I'm trying to think of the other things. You have activation, planning, preparation, planning, all the way, sometimes including relapse. That actually is not MI. That was described by Bill Miller as kissing cousins because they go really well, but that's not MI. Just so people are aware of that. Sometimes they get asked about that. The four processes of MI, again, is, I'm going to show the next slide here, is related, is these are the four processes. We have engaging. So when you meet somebody, you talk to somebody, that is engaging. They're learning about you. They see you. They hear your voice. They learn how you treat them, what they tell you. How do you respond? Do you respond critically? Do you respond kindly? Do you ask them questions? Do you tell them what to do? Do you answer their questions? So this is engaging, and this is going on the entire time. It's the foundation at the bottom, just because this isn't a linear model. It's more of like a cycle. They interpenetrate each other. Focusing is kind of collaboratively deciding what you're going to talk about together. It's like, it would be kind of what is the, there's multiple things going on. What are we going to talk about? Invoking is actually where MI comes in. It's where you're trying to evoke change talk. And planning is a stage you might not even get to an MI session, where you're actually, the client is able to verbalize, and you're helping them verbalize their thoughts on change. Spirit of MI, just say a couple words about this. Collaboration is a sharing of power. The therapist is not the expert. It is about a guiding style, where together, the client and the therapist can jointly work to try to work together. It's about asking permission. It's about sharing the relationships, about asking questions and wanting to know their ideas. And then up here, this kind of relates to evocation. Evocation comes in, it's because the client has their own reasons that they're going to change. That the goal of MI is to draw forth, elicit, evoke their reasons. Everything you're doing is basically trying to get them to evoke their reasons, which is change talk. And if you can get commitment language related to change talk, that is the thing. The more that you get them to talk about their reason for change, the more they're likely to change. Acceptance has a whole bunch of components, absolute worth, autonomy, accurate empathy, and affirmations and compassion. You're doing it on behalf of the client, not yourself. So this is kind of the ethos, the gestalt, how you want to come across to the client. Basic MI skills, I'm not going to say too much about this. It's about open-ended questions versus closed affirmations, affirming their strengths, efforts. Again, so related to taking medications, if you hear them giving change talk, you'd want to affirm that related to medication change. A lot of, again, the research by Dauber talked about reflections. Complex reflections and open-ended questions were most likely pertaining to addressing medication adherence. That's where 70% of the change talk came from. And summaries have a role, this has a very specific role as we move into kind of talking about kind of how to apply MI to severe mental illness with negative and positive symptoms. Information exchange, I'm going to touch on that briefly too. So informing the MI way, again, just briefly going to go over this. So you're not delivering detailed information, you're limiting and tailoring it to the client. So you're not telling them everything they need to know about medication, you're being strategic. You're creating an opportunity for the client to process and respond to the information. You're acknowledging the expert, their own life, and you're encouraging them to use it in a way that suits them. So I have the next slide, it's more helpful. So in particular, if you're a prescriber, this is really important. So when somebody is ambivalent, if you give them unsolicited advice, it doesn't often work. It doesn't work well, it's not effective. And so one way, this would be a slide I'd recommend looking at more, is to ask them, what do you know about taking medication for some of the symptoms you're having? What do you know about kind of those voices you're describing? What do you know about what medication can do for that? Or what do you know about the effects that medication can have on making you not feel so down and sad all the time? So you're finding out what they know. Maybe they've already spent a lot of time looking on the computer about this. And so you're finding out what they know first. And this allows kind of up here, the sharing and existing knowledge, They can tell you what you know and then you know more how to specifically cater it. And then you can reflect what they say. Maybe they know some really important information. You'd want to reflect that back. They're gonna also see that you're asking, you're curious about what they know. You're not treating them as somebody who knows nothing. It's really important to kind of treat them in a way that they know that like you want to know what they know first. Maybe they don't know something and that that's what you'll find out. And then so it can be it'd be also asking it's like I'm wondering could we talk a little bit about kind of what you know about kind of the use of medications for hearing voices or for kind of what you're describing or you just feel flat and you don't even almost have any thoughts or you're feeling so hyper sometimes that it scares you. That's one way. And then you might have some information then based on what they said that you want to provide. You might want to tell them about some possible options for medication. This is where you're providing the information. And actually information can be even expressing a concern. And so it'd be you know so I do have some information which you may or may not find helpful. But some people find this helpful. So if it's not helpful just you know we could have hopefully have a conversation about it. But would it be okay if I shared some information that I think kind of pertain to what we just talked about. So it's asking that permission that sharing power. It's being collaborative. And oftentimes again I don't know if I've ever had somebody tell me no. And again that engagement piece it's fostering trust. It's fostering this idea this person's going to ask me. They're not just going to tell me what they want me to do. And then after you've given information asking them so what do you think about I just told you. And that way you're seeing what they take away. What did they register? What do they understand? What was the takeaway? And then based on how they respond you have a conversation more about that. So it's like illicit provide illicit. And this is a really important slide. I think it's one of the most useful things probably in this presentation. Okay. Change talk, sustain talk. I'm going to be pretty quick about this to make sure we get through everything. So with NMI. So change talk favors change. It's self-expressed speech favors movement in the direction of change. Opposite is sustain talk. It's speech that favors things staying in a status quo. For example with medication adherence. Be like well sustain talk might sound like I just had a really hard time like you know no matter what I do I just can't seem to like get organized and take my medication. It feels hopeless. That would be sustained talk. Change talk would be it's like I actually set up my medication box this week. That would be change talk. And so when you hear change talk you want to reflect it. It oftentimes reflects the client's desires ability reasons or needs to change. It conveys optimism. It states a willingness and intention to change. And you want it so the target behavior so in this sense our target behavior is medication adherence. So ambivalence is so kind of what do they say about real estate. There's three important words location, location, location. When I'm talking about NMI I always say there's three important words ambivalence, ambivalence, ambivalence. It's about understanding ambivalence. You need to get so when you're using NMI it's like I entered this different space and what I'm hearing I'm hearing the nuances of ambivalence. Everything I'm hearing I'm hearing listening for the subtleties or the not so subtleties of ambivalence and how it comes out sometimes even in the same word because of the tone or maybe it's in the two the sentence they say that's you know two independent clauses. Not that they would think about pot perhaps that way. But you're hearing the ambivalence. The ambivalence was what you're responding to. That's the change talk and sustained talk. And then this is the this last bit of the presentation here which we're going to move through is then how to adapt NMI to work with SMI and how to do values work together with a client. So ambivalence. Understanding medication. This is the learning objective through NMI of ambivalence regarding modification to not take psychotropic medications as prescribed. So again ambivalence definition it's simultaneously wanting and not wanting something or wanting two incompatible things. It's human nature since the dawn of time. So it's not seen as denial. It's not seen as pathological. It's seen as part of the human experience. It's seen as normal. And it's to learn to appreciate and listen to and find and hear and hear the textures and richness of ambivalence. That's what it's one of the most important things that I would say in learning how to use NMI. And it's two sides of the same coin. So the client comes in with a dilemma or a problem. Maybe their dilemma is they're having they're not feeling right. They're having symptoms. And then of course through your conceptualization you're thinking of it from a provider's perspective they have this this illness. And then they might not think of it that way but they don't want to have those symptoms. They don't want to feel this way. That it's causing problems with all the realms of their life. They can't keep a job. They are having problems with their landlord. And so it's kind of thinking about this is the ambivalence and then we conceptualize it with NMI as change talk and sustain talk. Again with ambivalence again we have two doors that look very different but they're doors. If somebody says they like if they're ambivalent if they're like I don't know I like both these doors I'm gonna be putting one of these doors in my house. And then well I like the one on the left it's really plain and modern and elegant. They're like well but I don't know I like this other one. So with ambivalence the more the minute you kind of argue for one side the person's likely to flip and argue for the other. And so it's ineffective you have to be aware of that and that's where giving unsolicited advice is ineffective. It's also resisting the writing reflex which we'll talk about. The writing reflex is this well-intentioned sensation of wanting to reach out and fix what's wrong to set people promptly in a better course. And so being aware of that can really derail MI. Again there's some more information about the writing reflex. Kind of could read through this off about what the person should do. The patients are either motivated or not. How is it right for change? It's a tough approach. A tough approach is always best. I'm the expert. If the person decides not to change this consultation has failed. So now kind of some of the one of the second objectives here is how to apply MI to positive negative symptoms. So again with MI and this comes out of a 2008 book of using motivational intervening and treatment of psychological problems. Clinical issue is a lot of times when you're working an integrated treatment so a lot of times again people don't have a mental illness. A mood disorder or a psychotic disorder that might be substance use too. So you might have multiple related target behaviors. So you might be having to work with substance use. You might have to be working with medication adherence. You might have to be working with something related to housing. You might be related to having to work with something related to work. And so the challenge is kind of finding that common overall denominator and then when you're talking about medication adherence when something else comes up this that loops it's a factor in it. It's like well I don't really care about taking medication however like I really want to like have my own housing. And so then that would be change talk and kind of tying that back into medication adherence. And so it's kind of recommendations is attending the motivation for substance misuse or psychosis and how they interact. And again using open-ended debaculative questions targeting both medication adherence and substance misuse. So both integrated dual diagnosis treatment. Clinical issues dealing with cognitive parents often associated with severe mental illness. So multiple cognitive impairments working with memory, encoding, acquisition, word generation, verbal fluency, executive ability. Challenges patients have difficulty with self-reflection, cognitive tracking of conversations, appraisal of consequences, holding competing motivations for change. This is where MI gets a little more difficult if you're not used to using it with this population. So recommendations question reflect and summaries is clear in clear concise terms. Using less words, speaking slower, not using words. I once heard somebody use the word frenetic when I was coding a conversation. I thought wow like I I know what that words but I think a lot of people don't. I have no idea if the client knows what that word is. Making your vocabulary match the level of the clients. Simplifying things and then using successive reflection summaries. Use concrete and engaging methods to evoke change. Talks you're being succinct, less words, summarizing in clear and concise terms. These are general things to consider when using a MI with SMI. So using a MI with positive symptoms, which is actually described interestingly it was come up by a patient, which can be overwhelming to the client, is hot symptoms. A client came up with this Terry Moyer reflects about is as a way to describe it. Hot symptoms versus negative symptoms is cold. These were just kind of ways to think about it. So positive symptoms like delusions, hallucinations, bizarre behaviors, disorganized speech. Challenges that they complicate sessions with reflective listening. Patient's symptoms may increase if the clinician reflects emotionally charged content or focuses on ambivalence. So you would want to paraphrase. You want to do a lot of paraphrasing. You'd want to maintain a reality base. You would want to not like increase the ambivalence. You would want to kind of tone down some of the emotionally charged words. You might want to reflect underlying meaning or the parts that made sense. A lot of times when you're talking to somebody who has positive symptoms you can kind of follow what's being said. Like if you kind of take some of the content or some of the bizarre speech or something out of there and to reflect the part that makes sense. Keeping it simple, concise, reflecting the reality base. If you're able to use a metaphor or simile to make sense of a seemingly bizarre statement or gesture that's really helpful. There's an example in the book about that. That could also be problematic though in terms of like I guess if it's going to complicate things that are not going to track or follow that then I would caution against it. Not exploring negative life events or expressed emotions when they're experiencing positive symptoms. So again succinctly using not many words summarize ambivalence and soften sustained talk. Try to soften sustained talk or cultivate change talk. Succinct open-ended questions, reflections, reflecting underlying meaning, maintaining the kind of the reality base of the conversation. These are kind of some of the techniques and kind of what recommendations to adopt MI for using MI with positive symptoms. So with people who are experiencing predominantly negative symptoms, thought-blocking, social isolation, decreased emotional expression, impoverished thinking, processing speed, poverty of speech, diminished drive, challenges, again engagement, and then also paraphrase to stimulate the patient discussion. Allow sufficient time for reflection of questions. Use personalized feedback. Increase structure. The therapist is probably going to talk more. They're going to be talking more to kind of keep the conversation flowing. A lot of paraphrasing, a lot of summaries affirming where needed. And then there is a study again about using MI. It was by the VA looking at a lot of these things about SMI. Again a lot of the same, be concise, repeating information, provide structure, being sensitive, restating, slower pace, the process. There's visual aids which are really helpful especially importance and change rulers, personal values cards, roadmaps, bubble sorts. I have a link there that you can look at that can make it more concrete. Value card sorting. So it was developed. There's a number of different ways. I'll go, I'll skip over kind of the history of it, how it was developed. There's two different ways. One was developed specifically for SMI and then and that's the one we'll kind of be thinking about. So with value card sorting you have a stack of cards and there is a virtual app I saw that you could use if you're providing telehealth. And so you set, you explain the exercise. This is an exercise to help you kind of think about what's the most important to you. Whether you want to describe goals or values that might be beyond the complexity that you need to get into. What's most important to you. It helps, it's seen as you have three different categories with the way out the cards. Not important, important and very important up here. And then they start going through the cards and laying them out. It's really powerful. It says the actual act of laying the cards out versus just having them read through them and say it. Have them lay them out. And there's apps again you can use. And then have them sort out the very important. We have them narrow it down to their top five. And what it's meant to do is to help them kind of sort out their top five values. So the purpose would be then once you have those values and that might be something you haven't thought of. To facilitate a discussion of how kind of medication non-adherence or taking medication could tie into these values. It'd be there you can ask open-ended questions like what their life would be like if kind of like having fun. How do you think you could have more fun and take medication at the same time. Again there'd be a way to be evocative to prompt about this. And then there's a list of some resources for value card sorting which I encourage you to look at. And so the last thing is when MI is not appropriate. If they're too psychotic to benefit. The answer lies in the client's response. If the client's response becomes more disorganized. Consider providing more structure. If more structure of the session doesn't improve the response. It might not be appropriate for the client. When the client's response becomes less symptomatic. More organized. More logical in speech. They can recall and consider discussion. MI is appropriate. And then there's a brief inner study about MI for minority populations. And the main thing to take away is that it's more effective if you have somebody who's providing the therapies the same ethnicity. It speaks the same language. And that final suggestions. Consider MI training with formal feedback. Practice with colleagues. Practice one skill a day. Print out copies of the external aid. And that concludes my part. Thank you so much for an interesting presentation and very thorough Chris. One of the questions that came in was you know this is a challenge. So what do you do or how do you adjust the MI approach with a client who has really poor insight. Like they don't believe that they're sick. And this individual says you know it's the number one predictor of non-adherence according to DSM-5. Right. I would. There's one article I didn't include that said don't argue about diagnosis. So I would not argue with them. I would just reflect kind of what they're saying. So what was the question again? Could you restate it? Sure. What how do you how do you change your approach with a client who has poor insight into their illness? I would. Right. So poor insight. I would I would focus on what are the behaviors that are not working in their life right now. Like what are the outcomes? Like how how are they having trouble in their life? And so if it was related to kind of housing. If it was related to not having friends or people not wanting to talk to them or not getting out. I would focus a conversation on those things. And I would actually probably focus my MI session on that. And just try to make see if they heard me. That they understood that I was listening. And then at some point I would try to find a way to weave in how medication might come in. So I wouldn't try to increase their insight. There actually was a study that I didn't include to talk about how MI actually might increase insight in through the process of reflecting. And I don't remember the outcomes of that. But it would be to focus more on what are the concrete problems versus trying to convince them of like what their diagnosis is. And then having a conversation be more about what they want to talk about. And then trying to find an opportunity where medication might be some way can improve. Like getting what they're hoping for initial term. Right. So it sounds like focusing on functioning issues or recovery goals or something that's like slightly different than just the illness per se. Yes. And that might be the avenue to get to that medications. It would just it would be productive probably to focus on that. How do you what would you say to people who want to become better at MI? Like in terms of training or how can they improve their skills? There's a lot of resources out there. One thing is I would look at the MIT website. There's all different types of trainings. There's all different types of training even off of MIT. But with MIT you're gonna find people who are skilled and kind of went through a verification process. There's there's books there's videos there's there's so many resources. The thing that I would most highly suggest if you're really committed to wanting to get better I think it's the best way is to get to get fidelity driven fidelity driven feedback. And so for example some you can make a MI session with a friend where you're just discussing something that you're ambivalent about. So you wouldn't have to get like a release of information and deal with HIPAA. And then you can learn get feedback on what are your strengths of MI and what are the areas you can improve upon. Your conversations listen to it's coded and you're given a report. That's one way. It would also just be like attending I think I'm sure there's like webinars. But I highly lean toward getting data-driven fidelity based feedback for MI using for example the MITEI. Can you say again what the app is for the value cards? I don't know the app offhand. If you if you type in value card sort app I think that's how I found it. I didn't know if I should include it because I didn't know if there was a propriety issue and if I'd be giving somebody business that's why I didn't include it. That's right. You and I should make one and then we can make some business. That was that was the complexity of my search was like value card sort MI digital version and I came across something which I thought was interesting. Right, right, wonderful. All right well we're gonna move on from questions. Thank you again so much Chris. It's been a real pleasure today.

Motivational Interviewing

Serious Mental Illness

Medication Non-Adherence

Change

Enhance Stability

Collaborative Conversation

Ambivalence

Engaging

Focusing

Value Card Sorting