Motivational Interviewing for Risky Social Drinking - PDF Document

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  1. Motivational Interviewing for Risky Social Drinking Treatment Manual for College Students with Subclinical Social Anxiety and Risky Drinking Patterns By: Margo C. Hurlocker, Ph.D. Theresa B. Moyers, Ph.D.

  2. 2 Motivational Interviewing for Risky Social Drinking Table of Contents Motivational Interviewing Processes………………………………………………. 3 Goals of the Therapist………………………………………………………………. 5 Clinical Style………………………………………………………………………. 7 Motivational Interviewing Spirit…………………………………………………. 8 Core Motivational Interviewing Skills…………………………………………… 10 Implementing Session 1……………………………………………………………. 12 Therapeutic Considerations with Target Population……………………………… 14 Implementing Session 2…………………………………………………………….. 19 Therapeutic Considerations with Target Population……………………………… 21

  3. 3 Motivational Interviewing for Risky Social Drinking **Four MI Processes** 1.Engaging – During this phase, the therapist is focused on building rapport and establishing a safe and collaborative environment for the participant to share his/her drinking experiences. Essentially, the therapist is asking the participant: “Can we walk together?” a.The therapist’s interpersonal skills are critical during this phase. Attention to active listening, accurate empathy (i.e., reflective listening), and accepting the participant where they are at in the change process 2.Focusing – During this phase, the therapist works with the participant to determine the direction of the session, and what change the participant would want to work on. For the MI- RSD intervention, the participants are already aware that their drinking behavior in social situations is the target behavior, and this phase will allow the therapist and the participant to determine what, if any, changes the participant may want to make to their drinking behavior. Essentially, the therapist is asking the participant: “Where are we going?” a.Despite the participant volunteering for the study, and being aware of the target behavior in the MI-RSD intervention, there may still be a level of defensiveness and/or ambivalence surrounding potential changes to their drinking behavior. It is important for the therapist to view the defensiveness and/or ambivalence as a natural component of change. b.The focusing phase may be an important point to inform or reiterate to the participant that it is his/her decision on what changing his/her drinking behavior may look like, and at no point will you, as the therapist, tell the participant that he/she should stop drinking (or tell him/her what to do).

  4. 4 3.Evoking – During this phase, the therapist is focused on evoking desires, ability, reasons, and needs the participants may have to change their drinking behavior, typically done through open questions, affirmations, reflective listening, and summaries (OARS). Although the participant will likely have several reasons to maintain their current drinking behavior, acknowledging the positive aspects of drinking while evoking the concerns and reasons to change is important during this phase. Essentially, the therapist is asking the participant: “Why do you want to go there?” a.This phase may entice therapists to offer strategies/solutions to the participant on how to make the desired changes. The only time that therapists may offer suggestions/solutions is (1) if the participant asks directly for assistance, and (2) if the conversation has transitioned to the planning phase and the therapist asks permission to provide such information. 4.Planning – The therapist transitions to the planning phase if the participant has provided indications that they are ready to make a change. The therapist is focused on working with the participant to identify the specific strategies/methods to making the desired changes. Working collaboratively with the participant is critical during this phase, and the therapist may offer solutions only after obtaining permission from the participant. Essentially, the therapist is asking the participant: “How do we get there?” a.This is another opportunity to remind the participant that it is his/her choice on what changing their risky drinking may look like, and how best to make the desired changes. At no point during the MI-RSD intervention should the therapist propose abstinence as a goal for treatment, unless (1) the therapist is informing the participant that he/she will never tell the participant that they should be abstinent, or (2) the

  5. 5 participant identifies abstinence as the desired change they want to make in their target behavior. **Goals of the Therapist** The MI therapist holds the belief that the participant is responsible for and capable of making desired changes in their drinking, if the therapist creates an atmosphere that will enhance the patient’s own motivation for and commitment to change. The notion is that the therapist evokes reasons/motivations for the participant to change, which will then contribute to the participants’ decision to initiate, persist in, and comply with their personally-identified behavior change efforts. Below are four strategies that are important as the therapist and participant transition across the four MI processes. 1.Express empathy – Throughout an MI session, the therapist seeks to communicate respect and support for the participant. Expressing empathy entails the therapist complimenting rather than critiquing and empowering rather than disapproving of participant’s choices/decisions. 2.Develop discrepancy – A common method for increasing motivation surrounding change is to aid in developing discrepancies around the participant’s current behavior and what they want their behavior to look like in the future (i.e., cognitive dissonance). Sometimes discrepancy begins by heightening participant awareness with any problems they have with their current drinking, following which the therapist and participant can explore whether these problems are consistent with future goals/directions. Other times, the participant may be quite aware of the problems associated with their drinking, and thus developing discrepancy may entail resolving existing ambivalence and strengthening the participants’ motivation to change in a manner that is consistent with his/her goals.

  6. 6 a.The way in which participant-generated information is relayed back to the participant can help in developing discrepancy, especially for those participants who may not be ready to or even contemplating change. Among those are “ready,” there is still likely to be ambivalence present throughout the session. b.Remember, ambivalence is a natural aspect of the change process, and ambivalence is expected to be present if the participant is entering treatment seeking to discuss their risky drinking behavior. If people wanted to, and believe they could, change their drinking behavior without seeing a therapist, they would. So it is natural to have some ambivalence throughout the session, regardless of the participants’ readiness to make a change. 3.Avoid argumentation – Therapist should avoid arguing with the participant at all times during the MI sessions. Argumentation can elicit defensiveness by the participant, which may occur even without the therapist being argumentative, and how the therapist handles such instances is critical for the therapeutic relationship, change process, and likelihood of participant return to session 2. Confrontation with the participant is typically met with confrontation/argumentativeness from the participant. A primary goal of the therapist should be to minimize defensiveness, and not to fall into the expert trap that will likely lead to argumentation on your (therapist) part and defensiveness on the participants’ part. a.Similar to the therapist never suggesting the change behavior be abstinence, the therapist should never label the participant (e.g., alcoholic), nor seek to convince or prove to the participant that their current behavior is problematic and in need of change.

  7. 7 4.Support self-efficacy –regardless of the participants’ readiness or motivation to change their drinking behavior, they need to believe they are capable of changing for actual change to occur. Therefore, the therapist should emphasize client capabilities throughout the MI sessions in an effort to increase the participants’ confidence in their ability to making desired changes to their drinking behavior. a.Another way of thinking about supporting self-efficacy is instilling hope or optimism, which is not critical for the participant to make desired changes; rather, it will give the participant room during the session to consider and/or strengthen the belief in their capability of changing their drinking behavior. b.If the therapist assists in developing discrepancy for the participant yet the participant maintains the belief that he/she is unable to make the desired changes, then a defensive cognition will replace self-efficacy toward behavior change. Defensive cognitions include rationalization or denial, which will help reduce natural discomfort that arises from discrepancy instead of actually changing problematic behavior. **Clinical Style** Participants will vary in their readiness to change. The engaging, focusing, and evoking phases are meant to explore the participants’ initial readiness to change and to begin establishing commitment to change. Most participants will enter the session somewhere in the contemplation or preparation stage of change, meaning that they are aware of problems related to their drinking behavior in social situations and have considered and/or initiated steps to change their risky social drinking. However, some participants may enter session with an awareness of problems with their drinking in social situations but not necessarily be considering ways to change their drinking. For these participants, engaging and evoking during session 1 will be important.

  8. 8 A good way to think about session 1 is that you, as therapist are using a specific approach to draw out the participant’s own motivation that is currently stuck due to going up and down on the ambivalence see-saw. Remember, ambivalence around changing a specific behavior, especially risky social drinking, is a natural process for most individuals, and that you are not expected or instructed to force the participant to change. Your job during session 1 is not to create motivation; rather, you facilitate the growth of the client’s own motivation, which you assume is already present at the start of the session. Motivational Interviewing Spirit **Miller and Rollnick (2013) outline general strategies that reflect the clinical style of motivational interviewing, also called the Spirit of MI. The spirit of MI comprises four aspects. 1.Partnership – The therapist and participant are partners, and at no point should the therapist communicate with the participant in a manner that reflects a power differential (i.e., therapist acting as expert). The therapist should maintain the perspective that the participant is the expert in their own lives, and the therapist simply creates a positive interpersonal atmosphere that is facilitates change, not coercion. a.The therapist should enter the session with the perspective that they are doing MI with or for the participant, not to or on the participant. An MI therapist should view the partnership as a dance, which requires the therapist and participant to move together throughout the session. 2.Acceptance – it is critical for the therapist to accept what the client brings to the session. Importantly, acceptance does not mean approval of the participant’s behaviors or decisions; rather, it is accepting where the participant is at when they enter the session. Miller and Rollnick (2013) outlined four person-centered aspects of acceptance:

  9. 9 a.Absolute worth– originating from the work of Carl Rogers (1980), absolute worth is maintaining an attitude of unconditional positive regard toward the participant. More specifically, the therapist should respect and trust the participant as a unique individual that he/she is. [the opposite attitude is maintaining a stance of judgment, which suggests the participant needs to prove their worth] b.Accurate empathy - Accurate empathy entails reflective listening with the perspective of acceptance and support toward the patient in the process of behavior change. The therapist is committed to understanding the participant’s internal perspective or frame of reference. [the opposite of empathy is when the therapist imposes their own perspective into the situation, likely assuming that the participants’ views are irrelevant or misguided] c.Autonomy support - The therapist maintains the perspective that the participant makes the decision to change their drinking, and the therapist respects whatever choice the participant makes. Emphasizing the participant’s autonomy will naturally reduce potential defensiveness throughout the session and facilitate positive change. [the opposite of emphasizing autonomy and support of the participant is to make people do things or attempt to coerce/control the participant] d.Affirmation– The therapist acknowledges and relays participant strengths and efforts, further enhancing an attitude of acceptance. Affirmations do not refer to simple comments of appreciation toward the participant; rather, the therapist is demonstrating a way of being with the participant, which involves understanding the concerns as well as strengths of the participant. [the opposite of affirming the

  10. 10 participant is to focus only on what is wrong with the participant, and then how to fix the participant] 3.Compassion – A newer feature of MI, the therapist maintains a level of compassion for the participant through active promotion of the participant’s well-being. Compassion is critical to the MI spirit because the other three features can be practiced in pursuit of self-interest. Yet, compassion entails an active pursuit of the desires/interest of the participant that will facilitate their well-being. 5.Evocation - The therapist maintains the belief that the participant has ideas/strategies for changing his/her drinking behavior, and the therapist’s job is simply to evoke those reasons. The manner in which the therapist uses OARS will help ensure more attention is on the participant’s reasons for change rather than for maintaining the status quo. The implicit message the therapist is relaying to the participant through evocation is “You have what you need, and together we will find it.” Core Motivational Interviewing Skills 1.Asking open questions – open questions invite the participant to reflect and elaborate on their experiences surrounding a target behavior. Particularly useful during the engaging and focusing stages, open questions provide context and clarity surrounding the participant’s experiences and their desired direction during the intervention. Closed questions can limit the amount of participant disclosure, suggest that the therapist is simply gathering information about the participant, and portray an expert-client didactic that is counter to the purpose of MI. 2.Affirming the patient – the therapist assumes that the participant enters the session with personal motivation and resources to make changes to a target behavior. Therefore, a primary

  11. 11 skill of the MI therapist is to affirm the participant, regarding their general character as well as specific to the target behavior. The therapist is attentive to participant-identified strengths, resources, and intentions, and then reflects those statements back to the participant. 3.Reflective Listening – This skill is fundamental to MI, and entails the therapist reflecting participant’s statements with added meaning. Reflective listening permits a deeper understanding of the participant’s experiences through clarifying the accuracy of the therapist’s reflection and eliciting additional reasons for the participant to make any desired changes. Thus, reflective listening is also strategic in that the therapist does not reflect all participant statements; rather, the therapist attends to those self-motivational statements toward change (particularly during the evoking and planning stages). 4.Summarizing – Summaries are essentially a collection of statements the participant has made throughout the session, and helps ensure (1) the therapist and participant are on the same page, (2) the therapist is fully understanding the participant’s experiences surrounding a target behavior, and (3) a collaborative, trusting atmosphere is retained. Summaries can be offered at various points during an MI session, and a helpful next statement after offering a summary, particularly during the evoking stage, is “What else?” 5.Informing/Advising – Contrary to beliefs that information and advice should never be offered during MI, there are instances where it is both helpful and appropriate. Importantly, it is the way the therapist offers information/advice that differentiates MI from other, more directive therapeutic styles. Specifically, the therapist can provide advice/information if the client asks for it directly and/or if the therapist has asked permission to offer some advice/information.

  12. 12 Session 1: Engaging the client (building motivation) 1.Introductory statement a.Provide an overview of session structure (i.e., session duration), express interest in understanding participant’s experiences in social situations, particularly with regard to their drinking behavior, and then note that you will ask the participant to complete two brief questionnaires at the end of the session. THERAPIST: “We will be talking for about an hour today and I was hoping to learn about what you want out of our time together, how you see your current situation with a particular focus on what has been happening with regard to your drinking in social situations. I will ask you a couple questions, but I will mostly listen. Towards the end of our time together today, I will provide a little more information about the research intervention and ask you to complete two short questionnaires. How does that sound?” 2.Explore the participant’s current drinking behavior, particularly in social situations a.A general open question surrounding the participant’s drinking behavior in social situations is a good start to exploring his/her current drinking experiences. Example opening questions below: i.“Tell me about your recent drinking experiences, particularly in social situations, and how they may compare to your peers” ii.“I’m interested in learning about how your drinking fits into your social interactions, and if there are any concerns surrounding your drinking in these situations”

  13. 13 b.After an initial open question, you should spend most of the session engaging in reflective listening and responding to change talk. Example strategies below: i.You can explore any problems associated with drinking in social situations 1.“What concerns you about your drinking in social situations?” 2.“What problems do you notice while you are drinking in social situations, or problems you may experience the next day?” ii.You can affirm the client for their level of awareness of their drinking in social situations 1.Some individuals who are shy/socially anxious can be self-critical and concerned about what others think of them (including you); hearing you affirm their experiences, both positive and negative, can help the client feel more comfortable with sharing their drinking experiences and concerns about what others think of them when they are/are not drinking. iii.You can explore your participant’s different drinking situations. Exploring discrepancies with your participant surrounding their drinking behavior in various situations may increase his/her awareness of any problems/concerns with their social drinking. iv.You can explore the positive and negative aspects of your participant’s social drinking with the explicit purpose to elicit change talk. v.You can always elicit additional information by asking “what else?” **Things to consider when communicating with participants who experience shyness/social anxiety and engage in risky social drinking [use the diagram provided below to describe

  14. 14 the 3 categories of participants based on their readiness to change and elicit from the participant which category may best describe him/her] c.[Sheldon] Some individuals who experience social anxiety or shyness may only describe negative aspects of their drinking in social situations, giving several reasons to change their drinking behavior in social situations. Reflecting participant change talk will be important, including steps the participant has initiated/taken to change his/her drinking behavior. However, you should be cautious of jumping into the planning phase. Rather than ‘building motivation’, you are ‘strengthening motivation’ with this type of participant, and at the same time, gaining a clear picture of their current drinking behavior. Examples below: i.Asking an open question about why now is the time for the participant to change their risky social drinking can offer you with more context of the participant’s drinking behavior and future consequences should the participant choose not to change. ii.Explore ‘ready, willing, able’ rulers to determine (1) how ready, important, and confident the participant is in changing and (2) what potential barriers may impede the participant from achieving his/her desired goals. 1.These participants will likely report a high number in terms of readiness, willing, and/or able to change their drinking, so the follow- up questions are particularly important to ensure you are gaining a clear picture of the participant and their motivation to change. (1) “What can you do to get to [higher #]?”

  15. 15 (2) “A 10, it is clearly important to you to make some changes in your drinking, particularly in social settings. I’m wondering what, if anything, could get in the way?” d.[Raj] Some individuals who experience social anxiety or shyness will include both positive and negative aspects of their drinking in social situations. Reflecting the pros/cons of drinking is a useful tool for building rapport, and at the same time, the manner in which you reflect can also elicit more reasons the participant may want to change their drinking in social situations. Examples below: i.Double-sided reflection = highlight the positive aspects of drinking in social situations followed by the negative aspects ii.Reframing = participants may describe drinking to alleviate their anxiety/nervousness in social situations as positive. Reframing this statement to highlight that “you care about interacting with others, and whether or not you are drinking, you just don’t want your anxiety to get in the way of your social interactions” or “your drinking has been one way to help you manage your anxiety in social situations, and you enjoy socializing with others. Still, you may want to socialize with others where alcohol is not available and you are uncertain with how best to do that.” e.[Penny] Some individuals who experience social anxiety/shyness may only describe positive aspects of their drinking in social situations, giving little indication that they desire to change their drinking behavior. Exploring other general life areas that may be affected by your participant’s shyness and/or drinking can be a helpful avenue to determining what, if any, concerns the participant may have with his/her drinking.

  16. 16 i.Interpersonal functioning = developing relationships can be particularly challenging for individuals who experience shyness/social anxiety, and drinking likely serves as a helpful aid for such individuals to interact with others. 1.“How has your drinking affected relationships with family, friends, or your partner?” 2.“What concerns, if any, do you have when interacting with others?” 3.“How does your drinking look similar or different from your peers?” 4.“What feedback have you received from your peers about your drinking?” ii.Social functioning = engaging in social activities can also be challenging for individuals who are shy, and some may not engage in social activities unless alcohol is available. Exploring what social activities participants engage in and how these activities permit or do not permit drinking can help you and the participant understand the degree to which social activities include drinking, and then whether this is a concern to the participant. 1.“What does your social life look like? How does drinking fit in with your current or desired social activities?” 2.“How would your behavior look different in social situations without alcohol?” iii.Finances = depending on the social situations where participants typically drink, finances may be one consequence of drinking in social situations that warrants further exploration. Asking an open question about how the

  17. 17 participant’s finances have been impacted by drinking in social situations can allow for a conversation about concerns related to drinking. iv.Academic functioning = although participants may not articulate problems with their drinking while in social situations, they may experience challenges in their academic functioning as a result of their drinking. Exploring potential consequences from drinking outside the social situation may elicit client concerns surrounding the longer term impact of their drinking. 3.Provide rationale for the intervention a.Given that your participants will review a brief description of the intervention prior to participation, it will be important for you to elicit what the participant hopes to get out of your time together (over the two sessions). i.“I understand that you reviewed a brief description of the intervention, and I’m wondering what you hope to get out the intervention and/or our time together?” b.Example rationale for MI-RSD intervention THERAPIST: The MI-RSD intervention is based on the theory that individuals have the necessary skills and resources to make a desired change, and uncertainty or ambivalence about change is natural component. It is important to allow an individual to explore their thoughts, emotions, and behaviors around changing a target behavior and to identify the best solutions for their problems. Following this perspective, the process of therapy will resemble the natural decision-making process that enhances and fulfills our daily lives. My role is to help you explore your internal

  18. 18 motivations to address risky drinking in social situations with the same skills and perspectives that you have used to live a successful life.

  19. 19 Session 2: Evoking Change Talk (strengthening motivation) 1.Introductory statement a.“Welcome back” b.Provide brief overview of plans for the current session, reminding the participant that he/she will be asked to complete two brief measures at the end of treatment c.Offer a brief summary of potential changes (or concerns) the participant identified in the prior session, and it is important for you to elicit accuracy in the initial summary you offer (e.g., “Did I miss anything?”, “Does that pretty much cover it?”). d.You will also do a brief check-in with your participants about how things have been since prior session. i.This check-in should last no longer than 10 minutes (except if there is a crisis) –“how have you been doing since I saw you last?” 2.Explore ‘ready, willing, able’ rulers to determine how best to structure this session a.These rulers focus on how (1) important change is to the participant, (2) confident the participant can change, and (3) ready the participant is to make a change, using a 10- point scale ranging from 1 (not at all important/confident/ready) to 10 (extremely important/confident/ready) **For participants with ratings less than 6 = continue building motivation** b.Explore motivation ratings (e.g., “why # and not a lower #?”) c.Reviewing past successes strategy (particularly valuable with participants endorsing low confidence ratings)

  20. 20 i.This is an opportunity to explore prior successes the participant has had in reducing their risky drinking in social situations, or their risky drinking in general. ii.You can also ask about prior experiences in social situations that were beneficial and the participant was not drinking. Drinking does not have to be the focus of past successes; rather, past successes are opportunities for the participant to recall when they were able to perform a behavior well and it improved their overall quality of life 1.“What have you accomplished in the past where you were uncertain or had doubts about your ability to succeed?” 2.Ask for participant examples of how they overcame prior scary and/or uncertainty experiences. iii.You can also offer common approaches that others have tried in reducing their risky drinking that may be informative for the participant. 1.This may be a particularly useful approach with individuals experiencing shyness/social anxiety given that they are attentive to the behaviors of others, as well as their own behaviors in front of others. 2.If using this strategy, it will be important to provide examples that may be readily relatable to the participant’s experiences. **For participants with ratings 6 or greater = begin the planning phase** d.Explore why the participant is at the high motivation ratings, and how they could bump up their rating even higher (e.g., “why # and not a lower #?”;“what do you

  21. 21 think needs to happen to get you from # to a higher #?”; “How might I help you go from a # to a higher #?”) e.Explore steps that participant has thought about or has taken…this is a good opportunity to reflect any statements the participant made surrounding steps taken since prior session 3.Identify strengths and resources a.Regardless of whether this session is devoted to further building the participant’s motivation to change or devising a plan for how the participant would like to change, having a discussion with the participant about his/her strengths and resources will likely reinforce commitment to change. See potential strategies below i.Elicit strengths using open questions and reflective listening 1.“What kind of strengths and support do you have already to make these desired changes?” 2.“What is it about you, your personal strengths that will contribute to your ability and motivation to make these desired changes?” a.“In what ways are you a ___ person?” b.Characteristics of successful changers exercise (optional) i.One method for assisting the participant in identifying personal strengths is to provide the Characteristics of Successful Changers form (see Appendix) and ask the participant to select the words that best describes them. “Have a look at this list of strengths that people sometimes have, and circle a few that describe you.” (ideally 5 are selected) ii.When they offer one word, follow-up and ask “What else on this list?”

  22. 22 iii.After the participant has identified a reasonable number of strengths, offer a summary reflection and explore these strengths further by using open questions and reflective listening…after sufficient discussion of strengths, move on to discuss participant resources. **Things to consider when eliciting strengths with participants who experience shyness/social anxiety and engage in risky drinking in social situations a.Some individuals who experience social anxiety or shyness have difficulty identifying personal strengths or positive attributes. Individuals with higher levels of social distress can be quite self-critical, particularly about their behavior in social situations. Reflecting prior examples that the participant provided throughout the intervention may aid in eliciting personal strengths. Examples below a.Open questions surrounding how the participant had prior successes in reducing their risky drinking in social situations can elicit participant characteristics that are both motivating him/her to change and his/her level of commitment to be the person they want to be in such situations [it is important to use the participant’s own words when providing prior examples] “What did you tell yourself that led you to reduce your drinking in the past week compared to prior to us meeting?” “What did you like about yourself in social interactions when you were not engaging in risky drinking?” [this question will be modified based on the participant’s change goal, which may be to stop drinking, reduce drinking quantity/frequency, and/or minimize alcohol-related harm]

  23. 23 b.Reflecting on the types of interpersonal relationships, social involvement, financial responsibility, and/or academic goals that the participant already identified can elicit the qualities/values the participant desires. “If I recall correctly, communicating with friends at a party without being intoxicated will help you feel confident when you are with them in other situations” c.Summarizing the participant’s desire, ability, reason, and need to change their risky drinking in social situations, as well as potential commitments they have voiced can elicit the type of person the participant wants to be in social situations. d.With the participant’s permission, offering personal strengths that you identified in-session that can help the participant identify additional strengths and/or qualities. “May I share with you a strength that I noticed during our time together?” 4.End of session – Leave approximately 5 minutes at the end of the session to ask the participant about his/her interest in completing follow-up online surveys in exchange for a $20 Walmart gift card. a.“Thank you for participating in the research intervention. The final aspect of the research study involves asking you to complete two follow-up online surveys that are similar to the first online survey you completed prior to the research intervention. Your completion of these surveys will help us understand what aspects of the intervention are helpful and what may need to be changed. If you are willing, we would like to send you an email with a link to the online survey to complete in

  24. 24 approximately two weeks, and again in approximately one month. In exchange for your participation, we will give you a $20 Walmart gift card for each survey you complete, allowing you to receive two $20 gift cards. Is it okay if we email you with the survey link in approximately two weeks?”

  25. Appendix A. Optional session materials Perspectives of Social Drinking 3 Categories Sheldon Raj Penny You are seeing mainly the not-so-great aspects of drinking oWhen Sheldon drinks, he shows impaired thinking and notes negative feelings the next day. Social drinking has lost some of its initial fun aspects oSheldon does not remember what he did when drinking, and he does not like his friends when they are drinking. Thus, Sheldon would be considered someone who is ready to make a change You see the good and not-so-good aspects of drinking oWhen Raj drinks, he is able to speak to women (good), but his friends tell him he’s mean when he drinks (not-so-good). There are still some fun aspects of social drinking that make you unsure about changing your drinking oRaj does not talk to women and he tenses up in public when he is not drinking. Thus, Raj would be considered someone who is uncertain about changing You are seeing mainly the good aspects of drinking. oWhen Penny drinks, she can tolerate her friends better, and she is less worried about her financial/occupational problems. There are no serious concerns with how things currently are in relation to social drinking. oPenny sees drinking as a helpful way to manage her stress, have fun, and meet new people. Thus, Penny would be considered someone who is not ready to make a change

  26. Characteristics of Successful Changers Committed Flexible Accepting Persevering Stubborn Active Competent Focused Persistent Thankful Adaptable Concerned Forgiving Positive Thorough Adventuresome Confident Forward-looking Powerful Thoughtful Affectionate Considerate Free Prayerful Tough Affirmative Courageous Happy Quick Trusting Alert Creative Healthy Reasonable Trustworthy Alive Decisive Hopeful Receptive Truthful Ambitious Dedicated Imaginative Relaxed Understanding Anchored Determined Ingenious Reliable Unique Assertive Die-hard Intelligent Resourceful Unstoppable Assured Diligent Knowledgeable Responsible Vigorous Attentive Doer Loving Sensible Visionary Bold Eager Mature Skillful Whole Brave Earnest Open Solid Willing Bright Affective Optimistic Spiritual Winning Capable Energetic Orderly Stable Wise Careful Experienced Organized Steady Worthy Cheerful Faithful Patient Straight Zealous Clever Fearless Perceptive Strong Zestful Note. Miller (2004)

  27. 27 Appendix B. Therapist materials MI-RSA Session 1 Checklist Manual-specific content Reviewed and signed informed consent (gave copy of signed consent form to participant) Provided an introductory statement (overview of session structure) Elicited information about participant’s social drinking behavior Provided diagram to determine participants’ current motivation to change risky social drinking Ready to change (Sheldon) Elicited change talk Uncertain (Raj) Engaged in reflective listening (e.g., used double-sided reflections) Not ready (Penny) Explored concerns in other general life areas that likely associate with risky social drinking Described the treatment rationale Administered the two post-session questionnaires

  28. 28 MI-RSA Session 2 Checklist Manual-specific content Provided an overview of session structure and brief summary of prior session Utilized the ready, willing, and able rulers surrounding participant identified behavior change Participant endorsed less than 6 rating Explored motivation ratings and reviewed past participant successes Participant endorsed 6 or greater rating Explore motivation ratings and reviewed steps the participant has taken Discussed participant strengths and resources Queried for participant interest in completing the follow-up surveys Administered the two post-session questionnaires

  29. 29 Self-Reflection Exercise Please provide a brief description of what you did during the MI session, including your interpersonal style with the participant and MI behaviors you utilized. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________