Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II

PART 1

“I HAVE ALWAYS KNOWN THAT AT LAST I WOULD TAKE THIS ROAD, BUT YESTERDAY I DID NOT KNOW IT WOULD BE TODAY” Narihira

THREE THINGS TO REMEMBER AMBIVALENCE IS NORMAL EFFECTING CHANGE IS A PROCESS CLIENTS NEED TO COME UP WITH THEIR OWN ARGUMENTS FOR CHANGE

3 FACTORS THAT INFLUENCE MOTIVATION WILLING READY ABLE

MI WITHIN THE STAGES OF CHANGE Precontemplation RELAPSE CONTEMPLATION “LAPSE” MAINTENANCE PREPARATION ACTION Provider’s Role: To engage clients by utilizing an empathic style of reflective listening and to assist them in exploring and resolving their ambivalence.

What does not motivate people? Think of characteristics of your “Worst Teacher / Coach” What were things he / she did that made you feel defensive, avoidant and resistant? Chart: Ineffective Motivators

What does motivate people? What were the characteristics of your “Most Favorite Teacher / Coach”? Why was this person an influence on you? Chart: Effective Motivators.

A PROVIDER CAN SIGNIFICANTLY INFLUENCE CLIENT MOTIVATION MILLER’S RESEARCH A PROVIDER CAN SIGNIFICANTLY INFLUENCE CLIENT MOTIVATION MOTIVATION IS NOT SEEN AS A CLIENT TRAIT, BUT THE INTERPERSONAL PROCESS BETWEEN CLIENT AND PROVIDER HOW A PROVIDER THINKS ABOUT MOTIVATION AND CHANGE GREATLY INFLUENCES WHAT A PROVIDER DOES

What is Motivational Interviewing? …a collaborative, person-centered form of guidance to elicit motivation for change” Miller & Rollnick 2008

SPIRIT OF MI EMPATHIC COLLABORATIVE RESPECTS ONES AUTONOMY, CHOICE AND DECISION MAKING EVOCATIVE DIRECTIONAL

Early Counseling Traps “I’m the expert here.” “Hey! You’re not listening!”

Confrontation-Denial Trap Labeling Trap Premature Focus Blaming Trap Traps To Avoid Question-Answer Trap Confrontation-Denial Trap Labeling Trap Premature Focus Blaming Trap Expert Trap Role Play – nurse / employee – Gordon Roadblocks & videos doctor

Beware Of The Righting Reflex Our desire to keep people from going down the wrong path, and to set things aright Born of concern and caring There’s a problem? Let’s fix it! Fails to consider ambivalence in change process May engender resistance

MILLER’S BROAD PRINCIPLES Express empathy Develop discrepancy Roll with resistance (Avoid argumentation) Support self-efficacy Video - rounder

CONFRONTATION IS THE GOAL, NOT THE STRATEGY Assist clients in exploring their own arguments for change Clients come face to face with a difficult reality in a way that will change them

Getting Moving On OARS OPEN QUESTIONS Affirm Reflect Summarize

Open-ended Questions Questions that cannot be answered “yes/no”, but which encourage clients to express their thoughts, feelings, or concerns

Change to Open-Ended Questions Do you feel you have a problem with alcohol? 2. Is it important to you to complete supervision successfully? Anything else? Handout – c / o questions

Yes / No Role Play (1) Speaker: “One thing I like about myself is…” (2) Listeners: Tag team “By that do you mean…” Speaker: Only respond by saying: “Yes or No” *Everyone takes a turn.

Getting Moving On OARS Open Questions AFFIRM Reflect Summarize

Affirmation Expression of appreciation for client’s efforts or participation.

Affirmations Include… Commenting positively on an attribute You’re a strong person, a real survivor. A statement of appreciation I appreciate your openness and honesty today. Catch the person doing something right Thanks for coming in today! An expression of hope, caring, or support I hope this weekend goes well for you! A statement to support self-efficacy I noticed you showed up on time – How did you manage that?

Practicing Affirmations Write down 4 affirmations for the following statement: “I'm sick of this, everything just keeps getting messed up. I do good for a week and then the other kids start getting on my nerves, talking about my family. I go to that program, I'm learning stuff. I think it's helping and then the same day I get into a huge fight and end up in lockdown. Staff doesn't like me, I can't do anything right. They're always on my case. I don't know what you all want from me. I'm just trying to get by in here. It's not as easy as you make it sound.” Handout

Getting Moving On OARS Open Questions Affirm REFLECT Summarize

Reflective Listening Accurate understanding of client’s experience, communicated in a warm, non-judgmental manner.

Simple Reflections Repeat- These reflections add nothing at all to what the client has said, but simply repeat or restate it using some or all of the same words. Rephrase- These reflections stay close to what the client has said, slightly rephrase it, usually by substituting a synonym. It is the same thing said by the client, but in a slightly different way.  

Complex Reflections Paraphrase- These reflections change, or add to what the client has said in a significant way to infer the client’s meaning. Reflect Emotion- Regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimensions through feeling statements. Reflect Double – Sided Ambivalence – Sustain Talk & Change Talk – “good things and not so good things” about keeping the status quo.

Levels of Reflections C. Even though nothing has happened I’ve been feeling more depressed lately. I wish it would go away. Repeat: You’ve been more depressed lately. Rephrase: So your sadness is getting worse and you don’t know why. Emotion: You’re worried that nothing is going to change. Paraphrase: You would like to understand why your mood changes like that. Double-Sided: So on the one hand you’ve been living with depression and on the other hand you’re tired of it and wondering what to do.

Increase Quality of Reflections BY: Making sure inflection is a statement Strip statement down Clear and Concise Use reflections to continue the paragraph

Reflective Listening Exercises “I don’t know why this is such a big deal for everyone else. All my friends drink like I do.” “Everyone should just relax. I’m doing the best I can with trying to find a job.” “I know I’m suppose to take my meds but you don’t know my friends. It’s basically impossible to take them when we hang out.”

Reflective Listening Exercises “I am feeling very trapped and hopeless about my situation. No one seems to want to help me.” “People are always making me do things I don’t want to do. Even my wife keeps nagging me about taking those pills.”

(1) Speaker: “One thing about myself I’d like to change…” Reflection Role Play (1) Speaker: “One thing about myself I’d like to change…” (2) Listeners: Use reflections only; no questions. Make sure inflection is a statement and not a question. * Speaker stays in role and talks. ______________________________ Video : Miller – Simple / Complex Reflections

Getting Moving On OARS Open Questions Affirm Reflect SUMMARIZE

Summarizing Bringing together of several of the client’s previously expressed thoughts, feelings, or concerns, often including the clinician’s understanding of how these fit together.

Summaries can: Collect material already offered Link something just said with something discussed earlier Transition: Draw together what has happened and transition to a new task

Practice Summaries Groups of 3 - 1 Speaker – 2 Listeners 1 Speaker talks about something that has bothered you.. 2 Listeners just listen (no comments or questions). At the end provide 2 Summaries: 1st Listener – Collect 2’nd Listener – Link or Transition Switch Roles

PART 2

OARS TO…. AROSE Affirmation Reflective Listening Open-ended Questions Summarizing Elicit Change Talk

Change talk v. Sustain talk Sustain talk is client speech that favors the status quo Change talk is client speech that favors movement in the direction of change

Concerns Optimism Intention to Change Elicit Change Talk Why Is Change Important? Problem Recognition Concerns Optimism Intention to Change

Evocative Questions Open-ended questions related to behavior, that elicit change talk. “What do you want to do about this behavior?” “What makes you believe you can do this?” “Why would you want to make this change?” Handout

Recognize Change Talk Desire: I want to Ability: I can Reason: It’s important Need: I should Drumming Exercise

RESPONDING To Change Talk EARS Elaborating Affirming Reflecting Summarizing *It’s important to recognize and respond to Change Talk using the above skills.

Being Strategic with MI Strategies Client: “I don’t know, I really don’t want to go to that drug treatment program. I know I can quit on my own.” Non-Strategic Reflection: You don’t want to participate in the drug treatment program. Strategic Reflection: It’s really important to you to address your drug use and you realize that quitting is a strategy that will work for you.

Using EARS R I’d like to have better control of my drinking. E I think I could quit. R If want to get along with my family, then I have to do something about my temper E I’ve got to do something about my anger. A I’m going to start my cog program today E I am embarrassed about my lack of control. R If I want a good job, I have to get my GED. E I want to be a better dad to my son. R If I get a DUI, I will lose my license. E I finished my vocational program. R I’m not guilty, but I will go to the program. E I am under so much stress, all I do is yell at my family. Handout

Select something about yourself you want to change, you know you should change, but you haven’t yet changed….a health behavior or quality

Exercise: Eliciting Change Talk Groups of 3: 1 Speaker, 1 Listener, 1 Observer Eliciting need/desire change talk What might be some of the not-so-good things about your behavior? How do you feel about your future if you continue to live the way you’re living now? What kinds of things can you imagine happening in your life if you decide to make this change? Handout - (S-Talk about behavior L -EARS, O -Code Sheet Observer give Feedback / Debrief

Exercise: continue Switch Roles: Groups of 3: 1 Speaker, 1 Listener, 1 Observer Eliciting ability change talk What gives you the courage to go after what you want? What do you already do well that will help you make this happen? What kinds of things are you really good at? Handout - (S-Talk about behavior L -EARS, O -Code Sheet Observer give Feedback / Debrief

Exercise: continue Switch Roles: Groups of 3: 1 Speaker, 1 Listener, 1 Observer Eliciting reason change talk If you were to change your behavior, what would be your reasons? What would be the good things about changing your behavior? If you were able to change your behavior, what would the payoffs be for you? Handout - (S-Talk about behavior L -EARS, O -Code Sheet Observer give Feedback / Debrief

CONSOLIDATING COMMITMENT

Signs of Readiness Decreased sustain talk Decreased discussion about the problem Resolve Increased change talk Questions about change Envisioning change Experimenting with change

Recognize Commitment Commitment: I will Activation: I am ready Taking Steps: I am doing it now CARDS

Strengthening Commitment What Do You Want To Do About It? Ask An Action Question – Transition - “What are you willing to do now…Where do we go from here…What’s your next step..What do you want to do?” Provide Information or Advice – Start with what the person might know or has tried before that has worked Ask permission before providing advice

Plan of Action Connect Talk To Action Talk specifics about plan for changing behavior What – specifically will the behavior look like When-will the behavior occur Where- will the behavior occur Why-is behavior personally important How-can the behavior be achieved… How can I be of help

STEPS to Consolidate Big summary of all change talk Scale readiness if desired Key Action questions: What’s next? What changes do you think you will actually make? Where do we go from here? EARS Connect Talk to Action

PART 3

Doctor / Patient Video

Global Scale Rating: LOW 1 2 3 4 5 HIGH Motivational Interviewing Treatment Integrity (MITI) (Dr. Terry Moyers, Phd) Global Scale Rating: LOW 1 2 3 4 5 HIGH Empathy Collaboration Autonomy / Support Evocation Direction ------------------------------------------------------------------------------------------------ Behavioral Codes: Giving Information: MI Adherent: Asking Permission, Emphasize Control, Affirm, Support MI Non-Adherent: Advise, Confront, Direct Questions: Closed – Yes/No Open – Evocative ( What, Why, How) Reflect: Simple Complex – Add Meaning

Role Play – Putting It all Together (1) Speaker: Portray a client ambivalent about changing a behavior (i.e. Substance Use, Gambling, Eating Disorder, Leaving a Domestic Violent Relationship, Taking Meds., etc.) (1) Listener: Utilize the OARS (Remember 1 question every 2-4 reflections). (1) Recorder: Utilize Handout. Make a slash mark for Open-ended Questions, Closed Questions, Affirmations, Simple Reflections, and Complex Reflections. Summarize / Provide Feedback / Switch Roles

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