Motivational Interviewing in Respiratory Health Care: A Knowledge Translation (KT) Initiative Welcome participants to the training, and provide any housekeeping.

Motivational Interviewing in Respiratory Health Care: A Knowledge Translation (KT) Initiative
Welcome participants to the training, and provide any housekeeping announcements that you have: Location of exits, restrooms Sign-in sheet (if you are using one) Breaks, lunch (if applicable)

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What is your level of familiarity with motivational interviewing?
Never heard of this approach Heard about it from courses or articles, but never taken a full course or training Previous training, but not sure I remember much Previous training, but didn’t really apply it to my practice Previous training, and using it actively in my practice ASK participants to reflect on their skill level in MI with a partner. Give a couple of minutes for conversation, and then ask for feedback from the large group. There is likely to be a range of skill levels across the group, however a key point to emphasize is that regardless of skill level, we are all continuously learning and improving our clinical skills – no one is ever “perfect”, so invite participants to consider what areas/skills they could develop even more.

What is Motivational Interviewing (MI)?
Motivational Interviewing is a general approach to working with people who are ambivalent about making changes to their behaviour. MI is a set of techniques & also a philosophy or spirit. It has been variously defined in the literature and is an evolving approach, however the most current definition is on the next slide. Learning Objective: Define Motivational Interviewing (MI) and its relevance to respiratory health care and health behaviour change 4

www.motivationalinterview.org 5
The work of Carl Rogers has been especially influential in the development of MI. However, you can see that there are some important differences – most significantly, that MI has an explicit agenda (change), as opposed to undifferentiated validation of clients’ material. Miller found that confrontation with people with alcohol addiction elicited no change – just resistance – where MI spirit and listening encouraged change. This is the opposite of the philosophy behind TV shows like “The Intervention”– which can be likened to a “surprise party for people with addictions” (and which use a primarily confrontational approach). There are additional resources on the MI website. 5

Guiding: (Asking) Following: Directing: (Informing) (Listening)
Motivational Interviewing can be positioned along a continuum of types of counselling interventions, ranging from “following” (i.e., unconditionally validating a person, and working with whatever content comes up – with no explicit goal regarding behaviour change); to actively “directing” (i.e., the practitioner sets the behaviour change goal and agenda for the session. MI is somewhere in the middle – between “following” and “directing”, and can be considered a “guiding” style of counselling. That is, the practitioner and client work collaboratively to set goals for change and identify areas of focus. The client is regarded as the expert in his or her own life, and in what will work best for him or her, and this is valued equally to the professional expertise of the practitioner.

Direction Language “Directing” as a counsellor behavior
“Direction” as goal-orientation “Directional” rather than “directive” as a description of MI Motivational interviewing is “directional” (goal oriented) as opposed to “directive” in style and orientation. Recognize that many (most?) practitioners in health care have been trained to be directive. This works very well when patients approach us asking for advice or suggestions – they are clearly in the “action” stage of change. However, when patients are ambivalent or resistant to change, then a directive approach generally is counterproductive and often leads to patients not following through on treatment plans, getting into the “Yes, but…” trap (where our every suggestion for change is met with a “Yes, but…” response), and/or decreased patient rapport and engagement. MI is indicated for patients who are ambivalent about, or not considering, change.

Evidence base for MI in Respiratory Health Care
This section provides a brief overview of the evidence for MI. MI has been researched in over 200 randomized controlled trials, and there are literally thousands of publications documenting this approach. The range of health behaviours that have been investigated using an MI approach include: Public health & workplace Sexual health Dietary change Weight management Voice therapy Gambling Physical activity Stroke rehab Chronic pain Medication adherence Diabetes Mental health Addictions Fibromyalgia Chronic leg ulceration Self-care Criminal justice Vascular risk Domestic violence (Anstiss, 2009)

Key points from a review of 14 studies:
MI vs. brief advice or usual care yielded a modest but significant increase in quitting. Found that MI seems to be effective when given by general practitioners and by trained counsellors. Longer sessions (> 20 m) were more effective than shorter ones. Two or more sessions of treatment appeared to be marginally more successful than a single session treatment, but both delivered successful outcomes. Briefly summarize the points on the slide. Lai, D.T.C, Cahill, K., Qin, Y., & Tang, JL. (2010). Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews, (1), 40 pp.

Key points: Method and spirit of MI as applied to asthma management.
MI strategies have been modified such that HCPs can readily incorporate them into regular clinical care. In 2007, there were 117 National Institutes of Health–funded trials on MI, 2 of which were on asthma management, one with low-income adults and the other with inner-city teens. Demonstrating to HCPs that patient-centered counseling serves their needs by reducing daily frustrations of nonadherent patients, decreasing adverse events, and improving the quality of care with minimal drain on time could motivate HCPs to learn and use these skills. Briefly summarize the points on the slide. Borrelli, B., Riekert, K.A., Weinstein, A., & Rathier, L. (2007). Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. Journal of Allergy and Clinical Immunology, 20(5), pp.

Key points: Participants who received education alone showed a decreased level of readiness to adhere with their medications over time, whereas participants who received MI showed a stable or increased level of readiness. Among participants who described themselves as not consistently adhering with their medications at the first evaluation, those who received MI endorsed more positive attitudes toward taking medications over time. Briefly summarize the points on the slide. Schmaling, K., Blume, A., & Afari, N. (2001). A Randomized Controlled Pilot Study of Motivational Interviewing to Change Attitudes about Adherence to Medications for Asthma. Journal of Clinical Psychology in Medical Settings, 8(3), pp.

Key points: Does a motivational intervention for smoking parents of young children lead to reduced household passive smoke exposure? MI vs. self-help. Follow-up’s at 3 & 6 months. MI condition consisted of a m MI session at the participant's home with a trained health educator and 4 follow-up counseling calls. 6 M nicotine levels were significantly lower in MI households. Providers can help parents work toward reducing household passive smoke exposure using MI and providing a menu of approaches regardless of whether the parents are ready to quit. Briefly summarize the points on the slide. Emmons, K.M., Hammond, S.K., Fava, J.L., Velicer, W.F., Evans, J.L., & Monroe, A.D. (2001). A randomized trial to reduce passive smoke exposure in low-income households with young children. Pediatrics, 108(1),18-24 pp.

Key points: Reviews the empirical research regarding the effects of exposure on children with asthma and provides a brief overview of interventions to reduce ETS exposure. Health care providers (HCPs) can use medical encounters as "teachable moments" to advise parents to quit smoking and/or reduce ETS exposure in the home. Ask every caregiver of a child with asthma about their smoking status (& rest of 5 A’s). With practice MI can be incorporated into an office visit with minimal effort. Briefly summarize the points on the slide. McQuaid, E., Walders, N., & Borrelli, B. (2003). Environmental Tobacco Smoke Exposure in Pediatric Asthma: Overview and Recommendations for Practice. Clinical Pediatrics, 42(9), pp.

Take away points: Still a lack of adequate research within the field of MI and respiratory health/asthma. However, MI strategies show positive results when working with clients facing various chronic health concerns. Most effective interventions involved multiple repeated contacts (office, in-home, phone, text messaging) with trained HCPs. HCP’s office may be utilized as an effective channel for motivating behavior change among those facing respiratory conditions. You can access a brief summary of the evidence for MI in health behaviour change generally, and respiratory healthcare specifically, in the Addictional Resources section of the toolkit. You may want to provide participants with a copy of this resource as part of their workshop handouts.

Other Relevant Sources:
Borrelli, B., McQuaid, E.L., Becker, B., Hammond, K., Papandonatos, G., Fritz, G., & Abrams, D. (2002). Motivating parents of kids with asthma to quit smoking: the PAQS project. Health Education Research, 17(5), pp. Erickson, S.J., Gerstle, M., & Feldstein, S.W. (2005). Brief interventions and motivational interviewing with children, adolescents, and their parents in pediatric health care settings: a review. Archives of Pediatrics and Adolescent Medicine, 159(12), pp. Halterman, J.S., Riekert, K., Bayer, A., Fagnano, M., Tremblay, P., Blaakman, S., & Borrelli, B. (2011). A pilot study to enhance preventive asthma care among urban adolescents with asthma. The Journal of Asthma, 48(5), pp. Knight, K.M., McGowan, L., Dickens, C., & Bundy, C. (2006). A systematic review of motivational interviewing in physical health care settings. British Journal of Health Psychology, 11(Pt 2), pp. Lozano, P., McPhillips, H.A., Hartzler, B., Robertson, A.S., Runkle, C., Scholz, K.A., Stout, J.W., & Kieckhefer GM. (2010). Randomized trial of teaching brief motivational interviewing to pediatric trainees to promote healthy behaviors in families. Archives of Pediatrics and Adolescent Medicine, 164(6), pp. Powell, C. & Brazier, A. (2004). Psychological approaches to the management of respiratory symptoms in children and adolescents. Paediatric Respiratory Reviews. 5(3), pp. Riekert, K.A., Borrelli, B., Bilderback, A., & Rand, C.S. (2011). The development of a motivational interviewing intervention to promote medication adherence among inner-city, African-American adolescents with asthma. Patient Education and Counseling. 82(1), pp. Seid, M., D'Amico, E.J., Varni, J.W., Munafo, J.K., Britto, M.T., Kercsmar, C.M., Drotar, D., King, E.C., & Darbie, L. (2011). The In Vivo Adherence Intervention For at Risk Adolescents With Asthma: Report of a Randomized Pilot Trial. Journal of Pediatric Psychology, Online, Dec, 1-14 pp. Weinstein, A.G. (2011). The potential of asthma adherence management to enhance asthma guidelines. Annals of Allergy, Asthma and Immunology, 106(4): pp.

Motivational interviewing is encouraged to support patients’/clients’ willingness to engage in treatment now and in the future. (GR/LOR: 1B) Grade of Recommendation/Level of Evidence 1B = Strong recommendation, Moderate quality evidence This relates to the use of MI for tobacco cessation Encourage practitioners to join the CAN-ADAPTT website: CAN-ADAPTT is a national guideline development, dissemination and exchange project. An online network and coordinated engagement activities across Canada allow members to provide ongoing input into CAN-ADAPTT’s guideline; discuss best practices, identify research gaps and share resources. This Practice-Informed approach ensures the needs and experiences of the target end users are reflected in the CAN-ADAPTT guideline. CAN-ADAPTT: THE CANADIAN ACTION NETWORK FOR THE ADVANCEMENT, DISSEMINATION AND ADOPTION OF PRACTICE-INFORMED TOBACCO TREATMENT. 16

The “Spirit” of Motivational Interviewing
Introduce this section of the workshop by reflecting that the “spirit” of MI is a definable and integral part of the intervention. In fact, the spirit is actually of greater importance than the MI micro-skills, and can also be the most challenging to integrate because health practitioners have been trained to try to “fix” their patients (also known as the “righting reflex”. Mention that participants will have an opportunity to contrast the different styles (directing - or MI inconsistent – versus guiding – or MI consistent – in this section. Learning Objective: Operationalize the “spirit” of motivational interviewing in conversations with clients 17

Often, our work with clients feels like “wrestling” – with us on one side (change), and the client on the other side (no change). MI helps to alter this dynamic by creating a collaborative and more equal dynamic, that feels more like “dancing.” (Ballroom dancers may make a routine look effortless but it takes a lot of practice and sweat to get there!) 18

A-C-E V E R S U Autonomy Collaboration Evocation Authority Coercion
Education The three elements of the “spirit” of MI include: autonomy, collaboration and evocation of the client’s perspective and thoughts about change (Miller and Rollnick, 2002; Rollnick and Miller, 1995). These three elements can be expressed in the acronym “A-C-E”: Autonomy versus Authority; Collaboration versus Coercion; Evocation versus Education Autonomy is contrasted with authority, which honours the client’s control of his or her behavioural choices. Collaboration is valued over coercion, since the latter may actually stimulate resistance. Finally, evocation of the client’s own reasons for change is more compelling than education and information-sharing on the part of the counsellor.

In the end it is your choice – where would you like to go from here?
Autonomy In the end it is your choice – where would you like to go from here? Here is an example of how a practitioner might emphasize patient autonomy. She has just provided the client with some information and her recommendations, but instead of leaving it there she follows up by emphasizing that regardless of what she suggests, it is ultimately the client’s choice in how to proceed.

I’m interested in your ideas on how you want to tackle this
Collaboration I’m interested in your ideas on how you want to tackle this Here the practitioner invites the patient to actively collaborate in developing a treatment plan.

What do you know about the link between smoking and asthma?
Evocation What do you know about the link between smoking and asthma? In this example, the practitioner evokes the patient’s ideas and knowledge before providing information. This is something that we often forget or neglect to do, but eliciting the client’s knowledge and understanding first is an important principle of adult learning, and can help us to better understand any incorrect assumptions or gaps in the patient’s knowledge/understanding.

Understanding – and Resisting – The “Righting Reflex”
The “Righting Reflex” is a term that captures practitioners’ reflexive urge or need when we see a problem, to make it right. This can be counterproductive, as we will demonstrate in the following two exercises. 23

Persuasion Exercise Choose one person near you to have a conversation with, and work together One will be the speaker, the other will be a counsellor Read the instructions on the slide, and explain that this exercise will take approx 5 minutes. 24 24 24

Speaker’s Topic Something about yourself that you: want to change
need to change should change have been thinking about changing but you haven’t changed yet…in other words – something you’re ambivalent about Ask one person to volunteer to be the “speaker” – and note that they should choose something that they are ambivalent about, but also something that they are comfortable sharing with a partner. In other words, “we won’t be asking you to do intensive psychotherapy in the next 5 minutes”. You can suggest some possible areas for behaviour change, including: Getting more exercise Waking up earlier in the morning Keeping your desk organized Eating healthier Packing your lunch (instead of buying lunch) or bringing coffee from home (instead of buying expensive lattes) 25 25 25

Counsellor: Find out what change the person is considering making, and then:
Explain why the person should make this change Give at least three specific benefits that would result from making the change Tell the person how they could make the change Emphasize how important it is to change If you meet resistance, repeat the above. P.S. This is NOT motivational interviewing Facilitator: In introducing this slide, ask participants to engage authentically in this exercise. To make the point more impact fully, you can ask for a show of hands in response to the questions: Has anyone here ever explained to patients why they should change? Has anyone ever outlined the benefits of making a change to a patient? Have you ever given a patient some suggestions of ways to change? Have you ever stressed to a patient how important it is for him or her to change? This usually elicits nods of recognition and some laughter. Continue by saying: I’d like you to bring your “best self” to this activity, and use it as an experiment to get some honest feedback about how people experience these interventions, even when we are doing our best. Give approx 5 minutes for this activity

Common Reactions to Righting Reflex
Angry, agitated Oppositional Discounting Defensive Justifying Not understood Not heard Procrastinate Afraid Helpless, overwhelmed Ashamed Trapped Disengaged Not come back – avoid Uncomfortable The feelings on this slide should mirror the overall feedback from the previous activity

A Taste of MI: Conversation with one speaker and one listener
Something about yourself that you want to change need to change should change have been thinking about changing ……….but you haven’t changed yet i.e. – something you’re ambivalent about Explain to participants that they will now experience a “taste” of MI. Note that “this is only a taste, not the whole meal” and that the intervention is actually quite complex and rich in skills. However this exercise provides an entry point, in an experiential way, to what a motivational interviewing conversation looks and feels like. Ask the pairs to switch roles, so the other person now becomes the speaker and shares something they are ambivalent about (as in the previous exercise). This activity take approx 10 minutes.

Listener Why would you want to make this change?
1. Listen carefully with a goal of understanding the dilemma 2. Give no advice. 3. Ask these four open questions and listen with interest: Why would you want to make this change? How might you go about it, in order to succeed? What are the three best reasons to do it? On a scale from 0 to 10, how important would you say it is for you to make this change? Follow-up: And why are you at __ and not zero? Give a short summary/reflection of the speaker’s motivations for change Then ask: “So what do you think you’ll do?” and just listen Give approx 10 minutes for this activity, and go through the “script” for the listener (counsellors) in this exercise. Reinforce that this is just a taste of MI, and that in a “real” MI conversation, advice or information can be very much a part of the interview (but in MI, advice is prefaced by asking for the person’s permission to give advice/information). Practitioners often give too much advice, often to the detriment of real listening and reflecting (which is more at the heart of motivational interviewing). Therefore, ask the “counsellors” in the exercise to notice how hard or easy it is in the context of this exercise to refrain from giving advice.

Common Human Reactions to Being Listened to
Understood Want to talk more Liking the counselor Open Accepted Respected Engaged Able to change Safe Empowered Hopeful Comfortable Interested Want to come back Cooperative These feelings should echo those elicited from the large group in response to the previous slide. Would you rather work with these people. . .

…or these? Afraid Helpless, overwhelmed Ashamed Trapped Disengaged
Not come back – avoid Uncomfortable Angry, agitated Oppositional Discounting Defensive Justifying Not understood Not heard Procrastinate Add that clients’ motivation is often a product of we engage our clients. Motivation is a state (changeable) versus a trait (static), and can be affected or influenced by a skillful practitioner.

Summary of Skills “Spirit” of MI Autonomy (versus Authority)
Collaboration (versus Coercion) Evocation (versus Education) Resist the “Righting Reflex” Avoid rescuing or offering unsolicited advice/suggestions in response to a patient-articulated concern or problem Allow the patient to articulate his or her own reasons for change and next steps Briefly summarize the skills covered in this section

FOUNDATION SKILLS – OARS
OPEN questions (to elicit client change talk) AFFIRM the client appropriately (support, emphasize personal control) REFLECT (try for complex reflections) SUMMARIZE ambivalence, offer double-sided reflection Before showing this slide, can ask “Who here likes to cook?” Note that sometimes the best dishes are those with the fewest (but highest quality) ingredients. Ask participants of suggestions of dishes that use 5 or fewer ingredients. Then, change to this slide and note that one of the nice things about MI is that, at its essence, it has only four key ingredients. Note that the general guidelines are to offer two reflective statements for every question asked; to offer at least 50% complex (versus simple) reflections; and to do no more that 50% of the talking. Learning Objective: Review and practice foundation skills in MI 33

Open versus Closed Questions
FOUR KEY STRATEGIES – O A R S Introduce the first of the OARS skills: Open-ended questions

CLOSED questions invite a “yes/no”, one- word or very limited answer OPEN questions encourage elaboration – they evoke the client’s ideas, opinions, hopes, concerns, etc. You can note one or more of these “Top 10 useful questions” What changes would you most like to talk about? What have you noticed about . . .? How important is it for you to change . . .? How confident do you feel about changing . . .? How do you see the benefits of . . .? How do you see the drawback of . . .? What will make the most sense to you? How might things be different if you . . .? In what way . . .? Where does this leave you now? (Rollnick, Butler, et al., 2010, p.1244).

Read the following questions, and “vote” for whether each one is OPEN or CLOSED Introduce this activity by saying: “Here is a chance to see how well you can distinguish open versus closed ended questions”.

“Would you say you are motivated to quit smoking in the next 30 days?”
Open question Closed question Closed

“Tell me about how motivated you are to quit smoking in the near future – say, the next 30 days?”
Open question Closed question Open

“What made you decide to quit smoking in the next 30 days?”
Open question Closed question Open

How many cigarettes do you smoke in a typical day?”
Open question Closed question Closed

“Can you describe a typical day, and how smoking fits in?”
Open question Closed question Can note that this is a “trick” question – it is intended to be an open question, but is framed as a closed question

Praising versus Affirming
FOUNDATION SKILLS – OARS Affirmations Introduce the second of the OARS skills: Affirmations, as distinct from offering praise to clients. Praising versus Affirming

Affirmations: Go beyond “giving a good grade”
Are not about the practitioner’s approval of the patient Acknowledge the client’s experience, struggle, expertise, efforts, etc. The difference between praising and affirming can be subtle and sometimes difficult for practitioners to grasp. In general, praise refers to our (practitioner’s) approval of the person or the behaviour. Affirmations are more neutral and focused on the client – they acknowledge the person and their struggle with changing. This illustration can help: A client is asked about her longest period of abstinence from smoking, and tells you that once she was able to quit for 3 months. You respond: “Three months! That is really great.” The client then states, “Actually, they were the most miserable three months of my life!” Clearly, praise did not enhance the person’t motivation (and in this example was actually demotivating for the client). An example of affirming would have been to say: “You were determined to try to quit, and you were successful for three months even though it was hard.”

I think it’s great that you are planning to quit smoking!
Example of Praising: I think it’s great that you are planning to quit smoking! These next slides illustrate the “perils of praising” and how affirming can be more helpful in enhancing motivation. However, note to participants that we are not suggesting that praising is in all cases wrong or bad. Many clients seek our approval and appreciate praise for their efforts. But if our goal is to enhance a person’s intrinsic motivation for change, praising is a less effective strategy than affirming.

I really hope I don’t disappoint you…
Praising can lead to… Thank you! I really hope I don’t disappoint you… Notice how the patient’s “inside” voice is uncertain, and she feels constrained from disclosing this uncertainty or ambivalence to the practitioner.

You have really given this a lot of thought.
Example of Affirming You have really given this a lot of thought. In this example the practitioner affirms the patient for just thinking about changing a challenging behaviour (like smoking).

Affirming can lead to… Yes, and now that my grandson is older, I want to teach him it is never to late to change And the practitioner’s affirmation elicits change talk from the client.

Look how far you’ve come! I know you can do this.
Example of Praising: Look how far you’ve come! I know you can do this. Another illustration of praising that many practitioners can identify with.

But I am actually not so sure
Praising can lead to… I sure hope so... But I am actually not so sure But again we see the “inside voice” of the patient

You have hung in there even though the cravings have been pretty bad.
Example of Affirming You have hung in there even though the cravings have been pretty bad. This affirmation acknowledges the person’s effort and struggle along his journey of change and recovery

Maybe I can really do this!
Affirming can lead to… Yes – I can’t believe how far I’ve come Maybe I can really do this! …and again elicits change talk from the patient, as well as enhancing motivation.

Simple versus Complex Reflections
FOUNDATION SKILLS – OARS Reflective Listening Introduce the next OARS skill (and often the most challenging skill for practitioners to learn and practice with ease): Reflective listening Simple versus Complex Reflections

Simple reflection Complex reflection
Reflective listening is the most central of the OARS skills, and can also be the most challenging to learn and practice effectively. Many counsellors assume that they already know and practice reflective listening, yet when their interviews are recorded and reviewed, it becomes clear that many counsellors default to some combination of questioning, advising and affirming. For example, go back to the self-assessment at the beginning of this chapter: did either of your responses to the challenging client statements include a reflective response? Done well, reflective listening, on its own, can help open up new ground with clients and convey understanding and empathy. There are two types of reflective responses: (1) simple reflections essentially repeat back to clients the content of something they have said; (2) complex reflections include the unspoken meaning, feeling, intentions or experiences that a client has. In general, complex reflections are more effective at continuing and deepening the conversation. One way to understand the difference between these two types of reflections is to imagine a picture of an iceberg. The tip of the iceberg (above the water) represents the content (or the words the client speaks); a simple reflection focuses on the tip of the iceberg. The huge mass of the iceberg below the water represents all of the thoughts, feelings, meanings, etc. that lie behind the client’s words; a complex reflection focuses below the waterline.

“I am tired of people going on about my smoking
“I am tired of people going on about my smoking. I know it’s bad for me, but so are a lot of things.” Introduce this example, and explain that the following slides will illustrate different simple and complex reflections. The purpose of these illustrations it to demonstrate how there are countless reflections that can be offered in response to a single client statement. It is our own clinical judgment and skill as we use reflective listening to strategically guide the conversation: what we reflect subtly steers the conversation in a particular direction.

It is frustrating because it feels like “why pick on smoking”?
People are really on your case about this, even though smoking is not the only harmful thing out there. It is frustrating because it feels like “why pick on smoking”? Call attention to the difference between simple and complex reflections in the example, and notice how the complex reflection goes “below the waterline” in reflecting the person’s underlying feelings. Ask participants to see how a person may actually feel more understood and acknowledged by a complex (versus a simple) reflection. Practitioners often get stuck with how to continue the conversation after offering a reflective response, especially if the client is not especially vocal or forthcoming. Each of these slides has an example of a follow-up statement or question by the practitioner, but note that these are all representative of OARS skills. Follow up with: “What are some of the other things that you have been considering changing?” (open question)

Smoking has some negative consequences, and so do other things.
From your perspective, smoking is not the most harmful thing to be concerned about. In this example, the practitioner takes a risk by naming and making explicit the client’s ambivalence about changing. Follow up with: “It sounds like you might have some other general health behaviours or concerns aside from smoking.” (complex reflection)

It is like nagging, and that doesn’t feel very supportive or helpful.
A lot of people are pressuring you about something you already know is unhealthy. It is like nagging, and that doesn’t feel very supportive or helpful. This complex reflection moves the conversation towards the social support (or lack thereof) in the client’s life. Follow up with: What are some of the concerns that people have expressed to you about your smoking?” (open question)

Practicing Reflective Listening
Individually, take a moment to write down an example of a simple and a complex reflection for the following statement (coming up – next slide). Then compare what you wrote with others at your table. As a group, choose the best examples to share with the larger group. Tell participants that now they will have a chance to practice forming reflections, and comparing notes with colleagues. If you are short on time, you can choose to have participants go directly into small groups and say: “This is a reflective listening contest – the first table with one simple and one complex reflection, raise your hands! Ready…set…go…” This can also raise the energy in the room, and illustrates to participants that reflective listening is skill that needs practice to achieve fluency and proficiency. Individual exercise = 3-4 minutes Small group exercise = 10 minutes Large group sharing = 10 minutes

Practicing Reflective Listening (1)
“How I live my life is my own business.” Read the statement, then go to the next slide…

___________________________________
“How I live my life is my own business.” Simple Reflection: ___________________________________ Complex (Enhanced) Reflection: ___________________________________ Leave this slide up for the individual, small group and large group sections of the exercise. First elicit examples from the group, then reveal the sample responses on the next slide and compare with what the groups came up with. Note to the group the diversity of reflective responses, and how “what we reflect steers the conversation in a particular direction, so we can use reflective listening strategically to steer the conversation in the direction that we think will be most productive/lead to increased change talk”

Practicing Reflective Listening (2)
“I know you mean well, but I don’t need this medication any more.” Optional, if time – you can choose to do this as a large group now that they have some practice Note to the group that this is a skill that takes practice, and underlines the axiom that MI is “simple but not easy”

___________________________________
“I know you mean well, but I don’t need this medication any more.” Simple Reflection: ___________________________________ Complex (Enhanced) Reflection: ___________________________________ Again, leave this slide up while the group generates examples of simple and complex reflections…

“Bouquets of Change Talk with Sprigs of Sustain Talk”
FOUNDATION SKILLS – OARS Summary Statements Introduce the final OARS skill: Summary statements. Note that these are a form of reflective listening – we are pulling together and reflecting a number of different content areas that a person has discussed during the interview – optimally a summary statement focuses on summarizing and offering the examples of client change talk that we have heard. “Bouquets of Change Talk with Sprigs of Sustain Talk”

Why use summary statements?
To check your understanding of the person’s situation as a whole To reflect back key components of what the person has discussed To signal a transition to another topic or the end of the session/consultation To highlight change talk Outline the rationale for offering summary statements, and explain that you will be showing a video example that illustrates all of the OARS skills, with an example of how a summary statement can be integrated in the conversation with the patient.

Example of OARS (including Summary Statement)
“Angry Bob” Ask participants to watch for all of the OARS skills in the video, paying particular attention to the therapist’s use of a summary statement. After showing the video, ask participants what examples of the OARS skills they noticed, what the therapist did well, and what they could do differently. It is important when showing video examples to not present them as “perfect” illustrations of MI: explain that we are all striving to improve, and there are always things that we can do differently or better.

Summary of Skills: O A R S
Open-ended questions Affirmations (versus praise) Reflections (simple and complex) Summary statements Briefly summarize the skills covered in this section, and ask if there are any questions or comments from the group. This may also be an opportunity to incorporate an integrative role play or practice exercise. You can also invite someone to volunteer to come up to the front of the room with you (as the practitioner) and the volunteer as the “client”, sharing something that they are considering changing. Then you do the “real play” for approx 5 mins, debrief with the “client” and then with the large group. Suggested debriefing questions can include: For the “client”: What was this conversation like for you? What was helpful or unhelpful? What effect – if any – did this conversation have on your motivation for change? For the audience: What OARS skills did you notice? What would you have done differently? What seemed to work well, and what seemed less effective with (client)?

Recognizing & Responding to Change Talk
Introduce the next MI skills covered in this new section: Recognizing and responding to change talk. Learning Objective: Listen for and respond to client change talk

Change Talk Any speech moving in the direction of change
We don’t know if it’s change talk unless we know what the goal is “If I don’t quit smoking I know I will be back in the hospital.” Here are some additional examples of Change Talk versus Sustain Talk: “I really need to quit smoking because of the bad example I am setting for my kids…But I love to smoke, it is so much a part of my life.” “ I have started this exercise program, and things are going well…But I know I will go back to my old ways once the cold weather comes.” “ My gambling is totally out of control…But betting is the only way I can de-stress and forget all my problems for awhile.” “ I know I should take my medication every day…It’s just that I hate the side effects so much.” Expanding our understanding of what constitutes change talk can help us to know that we are on track – if we hear change talk that means that we are headed in the right direction. Reflecting change talk – and avoiding a focus on sustain talk – keeps the momentum of the conversation towards enhancing motivation for change.

Change Talk and Sustain Talk
“Opposite Sides of a Coin” Sustain talk is normal and expected – it is simply the flip side of change talk!

DARN CAT Desire Ability Reasons Need Commitment Action Taking Steps
Outline the acronym: DARN CAT, which summarizes different kinds of change talk: (here are some examples you can share, or elicit from the group) Desire: “Sure I want to be a good parent.” Ability: “I can quit anytime I want.” Reasons: “I think I’m getting too old for this lifestyle.” Need: “They will take away my kids unless I go to this program.” Commitment: “I am going to get help with my drug problem.” Action: “I’ve erased the dealers’ phone numbers from my contact list, and I am getting a new phone number so they can’t call me anymore.” Taking steps: “I’ve started taking a fitness class at the community centre twice a week in the evenings.”

MI Hill Yet another metaphor D A R N C A T Preparatory Change Talk
Mobilizing Change Talk Note that “DARN” statements can still reflect ambivalence towards changing, and can represent people in the pre-contemplation or contemplation stages of the change process. “CAT” statements represent commitment language, and are often heard during the preparation, action and maintenance stages of change. Miller has divided the two type of change talk into the categories of “preparatory change talk” and “mobilizing change talk” or commitment language. Preparation Action (Pre-) Contemplation 71

Resistance and Sustain Talk
Both highly related to practitioner style Respond to both in the same way (OARS) “I’m not going to quit.” (sustain talk) “You don’t understand how hard it is for me.” (resistance) Even the most highly skilled and seasoned clinicians encounter resistance and sustain talk; and it helps if we regard them as feedback pointing to a need to change strategies. In MI, resistance and sustain talk have distinct meanings. Resistance refers to client statements about the therapeutic relationship (for example, “You don’t understand what I’m going through”), while sustain talk focuses on the client’s behaviour and represents the opposite side of change talk (for example, “I don’t have a problem with drugs”). Resistance is a normal, human response to feeling pressured or challenged to do something about which a person is ambivalent. As well, sustain talk is simply the other side of a person’s ambivalence about changing. Both resistance and sustain talk can be by-products of how we engage the client. Resistance or sustain talk indicate that we need to walk carefully and be on our best “motivational behaviour.” The good news is that we respond to both resistance and sustain talk in the same way, and three particular types of reflective listening can be especially helpful ways to roll with resistance and ride the wave of sustain talk. The following strategies can open the door to a more productive conversation – that is, dancing versus wrestling.

Responding to Change Talk
Use O A R S strategies to elicit: Open questions: Ask for elaboration Affirmations: Affirm “DARN CAT” statements Reflect examples of change talk back to clients Summarize change talk The OARS strategies are a way to respond to, and elicit more, change talk. Outline how these strategies can be used (from the content on this slide), and explain that you will share some concrete examples on the next slide.

Preparatory change talk –
Example “I know I should use my inhalers, but I am always forgetting where I put them.” What kind of change talk is this? Preparatory change talk – “DARN” statement (NEED) DARN statement (Need)

Example “I know I should use my inhalers, but I am always forgetting where I put them.” What are some of the reasons you think it’s important to use the medication? You have been working hard to manage your asthma in spite of how hard it can be. You know that using the medication every day is very important. Let me make sure I understand what you’ve said so far: You’ve been having a lot of coughing at night; you came today to see me because you are worried about the symptoms you’re experiencing; you know what you should be doing – it’s just hard to actually put it into practice. Does that capture it, or did I miss anything? O A R Now use the same client statement and demonstrate how each of the OARS skills could be used to respond to this change statement. Note that you are not suggesting to use ALL of the OARS skills at once or in order – you are offering participants the “menu” of strategies to respond to change talk in a way that will evoke more change talk. S

What kind of change talk is this?
Practice Exercise “I have tried asking my partner to smoke outside, but she doesn’t listen.” What kind of change talk is this? Tell the group that now it is their turn to practice. As in the previous example, read the client statement and ask the group to “vote” for the type of change talk (see next slide). Commitment language (CAT – taking steps)

Practice Exercise O A R S
“I have tried asking my partner to smoke outside, but she doesn’t listen.” O A R Leave the slide up, and you can ask people to complete this exercise individually (5 mins) or in small groups (10-15 mins); or first individually and then share notes in a small group (20 mins). Then debrief and ask individuals and/or groups to share what they came up with. Sample responses are on the following slide. S

Agenda-setting Learning Objective:
Introduce the skill of Agenda-setting, in this section of the workshop. For clients with multiple, co-occurring problems, it can be overwhelming for both client and practitioner to know where to start. Agenda-setting is a useful way to prioritize behaviour change goals in a way that supports client autonomy and collaboration. Learning Objective: Apply agenda-setting as a strategy for working with clients with complex, co-occurring issues

Agenda Setting A brief discussion with the client, where he/she has the most decision-making freedom possible The client chooses what area toward better health they want to discuss No topic is off limits – success in one area can lead to success in another An agenda-setting conversation puts all of the issues “on the table” and invites the client to consider where his or her priorities are. Just naming an issue does not mean the person has to address it – the client is in charge of planning to where he or she would like to go with respect to health behaviour change.

Tips for Agenda Setting
Start with understanding the patient’s perspectives and preferences Try not to ‘trap’ the person by suggesting a lifestyle change (or focusing too soon on change) once the person raises a lifestyle area Outline these tips for practitioners. You may choose to hide this slide and just share this content verbally with the group.

Tips for Agenda Setting
Consider providing the patient with a finite list of topics to choose from, and asking them if any of the areas they want to discuss are included in that list After the patient responds, feel free to mention topics that you want to talk about You may choose to hide this slide and just share this content verbally with the group.

Strategies Include… Asking for elaboration Reflective listening
Emphasizing personal choice and control Asking permission before making suggestions Summary statements These are useful approaches in holding an agenda-setting conversation with your client. In general, we want to stay with where the person is at, and acknowledge that he or she is the expert in his or her life. Outline the points on the slide, and ask for any questions or comments.

Setting an Agenda for Change
Priorities (Adapted from Rollnick et al., 2008, p. 55) Also called a “bubble sheet”, and agenda-setting worksheet can be a blank piece of paper where you (practitioner) draw a series of circles, and invite the client to work with you to identify all of the possible issues or areas for change.

Priorities Asthma Medication Smoking You can “pre-populate” the sheet based on assessment findings, or start with a blank sheet with the client. Alcohol Diabetes

Priorities Healthy Eating Asthma Medication Finances Stress Smoking Clients often add areas that we as practitioners may not have considered, but which are important to them. Family Alcohol Diabetes

“Given these possible areas to focus, what would you like to talk about in our time together today?”
This is also a way to put some boundaries around the scope of the consultation. Another way to frame this question is to ask: “What would we need to cover in order for you to leave here feeling like you got what you came for?”

Priorities Healthy Eating Asthma Medication Finances Stress Smoking Invite the client to share his or her priorities. Even if we do not agree, we can be reassured that small, incremental changes in one area can lead to changes in other areas as well. Family Alcohol Diabetes

Video Demonstration Agenda setting conversation with "Sal"
Show the video (approx 4 minutes), illustrating an agenda-setting conversation with a client who is having difficulty managing his asthma, but is also struggling with numerous other issues. After the video, debrief by asking: What did you like about this example? What did you dislike or would want to do differently? How realistic is it for you to use agenda-setting with your own clients? How could you adapt this approach to clients with literacy issues or language barriers? (eg, could do this verbally, or use pictures, etc.) Agenda setting conversation with "Sal"

“Readiness Ruler” How important is it to change this behaviour?
People usually have several things they would like to change in their lives – this may be only one of those things. Answer the following three questions with respect to your goal for this week. How important is it to change this behaviour? How confident are you that you could make this change? How ready are you to make this change? At the end of the consultation, it can be helpful to check the client’s importance, confidence and readiness ratings on the “Readiness Ruler” Follow up with: (Why are you at (current score) and not zero? What would it take for you to get from (current score) to (higher score)? What would you need that would support you in making a change, if you chose to do so?) (Adapted from Miller and Rollnick, 2002) A useful follow-up to the Readiness Ruler is asking a key question to help facilitate clients’ explicit commitment to making a change. The key question essentially invites the client to talk about “What’s next?” with respect to making the change. Different ways to ask a key question include: “Given what we have talked about, what do you think you will do?” “Where would you like to go from here?” “What is your next step?”

Summary of Skills Recognizing change talk DARN CAT
Eliciting Change Talk OARS Agenda-setting Worksheet Readiness Ruler Follow-up questions Briefly summarize the skills covered in this section and ask if there are any areas needing further clarification or elaboration. Invite any additional comments from the group.

Putting It All Together
The Effective and Ineffective Practitioner Explain that you will show two videos that illustrate MI inconsistent and MI consistent approaches with a client who is ambivalent about change (approx 5 minutes per video). Let participants know that all of the three videos are freely available on the TEACH YouTube channel; and the TEACH channel includes a number of other clinical demonstration videos (both individual and group), as well as some informational videos by TEACH faculty (“A Minute of TEACH”) on a variety of topics related to motivational interviewing and tobacco cessation. Show the 2 videos, starting with the ineffective practitioner. You can ask the participants to code both of the videos, or only code one video, depending on time, using the coding sheet in the next slide. Make sure that participants have copies of the coding sheets in their handouts. Coding Results for BOTH videos are on the slide after the second video (effective practitioenr) and coding sheet. How NOT to do Motivational Interviewing: A conversation with "Sal" about managing his asthma Learning Objective: Recognize and integrate MI spirit and skills in practice

Motivational Interviewing Coding Sheet
Number of closed questions: __________ Number of open questions: __________ Number of simple reflections: _________ Number of complex reflections: _______ Change statements by client: _______ Sustain statements by client: __________ Therapist talk time (approx.): __________ % Targets: Twice as many reflections as questions At least 50% complex reflections No more than 50% therapist talk time MI “Spirit” (low) (high) Autonomy Collaboration Evocation After participants have viewed and coded the 2 videos, go through the scoring by asking people to call out their scores for each item. Then, you can share the coding scores and note that in MI coding it can take a great deal of practice for coding teams to achieve high inter-rater reliability, so it is expected that there will be variability. The point of the exercise is to help people to analyze motivational consultations with an eye to recognizing specific micro-skills being used:

The Effective Practitioner
“Sal” Ask participants to watch for all of the OARS skills in the video, paying particular attention to the therapist’s use of a summary statement. Make sure that participants have copies of the coding sheets in their handouts.

Number of closed questions: __________ Number of open questions: __________ Number of simple reflections: _________ Number of complex reflections: _______ Change statements by client: _______ Sustain statements by client: __________ Therapist talk time (approx.): __________ % Targets: Twice as many reflections as questions At least 50% complex reflections No more than 50% therapist talk time MI “Spirit” (low) (high) Autonomy Collaboration Evocation After participants have viewed and coded the 2 videos, go through the scoring by asking people to call out their scores for each item. Then, you can share the coding scores (see next slide), and note that in MI coding it can take a great deal of practice for coding teams to achieve high inter-rater reliability, so it is expected that there will be variability. The point of the exercise is to help people to analyze motivational consultations with an eye to recognizing specific micro-skills being used:

Hands-on Practice Each “Real Play” will take 5 minutes.
In groups of three, take three roles: Person “A” describe a change you are thinking of making in the next 6 months – 1 year Person “B” respond using motivational strategies Person “C” observe and give feedback Each “Real Play” will take 5 minutes. After each turn, rotate the roles so that everyone has a chance to practice and receive feedback. Please HOLD your feedback until everyone has had a chance to practice – you will have an opportunity to debrief as a small group at the end of this exercise This is an opportunity for participants to consolidate their learning over the course of the one-day workshop. You can make it optional for participants to use the coding sheets of you wish. However: One advantage to having participants follow the instructions on the slide (including use of the coding sheet) is that their feedback provides them with a personalized “road map” for further developing their skills in MI. This is important, because MI is not something that can be learned in a one-day workshop – the workshop introduces the skills and the approach, but proficiency comes with practice. Make sure that you keep track of time in facilitating this exercise: call “time” after each 5 minute interval so that people can switch roles (so that everyone has an opportunity to practice). Emphasize and remind the groups to hold their feedback until the very end – this is important as people will be tempted to start debriefing right after each interval – explain that you want to ensure that everyone has equal time to practice and receive high-quality feedback.

Number of closed questions: __________ Number of open questions: __________ Number of simple reflections: _________ Number of complex reflections: _______ Change statements by client: _______ Sustain statements by client: __________ Therapist talk time (approx.): __________ % Targets: Twice as many reflections as questions At least 50% complex reflections No more than 50% therapist talk time MI “Spirit” (low) (high) Autonomy Collaboration Evocation Make sure that participants have copies of the coding sheets in their handouts to score each other. It may be helpful to keep this slide up, so that participants who are in the role of “counsellor” can refer to the screen as a prompt for the skills they need to practice and use in their interview. Once everyone has had a chance to practice in their triad (5 mins each, 15 mins total), call “time” and ask people to share their feedback with each other (approx mins). Make sure that people have enough time to debrief in their small group and hear feedback, as this was a relatively “high risk” activity. After the triads have debriefed, bring the large group back together and go to the next slide inviting comments/questions/reflections on the activity and the skills.

Continuing Professional Development in Motivational Interviewing
The end of each workshop, whatever its duration, is an opportunity for participants to reflect on what they have learned, set concrete goals for practice, and identify avenues for continuing professional development. Emphasize that MI is not something that can be learned in a one-day workshop – the workshop introduces the skills and the approach, but proficiency comes with practice. Learning Objective: Set objectives and access resources for continuing professional development in MI skills

“Readiness Ruler” How important is it to start using some of these strategies/tools? How confident are you that you could apply them in your practice? How ready are you to actually use them? Invite participants to complete this “Readiness Ruler” with respect to their self-assessed importance, confidence and readiness to begin to actually practice the MI skills that they have learned in their own setting. Give a couple of minutes for this activity, then go to the next slide.

Practice Goals What is one thing you will commit to practicing with your clients this week? _____________________________________________ Now, ask participants to write down more concrete skills that they will commit to practicing in the coming week. Let them know that this is like a “contract with themselves”, and that the true value of the workshop lies in bridging the knowledge and skills they have learning to their clinical practice. Provide a couple of minutes for this activity, and then invite people t share (if they wish) what they wrote down. It can be motivating for others in the group to hear some of practice goals that their colleagues have set. Also highlight the additional resources that they can access (see next slide). This is also an opportunity to invite any additional comments or reflections. Conclude by thanking the group for their attendance and participation, remind participants to complete the workshop evaluation (a sample template can be found in this toolkit). You may wish to include a slide with your contact information. An energizing way to end the day is to hold a raffle for a MI book or other prize, if your budget permits.

Recommended Resources for Motivational Interviewing Skills Development
Martino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C., Hamilton, J., and Hausotter, W. (2006). Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA STEP). Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University. Matulich, B. (2011). How to do motivational interviewing: A guidebook for beginners. E-book available at: Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37, Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: The Guildford Press. First chapter and table of contents available at Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. New York: Guilford. Useful Websites Motivational Interviewing Website Motivational Interviewing Network of Trainers (MINT) Website Examples of Motivational Interviewing Videos on YouTube Leave this slide up at the end of the session as people are leaving, to reinforce the additional resources/readings that are available on MI. Remind participants to complete the workshop evaluation – see template in the tool-kit.

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Motivational Interviewing in Respiratory Health Care: A Knowledge Translation (KT) Initiative Welcome participants to the training, and provide any housekeeping.

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