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A taste of Motivational Interviewing
Michael McLain Director Outpatient Services Phoenix Center, Greenville SC
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A taste of MI A Taste of MI 2017
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A taste of MI - Round 1 The Client: Role play a client presenting for services, where there is a clear behavior change goal (finding work, better nutrition, parenting skills, etc.)You are ambivalent and somewhat resistant to change. A Taste of MI 2017
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A taste of MI - Round 1 Support Group Leader
Explain why the client should make this change. Give at least three specific benefits that would result from making the change. Tell the client how to change. Emphasize how important it is for the client to change, and Tell the client to do it. A Taste of MI 2017
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Process Role Play A Taste of MI 2017
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Compassionate Conversation
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MI Relational Style Empathic Warm & friendly Collaborative Accepting
Respectful Optimistic Eliciting & Listening Honoring of autonomy & choice A Taste of MI 2017
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Empathy Empathy is not: Empathy is:
Having had the same experience or problem Identification with the client Let me tell you my story Empathy is: The ability to accurately understand the client’s meaning The ability to reflect that accurate understanding back to the client A Taste of MI 2017
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A Taste of MI 2017
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What most people really need is a good listening to. ~Mary Lou Casey
Motivational Interviewing Basics with Native American Populations What most people really need is a good listening to. ~Mary Lou Casey June 13, 2011 A Taste of MI 2017
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Motivational Interviewing
Motivational interviewing is a person-centered, evidence- based, goal-oriented method for enhancing intrinsic motivation to change by exploring and resolving ambivalence with the individual. Motivational Interviewing 3rd Ed. Miller and Rollnick, (2012) A Taste of MI 2017
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Collaboration Compassion Acceptance MI Spirit Evocation
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Four Fundamental Processes of MI
Planning Evoking Focusing These are four fundamental processes utilized within MI, though they have broader applicability to the change process. These are generally thought to emerge in the order listed <click> and build upon each other. However, they are recursive and will likely need to be reworked. We will use these four domains to assist us in thinking about how we can broaden and deepen our skills in MI. I may describe each of these in more depth a bit later, but first I want to find out what ideas you have about these four processes. To help with that I’m going to give to you a speed task and have a bit of fun with it. I’m going to give you 2 minutes as a group to write down as many ideas as you can that match what your concept might mean in a helping context. [Assign groups and topics. Provide sheets and markers.] Now, I’m going to give you two more minutes to decide – as a group - what you think the three ideas that best capture this idea of what engaging means. [time 2 minutes] Okay, now you each need to appoint a spokesperson and your job is to be succinct. You’ll have one minute to explain these three concepts to the group. [time each group for one minute] If needed, add these ideas below, but its unlikely to be necessary. Engaging refers to meeting the patientwhere she or he is. Focusing is finding out what is important to the patientand then matching patientgoals to the treatment agenda. Evoking is the process of pulling forward internal patientmotivation for change, based on what’s important to him or her. Planning is helping the patientdetermine how he or she will succeed in acting on this change. <click> Engaging A Taste of MI 2017
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The processes are somewhat linear……
Engaging necessarily comes first Focusing (identifying a change goal) is a prerequisite for Evoking Planning is logically a later step Engage - Shall we walk together? Focus - Where? Evoke - Why? Plan How? A Taste of MI 2017
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FOCUSING: Negotiate the Agenda
Clinical Roadmap ENGAGING: Open the Conversation Explain role State appointment length Ask permission Provide Clinical Feedback Use visual support materials Be clear, succinct, and non-judgmental Compare to norms and standards Elicit Participant's interpretation Elicit - Provide - Elicit Education Advice Feedback Skills Referral FOCUSING: Negotiate the Agenda EVOKING: Build Motivation Ask evocative questions Encourage elaboration Looking back/Looking forward Explore/Amplify ambivalence Explore goals and values Assess importance/confidence Support the Transition: Recognizing readiness Summarizing the big picture Ask about next steps PLANNING: Strengthening Commitment Brainstorm ideas and opinions Negotiate a plan Explore barriers Identify support Elicit final commitment Close the Encounter: Summarize the session Show appreciation Support self-efficacy Arrange follow-up as appropriate Link with available resources A Taste of MI 2017
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Motivational Interviewing
Assumes motivation is fluid and can be influenced Motivation influenced in the context of a relationship – developed in the context of a patient encounter Principle tasks – to work with ambivalence and resistance Goal – to influence change in the direction of health A Taste of MI 2017
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AMBIVALENCE IS.... A Taste of MI 2017
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Motivational Interviewing UNDERLYING ASSUMPTIONS
Acceptance/Potential for Growth Autonomy/Choice Elicit versus Impart Ambivalence is normal Care-frontation Unconditional positive regard Change talk Righting reflex A Taste of MI 2017
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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 A Taste of MI 2017 19
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To avoid this… LET GO!!! A Taste of MI 2017
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Common Human Reactions to Being Listened to
Understood Want to talk more Liking the worker Open Accepted Respected Engaged Able to change Safe Empowered Hopeful Comfortable Interested Want to come back Cooperative A Taste of MI 2017 21
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OARS- MI Skills O – Open questions A – Affirmations R – Reflections
S – Summaries A Taste of MI 2017
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Closed Questions sound like…
Motivational Interviewing Basics with Native American Populations June 13, 2011 Closed Questions sound like… “Do you…Are you… Did you… Could you…Have you…?” “Did you get a job yet?” “Do you care about finishing your studies?” “Did you think before you did that?” “Do you have a drinking problem?” 64 When we get into these patterns it feels like ping-pong and eventually the patientjust sits back and lets you do the work. A Taste of MI 2017
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Open-Ended Questions sound like…
Motivational Interviewing Basics with Native American Populations June 13, 2011 Open-Ended Questions sound like… “What…. Which…. Where… How… Tell me…” “How does it feel to be back at work?” “Where do you think your biggest challenge lies?” “What do you think you’ll take care of first?” “Tell me about your relationship with your boss/partner/daughter” Which “W” is missing? (why) Why is Why missing? (Comes across judgmental or accusatory. Can demonstrate this with some humor by using a very non-judgmental tone with some who came in a little late: “Mary, why did you get here late today?” (Still feels very judgmental, even when not meant that way) 24 A Taste of MI 2017
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Motivational Interviewing Basics with Native American Populations
June 13, 2011 Affirmations… Affirmations are sincere, specific and immediate. Affirmations are not cheerleading. Emphasize the importance of making the affirmation very specific and genuine. Explain the “cheerleader” effect and how that can backfire. A Taste of MI 2017
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Affirmations Emphasize a strength
Notice and appreciate a positive action Should be genuine Build feelings of empowerment Instill hope and “can-do” attitude Express positive regard and caring Strengthen the clinical relationship A Taste of MI 2017
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Affirmations 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! A compliment I like the way you said that. An expression of hope, caring, or support I hope this weekend goes well for you! A Taste of MI 2017
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Motivational Interviewing Basics with Native American Populations
June 13, 2011 Reflections A Taste of MI 2017
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How to Form a Reflection
Motivational Interviewing Basics with Native American Populations June 13, 2011 How to Form a Reflection 1. You can reflect the patient’s… speech, facial expressions, behavior 2. Make a guess about the deeper meaning (therapeutic hunch) 75
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Reflective Listening A hypothesis (guess) about speaker’s meaning
A statement to convey understanding Intonation down Short stems “So…” “Sounds like…” “So you…” “Seems like …” “Its like…” “You feel…” Purpose: This slide introduces reflective listening to patients, and build on the hypothesis building of the previous exercise. Key Points: Reflective listening makes hypotheses about what the speaker means. Reflective listening conveys understanding/shows empathy Tone is important for reflective listening. Toning up makes a reflection a closed questions. Reflections should tone down or flat as a statement. Give some examples of reflections using the stems on the slide. Notes: The following slides will help patients differentiate reflections from questions. Increased questions can raise levels of defensiveness in the person we are talking to. The tone of a reflection only refers to the way that the tone goes at the end. Reflections do not need to be given in a toneless manner. It is helpful to demonstrate the tone of a reflection. Encourage patients to be confident in their hypotheses. A tone up at the end can mean a lack of confidence or comfort in the hypothesis. People sometimes do not feel comfortable making guesses because it feels invasive or they are afraid of being wrong. It is ok to make these hypotheses because it can guide the conversation and show empathy. If a reflection is wrong, the person you are talking to will correct you and put you both back on the same page. One of the main goals of reflective listening is to understand and show understanding. Example – A plane travelling from city to city is off course 90% of the time. How does it get there? Continual course corrections and being in constant communication with the ground (air traffic control). Reflections are similar in that we use them to make constant corrections to stay on the same page as the person we are talking to. Why is a reflection a listening behavior while questions are not? (Add that questions solicit information while reflections check understanding). A Taste of MI 2017 30
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Repeating (repeats an element of what the client said)
Simple (stabilizing) Repeating (repeats an element of what the client said) Rephrasing (uses new words) Complex (forward moving) Paraphrasing (makes a guess to unspoken meaning) Reflection of feeling (deepest form; a paraphrase that emphasizes the emotional dimension through feeling statements) A Taste of MI 2017
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What I’m hearing is… So you’re saying that…
You’re feeling like… So you…. Almost as if… Sounds as if you… For you, it’s a matter of…. From your point of view,… I’m hearing that you… I’m really getting that you… I get the impression that you… A Taste of MI 2017
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Simple Reflection Example
Client: “This whole thing has been so confusing.” Counselor: “It’s confusing…” A Taste of MI 2017
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Complex Reflection: Example
Client: “You’re not from around here. What do you know?” Counselor: “You’re worried that I might not understand you.” A Taste of MI 2017
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Double-Sided Reflection
“So one one hand, you are afraid if you quit drinking you will be bored and lose your friends.. But on other side, if you don’t, you are faced with losing your wife and family…..” Role Play Exercise A Taste of MI 2017
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The summary is like a bouquet of flowers that we give to the client.
Each flower is something they have told us, usually change talk. A Taste of MI 2017
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Summary Set up Bookend: “Let me see if I have this right…”
“Let me summarize what you’ve said…” Reflection, Reflection, Reflection Follow up Bookend: “So where does that leave you? “What else would you like to add?” “Now, tell me about ….” “Tell me more about…” The 4th basic skill of motivational interviewing is the summary. This slide tells us the structure of a summary. There are in fact three different types of summaries that have slightly different purposes. The purpose of summaries is covered on the next slide. Explain the structure of the summary as having bookends with at least 3 reflections in between. A summary starts off with a set up statement, and closes with a question (sometimes open and sometimes closed depending on your purpose.) For now emphasize the open question, as we have been encouraging people to use open questions in the previous activities. Also, point out that a summary is a type of complex reflection. A Taste of MI 2017 37
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Summaries Can… Give the message that the patient is being heard
Allow the patient to add important information Shift the direction of the interview Facilitate and guide Reflect ambivalence Accentuate “change talk” The patients do not need to know much about the three types of summaries, but they include: Transitional summaries – for changing the direction of an interview (Is that right? Now I need to ask you about ….?) Collecting summaries – for reinforcing change talk and continuing exploration (What else?) Linking summaries – for linking pieces of information e.g. something they’ve said with assessment results. (How does that fit together.) “Use summaries to collect important points and move forward” (Bill Miller, July 2006). A Taste of MI 2017 38
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Fundamental Belief The capacity and potential for change and adherence is within every person! A Taste of MI 2017
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Change and Sustain Talk
Ask group to: Define change and sustain talk Describe how practitioner behavior may influence the appearance of each Add information below only if needed Change and Sustain Talk are two sides of the same coin. These sides reflect the two sides of ambivalence. However, the frequency, intensity, and trajectory of each might predict outcome. Moreover, pratitioner behavior influences what type of language emerges from clients, which in turn predicts outcomes. Describe different types of patienttalk: There are parallels between these two types of patientlanguage. For example, we can identify two distinct types of language. There is preparatory language, which includes: Desire Ability Reason (benefits) Need (costs of the alternative) (Might give examples of patientstatements in each) And mobilizing language: Commitment Activation (ready, willing) Taking Steps (engaging in behavior) Our aim, as you will see, is to encourage Participantsto engage in change talk and avoid focus on sustain talk. <click> A Taste of MI 2017
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Change talk is like gold!
As Participants speak about change, they begin to see the possibilities No pressure or persuasion is needed Example: Doctor: What would be the benefits to you for cutting back to safer drinking limits? client: Well, my wife would quit nagging me, she’d be a lot happier. I’d probably also lose some of this weight I’ve put on lately. Doctor: So your home life would get better and you’d be healthier all around. A Taste of MI 2017
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Types of Change Talk: Desire I want to…. I’d really like to… I wish…
Ability I would… I can…. I am able to... I could… Reason There are good reasons to… This is important…. Need I really need to… Commitment I intend to… I will… I plan to… Activation I’m ready… I’m able Taking Steps I completed my class assignment on time A Taste of MI 2017
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Eliciting Change Talk What concerns you about your drinking/smoking/health habit? What are others worried about regarding your drinking/smoking/health pattern? What relevance/importance does smoking/drinking have in your personal goals? If you decided to change your drinking/smoking/health habit, how would that change your life? Your family’s life? A Taste of MI 2017
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DARN CATs A Taste of MI 2017
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What is Resistance? CHANGE TALK SUSTAIN TALK DISCORD
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Sustain Talk and Discord
Sustain Talk is about the target behavior I really don’t want to quit smoking I need my pills to make it through the day Discord is about your relationship You can’t make me quit You don’t understand how hard it is for me Both are highly responsive to practitioner style A Taste of MI 2017
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Ambivalence / Resistance
It sounds like the pros of using still far outweigh the cons for you. So it may be that you decide drinking is something that you don’t want to give up despite the consequences Sometimes, by siding with the client, it causes them to step back and move more towards our desired behavior. A Taste of MI 2017
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Change-talk Eliciting Strategies
Decisional Balance Ambivalence is a normal part of the change process Use ambivalence to promote positive change Weigh pros and cons of behavior Increase discrepancy A Taste of MI 2016 A Taste of MI 2017
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DECISIONAL BALANCE SHEET
1. Good things: 2. Not so good things: A Taste of MI 2017
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Importance/Confidence/Readiness Rulers
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Negotiate a plan of action
Invite active participation by the patient Patient determines goals & priorities Patient weighs options Together, work out details of the plan A Taste of MI 2017
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Giving Information and Advice: 3 Kinds of Permission
The participant asks for advice You ask permission to give advice You qualify your advice to emphasize autonomy MI Core Skills 2015 52
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Finalizing the motivational interview
Review the commitment Review the plan Set up a new time to meet/follow up Express encouragement A Taste of MI 2017
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A taste of MI - Round 2 The Client: Talk about something about yourself that you want to change / need to change / should change / have been thinking about changing etc., but haven't changed yet (i.e., something you're ambivalent about.) A Taste of MI 2017
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A taste of MI - Round 2 cont’d
Worker: Listen carefully with a goal of understanding the dilemma. Give no advice. Ask these four questions: 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? Give a short summary/reflection of the speaker's motivations for change. Summarize what they said about Desire for change, Ability to change, Reasons for change, Need for change. Then ask, "So what do you think you'll do?" and just listen with interest. A Taste of MI 2017
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Giving Advice / Information
Always ask for permission “Other clients have found ___ to be of help. Are you interested in knowing about that or is there something we should discuss first?” Offer alternatives (menu of options) “We could give you a list of local resources or set up a session with a treatment provider.” Provide more information according to the interest of the patient “Would you like to know more about AA?” Express concern when indicated “Would it be all right if I tell you one concern I have about this plan?” A Taste of MI 2017
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Strength: Commitment Language
HIGH I will / promise / swear / guarantee I intend to / agree to / am ready to I plan / expect / resolve / aim to I hope to / will try to / will see about /I guess / think / suppose I will LOW A Taste of MI 2017
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Extend gratitude Support autonomy Offer advice Voice confidence
Closing our Encounter Extend gratitude Support autonomy Offer advice Voice confidence A Taste of MI 2017
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The MI Shift From feeling responsible for changing clients’ behavior to supporting them in thinking & talking about their own reasons and means for behavior change. A Taste of MI 2017 59
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Michael McLain mmclain@phoenixcenter.org 864-467-3769
Thank you! Michael McLain A Taste of MI 2017
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