developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP

developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP
Using Motivational Interviewing to Help Your Patients Make Behavioral Changes /

6 on 6 exercise Participants working in small groups (up to 6) discuss the question for six minutes Report out Use MY skills of clarification, affirmation and Why Should We Be Interested In Patients’ Motivation For Behavior Change? /

Beliefs About Motivation (True or False?)
Until a person is motivated to change, there is not much we can do. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change. Motivation is influenced by human connections. Resistance to change arises from deep-seated defense mechanisms. Until a person is motivated to change, there is not much we can do – False – motivation is accessible and can be modified or enhanced at many points in the change process. Clients may not have to "hit bottom" or experience terrible, irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image. It usually takes a significant crisis (“hitting bottom”) to motivate a person to change – False – Sometimes this is how it happens, BUT clients do not have to "hit bottom" or experience irreparable consequences of their behaviors to become aware of the need for change. Clinicians and others can access and enhance a person's motivation to change well before extensive damage is done to health, relationships, reputation, or self-image. There are several types of experiences that may have effects, either increasing or decreasing motivation. Experiences such as: Distress levels: e.g., increased anxiety about the problem. Critical life events: e.g., spiritual inspiration/religious conversion through traumatic accidents or severe illnesses, deaths of loved ones, being fired, becoming pregnant, or getting married. Cognitive evaluation or appraisal, of the impact of substances in one’s life, can lead to change. This weighing of the pros and cons of substance use accounts for 30 to 60 percent of the changes reported in natural recovery studies. Recognizing negative consequences and the harm or hurt one has inflicted on others or oneself helps motivate some people to change. Helping clients see the connection between substance use and adverse consequences to themselves or others is an important motivational strategy. Positive and negative external incentives: Supportive and empathic friends, rewards, or coercion of various types may stimulate motivation for change. Motivation is influenced by human connections – True – Motivation belongs to one person, yet it can be understood to result from the interactions between the individual and other people or environmental factors. A person’s readiness for change fluctuates over time and depends a lot on the situation; it is not a static personal attribute. Motivation can vacillate between conflicting objectives. Motivation also varies in intensity, faltering in response to doubts and increasing as these are resolved. Motivation to change can be strongly influenced by family, friends, emotions, and community support. Resistance to change arises from deep-seated defense mechanisms – False – Denial, rationalization, resistance, and arguing, as assertions of personal freedom, are common defense mechanisms that many people use instinctively to protect themselves emotionally. When clients are labeled pejoratively as alcoholic or manipulative or resistant, given no voice in selecting treatment goals, or directed authoritatively to do or not to do something, the result is a predictable--and quite normal--response of defiance. Additionally, ambivalence is normal.

Beliefs About Motivation (True or False?)
People choose whether or not they will change. Readiness for change involves a balancing of “pros” and “cons.” Creating motivation for change usually requires confrontation. Denial is not a client problem, it is a therapist skill problem. People choose whether or not they will change – ultimately True – Although change is the responsibility of the client and many people change their excessive substance-using behavior on their own without therapeutic intervention, you can enhance your client's motivation for beneficial change at each stage of the change process. Readiness for change involves a balancing of “pros” and “cons” – True – Ambivalence needs to be resolved before the change can progress. Creating motivation for change usually requires confrontation – False – confrontation may promote resistance rather than motivation to change or cooperate. Research suggests that the more frequently clinicians use adversarial confrontational techniques with substance-using clients, the less likely clients will change. Denial is not a client problem, it is a therapist skill problem – True – MI views denial and resistance as behaviors evoked by environmental conditions, not as traits characteristic of substance abusers. A direct comparison of counselor styles suggested that a confrontational and directive approach may precipitate more immediate client resistance and, ultimately, poorer outcomes than a client-centered, supportive, and empathic style that uses reflective listening and gentle persuasion.

(C) Tom Broffman, PhD, LICSW, LCDP, CEAP
Learning Objectives At the end of the workshop, you will be able to: Define multiple MI techniques to help clients to change Describe the Stages of Change Complete a Stage of Change Assessment Define the 4 principles of MI Demonstrate skill with OARS Demonstrate at least 2 methods to elicit change talk Utilize a Readiness Ruler Complete a Decisional Balance Complete a Change Plan Describe MI strategies to deal with resistance to change DO NOT COPY WITH OUT PERMISSION

MI is A theory A set of skills A way of thinking A way of relating /

Experiential Exercise 1

copyrighted by Tom Broffman, PhD
Why Do People Change? ? Ask the participants Write onto news print Process with audience The first thing we need talk about in an introduction to motivational interviewing is motivation. From a motivational interviewing perspective motivation: “can be understood not as something that one has (it is not a personal attribute), but as something that one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy.” - Bill Miller When we talk about substance abuse we often wonder what is getting in the way of motivation for change, why do people get stuck/continue to engage in unhealthy behaviors? Please do not COPY without permission

Why Don’t People Change?
copyrighted by Tom Broffman, PhD Why Don’t People Change? ? Ask the participants Write onto news print Process with audience Please do not COPY without permission

Sound Familiar? “I tell them what to do, but they won’t do it.” “It’s my job just to give them the facts, and that’s all I can do.” “These people lead very difficult lives, and I understand why they _______.” “Some of my patients are in complete denial.” Historic advise giving and view of why peoples don’t change Rollnick, Miller and Butler. Motivational Interviewing in Healthcare /

Or Should We? Explain what patients could do differently in the interest of their health? Advise and persuade them to change their behavior? Warn them what will happen if they don’t change their ways? Take time to counsel them about how to change their behavior? Refer them to a specialist? More historic approached to advise giving……That don’t work well Rollnick, Miller and Butler. Motivational Interviewing in Healthcare /

The Righting Reflex: The Best Intentions Can Backfire
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP The Righting Reflex: The Best Intentions Can Backfire Most patients are ambivalent about unhealthy behaviors. When we (providers) see an unhealthy/risky behavior, our natural instinct is to point it out & advise change. The patient’s natural response is to defend the opposite (no change) side of the ambivalence coin. The Righting Reflex /

Avoid Righting Reflex: “Taking Sides” Trap
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Avoid Righting Reflex: “Taking Sides” Trap PROVIDER “You must change” “You’ll be better off” “You can do it!!” “You’ll die…” PATIENT “I don’t want to change” “Things aren’t half bad.” “No I can’t!!” “Uncle Fred is 89 and healthy as can be.” /

Experiential Exercise 2: The Change Exercise
Copyrighted Tom Broffman, PhD, LICSW, LCDS, LCDS, CEAP Experiential Exercise 2: The Change Exercise Please Do Not Copy Without Permission

Exercise: The Change Exercise
copyrighted by Tom Broffman, PhD Exercise: The Change Exercise Stand up and turn to stand face to face in pairs. Silently observe your partner for 15 seconds. Now turn back to back and change 3 things about yourself. When you are done, turn back to face your partner. Each person should take a minute to name the 3 things your partner has changed. Please do not COPY without permission

Change Exercise Questions
copyrighted by Tom Broffman, PhD Change Exercise Questions What was your comfort level during this exercise? What made you comfortable or uncomfortable? How hard was it to change things? How did you decide what things to change about yourself? What does this exercise tell us about change? Look around you did you notice how quickly people changed back to the way they started as soon as they sat down? What implications might this have about change for people and ourselves? Please do not COPY without permission

Change Exercise Key Points
copyrighted by Tom Broffman, PhD Change Exercise Key Points Change is difficult Change is not always comfortable Change requires creativity We tend to go back to old ways It is easier to stay the same We like our comfort zones Change requires an open mind Change has emotional and cognitive components Please do not COPY without permission

Change Exercise Key Points
copyrighted by Tom Broffman, PhD Change Exercise Key Points Change is a process Change happens over time The process is as important as the result Watch out for measuring success only if a change occurred Often there is a difference between what someone knows they should do and there readiness to do it. Greatest chance to impact change is pacing it to the specific stage of change Please do not COPY without permission

Why Are Health Care Professionals (Outside Behavioral Health) Interested In MI? Behavioral/lifestyle factors in health issues Exercise Smoking Weight control Treatment adherence Diet/nutrition Conceptual consistency with patient-centered approaches Positive and promising results from research on outcomes Chronic diseases—such as heart disease, cancer, and diabetes—are the leading causes of death and disability in the U.S. Chronic diseases account for 70% of deaths each year. Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. Adopting healthy behaviors such as eating nutritious foods, being physically active, and avoiding tobacco use can prevent or control the devastating effects of these diseases. Source: /

Definition of Motivational Interviewing
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Definition of Motivational Interviewing A patient-centered, yet directive method for enhancing intrinsic motivation for positive behavior change by exploring and resolving ambivalence.” What is motivational interviewing? “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” Each part of this definition is important for a full understanding of MI: “client-centered” The focus is on the person’s present interests and concerns and on the person’s own experiences and values. The focus is NOT on teaching coping skills, reshaping cognitions, or excavating the past. “directive” We intentionally work to help people resolve ambivalence, generally in the direction of change. In MI we selectively respond to the consumer’s talk/speech in a way that moves the person toward change. “method” Motivational interviewing is a style of or approach to communication, it is a way of being with a client, NOT just a set of techniques for doing counseling. “intrinsic motivation” Motivation to change is elicited from the client/from within the person. MI is NOT a strategy to impose change through extrinsic means or contingencies (e.g., legal, financial, threatened loss of job or family). MI relies upon identifying and mobilizing the client's intrinsic values and goals to stimulate behavior change. “by exploring and resolving ambivalence” The operational assumption in MI is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. MI assumes ambivalence can be resolved by working with your client's intrinsic motivations and values. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere. Miller, W.R. & Rollnick, S.(2002) /

Motivation is viewed as…
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Motivation is viewed as… multidimensional a state, which is dynamic and fluctuating modifiable influenced by communication style Our job is to elicit and reinforce patient motivation for change. /

Rapid Diffusion Into Health Care Settings…
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Rapid Diffusion Into Health Care Settings… /

Motivational Interviewing Practice Basics:
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Spirit, Principles, Micro-skills Motivational Interviewing Practice Basics: /

MI Spirit A way of being with patients which is… Collaborative Evocative Respectful of autonomy Collaboration: In MI there is a partner-like relationship, NOT an authoritarian one-up stance. The counselor honors the client’s experiences and perceptions. This creates an atmosphere conducive versus coercive to change. Confrontation, on the other hand, overrides the person’s impaired perspective and imposes awareness and acceptance of “reality” that the person does not see or admit. Evocation: In MI the resources and motivation for change are presumed to reside within the client. It is the counselor’s job to find intrinsic motivation and evoke it, call it forth. The style is one of eliciting things (e.g., wisdom, motivation) from the person NOT imparting, inserting, or installing them. Education, on the other hand, presumes that the person lacks key knowledge, insight or skills that are necessary for the change to occur. The counselor provides the requisite enlightenment. Respectful of Autonomy: In MI responsibility for change is left with the person, their autonomy is respected. The counselor affirms the person’s right and capacity for self-direction. The approach is empowering to consumers. Authority, on the other hand, takes the responsibility and power away from the person and the counselor becomes responsible for the change process. /

Collaboration (not confrontation)
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Collaboration (not confrontation) Developing a partnership in which the patient’s expertise, perspectives, and input is central to the consultation Fostering and encouraging power sharing in the interaction /

Evocation (not education)
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Evocation (not education) The resources and motivation for change reside within the patient Motivation is enhanced by eliciting and drawing on the patient’s own perceptions, experiences, and goals Ask key open ended questions /

Autonomy (not authority)
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Autonomy (not authority) Respecting the patient’s right to make informed choices facilitates change The patient is charge of his/her choices, and, thus, is responsible for the outcomes Emphasize patient control and choice /

Spirit of Motivational Interviewing
Motivations to change are elicited from within the client, not imposed from outside. It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. Direct persuasion is not an effective method for resolving ambivalence. Readiness to change is not a client trait, but fluctuating product of interpersonal interaction. Motivations to change are elicited from the client, not imposed from outside. This is different from other motivational approaches that have emphasized coercion, persuasion, constructive confrontation, or the use of external contingencies (e.g., threatened loss of job or family). Such strategies may have their place in evoking change, but they are quite different in spirit from motivational interviewing which relies on identifying and mobilizing the client’s intrinsic values, including cultural values and goals to stimulate behavior change. It is the client's task, not the counselor's, to articulate and resolve his or her ambivalence. Ambivalence takes the form of a conflict between 2 courses of action, each of which has perceived benefits and costs. Many clients have never had the opportunity of expressing the often confusing, contradictory and uniquely personal elements of this conflict, for example, “If I stop smoking I will feel better about myself, but I may also put on weight which will make me feel unhappy and unattractive.” The counselor’s task is to facilitate expression of both sides of the ambivalence impasse, and guide the client toward an acceptable resolution that triggers change. Direct persuasion is not an effective method for resolving ambivalence. It is tempting to try to be “helpful” by persuading the client of the urgency of the problem about the benefits of change. It is fairly clear, however, that these tactics generally increase client resistance and diminish the probability of change. Readiness to change is not a client trait, but fluctuating product of interpersonal interaction. The therapist is therefore highly attentive and responsive to the client's motivational signs. Resistance and "denial" are seen not as client traits, but as feedback regarding therapist behavior. Client resistance is often a signal that the counselor is assuming greater readiness to change than is the case, and it is a cue that the therapist needs to modify motivational strategies.

Spirit of Motivational Interviewing
The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. Positive atmosphere that is conducive but not coercive for change. The counselor is directive in helping the client to examine and resolve ambivalence. The therapeutic relationship is more like a partnership or companionship than expert/recipient roles. The therapist respects the client's autonomy and freedom of choice (and consequences) regarding his or her own behaviour. This creates a positive atmosphere that is conducive but not coercive for change. The counselor is directive in helping the client to examine and resolve ambivalence. The operational assumption in motivational interviewing is that ambivalence or lack of resolve is the principal obstacle to be overcome in triggering change. Once that has been accomplished, there may or may not be a need for further intervention such as skill training. The specific strategies of motivational interviewing are designed to elicit, clarify, and resolve ambivalence in a client-centered and respectful counseling atmosphere; it is directive in this way.

What MI is Not A way of tricking people into doing what you want them to do A specific technique Problem solving or skill building Just client-centered therapy Easy to learn A panacea for every clinical challenge Source: Miller & Rollnick (2009) /

Four Guiding MI Principles:
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Four Guiding MI Principles: Resist the righting reflex If a patient is ambivalent about change and the clinician champions the side of change… The righting reflex is a term that refers to the seemingly built-in desire of humans to set things right (more generally it refers to an animal’s ability to “land on its feet,” e.g., a cat). When presented with a problem, someone else’s problem, we have the tendency to offer solutions. When this instinct meets ambivalence, however, we know what happens, the person defends the status quo/argues against change. The major problem with this phenomenon is that the more a person argues on behalf of one position, the more committed to it he/she becomes. This an important principle demonstrated in social psychology. We can literally talk ourselves into (and out of) things. On the flip side, the more we can elicit change statements/talk from people, the more committed to change they become. /

developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Four Guiding MI Principles: Understand your patient’s motivations With limited consultation time, it is more productive asking patients what or how they would make a change rather than telling them that they should. /

developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Four Guiding MI Principles: Listen to your patient When it comes to behavior change, the answers most likely lie within the patient, and finding them requires some listening These guiding principles in motivational interviewing guide us to: express empathy, develop discrepancy, roll with resistance, and support self-efficacy. We will discuss each of these today. We will also discuss some of the more specific methods of motivational interviewing. Open questions, affirmations, reflective listening, and summaries are the primary skills necessary to practice motivational interviewing. These skills provide the foundation of motivational interviewing. Change occurs when people give voice to their own reasons for change. These skills encourage the client to explore their problems; they get the client talking. They are summarized by the acronym OARS. The OARS are derived largely from client-centered counseling, but, as we will see later, in MI they are used for a particular purpose: helping people to explore their ambivalence and clarify reasons to change. These skills can be useful from the first encounter and throughout the process of motivational interviewing. /

developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Four Guiding MI Principles: Empower your patient A patient who is active in the consultation, thinking aloud about the what and how of change, is more likely to do something about it. /

Core MI Skills – (OARS) Asking Listening Affirming /

Asking Use of open ended questions allows the patient to convey more information Encourages engagement Opens the door for exploration /

Closed Ended Question  Open Ended Question
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Closed Ended Question  Open Ended Question Are you having any pain today? Is there anything that is worrying you right now? Are you short of breath? Are you doing okay? Why haven’t you tried this exercise? Are you refusing treatment? Do you have a follow up appointment scheduled? /

Open-Ended Questions OARS What are open-ended questions?
Gather broad descriptive information Require more of a response than a simple yes/no or fill in the blank Often start with words like: “How…” “What…” “Tell me about…” Usually go from general to specific Does anyone know, what are open-ended questions? Open questions gather broad descriptive information. They require more of a response than a simple yes/no or fill in the blank. Open questions often start with words like, “How…” “What…” “Tell me about…” “Describe…” Finally, open questions usually start out general and then get more specific. Open questions encourage the client to do most of the talking, help us avoid premature judgments, and keep communication moving forward. Closed questions on the other hand gather very narrow specific information, tend to solicit yes or no answers or one or two word answers, and convey that agenda is about some other ends than the client (our own need to gather info, curiosity, complete a form). Example of an open question: What reason’s might you have to cut down on your drinking? By asking open-ended questions, the stage is set to utilize aspects of reflective listening, affirmations, and summarizing. OARS

Open-Ended Questions Exercise: Turning closed-ended questions into
open-ended ones [Read each closed question to participants and ask them to turn it into an open question. Then offer the example open question listed. Closed Question Open Question So you are here because you are concerned Tell me, what is it that brings about your use of alcohol, correct? you here today? How many children do you have? Tell me about your family. Do you agree that it would be a good idea for What do you think about the possibility you to go through detoxification? of going through detoxification? First, I'd like you to tell me some about your Tell me about your marijuana use marijuana use. On a typical day, how much during a typical week. do you smoke Do you like to smoke? What are some of the things you like about smoking? How has your drug use been this week, What has your drug use been like compared to last: more, less, or about the same? during the past week? Do you think you use amphetamines too often? 7. In what ways are you concerned about your use of amphetamines? How long ago did you have your last drink? Tell me about the last time you had a drink. Are you sure that your probation officer told you 9. Now what exactly are the conditions your that it's only cocaine he is concerned about in probation officer wants you to follow? your urine screens? When do you plan to quit drinking? 10. So what do you think you want to do about your drinking?

Open-Ended Questions OARS Why open-ended questions?
Avoid the question-answer trap Puts client in a passive role No opportunity for client to explore ambivalence The main reason to use open questions it to avoid the question answer trap. The question-answer trap is a pattern where the counselor asks questions and the client gives short responses, often yes/no responses. This pattern teaches the client to give short answers and subtly implies that the counselor is the active expert and the client is passive and if the counselor just asks enough or the right questions then he/she will have the solution to the problem. This is not motivational interviewing. In motivational interviewing the client does half or more of the talking. We need the client to talk so that we have material to work with. Closed questions afford the person little opportunity to explore ambivalence and offer change talk. Asking a series of closed questions or even a series of open questions is not as effective as using a mix of open questions and most importantly reflective listening. As a general guideline, the clinician should avoid asking three questions in a row. OARS

Affirmations What is an affirmation? OARS
Compliments, statements of appreciation and understanding Praise positive behaviors Support the person as they describe difficult situations What is an affirmation? An affirmation is a compliments or statement of appreciation and understanding. Affirmations are used to praise positive behaviors and support the person as they describe difficult situations. OARS

Affirmations Examples:
“I appreciate how hard it must have been for you to decide to come here. You took a big step.” “I’ve enjoyed talking with you today, and getting to know you a bit.” “You seem to be a very giving person. You are always helping your friends.” Some examples are: “I appreciate how hard it must have been for you to decide to come here. You took a big step.” “I’ve enjoyed talking with you today, and getting to know you a bit.” “You’re clearly a resourceful person to cope with such difficulties for so long.” “You seem to be a very giving person. You are always helping your friends.”

Affirmations OARS Why affirm?
Supports and promotes self-efficacy, prevents discouragement Builds rapport Reinforces open exploration (client talk) Caveat: Must be done sincerely We use affirmations in MI support and promote self-efficacy or self-confidence, which is a necessary ingredient for change. Affirmations can help us acknowledge the difficulties that the client has experienced. We can emphasize past experiences that demonstrate strength and success to prevent discouragement. Affirmations build rapport which also facilitates change; with affirmations we validate the client’s experience and feelings. Finally, Affirmations reinforce open exploration of client problems (client talk). Caveats: It is important to be sincere and watch the client’s response, cultural norms vary in comfort with affirmations. OARS

Express Empathy What is empathy? Reflects an accurate understanding
Assume the person’s perspectives are understandable, comprehensible, and valid Seek to understand the person’s feelings and perspectives without judging Before we move on to the R in the OARS, we are going to talk a little about empathy. Expressing empathy is one of the principles of motivational interviewing. What is empathy? Understanding or acceptance without judging or criticizing. Empathy reflects an accurate understanding. To express empathy we must assume the person’s perspectives are understandable, comprehensible, and valid. We must also seek to understand the person’s feelings and perspectives without judging.

Express Empathy Empathy is distinct from… Agreement Warmth
Approval or praise Reassurance, sympathy, or consolation Advocacy Empathy is distinct from a number of things: Agreement – we may understand fully without necessarily agreeing with the client’s perspective Warmth – we may work very hard to understand the client’s perspective but not be especially warm or friendly while doing so Approval or praise – approval is like agreement or endorsement. Understanding and praise are different. It’s okay to understand why someone likes to use, that doesn’t mean you approve! Reassurance, sympathy, or consolation Advocacy – we may be invested in helping the client gain services without a particular effort to understand their perspective

Express Empathy Why is empathy important in MI and IDDT?
Communicates acceptance which facilitates change Encourages a collaborative alliance which also promotes change Leads to an understanding of each person’s unique perspective, feelings, and values which make up the material we need to facilitate change Expression of empathy is a fundamental and defining characteristic of motivational interviewing. Empathy communicates acceptance which, paradoxically, facilitates change. When accepted as they are, people seem to be freed to change. Empathy encourages a collaborative alliance which also promotes change. When counselors have accurate understanding, clients feel understood, are more likely to explore ambivalence, and are more likely to change. When people feel “accurately understood” the need to explain or defend decreases and they are able to put their energy into personal exploration which facilitates the change process. Expression of empathy also leads to an understanding of each person’s unique perspective, feelings, and values which make up the material we need to facilitate change.

Express Empathy Tips… Good eye contact Responsive facial expression
Body orientation Verbal and non-verbal “encouragers” Reflective listening/asking clarifying questions Avoid expressing doubt/passing judgment Some tips for expressing empathy include: Good eye contact Responsive facial expression Body orientation Verbal and non-verbal “encouragers” Reflective listening/asking clarifying questions Avoid expressing doubt/passing judgment

Empathy is NOT… The sharing of common past experiences
Giving advice, making suggestions, or providing solutions Demonstrated through a flurry of questions Demonstrated through self-disclosure There are many things that are often mistaken for empathy. Empathy is not: The sharing of common past experiences Giving advice, making suggestions, or providing solutions Demonstrated through a flurry of questions Demonstrated through self-disclosure 48

The Bottom Line on Empathy
Ambivalence is normal Our acceptance facilitates change Skillful reflective listening is fundamental to expressing empathy - Miller and Rollnick, 2002 In summary, ambivalence is normal, our acceptance facilitates change, and skillful reflective listening is fundamental to expressing empathy.

Reflective Listening OARS
[Reflections are one of the hardest skills to learn, so depending on the group, slow down here.] Reflective Listening - This is a foundational skill in MI. It is a challenging skill where you demonstrate that you have accurately heard and understood a client’s communication by restating it’s meaning. It is essential in expressing empathy. OARS

Listening Clinician accurate empathy is a robust predictor of behavior change Involves careful listening with the goal of understanding the meaning of what the patient says Skillful reflective listening looks easy, but it’s a complex skill /

Reflective Listening “Reflective listening is a way of checking rather than assuming that you know what is meant.” (Miller and Rollnick, 2002) Reflective listening is a way of checking rather than assuming that you know what is meant. OARS

Reflective Listening Why listen reflectively?
Demonstrates that you have accurately heard and understood the client Strengthens the empathic relationship Encourages further exploration of problems and feelings Avoid the premature-focus trap Can be used strategically to facilitate change Offering reflections is a special way of checking for meaning that accomplishes multiple goals: Demonstrates that you have accurately heard and understood the client (expresses empathy) Strengthens the therapeutic relationship which promotes change Encourages further exploration of problems and feelings (client talk), helps you avoid the premature focus trap. Often the first problem that the client talks about is not the most important problem for them. Also, we do not want to focus prematurely on our own conception of the problem. Can be used strategically to facilitate change – we can be selective in what we reflect thereby reinforcing specific themes or types of talk.

Reflective Listening In motivational interviewing,
About half of all practitioner responses are reflections 2-3 reflections are offered per question asked In ordinary counseling, Reflections constitute a small proportion of all responses Questions outnumber reflections 10 to 1 In motivational interviewing, About half of all practitioner responses are reflections 2-3 reflections are offered per question asked In ordinary counseling, Reflections constitute a small proportion of all responses Questions outnumber reflections 10 to 1 Using reflective listening may feel awkward at first, asking questions is a less demanding skill, which may explain why we tend toward it. Reflective listening is a demanding skill that requires a way of thinking.

Learning Reflective Listening
Reflective listening begins with thinking reflectively Thinking reflectively requires a continual awareness that what you think people mean may not be what they really mean There is a way of thinking that accompanies good reflective listening. It includes interest in what the person has to say and respect for the person’s inner wisdom. The key element at this point, however, is a hypothesis testing approach to listening - the knowledge that what you think a person means may not be what he or she really means. This is the hypothesis generation and testing aspect of reflections.

Thinking Reflectively
Exercise: Split up into triads (1-speaker) (2-listeners). Each person will take a turn being a speaker. Each person will share a personal statement “One thing I like about myself is …” (e.g., I am organized. I am creative.) The listeners respond with “Do you mean that…..” (generate at least 5 for each). The speaker responds with only yes/no. We are going to start working on this skill by starting to think reflectively… Now I want to emphasize this is not reflective listening. [Exercise: instruct participants to: Split up into triads (1-speaker) (2-listeners) Each person will take a turn being a speaker Each person will share a personal statement “One thing I like about myself is …” (Example: I am organized. I am creative.) The listeners respond with “Do you mean that…..” (generate at least 5 for each) The speaker responds with only yes/no] The goal of asking questions is to determine the background of the statement. [This helps the group become comfortable with the notion that reflections can be hypotheses.] Debriefing… What was that experience like for you? What did you learn? Where there any surprises? What problems were encountered? [Often, participants find that many of their first guesses were not accurate. Also, speakers sometimes feel frustrated because they want to talk more, which is a good response to generate from those quiet ones that we interview. Listeners often find it difficult to generate more hypotheses without more information.] Often when we are talking about psychological constructs we all have very different meanings attached to them.

Reflective Listening A reflection is two things: OARS
A hypothesis as to what the speaker means A statement Statements are less likely than questions to evoke resistance The question format is very close to reflective listening. Reflections make a guess about the speakers meaning BUT reflections take the form of statements. Reflections are statements because statements are less likely to evoke resistance. A question requires a response. The person steps out of his/her experience and questions his/herself about whether or not they really do or should feel that way. A statement does not have this effect. OARS

Reflections Are Statements
“DO YOU MEAN……?” Use a statement to reflect your understanding Inflection turns down at the end “You...” “So you...” “Its...” “Its like...” “You feel...” Good reflective listening statements are very similar to, yet different from the “Do you mean…” questions. They do offer a hypothesis about what the speaker means, but this is done in the form of a statement rather than a question. Its inflection turns down at the end. “You’re angry about what I said? (up) “You’re angry about what I said (down) Some people find it helpful to have some words to get them started in making reflective listening statement. The common element is the word “you”. The stereotypic counselor statement (which we recommend never be used) is: “what I hear you saying is that you…” Some simpler forms: “You... So you... Its... Its like... You feel... Be careful with stems – no stem words are needed to form a reflection. [Demonstrate the skill by having someone from the audience volunteer a self statement such as: One thing you should know about me that….” And respond only with reflective listening statement, being careful to inflect them downward at the end.]

Reflections Are Statements
Question: You’re thinking about stopping? (inflection goes up) Versus a statement: You’re thinking about stopping. (inflection goes down) Another example/demonstration.

Reflective Listening Exercise:
Split up into triads (1-speaker) (2-listeners). Each person will take a turn being a speaker. Each person will share a personal statement “One thing I like about myself is …” OR “One thing about myself I’d like to change is…” The listeners respond with reflections only. The speaker can respond with yes/no and elaboration. [Exercise: instruct participants to: Use the same triads -- split up into triads (1-speaker) (2-listeners) Each person will take a turn being a speaker Each person will share a personal statement “One thing I like about myself is …” OR “One thing about myself I’d like to change is…” The listeners respond with reflections only The speaker can respond with yes/no and elaboration] [Stress that the difference between questions and statements is in their intonation. Statements can begin with “Stems” like “So..”, “So what you’re saying…” etc. The Speaker can respond with whatever information they want, not restricted to Yes or No. Move around the room listening for those groups stuck on questions and help them out. Debrief this exercise. Responses are usually, “I was surprised by how much I really had to listen; it helped me clarify some things; I felt listened to; etc.”]

Levels of Reflection OARS Simple Reflection – stays close
Repeating Rephrasing (substitutes synonyms) Complex Reflection – makes a guess Paraphrasing – major restatement, infers meaning, “continuing the paragraph’ Reflection of feeling - deepest Reflections fall on a continuum of depth or complexity. Sometimes a word or two can keep people moving. But sometimes reflections that simply repeat what the person has said can yield slower progress, more complex reflections may be needed to add momentum to the exploration process. Simple reflections stay close to what the person has said: Repeating is the simplest reflection and simply repeats an element of what the speaker has said. In rephrasing the listener stays close to what the speaker said, but substitutes synonyms or slightly rephrases what was offered. In complex reflections we are making more of a guess about meaning or feeling: Paraphrasing is more of a major restatement, in which the listener infers the unspoken meaning in what was said and reflects back in new words. This adds to and extends what was actually said. In artful form, this is like continuing the paragraph that the speaker has been developing saying the next sentence rather than repeating the last one. Examples: Client “Who are you to be giving me advice? What do you know about drugs? You’ve probably never even smoked a joint! Interviewer: “It’s hard to imagine how I could possibly understand.” Client: “I just don’t want to take pills. I ought to be able to handle this on my own.” Interviewer: “You don’t want to rely on a drug. It seems to you like a crutch.” Reflection of feeling. Often regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimension through feeling statement, metaphor, etc. In general simple reflections are used a first, when meaning is less clear, and deeper reflections are ventured as understanding increases. Jumping too far beyond what was said, however, can turn into interpretation (a roadblock). [Discuss overstating vs. understating a client’s statement.] Choosing a word that overstates the client’s feeling tends to cause the person to stop talking or back away from the experience. Using a word that understates the intensity of feeling tends to cause the person to continue experiencing and discussing it. OARS

Not Reflective Listening
Communication Roadblocks: Ordering, directing, commanding Warning, cautioning, threatening Giving advice, making suggestions, providing solutions Persuading with logic, arguing, lecturing Telling what to do preaching Disagreeing, judging, criticizing, blaming Several responses are not reflective listening and tend to close communication. These include: Ordering, directing, commanding Warning, cautioning, threatening Giving advice, making suggestions, providing solutions Persuading with logic, arguing, lecturing Telling what to do preaching Disagreeing, judging, criticizing, blaming

Not Reflective Listening
Agreeing, approving, praising Shaming, ridiculing, blaming Interpreting or analyzing, [also labeling] Reassuring, sympathizing, consoling Questioning, probing Withdrawing, distracting, humoring, changing the subject Agreeing, approving, praising Shaming, ridiculing, blaming Interpreting or analyzing, [also labeling] Reassuring, sympathizing, consoling Questioning, probing Withdrawing, distracting, humoring, changing the subject

Summaries OARS Pull together what has transpired thus far in a session
Strategic use: practitioner selects what information should be included & what can be minimized or left out Additional information can also be incorporated into summary – e.g., past conversations, assessment results, collateral reports etc. It is important to periodically summarize what has occurred in the counseling session. Summaries reinforce what has been said, show that you have been listening carefully, and prepare the client to move on. Summaries can be used to begin and end sessions and provide transitions. Summaries can also be used strategically: the practitioner selects what information should be included and what can be minimized or left out, thereby reinforcing talk that is in the direction of change. Additional information can also be incorporated into summary – e.g., past conversations, assessment results, collateral reports etc. – such that the client’s feelings of ambivalence are amplified. Examples of how summaries may begin: “So, let me see if I got this right…” “So, you’ve been saying… is that correct” “Make sure I’m understanding exactly what you’ve been trying to tell me…” OARS

Summarizing Exercise 3(part 1): Choose a partner.
Speaker: for 90 seconds talk about a habit, behavior, situation you are thinking about changing. Listener: listen only and then give a summary of what you’ve been told. Change roles and repeat. [Exercise (part 1): instruct participants to: Choose a partner. Speaker: for 90 seconds talk about a habit, behavior, situation you are thinking about changing. Listener: listen only and then give a summary of what you’ve been told. Change roles and repeat.] Listener do not try to solve the speaker’s problem or give advice. Your task is to listen and remember as well as you can, and give an exact summary as possible. When summarizing try to avoid changing or adding things to what you’ve been told.

Summarizing Exercise (part 2): Change partners.
Speaker: once again tell your story for 90 seconds w/out interruption. Listener: listen only and then give a summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story. Change roles and repeat. [Exercise (part 2): instruct participants to: Change partners. Speaker: once again tell your story for 90 seconds w/out interruption. Listener: listen only and then give a summary, but this time include what you think is the underlying meaning, feeling, dilemma in the story. Change roles and repeat.] The listener’s task is to be an interested listener without saying anything or asking questions, and then give a summary of what you’ve been told. Do not try to solve the speaker’s problem or give advice. However, your summary may now include what you think is the underlying meaning, feeling or dilemma in the story you’ve heard.

Listen For Change Talk DARNCAT Change Desire: I want/wish/prefer to Ability: I can, could, able, possible Reason: why do it? what would be good? Need: important, have to, matter, got to Commitment: I will/am going to – signals behavior change Activations: I am ready to do this Taking Steps: I am taking steps /

Affirming Supports patient self-efficacy Emphasize patient strengths Notice and appreciate positive action Genuineness is critical /

Affirmations May Include:
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Affirmations May Include: Commenting positively on an attribute (You are determined to get your health back.) A statement of appreciation (I appreciate your efforts despite the discomfort you’re in.) A compliment (Thank you for all your hard work today.) /

Theoretical Framework of Motivational Interviewing
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Theoretical Framework of Motivational Interviewing “Readiness to Change” 1. Precontemplation – not yet considering change 2. Contemplation – evaluating reasons for and against change 3. Preparation – planning for change 4. Action – making the identified change 5. Maintenance – working to sustain changes /

Experiential Exercise 4: The Persuasion Exercise
Copyrighted Tom Broffman, PhD, LICSW, LCDS, LCDS, CEAP Experiential Exercise 4: The Persuasion Exercise Please Do Not Copy Without Permission

How Do We Assist Others to Change?
copyrighted by Tom Broffman, PhD How Do We Assist Others to Change? Exercise has 2 parts: Use Persuasion Use Motivational Interviewing Reverse roles & answer same questions Please do not COPY without permission

Let’s see if it works… Persuasion Exercise
Utilizing MI Working with Children & Adolescents Let’s see if it works… Persuasion Exercise Ask your partner about a behavior that they have considered changing? Explain why participant should make a change List at least 3 specific benefits of making this change Tell the participant how to change Emphasize how important it is for them to make the change Tell the person to do it! Developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP

Exercise Part 3: Now Let’s Try Using MI
Utilizing MI Working with Children & Adolescents Exercise Part 3: Now Let’s Try Using MI Ask you partner to select a personal change they’ve have made in the past What change did you make? How did you decide to make this change? What people or events influenced your decision? What steps did you take to make the change? What did you learn from the process? Developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP

Exercise Part 3: Now Let’s Try Using MI
Utilizing MI Working with Children & Adolescents Exercise Part 3: Now Let’s Try Using MI Now, what’s a new change you’re considered now? What prompted you to this issue now? How might you go about it in order to it, succeed? What are the 3 reasons to do it now? Summarize what you heard. Close by asking, what will you do next? Developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP

Stages of Change Precontemplation Maintenance Relapse Contemplation Action Preparation - Determination /

Stages of Change Model CONCEPT DEFINITION APPLICATION PRE-CONTEMPLATION Not considering possibility of change. Does not feel there is a Problem. Goal: Raise awareness. Task: Inform and encourage. Validate lack of readiness. CONTEMPLATION Thinking about change, in the near future. Goal: Build motivation and Confidence. Task: Explore ambivalence. Evaluate pros and cons. PREPARATION Making a plan to change, setting gradual goals. Goal: Negotiate a plan. Task: Facilitate decision making. ACTION Implementation of specific action steps, behavioral changes. Goal: Implement the plan. Task: Support self-efficacy. MAINTENANCE Continuation of desirable actions, or repeating periodic recommended step(s). Goal: Maintain change or new status quo. Task: Identify strategies to prevent relapse. /

Remember: “Readiness to change” is a state, not a trait.
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Remember: “Readiness to change” is a state, not a trait. /

A Precontemplation Stage Tool Readiness Rulers /

Readiness Rulers: I-C-R
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Readiness Rulers: I-C-R Importance: The willingness to change Confidence: In one’s ability to change Readiness: A matter of priorities Confidence Readiness Importance / 80

Importance Ruler On a scale of 1 to 10, how important is it for you to make a change? 1 2 3 4 5 6 7 8 9 10 Not at all important Somewhat important Extremely Important /

Importance to Change Readiness Ruler
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Importance to Change Readiness Ruler We show the patient the Importance Readiness Ruler & ask: On a scale of 1 to 10, how important is it to you to make a change in ? Example, If you are a 5, why are you a 5 and not a 3? Or if you are a 5, what need to happen for you to go to a 7? How could I assist you in getting to a 7? /

Confidence Ruler On a scale of 1 to 10, how confident are you that you could make a change if you wanted to? 1 2 3 4 5 6 7 8 9 10 Not at all confident Somewhat confident Extremely confident /

Confidence to Change Readiness Ruler
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Confidence to Change Readiness Ruler We show the patient the Confidence Readiness Ruler & ask: On a scale of 1 to 10, how confident are you to make a change in ? Example, If you are a 5, why are you a 5 and not a 3? Or if you are a 5, what need to happen for you to go to a 7? How could I assist you in getting to a 7? /

Strategies to Enhance Confidence
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Strategies to Enhance Confidence Review past successes Define small steps that can lead to success Problem solve to address barriers Hypothetical change (“If you were able to quit smoking tomorrow, how do you think things would be different?”) Attend to the progress and use slips as occasions to further problem-solve rather than failure /

Simplified Motivational Categories
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Simplified Motivational Categories Importance of Change Confidence in Ability Low High Group 1 – Little interest in change; don’t think they could even if they wanted to. Group 2 – Want to change, but don’t think they are able. Group 3 – Believe they could change, but not interested right now. Group 4 – Want to change and believe they have the ability. /

Readiness Ruler On a scale of 1 to 10, how ready are you to make a change? 1 2 3 4 5 6 7 8 9 10 Not at all ready Somewhat ready Extremely Ready /

Readiness to Change Readiness Ruler
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Readiness to Change Readiness Ruler We show the patient the Readiness Ruler & ask: On a scale of 1 to 10, how ready are you to make a change in ? Example, If you are a 5, why are you a 5 and not a 3? Or if you are a 5, what need to happen for you to go to a 7? How could I assist you in getting to a 7? /

Exercise 4: The Readiness Ruler Exercise
Copyrighted Tom Broffman, PhD, LICSW, LCDS, LCDS, CEAP Exercise 4: The Readiness Ruler Exercise Please Do Not Copy Without Permission

Exercise 4: Let’s Try Using Readiness Rulers
copyrighted by Tom Broffman, PhD Exercise 4: Let’s Try Using Readiness Rulers How important is it for you to learn about MI? What are the challenges at your agency that makes this MI training important ? How confident are you that you can begin to use utilizing what you’ve learned about MI in the next week? How ready are you to start utilizing what you’ve learned about MI in the next week Please do not COPY without permission

Exercise 4: Utilizing Readiness Rulers
copyrighted by Tom Broffman, PhD Exercise 4: Utilizing Readiness Rulers You will be working with your partner in both the role of helper & helpee utilizing Readiness Rulers Start off by using the 3 questions from previous slide with your partner Then utilize importance, confidence & importance rulers Summarize outcome Please do not COPY without permission

A Contemplation Stage Tool Decisional Balance /

Decisional Balance: An Explanatory Model Of Behavior Change
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Decisional Balance: An Explanatory Model Of Behavior Change Highlights the individual’s ambivalence regarding maintaining vs changing a behavior it is a balancing of the costs of status quo with the costs of change and the benefits of change with the benefits of the status quo. /

Decisional Balance Decisional Balance Worksheet (Fill in what you are considering changing) Good things about behavior: Not so good things about behavior: Not so good things about changing behavior: Good things about changing behavior /

Decisional Balance Sheet
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Decisional Balance Sheet Reasons for staying the same Reasons for making a change Good things about: 1. 2. 3. Not so good things about: 1. 2. 3. Not so good things about changing: 1. 2. 3. Good things about changing: 1. 2. 3. /

Decisional Balancing—Benefits and Costs Worksheet
Copyrighted Tom Broffman, PhD, LICSW, LCDS, LCDS, CEAP Decisional Balancing—Benefits and Costs Worksheet Continuing Behavior Stopping Behavior Costs Benefits 1. 2. 3. 4. Costs Benefits 1. 2. 3. 4. Please Do Not Copy Without Permission

Conducting a Decisional Balance Discussion
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Conducting a Decisional Balance Discussion Accept all answers. (Don’t argue with answers given by patient.) Explore answers. Be sure to note both the benefits and costs of current behavior and change. Explore costs/benefits with respect to client’s goals and values. Review the costs and benefits. / 97

Exercise 5: The Decisional Balance Exercise
Copyrighted Tom Broffman, PhD, LICSW, LCDS, LCDS, CEAP Exercise 5: The Decisional Balance Exercise Please Do Not Copy Without Permission

Exercise 5: Decisional Balance
copyrighted by Tom Broffman, PhD Exercise 5: Decisional Balance Partners will take turns as helper & helpee. Helper begins by asking helpee to identify either: “something I know I need to change & am considering” or “something I feel 2 ways about” Helper assists helpee in completing a decisional balance Helper processes decisional balance with helpee using OARS Please do not COPY without permission

Exercise 5: Decisional Balance
Copyrighted Tom Broffman, PhD, LICSW, LCDS, LCDS, CEAP Exercise 5: Decisional Balance Ask your partner to think of an area of their life in which they have been contemplating making a change. For example: Starting a diet or exercise program Going back to school Moving to a new home. Ask your partner to think of an area of their life in which they have been contemplating making a change. For example: Starting a diet or exercise program Going back to school Moving to a new home. The person assisting the other should write out the decisional balance & use motivational skills as appropriate, such as— Open ended questions Reflective listening Affirmations Summarizing Normalizing ambivalence Weighs the pros and cons of changing a behavior. The actual number of reasons a person lists on each side of a decisional balance sheet is not as important as the weight—or personal value—of each reason. [get partner to list in priority order, i.e.., 1st, 2nd, 3rd, etc.] Please Do Not Copy Without Permission

Negotiating a Change Plan
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Negotiating a Change Plan Patient sets a goal Have patient develop a menu of strategies—brainstorm. Have patient decide on a specific plan & summarize it. Elicit commitment Have patient restate what they intend to do. Involve others: the more the patient verbalizes the plan to others, the more commitment is strengthened (“no going back now” concept) /

Summary: Benefits of Using MI
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Summary: Benefits of Using MI Evidence-based Patient Centered Provides structure to the consultation Readily adaptable to health care settings /

What Do You Think? On a scale of 1 to 10, how important is it for you to start using motivational interviewing in your practice? On a scale of 1 to 10, how confident are you to start using motivational interviewing in your practice? On a scale of 1 to 10,how ready are you to start using motivational interviewing in your practice? /

Thank You For Coming & Learning About MI! Any Questions?

More Information on Motivational Interviewing
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP More Information on Motivational Interviewing Literature on MI: Miller and Rollnick. Motivational Interviewing: Preparing People for Change. Guilford Press. New York and London. 2002 Rollnick, Miller and Butler. Motivational Interviewing in Health Care: Helping Patients Change Behavior. Guilford Press. New York and London. 2008 /

Other Experiential Exercises

Imagine Extremes “What is the worst that can happen if you continued?” What do you think would have to happen to make you decide to tell yourself, “ok that’s enough?” /

Looking Back “When was the last time things were going well for you and what was it like for you?” “What do you think could have prevented this setback? “What was your life like before this happened?” “As you step back and look at all this, what do you make of it?” /

Looking Forward “What would you like your life to be like in 2 years?” “How does what you are doing now make that difficult?” “What would it be like if you continue with the way things are now?” Suppose things don’t change, how do think your life will look?” /

Motivation for Change Motivation is an intrinsic process Ambivalence Alternative behaviors have pluses and minuses Motivation arises out of discrepancy Values/goals conflict with current behavior Ambivalence  discrepancy  change “Change Talk” facilitates change /

Strengthening Commitment
developed by Tom Broffman, PhD, LICSW, LCDP, LCDS, CEAP Strengthening Commitment Summarize patient’s own perception of problem, ambivalence, desire/intention to change, and can include your own assessment. Ask a “key question”, i.e.: “What is the next step?” /

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