1. Introductory Motivational Interviewing Workshop The University of Mississippi Medical Center Practice exercises adapted from MINT 2003, 2008; Concepts adapted from Miller & Rollnick 2002, 2012; and Rollnick et al., 2008

2. Objectives At the end of this training, participants should be able to: Objective 1: List the core features of Motivational Interviewing Objective 2: Demonstrate the Core Skills of Motivational Interviewing Objective 3: Discuss how to apply motivational interviewing to trauma-informed care

3. make your job easy? make your job difficult? Review: What are the characteristics of clients who: Client AClient B

4. A Demonstration A Discussion

5. What Motivational Interviewing is not (Miller & Rollnick, 2009) 1. The transtheoretical model of change 2. A way of tricking people into doing what you want to do 3. A technique 4. Decisional Balance 5. Assessment Feedback

6. What Motivational Interviewing is not (Miller & Rollnick, 2009) 6. Cognitive-behavior therapy 7. Client-centered therapy 8. Easy to learn 9. Practice as usual 10. A panacea (an answer or solution for everything)

7. What Motivational Interviewing is “A collaborative, person-centered form of guiding to elicit and strengthen motivation for change” (Miller & Rollnick, 2009) (This is not a NEW idea, it’s just a very useful integration of psychological principles and techniques from various traditions)

8. Four Foundational Processes Planning Evoking Focusing Engaging

9. Process where both parties establish a connection & working relationship A prerequisite for the rest of MI ▫ Person-centered style ▫ Listen – understand dilemma and values ▫ OARS core skills

10. Questions to Ask Yourself MI Consistent Engaging How comfortable is this person talking to me? How supportive & helpful am I being? Do I understand this person’s perspective & concerns? How comfortable do I feel in this conversation? Does this feel like a collaborative partnership?

11. Focusing – Strategic Centering Developing and maintaining a specific direction in the discussion. Clarify the direction toward which one wants to move What changes are expected from the interaction? ▫ Agenda setting  “If it’s okay with you, I’d like to chat a bit about your frustrations with money management.”  “It sounds like there is a lot going on right now. I’ve got a few minutes what would be most helpful for us to talk about?”

12. Questions to Ask Yourself MI Consistent Focusing What are this person’s goals for change? Do I have different goals than this person? Are we working together with a common purpose? Do I have a clear sense of where we are going? Are we moving together or in different directions?

13. Evoking Selective eliciting ▫ Try to identify the client’s own motivations for change Selective responding ▫ The client may be saying a lot – use reflective listening to emphasize things they are saying that will help them change Selective summaries ▫ To client statements in favor of change ▫ Help the client see all the reasons he or she has for desiring change

14. Questions to Ask Yourself MI Consistent Evoking What are this person’s reasons for change? Is the reluctance more about confidence or importance? What change talk am I hearing? Am I steering too far or too fast in a particular direction? Am I the one arguing for change?

15. Planning – The Bridge to Change Negotiating a change plan Consolidating Commitment Note – this is the part of MI that will feel most familiar This is the part we focus on the least in training If you develop the other skills, you will be able to do this without much direct training If you focus on this during the training, it will make it harder to develop the other skills The most difficult and important part of MI is getting clients ready to change, so usually we jump over or speed through that part, and focus on “how to change”

16. Questions to Ask Yourself MI Consistent Planning What would be a reasonable next step toward change? What would help this person to move forward? Am I remembering to evoke vs prescribe a plan? Am I offering information & advice with permission? Am I retaining a quiet curiosity about what works best for this person?

17. The “Spirit” of Motivational Interviewing MI Spirit Compassion Evocation Acceptance Collaboration

18. Evocation When it comes to lifestyle changes or management of chronic illness the best reasons and solutions will be “evoked” from the client, rather than “instilled” by the provider Hearing themselves talk about why they want to change and how they will do it actually helps clients change

19. Example: Evocation Provider Statement: What brings you in today? Client Response: My wife says I haven’t been the same since the car accident. Provider Responses: A lot of people develop symptoms after a car accident like nightmares or feeling jumpy or avoiding driving, so it’s good that you came in today. Let’s get started with the evaluation. What sorts of things has she noticed since the car accident?

20. Collaboration During MI, the provider forms a partnership with the client The provider is an expert on what has helped other people The client is an expert on themselves (what they like/don’t like, what has worked in the past, etc.) A collaborative solution is likely the best solution A collaborative provider avoids over- prescribing, and accepts and values clients contributions

21. Example: Collaboration Provider Statement: What brings you in today? Client Response: My wife says I haven’t been the same since the car accident. Provider Responses: She was right to send you here. If you don’t take steps to address your feelings about the accident things could get a lot worse. It sounds like you’re not sure whether she’s right or not. How do you believe the car accident has impacted you?

22. Compassion Added in 3 rd Edition of MI Text (November, 2012) Compassion is a deliberate commitment: To actively promote others’ welfare To give priority to others’ needs NOT sympathy or identification This means that MI is not to be used for provider gain If you are trying to get a client to do something because it is easiest or best for you, you are not doing MI If you are trying to get a client to follow your advice (when there are other reasonable options the client may prefer), you are not doing MI

23. Example: Compassion Provider Statement: What brings you in today? Client Response: My wife says I haven’t been the same since the car accident. Provider Responses: Sounds like you’re a perfect candidate for our residential trauma recovery program. If you are still being impacted by the accident there are a variety of different treatment options we can discuss, some here, some at other facilities, and some self-help activities you could do on your own.

24. Acceptance Affirmation Absolute Worth Autonomy Accurate Empathy

25. Affirmation Seek to acknowledge person’s strengths and efforts Not a private experience of appreciation, but a way of being and communicating “It’s true you aren’t doing the assignments, but at least you’re still coming” The opposite of evaluation, which tends to focus on finding out what’s wrong

26. Example: Affirmation Provider Statement: What brings you in today? Client Response: My wife says I haven’t been the same since the car accident. Provider Responses: Sometimes it takes someone else to help us see things. It sounds like you’re not so sure about that, but you were open to coming in to see what I my have to say.

27. Absolute Worth Identify the inherent worth in every client The opposite of this is judgment “He’s working the system” “She just doesn’t want to get better”

28. Example: Absolute Worth Provider Statement: What brings you in today? Client Response: My wife says I haven’t been the same since the car accident. Provider Thoughts: This guy is totally clueless about his emotions. Pretty impressive that this guy is coming in at the urging of his wife. A lot of husband’s wouldn’t do that.

29. Autonomy Support Regardless of what the provider wants, the client ultimately makes the decision about what he/she will do (or not do) Respecting client choice even when we don’t agree Share your concerns and at same time recognize you can’t force client change By giving clients the freedom to choose, you actually increase the likelihood they will make healthy decisions

30. Example: Autonomy Support Provider Statement: What brings you in today? Client Response: My wife says I haven’t been the same since the car accident. Provider Responses: Then it sounds like this has been impacting her too and you really need to take care of it. What’s most important is what you think.

31. Accurate Empathy Empathy is: Interest & effort to understand the other’s perspective This is not the same as acceptance This is not the same as sympathy In MI, empathy is achieved: By asking open ended questions Using reflective listening

32. Example: Accurate Empathy Provider Statement: What brings you in today? Client Response: My wife says I haven’t been the same since the car accident. Provider Responses: So you had a car accident and you haven’t been the same. So your wife says she has noticed some changes in you since the car accident

33. Basic Skills of Motivational Interviewing: O.A.R.S. Open-ended questions – Questions that do not invite brief answers Affirmations - Directly affirming and supporting the client during the interaction Reflections – Making a guess at what the speaker means, using a statement rather than a question Summaries – Summary statements link together and reinforce material that has been discussed

34. Skills that are not used in MI During an M.I. session, a provider uses very little: advice confrontation closed questioning and direct persuasion

35. Reflective Listening

36. Words the Speaker Says 2Words the Listener Hears 13 What the Speaker Means4 What the Listener Thinks the Speaker Means Thomas Gordon’s Model of Listening * Communication can go wrong because: (1) The speaker does not say exactly what is meant (2) The listener does not hear the words correctly (3) The listener gives a different interpretation to what the words mean * The process of reflective listening is meant to connect the bottom two boxes (4), to check on whether "what the listener thinks the speaker means" is the same as "what the speaker means."

37. Reflective Listening There is a way of thinking that accompanies good reflective listening. It includes, not only interest in what the person has to say respect for the person's inner wisdom. But also, a hypothesis testing approach to listening the knowledge that what you think a person means may not be what he or she really means. A good reflective listening response tests a hypothesis. It asks, in a way, "Is this what you mean?"

38. Thinking Reflectively Break into groups of 3-4. Each person in the group should be prepared to be speaker with “One thing I like about myself is that I…” When a speaker has offered a sentence, the other two serve as listeners and respond by asking questions of this form: "Do you mean that you___________________?" The speaker responds to each such question only with "Yes" or "No." No additional elaboration is permitted. After 4-8 questions, switch roles and have someone else serve as speaker

39. Forming Reflections Good reflective listening statements are very similar to the “Do you mean…?” questions we just practiced. Key difference – hypothesis about speaker’s meaning is presented as a statement (inflection down at the end) rather than a question (inflection up at the end).

40. Reflection Stems Some people find it helpful to have some words to get them started in making a reflective listening statement So you feel.. It sounds like you.. You're wondering if.. You..

41. Practice Exercise 3: Forming Reflections Break into groups of 3-4 Each person in the group should be prepared to be speaker with “One thing I’d like to change about myself is…” When a speaker has offered a sentence, the other two serve as listeners and respond with reflective listening statements The speaker responds to each statement with elaboration that probably includes but is not limited to "Yes" or "No." The next reflective-listening statement, then, takes this new information into account. After each listener has had 2-4 turns reflecting, switch speakers

42. Practice Exercise 3: Debriefing How did clients feel in this exercise as compared to the previous one? How easy was it to generate reflective listening responses? What difficulties were there?

43. Practice Exercise 4: Batting Practice Each table is a batting cage Each at the table will take a turn at bat. When you are the batter your job is to reflect whatever statement is pitched to you. Just like batting practice, the goal is not to hit a home run every time, but just to make contact with each statement Those who are not at bat, will “pitch” statements to the batter. These statements should be things that you might hear from clients (repetition is okay).

44. Practice Exercise 5: Observer Tracking – Reflection You are about to watch a video clip featuring Bill Miller conducting a Motivational Interview To help you get a sense of how often reflections are used relative to other utterances in motivational interviewing, you will keep track of the reflections, questions, and other utterances you hear from Dr. Miller as you watch the interaction

45. Practice Exercise 5: Observer Tracking – Reflection As you watch the video, mark an R (reflection), Q (question), or O (other) in each consecutive box to track Dr. Miller’s utterances (Tell me… statements count as questions) Let’s do the first 2-3 minutes together QRRRQ

46. Practice Exercise 5: Debriefing How many reflections did you count? How many reflections were there relative to questions? How was this the same or different than your typical first session with clients? How would the session have gone if Dr. Miller had asked more questions?

47. Reflective Listening Strategies: Simple Reflection This is a basic acknowledgement of what a person has just said. The provider restates without adding new meaning. 1. Repeating. The simplest reflection simply repeats an element of what the speaker has said. 2. Rephrasing. Here the listener stays close to what the speaker said, but substitutes synonyms or slightly rephrases what was offered.

48. Reflective Listening Strategies: Complex Reflections Complex reflections add meaning to what the speaker has said and can often be used to emphasize key elements (e.g., change talk) or even guide the session. 1. Paraphrasing. This is a more major restatement, in which the listener infers the meaning in what was said and reflects this 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. This is not the same as finishing someone’s sentence. 2. Reflection of feeling. Often regarded as the deepest form of reflection, this is a paraphrase that emphasizes the emotional dimension through feeling statements, metaphor, etc.

49. Reflective Listening Strategies: Double-Sided Reflection 3. Reflection of Ambivalence or Double-sided reflection. This can be considered a special case of reflection of feeling. A double-sided reflection is appropriate when the client is expressing some ambivalence about change. The counselor reflects that the person seems to “feel two ways about” the issue, “one the one hand….. and on the other hand…….”

50. Reflective Listening Strategies: Summary 4. Summary. A summary is simply a reflection that includes two or more separate ideas. A double-side reflection can be considered a type of summary. Summaries are useful after a sustained period of reflective listening for checking in with a client about what the counselor has heard, and allowing him/or her to elaborate on anything the counselor may have missed. As will be covered later, summaries can also be great tools for gathering change statements, and handing the client a “change bouquet.”

51. Reflective Listening Strategies: Expert Tip Using Similes and Metaphors as Reflections Metaphors and similes may be used as reflective listening. These are generally complex reflections and often work very well therapeutically: Kind of like... It's as though...

52. Reflective Listening: Overstating Versus Understating Choosing a word that overstates the client's feeling tends to cause the person to stop talking or back away from the experience So if a client is making resistant statements, overstating might cause a client to step back from counter-change statements.

53. Client: “I am not sure I need this medication any more.” Provider: “So you’re pretty confident that your symptoms won’t return if you stop taking it” Client: “Well, I don’t know about that. Last time I ran out I did get a little depressed. But I just don’t like the way it makes me feel.”

54. Using a word that understates the intensity of feeling tends to cause the person to continue experiencing and discussing it So if a client is making statements that are pro-behavior change, understating might cause a client to advocate for change.

55. Client: “I am not going to spend all my money this month.” Provider: “So you’re thinking about starting to save some money.” Client: “I am definitely going to save money. I want my own place and if I don’t save I’m never going to get there.”

56. Practice Exercise 6: Levels of Reflection On the worksheet provided, try to write down one simple and one complex reflection for each statement. Simple reflections are restatements of all or part of what was said or slight rephrasing Complex reflections are paraphrases, reflections of feeling, double-sided reflections, similes, metaphors, etc. In about 5 minutes we’ll discuss as a group Fisher & Rosengren, 2003

57. Practice Exercise 6: Client Statements 1. It’s been fun, but something has got to give, I just can’t go on like this any more 2. It’s been over a year since I’ve had an HIV test 3. You know if she would just back off, then the situation would be a whole lot less tense and then these things wouldn’t happen. 4. I’ve been depressed lately. I keep trying things to help me feel better but nothing seems to work.

58. Practice Exercise 7: Summarizing - Counselor 1 Role Break into pairs and decide who will be the client first. Each client will discuss “Something I’m considering changing is…” for 90 seconds The first counselor's task is to be an interested listener without saying anything and then summarize what you’ve been told DO NOT try to problem solve, give advice, or add or change anything you heard just summarize what you heard.

59. Practice Exercise 7: Summarizing – Counselor 2 Role Each client will discuss “Something I’m considering changing is…” for 90 seconds The first counselor's task is to be an interested listener without saying anything and then summarize what you’ve been told DO NOT try to problem solve or give advice, however, your summary may include what you think is the underlying meaning, feeling, or dilemma in the story you’ve heard

60. Practice Exercise 7: Debriefing What are the differences between the two types of summaries? How was it for the client? How was it for the counselor? Which summary was most difficult? Why?

61. Open-Ended Questions An open ended question is one that has a wide range of possible answers. The question may seek information, invite the client’s perspective, or may encourage self- exploration. The open question allows the option of surprise for the questioner. “Tell me more” statements are usually considered open questions.

62. Closed Questions Closed questions invite only a small range of answers Closed questions can’t and shouldn’t be avoided entirely. Even at expert proficiency in Motivational Interviewing, up to 30% of questions will be closed. Most people find that closed questions come more naturally, particularly in a first session. Therefore it’s a good idea to err on the side of asking open questions.

63. Open or Closed? 1. What do you like about drinking? OpenClosed 2. Where did you grow up? OpenClosed 3. Isn’t it important for you to have meaning in your life? OpenClosed 4. Are you willing to come back for a follow-up visit? OpenClosed 5. What brings you here today? OpenClosed 6. Do you want to stay in this relationship? OpenClosed

64. Open or Closed? 7. Have you ever thought about walking as a simple form of exercise? OpenClosed 8. In the past, how have you overcome an important obstacle in your life? OpenClosed 9. What would you like to set as your quit date? OpenClosed 10. What possible long-term consequences of diabetes concern you most? OpenClosed

65. Open or Closed? 11. Do you care about your health? OpenClosed 12. What are the most important reasons why you want to decrease your use of closed-ended questions? OpenClosed 13. Will you try this for 1 week? OpenClosed 14. Is this an open or a closed question? OpenClosed

66. Making Open Questions Each of the following is a closed question, try to rephrase it as an open question: Have you considered psychotherapy? Don’t you think it would be a good idea to have your cholesterol rechecked? What would you like to set as your quit date? How long have you been using cocaine? It’s very important that you start taking your medication every day. Are you ready to do that? Have you thought about the impact your death would have on your children?

67. Affirmations How do you affirm? Affirmations can come in the form of: Compliments or statements of appreciation and understanding. Commenting on the client’s strengths, abilities or efforts in any area (not simply related to the target behavior). Reviewing client’s past successes can help identify strengths, abilities, and efforts. An affirmation is typically more subtle than “praise” and doesn’t have the feel of a power differential.

68. Examples of Affirmations I appreciate that you took a big step in coming here today. You’re clearly a resourceful person to cope with such difficulties for so long. That’s a good suggestion. It seems like you’re the kind of person who once you make up your mind you are going to do it You are a really warm and caring person. Not everyone is willing to do the kind of difficult self-exploration you are doing It’s important to you be a good parent, just like your folks were for you. You’ve already taken some important steps toward reducing your risk for a future DWI.

69. Affirming “Difficult” Clients It can be difficult to affirm clients who are resistant to treatment It is natural to perceive weaknesses or faults more easily in these individuals than strengths are perceived It is difficult to support a client’s self-efficacy if you cannot see their strengths To practice affirming difficult clients, it can be useful to think of anyone you don’t like and try to think of one or more genuine strengths this person possesses

70. Other MI Behaviors Asking Permission Before Giving Advice or Information I have a suggestion about how you might remember to take your medication. Would it be all right if I shared it with you? Emphasizing Control Only you can decide whether or not you are ready to be tested for HIV Support This is a really difficult situation for you It must be difficult to manage all of these stressors at the same time

71. MI Inconsistent Behaviors Advise (without permission) I’d recommend you complete your homework assignments before watching television If I were in your shoes, I’d tell her that her snoring bothers you Confront You are an addict, and if you’re not willing to admit that, you can’t recover Your lack of participation in group is a clear indication that you are not serious about your recovery You need to stop calling your ex-husband or your never going to recover Direct Complete your second step by next Tuesday

72. Practice Exercise 8: Sustained Reflective Listening Break into pairs Participants in each pair decide who will be the first speaker. Each speaker will discuss “Something I’m considering changing is…” The listener's task is to respond only with reflective- listening statements. The speaker responds to reflection by continuing to elaborate. After 10 minutes you will switch Stay in role, not discussing or breaking role until I tell you to stop (if you get stumped, call a trainer over for coaching)

73. Practice Exercise 8: Debriefing How natural did it feel to be the speaker? How natural did it feel to be the listener? How was this experience different than the first exercise (Direct Persuasion)?

74. Change Talk

75. MI is Focused In MI, the counselor works with the client to collaboratively find a focus for the session and then “guides” the client toward positive change. In motivational interviewing clients are not “talked into” making a change or “convinced” to make a change. Direct persuasion, providing advice, and providing information are not tools of change used in MI. An important tool for guiding clients toward change is to elicit, explore, and reflect client change talk. Supporting self-efficacy is an important aspect of working with change talk. Clients must be hopeful that things can be different

76. “Equipoise” Although MI traditionally involves helping an individual move in a particular direction, sometimes the skills of MI will be used without taking a side, because there is not an “objectively good side.” This has been called “Equipoise” For example, if you are working with an individual who is dependent on the system and really would prefer to be independent (but is having difficulty moving in that direction) You might strategically elicit and reinforce change talk about becoming more independent to help him begin moving in that direction However, if that individual was trying to decide whether to move into a boarding home or his sister’s house, and both were reasonable options (i.e., safe, drug free, etc.), you might use reflections and questions to help that individual figure out what he wanted, but would not try to steer him toward one option or the other

77. What is Change Talk? Desire to change the behavior Ability to change the behavior Reasons to change the behavior Need to change the behavior Commitment to change the behavior Activating to change the behavior Taking Steps to change the behavior What will be observed most commonly during a motivational interview are statements about desire, ability, reasons, or need (DARN). Commitment to change is less likely to be spontaneously elicited, and must often be specifically elicited.

78. Practice Exercise 9: Identifying Change Talk We are going to watch a different video clip of Bill Miller using MI As you watch the video, try to keep track of client utterances that match each of these “change talk” categories Client Utterance CountGood Example Desire Ability Reasons Need Commitment, Activating, Taking Steps

79. Practice Exercise 9 How easy was it to find change talk in this video segment? How easy would it have been to miss it completely if you hadn’t been looking for it?

80. One Strategy for Evoking Change Talk: Decisional Balance Decisional Balance can be done formally (i.e., using a worksheet or a drawing of a pros and cons list on a blank sheet of paper) or informally (i.e., just discussing aloud the pros and cons of change) When presenting decisional balance you can ask about “good things” and “not so good things” about the change being considered. After completing the decisional balance, always summarize and ask the patient which way he or she is leaning. If patient reports few pros relative to cons, but concludes that he or she wants to change, you might probe further. Which of the pros are so important that they make it worth it despite the cons?

81. Pros and Cons of Change and Staying the Same Changing Pros Goals that will be achievable if change is made How life will be better if they change Cons Anticipated difficulties regarding change process Staying the Same Pros What are the good things about the status quo? (i.e. what would you have to give up if you changed?) Cons What are the not so good things about the status quo?

82. Decisional Balance Pros Pros of Changing -What will be better or different if you change? Cons of Staying the Same -What is bad about the way things are? Cons Cons of changing -What might be difficult about the change process? Pros of staying the same -What is good about the way things are/What do you have to give up if you change?

83. Practice Exercise 10: Decisional Balance Break into pairs of two Decide who will be the client and who will be the counselor The client will talk about something they are thinking about changing The counselor will use open questions, reflections, and summaries to assist the client in completing a decisional balance