advanced motivational interviewing€¦ · advanced motivational interviewing 2018 new england...

Advanced Motivational Interviewing

2018 New England School of Best Practices in Addiction TreatmentAugust 27 - August 28, 2018Waterville Valley Resort, Waterville Valley, NH

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Thomas E. Broffman, PhD, LICSW, CAADAC, CCS, CEAPSocial Worker

Harrington Hospital, CDU340 Thompson Rd.

Webster, Mass. 01570Phone: 508-640-2979

[email protected]

Course ScheduleWEDNESDAY, August 30

• 7:00 - 8:00 am: Breakfast

• 8:00 - 10:00 am: Wednesday Courses - 2 Hours

• 10:00 - 10:15 am: Morning Break

• 10:15 am - 12:00 pm: Wednesday Courses Continue -1.75 Hours

• 12:00 - 12:45 pm: Lunch

• 12:45 - 3:15 pm: Wednesday Courses Continue - 2.5 Hours

• 3:15 - 7:15 pm: Free Time/Dinner on Your Own

• 6:45 - 7:15 pm: Dessert Social

• 7:15 - 8:45 pm: Evening Plenary

• 8:45 - 9:30 pm: Support Groups

• TOTAL: 7.75 Contact Hours (6.25 for Wednesday Courses and 1.5 for plenary)

THURSDAY, August 31

• 7:00 - 8:00 am: Breakfast

• 8:00 - 10:00 am: Thursday Courses - 2 Hours

• 10:00 - 10:15 am: Morning Break

• 10:15 - 12:00 am: Thursday Courses Continue - 1.75 Hours

• 12:00 - 12:45 pm: Lunch

• 12:45 - 3:30 pm: Thursday Courses Continue - 2.75 Hours

• Total: 6.5 Contact Hours (6.5 for Thursday Courses)

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Course Description-Overview• This workshop is designed for professionals who have had some experience with

Motivational Interviewing and are interested in improving their skills.

• The workshop is appropriate for counselors, mental health professionals, doctors, nurses, recovery service counselors or anyone who is in the business of helping people change behavior and who has had some exposure to MI in the past.

• Day one will include a fast and brief review which pre-supposes a basic level of knowledge of the spirit and approach of MI and exercises to practice the techniques.

• The second day builds upon the first and introduces advanced strategies and more intense practice exercises with feedback.

• Upon completion of this two day workshop, participants will have not only learned and practiced a variety of effective techniques to working with clients dealing with behavior change but will also be introduced to coding client-counselor interactions to rate practitioner skill level and monitor improvement.

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Learning Goals• Specifically, participants will be able to:

1. * Assess their own level of skill at the beginning and end of the workshop.

2. * Review the “Spirit of MI,” and the specific techniques of MI.

3. * Discuss motivation as it pertains to their own clients.

4. * Review and practice specific techniques to increase client motivation.

5. * Employ several techniques to develop discrepancy between goals and current behavior.

6. * Use strategies to explore, amplify, and resolve ambivalence to change.

7. * Demonstrate the ability to elicit, recognize and reinforce “change talk.”

8. * Differentiate and practice simple and complex reflections.

9. * Employ several techniques to reduce client resistance to changing behavior.

10. * Be able to recognize and identify MI skills through practice and role plays.

11. * Describe how MI can be integrated into current practice.

12. * Observe demonstrations of MI techniques.

13. * Practice creating change plans and consolidating commitment from clients.4

Working Agreements1. We will treat others as we’d like to be treated

2. Share the time

3. What is said in the room stays in the room

4. Say OUCH, if someone says something that makes you uncomfortable

5. We’re in this together

6. Download the humor app & bring it to class

7. Be curious

8. Be open minded

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Who We Are?1. Name, Agency & Role?

2. Professional experience & professional training?

3. What would you like other to know about you?

4. What are some things you are really comfortable with or good at in your practice?

5. What are you less comfortable with in your practice?

6. What would you hope to be doing better after this training?

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Review: Your Experience With MI1. What MI skills have you been able to practice?2. What benefits have you noted from use of MI?3. How have clients responded?4. What has been challenging?5. What else do you need to help you to apply MI?6. What do I want to learn over the next 2 days?7. What’s my learning preference?

a) Auditoryb) Visualc) Kinesthetic

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Does This Look Like MI?• Chris Farley - Motivational speaker - SNL

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• To begin we must go backward to see what we already know…

• Before we may go forward to see what we can learn…

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4 Elements of MI

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Motivation & The Change Process

• People* are not unmotivated!

• They are just motivated to engage in behaviors that others consider harmful and problematic or not ready to begin behaviors that we think would be helpful.

• * MI side bar ± the importance of language. Person is used in lieu of patient or client; the people we work with have x, y, & x but they are not their diagnosis or problem or issue!

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Interactive Exercise 1: The Change Exercise

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Exercise: The Change Exercise1. Stand up and turn to stand face to face in pairs.

2. Silently observe your partner for 30 seconds.

3. Now turn back to back and change 3 things about your physical appearance (must be real changes).

4. When you are done, turn back to face your partner.

5. Each person should take a minute to name the 3 things your partner has changed.

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Change Exercise Questions

1. What was your comfort level during this exercise?

2. What made you comfortable or uncomfortable?

3. How hard was it to change things?

4. How did you decide what things to change about yourself?

5. What does this exercise tell us about change?

6. Look around you did you notice how quickly people changed back to the way they started as soon as they sat down?

7. What implications might this have about change for people and ourselves?

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Change Exercise Key Points1. Change is difficult

2. Change is not always comfortable

3. Change requires creativity

4. We tend to go back to old ways

5. It is easier to stay the same

6. We like our comfort zones

7. Change requires an open mind

8. Change has emotional and cognitive components

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Change Exercise Key Points9. Change is a process

10. Change happens over time

11. The process is as important as the result

12. Watch out for measuring success only if a change occurred

13. Often there is a difference between what someone knows they should do and there readiness to do it.

14. Greatest chance to impact change is pacing it to the specific stage of change

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The Stages of Change Are?

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Stages of Change• Recognizing the need to change and understanding

how to change doesn’t happen all at once. It usually takes time and patience.

• People often go through a series of “stages” as they begin to recognize that they have a problem.

Stages of Change• Pre-contemplation Stage – the person does not believe they have a problem or does not want to

change. During pre-contemplation the disadvantages of change outweigh advantages. You may be concerned about some consequence of your client’s behavior, but the client may accept this as okay for them.

• Contemplation Stage - The person is beginning to evaluate their use and starts to think about change. The balance of costs and benefits begin to shift, although the client may appear not interested in change. ‘I should give up because of all the problems. But what am I going to do instead? I’ll miss it and my friends.’

• Determination Stage (Readiness to change) - The person decides they do want to change. The balance has shifted. The client is preparing to take action and has confidence in their capacity to change. Change is seen as worthwhile. This is often a planning stage. Goal setting, identifying internal and external supports/resources and identifying strategies to support change can help.

• Action Stage - The person changes by undertaking behaviors from the planning stage. The client is taking steps to change. Support and specific skill training can be provided. Review initial reasons that led to the decision to change.

• Maintenance - The person maintains their new behavior. Changes in behavior maintained for six months or more are usually associated with substantial improvements in the quality of life (e.g. housing, employment, relationships, physical and mental wellbeing). Without such changes, the effort to change may not seem worth it and relapse is more likely. Encourage clients to talk about the positive reasons for maintaining change to reinforce their decisions.

• Relapse - the person returns to old behaviors or in the case of substance misuse it may be increased use

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STAGES OF CHANGE & PRACTITIONER TASKS

RELAPSE

CONTEMPLATION

PRECONTEMPLATIONRaise doubt - ,QFUHDVH�WKH�FOLHQW¶V�SHUFHSWLRQ�RI�risks and problems with current behavior

Tip the decisional balance - Evoke reasons for change, risks of not changing; Strengthen FOLHQW¶V�VHOI-efficacy for behavior change

PREPARATION Help the client to determine the best course of action to take in seeking change; Develop a plan

ACTION Help the client implement the plan; Use skills; Problem solve; Support self-efficacy

MAINTENANCEHelp the client identify and use strategies to prevent relapse; Resolve associated problems

Help the client recycle through the stages of contemplation, preparation, and action, without becoming stuck or demoralized because of relapse

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Goals by Stage of Change

• Relapse

• Precontemplation

• Contemplation

• Build commitment to change

• Make a plan for change

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• Preparation • Action • Maintenance

Short Scenarios To Determine Stages Of Change - Read & Identify the Stage of Change1. "I really don't need a program to help me manage my alcohol use. I only

drink when people try to control me or tell me what to do.“

2. "Over the past six months, my mom has told me almost daily how I'm behaving differently now. She says I'm not as uptight anymore and that I listen more. She's happy and I'm happy. This was the right thing for me.“

3. "I really don't want to lose my kids, but I'm not sure that jumping through your hoop is going to help me.“

4. "I'm working on controlling my marijuana use. I know I'm going to need as much help as possible.“

5. "When CPS became involved this time, I swore this was it. I'm now in a program, going to classes, and working to get my kids back."

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Short Scenarios To Determine Stages Of Change - Read & Identify the Stage of Change6. "I've been using the stuff that I learned in group so that I don't get so

angry and uptight. I haven't been very angry at anyone for over a month. I think I'll keep this up.“

7. "People are always on my case to do something with my life. But I know what I have to do to get my kids back. I can take care of myself- I just have to stay clear of my old friends.“

8. "This is my fourth week in treatment. I'm at the place now where I'm going to counseling because I want to instead of knowing that I have to.“

9. "Everyone I know smokes a little pot once in a while. It's not a big deal.“10. "I haven't used in six months and I've finished a group program for

substance abuse. Now I plan to attend NA once a week. I've learned a lot and like the people I meet. I think I'm doing pretty well."

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Short Scenarios To Determine Stages Of Change - Read & Identify the Stage of Change11. "I'm going to be finished with my CPS requirements in two weeks and

then I'm going to do something about getting a decent job. I think that I can finally feel some of the pressure lifting.“

12. "The only people I know that don't drink at parties are the kind of people who would never get invited anyway. Just because I made one stupid mistake doesn't mean I have a problem.“

13. "My social worker is telling me that he wants me to be in some treatment program. I want things to be different and I know I've got to start somewhere.“

14. "The doctor told me my blood pressure is way too high. My dad died from a heart attack and I know I need to watch what I eat and exercise more.“

15. "I've been working out four days a week. It's been almost a year now and I feel great. I can't imagine falling out of this routine."

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First Stage: Pre-contemplationPeople at this stage:

• Are unaware of any problem related to their drug use

• Are unconcerned about their drug-use

• Ignore anyone else’s belief that they are doing something harmful

Stages of Change

Precontemplation: No intention to change behavior in the foreseeable future. Individuals in this stage are unaware or underaware of their problems.

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Why a person might be in Precontemplation Stage-4 R’s

1. Resignation. Lack of energy and investment. Given up on possibility of change and seem overwhelmed by problem. (Instill hope and explore barriers to change.)

2. Rationalization. Has all the answers. Have reasons why problem is not a problem—or is problem for others but not them. Session feels like a debate. (Empathy and 2727reflective listening.)

3. Rebellion. You can’t make me. (Empathy and reflective listening.)

4. Reluctance – unsure, may or may not. (Instill hope and explore barriers to change.) 27

Readiness RulerReady

• Willing: The importance of change

• Able: Confidence for change

• Ready: A matter of priorities

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Readiness Rulers

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How to Use Readiness Rulers• The Readiness Ruler has two sides, each with one initial question

and a zero-to-10 scale to help people evaluate the importance of the personal changes they desire and to evaluate their confidence about making those changes.

• After a person chooses a number from the scale, ask these questions to elicit change-talk

• If you’re a X why not a Y (go 2 numbers lower; ie., if a 5 why not a 3?

• If you’re a X why not a Y (go 2 numbers higher; ie., if a 5 why not a 7?

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Readiness Ruler

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Score Readiness Stages of Change

0-3 Not ready Pre-contemplation4-7 Unsure Contemplation8-10 Ready Preparation;

Action

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Second Stage: ContemplationPeople at this stage are considering whether or not to change:

– They enjoy using drugs, but

– They are sometimes worried about the increasing difficulties the use is causing.

– They are constantly debating with themselves whether or not they have a problem.

Stages of Change (cont.)Contemplation: A person is aware that a problem exists

and are seriously considering changing, but have not yet made a commitment to take action. Contemplators need assistance to perform a risk-reward analysis. Ambivalence is the issue.

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AmbivalenceAmbivalence: Feeling two ways about something.

– All change contains an element of ambivalence.

– Resolving ambivalence in the direction of change is a key element of motivational interviewing

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The Concept of Ambivalence (2)• Ambivalence is normal

• clients usually enter treatment with fluctuating and conflicting motivations

• they “want to change and don’t want to change”

• ³ZRUNLQJ�ZLWK�DPELYDOHQFH�LV�ZRUNLQJ�ZLWK�WKH�KHDUW�RI�WKH�SUREOHP´

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 patient’s goals and values.

• Review the costs and benefits.

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Decisional Balance

• Ambivalence is a normal part of the process of change

• 8VH�³FRQIOLFW´�WR�SURPRWH�SRVLWLYH�FKDQJH• Weighing pros and cons of behavior

• Increasing discrepancy

• Most useful in Precontemplation and Contemplation stages as a tool to increase motivation

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Remember, it is the person’s decision to change; you just want to build ambivalence

Cost-Benefit Analysis Tips

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Decisional Balance WorksheetGood things Not so good

thingsCurrent Behavior[e.g., Non-adherence]

1.

2.

3.

4.

1.

2.

3.

4.

Change[e.g., Adherence]

1.

2.

3.

4.

1.

2.

3.

4.39

Decisional BalancingͶBenefits and Costs Worksheet

Continuing Behavior

Costs Benefits

1. 1.

2. 2.

3. 3.

4. 4.

Stopping BehaviorCosts Benefits

1. 1.

2. 2.

3. 3.

4. 4.

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Third Stage: Determination/PreparationPeople at this stage aredeciding how they aregoing to change

•They may be ready to change their

behaviour

•They are getting ready to make the change

It may take a long time to move to the next stage (action).

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Stages of Change (cont.)Preparation: Individuals are intending to take action and may

practice some of the behaviors necessary.

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Change Plan

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Fourth Stage: ActionPeople at this stage:

• Have begun the process of changing

• Need help identifying realistic steps, high-risk situations, and new coping strategies

Stages of Change (cont.)Action: In this stage individuals modify their behavior,

experiences, or environment in order to overcome their problems.

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Fifth Stage: MaintenancePeople in this stage:

– Have made a change and

– Are working on maintaining the change

Stages of Change (cont.)Maintenance: Individuals in this stage work to prevent relapse

and consolidate gains.

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RelapsePeople at this stage have reinitiated the identified

behaviour.

• People usually make several attempts to quit before being successful.

• The process of changing is rarely the same in subsequent attempts. Each attempt incorporates new information gained from the previous attempts.

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RelapseSomeone who has relapsed

is NOT a failure!

Relapse is part of the recovery process.

Original Spirit of MI

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The "Spirit" of Motivational Interviewing (MI) is more than the use of a set of technical interventions. It is characterized by a particular "way of being." This way of being is described as the "Spirit of MI." The "Spirit of MI" is the foundation of every MI conversation that takes place. It communicates compassion, acceptance, partnership, and respect.

What is the Spirit of MI• A

• C

• E

Original Spirit of MI

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Autonomy

EvocationCollaboration

Autonomy Versus Authority• Unlike some other treatment models that emphasize the clinician as

an authority figure, Motivational Interviewing recognizes that the true power for change rests within the client.

• Ultimately, it is up to the individual to follow through with making changes happen. This is empowering to the individual, but also gives them responsibility for their actions.

• Practitioners reinforce that there is no single "right way" to change and that there are multiple ways that change can occur.

• In addition to deciding whether they will make a change, clients are encouraged to take the lead in developing a “menu of options’ as to how to achieve the desired change.

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Collaboration Versus Confrontation• Collaboration is a partnership between the practitioner and the client,

grounded in the point of view and experiences of the client.• This contrasts with some other approaches to counseling/treatment,

which are based on the practitioner assuming an “expert” role, at times confronting the client and imposing their perspective on the client’s unhealthy behavior and the appropriate course of treatment and outcome.

• Collaboration builds rapport and facilitates trust in the helping relationship, which can be challenging in a more hierarchical relationship.

• This does not mean that the practitioner automatically agrees with the client about the nature of the problem or the changes that may be most appropriate.

• Although they may see things differently, the therapeutic process is focused on mutual understanding, not the practitioner being right. Motivational interviewing is done "with and for" someone, not "on or to" them.

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Evocation versus Explanation• The MI approach is one of the practitioner’s drawing out the

individual's own thoughts and ideas, rather than imposing their opinions as motivation and commitment to change is most powerful and durable when it comes from the client.

• No matter what reasons the practitioner might offer to convince the client of the need to change their behavior or how much they might want the person to do so, lasting change is more likely to occur when the client discovers their own reasons and determination to change.

• The practitioner's job is to "draw out" the person's own motivations and skills for change, not to tell them what to do or why they should do it.

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Revised Spirit of MI*

• There are two implied active ingredients in motivational interviewing – a relational component and a technical component.

• The spirit of motivational interviewing is concerned with this relational aspect.

• Miller and Rollnick comment on how they have, since the first publication of their book in motivational interviewing in 1991, placed less emphasis on techniques of motivational interviewing and ever greater emphasis on the fundamental spirit that underlies it.

• P• A• C• E*Miller and Rollnick’s MI textbook (“Motivational Interviewing: Helping People Change,” Third Edition, The Guilford Press: 2013).

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Revised Spirit of MI

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Partnership (or collaboration)

• Partnership or collaboration means working in partnership with the client, where the key the helper is supportive rather than persuasive.

• The aim is to minimize power differentials and views their clients as partners.

• It means working alongside a client rather than in front of or opposed to them.

• A confronting approach is the antithesis of the spirit of motivational interviewing.

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Acceptance• The spirit of motivational interviewing owes much to the Rogerian

person-centered counselling approach.

• Miller argues that 80% of motivational interviewing is about this.

• Acceptance is a very Rogerian term and in the context of motivational interviewing is divided into four key components:

1. Absolute worth

2. Autonomy and support

3. Affirmation

4. Accurate empathy

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Absolute Worth• Absolute worth is knowing and understanding that everyone’s

dignity is the same and that we are all trying to figure out who we are, where we are going and how we are going to get there.

• If the client feels their situation, no matter how dire, is understood and is given due respect, they will be far more likely to be open and honest regarding their issues.

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Autonomy & Support• Autonomy and Support in motivational interviewing terms means that the

responsibility for change is left with the client. • This means that the helper demonstrates respect for the client, for their

resourcefulness and their ability to make choices, and indeed respects that they may choose not to change.

• They do not push for an immediate commitment at the expense of ‘taking the long view’ about the option of change in the future.

• The antithesis of this is for the key worker to take an authoritarian approach where they tell the client what he or she must or should do, which comes from an assumption that you know better than the client.

• Helpers with poor adherence to client autonomy may have difficulty accepting that clients might choose to avoid or delay change, or may decide to proceed with change in an unconventional manner.

• They convey a sense of urgency about the need for change.

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Affirmation• Affirmation is about finding ways to point out positive things to the

individual.

• It is not about inundating the client with unwarranted praise nor is it about colluding with the client.

• What affirmation is really about is reinforcing those specific things the client says or does that may assist in understanding and/or making a change.

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Compassion

• Compassion means that as the helper we are trying to work with clients in a non-judgemental, non-blaming, non-shaming way and are striving to be as empathic as possible.

• Essentially we are trying to understand what this problem is like for the client and what it means for them.

• By doing this we are attempting to help them find some form of acceptance of what is going on or to move onto a different place regarding their issue(s).

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Compassion• In order to feel compassion for someone we must comprehend their point

of view and experience, at least to some degree.

• However compassion alone, without sustained empathetic understanding can be counter-therapeutic.

• It is not uncommon in everyday life for people to feel compassion based on the fact the other person is suffering.

• Despite this it is still possible to completely misperceive and misunderstand what the person is really trying to communicate, regarding what’s bothering them and their experience of that bother.

• Helpers can do this too, believing they are being empathetic because they feel compassion for the client’s situation, but misunderstand the complexity of the clients experience due to seeing the client through a ‘therapist’s theoretical preconceptions

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Compassion• On the other hand empathy without some kind of sympathy or

compassion could be used (intentionally or not) in a manipulative or cruel fashion.

• Perhaps it is fair to say that empathetic understanding without compassion can be manipulative and dangerous.

• Compassion without empathic understanding on the other hand can be short sighted and of limited therapeutic value.

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Compassion• Following these four steps as a guideline will prevent this situation from occurring:

1. Recognition of our emotions

2. Recognition of emotions in others

3. Being able to accurately feel what it would be like to be in that person’s position

4. Based on the above, be able to adjust our own behavior accordingly

• A minimal level of empathy appears to be a universal human necessity for effective interpersonal functioning.

• Those who can’t make sense of the mental states of others, at least to some degree, are limited in their interpersonal functioning.

• In addition, empathy often involves a more complex form of interpersonal understanding and involves the ability to really experience or taste and share the experience of the client, at least to some degree.

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Evocation• Evocation means to draw out of the client their own perceptions, goals

and values, thus helper starts with the assumption that the resources and motivation for change reside in the client.

• In practice, this means that the key worker is eliciting from the client, rather than imparting information or opinions and so is doing more listening than talking.

• Helpers high in evocation are curious and patient. • They give the client the benefit of the doubt about wanting to change and

show a focused intent to draw out the client’s own desire and reasons for changing.

• A helper with a poor adherence to evocation may focus on giving information, educating the client or giving logical reasons for changing, atthe expense of arranging conversations so that the client talks themselves into changing.

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Interactive Exercise 2: Persuasion versus MI

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Part 1: Persuasion Exercise• #1 asks #2 about a change they’ve been considering making

• #1 proceeds to provide #2 advice & reasons why to change

• #1 is to convince #2 of the necessity to change today

• #1 bottom line -- #1 needs to get #2 to agree to change

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MI Micro Counseling Skills• O

• A

• R

• S

Part 2: MI

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OARS

OARS

Open Ended Questions

Affirmations

Reflections

Summarizing

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(Asking) Open Ended Questions• Open-ended questions require that peoiple respond with more than

a yes, no, or other one word answer. • Often MI sessions involve asking an open-ended question and then

using reflections. • Open ended questions permit understanding person’s perspective

and motivation• Open-ended questions often foster engagement. • Questions are important in the MI process but they can limit

exploration. • Therefore, it is recommended that providers combine the use of

reflections and questions

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Open-Ended Questions

Using open-ended questions—• Enables the patient to convey more information

• Encourages engagement

• Opens the door for exploration

Open-Ended Questions (continued)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 such as—– “How…” – “What…” – “Tell me about…”

• Usually go from general to specific

Open-Ended Questions (continued)

• Why open-ended questions?

– Avoid the question-answer trap

• Puts patient in a passive role

• No opportunity for patient to explore ambivalence

Open-Ended Questions (continued)

• Why open-ended questions?

– Opportunity to explore ambivalence

Closed-Ended QuestionsPresent Conversational Dead Ends

Closed-ended questions typically—

• Are for gathering very specific information

• Tend to solicit yes-or-no answers

• Convey impression that the agenda is not focused on the patient

Affirming• Affirming involves accentuating the positive.

• Affirming recognizes person's efforts and strengths

• When a helper affirms, they recognize the good.

• This includes the person’s overall worth as a human.

• Affirmation also includes support and encouragement.

• Affirmation assists with engagement because it builds trust and can also can limit defensiveness.

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Reflections• Reflections are an important aspect of reflective listening.

• Reflecting in motivational Interviewing (MI) involves listening to the person and then making statements not asking the patient questions.

• Reflections are defined as statements of understanding.

• Utilizing reflections and reflective listening involves the helper listening to the person’s statements and the helper then making a statement that is a reasonable guess at the meaning of what the person has said.

• At first many feel uncomfortable with the idea of guessing at the meaning of person’s statements because they are afraid of being wrong.

• However, reflections, even if incorrect, can lead to more conversation and an opportunity to gain a better understanding of the person’s perspective.

• Usually people do not get upset, they typically clarify what they really mean and continue the conversation.

• Reflections also go beyond parroting what the person has said and try to get to deeper meaning.

• When reflections are well crafted they allow a natural flow to the conversation.80

Reflective Listening• Listening, really listening to a person is the cornerstone of

Motivational Interviewing (MI).

• Reflective listening is something that requires practice and patience.

• With practice helpers can become skillful at listening and reflection becomes natural.

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Types of Reflection• There are many different types of reflections. • Often these reflections are used to respond to sustain talk and these reflections include:• Straight Reflection – This includes a simple or complex reflection of what the person

states. This can assist in eliciting change talk.• Amplified Reflection – This occurs when a provider makes a reflection that overstates

what the person has said. This can help a person see through ambivalence and arrive at change talk

• Double Sided Reflections – This type of reflection is used by providers to demonstrate ambivalence. These statements often recognize a person’s sustain talk and combines it with change statements that the person has said previously. It is recommended to form these statements using the word “and” instead of “but” because but implies that the second half of the statement contains the important information. It is also recommended that you reflect the sustain talk before the conjunction and finish the statement with the change talk.

• A example of a double sided reflection would be: “You know that it will be a challenge to quit smoking and you also know it would be important to help manage your asthma.”

• Metaphor – Metaphors tend to be very complex reflections. Use of metaphors can be tricky in practice but can assist people to see their situation in a new way while giving organization for adding to the conversation. Metaphors provide peoples with a new way to understand and hopefully, respond to a situation.

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Summaries• Summaries are a type of reflection.

• Summaries pull together several things that the person as discussed.

• Summaries are used to assist people to hold on to or reflect upon many things that they have discussed.

• There are different types of summaries:

• Collecting summary ± These are used to connect interrelated conversational items.

• Linking summary – To use this type of summary the provider connects what the person said to something discussed previously.

• Transitional summary – This type of summary is typically used to end a task or session. It is used to put together what is important and/or transition to a new topic.

•

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Interactive Exercise 3: Putting It All Together

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Part 2: MI• #2 asks #1 about a change they have made in the past

• #2 asks why #1 decided to initiate the change

• #2 asks #1 how they made the change

• #2 asks 31 how they sustained the change

• #2 affirms #1 for having initiated & sustained the change

• #2 asks #1 what they learned about change through this experience

• #2 summarizes what #1 shared

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What is Change Talk?

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Change Talk Is• Change talk are statements made by people that indicate that they

are moving towards making a positive change in a problematic behavior.

• It is important to listen to people carefully and understand what indicates change talk.

• Change talk is associated with successful behavior change. • Therefore, the overall goal of MI is to elicit as well as reinforce

change talk related to the specific problematic behavior. • It is important to remember that recognizing the specific type of

change talk is not as important as being able to determine if change talk is present or not in a conversation.

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4 Elements of Change Talk• There are four elements that can help providers recognize statements as change

talk.1. Change talk are statements about change. This would include client statements

that indicate that they want or desire to change. This would also include statements revealing that they have the ability to change and/or see the benefits of behavior change. People may also see the difficulties associated with their problematic behavior or may be taking steps to change. Change talk can also include statements about being committed to change.

2. Change talk includes statements that are connected to the problematic behavior. Therefore, change talk is specific.

3. People are typically the source of change talk. This indicates that people are often the source of change talk. However, a helper could reflect on a person’s change talk and if the person endorses this reflection as accurate, then this would also be considered to be change talk.

4. Change talk should be in the present tense.

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DARN - Preparatory Client Change Talk• D

• A

• R

• N

DARN

DARN

Desire

Ability

Reason

Need

90

Desire• Desire – Desire indicates wanting and wanting is a part of

motivation for change.

• It is helpful if people want to change their behavior.

• However, people can and do make behavior changes that they don’t want to do.

• Typically these statements do not include commitment language.

• Desire for change: “I want to…”

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Ability• Ability – This includes the person's perception that they can

achieve the behavior change. • When a person makes statements indicating that they have the

ability to make a change it signals that they think the behavior change is possible.

• Typically, these t conversations can include statements about a person’s ability to change their behavior as well as how to change the behavior.

• These statements tend to end before commitment to change a behavior is expressed.

• Ability to change: “I know I can…”

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Reasons• Reasons – This is when the person states a specific reason for

changing their behavior.

• These statements reveal that the person sees a specific reason why the behavior change would be advantageous.

• Reasons to change: “It will help me to...”

93

Need• Need – This includes person’s recognition that there is a need for

behavior change.

• This includes language that reflects an imperative or urgency to change their behavior.

• Need to change: “I have to because…”

94

CATS -Mobilizing Change Talk

• C

• A

• T

• S

96

CATS

CATS

Commitment Language

ActivationTaking Steps

97

Commitment Language• Commitment Language – It is the most clear example of mobilizing

change talk and indicates that the person will likely take action.

• Commitment language is a important predictor of change.

• Commitment language includes statements that demonstrate a decision to change but may still show some doubt.

• Commitment Language Terms: Language Terms: Vow, promise, will, plan to, consider, may

98

Activation• Activation – This includes person’s language that indicates that they

are moving towards action but do not include commitment.

• These statements signal that they are leaning towards taking action.

99

Taking Steps• Taking steps – This includes statements a person makes that

indicate that they have already taken actions in the direction of changing the desired behavior.

• This can include a specific action, goal, or be less specific.

• An example that a person with an alcohol problem that attends AA may not be making a commitment to quitting drinking but is taking steps in that direction.

100

What is Sustain Talk?

101

Sustain Talk• Sustain talk is the opposite of change talk.

• Clients may use sustain talk to indicate: their desire to stay as they are, their worries about being able to change, reasons not to change; need to stay as they are.

102

Change Talk Sustain talkI really need to quit smoking because of the bad example I am setting for my kids

But I love to smoke; it is so much a part of my life.

I have started an exercise program, and things are going well.

But I know I will go back to my old ways once the cold weather comes.

My gambling is totally out of control. But betting is the only way I can de-stress and forget all my problems for a while.

I know I should take my medication every day.

It's just that I hate the side-effects so much.

Ten Strategies for Evoking Change Talk 1. Ask Evocative Questions: Ask open question, the answer to which is change talk.

2. Explore Decisional Balance: Ask first for the good things about status quo, then ask for the not-so-good things.

3. Ask for Elaboration: When a change talk theme emerges, ask for more details. In what ways? Tell me more…? What does that look like?4. Ask for Examples: When a change talk theme emerges, ask for specific examples.

• When was the last time that happened? Give me an example. What else?

5. Look Back: Ask about a time before the current concern emerged. How were things better, different?

6. Look Forward: Ask what may happen if things continue as they are (status quo). Try the miracle question: If you were 100% successful in making the changes you want,

• What would be different?

• How would you like your life to be five years from now?

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Ten Strategies for Evoking Change Talk 7. Query Extremes: What are the worst things that might happen if you don’t make this change? What are the best things that might happen if you do make this change?

8. Use Change Rulers: Ask, “On a scale from zero to ten, how important is it to you to [target change] - where zero is not at all important, and ten is extremely important?

• Follow up: And why are you at ___and not _____ [lower number than they stated]?

• What might happen that could move you from ___ to [higher number]? Instead of “how important” (need), you could also ask how much you want (desire), or how confident you are that you could (ability), or how committed are you to (commitment). Asking “how ready are you?” tends to be confusing because it combines competing components of desire, ability, reasons and need.

9. Explore Goals and Values: Ask what the person’s guiding values are. What do they want in life? Using a values card sort can be helpful here. If there is a “problem” behavior, ask how that behavior fits in with the person’s goals or values. Does it help realize a goal or value, interfere with it, or is it irrelevant?

10. Come Alongside: Explicitly side with the negative (status quo) side of ambivalence.

• Perhaps _______is so important to you that you won’t give it up, no matter what the cost.

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MI Principles• E

• S

• R

• D

105

106

Principles of Motivational InterviewingMotivational interviewing is founded on 4 basic principles:

– Express empathy

– Develop discrepancy

– Roll with resistance

– Support self-efficacy

107

Principle 1: Express empathy• The crucial attitude is one of acceptance

• Skillful reflective listening is fundamental to the client feeling understood and cared about

• Client ambivalence is normal; the clinician should demonstrate an understanding of the client’s perspective

• Labelling is unnecessary

108

Example of expressing empathy I am so tired, but I cannot

even sleep… So I drink some

wine.You drink wine to help you

sleep.…When I wake up…it is too late

already…Yesterday my boss fired me.

6R�\RX¶UH�concerned about not

having a job.

...but I do not have a drinking problem!

109

Principle 2: Develop discrepancy• Clarify important goals for the person

• Explore the consequences or potential consequences of the person’s current behaviours

• Create and amplify in the client’s mind a discrepancy between their current behaviour and their life goals

110

Example of developing discrepancy

Well…as I said, I lost my job

because of my drinking

problem…and I often feel sick.

I enjoy having some drinks with my friends…that’s all. Drinking helps me relax and have fun…I think that I deserve that for a change…

So drinking has some good things for you…now tell me about the not-so-good things you have experienced because of drinking.

111

Principle 3: Roll with resistance• Avoid arguing against resistance

• If it arises, stop and find another way to proceed

• Avoid confrontation

• Shift perceptions

• Invite, but do not impose, new perspectives

• Value the client as a resource for finding solutions to problems

112

Example of NOT rolling with resistance

You do not have the right to judge

me. You don’t understand me.

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

But, Anna, I think it is clear that drinking has caused you problems.

113

Example of rolling with resistance

That’s right, my mother thinks that I have a problem, but

she’s wrong.

I do not want to stop drinking…as I said, I do not have a drinking problem…I want to drink when I feel like it.

You do have a drinking problem

Others may think you have a

problem, but you don’t.

114

Principle 4: Support self-efficacy• Belief in the ability to change (self-efficacy) is an important

motivator

• The client is responsible for choosing and carrying out personal change

• There is hope in the range of alternative approaches available

115

Example of supporting self-efficacy

I hope things will be better this

time. I’m willing to give it a try.

I am wondering if you can help me. I have failed many

times. . .Anna, I don’t think you have failed because you

are still here, hoping things can be better. As

long as you are willing to stay in the process, I will support you. You have been successful before and you will be again.

4 Processes of MI1. Engaging

2. Focusing

3. Evoking

4. Planning

116

4 Processes of MI

117

4 MI Processes4 Processes Ǧ and skills/techniques for each

1. Engaging: listening to understand, use of OARS

2. Focusing: agenda setting, finding a common and strategic focus, exploring ambivalence, use of information and advice

3. Evoking: selective eliciting, selective responding, selective summaries toward change talk

4. Planning: moving to a change plan and obtaining commitment

118

Process I - Engaging• Goals

– Build a therapeutic relationship

– Understand the person’s reality

– Understand the person’s feelings, beliefs, values, concerns

– Recognize and affirm strengths, motivation

– Accept without judgment what you have learned

119

Engaging: The Relational Foundation • Listening; accurate empathy; striving to understand fully from the

client’s perspective without agenda; client-centered style; using OARS non-directively (to understand BOTH sides of the ambivalence or dilemma); avoiding righting reflex or “fixing”.

120

Process II - Focusing• Goals

– Agenda setting – identifying a strategic focus

– Exploring ambivalence

– Deepening understanding of motivation, listening for change talk

• Offering and sharing information

121

Focusing: Guiding Client To A Target Behavior That Is Important To Them• Helping client identify a target area about which s/he is ambivalent

or struggling to make a change. Using agenda setting, bubble chart, asking the client what’s important to him/her or what area of present behavior might get in the way of his/her goals. Being transparent about what the target is, once identified.

122

Process III - Evoking• Goals

• Strengthening and reinforcing change talk

• Guiding towards change – finding alignment (and discrepancy) between current behavior and goals and values

• Dancing with discord

• Summarize where you are, move to planning

123

Evoking: Drawing Out Client’s Intrinsic Motivation(Reasons/Importance For Change) And Their Own Ideas For Change• Drawing out client’s own ideas and reasons for change; listening for

and recognizing change talk; selectively reinforcing change talk; summarizing change talk (change talk bouquet). Avoiding expert trap.

• Using Elicit-Provide-Elicit and advice with permission only after asking the client his or her own ideas and reasons… (“What makes this change important to you?”

• “What makes you confident you can do it?”, etc.)

124

Process IV - Planning• Goals

• Summarizing where you are

• Developing a goal and plan

• Exploring and building confidence/selfǦefficacy

• Addressing barriers

• Arranging followǦup

• Approaches for Planning

• Collaborative

125

Planning: The Bridge to Change • Consolidating commitment by selectively reinforcing commitment

language; asking key questions to determine readiness for action planning; assisting with change plans; revisiting change plans to determine need for more work in former stages and/or changes/additions to the plan, etc.

126

Approaches for Planning• Collaborative Goal Setting

• Explore and supporting confidence

• Ruler for confidence

• SMART action planning

• Envisioning barriers to resolve

• ProblemǦsolving strategies

• Arranging followǦup

127

Action Planning – SMART Goals• Specific and behavioral

• Measurable

• ActionǦoriented

• Realistic

• TimeǦspecific

128

Collaborative Goal-Setting• Offer options

• “What is a reasonable next step?”

• “What appeals to you the most?”

• “What would you commit to?”

• “What else might you do?

• Support person’s choice of a goal

129

What is the Righting Reflex?

130

Righting Reflex• Helpers have a powerful desire to fix things

• Why is this a Problem?

• People have a tendency is to resist persuasion.

• People have a tendency is to resist persuasion, especially when ambivalent.

131

Resisting the Righting Reflex• How can you resist the righting complex?

• By recognizing:

• Person ‘s Role is to argue and provide reasons for change

• Helper s’ Role is to guide them guide them through ambivalence and understand their motivations

132

Day 1 Wrap-Up1. I learned?2. I relearned?3. I gained?4. I appreciated?5. One thing that surprised me?6. I could use more MI to?7. One thing I hope we cover in day 2 is?8. I am more confident that I can?9. When I get back to work, I can’t wait to try?

133

Day 1 EvaluationWhat do you think about? :DV�LW««««««««««««««

Too Little Just Right Too much1. Amount of material being covered? 1 5 102. Amount of time for questions & discussion?

1 5 10

3. Amount of structure in the training? 1 5 104. Amount of time practicing skills? 1 5 105. Amount of time watching demonstrations including videos?

1 5 10

6. Amount of time instructor was talking? 1 5 10

7. Amount of explanation for each method? 1 5 108. Amount for time for interactive exercises? 1 5 10

134

135

Day 1Questions?

Day 1 Comments?

Day 2: Practice, Practice, Practice

136

Interactive Exercises

137

Interactive Exercise 1: Interviewing your President or Governor

• Write 10 open-ended questions and 10 affirmations for the president or your governor.

• Share your work with the rest of the group

10 Min.

139

Interactive Exercise 2: Practicing Forming ReflectionsComplete the sentence, “One thing about myself I’d like to

change is ________.”

• Divide into groups of three (one speaker, one listener, and one observer).

• Speaker talks for 5 minutes or so about the issue.• Listener can only reflect.• Observer checks to make sure no questions are asked –

only reflections are made, which are statements.

Exercise 2 Debriefing• What did the participants learn?

• What surprises were there?

• What was it like to be the speaker?

• What was it like to be the listener

• What was it like to be the observer?

140

Interactive Exercise 3; Batting Practice

141

Batting Practice• Class divides into even lines; you should a partner standing directly

across from you

• Row A provides a statement & Row B responds with an open ended question; then you switch roles

• Row A provides a statement & Row B responds with an affirmation; then you switch roles

• Row A provides a statement & Row B responds with a refection; then you switch roles

• Row A provides 3 statements & Row B responds with a summarization; then you switch roles

142

143

Interactive Exercise 4: OARS role-playing

Use the OARS form• Divide into groups of three (one speaker, one listener, and one observer).

• Observe the role-playing

• Pay special attention to the use of OARS skills

• Count the number of times that you observed any of these skills.

• Using the OARS form, take notes on the “clinician’s” behaviour as he/she displays OARS.

20 Min.

Instructions

• Ask for a volunteer to play the client’s role for this role-play. Have the volunteer describe the client for the group and the change that he/she would like to have the client move towards.

• Dr. B will play the clinician. Clarify that the exercise is not “stump the clinician” and that the client should not role-play their nightmare case. Dr. B will use OARS strategies in the role-playing so that your audience can identify the skills used and how these skills may change or not change the client’s behavior.

• You may choose to do “right” and “wrong” techniques during the role-playing so the audience can give you feedback on both. For instance you may want to use confrontation (ask the volunteer in advance to react negatively to the confrontational strategies).

• Ask your audience to take notes on the OARS form. Ask participants for feedback and what they would do differently, noting that there is always more than one way to approach any given client.

144

145

Interactive Exercise 5: OARS rotating roles

Use the OARS form• Observe the role-playing

• Pay special attention to the use of OARS skills

• Count the number of times that you observed any of these skills.

• Using the OARS form, take notes on the “clinician’s” behaviour as he/she displays OARS.

.

35 Min.

Instructions

• We will divide the class into groups of three. Each person in the group will play each of the following three roles for 10 minutes: clinician, client, and observer. Use the same client that was role-played in the earlier session. Emphasize again that the person playing the client should not purposely be difficult.

• Ask your audience to role-play to practice their OARS skills.

• Once they have practiced their roles, ask participants to give you a report of what they have observed in others and themselves. Ask the observers to report on whether they saw all the OARS being used. Ask for feedback from the group about how it felt to be the client in that situation and how difficult or easy it was to use the new micro-skills. Which ones felt familiar and which ones will they need to practice?

146

Interactive Exercise 6 - Hypothesis Testing and the Formation of Reflections

147

Hypothesis Testing and the Formation of Reflections• We will break into small groups

• For the following statements generate at least five alternate hypotheses for each client statement below.

• Use the sentence stem “You mean that . . . ” to begin each sentence.

• This phrasing is a beginning form of reflective listening.

• Here’s an example.

148

Example• I am an organized person.

• You mean that . . . you like to have things orderly.• You mean that . . . you tend to rely on routines.• <RX�PHDQ�WKDW��\RX�GRQ¶W�OLNH�ZKHQ�WKLQJV�FKDQJH�

unexpectedly.• You mean that . . . your desk is neat.• You mean that . . . you think logically.• Notice that several of these statements/hypotheses go well

beyond what organized might mean. Some may be wrong, though all acknowledge some component of what could be considered organized.

• This process allows us to find where the boundaries might lie and what is core.

149

,�GRQ¶W�OLNH�FRQIOLFW�1. You mean that . . .

2. You mean that . . .




150

I have a sense of humor.1. You mean that . . .





151

I let things bother me more than I should.






152

I am loyal.1. You mean that . . .





153

Sample Response:,�GRQ¶W�OLNH�FRQIOLFW�1. You mean that . . . it makes you uncomfortable when people

disagree.

2. You mean that . . . you work hard to resolve differences.

3. You mean that . . . you avoid confrontations.

4. You mean that . . . you look for ways to work together.

5. You mean that . . . anger scares you.

154

Sample Response:I have a sense of humor.• You mean that . . . you like to laugh.

• You mean that . . . you find humor in daily life.

• You mean that . . . humor helps you lighten the load.

• You mean that . . . laughing is something you do easily.

• You mean that . . . you don’t take yourself too seriously.

155

Sample Response:I let things bother me more than I should.

• You mean that . . . you’re somebody who takes pride in the details.

• You mean that . . . you waste energy at times.

• You mean that . . . you’re sensitive.

• You mean that . . . you’re too sensitive.

• You mean that . . . you wish you didn’t worry about what others think.

156

Sample Response:I am loyal.• You mean that . . . you stand by people.

• You mean that . . . you’ll stand by people when maybe you shouldn’t.

• You mean that . . . if someone makes a mistake, you’re forgiving.

• You mean that . . . you value loyalty in others.

• You mean that . . . it makes you angry when others switch allegiances.

157

Interactive Exercise 7: Directive Reflecting

158

Directive Reflecting• Break into small groups • Read the sentence stem and write down three different responses

to each item. Each should emphasize a different aspect of the statement.

• Here is an example.• ,W¶V�EHHQ�IXQ��EXW�VRPHWKLQJ�KDV�JRW�WR�JLYH��,�MXVW�FDQ¶W�JR�RQ�

like this anymore.• 1. You’ve enjoyed yourself.• 2. You’re worried about what might happen.• 3. It’s time for a change.

159

I know I could do some things differently, but if she would just back off, then the situation would be a whole lot less WHQVH��WKHQ�WKHVH�WKLQJV�ZRXOGQ¶W�happen.

1. ____________________________

2. ____________________________

3. ____________________________

160

,¶YH�EHHQ�GHSUHVVHG�ODWHO\��,�NHHS�WU\LQJ�things other than drinking to help myself feel better, but nothing seems to work, except having a couple of drinks..

1. ____________________________

2. ____________________________

3. ____________________________

161

,�NQRZ�,¶P�QRW�SHUIHFW��EXW�ZK\�GR�WKH\�KDYH�WR�DOZD\V�WHOO�PH�ZKDW�WR�GR��,¶P�not 3!

1. ____________________________

2. ____________________________

3. ____________________________

162

6R��,¶P�QRW�WRR�ZRUULHG��EXW�LW¶V�EHHQ�RYHU�D�\HDU�VLQFH�,¶YH�KDG�DQ�+,9�WHVW�

1. ____________________________

2. ____________________________

3. ____________________________

163


• 1. You wish she would give you some space.

• 2. You’d like things to be less tense.

• 3. You could do some things differently.

164

,¶YH�EHHQ�GHSUHVVHG�ODWHO\��,�NHHS�WU\LQJ�things other than drinking to help myself feel better, but nothingseems to work, except having a couple of drinks.

• 1. You’ve been feeling down.

• 2. Drinking works in the short-term.

• 3. You might like if something other than drinking worked.

165

,�NQRZ�,¶P�QRW�SHUIHFW��EXW�ZK\�GR�WKH\�KDYH�WR�DOZD\V�WHOO�PH�ZKDW�WR�GR��,¶P�QRW��

• 1. Sometimes you make mistakes.

• 2. It bugs you when they tell you what to do.

• 3. You feel like you’re being treated as a child.

166


• 1. It’s been awhile.

• 2. You’re wondering about your HIV status.

• 3. You’ve a little worried.

167

Interactive Exercise 8: Deeping Reflections

168

Deepening Reflections• Break into small groups

• Read the sentence stems and write down each of the response types listed.

• Note that sometimes certain reflections may not fit as well (e.g., amplified reflections). Try to create one anyway. Here is a reminder of each form:

• Paraphrase: Moves well beyond the client’s words and presents information in a new light.

• Amplified: Overstates what the client has said, often increasing the intensity by pressing on the absolute or resistant element.

• Double-sided: Reflects both parts of the client’s ambivalence.• Affective: Addresses the emotion either expressed or implied.

169

Here’s an example• ,W¶V�EHHQ�IXQ��EXW�VRPHWKLQJ�KDV�JRW�WR�JLYH��,�MXVW�FDQ¶W�JR�RQ�

like this anymore.

• Paraphrase: So, the fun has come at a cost.

• Amplified: You’ve had a fabulous time.

• Double-sided: On the one hand, you’ve had a good run, and on the other, you can see that it’s coming to an end.

• Affective: You’re a bit worried about where this is taking you.

170


• Paraphrase:

• Amplified:

• Double-sided:

• Affective:

171

,¶YH�EHHQ�GHSUHVVHG�ODWHO\��,�NHHS�WU\LQJ�things other than drinking to help myself feel better, but nothing seems to work, except having a couple of drinks.

• Paraphrase:

• Amplified:

• Double-sided:

• Affective:

172

6R��,¶P�QRW�WRR�ZRUULHG��EXW�LW¶V�EHHQ�RYHU�D�\HDU�VLQFH�,¶YH�KDG�DQ�+,9�WHVW�• Paraphrase:

• Amplified:

• Double sided:

• Affective:

173

,�NQRZ�,¶P�QRW�SHUIHFW��EXW�ZK\�GR�WKH\�KDYH�WR�DOZD\V�WHOO�PH�ZKDW�WR�GR��,¶P�QRW��

• Paraphrase:

• Amplified:

• Double sided:

• Affective:

174

I know I could do some things differently, but if she would just back off, then the situation would be a wholeORW�OHVV�WHQVH��WKHQ�WKHVH�WKLQJV�ZRXOGQ¶W�happen.

• Paraphrase: You would like your situation to be different.

• Amplified: It feels like she’s totally responsible for it; like this is really her fault.

• Double-sided: So, she played a part in what happened, and you know there are parts you might want to do differently.

• Affective: You’re upset about this situation.

175

,¶YH�EHHQ�GHSUHVVHG�ODWHO\��,�NHHS�WU\LQJ�things other than drinking to help myself feel better, but nothingseems to work, except having a couple of drinks.

• Paraphrase: You keep looking, despite the lack of success, for ways other than drinking.

• Amplified: Drinking is the only possible way.

• Double-sided: Drinking helps in the short-term, and part of you recognizes that this may not be a great long-term strategy.

• Affective: You’re frustrated by the lack of payoff on your hard work.

176


• Paraphrase: You’ve had some risk behavior.

• Amplified: It’s no concern to you.

• Double-sided: You feel you’ve been pretty safe, while also recognizing there has been some risk.

• Affective: It’s like there is always a little uncertainty—a little fear—since you’ve chosen to be sexually active.

177

,�NQRZ�,¶P�QRW�SHUIHFW��EXW�ZK\�GR�they have to always tell me what to GR��,¶P�QRW��

• Paraphrase: They treat you like the parents you don’t want to have.

• Amplified: They don’t let you make any choices.• Double-sided: It feels like they’re being pretty

bossy, and, at the same time, you know there are some things you could do better.

• Affective: And as your anger grows, you may end up feeling like a moody 3-year-old who wants to pout and say “no.”

178

Interactive Exercise 9: Utilizing MI Processes

179

Utilizing the 4 MI Processes• Each triad will have a helper, a helpee & an observer

• Each group will have a helper scenario

• Helper is to demonstrate use of the 4 MI processes with helpee

• Observer is to document & rate the helper’s use of the 4 MI processes

180

MI Processes Case Scenarios• 1. A forty-one-year-old woman says: "Last night Joe really got high and

he came home late and we had a big fight. He yelled at me and I yelled back and then he hit me hard! He broke a window and the TV set, too! It was like he was crazy. I just don't know what to do!"

• 2. A thirty-six-year-old man says: "My neighbor really makes me mad. He's always over here bothering us or borrowing things that he never returns. Sometimes he calls us late at night after we've gone to bed and I really feel like telling him to get lost."

• 3. A fifteen-year-old girl says: "I'm really mixed up. A lot of my friends, they stay out real late and do things their parents don't know about. They always want me to come along and I don't want them to think I'm weird or something, but I don't know what would happen if I went along either."

•

181

MI Processes Case Scenarios• 4. A thirty-five-year-old parent says: "My Maria is a good girl. She's

never been in trouble, but I worry about her. Lately she wants to stay out later and later and sometimes I don't know where she is. She just had her ears pierced without asking me! And some of the friends she brings home--well, I've told her again and again to stay away from that kind. They're no good for her, but she won't listen."

• 5. A forty-three-year-old man says: "I really feel awful. Last night I got drunk and I don't even remember what I did. This morning I found out that the screen of the television is busted and I think I probably did it, but my wife isn't even talking to me. I don't think I'm an alcoholic, you know, 'cause I can go for weeks without drinking. But this has got to change."

• 6. A fifty-nine-year-old unemployed teacher says: "My life just doesn't seem worth living any more. I'm a lousy father. I can't get a job. Nothing good ever happens to me. Everything I try to do turns rotten. Sometimes I wonder whether it's worth it."

182

183

Interactive Exercise 10: The 3 Chairs Observe the activity and provide feedback.

15 Min.

Instructions• Begin this exercise by defining the client’s characteristics: age, gender,

drug of choice, economic status, family issues, etc. as a group exercise. Use a white board or newsprint to outline the group’s description of the client for this exercise.

• Dr. B will play the client’s role at first, and then asks for a volunteer to take on the role after a few rounds. The client can sit in either one of three chairs. The chair in the middle is a “neutral” chair. The chair on the left is designated as “motivated or cooperative” and the chair to the right is “defensive or resistant.” The client takes the middle chair or “neutral” chair and moves from chair to chair depending on how the clinician’s comments make him/her feel.

• Ask for three volunteers to play the role of the clinician. Each “session” will have 3-5 interactions with the client in which the clinician uses motivational strategies, and then passes to the next person who uses 3-5 interactions, and so on. The goal is to explore and possibly resolve ambivalence and to demonstrate how certain clinician responses elicit cooperation from the client and others elicit defensiveness.

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3 Chair Interactive Exercise Schematic

1 • Helpee• Motivated or

Cooperative

2 • Helpee• Nuetral

3 • Helpee• Defensive or

Resistant

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Helper

The MIǦYMCA SONG• A MI song to the tune of The Village People’s “YMCA.”

• OARS: THE MI SONG; Written by Julie Engberg, January 17, 2008.

• I invite you to sing along.

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Young man, are you stuck in a rut?I said, young man, feeling bad in your gut?I said, I know a new thing you can try/ƚ�ŝƐ�ŐƌĞĂƚ͊�/ƚ Ɛ͛�ĐĂůůĞĚ�D/.

ListenͶa key skill to learnThe foundationͶƚŚĞ�ƉĂƌƚŝĐŝƉĂŶƚ Ɛ͛�ƚƵƌŶTo share the real meaning behindEvery change they have in mind

Chorus (repeat twice)/ƚ Ɛ͛�ƚŝŵĞ�ƚŽ�ƵƐĞ�Ăůů�ƚŚĞ�KͶAͶRͶS/ƚ Ɛ͛�ƚŝŵĞ�ƚŽ�ƵƐĞ�Ăůů�ƚŚĞ�KͶAͶRͶSIt will make you feel goodThe participant tooIt will change everything you do.

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Affirming their changes right nowReflecting their words of howTo make change in their own wayYou summarize all they say.

Open are the questions that flowTo find out what they already knowAnd they tell you what they want to know moreAs you “Explore—Offer—Explore.”

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Chorus (repeat twice)/ƚ Ɛ͛�ƚŝŵĞ�ƚŽ�ƵƐĞ�Ăůů�ƚŚĞ�KͶAͶRͶS/ƚ Ɛ͛�ƚŝŵĞ�ƚŽ�ƵƐĞ�Ăůů�ƚŚĞ�KͶAͶRͶSIt will make you feel goodThe participant tooIt will change everything you do.Young man, if you want to know howInspire the changes right nowJust try it and give it a chanceMake your counseling into a dance.

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dŚĂƚ Ɛ͛�ǁŚĞŶ�ƚŚĞ�ƚĂďůĞƐ�ŚĂǀĞ�ƚƵƌŶĞĚzŽƵ�ĐĂŶ�ƉƌĂĐƚŝĐĞ�Ăůů�ƚŚĞ�ƐŬŝůůƐ�ƚŚĂƚ�ǇŽƵ͛ǀĞ�ůĞĂƌŶĞĚYou hear change talk and your spirits soar^Ž�ǇŽƵ�ƐĂǇ�͞dĞůů�ŵĞ�ŵŽƌĞ͘͟Chorus (repeat twice)/ƚ Ɛ͛�ƚŝŵĞ�ƚŽ�ƵƐĞ�Ăůů�ƚŚĞ�KͶAͶRͶS/ƚ Ɛ͛�ƚŝŵĞ�ƚŽ�ƵƐĞ�Ăůů�ƚŚĞ�KͶAͶRͶSIt will make you feel goodThe participant tooIt will change everything you do.

Day 2 Wrap-Up1. I learned?

2. I relearned?

3. I gained?

4. I appreciated?

5. One thing that surprised me?

6. I could use more MI to?

7. I am more confident that I can?

8. When I get back to work, I can’t wait to try?

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Day 2 EvaluationWhat do you think about? :DV�LW««««««««««««««

Too Little Just Right Too much1. Amount of material being covered? 1 5 102. Amount of time for questions & discussion?

1 5 10

3. Amount of structure in the training? 1 5 104. Amount of time practicing skills? 1 5 105. Amount of time watching demonstrations including videos?

1 5 10

6. Amount of time instructor was talking? 1 5 10

7. Amount of explanation for each method? 1 5 108. Amount for time for interactive exercises? 1 5 10

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Day 2 Questions?

Day 2 Comments?

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