motivational interviewing: core skills training · • client: smoking helps me reduce stress. •...

Motivational Interviewing:Motivational Interviewing:

Core Skills TrainingCore Skills Training

Alan Lyme, LISW, ICADC, ICCS,

alanlyme@gmail.com

MI Core Skills 2018

Motivational

Interviewing is Interviewing is

making KNOWN

what You KNOW

MI Core Skills 2018

Compassionate

ConversationConversation

MI Core Skills 2018

MI Core Skills 2018

•LISTEN!

•LISTEN!•LISTEN!

•LISTEN!

MI Core Skills 2018

•SHOW UP

•BEGINNERS MIND•BEGINNERS MIND

MI Core Skills 2018

MOTIVATIONAL INTERVIEWING

DEFINITION & SPIRIT

DEFINITION: Motivational interviewing is a

person-centered, evidence-

based, goal-oriented method

for enhancing intrinsic for enhancing intrinsic

motivation to change by

exploring and resolving

ambivalence with the

individual.

SPIRIT: Collaboration/Partnership;

Evocation; Acceptance; Compassion.MI Core Skills 2018

MI literature

1991, 2002, 2013

Motivational Interviewing:

Helping people changeMiller & Rollnick

2008 Motivational

Interviewing in Health

Care. Rollnick, Miller & Butler

MI Core Skills 2018

Motivational Interviewing in Groups 2012Christopher C. Wagner, Karen S. Ingersoll,

with Contributors

MI Core Skills 2018

Motivational Interviewing with Adolescents and Young Adults2010

Sylvie Naar King and Mariann Suarez

Collaboration/Partnership

MI Acceptance

Evocation

Compassion

MI

Spirit

“ A person-centered, goal oriented

intervention focused on resolving

ambivalence in the direction of change”

“…not a series of techniques … but a

way of being…”

(Information on MI adapted from Motivational Interviewing. Miller and Rollnick, 1991)MI Core Skills 2018

Four Fundamental Processes

Evoking

Planning

Engaging

Focusing

Evoking

MI Core Skills 2018

The processes are somewhat linear……

• Engaging necessarily comes first

• Focusing (identifying a change goal) is a prerequisite

for Evoking

• Planning is logically a later step

Engage - Shall we walk together?

Focus - Where?

Evoke - Why?

Plan - How?

MI Core Skills 2018

…and yet also recursive

• Engaging skills (and re-engaging) continue

throughout MI

• Focusing is not a one-time event. Re-focusing is

needed, and focus may change

• Evoking can begin very early• Evoking can begin very early

• “Testing the water” on planning may indicate a

need for more of the above

• The four processes are inter-woven

MI Core Skills 2018

Motivational Interviewing Process

FEAR CHANGE TALK•Desire•Ability•Reason

Lower fearIncrease desires

COMMITMENTLANGUAGE

•Reason•Need

CHANGE BEHAVIORTOWARDS and/or SUSTAIN

“HEALTH”

Notice

Observe

Motivational Interviewing

• Assumes motivation is fluid and can be influenced

• Motivation influenced in the context of a relationship – developed in the context of a Client encounter

Principle tasks – to work with ambivalence and • Principle tasks – to work with ambivalence and resistance

• Goal – to influence change in the direction ofhealth

MI Core Skills 2018

AMBIVALENCE

IS....

MI Core Skills 2018

Motivational Interviewing

UNDERLYING ASSUMPTIONS

� Acceptance

� Autonomy/Choice

� Less is better

� Elicit versus Impart

� Michelangelo Belief

� Ambivalence is normal

� Care-frontation

� Non-Judgmental

� Change talk

� Righting reflexMI Core Skills 2018

Common Reactions to Righting Reflex• Angry, agitated

• Oppositional

• Discounting

• Defensive

• Justifying

• Afraid

• Helpless, overwhelmed

• Ashamed

• Trapped• Justifying

• Not understood

• Not heard

• Procrastinate

• Trapped

• Disengaged

• Not come back – avoid

• Uncomfortable

MI Core Skills 2018

What does motivate people?

MI Core Skills 2018

OARSO: open-ended questions

A: affirmations

R: reflectionsR: reflections

S: summaries

MI Core Skills 2018

Closed Questions

• Have a short answer (like Yes/No)

– Did you drink this week?

• Ask for specific information

– What is your address?– What is your address?

• Might be multiple choice

– What do you plan to do: Quit, cut down, or keep on smoking?

• They limit the Client’s answer options

MI Core Skills 2018

Open Questions:

• Open the door, encourage the Client to

talk

• Do not invite a short answer• Do not invite a short answer

• Leave broad latitude for how to respond

MI Core Skills 2018

Open-ended Questions

• “How can I help you?”

• “What can you tell me about ___?”

• “How would you like things to be different?”

• “What are the good things about ___?”• “What are the good things about ___?”

• “What are the not so good things about___?”

• “What will you lose if you give up ___?”

• “What have you tried before?”

• “What do you want to do next?”

MI Core Skills 2018

Closed Versus Open-Ended Questions

• Do you feel you have a

problem with alcohol?

• Is it important to you to

complete this program

• What problems has your alcohol use caused you?

• How important is it for complete this program

successfully?

• Anything else?

• How important is it for you to complete this program successfully?

• What else?

MI Core Skills 2018

Open or Closed Questions?

• What helped you get to the office today?

• Was your family religious?

• What are the good things about your

smoking?smoking?

• What are the not-so-good things about it?

• If you were to quit, how would you do it?

• When is your court date?

MI Core Skills 2018

Open or Closed Questions?

• Don’t you think it’s time for a change?

• What do you think would be better for you –A.A. or NA?

• What do you like about not taking your meds?

• How will you get to the AA meeting tonight?• How will you get to the AA meeting tonight?

• Is this an open question?

MI Core Skills 2018

Some Guidelines with Questions

• Ask fewer questions!

• Don’t ask three questions in a row

• Ask more open than closed questions

• Offer two reflections for each question • Offer two reflections for each question

asked

MI Core Skills 2018

Affirmations

• Emphasize a strength

• Notice and appreciate a positive action

• Should be genuine

• Build feelings of empowerment• Build feelings of empowerment

• Instill hope and “can-do” attitude

• Express positive regard and caring

• Strengthen the counseling relationship

MI Core Skills 2018

Affirmations Include:

• Commenting positively on an attribute

– You’re a strong person, a real survivor.

• A statement of appreciation

– I appreciate your openness and honesty today.

• Catch the person doing something rightCatch the person doing something right

– Thanks for coming in today!

• A compliment

– I like the way you said that.

• An expression of hope, caring, or support

– I hope this weekend goes well for you!

MI Core Skills 2018

Reflective Listening

“Reflective Listening” is the key to this work. The best motivational advice we can give you is to listen carefully to your Clients. They will tell you Clients. They will tell you what has worked and what hasn’t. What moved them forward and shifted them backward. Whenever you are in doubt about what to do, listen”(Miller & Rollnick, 1991)

MI Core Skills 2018

The Accuracy Function of Reflection

What thespeaker means

What the listenerthinks the speaker means

1 4

Bridge the gap by reflection

R

SPEAKER LISTENER

What the speaker

says

What the listener hears

speaker means thinks the speaker means

3

2

MI Core Skills 2018

Types of Empathic Reflections

♥ Simple/Repeating - Reflect what is said

♥ Simple/Rephrasing – Slightly alter

♥Amplified - Add intensity to idea/values

♥Double Sided - Reflect ambivalence

♥Metaphor - Create a picture

♥ Shifting Focus - Change the focus

♥Reframing - Offer newmeaning

♥Emphasize personal choice

♥ Siding with the negative (paradoxical)MI Core Skills 2018

Levels of Reflection� REPEAT

(restate what Client has said)

� REPHRASE (synonym)

-------------------------------------------------� PARAPHRASE, infer meaning,

amplify concepts & values,amplify concepts & values,

double-sided, continue paragraph,

metaphor, understate feelings,

reframe

� SUMMARIZE

MI Core Skills 2018

Repeating: This is the simplest form of reflection,

often used to diffuse resistance

• Client: I don't want to quit smoking.

• Counselor: You don't want to quit smoking. • Counselor: You don't want to quit smoking.

MI Core Skills 2018

Rephrasing: Slightly alter what the Client says in order

to provide the Client with a different point of view.

This can help move the Client forward.

• Client: I really want to quit smoking.

• Counselor: Quitting smoking is very

important to you.

MI Core Skills 2018

Amplified reflection: Reflect what the Client has said in an

exaggerated way. This encourages the Client to argue less,

and can elicit the other side of the Client's ambivalence.

• Client: I don’t drink that much. • Client: I don’t drink that much.

• Counselor: You hardly drink at all and it’s hard to imagine what all the fuss is about (Note: it is important to have a genuine, not sarcastic, tone of voice).

MI Core Skills 2018

Double-sided reflection: Acknowledge both

sides of the Client's ambivalence.

• Client: Smoking helps me reduce stress.

• Counselor: On the one hand, smoking helps you to reduce stress. On the other hand, you said previously that it also causes you stress because you have a hacking cough, you said previously that it also causes you stress because you have a hacking cough, have to smoke outside, and spend money on cigarettes.

MI Core Skills 2018

Metaphor: Painting a picture that can clarify

the Client’s position

• Client: Everyone keeps telling me I have a

drinking problem, and I don’t feel it’s that bad.

• Counselor: It’s kind of like everyone is pecking

on you about your drinking, like a bunch of on you about your drinking, like a bunch of

crows pecking away at you.

MI Core Skills 2018

Shifting focus: Provide understanding for the Client's

situation and diffuse resistance

Client: What do you know about quitting? You

probably never smoked. probably never smoked.

MI Core Skills 2018

Counselor: It's hard to imagine how I could

possibly understand.

Reframing: Much as a painting can look completely

different depending upon the frame put around it,

reframing helps Clients think about their situation

differently

• Client: I've tried to quit and failed so many • Client: I've tried to quit and failed so many

times.

• Counselor: You are persistent, even in the

face of discouragement. This change must

be really important to you.

MI Core Skills 2018

Emphasizing Personal Choice: Reflect the Client’s

autonomy

• Client: I've been considering quitting for some

time now because I know it is bad for my

health. health.

• Counselor: And that is your choice. No-one

can decide that for you.

MI Core Skills 2018

Types of Empathic Reflections

• Simple/Repeating - Reflect what is said

• Simple/Rephrasing – Slightly alter

• Amplified - Add intensity to idea/values

• Double Sided - Reflect ambivalence

• Metaphor - Create a picture

• Shifting Focus - Change the focus

• Reframing - Offer newmeaning

• Emphasize personal choice

• Siding with the negative (paradoxical)MI Core Skills 2018

Summarizing

• Special form of reflective listening

• Ensures clear communication

• Use at transitions in conversation• Use at transitions in conversation

• Be concise

• Reflect ambivalence

• Accentuate “change talk”

MI Core Skills 2018

How Motivational Interviewing is

Directive

• Selective eliciting questions

• Selective reflection

• Selective elaboration• Selective elaboration

• Selective summarizing

• Selective affirming

MI Core Skills 2018

Fundamental Belief

• The capacity and potential for

change and adherence is within every change and adherence is within every

person!

MI Core Skills 2018

Fundamental Process

Evoking

Focusing

Evoking

Engaging

MI Core Skills 2018

• I would like to . . .

• I wish . . .

• I really want to weigh lessesire

• I think I could walk 2 times a week.

• I can skip that candy at bedtime.bility • I can skip that candy at bedtime.

• I am able to walk from the back of the parking lot.bility

• I know I would feel better if I lost 50 pounds

• I would have more energy if I started exercising

• I would worry less about my eyes if I went for regular check-ups.

easons• I should walk at least 3 times a week

• I should do this for my grandchildren.

• I have to lose weight if I am going to be able to walk upstairs.

eed

• I will make changesommitment

• I am ready, prepared, willing to changectivation

• I am taking specific actions to changeaking Steps

Yet another metaphor:

MI Hill

(Pre-) ActionPreparationContemplation

Thanks to Bill Miller

Match the sentence to the type of change talkMatch the sentence to the type of change talk

• I’d be healthier if I quit. Ability

Activation• I wish I could quit. Activation

• I’ll think about quitting. Need

• I’ve got to quit smoking. Desire

• I think I can quit. Reason

Match the sentence to the type of change talkMatch the sentence to the type of change talk

• I want to lose weight. Reason

• I could probably lose 20 pounds. Need• I could probably lose 20 pounds. Need

• I’d have more energy. Commitment

• I’m going to lose 20 pounds. Ability

• I’ve got to lose some weight. Desire

Sustain Talk and Discord

• Sustain Talk is about the target behavior

– I really don’t want to quit smoking

– I need my pills to make it through the day– I need my pills to make it through the day

• Discord is about your relationship

– You can’t make me quit

– You don’t understand how hard it is for me

• Both are highly responsive to practitioner style

MI Core Skills 2018

Change talk is like gold!

• As Clients speak about

change, they begin to see

the possibilitiesthe possibilities

• No pressure or persuasion

is needed

MI Core Skills 2018

Drum Roll

• I love to smoke my weed.

• I need to get high to feel right.

• I just want to wake up sober in the morning.

• I actually tested my blood sugars every day this week.week.

• I stayed away from drug dealing all week.

• It’s just such a hassle to floss my teeth.

MI Core Skills 2018

Drum Roll

• There’s no way I want to be on insulin.

• I definitely can’t afford to get another DWI.

• I wish I could lose weight easily.

• I don’t think I can eat any more fruits and vegetables than I am.vegetables than I am.

• I’ve been kinda forgetting to take my anti-depressants.

• I hate keeping food records

• I could probably take a walk after dinner.

MI Core Skills 2018

Drum Roll

• I’ll do anything to get rid of the pain.

• I’m sick of smoking; it disgusts me.

• I don’t want to set a bad example for my kids

• I don’t see how drinking 4 or 5 beers a night is a problem.problem.

• I’m killing myself.

• It’s important for me to get through this program

MI Core Skills 2018

Responding to Sustain Talk & Discord

• Ambivalence under pressure leads to discord

• Don’t ignore, but also try NOT to reinforce or

engage

• Responses are the same to either• Responses are the same to either

– Reflections – simple, amplified, double-sided

– Shifting focus

– Emphasizing personal choice

MI Core Skills 2018

Responding to Change Talk

All EARS

• E: Elaborating - asking for more detail, in what

ways, an example, etc.

• A: Affirming – commenting positively on the

person’s statement person’s statement

• R: Reflecting – continuing the paragraph, etc.

• S: Summarizing – collecting bouquets of

change talk

MI Core Skills 2018

Snatching Change Talk from the Jaws

of Ambivalence

• Change talk often comes intertwined with

sustain talk

• That’s the nature of ambivalence

MI Core Skills 2018

Snatching Change Talk from the Jaws

of Ambivalence

• I really don’t want to stop smoking, but I know

that I should. I’ve tried before and it’s really

hard.

– 1. You really don’t want to change– 1. You really don’t want to change

– 2. It’s pretty clear to you that you ought to quit.

– 3. You don’t think you can quit.

MI Core Skills 2018

• See, the thing is, all my friends drink. Some of them probably drink way too much too, but if I quit drinking, I don’t have any friends. I just stay home.

– 1. That would be pretty lonely

– 2. Quitting would cause a new problem for you.

– 3. And at the same time you recognize that you and probably some of your friends are drinking way too much.

MI Core Skills 2018

• I know you’re worried that I’m getting addicted, and I guess I can see what you mean, but I really need more pain medicine. I don’t know how I would get through the day without it. If you won’t prescribe it, then I’ll find someone else who will.– 1. You understand my worry about dependence.– 1. You understand my worry about dependence.

– 2. It’s hard to imagine how you would get along without more medicine.

– 3.One way or another, you’re going to get more medicine.

MI Core Skills 2018

Evoking Change Talk:

Desire, Ability, Reason, Need, Commitment

1. Why have you been thinking about changing your ------? (Reveals desire)

2. If you were to change your --------, how would you do it? (Evokes ability)

3. What are your three most important reasons for wanting to change? (Evokes reasons)to change? (Evokes reasons)

4. How would things be different (better) if you decided to change? ( Reveals the need)

5. What is the next step? On a scale of 1-10 , how willing are you to change. (Encourages commitment)

6. Summarize

MI Core Skills 2018

Change talk micro-skills….

MI Core Skills 2018

ENGAGING: Open the Conversation• Explain role• State appointment length• Ask permission

EVOKING: Build Motivation

FOCUSING: Negotiate the Agenda

Provide Clinical Feedback•Use visual support materials

•Be clear, succinct, and non-

judgmental

•Compare to norms and standards

•Elicit client’s interpretation

Elicit -

Provide -

Elicit• Education

• Advice

Clinical Roadmap

EVOKING: Build Motivation•Ask evocative questions

•Encourage elaboration

•Looking back/Looking forward

•Explore/Amplify ambivalence

•Explore goals and values

•Assess importance/confidence

PLANNING: Strengthening Commitment•Brainstorm ideas and opinions

•Negotiate a plan

•Explore barriers

•Identify support•Elicit final commitment

Close the Encounter:•Summarize the session

•Show appreciation

•Support self-efficacy

•Arrange follow-up as appropriate

•Link with available resources

Support the Transition:•Recognizing readiness

•Summarizing the big picture

•Ask about next steps

• Advice

• Feedback

• Skills

• Referral

MI Core Skills 2018

Importance Ruler• How important is it to you to change your ___________?

If 0 was “not important,” and 10 was “very important,” what

number would you give yourself ?

0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10

MI Core Skills 2018

• What does that number mean to you?

• Why are you there, not lower (if appropriate)

• Where would you like to be?

• What would need to happen for your

Exploring Importance

• What would need to happen for your

importance score to move towards that?

MI Core Skills 2018

Decisional Balance

• Ambivalence is a normal part of the change process

• Use ambivalence to promote positive change

• Weigh pros and cons of behavior

• Increase discrepancy• Increase discrepancy

MI Core Skills 2018

DECISIONAL BALANCE SHEET

1. Good things: 2. Not so good things:

MI Core Skills 2018

Decisional Balance Exercise

• What are some of the good things about your ___ (drinking, smoking, eating whatever you want)? What else?

• What are some of the not-so-good things about your ____? What else?

MI Core Skills 2018

Responding to decisional balance

• Reflection of both sides of the coin

MI Core Skills 2018

Four Fundamental Processes

Evoking

Planning

Focusing

Evoking

Engaging

MI Core Skills 2018

Negotiate a plan of action

• Invite active participation by the Client

• Client determines goals & priorities

• Client weighs options

• Together, work out details of the plan

MI Core Skills 2018

Giving Information and Advice:

3 Kinds of Permission

1. The Client asks for advice

2. You ask permission to give advice

3. You qualify your advice to emphasize 3. You qualify your advice to emphasize

autonomy

75MI Core Skills 2018

Thoughts about Useful Informing

• Slow down and progress may be quicker

• It’s a person not an information receptacle

• Consider the Client context & priorities• Consider the Client context & priorities

• Amount matters and depends on the Client

• Individualize it

• Beware of righting reflex

Thanks to David Rosengren

MI Core Skills 2018

Useful Informing

• Ask permission

• Offer choices

• Use other Client examples

• Chunk-Check-Chunk• Chunk-Check-Chunk

• Elicit-Provide-Elicit

MI Core Skills 2018

Confidence Ruler

How confident are you that if you wanted to change your smoking habit, you could do so?

If 0 was “not confident,” and 10 was “very confident,”

0 1 2 3 4 5 6 7 8 9 10

If 0 was “not confident,” and 10 was “very confident,”

what number would you give yourself ?

MI Core Skills 2018

Building Confidence

• What does that number mean to you?

• I’m curious about your confidence. What makes it an x and not a w?

• Where would you like to be?• Where would you like to be?

• What might move you towards that?

MI Core Skills 2018

• What have you found helpful in previous attempts to change?

• What have you learned from the last time you tried?

Building Confidence

you tried?

• If you were to decide to change, what might your options be?

• What ways do you know about that have worked for other people?

MI Core Skills 2018

Readiness Ruler

How ready are you at this moment to change your smoking habit?

If 0 was “not ready,” and 10 was “very ready,” what

number would you give yourself ?

0 1 2 3 4 5 6 7 8 9 10

MI Core Skills 2018

Exploring Readiness

• What does that number mean to you?

• Why there not lower? (if appropriate)

• Where would you like to be?

• What might move you towards that?• What might move you towards that?

• What would be your first step in making a

change?

MI Core Skills 2018

Finalizing the motivational interview

• Review the commitment

• Review the plan

• Set up a new time to meet• Set up a new time to meet

• Express encouragement

MI Core Skills 2018

Why use the MITI coding in supervision and training?

• Shows us whether the worker is utilizing Motivational Interviewing spirit, structure, skills.

• Allows us to provide feedback • Allows us to provide feedback that is structured and meant to “shape” Partnership, Empathy, Emphasizing Autonomy and Softening Sustain Talk

MITI 4.2MITI 4.2

Moyers, T.B., Manuel, J.K., & Ernst, D. (2014). Motivational Interviewing Treatment Integrity Coding Manual 4.1. Unpublished manual.

Technical Components

Cultivating

Change Talk

1 2 3 4 5

Softening

Sustain Talk

1 2 3 4 5

GLOBAL RATINGS

Sustain Talk

Relational Components

Partnership 1 2 3 4 5

Empathy 1 2 3 4 5

Giving Information (GI)

Persuade (Persuade)

Persuade with Permission

(Persuade with)

Question (Q)

Simple Reflection (SR)

Behavior Counts Total

Complex Reflection (CR)

Affirm (AF)

Seeking Collaboration (Seek)

Emphasizing Autonomy

(Emphasize)

Confront (Confront)

Cultivating Change Talk

Low High

1 2 3 4 5

Clinician

shows no

Clinician

sporadically

Clinician

often attends

Clinician

consistently

Clinician

shows a shows no

explicit

attention to,

or preference

for, the

client’s

language in

favor of

changing

sporadically

attends to

client

language in

favor of

change –

frequently

misses

opportunities

to encourage

change talk

often attends

to the client’s

language in

favor of

change, but

misses some

opportunities

to encourage

change talk

consistently

attends to the

client’s

language

about change

and makes

efforts to

encourage it

shows a

marked and

consistent

effort to

increase the

depth,

strength, or

momentum

of the client’s

language in

favor of

change

Softening Sustain TalkLow High

1 2 3 4 5

Clinician

consistently

responds to

Clinician

usually

chooses to

Clinician

gives

preference to

Clinician

typically

avoids an

Clinician

shows a

marked and responds to

the client’s

language in a

manner that

facilitates the

frequency or

depth of

arguments in

favor of the

status quo.

chooses to

explore, focus

on, or

respond to

the client’s

language in

favor of the

status quo.

preference to

the client’s

language in

favor of the

status quo,

but may

show some

instances of

shifting the

focus away

from sustain

talk.

avoids an

emphasis on

client

language

favoring the

status quo.

marked and

consistent

effort to

decrease the

depth,

strength, or

momentum

of the clients

language in

favor of the

status quo.

PartnershipLow High

1 2 3 4 5

Clinician

actively

assumes the

expert role for

the majority

of the

Clinician

superficially

responds to

opportunities

to

collaborate.

Clinician

incorporates

client’s

contributions

but does so in

a lukewarm

Clinician

fosters

collaboration

and power

sharing so

that client’s

Clinician

actively

fosters and

encourages

power

sharing in of the

interaction

with the

client.

Collaboration

or partnership

is absent.

collaborate. a lukewarm

or erratic

fashion.

that client’s

contributions

impact the

session in

ways that

they

otherwise

would not.

sharing in

the

interaction in

such a way

that client’s

contributions

substantially

influence the

nature of the

session.

EmpathyLow High

1 2 3 4 5Clinician gives

little or no

attention to the

client’s

perspective.

Clinician makes

sporadic efforts

to explore the

client’s

perspective.

Clinician is

actively trying

to understand

the client’s

perspective,

Clinician makes

active and

repeated efforts

to understand

the client’s point

Clinician shows

evidence of

deep

understanding

of client’s point perspective. perspective.

Clinician’s

understanding

may be

inaccurate or

may detract from

the client’s true

meaning.

perspective,

with modest

success.

the client’s point

of view. Shows

evidence of

accurate

understanding

of the client’s

worldview,

although mostly

limited to

explicit content.

of client’s point

of view, not just

for what has

been explicitly

stated but what

the client

means but has

not yet said.

Fair Good

Relational 3.5 4

Technical 3 4

% CR 40% 50%% CR 40% 50%

R:Q 1:1 2:1

Total MIA - -

Total MINA - -

Blend with MIA STEP

The MI Shift

From feeling responsible for

changing Clients’ (and

supervisees’) behavior to supervisees’) behavior to

supporting them in thinking &

talking about their own reasons

and means for behavior change.

MI Core Skills 2018