motivational interviewing: core skills training · • client: smoking helps me reduce stress. •...
TRANSCRIPT
Motivational Interviewing:Motivational Interviewing:
Core Skills TrainingCore Skills Training
Alan Lyme, LISW, ICADC, ICCS,
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