Furthering Your Motivational Interviewing Skills

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Furthering Your Motivational InterviewingSkills

• Presenter Ann Fields, M.S.E., CADC III, CGAC II

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PART 1
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I HAVE ALWAYS KNOWN THAT AT LAST I WOULD TAKE
THIS ROAD, BUT YESTERDAY I DID NOT KNOW IT WOULD
BE TODAY Narihira
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THREE THINGS TO REMEMBER

• AMBIVALENCE IS NORMAL
• EFFECTING CHANGE IS A PROCESS
• CLIENTS NEED TO COME UP WITH THEIR OWN ARGUMENTS
  FOR CHANGE

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3 FACTORS THAT INFLUENCE MOTIVATION

• WILLING
• READY
• ABLE

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MI WITHIN THE STAGES OF CHANGE
Precontemplation
RELAPSE
CONTEMPLATION
LAPSE
MAINTENANCE
PREPARATION
ACTION
Providers Role To engage clients by utilizing
an empathic style of reflective listening and to
assist them in exploring and resolving their
ambivalence.
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What does not motivate people?

• Think of characteristics of your Worst Teacher /
  Coach
• What were things he / she did that made you feel
  defensive, avoidant and resistant?
• Chart Ineffective Motivators

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What does motivate people?

• What were the characteristics of your Most
  Favorite Teacher / Coach?
• Why was this person an influence on you?
• Chart Effective Motivators.

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MILLERS RESEARCH

• A PROVIDER CAN SIGNIFICANTLY INFLUENCE CLIENT
  MOTIVATION
• MOTIVATION IS NOT SEEN AS A CLIENT TRAIT, BUT THE
  INTERPERSONAL PROCESS BETWEEN CLIENT AND PROVIDER
• HOW A PROVIDER THINKS ABOUT MOTIVATION AND CHANGE
  GREATLY INFLUENCES WHAT A PROVIDER DOES

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What is Motivational Interviewing?

• a collaborative, person-centered form of
  guidance to elicit motivation for change
• Miller Rollnick 2008

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SPIRIT OF MI

• EMPATHIC
• COLLABORATIVE
• RESPECTS ONES AUTONOMY, CHOICE AND DECISION
  MAKING
• EVOCATIVE
• DIRECTIONAL

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Early Counseling Traps
Im the expert here.
Hey! Youre not listening!
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Traps To Avoid

• Question-Answer Trap
• Confrontation-Denial Trap
• Labeling Trap
• Premature Focus
• Blaming Trap
• Expert Trap

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Beware Of The Righting Reflex
Our desire to keep people from going down the
wrong path, and to set things aright Born of
concern and caring Theres a problem? Lets fix
it! Fails to consider ambivalence in change
process May engender resistance
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MILLERS BROAD PRINCIPLES

• Express empathy
• Develop discrepancy
• Roll with resistance
• (Avoid argumentation)
• Support self-efficacy

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CONFRONTATION IS THE GOAL, NOT THE STRATEGY
Assist clients in exploring their own arguments
for change Clients come face to face with a
difficult reality in a way that will change them
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Getting Moving On OARS

• OPEN QUESTIONS
• Affirm
• Reflect
• Summarize

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Open-ended Questions Questions that cannot be
answered yes/no, but which encourage clients to
express their thoughts, feelings, or concerns
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Change to Open-Ended Questions

• Do you feel you have a problem with alcohol?
• 2. Is it important to you to complete
  supervision successfully?
• Anything else?
• Handout c / o questions

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Yes / No Role Play

• (1) Speaker One thing I like about myself is
• (2) Listeners Tag team
• By that do you mean
• Speaker Only respond by saying
• Yes or No
• Everyone takes a turn.

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Getting Moving On OARS

• Open Questions
• AFFIRM
• Reflect
• Summarize

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Affirmation Expression of appreciation for
clients efforts or participation.
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Affirmations Include

• Commenting positively on an attribute
• Youre a strong person, a real survivor.
• A statement of appreciation
• I appreciate your openness and honesty today.
• Catch the person doing something right
• Thanks for coming in today!
• An expression of hope, caring, or support
• I hope this weekend goes well for you!
• A statement to support self-efficacy
• I noticed you showed up on time How did you
  manage that?

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Practicing Affirmations

• Write down 4 affirmations for the following
  statement
• I'm sick of this, everything just keeps getting
  messed up. I do good for a week and then the
  other kids start getting on my nerves, talking
  about my family. I go to that program, I'm
  learning stuff. I think it's helping and then the
  same day I get into a huge fight and end up in
  lockdown. Staff doesn't like me, I can't do
  anything right. They're always on my case. I
  don't know what you all want from me. I'm just
  trying to get by in here. It's not as easy as you
  make it sound.
• Handout

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Getting Moving On OARS

• Open Questions
• Affirm
• REFLECT
• Summarize

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Reflective Listening Accurate understanding of
clients experience, communicated in a warm,
non-judgmental manner.
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Simple Reflections

• Repeat- These reflections add nothing at all to
  what the client has said, but simply repeat or
  restate it using some or all of the same words.
• Rephrase- These reflections stay close to what
  the client has said, slightly rephrase it,
  usually by substituting a synonym. It is the
  same thing said by the client, but in a slightly
  different way.
•  

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Complex Reflections

• Paraphrase- These reflections change, or add to
  what the client has said in a significant way to
  infer the clients meaning.
• Reflect Emotion- Regarded as the deepest form of
  reflection, this is a paraphrase that emphasizes
  the emotional dimensions through feeling
  statements.
• Reflect Double Sided Ambivalence Sustain Talk
  Change Talk good things and not so good
  things about keeping the status quo.

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Levels of Reflections

• C. Even though nothing has happened Ive been
  feeling more depressed lately. I wish it would go
  away.
• Repeat Youve been more depressed lately.
• Rephrase So your sadness is getting worse and
  you dont know why.
• Emotion Youre worried that nothing is going to
  change.
• Paraphrase You would like to understand why your
  mood changes like that.
• Double-Sided So on the one hand youve been
  living with depression and on the other hand
  youre tired of it and wondering what to do.

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Increase Quality of Reflections

• BY
• Making sure inflection
• is a statement
• Strip statement down
• Clear and Concise
• Use reflections to
• continue the paragraph

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Reflective Listening Exercises

• I dont know why this is such a big deal for
  everyone else. All my friends drink like I do.
• Everyone should just relax. Im doing the best I
  can with trying to find a job.
• I know Im suppose to take my meds but you dont
  know my friends. Its basically impossible to
  take them when we hang out.

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Reflective Listening Exercises

• I am feeling very trapped and hopeless about my
  situation. No one seems to want to help me.
• People are always making me do things I dont
  want to do. Even my wife keeps nagging me about
  taking those pills.

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Reflection Role Play

• (1) Speaker One thing about myself Id like to
  change
• (2) Listeners
• Use reflections only no questions.
• Make sure inflection is a statement and not a
  question.
• Speaker stays in role and talks.
• ______________________________
• Video Miller Simple / Complex Reflections

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Getting Moving On OARS

• Open Questions
• Affirm
• Reflect
• SUMMARIZE

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Summarizing Bringing together of several of the
clients previously expressed thoughts, feelings,
or concerns, often including the clinicians
understanding of how these fit together.
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Summaries can

• Collect material already offered
• Link something just said with something discussed
  earlier
• Transition Draw together what has happened and
  transition to a new task

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Practice Summaries

• Groups of 3 - 1 Speaker 2 Listeners
• 1 Speaker talks about something that has bothered
  you..
• 2 Listeners just listen (no comments or
  questions).
• At the end provide 2 Summaries
• 1st Listener Collect
• 2nd Listener Link or Transition
• Switch Roles

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PART 2
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OARS TO. AROSE

• Affirmation
• Reflective Listening
• Open-ended Questions
• Summarizing
• Elicit Change Talk

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Change talk v. Sustain talk

• Sustain talk is client speech that favors the
  status quo
• Change talk is client speech that favors movement
  in the direction of change

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Elicit Change Talk

• Why Is Change Important?
• Problem Recognition
• Concerns
• Optimism
• Intention to Change

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Evocative Questions

• Open-ended questions related to behavior, that
  elicit change talk.
• What do you want to do about this behavior?
  What makes you believe you can do this? Why
  would you want to make this change?
• Handout

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Recognize Change Talk

• Desire I want to
• Ability I can
• Reason Its important
• Need I should
• Drumming Exercise

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RESPONDING To Change Talk

• EARS
• Elaborating
• Affirming
• Reflecting
• Summarizing
• Its important to recognize and respond to
  Change Talk using the above skills.

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Being Strategic with MI Strategies

• Client I dont know, I really dont want to go
  to that drug treatment program. I know I can quit
  on my own.
• Non-Strategic Reflection
• You dont want to participate in the drug
  treatment program.
• Strategic Reflection
• Its really important to you to address your
  drug use and you realize that quitting is a
  strategy that will work for you.

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Using EARS

• R Id like to have better control of my
  drinking.
• E I think I could quit.
• R If want to get along with my family, then I
  have to do something about my temper
• E Ive got to do something about my anger.
• A Im going to start my cog program today
• E I am embarrassed about my lack of control.
• R If I want a good job, I have to get my GED.
• E I want to be a better dad to my son.
• R If I get a DUI, I will lose my license.
• E I finished my vocational program.
• R Im not guilty, but I will go to the program.
• E I am under so much stress, all I do is yell at
  my family. Handout

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Select something about yourself you want to
change, you know you should change, but you
havent yet changed.a health behavior or quality
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Exercise Eliciting Change Talk

• Groups of 3 1 Speaker, 1 Listener, 1 Observer
• Eliciting need/desire change talk
• What might be some of the not-so-good things
  about your behavior?
• How do you feel about your future if you continue
  to live the way youre living now?
• What kinds of things can you imagine happening in
  your life if you decide to make this change?
• Handout - (S-Talk about behavior L -EARS, O -Code
  Sheet Observer give Feedback / Debrief

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Exercise continue

• Switch Roles
• Groups of 3 1 Speaker, 1 Listener, 1 Observer
• Eliciting ability change talk
• What gives you the courage to go after what you
  want?
• What do you already do well that will help you
  make this happen?
• What kinds of things are you really good at?
• Handout - (S-Talk about behavior L -EARS, O -Code
  Sheet Observer give Feedback / Debrief

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Exercise continue

• Switch Roles
• Groups of 3 1 Speaker, 1 Listener, 1 Observer
• Eliciting reason change talk
• If you were to change your behavior, what would
  be your reasons?
• What would be the good things about changing your
  behavior?
• If you were able to change your behavior, what
  would the payoffs be for you?
• Handout - (S-Talk about behavior L -EARS, O -Code
  Sheet Observer give Feedback / Debrief

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CONSOLIDATING COMMITMENT
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Signs of Readiness

• Decreased sustain talk
• Decreased discussion about the problem
• Resolve
• Increased change talk
• Questions about change
• Envisioning change
• Experimenting with change

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Recognize Commitment

• Commitment I will
• Activation I am ready
• Taking Steps I am doing it now
• CARDS

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Strengthening Commitment What Do You Want
To Do About It?

• Ask An Action Question Transition - What are
  you willing to do nowWhere do we go from
  hereWhats your next step..What do you want to
  do?
• Provide Information or Advice
• Start with what the person might know or has
  tried before that has worked
• Ask permission before providing advice

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Plan of Action Connect Talk To Action

• Talk specifics about plan for changing behavior
• What specifically will the behavior look like
• When-will the behavior occur
• Where- will the behavior occur
• Why-is behavior personally important
• How-can the behavior be achieved How can I be of
  help

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STEPS to ConsolidateBig summary of all change
talkScale readiness if desiredKey Action
questions Whats next? What changes do you
think you will actually make? Where do we go
from here?EARSConnect Talk to Action
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PART 3
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Doctor / PatientVideo
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Motivational Interviewing Treatment Integrity
(MITI)(Dr. Terry Moyers, Phd)

• Global Scale Rating LOW 1 2 3 4 5 HIGH
• Empathy
• Collaboration
• Autonomy / Support
• Evocation
• Direction
• --------------------------------------------------
  ----------------------------------------------
• Behavioral Codes
• Giving Information
• MI Adherent Asking Permission, Emphasize
  Control,
• Affirm, Support
• MI Non-Adherent Advise, Confront, Direct
• Questions Closed Yes/No
• Open Evocative ( What, Why, How)
• Reflect Simple
• Complex Add Meaning

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Role Play Putting It all Together

• (1) Speaker Portray a client ambivalent about
  changing a behavior (i.e. Substance Use,
  Gambling, Eating Disorder, Leaving a Domestic
  Violent Relationship, Taking Meds., etc.)
• (1) Listener Utilize the OARS (Remember 1
  question every 2-4 reflections).
• (1) Recorder Utilize Handout. Make a slash mark
  for Open-ended Questions, Closed Questions,
  Affirmations, Simple Reflections, and Complex
  Reflections.
• Summarize / Provide Feedback / Switch Roles

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THE END