1

NEIAS

Motivational Interviewing

Basic Training

June 5 & 6, 2018

presented by:

John E. Brelsford, MINT

Goals of Training

◆ Participants will be familiar with the basic concepts of Motivational Interviewing.

– MI Spirit

– MI Skills

– MI Structure

◆ Participants will practice using MI.

The only kind of learning which significantly influences behavior is self-discovered or self-appropriated learning -truth that has been assimilated in experience.

- Carl Rogers

You can’t dance in your head--Sue Johnson

2

A little unlearning goes a long way.

---Richard Kehl

Applicability of MI

Used to work in:

▪ Addictions/Gambling/Tobacco

▪ Health Behaviors (Nutrition, Med adherence & Exercise)

▪ Chronic illness (diabetes, asthma, heart disease)

▪ Dental Hygiene

▪ Mental Health disorders

▪ Mandated clients & offenders

More or Less

Describe several things you experience in your work with clients that you would like to

experience less often.

Describe several things you experience in your work with clients that you would like to

experience more often.

3

Who has motivated you?

Think of someone who has had a profound positive impact on your life.

(e.g., parent, relative, teacher, coach, counselor, spiritual leader, supervisor)

What was it about them that accounts for their impact on you?

List Attributes

How did it impact you?

◆ What was touched in you?

◆ What part of you did your relationship with this person strengthen, bring out, help to grow, reassure?

Non-MI or: “Make ‘em change!”

o Tell the speaker why they should make the change.

o Tell the speaker the three best reasons you can think of for them to make the change. (This may include warning them of the risks of not making the change and emphasizing the importance of the change)

o Tell the speaker how to change (make suggestions).

o Get a commitment to change.

o Create an action plan.

4

A taste of MI

◆ Why would you want to make this change?

◆ What are the three best reasons for you to do it?

◆ If you did decide to make this change, how might you go about it in order to succeed?

◆ After you have heard all of the answers, give back a short summary of what you heard, of the person’s motivations for change. Then ask one more question:

◆ So what do you think you’ll do? And listen with interest to the answer.

Spirit of MI

“…not a series of techniques … but a way of being with

clients”

(Information on MI adapted from Motivational Interviewing in Health Care. Miller and

Rollnick, 2008)

“They may forget what you said, but they will

never forget how you made them feel.”

Carl Buechner

Spirit of MI

◆Respectful

◆Honoring of client autonomy

◆Collaborative

◆Evocative

◆Compassionate

5

Spirit Summary

Skills Intro

◆Without the spirit it is not MI

◆Spirit creates a kind of relationship that enables change to occur.

◆MI Skills are used to implement the spirit

One Definition of MI

Motivational Interviewing a conversation

designed to strengthen an individual's

motivation for and movement toward a

specific goal by eliciting and exploring

the person’s own reasons for change

within an atmosphere of acceptance and

compassion.

Definition of Listening

Focusing all of one’s attention on understanding what the SPEAKER’S message means to them.

What is the SPEAKER experiencing right now?

Hear what the speaker is NOT saying.

6

Chinese character for Listen

Listening Exercises

◆Presence

◆ Interest

◆Curiosity

“Attention is the rarest and purest form of generosity”

--Simone Weil

7

“Confrontation is the goal of MI, not its

method.”—Wm Miller

◆Change occurs when the client recognizes the discrepancy between his/her current behavior and his/her values.

◆The Spirit, Techniques, and Structure of MI are intended to help move the process toward that goal.

Persuasion

People are generally better

persuaded by the reasons which

they have themselves discovered

than by those which have come in

to the mind of others.

--Blaise Pascal

MI Skills: OARS

O: Open-ended questions

A: Affirmations

R: Reflections, simple and complex

S: Summaries

8

Closed Questions

Closed Questions:

Invite a short answer– Did you drink this week?

Ask for specific information – 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.

They keep the control with the worker.

Open QuestionsOpen-ended Questions :

Put speaker in charge by allowing them to decide where to take the conversation

Increase the ratio of speaker talk/worker talk

Elicit unanticipated information

Examples:

“How can I help you?”

“Tell me about ___?”

“How would you like things to be different?”

“What are the positive things and what are the less good things about ___?”

“What will you lose if you give up ?”

“What have you tried before?”

“What do you want to do next?”

Open/Closed Question Exercise

◆ What brought you here to day?

◆ Do you think of yourself as depressed?

◆ Do you have on average 3 or more drinks a day?

◆ How do you feel about being in this program?

◆ Did you graduate from high school?

◆ How old are your children?

◆ Do you like your job?

◆ What are the most important reasons for you to do this?

◆ Did you ever do something difficult like this before?

◆ If you decide to do this, how will you go about it?

9

Closed vs. Open

or

Fact gathering vs. Evocative

Affirmations

Are statements of recognition of the

person’s strengths/values.

Affirmations are not flattery.

Must be congruent, genuine and specific.

Affirmations serve to build confidence in one’s ability to change. They create forward momentum toward change.

Exercise: Affirmation vs.

Positive Judgments

◆ It was hard for you to come here today and you did it anyway.

◆ I know you are a good person.◆ I think that is a good decision.◆ It looks to me like that was a hard

decision to make and I really admire how you stuck with it.

◆ Being a good mother is important to you.◆ That’s right, it would be better to quit.◆ You really feel good that you are not afraid

to work hard.

10

All Judgment is violence

◆ “Beware of the pat on the back It just might hold you back.”

“Smiling Faces”—The Temptations

Accurate Empathic Reflection

◆ It is one of the most important skills in MI.

◆ It is a response to a client statement that is a clear assertive statement-reflecting what the speaker said or meant.

◆ It is NOT a question!

◆ It is a process of:

Hearing what the speaker said,

Making a guess at what they mean,

Stating it back to them.

30

REFLECTIVE LISTENING

WHAT IS SAID

WHAT IS HEARD

HOW IT’S INTERPRETED

CHECK FOR UNDERSTANDING

WHAT IS MEANT

30

11

Reflection Demonstration

32

REFLECTIONS

◆Let the speaker know that we heard their words and their meaning.

◆Checks our understanding of what was said.

◆Lets the speaker hear their own words again.

◆Underscores or emphasizes parts of what they said.

Levels of Reflection

Complex – adds significant new meaning

“A good reflection is not a repetition it

is a revelation.”

--Carl Rogers

Simple – stays close to the speaker’s content

12

Statue of David◆ What is David thinking

◆ What is David feeling

Pennies for Reflection

◆ Groups of 3

◆ Speaker, Worker, Coach

– Coach has 10 pennies

– Worker has 3 quarters

– Speaker has a topic

◆ Worker gets a penny for each reflection

◆ Worker pays a quarter for each question

◆ Goal is to earn 10 pennies before running out of quarters

Miller Video

13

Summarizingcollection of client statements

Summaries are:

➢ a series of reflections capturing significant

parts of client speech.

➢ used at the end of or at transitions in

conversation.

Summaries are intended to:

➢ Ensure clear communication

➢ Allow the speaker to hear significant parts of

their thinking again.

Summaries (cont.)

◆A good summary will:

➢Be concise

➢Reflect speaker ambivalence, if present.

➢Accentuate speaker change talk.

n.b. The speaker is the judge of the

completeness and accuracy of the summary.

Summaries can:

◆ Collect material already offered

– So far you’ve expressed concern about your family, getting a job, and staying clean…

– What else?

◆ Link something just said with something discussed earlier

– you told me other times about that lonely feeling you get when no one comes to visit.

◆ Transition Draw together what has happened and transition to a new task

– Let me summarize what you’ve told me so far. You came in because you were …, and it scared you when . . . Then you mentioned… and now…

– …Where does that leave you?

14

The Righting Reflex

“One of the hardest things we must do sometimes is to be present to another person’s pain without trying to ‘fix’ it, to simply stand respectfully at the edge of that person’s mystery and misery.

Standing there, we feel useless and powerless, which is exactly how a depressed person feels – and our unconscious need as Job’s comforters is to reassure ourselves that we are not like the sad soul before us.”

◆ Parker Palmer◆ Let Your Life Speak

UNDERLYING ASSUMPTIONS

Autonomy/Choice

Acceptance

Michelangelo Belief

Elicit versus Impart

Less is better

Ambivalence is normal

Resist the Righting reflex

Bem’s Self Perception Theory

Acceptance

X Y

15

The Curious Paradox

◆ “The curious paradox is that when I accept myself just as I am, then I can change.”

--Carl Rogers

Reflection Roundtable

◆Respond to the speaker’s statement with a reflection.

◆Go underneath the surface.

◆What are you: hearing, feeling, seeing?

◆Put it into words. Reflect it!

The Four Processes

Engaging (Shall we go for a walk?)

Focusing (Where shall we walk?)

Evoking (Why?)

Planning (How?)

16

Engaging

◆ Goal: Safety & Optimism

Engaging

Focusing

◆ Goal: Developing a target:Deciding what change is being considered

Focusing

Evoking

◆Goal: Elicit Change Talk & Develop Discrepancy

Evoking

17

Planning

◆ Goal: Gain Commitment to a Specific Plan

Planning

The Four Processes

Engaging

Focusing

Evoking

Planning

Change Talk(The active ingredient in MI)

◆Change talk is a general term referring to speaker language that expresses the importance they see in making a change and/or their confidence in their ability to make the change.

18

Listening for/Eliciting Change Talk

DARN (preparatory change talk)

♥ Desire: I want to… I really like to… I wish…

♥ Ability: I can…. I am able to... I could…

♥ Reason: I think it would be good to…

Someone wants me to… This is important…

♥ Need: I need to do this… If I don’t do this…

CAT (commitment language)

◆C commitment (I will stop)

◆A activation (I’m ready to stop)

◆T taking steps (yesterday I only had one drink)

Drumming for Change Talk

1. I think I'm doing about as well as I can at this point.

2. I certainly don't want to go to jail.

3. I probably could exercise more.

4. I need to get high to feel right.

5. These medications make me tired.

6. Well, I wouldn’t mind cutting down on stress in my life.

7. Yes, I’m going to take my medication every day.

8. If I lose my job my girl friend is definitely going to leave me.

9. I used to exercise regularly.

19

10. I’ve got to get my blood sugar under control!

11. I'm going to get my blood sugar under control.

12. These voices are making my life miserable.

13. I can’t keep going like this.

14. I’ll do anything to get rid of this pain.

15. I don't think I’m psychotic.

16. I totally cleaned the cigarettes out of my house and my car yesterday.

17. I don't like watching what I eat. I mean I guess I have to, but I don't like feeling restricted.

18. Weed is so damned expensive!

19. I might be able to cut down on beer.

20. I’m not much on eating vegetables. I guess I’ll eat more of them, but I don’t enjoy them.

Commitment Language

◆ These statements are correlated with change outside of session.

◆ They are action oriented– I will…– I’m gonna try…– I’ll start tomorrow.– As of right now, I don’t eat donuts.– I’m going to the gym tonight.– I’m going to the library to find out all the ways

people quit smoking.

◆ The more specific the better

To control my own life

To be capable

To belong

To love and be loved

20

Snatching change talk from the

jaws of ambivalence

1. Identify Change Talk & Kind of Change Talk.

2. Create a Reflective Statement to emphasize the change talk.

3. If there is no change talk, what might you say to elicit some?

Imagine the response to your statement: Is it change talk?

Menu

Main

Menu

Looking for change talk5 Minute Conversation about a change the

speaker wants to make but hasn’t yet made.

Worker’s task:

Do: Help the speaker hear themselves describe all the reasons it would be beneficial for them to change.

Do Not: Involve yourself in the question of how to change.

Change Plan

◆Specific Steps the client intends to take to address the issue of concern

◆

–The more specific the better

–Plan for roadblocks

21

Some More MI Assumptions◆ Motivation is fluid and can be positively

influenced.

◆ Motivation is influenced in the context of a relationship.

◆ The worker’s task is to guide the conversation toward increased motivation for change.

◆ Goal of conversation is to influence change in the direction of health.

◆ People have a desire to move toward health.

Cultivating Change Talk

and

Softening Sustain Talk

Secret Exercise

22

The Choice is Ours

◆ Research indicates that which set of behaviors our clients display is heavily influenced by staff behavior.

◆ Within a single session changes in therapist behavior change the ratio of client resistance statements to statements supporting change.

◆ Use of Motivational Interviewing session at onset of treatment is correlated with increased attendance in treatment sessions and better behavioral outcomes.

MI View of Resistance and

Response to it◆ Resistance is fear

◆ Resistance is a sign that the worker has moved ahead of the client’s readiness

◆ Resistance is a signal for the worker to change approach

◆ Discord vs. Sustain talk

◆ Roll with Resistance (reflect)

“Confrontation is the goal of MI, not its

method.”—Wm Miller

◆Change occurs when the client recognizes the discrepancy between his/her current behavior and his/her values.

23

If we don’t turn around now, we

may just get where we’re going.

--Native American saying

MI Coding

◆OARS Score Sheet

◆Score Each Worker “Utterance”

–Question: Open or Closed

–Reflection: Simple or Complex

–Affirmation

–Summary

–Non MI

Rounder

24

Rolling with Resistance

Reflection Exercise

◆Break in to groups of 5

◆Generate list of speaker resistance statements

◆Take turns reflecting speaker statements

SKILLS◆ Your most common response to what the person says

should be a reflection.

◆ On average, reflect two times for each question you ask.

◆ When you reflect, use complex reflections (paraphrase and summarize) over half the time.

◆ Use metaphors and storytelling – tap into your life changes to understand the person.

◆ When you do ask questions, ask mostly open questions.

◆ Avoid getting ahead of the person’s readiness stage.

Responsibility

◆The worker is responsible for the intervention; not the outcome.

25

Harvey Haddix

May 26, 1959

Pittsburgh Pirates vs.

Milwaukee Braves

Lew Burdette

Joe Adcock

13 innings

1-0

MI Coaching

1. Ask worker permission to give feedback.

2. If permission is given, give positive feedback.

3. Ask worker what, if anything, they would like to work on to improve MI proficiency.

4. Reflect (get to a plan if possible).

5. If you have additional feedback ask permission to give it.

6. If permission is given, offer the feedback.

7. Be collegial and kind.

MI Conversation-3 Things

You

Diet

Physical

Health

Spiritual

Practice

Nicotine

Use

Job

Education

Dream

?

Family

&

Children

Financial

Health

26

MI Conversation

◆ Speaker: Find a card that represents where you are right now in you life.

◆ Listener: Invite the speaker to tell you about the card. Use all your MI skills to develop and understanding of what they are saying. Look for and reflect the ambivalence in the story.

◆ Listener: Avoid closed questions, limit open questions, avoid sharing your own experience or point of view. Do not try to solve the problem for them! Avoid the righting reflex.

Closing Summary

◆Tip of the iceberg

◆Further training opportunities

◆Practice, Practice, Practice

Contact Information and

Resources◆Health Education and Training

Institute (HETI)– www.hetimaine.org

◆ John Brelsford, PhD, LMHC– jebrelsford@gmail.com–413 433-1775

◆Motivational Interviewing Network of Trainers (MINT)–motivationalinterviewing.org