motivational interviewing skills workshop · complex reflections add meaning or emphasis to what...
TRANSCRIPT
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C H R I S D E B E E R , L C S W , L C A S A
A U G U S T 1 3 T H, 2 0 1 8
Motivational InterviewingSkills Workshop
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Welcome!
Two Cards Take a card from the wall that has a value on it that you think
is important Use the index card on the table to write down something you
hear people say that you want to know how to respond to with MI
Housekeeping schedule breaks bathroom lunch
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Agenda
MI Spirit and the 4 Processes BREAK Engaging LUNCH Focusing/Evoking BREAK Evoking Wrap-up
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What we hope to accomplish
By the end of this training you should be able to…
Define MI Spirit and the four processes of MI
Describe how to use OARS to engage clients
Identify and respond to change talk when evoking
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Introductions
Name
In what contexts do you talk to people about change?
How does the value you picked relate to change?
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On a scale of 1-10…
How much do you know about Motivational Interviewing (MI)?
What comes to mind when you hear ‘Motivational Interviewing?”
How important is it for you to learn MI?
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A technical definition of MI
“a collaborative, goal oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploringthe person’s own reasons for change within an atmosphere of acceptance and compassion.”
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What makes up the spirit of MI?
MI Spirit
Partnership
Acceptance Compassion
Evocation
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The spirit of MI
Emphasized above technique: MI is a way of being with people rather than a set of techniques for doing therapy
Partnership◦ work in collaboration with the client; talk less than ½ the time
Acceptance◦ honoring their worth and humanity, and right to self-determination◦ (does not mean approving of all their choices)
Evocation evoke or elicit vs. educate; people are experts on themselves
Compassion we work to promote others’ welfare; an intention in MI
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What does this look like in real life?
Empathy vs. Sympathy (Brené Brown clip)
What ambivalence do you encounter when talking to others about change?
What discussions do you have with people where you might use MI?
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The spirit of MI
Direct persuasion is not an effective method for resolving ambivalence. we all want to be helpful. It is fairly clear, however, that these tactics
generally diminish the probability of change
The counseling style is generally a quiet and eliciting one. direct persuasion, aggressive confrontation, and argumentation are
the conceptual opposites of MI.
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The spirit of MI
Readiness to change is not a client trait, but a fluctuating product of interpersonal interaction.
“Resistance” and "denial" are seen not as client traits, but as feedback regarding therapist behavior.
Discord is often a signal that the counselor is ahead of the patient, and it is a cue that the therapist needs to modify motivational strategies.
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The spirit of MI
The therapeutic relationship is more like dancing than wrestling
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Change can be undermined by our Righting Reflex
What is…the righting reflex??
When you allow your righting reflex to kick in, you often elicit resistance in a person who is ambivalent about changing. “Yes, but….”
When doing MI you must learn to rein in your righting reflex
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The Four Processes
The four fundamental processes of MI engaging – connecting with the client focusing – setting a course; what’s the change behavior? evoking – moving toward change; eliciting and responding planning – consolidating commitment, making a plan
In this training we will focus on engaging and evoking
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The Four Processes
The four processes are somewhat linear
Engage Focus Evoke Plan
…and yet also recursive
If you are feeling stuck, you may need to go back to an earlier process
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Engaging
Favorite Mentor/Teacher/Guide
What gets in the way of engagement?
What creates engagement?
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OARS
Fundamental Skills captured by OARS:
Open-ended questions
Affirmations
Reflective listening
Summarizing
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MI skills - OARS
Open ended questions
Open-ended questions provide the opportunity for clients to create and rationalize forward movement that is internally motivated
While close-ended questions are sometimes necessary and have a time and place, generally open-ended questions encourage more engaged discussion
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Activities
1. Open or closed? Don’t you want to get more exercise? What would need to happen for you to stay calm in class? How many times have you been suspended? What concerns do you have about school? Are you taking any medications? Do you go anywhere after school? What supports did you use this week when you got depressed?
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Opening up questions
Do you plan to go to college? “What goals do you have after high school?”
When are you going to quit smoking? “How do you feel about your smoking right now?”
Is the student doing better after starting CIS? “What changes do you notice since the student started
CIS?”
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MI skills - OARS
Reflections
A part of active listening
What does it look like in practice?
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MI skills - OARS
Reflections Hear what the person is communicating Make a guess about what he/she means Verbalize this guess in the form of a statement
What they think
What they say
What you hear
What you understand
What you Reflect
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Repeating key information that the client says to you
No added meaning Indicates that you’ve been listening Allows people to consider their own
thoughts
Simple Reflections
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Complex Reflections
Adds meaning or emphasis to what has been said
Learning to make complex reflections is a more advanced skill
What the client says
What might the client mean: unspoken thoughts, emotions, values, and beliefs
Simple Reflection
Complex Reflection
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MI skills - OARS
Forming reflections Initially…◦ It sounds like you’re not ready to…◦ It seems that you’re having a problem with…◦ It seems like you are feeling…◦ So you tell me you’re bothered by…
Eventually you can shorten reflections…◦ You’re not ready to…◦ You’re having a problem with…◦ You’re feeling that…◦ You’re bothered by…
Maintaining MI Spirit is crucial!
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Activity
“You mean that…”
“One thing that I like about myself is that I…” “You mean that…” Only “Yes” or “No” Next person: “You mean that…”
Debrief
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MI skills - OARS
Reflecting is the main skill used by MI clinicians
MI clinicians reflect back only certain aspects of what a client says
What might you focus on reflecting back to your clients?
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MI skills - OARS
Complex reflections add meaning or emphasis to what the client has already said
Emotion: You name the emotion that the client implied but never actually stated You feel that…
Value: You name the underlying values that you hear from the client It’s important that you…
Double-Sided: You reflect two opposing sides of what the client has been saying On one hand....and on the other hand....
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MI skills - OARS
Affirmations Statements of appreciation for the client and
his/her strengths
Build rapport Reinforce patient participation in both the change
process and in counseling Counterbalances negative statements/thoughts Empowers the patient; identifies strengths
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MI skills - OARS
Examples of affirmations
“You quit smoking for a year before starting again. Quitting for that long must have taken a lot of effort.”
“You’ve got a lot of strength to have coped with these symptoms for so long.”
“You’ve been exercising for a month now. You know what it takes to make a serious change.”
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MI skills - OARS
Making successful affirmations focus on specific behaviors
avoid “I” statements
be objective, not evaluative
be genuine, be genuine, be genuine
what’s the difference between ‘cheerleading’ and affirming? Note: In MI, we affirm and do not cheerlead.
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Two Students Exercise
Describe a student that you found rewarding to work with. What qualities did you notice about them?
Describe a student that was difficult for you to work with. What qualities did you notice about them?
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Focusing
The four fundamental processes of MI engaging – connecting with the client focusing – setting an agenda; what’s the target behavior? evoking – moving toward change; eliciting and responding planning – consolidating commitment, making a plan
Focusing is an ongoing process of seeking and maintaining direction around a change behavior
You need a destination on the horizon when you put your OARS in the water
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Focusing
Sources of focus Patient: I know what I need to change Setting: target issue determined by program Clinician: clinical expertise identifies relevant goals
Focusing scenarios I know where we’re going, the focus is clear
Clear target There are several options and we need to decide
Agenda mapping The focus is unclear and we need to explore
Orienting
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Focusing Scenarios
“I know where we are going; the focus is clear.”
Clear Target
“There are several options, and we need to decide.”
Agenda Mapping
“The focus is unclear and we need to explore.” Orienting
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Focusing
Bubble sheet exercise
A useful way to find a target behavior A useful way to elicit multiple areas of concern Use open ended questions to then focus on one
concern
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Evoking
The four fundamental processes of MI engaging – connecting with the client focusing – setting an agenda; what’s the target behavior? evoking – moving toward change; eliciting and responding planning – consolidating commitment, making a plan
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Evoking
Moving towards change
Who is the expert?
Tuning your ear to change talk
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Change talk
Change talk – talk in favor of making a change
Sustain talk – talk about maintaining the status quo
MI emphasizes change talk over sustain talk
More client change talk = more likely to change
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Recognizing change talk
Preparatory MobilizingDesire Commitment
I’d like to, I want to... I am going to...
Ability Activation
I could... I am ready to...
Reasons Taking Steps
I have a good reason to... I have...
Need
I need to...
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Activity
Change talk demonstration
D – Desire (“I’d like to …” “I want to…”) A – Ability (“I could …”) R – Reason (“I have good reason to…”) N – Need (“I need to …”)
C – Commitment (“I do” or “I will”)
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Activity
Drumming for change talk
You listen and let us know when you hear DARN language
Finger drum role with preparatory language (DARN) and pearl fingers + “ooh!” with mobilizing language (CAT)
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Responding with EARS
E – Elaborate Tell me more
A – Affirm I see your resilience
R – Reflect I hear your change talk
S – Summarize Selecting flowers for the bouquet
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Want change talk? Ask for it!
Preparatory MobilizingDesire Commitment
-Why would you want to…? -What will you do?
Ability Activation
-How might you go about…? -What are you considering doing?
Reasons Taking Steps
-What are your reasons for…? -What have you already done to…?
Need
-How important is it for you to…?
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Evoking Practice
Roleplays vs. Realplays
When will you use this?
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Keep Practicing!Research suggests that after an initial training of at least 10 hours:⁺ Spike in skills, reflective listening.⁺ No decrease in inconsistent behavior⁺ Without follow up, skills return to
baseline after 4 months.⁺ Adding feedback and/or coaching helps
with adoption & maintenance.
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8 Tasks to Learning MI1. Spirit of MI and Four Processes2. OARS: client-centered skills3. Recognizing & reinforcing change talk4. Eliciting & strengthening change talk5. Responding to sustain talk and discord6. Negotiating change plans7. Solidifying client commitment8. Shifting flexibly between MI & other
approaches