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Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II
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Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Dec 18, 2015

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Page 1: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Furthering Your Motivational Interviewing

Skills

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

Page 2: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

PART 1

Page 3: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

“I HAVE ALWAYS KNOWN THAT AT LAST I WOULD TAKE THIS ROAD, BUT

YESTERDAY I DID NOT KNOW IT WOULD BE TODAY”

Narihira

Page 4: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

THREE THINGS TO REMEMBER

• AMBIVALENCE IS NORMAL

• EFFECTING CHANGE IS A PROCESS

• CLIENTS NEED TO COME UP WITH THEIR OWN ARGUMENTS FOR CHANGE

Page 5: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

3 FACTORS THAT INFLUENCE MOTIVATION

• WILLING

• READY

• ABLE

Page 6: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

MI WITHIN THE STAGES OF CHANGE

Precontemplation

PREPARATION

CONTEMPLATION

ACTION

MAINTENANCE

Provider’s Role: To engage clients by utilizing an empathic style of reflective listening and to assist them in exploring and resolving their ambivalence.

“LAPSE”

RELAPSE

Page 7: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 8: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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.

Page 9: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

MILLER’S 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

Page 10: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

What is Motivational Interviewing?

…a collaborative, person-centered form of guidance to elicit motivation for change”

Miller & Rollnick 2008

Page 11: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

SPIRIT OF MI

• EMPATHIC

• COLLABORATIVE

• RESPECTS ONES AUTONOMY, CHOICE AND DECISION MAKING

• EVOCATIVE

• DIRECTIONAL

Page 12: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Early Counseling Traps

“Hey! You’re not listening!”

“I’m the expert here.”

Page 13: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Traps To Avoid

• Question-Answer Trap

• Confrontation-Denial Trap

• Labeling Trap

• Premature Focus

• Blaming Trap

• Expert Trap

Page 14: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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 caringThere’s a problem? Let’s fix it!Fails to consider ambivalence in change processMay engender resistance

Page 15: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

MILLER’S BROAD PRINCIPLES

Express empathy

Develop discrepancy

Roll with resistance(Avoid argumentation)

Support self-efficacy

Page 16: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 17: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Getting Moving On OARS

OPEN QUESTIONSAffirm

Reflect

Summarize

Page 18: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Open-ended Questions Questions that cannot be

answered “yes/no”, but which encourage clients to express

their thoughts, feelings, or concerns

Page 19: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Change to Open-Ended Questions

1. Do you feel you have a problem with alcohol?

2. Is it important to you to complete supervision successfully?

3. Anything else?

Handout – c / o questions

Page 20: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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.

Page 21: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Getting Moving On OARS

Open Questions

AFFIRMReflect

Summarize

Page 22: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Affirmation Expression of appreciation for client’s efforts or participation.

Page 23: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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 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?

Page 24: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Practicing AffirmationsWrite 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

Page 25: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Getting Moving On OARS

Open Questions

Affirm

REFLECTSummarize

Page 26: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Reflective Listening Accurate understanding of client’s experience,

communicated in a warm, non-judgmental manner.

Page 27: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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.

 

Page 28: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Complex Reflections

Paraphrase- These reflections change, or add to what the client has said in a significant way to infer the client’s 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.

Page 29: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Levels of ReflectionsC. Even though nothing has happened I’ve been

feeling more depressed lately. I wish it would go away.

Repeat: You’ve been more depressed lately.Rephrase: So your sadness is getting worse and

you don’t know why.Emotion: You’re 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 you’ve been

living with depression and on the other hand you’re tired of it and wondering what to do.

Page 30: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Increase Quality of ReflectionsBY:

• Making sure inflection

is a statement

• Strip statement down

• Clear and Concise

• Use reflections to

continue the paragraph

Page 31: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Reflective Listening Exercises

“I don’t know why this is such a big deal for everyone else. All my friends drink like I do.”

“Everyone should just relax. I’m doing the best I can with trying to find a job.”

“I know I’m suppose to take my meds but you don’t know my friends. It’s basically impossible to take them when we hang out.”

Page 32: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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 don’t want to do. Even my wife keeps nagging me about taking those pills.”

Page 33: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Reflection Role Play

• (1) Speaker: “One thing about myself I’d 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

Page 34: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Getting Moving On OARS

Open Questions

Affirm

Reflect

SUMMARIZE

Page 35: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Summarizing Bringing together of several of

the client’s previously expressed thoughts, feelings, or concerns, often including the clinician’s understanding of how these fit

together.

Page 36: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 37: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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 – Collect2’nd Listener – Link or Transition

Switch Roles

Page 38: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

PART 2

Page 39: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

OARS TO…. AROSE

• Affirmation

• Reflective Listening

• Open-ended Questions

• Summarizing

• Elicit Change Talk

Page 40: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 41: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Elicit Change Talk

Why Is Change Important?

Problem Recognition

Concerns

Optimism

Intention to Change

Page 42: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 43: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Recognize Change Talk

• Desire: I want to

• Ability: I can

• Reason: It’s important

• Need: I should

Drumming Exercise

Page 44: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

RESPONDING To Change Talk

EARS

• Elaborating

• Affirming

• Reflecting

• Summarizing

*It’s important to recognize and respond to Change Talk using the above skills.

Page 45: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Being Strategic with MI Strategies

Client: “I don’t know, I really don’t want to go to that drug treatment program. I know I can quit on my own.”

Non-Strategic Reflection:You don’t want to participate in the drug treatment program.

Strategic Reflection:It’s really important to you to address your drug use and you realize that quitting is a strategy that will work for you.

Page 46: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Using EARSR I’d 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 I’ve got to do something about my anger.A I’m going to start my cog program todayE 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 I’m 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

Page 47: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Select something about yourself you want to change, you know you should change, but you haven’t yet changed….a health behavior or quality

Page 48: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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 you’re 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

Page 49: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Exercise: continue

Switch Roles:Groups of 3: 1 Speaker, 1 Listener, 1 ObserverEliciting 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

Page 50: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Exercise: continue

Switch Roles:Groups of 3: 1 Speaker, 1 Listener, 1 ObserverEliciting 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

Page 51: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

CONSOLIDATING COMMITMENT

Page 52: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Signs of Readiness

Decreased sustain talk Decreased discussion about the

problem Resolve Increased change talk Questions about change Envisioning change Experimenting with change

Page 53: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Recognize Commitment

• Commitment: I will

• Activation: I am ready

• Taking Steps: I am doing it now

CARDS

Page 54: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Strengthening Commitment What Do You Want To Do About It?

• Ask An Action Question – Transition - “What are you willing to do now…Where do we go from here…What’s 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

Page 55: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 56: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

STEPS to Consolidate

Big summary of all change talkScale readiness if desiredKey Action questions:

What’s next?What changes do you think you will actually make?Where do we go from here?

EARSConnect Talk to Action

Page 57: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

PART 3

Page 58: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

Doctor / PatientVideo

Page 59: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 60: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

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

Page 61: Furthering Your Motivational Interviewing Skills Presenter: Ann Fields, M.S.E., CADC III, CGAC II.

THE END