motivational interviewing skills workshop · complex reflections add meaning or emphasis to what...

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

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

Agenda

MI Spirit and the 4 Processes BREAK Engaging LUNCH Focusing/Evoking BREAK Evoking Wrap-up

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

Introductions

Name

In what contexts do you talk to people about change?

How does the value you picked relate to change?

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?

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.”

What makes up the spirit of MI?

MI Spirit

Partnership

Acceptance Compassion

Evocation

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

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?

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.

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.

The spirit of MI

The therapeutic relationship is more like dancing than wrestling

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

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

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

Engaging

Favorite Mentor/Teacher/Guide

What gets in the way of engagement?

What creates engagement?

OARS

Fundamental Skills captured by OARS:

Open-ended questions

Affirmations

Reflective listening

Summarizing

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

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?

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?”

MI skills - OARS

Reflections

A part of active listening

What does it look like in practice?

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

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

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

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!

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

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?

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....

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

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.”

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.

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?

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

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

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

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

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

Evoking

Moving towards change

Who is the expert?

Tuning your ear to change talk

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

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...

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”)

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)

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

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…?

Evoking Practice

Roleplays vs. Realplays

When will you use this?

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.

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