tips: · web viewclosed ended questions may be answered with a one-word response. multiple-choice...

Tailored Motivational Interviewing (TMI)

COMMUNITIES OF PRACTICEGUIDE

Last updated: 1/14/19 1


Communities of Practice OverviewCommunities of Practice (CoP) is a strategy to promote uptake and sustainability

of evidence-based practices. It is based on a view of learning as an individual and social phenomenon rather than a one one-way transfer of formal knowledge between groups or individuals. CoPs are groups of people who share a concern or passion for something they do, and they learn how to do it better as they interact regularly.

CoPs have three characteristics:1. Domain – There is a shared domain of interest. In this case, it is motivational

interviewing (MI).2. Community – Members of the CoP engage in shared activities and discussions.

They build relationships to learn from each other.3. Practice – The CoP actively promotes learning. It is not simply a group of people

with shared interests, but rather a group that interacts, shares information, and learns together.The intention in TMI is that the iTeam and staff will work together as a community

to continue developing and maintaining MI skills. The specific activities and practice opportunities to accomplish this goal will be selected by the CoP with guidance from the iTeam—and the iTeam is part of the CoP.

The iTeam guides development of the CoP by scheduling and assisting in setting the agenda at the end of the implementation period to encourage MI practice, engagement in peer coaching and potentially fidelity monitoring, and prevention of drift. In helping to create opportunities for group practice, the iTeam makes decisions regarding the context and formality of the practice and method of communication. For example, practice opportunities may occur in staff meetings, cross-site groups, or as part of informal staff contact. An iTeam may decide to hire an external training facilitator, develop internal expertise, and/or purchase learning materials such as MI books and videos. Communication during practice opportunities may be discipline-specific or multidisciplinary, and virtual or face-to-face. Although the CoP itself should be non-hierarchical, practice opportunities may be hierarchical or parallel. Decisions about CoP practice opportunities, resources, and other skill maintenance efforts should be informed by feedback from staff about their needs and interests. The CoP may also change its agenda over time to suit the needs of its members.

Although MI fidelity feedback will no longer be provided by the TMI team during the study’s sustainment phase (starting 1 year post-workshop), the iTeam is encouraged to review ongoing data regarding staff adherence to TMI as indicated by role play completion rates and patient outcomes on at least a quarterly basis. It is expected that doing so will help the iTeam to better understand barriers and facilitators to integrating implementation into ongoing procedures and practice as the TMI project comes to an end.



The remainder of this manual includes a table of MI skill adherence items that may be used to aid ongoing evaluation of MI skills and a collection of activities offered as a resource ongoing skill development and maintenance. It is recommended that other resources be created or gathered by the iTeam and members of the CoP as it continues to develop. Finally, a website will be available through Scale it Up (SIU) for TMI sites to use as they enter sustainment. It will initially serve as an information source and repository of resources and ideas. As more sites enter sustainment and use the website, its content and usefulness is expected to grow. This growth depends in part on the contributions of CoPs and iTeams at TMI sites. Suggested content may be sent to the TMI team at [email protected].



MI Skill Adherence Items



Activities for Communities of Practice:The below activities may be used to improve specific MI skills as identified through formal or informal evaluation processes as determined by the CoP, including self-evaluation. The numbered activities correspond to MI Skill Adherence Items (see table on previous page). For example, item 1 corresponds to activities 1.1 through 1.2. The number of activities for each item varies.

The terms “counselor” and “coach” are used generically in the below activities to help differentiate the roles of each CoP member during practice. Also, “counselor” is used to indicate a practitioner or other staff member.

ITEM 1. THE COUNSELOR CULTIVATES EMPATHY AND COMPASSION WITH CLIENTS. This item assesses the degree to which the counselor understands or makes an effort to grasp the client’s perspective and feelings, and convey that understanding to the client.

Activity 1.1: The Spirit of MIDirections

• The coach will ask the counselor to think about a client they struggle with.• The counselor then considers three questions about this client/parent;

– Where are you now in your work with him or her?– Where would you like to be?– What's getting in the way of that happening?

• Now put yourself in the patient’s shoes – how do you feel?Assessment: Discuss the answer to the how do you feel question and process.

Activity 1.2: Expressing Compassion

Directions

Counselor will write a description of an actual client for whom it is easy for them to be compassionate with. Also write down the kinds of statements the client says.

Counselor then write a description of an actual client for whom it is difficult to be compassionate, and write down statements that client says.

Assessment: The counselor forms 3 feeling reflections from the statements made by each client.

ITEM 2. THE COUNSELOR FOSTERS COLLABORATION WITH CLIENTS. This item assesses the degree to which counselors negotiate with clients and avoid an authoritarian stance. A metaphor for collaboration is dancing instead of wrestling. When providing information in a collaborative way, a key skill is Ask-Tell-Ask.

Ask - the counselor asks for permission to provide information or asks an eliciting question about interest or knowledge about the topic.

Tell - the counselor provides the information or advice in small, digestible chunks (Chunk-Check-Chunk).



Ask - the counselor elicits the client’s reaction with another question.

Activity 2.1: Ask – Tell – AskDirections

The counselor creates a scenario where they would have to give a client vast amounts of information on a certain topic. The counselor assesses the client’s interest or perceived importance of discussing the topic by asking any of the following questions:

a. “How interested are you in finding out more information about_______?”b. How important is it for you to find out more information about_______?”

Once the counselor finds out the interest or importance level of the client, then they can use ATA to give that information to the client.

The counselor then gives the information/advice in small chunks. Then checks after each chunk by using any of the following example questions

o “What do you understand about the information I just gave you?”o “What do you think you might do with this idea?o “Tell me in your own words what you got from this information?”

Assessment: Discuss when and where to use ATA and its purpose

Activity 2.2: Role Play Directions:

The coach creates a scenario in which they play a patient at 3 different knowledge levels (no knowledge, partial knowledge, and full knowledge).

The counselor then has to use ATA (and Chunk-Check-Chunk) to give the client information. But first the counselor must assess the patient’s knowledge base. The following sample questions may be used.

o What, if any, things have you heard about_______?o What else do you know about_______?

After assessing the clients knowledge base the counselor then gives the client information/advice in small chunks. Then checks after each chunk by using any of the following example questions

o What do you understand about the information I just gave you?o What do you think you might do with this idea?o Tell me in your own words what you got from this information?

Asking these types of questions helps the counselor assess the client’s knowledge base and also what amount of information to give to the client. It saves time and makes the patient feel that they are part of the session

Assessment: Discuss in detail the purpose of using the knowledge-based questions in the scenario. Then have the counselor practice giving information to patients with different levels of knowledge.



ITEM 3. THE COUNSELOR SUPPORTS THE AUTONOMY OF CLIENTS. This item assesses the degree to which counselors emphasize client’s freedom of choice and convey an understanding that the critical variables for change are within the client and cannot be imposed by others.

Activity 3.1: It’s All About YouDirections

The coach plays a patient who is ambivalent about changing. Also during the scenario the coach also keeps a count of the autonomy supportive statements.

The counselor then supports autonomy by using Ask-Tell-Ask instead of providing unsolicited advice about the benefits of changing. Add autonomy supportive statements to the TELL in Ask-Tell-Ask Example of supportive statements:

o “You said you wanted to…”o “Yes, you’re right. No one can make you ______”o “If you’re not ready to__________, we can find another area to focus on.”o “Nobody can make you change.”

Assessment: Discuss and explain the use of the use of the autonomy supportive statements used in the scenario. Give feedback on number of strategies used.

Activity 3.2: Menu of OptionsDirections

Coach plays a patient who wants to make a change but doesn’t know where to start. The counselor offers and then provides a variety of options rather than suggesting them one at a time. A

menu of possibilities prompts a different mindset: Which of these options might be best? Rather than coming up with objections to a single suggestion, the coach’s task is to consider a range of possibilities and choose among them.

Once the coach has chosen an option and the counselor has reflected and evoked. The counselor can then emphasize autonomy in the form of key questions:

o “So what will be your next step?”o “What do you want to do next?”o What is your choice?”

Assessment: Have the counselor explain in there own words the importance of using you statements throughout the session.

Activity 3.3: Role PlayDirections

The coach plays a client and identifies the target behavior (e.g., substance use, medication adherence, physical activity).

The counselor then uses the strategies in the handout below to support autonomy. The coach records the number of strategies to support autonomy that was used through out the role-play.



Autonomy Supportive Strategies

Use You statements –Your plan is to, You said you wanted to Emphasize Choice:

“I really respect the fact that you like to eat what you like to eat.”

“If at any time here it sounds like I’m telling you that you have to do something, remember this is what you want to do, so you can say no way.

“Yes, you’re right. No one can force you to take medications.”

“You’re the one who knows yourself best here. What do you think ought to be on this change plan?”

“The number of fruits and vegetables you choose to eat is really up to you.”

“If you are not ready to cut out sweets, we can find another area to focus on.”

"Nobody can make you change."

Support autonomy by using Ask-Tell-Ask instead of providing unsolicited advice. Avoid using words like “should” and “must.”

Add autonomy supportive statements to the Tell in Ask-Tell-Ask

“I don’t know whether this will concern you. . . . ”“See which of these you think might apply to you. . . . ”“This may or may not interest you. . . . ”“I wonder what you’ll think about this.”“You might disagree with this idea, and of course it’s up to you.”

Offer a menu of options - Provide a variety of options rather than suggesting them one at a time. Use key questions that are neutral and open-ended: “What will be your next step?” “What do you

want to do next?” “What is your choice?”

Assessment: Have the counselor explain which strategy they felt comfortable with and why.

ITEM 4. THE COUNSELOR WORKS TO ELICIT CLIENT’S IDEAS AND MOTIVATIONS FOR CHANGE. This item is intended to measure the extent to which the counselor conveys an understanding that motivation for change, and the ability to move toward that change, reside mostly within the client and therefore focuses efforts to elicit and expand it within the therapeutic interaction.

Activity 4.1: Eliciting Change TalkDirections

The counselor asks an open question to elicit change talk (DARN-C) The coach responds. The counselor then reflects the change talk, if any. If there is no change talk, the

counselor then asks another open question until change talk is heard.



Once the counselor responds to change talk, they are then to identify what type of change talk it is (DARN-C)

Sample open questions: Why would you want to consider physical activity (DESIRE)? What have you tried to help your child lose weight (ABILITY)? If you did lost weight in the next year, how would things be different for you (REASONS)? A lot of people are talking to you about your weight, why do YOU think you might need a change (NEED)? What is one thing you would consider trying (COMMITMENT/STEPS)?

Assessment: Counselor identifies the three-step sequences (open question, change talk, reflection).

Activity 4.2: Try The Ruler

Directions

One of the many useful evoking strategies is the ruler. The ruler is very helpful in eliciting change talk in a very short amount of time. Once the clients focus behavior has been determined, replace the blank with any focus behavior and then complete the ruler.

First demonstrate the importance ruler

On a scale from 1 to 10, how important is it for you to __________________ where 1 is not at all important and 10 is most important?

Reflect Why did you say xx and not a lower number? Reflect What would it take for you to get to a higher number? ReflectAssessment: Now have the counselor do it as a confidence ruler.

Activity 4.3: Eliciting Client’s Ideas About Change: The Change Plan Directions

The role-play starts with the client (coach) having already been through the engaging, focusing, and some evoking around the target behavior (e.g., improving medication adherence).

The provider (counselor) provides a summary of the previous processes (make it up!) then asks one of the key questions leading to the planning phase.

o Where you want to go from here?o What are your next steps?o Do you have a plan you want to discuss?

Once the question is answered, the counselor reflects the answer and runs through a change plan with the client, remembering to elicit change talk and reflect all the way through.

Assessment: Discuss the use and purpose of using a change plan.



My PLAN

Changes I would like to make:

__________________________________________________

__________________________________________________

__________________________________________________

These changes are important to me because:

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

I plan to take these steps (what, where, when, how):

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

(query about a target behavior if not spontaneously provided)

IF this gets in the way THEN try this



ITEM 5. THE COUNSELOR BALANCES THE CLIENT’S AGENDA WITH FOCUSING ON THE TARGET BEHAVIORS. This item measures the degree to which counselors maintain appropriate focus on a specific target behavior or concerns directly tied to it while still addressing the client’s concerns.

Activity 5.1: Focusing FunnelDirections

The coach (real play) – you want to get healthier but don’t share your target immediately. The counselor has to guide you to focus on target behavior

The counselor then has to guide the focus on target behavior with open questions and reflections. Start the real play with the following question. Ask – “How are you feeling about your health?

Explore agenda with open questions/reflections (reflect at least every answer) – Get more specific as the conversation continues

Avoid problem solving but off information/options with ATA if necessary At the end draw (or discuss) a funnel that shows where the coach started (getting healthy), where they got

to in the middle (e.g., improving nutrition) and where they ended (e.g., cutting back on sugar).

Assessment: Discuss the pros and cons of using the focus funnel

Example of Focus Funnel

Counselor: How are you feeling about your health? (Broad)

Coach: I feel ok, just need to lose some weight I think.

Counselor: You feel weight loss (narrow) is your main concern when it comes to your health. In dealing with weight loss, what areas would you like to address.

Coach: I guess nutrition (narrower) is where I want to starts.

Counselor: So your thinking nutrition. What part of your nutrition would you like to change?



Activity 5.2: Agenda MapDirections

The counselor asks the coach the following focusing question. “What is the most important thing that you are concerned about when it comes to your health?” Write the answer in the middle of a piece of paper.

You know have a temporary focus. Ask several open questions dealing with that focus such as “What other areas concern do you have about your health besides_____?” “What other areas of your life are related to your health?” “What gets in the way?” “What helps?” Now form branches leading off of the main focus to form subtopics of the focus.

The paper should now have a circle in the middle with several smaller circles branching off of the main focus (see Agenda Map in appendix)

Assessment: Discuss the importance of having a map. Discuss your next steps based on the map.



Activity 5.3: Three Types of FocusingDirections

Coach plays three different types of clients at the focusing level. First client-has no general focus. In this case the counselor can return to the engaging process, with a

particular emphasis on exploring values and goals to provide a general focus, then move to a structured conversation to develop more specific treatment targets

Second client-the focus may be clear based on the setting or your expertise. Example of the setting maybe someone being court-ordered for alcohol treatment or being enrolled in weight loss program by someone else. Focus maybe based on expertise but the client doesn’t see it.

Third client-multiple treatment goals. The coach must zoom in on a start point. A good place to start is a summarizing reflection of the engagement conversation and ask for permission to develop a shared agenda

Assessment: Discuss in detail the process of getting to share agenda for each client.

Activity 5.4: Agenda Setting

Directions

The provider (counselor) is supposed to address smoking (or choose another behavior), but the coach plays a client who wants to discuss getting food stamps (or choose another priority).

The counselor then practices the using any of the following statements. Then choses one and continues the role play until a clear focus behavior is established.

o “So getting food stamps is really a priority for you right now. I also need to discuss smoking. What would like to discuss first.”

o “You talked about food stamps, housing, and I also have some results about your smoking. Which of these would you like to consider first, the hardest one or maybe the easiest? OR which of these is most of a concern for you”

Assessment: Have the counselor discuss the advantages of establishing a clear focus while balancing the client’s agenda with the provider’s agenda.



ITEM 6. THE COUNSELOR USES REFLECTIVE LISTENING. This item primarily measures the frequency of reflective statements compared to questions. Simple reflections are a repetition or paraphrase of all or part of a client statement. Complex reflections include reflections of feelings, continuing the paragraph, double-sided reflections (on the one hand, and on the other hand), affirming reflections (see affirmations below), and summarizing reflections (see summaries below). Stacked questions (closed then open) count as open and as one question.

Activity 6.1: Menu of ReflectionsDirections

The coach reads 1 sentence stem from the list below, to the counselor. Then the counselor has to create 3 different types of reflections (Simple, Complex, Affirming) from that sentence stem.

Stem 1: I am just so sick and tired of people always telling me what to do. I mean really! Where do they get off thinking they have the right to say that?

Stem 2: It’s like this. I’ve tried everything and nothing seems to be working. So I don’t know what to do.

Stem 3: I don’t know why I keep doing this. I mean I’m an idiot. I know it can kill me. I just don’t have any will power I guess.

Stem 4: My kids are really important to me and I don’t want to anything that might hurt them

Stem 5: So, given the big picture, this thing we are talking about really feels like small potato.

Assessment: Discuss the types of reflections used. Then go over the three different types of reflections created by the counselor. Coach gives feedback in a MI style.

Activity 6.2: Reflection: Question Ratio

Directions

The counselor walks into a patient room (tell the coach scenario) with a guiding style. The counselor will also tally reflections and open questions

The coach then follows the scenario (be not too hot and not too cold). The coach also tally reflections and open questions

Assessment: Coach discusses the ratio with the counselor in an MI style. Asking several key questionso What do you think about your ratio?o What, if any improvements could you have made in your ratio?o Discuss how to maintain the 1:1 or 2:1 ratio.



Activity 6.3: Batting PracticeDirections

The coach uses real standard statements made by clients on a daily basis. The counselor then reflects each one of the statements created by the trainer. Also naming what type of

reflection they just used [Simple, Complex (including feeling), Affirming].

Assessment: Discuss and explain the use of reflections. Have the counselor create simple and complex reflections.

ITEM 7: THE COUNSELOR USES REFLECTIONS STRATEGICALLY. This item primarily measures the quality of the reflections. Low quality reflections are inaccurate, lengthy, or unclear. High quality reflections are used to express empathy, develop discrepancy, reinforce change talk (desire, ability, reasons, need and commitment to change), reduce counter change talk and discord (see item 12 below), and generally strategically increase motivation.

Activity 7.1: Drumming for Change TalkDirections

The coach creates and uses several non-change talk and change talk statements in a discussion with the counselor

The counselor then drums every time they hear change talk statementsAssessment: Discuss and explain the statements that were deemed as change talk. Then have the counselor create 3-5 change talk statements and counter change talk statements on his or her own.

Activity 7.2: Reinforcing Change TalkDirections

The coach uses real change talk statements made by clients on a daily basis. The counselor then reflects each one of the statements created by the coach emphasizing the change talk

made by the client. Then reinforces the change talk by reflecting and asking any of the following open questions: Tell me more about that? Why is that important? What makes you feel that way? Why is that?

Assessment: Discuss the answers to the questions making sure the counselor can express the need to reinforce change talk in their own words. Before you gave individual change talk statements, now try giving longer statements that include change talk and counter change talk, and the counselor has to reflect the change talk (pulling change talk out of the jaws of ambivalence). Now try open role play, and count the number of times the counselor reflects change talk.

ITEM 8. THE COUNSELOR REINFORCES STRENGTHS AND POSITIVE BEHAVIOR CHANGE WITH AFFIMATIONS/AFFIRMING REFLECTIONS. This item measures the extent to which the counselor affirms personal qualities or efforts made by the client that promote productive change or that the client might harness in future change efforts.



Activity 8.1: Affirming StemsDirections

The coach creates several client centered statements which include a changed behavior or about the client’s strengths or values

The counselor reflects each statement, but uses the affirming stems to respond.

Affirmation Stems

1. You’ve been working on <change effort> and it shows. 2. It takes <strength> to do that. 3. With your <knowledge, experience, or skill>, you have a lot to build on. 4. With your <knowledge, experience, or skill>, you’re in a great position to <client goal> when you’re

ready.

It’s great that you xxx, One of your strengths is xxxx, You seem like the kind of person who xxx, You seem like an xxxx (strength) person because you xxxx (behavior).

Assessment: Discuss the difference between affirming reflections compared to the other types of reflections.

Activity 8.2: Mining for AffirmationsDirections

The coach asks the counselor to identify strengths that their clients bring to their practice/clinic. Record these on a piece of paper. Try to elicit at least 5. Make sure these are stated positively.

Now that the counselor has the 5 strengths, they will now create 5 open questions to elicit each strength and an affirmation you might offer in response to this strength.

Assessment: Read and discuss the 5 open questions and affirmations. Discuss why specific affirmations are better than general ones.

ITEM 9. THE COUNSELOR USES SUMMARIES EFFECTIVELY. Summaries pull together points from more than two prior client statements. At least three different ideas must be conveyed, as opposed to two reflections of the same idea. Summaries are a way to express active listening and reflect back to the client the “story.” Summaries are also used to structure the session as well as to guide clients in the direction of change.

Activity 9.1: Power of 3Directions

The coach creates a scenario and starts a dialogue with the counselor. The counselor reflects 3 times then summarizes the conversation (coach can prompt if necessary). Repeat

the process 3 times. After repeating the process 3 times the counselor is then going to create a final summary covering the

following points



Final Summary Points1. Where the conversation started2. Affirmations3. Any change talk4. Where the conversation ended

Assessment: Discuss and explain why do we summarize after 3 reflections are given.

Activity 9.2: Summarizing ExerciseDirections:

The coach talks for 90 seconds about a habit, behavior, dilemma or situation that they are thinking about changing.

The counselor is to be interested in what the coach is talking about without saying anything or asking questions. Then give a summary of what you have been told by the coach. Do not try to solve the problem or give advice. Remember a summary must cover at least 3 major points.

Assessment: Discuss the purpose of summaries and have the counselor explain the purpose in their own words. Followed by a another example of a summary from the exercise

ITEM 10. THE COUNSELOR ASKS QUESTIONS IN AN OPEN-ENDED AND CLEAR WAY. An open question is one that allows a wide range of possible answers. Closed ended questions may be answered with a one-word response. Multiple-choice questions are considered open particularly with clients who struggle with open and more abstract questions. Ask-Tell-Ask closed questions don’t count. Stacked questions (closed then open) count as open and as one question.

Activity 10.1: Fielding PracticeDirections

The trainer throws out a closed ended question The coach then throws it back to the coach as an open-ended question. Play several rounds

Assessment: Discuss and have the counselor explain the difference between closed and open-ended questions.

Activity 10.2: Toolbox

Directions:

The coach and counselor will create a list of questions that the counselor can use in any MI session. Questions that the counselor should always have with them just in case they need to reach into their toolbox and pull out a question.

The coach will give the first example question in each category. Then helped the counselor create the other sentences



YOUR TOOL BOX!

TIPS:Reflect answers before asking next questionReinforce change talkSummarize every few pointsUse Ask-Tell-Ask (ATA) if necessary

Open questions for ENGAGING:Example: “What is most important to you right now?”Example: “What have you been up to since the last time we met?”Example: “What would you like to get out of this session today?”

Your Example: ___________________________________________________

Your Example: ______________________________________________________SUMMARIZE!

Open questions that work for FOCUSING:Example: “Of all the different things you mentioned when it comes to {target behavior}, what would you find most the helpful to discuss first?”Example: “If it is ok with you, I want to discuss {target behavior}. Or, is something else more pressing to you at this moment?”Example: “If you were going to change one thing about {target behavior}, what would it be?”

Your Example: ___________________________________________________

Your Example: _______________________________________________________SUMMARIZE!



Open questions that work for EVOKING:Example: “Of all the different things you mentioned when it comes to {target behavior}, what would you find the most helpful to discuss first?”Example: “What are some reasons for changing {target behavior}?”Example: “What would be the best thing that would happen to you if you changed {target behavior}?”Example: Use Importance and Confidence Rulers

Your Example: ____________________________________________________

Your Example: _____________________________________________________SUMMARIZE!

Open questions that work for PLANNING:Example: “What steps are you willing to take, in the next week, to reach your goal?”Example: “When and how will you start your plan?”Example: “What might get in the way of your plan and how will you handle it?”

Your Example: ____________________________________________________

Your Example: ____________________________________________________

REMEMBER FINAL SUMMARY (using the person’s own statements, in any order):

Where client startedWhere client endedEmphasize autonomyReflect commitment language or change talkAffirmation



Assessment: Do a 15-minute role play using the tool box. Alternatively, try a 5-minute role play with just one question from each process.

ITEM 11. THE COUNSELOR SOLICITS FEEDBACK FROM CLIENTS. This item assesses the degree to which the counselor asks clients for their response to information, recommendations, feedback, etc. This is analogous to the Ask-Tell-Ask strategy in Motivational Interviewing.

Activity 11.1: Chunk-Check-ChunkDirections

Develop a scenario where the client has no idea how to start changing. (e.g., I have no idea how to get started).

Counselor asks for permission to give information or advice. The counselor then gives information and advice in small chunks. Then checks after each chunk

by using any of the following example questionso “What do you understand about the information I just gave you?”o “What do you think you might do with this idea?o “Tell me in your own words what you got from this information?”

Assessment: Discuss the advantages of using check-chunk-check and how is used to elicit feedback.

Activity 11.2: Key QuestionsDirections

Role play a scenario. Counselor engages, focuses and evokes. Then, counselor provides a summary then asks key questions. Where do you want to go from here? What are your next steps? What would your plan look like if you wanted to achieve that goal you set? REFLECT responses.

Assessment: Discuss the need for eliciting feedback and how it fits with MI spirit.

ITEM 12. THE COUNSELOR MANAGES COUNTER CHANGE TALK (SUSTAIN TALK) AND DISCORD. This item addresses the skill in which the counselor responds to discord and sustain talk (i.e., counter change talk) either reflectively or strategically. Client may make statements against change either directly about the target behaviors, about engaging in the treatment program or discord in the relationship. Clients who are ambivalent may statements against change (sustain talk) with statements for change. Sometimes discord is more indirect – lack of homework completion, minimal communication in the session, or statements such as “I guess so” or “I will do that if you want me to” indicating acquiescence or half-hearted agreement with the plan for change, or agreement that does not ring completely true. Discord refers to tension between the client and counselor (wrestling). Counselors should have learned the Stop Drop and Roll approach in the initial workshop.



Activity 12.1: Dodge BallDirections

The coach throws out a typical client counter change talk or discord statement (“I hate coming here.” “There is really on reason for me to quit drinking right now.”)

The counselor then dodges the statement with empathy statement, autonomy supportive statement [e.g., It’s your choice, You know yourself best (see item 3)], apology, or shift focus.

Assessment: Discussion the responses utilized and why.

Activity 12.2: Addressing Counter Change Talk and Discord in a ConversationDirections* The coach plays 2 different types of clients

Client 1: The coach gives discord talk about the provider and/or treatmentClient 2: The coach gives counter change talk about not changing or sustaining current behavior

The counselor then reflects and uses a strategy from the list for each type of client.

Assessment: Discuss the strategies just used by the counselor and discuss the rationale. There is no right or wrong answer. Continue the role-play using different strategies and guiding towards change talk (e.g., items 4 and 6)

Strategies to Shift Counter Change Talk

1. Reflect with empathy and non-judgment or affirmation2. Shift focus - Do something different!3. Emphasize personal choice

It’s your choice It’s up to you Nobody can make you do this You need to decide for yourself

Strategies to Address Discord1. Shift focus (talk about something different but related)2. Apologize

FOUR MI PROCESSES:

For Engaging Process – See items 1, 2, 3, 6For Focusing Process – See item 5, 10For Evoking Process – See item 4, 7, 10, 12For Planning Process – See item 4, 10, 11


tips: · web viewclosed ended questions may be answered with a one-word response. multiple-choice...

Documents