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MI One

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by

Scott Ergen

on 15 May 2014

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Transcript of MI One

Some “MI” Benchmarks:

70 % open questions; 30 % closed.

Avoid doing more than 2 questions in a row.

Try for a ratio of two reflections to every question.

Client “talk time” = 60-80%; Practitioner “talk time” = 20-40%
Builds a WORKING ALLIANCE quickly
Focuses on a TARGET BEHAVIOR
Avoids PERSUASION
Decreases REACTANCE/RESISTANCE
The CLIENT does the change work
Is GUIDING in nature and can be very EFFICIENT
Pays close attention to client “CHANGE TALK”
RECAP so far: What Makes MI Unique?

PAIRS ACTIVITY:


What are typical behavior change “targets” that may come up for our clients, and where MI might be useful?
“Perhaps the best conversationalist in the world is the man who helps others to talk.”

~ John Steinbeck (East of Eden)
Introductions…

Who are you (name)?


What kind of training have you had in MI?

A fun or interesting fact about yourself
ASSESSMENTS.COM
5333 W. 2600 S. Suite 140
Bountiful, UT 84010
Phone: 1-877-277-3778
www.assessments.com
info@assessments.com
Thank You for Attending!
EckMaahs & Associates, LLC
1424 Victoria St. North
Saint Paul, Minnesota 55117
Phone: 651-489-1122
www.eckmaahs.com
seckmaahs@eckmaahs.com
Practice with your clients and staff on an ongoing basis


Complete client audiotapes and have them coded and/or listen with a trusted colleague


Individual Coaching Sessions


Coaching/Booster Sessions

Intermediate/Advanced Training
Continuing to Learn MI
The Big Picture
Let’s talk about “Resistance”!
I have no time to go to those parenting classes. Plus, it’s embarrassing to think about going to those things. People might see me! You know that I’m not hurting my kids anymore. I am impatient with them because I’m so miserable, but I can’t leave them alone and I don’t trust anyone else to take care of them the way I do.
Identify the Change Talk!
Not listening
Expert focus/trap
Busy gathering information
Hot on a trail (e.g., going for “why”)

Not “recognizing” what change talk is
Not directive enough (wandering focus)
Not knowing how to respond to change talk
Change Talk:
Reasons for missed opportunities…
GUIDING is a Central Component of MI…

When using MI, we are focused on guiding the client by listening for and selectively reinforcing language that favors, rather than dismisses, the possibilities for change. This language is called “Change Talk”.

When using MI, we don’t simply “follow” the client as we would in other situations, such as doing an assessment or a basic check in without an added MI component. We keep our focus on the target and try to draw change talk to the surface.
Roles (rotate): Speaker, Listener, Observer

Speaker: Offer one or two “lines” introducing your experience.

Practitioner: Respond with only reflections and an occasional open question if you get “stuck”

Observer: Keep track of the number of reflections and questions. If the speaker does more than one question in a row, gently redirect him/her.
EXERCISE (cont.)

“So far what I understand is that you are afraid of how family things are going for you and feeling a little overwhelmed. At the same time, you’re optimistic about the counseling and so is your wife. You want to follow through, also, so that you’re not putting yourself in the position of a possible probation violation.
You also said you like your new job and your sobriety is going well. Your UA’s have all been clean, too, which is great! Does that sound about right?”
Summarization Example

Client: The least of my problems is my using. I don’t need the stuff, it just helps me deal with everything I’m going through. My biggest problem is my girl. She’s on my case about it, even though I never do it in front of her or the baby. I hate it when we fight.

PO: On the one hand, you want to keep using because it’s not a problem for you. On the other hand, your relationship is stressed because of your use.
Using a Double-Sided Reflections to Develop Discrepency
Write one or two endings to these three statements:

One thing I like about myself is that I’m….
One thing you should know about me is that I’m…
One thing about myself that I’d like to change is…

Practitioner ask: Does that mean that you_____? (Ask 4 or 5 things)

Speaker answer only Yes or No.
EXERCISE: Thinking Reflectively:
“Is this what you mean?”


Review day 1…questions.

MI Challenge for the evening!
Option 1: Character level affirmation (s)
Option 2: Accurate empathy
Option 3: No “unsolicited advice”
Option 4: Only open questions
Day 1 Wrap Up
We can use open questions to facilitate solutions rather than dictate solutions:
We can use open questions to emphasize forward vs. backward focus…
Converting closed questions to open…
Improves behavior change, treatment retention & program outcomes

Helps develop a working alliance very quickly, express accurate empathy, & individualize the approach to the client

Hundreds of clinical trials and meta-analyses & thousands of research publications showing efficacy in situations where behavior change is needed/desired.

(People of color represent 40% of participants in the clinical trials; MI has been translated into 28 languages)
What Makes MI an EBP?
Practitioner’s Role
Speaker has same topic as last time.

Ask the open questions listed on your handout.

Listen carefully to the speaker with a goal of understanding the dilemma (i.e. both sides of the ambivalence) and draw out the person’s OWN reasons and ideas for possible change.

Give no advice!
A “taste” of MI
“What people really need is a good listening to.”

~ Mary Lou Casey
ACTIVITY: “Persuade Me!”

The speaker’s role; take five minutes to share something you have been thinking about changing, but really aren’t sure about changing, such as...

Quitting cigars/chewing/caffeine
Retiring early
Going back to school
Giving up something you like
Changing a behavior for someone else

IMPORTANT! Make sure it’s something you feel two ways about – “maybe I want to, but maybe not”!
Agreeing, approving, or praising
Shaming, ridiculing, or labeling
Interpreting or analyzing
Reassuring, sympathizing, or consoling
Questioning or probing
Withdrawing, distracting, humoring or changing the subject
What Good listening is NOT (cont.)
Ordering, directing or commanding
Warning or threatening
Giving advice, making suggestions, or providing solutions
Persuading with logic, arguing, or lecturing
Moralizing, preaching, or telling clients what they “should” do
Disagreeing, judging, criticizing, or blaming
What Good Listening is Not
(Roadblocks: Thomas Gordon, Ph.D)



Does working with clients ever feel like this?

Explain how MI is directive and practice the directive aspects of MI while working with clients.

Practice an MI style for meeting resistance with clients.

Practice recognizing, reinforcing, and drawing out the fundamental client language cues that indicate movement toward change (change talk).
Learning Objectives
Continued

“People are usually more convinced by reasons they discovered themselves than by those found by others.” ~Blaise Pascal
“Motivational Interviewing: Preparing People for Change” (2nd Ed.) by William Miller & Stephen Rollnick

www.motivationalinterview.org

casaa.unm.edu (Center on Alcoholism, Substance Abuse, and Addictions)
Great Resources:
Expect it!

Allow autonomy

Use Reflections

Remain non-judgmental

Don’t argue against it – “Roll with it”

Emphasize person’s ability to choose

Remember - it is just the other side of the ambivalence

Recognize and affirm personal success
Responding to Resistance:
Evocative Questions
Explore Pros/Cons
Ask for Elaboration/Examples
Look Back/Look Forward
Use Change Rulers
In your notes:
Specific Strategies for
Evoking Change Talk
Evoking: In what way… ?; Tell me more…;
What else?

Affirming: That took a lot of courage; You’re a person who can make changes when you need to; That shows real commitment…

Reflecting: You want to make some changes in… You realize it’s become a problem…

Summarizing: There are a number of things I’m hearing about your situation . First, you’re concerned about….. Also, you feel…, and you are thinking…
Responding to Change Talk: EARS!
EARS:
Elaboration (open question)
Affirming
Reflecting
Summarizing
When we hear change talk, it is important to reinforce it by responding immediately with….
I have no time to go to those parenting classes. Plus, it’s embarrassing to think about going to those things. People might see me! You know that I’m not hurting my kids anymore. I am impatient with them because I’m so miserable, but I can’t leave them alone and I don’t trust anyone else to take care of them the way I do.
Identify the Change Talk!
I wasn’t doing anything wrong! I just went along for the ride, and I didn’t know they were going to grab that lady’s purse. Now they’re saying I violated my probation. I guess it’s not smart to be cruising around at 2 in the morning, but it happened so fast, there was nothing I could do. I didn’t break any laws, and I’m not going back to jail for this.
Identify the Change Talk!
I wasn’t doing anything wrong! I just went along for the ride, and I didn’t know they were going to grab that lady’s purse. Now they’re saying I violated my probation. I guess it’s not smart to be cruising around at 2 in the morning, but it happened so fast, there was nothing I could do. I didn’t break any laws, and I’m not going back to jail for this.
Identify the Change Talk!

The first step is to become an “ambivalence” detective.

Listen for the “but” !

where there’s a “but”, there’s ambivalence, and change talk is usually buried in the language!
Snatching Change Talk from the Jaws of Ambivalence…

Open-ended Questions
Affirming
Reflective Listening
Summarizing
Putting it all together:
OARS RECAP….

Collection summary
Linking summary
Transitional Summary
# 4: Summarization
(A special form of reflection)

Use summary statements to link together ideas & topics presented by the client. This also helps you focus, and clarifies that you are listening.
Capture both sides of a client’s ambivalence

Use when client is dwelling on one side

Use client’s view of both sides, not your view of the other side

May need to use previous discussions

Can use conjunction “and” instead of “but”
Double-Sided Reflections
Reflect the client’s…
feelings,
speech,
facial expressions, or behavior
Make an hypothesis
Assess the deeper meaning
Capture only the key elements (often just a few words)
Voice inflects DOWNWARD (a statement, not a question)
Forming Reflections
Take “Does that mean that” off the front and state the inquiry as a ‘guess’ or ‘hypothesis’, as if you are testing a theory.

Make sure your voice is completely non-judgmental!

EXAMPLE: Instead of “Does that mean you are worried about retirement?” “You’re a little worried about retirement”.
EXERCISE CONT. -
Now, turn the question into an hypothesis:
What did you learn from your practice last night?

Motivational Interviewing- Day 2
Welcome Back!
“You put a lot of thought and time this apology letter.”



“You have put your family first. That shows a lot of integrity.”
“You’re really showing a lot of dedication to staying clean. ”


“ That was a difficult decision for you. You’ve come a long way!”
Specific !
Timely !
Genuine !
Effective Affirmations Are:


Encourages client to do the talking & think about the subject.

Less likely to feel like “interrogation”.

Elicits more detailed information.

Other reasons?
Why Favor Open-Ended Questions ?
“What…. Which…. Where… How… Tell me…”

“How does it feel to be on probation?”

“Where do you think your biggest challenge lies?”

“What do you think you’ll take care of first?”

“Tell me about your relationship with your boss/wife/daughter”
Open-Ended Questions sound like…
No correlation between observed and perceived style

Relatively small percentage of reflections

More questions… especially closed-ended
What we do, compared to what we think we do….
OARS: Why Practice!!???
The DUAL ROLE Recipe:
Active Listening with Directive Supervision
Ingredients:

Fairness/Support
Trust in client ability
Guiding vs. authoritarian
Clear about contingencies/No surprises!

NOTE: Leave out “Toughness” (authoritarian stance) it can lead to less success/more recidivism

Skeem, Louden, Camp,
Polaschek (in press)
The Black Box of Community Supervision Study* demonstrated that PO’s who adhere to risk, need and responsivity (as a result of good assessment and other EBP’s) WHILE also using positive reinforcement, empathy, openness, warmth, prompting and encouragement, prosocial modeling, etc. (MI) showed more reduction in recidivism among their clients.

Also, MORE recidivism resulted from significant time spent discussing conditions of supervision recidivism VS LESS recidivism when more time was spent discussing a targeted need area.

*Journal of Offender Rehabilitation, Vol 47, July 2008
MI supports other EBP approaches to decrease recidivism…
Corrections

Public Health

Primary care
Diet
Exercise
Smoking
HIV
Eating disorders
Substance Use Disorders

Education

Mental Health Disorders
Making appointments
Treatment completion & Engagement
Problem recognition
Many applications for MI
In pairs, take 8-10 minutes to write 4 resistant or challenging statements you might hear from your clients.
Zingers!
A person’s belief in the possibility of change is an important motivator.
The client, not the practitioner, is responsible for choosing and carrying out change (with support and assistance).
The practitioner’s belief in the client’s ability to change becomes a self- fulfilling prophecy.
Support Self-Efficacy
When Collaboration & autonomy should not be supported:

Immediate violence & aggression
Suicidal plans/ideations
Homicidal plans/ideations
Severe medical or mental consequences to behavior

Unethically, as with a purpose of getting information to prove a point or purposely get someone in trouble.

When there is no ambivalence about making the change.
There are times not to use MI:

A clear Target Behavior

Ambivalence around changing that behavior (or the possibility of building ambivalence)
MI is not for everything!

Ingredients needed for MI to be useful:
MI “Spirit” is demonstrated through…

Evoking:

Avoiding unsolicited advice-giving

Drawing out (or evoking) the client’s own desire and reasons for change!

Evoking change, instead of educating and advocating for change
The Spirit of MI can be considered the “roots” of the process for cultivating motivation. The spirit pieces ground us as practitioners. If these ingredients are not present, we are not doing MI:
Autonomy - Collaboration - Evoking
(Also, focus on client competence & success)
MI principles and strategies allow the client to say what I want to tell him or her.

We are hoping to hear change talk!
Another way to look at it..
Safe
Empowered
Hopeful
Comfortable
Interested
Liking/Respecting the practitioner
Open
Want to come back
Cooperative
Engaged
Able to change
Understood
Want to talk more
Accepted
Respected
Common Human Reactions to
Being Listened to
Why take the time to “evoke” solutions
from the client, when our experience tells us what to suggest?
WHY is this true?

…we often argue for and do the opposite!
IN FACT….


We rarely take responsibility to make changes when others are trying to “tell” us that we must and/or what we should do!
Many times the practitioner’s “goal” is to
“understand it”
“fix it”
“diagnose it”
“control it”

However, the client needs
to be listened to
to be understood
to be the source of the solution

The “Righting Reflex” =
A Practitioner Problem!

Partners role - TRY TO PERSUADE !



Follow the outline
on your handout as you:

Use roadblocks to persuade
` Become the EXPERT
Tell them what to do
Give lots of advice
Try & convince them to change
Minimize their excuses

PS…This is NOT Motivational Interviewing!
Have fun!

Be yourself - Choose subjects that have meaning for you.

Work with as many different people as you can.

Integrate the material throughout the workshop and observe outcome from any change in your approach.

Allow yourself to make mistakes!
A few learning tips….
Developed by EckMaahs & Associates, LLC., Updated November, 2010

Motivational Interviewing
For the Corrections Professional-Level I
One thing I learned was…
One thing I re-learned was…
One thing that surprised me was…
One this I appreciated was…
OR
The FIRST thing I am going to try is…
I have no right to want to change another if I am not open to being changed. -Martin Buber
Book # 1:
Motivational Interviewing: Preparing People to Change Vol. 1 – 1999

Book # 2:
Motivational Interviewing: Preparing People to Change Vol. 2 – 2002

Book # 3 on the way in 2012!
MI is also “learning” and growing…
Watch the video and keep an ear open for the practitioner’s use of MI Spirit and Principles, OARS, and eliciting change talk.

2. Fill out the observation sheet to the best of your ability.
Putting it all Together!:
Integrated Skills Example
Now we will practice using reflections to respond to client resistance

The idea is to “get some wood on the ball”, not to “hit a home run”!
Responding to Resistance: Batting Practice!
Opposite Sides of a Coin
Change Talk and “Sustain Talk”
I know I can quit if everyone just gets off my back.

I’ve got to have my GED to get the apprenticeship.

I don’t want my kids getting in the same trouble I did.

This time, I’m going straight to the halfway house from here.

My mom’s not going to let me back in the house if I don’t quit.

It ain’t worth it to be landing up in here again (jail).

This time I’m going to stay clean.
Desire
Ability
Reason
Need
Commitment
Identify the type of change talk
Problem Recognition
Concern about the problem
Awareness of the problem
Potential benefits of Change
Costs of not Changing
What does Change Talk “sound like” ?
Prepare to speak on a NEW topic that can be explored for at least 10 minutes.

Topic = An experience you’ve had that you believe would be quite difficult for another person to understand.
SUSTAINED
REFLECTIONS
PRACTICE
For more advanced reflections…
Try leaving the stem off:
INSTEAD OF: “So you’re saying that the group is confusing …”;

SAY:
“The group seems confusing” OR
“That makes you pretty upset” OR
“It’s not what you thought it would be”

OR Continue the thought:
…and it seems like…
…and that leaves you…
…and no-one really understands.
One level of affirmation expresses:

Appreciation
Understanding
Compliments

A deeper level speaks to something positive about the person’s character: “That shows real integrity”, “You are a creative person”.
provide statements that support, encourage, reinforce, and acknowledge appropriate attempts made by the client.
Affirmations…
Converting closed to open questions
EXERCISE
“Do you…Are you… Did you… Could you…Have you…?”

“Did you get a job yet?”

“Do you care about finishing your probation?”

“Were you thinking when you did that?”

“Do you have a drinking problem?”
Closed Questions sound like…
Instrument in Press. May use with permission from Skeem, et al. (contact info on tool).
The Dual Role Inventory…
Balancing the Roles of the PO
Confrontation-Denial Trap

Expert Trap

Labeling Trap

Blaming Trap

Premature Focus Trap

Question-Answer Trap
Watch out for the Traps !!

Change is motivated by a perceived GAP between present behavior and important personal goals or values
Develop Discrepancy
We will arrange you in Dyads:

Each person will take a turn talking for 3 minutes about What it was like for me growing up OR What would be my ideal future

After the 3 minutes the “listener” will try to capture the essence (not the exact words!) of what the person said. The idea is to “connect the dots” by hypothesizing what their words say about them or their experience.

Speaker will respond naturally.
Accurate Empathy EXERCISE:
The ability to accurately understand the client’s meaning = “Accurate Empathy”

The ability to reflect that accurate understanding back to the client.
Empathy is …
Feeling sorry for someone
Having had the same problem or experience
Identification with the client
Empathy is not…


Listen actively with the goal of understanding

Skill of reflective listening is fundamental

Acceptance facilitates change
Express Empathy:
Express Empathy

Develop Discrepancy

Roll with Resistance

Support Self - Efficacy
The Foundation Principles of MI:
MI “Spirit” is demonstrated through…

Autonomy:

Allowing client to have “the wheel”

Providing options whenever possible

Emphasizing client’s freedom of choice

Accepting that, in the end, the client has the right to choose NOT to change
Collaboration
Evocation
Autonomy


Also, focus on client success & competence
The “Spirit” of Motivational Interviewing is composed of:
“A collaborative, person-centered form of guiding to elicit and strengthen motivation to change.”
Miller & Rollnick, 2009
Motivational Interviewing Defined:
What did you notice about
the practitioner’s approach?
Contrasting Styles in
Working with Offenders: PO I & II
Problem Recognition
Concern about the problem
Awareness of the problem
Potential benefits of Change
Costs of not Changing
What does Change Talk “sound like” ?
Ambivalence is a state of mind in which a person has co-existing but conflicting feelings about something.

It is a fundamental and NORMAL part of the change process.

“I want to, but I don’t want to “
A Different Way:
Attending to AMBIVALENCE
(feeling two ways about change)
An increase in the rate and attractiveness of a “problem” behavior is likely if a person perceives that his or her personal freedom is being infringed upon or challenged!

Reactance Theory!
We are going to focus specifically on what happens with persuasion.
In a moment, we will divide you into pairs:
One of you will be the “speaker” and the other will be the “practitioner”…
ACTIVITY: “Persuade Me!”
Other Goals/Interests/Expectations for the training?
How Motivated are YOU?
Demonstrate an understanding of the basic approach of motivational interviewing (MI) and how to continue learning it while working with clients.

Demonstrate an understanding of the fundamental spirit and principles of MI.

Demonstrate an increase in the ability to use the foundation skills (OARS) in a targeted, MI adherent way.
Learning Objectives
William R. Miller, PhD
Most of the material contained within this presentation has been adapted from the work of William R. Miller, PH.D. and Stephen Rollnick, Ph.D (1999, 2002).

Additional credit goes to the members of the MINT (Motivational Interviewing Network of Trainers) who have so generously shared their ideas and resources.
Acknowledgments…
Just The Start!

This training provides the beginning steps for learning the skills of MI!



What are some things you can do to continue building your MI skills?
REINFORCE “CHANGE TALK”
HONOR, BUT MINIMIZE, “SUSTAIN TALK”
Our objective:
I know I can’t smoke weed, but I like my beer on the weekends.

There’s no way I’m going back to that program.

I need the stuff to come down after work. Otherwise, I can’t sleep at night.

I’d have no social life at all if I didn’t see my friends at the bar.

Mom doesn’t care what I do. She always takes me back.

No one’s gonna tell me what to do. Not even the judge!
Desire
Ability
Reason
Need
Commitment
Same pattern in reverse: Sustain Talk!

D - Desire to change (“want, like, wish…”)
A - Ability to change (“can, could…”)
R - Reasons to change (“If…then…”)
N - Need for change (“Got to, have to, need to”)
C - Commitment to change (“Will..., Am…)
Listening for Change Talk: DARN-C!
What are reflections?


What is their purpose?
# 3: Reflections
These are the tools for executing the spirit and principles of MI!

Open-ended Questions - avoid Yes/No

Affirming - support & encourage

Reflective Listening - repeat & clarify

Summarizing- link together & reinforce
The next level of practice:
OARS ~ Core listening skills!
The Corrections
Continuum:
TOUGH Fair/Clear Non-Directive Authoritarian Trust/Guide/Support Following
Roll with Resistance
Avoid arguing for change

Resistance is realized as a fluctuating product of interpersonal interaction

Resistance is a signal to respond differently
MI “Spirit” is demonstrated through…

Focus on Competence & Success:

Evoking client’s knowledge of his/her own abilities

Drawing out client’s recognition of his/her past & present successes

Affirming and reinforcing client’s successes

Enhancing client's self-confidence & self-reliance
MI “Spirit” is demonstrated through…
Collaboration:

Non-Authoritarian
Active listening
Starting where client is “at”
Guiding, but not “taking the wheel”
Negotiating whenever possible
“The more a person argues on behalf of a position, the more he or she is committed to it.”

We believe what we hear ourselves say.

When a person publicly takes a position, his/her commitment to that position increases.

Self-Perception Theory!
COMPLEX
SIMPLE
Repeating - simply repeat what was said

Rephrase - slightly reword/but not add anything new

Paraphrasing - infer unspoken content
/make hypothesis

Reflection of Feeling - infer emotional content
Levels of Reflection:
Traps!
Roadblocks!
MI Principles: Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy
Spirit of MI: Autonomy - Collaboration – Evoking
(Also, focus on client success & competencies)
Eliciting Change Talk
Traps
Traps
The Opening Strategies: Open Questions Affirmations Reflections Summarizations
Foundation Principles: Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy
Spirit of MI: Autonomy - Collaboration Respect - Focus on Competence Evoke
Traps
Traps
Core Listening Skills: Open Questions Affirmations Reflections Summarizations
Foundation Principles: Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy
Spirit of MI: Autonomy - Collaboration - Evocation Focus on Competence & Success
Reflective Listening
INTERFERENCE!
What listener
HEARS
What speaker
SAYS!
What listener
interprets
What speaker means
Where accurate understanding can break down
When using MI, we are focused on guiding the client by listening for and selectively reinforcing language that favors, rather than dismisses, the possibilities for change. This language is called “Change Talk”.

When using MI,
we don’t simply “follow” the client

as we would in other situations, such as doing an assessment or a basic check in without an added MI component. We keep our focus on the target and try to draw change talk to the surface.


70 % open questions; 30 % closed.

Avoid doing more than 2 questions in a row.

Try for a ratio of two reflections to every question.

Client “talk time” = 60-80%; Practitioner “talk time” = 20-40%
“Perhaps the best conversationalist in the world
is the man who helps others to talk.”

~ John Steinbeck (East of Eden)


Who are you (name)?

What kind of training have you had in MI?

A fun or interesting fact about yourself
“Motivational Interviewing: Preparing People for Change” (2nd Ed.) by William Miller & Stephen Rollnick

www.motivationalinterview.org

casaa.unm.edu (Center on Alcoholism, Substance Abuse, and Addictions)
Great Resources:
Practice with your clients and staff on an ongoing basis

Complete client audiotapes and have them coded and/or listen with a trusted colleague

Individual Coaching Sessions

Coaching/Booster Sessions

Intermediate/Advanced Training
Continuing to Learn MI
The Big Picture
Let’s talk about “Resistance”!
Evoking: In what way… ?; Tell me more…;
What else?

Affirming: That took a lot of courage; You’re a person who can make changes when you need to; That shows real commitment…

Reflecting: You want to make some changes in… You realize it’s become a problem…

Summarizing: There are a number of things I’m hearing about your situation . First, you’re concerned about….. Also, you feel…, and you are thinking…
Responding to Change Talk: EARS!
I have no time to go to those parenting classes. Plus, it’s embarrassing to think about going to those things. People might see me! You know that I’m not hurting my kids anymore. I am impatient with them because I’m so miserable, but I can’t leave them alone and I don’t trust anyone else to take care of them the way I do.
Identify the Change Talk!
I have no time to go to those parenting classes. Plus, it’s embarrassing to think about going to those things. People might see me! You know that I’m not hurting my kids anymore.

I am impatient with them because I’m so miserable
, but I can’t leave them alone and I don’t trust anyone else to take care of them the way I do.
Identify the Change Talk!
Identify the Change Talk!

Not listening
Expert focus/trap
Busy gathering information
Hot on a trail (e.g., going for “why”)

Not “recognizing” what change talk is
Not directive enough (wandering focus)
Not knowing how to respond to change talk

Change Talk:
How we might miss opportunities…

Roles (rotate): Speaker, Listener, Observer

Speaker: Offer one or two “lines” introducing your experience.

Practitioner: Respond with only reflections and an occasional open question if you get “stuck”

Observer: Keep track of the number of reflections and questions. If the speaker does more than one question in a row, gently redirect him/her.
EXERCISE (cont.)

Collection summary
Linking summary
Transitional Summary
# 4: Summarization
(A special form of reflection)

Use summary statements to link together ideas & topics presented by the client. This also helps you focus, and clarifies that you are listening.
MI is a person-centered communication method of fostering change by helping a person explore and resolve ambivalence. Rather than using external pressure, MI looks for ways to access internal motivation for change. It borrows from client-centered counseling in its emphasis on empathy, optimism, and respect for client choice. MI also draws from self-perception theory, which says that a person becomes more or less committed to an action based on the verbal stance he or she takes.
Thus, an offender who talks about the benefits of change is more likely to make that change, whereas an offender who argues and defends the status quo is more likely to continue his or her present behavior.

-NIC (National Institute of Corrections)
Motivational Interviewing Defined:
Write one or two endings to these three statements:

One thing I like about myself is that I’m….
One thing you should know about me is that I’m…
One thing about myself that I’d like to change is…

Practitioner ask: Does that mean that you_____? (Ask 4 or 5 things)

Speaker answer only Yes or No.
EXERCISE: Thinking Reflectively:
“Is this what you mean?”


Review day 1… questions.

MI Challenge for the evening!
Option 1: Character level affirmation (s)
Option 2: Accurate empathy
Option 3: No “unsolicited advice”
Option 4: Only open questions
Day 1 Wrap Up
We can use open questions to facilitate solutions rather than dictate solutions:
We can use open questions to emphasize forward vs. backward focus…
Builds a WORKING ALLIANCE quickly
Focuses on a TARGET BEHAVIOR
Avoids PERSUASION
Decreases REACTANCE/RESISTANCE
The CLIENT does the change work
Is GUIDING in nature and can be very EFFICIENT
Pays close attention to client “CHANGE TALK”
RECAP so far:
What Makes MI Unique?


PAIRS ACTIVITY:


What are typical behavior change “targets” that may come up for our clients, and where MI might be useful?
Why take the time to “evoke” solutions
from the client, when our experience tells us what to suggest?
Practitioner’s Role
Speaker has same topic as last time.

Ask the open questions listed on your handout.

Listen carefully to the speaker with a goal of understanding the dilemma (i.e. both sides of the ambivalence) and draw out the person’s OWN reasons and ideas for possible change.

Give no advice!
“What people really need... ...is a good listening to.”

~ Mary Lou Casey



The speaker’s role; take five minutes to share something you have been thinking about changing, but really aren’t sure about changing, such as...

Quitting cigars/chewing/caffeine
Retiring early
Going back to school
Giving up something you like
Changing a behavior for someone else

IMPORTANT! Make sure it’s something you feel two
ways about – “maybe I want to, but maybe not”!
Agreeing, approving, or praising
Shaming, ridiculing, or labeling
Interpreting or analyzing
Reassuring, sympathizing, or consoling
Questioning or probing
Withdrawing, distracting, humoring or changing the subject
What Good listening is NOT (cont.)




Does working with clients ever feel like this?


Explain how MI is directive and practice the directive aspects of MI while working with clients.

Practice an MI style for meeting resistance with clients.

Practice recognizing, reinforcing, and drawing out the fundamental client language cues that indicate movement toward change (change talk).
Learning Objectives
Continued
Developed by EckMaahs & Associates, LLC., Updated November, 2010

Motivational Interviewing
For the Corrections Professional-Level I
One new thing I learned was…
One thing I re-learned was…
One thing that surprised me was…
One thing I appreciated was…

I have no right to want to change another
if I am not open to being changed.
-Martin Buber
Watch the video and keep an ear open for the practitioner’s use of MI Spirit and Principles, OARS, and eliciting change talk.

Fill out the observation sheet.
Putting it all Together!:
Integrated Skills Example
Practice using reflections to respond to client resistance

The idea is to “get some wood on the ball”, not to “hit a home run”!
Responding to Resistance: Batting Practice!
Expect it!

Allow autonomy

Use Reflections

Remain non-judgmental

Don’t argue against it – “Roll with it”

Emphasize person’s ability to choose

Remember - it is just the other side of the ambivalence

Recognize and affirm personal success
Responding to Resistance:
Evocative Questions
Explore Pros/Cons
Ask for Elaboration/Examples
Look Back/Look Forward
Use Change Rulers


Specific Strategies for
Evoking Change Talk
I wasn’t doing anything wrong! I just went along for the ride, and I didn’t know they were going to grab that lady’s purse. Now they’re saying I violated my probation.
I guess it’s not smart to be cruising around at 2 in the morning
, but it happened so fast, there was nothing I could do. I didn’t break any laws, and I’m not going back to jail for this.
Identify the Change Talk!

The first step is to become an “ambivalence” detective.

Listen for the “but” !

where there’s a “but”, there’s ambivalence, and change talk is usually buried in the language!
Snatching Change Talk from the Jaws of Ambivalence…
Prepare to speak on a NEW topic that can be explored for at least 10 minutes.

Topic = An experience you’ve had that you believe would be quite difficult for another person to understand.
SUSTAINED
REFLECTIONS
PRACTICE


“So far what I understand is that you are afraid of how family things are going for you and feeling a little overwhelmed. At the same time, you’re optimistic about the counseling and so is your wife. You want to follow through, also, so that you’re not putting yourself in the position of a possible probation violation.
You also said you like your new job and your sobriety is going well. Your UA’s have all been clean, too, which is great! Does that sound about right?”
Summarization Example
Capture both sides of a client’s ambivalence

Use when client is dwelling on one side

Use client’s view of both sides, not your view of the other side

May need to use previous discussions

Can use conjunction “and” instead of “but”
Double-Sided Reflections
More reflections…
Try leaving the stem off:
INSTEAD OF: “So you’re saying that the group is confusing …”;

SAY:
“The group seems confusing” OR
“That makes you pretty upset” OR
“It’s not what you thought it would be”

OR Continue the thought:
…and it seems like…
…and that leaves you…
…and no-one really understands.
Reflect the client’s… feelings, speech,
facial expressions, or behavior
Make an hypothesis
Assess the deeper meaning
Capture only the key elements
(often just a few words)
Voice inflects DOWNWARD
(a statement, not a question)
Forming Reflections
Take “Does that mean that” off the front and state the inquiry
as a ‘guess’ or ‘hypothesis’, as if you are testing a theory.

Make sure your voice is completely non-judgmental!

EXAMPLE: Instead of “Does that mean you are worried about retirement?” “You’re a little worried about retirement”.

Now, turn the question into
an hypothesis:
What did you learn from your practice last night?

Day 2
Welcome Back!

“You put a lot of thought and time in this apology letter.”



“You have put your family first. That shows a lot of integrity.”
“You’re really showing a lot of dedication to staying clean. ”


“ That was a difficult decision for you. You’ve come a long way!”
Specific !
Timely !
Genuine !

Effective Affirmations Are:
Converting closed questions to open…
Why Favor Open-Ended Questions ?


Encourages client to do the talking & think about the subject.

Less likely to feel like “interrogation”.

Elicits more detailed information.

Other reasons?
“What…. Which…. Where… How… Tell me…”

“How does it feel to be on probation?”

“Where do you think your biggest challenge lies?”

“What do you think you’ll take care of first?”

“Tell me about your relationship with your boss/wife/daughter”
Open-Ended Questions sound like…

No correlation between observed and perceived style

Relatively small percentage of reflections

More questions… especially closed-ended
What we do, compared to what we think we do….
The DUAL ROLE Recipe:
Active Listening with Directive Supervision
Ingredients:

Fairness/Support
Trust in client ability
Guiding vs. authoritarian
Clear about contingencies/No surprises!

NOTE: Leave out “Toughness” (authoritarian stance)
it can lead to less success/more recidivism

Skeem, Louden, Camp,
Polaschek (in press)
The Black Box of Community Supervision Study* demonstrated that PO’s who adhere to risk, need and responsivity (as a result of good assessment and other EBP’s) WHILE also using positive reinforcement, empathy, openness, warmth, prompting and encouragement, prosocial modeling, etc. (MI) showed more reduction in recidivism among their clients.

Also, MORE recidivism resulted from significant time spent discussing conditions of supervision recidivism VS LESS recidivism when more time was spent discussing a targeted need area.

*Journal of Offender Rehabilitation, Vol 47, July 2008
MI supports other EBP approaches to decrease recidivism…
Corrections

Public Health

Primary care

Diet

Exercise

Smoking

Eating disorders
Substance Use Disorders

Education

Mental Health Disorders

Making appointments

Treatment completion & Engagement

Problem recognition
Many applications for MI
Improves behavior change, treatment retention & program outcomes

Helps develop a working alliance very quickly, express accurate empathy, & individualize the approach to the client

Hundreds of clinical trials and meta-analyses & thousands of research publications showing efficacy in situations where behavior change is needed/desired.

(People of color represent 40% of participants in the clinical trials; MI has been translated into 28
languages)
What Makes MI an EBP?
Confrontation-Denial Trap

Expert Trap

Labeling Trap

Blaming Trap

Premature Focus Trap

Question-Answer Trap
Watch out for the Traps !!
In pairs, take 8-10 minutes to write 4 resistant or challenging statements you might hear from your clients.
Zingers!
The ability to accurately understand the client’s meaning = “Accurate Empathy”

The ability to reflect that accurate understanding back to the client.
Empathy is …
Feeling sorry for someone
Having had the same problem or experience
Identification with the client
Empathy is not…
When Collaboration & autonomy should not be supported:

Immediate violence & aggression
Suicidal plans/ideations
Homicidal plans/ideations
Severe medical or mental consequences to behavior

Unethically, as with a purpose of getting information to prove a point or purposely get someone in trouble.

When there is no ambivalence about making the change.
There are times not to use MI:

A clear Target Behavior

Ambivalence around changing that behavior (or the possibility of building ambivalence)
MI is not for everything!

Ingredients needed for MI to be useful:
Motivational Interviewing (MI) arose during the 1980s from alcohol counseling research. This
research began to suggest that certain types of brief counseling interactions could be as effective as more lengthy interventions and that a certain kind of provider style was better at eliciting change.
Motivational Interviewing Defined:
MI principles and strategies allow the client to say what I want to tell him or her.

We are hoping to hear change talk!
Another way to look at it..
Ambivalence is a state of mind in which a person has co-existing but conflicting feelings about something.

It is a fundamental and NORMAL part of the change process.

“I want to, but I don’t want to “
A Different Way:
Attending to AMBIVALENCE
(feeling two ways about change)
WHY is this true?

…we often argue for and do the opposite!
IN FACT….


We rarely take responsibility to make changes when others are trying to “tell” us that we must and/or what we should do!
Many times the practitioner’s “goal” is to
“understand it”
“fix it”
“diagnose it”
“control it”

However, the client needs
to be listened to
to be understood
to be the source of the solution

The “Righting Reflex” =
A Practitioner Problem!








Use roadblocks to persuade
` Become the EXPERT
Tell them what to do
Give lots of advice
Try & convince them to change
Minimize their excuses
Ordering, directing or commanding
Warning or threatening
Giving advice, making suggestions, or providing solutions
Persuading with logic, arguing, or lecturing
Moralizing, preaching, or telling clients what they “should” do
Disagreeing, judging, criticizing, or blaming
What Good Listening is Not
(Roadblocks: Thomas Gordon, Ph.D)
Have fun!
Be yourself - Choose subjects that
have meaning for you.
Mistakes are part of the process.

A few learning suggestions….
Demonstrate an understanding of the basic approach of motivational interviewing (MI) and how to continue learning it while working with clients.

Demonstrate an understanding of the fundamental spirit and principles of MI.

Demonstrate an increase in the ability to use the foundation skills (OARS) in a targeted, MI adherent way.
Learning Objectives

“People are usually more convinced by reasons they discovered themselves than by those found by others.”
~Blaise Pascal
ASSESSMENTS.COM
5333 W. 2600 S. Suite 140
Bountiful, UT 84010
Phone: 1-877-277-3778
www.assessments.com
info@assessments.com
Thank You for Attending!
EckMaahs & Associates, LLC
1424 Victoria St. North
Saint Paul, Minnesota 55117
Phone: 651-489-1122
www.eckmaahs.com
seckmaahs@eckmaahs.com
Book # 1:
Motivational Interviewing: Preparing People to Change Vol. 1 – 1999

Book # 2:
Motivational Interviewing: Preparing People to Change Vol. 2 – 2002

Book # 3 on the way in 2012!
MI is also “learning” and growing…
EARS:
Elaboration (open question)
Affirming
Reflecting
Summarizing
When we hear change talk, it is important to reinforce it by responding immediately with….
Opposite Sides of a Coin
Change Talk and “Sustain Talk”
I know I can quit if everyone just gets off my back.

I’ve got to have my GED to get the apprenticeship.

I don’t want my kids getting in the same trouble I did.

This time, I’m going straight to the halfway house from here.

My mom’s not going to let me back in the house if I don’t quit.

It ain’t worth it to be landing up in here again (jail).

This time I’m going to stay clean.
Desire
Ability
Reason
Need
Commitment
Identify the type of
change talk

Listening for Change Talk: DARN-C!

D -
Desire to change (“want, like, wish…”)
A -
Ability to change (“can, could…”)
R -
Reasons to change (“If…then…”)
N -
Need for change (“Got to, have to, need to”)
C -
Commitment to change (“Will..., Am…)
Problem Recognition
Concern about the problem
Awareness of the problem
Potential benefits of Change
Costs of not Changing
What does Change Talk “sound like” ?

Open-ended Questions
Affirming
Reflective Listening
Summarizing

Putting it all together:
OARS RECAP….

One level of affirmation expresses:

Appreciation
Understanding
Compliments

A deeper level speaks to something positive about the person’s character: “That shows real integrity”, “You are a creative person”.
provide statements that support, encourage, reinforce, and acknowledge appropriate attempts made by the client.
Affirmations…
“Do you…Are you… Did you… Could you…Have you…?”

“Did you get a job yet?”

“Do you care about finishing your probation?”

“Were you thinking when you did that?”

“Do you have a drinking problem?”
Closed Questions sound like…
These are the tools for executing the spirit and principles of MI!

Open-ended Questions - avoid Yes/No

Affirming - support & encourage

Reflective Listening - repeat & clarify

Summarizing- link together & reinforce
The next level of practice:
OARS ~ Core listening skills!
Instrument in Press. May use with permission from Skeem, et al. (contact info on tool).
The Dual Role Inventory…
Balancing the Roles of the PO
A person’s belief in the possibility of change is an important motivator.
The client, not the practitioner, is responsible for choosing and carrying out change (with support and assistance).
The practitioner’s belief in the client’s ability to change becomes a self- fulfilling prophecy.
Support Self-Efficacy

Change is motivated by a perceived GAP between present behavior and important personal goals or values

Develop Discrepancy
We will arrange you in pairs:

Each person will take a turn talking for 3 minutes about What it was like for me growing up OR What would be my ideal future

After the 3 minutes the “listener” will try to capture the essence (not the exact words!) of what the person said. The idea is to “connect the dots” by hypothesizing what their words say about them or their experience.

Speaker will respond naturally.
Accurate Empathy EXERCISE:
Express Empathy

Develop Discrepancy

Roll with Resistance

Support Self - Efficacy
The Foundation Principles of MI:
MI “Spirit” is demonstrated through…

Non-Authoritarian
Active listening
Starting where client is “at”
Guiding, but not “taking the wheel”
Negotiating whenever possible
MI “Spirit” is demonstrated through…


Allowing client to have “the wheel”

Providing options whenever possible

Emphasizing client’s freedom of choice

Accepting that, in the end, the client has the right to choose NOT to change


Autonomy

Collaboration

Evocation

Also, focus on client success & competence
The “Spirit” of Motivational Interviewing is composed of:
Problem Recognition
Concern about the problem
Awareness of the problem
Potential benefits of Change
Costs of not Changing

What does Change Talk “sound like” ?
“The more a person argues on behalf of a position, the more he or she is committed to it.”

We believe what we hear ourselves say.

When a person publicly takes a position, his/her commitment to that position increases.

Self-Perception Theory!

Common Human Reactions to
Being Listened to


An increase in the rate and attractiveness of a “problem” behavior is likely if a person perceives that his or her personal freedom is being infringed upon or challenged!

Reactance Theory!

We are going to focus specifically on what happens with persuasion.
In a moment, we will divide you into pairs:
One of you will be the “speaker” and the other will be the “practitioner”…
ACTIVITY: “Persuade Me!”
Expectations for the training?
How Motivated are YOU?
William R. Miller, PhD
Most of the material contained within this presentation has been adapted from the work of William R. Miller, PH.D. and Stephen Rollnick, Ph.D (1999, 2002).

Additional credit goes to the members of the MINT (Motivational Interviewing Network of Trainers) who have so generously shared their ideas and resources.
Acknowledgments…


This training provides the beginning steps for learning the skills of MI!



What are some things you can do to continue building your MI skills?
REINFORCE
“CHANGE TALK”

HONOR...


BUT

MI
NIM
IZE,

“SUSTAIN TALK”

Our objective:
I know I can’t smoke weed, but I like my beer on the weekends.

There’s no way I’m going back to that program.

I need the stuff to come down after work. Otherwise, I can’t sleep at night.

I’d have no social life at all if I didn’t see my friends at the bar.

Mom doesn’t care what I do. She always takes me back.

No one’s gonna tell me what to do. Not even the judge!
Desire
Ability
Reason
Need
Commitment
Same pattern in reverse:
Sustain Talk!
What are reflections?


What is their purpose?
# 3: Reflections
The Corrections
Continuum:

TOUGH Fair/Clear Non-Directive Authoritarian Trust/Guide/Support Following
Roll with Resistance
Avoid arguing for change

Resistance is realized as a fluctuating product of interpersonal interaction

Resistance is a signal to respond differently


Listen actively with the goal of understanding

Skill of reflective listening is fundamental

Acceptance facilitates change
Express Empathy:
MI “Spirit” is demonstrated through…

Focus on Competence & Success

Evoking client’s knowledge of his/her own abilities

Drawing out client’s recognition of his/her past & present successes

Affirming and reinforcing client’s successes

Enhancing client's self-confidence & self-reliance
MI “Spirit” is demonstrated through…


Avoiding unsolicited advice-giving

Drawing out (or evoking) the client’s own desire and reasons for change!

Evoking change, instead of educating and advocating for change

E-P-E (Evoke - Provide - Evoke)
What did you notice about
the practitioner’s approach?

Contrasting Styles in
Working with Offenders: PO I & II

COMPLEX
SIMPLE
Repeating - simply repeat what was said

Rephrase - slightly reword/but not add anything new

Paraphrasing - infer unspoken content
/make hypothesis

Reflection of Feeling - infer emotional content
Levels of Reflection:
Eliciting Change Talk
Traps
Traps
The Opening Strategies: Open Questions Affirmations Reflections Summarizations
Foundation Principles: Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy
Spirit of MI: Autonomy - Collaboration Respect - Focus on Competence Evoke
Reflective Listening
What listener
HEARS
What speaker
SAYS!
What listener
interprets
What speaker means
Where accurate understanding can break down
Partners role - TRY TO PERSUADE!
PS...This is not Motivational Interviewing!
ACTIVITY: Persuade me!
Autonomy:
Collaboration:
Evoking:
Want to come back
Cooperative
Engaged
Able to change
Understood
Want to talk more
Accepted
Respected
Safe
Empowered
Hopeful
Comfortable
Interested
Liking/Respecting the practitioner
Open
Backward Focus
Why did you do that?

Why can't you do that?

Why havn't you been able to get a job?

Why didn't you follow through with that?
Forward Focus
How can you get back on track?

How could you do that?

What can you do this week to move forward?

What will help you follow through with that?
Dictate Solutions
Facilitate Solutions
Why can't you borrow your
mothers car for meetings?

What ab out that job at
Mcdonalds?

What about counting to 10 before acting?
How are you going to make it to your meetings?

Sounds like McDonald's might be one option. What else have you thought of?

When you think about times you've been able to manage your anger, what things have worked for you?
Its like learning to play the piano... guided practice , with coaching feedback = proficiency.
Some "MI" Benchmarks
Guiding is a Central Component of MI...
M.I.
M.I.
Client-Focused
Change Talk
Commitment Language
Taking Steps to Change!
The BIG picture...
Just the Start!
Introductions
Common reactions to being listened to cont...
I wasn't doing anything wrong! I just went along for the ride and I didn't know they were going to grab that lady's purse. Now they're saying I violated my probation. I guess it's not smart to be cruising around at 2 in the morning, but it happened so fast, there was nothing I could do. I didn't break any laws, and I am not going back to jail for this.
Identify the Change Talk.
I have no time to go to those parenting classes. Plus, it's embarrassing to think about going to those things. People might see me! You know that I'm not hurting my kids anymore. I am impatient with them because I am so miserable, but I can't leave them alone and I don't trust anyone else to take care of them the way I do.
Identify the change talk.
Full transcript