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Motivational Interviewing

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geraldine mcdarby

on 5 February 2016

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Transcript of Motivational Interviewing

MI
Processes
eflective Listening
The function of reflection
pen Questions
Cannot be answered in one word
Create forward moving momentum
Encourage clients to talk, express themselves & set agenda
Help establish an atmosphere of trust and acceptance by allowing the clients to do most of the talking
Asking is not the same as listening!
ummaries
a special application of reflective listening
Motivational
Interviewing

Microskills "OARS"
ffirmations
O
A
R
S
speaker
listener
meaning
words
words
meaning
Genuine & Non judgemental
“Motivational interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.”
William R. Miller
Change
Talk
MI
Spirit
MI Skills
O
pen Questions
A
ffirmations
R
eflective Listening
S
ummarising
Identifying open/closed questions
What has changed in your life since you put on weight?
Where did you grow up?
Do you want to be fitter?
Have you ever through about walking as a simple form of exercise?
Do you think you will ever be able to change?
What are some reasons you have for starting exercise?
Is this an open question?
What questions have you for me?
Converting Closed Questions
large group exercise
in groups of 2/3
come up with 2 open alternatives to each of the following closed questions
Are you doing okay today?
Are you married?
How much do you drink on a typical drinking occasion?
Did you have a good day at school today?
Can't you see what your sexual practices are doing to you?
Aren't you concerned about your inactivity?
Are you thinking about changing your lifestyle?
Feedback to group
Forming Good Questions
continue in groups of 2/3 but change group
Read the statement and then write 2 open-ended questions matched to the content.
So, instead of smoking, I went for walks twice this week and thought about what I wanted to do.
What has been good in your day so far?
Where would you like to start today?
How did you keep yourself from smoking?
What was that like-going for a walk instead of smoking?
I don't get what we are supposed to be doing here.

I love my kids, but sometimes they push me to the edge and then I do things I shouldn't.

I am really tired of dealing with all of this crap. I just can't do it anymore. Something has got to change.

My problem is my wife and her constant complaining.

Here we go again. Same old stuff, just a different version.
To encourage patients to open up, to show interest
to feedback to patients their strengths and abilities
to enhance self efficacy & to empower
positive statements
praise affirmation
Finding Affirmations
Read and consider the following situations. Write down any strengths you observe, then form an affirmation based on those strengths
Trudy smokes. She knows it isn't good for her and is fed up of people reminding her of it. Over time, she has come to realise that her social habit has moved into a full-fledged addiction. At some point she will stop, but just not yet. Indeed, with all the other things going on in her life, this is the one area that she feels is her own. She feels guilty about and tries to hide it from her son and avoids the topic with her husband. She knows he's right when he brings it up but it still annoys her.
Strengths: Independently minded
Aware of changes in her behaviour
Wants to be more healthy
A person with diabetes recently switched to using an insulin pump and has been having high and low blood sugar levels. She is checking her BSL at least 8 times a day and is using the pump to deliver extra insulin as she needs it, but this may also be causing the highs and lows, as she tries to correct the problems. She is being awakened by low blood sugar in the middle of the night. Her diabetes educator has tried to talk with her about this pattern, but she responded by noting that it was their idea she go on the pump.
A young man stands before a juvenil justice judge for the 3rd time in less than a year. He was arrested for possession of marijuana. He was hanging out with a group of other homeless young people on the avenue when some college students started hassling them. He jumped in and a brawl ensued. As the police arrived and broke up the fight, a bag of marijuana fell out of his pocket. He takes an insolent attitude in the courtroom each time he is there.
A harried executive complains that she is struggling to manage the many tasks in her life. She is always tired and finds it a struggle to get out of bed when the alarm goes off at 5am. she finds herself drinking more than she did a few years ago just to unwind at the end of the night, after her kids are in bed and the last e-mails of the day have been sent. Her husband is worried about her stress, but his attempt to talk about its impact are met with snarling responses about her needing to wear the pants in the family.
Elmer is 95. He used to live alone but now resides in a care facility. He attends exercise groups intermittently and enjoys interacting with the other residents. He goes to family gatherings but has trouble hearing in group situations and so often feels isolated. Increasingly forgetful, he requires that things be explained repeatedly. To his son, the recipient of these repeated requests and his father's frequent complaints, these communications feel manipulative.
Amos is a 'man's man' As he puts it, 'I work for a living'. He hands steel on high risk buildings. He works in an environment where one false step could lead to a very long fall. He doesn't take crap from anyone, including his superiors and this has cost him at times. His wife complains about his being distant, and he's not even sure he knows what this means. Although he does love her and tells her so, he is also annoyed by her constant nattering and demands that he talk more. He buys flowers for her, watches her programmes on tv occasionally and does her 'to do list' faithfully. He finds himself becoming increasingly
MI
Talker: Think about a behaviour you want to change
Listener: Explain why the person should change
Give 3 specific benefits
Tell the person how to change
Emphasize how important it is to change
Tell/persuade the person to change
Listener: Why would you want to make this change?
If you decided to make this change, how might you go about it in order to succeed?
What are the 3 best reasons for you to do this?
How important is it for you to make this change on a scale from 0 - 10? (0 = not at all; 10 = very important)
After listening to the patient, give a short summary
So what do you think you’ll do?
A Taste of MI
In groups of 2- talker turns back to screen
Swap roles
Feedback to group
Affirmation: You are somebody who makes up her own mind. You wont simply cave to the desires of others, and in fact you are quite determined once you have made up your own mind.
Strengths: Engaged in her diabetes management
Persistent

Affirmation: You are quite determined to get this under control despite some difficulties
Strengths: Defends his friends
Willing to stand up for himself, even if it costs him
Affirmation: You are a loyal friend, willing to defend others, even when it causes trouble for you
Strengths: Works very hard for her family
Continues to rise to the challenge, even though its getting harder
Affirmation: You are someone who is able to work extremely hard, even to the point of delaying your own needs until others are met
Strengths: Independent and social
Continues to seek out ways to be healthy and active
Wants to engage with his family
Affirmation: You are someone who really wants to be engaged with people, especially your family
Strengths: He loves his wife and expresses it, in his own way
He is willing to stand in the face of criticism and disagreement
He recognises when he has gone too far
Affirmation: You are someone who cares deeply for your wife, and you're willing to show it in ways that make sense to you
Non-verbal listening exercise
Before starting to shape reflective listening, it can be useful to increase awareness of the importance and value of nonverbal or passive listening skills
in groups of 2 choose a speaker and a listener
Speaker: choose one of the following topics to speak about for 5 minutes
What it was like growing up in my home
Ways in which I have changed as a person over the years
The good and bad things about my school years
What I hope and plan to do over the next 10 years
Describe one of your parents, or someone else close to you
Listener: say nothing at all, not even "mh hmm" or other vocal noises. Use nonverbal skills to communicate that you are listening and understanding
Feedback to the group: What was this experience like for the speakers?
For the listeners?

Switch roles
Thinking and forming reflections

Do you mean that......?
In groups of 2 or 3
Think of 3 personal statements about yourself (characteristic you like in yourself or a behaviour you would like to change)
again, not deepest, darkest secret!
Take turns, in rotation, saying one of the statements to your partner(s)
When a speaker has offered their statement, listeners respond by asking questions of this form only: "Do you mean that................?"
The speaker responds to each question only with Yes or No.
No additional elaboration is permitted
Swap roles
Feedback to group
Hypothesis testing
Directive reflecting
Deepening reflections
groups of 3
reflective statements
reflective questions
Speaker offers a personal statement
Listener responds with reflective statement
Speaker responds, this time not limited to Yes/No
Listener responds to each elaboration with a reflective statement
Swap roles
Feedback to group
You're angry about what I said?
vs
You're angry about what I said.
in groups of 2
Read the sentence stem and write 3 different responses to each item. Each response should emphasize a different aspect of the statement
experience
assumptions
prejudices
judgement
Reflective statements
hypothesis testing
simple reflection
complex reflection
stays close to what the patient has said
goes beyond what the patient has said
infer meaning
cognitively reframe
affect (emotional content)
depth-amplified reflections (over/understate)
movement/direction-leading/following
"I'm not sure I buy this MI stuff"
"you're not sure"-simple
"you're not sure about MI, but you're willing to give it a try"
-leading/double sided
evoke/create movement
2:1
reorient the patient to the resources they have available for this effort
multiple unsuccessful attempts
negative or resistant attitude
It's been fun, but something has got to give. I just can't go on like this anymore.
-suggest persistence and strong desire for change
-"you must have a lot of resolve to come here despite your reservations"
-"it must have taken a lot of determination to come back, given your experiences"
1. You've enjoyed yourself.
2. You're worried about what might happen
3. It's time for a change
I know I could do some things differently, but if she would just back off, then the situation would be a whole lot less tense; then these things wouldn't happen.
1. You wish she would give you some space
2. You'd like things to be less tense
3. You could do some things differently
I've been depressed lately. I keep trying things other than drinking to help myself feel better, but nothing seems to work, except having a couple of drinks.
1. You've been feeling down
2. Drinking works in the short term
3. You might like it if something other than drinking made you feel better
So, I'm not too worried, but its been over a year since I've had a HIV test.
1. It's been a while since you had a test
2. You're wondering about your HIV status
3. You're a little worried
I know I'm not perfect, but why do they have to always tell me what to do. I'm not 3!
1. Sometimes you make mistakes
2. It bugs you when they tell you what to do
3. You feel like you are being treated like a child
My daughter thinks it's her body and therefore she should be able to do what she wants with it. Hooking up is no big deal to her. She just doesn't get why I wont back off.
1. She has been arguing with you
2. Her sexual behaviour is a concern
3. She doesn't see how much you care
Continue in groups of 2
Feedback to group
Using the same sentences, write a reflection for each of the response types. In some, certain reflections may not fit as well, but try to create one anyway.
response types:
paraphrase: moves beyond simple reflection, presenting information in new light
amplified: overstates, increases the intensity of an element
double sided: reflects ambivalence
affective: addresses the emotion (expressed or implied)
"you hate that you have to be here"-affect/amplified
?accuracy
It's been fun, but something has got to give. I just can't go on like this anymore.
I know I could do some things differently, but if she would just back off, then the situation would be a whole lot less tense; then these things wouldn't happen.
I've been depressed lately. I keep trying things other than drinking to help myself feel better
So, I'm not worried, but it's been over a year since I've had a HIV test.
I know I'm not perfect, but why do they have to always tell me what to do. I'm not 3!
My daughter thinks it's her body and therefore she should be able to do what she wants with it. Hooking up is no big deal to her. She just doesn't get why I wont back off.
paraphrase:
amplified:
double sided:
affective:
paraphrase:
amplified:
double sided:
affective:
paraphrase:
amplified:
double sided:
affective:
paraphrase:
amplified:
double sided:
affective:
paraphrase:
amplified:
double sided:
affective:
paraphrase:
amplified:
double sided:
affective:
So, the fun has come at a cost
You've had a fabulous time
On one hand, you've had a good run, and on the other you can see it's coming to an end
You're a bit worried about where this is taking you
You would like your situation to be different
It feels like she's totally responsible for it, like its really her fault
So, she played a part in what happened, and you know you could also do things differently
You're upset about the situation
You keep looking, despite the lack of success, for ways other than drinking
Drinking is the only possible way
Drinking helps in the short term and part of you recognises this may not be a great long term strategy
You're frustrated by the lack of payoff on your hard work
You've had some risky behaviour
It's no concern to you
You feel you have been pretty safe, while also recognising you may have taken some risks
It's like there is always a little uncertainty-fear since you have chosen to be sexually active
They are the parents you don't want to have
They don't let you make any choices
It feels like they're being pretty bossy and at the same time you know there are things you could do better
As your anger grows, you end up feeling like a petulant 3 year old who wants to pout and say 'no'
She doesn't see your concern, only your meddling
You don't feel she is capable of making these types of choices
On the one hand you want to help your daughter, and on the other you can see that your methods are causing some conflict
You're scared to death about what might happen to her
Feedback to group
Now try these:
I've tried everything you have told me to do, and I'm just getting worse!
I'm sick and tired of you people!
I'll do anything to get better!
Thank you for all of your help, I could not have done it without you.
evaluative judgment
often begin with "I"
I think you are very determined
communicate an appreciation of who the client is
can begin with 'you'
you are very determined
I'm very proud of the work you have accomplished
you have accomplished a great deal here
patients often find praise/compliments judgemental or patronising
External
Internal
VS
tips to avoid evoking feels of judgement or of being patronised:
focus on specif behaviours instead of attitudes, decisions and goals
avoid using the word "i"
focus on descriptions and not evaluations
attend to nonproblem areas rather than problem areas
think of affirmations as attributing qualities to patients
nurture a competent instead of a deficient world view to clients
collecting

linking

transitions
Be Brief & don' t overdo it!
provide structure
gather & present information
keep the conversation moving forward
present contrasting information
develop discrepancy & explore ambivalence
choose or change direction (end session, move to planning)
Summarising exercise
in groups of 2
Talker: Talk for 2 minutes about a habit, behaviour, dilemma or something you are thinking about changing
Listener: Be an interested listener without saying anything or asking questions. At the end of 2 minutes, give a summary of what you were told. Summarise only.
change roles
Feedback to group
Talker: tell your story again without interruption
Listener: Give a summary of what you were told, but this time, give a summary of what you think is the underlying meaning, feeling or dilemma.
change roles
Feedback to group
What reflective listening is not:
ordering, directing or commanding
Warning or threatening
giving advice, making suggestions, providing solutions
persuading with logic, arguing, lecturing
moralising, preaching, telling patients their duty
judging, criticising, disagreeing, blaming
agreeing, approving, praising
shaming, ridiculing, name calling
interpreting, analyzing
reassuring, sympathizing, consoling
questioning, probing
withdrawing, distracting, humoring
Thomas Gordon's 12 Roadblocks
Homework
choose interview (as group)
listen for roadblocks and OARS
answer the questions
Code interview
OR
watch 2 videos and comment
Full transcript