10/25/18 1 What are the four elements of MI spirit? Partnership Acceptance Compassion Evocation Pop Quiz What are the four processes that guide MI conversations? Engaging Focusing Evoking Planning Pop Quiz What are the four core skills used in MI? Open questions Affirmations Reflective listening Summaries Pop Quiz Change Talk in MI Why Change Talk Matters “Change talk predicts behavioral change” Miller & Rose. Toward a Theory of MI Recognizing Change Talk Client Speech Neutral talk is “other talk” Sustain talk favors the status quo, not changing (different from resistance) Change talk favors movement in the direction of change Change Talk: DARN - CAT Preparatory change talk ● D esire to change (I want, like, wish) ● A bility to change (I can, could) ● R easons to change (if…then) ● N eed to change (I have to, got to) Mobilizing change talk ● C ommitment (I will, I promise) ● A ctivation (I’m willing, am ready to) ● T aking steps (I made an appointment)
Transcript
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What are the four elements of MI spirit? PartnershipAcceptanceCompassionEvocation
Pop Quiz
What are the four processes that guide MI conversations?EngagingFocusingEvokingPlanning
Pop Quiz
What are the four core skills used in MI? Open questionsAffirmationsReflective listeningSummaries
Pop Quiz
Change Talk in MIWhy Change Talk Matters
“Change talk predicts behavioral change”
Miller & Rose. Toward a Theory of MI
RecognizingChange Talk
Client Speech
Neutral talk is “other talk”
Sustain talk favors the status quo, not changing (different from resistance)
Change talk favors movement in the direction of change
Change Talk: DARN-CATPreparatory change talk● Desire to change (I want, like, wish)● Ability to change (I can, could)● Reasons to change (if…then)● Need to change (I have to, got to)
Mobilizing change talk● Commitment (I will, I promise)● Activation (I’m willing, am ready to) ● Taking steps (I made an appointment)
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Change talk sounds like...Focus: Getting in better shapeD: I’d like to feel more fit
A: I could probably jog or swim
R: If I exercised more, I’d feel a lot better
N: I’ve got to get off this couch and do something
_____________
C: I plan to bicycle more, and drive less
A: I’m ready to get started tomorrow
T: Yesterday, I walked a mile after lunch
Activity: DARN-CATFocus: _____________Preparatory change talk● Desire to change (I want, like, wish)● Ability to change (I can, could)● Reasons to change (if…then)● Need to change (I have to, got to)
Mobilizing change talk● Commitment (I will, I promised myself…)● Activation (I’m willing, am ready to) ● Taking steps (I went to a support meeting)
“Will you take this personto be your lawfully wedded spouse, and be wholly faithful, for richer and poorer,
in sickness and health, so long as you both shall live?”
Degrees of Change Talk
I want to (desire)
I could (ability)
I should (reasons)
It’s important to me (need)
I DO! Is it change talk, sustain talk, or something else?
Activity I like to drink. It’s what I do.
Focus: Drinking
If I drank less, I’d probably feel less groggy the next day.
Focus: Drinking
I’d like to quit, but it’s so hard.
Focus: Drinking
I drink way less than most of my friends.
Focus: Drinking
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I’ve got to do something about mydrinking. It’s really getting out of hand.
Focus: Drinking
Who are you to give me advice! I saw you walking into a bar just last week.
Focus: Drinking Focus: DrinkingI’ve tried to quit more times than I can
remember, and I’m done trying.
Focus: DrinkingI’ve tried to quit more times than I can
remember, but I’m willing to try one more time.
Focus: DrinkingI’ve tried to quit more times than I can
remember, and I’m not sure I want to try again.
Focus: DrinkingIf I quit, I’m sure my liver will thank me.
Focus: DrinkingMaybe I could cut back by drinking less
whiskey and more beer.
Activity: Change Talk Activity1. Underline the client’s change talk2. Drum for change talk3. Note which OARS used by interviewer4. Practice
ActivityListening for Change Talk
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Activity: Listening for Change Talk
Maté, Gabor. In the Realm of Hungry Ghosts: Close Encounters with Addiction. Toronto: Knopf Canada, 2008.
Jake- It’s hard to get away from it.- When I’m older, I’ll worry about pension plans and stuff.- I don’t see my own family for a year, and I don’t care...- Yeah, the coke’s my life...I care more about the dope than my loved ones or anything else- I don’t know how to be without it. I don’t know how to live everyday life without it.
Jake- You take it away, I don’t know what I’m going to do- If you were to change me and put me in a regular-style life...- I was there once in my life.- Do you think you could send me to a skin specialist?- I’ll go, Doc. Don’t worry, I’ll go.- That frog you’re talking about. That’s me.
Eliciting and StrengtheningChange TalkChange talk often flows naturally by simply using OARS.
When it doesn’t occur naturally, we can elicit and strengthen change talk using various strategies.
Strategies forEliciting Change Talk
Ask evocative questions
Use importance and confidence rulers
Query extremes
Look back/Look ahead
Explore values and hopes
Evocative questionsWhat’s important to you in life?
What concerns, if any, do you have about getting screened? How might it benefit you?
How do you know when your stress is and is not well controlled?
What does heroin do for you? What concerns do you have about using it?
What are some things that you know can be triggering for you?
Evocative questionsWhat would you lose if you gave up smoking?
What’s at stake if you don’t make this change?
What would be some possible benefits of limiting your screen time?
What strengths do you bring to this situation ?
What do you think you’ll do next?
How can I, or others, support you?
Importance RulerAsk“On a scale from 0 to 10 (0=not at all important;
10=totally important/urgent), how importantis it to you at this time to make this change?"
Explore“What makes it already a ___ and not a ___
(several numbers lower)?”“If you were to move from a ___ to a ___ (the next
highest number), what would that be connected to for you?”
“How might I help you with that?”
Confidence RulerAsk“On a scale from 0 to 10 (0=not at all important;
10=totally important/urgent), how confidentare you that you would be able to make this change?”
Explore“What makes it already a ___ and not a ___
(several numbers lower)?”“If you were to move from a ___ to a ___ (the next
highest number), what would that be connected to for you?”
“How might I help you with that?”
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Query Extremes
“What concerns you absolutely most about _____?
What are the very best results you could imagine if you _____?
Looking Back
“What were things like before ____?
“What has changed?”
Looking Ahead
“How would you like things to be different a month/a year/three
years from now?”
Values and Hopes
“What are the rules you’d say you live by?”
“How does ____ impact the person you want to be?”
“What do you long or yearn for?”
“Where do you find meaning in life?”
“What gives you joy?”
“What are your hopes for the future?”
Exchanging Information
“It is easy to overestimate how much information and advice
clients need to be given.”Miller & Rollnick
A simple strategy for exchanging information
Elicit-Provide-Elicit
Elicit
- Ask what person already knows
- Ask what person would like to know
- Ask permission to provide information
Elicit-Provide-Elicit Elicit-Provide-ElicitProvide- Prioritize what person most wants to know- Be clear; use everyday language- Offer small amounts of information with
time to reflect- Acknowledge freedom to disagree or
ignore
Elicit
- Ask for person’s response, interpretation, understanding
Elicit-Provide-Elicit
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Activity: E-P-EElicit- Ask what person already knows - Ask what person would like to know- Ask permission to provide informationProvide- Offer small dose of suggestions, adviceElicit- Ask for person’s response
Using MI across the Four Processes
engaging: the relational foundation
Provide safe space and warm welcome; show genuine interest in the person as a person
engaging: the relational foundationWhat would you like me to know about yourself?
What’s going well in your life overall? What’s going less well?
Tell me about (family, work, school, etc.)
focusing: the strategic direction
Mutually establish the agenda. Ask what the person wants to focus on. State what you wish to address (if anything).
focusing: the strategic direction
What would you like to focus on today?
We could discuss A, B, C or something else.
Would it be all right if we took a look at…
Tell me a little more about...?
What’s working? What’s not?
evoking: preparation for change
If you were to make this change...
What would be your reasons to do so?
What would be your best reason?
How might you go about it in order to succeed?
evoking: preparation for change
How important is it to you to make this change?
How confident are you that you could make this change?
evoking: preparation for change
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Importance rulerAssess On a scale from 0 to 10, how important is for you to make this change?
Explore“What makes you say ___ and not ___ (several numbers lower)?”
“What would it take to move from a ___ to a ___ (next highest number)?”
“How might I or others help you with that?”
Confidence rulerAssess On a scale from 0 to 10, how confident are you that you could make this change?
ExploreWhat makes you say ___ and not ___ (several numbers lower)?
What would it take to move from a ___ to a ___ (next highest number)?
How might I or others help you with that?
planning: the bridge to changeAsk what person plans to do next; assist with developing a change plan; discuss how you and others can provide support
What remaining concerns do you have?
What do you think you’ll do next?
How might I or others help you with that?
planning: the bridge to change Activity: A Guided
Conversation Across the Four Processes of MIPairsInterviewer: Use handout (p.19) as a guide
Respondent: Real-play
Responding to discord *
* formerly known as resistance
Discord - interpersonal behavior that reflects dissonance in the the working relationship - e.g. arguing, interrupting, discounting, ignoring
Responding to discordHow to increase it
Ask “Why don’t/won’t/haven’t you...?”
Try to “fix” the person or situation
Confront what you don’t agree with
Insist people tell you the truth
Take things personally
Responding to discord
How to decrease it
Seek to understand the person’s point of view.
Responding to discord
Ways to respond to it
Use reflective statements
Apologize when necessary
Be affirming
Shift the focus
Emphasize personal choice and control
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Video: Responding to Discord
PracticeGroups of three
Three 8 minute motivational conversations
Rotating roles- Interviewer: Use MI skills across the 4
processes
- Client: Real-play
- Observer: Brief MI Measurement Tool
DebriefEight minutes1. Interviewer – all the good stuff you did,
one area for improvement
2. Client – subjective experience, the good stuff, one suggestion for improvement
3. Observer – comments based on Brief MI Measurement Tool
In conclusion…
BreatheLet MI spirit guide youKnow where you areUse your OARSTrust reflectionsElicit more, impart lessFocus on the good stuffInvite to actionBreathe
General Practice Guidelines Now What?Read more about MI
Get additional training
Observe and discuss professional training videotapes
Tape and critique your own practice
Work with someone knowledgeable about MI to provide coaching and feedback
Form a learning circle to support mutual skill-building
Motivational Interviewing in Health Care, Rollnick, S, Miller, WR and & Butler, C. The Guilford Press, 2008.
Motivational Interviewing in the Treatment of Psychological Problems, Edited by Arkowitz, Westra, H, Miller, WR, & Rollnick, S, The Guilford Press, 2007.
Motivational Interviewing DVD, 2013. The Change Companies www.changecompanies. net/motivational_interviewing.php
