Motivational Interviewing: 101 Luis Lopez MS Implementation Specialist, Trainer Center for Practice Innovation @ Columbia Psychiatry New York State Psychiatric Institute

lopezlu@nyspi.columbia.edu

Today’s Outline Welcome What Is Motivational Interviewing (MI)? MI Spirit and Processes Roadblocks and Traps Core Skills – Open questions, Affirmations, Reflective Listening & Summaries Putting It all Together

Q & A Raise your hand if you had at least some training in MI? How have you used motivational interviewing?

Ambivalence: Exercise Find a Partner Each of you write down something you want to change, need to change, should change, have been thinking about changing but you haven’t changed yet Select who will speak first The speaker then presents what it is they would like to change (but haven’t done yet)

Ambivalence: Exercise The listener (counselor) then: Explains WHY the person should change, tells the person HOW they should make the change, emphasizes HOW IMPORTANT it is to change and PERSUADES the person to do it Speaker your job is now to listen and note what you are thinking and feeling Debrief

Motivational Interviewing: Definition A person-centered counseling style for addressing the common problem of ambivalence about change It is a collaborative conversation style that helps strengthen an individual’s own motivation and commitment to change Miller and Rollnick (2013)

The Spirit – the Heart of MI Collaboration (partnership and share decision making) Acceptance (empathy, affirmation, autonomy) Compassion (caring what happens to the person) Evocation (eliciting a persons own reasons fro change) (Miller and Rollnick 2013)

The Spirit – the Heart of MI Openness to a way of thinking and working that is collaborative rather than prescriptive Honors the consumer’s autonomy and self-direction, and is more about evoking than installing Involves at least a willingness to suspend an authoritarian role

The Spirit – the Heart of MI Explore consumer capacity rather than incapacity (strength based) Genuine interest and active curiosity in the consumer’s experience and perspectives The spirit in which we work with consumers is key to engagement – engagement is key to everything else!

Four Processes Engaging: the process by which both parties establish a helpful connection and a working relationship “Shall we work together?” Focusing; a collaborative process by which you develop and maintain a mutually agreed direction in your conversation based on what the consumer wants to talk about “What do we want to do together?”

Four Processes Evoking is the process of eliciting the consumer’s own reasons for making a change “How important is this to you?” Planning collaboratively designed action plans. In MI it is to be with someone while he or she forms plan of change that will work “How” and “When” (Martino, S., et al. 2007)

ONE STOP: ROADBLOCKS Gordon (1970) outline 12 communication roadblocks Ordering Name Calling Warning Diagnosing Preaching Praising Advising Sympathizing Lecturing Cross Examining Blaming Sarcasm

Traps to Avoid Question-Answer Trap Expert Trap Premature Focus Trap The Labeling Trap Confrontational Trap The Blaming Trap

Core Skills - OARS Affirm strengths Summarize Ask Open questions Listen actively and Reflectively Summarize

Open-Ended Questions Can’t be answered with a “yes/no” or otherwise limited response Invites elaboration Deeper thinking Creates forward momentum in exploring reasons for change Melanie We’re now ready to move on to the O and A in OARS. Open ended questions: What (might be some) reasons do you have for changing…staying the same? What steps have you already taken? What about a time when you were successful in making a change? What worked? If you do nothing about changing, where do you suppose you might be in about 5 years? What’s might your life look like if you did decide to change? Affirmations: Ties into a strength's based approach. Builds self efficacy. Shows young people that you see then good in them and that they are trying. I see how important this change is to you You’ve made some huge changes thus far Its your tenacity that has gotten you this far You clearly have a lot of skills and abilities to tap into

Open Ended Questions Practice

What is Reflective Listening? A guess at what consumer means by what they just said (not an interpretation) Is always in the form of a statement never a question It can be simple or complex Complex reflections add meaning or emphasis to what has just been said

What is Reflective Listening? It is collaborative/non-authoritarian It is never critical, judgmental, confrontational It can be directive (selective) but never directs by giving advice/suggestions without permission It is reinforced by consumer’s response

Advantages of Responding with a Reflective Listening Statement It is unlikely to evoke resistance It encourages consumers to keep talking and exploring the topic It communicates respect and caring and builds the therapeutic alliance It clarifies for you exactly what the consumer means It can be used to reinforce ideas expressed by the consumer

Thinking Reflectively The first step in using reflective listening is to listen carefully and think reflectively The key to doing this is to think in terms of hypotheses This means that when you hear someone say something, you form a hypothesis or a best guess about what the consumer means

Types of Reflections Repeat what the person said using exact words Rephrase what the person said using slightly different words to clarify meaning Paraphrase what the person said using different words to emphasize contradictions, convey underlying meaning, or complete a thought Communicate understanding of underlying emotions or feeling, particularly when the person has not explicitly stated them Melanie: With that practice, you can see that thinking reflectively can be translated into using reflections as you’re talking with young people. This slide lists different types of reflections. Repeat what the person said using exact words Rephrase what the person said using slightly different words to clarify meaning Paraphrase what the person said using different words to emphasize contradictions, convey underlying meaning, or complete a thought. Communicate understanding of underlying emotions or feeling, particularly when the person has not explicitly stated them Summarize by grouping several reflections together

Examples of Reflections “Everyone keeps telling me to take this medication, it will make me feel better. They don’t understand that the side effects make me feel really bad.” Repeating: “Your medication gives you side effects that make you feel bad.” Rephrasing: “While you are hopeful that the medication will help you in many ways, right now you’re finding that it’s hard to deal with the side effects.” Paraphrasing: “People just don’t get what it is like to take this medication.” Underlying emotion: “You’re tired of feeling bad from the medication side effects.” Melanie

Reflections Practice

Affirmations Recognize strengths Build rapport Help see the individual in a positive light Must be congruent and genuine Instills hope that change is possible Affirmations different than rewards

Affirmations I appreciate that you are willing to meet with me today You are clearly a very resourceful person You handled yourself really well in that situation That’s a good suggestion. You’ve really thought about this If I were in your shoes, I don’t know if I could have managed nearly so well Melanie Not reinforcement (“good job”, “great question”) Examples of affirming responses: I appreciate that you are willing to meet with me today. You are clearly a very resourceful person. You handled yourself really well in that situation. That’s a good suggestion. You’ve really thought about this. If I were in your shoes, I don’t know if I could have managed nearly so well. I’ve enjoyed talking with you today. You helped me understand what’s going on.

Affirmations Practice

Summaries Summarize by grouping several reflections together Gather what was said and present them back to the consumer Used strategically to attend to aspects of change Can highlight both sides of ambivalence Can be used to end a session, or move on during a session “what’s next?” Examples Rusty: Let’s start with the R and the S in OARS. Reflections: Conveys that you heard the individual (the young person and understood what they meant) Involves statements, not questions Use of openers such as: “it sounds like you…” or “So you’re feeling…” Ratio should be 3+ reflections for everyone 1 question Summaries: A type of reflection Gathering parts of what the client has said and presenting them together Selective in which parts are presented back

Putting It All Together - You Try It Find a partner, decide who will be the first speaker Speakers, your role is to talk to the listener about the following topic “one thing about myself that I would like to change is…” The listener’s task is to respond using the OARS but primarily with reflective listening statements The speaker responds by continuing to elaborate Stay in role. Do not discuss or break role until we tell you to switch roles. Be prepared to discuss experience

Thank You!!!