1. Having Difficult Conversations Darryl Tonemah Ph.D., M.Ed.

2. Always remember that a participant is motivated for whatever they are doing, and they are acting autonomously. They are in charge. 2

3. What we have learned from stages of change is that change is a spiraling process, not so linear. What we have learned from stages of change is that change is a spiraling process, not so linear. Patient’s/participant’s motivation for change is effected by life, love and the pursuit of all things fried. Patient’s/participant’s motivation for change is effected by life, love and the pursuit of all things fried. Our role is to have skills in our tool box that recognize when an individual has moved to a different stage and use those tools to adjust motivation toward change. Our role is to have skills in our tool box that recognize when an individual has moved to a different stage and use those tools to adjust motivation toward change. REMEMBER we are motivated for whatever we are doing...So what motivates us for behaviors? REMEMBER we are motivated for whatever we are doing...So what motivates us for behaviors? Getting Started!

4. Its not a volume issue, it’s a clarity issue.

5. Motivation Shift is: ✦ a cue to change strategies ✦ a case manager problem, not a client problem ✦ easy to provoke Resistance exists between people, there has to be someone/thing to resist. If I stop pushing back, there is nothing to resist.

6. Roll with it Not taking it personally Recognize that people will not do anything they don’t want to do - it is their decision

7. Thermostat vs Thermometer A thermometer determines the temperature of a room. A thermostat responds to the temperature.

8. Options MI Appreciative Inquiry Cognitive Behaviorism ALWAYS listen for the nuggets of motivation the participant will offer 8

9. MI step 1 Listen Listen Listen 9

10. Related Motivational Interviewing Principles Avoiding arguing Rolling with resistance

11. Avoid Arguing Sometimes our natural tendency is to push back or argue for the side of change. Unfortunately, that actually makes the patient/client defend not changing. We would be speaking the language of the action stage of change, and they are speaking the language of pre-contemplation or contemplation. Breathe for a moment and open your tool box.

12. Roll with Resistance Resistance is energy. It requires energy to be resistant, but rather than meet resistance with resistance. Don’t take it personally. If there is not someone at the other end of the argument, there can’t be a back and forth.

13. Avoid the Traps Expert- Trying to have all the answers Labeling- You’re the one with diabetes!

14. Reflective Response Simple Reflection - Meeting resistance with non-resistance. Reflecting back meaning or a few words they stated back to the patient/participant/client. Really not adding interpretation. Its a statement, not a question.

15. Strategic Response - Develop Discrepancy Motivation for change increases when a patient becomes aware of discrepancies between current situation and goals or hopes for the future. Creates dissonance. Don’t argue the patient’s cons for change; forces patient to defend the cons, reinforcing them for him/her.

16. Repeat Pros and Cons “It sounds like, on the one hand, you want to reduce your risk of complications by lowering your blood sugar, but on the other hand its hard to keep up the effort and coming to class, can you tell me a little about that?”

17. Ask questions about behaviors that don’t support goals set by participant “Mr Frybread it seems you’ve lost some momentum in attending and exercise/activity. You had said before how important your health is to you. Has that changed for you? How?”

18. The Colombo Approach http://www.youtube.com/watch?v=pZiv8vkxMac 18

19. At some point it will be easy to get back into MI process 19

20. Appreciative Inquiry A major assumption of AI is that in every participant something works. Change can be managed through the identification of what works, and focus on how to build on it. Focusing on what works as opposed to what problems the participant is having differentiates AI from traditional problem solving approaches. 20

21. Appreciative Inquiry cont. Inquiry into the “art of the possible” should begin with appreciation. The first task is to describe and explain those exceptional moments which give energy and activate members’ competencies and energies. Inquiry into what’s possible should be collaborative. Energy flows where attention goes; create a positive loop 21

22. Appreciative Inquiry cont. Appreciative inquiry helps us to understand the “best of what is” in a participant; and leads to imagining and creating a shared vision of a healthier future. 22

23. Appreciative Inquiry cont. Inquiry is our most important tool in creating positive change. The seeds of change are implicit in the questions we ask. The more positive the question, the longer-lasting the change 23

24. After 48 hours A participant will recall 30% of what you say and 78% of what they say. Courageous conversation 24

25. Problem Solving vs. Appreciative Inquiry "Felt Need" Appreciating Identification of ProblemThe Best of "What is" Analysis of CausesImagining What might be" (Begin with the end in Mind) Analysis of Possible Solutions Shared Dialogue "What we most want“ (win – Win) Action Planning Innovating "What will be" (synergize) BASIC ASSUMPTION:BASIC ASSUMPTION: LIFE IS A PROBLEMLIFE IS A MYSTERY TO BE SOLVEDTO BE EMBRACED Note: From D. L. Cooperrider and Associates (1996). A constructive approach to organization development and change.

26. Possible Questions What have you enjoyed about the program? What have you enjoyed about changing your health? If things worked out great how would things be (looking forward, what might be) Lets talk about a time when this wasn’t an issue (looking back) What are your best outcomes (What we most want) 26

27. Cognitive Behaviorism 27

28. Definition Many psych/behavioral problems stem from unwell thought processes These thoughts have biological and psychological roots Individual responses are influenced by the way they structure/perceive their environment 28

29. Modification Modifying this thinking and behavior leads to improvement in symptoms Modifying unwell core beliefs which underlie dysfunctional thinking leads to more durable improvement 29

30. Key tenets Talking back to negative thoughts Problem Solving Cognitive reframing 30

31. “ The ancestor of every action is a thought” Ralph Waldo Emerson 31

32. Brief Encounter I RAN INTO THE PARTICPANT THAT HASN’T BEEN HERE IN 6 MONTHS AT THE STORE!!! 32

33. What to do Assess situation- Chilly-Warm Maintain positivity Wait for them to introduce you if they are with others “How have you been” 33

34. If they open door “We’ve missed you” “You bring so much to the group with you energy/stories/humor etc.” “Would it be ok if I called/stopped by? When is a good time for you?” 34

35. If they seem chilly ?????? 35

36. 36 Let’s take care of each other Be Well Thank You