What you will learn?
Try this!
The spirit of MI, noted as critical to doing MI, is better shown than described. Fortunately, most of us have experienced an example of that type of spirit in our lives through either a teacher or a supervisor. Here is an activity, based on the Favorite Teacher Exercise used by trainers of MI, which exemplifies that type of spirit. Subsequent exercises help you recognize MI spirit and help you build the empathy "muscle." Fianlly, the partner work helps you focus on your strengths and capacities as a person, which in turn you can use to help your clients.
Exercise 1: Favorite Teacher or Supervisor
Who was a person that motivated you to learn, inspired you to excel and to try harder than you otherwise would have? You'll be ased to think about this person and then answer some questions. The aim is to draw out characterisitcs about him or her and how you felt and responded when you were with that person. If you cannot choose one as a favorite, simply choose among your favorites for the purpose of this exercies (and consider yourself fortunate indeed!)
Exercise 2: Is it MI spirit?
It can be very helpful to look at exchanges between clients and practitioners to observe if the MI spirit is present. The worksheet for exercise 2 contains examples of short client statements and practitioner responses. You'll review these exchanges and then decide if the practitioner's response is consistent with the spirit of MI (thumbs up) or not (thumbs down). Then write your reasons so you can compare with the analysis, which follows the items.
Exercise 3: Driving in Cars
Sometimes clients are really easy to feel empathy and understanding for, but sometimes they are not. Here are a couple of methods to practice empathy skills while driving in your car. In this exercise you'll take a couple of common events that can occur during communiting and use them as opportunities to build empathy. One involves developing a "back story" for someone who has made a silly or risky driving decision that comes to your attention. If you don't drive, you can also use other opportunities to observe these types of behaviors. The second activity involves listening toa radio and providing reflections.
Exercise 4: A difficult client
We all have difficult clients. These individuals put us through our paces and may leave us feeling uneasy about our work or even dreading their next visit. Consider your work siutaion and think about who that client might be. Then complete the worksheet for exercise 4.
Exercises 1, 2, and 4 can all be done as activities with a partner. Exercise 3 should also be done as a team activity. In addition you might consider exercise 5.
Exercise 5 - A Favorite Memory
This activity is based on an exercise called "Reliable Strengths." In this exercise each of you will take turns recalling memories from childhood and describing them to your partner, who will in turn draw ideas about strengths that you demonstrate in these stories.
Other thoughts:
Many MI trainers use ballroom dancing as a metaphor for MI. That is, ballroom dancing can only occur when the two people move together in partnership. When done well, the movement unfolds through a series of subtle presses. This stands in contrast to wrestling, where one grappler attempts to assert his or her will over the opponent. So, one qeustion you might ask yourself in times of frustration and client resistance is, are you dancing or are you wrestling?
A common misconception about MI is that it is a method for manipulating clients into making changes they do not really want to make. Another misconception is that MI is clinically useless, sincce it works only when clients want to change anyway. I hope that this lesson has illustrated that it is really neither of those things. MI is a series of specific strategies, informed by respect for client autonomy and values, for maximizing the chances that clients will choose adaptive behavior change. MI takes advantage of the natural tendency of human beings to choose what is best for them in the long run by working collaboratively to identify clients' desire for change within apparently destructive behaviors.
Finally, the fact that there is only one brief reference to Prochaska and DiClemente's transtheoretical model in this course on the foundations of MI may surpirse some peopole. In the 1991 MI edition and earlier writings, TTM figured more prominently, though in the second edition TTM was moved to the second half of the book. It's clear that over time TTM generally and the stages of change element of the model particularly have become conflated with MI. These are not MI, as Miller and Rollnick (2009) noted recently, though they share a common heritage. hence, its deemphasis in a course on learning MI.
You must pass the quiz with a 70%.
Let's review what we have covered so far.
Although MI builds on Carl Rogers' ideas, it adds more than attitude. MI is a combination of directiveness, motivation building, rolling with resistance, attending to change talk, and bringing a particular spirit to the encounter. There have been many sources for the concepts and techniques used in MI. However, this is not the same as saying that MI is simply a new version of an old concept. There are unique elements to MI. We avoid arguing with clients because to do so engenders resistance. This does not mean that we will always agree with everything a client says. MI uses many methods (describe din the lesson) for providing alternative views. However, we begin with a basic stance of curiosity, wherein we try to comprehend how the client understands the world. Reflective listening is a critical skill in MI, but is NOT MI. Indeed, I have observed practitioners forming very accurate, but MI-inconsistent, reflective listening statements. However, I do not believe that you can do MI well without being able to do reflective lsitening well. Evocation, a component of MI spirit, refers to a stance of constantly trying to draw out information, wisdom, solutions, etc., from clients. We also use evocation to draw out motivation and then hold this inofrmation as in a mirror, for the client's consideration.
The attitude and intent of the practitioner are critical in terms of how communications are received and used. For example, a sarcastic question that asks, "And how is that working for you?" has a very different impact than a question that comes from an attitude of curiosity using the exact same words. Although ambivalence can keep people stuck, and its resolution is a central aim of MI, it is not the same as denial. nor is it a problem. It is a normal part of any change process and should be expected. Resistance is not something inherent in a particular disease or disorder. Rather, it is part of an interpersonal process that can be influenced - for better or worse - by the practitioner and should be used as a cue for the practitioner to change strategies.
Directiveness, a key concept in MI, has two elements: paying attention to parts of conversation that support client change and steering the conversation in productive directions. We will attend to some things and not to tohers. The practitioner works to build motivation, reduce resistance, and elicit change talk through providing attention and steering the conversation. Recognizing client autonomy does not negate practitioner goals. Within MI there are target behaviors for change; if there are no such targets, then this is probably not MI but more akin to client-centered counseling. Within the MI framework, we (as practitioners) may have an aim we think is important: increasing sexual safety, reducing recidivism, improving diet and exercise, reducing authoritarian and enhancing authoritative parenting, or stopping drug use. Clients will also have goals. We work actively to bring these different agendas into alignment (Steve Rollnick refers to this process as "agenda matching"), while recognizing that clients will and must choose the destination for any change.
Let's review.
Self-perception theory points out why we don't wish to strengthen resistance but instead "roll with it." Rather than engaging in an argument, we find another approach - including understanding the client's position. Increasingly, MI experts differentiate sustain talk and change talk. In a consensus statement about change talk, Miller, Moyers, et al. (2006) recommend that trainers use sustain talk to identify client statements that favor maintaining the status quo and use resistance to describe client behavior that signals "dissonance" in the clinical relationship itself.
Desire, ability, reason, and need for things to stay the same, as well as commitment to sustaining current behavior, may all describe client statements about sustaining the status quo, acording to the change talk consensus statement. If more sustain talk is happening than gange talk, it generally suggests change is unlikely to happen. It may not be the exact amounts of each that matter, but rather, their trajectory over the course of a session. If there is a lot of sustain talk, and very little change talk, at the beginning, but then sustain talk diminishes while change talk rises then change is more likely. Further research is needed to confrim this trajectory, though initial data from Amrein and colleagues suggests that this might be so. Nevertheless, in general, more sustain than change talk indicates that change is less likely.
Sometimes clinicians can see the beneifts of MI in "counseling" situations but feel that it may not be enough when there is great risk. Although Miller and Rollnick might agree that a more advice-giving, directive role may be needed in some situaitons, this would not lead them to endorse an aggressive denial-busting approach. Instead, they would argue that advising can be done in a variety of ways, some of which will be more effective than others. A denial-busting mode, in contrast, is likely to engender resistance, and resistance is likely to lead to worse outcomes. Sean's example, from the beginning of the lesson, illustrates the peril in this approach. miller notes, "If you have very little time in which to evoke behavior change, you don't have time not to listen."
Skillful reflections often have the effect of reducing resistance. Remember, it is tough to sustain resistance without someone pushing against it. If the practitioner's reflections do not push against the resistance, then the energy is likely to dissipate. Amplified reflections can be very useful when clients take a particularly strong stance. The amplified reflection often "presses against" the resistant element in a client statement. Many times (though not always) this approach will cause the client to back away from the absolute. If the person does not, it means that your reflection was simply accurate. It may be time to shift focus. Simple reflections are a helpful place to start with angry clients. Typically, the practitioner will move on to other types of reflections as the interchange progresses, but this is a very good place to begin. Remember, simple is not the same as easy, and there is skill required in what the practitioner decides to attend to.
We are just mkaing the obvious obvious. ALthough there may be contingencies present, it is still up to clients to decide if they will go with the reinforcements or press against the consequences. Amplified reflections involve pushing on the resistance or sustain element with the intent of moving a client away from an absolute position. Siding with the negative involves agreeing that this may not be the right time, place, or method for change, again with the intent of nudging the client to explore this idea more fully.
You will next take a quiz. In order to pass the course, you must receive a 70% or higher.
Let's review really quickly:
Ambivalence is normal. Reflect. Engle and Arkowitz (2006) Make a clear differentiation between the uncertainty of making a change and the active pushing back in which clients sometimes engage. This assertion is similar to the comments about sustained talk and resistance. OARS alone can be enough, thought sometimes a more formal approach can yield a fuller picture of the situation and assist the person in moving forward toward readiness. Decisional balance is not MI. Although it may be useful in some specific situations, it is not necessary and may even be problematic because it elicits status quo talk. Although the definition of MI refers to an exploration of ambivalence, this focus is not meant to involve a lengthy elicitation of all the reasons for the status quo. Instead, it is a targeted approach that selectively elicits and reinforces change talk.
Although evocative questions may indeed evoke emotion, that is not the intent behind these types of questions. These queries are meant to draw attention to elements focused on change and ask the client to speak directly to these elements. Most of the time picking the flowers involves change talk. However, there may be times when preliminary steps – like in the conversation with Carrie – focus on the change element but don’t meet the standard fro change talk (i.e., noting the department’s requirement that she must engage in this activity). This is not the same as change talk, yet it puts us on the path where change talk may happen. We may need to attend to these elements until change talk emerges. Once it does, change talk is the primary focus.
The VCS technique is not highly technical, though some practice and experience with it is clearly important to use it effectively. Like many of the areas I’ve discussed, it will be the small nuances and skilled reflections and questions that ultimately determine the effectiveness of the technique. However, this does not prevent people who are learning MI from using this technique effectively. The VCS exercise can elicit affirming and shaming, and both can serve as motivators, though the latter is a much more complicated situation. In general, MI does not seek to elicit shame because this response does not create a safe environment for change. On the other hand, in the course of careful review and discussion, people might become quite aware that their behavior has not matched their expectations for themselves (or that others held). The aim is not to elicit feelings of shame, but, if they are brought forth, then the goal is to move to a situation where behavior feels more congruent with values. This process requires skill. It is the art of doing MI well and for which there is nothing like practice, feedback, and coaching.
About the course
This course covers the foundations of motivational interviewing as well as the stages of change model based on the Transtheoretical Model of change by Prochaska and DiClemente. This course covers the use of MI and teaches the basics. We will learn OARS skills and how to use the spirit of MI in counseling and across genres.
This course is useful for practitioners in the substance use field, but is also useful for other practicitioners such as paraprofessionals, corrections workers, perer counselors, physicians, dental hygienists, diabetes educators, chemical dependency professionals and counselors, or anyone else working in helping situations.
