PRIME Conversations: Motivational Interviewing Skills for Instructors David B. Rosengren, Ph.D. Prevention Research Institute CE Conference 2012
Persuasion?
Overview Overview of Day Expectations-skill development Modeling as teaching Building Relationship to working with, finish line focus, & defusing dissent
Readiness to Change
Ambivalence is normal occurs throughout the change process reflects costs and benefits of change and status quo is uncomfortable may become chronic resolved by participant Bem s Self-Perception Theory
Bem s Self-Perception Theory We discover other s beliefs by Listening to them talk Observing their actions When not sure what we believe? Listening to ourselves talk Observing our behavior Not attributed to some external force
A Comment on the Transtheoretical Model and MI Transtheoretical Model (TTM) Model for how change happens Four primary components Processes of Change (10 total) Stages of Change (5) Context of Change (5) Markers of Change TTM/SOC are cousins, but not MI
Three Communication Styles Directing, following, & guiding All have strengths & limitations Mismatches cause trouble Move fluidly among three Rollnick, Miller & Butler, 2008
Video Doctor providing post heart attack care What style does Doc use? What tells you that it s that style? What is the participant s response? Is readiness to change enhanced?
Definitions of Motivational Interviewing (MI) from MI-3 Three levels of definition: Layperson - What s it for? Pragmatic practitioner - Why would I use it? Technical therapeutic How does it work? Miller & Rollnick, 2011
Definitions of Motivational Interviewing (MI) from MI-3 Layperson - What s it for? MI is a collaborative conversational style for strengthening a person s own motivation for commitment and change Miller & Rollnick, 2011
Definitions of Motivational Interviewing (MI) from MI-3 Pragmatic practitioner - Why would I use it? MI is a person-centered counseling method for addressing the common problem of ambivalence about change Miller & Rollnick, 2011
Definitions of Motivational Interviewing (MI) from MI-3 Technical therapeutic How does it work? MI is a collaborative, goal-oriented style of communication with particular attention to the language of change. designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person s own reasons for change within an atmosphere of acceptance and compassion. Miller & Rollnick, 2011
Two Components Relational Spirit of MI Technical 4 Processes Microskills Strategies Must have both
Exercise: Going Live Close your eyes Think of something you ve done that you regret Not many know Don t want many to know Imagine you must talk to this group about it Can t receive credit for this seminar until you do Concentrate on & remember these feelings What do you need from me and the other s to feel more comfortable? What qualities? Remember Adapted Activity from Judith Carpenter
Spirit of MI Partnership Honors client expertise and perspective Creates an environment that supports change Acceptance Right and capacity for self change (& not) Facilitate informed choice Compassion Goes beyond care and concern Work on behalf of the client Evocation Resources lie within client Enhance intrinsic motivation (less about external pressures)
Four Fundamental Processes Planning Evoking Focusing Engaging
Change Talk Four Components Statements about possible change Not typically instructor statements Specific to a behavior, choice, attitude Present tense PFL, like MI, elicits this talk Our aim is to more actively reinforce it
Change Talk Preparatory: Desire, Ability, Reason & Need Mobilizing: Commitment, Activation, & Taking Steps May vary in intensity Trajectory is critical
Mobilizing Language Commitment Taking Steps Activation (e.g., readiness, willingness to change)
Video Bill & the Soccer Guy How does Bill exemplify Spirit of this conversation? What processes does he use What change talk do you observe? DARN Commitment Talk or Taking Steps Is this guy resistant? Why or why not?
MI Microskills OARS-O Open-ended Questions Affirmations Reflective listening Summaries Offering Information Rollnick & Miller, 2012
Open-ended Questions Sets the tone for MI work Creates momentum Focus broadly Cannot answer with a yes or no Rule of thumb: 2 reflections for every question
Affirmations Participants can be demoralized Orients people to their resources Be genuine Probe partial successes Reframe resistance into an affirmation What and how questions are helpful Use you statements, not I Like salt a little goes a long way
Exercise: Mining for Affirmations What are strengths of your participants? What do they do well? What do they do to survive or thrive?
Reflective Listening MI is built on this skill Directive use of listening Attend to some things and not others Create awareness of gaps Reinforce change talk
Reflective Listening More than paying attention More than repeating words Way of thinking Hypothesis testing
Reflective Listening Content may be similar to question Goal - keep momentum going Voice drops at end of sentence
Reflective Listening Two levels of reflection Simple Content stays close Not easy Deeper Goes beyond what is said Offers new perspective May shift participant understanding
Simple Reflections Musical Chairs Repeating - repeats an element of what the speaker has said What s the story behind your name? Rephrasing - listener stays close, but substitutes synonyms or phrases What is the first movie that you really remember and why?
Complex Reflections Guess at the unexpressed major restatement that infers meaning. What do you like to do on Saturdays (or your day off)? Reflection of feeling emphasizes emotional aspect If you could do college (or your young adulthood) over again, what would you do differently?
Complex Reflections Continuing the paragraph (anticipates) a logical extension of the conversation What do you hope and plan to do over the next 10 years? Metaphors Images that organize a participant s experience What s the next step in your life that would most support your health and well-being?
Being Directional Not telling participant what to do Choosing to attend to different elements Usually multiple elements in a statement Focus will determine path
Examples of being directional I m tired and it feels impossible right now. You re worn out. It feels really hard to do. Right now is a problem, but maybe later won t be.
Summaries Special form of reflective listening There are different kinds Today focus on a generic form Indicate you re about to summarize Be selective Attend to ambivalence Target change talk Help organize the participant s experiences
Hallway Conversation Practice skills in opportunistic setting Talker : You just heard about the low risk guidelines You re drinking above the guidelines intermittently You re wondering how these will fit for you
Hallway Conversation Listener Two goals: Work to understand the person be curious Support, but do NOT defend the guidelines Techniques: 3 Questions - Use reflections or summaries You ll have five minutes!
Offering Information Generally we use Persuasion Theory and Process However, other times do arise then It s about information exchange 2 way Offer don t impose It s a person, not a receptacle Ask permission Use a menu Use other clients as models Elicit-Provide-Elicit
Goals? Resolve ambivalence Increase change talk Reduce or avoid sustain talk or discord
Sustain (or Status Quo) Talk Flip-side of Change Talk Why I don t want or need to change Reflect ambivalence Ambivalence under pressure creates discord (or dissent) and push back
Responding to Sustain Talk or Discord Skills already practiced May not eliminate, but can reduce heat Three reflective types are particularly helpful: Simple Amplified Double-sided Two Strategies Shifting focus Emphasize personal choice
Video: Rounder DUI Evaluation prior testing What techniques does the provider use? What elicits change talk? How does she handle sustain talk? Discord? How does this fit for what you do in PFL?
Resources Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner s Workbook. New York: Guilford Press. Wagner, C.C., & Ingersoll, K. S. (2012). Motivational Interviewing in Groups. Guilford: New York. Miller, W.R., & Rollnick, S. (2012). Motivational Interviewing (3 rd Ed): Helping People Change. Guilford: New York. MI Website: www.motivationalinterviewing.org