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Planning for Positive Change

In each of three previous posts, we looked at Motivational Interviewing (MI) as having four key processes and reviewed practice exercises targeting the first three processes:  engagingfocusing and evoking. In this article we examine the fourth MI process: planning.

Commitment language is predictive of behaviour change, and is distinct from preparatory change talk in that it embodies implementation intentions. Consider the following example:

commitment language continuum

Reference: Miller and Rollnick, 2012: 290

 

What’s the hurry?

Practitioners often rush toward action planning prematurely, resulting in clients’ reactance and disengagement. Learning to recognize – and strengthen – commitment language signals to us when it is appropriate to move toward the planning process in MI. Also, remember that the four processes are recursive. In other words, even when we hear strong commitment language, clients may still experience ambivalence (evoking process)  and decide to re-examine their goals (focusing process).  And, as always, we need to continuously engage and re-engage with the other person (engaging process).

 

Strategies to Strengthen Commitment

Here are some strategies to strengthen clients’ commitment for change:

  • Engaging in a supportive and collaborative working relationship
  • Focusing on clear goal(s) for change
  • Linking the person’s values with their goals
  • Evoking the person’s own motivations for change
  • Developing a specific change plan
  • Determining what step(s) the person is ready, willing and able to take.

 

MI commitment language

 

 

We can’t force a plant to grow, but plants are likely to thrive under the right conditions. What about human growth and realizing our potential? Motivational Interviewing provides the “right conditions” in which people can become ready, willing and able to make positive change.

 

Reflective Practice Questions

Consider a challenging client – one who does not seem to be making progress. Based on your understanding of the four processes of MI (engaging, focusing, evoking, planning), where do you think you need to be with this client? Are there avenues for small, incremental change that you could focus on to evoke commitment language? What might these be?

Come up with a reflection or a question that would evoke commitment language.

 

Garden tools and watering can with grass

Evoke change talk to enhance motivation for change

 

Previously, we looked at Motivational Interviewing (MI) as having four key processes and reviewed practice exercises targeting the first two processes:  engaging and focusing. This week’s intentional practice centers on evoking, specifically on evoking change talk.

Once we have engaged with our client and have collaboratively identified a goal (focusing), ambivalence about change is still common. Increased client change talk is associated with increased likelihood for change. Evoking change talk is key. When ambivalence is present, it is normal for change talk to occur within the context of sustain talk. This activity will help you practice selectively reflecting the change talk content contained within ambivalence.

 

Instructions: Review the client statements below, containing both change talk and sustain talk, and develop reflective statements that are focused on the change talk.  

Here’s a pre-test to get you started:

Client statement:

“I am 78 years old, and this medication is ruining what life and pleasure I have left. I know the doctor said there is a good chance it will help things, but I just don’t think these side effects are worth it.”

Sample therapist responses: Which reflective response focuses on the change talk in the above statement?

a. You really don’t want to continue with this medication.

b. It’s pretty clear that the doctor wants you to continue.

c. You’re not sure whether it’s worthwhile to continue the medication.

(check out the end of this article for the correct answer)

 

Note: The point of this exercise is not to do a double-sided reflection, but rather to listen for and select the change talk, and make that your focus in your reflective statement.

Client Statement: Start out by underlining the change talk in the statements below

 

Reflection: Now write down a reflection that selectively responds only to the client change talk contained in the statement
1.      The material the clinic gave me for my high blood pressure said I should avoid processed food, or else read the labels. I’m so busy I barely have time to eat, let alone shop, analyze my groceries, and spend half the night in the kitchen. These people do not live in the real world.

 

 
2.      Is it such a crime that I want to enjoy life while I’m still young? Once I’m tied into work, paying the bills, kids and all that I can scale things back.

 

 
3.      It is so frustrating that the minute you get pregnant everyone expects you to be perfect! I am so stressed out, it can’t be good for the baby. I am only having a few cigarettes a day, and my partner is totally on my case about it.

 

 

Reflective practice questions:

  1. How easy or difficult was it for you to identify the change talk in each of the client statements?
  2. How easy or difficult was it for you to frame a complex reflection that would further evoke change talk?
  3. What are the implications of this for your own continued growth and practice as a Motivational Interviewing practitioner?

(Correct answer: b. It’s pretty clear that the doctor wants you to continue.)

Adapted from: MINT TNT Manual (2014), various authors. 

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Focusing means strategic centering with a collaborative goal

 

In a previous article, we looked at Motivational Interviewing (MI) as having four key processes: Engaging, Focusing, Evoking and Planning.

Motivational Interviewing is directional – not directive. There is a horizon, something that we and the client are committed to working toward. However, finding and collaboratively agreeing on goals can be a challenge! This week’s intentional practice looks at the process of working with your client to jointly identify an agreed-upon goal. Below are two brief case scenarios. With a partner, you will each take a turn with one of the scenarios as a departure point for a follow-up session with a client with the intention of setting an agenda for change. The skills for intentional practice in this activity are to:

Practice a focusing conversation using the skills of MI – with special attention to those noted above. How can you practice these skills to guide the client toward focusing on a meaningful and collaborative goal? Take five minutes and then switch roles. After you have both had an opportunity to practice, take five minutes to debrief and share feedback with your learning buddy.

 

Case Example 1:

You are meeting with your client, Akilesh, for a follow-up appointment. In your initial session, you learned that he has been under a great deal of stress due to impending lay-offs at his work place. To make matters worse, his wife is in her first month of maternity leave with a reduced income. His mother’s health is failing, and his older son has been acting out at school: hitting and spitting at other children in his class, and on one occasion, his teacher. Finally, at the end of your first session, Akilesh “came clean” with you and acknowledged that he smokes 10-15 cigarettes per day.

 

Case Example 2:

You are meeting with your client, Elina, for a follow-up appointment. At the end of your initial session, Elina reluctantly agreed to come back and see you again. You suspect that in addition to appeasing her cardiologist by attending the referral appointment with you last time, she is now coming back for this second appointment because she wants to appease you. In the previous session, Elina acknowledged that she would probably be healthier if she quit smoking, but stated that smoking is a profound pleasure for her. She shared that she has already made so many changes, she just can’t see herself giving up her cigarettes.

 

Reflective practice questions:

Was your “righting reflex” triggered by anything in the case example, or by any of the client responses in your role play? To what extent were you able to maintain MI Spirit throughout the conversation?

 

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Engaging is the Relational Foundation

 

In their 2012 edition of the Motivational Interviewing “textbook”, Miller and Rollnick outline four recursive processes of MI. My colleague Wayne Skinner and I summarized these in a recent book chapter on MI:

Engaging: Client engagement is essential to the helping relationship. Without engagement, it is not possible to proceed, as the client makes a decision about whether to join with the practitioner and actively participate in treatment. The skills of engagement must also continue throughout all stages in the helping relationship.

Focusing: This “strategic centering” process hones in, with the client as equal partner, on the possible target(s) or direction(s) for change. At all times, client autonomy is respected – it is for the client to determine what he or she would like to address or work towards in treatment. Periodic “re-focusing” may be needed as goals evolve or change over time.

Evoking: Once the client is engaged in treatment, and client and practitioner have agreed on areas of focus, it is the practitioner’s task to evoke from the client his or her ambivalence about changing, reasons for change and strategies for change. In this stage the skills of MI become strategic in guiding the person in the direction of change by paying special attention to evoking change talk.

Planning: The process of planning can occur when (and only when) the client is ready to make a commitment to change. The skills of evoking commitment language, as well as the client’s strategies and ideas for change are key in this process.

Note that these processes follow a logical sequence, as each builds on the one before. However, practitioners may circle back to previous processes throughout the helping relationship.

 

Advancing Practice

Advancing our clinical practice takes practice. People often ask how they can access further training in Motivational Interviewing (MI), and there are lots of options available, but the most effective way is to just practice the skills! Peer practice is a good approach especially for those new to MI. I like case-based simulation as a teaching tool in MI to support integrated practice.

 

Case-based Learning

This exercise challenges you to intentionally practice the spirit and skills of Motivational Interviewing as they relate to engaging with our clients. The first few minutes of the very first session are powerful: this time communicates a wealth of information to your client about who you are as a person and a practitioner, as well as how you regard them. As you practice, consider how you can optimize the spirit and skills of MI as a powerful and impactful entry into engagement.

Below are two brief case scenarios. With a partner, you will each take a turn with one of the scenarios as a departure point for the first five minutes of your consultation. Remember that your purpose in this activity is to:

  • Intentionally embody the spirit of MI: partnership, acceptance, compassion and evocation
  • Beware the “righting reflex” – your task is to engage, not to fix it!
  • Practice reflective listening – incorporate at least three reflective responses in your practice.

Take five minutes and then switch roles. After you have both had an opportunity to practice, take five minutes to debrief and share feedback with your learning buddy.

Case Example 1:

Akilesh has been referred to your clinic because he has just been diagnosed with Type 2 diabetes. He is not overly concerned, as he was told that his condition at this time is not severe and can be controlled with diet. He is hoping for some clear guidelines and advice about foods to stay away from, and how to adapt his eating patterns. His chart states that he does not drink alcohol and that he is an “occasional smoker”. When he comes into your office, you notice that he smells strongly of tobacco smoke.

Case Example 2:

Elina is attending her appointment to appease her cardiologist, who is very concerned because of her continuing heavy tobacco use following her heart attack nine months ago. Elena is polite but clear that she does not intend to quit smoking. She has started an exercise program and is now eating a healthier diet, and feels that there is a limit to what changes she is willing to make in order to maintain her “quality of life”.

Reflective practice questions:

Was your “righting reflex” triggered by anything in the case example, or by any of the client responses in your role play? To what extent were you able to maintain MI Spirit throughout the conversation?

street art basketball

 

 

Nothing is possible without engagement

In any interpersonal interaction, nothing is possible unless there is engagement. This is true whether it’s a one-to-one counselling session, a classroom full of students, or a company team meeting. Engagement is the foundation of relationship, collaboration and change.

Enter Motivational Interviewing: A collaborative conversation for exploring and resolving ambivalence about change.

It seems like no matter how many years I have spent as a Motivational Interviewing trainer and practitioner, I still find nuances and insights in this model of practice decribed as ‘simple, but not easy‘. Lately I have been thinking about engagement as the essential underlying process in Motivational Interviewing, and mulling over how we can translate the clinical skills of establishing engagement with clients to our everyday skills in educational and work place settings to foster student and employee engagement.

 

Engagement is less about skill than it is about the spirit in which we practice – as clinicians, educators and leaders

What would our conversations, classrooms and meetings look, sound and feel like if we were able to deeply and consistently enact the four components of MI Spirit?
  1. We come to the relationship from a stance of respectful partnership, where all individuals bring valued and equal expertise
  2. We unconditionally accept others’ autonomy, worth and capacity – even when their intentions or actions don’t align with what we think best
  3. We are deeply committed to the highest interests of the other, rather than advancing our own agenda: compassion
  4. We are as eager to hear others’ stories, perspectives, beliefs, wisdom and values as we are to share our own: evocation as opposed to installation or education.

First and foremost, the spirit of Motivational Interviewing is more important than the skills.

Simple but not easy

When we like what we see, hear and feel, it’s relatively straightforward to respect what others bring to the table (partnership), to affirm their absolute autonomy (acceptance), to act with their best interests at heart (compassion), and to create a space in which their voice is heard and affirmed (evocation). The going gets tough when we don’t like what we’re seeing, hearing or feeling. That’s where our real work begins, and where we are most tested as clinicans, educators and leaders.

Authority is the enemy of engagement

Engagement isn’t the whole story, but it’s the essential beginning. Nothing substantive happens without it.
And when we have it, all things become possible.
compassion motivational interviewing quote

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Honesty is the best poetry

I’ve written elsewhere about “PowerPoint Best Practices” and why slide design can make the world a happier place. Images are like poems: their economy is such that they immediately engage our affective (versus cognitive) domain – and affect is hugely influential in learning and knowledge retention. I was briefly obsessed with imagist poetry as a teenager: “that which presents an intellectual and emotional complex in an instant of time”.  (It left its mark.)

The same disciplined simplicity is at the heart of the best and most effective use of beautiful/disturbing/thought-provoking/unexpected visuals accompanying a presentation. (PS: Check out this anthology if you want to learn more about imagism)

“Sounds good, but how can I visually translate MY ideas?”  (especially an image that is compelling, novel and adds value)

It’s a fair question. Most academics are trained to frame our ideas and concepts in words, not pictures. Yet words and pictures are both just symbols. For example, this slide deck for a full day workshop on advanced practice in Motivational Interviewing is approximately 80% images – used as placeholders for each of the practice-based activities I facilitated throughout the day.

In short: think about how you would define or translate the one key idea behind what you are trying to communicate. It is more than an excercise in finding pretty pictures – ruthless simplification forces us to reflect on the essential. That which we intend to be most memorable. This can only be a good thing for both presenter and audience!

Major Caveat: Visual communication is especially critical in relation to numeric data. Twenty years ago I never thought of data visualization as a career path, yet these modern-day dowsers are crucial to our understanding of the digital ocean. And that’s a whole other conversation: check out Big Data Science on Twitter. I am a rank amateur compared to what these people do.

If I were presenting this article to you, here is my slide:

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(Honesty is the best poetry, Queen St West, Toronto, Canada )

little green flying insect

It’s the practice itself that really matters

I found this on Twitter the other day, and it got me thinking about the art of listening…

While someone else is speaking, how often am I busy framing a reply? And if I’m focused on thinking about what I’m going to say next, that’s not actually listening. And then, I started thinking about how many conversations occur where both parties are more engaged in their own internal dialogues rather than a real, authentic, “I’m listening to you” dialogue.

Through this lens, silence isn’t just not speaking while someone else has the floor. Silence is a way of being, an inner stillness. In addition to silencing my “outside voice” (i.e., not interrupting), listening includes silencing my “inside voice” (see above) … and paying complete attention: with ears, eyes, undivided attention and heart.

I’ve been delivering training on Motivational Interviewing for about the last 15 years, and have spent much of that time focusing on the skill of reflective listening in clinical practice. In fairness, I also endeavor to “walk the walk” in everyday life. But something about that tweet caught my attention and made me pay attention.

Every conversation is an opportunity to simply practice listening. And like any discipline, it’s the practice itself that really matters.

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