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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?

 

1 engaging

 

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?

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