herie advanced groups 2013 final pub

Advanced Practice in Group Facilitation Integrating Motivational Skills and Strategies

Dr. Marilyn Herie PhD, RSW

Brain Tumour Support Group Facilitator and Convenor Workshop April 13, 2013 Brain Tumour Foundation of Canada

Confidence Ruler

What do you most want to take away from today?

• Turn to the person next to you and share your responses

• One or more key things you would like to take away from this workshop?

• We will check in as a large group in 5 minutes

Learning Objectives At the end of this session, you will be able to… 1. Resist the “righting reflex” in favour of “PACE”

(Partnership, Acceptance, Compassion, Evocation) 2. Practice the foundation skills of Motivational Interviewing

(Open questions, Affirmations, Reflections, Summaries, Information)

3. Apply the foundation skills in shaping group conversation and engaging with challenging group members

4. Adapt motivational group activities for your own groups 5. Identify your preferred facilitation style, and increase

flexibility in incorporating other styles.

“Group Dynamics 101” Quick Review

What is the value of groups? 1. To communicate key

information 2. To effect behaviour change 3. Mutual support and

empowerment

Content

Process

Content versus Process

A person will not always remember what you said

or did, but they will always remember how you made

them feel.

Some challenging issues… • A member monopolizes the conversation • A member discloses she is having small

seizures but has not told her doctor because she wants to retain her driver’s license

• A member starts to disclose childhood abuse or trauma

• A member repeatedly talks about how much he loved injecting opioids and this is upsetting to other group members

Examples of Group Norms • Making sure that everyone has a voice (“Is

it OK if I sometimes interrupt or redirect the group to keep us on track?”)

• Mutual respect • Being on time • Missing a session • What this group can and cannot do • “Taboo subjects” • How we support ourselves and each other

when difficult feelings come up

Some challenging issues (revisited)

• A member monopolizes the conversation… Making sure we all have a voice in this group/ Mutual respect and inclusion

• A member discloses she is having small seizures but has not told her doctor because she wants to retain her driver’s license… Confidentiality & Duty to Report

• A member starts to disclose childhood abuse or trauma… What this group can and cannot do

• A member repeatedly talks about how much he loved injecting opioids and this is upsetting to other group members… Taboo subjects and how we talk about/handle them

Stages and Tasks

1. Orientation stage 2. Dissatisfaction

stage 3. Resolution stage 4. Production stage 5. Termination stage

Belonging Fight-flight

Trust

Consolidation, ending

Interdependence

The Art of Counselling

• Attending to process and content • Adapting materials to the needs of the

client and group • Eliciting and integrating client feedback • An ongoing development process…

Easier More Difficult

Format Support Psychoeducational Psychotherapeutic

Structure Structured Semistructured Unstructured

Composition Homogenous Heterogeneous

Size 5 15

Session Length

60 minutes 120 minutes

Admission Staggered Closed Open

Wagner & Ingersoll (2013) p.103

Confidence Ruler

Best Practices in Group Facilitation

What is MI? Motivational interviewing is a collaborative conversation to strengthen a person’s own motivation for and commitment to change.

Miller & Rollnick, 2013

Follow (Listen) Direct (Inform)

Guide (Ask)

Research publications evaluating MI effectiveness have been doubling every three years.

www.motivationalinterview.org

MI Outcome Studies by Era

020406080

100

1988-94 1995-99 2000-02 2003-06

Alcohol Drugs Dual Dx GamblingOffenders Eating Dis Adh/Retention SmokingHIV Risk Cardiac Diabetes PsychiatricHealth Prom Family Violence AsthmaDental

31 Slide from Bill Miller, 2010

MI Applications • Public health &

workplace • Sexual health • Dietary change • Weight management • Voice therapy • Gambling • Physical activity • Stroke rehab • Chronic pain

• Medication adherence • Diabetes • Mental health • Addictions • Fibromyalgia • Chronic leg ulceration • Self-care • Criminal justice • Vascular risk • Domestic violence

Anstiss, 2009

Spirit of MI

http://tinyurl.com/c5gamll

The “Spirit” of Motivational Interviewing

• Partnership • Acceptance • Compassion • Evocation

• Absolute worth • Accurate empathy • Autonomy support • Affirmation

36

Partnership

“You are the best judge of what is going to work for you.”

Acceptance

“I am here to help whatever you decide to do.”

“People are most able to change when they feel free not to.”

- Carl Rogers

Compassion

Guide me to be a patient companion, to listen with a heart as open as the sky. Grant me vision to see through his eyes, and eager ears to hear his story…Let me honour and respect his choosing of his own path.

Adapted from Miller, 2013, “A Meditative Preparation” (p.24)

Evocation

“What were you hoping for by coming here today?”

“A Psychological Law”

I learn what I believe as I hear myself speak.

Bill Miller (Based on D. Bem, 1967, “Self-Perception: An alternative interpretation of cognitive dissonance phenomena”)

Engaging

Focusing Evoking

Planning

Four Processes in MI

Adapted from Miller and Rollnick, 2013, p. 26


1. Engaging: The relational foundation 2. Focusing: Clarify directions: What is the

horizon? 3. Evoking: The person’s own arguments for

change 4. Planning: Developing commitment to

change + formulating a plan of action

Miller and Rollnick, 2013

Engaging

• Opening check-in • Attention to content

(e.g. what people say) and process (e.g. how they say it & others’ responses)

• Openness and flexibility – what does the group want or need?

Focusing

• What are we covering in this session?

• Therapist session checklist and group input

Agenda-Mapping

So many choices, so little time…

Agenda-Mapping Worksheet Priorities

Agenda-Mapping Worksheet Priorities

Strengths & Successes Relationships Grief & Loss

Loneliness/ Isolation

$$ Issues Symptoms and Coping

??? ??? ???

“Given these possible areas of focus, what would should we talk about in our time here today?”

Evoking

• “I learn what I believe as I hear myself speak”

Planning

What is on the horizon? What is the person working towards changing?

Engaging

Focusing Evoking

Planning


Adapted from Miller and Rollnick, 2013, p. 26

Confidence Ruler

Foundation Skills:

O A R S

FOUR KEY STRATEGIES – OARS OPEN questions (to elicit client change talk)

AFFIRM the client appropriately (support, emphasize personal control)

REFLECT (try for complex reflections)

SUMMARIZE ambivalence, offer double-sided reflection

Open Questions always the beautiful

answer

who asks a more beautiful

question - e.e. cummings

Open versus Closed Questions • CLOSED questions invite a “yes/no”,

one- word or very limited answer • OPEN questions encourage elaboration –

they evoke the group’s ideas, opinions, hopes, concerns, etc.

Open versus Closed Questions

Read the following sample questions, and “vote” for whether each one is

OPEN or CLOSED

a. Open question b. Closed question

“Would you say you are looking forward to these group sessions?”


“Tell me some of your thoughts about coming to these group sessions?”

“What made you decide to sign up for this group?”


How severe would you rate your symptoms right now?


Can you describe some of the adjustments you’ve had to make?


If you were me… 1. Formulate two open questions to a

participant: One focused on content One focused on process

2. Formulate two open questions to the group:

One focused on content One focused on process

When you are not sure where to go next…

“Tell me more…Tell me more…”

Affirmations

Allusions = To what has been said…

• That sounds like a good idea... • I think that could work... • I think you’re right about that... • It’s important to you to be a good parent… • I can see how that would concern you…

Andréasson, Farbring, Miller & Resnicow (2002) http://www.motivationalinterviewing.org/sites/default/files/MINT9_2.pdf

Attributions = To make someone feel noticed and “seen” as a person…

• You are a bit of a philosopher really. You are reflecting on some really deep issues here…

• You are the kind of person who cares a lot for other people…

• You are a very creative person. It reflects a lot in your personality…

• You have what it takes to be a leader. Other people listen to you…

• You are the kind of person who does not like to talk behind the backs of other people. You have a lot of integrity…

Andréasson, Farbring, Miller & Resnicow (2002) http://www.motivationalinterviewing.org/sites/default/files/MINT9_2.pdf

Example of Praising:

Look how far you’ve come! I know you can do this.

I sure hope so...

Praising can lead to…

But I am actually not so

sure

Example of Affirming You have hung in there even though things have been very stressful.

Affirming can lead to… Yes – I can’t believe how far I’ve come

Maybe I can really do this!

Example of Praising:

You are such a wonderful group - I have really enjoyed our session.

Example of Affirming The group has worked hard today in exploring some tough issues, and we have come closer as a result of that.

Choose one of your most challenging groups – and come up with an affirmation that you could offer

Reflections

EAR

EYES

UNDIVIDED ATTENTION

HEART

“To Listen”

IMPERIAL

Simple Reflection

Complex Reflection

Simple Reflection

Complex Reflection

They are really on your case about coming to this group.

It wasn’t your idea to come to group, and you’re not sure this is going to be at all helpful to you.

“I’m only coming to group today because my doctor and my wife are both pressuring me.”

Practicing Reflective Listening

Individually, take a moment to write down an example of a simple and a complex reflection for the following statement (coming up – next slide).

Then compare what you wrote with others at your table. As a group, choose the best examples to share with the larger group.

Practicing Reflective Listening (1) Individual Simple & Complex

“I’ve been told I can’t return to my job, and now they are taking away my driver’s license!”

Individual Simple Reflection:

___________________________________

___________________________________

Individual Complex Reflection:

___________________________________

___________________________________


Individual Simple Reflection:

First one thing, and then another!

Individual Complex Reflection:

You’re feeling like pieces of your life are being taken away, one by one.


Individual Reflection

Group Reflection

Individual Reflection

Group Reflection


Some people are here because they chose to come, while others have been “mandated” to attend.

It wasn’t your idea to come to group, and you’re not sure this is going to be at all helpful to you.

Practicing Reflective Listening (2) Individual & Group Reflections


Individual Reflection:

___________________________________

___________________________________

Group Reflection:

___________________________________

___________________________________


Individual Reflection:

You’re feeling like pieces of your life are being taken away, one by one.

Group Reflection:

These are major losses, and it’s hard to imagine how to cope with all of the changes that people are experiencing.


Group Simple Reflection:

___________________________________

___________________________________

Group Complex Reflection:

___________________________________

___________________________________


Group Simple Reflection:

Everyone is experiencing major losses and change.

Group Complex Reflection:



Group Content Reflection

Group Process Reflection

Content Reflection

Process Reflection

Whatever your reason for coming to group, ultimately everyone would like to get something of value for the time spent here.

Some people are here because they chose to come, while others have been “mandated” to attend.


Practicing Reflective Listening (3) Group Content & Group Process


Content Reflection:

___________________________________

___________________________________

Process Reflection:

___________________________________

___________________________________


Content Reflection:


Process Reflection:

We’ve heard about a lot of loss in the group today, and it’s not always easy to hear that or talk about it and still feel hopeful.


Reflecting Panel

1.Three volunteers: Panel (Facilitators)

2. Four volunteers: Clients Something that irritates you

3. One volunteer: Coach A sounding board for the group

Reflecting Panel Instructions

Reflecting Panel Instructions

1. Group: Each share one thing that you find irritating or annoying

2. Panel: Take turns offering a single reflection 3. Group: After ALL Panel members are done,

talk to your coach about which reflection resonates most for you and why

4. Group: Offer this feedback to the panel, and continue the paragraph

Individual Reflection: Simple or complex

Group Reflection: Simple or complex

Group Content or Group Process Reflection

Confidence Ruler

http://tinyurl.com/ara93vh

…and the day came when the risk it took to remain tightly closed in a bud was more painful than the risk it took to bloom.

(Anais Nin)

The 5th Foundation Skill:

Providing Information in a Motivational Way

“Unsolicited advice is the junk mail of life.” (Bern Williams)

The 5th Foundation Skill:

Providing Information in a Motivational Way

Elicit Provide

Elicit

Elicit/Provide/Elicit • Elicit: What ideas do you (group) have

about coping with…? • Provide: Can I offer some other

suggestions? You might consider… • Elicit: How does this fit for you

(group)?

Mark Twain

Habit is habit, and not to be flung out of the window by any [one], but coaxed down the stairs a step at a time.

Critical Issues in Group Facilitation

A Strategy for “Taming” Skeptical/Hostile Participants:

• Thank the person asking • Acknowledge their experience/

commitment/willingness to take a risk • Mirror the question or comment back • Extrapolate to a broader context or

principle • Respond to the question or comment • See what others think and check back

TAMERS

“I don’t really need to be here”

Here’s how we see the group issue from our perspective:

Let’s re-imagine this issue in a different way

The goal is to find a way in

What are some compassionate possibilities in how we respond?

What strategy could you use? • Open question • Affirmation • Reflection

Individual content reflection Individual process reflection Group content reflection Group process reflection

“It’s all about me!”

“Us versus Them”

“I don’t know why he even bothers coming to group”

“This is a really good class”

Basic MI Conversational Shaping Strategies

• Establishing, developing, holding focus • Changing focus • Accelerating and Decelerating • Broadening and Narrowing • Deepening and Lightening

When you are not sure where to go next…

“Tell me more…Tell me more…”

Confidence Ruler

The main course!

148

Four Group members: • Something about yourself that you

want to change need to change should change have been thinking about changing

but you haven’t changed yet i.e. – something you’re ambivalent about

Putting it all together…

149

Facilitator

150

• Listen carefully with a goal of understanding the dilemmas you hear from group members

• AVOID giving advice unless you are explicitly asked • Ask these four open questions of the group, follow with

reflective listening/affirmations…and listen with interest: 1. Why would you want to make this change? 2. How might you go about it, in order to succeed? 3. What are the three best reasons to do it? 4. On a scale from 0 to 10, how important would you say it

is for you to make this change? Follow-up: And why are you at __ and not zero? • Give a short summary/reflection of the group’s

motivations for change • Then ask: “So what do you think you’ll do?” and just

listen

Confidence Ruler

Barriers and Enablers to Practice Change

What are your next steps? • What will you commit to doing to continue to

develop your facilitation skills? Some ideas…

– Start or continue a peer supervision group focused on the issues and topics we’ve discussed

– Observe colleagues’ group facilitation and spend time debriefing with them before and after

– Ask clients for their feedback about what went well and what you could do differently as a facilitator

– Buy a book on presentation, teaching or facilitation skills and/or surf the web

– Set concrete goals and check back – Others?

Confidence Ruler

Wrapping Up

Summary

Quick review of group dynamics and practice implications Overview and practice: Resist the Righting

Reflex and evidence base for MI Integrating MI best practice skills (MI Spirit,

Four Processes & OARS skills) Agenda Mapping and providing information Critical issues in group What is your style: Guide, Follow or Direct? Implementation planning & next steps

Recommended Resources Martino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C., Hamilton,

J., and Hausotter, W. (2006). Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA STEP). Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University.

http://www.motivationalinterview.org/Documents//MIA-STEP.pdf Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (Third

Edition). New York: Guilford. Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural

and Cognitive Psychotherapy, 37, 129-140. http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416

Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: The Guildford Press.

First chapter and table of contents available at www.motivationalinterview.org Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. New

York: Guilford. Wagner, C.C. & Ingersoll, K.S. (2013). Motivational Interviewing in Groups. New York: Guilford Useful Websites Motivational Interviewing Website http://www.motivationalinterview.net/ Motivational Interviewing Network of Trainers (MINT) Website www.motivationalinterviewing.org Examples of Motivational Interviewing Videos on YouTube http://www.youtube.com/user/teachproject#p/u

http://www.motivationalinterview.org/Documents/MIA-STEP.pdf

http://www.motivationalinterview.org/Documents/MIA-STEP.pdf

http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416

http://www.motivationalinterview.org/

http://www.motivationalinterview.net/

http://www.motivationalinterview.net/

http://www.motivationalinterviewing.org/

http://www.motivationalinterviewing.org/

http://www.youtube.com/user/teachproject

http://www.youtube.com/user/teachproject

Engaging

Focusing

Evoking Planning

Motivational Interviewing: Practice Tips

MI Spirit: The Essential Foundation

Partnership: You and the client are equal experts

Acceptance: Absolute worth, accurate empathy, autonomy support, affirmation

Compassion: Beneficence, caring, focus on the other

Evocation: The client’s wisdom is most important

OARS: Key Skills

Open Questions: What are your reasons for change? How might you go about it in order to succeed?

Affirmation: You have worked hard to make this happen. I can see that you’ve given this a lot of thought.

Reflections: You wish that… You would like to…

Summary Statements: Let me make sure I understand how this all fits together…

Diagnosis Treatment Plan

Symptoms

Benefits

Finances

Stress

Relationship

Agenda-Mapping Can we take a few minutes to talk about the different issues or concerns that you or others have? Just to get a “big picture” view of what you are coping with right now…

Given all of these possible areas for change, what are your priorities? Where would be the most helpful place for us to start?

0 1 2 3 4 5 6 7 8 9 10

People usually have multiple or competing priorities. On a scale of zero-to-ten, how important is it to change…? How confident are you that you could make this change?

Readiness Ruler

Why did you say [lower number] and not [higher number]?

What would it take to go from [lower number] to [higher number]?

Elicit: What do you already know about…?

Provide information: Be brief!

Elicit: How does that fit for you? What do you make of that?

Listen for Change Talk: DARN CAT

Desire, Ability, Reasons, Need

Commitment, Activation, Taking Steps

Reference: Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd Edition). New York: Guilford. 2013 Marilyn Herie, PhD RSW [email protected]

Four MI Processes

“When people are ready to, they change. They never do it before then, and sometimes they die before they get around to it. You can't make them change if they don't want to, just like when they do want to, you can't stop them.” ― Andy Warhol, Andy Warhol in His Own Words

http://en.wikipedia.org/wiki/File:Warhol-Campbell_Soup-1-screenprint-1968.jpg

Remember to complete the Workshop Evaluation

Thank you

[email protected]

www.educateria.com

@MarilynHerie

If you have built castles in the air, your work need not be lost. That is where they should be. Now put the foundation under them. Henry David Thoreau

Castles in the air?

herie advanced groups 2013 final pub

Health & Medicine

group conversationand

group eliciting

group mutualrespect

group dynamics

large group

motivational group activities

challenging group members4

examples of group norms