motivational interviewing
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https://learn.extension.org/events/2638
Motivational Interviewing
Connecting military family service providers and Cooperative Extension professionals to research
and to each other through engaging online learning opportunities
www.extension.org/militaryfamilies
MFLN Intro
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Dr. David Christian•Dr. Christian served as a professor, clinician and researcher at University of Idaho for six years.•He practices “know-do” principles with the 25 clients he sees each week.•He provides training in these principles at national and international professional conferences, where audiences include financial counselors, educators, physicians, nurses, social workers, activists, psychologists, attorneys and computer specialists. •Dr. Christian has a broad background in behavioral research and clinical psychology.
Today’s Presenters
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Using Motivational Interviewingto Facilitate Collaboration and Change
Webinar Presented To Military Families Network
July 19, 2016 By David Christian, Ph.D.
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Overview of Workshop
• How I came to MI• History of MI• Overview MI• Apply it to your work. .• MI is like learning a language.
– Today: Minimally Conversant– Ongoing practice: Fluent.
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St. George, Utah
How I Came to MI
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Ambivalence
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“I need your help…” 8
Why did that work?•Put me in the lead. •Reflected my values.•Resolved my ambivalence.•Used MY solution.
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Motivation and Behavior
Change
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Extrinsic Motivation
(limited)
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University of Utah
Motivation is idiosyncratic. Must tap into personal values
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Professional And Scientific Psychology1983: Utah State University
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Motivation: The Obesity Problem
Solution: Eat less, exercise more.14
Know Do
The Know-Do Gap
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Master’s thesis: Meta-Analysis Best Treatments
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Motivational Findings from 85 Treatment Studies
•Autonomy/Choice•Collaboration•Modest Expectations Pe
rfor
man
ceExpectation
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Dissertation: Cognitive Motivation Factors
Effective: Self-Efficacy (believing you can)Resolving AmbivalenceSelf-Concept (your values)
Ineffective:Knowledge
Thoughts
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1983: Bill Miller puts it all together.
Motivational Interviewing19
MI: a relationship that:
• Resolves ambivalence• Promotes intrinsic motivation• Promotes Self-efficacy• Offers Autonomy/Choice• Uses Collaboration• Employs Modest Expectations
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U. Of MS Medical Center/VA
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University of Idaho
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Changing Professional RolesIn the Information Age
• Information is abundant. • Less reverence for authority.• Greater value of autonomy. • Professionals partner for change.
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Private Practice Training, Consultation
Career Shift
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PsychologistsPhysicians/Nurses
Info Technicians
Business
Finance
Lobbyists/Activists
Educators Agencies25
Financial Example of the Know-Do Gap: Utah
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82nd Percentile in Educational Attainment:
Educational Attainment by State". U.S. Census Bureau. 2011. 27
Lots of Financial Advice
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#5 for Bankruptcy#1 for Affinity Fraud
Donovan Baltich, June 16, 2014. The Digital Universe29
Motivation And Stages Of Change In Financial Counseling: An Application Of A Transtheoretical Model From Counseling Psychology, Barbara C. Kerkmann,
©1998, Association for Financial Counseling and Planning Education.
Family finance texts and literature seem to agree on what constitutes good financial management practices. Record keeping, using a written spending plan or budget,comparing records to a spending plan, and estimating net worth and its changes over time, are widely taught as well as studied…
While many authors appear to agree on the advisability of such money management practices, research indicates that comparatively few people actually follow them. There appears to be little consensus about what motivates individuals to put financial management advice to use; or how to move seemingly unmotivated or resistant clients to make necessary changes in their financial management habits.
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How can MI help YOU?
•Most common motivational problems?•What else?
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Ask Questions
How does this apply to mysituation, problem, client, etc. ?
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Defining MI
“MI is a collaborative conversation style for strengthening a person’s own motivation and
commitment to change.” MI 3rd Ed.
Talking about change in a way that fosters it.
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Name Your Favorite Teacher
What did you like about them? 34
Continuum of Counseling Styles
Professional training leans toward directing.
Directing(Napoleon)
Guiding(Hillery/Norgay)
Following(Holmes/Watson)
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Our training promotes the “righting reflex.”
• Fixing• Correcting. • Advising• Directing • Educating
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Demonstration: What change are you struggling with
(ambivalent about)?
Examples:•Eating Healthy•More Exercise•Volunteer work•Reducing TV time•Procrastination •Being kinder•Etc.
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I’ll help you!1. You: Tell me what you would like to do.2. Me: I will help motivate you.
1. Traditional approach2. MI
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CommonHelping
Methods
Thomas Gordon
1. Ordering, Directing2. Warning, Threatening3. Moralizing, Preaching4. Advising, Giving Solutions5. Persuading with Logic, Arguing6. Judging, Criticizing, Blaming7. Praising, Agreeing8. Name-calling, Ridiculing9. Analyzing, Diagnosing10. Reassuring, Sympathizing11. Questioning, Probing12. Diverting, Sarcasm, Withdrawal
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What Happened?
• The righting reflex• Change talk and sustain talk• Discord (resistance) • Arguing for change invites…
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Lesson from a Goat:
What works may be
counterintuitive.
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Let’s try MI
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 for you to do it? 4.How important is it for you to make this change and why? 5.So, what do you think you will do?
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4. Evoke Change Talk: DARN CATDesireAbilityReasonsNeedCommitmentAction TakenTake Steps
3. Core Skills: OARSOpen-ended questionsAffirmationsReflective ListeningSummaries
MI Overview
2. Four ProcessesEngage: Establish partnership.Focus: Clarify their agenda. Evoke: Elicit reasons for change. Plan: Commit to a plan of action.
1. Spirit of MIPartnership of EqualsAcceptance: empathy, autonomyCompassion: Caring for themEvocation: Use their wisdom
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MI History
• 1983 Bill Miller finds the “Collaboration Code.”• Research: 1200 studies and meta-analyses.• Breadth: Application across professions, client types,
settings.44
The Stages of Change and MI
Changing for Good, by Prochaska, Norcross, DiClemente
80 % of clients entering counseling are in Stages 1-3.
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The Spirit of MI: PACE
PartnershipAcceptanceCompassionEvocation
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The Four Processes
• Engage: Establish a working relationship.• Focus: Clarify their agenda. • Evoke: Elicit their reasons for change. • Plan: Develop and commit to a plan of action.
Engage
PlanEvoke
Focus
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To Engage, Use the Core Skills: OARS
• Open-Ended Questions• Affirmations• Reflectively Listen • Summarize
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Open Doors with Open Questions
Closed: Are you ready to start?
Open: How would you rate your readiness to start (from 0-10)?
(Ruler Method)
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Open Questions: Try the 6 W’s
Affirm Them.
Spotlight their: – Abilities– Strengths– Efforts– Values – Intentions
Recognition vs. Praise
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Reflectively Listen
Reflect their thoughts and feelings.
Also reflect their resistance and objections.52
Reflecting: Lessons from Scoutmaster Bart
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Reflect so that you move toward your goal. 54
Offer a Summary Bouquet
Periodically summarize:• The problem as they see it • Options they like and why.• Agreements and follow-up plans.
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Engaging
FoundationCreate working PartnershipTrusting, Respectful working relationship.
Agreed goals. Mutually negotiated tasks.
Engage
PlanEvoke
Focus
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Traps that Prevent Engagement
• Assessment: Problem focused. • Expert: Assumes responsibility• Premature Focus: Misses the bigger picture. • Labeling: Stereotypes can blind us. • Blaming: Triggers defensiveness• Chatting: Misses the point
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To Build Engagement:
• Align with their goals.• Connect with what’s important to them. • Make a positive experience. • Meet or exceed expectations.• Build hope that this will help
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Avoid the Dirty Dozen1. Ordering, Directing2. Warning, Threatening3. Moralizing, Preaching4. Advising, Giving Solutions5. Persuading with Logic, Arguing6. Judging, Criticizing, Blaming7. Praising, Agreeing8. Name-calling, Ridiculing9. Analyzing, Diagnosing10. Reassuring, Sympathizing11. Questioning, Probing12. Diverting, Sarcasm, Withdrawal 59
Engaging with OARS Skills
• Open Questions: – focus and deepen
• Affirming: – highlighting positive actions and
intentions. – Reframing things in a positive light.
• Seeing the glass half full. 60
Reflective Listening Guidelines
• Makes a guess about what the person means; a statement-tone drops).
• Continue the paragraph to encourage them- make a reasonable guess.
• Reflection stops dead horse beatings. • Simple reflection shows the exposed
iceberg.• Complex reflection adds meaning,
feeling or emphasis, showing the submerged iceberg.
• Best to understate slightly. • Keep it brief.
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Summarize
• Reflections that pull together bigger pieces of meaning.
• Build an affirmative story about them and their goals.• Ask “what else?” to check for more of their story.• Use a linking summary to connect the past and future. • Use a transitional summary to segue to the next thing. • Good summaries help clients see their forest for their
trees. 62
Practice OARS
Counselor- Practice OARSClient- Real play personal change problem or a client problem. Observer- Score Frequencies of OARS
Open Questions: ///Affirmations: //Reflections: //Summaries: //////
Counselor
Observer Client63
Process It
• Counselor’s Experience• Client’s Experience• Observer’s Comments:
– What worked– One suggestion
Counselor
Observer Client
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Engaging: Explore
Values and Goals
• Consider where they are on Maslow’s Hierarchy (don’t get ahead)
• Knowing their broader values is KEY to motivation.
• Discuss the gap between their values and actions.65
Engage with Open-Ended Values Interview
1.What do you care most about in life?2.What matters most to you? 3.What rules do you live by? 4.How would you like things to be in 5 years?
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Focus: Find and Maintain Direction
Engage
PlanEvoke
Focus
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• Most change starts with ambivalence – (torn between two incompatible options)
• Change talk: – Self-expressed language that argues for change.
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Focus Arises From:
•Your Client•Your setting•Your expertise
– Required to ignite action.
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Three Possibilities
If: •Focus is clear- move to planning•Several options are open- evaluate •No idea where to start- explore
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HelpingParents
To Focus: Try Agenda Mapping
• List their options.• Anything more? • Offer your options with permission.• Incidental topics “by the way…• Zoom in on, circle priorities.
AvoidBankruptcy
CollegeSavings
MedicalExpenses
Refinance Mortgage
Retirement
LifeInsurance
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Exchanging Information: Avoid Traps
• The Expert- dispensing info• The investigator- collecting info• The Helper- filling in info• The Fear Monger- scaring with info• The Mom/Dad- parenting with info
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Providing Info: Elicit their needs, prior knowledge, interests:
Ask permission to explore and shareExplore what they knowAsk about their interest
Provide information:Prioritizing what they want or need mostClearly, in manageable dosesSupporting their autonomy
Elicit their response to the information you provided:
Is it clear, helpful, their reaction.
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Sharing Assessment Feedback
• Precede any assessment with engagement.• Ask about their interpretations and concerns.
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Evoking Evoke Change Talk
(Their Reasons for Change)
Engage
PlanEvoke
Focus
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Respond to the wind: Change Talk vs. Sustain Talk
Change Talk: movement toward change. Sustain Talk: sustaining the status quo.
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Evoke their Motivation
• People commit to what they hear themselves saying. • Public statements and commitments build motivation. • Do what triggers more change talk and less sustain talk.
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Evoke Change Talk
•Change talk predicts change. •Most change starts with ambivalence •Change talk: Self-expressed language that argues for change.
TChange Talk
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Preparatory Change Talk (DARN)
Desire- wanting somethingAbility- feeling able to do itReasons- the “why” of actingNeed- sense of urgency
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Lobbying Rob Bishop:
Mistake: Talking about facts and our agenda.
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• Carbon sequestration• Corridors for
renewable power transmission
• Economic growth and sustainability
Asking about Rob’s desires:
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Mobilizing Change Talk
Signals movement resolving ambivalence: Commitment- intention to actActivation- willing, ready, prepared to act. Taking Steps- action is underway.
TChange Talk
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Ask Evocative Questions
Start with DARN, then CATFor Need, try the importance ruler (0-10)
Why did you not rate it lower? What would it take to move you higher?
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Query Extremes
• What concerns you the most about ___?• What is the worst case scenario if___? • How good might it be if you fully succeed ___?
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Look Back and Forward
Look BackWhat was different when things were better?How have things changed since ___?
Look ForwardHow might things be in 1, 5, 10 years if you do/not succeed? How would you like your future to be?
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Explore Their Broader Goals and Values
• What’s most important in your life? • What do you want to be doing? • What kind of person do you want to be?
– SELF WISH• Social• Education• Leisure• Family• Work• Intimacy• Spiritual• Health
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Responding to Sustain Talk
• It’s a normal side of ambivalence• Resist it and it will persist• Don’t go fishing for it- you’ll get more. • Try Amplified Reflection- turn up the volume on their statement.• Try Double-Sided reflection: “On the one hand (sustain talk) and
on the other hand (change talk).”• Emphasize autonomy “No one can make you do it.” • Reframe- offering a more positive meaning/perspective. • Agree with a Twist: add a reframe that moves toward change. • Running Head Start: Acknowledge advantages of status quo, then
ask for change talk. • Come Alongside: Join sustain talk and one up it “… maybe you
shouldn’t change.”
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Evoke Confidence
Confidence is the A in DARNTry the Confidence Ruler
Why are you not at 0?What would it take to go higher?How might I help with that?
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Evoke Hope(A thing with feathers)
•Offer advice if they are open.•Affirm strengths and skills they exhibit. •Review past successes.•Brainstorm.•Reframe negatives.•Imagine you succeed and look back. What would you see? •Role Switch: I’ll be you. You consult with me. •Respond to confidence talk with OARS.
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Planning Create a Bridge to Action
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Planning Creates a Bridge to Action
Planning reduces dissonance by paving a way for action. Readiness is signaled by:
Taking small stepsLess sustain talkResolveEnvisioningChange questions.
Overview their change talk, then ask:“What do you think you will do?”
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Develop a Change Plan
If there’s a clear plan: Call the CATs: – Elicit Mobilizing Change Talk– Troubleshoot- what might go wrong? – How will they cope?
Create a goal attainment scale:from -3 (much worse) to +3 (excellent).
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When There are Several Options
Confirm the goalItemize the OptionsElicit their hunches about Plan A, B, CPick the one they like bestTroubleshoot
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Creating Plans from Scratch
Brainstorm possible options. Generate multiple optionsSuspend judgment.
Evaluate their pros/consSelect the best.
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Support Change
Avoid all or nothing goals. Black and white (AVE)Set up success on a continuum. Flexibly revisit the four processesRemind, Refocus, Reengage
SuccessFailure
Success95
Experience of MI
Are you dancing or wrestling? Check engagement, focus, evoking, planning.
Is it collaborative?MI can be done quickly.
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Be a Duck
Calm on the surface but… paddling fast underneath. Hold the past, present and future together.
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You Don’t Have to Go in Order!
Use what works for you. 98
MI is a language of change and collaboration.
Aware: You’re there!Conversant: Hours-days.
Fluent: Years. 99
Mastering MI
• Books: Motivational Interviewing.• Web: “MINT” (MI Training)• Professional coaching.• Buddy system for feedback.• Taping sessions.• Your clients!
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4. Evoke Change Talk: DARN CATDesireAbilityReasonsNeedCommitmentAction TakenTake Steps
3. Core Skills: OARSOpen-ended questionsAffirmationsReflective ListeningSummaries
MI Overview
2. Four ProcessesEngage: Establish partnership.Focus: Clarify their agenda. Evoke: Elicit reasons for change. Plan: Commit to a plan of action.
1. Spirit of MIPartnership of EqualsAcceptance: empathy, autonomyCompassion: Caring for themEvocation: Use their wisdom
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What is one significant thing you learned today?
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