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# Treatment Modalities & Therapies

The Four Processes of Motivational Interviewing

Estimated watch time: 54 mins

Available credits: none

Objectives and Summary:

Johanna Leal continues her in-depth discussion of effective communication building blocks in the third part of her four-part series on motivational interviewing (MI). In this session, Johanna provides examples of using the four processes of MI strategy to help mental health care professionals have deeper conversations with clients that help create trust, understanding and long-lasting change.

After watching her presentation, the viewer will be able to:

Name the four processes of MI strategy, how they’re used and why they’re important.
Understand what’s needed to begin an effective conversation and prevent communication from falling apart.
Reflect on a real-life example of what happens when MI strategies are not used and the practitioner/client relationship is essentially irreparable.
Avoid communication missteps and create better foundations of empathy and understanding.

Presentation Materials:

Transcript:

Welcome to the Community Education Series hosted by The Recovery Village and Advanced Recovery Systems.rnrnu003cstrongu003eJohanna:u003c/strongu003ernWelcome, everyone, I’m reading the chat and we have people from everywhere — people locally here in Denver, and Oregon, Washington, Florida. I’m really happy you’re all able to attend today. This is the third part of a four-part series in motivational interviewing. Oh, also Madison and Wisconsin. Each session has built upon the last session, but I’m trying to at least incorporate some consistency so you can get something out of any session that you join.rnrnI really love MI. It’s one of the many interventions that we help organizations implement with my Alliance for Community and Justice Innovation. And one of the reasons I love MI so much is that it’s just such a wonderful practice — you can really see changes with the people you’re working with when you use MI — and it has over 30 years of evidence backing. It really can move the needle on behavioral change. I’m excited to bring this to you today. A couple things are going to be using the chat feature a lot, so please keep it open. I will try to read it as I do this, but I’m not always great at multitasking, so I will have time at the end also for questions. I am putting in the chat right now a link to a Google drive that has some materials that may be helpful for you. Some of the materials are practice sheets or summaries from what we go over today, and then there’s a transcript in there also of some audio we’ll be listening to today, if you’re someone who likes to read along while you listen.rnrnLet’s jump in; we have a lot to do. In our last two sessions, we focused on MI spirit, and you could see spirit is the bottom of the pyramid or, really, the foundation of MI. MI spirit encompasses partnership, autonomy and empathy. We talked in the first session a lot about spirit and how active listening and curiosity are the skills utilized to create kind of that environment which is conducive of a conversation about change.rnrnWe also talked about reflections as being the core skill of MI and how the more complex or below the surface that the reflection goes, the more effective we are at discovering what attitudes, thoughts and beliefs keep people stuck and what their motivators are to actually change. Then, we build upon those skills. In our last session, we talked about how to tune our ears to change talk, how to listen for change talk and sustained talk, and how to respond to those different things in order to begin to use reflections strategically and to help people resolve the ambivalence that comes with the change process and try to increase their motivation to change by really strengthening their own reasons and arguments to change their lives.rnrnToday, we’re going to go dive deeper into MI strategy and really talk about the overall arc of an MI conversation through what is called the four processes in MI strategy. A lot of MI training starts at the skill-building piece, which you can see in the middle of that pyramid, without diving deep into the strategy. What I found is that, a lot of times, practitioners stop using MI because it feels too unfocused or like the conversation takes too long or is going in circles, and those are all real symptoms of just a lack of strategies. This framework can really help us know what to do, when to do it and why we’re doing it.rnrnSo let’s take a look. Alright, strategy in MI Is broken down into four processes, like I said, and this is kind of a roadmap or a guide for the interaction between practitioner and client. These four processes are engaging, focusing, evoking and planning. Basically, these four processes tell us where we are in a conversation, what needs to happen and what we’re aiming for ahead. So, to focus on engaging: Engaging is building a supportive alliance or a safe space for a person to explore change. We all know that change is difficult work and can make people feel really vulnerable. Focusing is about finding a specific change goal or target behavior that’s important to the client. Evoking is pulling out a person’s own reasons for wanting to change, and planning is putting together action steps for a client to actually make that change.rnrnThese four processes can be thought of as like the meta conversation, or an overarching structure of the MI conversation. These processes kind of tell us something about how far a person is in the stages of change and can help us understand, in the moment of the conversation, what our goals are for that and how to move a person through those four processes and kind of get them unstuck and moving further along in their own change. Within this structure, it’s really helpful to think about this as fluid — we can actually slide back and forth through the entire conversation. For example, you can lose engagement with someone at any point in the conversation, and you probably have this experience, right? Things are going along well and suddenly there seems to be defensiveness or a barrier or resistance that comes up. So we need to be keeping these processes in mind the whole time.rnrnAlso part of this is that you may not get through all four of these processes in a conversation, and for some people, you may be stuck in engaging with them until you can build trust and alliance for a few sessions. Each of these processes is sort of contingent upon the process before it, so without engagement, it’s challenging to find a focus or a change goal that’s really meaningful to a client. And if we have the wrong focus, then it’s really hard to attempt to evoke or call forth a person’s own reasons to change or to strengthen commitment to a focus that they might not believe in. Also with this strategy that we’re going to look at, it gets really easy to think through once we diagnose the problem, we feel tempted to jump right into planning, right?rnrnSo, we think we know what’s going on — let’s create some action steps and get into action. The four processes really create a strategic framework to be more intentional and to spend time in building alliance, finding the right target, enhancing and strengthening commitment to change before we jump right into action steps and planning. Sometimes, people don’t use MI ‘cause they think it’s going to take too long. Because when you look at this, you think, “I don’t have that much time with people.” But when you really do master this strategy, it’s a really impactful intervention that really takes only minutes, or it can also be blended into other things that you’re already doing.rnrnSo today, we’re going to go through engaging and focusing, and next time, we’re going to jump into evoking, planning and pulling it all together. So, let’s dig into engagement. Engagement — the first process in MI strategy. It comes first because engagement is really the critical piece to creating a supportive and safe enough environment for people to even want to have a conversation with us about real change. We create and maintain engagement by building supportive alliance through active listening, through self-awareness and by building MI spirit with partnership, autonomy and empathy. I was curious — if you wanted to jump in your chat, how do you know when you have client engagement? What does it look like? I’d love to see.rnrn“Eye contact.” That’s great. “Leaning into the conversation,” so there’s so many non-verbals. “More fluid conversation,” both people are really present, right? So, it takes two people to create engagement. There are questions and conversation. It’s a lot of comments about body language, body position and active participation. Those are great, right? So, we know when we have it and I’m sure we all know when we lose it. The research here is really clear that supportive alliance, or that a meaningful relationship between practitioner and client, is vitally important. In fact, it’s far more important than the application of any specific technique, program model or curriculum you have that you’re using for client success. Things like perceived empathy, acceptance, warmth, trust, autonomy, self-expression — they really strengthen the partnership and actually are more predictive, in terms of client outcomes and behavioral outcomes, than any methodology you apply. This is why engagement is the first of the four processes. Without it, you just cannot proceed. It’s hard to talk about engagement without talking about the opposite, which sometimes is talked about in terms of resistance, right?rnrnDeveloping engagement is really a subtle, ongoing process, but it’s usually pretty clear and abrupt when you’ve lost it. Some people talk about this as resistance — the opposite of engagement. But the problem with many of the ways we think about and handle resistance is that we make it exclusively the other person’s problem or we ourselves become defensive, which leaves us with really very few options to address it and move forward productively.rnrnIn MI, resistance is thought of as a really predictable and natural part of the change process, and in order to understand how to respond to resistance in the most impactful way, it’s helpful to think about two really different kinds of resistance. Those are discord and sustained talk. Discord is resistance to us or to the system we may represent in our roles and in our jobs. Sustained talk, on the other hand, is resistance to change. It’s important to know the difference because there are really two different sets of strategies to use with discord than there is with sustained talk. Last time, we talked a lot about sustained talk, and sustained talk can show up and sound like excuses. It’s a really normal and expected part of the change process, and it kind of — with a tuned ear — gives us an insight into where someone is in their readiness to change. But discord, on the other hand, is resistance to us, and it really needs to be resolved in order to establish engagement — to move forward with the conversation about change. So while we address sustained talk as kind of softening it, kind of ignoring it and moving towards change talk, when we hear discord, we address discord by using empathic reflections.rnrnEmpathy here is what actually is the skill that creates and restores alliance and partnership. This is also the same skill, if you’ve ever taken de-escalation training, that can de-escalate tense interactions, but it can also just help build trust and re-engage at any point in the conversation. In order to do this well, we have to be checking in with ourselves and kind of taking our own temperature in order to restore partnership, autonomy and empathy throughout those MI processes. Without this, you just really can’t proceed. So let’s talk a little bit more about that and the emotional contagion. I think the emotional contagion is really interesting science. How we respond to discord can really determine whether or not resistance escalates or if we can rebuild engagement.rnrnWhen someone’s experiencing a state of discord, they’re typically operating with their limbic brain. AWhen that happens, any attempt on our part to rationalize or explain really becomes futile because people are in their fight, flight or freeze response and really not operating from their prefrontal cortex, which is really responsible for our rational decision-making. So, the limbic system is an open loop; that means that it’s looking for external factors to manage internal processes and emotional states. This is what they call the emotional contagion, and science explains how it primes us to kind of appropriate our feelings and attitudes from the people around us, sort of like electricity over a network. So without intentional effort and awareness to try to control our own emotional response and situations, what ends up happening is moods, attitudes, feelings, responses kind of spread like a contagion. Not a great metaphor for now, but spread quickly and can really compromise the psychological safety for yourself and for your client.rnrnSelf-awareness around your own triggers and your own hot buttons can really close this open-loop system and provide you with a greater range of options for emotional control when you find yourself in these discord situations. Whenever we feel threatened, a part of our brain called the amygdala gets activated, and the amygdala is a super important function to keep us safe. It’s sort of this primal set of circuitry that evolved to warn us of things like animals attacking and rocks falling. But this alarm system can get activated by even perceived threats, and those perceived threats could even be things like ego threats. So this other part of the brain — the prefrontal cortex, which is our center of thinking, reasoning and creativity — also helps to downregulate kind of this overstimulated and really easily stimulated amygdala. It’s important that we all are actively practicing and modeling for the people we work with how you kind of show the resilience of being able to bounce back from these triggering moments. Because they happen to all of us — your brain, they’re happening to you. To take that control — that really starts with bringing awareness to your own triggers, and that’s like the first important step in calming that really intense amygdala.rnrnI like the metaphor of hot buttons. There’s some really cool activities you can do around this and work that you can do to purposely manage your own hot buttons. So, reactions to conflict and situations that tend to make our temperature rise or cause defensiveness and anger — they tend to happen quickly, and they’re pretty immediate. We don’t have a lot of reaction time and they’re really the result of just getting triggered. When we reflect on our hot buttons and identify our own triggers, it can really help bring some awareness to what I’m experiencing right now and kind of wake up that decision-making part of your brain, so we can increase the reaction time between our trigger and response and be better prepared as they pop up.rnrnThis happens to everyone, and it’s helpful to think of a situation that you’ve been in when someone has become escalated. It may not have reached, like, confrontation level, but perhaps there was some discord and maybe it was directed at you. An important feature of discord is it’s really not personal or it’s not about you; it may be directed at you because of frustration with the larger system, especially if you’re working in a court-ordered program or at a justice program. But really, if we can take ourselves personally out of this situation and think of just behaviors, communication, we can begin to turn down the volume on the discord and really have the presence of mind to be able to respond with empathic reflections while controlling our own response and defense.rnrnEmpathic reflections are exactly what they sound like: They are reflections that are expressing feeling or empathy. In our first session, we practiced going under the surface to try to reflect back some of the attitudes and mindsets and beliefs that people may have that keep them stuck. Empathic reflections also are trying to describe the underlying feelings that may be driving the discord, and it requires intense listening for what we think might be going on below the surface and trying to reflect back the feeling. It could sound like, “You’re really frustrated. This is really difficult. You’re tired of explaining yourself,” right? People may come to us with all kinds of discordant statements: “You don’t understand what I’m going through. You’re just here to make a paycheck.” Whatever is coming out, the point of an empathic reflection is to lower the temperature of the situation so you can really get back to the business of talking about change. These are empathic reflections because they kind of require us to connect to something inside of us that might be happening for the other person who is experiencing discord.rnrnDoing that requires suspending judgment — suspending whether we agree or disagree with where they’re at. It’s really trying to connect to the feeling and doing it authentically because an empathic reflection that isn’t delivered authentically, like if you don’t mean it, is not going to de-escalate anything. You really need to believe it. And the thing here is when people are escalated and they’re in their limbic brains, they’re not really thinking with the rational part of their brain. Here, we’re thinking the shorter is sweeter. “You’re frustrated right now. We’re listening to you.” Reflections like that.rnrnAlright, so we’re going to practice this a bit. I’d like you to use your chat, and let’s choose one of these. Someone says to you, “What do you know about me?” That’s a discourse statement. It’s not reflecting change talk. It’s not necessarily resistance to change — it’s resistance to the system or us or what we’re representing. So in your chat, take a moment to type a reflective and empathic reflection that might turn down the volume on this kind of discord. Remember, short and sweet here; one of the best empathic reflections I ever heard was one word, and it was scary. “It takes a lot of strength for you to be here right now.” That’s awesome. “You’re right. I don’t, but I’d love to hear more about you.” Great. “Could you help me get to know you more? What would you like me to know about you? I’d like to get to know you. That’s what I’m here to find out, if you let me. Help me understand, tell me more.” These are great.rnrnA lot of these are also questions, and those are great follow-ups to empathic reflections. The empathic reflection is acknowledging the feeling so somebody feels understood. Then, you can really jump into maybe asking a question like, “Tell me more.” Because sometimes when people have a heightened state and they’re in fight or flight, they’re not necessarily in the part of the brain that is even processing what you’re saying, so it’s really about the feeling. When you think about the feeling for, “What do you know about me,” is, it’s really feeling misunderstood, right? No one here knows you. No one’s taken time to get to know you. You’re feeling really misunderstood, No one’s listening to you, right? So, really trying to get at what’s going on under that feeling. Like we said before, with hot buttons, it’s hard to do that if we’re getting triggered, right? It’s not easy, if someone’s coming at you, to just pause and have that presence of mind to jump into empathy, but it really is a skill that with practice you can build.rnrnLike last time, I wanted to give it a shot and listen to a conversation and to listen for discord and what we hear going on between the client and the practitioner in this scenario. So in this scenario, we’re going to hear a conversation between Mike and Donna. Mike is a client at a treatment facility and Donna is an intake practitioner; this is their first conversation. While you’re listening in, I want you to tune your ear to discord and think about some of these questions you can see here. How would you describe the client engagement? So, what words would you use to describe? You can chat live because it’s kind of fun to see an ongoing commentary of what you’re hearing. What roadblocks to listening do you think might be happening?rnrnIn our first session, we talked about roadblocks to listening for things like judging, advising and teaching at the wrong time. Criticizing can be roadblocks and create discord. Then, how does the practitioner respond and how do her responses either increase or decrease discord with the client? Kind of in real-time, what is she doing and what are you noticing and how does MI spirit show up or not? Does it? Are you hearing things that reflect autonomy for the client? Are you hearing things that reflect supportive alliance or partnership between practitioner and client? Are you hearing things that communicate empathy or not? Again, if you’re a read-along person, you can download the transcript from the Google Drive. I’ll put it there one more time. Let’s listen.rnrnDonna:rnHey, Mike. How you doing today?rnrnMike:rnDoing okay. I wish I understood why I had to be here right now.rnrnDonna:rnWell, I’ll tell you exactly, if you want, why you’re here. I’m Donna, by the way. I’m the intake person here at the treatment center. We deal with this all the time because you’re here because you’re, you know, — I can look at your file, and you failed your drug test and your employer is one of our clients. Whenever someone fails the drug test, they end up coming here so that we can hopefully help you keep your job.rnrnMike:rnWell, I get a little bit frustrated that I have to take a drug test off a simple mistake at work. And there’s no proof that I did anything wrong at work. I don’t see why I should have to be here for stuff I do on my own time.rnrnDonna:rnYeah, I hear that a lot. I mean, that’s the way a lot of people feel, but the bottom line is that that’s the policies and procedures of your workplace. And if you want to, they require that you have a job that’s — it looks like, what do you do? It looks like you drive heavy equipment.rnrnMike:rnYeah. Most of the time, I’m a loader and I operate one of the smaller forklifts. Loading and unloading their larger trucks, warehouse-type job. I get the call to come in and take a drug test after, right? A simple mistake, and I just got distracted at work.rnrnDonna:rnWhat did you do?rnrnMike:rnI dropped part of a partial pallet on the floor. I got distracted by someone else moving, and I hit the brakes too hard and some of the product fell on the floor.rnrnDonna:rnWell that is something, you know, when somebody is impaired. And marijuana is particularly bad for that, but that looks like what you failed on your drug test was the marijuana. And that’s particularly bad for that — it makes those mistakes a lot more likely to happen.rnrnMike:rnBut I, you know, I’ve never smoked marijuana at work or before work.rnrnDonna:rnWell, how much do you smoke?rnrnMike:rnI might smoke a little bit with my girlfriend when we get home from work and we’re relaxing and every once and a while on the weekends or barbecuing with our friends. Yeah, nothing like at work.rnrnDonna:rnSo, it sounds like you smoke almost every day.rnrnMike:rnYeah, but not that much. It’s kind of just to unwind at the end of the day.rnrnDonna:rnWell, yeah, but it stays in your system. That’s the bottom line here, too, is that it stays in your system and it really does affect you. I know you don’t think it affects you that much, you’re not smoking that much, but it’s still a drug and it still affects you.rnrnMike:rnWell, I think my issue, as far as the company is concerned, is that the testing is supposed to happen only if they have probable cause. And I feel like people make errors at work all the time. People get distracted because of stuff that’s gone on, kids or their wife, who knows what else, their credit cards — and they make mistakes at work and they don’t get drug tested, right? I just got chosen, so yeah.rnrnDonna:rnI hear that a lot too, where people in your situation feel like they’re picked out, but that’s just not the case. It’s just the policy.rnrnMike:rnWell, like I said when we started, what am I going to do here? I think I need to get back to work, and this is wasting time and reducing my paycheck.rnrnDonna:rnWell, I’ll tell you what the requirements are. We have a program that’s designed specifically for this, and first of all, you have to sign an agreement that you won’t smoke any pot or do any other things — any other drugs — for the next six months. And that’s part of the program; you need to sign that you can do that. You need to be able to come here twice a week, and we’ll go through an intake and that’ll determine more about how much time you need to spend here. We need to get a lot more information from you about what your history with drug use is, but the minimum is that you’d have to come here twice a week. Then, we also require that you go to meetings and you go to a couple of those a week too, and we’ll get a signature for that too.rnrnMike:rnWhat kind of meetings are we talking about?rnrnDonna:rnMost people that come in for marijuana go to NA meetings.rnrnMike:rnYeah. You know, I have a friend who had to go through AA stuff ‘cause of an arrest. I had been tagging along to ones just to show me what he had to do every week, and I don’t feel comfortable going to those meetings.rnrnDonna:rnWell, in this case, you just don’t really have a choice if you want to keep your job. It’s just the way the program is set up. And we also know that that’s what helps people get off of it because clearly you would have given it up already if you weren’t having some serious problems with it. You would have already given it up.rnrnMike:rnI’d given what up? Smoking pot?rnrnDonna:rnYeah, because you knew it was against the regulations. So if it had been important enough to you to keep your job, you would have probably given it up before.rnrnMike:rnWell, I’ve been working for the same company for 13 years and I’ve never had an issue. So I don’t see it as some sort of problem, what I do on my own time.rnrnDonna:rnWell, it’s caused a problem now because you’re here and you’re having to deal with it. So it’s sort of like, “Well, I’ve got to just face the problem and it’s here and that’s the way,” you know. I mean, I guess you could decide it’s not worth it to you and you could just walk out that door, but yeah. It’s what it is. So, can I set you up with an intake appointment? That’s a couple hours long, and they just find out really exactly what your whole history is and how much you’ve always been using and what kind of use you’ve had to help determine what the best treatment for you is.rnrnMike:rnWell, I guess you just told me that this intake appointment is supposed to determine how much I have to come in here. What motivation do I have to tell the truth about any past drug use?rnrnDonna:rnWell, we’re going to be testing every week. So anything that you use — just about anything you use — will be in your system. And we have to report those tests back to your employer; we have to report the results of those. So it’s sorta like a probationary thing that they have you on. They give you this opportunity; this is an opportunity for you to get better and do it, and that’s sort of where we are. So, what do you think? Shall I make an appointment?rnrnMike:rnYeah. I guess I don’t have a choice.rnrnDonna:rnOkay, good. Well, we’ll call down and make you an appointment.rnrnJohanna:rnAlright. Thank you for enduring that. I really appreciated so many of your reflections in the chat box. I heard so many things. I hope you all are reading along, but “defensive, belittling, judgmental, just the tone of hostility, burnout,” I heard, which is just so interesting — how taking care of ourselves impacts the care we can provide to others.rnrnI’m curious, what do you think Donna’s triggers or stories are that are impacting her? What story is burnout, right? What story is she telling herself about Mike in this situation? “I’ve heard this all before, not the first time I’ve seen this, you’re just like so and so,” right? This really illustrates how important engagement is. So, I want to talk first about this conversation globally in terms of some of the roadblocks to listen to him and some of Donna’s responses. We heard disagreeing, demoralizing, warnings, threatening, disapproval, right? Lots of judgment. Also there’s an uneven power dynamic in that setup from the very first statement, right? So Donna, definitely in her first response, dampens the spirit of autonomy, partnership, empathy. Generally, the conversation just never even got to the first process of MI, which is engagement. So, not successful building supportive alliance, never going to get to behavior change and really only creating deeper discord throughout the course of the conversation.rnrnNothing describes the deficit in this conversation — the deficit of MI spirit — more than Mike’s last statement, if you caught it, which is, “I guess I don’t have a choice,” right? When we think about behavior change in terms of intrinsic motivation — autonomy, partnership — “Um, I guess I don’t have a choice,” really just I think sums it all up. For me, this is an interesting clip. It’ll be a little painful to listen to because it really does illustrate just how quickly you can lose engagement from your very first utterance. I’ve done a lot of work with organizations really just to become more purposeful on framing the first interaction or the first intake conversation they have with a client for this very reason. It really can set the stage and tone for whether this is a place supportive of change or not.rnrnLet’s think, how could this conversation have played out differently? You can see Donna starts out with, “Hey, Mike, how are you doing today?” Mike says, “I’m doing okay. Wish I understood why I have to be here right now.” So, “I wish I understood why I have to be here right now,” is a pretty classic discord statement, right? What else could Donna have said to respond to that statement that could have set the conversation off on an entirely different trajectory? What can be an empathic reflection or response that would have just really changed the entire tone and kind of increased engagement?rnrnI’m giving you a few examples: “It sounds like this might not be the place for you. How do you think the program can help you? You’re not sure you want to be here. You’re feeling pretty frustrated having to be here. No one’s listening to you. You feel really misunderstood.” So, when we are approached with discord, it’s probably not the time to take the approach that Donna took, which is, “Let me tell you exactly why you’re here.” We’re not explaining or teaching or telling — it’s really just about feeling with someone.rnrnEven just relating as, “It sounds like this might not be the place for you,” or, “It sounds like you’re not sure what you’re doing here. It sounds like you’re not sure we can help,” are all really great ways to just turn the volume down so you can keep the conversation going toward change and building engagement. Yeah, “What reason do you think you’re here,” is a great reframe for that, “What would you like to get out of this,” right? “You don’t see a value in being here,” and it’s really about making a person feel understood. Your discord statement’s working when you get a head bouncing, right? Like they just feel understood, and you’re going to feel the interaction change immediately. So in MI, engaging is the first process in the strategic conversation. When it’s done strategically about the reflection, active listening and supporting autonomy is really what builds the partnership to move the conversation quickly forward. But with no understanding of the strategy or roadmap, a lot of conversations — like Donna’s and Mike’s — never make it out of the engaging stage.rnrnI wanna talk about another strategy and skill that helps you build and keep and rebuild engagement, and that’s around affirmations. So, I want to introduce you to Betty. This is Betty’s third time on probation for charges of possession of a controlled substance. She’s got four kids. I just want you to reflect on your own and fill in the gaps to her story. So, what’s Betty like? What does Betty do? What’s the picture that’s painted around Betty’s life?rnrnNow when we think about Betty and we think about sometimes our triggers and hot buttons are triggered by certain words, we hear certain situations. We see people in maybe certain backgrounds or crimes that they’ve had. So when we think through the strengths-based lens, it’s really about just getting very intentional on how we can frame Betty’s abilities and strengths and what struggles and efforts that you can affirm. So when you think of Betty, think through what strengths or abilities might she possess? What struggles do you think she has overcome that you might be able to affirm? And what might be three priorities in Betty’s life right now? If you were to look at this through a strengths-based lens, chatting it out, what would you guess are some of her priorities and aspirations?rnrnSurvivor, that’s right. Her kiddos, totally. Affirmations in MI are really an effective strengths-based approach to keeping in building this engagement, and because talking about change is so difficult and vulnerable, sometimes we push too quickly or push too hard and we can lose engagement at any point. So affirmations really build upon a person’s strengths, their capacity and self-efficacy to support themselves moving through ambivalence and doubt and fear and everything that comes along with change. But because many of the people we work with may have had many failed attempts at changing a problem behavior, they may expect others to point out their failures right away, and that’s what can create the discord. The inner dialogue may be doing that all day, right? People are coming to us expecting failure, and they might have an inner dialogue that is reaffirming that throughout the day, before they even approach us.rnrnBeing really intentional about affirmations is really important in kind of building up that supportive alliance by establishing hope, expectancy and a belief that really, indeed, change can happen. I just want to say a couple of things about affirmations because I’m sure you’re all really good at affirmations already, but affirmations can be tricky because they can make a person feel judged or patronized. That’s why it’s important that an affirmation be focused on specific and concrete behaviors rather than evaluative and cultural assumptions that we think are good about a person, right?rnrnSo affirmations, in fact, should have nothing to do with us. They’re not compliments and typically don’t start with “I.” In MI, adhere affirmation, communicate a recognition or appreciation for who a person really is. I wanted to give you a few examples just to see if you felt any difference when you take the “I” out of an affirmation. In the first example, “You worked really hard to get here today,” right? It’s affirming a struggle — work, determination — versus, “I’m glad you’re here on time.” And, “You’re someone who cares deeply for your kids,” versus, “I think you’re a good mom.” So in your chat, I’d love to know: How do these two examples feel different to you in terms of engagement and supportive alliance? What’s the difference when you take the “I” out of affirmation?rnrn“The focus shifts,” exactly. “It becomes client-centered; the focus shifts away from the counselor. It validates the client’s effort. Better versions are statements of fact.” Yes, and not just opinion or judgment. “It feels less like a judgment, recognizes strengths,” you guys are awesome. Such thoughtful responses here. “It doesn’t state a personal opinion,” you got it. So affirmations can really serve to build hope, expectancy and supportive alliance for that first process of strategy. But if you don’t believe the affirmation or the affirmation is delivered in a way that could be patronizing, it can actually create discord.rnrnThe next strategy is focus, and I think what I’m going to do is introduce focus and then continue focus in the next session along with evoking so that we can spend a little more time on it. So where engaging provides the supportive alliance necessary to talk about change, focus is really about creating a clear change goal. It really is possible to be fully engaged with someone and be having a great conversation with awesome empathy, amazing supportive alliance — a great conversation — with no clear direction or goal. That’s why focusing is the second part of MI strategy: because MI is a conversation about specific behavior change.rnrnFinding a focus in MI conversations is so important, and it’s because it’s not uncommon that people participate in interactions or office visits and spend no time at all talking about specific problem behaviors or change. And research into case management and things like re-entry community supervision really does show what we talk about in-office-visit matters in terms of lasting behavior change. In summary, you search re-entry — any programs that focus exclusively on kind of stabilization factors and resource brokering like housing, transportation, benefits, rather than behavior change — those programs showed no significant impact on recidivism or going back to present. The same results are evident in community supervision. So with probation and parole officers, those officers who focus exclusively on rules or terms and conditions rather than long-term behavioral change and motivational drivers showed no impact on long-term behavior change.rnrnYou can see similar outcomes in health care, right? Simply prescribing medication doesn’t mean a person will change their behaviors and lifestyle behaviors that led to that issue to begin with, and it doesn’t even mean that someone’s going to take the medication as prescribed. What we’ve learned from all of this research about it says what we’re focused on inside of the conversation in terms of lasting behavior change matters. That’s where focusing is the second strategic piece of MI.rnrnFocusing on a specific change really allows you to give your full attention to important areas of need, so you can build out the strengths and affirmations around what the problem is we’re really trying to solve. And finding that meaningful focus really can’t happen without having that engagement because oftentimes what we may think are the underlying issues may not be what’s important to that person. So finding a focus really does come after the engagement. And a lot of programs — yours may be one of these — already have intake assessments, questionnaires, things designed for case planning or for identifying needs and establishing target goals. So motivational interviewing can actually be blended with some of your more formal assessments to really positively frame and talk about assessment results in a way that are important and meaningful for the client you’re working for and where they are in their lives.rnrnThe last thing I’m going to say about focus for today is, thinking through when you leave here today, what are the ways in which you’re already collecting assessment information or information around needs with the people you’re working with? And how can you blend MI into some of those more formal processes that you have to begin to have a conversation that builds in some intrinsic motivation for change? So it could look like simply sharing the results really intentionally with someone, explaining why those questions are asked. It’s understanding how they understand them, asking them, “What do you think of the results,” or even really adding additional questions to the way you use your assessments.rnrnLike “What are your most important health goals and what are the things that are getting in your way, or you’re struggling with, to achieve those goals?” Next week, we’re going to pick up on focus and continue to go through all four processes of MI strategy. These are great. I wanted to leave a couple of minutes at the end if you want to ask any questions, and you can chat me or take yourself off mute. I also wanted — someone asked for reading recommendations — just to share with you a few of my favorite books that I have on my shelf. The first one is Motivational Interviewing, Third Edition: Helping People Change by William Miller and Steven Rolnick themselves.rnrnAnd the third edition’s the greatest one because it does have just a really deep dive into strategy, and you can see I use it all the time, so a bunch of sticky notes. Here’s another one of my favorites, which is Building Motivational Interviewing Skills, Second Edition. This one is written by David Rosenblum Grant, and it’s pretty awesome if you want to take practical activity skills to your teams and continue to build your own skills. And it really shows what these things look like in practice. And then this book I’ve been reading lately, which is Motivational Interviewing and CBT: Combining Strategies for Maximum Effectiveness. This book is great because you could do something I use a lot, and it really shows how blending MI works and how you can blend them with maybe other interventions that you’re using.rnrnThank you for watching this video. We hope you enjoyed the presentation.

Presentation:

Johanna’s Motivational Interviewing Part 3 Presentation (PDF)

Other videos in series:

Motivational Interviewing: Overview of Spirit & Skills

Motivational Interviewing: What is Change Talk?

The Four Processes of Motivational Interviewing

Transcript:

Welcome to the Community Education Series hosted by The Recovery Village and Advanced Recovery Systems.

Johanna:
Welcome, everyone, I’m reading the chat and we have people from everywhere — people locally here in Denver, and Oregon, Washington, Florida. I’m really happy you’re all able to attend today. This is the third part of a four-part series in motivational interviewing. Oh, also Madison and Wisconsin. Each session has built upon the last session, but I’m trying to at least incorporate some consistency so you can get something out of any session that you join.

I really love MI. It’s one of the many interventions that we help organizations implement with my Alliance for Community and Justice Innovation. And one of the reasons I love MI so much is that it’s just such a wonderful practice — you can really see changes with the people you’re working with when you use MI — and it has over 30 years of evidence backing. It really can move the needle on behavioral change. I’m excited to bring this to you today. A couple things are going to be using the chat feature a lot, so please keep it open. I will try to read it as I do this, but I’m not always great at multitasking, so I will have time at the end also for questions. I am putting in the chat right now a link to a Google drive that has some materials that may be helpful for you. Some of the materials are practice sheets or summaries from what we go over today, and then there’s a transcript in there also of some audio we’ll be listening to today, if you’re someone who likes to read along while you listen.

Let’s jump in; we have a lot to do. In our last two sessions, we focused on MI spirit, and you could see spirit is the bottom of the pyramid or, really, the foundation of MI. MI spirit encompasses partnership, autonomy and empathy. We talked in the first session a lot about spirit and how active listening and curiosity are the skills utilized to create kind of that environment which is conducive of a conversation about change.

We also talked about reflections as being the core skill of MI and how the more complex or below the surface that the reflection goes, the more effective we are at discovering what attitudes, thoughts and beliefs keep people stuck and what their motivators are to actually change. Then, we build upon those skills. In our last session, we talked about how to tune our ears to change talk, how to listen for change talk and sustained talk, and how to respond to those different things in order to begin to use reflections strategically and to help people resolve the ambivalence that comes with the change process and try to increase their motivation to change by really strengthening their own reasons and arguments to change their lives.

Today, we’re going to go dive deeper into MI strategy and really talk about the overall arc of an MI conversation through what is called the four processes in MI strategy. A lot of MI training starts at the skill-building piece, which you can see in the middle of that pyramid, without diving deep into the strategy. What I found is that, a lot of times, practitioners stop using MI because it feels too unfocused or like the conversation takes too long or is going in circles, and those are all real symptoms of just a lack of strategies. This framework can really help us know what to do, when to do it and why we’re doing it.

So let’s take a look. Alright, strategy in MI Is broken down into four processes, like I said, and this is kind of a roadmap or a guide for the interaction between practitioner and client. These four processes are engaging, focusing, evoking and planning. Basically, these four processes tell us where we are in a conversation, what needs to happen and what we’re aiming for ahead. So, to focus on engaging: Engaging is building a supportive alliance or a safe space for a person to explore change. We all know that change is difficult work and can make people feel really vulnerable. Focusing is about finding a specific change goal or target behavior that’s important to the client. Evoking is pulling out a person’s own reasons for wanting to change, and planning is putting together action steps for a client to actually make that change.

These four processes can be thought of as like the meta conversation, or an overarching structure of the MI conversation. These processes kind of tell us something about how far a person is in the stages of change and can help us understand, in the moment of the conversation, what our goals are for that and how to move a person through those four processes and kind of get them unstuck and moving further along in their own change. Within this structure, it’s really helpful to think about this as fluid — we can actually slide back and forth through the entire conversation. For example, you can lose engagement with someone at any point in the conversation, and you probably have this experience, right? Things are going along well and suddenly there seems to be defensiveness or a barrier or resistance that comes up. So we need to be keeping these processes in mind the whole time.

Also part of this is that you may not get through all four of these processes in a conversation, and for some people, you may be stuck in engaging with them until you can build trust and alliance for a few sessions. Each of these processes is sort of contingent upon the process before it, so without engagement, it’s challenging to find a focus or a change goal that’s really meaningful to a client. And if we have the wrong focus, then it’s really hard to attempt to evoke or call forth a person’s own reasons to change or to strengthen commitment to a focus that they might not believe in. Also with this strategy that we’re going to look at, it gets really easy to think through once we diagnose the problem, we feel tempted to jump right into planning, right?

So, we think we know what’s going on — let’s create some action steps and get into action. The four processes really create a strategic framework to be more intentional and to spend time in building alliance, finding the right target, enhancing and strengthening commitment to change before we jump right into action steps and planning. Sometimes, people don’t use MI ‘cause they think it’s going to take too long. Because when you look at this, you think, “I don’t have that much time with people.” But when you really do master this strategy, it’s a really impactful intervention that really takes only minutes, or it can also be blended into other things that you’re already doing.

So today, we’re going to go through engaging and focusing, and next time, we’re going to jump into evoking, planning and pulling it all together. So, let’s dig into engagement. Engagement — the first process in MI strategy. It comes first because engagement is really the critical piece to creating a supportive and safe enough environment for people to even want to have a conversation with us about real change. We create and maintain engagement by building supportive alliance through active listening, through self-awareness and by building MI spirit with partnership, autonomy and empathy. I was curious — if you wanted to jump in your chat, how do you know when you have client engagement? What does it look like? I’d love to see.

“Eye contact.” That’s great. “Leaning into the conversation,” so there’s so many non-verbals. “More fluid conversation,” both people are really present, right? So, it takes two people to create engagement. There are questions and conversation. It’s a lot of comments about body language, body position and active participation. Those are great, right? So, we know when we have it and I’m sure we all know when we lose it. The research here is really clear that supportive alliance, or that a meaningful relationship between practitioner and client, is vitally important. In fact, it’s far more important than the application of any specific technique, program model or curriculum you have that you’re using for client success. Things like perceived empathy, acceptance, warmth, trust, autonomy, self-expression — they really strengthen the partnership and actually are more predictive, in terms of client outcomes and behavioral outcomes, than any methodology you apply. This is why engagement is the first of the four processes. Without it, you just cannot proceed. It’s hard to talk about engagement without talking about the opposite, which sometimes is talked about in terms of resistance, right?

Developing engagement is really a subtle, ongoing process, but it’s usually pretty clear and abrupt when you’ve lost it. Some people talk about this as resistance — the opposite of engagement. But the problem with many of the ways we think about and handle resistance is that we make it exclusively the other person’s problem or we ourselves become defensive, which leaves us with really very few options to address it and move forward productively.

In MI, resistance is thought of as a really predictable and natural part of the change process, and in order to understand how to respond to resistance in the most impactful way, it’s helpful to think about two really different kinds of resistance. Those are discord and sustained talk. Discord is resistance to us or to the system we may represent in our roles and in our jobs. Sustained talk, on the other hand, is resistance to change. It’s important to know the difference because there are really two different sets of strategies to use with discord than there is with sustained talk. Last time, we talked a lot about sustained talk, and sustained talk can show up and sound like excuses. It’s a really normal and expected part of the change process, and it kind of — with a tuned ear — gives us an insight into where someone is in their readiness to change. But discord, on the other hand, is resistance to us, and it really needs to be resolved in order to establish engagement — to move forward with the conversation about change. So while we address sustained talk as kind of softening it, kind of ignoring it and moving towards change talk, when we hear discord, we address discord by using empathic reflections.

Empathy here is what actually is the skill that creates and restores alliance and partnership. This is also the same skill, if you’ve ever taken de-escalation training, that can de-escalate tense interactions, but it can also just help build trust and re-engage at any point in the conversation. In order to do this well, we have to be checking in with ourselves and kind of taking our own temperature in order to restore partnership, autonomy and empathy throughout those MI processes. Without this, you just really can’t proceed. So let’s talk a little bit more about that and the emotional contagion. I think the emotional contagion is really interesting science. How we respond to discord can really determine whether or not resistance escalates or if we can rebuild engagement.

When someone’s experiencing a state of discord, they’re typically operating with their limbic brain. AWhen that happens, any attempt on our part to rationalize or explain really becomes futile because people are in their fight, flight or freeze response and really not operating from their prefrontal cortex, which is really responsible for our rational decision-making. So, the limbic system is an open loop; that means that it’s looking for external factors to manage internal processes and emotional states. This is what they call the emotional contagion, and science explains how it primes us to kind of appropriate our feelings and attitudes from the people around us, sort of like electricity over a network. So without intentional effort and awareness to try to control our own emotional response and situations, what ends up happening is moods, attitudes, feelings, responses kind of spread like a contagion. Not a great metaphor for now, but spread quickly and can really compromise the psychological safety for yourself and for your client.

Self-awareness around your own triggers and your own hot buttons can really close this open-loop system and provide you with a greater range of options for emotional control when you find yourself in these discord situations. Whenever we feel threatened, a part of our brain called the amygdala gets activated, and the amygdala is a super important function to keep us safe. It’s sort of this primal set of circuitry that evolved to warn us of things like animals attacking and rocks falling. But this alarm system can get activated by even perceived threats, and those perceived threats could even be things like ego threats. So this other part of the brain — the prefrontal cortex, which is our center of thinking, reasoning and creativity — also helps to downregulate kind of this overstimulated and really easily stimulated amygdala. It’s important that we all are actively practicing and modeling for the people we work with how you kind of show the resilience of being able to bounce back from these triggering moments. Because they happen to all of us — your brain, they’re happening to you. To take that control — that really starts with bringing awareness to your own triggers, and that’s like the first important step in calming that really intense amygdala.

I like the metaphor of hot buttons. There’s some really cool activities you can do around this and work that you can do to purposely manage your own hot buttons. So, reactions to conflict and situations that tend to make our temperature rise or cause defensiveness and anger — they tend to happen quickly, and they’re pretty immediate. We don’t have a lot of reaction time and they’re really the result of just getting triggered. When we reflect on our hot buttons and identify our own triggers, it can really help bring some awareness to what I’m experiencing right now and kind of wake up that decision-making part of your brain, so we can increase the reaction time between our trigger and response and be better prepared as they pop up.

This happens to everyone, and it’s helpful to think of a situation that you’ve been in when someone has become escalated. It may not have reached, like, confrontation level, but perhaps there was some discord and maybe it was directed at you. An important feature of discord is it’s really not personal or it’s not about you; it may be directed at you because of frustration with the larger system, especially if you’re working in a court-ordered program or at a justice program. But really, if we can take ourselves personally out of this situation and think of just behaviors, communication, we can begin to turn down the volume on the discord and really have the presence of mind to be able to respond with empathic reflections while controlling our own response and defense.

Empathic reflections are exactly what they sound like: They are reflections that are expressing feeling or empathy. In our first session, we practiced going under the surface to try to reflect back some of the attitudes and mindsets and beliefs that people may have that keep them stuck. Empathic reflections also are trying to describe the underlying feelings that may be driving the discord, and it requires intense listening for what we think might be going on below the surface and trying to reflect back the feeling. It could sound like, “You’re really frustrated. This is really difficult. You’re tired of explaining yourself,” right? People may come to us with all kinds of discordant statements: “You don’t understand what I’m going through. You’re just here to make a paycheck.” Whatever is coming out, the point of an empathic reflection is to lower the temperature of the situation so you can really get back to the business of talking about change. These are empathic reflections because they kind of require us to connect to something inside of us that might be happening for the other person who is experiencing discord.

Doing that requires suspending judgment — suspending whether we agree or disagree with where they’re at. It’s really trying to connect to the feeling and doing it authentically because an empathic reflection that isn’t delivered authentically, like if you don’t mean it, is not going to de-escalate anything. You really need to believe it. And the thing here is when people are escalated and they’re in their limbic brains, they’re not really thinking with the rational part of their brain. Here, we’re thinking the shorter is sweeter. “You’re frustrated right now. We’re listening to you.” Reflections like that.

Alright, so we’re going to practice this a bit. I’d like you to use your chat, and let’s choose one of these. Someone says to you, “What do you know about me?” That’s a discourse statement. It’s not reflecting change talk. It’s not necessarily resistance to change — it’s resistance to the system or us or what we’re representing. So in your chat, take a moment to type a reflective and empathic reflection that might turn down the volume on this kind of discord. Remember, short and sweet here; one of the best empathic reflections I ever heard was one word, and it was scary. “It takes a lot of strength for you to be here right now.” That’s awesome. “You’re right. I don’t, but I’d love to hear more about you.” Great. “Could you help me get to know you more? What would you like me to know about you? I’d like to get to know you. That’s what I’m here to find out, if you let me. Help me understand, tell me more.” These are great.

A lot of these are also questions, and those are great follow-ups to empathic reflections. The empathic reflection is acknowledging the feeling so somebody feels understood. Then, you can really jump into maybe asking a question like, “Tell me more.” Because sometimes when people have a heightened state and they’re in fight or flight, they’re not necessarily in the part of the brain that is even processing what you’re saying, so it’s really about the feeling. When you think about the feeling for, “What do you know about me,” is, it’s really feeling misunderstood, right? No one here knows you. No one’s taken time to get to know you. You’re feeling really misunderstood, No one’s listening to you, right? So, really trying to get at what’s going on under that feeling. Like we said before, with hot buttons, it’s hard to do that if we’re getting triggered, right? It’s not easy, if someone’s coming at you, to just pause and have that presence of mind to jump into empathy, but it really is a skill that with practice you can build.

Like last time, I wanted to give it a shot and listen to a conversation and to listen for discord and what we hear going on between the client and the practitioner in this scenario. So in this scenario, we’re going to hear a conversation between Mike and Donna. Mike is a client at a treatment facility and Donna is an intake practitioner; this is their first conversation. While you’re listening in, I want you to tune your ear to discord and think about some of these questions you can see here. How would you describe the client engagement? So, what words would you use to describe? You can chat live because it’s kind of fun to see an ongoing commentary of what you’re hearing. What roadblocks to listening do you think might be happening?

In our first session, we talked about roadblocks to listening for things like judging, advising and teaching at the wrong time. Criticizing can be roadblocks and create discord. Then, how does the practitioner respond and how do her responses either increase or decrease discord with the client? Kind of in real-time, what is she doing and what are you noticing and how does MI spirit show up or not? Does it? Are you hearing things that reflect autonomy for the client? Are you hearing things that reflect supportive alliance or partnership between practitioner and client? Are you hearing things that communicate empathy or not? Again, if you’re a read-along person, you can download the transcript from the Google Drive. I’ll put it there one more time. Let’s listen.

Donna:
Hey, Mike. How you doing today?

Mike:
Doing okay. I wish I understood why I had to be here right now.

Donna:
Well, I’ll tell you exactly, if you want, why you’re here. I’m Donna, by the way. I’m the intake person here at the treatment center. We deal with this all the time because you’re here because you’re, you know, — I can look at your file, and you failed your drug test and your employer is one of our clients. Whenever someone fails the drug test, they end up coming here so that we can hopefully help you keep your job.

Mike:
Well, I get a little bit frustrated that I have to take a drug test off a simple mistake at work. And there’s no proof that I did anything wrong at work. I don’t see why I should have to be here for stuff I do on my own time.

Donna:
Yeah, I hear that a lot. I mean, that’s the way a lot of people feel, but the bottom line is that that’s the policies and procedures of your workplace. And if you want to, they require that you have a job that’s — it looks like, what do you do? It looks like you drive heavy equipment.

Mike:
Yeah. Most of the time, I’m a loader and I operate one of the smaller forklifts. Loading and unloading their larger trucks, warehouse-type job. I get the call to come in and take a drug test after, right? A simple mistake, and I just got distracted at work.

Donna:
What did you do?

Mike:
I dropped part of a partial pallet on the floor. I got distracted by someone else moving, and I hit the brakes too hard and some of the product fell on the floor.

Donna:
Well that is something, you know, when somebody is impaired. And marijuana is particularly bad for that, but that looks like what you failed on your drug test was the marijuana. And that’s particularly bad for that — it makes those mistakes a lot more likely to happen.

Mike:
But I, you know, I’ve never smoked marijuana at work or before work.

Donna:
Well, how much do you smoke?

Mike:
I might smoke a little bit with my girlfriend when we get home from work and we’re relaxing and every once and a while on the weekends or barbecuing with our friends. Yeah, nothing like at work.

Donna:
So, it sounds like you smoke almost every day.

Mike:
Yeah, but not that much. It’s kind of just to unwind at the end of the day.

Donna:
Well, yeah, but it stays in your system. That’s the bottom line here, too, is that it stays in your system and it really does affect you. I know you don’t think it affects you that much, you’re not smoking that much, but it’s still a drug and it still affects you.

Mike:
Well, I think my issue, as far as the company is concerned, is that the testing is supposed to happen only if they have probable cause. And I feel like people make errors at work all the time. People get distracted because of stuff that’s gone on, kids or their wife, who knows what else, their credit cards — and they make mistakes at work and they don’t get drug tested, right? I just got chosen, so yeah.

Donna:
I hear that a lot too, where people in your situation feel like they’re picked out, but that’s just not the case. It’s just the policy.

Mike:
Well, like I said when we started, what am I going to do here? I think I need to get back to work, and this is wasting time and reducing my paycheck.

Donna:
Well, I’ll tell you what the requirements are. We have a program that’s designed specifically for this, and first of all, you have to sign an agreement that you won’t smoke any pot or do any other things — any other drugs — for the next six months. And that’s part of the program; you need to sign that you can do that. You need to be able to come here twice a week, and we’ll go through an intake and that’ll determine more about how much time you need to spend here. We need to get a lot more information from you about what your history with drug use is, but the minimum is that you’d have to come here twice a week. Then, we also require that you go to meetings and you go to a couple of those a week too, and we’ll get a signature for that too.

Mike:
What kind of meetings are we talking about?

Donna:
Most people that come in for marijuana go to NA meetings.

Mike:
Yeah. You know, I have a friend who had to go through AA stuff ‘cause of an arrest. I had been tagging along to ones just to show me what he had to do every week, and I don’t feel comfortable going to those meetings.

Donna:
Well, in this case, you just don’t really have a choice if you want to keep your job. It’s just the way the program is set up. And we also know that that’s what helps people get off of it because clearly you would have given it up already if you weren’t having some serious problems with it. You would have already given it up.

Mike:
I’d given what up? Smoking pot?

Donna:
Yeah, because you knew it was against the regulations. So if it had been important enough to you to keep your job, you would have probably given it up before.

Mike:
Well, I’ve been working for the same company for 13 years and I’ve never had an issue. So I don’t see it as some sort of problem, what I do on my own time.

Donna:
Well, it’s caused a problem now because you’re here and you’re having to deal with it. So it’s sort of like, “Well, I’ve got to just face the problem and it’s here and that’s the way,” you know. I mean, I guess you could decide it’s not worth it to you and you could just walk out that door, but yeah. It’s what it is. So, can I set you up with an intake appointment? That’s a couple hours long, and they just find out really exactly what your whole history is and how much you’ve always been using and what kind of use you’ve had to help determine what the best treatment for you is.

Mike:
Well, I guess you just told me that this intake appointment is supposed to determine how much I have to come in here. What motivation do I have to tell the truth about any past drug use?

Donna:
Well, we’re going to be testing every week. So anything that you use — just about anything you use — will be in your system. And we have to report those tests back to your employer; we have to report the results of those. So it’s sorta like a probationary thing that they have you on. They give you this opportunity; this is an opportunity for you to get better and do it, and that’s sort of where we are. So, what do you think? Shall I make an appointment?

Mike:
Yeah. I guess I don’t have a choice.

Donna:
Okay, good. Well, we’ll call down and make you an appointment.

Johanna:
Alright. Thank you for enduring that. I really appreciated so many of your reflections in the chat box. I heard so many things. I hope you all are reading along, but “defensive, belittling, judgmental, just the tone of hostility, burnout,” I heard, which is just so interesting — how taking care of ourselves impacts the care we can provide to others.

I’m curious, what do you think Donna’s triggers or stories are that are impacting her? What story is burnout, right? What story is she telling herself about Mike in this situation? “I’ve heard this all before, not the first time I’ve seen this, you’re just like so and so,” right? This really illustrates how important engagement is. So, I want to talk first about this conversation globally in terms of some of the roadblocks to listen to him and some of Donna’s responses. We heard disagreeing, demoralizing, warnings, threatening, disapproval, right? Lots of judgment. Also there’s an uneven power dynamic in that setup from the very first statement, right? So Donna, definitely in her first response, dampens the spirit of autonomy, partnership, empathy. Generally, the conversation just never even got to the first process of MI, which is engagement. So, not successful building supportive alliance, never going to get to behavior change and really only creating deeper discord throughout the course of the conversation.

Nothing describes the deficit in this conversation — the deficit of MI spirit — more than Mike’s last statement, if you caught it, which is, “I guess I don’t have a choice,” right? When we think about behavior change in terms of intrinsic motivation — autonomy, partnership — “Um, I guess I don’t have a choice,” really just I think sums it all up. For me, this is an interesting clip. It’ll be a little painful to listen to because it really does illustrate just how quickly you can lose engagement from your very first utterance. I’ve done a lot of work with organizations really just to become more purposeful on framing the first interaction or the first intake conversation they have with a client for this very reason. It really can set the stage and tone for whether this is a place supportive of change or not.

Let’s think, how could this conversation have played out differently? You can see Donna starts out with, “Hey, Mike, how are you doing today?” Mike says, “I’m doing okay. Wish I understood why I have to be here right now.” So, “I wish I understood why I have to be here right now,” is a pretty classic discord statement, right? What else could Donna have said to respond to that statement that could have set the conversation off on an entirely different trajectory? What can be an empathic reflection or response that would have just really changed the entire tone and kind of increased engagement?

I’m giving you a few examples: “It sounds like this might not be the place for you. How do you think the program can help you? You’re not sure you want to be here. You’re feeling pretty frustrated having to be here. No one’s listening to you. You feel really misunderstood.” So, when we are approached with discord, it’s probably not the time to take the approach that Donna took, which is, “Let me tell you exactly why you’re here.” We’re not explaining or teaching or telling — it’s really just about feeling with someone.

Even just relating as, “It sounds like this might not be the place for you,” or, “It sounds like you’re not sure what you’re doing here. It sounds like you’re not sure we can help,” are all really great ways to just turn the volume down so you can keep the conversation going toward change and building engagement. Yeah, “What reason do you think you’re here,” is a great reframe for that, “What would you like to get out of this,” right? “You don’t see a value in being here,” and it’s really about making a person feel understood. Your discord statement’s working when you get a head bouncing, right? Like they just feel understood, and you’re going to feel the interaction change immediately. So in MI, engaging is the first process in the strategic conversation. When it’s done strategically about the reflection, active listening and supporting autonomy is really what builds the partnership to move the conversation quickly forward. But with no understanding of the strategy or roadmap, a lot of conversations — like Donna’s and Mike’s — never make it out of the engaging stage.

I wanna talk about another strategy and skill that helps you build and keep and rebuild engagement, and that’s around affirmations. So, I want to introduce you to Betty. This is Betty’s third time on probation for charges of possession of a controlled substance. She’s got four kids. I just want you to reflect on your own and fill in the gaps to her story. So, what’s Betty like? What does Betty do? What’s the picture that’s painted around Betty’s life?

Now when we think about Betty and we think about sometimes our triggers and hot buttons are triggered by certain words, we hear certain situations. We see people in maybe certain backgrounds or crimes that they’ve had. So when we think through the strengths-based lens, it’s really about just getting very intentional on how we can frame Betty’s abilities and strengths and what struggles and efforts that you can affirm. So when you think of Betty, think through what strengths or abilities might she possess? What struggles do you think she has overcome that you might be able to affirm? And what might be three priorities in Betty’s life right now? If you were to look at this through a strengths-based lens, chatting it out, what would you guess are some of her priorities and aspirations?

Survivor, that’s right. Her kiddos, totally. Affirmations in MI are really an effective strengths-based approach to keeping in building this engagement, and because talking about change is so difficult and vulnerable, sometimes we push too quickly or push too hard and we can lose engagement at any point. So affirmations really build upon a person’s strengths, their capacity and self-efficacy to support themselves moving through ambivalence and doubt and fear and everything that comes along with change. But because many of the people we work with may have had many failed attempts at changing a problem behavior, they may expect others to point out their failures right away, and that’s what can create the discord. The inner dialogue may be doing that all day, right? People are coming to us expecting failure, and they might have an inner dialogue that is reaffirming that throughout the day, before they even approach us.

Being really intentional about affirmations is really important in kind of building up that supportive alliance by establishing hope, expectancy and a belief that really, indeed, change can happen. I just want to say a couple of things about affirmations because I’m sure you’re all really good at affirmations already, but affirmations can be tricky because they can make a person feel judged or patronized. That’s why it’s important that an affirmation be focused on specific and concrete behaviors rather than evaluative and cultural assumptions that we think are good about a person, right?

So affirmations, in fact, should have nothing to do with us. They’re not compliments and typically don’t start with “I.” In MI, adhere affirmation, communicate a recognition or appreciation for who a person really is. I wanted to give you a few examples just to see if you felt any difference when you take the “I” out of an affirmation. In the first example, “You worked really hard to get here today,” right? It’s affirming a struggle — work, determination — versus, “I’m glad you’re here on time.” And, “You’re someone who cares deeply for your kids,” versus, “I think you’re a good mom.” So in your chat, I’d love to know: How do these two examples feel different to you in terms of engagement and supportive alliance? What’s the difference when you take the “I” out of affirmation?

“The focus shifts,” exactly. “It becomes client-centered; the focus shifts away from the counselor. It validates the client’s effort. Better versions are statements of fact.” Yes, and not just opinion or judgment. “It feels less like a judgment, recognizes strengths,” you guys are awesome. Such thoughtful responses here. “It doesn’t state a personal opinion,” you got it. So affirmations can really serve to build hope, expectancy and supportive alliance for that first process of strategy. But if you don’t believe the affirmation or the affirmation is delivered in a way that could be patronizing, it can actually create discord.

The next strategy is focus, and I think what I’m going to do is introduce focus and then continue focus in the next session along with evoking so that we can spend a little more time on it. So where engaging provides the supportive alliance necessary to talk about change, focus is really about creating a clear change goal. It really is possible to be fully engaged with someone and be having a great conversation with awesome empathy, amazing supportive alliance — a great conversation — with no clear direction or goal. That’s why focusing is the second part of MI strategy: because MI is a conversation about specific behavior change.

Finding a focus in MI conversations is so important, and it’s because it’s not uncommon that people participate in interactions or office visits and spend no time at all talking about specific problem behaviors or change. And research into case management and things like re-entry community supervision really does show what we talk about in-office-visit matters in terms of lasting behavior change. In summary, you search re-entry — any programs that focus exclusively on kind of stabilization factors and resource brokering like housing, transportation, benefits, rather than behavior change — those programs showed no significant impact on recidivism or going back to present. The same results are evident in community supervision. So with probation and parole officers, those officers who focus exclusively on rules or terms and conditions rather than long-term behavioral change and motivational drivers showed no impact on long-term behavior change.

You can see similar outcomes in health care, right? Simply prescribing medication doesn’t mean a person will change their behaviors and lifestyle behaviors that led to that issue to begin with, and it doesn’t even mean that someone’s going to take the medication as prescribed. What we’ve learned from all of this research about it says what we’re focused on inside of the conversation in terms of lasting behavior change matters. That’s where focusing is the second strategic piece of MI.

Focusing on a specific change really allows you to give your full attention to important areas of need, so you can build out the strengths and affirmations around what the problem is we’re really trying to solve. And finding that meaningful focus really can’t happen without having that engagement because oftentimes what we may think are the underlying issues may not be what’s important to that person. So finding a focus really does come after the engagement. And a lot of programs — yours may be one of these — already have intake assessments, questionnaires, things designed for case planning or for identifying needs and establishing target goals. So motivational interviewing can actually be blended with some of your more formal assessments to really positively frame and talk about assessment results in a way that are important and meaningful for the client you’re working for and where they are in their lives.

The last thing I’m going to say about focus for today is, thinking through when you leave here today, what are the ways in which you’re already collecting assessment information or information around needs with the people you’re working with? And how can you blend MI into some of those more formal processes that you have to begin to have a conversation that builds in some intrinsic motivation for change? So it could look like simply sharing the results really intentionally with someone, explaining why those questions are asked. It’s understanding how they understand them, asking them, “What do you think of the results,” or even really adding additional questions to the way you use your assessments.

Like “What are your most important health goals and what are the things that are getting in your way, or you’re struggling with, to achieve those goals?” Next week, we’re going to pick up on focus and continue to go through all four processes of MI strategy. These are great. I wanted to leave a couple of minutes at the end if you want to ask any questions, and you can chat me or take yourself off mute. I also wanted — someone asked for reading recommendations — just to share with you a few of my favorite books that I have on my shelf. The first one is Motivational Interviewing, Third Edition: Helping People Change by William Miller and Steven Rolnick themselves.

And the third edition’s the greatest one because it does have just a really deep dive into strategy, and you can see I use it all the time, so a bunch of sticky notes. Here’s another one of my favorites, which is Building Motivational Interviewing Skills, Second Edition. This one is written by David Rosenblum Grant, and it’s pretty awesome if you want to take practical activity skills to your teams and continue to build your own skills. And it really shows what these things look like in practice. And then this book I’ve been reading lately, which is Motivational Interviewing and CBT: Combining Strategies for Maximum Effectiveness. This book is great because you could do something I use a lot, and it really shows how blending MI works and how you can blend them with maybe other interventions that you’re using.

Thank you for watching this video. We hope you enjoyed the presentation.

Medical Disclaimer

The Recovery Village aims to improve the quality of life for people struggling with substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare providers.

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