Continued part 1, part 2 of ebook Building motivational interviewing skills: A practitioner workbook (Second edition) provide readers with content about: evoking - preparation for change; planning - the bridge to change; the practice of MI;... Please refer to the part 2 of ebook for details!
PART IV Evoking Preparation for Change Merriam-Webster’s definition of evoke includes: • To bring (a feeling, memory, image, etc. . . . ) into the mind • To call forth or up • To cite, especially with approval or support • To bring to mind or recollection • To recreate imaginatively • To cause (a particular response or reaction) to happen We’ve now established the direction we wish to travel together Wouldn’t it be lovely if that were all we had to do? Clients become clear about what needs to happen and off they go Our clients would shake our hands, thank us, and then be on their way Sometimes that happens; more often the process is complicated Why is that? Let’s begin with the obvious answer: Change is hard It is important to acknowledge this truth Thinking of our own lives, we can probably identify examples of things we know need to change, have clear ideas about how to change, and yet somehow we just can’t quite make that change happen We should eat less, eat healthier, exercise more, get to bed earlier, spend more time with our loved ones, put down the electronic device, things that are more creative, volunteer our time, take care of that mess, clean that bathroom, write that note—and despite knowing this, it’s hard to make it happen In fact, one of my favorite quips acknowledges this reality and our foibles on this account: “Change is hard You go first.” Yet, there are some exceptions when change is not hard or complicated When the change is straightforward and not particularly complex, then people can move forward 255 256 Evoking with additional information from us (or someone else) This is a bit like clients asking us for directions about the “change river” and then hopping into the raft The current pulls gently, and so they move down stream with relative ease Clients might need to paddle to keep the raft in the middle of the river and away from the weeds at the side, but it’s more or less a gentle float, and they don’t need more help from us on this trip However, research tells us this process is not typically the case when attempting to make complex behavioral changes When the change is complex, information may be necessary, but it’s rarely sufficient to cause change (Fisher, Fisher, & Harman, 2003) For those more complex situations, clients will need a combination of information, motivation, and an ability to enact the change Although our presence still might not be required on the trip, or might be needed for only a part of the trip, this remains a more complex and challenging river for clients to navigate Although we’ve described the situation and hinted at what is important (i.e., motivation and skills), it does little to help us understand what needs to happen next for either our clients or us To that, we return to that familiar traveling companion: ambivalence In Chapter 2, we introduced ambivalence as a normal part of the change process It contains all the crosscurrents of why we think change might be a good idea and why it might be hard, as well as all the reasons to maintain the status quo and why giving it up might be a good idea It represents two sides of the same coin Although ambivalence manifests behaviorally, it also happens internally for clients and is expressed in their language Moreover, the research that Terri Moyers and others have done demonstrates that this language not only reflects what is happening internally, it also helps to create what is happening behaviorally (Glynn & Moyers, 2010) and predicts what will happen with a client (e.g., Apodaca et al., 2016) For these reasons, in MI we pay particular attention to client language and respond differentially to what we hear Attention to language and differential responding are the essence of the evoking process We can think of client language falling into three categories: talk about change; talk about sustaining the status quo, including discord; and neutral talk Change talk indicates the person is considering the possibility of change This is one side of ambivalence Sustain talk indicates the person is considering the possibility of things remaining unchanged Discord is a special form of sustain talk and indicates that the person is not just considering the possibility of avoiding change, but he or she is feeling pressure to change and is actively pushing back against us Notice the “us.” From an MI viewpoint, discord either arises or strengthens as part of an interpersonal process; as a result, the term resistance is no longer used because it suggests that this resistance resides solely within the individual rather than in the midst of an interpersonal process Instead, in MI we talk about discord as ambivalence under pressure.1 Taken together, sustain talk and discord represent the other side of the ambivalence coin Neutral talk refers to statements that are neither for nor against change It is simply neutral on this account or on another topic altogether These categories are things we already know and hear as a practitioner For example, read these smoker statements aloud and then decide into which category each of these would fall: 1 Thanks to Allan Zuckoff for this really helpful way to frame discord Evoking 257 “I don’t think my smoking is that big of a deal.” “You don’t understand I’ve tried that and it doesn’t work for me.” “I hadn’t really thought about it either way.” “I will quit at some point because I know it’s not good for me.” Did your practitioner ear help you know where these things fell? Here is how I would sort these statements: 1—Sustain; 2—Discord; 3—Neutral; 4—Change Don’t worry if your categories looked a little different Chapters and 11 will provide additional information about these categories, which will help fine-tune your sensitivity to these language categories For now, it’s enough to discover these are things you’ve already heard and known, but might not have put into words With this information about ambivalence and language in mind, let’s consider four ideas First, the path we select determines the conversational direction we travel Second, this conversation is mutually influencing Third, the conversation itself helps organize clients’ experience Finally, the conversation does not just describe the experience, it helps create it We’ll take each of these ideas in turn The first idea seems like common sense Of course, your path will determine where you end up Yet, it’s easy to lose track of this simple idea in our busy work situations We feel compelled to gather particular bits of information or solve certain problems In this process we may become reactive rather than intentional in choosing where we will focus our attention Or we become intent on collecting the data and not hearing the client’s story and the paths it suggests Part of the art of becoming a proficient MI practitioner is becoming intentional in which conversational paths we choose The second idea builds on this first one, and also extends it Again, it is no surprise that conversations are mutually influencing We are traveling together, and what each of us does affects the other What might be less immediately evident is that clients influence our use of MI and in ways we might not predict Zach Imel has done some very interesting research that suggests there is significant variation in our use of MI based on clients Of particular interest is that we tend to be less proficient in our use of MI when clients are less challenging (Imel, Baer, Martino, Ball, & Carroll, 2011) It seems we might be more inclined to the righting reflex at these times and less likely to use evoking Thus, as the client begins moving toward change, we need to be mindful of staying within that MI spirit and using those OARS+I to evoke within the client the processes that will sustain the change effort Third, much as the narrative therapists have taught us, we help clients to organize their experiences in a manner they can use This idea becomes especially important as we think about our task as practitioners If we simply return to clients what they’ve told us—in the manner they’ve told us—we haven’t helped them organize this experience This might be why surface-level reflections are a useful but limited tool Deeper reflections and summaries, as well as affirmations, well-targeted information and questions, help clients see and understand their situation in a new light They see a possible way forward Fourth and finally, the conversations between clients and practitioners might not just describe the experiences, but also create them Here we slip into metacognition or thinking 258 Evoking about thinking An example is helpful in describing this concept Read these two statements aloud: “That is a problem.” “That is a challenge.” As you read these two statements, did you find yourself reacting to each of them differently? Most people experience a difference and noticing this difference is the essence of metacognition That is, how we think and talk about an issue affects how we understand the thing itself With regard to client change, then, what we choose to respond to and how we respond to it affects not only the path we’re traveling, but also our understanding of what the path is and where we’re going It makes us ever more mindful that language matters and that we want to be intentional in how we use it Keeping these points in mind, let us return to our river of change metaphor and those three elements: where, what, and how With regard to where we are in the river, we are at the point where the client has identified a direction toward which he or she would like to travel Notice that it is the client who chooses that direction, not the practitioner That is the outcome of the focusing process and the point at which we begin this process Our goals in this situation are to help clients remain focused on this direction, to evoke their reasons for why they have selected this direction, to evoke what they are moving toward, and then to help them commit to that change In this section of the book, we target our core skills to evoke and reinforce change talk, to soften sustain talk, and to “defuse” discord Let’s see how that might show up in our continuing conversation with Russell ACTIVITY IV. Evoking with Russell The conversation with Russell continues to move forward Read the counselor statements and decide which skill you think is being used Under the “Russell talk category,” indicate whether you think the language is moving toward change, moving away from change, or hovering somewhere in the middle Use those labels: “moving toward,” “moving away,” or “in the middle.” Later we will talk about the specificity of change talk For now, just keep in mind whether the client’s language is moving toward change in the topic under discussion (e.g., marijuana, parenting) in each client response In the next chapters we’ll get more detailed about this information Counselor skill category/ Russell talk category C: So, let me step back and summarize what we’ve talked about You’re not sure this marijuana stuff is worth talking about, but you’re here There are some things you would like to see change, and perhaps the most important of those things to you is finding tools for managing things with your daughters How does that fit? R: No, I am certain Marijuana is not an issue for me, and I think it’s a waste of time talking about it C: You want to focus elsewhere—like on your kids and being a good parent R: Exactly C: One of the things that I would find helpful is to understand where this commitment to being a good parent comes from R: Sure Yeah, why not I had great parents They weren’t perfect, but they tried really hard to understand me and provide what I needed Which doesn’t mean it was always easy There were expectations for me I mean, I was probably the only kid who hated 3-day weekends because there would be a big project to around the house when those rolled around There was no sleeping late on weekends My friends did, but not me (laughs) We were up and ready to work by eight in the morning (shakes head) C: (Chuckles.) There were parts you didn’t like, and yet you knew they also tried to see things from your view (cont.) From Building Motivational Interviewing Skills: A Practitioner Workbook, Second Edition, by David B Rosengren Copyright © 2018 The Guilford Press Permission to photocopy this material is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download a version of this material (see the box at the end of the table of contents) 259 Evoking with Russell (p of 3) Counselor skill category/ Russell talk category R: Not that it changed the projects (snorts), but we would always talk at the dinner table They would ask questions and really listen to what I would say They didn’t tell me I was wrong or I didn’t understand They didn’t discount what I had to say, like my friend’s parents [who’d say], “You’ll see it differently when you’re older.” C: And you really knew the benefits of people not just saying they were listening, but really doing it That’s what you want your daughters to have R: Yes I want them to know that I really care what they think But, like with my parents, I also want them to know there are things that must be done when you’re part of a family C: You want them to understand that it’s not just about them R: Right C: They need to contribute and not just take R: Exactly But that’s not always easy In fact, it’s hard It feels like when they come to my house, we sort of have to start over each time C: Each week R: Yeah, their mom and me have different styles She doesn’t want to be the bad guy—I get it C: You understand why she might that R: Yeah, but at the same time it sort of pisses me C: It’s frustrating, and yet you reset those expectations because you know that it’s important for the girls It’s about them and not about you R: That is one of the things my parents gave me I knew I was important, but the world didn’t revolve around me It’s a tricky balance 260 Evoking with Russell (p of 3) Counselor skill category/ Russell talk category C: But one you understand is part of being a good parent The girls need to know they’re loved and that being part of a family means it’s not just about them That’s a pretty deep lesson you learned and carried forward R: Yeah, it’s funny because I hadn’t really thought about it, but that is true I know I have to this C: You know what to R: I It’s funny because this has always been a source of friction between my ex and me, like it’s her problem because she’s lax But it’s really my job It’s not about her—it’s about me C: That understanding changes it for you R: Yeah I don’t really need to change what I am doing, but I need to change how I am looking at it C: And that will reduce some of the stress R: It’s funny, but that feels right C: Like your body knows it’s true R: Yeah C: It seems like you’ve made a decision R: I have I don’t need to change what I’m doing—that’s right on But, I need to change how I am looking at it C: Let me see if I’ve understood all of this Your parents laid out a roadmap for good parenting that you’ve been following You know in your very bones that good parenting includes making sure your daughters feel loved, but it also includes expectations about contributing to the family so they know it’s not just about them You’ve already been doing these things, but you recognize that it’s felt more like a burden then the task of being a good parent You realize that you need to embrace it R: I think you got it C: So, what now? 261 Key for Activity IV Counselor skill category/ Russell talk category C: So, let me step back and summarize what we’ve talked about You’re not sure this marijuana stuff is worth talking about, but you’re here There are some things you would like to see change and perhaps the most important of those things to you is finding tools for managing things with your daughters How does that fit? Summary R: No, I am certain Marijuana is not an issue for me and I think it’s a waste of time talking about it Moving away from change C: You know you want to focus elsewhere—like on your kids and being a good parent Deeper reflection R: Exactly In the middle C: One of the things that I would find helpful is to understand where this commitment to being a good parent comes from Statement that acts as a question R: Sure Yeah, why not I had great parents They weren’t perfect, but they tried really hard to understand me and provide what I needed Which doesn’t mean it was always easy There were expectations for me I mean I was probably the only kid who hated 3-day weekends because there would be a big project to around the house when those rolled around There was no sleeping late on weekends My friends did, but not me (laughs) We were up and ready to work by eight in the morning (shakes head) In the middle C: (Chuckles.) There were parts you didn’t like and yet you knew they also tried to see things from your view Double-sided reflection R: Not that it changed the projects (snorts), but we would always talk at the dinner table They would ask questions and really listen to what I would say They didn’t tell me I was wrong or I didn’t understand They didn’t discount what I had to say, like my friend’s parents [who’d say], “You’ll see it differently when you’re older.” In the middle C: And you really knew the benefits of people not just saying they were listening, but really doing it That’s what you want your daughters to have Deeper reflection (cont.) 262 Key for Activity IV (cont.) Counselor skill category/ Russell talk category R: Yes I want them to know that I really care what they think But, like with my parents, I also want them to know there are things that must be done when you’re part of a family Moving toward C: You want them to understand that it’s not just about them Deeper reflection R: Right Moving toward C: They need to contribute and not just take Follow-up reflection R: Exactly But that’s not always easy In fact it’s hard It feels like when they come to my house we sort of have to start over each time Moving toward and moving away C: Each week Surface reflection R: Yeah, their mom and me have different styles She doesn’t want to be the bad guy—I get it In the middle C: You understand why she might that Surface reflection R: Yeah, but at the same time it sort of pisses me In the middle (though he’s mad at his ex-wife) C: It’s frustrating and yet you reset those expectations because you know that it’s important for the girls It’s about them and not about you Double-sided reflection R: That is one of the things my parents gave me I knew I was important, but the world didn’t revolve around me It’s a tricky balance In the middle C: But one you understand is part of being a good parent The girls need to know they’re loved and that being part of a family means it’s not just about them That’s a pretty deep lesson you learned and carried forward Reflection, followed by affirmation R: Yeah, it’s funny because I hadn’t really thought about it, but that is true I know I have to this Moving toward C: You know what to Deeper reflection that affirms (cont.) 263 Key for Activity IV (cont.) Counselor skill category/ Russell talk category R: I It’s funny because this has always been a source of friction between my ex and me, like it’s her problem because she’s lax But it’s really my job It’s not about her—it’s about me This is tricky because it feels like it’s moving toward change, but it could also be argued that it’s in the middle We’ll come back to this in the chapter ahead C: That understanding changes it for you Reflection R: Yeah I don’t really need to change what I am doing, but I need to change how I am looking at it Moving toward C: And that will reduce some of the stress Reflection R: It’s funny, but that feels right Moving toward C: Like your body knows it’s true Reflection R: Yeah Moving toward C: It seems like you’ve made a decision Reflection R: I have I don’t need to change what I’m doing—that’s right on But, I need to change how I am looking at it Moving toward C: Let me see if I’ve understood all of this Your parents laid out a roadmap for good parenting that you’ve been following You know in your very bones that good parenting includes making sure your daughters feel loved, but it also includes expectations about contributing to that family so they know it’s not just about them You’ve already been doing these things, but you recognize that it’s felt more like a burden then the task of being a good parent You realize that you need to embrace it Transitional summary R: I think you got it Moving toward C: So, what now? 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(1979) Understanding human values New York: Macmillan Rollnick, S (2016, November 28) Re: MI and Radicalism [Online forum comment] Retrieved from http://motivationalinterviewing.org/mintforum/message Rollnick, S., Kaplan, S G., & Rutschmann, R (2016) Motivational interviewing in schools: Conversations to improve behavior and learning New York: Guilford Press Rollnick, S., Mason, P., & Butler, C (1999) Health behavior change: A guide for practitioners London: Churchill-Livingstone Rollnick, S., Miller, W R., & Butler, C (2008) Motivational interviewing in health care: Helping patients change behavior New York: Guilford Press Rosengren, D B., Baer, J S., Hartzler, B., Dunn, C W., & Wells, E A (2005) The Video Assessment of Simulated Encounters (VASE): Development and validation of a group-administered method for evaluating clinician skills in motivational interviewing Drug and Alcohol Dependence, 79, 321–330 Rosengren, D B., Hartzler, B., Baer, J S., Wells, E A., & Dunn, C W (2008) The Video Assessment of Simulated Encounters—Revised (VASE-R): Reliability and validity of a revised measure of motivational interviewing skills Drug and Alcohol Dependence, 97(1–2), 130–138 Ross, L (1977) The intuitive psychologist and his shortcomings: Distortions in the attribution process In L Berkowitz (Ed.), Advances in experimental social psychology (Vol 10, pp. 173–220) New York: Academic Press Ryan, R M., & Deci, E L (2000) Self-determination theory and the facilitation of intrinsic motivation, social development, and wellbeing American Psychologist, 55, 68–78 Schoener, E P., Madeja, C L., Henderson, M J., Ondersma, S J., & Janisse, J J (2006) Effects of motivational interviewing training on mental health therapist behavior Drug and Alcohol Dependence, 82, 269–275 Schumacher, J A., & Madson, M B (2015) Fundamentals of motivational interviewing tips and strategies for addressing common clinical challenges New York: Oxford University Press Schwalbe, G S., Oh, H Y., & Zweben, A (2014) Sustaining motivational interviewing: A meta- analysis of training studies Addiction, 109, 1287–1294 Silver, H F., Strong, R W., & Perini, M J (2000) So each may learn: Integrating learning styles and multiple intelligences Trenton, NJ: Silver Strong Simpson, D D (2002) A conceptual framework for transferring research into practice Journal of Substance Abuse Treatment, 22, 171–182 Simpson, D D., & Joe, G W (1993) Motivation as a predictor of early dropout from drug abuse treatment Psychotherapy, 30, 357–368 Smith, J L., Amrhein, P C., Brooks, A C., Carpenter, K M., Levin, D., Schreiber, E A., et al (2007) Providing live supervision via teleconferencing improves skill acquisition of motivational interviewing skills after workshop attendance American Journal of Drug and Alcohol Abuse, 33, 163–168 504 References Steele, C M (1988) The psychology of self-affirmation: Sustaining the integrity of the self In L Berkowitz (Ed.), Advances in experimental social psychology (Vol 21, pp. 261–302) San Diego, CA: Academic Press Steinberg, M P., & Miller, W R (2015) Motivational interviewing in diabetes care New York: Guilford Press Stinson, D., & Clark, M D (2017) Motivational interviewing with offenders: Engagement, rehabilitation, and reentry New York: Guilford Press Vader, A M., Walters, S T., Prabhu, G C., Houck, J M., & Field, C A (2010) The language of motivational interviewing and feedback: Counselor language, client language, and client drinking outcomes Psychology of Addictive Behaviors, 24(2), 190–197 Villaume, W A., Berger, B A., & Barker, B N (2006) Learning motivational interviewing: Scripting a virtual patient American Journal of Pharmacy Education, 70(2), 1–9 Voss, J D., & Wolf, A M (2004) Teaching motivational interviewing in chronic care: A workshop approach Journal of General Internal Medicine, 19, 213 Wagner, C C., & Ingersoll, K S (2013) Motivational interviewing in groups New York: Guilford Press Westra, H A (2012) Motivational interviewing in the treatment of anxiety New York: Guilford Press Zuckoff, A., & Gorscak, B (2015) Finding your way to change: How the power of motivational interviewing can reveal what you want and help you get there New York: Guilford Press Index Note: f following a page number indicates a figure Ability to change See also Change talk exercises to try, 294 overview, 269–270, 275 sustain talk and discord and, 366 Absolute worth, 15 Acceptance information exchange and, 214 MI spirit and, 14–15 planning and, 410 Accurate empathy, 15 Activation, 272, 366 See also Change talk Adherence talk, 282 Administrative support, 481–482 Advice compared to providing information, 208 exercises to try, 37–43, 86–88, 222–223, 239–253 as a roadblock towards change, 72f Affirmation, 15 Affirmations See also Core skills; OARS+I acronym change plan and, 433–434 example of, 117–120 exercises to try, 121, 129–132, 395–404 overview, 16, 108–112, 116 training in motivational interviewing and, 489–490 Agenda mapping See also Agendas example of, 183–185 exercises to try, 185–186, 188–205 overview, 174, 175–178, 182–183 Agendas See also Agenda mapping; Focusing process concept quiz regarding, 181–183 continuum of, 174–179 difficult subjects and, 179–181 overview, 171–181 Agreement See also Agenda mapping; Agreement with a twist strategy agendas and, 175–176 exercises to try, 86–88 as a roadblock towards change, 72f Agreement with a twist strategy See also Agreements exercises to try, 380–382, 383–384 sustain talk and discord and, 363, 364, 374 Ambivalence about change change plan and, 437, 441–442 change talk and, 273, 276 evocation and, 256 exercises to try, 37–43 overview, 12, 19 planning and, 410, 413–414 Amplified reflections See also Reflections; Reflective listening exercises to try, 98–100, 370, 377–379, 383– 384, 395–404 overview, 76, 77f, 78 sustain talk and discord and, 362, 366, 367, 374 Analyzing exercises to try, 86–88 as a roadblock towards change, 72f Approval exercises to try, 86–88 as a roadblock towards change, 72f Arguing with clients discord and, 274 evocation and, 316 exercises to try, 86–88 overview, 18 as a roadblock towards change, 72f 505 506 Index Ask–provide–ask method, 212 See also Elicit– provide–elicit (E-P-E) method; Information exchange Assessment agenda mapping and, 177–178 engagement and, 52 evocation and, 306–307 Assumptions, 208–209 Autonomy exercises to try, 395–404 information exchange and, 210, 217–218 MI spirit and, 15 overview, 19 B Behavior, 15, 308–309 Below the waterline level reflections See also Reflections; Reflective listening exercises to try, 82, 83, 90–94, 98–100, 259–264 overview, 75, 75f, 77f Blame exercises to try, 86–88 as a roadblock towards change, 72f Brain imaging research, 110 Brainstorming, 437 Broaden and build theory of positive emotions, ix–x C Central MI processes, 48–50, 489–490 See also Change processes; Engaging process; Evoking process; Focusing process; Planning process Challenging clients See Difficult clients Change See also Change plan; Change talk evocation and, 255–256 overview, 428–436 training in motivational interviewing and, 478 Change, readiness for See Readiness to change Change plan See also Planning process challenges in, 441–442 concept quiz regarding, 436–437 example of, 438–439 exercises to try, 439–441, 443–471 form for, 440, 453–454 overview, 428–436, 441–442 training in motivational interviewing and, 487–490 Change processes, 48–50 Change talk compared to sustain talk, 372 concept quiz regarding, 275–276 eliciting from clients, 16–17 evocation and, 302–309, 310 example of, 277–280, 311–314 exercises to try, 280–282, 283–300, 314, 317–332, 415–419 overview, 17–18, 17f, 256–257, 265–269 planning and, 406–407, 410 questioning and, 116 training in motivational interviewing and, 483, 487–488, 489–490 Changing the subject exercises to try, 86–88 as a roadblock towards change, 72f Chatting, 52 Cheerleading, 112 Choice exercises to try, 380–382, 383–384 sustain talk and discord and, 374 Chunk–check–chunk method, 213–214 See also Information exchange Client statements, 211 Clients, difficult establishing an MI learning community and, 496 exercises to try, 23, 44–45, 371, 391 Closed questions, 116, 120, 124–125 See also Questioning Coaching example of, 483–485 exercises to try, 485–491 overview, 486 training in motivational interviewing and, 480 Collecting summaries, 112–113, 114 See also Summaries Coming alongside technique See Siding with the negative strategy Commands exercises to try, 86–88 as a roadblock towards change, 72f Commitment language See also Change plan; Change talk change plan and, 433–436, 437 example of, 277–280 overview, 269, 271–272, 276, 428–436 sustain talk and discord and, 366 training in motivational interviewing and, 487–488 Compassion affirmations and, 110 MI spirit and, 15 Compliance, 273–275 Compliments, 109 See also Affirmations Concerns, 214–215 Confrontational approaches, 179–181 consoling exercises to try, 86–88 as a roadblock towards change, 72f training in motivational interviewing and, 489–490 Consultation, 486 Context, 223–224 Continuing the paragraph reflections, 77f See also Reflections; Reflective listening Control, 374 Conversations about change See also Motivational interviewing in general evocation and, 257–258 exercises to try, 103 overview, 11–14 Core skills See also Affirmations; OARS+I acronym; Open-ended questions; Reflective listening; Summaries example of, 69–70 overview, 70, 78 training in motivational interviewing and, 480–481, 487–488 Counterarguments, 143 Criticisms exercises to try, 86–88 as a roadblock towards change, 72f Curious mindset, 410 D Dangerous situations, 215–217, 219 See also Difficult subjects DARN acronym See also Change talk exercises to try, 281–282, 294 overview, 269–270, 276 Defensive bias, 122 Defensiveness, 410 Denial, 274 Depth of reflections See also Reflections; Reflective listening example of, 117–120 exercises to try, 82, 83, 90–94, 98–100, 259–264, 370, 377–379, 383–384, 388–389, 395–404 overview, 74–77, 75f sustain talk and discord and, 361–362, 366, 374 varying, 75–76, 78 Desire to change See also Change talk exercises to try, 294 overview, 269, 275 sustain talk and discord and, 366 Index 507 Difficult clients establishing an MI learning community and, 496 exercises to try, 23, 44–45, 371, 391 Difficult subjects agendas and, 179–181, 183 exercises to try, 185–186, 195–204 information exchange and, 215–217 Directing style of the practitioners agendas and, 178 change plan and, 441–442 exercises to try, 86–88 overview, 11 as a roadblock towards change, 72f Directionality, 19, 489–490 Disagreeing discord and, 274 exercises to try, 86–88 information exchange and, 210 as a roadblock towards change, 72f Discord agendas and, 179 concept quiz regarding, 275–276, 365–367 difficult subjects and, 179–181 example of, 367–369 exercises to try, 369–371, 374–391 overview, 13, 18, 19, 256–257, 273–275, 359–365 planning and, 410 reflective listening and, 77 training in motivational interviewing and, 487–488, 489–490 Disengagement, 51–54 See also Engaging process Distraction exercises to try, 86–88 as a roadblock towards change, 72f Double-sided reflection See also Reflective listening change plan and, 433–434 exercises to try, 98–100, 259–264, 370, 377– 379, 383–384 overview, 76, 77f sustain talk and discord and, 362, 374 E EARS acronym See also Evoking process example of, 314 exercises to try, 353–357 overview, 302–303, 310 Elaboration, 303–304 Elicit–provide–elicit (E-P-E) method See also Information exchange evocation and, 316 exercises to try, 395–404 508 Index Elicit–provide–elicit (E-P-E) method (cont.) overview, 212 training in motivational interviewing and, 478–479 Empathy, 15, 23 Engaging process affirmations and, 111–112 agendas and, 179 change plan and, 430, 436 difficult subjects and, 179–181 evocation and, 316 exercises to try, 55–68, 83, 101–102, 120, 126–128, 468–470 information exchange and, 208, 219 open-ended questions and, 105–106 overview, 48, 51–54, 139, 187 planning and, 406 questioning and, 308–309 summaries and, 115 sustain talk and discord and, 369 values and goals and, 140, 144, 148 Envisioning exercises to try, 415–419 planning and, 407, 410 Evocative questions, 303 See also Evoking process; Questioning Evoking process change plan and, 430 concept quiz regarding, 309–310 example of, 311–314 exercises to try, 259–264, 314–358 hopes and goals and, 142 information exchange and, 219 overview, 15–16, 19, 48–50, 139, 255–258, 301–309 planning and, 406, 407, 410 sustain talk and discord and, 369 values and goals and, 144 Expectations, 52 Expertise engagement and, 52 evocation and, 310 Extremes, 304 F Feedback See also Evoking process from assessments, 306–307 overview, 310 training in motivational interviewing and, 480, 486 Feeling level reflections, 77f, 98–100 See also Reflections; Reflective listening FOCUS acronym, 218 See also Information exchange Focusing process See also Agendas; Information exchange agendas and, 175–176 change plan and, 430, 436 evocation and, 316 example of, 145, 183–185 exercises to try, 168–170, 185–186, 188–205, 221–223, 225–254, 395–404, 468–470 hopes and goals and, 142 overview, 48–50, 139, 165–167, 171–172, 173, 187, 208 planning and, 406 Focusing summaries, 115 See also Summaries Following style of the practitioner agendas and, 178 overview, 11 reflective listening and, 76 Four central MI processes See Central MI processes Future timeline approach, 142 G Goals change plan and, 431, 437 change talk and, 269 concept quiz regarding, 143–144 engagement and, 52 evocation and, 305–306 example of, 144–145 exercises to try, 146–147, 153–158, 395–404, 415–419 focusing process and, 173 information exchange and, 208 overview, 138–139, 141–143 “Good” advice See Advice Guessing exercises to try, 82 reflective listening and, 76–77, 79 Guiding style of the practitioner agendas and, 178 change plan and, 441–442 overview, 11–12 planning and, 410 training in motivational interviewing and, 478–479 H Hopes See also Goals example of, 144–145 exercises to try, 153–158 overview, 141–143 “Hot” words, 77 Humor exercises to try, 86–88 as a roadblock towards change, 72f I Implementation support, 481–482 Importance of the presenting issue, 52 Influence exercises to try, 55–59, 395–404 information exchange and, 217–218, 220 Information exchange See also Focusing process; OARS+I acronym agendas and, 175 change and, 256 concept quiz regarding, 218–220 dangerous situations, 215–217 engagement and, 53 evocation and, 310 example of, 117–120, 220–221 exercises to try, 221–223, 225–254, 395–404 methods of, 212–214 offering a concern and, 214–215 overview, 16, 206–218 training in motivational interviewing and, 489–490 Integrity, 142–143 Interpretation exercises to try, 86–88 as a roadblock towards change, 72f Interruptions, 275 J Judging exercises to try, 86–88 as a roadblock towards change, 72f K Key questions See also Questioning evocation and, 303 exercises to try, 425–426 planning and, 408, 410 Known agenda, 174 See also Agendas L Labeling, 52 Language, 266–267, 276 See also Change talk; Neutral talk; Sustain talk Index 509 Leading style of the practitioner, 76, 78 Learning community, 7, 493–496 Learning MI See also Motivational interviewing in general; Training in motivational interviewing concept quiz regarding, 482–483 establishing an MI learning community and, 493–496 example of, 483–485 exercises to try, 485–491 overview, 475–482, 486 Lectures exercises to try, 86–88 as a roadblock towards change, 72f Linking summaries, 112–113, 114 See also Summaries Listening See also Reflective listening engagement and, 53 exercises to try, 82, 84, 89 overview, 182 Logic exercises to try, 86–88 as a roadblock towards change, 72f Looking back technique, 304–305 See also Evoking process Looking forward technique, 305 See also Evoking process Love, 110 M Mentors, 22, 25–26 Metacognition, 257–258 Metaphors in reflection, 76–77, 77f See also Reflective listening MI processes, central See Central MI processes MI spirit evocation and, 19 exercises to try, 22, 27–30 overview, 17–18, 17f training in motivational interviewing and, 487–488, 489–490 Mobilizing language, 268, 271–272 See also Change talk Moralizing exercises to try, 86–88 as a roadblock towards change, 72f Motivational interviewing in general See also Learning MI; Practice of MI; Training in motivational interviewing concept quiz regarding, 18–19 example of, 19–21 MI spirit, 14–18, 17f overview, ix–x, 10–18, 17f, 24 510 Index N Name calling exercises to try, 86–88 as a roadblock towards change, 72f Need to change See also Change talk exercises to try, 294 overview, 270–271, 275 sustain talk and discord and, 366 Neurobiological factors, 268 Neutral talk example of, 277–280 exercises to try, 281, 295–298 overview, 256–257 Normalizing of behavior difficult subjects and, 180–181 exercises to try, 186 O OARS+I acronym See also Affirmations; Core skills; Information exchange; Open-ended questions; Reflective listening; Summaries agendas and, 175 change plan and, 431, 435 concept quiz regarding, 115–116 difficult subjects and, 181 evocation and, 302–303, 316 example of, 69–70, 79–81, 117–120 exercises to try, 120–122, 124–137, 395–404 overview, 16, 17–18, 17f, 49, 70, 78, 104–105, 122–123 sustain talk and discord and, 362 training in motivational interviewing and, 487–488 values card sort and, 140 Open-ended questions See also Core skills; OARS+I acronym; Questioning example of, 117–120 exercises to try, 120, 124–128, 153–158, 395–404 overview, 16, 105–108, 116 training in motivational interviewing and, 489–490 Open-ended statements, 106 Opinions, 211 Optimism, 269–270 See also Change talk Options See also Agenda mapping change plan and, 432, 437 information exchange and, 211 overview, 175–176 Ordering exercises to try, 86–88 as a roadblock towards change, 72f Organizational support, 481–482 Orienting, 174–175, 178–179 See also Agendas Overprescription, 441–442 Overstatement, 76 P Partnership, 14 Perceptions, 219 Permission exercises to try, 395–404 information exchange and, 210, 217–218, 219 Perspective, broadening exercises to try, 147, 161–163 information exchange and, 210 Persuasion exercises to try, 86–88 information exchange and, 217–218, 220 as a roadblock towards change, 72f Planning process See also Change plan concept quiz regarding, 409–410 example of, 183–185, 411–412 exercises to try, 395–404, 412–413, 415–427 information exchange and, 208, 219 overview, 48–50, 393–394, 405–409, 413–414, 432 recapitulation and, 407–408 signs of readiness and, 406–407 values and goals and, 148 Positive psychology, 110 Positivity, 52 Practice of MI, 473, 494 See also Learning MI; Motivational interviewing in general Practitioner behavior engagement and, 52 evocation and, 309 exercises to try, 22–23, 31–43, 46–47, 55–59 information exchange and, 208–209 planning and, 408–409 reflective listening and, 71–77, 72f, 75f sustain talk and discord and, 367–369 training in motivational interviewing and, 476–477 Praise exercises to try, 86–88 as a roadblock towards change, 71, 72f Preaching exercises to try, 86–88 as a roadblock towards change, 72f Pregnant pause exercises to try, 413, 427 planning and, 408–409 Premature focus, 52 Preparatory language, 268, 281–282 See also Change talk Probing affirmations and, 111 exercises to try, 86–88 as a roadblock towards change, 72f Problem solving difficult subjects and, 179–181 values and goals and, 148 Processes of change, 48–50 See also Central MI processes Proficiency in MI skills, 477–482 Q Questioning See also Open-ended questions agenda mapping and, 177–178 change plan and, 431, 455–459, 465–467 difficult subjects and, 179–181 evocation and, 303 exercises to try, 86–88, 120, 124–128, 222, 225–228, 315, 333–337, 415–419, 440, 455–459, 465–467 hopes and goals and, 141–142 overview, 143 planning and, 407, 408, 410 as a roadblock towards change, 72f, 73–74 values and, 148, 308–309 R Readiness for treatment, 282 Readiness rulers method, 307, 310 See also Evoking process Readiness to change change plan and, 437 exercises to try, 412, 415–419 overview, 12–13, 182, 282 planning and, 406–407, 410 Reaffirming commitment, 433–434, 437 Reasons for change See also Change talk exercises to try, 294 overview, 270, 275 sustain talk and discord and, 366 Reassurance exercises to try, 86–88 as a roadblock towards change, 72f Recapitulation, 407–408 Recordings of MI sessions, 495–496 Reengaging See also Engaging process change plan and, 436 exercises to try, 468–470 Index 511 Reflections See also Reflective listening change plan and, 433–434, 441–442, 460–464 example of, 144–145, 367–369 exercises to try, 153–158, 222, 229–232, 259–264, 315, 338–349, 370, 371, 375–384, 388–389, 395–404, 440, 460–464 information exchange and, 212 open-ended questions and, 106–107 overview, 143 summaries and, 112–113 sustain talk and discord and, 361–362, 366, 367 training in motivational interviewing and, 478–479, 489–490 values and goals and, 148 Reflection-to-question ratio See also Questioning; Reflections training in motivational interviewing and, 489–490 values and goals and, 148 Reflective listening See also Core skills; Listening; OARS+I acronym; Reflections affirmations and, 110 concept quiz regarding, 78–79 example of, 79–81, 117–120 exercises to try, 81–103 overview, 6, 16, 19, 69–77, 72f, 75f, 77f, 84–85 sustain talk and discord and, 361–362 Refocusing See also Focusing process change plan and, 436 exercises to try, 468–470 Reframing exercises to try, 380–382, 383–384 sustain talk and discord and, 363–364, 374 Relationships affirmations and, 110–111 information exchange and, 215 Reminding change plan and, 435 exercises to try, 468–470 Replanning, 435, 468–470 See also Planning process Resistance, 13, 256–257, 273–275 Resolution exercises to try, 415–419 planning and, 407, 410 Ridiculing exercises to try, 86–88 as a roadblock towards change, 72f Righting reflex agendas and, 179 change plan and, 431 exercises to try, 37–43 overview, 13–14, 441 512 Index Risks, 273 Roadblocks, 70–71, 72f, 81–82, 86–88 S Safety, 52–53 Scaling questions, 307, 310 Self-affirmation, 111, 122–123 See also Affirmations Self-efficacy, 477 Self-perception theory, 267–268, 275, 366 Shame exercises to try, 86–88 as a roadblock towards change, 72f Shifting focus exercises to try, 380–382, 383–384 sustain talk and discord and, 374 Siding with the negative strategy exercises to try, 380–382, 383–384 sustain talk and discord and, 363, 364–365, 374 Silence, 408–409 Small talk, 52 SOARS acronym change plan and, 437 exercises to try, 471 Social psychology principles, 122–123 Solution-focused therapy, 111 Solutions exercises to try, 86–88 as a roadblock towards change, 72f Spirit of motivational interviewing See MI spirit Strengths affirmations and, 111 exercises to try, 121, 129–134 Structuring statement, 175–176 See also Agenda mapping Subjects, difficult agendas and, 179–181, 183 exercises to try, 185–186, 195–204 information exchange and, 215–217 Suggestions exercises to try, 86–88 as a roadblock towards change, 72f Summaries See also Core skills; OARS+I acronym example of, 117–120 exercises to try, 121, 135–137, 395–404 overview, 16, 112–115 training in motivational interviewing and, 489–490 Surface level reflections See also Reflections; Reflective listening exercises to try, 82, 90–94, 259–264, 370, 375–376, 383–384 overview, 74–75, 75f, 77f, 78 sustain talk and discord and, 361, 366, 374 Sustain talk compared to change talk, 372 concept quiz regarding, 275–276, 365–367 example of, 277–280, 367–369 exercises to try, 37–43, 280–281, 283–286, 295–298, 369–371, 374–391, 415–419 overview, 256–257, 265–266, 272–273, 359–365 planning and, 407, 410 training in motivational interviewing and, 483, 489–490 Sympathizing exercises to try, 86–88 as a roadblock towards change, 72f T Targeting questions See Questioning Targeting reflections See Reflections Therapeutic alliance affirmations and, 110–111 change talk and, 268 engagement and, 52 information exchange and, 215 “Therapizing,” 74 Threats exercises to try, 86–88 as a roadblock towards change, 72f Timeline, future, 142 Topics, difficult agendas and, 179–181, 183 exercises to try, 185–186, 195–204 information exchange and, 215–217 Training in motivational interviewing See also Learning MI concept quiz regarding, 482–483 establishing an MI learning community and, 493–496 example of, 483–485 exercises to try, 485–491 overview, 4, 5, 9, 475–482, 486 Transition summaries See also Summaries exercises to try, 264, 420–424 overview, 112–113 planning and, 407–408, 410 Transparency, 173–174 Transtheoretical model, 12–13, 48 Trust, 52 U Understanding the client, 53 Understatement, 76 V Values concept quiz regarding, 143–144 difficult subjects and, 179–181 engagement and, 52 Index evocation and, 308–309 exercises to try, 55–59, 146, 147, 149–152, 159–160, 316, 358 overview, 138–140 Values card sort (VCS), 140, 159–160, 316 Video Assessment of Simulated Encounters— Revised (VASE-R), 122, 494 W Warnings exercises to try, 86–88 as a roadblock towards change, 72f Withdrawal exercises to try, 86–88 as a roadblock towards change, 72f 513 ... potential to make a change In summary, Miller and Rollnick (20 13) view preparatory language as the pro-change side of ambivalence and mobilizing language as movement toward a resolution of ambi valence... clear this area was a critical target if she was to succeed in a vocational process Here is an example of how agenda can unfold for both client and practitioner A focused discussion about maintaining... language (e.g., Apodaca et al., 20 16; Barnett, Spruijt- Metz, et al., 20 14; Bertholet, Faouzi, Gmel, Gaume, & Daeppen, 20 10; Borsari et al., 20 15; Glynn & Moyers, 20 10) If client language matters,