Instructor Responses to Week 1 Homework

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    Patricia Burke
    Keymaster

    Applications of Motivational Interviewing in Behavioral Health

    Week 1 Instructor Responses

    Thanks so much for doing the homework exercises and your extensive responses to the homework questions.

    1) What are your general reactions to the confrontational and Spirit of MI styles of the interviewing in the two videos? How does Sal respond to the confrontational style? How does he respond to the Spirit of MI style? Which of the two interviewing styles helps Sal move closer toward some kind of action to improve the management of his asthma? Why? Be specific.

    You all made some interesting observations regarding the difference in Sal’s reactions to the confrontational style of the first interview and the second interview, which was done in the Spirit of Motivational Interviewing. In the first video you noted that the provider was confrontational, dishonoring, non-validating, pushy, and judgmental. The provider also minimized Sal’s feelings.

    Some of your observations regarding Sal’s reactions to the service provider’s authoritarian stance included Sal becoming frustrated, agitated, defensive, argumentative, closed in non-verbal communication, less verbal, “resistant,” and automatically taking the opposite side from the provider,

    Many of you observed that in the second interview the service provider’s MI stance of being respectful, genuinely curious, empathetic, open to listening, and working collaboratively with Sal invited Sal to be more receptive, relaxed, calmer, engaged, and more willing to participate in the conversation. You also noticed that Sal leaned into the conversation and was more motivated to work toward his own health goals regarding managing his asthma. As Melissa noted, “The MI styles seemed to move Sal closer to the action stage. He was willing to discuss how he would wheeze when the dog laid down next to him. He seemed more willing to work with the provider to discover what was best for him and did not dismiss her ideas about his dog.” Charles commented that, “Sal took a closer look of the importance of taking his medication as prescribed and the potential impact it would have on his child.” Colleen noted that “he was more willing to explore options and to start problem solving his situation, for example he stated he plans to now weigh the pros and cons of the situation.” And Gigi noted,” He seems more relaxed and even excited about a plan.”

    The key to an effective MI approach to helping people change health risk behaviors is to engage people, first and foremost, in the Spirit of MI. This means taking the relational stance demonstrated in the second interview with Sal in which the service provider sees herself as a partner with Sal (not as an authority) in working together to help him move closer to making changes that are in alignment with his own health goals.

    2) Tell us the behavior you feel two ways about. Tell us the 3 statements of ambivalence as in my example. Share 3 examples of a double sided reflection of meaning or feeling using your expressions of ambivalence. Use “you” as if you were a provider offering reflective listening responses to you as the consumer. What are your general reactions to this exercise? What, if any, impact did the reflective listening responses have on your ambivalence? Be specific.

    Thanks for trying this exercise on double-sided reflections. I appreciate your honesty and openness to trying out this exercise. I think doing this for yourselves helps you understand how strong ambivalence about change can be for the people we work with and how important this exploration is.

    I have found double sided reflective listening responses are very important in helping people resolve ambivalence about changing health risk behaviors and engaging in behaviors that enhance well-being. As Melissa commented, “I found this to be an interesting exercise. I started off being very ambivalent about wanting to go out and walk. As I was doing the double reflections. I noticed myself becoming more encouraged to give it a try. I found myself playing with my schedule my head in order that I am able to incorporate exercise over the next few weeks. I even reminded myself of the time change that may help motivate me to exercise after work.” Betsey noted, “I found that after doing this, my ambivalence was largely resolved. As much as I may enjoy just sitting with clients, it would be far harder on me to spend my whole weekend doing notes. I’d be exhausted and have that much less to bring to the table, so to speak.” Charles remarked that after doing the exercise, “It got me to think about different ways to look at taking a walk in the woods. I realized that if I took a break (to meditate) in the middle of the walk, it would help to at least minimize feelings of physical discomfort, if not eliminate it completely, and I still achieve the spiritual, mental and physical benefits.” Colleen mentioned, “I found this exercise helpful in trying to come up with the wording for reflection statements instead of jumping to suggestions.” Danielle commented, “I found this exercise to be surprising and empowering. To look at a problem without judgment, just a choice to make. I could see how this could encourage change, which is often hard, even if it is a small change or in your own benefit.” Nichole wrote: “ I think it moved my ambivalence a little more toward thinking about what I can control and what I can change.”

    The key to an effective double-sided reflection is to end with the reflection that highlights the person’s movement toward change. So, it is very important to be mindful of how you offer the double-sided reflection. This emphasis on what is important to a person engages them in a values conversation. When we can engage people in conversations about their values, it invites them to rethink the ways that engaging in health risk behaviors is not consistent with their values and can have the effect of moving a person out of ambivalence, toward behavior change.

     One other tip I have found useful in offering double-sided reflections is to use the word “and” instead of the word “but” as the connector between the two sides of the reflection. Notice the difference in my example of a double-sided reflection to myself about brushing my teeth.  

     1) “Patricia, one the one hand you are tired at night but it can feel overwhelming to brush your teeth with all the other things you have to do to get ready for bed. On the other hand brushing your teeth fits into you overall plan for being healthy but being healthy is very important to you.”

     2) “Patricia, one the one hand you are tired at night and it can feel overwhelming to brush your teeth with all the other things you have to do to get ready for bed. On the other hand brushing your teeth fits into you overall plan for being healthy and being healthy is very important to you.”

    Using the word “but,” tends to minimize the second part of the statement. The word “and” tends to make the two sides more equal.

    Here are some other examples of double-sided reflections from your homework responses. Notice the difference in the reflection when the statement ends with movement toward change or reasons to continue the status quo and in the use of the word but or and.

    * Regular Exercise: “. . .on the one hand you work long shifts and you are not sure when exercise would fit into your schedule. On the other hand, you understand that regular exercise will help reduce stress and anxiety.”

    * Doing Documentation: “. . . on the one hand, you know that doing concurrent documentation is smart as it means you won’t fall behind on your paperwork and won’t have to think about it later. On the other hand, you feel like it takes away from your presence in session with clients.”

    * Avoiding Sweets: “. . . you really enjoy deserts, but you can see how eating them don’t support your health goals.

    * Finishing Clinical Notes: “. . . you’re expressing some ambivalence about getting your notes done daily and you indicated that you have a difficult time focusing by the end of the day. You are also expressing that you feel more accomplished and less stressed if you do them daily.”

    * Eating Sugar: “. . . on the one hand sugar is a reward you give yourself to feel happy. On the other sugar is not good for your health and your health is important to you.”

    * Walking: “. . . Walking is great for overall good health and it sounds like it is an important part of your day. You live in Maine. If poor weather contributes to dread and overall discomfort is getting out there everyday helpful or a hinderance to overall good health?

    * Regular Exercise: “. . .  I heard you say that you know that exercise always makes always makes you feel better in the long run, but it take a significant amount of motivation to get started.”

    *Drinking Diet Soda: “. . . on one hand you like the energy you get from the caffeine in your diet soda, but on the other hand you want to be a healthy role model for your students and your own children.”

    * Showering Everyday: “. . . on one hand you now good hygiene is the best every day to be healthy on the other hand you feel that it takes too much time to complete.”

    * Daily Exercise: “. . . It sounds like you want to create a space for you to relax and stay fit with your friends. It also sounds like it’s hard to commit because it can be expensive and you don’t like the way you feel when you are done exercising.”

    3) Respecting the confidentiality of the person you work with, tell us the 3-4 consumer-generated target behaviors that this consumer might be willing to discuss with you. Tell us 3-4 target behaviors on your own agenda. Describe any discrepancies between these two lists. Describe some of your “righting reflex” responses to the consumer-generated target behaviors that do not match up with your list of target behaviors? Describe how you might use the MI Agenda Setting strategy described in this lesson to engage this person in a person-centered conversation about what he or she would like to discuss with you. Be specific.

    It is clear from your homework responses to this exercise how important it can be to be aware of when our own agendas for behavior change are different than the client or consumer’s agenda for behavior change. It is through this awareness that we can begin to identify the places in the conversations where the “righting reflex” will show up most strongly. It is only then that we can practice refraining from jumping in to “fix” the client or consumer, take a deep breath and get back to the Spirit of MI, when we are in listening and reflecting mode.

    Here are some examples of the ways the “righting reflex” shows up for you when there is a discrepancy between your agenda and your client’s or consumer’s agenda for behavior change:

    * The righting reflex I participate in are the ones to encourage the client to take medication related to their seizures. This does not always line up with my clients desire to improve their quality of life or independence.

    * In terms of the righting reflex, I found I want to immediately problem-solve with her around these goals instead of looking at what is sustaining them.

    * I would like my client to live in a safe environment now, and my urge is to problem solve to make this so.

    *  I may be inclined to right the clients thinking by insistence that my agenda or preferences is the only way success can be achieved with past consequences of behaviors such as overeating, alcohol/drug abuse or domestic and legal issues.

    * I may be swayed to offer unsolicited advice such as attendance in peer-support groups, IOP’s, psychotherapy, or inpatient treatment.

    * Putting my goals first will only create confrontation.

    * With my “righting reflex” I want to show them how to set medication reminders on their phone and how to make sure they remember their doctors visits and allow enough time so that they aren’t late to their appointments (by using alarms on their phone and mapping their route in advance).

    Thank you for being so honest about your “righting reflex.” We all experience this knee jerk reaction to another’s suffering and we are trained in our culture of “quick fixes” and “following the expert’s advice” to jump in with our own ideas about what is best for others. However, in the Spirit of MI, our task is to notice the “righting reflex” when is shows up, take a deep breath, and return the focus of attention to the person who is seeking help and what his or her values, goals, hopes and dreams are. It is very much like a meditation. . . . notice the thoughts, take a deep breath, return to your point of focus . . .

    A number of you had great ideas for using the MI Agenda Setting strategy to help you shift the attention away from your own agenda to the client’s or consumer’s agenda. Here is a sampling of your responses:

    * I would start off by asking my client where they would like to begin. I may also have them list the topics that they wanted to make sure we discussed. . . I may ask them how much time the believe we should try to spend on each topic.

    * I would ask my client what she would like to be sure to focus on and take notes to ensure these are addressed in our time. I would use reflective listening to ensure I heard correctly and would ask client to start when ready. During the session, I would summarize periodically and be mindful of the time for client so that she got what she needed or ask if she wanted to stay on the topic she was as our time was running out.

    * I followed her lead during the assessment, but also asked for an ROI to communicate with her counselor about her current engagement in treatment.

    * My best course would be to listen to the client articulate his or her needs and what they think is the best course of action particular to their situation. If I wish to give advice, I should ask permission first.

    *  I would reflect to the client the two sides to their ambivalence. Once the client agrees that that is what they feel I would present the double-sided reflection. This gives the client a chance to see the possibility of change as a choice for them to make.

    *  I would start by asking them what goals they have and what ways they have imagined changing these. I would then reflect their answers and determine if there is any ambivalence present. Then we could move into exploring what stage of change they are in.

    * I would start by asking them what brings them to meet with me, and if other people told them they need to work on something specific, I would ask if that is a goal of theirs as well. If it was not, I would ask them what they would like to get out of our work together.

    * I like the idea of using the “dinner plate” example presented in the lesson and allow the client to choose and prioritize her own agenda.

    * I would provide structure and flexibility. If I already have some background info, I might generate a concept list or visual and ask client where they want to start while also indicating the client could talk about something else

    When we notice that our agenda doesn’t match the client’s agenda, it is important re-focus the conversation on a target behavior that the client is willing to focus on.

    I would like to make the distinction between holding a focus for the conversation and setting the agenda. As clinicians, keeping the conversations focused is one of our roles and it is where we have a certain expertise. At the same time, it is important for the client or consumer to set the specific agenda for the meeting, otherwise, we can get stuck in the kind of non-productive conversation that was demonstrated in the first video with Sal.

    Thanks again, to all of you for working so deeply with the ideas presented in the class by doing the homework exercises. I appreciate your thoughtful responses to the homework questions.

    In Class 2 we will explore Exploring Values, Building Discrepancy and Evoking Change Talk.

    ~Patricia

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