Instructor Responses to Week 2 Homework

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    Patricia Burke
    Keymaster

    Applications of Motivational Interviewing in Behavioral Health

    Week 2 Instructor Responses to the Homework

    Again, I appreciate your efforts in grappling with the homework exercises and your thoughtful responses to the homework questions.

    1) What are your general impressions of and reactions to the MI interview of Terry Moyers and “The Rounder?”

    Most of you had a favorable impression of Terry Moyer’s MI approach with Rounder and observed that she, first and foremost, engaged him in the Spirit of MI in a respectful, non-judgmental, non-threatening, non-confrontational manner that facilitated the building of rapport and trust, established a collaborative partnership, and helped Jim move toward change. For example, Ruth wrote: “The session felt fluid in how it unfolded, from resistance to willingness to consider addressing his drinking. I like how she was able to roll with the resistance. . .” Danielle mentioned, “I watched it a few times and the conversation about his issues with blond hair and her having blond hair the same as his probation officer. Asking him to tell her more instead of being defensive or offended, keeps him engaged and talking. I could see how effective this was and how it could easily have gone in a bad direction otherwise.” Terrific observations and reflections on Terry’s MI approach with Rounder. Colleen commented, “The interviewer took a patient approach and validated what Jim was expressing about his lack of desire to be involved in treatment. . . I think she created a comfortable space for him to voice his opinions and to provide feedback.” Monica remarked, “Terry was able to help meet him where he is and provide an understanding of his concerns and thoughts. This helped to gain rapport and build trust between Terry and Jim to move forward with finding his goals and how to achieve them.” Gigi commented, “She does a beautiful job of building trust and turning the conversation around. I love the scale of 1 to 10 method, and using the scale to ask why he didn’t pick a lower number. Brilliant.” Jennifer wrote: “The video was interesting to watch how Jim transformed from ambivalence with his drinking and treatment to willingness and acceptance. The interviewer used open ended questions and reflective listening which was effective with Jim . . .”

    I was impressed with how respectful Terry was and that before giving feedback or information she waited until Rounder indicated that he wanted it or she asked permission. Terry also used strategic and reflective responses to Rounder’s sustain talk that kept the conversation moving forward instead of getting stuck or reacting to Rounder’s anger. As Melissa noted, “Terry was able to help him shift his language from sustained speech to change speech.”

    Terry kept bringing the focus back to Rounder in a respectful and non-judging way that also emphasized his autonomy. As Kristine noted, “Terri didn’t make promises and she kept bringing things back to him, how the results would vary according to what Jim is willing to do and what changes he is willing to make.” And Carol commented, “Terry did not make any promises but stated to Jim that this was his decision on how he wanted to help him self as well as giving feedback to his statements and concerns of how he was going to address his situation.”

    I was also struck with Terry’s skillful use of the strategic strategy of emphasizing personal autonomy with Rounder. This can be a very helpful MI strategy when working with people who are mandated to treatment or feel like they are being pushed into it by family or friends. As Ruth commented, “Each one of her responses supports him in moving towards change, creating an environment where he can put his own thoughts and intentions together to make this plan rather than being told he must.” Emphasizing personal choice, can help people remember that they are still in charge of their own lives, and yet, there are consequences to the choices they make.

     I was also impressed with Terry’s ability to focus on Rounder’s point of view, without agreeing with him and her skillful refraining from the “Righting Reflex.” There were a number of times, early in the video that I felt my own impulse to jump in and say, “Yeah, but . . .” and offer unsolicited advice. But Terry stayed close to Rounder’s experience and didn’t let her possible discomfort with his initial anger and sustain talk divert her attention.

    2) Give two or three examples of “Rounder’s” Sustain Talk and two or three examples of “Rounder’s” Change Talk and identify if it is a Desire, Ability, Reason, Need or Commitment, Activation, or Taking Steps type of Change Talk. Give two or three examples of the interviewer’s use of complex reflective listening and strategic responses to “Rounder’s” Sustain Talk. What impact does the interviewer’s use of complex reflective listening and strategic responses have on “Rounder’s” Sustain Talk and Change Talk? Be specific and elaborate.

     You all did a great job of identifying the different expressions of Rounder’s ambivalence as exemplified by his sustain talk. You also made note of some of the key examples of Terry’s responses to that sustain talk and how they moved the conversation toward change talk. Here are some of examples of Rounder’s sustain talk, change talk, and Terry’s strategic and reflective listening responses during the interview.

    Rounder’s Sustain Talk Terry’s Reflective Responses Terry’s Strategic Responses
    I’m not real happy about being here I hear you really don’t want to be here. (Amplified Reflection) You’re not here because you think you have a problem, you’re here because they sent you here….and that’s the only reason you are here. (Coming Alongside)
    And I’m about up to here with this kind of stuff.

     

    You’re pretty fed up. (Feeling Reflection)

     

    I don’t understand why my daughter thinks I need help.

     

    It’s kind of a mystery to you why your daughter would think that. (Meaning Reflection)
    She doesn’t want me to drink when I see the grandkids. I would never drive them around if I’d been drinking. So she’s afraid that if you take the children with you that you’ll be drinking and then you might hurt them or get in an accident. So the fact that your daughter won’t even take your word for the fact that you won’t drink kind of bites at you a little bit. (Feeling and Meaning Refection about a family member’s concern.)

     

    Well, I’m kind of an uptight guy. I have a hard job. I work around a lot of old boys that are pretty rough and tumble. I drive a long ways and I unload big trucks. I get tired sometimes. I like to sit down and have a drink.

     

    So drinking kind of helps you relax and, you know, cope with your life. (Feeling and Meaning Reflection)

     

    And he says, “You’ve got a drinking problem.”  Hell, you know I’ve had to take him home a lot of times, that I’ve been the one standing and he has been passed out and couldn’t walk. It doesn’t make sense.  None of this makes sense.

     

    So it’s confusing to you why your drinking should cause a problem or everybody should be talking about that when you look around and you see that other people drink more than you do. (Feeling Reflection)

     

    So, it’s kind of the same thing you were saying before which is that it feels like everybody’s looking at your drinking but it’s just not as bad as everybody thinks it is. ” (Coming Alongside & Amplified Reflection)

     

    People keep saying that I need to stop drinking and I aint’ never done that either. It almost sounds like you don’t even know whether you could stop even if you wanted to. (Agreement with a Twist)

     

    Everyone is telling me I have to stop drinking. So, it’s kind of the same thing you were saying before which is that it feels like everybody’s looking at your drinking but it’s just not as bad as everybody thinks it. (Amplified Reflection) Since you’ve been forced to come here and since you’re feeling like everyone’s kind of pecking on you like a crow, there’s a bunch of crows flying around pecking on you about this thing about your drinking… What would you like to do with the time that you spend with me here? What would be helpful for you? (Emphasizing Personal Autonomy)

     

     

    Yeah and I don’t know how they’d [friends] feel about me quitting drinking.  I don’t what they’d call me What would that be like for you?  If you didn’t drink and you were around them? (Looking Forward)

     

    But, boy I tell you what, I’m sure not really looking forward to any of this. So you kind of feel two ways about it. On the one hand, you know, you think you’d like to have a change and you’d like to quit drinking. On the other hand you think you kind of dread it.  (Double Sided Reflection)

     

     

     

     

     

    Change Talk DARN-CAT Terry’s Responses
    I want something to help me in court.

     

    Desire

     

    I think I could. I’ve tried a couple of times and I wasn’t very… I think one time I quit for a week or two just to show people I could stop drinking.

     

    Ability

     

    You were successful in changing your habits for short periods in the past (Simple Reflection to enhance confidence)

     

    I did something about the fighting thing. I just didn’t go to the bars no more.

     

    Ability

     

    You were successful in changing that in the past and sounds like you’d kind of like to be successful changing this. (Simple reflection to enhance confidence and emphasize ability)

     

    My daughter. . .won’t let me see the kids. . . afraid I’ll take them around drinking and driving.

     

    Reason

     

    It got pretty costly doing that . . . it got a little bit costly, I got a bad name in town, thinks like that

     

    Reason

     

    The only reason I’m coming here is so maybe I can save my driver’s license and my job.

     

    Reason

     

    If I don’t stop drinking I’m probably going to be right back in this mess again.

     

     

    Need

     

     

    If I can save my house and my job I’d better do something that’s gonna keep me from doing this again, don’t you think?

     

    Need

     

    As long as I’m putting all this money into it I’d like to come out with something

     

    Activation

     

    I wouldn’t mind coming here to live.

     

    Activation

     

    How long do you think I’d be here?

     

    Activation

     

    Do you think I would have to come here and live?

     

    Activation

     

    . . .you’re the one that really needs to make that decision   about what’s the right kind of treatment for you.                  (Emphasizing Personal Autonomy)

     

    Cause, if I get out of this, if I can save my house and my job I’d better do something that’s gonna keep me from doing this again, don’t you think?

     

    Activation

     

     

    It’s time for you to really get serious about this.

     

    Terry’s skillful use of open-ended questions, reflective listening and strategic responses to Rounder’s sustain talk facilitated his own movement from pre-contemplation and anger, to contemplation of his need to do something about his drinking. He shifted from being closed, to being open and his motivation to change came to the forefront.

    He moved up the mountain of ambivalence and was at the top, expressing activation change talk and the possibility of taking steps toward change. By the end of the brief session, Rounder is beginning to reflect on the possibility that he might need to do something about his drinking otherwise he realizes that he will likely be back in the same or similar situation again. Terry’s response to Rounder’s change talk is a combination of skillful complex reflective listening response of feelings and a strategic response (Looking Forward): “It sounds like if you look ahead and take a look at your drinking and where you are going with this you are worried.” This is the first time in the session that Rounder touches into his own desire to do something about his drinking, instead of simply reacting angrily to others’ concerns or the outside authority’s demands that he do something about his drinking. And although he has not yet made a commitment to change, he appears to be getting ready. This is a key moment in the conversation that happens because of Terry’s skillful use of MI strategies.

    3) Give two or three examples of “Rounder’s” signs of readiness to change. If you were interviewing “Rounder” and you noticed these signs of readiness to change what would your next step be in this interview? Be specific and elaborate.

    Here are some examples of the signs of Rounder’s readiness to change:

    Resolve

     * “I wouldn’t mind doing some of this stuff if there was anything in it for me.”

    * “If I don’t stop drinking, I will probably end up in this mess again.”

    *”Yeah. Cause, if I get out of this, if I can save my house and my job I’d better do something that’s gonna keep me from doing this again, don’t you think?”

     Sustain talk decreases and change talk increases

    * “Well, I want something that will help me with court”.

    * “I wouldn’t mind coming here to live, but I wouldn’t want to be in one of those places where you sit around in pajamas a bunch of longhaired hippie types crying and bitching and stuff like that.”

    * “As long as I’m putting all this money into it I’d like to come out with something.”

    * “there’s a lot of things I can do, but I’ve never tried to stop drinking, I get thinking about it, honestly.”

    * “I think I could stop drinking.”

     Increased questions about change

    * “This treatment center thing—is that here at this facility? . . . And what do ya’ll do?”

    * “You said people come here to live, do you think I would have to come here and live?” *”How long do you think I would have to be here?”

    * “Is there anything maybe you guys can do maybe about me keeping my license and all that?”

    One of the things that I noticed in the video that was not a verbal expression of readiness to change, was that toward the end, Rounder seemed to get more relaxed. His anger subsided and his non-verbal cues indicated that he was coming to more of a place of resolve rather that resignation. I also observed that Rounder started expressing activation change talk and some other clear signs of readiness to change.

    Here are some of your comments regarding the next steps you would take if you were interviewing Rounder:

    *  I would begin to ask questions and use reflective listening skills to help him continue on the path of deciding to move in and begin the process. I would start talking about different steps he could take. . .  I would also try and help him verbalize that he is ready to take the necessary steps.

    * Jim says: “…the only reason I’m coming here is to maybe same my license so I won’t lose my job and lose my house.” I would run with this for starters – keeping him motivated to do what he had to do the save his license, job and house.

    * I would work towards getting more clarification about what he was looking for from a program and ask if I could explain further about what the treatment center has for programs, together looking for a match.

    * I would look for opportunities to validate that it’s his choice to enter treatment/make changes and support a verbalization to committing to give treatment a try.

    * Once he expressed an intention to change, I would ask him to express his commitment to change to me and someone else in his life like his daughter or wife.

    *  I would continue the conversation and ask him if he would like more information about treatment options. I might also ask him to elaborate on what some of the positive outcomes he might experience if he were to quit drinking. I might ask him what steps he would be willing to take within the next day, week or month towards and action plan for change.

    * I would start talking about what some of his goals are; having a better relationship with his family, being a better worker, keeping his independence, etc. I would ask him how he thinks he could reach these goals and provide him with a direction on how we could help him get to these goals.

    * My next step would be to ask him to measure where he is at on a scale of 1 to 10 with regard to his readiness, ask what puts him there, and try to find out either what step he is ready to take if his response is indicative of being at that stage, and if not, I would ask what he thinks would increase his readiness.

    * Jim says,” As long as I’m putting all this money into it I’d like to come out with something. You’d like to get something for your money, huh?” At this point, I would talk about value of money and commitment since finances appear to be important to client.

    My next step would be to summarize what we had discussed, being careful to mostly emphasize his change talk and his own concerns about his drinking and then ask a key question, like “What do you think you’d like to do next?” or “Where would you like to go from here?” Although, he is still expressing some ambivalence about stopping drinking, he has become clearer about his reasons for change. I think that the biggest stumbling block for Rounder as he moves forward is not that he would not be motivated to stop drinking, but that he is low on the confidence scale about his ability to stop. This is where I would want to explore more with him about how he was able to stop the bar room brawling and how he might apply his knowledge and skills in that area to stopping drinking.

    Thanks for your thoughtful comments and reflections on the Rounder video. It is one of the classic examples of how to apply MI to helping someone who is very ambivalent (not resistant!) About changing a health risk behavior.

    In Class 3 we will explore change planning and giving advice skillfully.

     

    ~Patricia

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