Instructor Responses to Week 3 Homework

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    Patricia Burke

    Applications of Motivational Interviewing in Behavioral Health 

    Week 3 Instructor Responses to the Homework

    Once again, I appreciate your efforts in reviewing the videos for this week’s lesson and your comprehensive responses to the homework questions.

    1) What are your general reactions to these two video role plays of a counselor using MI strategies to help a client develop a change plan to stop drinking? Overall, how effective is the counselor’s use of MI in evoking Commitment, Activation, and Taking Steps change talk? How effective is the counselor’s use of MI to help the client develop a specific change plan? Be specific.

    There were some mixed reactions in your comments about how the counselor engaged this client in the change planning process regarding his decision to stop drinking, however, the general consensus was that he was effective in helping the client develop a change plan (with specific steps to take) that was appropriate, accessible, and acceptable to the client. As Melissa commented, “Throughout the video, the counselor uses both simple reflection and complex reflection to help solidify the clients decision to stop drinking. He also provides the client with multiple options.” Colleen remarked, “My overall impression of the two videos is that the use of MI was noted, but spotty.” Betsey noted that, “The counselor seemed very comfortable rolling with the resistance that presented and kept a low energy level throughout the interviews.” Charles commented, “The counselor appeared to successfully utilize MI techniques, i.e. open-ended questions, simple and complex reflections, summaries and information after asking permission.” Jenai remarked, “Overall, I really saw the spirit of MI in these videos through the comradery that was formed between the client and the clinician. They were able to laugh and joke together throughout the conversation which I think lightened the mood and showed the true sense of support without diminishing the seriousness of the conversation and the need to change.”

    An interesting observation about the progression of the interview between the first and second video is that the first video is focused on DARN change talk and the second is more focused on CAT change talk, which leads to the development of a specific change plan. As Nichole commented, “The counselor was effective in evoking commitment, activation and change talk. Initially, the client started out with resistance to considering AA, particularly when he talked about not wanting to have anything to do with church. Then the client moved into activation and taking steps change talk by saying that he would call a friend to inquire further about AA. By the end of the second video, the client was considering next steps for engaging in counseling and was committed to steps to rid his home of alcohol and to begin the process of becoming involved in AA

    The counselor used a number of MI strategies effectively. For example, he asked Key Questions to elicit commitment talk from the client. Although there was some back and forth with the counselor about next steps, asking key questions reinforced the client’s commitment to change and indicated to the counselor that it would be appropriate to guide the conversation to the specifics of change planning. For example, Betsey wrote: “1st video-:22-Counselor stated, “So where do we go from here? What are the options?” He went on to say, “Where are we at?” Client seemed to respond well to this energizing, focused interviewing and went on to say what was motivating him and what he wanted to see happen.” And Jenai noted, “The clinicians focused questions lead to this. At 2:07 the clinician asked “So what do you want to do”. He then followed this up by saying that the plan can be refined and changed which was another way of giving the client control in the situation. . .”

    The counselor also used OARS effectively to move the conversation towards change, however, tended to jump into being more directive than guiding and offered ideas and information without eliciting permission from the client (except at the end of the second video). This had the effect, at times, of short circuiting client-generated strategies for change. As Diane mentioned, “The clinician did ask if the client had any ideas about what he might like to do, then answered his own question by offering three ideas that the client had already mentioned (staying away from bars, dancing, and church) and offered a solution of his own (AA meetings).”

    Overall, the counselor was very respectful of the client and used OARS to elicit change ideas from the client.

    Here are some of the ways you thought that counselor was not engaging in MI with the greatest efficacy:

    * My only concern was that the counselor appeared a little pushy.

    * the counselor asked a lot of closed-ended questions (more often than open-ended questions), he interrupted the client a few times, often did not ask permission before providing information (it was used some, but not as much as I would anticipate with the use of MI strategies) and he tended to use simple reflections over complex, reflective listening.

    * The counselor engaged in teaching that was not MI about AA. I was surprised how well it was tolerated.

    * Not sure if I would have discussed the “God” aspect of AA unless the client brought up concerns about God and the higher power part. Counselor seemed to offer that information unprompted.

    * The client identified that things need to change, but it seemed as though the development of a plan was primarily counselor driven, and not a lot of time went into resolving ambivalence.

    * After watching each of the videos a few times, it does not seem like a solid change plan was actually developed and I did not hear the client state his reasons for wanting to quit drinking.

    2) What, if anything, would you have done differently if you were the counselor in this role play? Would you have used different MI strategies for change planning? Which ones? Why? Be specific. If you would have used the same MI strategies, how would you improve on what the counselor in the video did? Why? Be specific?

    Here are some ways that you would have done things differently than the counselor:

    * I would’ve probably given the client more time to explore his options and for him to develop the list of ideas and steps he was going to take instead of the counselors appearing to push the list upon him.

    * I feel the counselor missed some opportunities to deepen the activation for change talk. For example: Counselor summarized and moved to planning talk before really identifying a strong commitment from the client. He went on to summarize stating “you’ve said you’re reasonably committed.” I’d want that to be stronger and have the client state it further and build upon his motivation for change. I’d work to elicit a stronger commitment by using scaling questions.

    *  I’d also ask some of the scaling questions to try to better understand what client was thinking about effectiveness and confidence around the options he was discussing.

    * One thing I would do different is, after soliciting permission to offer information, told the Client about other peer-support networks that are available like SMART Recovery, Life Ring, Refuge Recovery and area treatment center based Outpatient recovery groups.

    * There were occasions that the counselor used close ended questions and I think I might have used more open ended ones or reflections.

    *  I may have engaged the client in more action steps relating to these situations through using more information and reflections on what client may experience.

    * I  would have started with a summary of the reasons why the client wants to quit drinking, and then asked, “I’m wondering if you have any ideas about how what might work for you to accomplish your goal?” To the client’s response of “I don’t know”, I may have used skillful advice giving, asking permission to offer suggestions, offered to brain-storm for ideas, or offered the client a menu of choices, rather than a single idea.

    *  One strategy that I would utilize if I were the counselor include using a scale to elicit and reaffirm the commitment to better understand the willingness the client has for following through with his goals.

    * I think the only thing I would do differently is try to connect the clients change to his daughter more.

    * I would have allowed client to expand upon and own his solutions. Keep asking open-ended questions to keep the client talking and engaged. I would have provided info if client asked for the information first.

    Thanks for all of your reflections. It interesting that there is such diversity about how and where you each might focus your interview with this client. This is one of the great things about MI; it provides an overarching framework to shape conversations, but there are many ways to get to the same goal. . .enhancing client motivation to change a target behavior.

    Overall, I thought the counselor used MI strategies effectively to elicit commitment and to help the client develop an immediate change plan. If I were interviewing Pat I think I would have used elicit-provide-elicit to elicit more of his understanding of AA and how it might be helpful to him. The counselor tended to jump in with non-adherent talk around AA, trying to educate Pat instead of keeping Pat in the center of the conversation around this topic.

    There are times in the interview that the counselor says “good” and praises the client when the client makes a change statement. I want to make an important distinction between cheerleading and engaging in reflective listening. Judgments can be both negative and positive. While it is sometimes helpful to praise a client in a session, it is technically not reflective listening.

    3) How do you or would you envision using some of the MI strategies for change planning discussed in this lesson in your own work with consumers/clients/patients?

    Here are some of your creative ideas about how you might use MI strategies for change planning in your own work:

    * In future I may spend more time brainstorming different options with my client. I like the idea of eliciting from my clients the options and steps they could take to reach their goals.

    * I want to practice the flow of MI like a more natural conversation.

    * When working with an older teenaged client who is initially ambivalent about trying a new treatment or medication I may ask some open-ended questions and use reflective listening to help the client think about things in a different way.

    *  I particularly liked the chart of the desired change, with brainstorming options then rating them on effectiveness and confidence. I could see this as really helpful, maybe doing with client on a white board in session or have them write things down if working remotely.

    * This has reminded me how useful it has been to have the client tell me what to type out for them in patient instructions.

    *  I often have clients that are contemplating motivation to engage in exercise or healthier lifestyle choices. I use MI to move them forward in the process.

    * In my own work with students I can envision myself eliciting information before providing any. I also can see myself using their values as a way to increase motivation for change. I really like the confidence scaling question, as well, and I can see some ways that could be used in my daily practice.

    *  I also realize I use these tools quite often with participants of our program. Much of our program is around setting goals and making changes. When some are resistant, I talk with them and do a lot of listening and collective brainstorming once there seems to be some motivation and commitment on their part.

    * I think I have viewed treatment planning and change planning as being the same process and can now see the distinction. Moving forward I think that using the change planning strategies as a prerequisite would lead to better treatment planning and allow client’s to feel a sense of accomplishment earlier in the treatment process.

    * My favorite part of this lesson was around exploring confidence. As someone who works with youth, I think confidence and self-efficacy are really important factors as many of the resources the kids need are actually provided to them through our clinic or service.

    *  I liked the empowering part. . .Focusing is harder with the ever changing mind set of my clients and this can help me stay on tract and keep the client on track for change.

    * I need to remember to get the client to talk about goals and plans without input from me unless client asks for information or feedback. The client will feel more empowered if the plan is seen as formulated and implemented by the client.

    * With my clients I would utilize simple reflection and open-ending questions. I would discuss the actions steps to change but break them down as simple as possible.

    In Class 4 we will explore applications of MI in mental health, co-occurring disorders, and changing health risk behaviors in healthcare settings.


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