Instructor Responses to Week 4 Homework

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    Patricia Burke

    Applications of Motivational Interviewing in Behavioral Health 

    Week 4 Instructor Responses to the Homework

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

    1) What are your general reactions to the way the physician used MI to shape these brief conversations with his “patient?” What, if anything, would you have done differently? Why?

    Overall, the general consensus was that the physician engaged the patient in the Spirit of MI and used MI strategies effectively to shape the conversation in ways that help the patient resolve ambivalence, increase confidence, develop a change plan, and move toward her stated goal of quitting smoking. For example, Betsey wrote: “I’m impressed with how collaborative and respectful MI is. The physician was great in terms of summarizing, using OARS ways of communicating and used the scaling questions appropriately, even switching to percentages which was the language of the client, without missing a beat. He did a nice job exploring the reasons for wanting to smoke and reasons for wanting to quit.” Melissa commented, “I think he did a great job reflecting her thoughts and feelings, especially during the first video. He acknowledged that there were benefits to smoking and why she started. He was interested in her telling her story.”

    Some of you had some ideas about things you would have done differently or when the physician seemed to stray from the Spirit of MI.  Betsey commented, “I feel that he missed a crucial piece, which was the peer group element and feeling a sense of connection during smoke breaks. I wished he had reflected on this and explored how to meet this need in another way. He interrupted her once, which was not helpful.” Nichole remarked, “I think that he had more opportunities to use scaling questions, particularly in the second video. I would have used these to more fully understand how she was progressing through the process.” Colleen wrote: “There are two things I think I would have done differently, had I been the physician using MI with Jean. 1- I would have tried to spend a little more time with Jean working through eliciting ideas for why she was feeling so ambivalent about quitting in the beginning. 2- I would have asked her permission before providing information about options (such as the medications mentioned in the third video).

    I appreciated how the physician worked with her ambivalence about quitting which was related to her low confidence in her ability to quit. I would suggest that since she has not set a specific quit date and is looking at quitting in six months that that suggests the possibility that she does still have some ambivalence about quitting. Since the patient is initially still a bit ambivalent and she is low in confidence, it was important for the physician to engage her in a less challenging activity than jumping right into a plan to quit. Just because she says she wants to quit and needs to quit (DARN change Talk) doesn’t mean she is ready to quit now (i.e. she is not engaged in ACT change talk initially). This suggests to me that the ambivalence is still hanging around.

    I also think she is also anxious about trying to quit again after a number of attempts, however, I would suggest that she has low confidence about quitting and the physician used the confidence ruler and incremental steps to help boost confidence and self-efficacy. I think the physician did a good job of staying with her in the contemplation stage of the Stages of Change and not jumping into an action plan too quickly. It is a complex dance when a client is ready to change a risk behavior, but low on confidence.

    2) What are your thoughts on how the physician used MI to help this woman resolve her ambivalence about quitting, develop discrepancy, and increase her confidence about quitting? Which MI strategies were used to help her resolve ambivalence, develop discrepancy and increase confidence? Be specific.

     A number of you mentioned how the physician in the video helped the patient resolve ambivalence and discrepancy by exploring the pros and cons of smoking. For example, Charles commented, “He motivate the Pt. to do an informal cost benefit analysis, contemplate change despite lack of confidence, suggest “baby steps” to initiate change talk and a change plan, and committing to the change plan and a follow up one week later.”

    Evaluating the pros and cons of behavior change can bring to light a person’s ambivalence, but also, when spoken aloud, can help reinforce the reasons for change as well. The key is to allow the person time to tell the story of ambivalence (as the physician does in the video) and use reflective listening. When the physician reflects back to the patient her own understanding of “what’s good about smoking,” she feels heard and understood. When the physician reflects back her statements regarding the “not so good things about smoking,” she hears her own stated reasons for quitting spoken out loud one more time. This can have the impact of reinforcing change talk. It is most effective to explore the pros of smoking first, then the cons of smoking. If you reverse it, you will end up reinforcing the “good things” about smoking. Also, it is important to not spend too much time on the “good things” about smoking. This could lead to a conversation that reinforces the person’s sustain talk (i.e. reasons for not quitting.”

    The physician also used an importance scaling question to help the patient verbalize desire change talk and the confidence scaling question to not only assess confidence, but the follow-up questions help the patient identify what might help increase her confidence about quitting.  As Betsey noted, “The physician used scaling questions to identify why she wasn’t identifying a lower confidence level.” Melissa remarked, “He also used scaling questions and had her explain why she chose 35-45% confidence level. This helped her acknowledge that it was not at a 10-20%.” These follow-up questions are very important because they engage people in a conversation that actually helps enhance their confidence about behavior change.

    Colleen noted the MD’s effective use of double sided reflections to reduce ambivalence: “He also used double-sided statements about her ambivalence and checked with often to ensure he understood her thoughts and feelings about the situation. His use of MI techniques seemed to help Jean think about her options more, and she had already come up with some coping ideas and techniques to use before he suggested them.”

    The physician’s use of an incremental change plan was very effective in helping raise the patient’s confidence about eventually quitting completely. As Robert noted, “It helped having incremental goals such as reducing the number of cigarettes per day and writing a journal to help keep track of thoughts, amounts, and situations. Check-ins were also part of the plan to help with accountability. Client was proud of incremental successes that she made a commitment to cut back on the number of cigarettes smoked per week even further.” And Monica remarked, “The client seemed to gain more confidence over the course of the interview by breaking down the goal instead of seeing one big goal of completely cutting out cigarettes.” This is a key point. Success builds upon success as confidence increases.

    The doctor was always in tune with where Jean was in the stages of change and supported her to make small changes toward her stated goal of quitting smoking, instead of pushing her to quit completely. He listened to her carefully in the initial interview when she told him that she thought she might be able to quit in six months and shaped the conversation using OARS to support her to make small changes over time. So each of these small steps built a foundation for Jean to eventually reach her stated goal. By the third session Jean’s confidence has increased dramatically.

    3) Evaluate the physician’s efforts to adapt MI to a series of brief interventions in a primary care setting, focusing specifically on his use of Asking, Listening and Informing? Be specific. What are your thoughts on the “patient’s” reactions to his use of MI? Be specific.

     Overall, your evaluations of the physician’s efforts to adapt MI to a series of brief interventions were quite positive. For example, Nichole wrote: “The physician did well with adapting to a series of brief interventions. He did well to ask questions to understand where the patient was in the change process. He then listened to what the patient had to say about what she wanted to do and what would get in her way. Ultimately he guided her to choose her own steps and commit to the change process.” Jenai commented, “. . . the process of multiple checks in worked for this patient as she expressed she need support and someone to talk to. This format definitely benefited this client. With limited time the ask, listen, inform approach seems like a great fit.” Ruth remarked, “I liked how this PCP used complex reflections to help highlight her reasons for quitting as well as the ways that she had been successful (if even briefly) in the past.” Ruth wrote: “ . . the patient respond positively to his genuine praise/amplified reflection and she sounded much more confident and less scared by the third session. I also note that the second session was only 3min and yet he still accomplished a great deal with the pt.

    The physician’s overall guiding style demonstrates an effective use of Asking, Listening, and Informing. As Melissa noted, “In the first video, he appeared to do a lot of asking and listening which helped her tell her story. At the end, he informed her about the strategy of mindfulness and taking small steps towards her goal. The patient appeared to respond to these tactics very well.”

    I think that this series of short video clips demonstrates how MI can be adapted to a primary care setting, which was very different than the outpatient counseling setting in which the Rounder interview took place. As Diane commented, “What impressed me most was that this change occurred in a “brief” setting. The physican directed the conversation, which never seemed rushed or short, the intervention was person-centered, respected the woman’s autonomy, and used basic strategies of MI. The woman remained engaged and motivated throughout the process and reacted positively to the physician’s guidance.”  The physician used a nice balance of asking both open-ended questions to elicit the patient’s story of smoking and attempts at quitting and closed questions to elicit necessary information.

    I really appreciated his brief interventions, over time. This is key when working in healthcare settings or other settings where you don’t have the luxury of 45-55 minute counseling sessions. As Colleen noted, “I think he did a great job balancing the use of their limited time, with the use of MI techniques, while still using phrases to indicate that Jean was the one making the decisions and that it made sense that she was feeling the ways that she was. He didn’t really start providing her with much information about options to help Jean quit (such as medication) until the third video, which allowed Jean to brainstorm ideas and try to use what she felt would work best for her first.” The MI approach is very effective in both settings.

    In brief interviews, the key is to engage the person in the Spirit of MI, allow the person to set the agenda, then do the work on resolving ambivalence, developing discrepancy, eliciting change talk, and change planning in a series of brief interviews. I thought the physician was very effective in establishing rapport and supporting the patient to reach her stated goal. I think this is demonstrated by the shift in Jean’s demeanor over the three encounters. Initially she is anxious and has very low confidence. By the third session she is feeling more confident and has a sense of accomplishment regarding the changes she is making in her life.

    4) Take a moment to reflect on the course material over the past four weeks and the new insights you have gained about Motivational Interviewing and the specific MI skills you have developed. How do you envision bringing this new insight and these skills into your work with people who are considering changing health or health-risk behaviors?

     Here are some of your reflections on the course material and how you envision bringing MI into your work with others:

    * I have one client in particular, who is morbidly obese (300+ pounds) and desperate to make change at this time. I have begun to use MI more with her and she is responding well to it.

    * I am excited to start using this more mindfully in my practice as I am a huge believer in people’s ability to make changes and get healthier. It will be important to manage right reflexes.

    * It is apparent that it’s best to take a softer approach with a Ct. to effect behavioral change rather than expound on the consequences of the behavior that the Ct. has exhibited – and may or may not be open to changing.

    * I have learned that I do not consistently implement these strategies. Over the past few weeks, by being more mindful of their implementation, I have seen more movement with my clients.

    * I have thought back on the previous material and have found my self using the information that I have learned to show that I am showing empathy and active listening to better understand my clients needs.

    * I don’t think I learned anything necessarily new, but it definitely helped me refocus on the core components and expand my skill levels. I have already been more actively using this with my current clients and am noticing changes in motivation and commitment to the change process.

    * Going into this course I knew very little about MI. It was reassuring taking this class and realizing that there are many small ways I can bring the spirit of MI to my work. I never have more than 10 minutes with patients due to the nature of our clinic flow but with a few key techniques like Asking, Listening, and Informing, and with confidence and importance scales, I can build a better foundation for communicating with patients and leading them towards behavior change.

    * I think after taking this training I will continue to incorporate and increase the use of MI in the work that I do with clients. I think it has helped me find awareness that I am quick to use the “righting reflex”, out of a desire to help others, and having that awareness will help me use more pause and time for clients to consider things on their own.

    * I am taking with me the 1-10 scales, and the follow up question of why that number and not a lower number. I love that. I will also share with my colleagues the change plan worksheets, and the personal values card sort. We actually use a card sort with our participants about Money Habitudes.

    *  I recognize that I have become much more solution focused over the years and this has been a good reminder for me to slow down in my sessions. I recognize that at times I tend to not being the best listener, especially if the client is on probation or need DEEP services.

    * I have been finding that these skills come to mind more often and I can use them with more ease. I would like to figure out how to use them more successfully while doing an assessment in the time allotted. I find that I need to practice patience and sit with my own “righting response” and let the process work, though the pressure to stay on time pushes me to be more directive.

    * I don’t often work with clients for long periods of time and health risks are not usually the primary focus. That being said, I can see the benefit of using MI when trying to set goals both long and short term.

    * I do utilize and implement some of MI techniques such as reflective listening and open-ending questions. Watching the videos gave a better insight for me into MI and how it impacts the treatment.

    * I like the idea of focusing on goals and exploring options in a more collaborative and empowering way. Clients may be more receptive to change when it appears more attenable, concrete, and within their power.

    * This course has helped me increase my skills and I can see how MI can be combines with techniques like CBT and BA to help clients stay engaged and motivated to move forward. I also learned that MI is a skill that comes with practice, practice, practice.

    *This course has helped me to better communicate with my clients and help them to gain more independence and confidence with their treatment. Although my intention is always to help them, this course has helped me to take a step back and instead of just providing them with information taking the time to step back and see their thoughts.


    If you are interested in some strategies for incorporating MI into traditional mental health/substance misuse assessment procedures, here is a resource that describes steps for integrating MI conversations into formal assessment.

    Final Thoughts

    I am a big fan of the respectful, client-centered MI approach and I deeply appreciate how all of you engaged with the content of this course in ways that have enhanced your understanding of MI, the Spirit of MI, and specific strategies that MI employs to help people resolve their ambivalence about changing health risk behaviors. I also appreciate your intention and commitment to apply what you have learned to your own clinical practice. Thank you and keep up the good work!


    Michael Bean

    Thank you! I learned a lot….

    Michael Bean

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