[Tiffany Albert]

Question 1
I found the physician’s use of MI to be very effective. He was open, non-judgmental and took an active interest in what the patient had to say. His use of skills allowed him to move the conversation into talk of acts of change rather quickly. Regarding what I would have done differently there were a few moments towards the end of the first video in which the physician directed the conversation towards what changes could be made (writing down each time the patient was smoking). Any suggestions I would have would be to elicit thoughts from the patient about what next steps might be helpful and to offer thoughts once the patient was agreeable to hear them.

Question 2
The physician’s use of MI strategies allowed the patient to identify that she wanted to quit smoking, why she wanted to quit and improve her belief in her own abilities to quit. This was primarily done through reflection, summarizing and open-ended questions that lead to develop discrepancy for the patient. As the patient continued to work with the physician and was able to identify that she wanted to quit smoking, she was given the encouragement and space to identify what might work for her. The more successful she became in completing the steps towards change, the more confident the patient became. Once the physician was then able to offer information about medication to support the process of change, the patient became additionally confident in her ability to quit successfully.

Question 3
The physician was quite skilled at using the skills of asking, listening, and informing. His use of asking and listening allowed the patient to identify discrepancy quickly and move towards change talk. The physician did engage in informing the patient of techniques that he has seen be beneficial and other forms of support to aid in quitting, but did so only when the patient seemed ready. The physician did not rush or push the patient into change. His use of these skills allowed the patient to feel heard and inevitably supported her plan for change as she began to build confidence.

Question 4
Throughout this course I have found myself utilizing the skills learned in daily sessions with patients. I work with teens and often there is ambivalence about different areas in their lives. I typically use a patient-centered focus, and this has reinforced that for me. I have found myself allowing the patient to lead more and asking for permission to offer information rather than just providing it and will continue to work on this. I believe that incorporating these skills will be greatly beneficial for many of my patients and I will continue to be mindful of how my interactions would most benefit those who are ambivalent about change.

[Tiffany Albert]

Question 1: My general reaction to the two videos is that the counselor did not fully understand the spirit of MI. The counselor often interrupted the patient, played the role of expert/educator most often rather than a collaborator and did not allow for space for the patient to process through their own ideas of change and what that would look like. The counselor’s use of MI was somewhat effective, as the patient did become less ambivalent about change, but I still felt that the patient did not fully commit to making said change. In the development of the change plan the patient still exhibited some hesitancy, which is likely the result of the counselor’s direction of change (“Hopefully that will lead you to going to an AA meeting”) rather than the patient exploring and identifying what he thinks will work for him.

Question 2: If I were in the role of counselor, I would have focused more on allowing the patient to express his own thoughts of change, encouraging him to share what changes he felt he could do, only offering advice/information if asked or with permission and allowing space for reflection without judgement. In the video the counselor seemed to have an agenda as he spoke over the patient, made statements about expectations (“So you can talk to that guy about AA. He will be helpful with that.”, and did not leave much room for the patient to come up with his own plan for change. In the role of counselor, once the patient identified what changes he would like to make, I would solidify a plan with him by summarizing his change talk and working with him to identify what tangible steps he can take to make these changes. The counselor in the video made a plan based on his own suggestions in addition to a few points the patient made. He also did not have a solid plan for follow up, wishing the patient good luck and then telling him to check in about how it went.

Question 3: Within the work that I do I have found that I already engage in some of the MI strategies and have been incorporating more since beginning this training. I work with teens who are often ambivalent about making changes in their lives (mental health treatment, drug use, behavioral changes, etc) and I have seen this strategy help a population that is struggling with a desire to be autonomous the opportunity to do just that. I find that when given a space to work through their own problems, without judgement, with their own direction leading the way, patients often make good choices for their lives and are more successful and stick to their decisions.

[Tiffany Albert]

Question 1: General Impressions
This video shows the gradual transition of a patient who does not recognize/acknowledge a need for change to someone who is not only open to change but recognizing the need to make change. Rounder is a more challenging patient to begin, not in session because he wants to be but because the court has put him there. The Spirit of MI allows a natural flow, opening the possibilities of change and what this might look like. It was an impressive process.

Question 2:
Examples of sustain talk:
1) “I don’t know what the hell she means I need help.”
2) “… the only reason I’m coming here is so I can maybe save my driver’s license, so I won’t lose my job and so I won’t lose my house. It’s not because I wasn’t to do any of this crap you know.”
3) “I drink a little bit but I work hard.”
Examples of change talk:
1) “I can do just about anything but I can’t say yes to that, that I can stop drinking” – this is an example of change step ability (DARN) where patient is unsure of his ability to be successful with change.
2) “I wouldn’t mind coming here to live…” – this is an example of desire (DARN) as pt is beginning to envision himself being a part of the program, suggesting desire for change
3) “If I don’t stop drinking I’m probably going to be right back in this mess again” – this is an example of reasons (DARN) as pt is beginning to identify why change may need to happen
Question 3:
Examples of interviewer’s use of complex reflective listening and strategic responses with impact:
1) “You’re not here because you think you have a problem. You’re here because they sent you.” – This reflection is at an important time. It shows that the psychologist is listening and recognizing what the patient is saying, without any judgement. Rounder begins to open up about how he feels about the situation and what has been going on.
2) “What do you think caused you to kind of become more… less angry and less violent” – this response encourages the idea of change, that Rounder has engaged in change previously.
Question 4:
Examples of readiness to change:
1) Rounder begins envisioning the possibility of being a part of the treatment facility – “I wouldn’t mind coming here to live…”
2) Rounder recognizes that drinking is having a negative impact on his life – “If I don’t stop drinking I’m probably going to be right back in this mess again.”
3) Rounder increases his questions about change, asking about his own ambivalence and whether or not this is normal.
Next steps: I would summarize the change talk that Rounder has begun, reiterating his statements about how he believes continued drinking will cause more challenges like this in the future and that he could see himself living at the facility. This would be an opportunity to offer/provide more information about the facility, answer questions about treatment and inquire from Rounder what he would like to see happen, how he would like to move forward for the next session.

[Tiffany Albert]

Question 1: The Spirit of MI and the confrontational styles provide a clear difference in response from Sal. The confrontational style elicits a defensive, resistant and overwhelmed response from Sal. He clearly becomes more focused on defending himself than looking at the potential for change. The Spirit of MI style, being client driven, provides an open dialogue that encourages Sal to express his thoughts and ambivalence about making changes. Sal responds to this approach by being more expressive of his emotions and thoughts, including his ideas of change (reducing smoking, reducing drinking to 3 drinks a night) rather than defending his behavior. The Spirit of MI style gives Sal space to share his ambivalence and move toward engaging in action on his own terms, calmly, without fear of judgement.

Question 2: The behavior I feel ambivalent about is waking up earlier in the morning during the work week.
Ambivalence statements:
1) “I’ll have to go to bed earlier and won’t be able to watch my tv shows”
2) “I’ll feel too tired all day if I get up too early”
3) “I don’t know that it will be worth it.”
Other side of ambivalence:
1) “Getting up earlier will mean I can get more done before work”
2) “If I get up early, I will have more time for my morning routine and not feel so rushed.”
3) “Getting up early will mean I can have more time to myself before the kids get up.”
Double sided reflections:
1) “You feel like you would have to miss out on your television shows in order to get enough sleep, but also feel like you will be more productive if you get the rest and get up earlier.”
2) “On the one hand you will be tired if you get up early, but you will also be able to take your time and not be rushed in getting ready”
3) “You are questioning if getting up will be beneficial to you but also are thinking that you may be able to have more self-care with time to yourself before the kids get up.”
By identifying the ambivalence and then reflecting on them, it encourages thinking about what is more important to me. Once I did the reflective listening responses it felt like a “duh” moment – why wouldn’t I want to make changes? The positives outweigh the negatives for change.

Question 3:
Consumer-generated target behaviors that may want to be discussed:
1) Less swearing
2) Not getting as many demerits at school
3) Not being bored
My own agenda:
1) Increasing exercise to improve self-image
2) Getting involved in activities
3) Reducing caffeine intake
Within the two lists there are some overlapping target behaviors, however the ones I identify are more specific, based in my own beliefs of what I think is best, and do not allow for choice from the client. This clearly shows a “righting reflex”, a desire to push the client in the direction of what I feel is the right thing to do. In order to avoid engaging in this behavior as the therapist, my focus should be on supporting the patient in identifying what he wants to address, allowing him to take the lead. The approach is best supported by open ended questions, affirmations, reflective listening and summarizing the information provided by the patient, not interjecting the personal views of the therapist. This would look like asking the patient what he would like to address, using open-ended questions to encourage expression of his views on what has worked/not worked, and summarizing the information provided (being sure that the patient agrees with the summary).

[Tiffany Albert]

Hello! My name is Tiffany and I’m a LCPC at PCHC providing therapy for kids in the Brewer School Based Health Center. I have worked with kids for many years in a variety of settings and I am hopeful that this course will help me with additional tools to support/encourage change for my patients.

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