Hey everyone, welcome back to part three of motivational interviewing and today we're going to be talking about the actual methodology of motivational interviewing itself. So this is going to be going through some of the more concrete steps of what's involved in taking someone through a motivational interviewing process. Here we go, we're off and running. Okay, so there's four processes in motivational interviewing. The first process we're going to talk about is engaging.

Engaging is the process where both parties establish a helpful connection and a working relationship. So this is the idea of engaging in that healthy relationship, creating that therapeutic relationship. The second aspect is focusing. So the process of engaging then leads to being focused on a particular agenda, what the person came to talk about, what the behaviour changes that we need to try and elicit.

The provider may also have an agenda, some of which might overlap with the client and some of which may not. One or more change goals may emerge and the focusing process helps us clarify on the direction. So this is about trying to clarify exactly what we're trying to change and collaboration between both people's perspective on that. Once we've done this, we're trying to evoke and elicit the patient's own motivation for change. So this is the next step we're trying to...

we talked about this before, bringing out within that patient their own motivation for change. Most simply put, evoking is having the person voice their arguments for change. So this is when that person is voicing that idea of change, these are the reasons why I think I should change. And once we've done that, planning.

Planning encompasses both the commitment to change and formulating a specific plan of action. So the first thing we're going to talk about is that engagement and the factors that influence. creating that engagement.

So desires or goals, creating the importance, finding out what are these things that are motivating to them, how important is it to create this change, trying to build positivity into it so that this is done through a positive sort of view, and also within that creating realistic expectations with a sense of hope that kind of evades the whole thing. So this is that idea that We're trying to engage with these ambivalent thoughts in a way that may elicit further change. So each of these factors should be attended to in the first visit when engagement is the goal. So this is our first visit where we're just looking to engage the idea of behavior change.

The clinician's point of view is that motivational interviewing is that collaborative conversational style. So it's collaborative, it's conversational. It's in a relaxed way we're exploring these ideas and the job, sorry, our approach is to try and strengthen a person's own motivation for change and then motive and strengthening their commitment to change.

The overall style of motivational interviewing, again we've talked about this, it's a guiding style that's in the middle of the continuum within psychology. So there's more of like a directing style on one side where the clinician or the therapist as directing where we need to go. There's a following style.

We're looking at following wherever the patient is willing to take you. And then there's a guiding style, which sits somewhere in between the two. And this is the idea that we're working as a team to try and guide them towards where the most useful answer might be. And they elicit the idea that a skillful guide is a good listener, but also is able to offer expertise when needed.

Motivational interviewing lives in that middle ground of styles between directing and following. and often incorporating elements of both but not doing too much of either. So this is that fine balancing act where you may have moments where you're following or even some moments perhaps when you are directing but most of the time it sits somewhere in a collaboration between the two. The next thing we're talking about is evoking. So this premise is that people, the premise that underlies evoking sorry, is that people already have within them much of what is needed.

And our job as a therapist is to evoke from them that kind of ability to create change. So our job is to try and call it forth. The message, the overarching message of evoking, sorry, is that you have what you need already in you basically.

And that together we're going to find this. We approach it by drawing out this evocation of this self-belief, this self-efficacy. The motivational interviewing perspective is that the belief that there was a deep well of wisdom and experience from that person.

from which within the counselor or the therapist or the clinician can draw motivational interviewing is a book is about evoking what is already present um not putting in or installing what is potentially thought to be missing so people who are ambivalent already have the pro-change argument within them right we've already you know you realize most people particularly like smoking just an easy example to kind of draw on if someone is a smoker they already have inside them the reasons why they should stop smoking and they have the motivation to create that change often as well if they're in this point and that behavior change so if they've got that already within themselves our job is to try and bring that out of them because again it's that idea that we can't tell them what's going to be right for their life there they know inherently what's right for their life themselves and our job is to bring that out of them rather than telling them what that is so our task then is to evoke and strengthen these change behaviors which are already present. So we're trying to evoke this idea of change talk and this idea of change talk encourages the patient or client to consider an alternative perspective on the problem. The intention is to transfer responsibility for arguing for change to the client by eliciting what is termed change talk.

So instead of us sitting here telling the patient why they should create this change, we elicit within the patient this ability to create this change talk within themselves. So, you know, they are literally getting into an argument with themselves where they're looking at both sides of the coin. These are overt declarations by the patient that demonstrate, or client, recognition of the need for change, concern for the current position, the intention to change, and then the belief that the change is possible.

All of these things, so that recognition... the concern that intention for change and the belief that change is possible is all considered change talk. Completing the arrow there, the evidence suggests that change talk is predictive of successful treatment outcomes and massively increases this.

So the more amount of change talk you can get out of your patients, the more likely they are to have a successful outcome. One little technique here that we're including is this idea of the use of rulers. So this is just a little technique that maybe increases your ability to create change talk within your patients.

And so it's the idea to ask about confidence and importance for change. Usually these scales can go from zero to ten and when they give you a number you can use these types of follow-up questions to reframe as change talk. So you feel you're a seven on confidence.

Why are you a 7 and not a 3? Asking why are you not a 10, as you might want to, which is kind of like this writing reflex, why are you not a 10, why are you doing things perfectly, would elicit sustained talk. So this is that idea that we're trying to create that positive reinforcement there. That's great that you've already achieved a 7, why are you not a 3, as opposed to that's interesting that you're a 7 and not a 10, why is that? So there's a couple of things that will give a way of highlighting to us that the person is creating change talk.

And they come into four categories. These are called the D.A.R.N.S. So it seems to be that as I was going through this motivational interviewing material, they really enjoy acronyms. And this is going to be another one. So we talked about P.A.C.E. and D.A.R.S. last time.

This time we're going to be talking about D.A.R.N.S. And a couple of other areas as well, actually. Okay. So. Each of these things reflect the pro side of ambivalence.

They are considered preparatory change talk because none of them alone altogether indicate that change is going to happen. But they are heading in the right direction. We can try and use evocative questions to try and elicit these.

How would you like your life to be different? This is the idea of trying to create these comments along this idea of darn. The first one is desire.

That's the D. How would you like your life to be different? How do you want your life to be different?

You've got a desire for some sort of change. Of these various options you have considered, what seems to be the most possible? How might you go about it in order to succeed?

This is the second aspect, trying to create the A, which is the ability. So it's looking at what would be the steps you need to take to actually make this change. Why would you want to get more exercise? Why would you want to make this change?

What are the three best reasons you could for you to do it? So this is again looking at the ah this is looking at the reasons. What are the reasons for why you want to create change? And the last one in Dhan is in need. How serious is this for you?

How important is it for you to make this change and why? So this is again looking at the importance and tapping into their inherent core values to see how important is this um this change to you. If we can do this this going to potentially then create more of this highlighting the ambivalence showing that yes this is something really important to me even though I'm doing something different a few other evoking a questions that could be useful that you might be able to use what concerns you the most about do you remember a time when things were going well for you one seems a little bit sad but it's that idea that You're looking to highlight to them maybe some of the behaviours that have created the situation that they're in.

If you did decide to make this change, what do you hope would be different in the future? Or suppose you didn't want to make any change, what do you think the future would hold? So again, looking at these ideas of consequences, looking at where you are now and where this may end up. So again, you're looking at these outcomes.

We explore broader goals and values, right? Some of the questions that might not be so useful, and these, I mean, these are not necessarily wrong questions, but things to avoid, and they could be ill-advised from a motivational interviewing perspective. Why haven't you changed?

What keeps you doing this? Why do you smoke? Why aren't you trying harder? Why can't you?

Right, so you can see that these things are very accusatory. This is very much in a way where you're really pushing something on someone. And that may be your values, pushing your values onto someone else's point of view. And this takes away from those things that we talked about, within the spirit of motivational interviewing, that idea of pace in particular, that we're not creating the self-efficacy and these feelings of looking at things from a compassionate, empathetic point of view, which can help build the patient up, because this is more about pushing the patient down and making them feel like perhaps...

there's more negative aspects of this behavior change which depowers them and takes away their ability to change. The second acronym that we're going to explore is this idea of CATS. So we've talked about DARN before.

Now we're going to be talking about mobilizing change talk. So the last one was preparatory change talk. This is more of that mobilizing. The CATS signal this movement to the therapist that there's been movement towards resolution of the ambivalence in favor of change.

So we've developed the ambivalence before, we've created some change talk with that idea of Darnes, now we're moving on to this idea of Katz where we're starting to try and identify is this person starting to say to me you know there are certain things that are really making me work towards the resolution of this ambivalence. The first one to see is commitment. This signals a like of action. So if you're hearing your patient say things like, I will, I promise, I guarantee, I intend to do A, B, C, D. I'm going to stop smoking.

I'm definitely promise I'm going to start doing exercise program. I guarantee that X, Y, Z. The second one is activation, movement toward, but not quite a commitment. I am willing to try.

I'm ready to, I am prepared to. So we're trying to create this sort of change talk within our patients. The T is taking steps.

The client has already done something in the direction of change. I bought nicotine patches. I didn't snack any evenings this week. I quit smoking inside my household car. These types of comments would make you recognize that this person is moving towards resolution of that ambivalence.

So this darn cat's language, we talked about the darn before and then the cats is the second aspect, the mobilize and change talk. This signals that the person is moving towards change. And a real positive thing if you start seeing these sorts of comments sitting alongside the behaviors we're trying to change.

So once we've heard this, we need to be able to respond to it. And you guessed it, we've got an acronym for that as well. So the acronym for this is OARS. So once we hear that there's been change talk, we need to be able to respond to it. So try and encourage either more change talk or more preparation or more moving towards change.

So once we've heard the sort of change talk, we try and use open ended questions. We ask for more detail or examples. Affirmations, commitment to a positive comment about what you heard.

Oh, that sounds really great. It sounds like you're doing exactly what we talked about. And that's a great achievement. Reflections.

These can be simple or complex. How did you feel when you made these changes? Getting the person to reflect more about this sort of change talk.

And then this idea of summaries, including the change talk content and summaries. You have said to me that you're looking at changing this behaviour and you're going to do it this way. and this is the steps that you've already taken. Is that right? What do you think about all these changes you've made?

You know, you can see that you're trying to just explore this change talk in more and more detail to elicit more change talk from the patient and then potentially behaviors as a result of that. The flip side of that that we see is this idea of sustained talk. So we talked about change talk.

Now we're looking at the conflicting thought, the sustained talk. We can also call this resistance to change. So this is a normal part of the change process and again it's due to that ambivalence because we've got this conflicting thought.

However it's not desirable and motivational interviewing to evoke and explore all of the patient's reasons or client's reasons for maintaining the status quo. It's not necessarily useful to continue to look at all the reasons why they should stay the same if that's the behaviour you are looking at trying to change. Motivational interviewing currently uses the term sustained talk to describe patient communication that indicates a desire, plan or commitment to stay the same. They may not want to make changes suggested to them and may argue strongly against making these changes. They may do a number of things which could indicate to you that they're not ready to make change and this is this idea of sustained talk.

If you're seeing much more sustained talk than change talk, you can understand where there's going to be not too much change. And our job, rather than to try and continually explore all the reasons why they're not doing something, because they're not doing it, they haven't made that change, let's explore some of the things of why you're considering or looking at creating that change. If we look at some clear examples of sustained talk, I don't have a problem, it's all a mistake. I don't drink any more alcohol than the judge does.

Maybe you've got an alcoholic judge, who knows? You people just aren't out to make money on this. You people just aren't out to make money on this. Oh, I see. My wife thinks everyone has a problem because her father is an alcoholic.

I know I need to cut down, but I can do it on my own. So there's a number of barriers that they might throw up towards that change talk. And particularly, this was taken from psychology work. Within physiotherapy, it might be a bit more specific.

to the sorts of problems that we're seeing. In motivational interviewing, sustained talk is not ignored. It's still within that spirit of acceptance.

It's reflected, it's respected, and included in the larger picture, but it's not really lingered on because we're looking to try and highlight that ambivalence. So to try and respond to sustained talk, one of the goals of motivational interviewing is to increase the amount of time the patient spends engage on that change talk, which is what we just talked about, and minimise the amount of time spent in the sustained talk because they're already sustaining that particular behaviour. Specific techniques have been shown to decrease resistance or sustained talk. Simple reflection, so reflecting back the information that they're giving you, or complex and advanced reflection.

So this is the idea of getting the patient to reflect back on the entire aspect of their ambivalent thoughts. Simple. A simple reflection mirrors or reflects back to the patient the content, feeling or meaning of his or her communication. An example of this might be that, you know, the patient says to you, I know I made a mistake, but the hoops they are getting me to jump through are just getting ridiculous.

OK, so maybe there's some sort of difficult situation that they feel like they're having to do a lot of things to keep someone happy. In this particular example, the clinician may say something along the lines of. reflecting back a simple reflection back to the patient you are pretty upset about all this it seems like everyone is overreacting to a mistake so basically just reflecting back this idea to them so that they feel like they have had their feelings acknowledged and accepted and viewed from an empathetic point of view not kind of shut down and pushed away but you can see that within this simple reflection it's not really amplifying it it's not looking at making it bigger it's just reflecting back what was already being said to enable that aspect of empathy and this idea of amplified reactions.

An amplified reaction takes what the patient has said and increases the intensity of sustained talk. When hearing an amplification, a patient or client will often reconsider what he or she said and clarify. So this is another technique that we can use when we're getting a lot of sustained talk given towards us. This is the example. So the patient says, I know I made a mistake, but the hoops that they're getting me to jump through are just getting ridiculous.

And then the patient, sorry, the clinician may amplify this, amplified reflection. You don't agree with any of what they are making you do. So you can see that the patient has said something that they're unhappy with. The clinician is taking that same concept and amplified it, made it bigger.

And then the patient responds with, no, no, I don't need to do some of the things to make this right. But I am frustrated with all these meetings. And you can see that what this means is that. in this situation anyway, the patient kind of clarified what they were looking at and has even de-escalated the situation a little bit and kind of focused on even more on the actual problem. The next technique is double-sided reflection.

So this is the attempt to reflect back both sides of the ambivalence that the client experiences so that the client can hear back both the sustain and the change talk in the same thing. And this is back. complex one that I was talking about before.

So the patient says something along the lines of, I know I made a mistake, but the hoops they are making me jump through are getting ridiculous. The clinician with a double-sided reflection may say something that reflects both sides of the coin. You made a mistake and it should make you feel badly about that. Sorry about this guys.

And it should. like you feel badly about this, but you also think that people are asking you to do too much. So on one side, in that mashed up sentence, there's the idea that the patient did make this mistake and potentially they feel badly about that. But you also, on the flip side of things, feel like people are asking you to do too much. These are just some simple techniques that people can use when they have a lot of the sustained talk coming back at them.

So all these things are reflecting back. but they're reflecting back in a particular way so that we start to explore more about the person's comments. So just to review for this session, we've talked about the idea of creating engagement with the patient, creating change talk, and then responding to that change talk.

And we talked about three key points there. We talked about the idea of DANS, which is this idea of preparatory change talk. We talked about CATS, which is that mobilizing change talk.

And we talked about OARS, and OARS was the idea of reflecting that change talk. Perfect. Thanks everyone and I'll see you in the next little module.