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 skips of what's involved in taking someone through a motivational interviewing process here we go working off we're off and running okay so there's four processes and 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 it will end in a working relationship so this idea of engaging 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 behavior changes that we need to try to listen 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 to change so this is the next step which one we talked about this before bringing out within that patient their own motivation for change most simply put a voting as having the person voice their arguments for change so this is when that person is voicing that played you have changed what 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 original bar 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 pervades the whole thing so this is that idea that we're trying to engage with these ambivalent thoughts in a way that may elicit through the change so each of these factors should be attended to and the first visit when engagement is the goal so this is our first day that we were just looking to engage the idea of behavior change the clinicians point of view is their motivational interviewing is that collaborative conversational style right so it's collaborative it's conversational it's in a relaxed way we're exploring these ideas and the job sorry approach is to try and strengthen that person's own motivation to change and then load of and strengthening their commitment to change the overall style of motivational interviewing and game was talked about this it's a guiding style that's in the middle of the continuum within psychology so there's more like a directing style on one side where the clinician or the therapist is directing where we need to go there's a following style we're looking at following wherever the patient is going to take you and then there's a guiding star which 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 they elicit the idea that this skillful guide is a good listener but also able to offer expertise when needed motivational interviewing lives in that middle ground of styles between directing the 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's it's somewhere in a collaboration between the two the next thing we talk about is invoking so this premise is that people the premise that underlies of loking story 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 forth the message the overarching method of message of revoking sorry is that you have what you need already and you basically and that together we're going to find this we approach it by drawing out the Sandusky vocational this self-belief their self-efficacy the motivational interviewing perspective is that the belief that there is a deep well of wisdom and experience from that person from which within the counsel all the therapists all the clinician can draw motivational interviewing is about is about a VOC in what is already prison not putting in or install and what there's potential being thought to be missing so people who are ambivalent already have the pro change argument less than the right we've already you know you realize most people think we have 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 at this point and that behavior change so if they've got that already was new 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 they know and hearing what's life with your life themselves and our job is to bring that out of them rather than telling them what that us so our task needs to evoke and strengthen just these change behaviors which are already present so we're trying to evoke this idea of change talk and this like you have changed too it 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 quite eliciting worst hearing change talk so instead of us sitting here telling the patient why they should create this change we elicit within the patient disability to create this change talk within themselves so you know they they're literally getting into an argument with themselves where they're looking at both sides the of the coin these are over declarations by the patient they demonstrate or claim recognition of the needs of change concerns with a current physician the intention to change and then the belief of the change is possible all of these things so that recognition the concern that intention for change and the belief that change is possible there's all considered change talk completing the arrow via the evidence suggests that change talk is predictive of successful treatment outcomes it massively increases this so the more amount of changed what you can get out of your patients the more likely they are to have a successful outcome one of them technique here that we're including is this idea of the use of rollers 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 that change usually these scales can go from 0 to 10 and when they give you a number you can use these types of follow-up questions to refrain it's change them so you feel you're a Steven on confidence while your sim in another three asking why are you not a 10 as you might want to which is kind of like this waiting reflex why why you've got a team way doing things perfectly would elicit sustained walk so this is that idea that we're trying to create that positive reinforcement there you know that's great thing you've already achieved a 7 why you not a 3 as opposed to that's interesting that you're assuming I'm not a team 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 downs so it seems to be that as I'm going through this motivational interviewing material they really enjoy acronyms and this is going to be another one so we talked about pace endears last time this time we're going to be talking about and a couple of other areas as well actually okay so each of these things reflect the pro side of ambivalence they're considered preparatory changed because none of them alone or together indicate that change is going to happen but they are getting in the right direction we can try and use evocative questions to try and elicit these how would you like to your life to be different right this is the idea of trying to create these comments along this idea of done the first one is the desire that's the date how would you like your life to be different how do you want your life to be different if their 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 that in order to succeed this is the second s being trying to create the a which is the ability so it's looking at what would be the steps you need to take the action makes this change why would you want to get more exercise why would you want to make this change one of the three best reasons you could for you to do it so this is again looking at the arthas's looking at the reasons what are the reasons for why you want to create change and the last one 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 the air and hearing core values to see how important is this this change to you if we can do this this is 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 revoking a questions that could be useful you might be able to use what can send 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 were looking to highlight to them maybe some of the behaviors that have created the situation that they're in if you do decide to make this change and what do you hope 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 doesn't get where you are now and where this mean that so again you you're looking at these 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 engineering 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 were you really pushing something on someone and that maybe your values pushing your values on to someone else's point of view and this takes away from those things that we talked about literally the spirit of motivational interviewing that idea of pace in particular there 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 consequence of a specs of this behavior change which deep hours them and takes away their ability to change the second exocrine on that we're going to explore is this idea of cats so we've talked about Dan before now we're going to be talking about mobilizing change talk so the last month peremptory changed up this is more of them mobilizing the cat single this movement to the therapist that there's been a movement towards resolution of the imbalance and favor of change so we developed the ambivalence before we've created some change talk with their idea of dance now we're moving on to this idea of cats where we're starting to try and identify is this person and starting to say to me you know there are certain things that are really making me work towards the resolution of us in divorce the first one to see is commitment this signals a likelihood of action so if you're hearing your patients say things like I will I promise I guarantee I intend to do ABCD I you know I'm going to spot smoking I'm definitely promise I'm going to start to an exercise program I guarantee that XYZ the second one is activation movement toward but not quite the commitment I'm willing to try I'm ready to I am prepared to so we're trying to create the sort of change to us in our patients the T is taking steps the claim has already done something in the direction and change I bought nicotine patches I didn't snack it's evening sorry 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 on flat ambivalence so there's Dan Kent's language we talked about the Dan before and then the cats is the second aspect them to mobilize and change talk and 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 pause so we're once we hear that there's being changed 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 this sort of change till we try and use open-ended questions we ask for more detail or examples affirmations commitment a positive comment about what you hear 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 those changes getting the person to reflect more about this sort of change talk in this idea of summaries including the change to a plum team in summary you have said to me that you're looking at changing with this behavior 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 talking more and more detail to elicit more change talk to the patient and then potentially behaviour 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 walk I can also call this resistance to change so this is a normal part of the change process and again it's due to their loved ones because we've got this conflicting laws however it's not desirable and motivational interviewing to evoke and explore all of the patients and 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 shouldn't stay the same if that's the behavior you were looking at trying to change motivational interviewing currently uses the term sustained talk to describe patient communication then indicates a desire plan or commitment to stainless name 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 to look if you're seeing much more sustainable then change talk you can understand where the there's going to be not too much change in 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 treading that change if we look at something clear examples of sustained talk I don't have a problem that's all on a snake I don't drink any more alcohol then the judge does maybe you've got alcohol at judging those you people just aren't out to make money on this you people just hang out to make money on this no I said my wife thinks everyone has a problem because it's part your 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 to walk in and particularly this was taken from psychology work within physiotherapy it might be a bit more specific to the sort of problems that we're seeing in motivational interviewing sustained talk there's not ignored it's you know it's still watching 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 at to try and highlight that in Belize so to try and respond this is Dane talk one of the goals of motivation of using this to increase the amount of time the patience means engage and that changed although should what we just talked about and minimize the amount of time spent in the sustain tool because they're already sustaining that particular behavior specific techniques have been shown to decrease resistance or sustained or symbol reflection so reflection reflecting back the information that they're giving you or conflicts in advance reflection so this is the idea of getting the patient to reflect back on the entire aspect of their invisalign thoughts simple the simple reflection mirrors are a flicks back to the patient the contact 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're getting me to jump through are just getting ridiculous okay so maybe there's some sort of difficult situation they feel like they're having to do a lot of things to keep someone happy and this particular example the clinician may say something along the lines of reflecting back a simple reflection back to the patients 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 I mean 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 been said to enable that aspect of empathy then this idea of amplified reactions and amplified reaction takes what the patient said and in traces the intensity of sustained walk 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 hopes the beginning me to jump through are just getting or getting ridiculous and then the patient sorry the clinician may amplify this amplified reflection you don't agree with any of what they're 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 notice no I don't need to do some of the things to make this right but I am crushed better with all these meetings and you can see that what this means is that the in this situation anyway the patient couldn't clarify what they were looking at and has even de-escalated the situation a little bit and kind of focused an even more on the actual problem the next technique is double sided reflection so this is the attempter of slicked-back both sides of the ambivalence that the client experiences so that the client can hear back both the sustained and the change talking the same thing this is that 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're making me jump through are getting ridiculous the clinician was a double-sided reflection may say something that reflects on both sides of the coin you made a mistake and it should and it shouldn't like 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 asking you to do too much so on the on one side then that mashed up sentence there's the idea that the patient did make this mistake and you know 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 have a lot of the sustain to what coming back at them so all these things are reflecting back but they were slinking 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 that we talked about the idea of Don's which is these this idea of preparatory change talk we talked about cats which is that mobilizing change talked and we talked about ORS and always was the idea of of reflecting that challenged walk perfect thanks everyone and I'll see you in the next little module