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BEGIN TRANSCRIPT:

LAURA GALBREATH: Good afternoon everyone and welcome to the SAMHSA-HRSA Center for Integrated Health Solutions’ final webinar in our motivational interviewing series. My name is Laura Galbreath, Director of the SAMHSA-HRSA Center for Integration Health Solutions, here at the National Council for Community Behavioral Healthcare, and I will serve as your moderator for today’s webinar. As you may know the SAMHSA-HRSA Center for Integrated Health Solutions, the IHS, promotes the development of integrated primary and behavioral healthcare services to better address the needs of individuals with mental illness and substance use conditions, whether they’re seen in behavioral health or primary care provider settings. In addition to national webinars designed to provide providers integrated care, the center is continuously posting practical tools and resources to the CIHS website, providing direct phone consultation to providers and stakeholders groups, in working with SAMHSA, primary and behavioral healthcare integration grantees, as well as HRSA funded health centers. [0:01:02.2]

Your presenter for today’s webinar is Jeremy Evenden, consultant and trainer for the Center for Evidence Based Practices at Case Western Reserve University in Cleveland, Ohio. In this position, he provides integrated dual disorder treatment and motivational interviewing consulting and education. He’s also an adjunct professor at the Mandel School of Applied Social Sciences, where he teaches motivational interviewing. Prior to joining Case Western, he worked in community mental health as a case manager, therapist and clinical supervisor. In this capacity, he obtained experience implementing integrated dual disorder treatment, motivational interviewing, supportive employment and dialectic behavioral therapy. The center promotes knowledge development - the Case Western Center promotes knowledge, development and implementation of evidence based practices for the treatment and recovery of people diagnosed with mental illness and co-occurring mental illness and substance use disorders. [0:01:58.7]

We’re very happy to welcome Jeremy today and before we get started and turn this over to him, I just want to give you a few housekeeping tips. Today’s webinar is being recorded and that all participants are in a listen only mode. You can find the call-in number for the webinar on the right-hand side of the screen. Questions may be submitted throughout the webinar by typing your

______0d169c6072783d120840b4b273d8111c.doc Page 1 of 21 question into the dialogue box and sending it to the organizer. We’ll answer as many questions as time allows. This has been a very popular series and we anticipate that we’ll hit our maximum capacity of 1,001 participants. The slides for today are already posted on the center’s website, at integration.samhsa.gov. Go to the webinar section and you’ll find the slides posted there for you if you’d like to access them before we get started. Lastly, please take a moment to provide your feedback by completing a brief survey at the end of today’s webinar. We use all of your feedback to inform future CIHS webinar and other content needs. With that, I’ll turn it over to Jeremy to get us started on today’s webinar on motivational interviewing for behavioral healthcare settings. [0:03:08.6]

JEREMY EVENDEN: Good afternoon everybody. I’m pleased to be with you again. I spent some time with you on the first webinar, for those of you who were able to join us for that. My colleague Debra, spent some time with you talking about strategies to promote change in primary care settings in our last webinar, and now we’re going to talk about how this applies to behavioral healthcare settings. Appreciate SAMHSA and the national council and all those involved in allowing us to do these webinars and talk a little about these approaches that will help you engage and improve discussions about change related - improve change related discussions rather. [0:04:04.9]

Here’s some learning objectives for today. I want to just go back over, for those of you who might not have been on the first two webinars. Remember, our purpose would be just to make sure that everybody walks away with something, whether you’ve been on all of the webinars or just a few or none of them. We want you to be able to walk away with some important information about motivational interviewing and helping people change. In this first objective, we’ll go over some of the core aspects that we talked about in the first webinar, just to get everybody up to page with some of the foundational aspects of motivational interviewing. And then we’ll work to identify and apply strategies to engage people in discussions about behavior change. Much of that has to do with being able to recognize when somebody is talking about making a change and what that sounds like when we begin to hear it, and then also being able to elicit more of it and continue to develop the motivation, the energy towards making a change for the person. [0:05:19.9]

So you remember from the first two webinars, a few key points that we talked about in relation to engaging people in a conversation about change. The first one is to just make it a conversation. It shouldn’t sound like a therapeutic technique or a therapeutic intervention when you’re engaging people in these discussions. It really should just be a conversation between two people. There’s a little bit of skill level that goes into this and practice that goes into making it sound more like a conversation when you’re learning these skills, but one of the things that really helps with that is to listen to the person. Listen to what they have to say, rather than just jumping in with our goals, our objectives, what we want the person to achieve. Spending some time listening to them and then being able to communicate understanding back to them, that we understand where they’re coming from, their perspective, what they view as important. And we do this through reflective listening. Remember, if you were on the earlier webinars, we talked about reflective listening; either saying back to the person what they have just said to reiterate that we’re with them or to go deeper into how they’re feeling or the meaning behind what they’re saying, all communicates understanding. When we communicate understanding, then the person

______0d169c6072783d120840b4b273d8111c.doc Page 2 of 21 tends to trust us a little bit more, they open up a little bit more, and we’re able to have a collaborative relationship. [0:07:04.4]

We always want to convey hope and optimism when we’re interacting with folks that we serve. Many times people will come in you know, multiple times into our agency with very similar problems and even if we worked with this person multiple times before and it seems like the situation is always the same when they come in, you really need to work hard to maintain hope and optimism that this person can recover. I’m sure many of you, as well as myself, have been surprised at people that we thought couldn’t recover, would never recover, and in fact they do make changes in their lives. We never want to discount somebody. We always want to believe that they can move forward and change, and that goes even if the person has lost all hope and optimism themselves that they can change. It’s really important that we as helping professionals, staff at agency, maintain hope and optimism that this person will recover. Research will bear that out. There’s quite a few studies, quite a bit of evidence out there to show that just maintaining optimism with a person can have an effect on outcomes in the treatment process. [0:08:27.4]

A few more things here in review. We talked about guiding more than directing. Our gut reaction many times when we identify the problem is to jump in after the problem and begin to try and solve it, and tell the person what to do to solve it. We want to kind of hold back the reins on ourselves a little bit when we feel that gut reaction coming up, and instead of directing being our go to, telling the person what to do, we want our go to strategy to be more guiding, collaborating with the person, asking some questions and learning about their perspective first, before we move into finding some solutions together with them. So helping them move along and always maintaining control in their corner, putting them in the drivers seat. [0:09:20.3]

When we do share information, we want to ask permission in order to maintain that autonomy, and we also want to share small amounts of information at a time. Debra talked a little bit about this in webinar two. We don’t want to overload the person with everything that we know about mental illness, their particular mental illness, or everything that we know about substance use disorder and how those affect people. We really want to share little bits of information, check in with the person, see whether they find that that applies to their situation and their understanding of that information, so then you don’t overwhelm them. When people get overwhelmed, they stop listening, and so sharing large amounts of information isn’t particularly effective in helping the person come to the change. [0:10:17.3]

Always want to respect autonomy. When we start taking over and directing, very often we get into a tug of war with the person and they start fighting to regain control and that demonstrates itself in terms of resistance or a pushback to regain control over their own lives. So we always want to either say outright that we respect that they have control over their own lives and that they get to choose whether they change or not, or show that through our mannerisms, with how we interact with them. And finally in review, we want to promote rapport and reduce resistance at all times. We’re continually trying to maintain a relationship with the person; that’s the primary and most important goal when we’re engaging folks in thinking about change, is having that connection, having that relationship. If that’s not there, then it’s very likely that change will not occur and it’s also very likely that you will miss the opportunities to help them change. And so again, maintaining that relationship. We want to reduce the amount of problems that we have

______0d169c6072783d120840b4b273d8111c.doc Page 3 of 21 in the relationship, otherwise known as resistance, this fighting between two individuals to gain control over the situation. We want to reduce that as much as possible, because that will predict - the more resistance that we are seeing, that will actually predict the person not changing this area of their lives, which is pretty critical. [0:11:56.5]

I wanted to talk to you about an article by Bill Mill and Steve Rollnick, a more recent article. It’s a fairly good read, it’s an interesting read, an easy read. It’s doesn’t have research language within the context of the article so it’s something that if you wanted to pick it up and learning something more about motivational interviewing you can. They did an interesting spin on this. They talked about ten things that motivational interviewing is not, and that’s just to kind of clear the air about what MI is and what it isn’t, because there’s been some confusion over the years. The first thing is that it’s not the stages of change. We talked about the trans theoretical model in the first webinar, to kind of put motivational interviewing strategies in context or engagement strategies in context with the broader recovery or viewing the broader recovery process. Stages of change covered all aspects of the recovery process and motivational interviewing fits in with a specific area, primarily the early stages of recovery, pre-contemplation, contemplation and preparation, if you remember or you’re familiar with that. But the two models are very different and however, they work very well together, so it’s easy to implement them together in your individual setting. [0:13:31.3]

Motivational interviewing isn’t a way of tricking people into doing what you want them to do. It can feel kind of tricky at times. Many times too, our clients, people who serve because they’re not used to talking about change so quickly. They walk into our setting or they walk into interactions with us thinking that we’re going to tell them what to do and how to change, and how they’re going to go about that, and so they’re kind of ready for some of that argument and when that doesn’t happen and it’s very easy and it’s a conversation, they begin opening up and actually talking about change. Many times they surprise themselves. And so that can feel like we’re using something that’s a tricky way of getting them to move towards change, but really if motivational interviewing isn’t transparent, open, with the person that we’re working with, if we’re not open about what we need to accomplish as a result of our positions within the agencies that we work in, or we’re not open about what we hope for this individual long-term in their lives, then we’re truly not - we’re doing a disservice to the person and we’re truly not using motivational interviewing. [0:14:50.5]

It’s not a technique. Motivational interviewing is much bigger than a technique. It’s a philosophy, it’s a way of interacting with people and a way of viewing the change process and how people begin to think about change. It’s a philosophy, it’s a model, it’s an approach. It’s much bigger than just a few minor skills that we might use to help ourselves with a particular problem. It’s much bigger than that.

It’s not a decisional balance. We’re going to talk about decisional balance, weighing pros and cons, compare matrix today, as a strategy to elicit change talk. So you can think about a decisional balance as part of what we do in motivational interviewing to achieve some of the goals that we’re looking for, but just doing decisional balance is not motivational interviewing in and of itself. It’s a great way to elicit language in the direction of change. [0:15:53.3]

______0d169c6072783d120840b4b273d8111c.doc Page 4 of 21 It’s not assessment feedback. Motivational interviewing started out as feedback after an initial assessment, gauging the extent of a problem that the person was facing, and so it quickly got tied in with assessment early on. Motivational interviewing can be used throughout the change process as a person is ambivalent about change and thinking about change. Once they’re ready to change and committed to it, then we’re using other strategies. It’s a really good way of giving a person feedback at assessment, in order to engage them for the next session, but that’s not all that it’s used for.

It’s not a form of cognitive behavioral therapy. You might see a lot of overlap between cognitive behavior therapy and motivational interviewing, in the skill, active listening versus reflective listening, normalizing situations, but it is closer tied with client centered counseling or Carl Rogers’ work, if you’re familiar with that. We know these strategies in motivational interviewing as the OARS; open ended questions, affirmation, reflections and summaries. This forms the foundation of motivational interviewing, but motivational interviewing goes beyond what Carl Rogers was trying to do. He was trying to develop a relationship, demonstrate empathy with a person, connect with the person, and in doing so, he got some great results, great outcomes in the change process. Motivational interviewing goes further than that. It looks for a focus, a change target, something that you’ve agreed with the client on, in order to work towards, and you’re constantly looking for opportunities to reinforce something that the person is saying in the direction of change or elicit more language about change. And really, we’ve always got one eye on the change that we’re working towards. It doesn’t mean that we’re not flexible if that change target changes along the way and the person wants to work on something else. It just means that we have that constant focus on where we’re going and what we’re doing and what the person is saying in relation to a change. [0:18:31.2]

It’s not easy. It looks real easy when you’re sitting in a webinar looking at slides. The concepts are fairly simple to pick up. It’s easy to understand, not so easy to do and practice. Very often people struggle more with taking the skills and then applying them in real life, when things are moving very quickly, when the person has multiple situations that they’re dealing with, multiple problems areas, behaviors that they trying to change, and that becomes really difficult. How do I respond based on what the person is saying in the moment, in a way that keeps the conversation going? And it’s not necessarily what you’re already doing. You may be doing various aspects of motivational interviewing. The model and all of those aspects can be very helpful in engaging folks, but the model is the collection of all of the skills that we use, and the approaches and the philosophy, and using that in a focused way to help people move towards change. So many times we find that people are using pieces but not the entire thing. [0:19:44.8]

And it’s not a panacea, it’s not a cure all. It’s not something that you can just implement across your agency and all your problems will be solved. It’s meant for a specific area of the change process, like I said before. It doesn’t work with everybody, it’s not a hundred percent effective, and so in that way it’s something that we bring along as staff persons, as people are trying to help those who we sort of change. It’s a group of skills and strategies and a philosophy that we can utilize from time to time when it’s appropriate, when we’re noticing that ambivalence is present or that the person is considering change, but it’s not going to solve all your problems.

______0d169c6072783d120840b4b273d8111c.doc Page 5 of 21 We talked about a definition last time and I talked about many of these pieces of motivational interviewing already, so I’m not going to go into this a great deal other than just knowing that this is one of the most recent definitions for motivational interviewing, a collaborative person centered form of guiding to elicit and strengthen motivation for change. [0:21:00.9]

Here are the OARS, or the person centered skills, originally developed by Carl Rogers, now the foundation of what we know as motivational interviewing. And just recall from last time that when we’re utilizing OARS, we’re trying to develop relationships, we’re trying to open up conversation and connect with the person. We’re trying to develop trust and this really builds the foundation for moving for moving towards change. It will also draw out talk about change, if we’re doing this in a focused way. So when we’re asking open ended questions, these are questions that have a broad range of answers. Tell me about how your week went. Tell me about what brings you in here today. What’s going on with this particular situation in your life? Versus, did you have a drink this past week? What kind of substances did you use? How much, how often? Very focused, yes or no, or short answered types of questions. Did you take your medication, did you go see a doctor? You want to stay away from the closed ended questions and use more open ended questions than closed ended questions. [0:22:18.1]

We’re trying to affirm the person, point out strengths, instead of getting so problem focused like we do many times; focus on the problem and find solutions. We want to focus on strengths first, point those out to the person. It’s really dedicated to come in here when things are so overwhelming for you. Still, you made it in here and you’re really dedicated to finding some solutions. It’s affirming the person, a strength that they have, even when it appears that things aren’t so good, that things aren’t going so good and that there aren’t a whole lot of strengths or good things about the situation. Also want to reinforce any efforts that they’re making in the direction of change using affirmation.

We want to reflect, use our reflections to demonstrate to them that we understand and that we empathize with their situation. So we’re reflecting feelings, what’s behind what the person is saying and language. Anything that they mention in the direction of change, we want to spend time reflecting that as well. And these are just statements. They’re not questions, they’re statements that we make that are in response to something that the person said. And then summaries have often been referred to as a collection of reflections, gathering a bunch of things that the person said. Our primary focus here is to gather all of the statements in the direction of change that the person has made, and then that way we can really drive the bus towards making a change for the person. It really helps them hear it all at once and then creates a situation where they really want to pursue it, based on information that they’ve shared with us. [0:24:10.9]

So once we open up conversation with the person, many times we find that there’s a bunch of different things going on and we’re really not sure where to start or where to go next. Great, I’ve got conversation going, I’ve got a relationship with the person, we’re talking really well, but we kind of feel like we’re going around in circles here, we’re not really moving in any particular direction. So how do you establish a focus when somebody has multiple areas of concern, and also we have areas of concern as the person talks that we want to talk about as well. So we want to use a collaborative approach, looking at all of these areas, and we really want to make sure that we’re balancing the person’s concerns with our own concerns so that again, the collaborative

______0d169c6072783d120840b4b273d8111c.doc Page 6 of 21 approach, we’re bringing it all to the table and we’re ultimately writing it down and paying attention to all the areas that we could potentially process. How do you do that? Use open ended questions to get the concerns, first and foremost. Tell me a little bit about why you’re coming in here. What is it that concerns you? That gets the conversation going, along with reflection. [0:25:28.3]

And then at some point we want to share our concerns as well. As you were talking there, I had some things that kind of popped up in my mind that I’d like to share with you if it’s okay. We’re asking for permission to share our concerns and then we’re adding our concerns to the mix of things that we’re going to talk about. Prioritize what the person wants to address first and foremost during the appointment, and then we also stay flexible in terms of reprioritizing if things change. You know one week this is the most important thing that we can talk about and then the next week things change, life is different. We need to be flexible enough to move to a different concern. So how do you do that? Let’s consider a behavior change scenario to demonstrate how you might go about establishing a focus. [0:26:29.8]

We’re meeting a person for the first time, as a typical situation we might run into in a behavioral healthcare setting. Meeting with a person one week after discharge from a psychiatric hospital. The discharge report that we’re seeing indicates that she was hospitalized after expressed suicidal ideation when she went into to see her primary care doctor, and the toxicology screening that the hospital sent back to us at the time of admission indicated that she was also using opiates in her system, even though she was telling us that she wasn’t using any substances prior to hospitalization. She acknowledged in the hospital that in fact she did use; however, she’s not seeing this as a problem at this point. A pretty typical situation we might run into in behavioral healthcare. A lot of different things that we see here going on; the psychiatric hospitalization, suicidality, the drug use that we didn’t know about before. Our gut reaction might be to go after that thing that’s a surprise and talk about that, make sure that we talk about with the person and bring that up and address that right away. [0:27:53.9]

And so we’ve got an example here of a professional doing that using some MI inconsistent interventions. Some of the things that we talked about, the areas that we get caught up in as professionals, that make our job a little bit more difficult and increase resistance in the people that we serve. This professional says look, we need to talk about your drug use. How could you come up positive for opiates when you’ve been telling me that you haven’t been using? Blaming the person a little bit for not being open and honest with us and also engaging in premature focus. We’re going right after what we view as the problem, trying to find the solution, trying to address what we think is the issue, versus opening it up before we go there. The person responds that’s no big deal, it was a mistake. I’ve been feeling really depressed lately and I just needed to escape. It’s not like I do it every day. So we see those defenses go up or we blame somebody or we go right after a problem that we view is the issue. A lot of times those defenses will go up, we’ll see some resistance or some talk away from change happen and the person is less likely to change the more this goes on. There’s a tug of war going on at this point. [0:29:22.8]

And so then we as the professional might continue with our guts here and say it is a big deal. We need to talk about how using opiates is going to affect your treatment, or some variation thereof, but there’s this back and forth going on. We’re not collaborating, we’re not working together,

______0d169c6072783d120840b4b273d8111c.doc Page 7 of 21 we’re fighting against each other and it’s largely because we haven’t established a focus that we both agree that we can work on. In this last statement, as the professional, I am engaging in the expert trap. I know exactly what we need to work on and why we need to work on it, and I’m directing the person and I’m also arguing for change, versus understanding the side, that doesn’t limit you.

Here’s another way that we could go about that very same situation. Professionals says, there’s a lot of things happening here. We could spend time talking about this recent episode of depression or the toxicology report, where would you like to start? So I’m identifying two potential areas of concern, and then the person brings up another area of concern. I’m just really missing my mom since she died last year, I’d like to talk more about that. And instead of fighting against that and continuing to drill away at the toxicology report, I’m open to that being another area that we might talk about, another agenda area. Discussing your mom is a high priority for you, how about we spend most of our time talking about your mom and a few minutes at the end discussing the toxicology report. Would that be okay with you? Asking permission and we’re balancing my concerns with the person’s concern, putting highest priority on what they’re concerned about. As a professional I’m thinking, I’m going to have opportunities in the discussion about her relationship with her mom. I’m going to have opportunities to talk about drug use, to talk about mental health issues, and so I’m just choosing not to go there so that I could get on common ground with this person at this point in time. So it’s not that we’re not addressing the issue. It’s just that we’re choosing a strategy that’s more likely to lead to this person talking about change. [0:31:48.8]

And so we fit in these statements under the various strategies that we talked about in establishing a focus. So that’s just there for you to connect the skill with the statement. And then we might also organize it in a way that shows - on a piece of paper. It doesn’t have to be pictures, it can be written down areas of focus. We’ve got a picture of a mother and her daughter here that depicts that relationship that’s most important to the person. We’ve got pills that are being abused, this hospital stay looks pretty concerning and this person hasn’t been in the hospital lately and the feelings of depression, suicidality, demonstrated here. And we might even ask the person, well we’ve got all of these things laid out on this sheet, is there anything else that you feel is pretty important that we talk about? And that’s your question mark there. Actually writing this down or having the person write this down, can be really, really useful in agenda setting, what we call agenda setting or establishing a focus. [0:33:06.6]

So at this point I want to open it up to some questions. We talked about some older material and some new material here and I want you to have an opportunity to chime in.

LAURA GALBREATH: Great, thank you Jeremy. Participants, please know that you can just type in your question and we will answer a few of those before we continue with the presentation. So feel free to do that at this time. We’ll give folks just a second to ask any of their questions and then we’ll keep going. So one of the questions we have Jeremy, is how do you address frequent changes in priorities? Slide 12, where you talk about flexibility.

JEREMY EVENDEN: Right. Sometimes this happens and we could see a definite reason for priorities shifting, and so we need to make some adjustments in the plan. Sometimes it requires a

______0d169c6072783d120840b4b273d8111c.doc Page 8 of 21 deeper conversation. I notice that this area was particularly important for you to talk about last week and now you’re saying you’re not interested in talking about it. It makes me think that there’s something that happened this week that changed your mind on that. Tell me a little bit more. So we want to explore that, we want to reflect back to the person that they’re wanting to change priority. So sometimes it just becomes too uncomfortable for a person to talk about. For instance in this situation, the relationship with the mother might be particularly painful to talk about, and they didn’t anticipate that coming in. Those are things that we need to know about and so we address that by asking questions about it and reflecting back to the person how they’re feeling, so that we can understand them. We might also develop discrepancy about them wanting to shift focus when it was such an important topic before, that there’s something here that doesn’t quite make sense to us and so we’re being inquisitive about that. Yeah, so it’s not just a matter of shifting to a different topic when the person requests that, but we want to spend some time exploring it as well. [0:35:32.2]

LAURA GALBREATH: Great. I’m going to share a comment and then one other question and we’ll continue and get back to these other questions that folks have typed in. I think one comment here that I wanted to share was as a peer provider, I found I have much credibility, commonality and trust with clients. I use my successes and failures to help motivate. So that was a comment from a peer provider, and then there was a question about in this planning for each session. Is this planning for each session or just the first few sessions related to treatment goals?

JEREMY EVENDEN: Yes. This would be something that we would do very early on, in the first couple of appointments with the person, to establish an agenda, a focus of what we’re working on. And you can see, there’s multiple things here that would take us quite a bit of time to address all of these things. So we’re just trying to establish an initial priority area for the person. What we’re trying to accomplish here is to connect with what’s most important to the person that we’re working with and through talking about what’s most important to them in terms of making a change, very often we find opportunities to then explore other areas that we view as important. But it’s really, it’s establishing this collaborative approach right off the bat, it’s doing it in a way that saves some time, it’s much more efficient. You don’t spend a lot of time just rolling around all of these different areas and you really feel like you’re spinning your wheels. You get at a focus that’s important to the person right away and get moving. It’s something that you do early on and then you maintain it over the course of working with the person. So you would go back to this thing and be flexible and look at okay, what’s our priority now, what’s the next thing that’s really important, after you make some headway with that initial plan. [0:37:48.0]

LAURA GALBREATH: Great, thank you. Two things before we continue on. One Jeremy, I know some people said that your audio, it sounds like it comes in loud and then it goes soft, so if there’s anything you can do on your end, that would be helpful, we appreciate that. Also, the second item is there’s quite a few people asking about wow, how do we do this when there are so many issue we’re working with our client, be it you know, around integration and I’m addressing their diabetes as well as their symptoms with their schizophrenia. Or, because then you add in factors related to family or employment, so as you go forward, you can kind of touch on that in terms of using motivational interviewing when you have so many different things you’re trying to address, that would be great. And with that, I’ll turn it back over to you.

______0d169c6072783d120840b4b273d8111c.doc Page 9 of 21 JEREMY EVENDEN: Good, yeah, just a comment on that. You’ll find that all of these things aren’t isolated situations right? The diabetes will affect mental health, medications will affect diabetes, smoking will affect diabetes, substance use will affect all of these things, and so they’re not isolated incidents. So part of what we’re doing is looking for opportunities as we maintain the focus on the person’s goal, the client’s goal, looking for opportunities to address some of these other areas. So in that way, we begin to address them along the way. So that’s just one way that we go about incorporating other areas of focus into what we’re talking about. The person is more likely to be willing to talk about their diabetes if you’re doing it within the context of what’s important to them, you know some other area of healthcare or their mental health. And so we’re constantly trying to do that in motivational interviewing, to smooth the road towards change a little bit. [0:39:50.3]

So let’s talk about how we explore change. Now that we have a focus, we’re starting to hear from the person about some things that they would like to change. How do we go about doing that, what are some skills that could really help us with that? One thing we’ve touched on already is exploring what’s most important to the person and then looking for connections out of the concerns. Here’s an example of that. When the person says shortly after my mother died, I started using pain pills to feel better. She was so strong, she never had to lean on anything to cope. And then we reflect - so a slightly different spin on this. She really wouldn’t like the idea of you leaning on pills to cope. So in this sense, we started out talking about the mother and now we’re moving into the pain pill medication use or abuse. What would you like to - what do you like about using pain pills? Notice that I don’t go right into what’s the downside of using pain pills, why shouldn’t we use pain pills. I’m recognizing that there’s a part of this person that might want to consider stopping using because their mother really wouldn’t like it and they had a good relationship with the mother, but my first question is on the side of not changing. What do you like about using pain pills? And that leads me into this decisional balance skill that we use, or activity that we use many times, called the decisional balance, when it’s pros and cons of changing, called the payoff matrix. When it’s the pros and cons of changing and the pros and cons of not changing. [0:41:44.5]

So this first question in the quadrant of pros of not changing is directly related to that conversation I just shared with you. What do you like about using pain pills? The person doesn’t expect this. It breaks down some barriers a little bit. They expect us to start talking about the consequences of using pain pills and how bad that is, but we start asking them what do they like about it and not only are we asking what they like about it, but we’re allowing them some time to each us versus us teaching them. So this really breaks down a lot of obstacles, a lot of barriers, a lot of resistance to having this discussion.

I would then move into what would be the downside of not using pain pills. So still on the side of not changing, but a little bit different spin on this area. What would be the downside of not using pain pills? If you did quit, there’s going to be some downside to that for you, what would that be? All of this is really important in engaging a person in conversation, developing a relationship. It draws the person into this conversation, but it also gives me some really good information about relapse prevention. I begin to understand some of the things that might get in the way of this person changing, achieving abstinence in this area of this life long term. I know what kinds of things lead to them relapsing if I have this conversation. [0:43:13.7]

______0d169c6072783d120840b4b273d8111c.doc Page 10 of 21 And then it’s easier to shift over to what are the not so good things about using pain pills and/or what would be the good things about not using pain pills. So now, since I’ve engaged the person around where they’re more likely to go, that I don’t want to change. Now they’re much more likely to have a conversation with me about the downside of using and the good things about stopping use of pain pills. And so this conversation, it helps us stay objective, helps us look at the big picture of the situation, all of the different areas and how this person might be looking at it. It helps us view the balance, where the person is at in terms of thinking about changing. It also helps us identify some early change talk statements, so some language about change. If we look in the quadrants after we’re done filling out a form like this or going through this exercise. It could be verbal or it could be written, or both. [0:44:24.9]

When we ask, what are the not so good things about using pain pills, these are going to be reasons to change, things that they want to do, things that they think they might be able to do. What would be the good things about not using pain pills. Again, reasons to make a change. Very early language about making a change can be drawn out using this exercise, in a person that may actually not be ready to make any movement yet at all, but they’re willing to at least talk about it.

So what does that language look like when we see it? We start to draw this out from this exercise, what does it look like? How do we identify it? How do we know that it’s language in favor of change? Number one goal in focusing on this particular type of language is that if we focus on it, the more we focus on it, the more we draw it out from the person, elicit it, get them to talk more about it, the more likely the person is to be motivated to change. And so we try and catch it even early on, and many times it can be difficult to catch when we begin these conversations. So we identify a focus and many times this change language is mixed in with a lot of talk about not changing, you know my mom really wouldn’t like me using pain pills but I don’t know how I’m going to deal with life without it. I’m really in a stressful situation right now and if I stopped using them, boy things would be worse, I’d be feeling even more suicidal. So right in the beginning there, we heard some language in the direction of change; my mom really wouldn’t like me using these pain pills. That’s a reason to consider stopping using it, and we need to be able to hear that in the midst of all of this talk about not changing. That can be a pretty tricky thing early on, so we need to know how to identify that. [0:46:32.0]

There’s two different types; preparatory language and commitment language. And I’m simplifying this a bit. If you know more about motivational interviewing, for the purpose of this webinar, I’m simplifying this a little bit folks, but using the core essentials to language in the direction of change. So early on, very early on in a conversation we might hear things like boy, I really wish I could but I don’t know if I can. Maybe I could do that, maybe I could try this or try that. Desire and ability. Reasons. My mom really wouldn’t like me to do this or I really don’t feel so good after I use. I guess the medications help with my symptoms a little bit, help with depression a little bit, but I don’t know if I want to take them the rest of my life. Some reasons to take psychiatric medications there, beginning to come out. It doesn’t mean that the person will change, it doesn’t mean that they’ll stick with it. It just means that we’re seeing a crack in the door, we’re seeing a little bit of light here that if we focus on it and we reinforce it and we elicit more of it, the person will be much more likely to change. [0:47:52.5]

______0d169c6072783d120840b4b273d8111c.doc Page 11 of 21 Need. I have to follow through with my treatment regimen or I go back to jail, you know I have to go to treatment. I need to, I’ve got to. If I don’t take my medications, I’m going to go back to the hospital. That’s a reason to take medication.

Some more examples for you. I think I could cut back on my pain pill use, that’s ability, an ability statement. I’ve got to find another way to cope with losing my mom, that’s need. I don’t ever want to go back to the hospital but if I keep using I will, that’s a reason. I’d like to quit but I don’t know if I can, that’s a desire to change. Very early things that we might hear in a conversation, even if the person is in pre-contemplation; you know I’m not ready right now to make a change, I’m not considering a change you know, in the next six months. I might hear I’d like to quit but I don’t know if I can, so I’m not going to try right now. [0:49:06.6]

And then commitment language, the next step. So if we think about this as a spectrum, early on we’ll start to hear this preparatory language and then as that builds, as the person talks more and more about change, then we start to hear some commitment language, intention or decision to do it. I’m ready, I’m prepared, I’m willing to make a change, or I’m taking some small steps already. I’m cutting down a little bit or I tried that medication the doctor prescribed to me and it wasn’t as bad as I thought. I’m starting to do some things in the direction of making this bigger change. It’s important to remember that this type of language, intention, decision, readiness, preparedness, willingness and taking steps, are things that actually predict change when we look at the research. Some of Amrhein’s work, in the research shows that we’ll see this language, we can actually predict very often, if the person will follow through. The more intensified this gets, the more strong it gets; I probably will cut down on my use versus I’m going to stop using, I can’t do this any more. The more we increase that intensity, that also helps to predict change. [0:50:22.6]

Here’s some examples. Going to find a treatment center and then quit, intention. I’m done using drugs. Again, this is a commitment to stop using. I’m willing to try to quit, that’s lower intensity here but it’s still this willingness, this readiness, and then slowly cutting back on how much I’m using. They’re cutting down, they’re taking some steps. They’re not totally there yet, they haven’t arrived at abstinence, but they’re cutting down on some use.

And so that completes the section on identifying language in favor of change, and I want to give you another opportunity here to ask some more questions about the material.

LAURA GALBREATH: Thank you Jeremy, we have quite a few questions. A lot of people are very engaged in this, so I’m going to go through just a couple rather quickly. Motivational interviewing is not a form of cognitive behavioral therapy, but it sounds very similar to it. For example, agenda setting, client-clinician collaboration. What are some distinct differences between MI and CBT? [0:51:35.2]

JEREMY EVENDEN: There is a lot of overlap there between the two. CBT historically, as it was developed, tends to be closer to - so if we think about the stages of change, it tends to focus closer on action oriented types of intervention. Some of the exploratory stuff with CBT is earlier stage type things, but in CBT there’s understanding here that there are things that the person

______0d169c6072783d120840b4b273d8111c.doc Page 12 of 21 needs to change in order to feel better about their lives, in order to change behavior. They need to change some of these thoughts that they’re having, these automatic thoughts that lead towards some of these feelings and behaviors. So in that sense it can be a more action oriented type of intervention. There’s this assumption there that a person needs to change these things in order to move on. Motivational interviewing works really well as a precursor to that and in fact, when we see this in research, the outcomes of motivational interviewing and the outcomes of cognitive behavioral improve when they’re dovetailed together. So I would use motivational interviewing to engage the person in a discussion about change, without increasing resistance. We talk about both sides of it, we talk about the ambivalence, to gradually move the person towards making a commitment to changing this area of their life, and there is a lot of overlap there between the two approaches, which is why they work so well together. [0:53:23.4]

And then once the person is committed to make a change in this area, then at that point I would be talking about you know, in our previous conversations you were saying that every time that you think about using, you have the thought that you know, I’ve got to use, I won’t be able to manage the stress without it. I’ve noticed that that leads you to actually following through with use. So now we begin to educate the person about those processes. So it’s not that they’re totally different. They work very well together, but the approach is more helping a person consider change versus what do you do when the person is ready to change or getting ready to change. That’s the clear difference.

LAURA GALBREATH: So we have some questions about specific populations that people are working with, and we’d like to answer some of those towards the ends of the webinar, so we can give some examples there. There was a question about the six stages of change, the six being relapse, and then rather than accepting this stage, is there something else we can tune our conversation to, which will develop greater long-term behavior? If not, what is the advantage of keeping relapse as the sixth change? [0:54:48.8]

JEREMY EVENDEN: Well, first of all, relapse is not technically a stage of change. Relapse is something that can occur at any point along the process, so that’s something that’s important to recognize there. A lot of the depictions, including the one that I used in webinar one, if you’re looking at those slides, it looks like it’s an actual stage in and of itself. This is really something that just happens along the way at any point, and it can lead towards the person moving back in the stages, towards being more ambivalent. I don’t think I can do this now it’s just too hard. The reason why we bring up relapse and why it’s so important is historically, we’ve looked at relapse as a failure, as the person is not following through and doing what they’re supposed to be doing in order to achieve abstinence, for instance. We could also connect this with mental health treatment too. The person is just not taking their medication, just not coming in to see their doctor, just not following through with the case manager and so things are going bad, they’re ending up in the hospital. [0:56:07.1]

The shift in the thinking about relapse or recurrence of behavior is that we accept that that’s going to be a natural part of behavior change. If I expect, when I’m working with somebody on behavior change, I expect the person to fall back from time to time, to have a recurrence of the behavior, to begin to have thoughts about boy, it would really be good if I could have a drink right now. That’s an expectation. Not that I’m saying you’re going to do this at some point, but

______0d169c6072783d120840b4b273d8111c.doc Page 13 of 21 when it does happen, I address it as a learning process. This is a natural part of changing behavior. Most people, when they try and change a behavior, fall back into the old behavior. Most people, when they try and stop smoking or stop using tobacco for instance, will have multiple relapses in using tobacco before they’re actually successful, using. That’s based on research. So it’s this idea that relapse is a part of recovery, that it’s a part of the process, it’s normal, it’s natural, and this is an opportunity for us to learn and grow and be more effective and more successful at our attempts at change. [0:57:34.9]

LAURA GALBREATH: Thank you. I think we’ll go ahead and continue and get to some of the other questions towards the end.

JEREMY EVENDEN: So once we hear language in favor of change, what do we do with it? How do we respond in order to continue to build this and move in the direction of change? Well when you hear it don’t just sit there, reflect it, respond to it, elicit more of it, do something about it. And so this is a way for us to remember what to do when we hear that language. We want to elaborate more. Tell me more about that. How were you successful at achieving that in the past? What did you do to get one step closer towards changing? So we’re asking more questions, the answer to which are going to be more change talk. And then that’s we’re intensifying it. [0:58:34.7]

We want to affirm any language that the person is sharing us in the direction of change. You know, you’re really being pretty thoughtful about this process and you’re really working hard to incorporate these things that you’ve learned about taking medication into this attempt this time, to stay out of the hospital, and that’s something that’s really going to help you be successful in the long run. So affirming those attempts, those things that they’re doing right in the direction of change can strengthen additional attempts to do so.

Reflecting back or continuing the paragraph. So the person is talking about change and then we’re continuing on, and this helps move the person towards intensifying their thinking about change. You know, I really wanted to stop using, my mom wouldn’t want me to be using these pain pills. And you’re thinking, if you did stop using, you’d be better off. That’s continuing the paragraph, that’s continuing on in what the person is saying. What would they say next? Summarizing. It’s collecting all of this change language together, multiple statements that the person has made in the direction of making a change. And the person hearing that said back to them all at once. It’s really a powerful way to build on motivation to continue actions to make this change and to intensify that language, and so we’re gathering together all those statements that they’ve made, all the reasons, all the desire, things that they’re able to do in the direction of change. [1:00:31.0]

Here’s an example of responding to language in favor of change. So the person might - this particular person that we’ve been looking at here, might make the statement, I really don’t want to stop taking pills but I know that I should. I’ve tried before and it’s really hard. You get two statements of not wanting to change on either side of a statement indicating that they want to change, “but I know that I should.” And so the question here is, in terms of thinking about what we do when we hear language in favor of change, what would you reflect here, what do you think you would reflect? Do you reflect you really don’t want to quit, would you reflect it’s

______0d169c6072783d120840b4b273d8111c.doc Page 14 of 21 pretty clear to you that you ought to quit, or would you reflect that you’re not sure if you can quit? Here you would want to focus on it’s pretty clear to you that you ought to quit. This primarily focuses on the language in the direction of change that we’re hearing, “I know that I should.” It’s pretty clear to you that you ought to quit. The other two statements focus on not wanting to change, and so if we spend too much time focusing on the language that is about not wanting to change, then we’re likely to reinforce that and increase the amount of talk on the side of not changing. So our priority is the language about change. It’s not that we wouldn’t address these other areas. We might do a double sided reflection for instance. You’re really not sure if you could quit, even if you tried, but it’s pretty clear to you at this point that you need to think about it, or and it’s pretty clear to you at this point that you need to think about it. They’re feeling two ways about it. [1:02:30.5]

And the person might respond to this statement, it’s pretty clear to you that you ought to quit, by saying I just don’t know how I would cope with my depression if I quit. How have other people coped with this? This is an indication that the person is moving in their readiness to change. It’s one indication. They’re starting to ask questions about change. How have other people coped with this? So one of the things that we might do at this point, they’re asking us a question, they’re asking for information. They’re giving us permission to share some information with them and so we might use a skill like ask, inform, ask, to provide this information to them. So in this case the person has already given us permission to share information. We would provide the additional or missing information. We would provide additional information, and then we would ask, how does that apply to you, how does that fit in to your situation here? Where do you see that helping you in continuing to move towards change? [1:03:44.3]

Another way of going about that is what’s listed on this slide. What do you already know about the use of pain pills and the affect on depression, or the use of substances and the affect on diabetes, getting back to the earlier question. This is one way that we can incorporate some of those other areas that we view as problematic, while staying focused on what the person is interested in working on. What do you already know about the use of pain pills and how it affects depression? The person shares with you what they already know and you might find that there’s some holes in their information. So then you would provide additional or missing information, fill in the holes, and then you ask them, so what do you make of that, what do you think, where do you go from here? You’ll notice that the control in this situation is moving. You’re asking you know, can I take control for just a little bit and share some information with you. I’m taking control just for a second, sharing information, and then I’m giving control right back to the person. It maintains autonomy, their autonomy, it respects their autonomy and it reduces the likelihood of resistance, because they feel like they’re staying in control, and they’re more likely to hear what you have to say, interestingly enough, when you ask permission first. It gets their attention, they listen in, versus just sharing information and overloading the person with information that we might have to share. [1:05:27.3]

Here are some other options for listening for change language, that I won’t go into, but there are some resources out there on our website and the motivational interview .org website, that I’ll share with you later, that help expand these out for you and make it more usable. These are just some examples that you can refer to in the future, and notice these can change depending on what your agenda focus is. So for instance, what would life be like without the pills? We can

______0d169c6072783d120840b4b273d8111c.doc Page 15 of 21 change that up and focus on mental illness situations. What would life be like if you didn’t have to go back to the hospital ever again? What would life be like if you continued to take your medication as it’s prescribed? So we can just take out one focus and put in another focus here and continue use those. All of these questions, the answer will be change talk. And so now we’re not just using open ended questions for the sake of asking open ended questions. We’re asking open ended questions the answer to which is change talk. [1:06:58.6]

Here’s one example of an exercise, kind of a broader set of questions that helps you get at change talk, and this is an actual product that we have available on our website - you’ll see our website a little later - that you can get your hands on if you’re interested, the importance and confidence rulers. The importance ruler asks the question using a Likert scale here, asks a question on a scale of zero to ten, ten being the most important thing to you in your life right now, zero being not important to you at all. How important is it for you to quit using pain pills? The person rates themselves, I’m about a five, you know really, I know that it’s bad for me but I don’t know how I could ever you know, stop using and be able to cope with my life. I know it’s affecting me in a bad way, you know it may have had something to do with me being in the hospital, certainly it’s not what folks that care about me want me to be doing. I know there’s a better way but I just don’t know how I would change. So they’re giving you a lot of reasons here, why they might want to quit using pain pills, and asking follow-up questions might give you even more change talk. Why are you at a five and not a zero or why are you at a five and not some lower number? This again will elicit reasons, need, desire to change, in answering that question, because it’s assuming that they might be lower but they’re not, they’ve moved up to a five somehow, and the answer to that is change talk. What would it take for you to go from a five to one number higher, a six? The answer to that is change talk as well. Well I could probably do this, that’s an ability statement. Well if this happened then I might feel a little bit better about it or it might be more important to me. You know if my health was a little bit more affected as a result, that would be a reason for me to change. [1:09:26.1]

So all of these follow-up questions are extremely important; otherwise you just have a number. And you want to ask them in this way. If I asked why are you a five and not a six or not a ten, it can be pretty overwhelming to the person and the answer to that is going to be, I really can’t change right now, I don’t know how I would, it’s too stressful. What would it take for you to be one number higher, versus what would it take for you to be a ten, is less overwhelming. The person is more likely to come up with some reasons how they could get one step higher in their change process or one step further in this process towards change.

The flipside of this is the confidence ruler. So now that I know how important it is to the person, gauging how confident that they are that they can follow through with it is very important. Very often people feel that it’s really, really important, I’ve got to change, I need to change, if I don’t change I’m going back to jail, if I don’t change I’m going back to the hospital, if I don’t change I’m going to change my diabetes behavior, then I’m going to - my doctor is telling me I might lose limbs and organs and stuff like that, and I really don’t want that to happen, but I don’t know if I can. I don’t know if I could stick to this medication regimen every day. I don’t know if I can check my blood every day. I don’t know if I can remember all that stuff, that’s a lot to take on. I don’t know if I can change my diet or exercise every day. [1:11:00.4]

______0d169c6072783d120840b4b273d8111c.doc Page 16 of 21 So very often the problem is it’s not that they don’t feel it is important. It’s that they’re not confident. They don’t know if they can actually be successful with it, and this is the sticking point, so that’s why we look at both sides of this. On a scale of zero to ten, how confident are you, ten being the most confident you’ve ever been in your life that you can quit using pain pills. About a two. I really don’t know how I’d deal with stress without them. Why are you at a two and not a zero? Still, a very low number for the person, but there’s something that’s getting them to that point of being a two, and so we’re recognizing that and again the answer here is going to be change talk. Well, I quit once before and so you know, I was successful then, I might be able to be successful now, it’s just that things are pretty hard. What would it take for you to go from a two to a three, in terms of feeling like you can do this? Well maybe if I talk to some more people about how they did it, how they were able to stop using, then that might be helpful. So that’s looking at some steps that the person could take. I might be thinking at this point as the provider, that getting involved with peer support, getting involved with a group might be really helpful, to talk to some other people that have experienced it. This really helps me build the likelihood that the person is going to change. [1:12:43.3]

And so we talked about signs of readiness earlier on. When a person starts asking questions about change, that’s one sign of readiness, but the overarching question here is how do we know that a person is actually ready to change, ready to do something about this area of their life? One way is that we have decreased discussion about the problem. They’re not talking so much about the problem and they start to talk about some solutions. I don’t know how I could live without pills, is where they started. I think I could cut down gradually and then quit. Maybe it’s not getting abstinent but maybe it’s I can at least see this happening in small steps. So they’re beginning to talk about solutions and talk about things they could do.

Another way that we know a person might be ready for change is if we start to hear this increase in language in favor of change. So it’s intensifying, we’re hearing more of it than we’re hearing resistance or talk about not changing, and so that’s an indicator, that’s a flag for us that they might be ready to move forward. They’re questioning change, what have other people done to cope with depression. I mentioned that one earlier. [1:14:01.7]

Imagining what change might be like. If I do quit, I’m going to need to learn how to manage my stress better. That’s one of the main sticking points here is feeling like I’m able to change. So I’m imagining what needs to happen in order for me to make this change in my life. I have some resolve at this point, I made the decision, I can’t go on like this, something has to change. I’ve decided I want to make a change and so now I need to begin the business of learning about it, another sign of readiness for change. And finally, taking some steps. I’ve cut down on the pills, I’m taking as much as I was before, and it hasn’t been as bad as I thought it would be. Actually taking some small steps towards change indicates that the person might be ready to move towards the full change process. Very often people put their foot in the water before they take a dive into the pool, to test the water. So we need to recognize when this taking steps is occurring, as a potential sign of readiness. [1:15:11.5]

So a combination of various signs of readiness here might indicate to us that the person is ready to move forward, into planning how they’re going to do this, and this is a transitional point that’s pretty important. If we jump ahead into planning, if we’re just starting to hear boy, I really wish I

______0d169c6072783d120840b4b273d8111c.doc Page 17 of 21 could do that, and I start talking to the person about okay, well let’s talk about how you’re going to do this, let’s plan it out, let’s develop a plan for carrying this out, I’m going to scare them off. They’re going to move away from change instead of towards change. So I need to start hearing these signs of readiness in order to be confident that the person can move towards change without slipping back into ambivalence.

One of the things that we can do to continue to strengthen their commitment to change at this point, because it’s still pretty early on. We’re hearing some signs of readiness and we’re trying to continue to build up the intensity of this person’s desire to change, is summarizing their perception of the problem. Any potential ambivalence that might still be floating out there, it’s really important to not underestimate ambivalence at this point. Talk about objective evidence, things that we can observe that demonstrate that this person needs to change. Increased health problems as a result of their smoking or their substance use. Quite a few psychiatric hospitalizations as a result of going on and off their medication. This is evidence that we can measure and help the person to discover as evidence that they need to change at this point. [1:17:02.5]

A restatement of any statement that they’re making in favor of change, as we discussed before, and at this point you develop some relationship with the person in the process. They’ve developed some trust with you and so it’s okay, in your summaries, after they’ve shown some signs of readiness, to give your assessment of the situation. You know you’ve really thought through this a lot. You’ve come up with a lot of different things that you could do to make this change and I really feel like you’re ready to give this a shot this time, that it’s going to be different this time. That’s your assessment of your situation.

Key question helps us transition from talking about it to doing something about it. What now? Where do you go from here, what’s next for you? What are your thoughts about how you could cope with depression? You start to see the early signs of a change plan beginning here, steps that I can take for change, as a result of this question. [1:18:10.0]

Further strengthening commitment. We’re noticing here that the individual at this point is willing and able to change, they’re on the threshold of getting ready to change. We’ve done what we can to strengthen and support that commitment in making the change. We’ve asked them, is this something that you really want to do, is this a change you really want to make, consolidating commitment there, and now we begin the process of developing and negotiating a change plan with the person. And this is a plan that sets very specific goals about how they’re going to change. We’re still working with the person. I’m not directing the person on how this is going to go. These are steps that they view that they can achieve. There’s a range of options for them to choose from, they don’t have to do it in any particular way, and we’re writing it down. Ideally, the person is writing down the plan, not me, helps them with remembering the plan and remembering steps that they’re going to take, and being committed to it. Eliciting commitment to the plan is really important. Is this really something you want to do? Is this a plan that you’re comfortable with? It makes it their own, they take ownership of the plan, and they’re much more likely to follow through if the steps are things that they view as achievable and steps that they could do. [1:19:43.7]

______0d169c6072783d120840b4b273d8111c.doc Page 18 of 21 So in summary, as we’re helping people built momentum towards change, some things to remember here. Always explore the person’s concerns first. Pay attention to their concerns and demonstrate that you understand where they’re coming from, and then balance that with our concerns. Focus on what the person is saying, whether that be change talk or whether that be some pretty important things that are getting in the way of this person changing. One of the primary ways that we maintain focus is listening to the person and knowing that we’re going to have to reflect something about what they just told us. So those reflections can help us check understanding with the person, make sure we’re on the same page. It can also help us stay engaged in the conversation. [1:20:39.8]

We want to let the person voice the reasons for change. The direction of the arguments for change ought to always be coming from the person to us, never from us to the person. That’s what really helps them continue to move forward, they’re going at their pace and checking in on their readiness. We’re assessing important, confidence and readiness along the way and trying to increase those areas. So we might be asking questions or reflecting statements related to importance and confidence. It might be affirming them, which builds confidence. Yeah, I do have some strengths that can help me achieve this situation, yes I am ready. How ready area you? How do we know that? And taking a look at those signs of readiness.

Always going at the person’s pace, always checking in. Where are you at with ambivalence? Where are you at with thinking about making a change versus not making a change, and staying there, where they are, while maintaining a focus on our end goal and looking for opportunities to move one step closer towards that change. [1:21:56.9]

I’ve got some resources for you that can help you to continue to learn about motivational interviewing in general. The first one is the text, and there is a third edition coming out very soon, of the textbook, so you may want to hang out and wait for an opportunity to order or purchase that one, versus the older editions. There are some changes in how we’re viewing and understanding motivational interviewing. We’ve got a textbook on motivational interviewing and the treatment of psychological problems, which talks about a variety of different areas of mental illness and trauma and how motivational interviewing needs to be tweaked in each of those areas. There’s a book on continuing to build your motivational interviewing skills, by Rosengren here, which is really helpful in continuing to practice these skills versus just listening to somebody like me talk about them. Practice is critical in getting better at these strategies. And then finally, we had quite a few people that were working with adolescents the last time. I wanted to point this textbook out, Motivational Interviewing with Adolescents and Young Adults. There are some things that need to be modified when you’re working with adolescents and young adults, and the parents, and so I wanted to just point this out, that that’s available out there. The website, motivational interview .org, can give you a wealth of free resources to help you in applying these strategies of motivational interviewing to your work, and as always, we are available to you if you’re interested in resources like the readiness ruler or other resources that are downloadable on our website, that I’ve talked to you about previously. [1:23:53.7]

Hopefully, you’ll come and check us out, and talk to us about your interest. And so I thank you very much for the opportunity and I want to open it up again to some more questions, with the time that we have left.

______0d169c6072783d120840b4b273d8111c.doc Page 19 of 21 LAURA GALBREATH: So we have five minutes, so Jeremy, if we can do kind of a quick fire Q&A session, that would be great. So I’m going to jump right in. Can you just briefly touch on one or two needs that may be modified to work with adolescents, in terms of you know, the child may have different motivations compared to the parents or caregivers.

JEREMY EVENDEN: Yeah. Part of that is using things like agenda setting, to get everybody on the same page, that’s a critical piece. Reflecting everybody’s perspective in the room, making sure you’re connecting with everyone. If you’re hearing resistance from one side or the other, focusing on reducing that resistance so that people can move forward. Making sure that the child’s voice is heard in the process is really critical, but you’re trying - it’s much more challenging if you’ve got a lot of people in the room. And then for much younger children, think about how motivational interviewing can be used with the parents, to help with adherence to treatment. [1:25:16.9]

LAURA GALBREATH: Great. What if you were not working with such an articulate patient? Most of our patients are not very self-aware and may have minimal insights.

JEREMY EVENDEN: First of all, you want to be careful assuming on the front end that they’re not going to be able to stay with you on some of these conversations. I’ve been proven wrong way too many times to just walk in assuming that the person can’t handle these types of conversations. So I would try some of this stuff out. If I’m noticing that they’re really struggling with it, I might shift my approach, my strategy, to more direction in terms of more structure, more behavioral types of interventions, while still trying to reflect how the person is feeling and connect with them and engage them in the process, allow them to make some decisions for themselves. [1:26:23.7]

LAURA GALBREATH: Great. One individual speaking to a very specific population, is facilitating mandated classes for DUI offenders. All the members have had lethal consequences or AOD use, not all have serious abuse or dependency. Do you have any advice for maintaining a focus on their relationship with AODs? I guess alcohol and other drugs.

JEREMY EVENDEN: Right, alcohol and other drugs. So, a lot of times when somebody is mandated to a particular treatment process, that can cause some specific challenges in and of itself. There’s some obstacles that we need to get over in terms of the person fighting against the mandates, and recognizing how they’re feeling, using reflections, connecting with where they’re coming from, is an important first piece. Also being open and transparent about what our responsibilities are in terms of the reporting back to probation officers, to the criminal justice system, is really, really important. If you’re able to give choices under the context of your DUI program, so how can people choose different options within that program, instead of a one size fits all. Many times people are mandated to treatment but it’s not - but how treatment goes along can be varied slightly. So think about how you can give people more choices. But ultimately, you may be focusing on a goal of how do I get the courts off my back, as opposed to how do I change my drinking behavior, initially. So that’s an example of focusing on the person’s goal and then looking for opportunities to then talk about the substance use and how that’s affecting the courts being involved. I hope I answered that question. [1:28:33.7]

______0d169c6072783d120840b4b273d8111c.doc Page 20 of 21 LAURA GALBREATH: That helps definitely, thank you. How do you help a client get out of thinking of hopelessness? This client was on the wagon for a year and hit rock bottom and began to binge drink alcohol, lost employment and housing, now is in incarcerated and is at a stage of hopelessness. However, the cry out for help is there at a very minimal.

JEREMY EVENDEN: Right. It’s understandable, looking at people’s situations, why they would lose most or all of their hope, and so I would start with connecting with that first. How they’re feeling as a result of this happening. And then I would move into providing some affirmations and strengths, some rephrase on this situation. You’ve learned a lot from this experience, you’ve learned what not to do and in that sense you’re better able to handle things that come at you down the road. Let’s talk more about what you’ve learned from this experience. The idea that relapse is a part of recovery and that it’s an opportunity to learn. I would use an awful lot of rephrase, an awful lot of affirmations, to build that person’s hope back that they can achieve, that they do have some strengths. [1:29:52.7]

LAURA GALBREATH: Great. Thank you so much, that’s a great place to conclude our webinar today, because that is all the time we have. I think talking about the sense of hope and the work that we do with individuals every day, to help grow that sense of hope and sense of recovery and health and wellness. And once again, just some housekeeping. A recording and a transcript of today’s webinar is available on - or will be available on the center’s website. Once you exit the webinar, you will be asked to complete a short survey. Please be sure to offer your feedback on today’s webinar. Your input is very important to us and definitely helps to inform the development of future CIHS webinars.

Lastly, I’d like to give a big thank you to our presenter, both our presenters from Case Western, for their excellent work across these three webinar series. We really appreciate their very practical tips and help that they’ve been able to provide. I want to thank all of you for joining us on our webinar today and please stay tuned for more CIHS webinars and resources in the near future. Have a great afternoon.

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