I was born by the river in a little tent Like the river I've been running, running ever since It's been a long, long time coming But I know change gonna come Oh yes it will It's been too hard a living But I'm afraid to die Cause I don't know what's up there Beyond the sky It's been a long, long time coming But I know change gonna come Oh yes it is Then I go to my brother And I say brother, help me please But he winds up knocking Back down on his knees There've been times that I thought I couldn't last for long But now I think I'm able, I'm able father To carry on It's been a long, been a long A long time coming But I know change gonna come Oh yes it is, yes it is, yes it is Said I know, I know, I know That a change is gonna come one day I know a change gonna come Yes it is, I know, I know Said life can be hard, oh yeah And times can get rough But still I know, I know, I know, I know Still I know, I know a change gonna come Oh yes it will, it will, it will, it will Yes it will I know a change will come Good morning, everyone. Thank you for joining us. We were, this is Ken's second session with all of you. We did the trauma-informed care back in August, I believe. And I think most of you were at that session as well. But we're excited to be back with you today for this motivational interviewing session. It's gonna be more of an introduction, but we'll have a lot of great content. And I did talk about the ORIN a good amount last time, so I won't go through all of that again. But I do want to just acknowledge again that this training was made possible in part by funding from SAMHSA, who funds the Opioid Response Network through a grant. So we're glad to be back with you. And just a note, we are recording this session and we will have it available for viewing in a couple weeks. Also, if you have questions, please feel free to put them in the chat as they come up and we will do our best at answering them. We do like to answer questions in the moment as opposed to waiting until the end. And I think that's everything, so I'll pass it over to you, Ken. Thank you all. All right. Thank you, Emily. And welcome to all of you. It's a delight for me to be back with you after we had spent some time looking at trauma-informed care a number of weeks ago now. Delighted to see the ASL signing. Thank you for that. It's a beautiful thing. So, yeah, this is a two-hour overview of motivational interviewing. And particularly with the bent towards helping people with IDD in talking with them about areas of their lives where they might want to make some changes and also how they might grow in different ways. Just as a bit of a background, I first was introduced to motivational interviewing in the early 1990s, soon after the first book came out, actually, in 1991. And as a bit of a skeptic, I thought, well, here comes one more kind of newfangled thing, and we'll see about it. I'll check it out because I have a spirit of curiosity anyway. But as I learned about motivational interviewing, one of the things that happened for me is that I really found that there was an embrace that I had for it, not just for the ideas behind it, but for the values that it brought forward, which were very much in consistency with my own personal and life values. So that for me has been part of the journey that has now led me to continue both using and teaching MI over the past many years. I have come to see it as being foundational in many ways to all of the best practices that we have at our disposal as we work with people with different challenges in their lives. I'm guessing that many, if not most of you, who have had some exposure to motivational interviewing as well, perhaps reading about it, perhaps going to trainings, perhaps you're an avid practitioner of motivational interviewing, I don't know. But my hope is for this two hours together that a little review, as well as for those of you for whom it's newer, that it might be something that you get interested in and stay curious about and see what you make of it. I want to say one thing. I'm presenting this today as I would to most any group of practitioners. That said, I'm also going to acknowledge upfront, and I'll say more about this midway through, that when we use any best practice, we have to adapt it to the folks that we work with. And in this case, the language that we use in the form of questions we ask, the reflective statements we make, that language may need to be adapted for certain individuals at least, who might have some difficulty understanding like certain words or certain concepts. And so throughout, I'm going to try to do a little bit of sort of adapting myself in the language at times, but I'm going to invite you to do the same as we do that. So I'm going to begin here with what I'm calling an MI meditation. This comes, as you can see, from a workbook that was designed for Native American practitioners in motivational interviewing. And I offer this because I think that one, it's always a good way to start any training, both with music, but also with just a quieting ourselves and a centering ourselves. And this particular meditation also speaks very deeply to what we call the spirit of motivational interviewing, the mindset that we come forward with, the heart set, the value set. And so what I'm going to do is read this to you. You're welcome to follow line by line on the screen, or you might want to just close your eyes, turn off your screen and listen. But I'll invite you at the end to just maybe a few of you to comment on what speaks to you, particularly as it might apply to how you work with people that you do. So here we go. Guide me to be a patient companion, to listen with a heart as open as the sky. Grant me vision to see through this person's eyes and eager ears to hear their story. Create a safe and open meadow in which we may walk together. Make me a clear pool in which they may reflect. Guide me to find in them your beauty and wisdom, knowing your desire for them to be in harmony, healthy, loving, and strong. Let me honor and respect their choosing of their own path and bless them to walk it freely. And may I know, once again, that although they and I are different, yet there is a peaceful place where we are one. So I'll invite you in the chat box, or if you choose, you can come off mute. Totally up to you. And if you want to sort of speak to something here that resonates with you, I'd be delighted to hear from you, particularly as it applies to the work that you do. So I've got my chat on, and I'll just see what shows up here. Yeah, Kelsey, thanks for starting us off. This felt very loving and would be a great group agreement prior. Huh, I like that. I like that. Love the visuals, especially the clear pond. Yeah, there's a lot of visuals here, aren't there? Very nature-based, very much so. Yeah. What do other people see or hear? Yeah, Elizabeth, thanks. This part about the pool in which they can reflect is very inspiring. So we can be, for people, a way of reflecting back to them, both what they say, but we can also reflect back to them maybe some of our own way of being in which they might see in us a way of modeling, perhaps. The companioning, yeah, this idea of it not being a one-up relationship necessarily, although it is at some level, but we can minimize that, but keeping it in the context of two people walking the face of the earth together, each with our own expertise, each with our own interests and concerns. Yeah, thank you. Unconditional positive regard, absolutely. I think the whole thing speaks to that and desire to see and understand another's experience, which is all about empathy, right? So which is so central to everything we do. The language being, may let grant guide make me feel, huh, that's a really interesting observation. This kind of openness and permission giving, right? There's nothing that's sort of trying to push or coerce here, right? Listening actively, meeting people where they are, celebrating diversity, all of these things and more. Thank you. Thank you all. And feel free to continue to contribute as we move ahead. I will say that this is for me, one way of encapsulating the way that we want to be with people. And I also want to acknowledge that we don't do this perfectly all the time, do we? Despite our best intentions. And so we continue to do it to the best of our ability, acknowledging our own humanity, our own imperfections as well. So three invitations here. It's for you to decide if you want to help co-create the training. You've already done that. Thank you. And invite you to continue doing that. I hope that you will use this opportunity to reflect on your own practice and how you work with people, particularly the kinds of conversations you have and the way that you come forward in the relationships that you develop. And also to share your perspectives on equity, diversity, inclusion, inclusion, and all of those really important things that both create differentness in us, but also create a certain unity for us as well. So a few things that I've picked out that I'm hoping that you'll walk away with, but there's certainly a whole lot more that's not mentioned here, but I hope you'll notice how motivational interviewing or what I'll sometimes call motivational conversations use a guiding much more so than a directing approach. It's this idea of we're not following necessarily, and we're not out front directing, but we're somewhere in between guiding as we work in companionship with people. We'll be looking at the four elements of what we call the mindset and heartset of MI. Some key questions that we can ask that help to elicit from people their own motivations and how we can help strengthen motivation for change. And then we'll look at four tasks that really guide conversations in a way that helps us sort of be deliberate in how we approach our conversations with folks. For those of you familiar with MI already, you'll know that some of these kind of concepts and names for them are coming from the fourth edition of Motivational Interviewing that was published really within just the last half year. And so some of the nomenclature might be a little different for you. For example, the tasks were once called the four processes that guide motivational conversations. Well, I'm wondering if, we won't linger here a long time, but what are some of the common dilemmas and issues that you explore with people that you serve in which there might be an opportunity for a conversation about moving towards change? Just curious what, in your own work context, what do you end up talking with people about? What comes up? What's important to them? And I know that some of the things that come up are requests for assistance in certain ways, and those are absolutely important. But I'm thinking here more about the kinds of things that people might be ambivalent about, go back and forth about, or contemplating change, but maybe haven't yet done so. So substance use certainly, yes, thank you, is going to come up. And how to have intimate relationships, yeah, and all that that entails. How to engage with others, how to connect with people, how to have relationships. Moving out, becoming more independent, yeah, yeah. Understanding their own lived experience and a desire for autonomy, absolutely. Your fears, what's holding you back, right? And resources for sure. And what do they want when their elderly caregiver dies? Whoa, so hard, hard and challenging issues that come up and so much more. I'm just gonna list here a few things that were kind of my wild guesses that do and don't include everything you've put here. I guess my point being is that virtually anything that has a little bit of edginess to it that isn't clear cut is a ripe opportunity to have a conversation with people about change. And so certainly everything from substance misuse to mental health challenges, to learning, to sort of embracing your own identity and your own strengths as well as maybe limitations and maybe stigma is involved in that, right? And relationships in general and how to emancipate and so on and so forth. So again, in helping co-create the training, what do you already know about how to facilitate a conversation with people you serve that's going to be helpful, that's going to help strengthen it and make it more likely to result in a positive conversation about change and growth? What are the ingredients that you already know these things that go into a style and a conversation? So I love Rusak, I am not sure what your actual name is, Russell maybe, but I love that you mentioned listening as the starting point, yeah, absolutely. Engaging, focusing on desired outcomes, knowing what they love, yeah, that's fabulous. Being curious, lots of open-ended questions, yep. We might add reflective listening in there, reflective statements, affirming strengths and then having a certain guiding style that actually moves the conversation or guides the conversation along. So you know these things and it's not unique to motivational interviewing to apply these kinds of things, but there are some unique ways that motivational interviewing utilizes these skills and these approaches. So I'm gonna start here with a little quiz. I don't know if you studied for it or not, but this is actually a little bit of silliness here, but I'm gonna use the term, am I a lot instead of motivational interviewing. Is this am I, would you say? And if you know what it is, feel free to put it in the chat box or shout it out. Anybody recognize this? Yes, thank you, Mawisha. Yeah, yeah, Mavish, Michigan, it's the state of Michigan. If you send a letter to the state of Michigan, you'll put am I, but we didn't come to talk about that, right? How about this one, is this am I? This is kind of a fun one to say. It's the fancy word for a heart attack. Anyone wanna hazard putting it out there and spelling it? Good job, Jennifer. Yeah, all of you, myocardial infarction. What about this, am I? This might be a little more challenging, except for some of you in a certain age set perhaps, or those of you who love history. Yes, indeed, it's the original cast of the TV show, Mission Impossible, there it is. But what we really came to talk about is this. Thank you for participating in that little quiz. So this is an image of the fourth edition of Motivational Interviewing. Certainly the third edition, which preceded it, is also a really fine text and valuable one. But I will say, if you're inclined to buy a text, it's worth probably going for the fourth edition or seeing if your organization will buy it for you. And so let's start out with just using the general definition used in this particular edition. That is, am I is a particular way of talking with people about change and growth to strengthen their own motivation and commitment. So a particular way is what we're going to explore. The topical area is going to be how we focus our conversations on helping people identify for themselves what areas they might want to explore to make changes in their lives or to resolve dilemmas in their lives or to problem solve in their lives. And what we're about here is really trying to help people identify their own internal motivation and help them strengthen that and grow in their commitment to it so that it might actually lead to taking action. So there's been a history of editions, as you can see. 1991 was the first. Sorry, I thought I had the dates in there. And that was followed up by the second edition in 2002. You'll notice that the first edition was totally focused on addictive behavior. That was where MI started and comes from. And then it moved gradually to additional areas and behavioral health in particular. And then by the third and fourth editions, we see motivational interviewing being utilized in virtually all areas of health and human services, schools, corrections, anywhere where people are having conversations with others about change. So I'm gonna share this video with you as a way of kind of just providing a brief introduction and synopsis to the basics of motivational interviewing. And it's entitled, Lifting the Burden in Motivational Interviewing. So I'll ask you at the end, and it's only a few minutes long, why do you think it's entitled, Lifting the Burden? And so as you watch, and I often say, and so as you watch, and I also encourage you to pay attention to the graphics. I think they're very fun, but see what we might find that resonates with us, and we can comment on that then after we show it. Here goes. Fundamentally, motivational interviewing involves a change in role, a change in how you think about what you're doing. You're not the expert there to fix the person. You don't have to make the person change. The truth is, in fact, that you can't make a person change. You don't have to be the one to come up with all the good ideas. A person with really good ideas is sitting across from you and may have better ideas than you do. It's not like a competitive sport. It's not like wrestling where you try to defeat and pin and outsmart and outwit the person. It's more like dancing together, moving together, adjusting your movements to the other person. Overall, motivational interviewing is not a directive approach. Neither is it just a following approach. Following is listening to the person and kind of going wherever they go. Motivational interviewing is in the middle between those two, and we describe it as guiding. If you go to another country and you hire a guide, you don't expect the guide just to follow you around. That's not what you're looking for. Neither do you expect the guide to order you when you will arrive, when you will leave, what you want to see, what you will enjoy, what you're going to do. That's not a good guide either. Good guiding involves good listening as well as using your own expertise. A good guide will find out where you want to go, what you're interested in, what you're hoping for on this journey, and then help you get there using his or her own expertise enjoyably, safely, efficiently, perhaps. That's the guide's job. Not solely directing, not solely following. There's some of each in it, but it's a blend of those things. This may or may not be the way you've been thinking about your own work, but we invite you to try it out. Thank you. Any brief comments before we move ahead? What resonated with you? And this is in some ways sort of harkens back to that beginning meditation, right? There were some themes that came up here that we might pull out, but anything in particular for anybody? Yeah, Kelsey, thanks. Yeah, a lot of validation about how important validation can be. Yeah, affirming people for who they are, for their intrinsic worth and value, but also for the strengths they bring. Seeing possibilities, not limitations. Yeah, it's not ignoring limitations entirely, but it's really putting a focus on what can be, what people are hoping for. Yeah, I was thinking already about how you do this. And I wanna just pause for a moment and say there's so much about motivational interviewing that I think you will find is already within you that you've already been practicing. So this is not likely to be brand new by any means or a huge sea change in how you go about your work. And my hope is in some ways, motivational interviewing and how I present it will be a way of you affirming and validating your own practice in how you do things. And at the same time, perhaps there are some things that you are doing currently or an approach you're taking that you might want to question, call into question, consider letting go of, or adding more to it, that kind of thing too. So I think we're always all in a position of learning and growing ourselves. This idea of guiding conversations includes Tutta Tango. Yeah, it's a dance, right? And I don't know if you dance with me, I'll still step on your toes every now and then and I'll apologize and move on. But that's so different than wrestling, right? Which chances are we've all had wrestling matches with clients we've worked with in the past as well. And that never turns out well. This describes the sweet spot of an inclusive and interactive conversation. Wow, that's really lovely the way you put that Shannon. Yeah. So I think, again, this mindset, this heartset, this way of seeing, this way of doing is already probably deeply ingrained in all of you in many respects. Although that said, we also get tempted sometimes to take a more directive role or to a fix it role or that kind of thing. And we'll look at that a little bit more carefully too. The question here, how am I different from coaching? Actually, not a lot, frankly. Now it depends a little bit about what kind of coaching. If it was the coach I had in high school, not that kind of coaching in baseball. But if it's the kind of coaching where you're also seeking to find out where the person's wanting to head, what they're hoping for, and then help them both discover for themselves what's important to them and what their own ideas are about change. But then also, and maybe more so in coaching than in MI, although it happens in MI, there's a teaching component as well. There's a way of providing sound information to people to assist them in their thinking and in their decision-making. But I've done a lot of, a lot. I've done MI training with health coaches, for example, and other coaches, and it's very consonant with what we, these days, are thinking about, I think, in terms of coaching. Marnie says, the true secret of giving advice is after you have honestly given it to be perfectly indifferent whether or not it's taken. And never persist in trying to set people right. That's a quote I see. Yeah, yeah, that is so accurate, so right on. And I would add to that, the true secret of giving advice is to wait to give it and see what the person's own advice is for themselves, if you will, and then to ask permission to offer that advice as a way of just kind of creating a little bit more of a softening of what can be sometimes jarring and just offering advice, depending on the relationship. But that's a fabulous quote. Thank you, Marnie. So what are the ingredients? If you're gonna make an MI stew or a salad or a casserole or whatever you wanna make, what goes into it? Well, I'm just gonna list here briefly because we're not gonna be able to go into all of these in depth. But these are the key ingredients that go into this kind of motivational conversation. First of all, what we've already been sort of talking about, and we talk about the four spirit elements of partnership or companionship, of acceptance, compassion, empowerment. We also then talk about these guiding tasks that kind of define the flow of any conversation, whether it's, frankly, two minutes or 15 minutes or 30 minutes or longer. Typically, the guiding flow includes some of what we call engaging, getting to know the person as a person, finding a focus, and then evoking around that focus, sort of asking people interesting open questions to draw out their own thinking and ideas, and then a planning phase, potentially. It doesn't have to get to that, but if the timing is right, then we might move into a planning phase as well. And we guide these conversations with these four conversation skills of open questions, affirming strengths, making reflective statements, and offering up summaries. And then a fourth element of all of this is this idea of change talk, which is shorthand for any kind of things that people say or indicate that suggest an interest in moving, hopefully, in a positive direction, right? So, linguists have listened in on conversations about change, and they've kind of parsed out, well, what are we hearing here? And oftentimes, it comes down to hearing statements of desire to change, I want to, I wish I could, an ability, I could do this, reasons, if I did this, then maybe, and we also then think about the need. And here we're talking about need as in urgency or in not just waiting any longer. So, we talk about those four as being kind of preparatory change talk, because they're not yet ready for action, but they're the way that people build motivation. And we want to draw out from people statements of desire and ability and reasons and need in order to build motivation and to strengthen it. And then there's also the change talk that hopefully eventually will come where there's a commitment to taking steps and activating a change plan of sorts. All right, I'm going to leave that there for now and just say that when we take these four different ingredients of conversation and we mix them together, we stir them, right? We use them interchange, not interchangeably, but we use them certainly all the time in different ways, and we mix and match, and they're all part of the conversation. And we stir them and allow them to sit. And we don't rush the recipe. We don't rush the cooking phase. We allow them to simmer. And by that, I mean that we know that particularly changes that are difficult and are hard to come to, they take time and they require some simmering. And if you think about your own life and a change you've made in your own life, some of them have been fairly made in short order, but some of them you've thought about for weeks and months. Some of you have thought about them for years and maybe still haven't made the change. But the fact is that that simmering process is a way of just reminding ourselves that we are not trying to coerce people into change, rush them into change. We're wanting to guide them in a way that in their own timing, when the time is right, when the tipping point comes, that they say, I'm ready. And then of course that's only the beginning of a whole new journey, right? When people say, I'm ready to make a change. I want to show you two videos, relatively brief videos, and they are examples, in this case, the first one of how not to do motivational interviewing. This happens to be a dentist who's talking with somebody about their tobacco use. Now, I recognize that you're likely not dentists, any of you, but we've all gone to the dentist, right? And we've all gone to health providers and sometimes they talk to us about different things, whatever that might be, high blood pressure, smoking, drinking, it might have to do with exercise, whatever. But it's not an easy conversation to have all the time. And there are helpful ways to have the conversation and less than helpful ways to have it. So in this particular video, I'm going to invite you to listen in on this conversation. And what I'll do then is ask you to go ahead and respond to these questions. Sorry, let's leave it there. But I'm going to ask you to respond to, first of all, what are her intentions? What are her hopes? Secondly, what is her method or methods that she's using to try to, in this case, get him to change his smoking? And then thirdly, what's the outcome? What's the impact on the patient whose name is David, who you'll meet in a moment? So feel free to comment in the chat box as we go, or we'll wait till the end. So let's go ahead and take a listen to this brief video of how not to do MI. Okay, so why don't you have a rinse, David? How are you feeling? Okay. Good. Here, take a look. See what you think. I think that feeling, and the color's okay. You know, there is quite a lot of staining, so I'm just wondering about some concerns about smoking, possibly coffee, tea. Yeah, you've heard this before, I'm sure. I do all of the above, yeah. So, you know, the smoking is going to be related not just to some of the other negative consequences, you know, physically. It affects dental caries, dental cavities, healing in your mouth. Okay. Sure. I've heard it all, but I just want to get my teeth fixed. Yes, and I really want to be helpful. I really want to, you know, my commitment is to your oral health. So there are lots of medications out there, David, that actually take away a lot of the cravings. They make quitting so much easier. I did try. I just did the pills and they didn't work. It was a waste and it caused more side effects. No, but David, it's not a waste. Research shows that people take on average about seven tries before they quit smoking. So think of it as your one step closer to quitting. Or seven lectures along the road. Well, I don't think I'm giving you a lecture. That's certainly not what I meant. No, I just feel that way. I get very defensive about it because I get it from my family doctor, my cardiologist, everybody. I'm not a complete fool. I am for smoking. Well, there's a reason that people are concerned. But it's not easy to quit. No, but as I said, these medications. So you've tried the medication. You've been willing once. Then can I write you a prescription for the medication? Can we talk about how you could use it? Because this is something that's very important, not just for your overall physical I guess I've got to really want to. Things I've tried usually cause me more problems than they helped. Oh, no. The smoking is going to cause you more problems than anything else. I can promise you that, David. The side effects from the medications are nothing compared to what can happen from the smoking. Like that's the, I think, thing to really consider. Okay. Well, can I go now? Okay. But I know what I know. I know, Doc, what you're trying to do with it. I just don't want to get into that right now. Okay. Well, thanks for listening. And honestly, I am really worried about the smoking. So I appreciate your care. I'm here to help. Okay. Okay. All right. Shannon, I did see your message and I attempted to turn on the CC, although I was late in doing it. It says subtitles aren't currently available. I might have to check my privacy settings, but apologies for not getting that to work. Um, so let me ask those of you who are sort of, uh, kind of willing and ready to share what are her hopes for this patient? And actually I'm going to answer that question because I think they're abundantly obvious. She, she wants him to quit smoking, right? She cares about his oral health. So she's got the best of intentions, undoubtedly. How would you describe her methods? And you don't have to use clinical terms here, such as, uh, Kim, you didn't, I want to punch her. Thank you for that frankness there. Um, yuck, super luxury, not person centered. Uh, yeah. Wow. She minimizes his trouble with side effects. Doesn't listen. Uh, feels like a typical dentist, unfortunately. Yeah. Very confrontational. Uh, hard to watch. Yeah. I guess we don't have to say a whole lot more, right? Um, I will say, what, what, what do you think it was happening with David when he walks out of here? What, what's he likely to be thinking? What's he likely to do? Um, anyone? Thanks Kim for, uh, telling, letting us know that you have some, uh, control over yourself. We appreciate that. Yeah. He's thinking about getting a new dentist. He's not going to go back probably. Right. Uh, he's absolutely gonna light up a cigarette. Uh, maybe he'll light up two at a time. I don't know, but he's going to definitely grab a cigarette and be frustrated, not wanting to go back and really doubling down on continuing saying, you can't tell me what to do. And so I'll show you that's a pretty typical thing that happens when we try to coerce people. Right. And so a lot of guilt, maybe shame, uh, that comes into there. What he's not thinking about is, oh, I should probably quit. Now I'm, I'm going to say this, uh, there are on some occasions when people are receptive to this very directive message for whatever reasons, and they say, oh yeah, I need to quit. And we scare them. Right. But that is rarely helpful. And it's not a well, uh, researched way to help people, uh, come into making change decisions. So David's out there continuing to smoke, smoking maybe even more, not thinking about changing, probably looking for a new dentist, dreading going to that dentist as well. And so I'm going to request that we give the dentist a second chance. And maybe in the meantime, she's gotten, uh, some, some training and some new ways of approaching patients. So let's watch this one and then we can have the same conversation. Uh, it does look like you can turn on the CC in your own screen from what somebody has shared. So hopefully that will work for folks. Okay, David. So why don't you take a rinse and how are you feeling? Pretty good. Would you like to check this out? What do you think? Oh, that one's fixed really nice. Yeah. You got rid of that bad discoloration that was there. Yeah. No, I like that. It went well. Good. Excellent. I did notice quite a lot of staining, actually. I'm wondering what are your thoughts about what might be related to that? Well, the usual suspects, smoking, wine, coffee. Yeah. All of the above. Any thoughts on considering quitting smoking at this time? Yeah, I thought about it. I'm just, it's not my cup of tea. I, I, I hear it from everybody and, uh, I've tried, I've tried before. It didn't work. I get it all the time. Okay. And it's like, here I am, one more person, the next, the next doctor who's saying, you need to quit smoking, David. And I'm sorry, that's not how I mean to come across it. I know I'm not an idiot and people know that smokers are, you know, how can you smoke today? It's just not that easy to, uh, quit. And if it was as easy as a doctor saying, or, or your partner saying. Who wouldn't be? You'd have to be a real fool not to do it if he was going to make it like that. Yeah. I just hear it every day. Yeah. And what's been your past experience with smoking? Tell me, can you tell me a little bit about kind of how the role it plays in your life? How long you've smoked? I've smoked for 40 years since I was 14 and quit a couple of times off and on in the 20s, but you know, it's been consistent and I can't see myself changing now, no matter what kind of talk I get or what they come up with. It sounds like almost you've tried a lot of things that are out there and it's not something that can work for me. Yeah. Yeah. No. Yeah. I know cold turkey is probably the only thing that's ever going to do it. Anybody that's done it in my group, it's been cold turkey and then they fight it, but it's my choice and I don't like lectures about it. Yeah. And it really is your choice. You're absolutely right that nobody has the right to tell you what to do. Um, can I ask if you were to, if there was to be a situation where you decided I must quit, what would that situation be? Hard to tell because I've already had open heart surgery that didn't do it. Prostate cancer that didn't do it. Right. I don't know. I really don't know. I just don't really want it. So this is something that you have to pretty much see yourself doing for. Yeah. A while, quite a while yet. Yeah. Okay. Well, I really appreciate you being willing to even talk about it. And I get that right now, this is not something that you want to pursue. Would it be okay if I brought it up at our next visit? Because I know that you've said you don't want to lecture, but on the other hand, I am, I am concerned. Okay. Yeah. I could go for that. I'm always open to something, you know, to listen. As long as I don't talk too much. Okay. Give me options. I had some, I had my surgeon just go like, here, why do I even keep you as a patient? He's good though. You were glad to keep him as a doctor. Yeah. Yeah. Well, and David, honestly, wherever you're at, we'll work with it. And so thanks for, thanks for taking a couple of minutes and talking about smoking. Thanks doc. All right, and Shannon, again, apologies. I was hoping you could turn on the CC on your own, as was suggested by somebody else, but apparently that didn't work. Once again, her hopes haven't changed, have they? She hopes he will quit. She hopes he'll improve his oral health, but certainly her methods have changed, and already some of you have commented, love the open-ended questions. Yeah, there are lots of them, and Kelsey says, judgment and lecture never effective. Highlighting positive outcomes and accessing the barriers can certainly be promoting change, absolutely. The doctor let the conversation be about David. Yeah, that's a really nice, succinct way to put it, right? She guided it, for sure, but it was all about him and his input. She was on his side. They were companions in that conversation, and Tara, yes, I love the humor that seeps in there, as long as I don't talk too much, kind of thing, and I think overall you just notice a little bit more lightness in the room itself, in terms of the conversation, because it's not adversarial. They're not wrestling, right? And Chris, you're commenting on that, the non-verbals, the body language, more friendly, more open. Yeah, it was enjoyable, even, and imagine that if our conversations and the work we do were enjoyable. I hope they are already, but they should be in many ways, even though they're about serious issues and content. There's something enjoyable about being in a dance with somebody and exploring things, and so the question here is, I think, Emily or Elizabeth says, I like that she dropped it and said, maybe we can talk about it next time. Yeah, I think, you know, if we think about that phase where we go from engaging to focusing to evoking to planning, that plan doesn't have to be a whole written change plan sheet, right? It might be, let's take this conversation up next time, and in the meantime, you know, might be something to think about or even talk to others about. I think oftentimes that's part of that simmering process, too, is that we don't want to try to bring it to a boil or overcook things. We just want to let things move at their own pace, but there was at least an indication of a next step, right? And so I think that's a really helpful thing for all of us to remember that that might not look good on a chart necessarily and say, well, we're going to talk about it next time. That's the plan, but that's really valuable in motivational interviewing. Anybody want to become David and come off mute and tell us how you're thinking and feeling and what's on your mind? Or feel free to share in the chat box. But what do you think the impact here is on David for this conversation, would you say? I see a raised hand there. Yeah, go ahead. I'm not entirely sure who that is, but feel free to go ahead and speak up. So it opens the conversation up to him thinking about it later, even when she's not around, instead of him, like, doubling down and, like, becoming very stubborn about it. And the fact, the good thing is that she's not emotionally connected to the patient, meaning, like, she's not a family who has had the conversation multiple times, and she's not, you know, and, like, is emotionally affected by the client, which makes it easier for her to have that conversation, although she cares. She cares in a way that, like, her personal life isn't impacted. So it makes it easier to be more, to keep that up. Thank you. Yeah, absolutely. You kind of make two main points. One being, he is now more open to thinking about smoking. He's not feeling defensive, and he might, in fact, revisit some of those old friends that, who use cold turkey, right? Or he might talk to someone else, or he might decide to do a little research on the internet. He might, who knows, he might even decide, well, maybe I can just cut back just by one cigarette a day, or who knows? But the openness, the curiosity is there, and it hasn't been squelched. And the second piece that you mentioned is so important, too, that I'm going to call it compassionate detachment, for lack of a better term, but it's this idea that you are connected, you care, you have compassion, but you're also at enough distance that you don't get enveloped into and meshed into the helping relationship, and that's critically important, too. Any other comments here? So let me just say a few things yet, to highlight a few things, because I think the anatomy of this conversation is really helpful to spotlight. First of all, she starts by saying, I noticed some staining. Instead of saying what she thinks it's about, she says, what are your thoughts about that? So immediately she draws him into the conversation, and he hears himself say, smoking, wine, coffee, all those usual suspects, right? It's different for somebody else to tell you something than for you to put it into words and say it. And so I bring that up because part of the magic, if you will, of motivational interviewing is giving people an invitation to talk about things and say them out loud, because we hear things differently when we say them out loud, and with a little bit more impact, usually. And then she cuts to the chase. And this is fine, you don't have to do it this way, but she doesn't have much time, so she says, any thoughts on quitting smoking? And he's not feeling put off by that, and he answers honestly, no. He said, you know, I've tried, and it didn't work. I get it all the time. And so he elaborates on that, but it's clear to him and to her that this is something he's not at this point thinking about, contemplating. And then she has a little bit more, you know, lightness and humor. At one point she asks then an interesting question, what has been your past experience with smoking? So she invites him to look to the past, and there he tells the narrative of his own smoking, of he's been doing it, he hears himself say, I've been doing it for 40 years. I tried to quit a few times in my 20s, but my smoking has been pretty consistent, and I really don't see myself changing now. So again, he reiterates that stance that he's not ready to change. And her reflective statement back is, you've tried a lot of things out there. You could have, she could have said that in different ways, but you have thought about it, and there have been times when you thought maybe you ought to consider doing that. And she just leaves it hang there, right? But he then goes on to sort of keep saying, you know, none of it's going to work for me, although cold turkey is how some of my friends did it. And so he actually raises that possibility of cold turkey as being one way that maybe it could happen at some point. And then he says something which is, this is I think a critical piece. She said, he says, I get it all the time, and it's my choice. And she says, absolutely, it's your choice. You're absolutely right. Nobody can tell you what you should do. And there's that autonomy piece being affirmed, right? Which is so critical in motivational interviewing and in relationships in general. And then she asks a question that doesn't go to the past, but goes to the future. If there was a situation where you said, I must quit, what would that be? So in motivational interviewing, we often want to integrate questions that look at the current situation, look at the past, but then also invite people to imagine a future. And so in this case, she says, if there did come a day when you decided, you know, I've got to give these things up, I've got to give these things up, or maybe I've got to cut back dramatically, what would cause that to happen? And then he says, well, I don't know. I really don't know. And then he gets into the litany of how he's had prostate cancer and open heart surgery. And then he just continues to say, I just really don't want it. Don't really want it. And she says in a reflective statement, you pretty much see yourself doing this for a while. Notice she doesn't say, you pretty much see yourself doing this forever. That feels a little condescending and a little judgy, but you see yourself continuing to do this for a while longer, right? And then as they draw to a conclusion, she says, would it be okay if I brought this up in the next visit? Because I do care. And at that point, he's open to that, just given that she has built some trust with him, right? And then she has this kind of closing statement, which I think is a really beautiful statement. She says, wherever you're at, David, we'll work with it. Thank you for taking a few minutes and talking with me about smoking. And so that takes us back to, I think, Elizabeth's comment about, I like the way that she dropped it and said, maybe we can talk about it next time and let him choose that option. Absolutely. Any other comments before we move on about this interchange, anything that stood out or you have questions about, any thoughts, anyone at all? Yeah, this idea of meeting someone where they're at in the continuum of change is paramount. Absolutely. Absolutely. Yeah. And we also know that where people are at can shift and change too, right? We don't stay static all the time. Although in this case, David's still pretty resolute about he's not ready. But I do wonder when David leaves here, what might transpire? We don't know. And that's the thing about MI too, is that oftentimes a person's decision to change often doesn't come in our presence. It comes down the road, which is unfortunate for us and our own ego. But anyway, we hope that sometimes people will make those changes in our presence as well. All right. Well, I want to offer you a personal taste of MI. And you don't have to do this if you don't want, but I'm not going to ask you to share anything with anybody. I'm going to ask you to just do this self-reflective exercise. So if you're inclined, I'm going to invite you to think of some kind of dilemma that you yourself are facing. Maybe it's an attitude, maybe it's a behavior, something concerning you. It can be pretty much anything that you've been thinking about changing, but haven't changed yet. Or maybe you've made some attempts, but kind of drop back to usual behavior. And what I'm going to do is invite you to respond to about six questions that I'm going to ask that are designed specifically in MI. And they're not the only six by any means, but these are sample questions that we might ask of somebody to draw out motivation. Now, for those of you who can't imagine anything about yourself that needs to change, you know who you are. This slide is for you. Okay. So this is way too fine print, but you can see it, I think. But again, I use this as an illustration that there are so many different things that we can have conversations about with people, including ourselves, about change. So yes, you're going to see the standard drugs, alcohol, sex, and rock and roll, but you're also going to see things that are a little bit more subtle maybe about attitude sets or behaviors, like being overly critical or complaining or being unforgiving or worrying too much or being perfectionistic. I'm just hopping and skipping over these just to highlight some of them. Maybe it's around money management. Maybe it's around cleanliness in the house. Maybe it's around gossiping, food choices, fighting lost causes. It might be any manner of things. So assuming that you yourself have come up with one thing that you're willing to just have a little conversation with yourself about, and I'll be your guide, let's move ahead. And if you wish, you can jot down your answers to these questions, or you can just think about them. I'm not going to leave long, long pauses. So it's not like it's going to be, this is not a therapy session, although, because it doesn't include a back and forth. It's just me asking questions, which is not what we do in our approach. But I'm asking them for the purpose of highlighting some of the kinds of questions we can ask to elicit what we'll call change talk. So the first question is, what might be some benefits of changing in this particular issue that you're thinking about? What might be some benefits? What might be some positive outcomes? What might be some good stuff about changing that could happen? Another question we might ask, and again, you're welcome to put something in the chat box, but this is intended to be primarily a private exercise. It's up to you. But what might be at stake if you don't change? What might be some negative consequences or some bad stuff that could happen if you choose to just let things be the same? Yet another question might be, if you were to change, how might you go about it in order to be successful? There are many pathways to change, many pathways to recovery, many pathways to roam. What do you think might work for you? This is just conjecture at this point. What would you say are your three best reasons to change, or one or two or three best reasons to change? There are a variety of reasons perhaps why you might want to make this change that you can identify. What would be the ones that come to the top of the list? A fifth question we might ask is something along the lines of who could support you in making this change? We know that making a change all by ourselves without anybody else being in on the secret is possible, but not always easy. And it can be helpful to have somebody in your corner who is there to support you, to encourage you, to call you out maybe in a loving way. But who might that be? And it could be more than one person, but who's at least one person that that could be? And then lastly, if you were to imagine yourself sometime in the future moving and taking action in the direction of change, what might be the very next step or two in very concrete terms? You know, what would be something that like picking up the phone and making a call or purchasing something or talking to somebody or research something, but what for you might be a next step or two that if you're not ready now you could take in the future when you're ready to do that? All right, so I'm just going to leave this screen up for a moment and just invite you to either comment on maybe which one of these in particular resonated with you. I find that different questions have different kind of power for people. I'd also invite you to suggest questions that aren't here that could be here, because there are many here, especially ones that are focused on evoking change talk and helping open up the conversation for people to talk further about change. So you'll remember that some of the change talk types are desire, an ability to change, reasons to change, a need to change, a commitment to change, next steps to change. Anyone see any other questions here that you might ask that could also be woven in here? And I want to just be very clear, too. I'm not at all here suggesting that you go back to your work and in your next encounter that you say, I have six questions for you. Please answer these. No, not at all. These are intended to be woven in, and you might end up just asking one question, and that will be more than sufficient to get a really good conversation going. Well, some of the things that come to my mind that we might include would be, how confident are you that you could make this change? We might ask, what might get in the way? What do you think might be challenging for you, right? Any other thoughts? Yeah. What have you done so far in moving in this direction? Because oftentimes people have already taken a step back in moving in this direction, because oftentimes people have already taken some steps when they're thinking about it. Or what have you thought about? What have you done? You might ask, in terms of people you know who have made a similar type change, what worked for them? Or what do you know about how they did that? What information would be helpful to you at this point? You know, information doesn't necessarily mean that it's going to be the tipping point for motivation, but information can sometimes be helpful too. So yeah, there are lots. And the thing about MI is you're invited to use your imagination, and it's kind of like improv theater. You know, you don't have a script, but you have a few questions. You have a few things in mind about what you want to keep in mind. But it's really intended to be a conversation that is really coming from your voice, coming from your personality, your own quirkiness, your own humor, whatever that is, your own genuineness, right? Your own authenticity. That's what makes for the best MI conversation ever. Not when it sounds like MI, but it sounds like you having a genuine interest in somebody else and caring and listening and all of those things. Well, here are how most people feel when they experience a conversation with this kind of spirit and these kinds of questions. And I think you would all agree that this is what we would hope for in working with people. So I'm going to very pretty quickly go through this, but I want to just share a few thoughts. When we talk about the so-called spirit of MI, and the authors talk about how when they first started teaching motivational interviewing, they were really teaching the skills of open questions, reflective statements, affirmations. But they said, you know, we focused on these techniques, but over time we realized something was missing. And they say, as they watched people practicing these techniques, it was as though we had taught them the words, but not the music. And so it's this music, this richness that surrounds the techniques that is really this underlying spirit of MI. And in MI, we talk about it in terms of these four different elements. The first of which is partnership. And so again, we've already spoken about companionship. It's a collaborative relationship. It's demonstrating profound respect for the person, acknowledging that the person in front of you, regardless of any limitations they have, already has strengths, has expertise, has know-how. They have knowledge about themselves. And so we dance together, right? We also talk about acceptance as being prizing people for their absolute inherent worth and potential for who they might be and become. We know that acceptance also involves providing accurate empathy, accurate empathy being as accurate as we can be in making guesses about what people are thinking, feeling, hoping for, wondering about, concerned about, this kind of thing. And we do this through using reflective statements mostly. We support autonomy because we know that for everyone, we want to make our own decisions, particularly as clients are emancipating from home, right? But even before them, we all, that's part of being human is making decisions for ourselves, hopefully well-informed ones, but nonetheless. And affirming strengths also falls under this category of acceptance, of seeing people for the good stuff that they have inside them, that they do. This is, can apply to most anything. And then we talk about compassion, this idea of coming alongside people in their suffering or their difficulty. It turns out that the word passion literally means suffering from its root meaning. And so, come means with. And so, one way to think about compassion is coming alongside people in their suffering and walking there in solidarity in solidarity with them without trying to make it all better or fix it, right? And what I mean by that is by using platitudes, oh, this too shall pass, or you can do this, which is a little cheerleading, right? Or it might be related to some kind of a way of saying, you know, you know, it was meant to be, these kinds of things. Maybe sometimes those things are helpful, but most of the time, I don't think they're particularly helpful. Now, I mentioned earlier, practicing with compassionate detachment, which suppose could be described in other ways, but it's this idea that we respect client's power enough enough to not sort of rescue, not overtake them or step in for them when they can do something for themselves while extending loving compassion to them. And at the same time, it's respecting ourselves enough to not take on a person's challenges as our own, and thereby allowing it to sort of wash over us in a way that it kind of seeps into our being and affects our dreams and our every waking moment. We could spend a whole lot more time about this, and it might be a conversation you want to have in your teams, but I think this idea of compassionate detachment is a way of thinking about centering ourselves and finding that sweet spot where we are able to continue being helpful without being overwhelmed by what's in front of us. And I want to acknowledge that God, there's so much suffering in the world, right? Not just in our work, but all around us, and this is hard. This is challenging. This is not something that's easy, and it needs to be done, I think, not individually so much as with others, but how do we find the ability to continue on, to not burn out, right? To not be overwhelmed by compassion fatigue. And then the last of these is what, in the fourth edition, the authors are calling empowerment, and this is really helping people realize and utilize the already existing strengths and motivations and resourcefulness they have inside them. And it's kind of summed up in this quote from William Miller, you already have what you need inside you, and together let's find it, right? You already have a desire, a wish, hopes, thoughts, dreams, and abilities, and intellect, and passions, and let's uncover those. Let's draw them out and let them come see the light of day and explore them together. So, I don't know about you, but I find that these four elements really are applicable to not just my professional life, but to my personal life, and I find that these are really wonderful qualities of living my everyday life, and so that may or may not be the case for you, but if you're looking for an acronym, you can see one there, or you can make up your own. It's totally up to you. Some people like pace, some people like a cape, or something else. All right, any comments, thoughts, before we move on? Really appreciating your attentiveness. I know that two hours gets to be kind of a long time, but appreciate your hanging in there. So, let's talk about these four tasks that I mentioned earlier, the first of which is engaging, and then we find a focus, and then we evoke. This is where a lot of those questions come in, and then we also move into a planning phase potentially. So, engaging is something that happens obviously when you're first meeting someone for the very first time, but it's also something that is ongoing. It never goes away, and so maybe between sessions or between times you see somebody, you'll often start again by saying, hey, how's it going? How was your week? Tell me about that new part-time work that you took up. How's that going? How's your progress going towards finding your own place? You can just, but the idea here is you're, we're just finding out in general how the person's doing, and getting their temperature, and we're showing a genuine interest and compassionate curiosity for them, right? Now, this might take 30 seconds. It might take much longer depending on the level of trust there is. There are some people for whom engaging and trust is really, really hard, and so we continue to find ways to build the relationship, and for others it comes more easily. Eventually, we want to move into a situation where we are going to wonder, well, is this person at the place where they're ready to find a focus for something for us to have further conversation about? So, you might say, well, as you and I were talking just now, I heard you bring up this, and that, and one other thing. I wonder if one of those things would be something that we might want to talk about further, or maybe there's something entirely else, but it's kind of our way of moving from engaging to focusing, and when we get to that point of readiness, we will ask somebody, well, what would you like to spend time talking about? What's important to you right now? What's most important? What matters to you? What can we look at together? And yes, it might be about problem-solving, something that is having to do with concrete actions, and you go with that if that's the case, but it might also be, and you can seed the conversation by saying, you know, sometimes people want to talk about relationships, or sometimes people want to talk about what it's like to move out of your home, and some people might want to talk about their drinking, or their substance misuse, whatever. How about for you? What would you like to talk about? It might also be that you have something that you feel compelled to bring up, and so you might say, I would like to talk to you as well about such and such. Where shall we start? And so it's, again, this invitational approach, but it's for the purpose of moving, not just from, shall we say, small talk or interpersonal talk, to finding something where we can begin to explore. It might be for some people that it would be useful to create a little chart, a visual of some sort, and write in the circles all the different things that you might talk about, and then find one that seems most important. Imagine you already use these kinds of devices to help with conversation, where maybe verbal skills don't come as easily for some people. Once we have a focus, and the focus might change along the way, but we want to start asking ourselves, do we have an understanding of what they would like to spend time talking about in the moment? Are we working in a common purpose? Do we have a sense where we're going? And then we might begin to ask questions, and these will start sounding familiar to you, although, again, there's multiple ways and content that we can ask, but we want to focus we want to focus these questions on things that will elicit change talk. So, what might be some benefits of making a change in this area? What might be at stake? You can tell these are my favorites, right? But you can come up with your own favorites. How might you go about it? These all map onto those different change talk approaches that have been identified, right? What are your best reasons to make this change? How important is it for you to make this change at this point, given everything else going on? How confident are you that you could make this change, and so on and so forth? So, this is a piece where I want to just focus in on adapting MI, particularly around the evoking phase, but in all aspects, to working with people with IDD. And this is coming from the source at the bottom that I've really come to appreciate, and you may be familiar with it. I'm going to go through these ever so quickly, but I think they'll be familiar to you and probably come naturally to you. But we adapt the language level, right? And find language that this person is likely to best understand. We keep things clear, concrete, simple. We use short sentences. We don't use long paragraphs. We focus the question on something very specific. We start questions with how, when, what are your thoughts? Keep them simple, right? We generally don't want to use the question, why? I think there's times we can say, well, why do you think that was? But when we use why in a way of sort of pinning people against the wall, why did you do that? That's not a good use of why, right? Don't pile questions on top of each other. Just ask one at a time, right? These are good skills, by the way, for all of us, not just for people you serve. Provide ample time for people to respond. Maybe it takes time to articulate something or to bring it to mind. Be patient, allow that to happen. Ask every question only once, right? Or you might end up asking questions in different ways if the one way that you have asked it doesn't resonate. If someone doesn't understand, try rephrasing it. Try using picture language, try role-plays, try, and you could give me much better ways of adapting than probably I can. And Sophia, you're right. Why tend to trigger a combative response? Yeah, yeah. If somebody has difficulty answering, give them maybe a menu of options of what might be the answers that they could potentially be thinking about, but acknowledge that maybe it's not either. But sometimes it is helpful to seed the conversation in a way that helps people maybe borrow from us, right? Constantly testing for understanding and acknowledging and letting clients admit that they don't understand and saying to them, it's perfectly fine if you don't understand, please ask and we can make sure we find a way so that you do help people verbalize their thoughts and feelings. And so this is moving towards a deeper kind of conversation, right? And sometimes people don't know feeling words very well. And so maybe we, again, offer, sometimes we have charts with feeling words on them. And so we use that and we ask people, so which of these words maybe best describes how you're feeling right now? Help people with structure of their language if that's necessary. Summarize what was discussed. I find this so helpful in motivational interviewing. It's one of the skills is that we have a brief conversation maybe for five minutes and then we say, so let me just summarize here. Let me just see if I got it right, right? And then we make the key points and then we say, what your thoughts, what did I miss or what would you add to that? Helping clients imagine hypothetical situations if possible and imagining, so if you were to do such and such or if this were to happen, what do you think you might do, right? And obviously assisting clients and making connections between the advantages and disadvantages of change because every change comes with some downsides because it's change, right? But here we can ask people even simple, what do you think might be the good things about making a change? What might be some of the hard things or not so good things? And just have that conversation. Let me just pause for a moment and see what you all wanna add to that or other kinds of things that you might apply, suggest here for adopting our conversations so that they work well for people we serve. All right, again, I appreciate you're hanging in there. So we might end up moving to planning. And so the miracle question is when it comes up, yeah. You might ask, so, you know, if all the stars aligned, what would be the best possible outcome here? That kind of thing, right? So when we move to planning, we're, you know, sort of, we don't wanna push prematurely towards planning, but we don't wanna miss the opportunity if somebody's feeling ready to make a step or two. We might wanna review what the person's reasons and values are for making the change. You mentioned this, and that might be a good thing about it. And so we can, you know, reinforce that. We can also reinforce the strengths and skills that people have by us naming what we see or even asking them, what do you see as the strengths and skills that you bring forward to this situation? And ask, are you feeling ready to move ahead? Are you feeling ready to at least give this a go? And we might, excuse me, also say, you know, here's what I've heard you say. It makes me wonder if this is a good time to look at options to move ahead. And so a change plan might look like, so let's say specifically, what is the change that you're wanting to make? And then we can break it down into small steps. We can repeat what the reasons are, strengths, skills. Starting to repeat myself here. The next steps I plan to take, how will I know if it's working? Who will I turn to if I get discouraged? How can I, as your counselor or whatever your name is, how can I be of assistance to you? How can we celebrate successes along the way? These are all pieces that might be part of a change plan, right? And you have a copy in your handouts that you'll be receiving, your MI handouts, it's 20 some pages, but one of them is a change plan worksheet if you find that useful. And you can adapt them, of course. Well, I'm gonna show you another video here. And I acknowledge this isn't about working with people with IDD. I simply could not find an MI video in that genre, if you will. The reason I wanna show you this is because oftentimes when we learn about MI, we learn about it and read about it and see case examples that come from a very Eurocentric, very sitting in the office kind of approach, clinical kind of way. And I wanna just say to you, there is nothing that requires practicing MI that requires sitting in an office across from one another or in a dental chair. And I appreciate the comment earlier that one of you made about, what if he had been invited to come out of the dental chair and just have a conversation side-by-side? That would have even been better, I think, for an MI conversation. But this is a street outreach scenario. I was involved in helping sort of create it. And by saying that, I wanna be clear, we did not script this out at all. It's totally spontaneous. Raquel Garcia, who you're looking at here on the screen, is somebody who's been a colleague. And we asked her to go ahead and do a demo of a street outreach encounter using MI. And JC, who you're gonna see in the other screen, was somebody who was willing to play the role. Now, it turns out that both are people with lived experience in homelessness, struggling with mental health and substance use issues. They both come with their own recovery story. But what I love about this video is that it portrays an encounter that is stripped of all the kind of, I don't know, niceties, if you will, in some ways. And it's just a real, genuine encounter. And it is motivational interviewing in action. And so it also brings up some kind of cultural differences that we might see too. So I'm gonna invite you to look at it and just enjoy it for what it is, but also see what you see in it that might be useful for adapting to your own style. Because remember I said, MI at its best is about you being you and using your own style and personal characteristics to move forward. So here goes. Hey, JC, how you doing? Hey, girl, what's up? Good to see you again. It is good to see you too. I ain't seen you around here in a minute. What you been up to? Just trying to make it. I mean, you know, hustling, nickel and diamond. You know, they tried to tell me that if I do anything more, I'm gonna probably end up in jail. So it's like, what can I do? Just, it's always kind of like not quite making it. Just not quite making it. Well, what is making it? What does making it seem like? Is making it for me is different than making it for you. So what's making it? Making it. You know. So I'm seeing the request to click the CC button. So I'm gonna do that and see if that makes a difference here. And there's also one on the YouTube screen on the bottom right. Oh, okay. Let's try that. Let me get rid of some of this here. When you, oh yeah, there it is. Okay. All right, let's try that. doing? Hey girl, what's up? Good to see you. It is good to see you too. I ain't seen you around here in a minute. What you been up to? Just trying to make it. I mean, you know, hustling, nickel and diamond. You know, they tried to tell me that if I do anything more, I'm gonna probably end up in jail. So it's like, what can I do? It's always kind of like not quite making it. Just not quite making it. Well, what is making it? What is making it seem like? Because making it for me is different than making it for you. So what's making it? Making it. You know, I'd love to be able to take a girl home, take a girl out like you sometimes, you know? I'd love to be able to ride around in the car like the boys I see all the time, be hollering at the car. You know, I'd like to have a place, you know, instead of sleeping over at somebody's house all the time. You know, my own place, my own stuff. All the time, bumming. I'm tired of it. Tired of bumming. Yeah, girl. So I'm hearing you ready to level up a little bit, JC. What kind of, what kind of, what do you think a girl like, you know, a girl like me and them girls you want to take out, what do you think they're looking for, JC? I can't handle it. I tell you right now, high maintenance. I'm just hoping that I can eventually be able to live like a normal person. I'm just, I'm tired of the hustle. It's every day, day in, day out, nickel and diamond. I just like to be able to relax, you know? And then I'm sure, you know, like myself, man, I, you know, I can pick up a girl here and there. That ain't no big deal. Well, you got some good, you got some good sales skills, JC. Why don't you apply those a little bit differently, brother? What do you mean? Like how? Make some money selling cars one day. There's a lot of things you can do to make money. I tend to used to be a hustler, but now I tend to hustle money a little differently. Not in the way I used to on the street. Girl, you know, I got some bad paper. I don't know if they'll let me in the damn car place. They probably think I'll be taking their cars. Look at me, girl. They won't let me up in there. I mean, there's all kinds of sales jobs that you could apply that skill to, JC. Oh, well, like, well, you know, talk to me. You know, I can't go in there making no 7.95 or whatever. What is the damn minimum wage nowadays anyway? It's the same as it was when I was a kid. No, the minimum wage is up. Minimum wage out here hustling. Nickel and diamond. Nickel and diamond. Yeah, but I hear you're ready to trade all that hustle in for stability. I hear you're ready to trade all that in for what you said was a normal life. So what's that normal life? Is it getting up? Is it running your own schedule? What's that normal life look like for you, JC? You know, I had a normal job since I was a kid. I think I threw newspapers. You know, that was the last time I had a job working for the man. I think it looks like, you know, I get up in the morning, you know, shower and shave. There's some other essence in there somewhere. But, you know, I basically, you know, you have responsibility. You know, I want to be responsible for myself. But, you know, it'd be nice to to be able to branch out a little bit. Maybe even one day have a family. You know, I can't get no family out here. I can hardly take care of myself after time. That sounds like a beautiful dream, JC. I hear you want to have a family and some stability and maybe a little bit of rhythm to your life. You know, people call it obedience, but you and me don't like that word. Just a little rhythm, right? A little stability, a little rhythm to your life. Sounds like you're ready for that instead of that like reactive hustle all the time. It's exhausting. It's tiring. Yeah. So are you open? Are you open into are you open to education? Are you ready? Would you be willing to try and learn something new? Are you going to teach me? I got people that will if it ain't me. I'm not a teacher. It ain't mine. It is not. That's not my role. But I might have access to programs and things like that that you could at least start looking into. Curiosity. Curious. I see it in you. Yeah, I'm kind of curious. I mean, you know, you ain't never talked to me like this. I just I just thought you was out here helping them homeless people. I'm not homeless. I'm not like them. You know, I could at least speak in whole sentences. Yeah, but you deal certain things and I deal hope and opportunity in a different way. Oh, damn, that sounds nice. Hope and opportunity. Well, show me then show me what it is you're talking about. I'd be willing to look at it. You know, I'm not making no promise. But, you know, if you got something to show me, I'll take some time to look at it. I got a good friend named Shana. She runs an organization. She can help you look into that kind of thing. Look at your strengths and the things that make you you and see where you can apply the skills you already have to get the life that you want. Is it something you're interested in? She ain't gonna be like investigating me or nothing like that. Nah, she's one of us. You'll love her. I wouldn't bring you. You know, I wouldn't drive you. Come on now. You know what? I like you. So I think I'll go with you. Take me on over there. Yeah, I got you. Come on. Come on. Let's go have some coffee. I'll give her a call. She'll meet us over at the shop. You called me out girl. Coffee. Let's go. Let's go. So out of curiosity, what do you think Raquel's hopes going into that conversation were? It's not quite so simple as she wants him to get to stop smoking. So what do you think she had in mind? What was what was behind her thinking as she went into that conversation? Any thoughts on that? Yeah, I think absolutely this idea of keeping him engaged and re-engaging and empowering him, letting him see his own power to get him thinking, to create some curiosity in his own mind, to open it up, help him realize his potential, to see his potential, see himself in a different way, determine what's important to him, all of those things, absolutely. So those are hopes I think all of us hopefully carry with us in our work, right? Whether or not it might be more concrete than not really depends on our role. But again, we're back to meeting him where he's at and capitalizing on his own desire to do better, which clearly comes out, right? Yeah, this more than nickel and diming, it's something that he says repeatedly, right? And she picks up on that and she even provides sort of a simple reflective statement sometimes repeating exactly what he's saying just for emphasis. But she asks some key questions then too, doesn't she? What's a normal life look like for you? What are your thoughts about using your skills in different ways? Curious? You know, this kind of thing. So yeah, again, if you've seen one example of motivational interviewing, you've seen one example of motivational interviewing and each one will look different. And so this is why we practice and we try it out and even with different clients, it's going to sound a little different and the approach we take. But her methods were to ask some really key open questions to affirm his strengths and to really listen well to him. And Elizabeth, I'm seeing you say, I like that she said your idea of it is different than my idea of it. So what is it for you? That's a really lovely way of affirming the distinction and even the autonomy piece of that. Absolutely. And so the outcome in this case is that he was ready and willing to at least go have a cup of coffee, right? And to check it out. And I think the other thing I'll just comment here before we move on is she really, I think, does a really nice job of sort of letting go and keeping to the side the obvious misogyny, the obvious criticism of homeless people and putting them down. I mean, there are things he says that are, you know, they're distasteful, absolutely. And that's not for now at least where this conversation was going. And so I think that's worth noting as well. All right. So in the time we have remaining, I just want to go over a few more things. One of the central roles of, or one of the central themes in MI is this belief that it's ambivalence that gets in the way of change. It used to be when MI was, or before MI came about, and when we would work with people with substance use issues, it was believed they were in denial, that they couldn't see the consequences of their actions, that they didn't even recognize their behaviors. And that has shifted over time, certainly with MI, to believe that people live with ambivalence, that it's normal. We all live with ambivalence. And it's this simultaneous presence of competing motivations, both for and against change. So you've probably seen this symbol comes from the state south of us here. But I found this meme many years ago and thought it was pretty funny. But it really is the epitome of ambivalence. We kind of want to do something, but not really, right? And we see ambivalence in the air. We see it in quotes, in song lyrics. My sweet tooth says I wanna, but my wisdom tooth says no. Or I feel so miserable without you, it's almost like having you here. Don't try that at home. One of my favorites comes from Gillian Welch. I wanna do right, but not right now, right? So ambivalence is everywhere. It's within us, it's within our clients, and we want to explore it. And one side of ambivalence is what we call sustained talk, keeping things as they are. And the other side of that is change talk. I want to, but, is often what it sounds like. And so, depending on where we want to go with the conversation, we're likely to have a more fruitful conversation if we go with the change talk and explore it and strengthen it, as you can imagine. I'm going to show you yet another video. I'm going to see if we can get the closed caption on this one too. This is a brief video with Billy Miller some years ago, talking about what happens when you meet somebody who's ambivalent, and you come forward with what we call the writing reflex or the fixing reflex, trying to make it all better. And I can virtually guarantee that everyone in this seminar has fallen to the temptation of trying to fix people up one time or another. It's just human nature. It's nothing to be ashamed of. It just is. But we also have to resist it in order to be able to be helpful to people. So let's take a listen. Well, Steve Rowling and I have written about the writing reflex, which I think comes with being a helper. It comes with wanting to make a positive difference in people's lives. I don't see that the CC is working. I'll try it one more time, but sorry if it's not. It's not where I wanted to go. Well, Steve Rowling and I have written about the writing reflex, which I think comes with being a helper. It comes with wanting to make a positive difference in people's lives. And when you see someone going down the wrong road, somewhere that's going to lead them to painful outcomes, you want to run around and get in front of them and say, stop, go back, don't you see? Go this way instead. And it's just a natural outcome of that desire that draws us into helping, which is fine. But the problem is what happens when you do that with an ambivalent person. When you take responsibility for the change, when you say, this is a problem and here's what you need to do, you elicit from the client exactly the other side of the ambivalence because they have both sides inside of them. And so they're then likely to say, well, it's not that bad or I'm not sure I need to do that. And you wind up kind of acting out their ambivalence between the two of you with you taking the good lines and you're leaving the more resistant or reluctant lines to the client. And that's not good because we hear ourselves talk. And as I hear myself talk, I get committed to what I'm saying. So ironically, if you follow your helper instinct and try to advocate for and persuade and coax and cajole and coerce and confront people into changing, you can actually have the paradoxical effect of eliciting from them lots of resistance, which makes it less likely they're going to change. And so I think that those behaviors come out of the best of intentions and come from a heart of wanting to help. But we have to learn to suppress these. And after 20 years of practice more, 25 years of practice of motivational interviewing, I still have to suppress my writing reflex and my desire to take up the good side of the argument now because I know that's not the best thing to do and instead to let the client make those arguments. All right, I'm going to continue moving ahead. I will say it's always heartening to me to hear William Miller say after 25 years of practicing MI, he still has to resist that temptation. Again, just in terms of imagery, we can look at clients as being a glass filled or a glass empty. And of course, we want to see them as already filled with many things. And there's a certain inherent ambivalence here. There's hurts and hopes or a dichotomy rather, nightmares and dreams. There's addictive behavior, but healthy desires. We're all a little delusional at times, but we're also wise and so on and so forth. And so am I really, instead of saying, well, I need to give people what they lack. Instead, what we want to do is evoke from people what they already have inside. And the idea here is that people already have substantial expertise and wisdom about themselves. And that if we offer them a condition in which we offer positive direction and give them proper conditions and support, they will be able and willing to access that many times. It's not unlike growing a seed. We can't make a seed grow, but we can give that seed the proper conditions in which to grow, and then hope that it will grow. Again, this quote, you already have what you need and together we will find it, I think is a really helpful guiding mantra for how we go about our work. So this brings us to use of the skills in oars that we use. And again, given time, I'm going to do a quick bounce through these. But I'll say this, that in learning MI, it requires practice, and it requires practice to use these skills. And that will be for another day potentially for you if you've not already had training where you actually practice and get accurate feedback in your practice. But I will say this about the oars. If they were a rock and roll band, such as the Beatles, the one that would be the most prominent, actually the lead singer, would be reflections. In this case, John Lennon. And second, coming in second, would be use of open questions. Paul McCartney here, if you can abide by my analogy. And the affirmations and summaries, which are used less frequently but are still critically important, would be in the background with George and Ringo. The point here is that in most therapy styles, you'll find that the preponderance of approaches include questions, closed and open questions. And that's not all bad, but it turns out that in MI, that gets flipped on its side and end. And we actually want to use more reflective statements than even questions, maybe one-to-one or two-to-one or three-to-one even, which means we tend to want to lead in MI with a reflective statement rather than conjuring up a question to ask next. Partly the reason for that is because questions, as helpful as they can be, can also start being interrogative and they can start demanding information from people kind of in a subtle kind of way, whereas reflective statements serve a similar purpose of drawing people out. But they're much softer, they're much more intuitive, and they actually allow people to think reflectively more so and to move forward. And so that's in part the rationale for why we want to lead with reflective statements, do more reflecting, and then open questions, and certainly tossing in affirmations of people's strengths and summaries, which are really just a collection of reflections. And so, um, I think, you know, open questions have many purposes. It makes a difference. We know that we normally, at least most human beings, naturally try to frame questions as closed because there are so many ways to do it, as you can see here, but oftentimes when we ask an open question, it's going to sound like, well, tell me more about that, or help me understand, or what was that like, or how was that for you? It might be, why do you think that happened, or what are your thoughts, or why do you think you might want to make, take a different approach sometime in the future? To what extent did that work for you? To what extent do you want to try something different? If you were to, and here's that future-oriented phrase that we might use, if you were to, in the future, consider making this change, or if you were to, what are your thoughts about how you might go about it, that kind of thing? And so, if somebody were to say, I'd like to do a little part-time work to get some extra money in my pocket, but who's going to hire somebody like me? What might be some open questions we might ask? And I'll invite you to put those in the chat box, just as a playing around with this a little bit. What open questions? Ah, Justin, yeah, someone like you. I really, I appreciate your starting with that, because I think that is the most germane to this sentence that this person says, right? But that said, we might also ask, and phrase it differently, too, but we might say, when you say somebody like me, what does that mean? But we might also want to learn about their interest in work, and getting some extra money, and how that might benefit them, and things like that. But I think, Justin, you kind of nailed it in terms of what I consider the priority question here. All right, I am going to just offer up a few of these. I realize I'm moving fast. I'm going to provide all of these slides to you, should you want to come back and take a look. But I want to take a few moments yet to look at reflective listening, and at the affirmations before we go. And I'll just say that a reflective statement is basically like in physics, in this case, a bending back of words, or ideas, or a remark that we make in turning back one's thought on something they said. I'm not going to show this video, although it's very funny, but we'll save it for another time. But reflections are offered as statements, not questions, and the inflection at the end of the reflection actually goes down as compared to goes up in most of the way that we talk. Reflections follow, and so you can't have a pre-arranged reflection I'm going to make to somebody. You can have a pre-arranged question, but the reflection means you're listening intently, you're hearing what the person is saying, and then you're making an educated guess. Maybe sometimes we reflect immediately back like Raquel did with nickel and diming, but most of the time we want to reflect back something that goes beyond the words and makes a guess about what's surrounding the words in terms of feelings, or thoughts, or hopes, and that kind of thing. This is not about you reflecting your advice or your counsel. This is about you reflecting back what you heard from the person, and what the meaning is behind it. And sometimes it's simple. We just make a guess or paraphrase a little bit and don't go far beyond the meaning, but sometimes we do. Sometimes we, not far afield, but we make guesses that I get a sense that you're wondering if, or you're feeling that, or perhaps so on and so forth. So in case of an example here, if we're talking about with somebody about an example of a reflection, the client says, my drinking has increased in the past year. Well, a simple reflection might be you're drinking more than you used to. It doesn't really go beyond anything. And that's fine, but if you keep just doing simple reflections, it'll get old and wearying very quickly for both of you. But if you guess what the person means, you might say something like, you're really noticing a difference, or this is different than it used to be. And that's likely to invite more conversation. Or you might look at the person's feelings or values. You're concerned about this increase in your drinking. Again, you're making a guess, but you're picking it up from what you're seeing. I want to say this about making reflective statements. There are many ways to start a reflective statement. The very first one you see here, it sounds like, is very commonly used. It's not wrong. It's great, in fact. But what happens is sometimes we get to using things repetitively, and then we start feeling like a reflection machine. So I would strongly encourage those of you who are working at deepening your reflections and also varying them to really begin to think about using different sentence stems. And you can see some of these guide you to look at the past or guide you to look forward to the future. Some are focused on feelings, some are focusing on aspirations, and so on. So, once again, I'll just offer this as an example as we soon come to a close. But what might be a reflective statement sound like here? Well, it might be you're worried whether somebody will hire you, or you're feeling like there's something about you that's undesirable, or you're concerned about that tattoo on your face if you observe something like that. I mean, again, it could be many things. It might also be, you know, you're interested in getting something that will give you a little more opportunity to go to do fun things, whatever it is, right? All right. Well, what I'm going to do is I'm going to stop share here for just a moment, and I'm going to...I don't think you can see this right now. Have I stopped share? No, I haven't. There we go. All right. I just want to jump to a few more slides, and then we'll be done. This always happens for me. I never know how much ground we're going to cover, and it's just the way it is. So, I invite you to certainly look at the slides, read the materials I've sent, but I just want to say a few more things as we close in the next few moments. Let's see if I can find this sharing button again. All right, and thank you for staying an extra minute if you're willing, but I just want to say that MI is something that can be integrated into your work regardless of the kind of work you do. You might be a case manager, you might be somebody who is just passing conversations, but you can still incorporate the spirit in some of these things. But in general, these are my own ways of saying breathe, let that spirit guide to where you go, find the ores and use them to know where you are in the process and to elicit motivation, focus on people's goodness and the good things about them, and invite them to action. And just as a way of summarizing a few key ideas here, this is not an expert recipient relationship. This is a partnership. Acceptance and compassion are always at the heart of this conversation and people, even if your techniques aren't all that stellar, your acceptance, compassion, your integrity, your authenticity will come through and that makes a huge difference, right? Motivation to change is elicited from a person. We don't motivate people, we create the conditions under which they can hopefully feel more motivated. We also know that direct persuasion is rarely helpful, that we primarily use a guiding style, and that it's the task of the people you serve to resolve their own ambivalence and determine their own reasons for change and determine their own readiness to take action. So many ways to continue the learning. Again, I'll send you a few things that also speak to this, but if this is of interest to you to continue the learning, and I hope it is for all of you, regardless of where you are in your learning journey, I invite you to do so. And so, Emily, you want to say anything about this? Yeah, this is just the link to a quick survey about today's session. Your feedback is really important to us. I also put the link in the chat, so you can just click that. You don't have to fill it out right now, but it will just open it up and you can fill it out whenever you have time today. And we really appreciate your taking time to fill it out because it helps us maintain our funding. And I'll just say thank you, and then I'll bring it back to that. And so appreciate being with you, appreciate your attentiveness, and I hope you have a wonderful remaining part of the day. Thank you. Thank you, Ken. Thank you, everyone.

motivational interviewing

empathetic dialogue

Ken

partnership

acceptance

compassion

empowerment

guiding style

ambivalence

intellectual disabilities

developmental disabilities

interactive resources

nonjudgmental

supportive approach

personalizing practice