I think everyone's in, so good morning. Thank you for being here with us. My name is Emily Mossberg, and I am a technology transfer specialist with the Opioid Response Network. Before we start today's training, I'm going to briefly just share some information about the Opioid Response Network and the work that we do. So the Opioid Response Network was initiated back in 2018 in response to the opioid crisis in our country. We are funded by a grant from SAMHSA to provide no-cost training and consultation to enhance prevention, treatment, recovery, and harm reduction efforts across the nation. To do this work, we utilize a pool of consultants who are located all over the country and who can respond to local needs. We operate on a request basis, and anyone can submit a request for assistance on our website at OpioidResponseNetwork.org. Today, we are honored to be here with you to provide an introductory training on motivational interviewing. Please note this session is being recorded and will be available for sharing in about two weeks. And before I introduce our presenter for today's session, I'd like to open our session in a good way by sharing a land acknowledgement. Our work intends to reach the addiction workforce in the Northwest TOR region. This includes Alaska, Idaho, Oregon, and Washington. This region rests on the ancestral homelands of the Indigenous peoples who have lived on those lands since time immemorial. Please join us in support of efforts to affirm tribal sovereignty and explain respect and gratitude for our Indigenous neighbors. We acknowledge and honor all Indigenous communities, past, present, and future. All right, today's session will be led by consultant Dr. Cody Chipp, and I will now go ahead and share his introduction. Cody Chipp is a licensed psychologist and organizational consultant. Dr. Chipp has provided clinical services, research analytics, and organizational leadership to enhance behavioral health services throughout Alaska for 20 years. Dr. Chipp provides comprehensive clinical services, research analytics, and organizational leadership to enhance behavioral health services throughout Alaska. Prior to starting his independent practice in 2022, he was the Director of Behavioral Health at the Alaska Native Tribal Health Consortium for nearly five years. In this role, he directed initiatives to promote statewide behavioral health service capacity and enhancements across the Alaska Tribal Health System, including the launch of the Behavioral Health Wellness Clinic. And with great gratitude, I will now pass it over to Dr. Chipp. Hello, good morning. Thank you for the opportunity to be here and connect with you all today. Of course, as I start talking, my dog starts barking, so that's not going through too much. She has a lot to say, but anyway, thank you. Today I'll be doing an introduction, as the slide implies, and why you're all here around motivational interviewing. You will not leave this next 90 minutes as an expert in motivational interviewing. That takes significantly longer, but I think I'll be connecting with a number of you, if not all of you, here in a couple of weeks. To do a more in-depth training around motivational interviewing. But I do hope you walk away with understanding what motivational interviewing is and what it is not, as well as some skills that regardless if you're able to attend the day and have training or not, that might be helpful in some of the work that you do. Also, Trish Colgrove has shared some of the background work that your tribe and your team has done over the recent years, and it's incredible work. I'm really excited to connect with you and learn more here in a few weeks. I'm going to skip over some of these things, as Emily has already covered them, the role and how to connect with the Open Response Network. I don't have any conflicts of interest that I'm aware of to disclose today. Some of the objectives that I hope you take away from our time together today is to look at and be able to describe what stages of behavior change are, what the spirit, underlying intention of motivational interviewing is, and at least one skill that you'll be able to walk away with today. Before I continue on, I just want to do a quick audio check, just make sure I'm coming through okay. Is that everything okay? Okay, great. Again, I'll be walking through looking at what are stages of change and also reasons why people don't change. All of us here today have probably had some things that we'd like to do differently in our lives, or others would like us to do differently in our lives, and there's reasons why we don't do that. I will talk about that, as well as looking at some skills and techniques to help increase behavior change. We'll do a couple of questions here. We'll do one at a time, and Emily will pull up the poll. Why we're using the poll, well, we can't, unfortunately, can't share the direct text. Well, I won't get into all that. I won't get all the technical stuff, but as you answer these questions, you can give an example of a health behavior that you've tried to change in your life, be it that you've been successful or not. It's okay if you've tried to make a change in your life, and it wasn't successful, or you did make a change in your life that was successful. If you could share that, and this is anonymous. We're not using the chat box for that reason. We're using the poll to keep it anonymous, and so we're just going to start with the first poll question here. If you could share an example of a health behavior that you've tried to change in your life, for example, quitting smoking or exercising more, changing diet, maybe less phone use, not checking your work email at 10 o'clock at night, things like that. I'll give you a minute or two to answer. at 11 of 17 participants. We'll just give it a few more seconds here. Right, I think we can, most everyone has had a chance to answer. So we'll go ahead and take a look at those results. Is it only showing individual answers? I click on share, but I think it only shows your response. Okay. All of them in the. Yeah, unfortunately the text-based poll questions, it doesn't, like, blast them all out. So thank you, Emily, for putting, again, these are anonymous, so putting the response that people provided in the chat here. And so just to kind of read these out loud, reacting to someone being rude to me, eating habits, exercising more, walking more, been 10 years since stopped using cigarettes, daily walks, medication, more activity, going to, getting mental health support, canceling medication, being more active, eliminating coffee, and again, healthy eating, exercising, sleep, awesome, and again, being more active, exercising more. So I would say 90% of these are things that I also would respond to, and probably many of us on the call today. And so thank you, thank you for taking the time to share that. And as I think, you know, while I'm not asking people to speak to this directly, as you have all probably likely experienced, making a behavior change is very difficult, right? And not only, you know, making the change itself, but maintaining that change is incredibly challenging. And so, which leads to our next poll question, in your experience, either directly, like, in ways that you've tried to make a change and that change didn't occur or wasn't long lasting, if you could share what that might have been, or if you don't feel comfortable sharing that, maybe something you've seen among others that people have tried to make a change and it didn't occur. So we'll give you a few minutes to reply to that poll. Okay, we got just about everyone filling that out. Give it just another second or two, or a moment or two. Thank you. Thank you, Emily, for closing out that poll. We'll just give it a minute here. We'll look at the results in the chat. Thank you. Thanks for Emily for putting the, so in the second block of text in the chat, or reasons that people have either experienced themselves or seen in others, why behavior change doesn't occur. So, so habits kind of ingrained, you know, things that have just been the way they've been for a very long time, stress, fear of change, making the time, never addressed or ignored it. Not recognizing that a change might need to occur, that the behavior is being harmful to themselves or to others. Certainly peer pressure, kind of the procrastination, low self-worth, kind of this perspective of discipline, right? Maintaining that change. Occupied behaviors, it's great. So it's another, definitely a difficult one to overcome. Yeah. And being too busy. Absolutely. Absolutely. And these are all great examples of what we might say is kind of maintaining the status quo, maintaining the status quo of behavior. And again, we'll, we'll get into that kind of more and more directly here around kind of what, what the role of motivational interviewing is and how, you know, when we're looking at behaviors, what our goal, goal through that is to help kind of move past the status quo. So, and so when, and thinking about the, the, the individuals you work with in your, in your roles, reasons why behavior change might not occur, right. And you've kind of all kind of hit on most of these, even in your, in your own words here, and the advantages outweigh the disadvantages, right. So like, so, you know, the, it's a lot, it's a lot nicer and easier in the moment, in the short term, right. To sit on a couch, watch Netflix than it is to, you know, get up and run and, or, or, you know, go do exercise, a feeling of shame and kind of holding oneself back. And again, people mentioned low self-esteem or low confidence feeling like they don't have the ability to make a change. I've tried in the past and weren't successful. So I do have previous failure, some mental health concerns can stay in the way. Again, this lack of acknowledgement, somebody put being not accountable, but some people just lack the information on, on why the behavior might be harmful. You know, some of the stuff that, that we might do in our lives as modeled by our family. And like, that's just, you know, like that's okay. And that goes along the lines of peer pressure too, around, you know, making a significant change in your life might, might feel like you're alienated from your family. And, and kind of, again, kind of that peer pressure nagging harassment for others. So there's a lot of reasons why behavior doesn't change. Right. I think if, if, if it was easy, we'd all be very, very happy or not happy, be very healthy, much healthier lives. And again, there's a lot of competing demands, a lot of pressures to keep, keep our behaviors the way they are. And part of it, this all lines up with kind of what's, what's called the stage of the change. Some of this is probably review for, for most, and some of this might be new information for others. So I'm just going to walk through them. And so these, these researchers that are up, this is often attributed to, or Prochaska and DiClemente, quite, quite some time ago, 1983. So about four years ago, where they're looking at like, what are kind of these stages of change that people go through as, as they, as they navigate a behavior change, be it, you know, reducing alcohol use, reducing tobacco use, engaging in healthier exercises, you know, eating healthier foods. And, and they've kind of broken down these, these stages of change. And while the, the, there, you know, we talked about on the stage as it's almost like a linear, like a straight line. It really isn't, people kind of bounce back and forth and then kind of hang in between a couple of them. But, but it helps kind of just kind of put some buckets around kind of what are some general ideas around what are these stages of change. So the first area is this idea of pre-contemplation. So it's like not even thinking about, not even thinking about making a change, not even considering it, it's not even on their radar. So it might be somebody who has a problematic alcohol use and, and they don't, they don't see the issue. They don't even mean, you know, they're, and they haven't faced any issues that, you know, any relationship issues or health issues or, you know, legal issues, things like that. They're just like, it's like all fun and games, right. And they're not even aware about, you know, the thought of a change just doesn't, doesn't make any sense. Versus contemplation is where, where this is where people sit a lot of times and thinking about making a change, like they know what they're doing isn't healthy. They want to feel different. They want things to be different. But they're not ready yet to make that leap into, to, to change. And so this is where people spend a lot of time thinking about a change. You know, they might've had family members say, you know, I don't, I don't like it when you, when you, when you show up to, you know, family dinner intoxicated, or you come home late, or, you know, you know, you're, you're on your phone reading your email, you know, during, during dinner or, you know, things like that. These are like, you know, where they've heard, heard voices, you know, from their families and friends about, you know, how their behavior might be impacting them, or they, they themselves say, you know, I don't, you know, when it comes to alcohol use, I don't like waking up hungover, spending a lot of money, I'm fighting more, I don't feel good. You know, those are these kind of this idea of this contemplating, I wish things were different. Then people go kind of from contemplation to preparations, we're planning for the change, you know, thinking about like running and exercising more, somebody might, you know, start looking at getting a gym membership, or maybe getting new shoes, or trying on new clothes, and kind of, you know, thinking about like, you know, for me to be successful, what do I need to do to get get everything lined up to make that change? And act the action stage speaks for itself, it's make the change where where somebody actually tries to try to engage in that new new behavior. So again, coming back to alcohol use might be, you know, drinking or drinking less, you know, going from six, six beers a night to three beers a night, or two beers a night, or no beers. And actually, like implementing that change, or some of these exercises, actually, you know, actually exercising, going on that walk, going to the gym, you know, reduced phone use, you know, it's actually putting the phone in another room or, you know, setting permissions on it, or locking it down, so they can't use their own phone, or, or their, or their, you know, locking down their teenagers phone. And then maintenance is this idea, you know, you just, you just keep on going and continue with the change, you enjoy the change, and you actively work to maintain that change. So this is like an underpinning theory, that that's, that's foundational for motivation. This is not motivational, it's just the stage of the change around behavior change. But motivational interviewing really hooks into this directly around getting people mainly through these stages of change and maintaining that it's a series of skills and ways to engage someone who can help them meet their own voiced goals, not the goals we hold for them, but their own goals. And we'll talk about that here in a minute around kind of what the spirit of motivational interviewing is. Really leads me to my next slide here. So while the stages of change, again, is this this underlying theory around how people kind of make behavior changes, motivation interviewing is, is a series of skills and techniques, and more importantly, a spirit of how to engage with others on how to help them see the change they'd like to see in themselves. And through that, that spirit of motivation interviewing, the empathy is that foundational spirit. And empathy is, is, you know, might be kind of different perspectives on it. But really, the empathy is trying to understand where that person's at in their life, meeting the person where they're at, and helping them realize their own goals, and not the goals we hold for them. Oftentimes, in healthcare and behavioral health, and lots of different settings, we come at people, and people have come at us with like, what their goals are for us, or what they want, you know, what they want us to do, versus like taking a step back, taking a moment to breathe and say, you know, what, what, how would you like to see things differently for yourself. And for some people in the pre contemplation stage, they don't want to see anything different. And, and that's okay. Like, I mean, they will face consequences. And that's the consequences for them to face. But that is meeting them with with a pile of knowledge or goals are saying you should you should do this, you should do that actually drives people to maintain that behavior, versus giving them space and time to think and breathe around, you know, with how that behavior may or may not be impacted. So I'm going to share a brief video. And I guess I'm sorry, for why empathy, it's, it's why this focus on empathy, it's actually one of the best predictors of client outcomes across lots of different behaviors. You know, our, you know, motivational living really was Bill Miller, who's the creator of motivational interviewing was really focused on alcohol use. And, you know, being able to look at how empathy, the the display of empathy from a therapist or an interventionist, was really the best predictor of a client outcome. And I'm going to share a brief video. Well, the video itself is very long, but we're only going to watch six minutes of the video of of of him walking through that. And we'll go ahead and do that now. Hopefully this works out. Okay. Before I play it further, I just want to do an audio check. Is that coming through? Okay. Yes, yes, we can hear it empty. It looks great. Well, I never know at one mid forum, what I'll be talking about at the next. And by the time it rolls around, there's something new. And so I want to talk a bit about where my own thinking has been going from what we've learned in motivational interviewing. And it's broadened to this topic of what, what is it that makes helpers helpful? It's a, it's a puzzle that it's a puzzle that I've been thinking about for a long time. And I want to share some pieces of that puzzle. And we'll see where it goes. The first one is, it's been clear for a very long time, that accurate empathy, that the skill of understanding what someone is saying and reflecting it back to them accurately, is really important. I'll talk a little bit later about this effect size of 0.58. But it has a medium effect size across all kinds of treatment and all kinds of issues. Very large samples. It's what Carl Rogers was talking about and writing about in the 1950s. And that quality of helpers, not just therapists, but the helpers, seems to be a really important piece of what helps people to change. I want to go back to my early wake-up call about this, because when I came to New Mexico, I was teaching and doing behavior therapy for people with alcohol problems. But I was also teaching Carl Rogers to my therapists and my students. And in the study I'm going to be talking about, the citation for which is at the bottom of the screen, we had nine counselors. And we trained them all together, and they were all being supervised. We were watching their practice. They're all working from a manual. So they were allegedly doing the same treatment, manual guided treatment, for people with alcohol use disorders. And three of us independently rated these nine therapists for how empathic they were, using a measure developed by Carl Rogers' own students, Tureks and Karkov, published back in 1967. When we got our client outcomes, we found that the outcomes were very different, depending on who the therapist was. Even though they were all using the same manual, they were all trained together. They were all allegedly doing the same treatment. The success rates varied from 100% to 25%. And as you can see from the graph, it was quite related to how empathic the therapist was while practicing this behavior therapy. So the most empathic therapist, the one all of us rated as number one, had 100% success rate. 100% of her clients changed in a positive direction. At the other end of the scale, another therapist using the same manual and the same behavior therapy had a 25% success rate. And the correlation was pretty strong. And in this study, we also had a group who were given self-help materials and sent home. And they had a 60% success rate. Now, if you compare 60% for that group with all the therapists averaged, the therapists averaged 61% success. And so it could lead you to say, well, therapists are no different from self-help manuals. But you would be wrong, because five of these therapists had success rates higher than people working on their own. One had just exactly the same success rate. And in the case of three therapists, it looks like the clients would have been better off going home with self-help materials than working with this counseling. And so averaging across therapists is kind of misleading. You're missing something important. And it was with that study that I went off to Norway and to the meetings that would eventually lead to motivational interviewing. Seeing how important empathy was to outcomes, we were accounting for a large proportion of variance. At six months, we could predict with a correlation of 0.82 how many drinks per week clients would be having based on how well their therapist listened to them. And even two years later, we're still accounting for a quarter of the variance in how many drinks per week based on how empathic the behavior therapist was. Second piece of the puzzle, I didn't really expect that motivational interviewing would be a standalone intervention. I was thinking of it originally as just a way of preparing people for treatment. But in study after study, we began finding that based on a motivational interview alone compared to no treatment, people were making significant changes. We're seeing big decreases in behavior that did not occur on a waiting list. So it's looking like motivational interviewing by itself is having an impact, not something that I had initially expected, but now confirmed in multiple meta-analyses. Third piece of the puzzle. I'll stop that there. Just a quick audio check. Can you still hear me OK? Yes. OK, great. So again, Bill Miller, the founding individual around motivational interviewing and, of course, the research team. Just to summarize those last six minutes is really looking at empathy, the ability for one to take that information and share that accurately back to the individual who shared it. So as a client sharing the challenges they're facing and the therapist or the interventionist or helper, whatever term you want to use, taking in that information and sharing it accurately back to the individual was a predictor that they can even predict how much somebody might use alcohol with 0.82. That's a very high rate of prediction. If one could predict the lottery numbers with that level of prediction, it would be very rich. And so the ability just to base off empathy alone, regardless of what other skills or modality of treatment, treatment setting even, empathy alone was the best predictor of somebody's success. And as he shared, there might be therapists, and I'm sure you've ran into people like this. Not necessarily therapists, but lots of different medical professionals and professionals in the helping field who, with very good intention, may actually unintentionally be actually doing a disservice to people. I won't go as far as to say harming individuals, but they might actually be making it less likely that somebody is actually going to make a positive behavior change. And so again, based off of that, the empathy of somebody who's not empathic or doesn't utilize skills to increase their empathy might actually be causing more harm than good. Also, that clip briefly touches on original intention motivation was not to be a standalone intervention, but it actually ended up being and being reliably demonstrated to be a standalone intervention, not only for reducing people's alcohol use, but across so many different health behaviors. I mean, dentists are using it to increase people to floss and rush more. And medical professionals are using it all the time to help with diabetes management, chronic pain management, or other chronic health conditions. Of course, substance use, that's where it grew out of. Child protection services use it a lot as well. I mean, it's across so many domains around health and behavior that has just, again, been reliably demonstrated to be a really incredible intervention. Again, today he won't leave as an expert of that, but hopefully you'll get what it is and what it isn't. And I'm looking forward to connecting in the next coming weeks to dig in more. Really, the spirit of motivation interviewing is around being empathic and meeting the client where they're at. The goal of motivation interviewing, the mechanism around change, is really to increase the intrinsic motivation, so the internal motivation that one has to make a change and reduce their ambivalence. And full transparency, when I was getting into this about 20 years ago, I think I had a misunderstanding what ambivalence was and didn't really understand it, despite years of college and whatnot. So just to say it out loud just in case to make sure nobody is falling into the same trap I fell into, ambivalence is a fancy way of saying feeling two ways about something. It's on one hand, I want to be healthier, but on the other hand, man, I really like potato chips. On one hand, I really might have a goal of losing weight, but somebody put in the chat box, but dang that New York cheesecake, right? So it's feeling two ways about something. On one hand, I want to spend more time and be more attentive to my family. On the other hand, I have a boss that's breathing down my neck, and if I don't answer this email right now, I'm going to take a lot of heat for it tomorrow. It's feeling two ways about something. So the goal of motivation is to help reduce that ambivalence and increase the internal motivation that a person has to making a behavior change. And how that works and the mechanisms of that is really that relationship between the provider, or maybe helper is a better term here, and client, patient-client relationship, where you want that relationship to be collaborative. You don't want it to be one-sided. You want to recognize that each individual coming into that relationship holds expertise. Us as helpers, we might hold expertise and knowledge around the negative effects of alcohol use or the experience of childhood trauma or whatever our expertise is. But the person who we're working with holds expertise of their experts in their own lives. They know what's going to work for them and what's not going to work for them. We can come with somebody with 100 different solutions, but if none of them are going to work for them, you know, then that's not helpful, right? We need to tap into their expertise of what's going to be most helpful for them. And most importantly is really respecting the client autonomy, client or patient autonomy around, at the end of the day, they are autonomous. They make the choices. They make the actions. We don't. And hopefully they make actions and choices that lead them to more positive health and maybe health for their family. And other times they may not. And that's really difficult. It's really difficult as a helper, somebody who really strives to help others and see others, you know, live a healthy life. But at the end of the day, it is their relationship or it is their autonomy. It's their choice to make that change. And so again, kind of the overall spirit of motivation interviewing is really a focus on empathy, which is rooted in this idea of a collaborative relationship between the client and helper, that each person comes to their roles with their own type of expertise and that truly the client is autonomous in making their own choices of how to carry forward with whatever they choose to do. Before I move on, are there any questions up to this point? I'm not hearing or seeing any, okay, continue forward here to really look at some of the specific interventions and skills of motivational interviewing. Again, this is just a brief introduction, and again in the coming weeks we'll dig more into this for those who are able to attend. One of the main things that we talk about in motivational interviewing is rolling with resistance. And so when a provider or helper's approach does not match where that patient or client is in their stage of change, what we end up with is what we'd call resistance, right? Like, I'm trying to get you to stop drinking. You don't want to stop drinking, and here we are, you know, kind of pushing against each other, right? There's this idea of resistance. And so we'll do another poll question here. Can you give an example of what resistance might look like? And you can either take it from your personal life, where you might have been resistance to change, or clients that you work with in your current capacity, what that resistance might look like. Again, if you can give some examples of what you think resistance might look like. About almost half the people are responding, we'll give it some more time here. I've seen a few more come through here. I'll give it about 10 more seconds or so. About 80% or so of folks have entered in, we'll go ahead and close the poll now. I will be taking that information from the poll I'm putting in the chat here in just a moment. All right, thanks Emily for putting that in the chat. All right, so somebody might not recognize that they have a mental health concern and are resistant to the provider's way of doing things. Absolutely, yeah, so the resistance might look like, well, we'll probably have some examples here below what some of that resistance might look like. So yeah, so they won't engage, right? So if it's in like a classroom setting, right? You've seen students, or maybe you were that student who wouldn't ever respond in class and just kind of sat back with their arms folded, that type of type of behavior, right? It's for freezer to respond to provider's phone calls or messages. You know, I'm just flat out, I'm not gonna stop doing what I'm doing. Aggression for sure can come out in different ways, either verbal aggression, hopefully not physical aggression, but that does happen. Absolutely showing up, I'm not sure why I'm here, there's nothing wrong with me. It's so-and-so's problem, it's not my problem. Yeah, joking, yeah, joking, that's a great example, joking, how it doesn't feel like resistance at first, but then you start to realize that it's really just like, as somebody mentioned about deflection, kind of pushing it off. Yeah, shame, shame is absolutely a significant barrier to change and shame of kind of recognizing that it's made some past actions or current actions or how they're impacting others. Certainly in the no contact, pushing themselves away from others, lack of engagement. Yep, told you I don't have a problem, it's not a priority for me. Anger for sure, minimization, you know, well, it's only my first DUI, it's fine, you know, things like that. You know, yeah, agreeing to something verbally but not following through later, for sure, you know. Sure, doc, I'll work on that exercise and not, you know, coming back. And I think not coming back is also a sign of resistance where it might, it's something that, where a provider or helper might've been kind of over, overenthusiastic is a nice way to put that. Bossy is another way to put it. Where you're kind of pushing someone too far, too fast and they're like, oh, no way, they get, you know, might kind of quote unquote get scared or, you know, but really not meeting the patient where they're at, right. And they feel overwhelmed and don't want to come back, not showing up, no shows. Yeah, finding reasons, kind of verbalizing, I'm not going to do, you know, the, you know, this idea of kind of making excuses, right. Or finding reasons not able to do something, again, minimization. Absolutely, these are all great examples of what resistance might look like. And, no, no, we're mainly using the chat here today. I'm looking forward to being in person, being able to talk more with people and seeing people. One of the things that as a helper, when you bump into these things, I don't know if anybody feels comfortable, I'm kind of going off script here a little bit, but if anybody feels comfortable putting in the chat, like as the helper, when you bump into resistance, like how do you feel? Like, what are some of the feelings that you have when you bump into bump of this? If anyone would feel comfortable, I'm kind of putting forward maybe that in the chat. And if not, that's okay. I just, I'd love to hear from you. I could give you examples of how I have felt, but I'd love to hear from the group kind of some of the feelings that they might've experienced. Frustration, absolutely, that is the main one. Feeling like talking to a wall for sure. Yeah, you're like, what am I getting that frustration, or what am I even doing here? How can they not see what's happening? Um, yes, sad, particularly, um, I know a number of you kind of intersect or work directly in the child protection services, child welfare. Um, it's incredibly, incredibly heartbreaking at times. Yeah. Yeah. Yeah, wanting to argue my case even more, right? If you'd only listen, this wouldn't happen, right? If you'd only read the warning labels, you know, tobacco will give you cancer, right? And this is where, um, I found a lot of, uh, personally found a lot of relief in motivation interviewing, um, and I, and I hope others do too, but, um, um, that's not to say to take the emotion out of it. Cause the emotion I think helps, helps drive us. And, you know, most of us, um, or probably all of us on this call are generally pretty empathic people or we wouldn't be in the helping field. Um, but really recognizing that at the end of the day, it's, it's, it's a person's choice on what they, what they choose to do. Um, and that as long as we come to that individual, but with a role of empathy and, um, uh, and recognition that, um, and that, you know, they, they make their own choices like to, to not feel, um, I guess for me personally, like such a failure that they didn't do something different. Um, and you know, that frustration and that anger, um, angst kind of hopefully helps, helps resolve away. It doesn't, doesn't mean it disappears completely. I don't want to pretend it doesn't because, um, particularly where you, where you're working with individuals in child welfare, right? Like you just, it's, um, or you might see, see kids just, um, maybe not, you know, you see some heartbreaking situations. I'll just say that. Um, and, um, um, but it's at the end of the day, you know, it is that person's choice and, uh, uh, and it gives a little, a little bit of space, a little bit of breathing room to, to maybe not for me anyway, to not take things so personally. Um, um, and, um, I, again, I kind of should have started with this, but to go back in time, um, a little bit here, my, my own professional trajectory, I was very, very fortunate, um, to be exposed to motivation intervening very early on in my career. Um, it was like, you know, 18 months into my, my career, um, you know, as a therapist and it was just, um, and I was actually part of a research study. So I had actually somebody record every, like literally record every word I said and coded it to see how much empathy I exuded, if it was accurate or not. And it was, and I, then I got coached and I had to get better and better and better. Um, and by the time I met like this, the threshold that they'd call, um, uh, treatment fidelity, I mean, that was, it was, I was, I was meeting a set of criteria to be delivering motivation intervening completely. Um, I actually saw a change in clients. Um, um, and it really comes down to, I was actually meeting, you know, I was accurately meeting the person where they're at and they're, they're actually, they're, they're, they're alcohol use reduced. And they're, and at the time it was also focused on high-risk sexual behaviors. Um, their, their high-risk behavior is also reduced. And so it was like, and I got really lucky in that because I had also, um, helped me recognize and understand that, um, that, that, that reliance on patient autonomy or client autonomy, again, gave me that space where my first, you know, again, my first 18 months were met with a lot of frustration and anger. Um, and this kind of helped give me some breathing room around that and help, help sustain me, um, over the last couple of decades. So, um, so to help kind of address resistance and, and again, coming back to this idea that when a provider's approach does not meet a person's stage of change, this is where you're going to get into resistance. Um, uh, we, we want to look at different tasks, like different skills or specific interventions on how to better align with that person's stage of change. Um, and so, um, and so again, uh, if somebody is in that pre-contemplation stage, um, around like, they're not even thinking about making a change, they don't want to make a change, uh, really is to just kind of help, you know, accurately understand where they're at. It's like, like, you know, and even that, you know, we'll get in again in a couple of weeks, get into specific skills around, around how to do this. But, uh, one of those is just kind of reflecting back like, oh, you know, you, you don't think, you know, drinking six beers a night is a problem for you. You know, you don't, you don't understand why other people have problems with, with, um, with your, with your drinking, you know, not, and not in a sarcastic way, you know, I could come off cross very sarcastically, but, but to, uh, you know, and it kind of helps like take the energy and angst out of the person you're working with. Cause you know, they've, they've been butting heads with people saying, I don't have a problem. I don't have a problem. I don't even know why I'm here. And they show up and you, and you just say that you, you know, you know, you know, repeat it back to them, reflect it back to them. You're not even sure why you're here. You don't feel like you have a problem. And that actually, actually helps diffuse the situation. Um, and then, and at that point, um, you can ask to share information. You don't just drop a bunch of information, Adam. Um, but you actually asked to be, you know, um, to, to request if, you know, um, to be able to share that information. So, so it's like inviting in that information and instead of saying, oh, well, let me, you know, you don't see why you have a problem, but let me tell you the issues with binge drinking and how, and why you meet binge drinking criteria. You don't, that's, that's the opposite of what you'd want to do in motivation, motivation interviewing. You'd say, oh, you don't feel like you have an issue. You're really frustrated that a lot of people are telling you, you should be here when you feel like you shouldn't be here. Um, would it be okay if I share information with you and asking that, would it be okay? It's kind of this, this, uh, this kind of softens it a little bit. And if the person says, no, I don't want to hear it. Then you say, okay, well, well, thank you for your time. Um, and you just kind of leave it at that. Um, even if you do that, then they're like, well, I guess we're already here. I guess you can tell me what you want to tell me, you know, and, um, that's, that's happened to me before. I was like, okay, you don't want to hear what I, you know, you don't want to hear what I have to say that that's okay. You know, I hope you have a great day. And they're like, well, I'm already here. I guess it doesn't hurt for me to listen. Um, so anyway, kind of softening that. And then the idea of raising awareness, providing health information around, um, what, depending on what your target behavior is, um, again, alcohol use is, is a common one here. Um, you know, talking about, you know, what, what is the criteria for binge drinking? You know, what is the standard drink? And, you know, and, and asking them, you know, you know, this is, you know, one beer is considered a standard drink, binge drinking, you know, uh, five or more drinks in one sitting or four more drinks in one sitting, um, you know, what do you think of that? And, and just having a conversation instead of saying, let me tell you all the dangers of binge drinking and why you're been shrinking. You know, the, the, the kind of sets the, sets the tone differently. Again, that's in this pre-conflation stage. Conflation is again, uh, I think we're, we're, we're. Chances are is where you spend a lot of your time, um, working with individuals, uh, or I should say that's where I've, I've spent a lot of my time working with individuals. Um, at least early contact, you know, first couple of sessions is this idea of, you know, somebody, somebody has either been court ordered or, or has shown up, um, to be there, uh, showed up on their own, on their own desires. Um, it's really helping, helping people walk through and talk out like why they want to make a change. Um, and, and really helping to push them what we call change talk, which again, we'll get into in a couple of weeks. It's a really verbalizing again, the reasons for change. And we're going to give an example of that here in a little bit next skill to help, help boost what we call change talk. Cause the more people talk about. The target behavior, more people talk about ways in which their lives would be better if they made a change, the more likely they are going to make that change. And that's the danger of resistance where you don't match the client where they're at is when you are, are coming to them with, um, all your ideas and solutions and they, and you find that they're, and they're arguing against every single one of them, what they're doing is they're arguing to maintain the status quo. And the more they argue for that, the more likely they will maintain in that status quo. Um, and so again, meeting the patient where they're at and, and, and resolving this ambivalence and helping move through resistance is the goal motivation interviewing. And, um, again, I, I know I keep saying this, but in a couple of weeks, we'll get more, more and more directly around the neutral skills, but, um, and I'll, I'll, I'll give an example of one here momentarily. Um, and as people work their way at a contemplation, um, then you help them come up with a plan to prepare, um, and absolutely very targeted action steps and action items and, and, and goals and help, you know, um, we'll talk about some articles in a couple of weeks, but really the help help helps an individual be successful, right? Like if somebody says, I'm really thinking about making exercise, starting exercise and you help them work through their ambivalence as to why your first goal isn't, I'm going to go run a marathon, you know, like that, that's outlandish. Right. Um, similarly with alcohol use, you might say like your first goal isn't to, to, to, to, you know, to drop everything. I think ideally that is the goal, but, but for somebody that, that might not be realistic. Right. And so to help help structure or to, um, that's not a very good example, but, um, I'd be to say like, oh, I'm not going to be, you know, I'm not going to hang around anyone who uses alcohol. It's like, well, your spouse drinks every night. Are you going to not, not go home tonight? Like, well, no, I need to still need to go home. It's like, okay, well, let's, let's come up with a plan of how you're going to manage your own alcohol use while your spouse also drinks every night. You know, let's, let's figure out how to help you be successful in managing that relationship while, while at the same time working towards your goal of reuse alcohol use. So, um, so that's kind of really the preparation stage, moving out of contemplation preparations, helping come with plan action again, as, as somebody who's making that behavior change. And again, hopefully they'll continue to see you. You'll continue to see them. And it's, it's getting a lot of affirmation and really support to say, well, you, you know, it's so awesome to see you make this change, you know, and it needs to come from an authentic and genuine place. Even if somebody is really struggling and maybe hasn't made a lot of changes, even just being authentic, say, well, this is really hard. I'm really, it's really, you know, this is really challenging and it's inspiring to see you, see you try to take this on this challenge, even if, even if they haven't made much progress, right. In a really authentic and genuine way to affirm, affirm their, their approach, right. Even if it's, they've had, you know, a relapse or symptom recurrence, trying to get away from the term relapse, but here, but you know, maybe they've continued their alcohol use, but they still came back to you. Even affirming like, oh man, I know you, I know you weren't as successful as you wanted to be. I know you probably feel really, really frustrated and discouraged about drinking again. But I'm, I'm, I'm so, you know, I'm so excited to see you here today. Those are, those are ways to help kind of, again, push people to action and affirm and again, increase that intrinsic motivation, that internal motivation to continue making that behavior change. As people move into maintenance, that's, you know, there's different measures of that. Some people would say, you know, behavior, sustaining a health behavior for two or more weeks, I might say four weeks, I might say six weeks, regardless, the idea is just again, to reinforce that, that, that patient success and, and our other client success, and also maybe help them develop maybe new skills and to target new health behaviors. Again, we'll walk through this a little bit more. I kind of provided a detailed overview already here, but in pre-pre contemplation, in motivation, we say, you know, we want to respect the patient autonomy and resist what's called the writing reflex, like writing reflexes. Let me tell you how I'm right. I'm, I'm the expert here. Let me tell you how I'm right. You know, we want to resist that. I'm sure we've all been on the receiving end of that, or our loved ones have been. And it's, you know, it's very demoralizing, I think. And so to, to, you know, we want to be sure we are resisting that. And then again, providing factual information or explore the events that brought the patient to the appointment, right? Like, I don't have a problem with drinking. That other guy ran the stop sign. Wasn't my fault. They crashed into me, you know, just because I had six beers. That's why I'm here. You know, I got the DUI, even though the other person's the one who crashed into me, right? Like, like exploring, like, that's an example of like, well, let's, let's talk about why you're here today. They might come with a lot of resistance and say, I drive fine, you know, while drinking six, six beers, I shouldn't have got that DUI, right. And kind of walking through maybe what that means for them. Again, in contemplation, we're looking at that change talk. Words like I wish I wish I wish things were different for me. I would like to be healthier. I'd like to be 20 pounds lighter, you know, it would be better if I had more stamina to play with my kids, you know, things like that. You can also use screening measures to begin those conversations and ask him permission that kind of goes floats back and forth between pre contemplation, completion. And the readiness ruler is something that I want to spend a little bit of time on because I find this to be one of the most helpful tools to elicit change talk. Now there's other tools out there, and other other skills, but this is the one that I that I find particularly helpful. And again, you don't want to do this in pre contemplation, because it's not going to work. That's not why the person's there. But if you find that somebody is really thinking about making a change or really struggling with this ambivalence on this is this is an incredible tool to help, help, help, help people to get to, again, say more of that change talk, help people again, to say more and more of the reasons why they'd like to make a change. So. So I'll give an example here. Say somebody came to see me. Well, so I mean, lots of examples like this. You know, I was working, I was working in a withdrawal management program, so detox program, and working with individual who's, you know, was there. And I was asking them, like, you know, you know, they were saying that, you know, they wish things were different. They don't like being there. They don't want to see the change. I said, Well, what do you think about doing? They say, of course, I want to, I want to stop, I want to stop drinking. And so what I would say is how to use the readiness ruler is on a scale of zero to 10. How important is it for you to make this change? And let's say they say six. Okay, so six out of 10, and level of importance. So it's not the most important thing in your life. But it's not the least important thing in your life. So zero is the least important thing. 10 is the most important thing. Zero to 10. How important is it for you to make this change your life? They say six. What I would say is what our natural reaction is, say, well, why do you say a six and not an eight? Because here you are, you know, puking your guts out, you look terrible, you've lost 80 pounds, like, you know, you know, you're, you know, like, the writing reflexes say, why only a six, you know, you should, why are you this? Why is this not important to you? You know, but actually, you want to do the opposite is you say, how come you chose a six and not a three? And they will go on to tell you why it's more important than not important. So they say, well, and they often look confused, because no one's ever asked them. Why, why something, you know, no one's ever asked them why it's not important in their lives, right? Like, oftentimes, people will say, why is this not more important? Or why aren't you making this change? No one's ever asked them, what's keeping you here? And so, you know, they might say, like, well, you know, I haven't had to go to the hospital, I don't have cancer, or I'm sorry, going backwards here, they might say why it's a six, not a three is, you know, I'm messing time with my kids, I'm losing work. I have legal bills, you know, medical bills, you know, they'll explain all the reasons why it is important for them. And so you get them to talk about the reasons why it's more important for them than not. And then the next stage of this is to say, what would it take to get you from a six to an eight? What would have to happen in your life to make this even more important of a change? And here is where somebody might then start to say, well, if I was diagnosed with liver cancer, maybe I would, I would stop drinking even more, or if I fully lost my job, or if I got a DUI, then it would be more important in my life. You don't want to spend a lot of time there. Because again, that's starting to argue for the status quo. But what you want to do is kind of come back to, again, reinforcing why they're making a change and, and how to how to get how to get further along. And so, again, the readiness rule. So on the importance, so you ask that the importance, how important is it for you to make a change? And then you walk through the next two questions, how confident are you that you're able to make the change in the same thing? On a scale of zero to 10? Zero being not confident at all that you can make a change and 10 being the most confident and you'll ever feel in your life to make that change? How confident do you feel like you can make this behavior change? How confident do you feel like you can can stop drinking? As an example, let's say the person says, I'm a two, you know, on the lower end of confidence, like they don't really feel like like they can actually make make the change. And again, say, why do you say two and not a zero, and then they'll go on to share why they feel a little bit confident about making a change, right? They'll go on to share like, well, you know, I've cut down in the past. You know, I got a friend of mine that that might be that I might be able to stay with who doesn't use, you know, things like that. So we kind of walk through each of these. And again, on the ready, I'm ready then, how ready are you make this change again, the same same thing. And it feels a little repetitive, like on this slide, I know it feels repetitive, and it feels repetitive, as I'm talking about it. But when working with someone, it doesn't feel as repetitive. And it helps. It helps really kind of answer the questions of, you know, kind of the classic questions are ready, willing and able, right? The willingness is importance. Able is confidence. How confident do you feel like you are? How able are you to make this change and ready is ready? You know, how ready are you right? Because if somebody could be ready to make this change today, but if they feel like they can't do it, or don't want to do it, they're not going to make a change, right? Similarly, if somebody thinks like, man, I really need to stop drinking, I'm going to get you know, cirrhosis and jaundice and whatever else. But they don't feel like they can do it and just start ready. They're also not going to change. And so you really need to get all three of these to line up, or at least identify how to shift someone from how to get them more along the lines of being ready, willing and able to make a change, make it important for them, feel like they have the ability to make the change. And then if they have the ability and importance, they will likely carry forward and make that change. And if somebody identifies, you know, say, yes, I'm going to make a change, however big or small the behavior change is, then you want to move into the preparation stage to help them get moving preparation, where you provide a menu of options, you identify, you help them walk through what some of the barriers might be in helping to make the change. And really helping with identifying those goals. Some people might just come out and get with very aspirational goals, and you don't want to necessarily suck the wind out of their sails in those aspirations, but you also want them to be successful. That's where a template called SMART goals, you may have seen those before, but SMART stands for specific, measurable, attainable, realistic and timely. I'm not going to walk through SMART goals very much today. But really, it's just it's a nice format and template to help really narrow in like, okay, you say you're going to stop drinking, what does that look like? You know, is that going from like, six beers a night to zero beers, six to two, and you kind of really get kind of down to the details on what that behavior change might look like. And, and then you kind of set up time parameters and when to check in with someone. And then it's just it's just a nice template to help walk through some of this stuff. Then there's action, action and maintenance, again, really providing that positive reinforcement, helping encourage and affirming, you know, that change is occurring. And if they and, you know, hopefully, as long as you're, you're medium on their stage of change, and coming across empathically, they will continue to meet with you. You know, there might be challenges, right, there might be slip ups, or might be, you know, what we call relapse or symptom recurrence. And one that really, again, help affirm that progress that's been made so far. And, and really help reframe that as a kind of learn opportunity around how easy it is to have symptom recurrence or relapse when when when trying to make a change, right? And to help really explore kind of what led up to that, what are the antecedents? Like, what are what are the things that led up to that, that that slip up, you know, you know, I'm usually moving away from alcohol use, you know, looking at like, the behavior of, you know, really trying to keep my work day to my work day as much as possible and spend time with my family after hours. And next thing I know, you know, I'm on my laptop cranking out, you know, a grant application, you know, and so and I'm missing out on my son's soccer game, right? Like, like, you know, that's counter to the behavior, maybe I wanted to spend more time with my family, right? Or the goal is to spend more time with my family. So exploring those antecedents would be like, well, what led up to that, you know, you knew 30 days ahead of time that this grant was due, why are you working on it the night before submission, you know, and kind of thinking about like, you know, what are maybe some of the helping to look at like time management practices and things like that, you know. So as, as something that I've lived in my life, and maybe others have lived in their lives as well as in this call. And again, when somebody experiences symptom recurrence, or relapse, really also get into it, not only affirm kind of where they've been, but also to instill hope, as they move forward. And again, maintain that support of contact. The last thing you want to do, right, as soon as experience, experience relapse is to provide any guilt or shame. And, and if they've come to you after relapse of some kind, like they're looking for support, right? Even if they're court ordered, right, again, people have people have autonomy to choose to do whatever they want. They still showed up. And so meeting them with a sense of support and hope, and really helping to reduce that shame and guilt of failing, failing to meet their own goals, will propel them to be more successful in the future. And really help kind of strengthen that relationship that you have with that individual. As we actually kind of ahead of schedule, but that's okay. And actually kind of wrapping up here. Again, as this is an introduction to, to future work, and I hope that you know, welcome to take any questions or discussion, left kind of a pretty big chunk of time for that here. But just to kind of go to share what I've been talking about in the last hour or so is, again, motivation is not only is it a set of skills and specific skills and interventions, but it's really an underlying spirit of how you interact with clients, or patients. It's, again, respecting that patient choice, not pushing them. It's meeting them where they're at. And gently and respectfully highlighting their own motivations to change and helping them verbalize reasons why they'd like to change or reasons why they should change or could change. And, and really helping to be, you know, helping them navigate and helping them be successful and planning out how they want to make that change, how they're going to really execute that change and maintain their change. And again, while we come forward with our level expertise in our own domains, they are the experts in their lives, right? The clients we work with are the experts in their lives. And so meeting them where they're at and meeting them and helping them identify their goals and helping them navigate towards those goals, versus us coming forward with goals that they should do or shouldn't do. So lots of references and resources there. Well, when I definitely lose time for questions and discussion, I also want to, you know, highlight if you're able to provide an evaluation, complete this evaluation survey, and love to hear your feedback. I am really looking forward to connecting with people here in a couple of weeks. And, and I know I've spent a lot of time talking in this format, and really isn't the best for a lot of interactive engagement, but I am really looking forward to connect with people in person. And those are able to do a lot more interactive style of engagement versus just me talking for 12 hours, because that would be miserable for everyone. So I just want to say thank you. Thank you so much for your time. Thank you, Emily, for putting the link in the chat as well to make it easy to get to you have to pull out a separate device. And I love to see your feedback and evaluation as well as I'll just stop here. And I'll leave the link up or stop here since links in the chat. Stop here and just welcome any any questions or comments or discussions that folks have. I'm not seeing any questions or comments other than some thank yous in the chat, which I appreciate. I'll always take a thank you. So again, I really appreciate the opportunity and time to connect with folks today. Again, I hope this just provides an introduction. We'll talk in more detail about everything I've talked about today. I have a number of more videos and interactive activities as well. So again, it's just an introduction. So I'm looking forward to seeing you all in a few weeks now. So again, if you take the time to tell the evaluation, that's great. And otherwise, I don't know, Emily or Chelsea, I don't know if there's any other housekeeping we can do before we wrap up for today. Odie, for today's presentation, and I will have this recording out for sharing within two weeks. So if anyone missed it, or if you want to review it, you can do that. But that's everything. So if we're done early and there's no questions, we can wrap up now.

motivational interviewing

Dr. Cody Chip

empathy

stage of change

readiness ruler

smart goals

positive reinforcement

client autonomy

writing reflex

intrinsic motivation

behavior change