Structured Practice Example 2: Thinking Reflectively
* Explain that there is a way of thinking that accompanies good reflective listening. It includes, of course, interest in what the person has to say, and respect for the person's inner wisdom. The key element at this point, however, is a hypothesis testing approach to listening - the knowledge that what you think a person means may not be what he or she really means.
* A good reflective listening response tests a hypothesis.
Structured Practice Example 3: Forming Reflections
'''Aim''': To help trainees learn how to form effective reflective-listening statements.
'''Time''': 20 minutes plus discussion.
'''Format''': Participants are arranged in groups of three.
* The questions asked in the last exercise are very close to reflective listening, but not quite.
Structured Practice Example 4: Sustained Reflective Listening
'''Aim''': To give each trainee an opportunity to practice reflective listening as a dominant style in one-to-one conversation.
'''Time''': 20 minutes plus discussion.
'''Format''': Trainees are arranged in pairs.
* Some of the finer points of reflection can be discussed in preparation for this exercise.
The concept of levels of reflection may be helpful:
1. Repeating. The simplest reflection simply repeats an element of what the speaker has said.
===Structured Practice Example 1: Nonverbal Listening===
Before starting to shape reflective listening, it can be useful to increase awareness of the importance and value of nonverbal ("passive") listening skills. The training exercise for this step is relatively simple.
* Pair up trainees and have them decide who will speak and who will listen.
'''Abstract''': Affirmations are closely tied to values. What feels affirming to one person may feel false or irrelevant to another. This exercise is a way to consider what a genuine affirmation feels like to each participant.
'''Overview''': Affirmations are the A in OARS skills and are sometimes overlooked by trainees. Yet an accurate affirmation can support self-efficacy and enhance therapeutic rapport.
'''Guidelines''': The trainer asks the trainees to remember a time when they received a deeply meaningful compliment from someone they trusted and respected.
'''Abstract''': Participants try to identify change talk within ongoing dialogue.
'''Overview''': Provide a sample of dialogue. It can be from a motivational interview, or even from a film, song, TV show, etc. On first try it is helpful to work from a transcript, to slow down the process.
'''Guidelines''': Explain clearly what constitutes change talk. You can draw on coding guidelines from the MISC of MITI for clarity. (e.g., talking about past-tense motivation is not change talk).
Rowing with OARS (with Observer)
'''Abstract''': The counselor practices how to use OARS directively, to move toward a particular change goal.
'''Overview''': Once one is comfortable using OARS in a nondirective manner, the next task is to learn how to use selective questions, affirmations, reflections and summaries to evoke change talk, with particular emphasis on exploring the importance of change.
'''Guidelines''': Work in groups of four: One speaker, one counselor, and two observers at a time.
'''Abstract''': The counselor practices how to use [[OARS]] directively, to enhance confidence for change.
'''Overview''': This is a variation on the prior [[Rowing with OARS]] exercise, with particular attention on building confidence for change. It addresses the client for whom confidence may be lower than importance.
'''Guidelines''': Work in groups of four (if two observers are to be used): One speaker, one counselor, and two observers at a time.
'''Abstract''': Trainees practice asking open questions that elicit change talk, and learn about the linkage between the two.
'''Overview''': In an exercise that involves movement, trainees reflect on and practice open questions that will elicit change talk. The exercise parallels the TV game show Jeopardy in which the trainee is given an answer, and has to come up with the appropriate question that would elicit the answer.
'''Guidelines''': First have all trainees write down several change talk statements that are typical from their own work settings.
'''Abstract''': Participants or teams try to be first to elicit all five forms of change talk.
'''Overview''': This exercise stimulates trainees to think about the various forms of change talk, and how they might specifically elicit each one.
'''Guidelines''': This exercise requires groups of at least three: one speaker, one interviewer, and one observer. Identify the speaker for each group (if there is more than one group), whose task is to talk about a change that he or she is thinking about making. Have the speakers leave the room temporarily.
'''Abstract''': This exercise can be done if the training room has a dimmer switch that allows continuous adjustment of the brightness of lighting in the room. In an MI interaction, when change talk is elicited the room lights brighten. When counter-change talk is elicited, the room lights dim.
'''Overview''': A trainee or team is assigned to elicit change talk from a speaker who is talking about am ambivalent change topic.
Abstract: Trainees draw from a hat the kind of response they are to generate
Overview: A hat contains slips of paper that name particular MI-consistent responses. Within a structured exercise, trainees draw a slip of paper from a hat and perform the type of response named on the paper.
Guidelines: Set up an appropriate client stimulus to which trainees will respond. Prepare a set of slips of paper naming particular MI-consistent responses and place them in a hat.
Snatching Change Talk from the Jaws of Ambivalence
'''Abstract''': Participants practice selectively reflecting the change talk content within ambivalence.
'''Overview''': When ambivalence is present, it is normal for change talk to occur within the
context of sustain talk. Participants are presented with client statements containing both
change talk and sustain talk, and form reflections focused on the change talk.
Guidelines: Generate some client statements, appropriate to your training audience and topic, in which change talk is embedded within at least two bits of sustain talk.
===Dr. Clark's Referral: Four Possible Summaries===
Below are four possible summaries of the above dialogue, all intended to be helpful to Sylvia. What is being emphasized in each one? In each summary, what seems to have guided the counselor in choosing what to include or not include? How consistent is each summary with the spirit and style of motivational interviewing? Why?
'''Summary 1''': Well, it sounds like your life is pretty stressful. When you wake up in the morning you often feel bad. You have a stressful commute in traffic in the morning, and you put in a lot of time at work.
'''Abstract''': Participants practice offering reflections, affirmations, and asking for elaboration in response to change talk.
'''Overview''': This exercise was developed specifically to help people practice MI-consistent ways of responding to change talk when it occurs.
'''Guidelines''': In order to generate change talk statements as stimuli for this exercise, have all participants think of a change that they are considering making within the next six months, and then have them write down at least four change talk statements about this change.
Following a routine physical examination, Dr. Clark referred Sylvia to a behavioral health counselor to discuss her drinking. The referral indicates that the physician smelled alcohol on her breath during the examination, and added an alcohol screen to the panel of lab tests ordered. The lab report indicated a blood alcohol level of 90 mg%, and also a slightly elevated GGT level. After introductions, the consultation begins.
Counselor: There's not much information on this referral, Sylvia. Perhaps you could tell me how you understand why Dr.
Choosing Elements: Selectively Reflecting
'''Time''': 15 – 20 minutes
• Increase awareness of directive use of reflective listening
• Distinguish between roles of small reflections and more complex reflections in directing conversation
• Discuss use of reflectively listening and change talk (DARN-C)
• Continues to build listening skills in a graduated manner
• Differentiate between nondirective and directive listening
• Discuss the use of reflections to move towards or away from an area
• Highlight the use of MI to reinforce
Abstract: Trainees explore various strategies for resolving ambivalence
Overview: This exercise is especially helpful in clarifying the role of the counselor in influencing the person=s level of readiness for change.
Guidelines: In groups of six, discuss for about 20 minutes. The client role is to discuss an issue on which he or she is ambivalent or undecided; e.g., whether to stay in a present job. Four protagonists are assigned particular roles, and each takes 3-5 minutes to be a counselor with the client.
Abstract: This is an exercise specifically about recovering from mistakes. You can describe and model a variety of ways of recovering from a misstep, and then have trainees practice.
Overview: Everyone makes mistakes, and when you do it is often quickly apparent in the client’s response. When you see your client becoming more defensive, resistant, evasive, etc., how do you recover? There are, of course, a variety of ways to do it successfully after a gaff.
Rolling Out the Rug of Resistance
Abstract: To increase awareness of the concept and presence of resistance in client-counselor exchanges
Overview: An interactive discussion in which participants consider the nature of resistance, and what counselor responses are likely to increase or decrease it. It particularly highlights the counselor’s very active role in responding to and managing resistance.
Materials: Whiteboard or flip chart, handout with the chart below can be helpful for the participants.