Motivational Interviewing in respiratory health care - CAMH ...

MotivationalInterviewingin respiratoryhealth careTrainers’ toolkitA collaboration between Training Enhancement in Applied Cessation Counsellingand Health (TEACH Project—Centre for Addiction and Mental Health)and the Ontario Lung AssociationA knowledgetranslation initiative

MotivationalInterviewingin respiratoryhealth care

MotivationalInterviewingin respiratoryhealth careTrainers’ toolkitA collaboration between Training Enhancement in Applied Cessation Counsellingand Health (TEACH Project—Centre for Addiction and Mental Health)and the Ontario Lung AssociationA knowledgetranslation initiative

Library and Archives Canada Cataloguing in PublicationMotivational interviewing in respiratory health care : trainers’ toolkit:a knowledge translation initiative / a collaboration between TrainingEnhancement in Applied Cessation Counselling and Health (TEACHProject--Centre for Addiction and Mental Health) and the Ontario LungAssociation.Issued also in electronic formats.ISBN 978-1-77114-109-31. Respiratory therapy. 2. Motivational interviewing. 3. Training.I. Ontario Lung Association II. Centre for Addiction and Mental HealthRC735.I5M68 2012 615.8’36 C2012-906714-8ISBN: 978-1-77114-109-3 (PRINT)ISBN: 978-1-77114-110-9 (PDF)ISBN: 978-1-77114-111-6 (HTML)ISBN: 978-1-77114-112-3 (ePUB)PZ171Printed in CanadaCopyright © 2012 Centre for Addiction and Mental HealthCopying or distribution of these materials is permitted, providing the followingcopyright notice is noted on all electronic or print versions: © CAMH/TEACH 2012.No modification of these materials may be made without prior written permissionof CAMH.This publication may be available in other formats. For information about alternativeformats or other CAMH publications, or to place an order, please contact Salesand Distribution:Toll-free: 1 800 661-1111Toronto: 416 595-6059E-mail: publications@camh.caOnline store: http://store.camh.netWebsite: www.camh.caThis manual was produced by CAMH’s Knowledge and Innovation Support Unit.4626 / 10-2012 / PZ171

Acknowledgmentsteach project, centre for addiction and mentalhealth (camh)Marilyn Herie, PhD, RSW: DirectorStephanie Cohen, MSW, RSW: Social Worker II, Nicotine Dependence ServiceRosa Dragonetti, MSc: ManagerKarina Czyzewski, MA: Aboriginal Projects Co-ordinatorLisa Brousseau, MSW candidatePeter Selby, MBBS, CCFP, FCFP, dip ABAM: Executive Directorontario lung associationCarole Madeley, RRT, CRE, MASc: Director, Respiratory Health ProgramsConnie Wong, BES: Air Quality/Smoke-Free Homes and Asthma Co-ordinatorAndrea Stevens Lavigne, MBA: Vice-President, Provincial Programscurriculum planning groupRobin Brown, Mount Forest FHTDilshad Moosa, The Lung AssociationBryan Falcioni, Mount Forest FHTKathleen Milks, Thunder Bay Regional Health Sciences CentreCarolyn Plater, Ontario Addiction Treatment CentresVirginia Myles, Royal Victoria HospitalMary Kate Matthews, Hamilton FHTMaria Savelle, Stratford FHTSuzanne Corby, Cottage Country FHTKaren Brooks, Picton Doctors Group & PEFHTJeff Daiter, Chief Medical Director, Ontario Addiction Treatment CentresAna MacPherson, The Lung AssociationMelva Bellefontaine, Prime Care FHTMadonna Ferrone, Asthma Research Group Inc.©2012 CAMH/TEACHv

ContentsIntroduction..................................................................................................................... 1SECTION 1: PLANNING TIPS FOR FACILITATORSPresentation delivery ....................................................................................................... 7Seven tips to activate your session................................................................................ 10Information on accrediting training eventsand continuing education (CE) credits........................................................................ 11Additional reading on presentation, facilitation and teaching................................... 13Webliography: Leadership development and presentation tips.................................. 15SECTION 2: FACILITATOR RESOURCESWorkshop overviews ..................................................................................................... 19Presentation slides: Facilitators’ notes.......................................................................... 37Interactive learning activities....................................................................................... 174Case-based learning activities and case examples...................................................... 183Case-based video demonstrations of MI skills........................................................... 202SECTION 3: PARTICIPANT RESOURCESPre-reading for participants: Evidence base forMotivational Interviewing in respiratory healthcare: A brief summary, by Karina Czyzewski,Marilyn Herie, Stephanie Cohen and Peter Selby...................................................... 205Workshop overviews.................................................................................................... 217Presentation slides........................................................................................................ 223Case-based video demonstrations of MI skills........................................................... 273Resources...................................................................................................................... 287APPENDIXFacilitator evaluation of curriculum materialsand participant responses............................................................................................ 293Workshop evaluation for participants........................................................................ 297Practising MI skills cards............................................................................................. 299Teach-back cards.......................................................................................................... 301©2012 CAMH/TEACH vii

IntroductionThis toolkit is the result of a collaborative partnership between the Ontario LungAssociation’s (OLA) Smoke-Free Homes and Asthma Project and the Centre forAddiction and Mental Health’s (CAMH) TEACH Project. Since 2006, the SmokeFree Homes and Asthma program has been focused on research reviews and theimplementation of a pilot study to determine the effectiveness of addressing issuesinvolving asthma and second-hand smoke (SHS) exposure among children. Alsosince 2006, TEACH (Training Enhancement in Applied Cessation Counsellingand Health) has developed and offered accredited continuing professional educationto health and allied health practitioners in tobacco cessation interventions andhealth behaviour change. The foundational psychosocial approach in TEACH isMotivational Interviewing (MI), a “collaborative, person-centred form of guiding toelicit and strengthen motivation for change.” 1 MI is an evidence-based interventionacross a range of health behaviours, including patient self-care for asthma; adherenceto asthma management treatment plans; tobacco cessation; and general healthbehaviour change. 2,3,4 However, there is a need and demand for MI training amonginterprofessional health care practitioners in order to build capacity and, ultimately,to improve patient engagement, treatment retention and outcomes.This Trainers’ Toolkit has been developed specifically for practitioners workingin respiratory health care, and incorporates the expertise and feedback from a provincialNeeds Assessment Survey and a diverse curriculum planning group. The preliminaryNeeds Assessment survey was used to evaluate MI proficiency, identify specificMI content areas that are relevant to respiratory health practitioners, and recruitkey subject matter experts to attend a curriculum planning session. These individualsattended a two-day training and curriculum development session and provideddetailed qualitative feedback about the toolkit’s content, and shared case examplesand instructional enhancements designed to be most relevant to respiratory care.1. Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not.Behavioural and Cognitive Psychotherapy, 37, 129–140.2. Anstiss, T. (2009). Motivational Interviewing in primary care. Journal of Clinical Psychology inMedical Settings, 16(1), 87–93.3. Lundahl, B. and Burke, B.L. (2009). The effectiveness and applicability of MotivationalInterviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology,65(11), 1232–1245.4. Lundahl, B.W., Kunz, C., Brownell, C., Tollefson, D., and Burke, B.L. (2010). A meta-analysisof Motivational Interviewing: Twenty-five years of empirical studies. Research on Social WorkPractice, 20(2), 137–160.©2012 CAMH/TEACH 1

Motivational Interviewing in Respiratory Health CareThe toolkit is organized into three general sections:1. Planning tips for facilitators2. Facilitator resources (for faculty providing MI training in one-day, half-day orone-hour formats)3. Participant resources (for practitioners attending training in one-day, half-day orone-hour formats).This toolkit includes facilitation tips and suggestions, learning objectives anddetailed lesson plans, presentation slides and speakers’ notes, clinical video vignettesand coded video transcripts, interactive exercises and case examples, and additionalreadings and resources. The accompanying CD contains all of the lesson plans,slides, videos, handouts and resources in electronic form.We hope that you find these materials helpful in your work as a practice leaderin Motivational Interviewing and respiratory care, and we wish you all the best inyour clinical leadership and capacity building!How to use this facilitator’s toolkitThis toolkit is made up of a wide range of materials, developed by a team of contentexperts and interprofessional health care practitioners to help you plan a successfultraining event. You can use them in the format provided, or adapt them to yourown practice context and the learning needs of your group. Moreover, you shouldfeel free to supplement the package with your own materials. We have organized thetraining materials into the following categories:1. planning tips for facilitatorsYour training session can be designed for as many or as few people as desired. Thereare several optional tools in this section that may facilitate planning of logistics onthe day of training, and that provide you with checklists and timelines to adequatelyprepare you for holding your own training event. This section may be of particularrelevance to you if you are planning a larger training event.2. facilitator resourcesThe course content is organized by learning objectives, and can be offered in a fullday, half-day or one-hour format:Learning objectives: One-day format1. Define Motivational Interviewing (MI) and its relevance to respiratory health careand health behaviour change.2. Operationalize the “spirit” of MI in conversations with clients.2©2012 CAMH/TEACH

Introduction3. Review and practise foundation skills in MI.4. Listen for and respond to client change talk.5. Apply agenda-setting as a strategy for working with clients with complex, cooccurringissues.6. Recognize and integrate MI spirit and skills in practice.7. Set objectives and access resources for continuing professional development inMI skills.Learning objectives: Half-day format1. Define Motivational Interviewing (MI) and its relevance to respiratory health careand health behaviour change.2. Operationalize the “spirit” of MI in conversations with clients.3. Review and practise foundation skills in MI.4. Set objectives and access resources for continuing professional development inMI skills.Learning objectives: One-hour format1. Define Motivational Interviewing (MI) and its relevance to respiratory health careand health behaviour change.2. Operationalize the “spirit” of MI in conversations with clients.3. Set objectives and access resources for continuing professional development inMI skills.Detailed lesson plans accompany each of the workshop formats, including suggestedtiming and activities. In addition, the facilitator slides contain detailed speakers’notes, with key points to emphasize and tips for introducing and debriefing thevarious learning activities.Four brief clinical videos specific to respiratory care are also included; each ofthese has been transcribed and coded to illustrate discrete MI microskills. Transcriptsof the videos can be found in the Participant Resources section of the toolkit.Finally, a range of additional interactive learning activities and a compendium ofcase-based activities and case examples are provided in the Facilitator Resources, sothat trainers can adapt the workshop sessions for diverse audiences. In order to keepyour audience engaged and promote enhanced learning, a good rule is to plan for atleast 25%–50% interactivity.Note that training can be offered all at once, or in modules over time—feel freeto adapt the materials to your own audience and learning needs.3. participant resourcesThis section contains Learning Objectives and Workshop Agenda templates for fullday,half-day and one-hour sessions. Additional resources for participants include anabbreviated PowerPoint slide handout, a summary handout of the evidence base for©2012 CAMH/TEACH 3

Motivational Interviewing in Respiratory Health CareMotivational Interviewing in respiratory care, video transcripts coded with MI skillsused by the therapist, additional readings and suggested books, articles and websitesrelated to MI.As a trainer, you can choose what to include and provide to participants in thesession you are facilitating.appendixThere are two evaluations included in an appendix to this toolkit. One is intendedfor the facilitator to complete and return to TEACH (teach@camh.ca) after eachtraining event. In this evaluation, demographic information is requested, along withquestions about the content of the toolkit and how your training was conducted. Theother evaluation is intended for participants. Please distribute it after each of yourtraining sessions to gather feedback on yourself as a facilitator. The participant evaluationdoes not have to be returned to TEACH.cdWe have included a CD containing electronic copies of all of the materials containedin the print version of the facilitator’s guide, including the lesson plans, facilitatorslides and speakers’ notes, participant materials, clinical video vignettes, case examples,supplementary resources and evaluations.4©2012 CAMH/TEACH

Section 1:Planning tips forfacilitators

Section 1: Planning tips for facilitatorsIntroductionA well prepared and engaging workshop can have a significant impact on participantlearning. However, presenting to a group can provoke anxiety even in seasonedfacilitators. The following tips and suggestions may be helpful in preparing for—anddelivering—your workshops.Create an inviting spaceDon’t underestimate the importance of room set-up for audience engagement.Grouping people at tables, as opposed to setting chairs up lecture-style, allowsparticipants to more readily connect and network with each other, and facilitatesbetter small group discussion.It is also crucial to check sightlines throughout the room to ensure that all participantscan see the screen(s) and you, the facilitator.Presentation delivery• Polish your verbal and nonverbal skills.• Know your material.• Express confidence.• Be yourself.verbal skillsSpeak clearly: Be sure to pronounce and articulate your words clearly. You will alsowant to speak loud enough that the back row can hear you clearly (depending on thesize of the audience, you may want to ensure that microphones are available to use).If you are using a microphone, test the audio ahead of time, so that the sound levelsare adjusted to your voice and you know how closely you need to hold the microphoneto your mouth. If you are using a hand-held microphone, make sure that youhave extra batteries in case the power runs low.Speak expressively. Speaking with expression isn’t just a matter of not speakingin monotone. It is about working on your emphasis, pace and timing, which willhelp your audience better understand the information you are delivering.Pausing is a great way to emphasize key points and always refocuses the audience’sattention.©2012 CAMH/TEACH 7

Motivational Interviewing in Respiratory Health Carenon-verbal skillsDress professionally and appropriately: Avoid wearing anything that distracts theaudience (e.g., clothing or jewelry that jangles, distracting patterns, etc.). A goodguideline is to dress slightly more formally than your audience. If you plan to usea lapel microphone, it is better to wear something with a collar (to affix the microphone)and something with a pocket or waistband (to affix the power pack).• Be aware of your mannerisms and body language: When you present, what areyour face, hands and feet doing?• Keep audience attention by making eye contact.• Don’t forget to smile.• Avoid defensive gestures such as crossing your arms or putting your hands onyour hips.• Watch for repetitive hand gestures that can get distracting.• Keep your weight evenly on both feet; crossing your legs, bouncing ortapping can be distracting.• Move around to avoid getting “glued” to the podium. Use the spaceat the front of the room.• Be ENTHUSIASTIC! If you are excited about what you’re presenting,the audience will be excited to learn about it.know your materialPractise! Practise! Practise! Try practising the material one section at a time.Practise each session until you are comfortable and fluent with the material. Try toavoid relying too much on speakers’ notes or your own notes.Visual aids and activities: Get comfortable with using visual aids and activities,as these are great tools to engage and maintain interest with the audience.Questions: Questions can be challenging, but they also provide further learningopportunities. It is a good idea at the beginning of the presentation to tell theaudience when you are going to take questions. Will you designate time at the endof each section, or throughout the presentation? If you do not know the answer toa question, it is always best to say “I don’t know,” but be sure to follow up with theanswer later on.8©2012 CAMH/TEACH

Section 1: Planning tips for facilitatorsexpress confidenceIf you have done your homework, and have practised the material until you feelcomfortable with it and with the visual aids, you should feel confident and ready topresent. Nonetheless, nervousness and anxiety are both common and normal.Here are some tips to alleviate “performance anxiety”:• If you can, exercise or go for a walk before the workshop to help burn off excess energy.• Getting to know individual audience members prior to the start of the workshopcan help alleviate anxiety. This allows time for you to (a) connect with some membersof the audience before the workshop begins, and (b) better understand thelearning needs of some of the group members.• Be sure to focus on your breathing: take deep, slow breaths.• If something goes wrong, don’t ignore it. This can be an opportunity for humourand to show the audience how calm and collected you really are.Read the groupBe sure to stay connected with the participants and be mindful of their body languageand expressions, as this will help you understand how they are absorbingthe material. Be prepared to adjust your instructional style to suit the learningneeds of the participants. This can be challenging, but will have a positive impacton both the presentation flow and participant learning. If people seem to be tuningout, perhaps it is time to call a short “stretch break.”be yourselfWhen giving a presentation, remember that you’re presenting yourself, not just theinformation. Authenticity goes a long way in connecting with a group.Keep the following checklist in mind when preparing and practising your material:• Practise delivering your material out loud at least once or twice.• Speak clearly.• Speak at a good pace, using pauses to emphasize points.• Take advantage of the visual aids, demonstrations and exercisesin this toolkit.• Use variety in your voice.• Move around, but don’t pace.©2012 CAMH/TEACH 9

Motivational Interviewing in Respiratory Health Care• Be a little conversational.• Use humour if you are comfortable doing so, but make sure thatit is respectful and appropriate.• Plan to take some time during the presentation to review and summarize if thecontent is complex, or if the group will be unfamiliar with the content.• Relax, take a breath, be yourself.Keep the following checklist in mind during your presentation:• Talk with participants before the session and during the breaks.• Maintain eye contact.• Check for understanding and keep the group involved (i.e., askquestions, poll the group).• Watch the group’s attention span.Seven tips to activate your sessionIt is important to pay attention to the mood in the room. Although this MotivationalInterviewing Trainers’ Toolkit includes interactive instructional design, there may betimes when you as faculty would like to introduce an added interactive technique tofurther engage participants. Here is a list of possible constructivist strategies. Notealso that a more detailed description of specific interactive learning exercises can befound in the “Facilitator Resources” section of this toolkit.1. Large group Q & A (time varies, dependent on facilitator)--Audience interaction should be encouraged throughout the session, with facultyprompting questions and facilitating discussions.--Having standing microphones and/or microphone runners available throughoutthe room can help facilitate contributions from participants.2. Case scenarios (15–30 minutes)--Case-based learning activities and a compendium of case examples are includedin this toolkit. Time can be allotted for case scenarios to be discussed and/orpractised within pairs and smaller groups, and then debriefed as a larger group.3. Role plays (15–30 minutes)--Role plays allow participants to practise particular skills, such as MI skills, orto observe how one of the practitioners would respond to a specific issue orclient statement.10©2012 CAMH/TEACH

Section 1: Planning tips for facilitators4. Panel Q & A (90 minutes)--Participants can pose questions to three to five faculty (from various professionalbackgrounds/disciplines) who form an expert panel on issues related toMotivational Interviewing and respiratory health care.5. Dyads (1–10 minutes)--Participants get into pairs and discuss a key learning point/issue.6. Individual exercise (5–10 minutes)--Each participant writes down three key points, experiences or reference statementswith regards to a particular issue being discussed.7. Large group demonstration or role play (15–30 minutes)--The facilitator asks for one of the participants to volunteer to play the role ofa patient or client, while the facilitator plays the role of clinician. Immediatelyafter the role play, reflect and discuss with the larger group. You may even wantto reward the volunteer with a prize (i.e., a book or a gift certificate).Information on accrediting training eventsand continuing education (CE) creditswhat is accreditation?Accreditation is the process by which a discipline-specific college or professionalorganization awards certain continuing education credits to a workshop for theirmembers.why get your training accredited?To maintain good standing within a professional discipline or regulatory body,members have to complete a certain number of continuing education hours everyyear. Program accreditation means that participants can get credit (continuing educationhours) by attending your session. If the workshop is not accredited, participantsmay still be able to receive continuing education credits for their attendance,but they will need to submit proof of their attendance (a letter or certificate ofcompletion).who receives accreditation?Accreditation is granted on the basis of the sponsor’s demonstrated ability to planand implement an event/workshop in accordance with the accrediting body’s criteria.©2012 CAMH/TEACH 11

Motivational Interviewing in Respiratory Health Carewho accredits teach workshops?Please note: Your Motivational Interviewing workshop is not accredited until you applyto the relevant organization(s) (see below). Please review this information to determinewhether your workshop meets the criteria for accreditation from the following organizations.You are not required to have courses or seminars accredited—this is an organizationspecificdecision in which you take into account your time, resources, audience needs andother considerations.TEACH applies for accreditation from the following professional organizations:College of Family Physicians of CanadaThe College of Family Physicians of Canada (CFPC) is a national professional organizationof family physicians that makes continuing medical education (CME) ofits members mandatory. The CFPC strives to improve the health of Canadians bypromoting high standards of medical education and care in family practice, and bycontributing to public understanding of healthful living.Family physicians wishing to receive Mainpro-C credits for attending the MIworkshop should be directed to the CFPC’s Linking Learning to Practice document,at this URL: www.cfpc.ca/Linking_Learning_to_Practice.CFPC members can use this document to create an outline of how their learningrelates to their clinical practice, and then submit this material via the CFPC websiteto obtain CME credits.Note that the CFPC has a detailed system of program accreditation. For moreinformation, please contact the TEACH project at 416 535-8501, ext. 1600, or e-mailteach@camh.ca.Royal College of Dental Surgeons of OntarioThe Royal College of Dental Surgeons of Ontario (RCDSO) is the statutory governingbody for dentists in Ontario that protects the public’s right to quality oral healthservices by providing leadership and education to the dental profession in selfregulation.If you are interested in having your program approved by RCDSO’s QualityAssurance Program, please visit this link:www.rcdso.org/quality_assurance/continuingEd.html.Please note: RCDSO does not accredit courses, they simply approve them.Ontario College of PharmacistsThe Ontario College of Pharmacists (OCP) is the regulatory body for pharmacypractice in Ontario. All persons within Ontario who wish to dispense prescriptions12©2012 CAMH/TEACH

Section 1: Planning tips for facilitatorsand sell products defined as drugs to the public must first have met the professionalqualifications set by the College, and be registered as pharmacists.If you are interested in OCP accreditation, please visit this link:www.ocpinfo.com/Client/ocp/OCPHome.nsf/object/CE+Accreditation+Form/$file/CE+Accreditation+Form.pdf.Canadian Addiction Counselling Certification FederationThe Canadian Addiction Counselling Certification Federation (CACCF) strives tocontinuously offer the most effective and credible certifications to all addictionspecificcounsellors in Canada.If you are interested in CACCF accreditation, please visit this link:www.caccf.ca/images/pdf/Approval_Continuing_Ed.pdf.Other disciplinesThe following professional organizations ask members to self-monitor their continuingeducation by developing an individualized learning plan or portfolio. Membersof these colleges may add the completion of the MI workshop as a way to meet a specificlearning goal that they have identified.• College of Dental Hygienists of Ontario (CDHO, www.cdho.org/)• College of Nurses of Ontario (CNO, www.cno.org/)• College of Occupational Therapists of Ontario (COTO, www.coto.org/about/)• College of Respiratory Therapists of Ontario (CRTO, www.crto.on.ca/)• Ontario College of Social Workers and Social Service Workers (OCSWSSW,www.ocswssw.org/).Additional readingpresentation, facilitation and teachingAtkinson, C. (2008). Beyond Bullet Points: Using Microsoft PowerPoint to CreatePresentations That Inform, Motivate and Inspire. Redmond, WA: Microsoft Press.Bender, P.U. (1991). Secrets of Power Presentations. Toronto: The AchievementGroup.Bienvenu, S. (2000). The Presentation Skills Workshop: Helping People Create andDeliver Great Presentations. New York: Amacom.Duarte, N. (2008). Slide:ology: The Art and Science of Creating Great Presentations.Sebastopol, CA: O’Reilly.Guilfoyle, D. (2002). The Charisma Effect: How to Captivate an Audience and Delivera Winning Message. Toronto: McGraw-Hill.©2012 CAMH/TEACH 13

Motivational Interviewing in Respiratory Health CareHall, R. (2007). Brilliant Presentations: What the Best Presenters Know, Say and Do.New York: Pearson Prentice Hall Business.Henderson, J. & Henderson, R. (2007) There’s No Such Thing As Public Speaking:Make Any Presentation or Speech As Persuasive As a One-on-One Conversation. NewYork: Prentice Hall. (See also www.theresnosuchthingaspublicspeaking.com/)Hindle, T. (1998). Making Presentations. Bolton, ON: Fenn Publishing.Jackson, P.Z. (2001). The Inspirational Trainer. London, U.K.: Kogan Page.Jolles, R.L. (1993). How to Run Seminars and Workshops: Presentation Skills forConsultants, Trainers and Teachers. New York: John Wiley and Sons.Klatt, B. (1998). The Ultimate Training Workshop Handbook: A Comprehensive Guideto Leading Successful Workshops and Training Programs. New York: McGraw-Hill.McKeachie, W.J. (Ed.). (1999). Teaching Tips: Strategies, Research and Theory forCollege and University Teachers (10th Ed). Boston, MA: Houghton Mifflin.Renner, P. (1999). The Art of Teaching Adults: How to Become an ExceptionalInstructor and Facilitator. Vancouver, BC: Training Associates.Reynolds, G. (2008) Presentation Zen: Simple Ideas on Presentation Design andDelivery. Berkeley, CA: New Riders.constructivist learningWhat is constructivist learning?In a constructivist model, learning is an active process of constructingknowledge, while instruction is a process of supporting that construction.Constructivism seeks to be “REAL” by providing a Real Environment for ActiveLearning. For more on constructive approaches to adult education, you may findthe following resources fruitful.Dean, R.G. (1993). Constructivism: An approach to clinical practice. Smith CollegeStudies in Social Work, 63(2), 126–146.Duffy, T.M. & Cunningham, D.J. (1997). Constructivism: Implications for thedesign and delivery of instruction. In D.H. Jonassen (Ed.), Handbook of Researchfor Educational Communications and Technology, pp. 170–198. New York: Simon &Shuster Macmillan.Fenwick, T. and Parsons, J. (1998). Boldly solving the world: A critical analysisof problem-based learning as a method of professional education. Studies in theEducation of Adults, 30(1), 53–66.14©2012 CAMH/TEACH

Section 1: Planning tips for facilitatorsHerie, M. (2005). Theoretical Perspective in Online Pedagogy. In R.J. MacFaddenet al. (Ed.), Web-Based Education in the Human Services: Models, Methods and BestPractices, pp. 29–52. New York: Haworth Press.Hsu, P.W. (2008). In search of a constructivist paradigm to guide the practice ofadult information technology education. Dissertation Abstracts International SectionA: Humanities and Social Sciences, 68(10-A), 4166.Huang, H-M. (2002). Toward constructivism for adult learners in online learningenvironments. British Journal of Education Technology, 33(1), 27–37.Illeris, K. (2003). Towards a contemporary and comprehensive theory of learning.International Journal of Lifelong Education, 22(4), 396–406.Rossiter, A.B. (1993). Teaching from a critical perspective: Towards empowermentin social work education. Canadian Social Work Review, 10(1), 76–89.Stojnov, D. (2004). Teachers as Personal (Construct) Transformers. PsycCRITIQUES,49(1).Van Petegem, P., Donche, V, & Vanhoof, J. (2005). Relating pre-service teachers’approaches to learning and preferences for constructivist learning environments.Learning Environments Research, 8(3), 309–332.Webliography: Leadership developmentand presentation tipsFacilitation is a critical skill in leading groups and presenting ideas to others. Tobuild this expertise, consider exploring the following websites, which offer resourcesto build skills in group facilitation, interactive exercises and presentations.• The International Association of Facilitators (IAF)—Dedicated to providingmanagers, team leaders and facilitators with online and face-to-face tools for creating,leading and following up group meetings. It includes hundreds of methodsthat can be used in facilitating group processes. Some methods are suitable foruse by group members; others require the help of a group facilitator. Both membersand facilitators can make use of the database and its associated newsletter todownload resources, learn about methods or to prepare for a specific group meeting.You can join this association for free instantly and log on as a member to gainaccess to the many resources and links. Just follow the prompts on the home pageto register. www.iaf-methods.org/• Strengthening Personal Presentations—A PowerPoint presentation from theHealth Communication Unit (HCU) at the University of Toronto on developing©2012 CAMH/TEACH 15

Motivational Interviewing in Respiratory Health Carepresentation skills. One of many free resources that can be downloaded from theHCU. www.thcu.ca/resource_db/pubs/570623888.pdf• Leadership Resources for Student Leaders and Advisors—Directed towards universitystudents and their advisors, but useful for group situations and developingorganizational leadership in general. Offers easy-to-read two-page PDF files coveringmore than 40 topics, from the basics of starting an organization to managinggroup dynamics to leading meetings efficiently. www.letu.edu/opencms/opencms/_Student-Life/student-activities/student-organizations/LeadingBits/• Leadership Development Resources—Free articles and information on transformationalleadership development, and on developing skills in the following fourareas:--knowing how to turn knowledge into skills--exercising influence, not authority--transforming the self; accessing mental resources--fine-tuning the transformational mind-set and developing a leadershipphilosophy.www.legacee.com/index.htmlwww.legacee.com/Services/Leadership/LearningSkills.html• Effective Group Facilitation—39-page PDF file on facilitation skills.http://tjd.uua.org/resources/EffectiveGroupFacilitation.PDF• Thiagi Group—Website with many free resources for group participation andtraining games, icebreakers, interactive experiences, newsletters and more.www.thiagi.com/index.html16©2012 CAMH/TEACH

Section 2:Facilitatorresources

Section 2: Facilitator resourcesWorkshop overviewsone-day workshopSummaryMotivational Interviewing (MI) is a “collaborative, person-centered form of guidingto elicit and strengthen motivation for change” (Miller and Rollnick, 2009). MIhas a robust evidence base across a range of health behaviours, including respiratoryhealth care. This workshop addresses the foundation skills and underlying philosophyof MI using case-based learning, hands-on practice and take-away resources.Learning objectivesAt the end of this workshop, participants will be able to:• define MI and its relevance to respiratory health care and health behaviour change• operationalize the “spirit” of MI in conversations with clients• review and practise foundation skills in MI• listen for and respond to client change talk• apply agenda-setting as a strategy for working with clients with complex, cooccurringissues• recognize and integrate MI spirit and skills in practice• set objectives and access resources for continuing professional development inMI skills.©2012 CAMH/TEACH 19

Motivational Interviewing in Respiratory Health CareLesson plan: One-day workshopSuggested time Topic/activity Lesson plan/notes Slide #s9:00–9:15(15 mins)Welcome andIntroductionsAcknowledgementsWelcome participants to the training, and provide any housekeepingannouncements that you have:• location of exits, restrooms1–4Disclosures• sign-in sheet (if you are using one)• breaks, lunch (if applicable).9:15–9:30(15 mins)Learning Objectivesand WorkshopOverviewIn groups of 20 or fewer, ask participants to go around and introducethemselves; in groups of more than 20, ask participants to introduce themselvesto 3–4 other people around them.Briefly review the content of the session.Ask participants: “How does this fit with your learning goals for today?”Elicit comments and questions from the large group, and write these on aflipchart. Keep them posted on the wall throughout the workshop and referback to them as you cover the session content.5–11Be clear about what you can and cannot cover. If someone asks a questionor raises a topic that you will not be able to cover, offer to forward aresource or further information to them after the session.Ask participants to reflect on their skill level in MI with a partner. Give acouple of minutes for conversation, and then ask for feedback from thelarge group.20©2012 CAMH/TEACH

Section 2: Facilitator resourcesSuggested time Topic/activity Lesson plan/notes Slide #s9:30–9:50What Is MI?There is likely to be a range of skill levels across the group; however, a keypoint to emphasize is that regardless of skill level, we are all continuouslylearning and improving our clinical skills. No one is ever perfect, so inviteparticipants to consider what areas and skills they could develop evenmore.Learning objective #1:12–29(20 mins)Evidence Base forMIDefine MI and its relevance to respiratory health care and health behaviourchangeThis material sets the stage for the session by defining MI and establishingthe evidence for it. Before the workshop, review the articles referenced inthe slides to familiarize yourself with the content. Refer to the facilitators’notes (p. 37) for key points to emphasize on the slides.You may wish to skip or omit slides, depending on the audience. Note thatyou do not have to spend a lot of time on every slide.Leave a couple of minutes at the end for questions.As an alternative to showing the evidence slides, you may choose to distributecopies of the document summarizing the evidence base for MI(p. 205), and lead a group discussion of key points in the document.©2012 CAMH/TEACH 21

Motivational Interviewing in Respiratory Health CareSuggested time Topic/activity Lesson plan/notes Slide #s9:50–10:30(40 mins)The “Spirit” ofMotivationalInterviewingLearning objective #2:Operationalize the “spirit” of MI in conversations with clientsIntroduce this section of the workshop by reflecting that the “spirit” of MIis a definable and integral part of the intervention. Mention that particpantswill have an opportunity to contrast the different styles (directing, orMI-inconsistent, versus guiding, or MI-consistent) in this section.30–47Refer to the facilitators’ notes for detailed instructions and key points toemphasize.Suggested timing:• Overview of the spirit of MI: 10 mins (slides 30–35)• “Righting Reflex” and persuasion exercise: 10 mins (slides 36–41)• “Taste of MI” exercise and debrief: 15 mins (slides 42–46)• Summary of skills: 5 mins (slide 47).10:30–10:45(15 mins)You may want to add or substitute other cases or activities (see “Case-Based Learning Activities and Case Examples,” p. 182), and adjust the timingaccordingly.BREAK This is the suggested time to hold a break (usually 15 minutes), but it ismore important to pay attention to the energy level of the group, and proposea break when it seems like people are tired or losing focus.4822©2012 CAMH/TEACH

Section 2: Facilitator resourcesSuggested time Topic/activity Lesson plan/notes Slide #s10:45–12:00(75 mins)Foundation Skills:OARSOpen QuestionsAffirmationsReflective ListeningSummaryStatementsLearning objective #3:Review and practise foundation skills in MIIntroduce the four foundation skills. Each skill is briefly discussed and followedby an interactive exercise (refer to the facilitators’ notes for detailedinstructions and key points to emphasize from the slides).Suggested timing for each of the four skills and accompanying activities:• Introduction of OARS: 3 mins (slide 49)• Open Questions: 12 mins (slides 50–62)• Affirmations: 15 mins (slides 63–73)• Reflective Listening: 30 mins (slides 74–86)• Summary Statements: 10 mins (slides 87–89)—Use the video“Angry Bob”• Summary of OARS Skills: 5 mins (slide 90).You may want to add or substitute other cases or activities (see the “Case-Based Learning Activities and Case Examples”), and adjust the timingaccordingly.12:00–1:00 LUNCH If you are doing a full-day workshop, this may be the optimal time for alunch break. However, you can choose to extend or shorten the time forany of the preceding activities and exercises, based on the group’s needsand your own agenda for the session.91©2012 CAMH/TEACH 23

Motivational Interviewing in Respiratory Health CareSuggested time Topic/activity Lesson plan/notes Slide #s1:00–1:40(40 mins)Recognizing andResponding toChange TalkLearning objective #4:Listen for and respond to client change talkIntroduce the MI skills covered in this section: Recognizing and respondingto change talk. Each skill is briefly discussed and followed by an interactiveexercise (refer to the facilitators’ notes for detailed instructions andkey points to emphasize from the slides).92–111Suggested timing for the skills and accompanying activities:• Introduction to change talk: 10 mins (slides 92–97)• Recognizing change talk activity: 10 mins (slides 98–103)• Responding to change talk: 20 mins (slides 104–111).1:40–2:15Agenda-Setting Learning objective #5:You may want to add or substitute other cases or activities (see “Case-Based Learning Activities and Case Examples”), and adjust the timingaccordingly.112–124(35 mins)Apply agenda-setting as a strategy for working with clients with complex,co-occurring issuesIntroduce the skill of agenda-setting. Tips and strategies for agenda-settingare briefly discussed and followed by a video example (refer to the facilitators’notes for detailed instructions and key points to emphasize from theslides)24©2012 CAMH/TEACH

Section 2: Facilitator resourcesSuggested time Topic/activity Lesson plan/notes Slide #sSuggested timing:• Introduction and tips for agenda-setting: 15 mins (slides 112–121)• Video demonstration and debrief: 10 mins (slide 122)—use the video“Agenda-Setting Conversation with Sal”• Overview of Readiness Ruler: 5 mins (slide 123)• Summary of skills (Change Talk and Agenda-setting): 5 mins (slide 124).2:15–2:30(15 mins)2:30–3:45(75 mins)You may want to add or substitute other cases or activities (see “Case-Based Learning Activities and Case Examples”), and adjust the timingaccordingly.BREAK This is the suggested time to hold a break (usually 15 minutes), but it ismore important to pay attention to the energy level of the group, and proposea break when it seems like people are tired or losing focus.Pulling It AllTogetherLearning objective #6:Recognize and integrate MI spirit and skills in practise125126–133This section of the course integrates all of the MI skills covered inthe workshop. Explain that you will show two videos that illustrateMI-inconsistent and MI-consistent approaches with a client who is ambivalentabout change (approx. 5 minutes per video).Refer to the facilitators’ notes for detailed instructions and key points toemphasize from the slides. (N.B.: if you are going to ask participants tocode the videos and/or each other, make sure that each person has at leastthree coding sheets.)©2012 CAMH/TEACH 25

Motivational Interviewing in Respiratory Health CareSuggested time Topic/activity Lesson plan/notes Slide #sSuggested timing:• Ineffective practitioner video and coding exercise: 15 mins (slides 126–127)—use the video “How NOT to Do Motivational Interviewing”• Effective practitioner video and coding exercise: 15 mins (slides 128–129)—use the video “A Conversation with Sal about His Asthma”• Debrief and review of coding scores and discussion of MI skills demonstrated:15 mins (slide 130)• Hands-on practise coding exercise in triads: 30 mins (slides 131–132)• Large group debrief and discussion: 15 mins (slide 133).3:45–4:00 ContinuingProfessionalDevelopmentin MotivationalInterviewingYou may want to add or substitute other cases or activities (see “Case-Based Learning Activities and Case Examples”), and adjust the timingaccordingly.Learning objective #7:Set objectives and access resources for continuing professional developmentin MI skillsThe end of each workshop is an opportunity for participants to reflect onwhat they have learned, set concrete goals for practice, and identify avenuesfor continuing professional development.134–137Emphasize that MI is not something that can be learned in a one-dayworkshop—the workshop introduces the skills and the approach, but proficiencycomes with practice.26©2012 CAMH/TEACH

Section 2: Facilitator resourcesSuggested time Topic/activity Lesson plan/notes Slide #sRefer to the facilitators’ notes for detailed instructions and key points toemphasize from the slides.Thank participants and remind them to complete the workshop evaluation(see Appendix).Complete your own facilitator evaluation and send to teach@camh.ca withyour feedback on this toolkit.©2012 CAMH/TEACH 27

Motivational Interviewing in Respiratory Health Carehalf-day workshopSummaryMotivational Interviewing (MI) is a “collaborative, person-centered form of guidingto elicit and strengthen motivation for change” (Miller & Rollnick, 2009). MI has arobust evidence base across a range of health behaviours, including respiratory healthcare. This workshop addresses the foundation skills and underlying philosophy of MIusing case-based learning, hands-on practice and take-away resources.Learning objectivesAt the end of this workshop, participants will be able to:• define MI and its relevance to respiratory health care and health behaviour change• operationalize the “spirit” of MI in conversations with clients• review and practise foundation skills in MI• set objectives and access resources for continuing professional development inMI skills.28©2012 CAMH/TEACH

Section 2: Facilitator resourcesLesson plan: Half-day workshopSuggested time Topic/activity Lesson plan/notes Slide #s9:00–9:15(15 mins)Welcome andIntroductionsAcknowledgementsWelcome participants to the training, and provide any housekeeping announcementsthat you have:• location of exits, restrooms1–11Disclosures• sign-in sheet (if you are using one)Learning Objectivesand WorkshopOverview• breaks, lunch (if applicable).Briefly review the content of the session.Ask participants: “How does this fit with your learning goals for today?”Elicit comments and questions from the large group, and write these on a flipchart—keepthem posted on the wall throughout the workshop and refer back tothem as you cover the session content.Be clear about what you can and cannot cover. If someone asks a question orraises a topic that you will not be able to cover, offer to forward a resource orfurther information to them after the session.Ask participants to reflect on their skill level individually.There is likely to be a range of skill levels across the group; however, a key pointto emphasize is that regardless of skill level, we are all continuously learning andimproving our clinical skills. No one is ever perfect, so invite participants to considerwhat areas and skills they could develop even more.©2012 CAMH/TEACH 29

Motivational Interviewing in Respiratory Health CareSuggested time Topic/activity Lesson plan/notes Slide #s9:15–9:35What is MI? Learning objective #1:12–29(20 mins)Evidence base forMIDefine MI and its relevance to respiratory health care and health behaviourchangeThis material sets the stage for the session by defining MI and establishing theevidence for it. Before the workshop, review the articles referenced in the slide tofamiliarize yourself with the content. Refer to the facilitators’ notes (p. 37) for keypoints to emphasize on the slides.You may wish to skip or omit slides, depending on the audience. Note that youdo not have to spend a lot of time on every slide.Leave a couple of minutes for questions.9:35–10:15(40 mins)The “Spirit” ofMotivationalInterviewingAs an alternative to showing the evidence slides, you may choose to distributecopies of the document summarizing the evidence base for MI (p. 205), andlead a group discussion of key points in the document.Learning objective #2:Operationalize the “spirit” of MI in conversations with clientsIntroduce this section of the workshop by reflecting that the “spirit” of MI isa definable and integral part of the intervention. Mention that participants willhave an opportunity to contrast the different styles (directing, or MI-inconsistent,versus guiding, or MI-consistent) in this section.30–47Refer to the facilitators’ notes for detailed instructions and key points to emphasize.30©2012 CAMH/TEACH

Section 2: Facilitator resourcesSuggested time Topic/activity Lesson plan/notes Slide #sSuggested timing:• Overview of the spirit of MI: 10 mins (slides 30–35)• “Righting Reflex” and persuasion exercise: 10 mins (slides 36–41)• “Taste of MI” exercise and debrief: 15 mins (slides 42–46)• Summary of skills: 5 mins (slide 47).10:15–10:30(15 mins)10:30–11:45(75 mins)You may want to add or substitute other cases or activities (see “Case-BasedLearning Activities and Case Examples”), and adjust the timing accordingly.BREAK This is the suggested time to hold a break (usually 15 minutes), but it is moreimportant to pay attention to the energy level of the group, and propose a breakwhen it seems like people are tired or losing focus.Foundation Skills:OARSOpen questionsAffirmationsReflective ListeningSummary statementsLearning objective #3:Review and practise foundation skills in MIIntroduce the four foundation skills. Each skill is briefly discussed and followedby an interactive exercise (refer to the facilitators’ notes for detailed instructionsand key points to emphasize from the slides).Suggested timing for each of the four skills and accompanying activities:• Introduction of OARS: 3 mins (slide 49)4849–90• Open Questions: 12 mins (slides 50–62)• Affirmations: 15 mins (slides 63–73)• Reflective Listening: 30 mins (slides 74–86).©2012 CAMH/TEACH 31

Motivational Interviewing in Respiratory Health CareSuggested time Topic/activity Lesson plan/notes Slide #s• Summary Statements: 10 mins (slides 87–89)—Use the video “Angry Bob”• Summary of OARS Skills: 5 mins (slide 90).11:45–12:00 ContinuingProfessionalDevelopmentin MotivationalInterviewingYou may want to add or substitute other cases or activities (see “Case-BasedLearning Activities and Case Examples”), and adjust the timing accordingly.Learning objective #4:Set objectives and access resources for continuing professional development inMI skillsThe end of each workshop is an opportunity for participants to reflect on whatthey have learned, set concrete goals for practice, and identify avenues for continuingprofessional development.134–137Emphasize that MI is not something that can be learned in a half-day workshop.The workshop introduces the foundation skills and the approach, but proficiencycomes with further training and practice.Refer to the facilitators’ notes for detailed instructions and key points to emphasizeon the slides.Thank participants and remind them to complete the workshop evaluation (seeAppendix).Complete your own facilitator evaluation and send to teach@camh.ca with yourfeedback on this toolkit.32©2012 CAMH/TEACH

Section 2: Facilitator resourcesone-hour workshopSummaryMotivational Interviewing (MI) is a “collaborative, person-centered form of guidingto elicit and strengthen motivation for change” (Miller and Rollnick, 2009). MIhas a robust evidence base across a range of health behaviours, including respiratoryhealth care. This workshop addresses the philosophy of MI in an experiential way,and includes take-away resources.Learning objectivesAt the end of this workshop, participants will be able to:• define MI and its relevance to respiratory health care and health behaviour change• operationalize the “spirit” of MI in conversations with clients• set objectives and access resources for continuing professional development inMI skills.©2012 CAMH/TEACH 33

Motivational Interviewing in Respiratory Health CareLesson plan: One-hour workshopSuggested time Topic/activity Lesson plan/notes Slide #s9:00–9:05(5 mins)9:05–9:15(10 mins)Welcome andIntroductionsAcknowledgementsDisclosuresLearning Objectivesand WorkshopOverviewWhat is MI?Evidence base forMIWelcome participants and briefly review the content of the session.Ask participants to individually reflect on their skill level in MI.There is likely to be a range of skill levels across the group; however, a key pointto emphasize is that regardless of skill level, we are all continuously learning andimproving our clinical skills. No one is ever perfect, so invite participants to considerwhat areas and skills they could develop even more.Learning objective #1:Define MI and its relevance to respiratory health care and health behaviourchangeProvide an overview of MI (definition and guiding-style intervention).1–1112–1627–29Show the summary of evidence (slide 27) and distribute copies of the documentsummarizing the evidence base for MI (p. 205), and briefly discuss key points inthe document.You may also want to show one or both of the “Sal” videos (ineffective vs. effectivepractitioner) as a way to contrast the guiding style of MI with a more directivestyle. Note that the videos are approximately 5 minutes each, so you willneed to adjust your time accordingly in the next section.34©2012 CAMH/TEACH

Section 2: Facilitator resourcesSuggested time Topic/activity Lesson plan/notes Slide #s9:15 – 9:55(40 mins)The “Spirit” ofMotivationalInterviewingLearning objective #2:Operationalize the “spirit” of Motivational Interviewing in conversations withclients30–47Introduce this section of the workshop by reflecting that the “spirit” of MI isa definable and integral part of the intervention. Mention that participants willhave an opportunity to contrast the different styles (directing, or MI-inconsistent,versus guiding, or MI-consistent) in this section.Refer to the facilitators’ notes for detailed instructions and key points to emphasize.Suggested timing:• Overview of the spirit of MI: 10 mins (slides 30–35)• “Righting Reflex” and persuasion exercise: 10 mins (slides 36–41)• “Taste of MI” exercise and debrief: 15 mins (slides 42–46)• Summary of skills: 5 mins (slide 47)You may want to add or substitute other cases or activities (see “Case-BasedLearning Activities and Case Examples”), and adjust the timing accordingly.©2012 CAMH/TEACH 35

Motivational Interviewing in Respiratory Health CareSuggested time Topic/activity Lesson plan/notes Slide #s9:55 – 10:00(5 mins)ContinuingProfessionalDevelopmentin MotivationalInterviewingLearning objective #3:Set objectives and access resources for continuing professional development inMI skillsThe end of each workshop is an opportunity for participants to reflect on whatthey have learned, set concrete goals for practice, and identify avenues for continuingprofessional development. Emphasize that MI is not something that canbe learned in a one-hour workshop—the workshop introduces the approach, butproficiency comes from further training and practice.134–137Refer to the facilitators’ notes for detailed instructions and key points to emphasizefrom the slides.Thank participants and remind them to complete the workshop evaluation (seeAppendix).Complete your own facilitator evaluation and send to teach@camh.ca with yourfeedback on this toolkit.36©2012 CAMH/TEACH

Section 2: Facilitator resourcesPresentation slides: Facilitators’ notesslide 1Welcome participants to the training,and provide any housekeepingannouncements that you have:• location of exits, restrooms• sign-in sheet (if you are using one)• breaks, lunch (if applicable).©2012 CAMH/TEACH 37

Motivational Interviewing in Respiratory Health Careslide 2Show this slide to briefly acknowledgethe contributors to the developmentof the workshop content .38©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 3©2012 CAMH/TEACH 39

Motivational Interviewing in Respiratory Health Careslide 4Add any disclosures that you havewith respect to funding or fundsreceived (for example, from industryor other sources). If you have nothingto disclose you may omit thisslide.40©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 5Review the Learning Objectives forthe course (this slide covers theobjectives for a full day of trainingin MI).©2012 CAMH/TEACH 41

Motivational Interviewing in Respiratory Health Careslide 6Review the Learning Objectives forthe course (this slide covers theobjectives for a half day of trainingin MI).42©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 7Review the Learning Objectives forthe course (this slide covers theobjectives for one hour of trainingin MI).©2012 CAMH/TEACH 43

Motivational Interviewing in Respiratory Health Careslide 8Briefly review the content of the session.This outline relates to a full-day MIworkshop.Note: As a facilitator, you can chooseto combine the specific content areasin whatever ways make the mostsense for your audience and practicesetting(s). However, it is recommendedthat you always include:• definition of MI• evidence base for MI• spirit of MI• practice goals and additionalresources.Ask participants: “How does this fitwith your learning goals for today?”Elicit comments and questions fromthe large group, and write these on aflipchart—keep them posted on thewall throughout the workshop andrefer back to them as you cover thesession content.Be clear about what you can and cannotcover. If someone asks a questionor raises a topic that you willnot be able to cover, offer to forwarda resource or further information tothem after the session.44©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 9Briefly review the content of the session.This outline relates to a half-day MIworkshop.Ask participants: “How does this fitwith your learning goals for today?”Elicit comments and questions fromthe large group, and write these on aflipchart—keep them posted on thewall throughout the workshop andrefer back to them as you cover thesession content.Be clear about what you can and cannotcover. If someone asks a questionor raises a topic that you willnot be able to cover, offer to forwarda resource or further information tothem after the session.©2012 CAMH/TEACH 45

Motivational Interviewing in Respiratory Health Careslide 10Briefly review the content of the session.This outline relates to a one-hour MIworkshop.Optional, if time allows: Ask participants:“How does this fit with yourlearning goals for today?”Briefly elicit comments and questionsfrom the large group.Be clear about what you can and cannotcover. If someone asks a questionor raises a topic that you willnot be able to cover, offer to forwarda resource or further information tothem after the session.46©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 11Ask participants to pair up and reflecton their skill level in MI with theirpartners. Give a couple of minutesfor conversation, and then ask forfeedback from the large group.There is likely to be a range of skilllevels across the group; however,a key point to emphasize is thatregardless of skill level, we are allcontinuously learning and improvingour clinical skills. No one is everperfect, so invite participants to considerwhat areas and skills they coulddevelop even more.©2012 CAMH/TEACH 47

Motivational Interviewing in Respiratory Health Careslide 12Motivational Interviewing is a generalapproach to working with people whoare ambivalent about making changesto their behaviour.MI is a set of techniques and also aphilosophy or spirit.It has been variously defined inthe literature and is an evolvingapproach; however, the most currentdefinition is on the next slide.48©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 13The work of Carl Rogers has beenespecially influential in the developmentof MI. However, you can seethat there are some important differences—mostsignificantly, that MIhas an explicit agenda (change), asopposed to offering undifferentiatedvalidation of clients’ material.Miller found that confrontation withpeople with alcohol addiction elicitedno change—just resistance—whereasMI spirit and listening encouragedchange. This is contrary to the philosophybehind TV shows like “TheIntervention,” which can be likenedto a “surprise party for people withaddictions,” and which uses a primarilyconfrontational approach.There are additional resources on theMI website.©2012 CAMH/TEACH 49

Motivational Interviewing in Respiratory Health Careslide 14A continuum of styles of counsellinginterventions exist, rangingfrom “following” (where the practitionerunconditionally validatesthe client, and works with whatevercontent comes up, with no explicitgoal regarding behaviour change) toactively “directing” (where the practitionersets the behaviour changegoal and agenda for the session).MI is somewhere in the middle ofthis range, and can be considered a“guiding” style of counselling. Thatis, the practitioner and client workcollaboratively to set goals for changeand identify areas of focus. The clientis regarded as the expert on his orher own life, and on what will workbest for him or her, and this is valuedas much as the professional expertiseof the practitioner.50©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 15Motivational interviewing is “directional”(goal oriented) as opposed to“directive” in style and orientation.Recognize that many (most?) practitionersin health care have beentrained to be directive. This worksvery well when patients approachus asking for advice or suggestions—theyare clearly in the “action”stage of change. However, whenpatients are ambivalent or resistantto change, a directive approachgenerally is counterproductive andoften leads to patients not followingthrough on treatment plans, gettinginto the “Yes, but . . .” trap (whereour every suggestion for change ismet with a “Yes, but . . .” response),and/or decreased patient rapportand engagement. MI is indicated forpatients who are ambivalent about,or not considering, change.©2012 CAMH/TEACH 51

Motivational Interviewing in Respiratory Health Careslide 16This section provides a brief overviewof the evidence for MI. MI has beenresearched in over 200 randomizedcontrolled trials, and there are thousandsof publications documentingthis approach. The range of healthbehaviours that have been investigatedusing an MI approach include:• public health and workplace health• sexual health• dietary change• weight management• voice therapy• gambling• physical activity• stroke rehab• chronic pain• medication adherence• diabetes• mental health• addictions• fibromyalgia• chronic leg ulceration• self-care• criminal justice• vascular risk• domestic violence.(Anstiss, 2009)52©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 17This review summarizes the evidencefor MI in smoking cessation. Keypoints can be found on the followingslide.It is recommended that facilitatorsaccess and read this article beforetraining.©2012 CAMH/TEACH 53

Motivational Interviewing in Respiratory Health Careslide 18Briefly summarize the points on theslide.54©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 19This review summarizes the evidencefor MI in asthma medication adherence.Key points can be found on thefollowing slide.It is recommended that facilitatorsaccess and read this article beforetraining.©2012 CAMH/TEACH 55

Motivational Interviewing in Respiratory Health Careslide 20Briefly summarize the points on theslide.56©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 21This research study investigated MIcombined with brief education, asopposed to MI alone, in changingpatients’ attitudes towards asthmamedication adherence. Key pointscan be found on the following slide.It is recommended that facilitatorsaccess and read this article beforetraining.©2012 CAMH/TEACH 57

Motivational Interviewing in Respiratory Health Careslide 22Briefly summarize the points on theslide.58©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 23This research study investigated MIversus self-help in reducing passivesmoke exposure. Key points can befound on the following slide.It is recommended that facilitatorsaccess and read this article beforetraining.©2012 CAMH/TEACH 59

Motivational Interviewing in Respiratory Health Careslide 24Briefly summarize the points on theslide.60©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 25This article reviews evidence-basedinterventions (including MI) in reducingETS. Key points can be found onthe following slide.It is recommended that facilitatorsaccess and read this article beforetraining.©2012 CAMH/TEACH 61

Motivational Interviewing in Respiratory Health Careslide 26Briefly summarize the points on theslide.62©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 27You can access a brief summary ofthe evidence for MI in health behaviourchange generally, and respiratoryhealth care specifically, in the section“Pre-reading for Participants” (p. 205).You may want to provide participantswith a copy of this document as oneof their workshop handouts.©2012 CAMH/TEACH 63

Motivational Interviewing in Respiratory Health Careslide 28You can briefly show this slide, orprovide it as a handout to participantsinstead.64©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 29This relates to the use of MI fortobacco cessation.“Grade of Recommendation/Level ofEvidence 1B” indicates a strong recommendationand moderate-qualityevidence.Encourage practitioners to join theCAN-ADAPTT website:• CAN-ADAPTT is an acronym thatstands for the Canadian ActionNetwork for the Advancement,Dissemination and Adoptionof Practice-Informed TobaccoTreatment.• CAN-ADAPTT is a national guidelinedevelopment, disseminationand exchange project.• An online network and coordinatedengagement activitiesacross Canada allow members toprovide ongoing input into CAN-ADAPTT’s guideline, discuss bestpractices, identify research gaps,and share resources. This practiceinformedapproach ensures that theneeds and experiences of the targetend users are reflected in the CAN-ADAPTT guideline.©2012 CAMH/TEACH 65

Motivational Interviewing in Respiratory Health Careslide 30Introduce this section of the workshopby reflecting that the “spirit” ofMI is a definable and integral part ofthe intervention. In fact, the spirit isactually of greater importance thanthe MI micro-skills, and can also bethe most challenging to integratebecause health practitioners havebeen trained to try to “fix” theirpatients (also known as the “rightingreflex”).Mention that participants willhave an opportunity to contrastthe different styles (directing, orMI-inconsistent, versus guiding, orMI-consistent) in this section.66©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 31Often, our work with clients feelslike wrestling—with us on one sidestruggling for change, and the clienton the other side struggling to preventchange. MI helps to alter thisdynamic, creating a collaborative andmore equal dynamic that feels morelike dancing.(Ballroom dancers may make a routinelook effortless, but it takes a lotof practice and sweat to get there!)©2012 CAMH/TEACH 67

Motivational Interviewing in Respiratory Health Careslide 32The three elements of the spirit of MIare autonomy, collaboration and evocationof the client’s perspective andthoughts about change (Miller andRollnick, 2002; Rollnick and Miller,1995). These three elements can beexpressed in the acronym “A-C-E”:• Autonomy versus Authority;Collaboration versus Coercion;Evocation versus Education.• Autonomy is contrasted withauthority; the former honours theclient’s control of his or her behaviouralchoices. Collaboration is valuedover coercion, since the lattermay actually stimulate resistance.Finally, evocation of the client’sown reasons for change is morecompelling than education andinformation-sharing from the counsellor.• In addition, empathy and compassionare at the heart of the MIapproach.68©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 33Here is an example of how a practitionermight emphasize patientautonomy.She has just provided the client withsome information and her recommendations.Instead of leaving itthere, she follows up by emphasizingthat regardless of what she suggests,the choice of how to proceed is ultimatelyhis.©2012 CAMH/TEACH 69

Motivational Interviewing in Respiratory Health Careslide 34Here the practitioner invites thepatient to actively collaborate indeveloping a treatment plan.70©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 35In this example, the practitionerevokes the patient’s ideas and knowledgebefore providing information.This is something that we often forgetor neglect to do, but eliciting theclient’s knowledge and understandingfirst is an important principleof adult learning, and can help usto better understand any incorrectassumptions or gaps in the patient’sknowledge or understanding.©2012 CAMH/TEACH 71

Motivational Interviewing in Respiratory Health Careslide 36The “righting reflex” is a term thatdescribes practitioners’ reflexive urgeor need, when we see a problem, tomake it right. This can be counterproductive,as we will demonstrate inthe following two exercises.72©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 37Read the instructions on the slide,and explain that this exercise will takeapproximately five minutes.©2012 CAMH/TEACH 73

Motivational Interviewing in Respiratory Health Careslide 38Ask one person to volunteer to be the“speaker,” and note that they shouldchoose something that they areambivalent about, but that they arecomfortable sharing with a partner.In other words, “we won’t be askingyou to do intensive psychotherapy inthe next five minutes.”You can suggest some possible areasfor behaviour change, including:• getting more exercise• waking up earlier in the morning• keeping your desk organized• eating more healthily• packing your lunch (instead of buyinglunch) or bringing coffee fromhome (instead of buying expensivelattes).74©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 39In introducing this slide, ask participantsto engage authentically inthis exercise. To give the point moreimpact, you can ask for a show ofhands in response to the questions:• Has anyone here ever explained topatients why they should change?• Has anyone ever outlined thebenefits of making a change to apatient?• Have you ever given a patient somesuggestions of ways to change?• Have you ever stressed to a patienthow important it is for him or herto change?This usually elicits nods of recognitionand some laughter. Continue bysaying:“I’d like you to bring your ‘best self’to this activity, and use it as anexperiment to get some honest feedbackabout how people experiencethese interventions, even when weare doing our best.”Allow approximately five minutes forthis activity.©2012 CAMH/TEACH 75

Motivational Interviewing in Respiratory Health Careslide 40Debrief with the large group beforeshowing the next slide. In general,people will react negatively to theexercise; however, there are often oneor two participants who state thatthey found this approach helpful.Underline the point of the exercise byasking:“On the whole, would you say thatyou were already quite motivated tochange the behaviour you identifiedin this activity?”In general, people will say yes—allowing you to point out that MI isless helpful, and less necessary, forpatients who are already motivatedto change. It is for people who areambivalent that MI is most helpful.76©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 41The feelings on this slide should mirrorthe overall feedback from the previousactivity.©2012 CAMH/TEACH 77

Motivational Interviewing in Respiratory Health Careslide 42Explain to participants that theywill now experience a “taste” of MI.Note that “this is only a taste, notthe whole meal.” MI is actually quitecomplex and rich in skills; however,this exercise provides an entry point,in an experiential way, to what aMotivational Interviewing conversationlooks and feels like.Ask the participants to stay in theirpairs but switch roles, so the listenernow becomes the speaker and sharessomething they are ambivalent about(as in the previous exercise).78©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 43Give about 10–15 minutes for thisactivity, and go over the script on theslide for the listeners (counsellors) inthis exercise.Reinforce that this is just a taste ofMI, and that in a real MI conversation,advice or information can bevery much a part of the interview(but is usually prefaced by a requestfor the person’s permission to giveadvice/information).Practitioners often give too muchadvice, often to the detriment of thereal listening and reflecting that ismore at the heart of MotivationalInterviewing. Therefore, ask the“counsellors” in the exercise tonotice how hard or easy it is, in thecontext of this exercise, to refrainfrom giving advice.©2012 CAMH/TEACH 79

Motivational Interviewing in Respiratory Health Careslide 44Again, debrief with the large groupbefore showing the next slide.In general, the responses will bepositive. If there are a few peoplewho found the exercise irritating, youcan again ask them about their levelof motivation for change, and notethat too much reflective listeningcan be annoying for someone who isactively ready for change and lookingfor advice and suggestions.You can ask the group: “Did anyonefind that their level of motivation forchange actually increased after thisactivity?”Usually a few people will put up theirhands, allowing you to reinforce thepoint that even a few minutes ofmotivational conversation can havea positive impact on motivationfor change in clients, and that thisapproach does not need a lot of timeto be effective—and can actually savetime in many instances.80©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 45These feelings should echo thoseelicited from the large group inresponse to the previous slide.©2012 CAMH/TEACH 81

Motivational Interviewing in Respiratory Health Careslide 46Add that our clients’ motivation isoften a product of how we engagewith them. Motivation is a state(changeable) rather than a trait (static),and can be affected or influencedby a skillful practitioner.82©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 47Briefly summarize the skills coveredin this section.©2012 CAMH/TEACH 83

Motivational Interviewing in Respiratory Health Careslide 48This is the suggested time to holda break (usually 15 minutes), but itis more important to pay attentionto the energy level of the group, andpropose a break when it seems likepeople are tired or losing focus.84©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 49Before showing this slide, you canask, “Who here likes to cook?” Notethat sometimes the best dishes arethose with the fewest, but highestquality, ingredients. Ask participantsfor examples of dishes that use fiveor fewer ingredients.Then, change to this slide and notethat one of the nice things about MIis that, at its essence, it has only fourkey ingredients.Note that the general guidelines areto offer two reflective statements forevery question asked; to offer at least50% complex (versus simple) reflections;and to do no more that 50% ofthe talking.©2012 CAMH/TEACH 85

Motivational Interviewing in Respiratory Health Careslide 50Introduce the first of the OARS skills:Open questions.86©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 51You can cite one or more of these“Top 10 useful questions.”• What changes would you most liketo talk about?• What have you noticed about . . . ?• How important is it for you tochange . . . ?• How confident do you feel aboutchanging . . . ?• How do you see the benefits of . . . ?• How do you see the drawbackof . . . ?• What will make the most sense toyou?• How might things be different ifyou . . . ?• In what way . . . ?• Where does this leave you now?(Rollnick, Butler, et al., 2010, p. 1244).©2012 CAMH/TEACH 87

Motivational Interviewing in Respiratory Health Careslide 52Introduce this activity by saying:“Here is a chance to see how wellyou can distinguish open versusclosed questions.”88©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 53Closed©2012 CAMH/TEACH 89

Motivational Interviewing in Respiratory Health Careslide 54Closed90©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 55Open©2012 CAMH/TEACH 91

Motivational Interviewing in Respiratory Health Careslide 56Open92©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 57Open©2012 CAMH/TEACH 93

Motivational Interviewing in Respiratory Health Careslide 58Open94©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 59Closed©2012 CAMH/TEACH 95

Motivational Interviewing in Respiratory Health Careslide 60Closed: Often, practitioners define“closed” questions as those elicitinga “yes or no” response. However,technically, any question that elicitsa narrow and specific response is aclosed question.96©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 61Closed©2012 CAMH/TEACH 97

Motivational Interviewing in Respiratory Health Careslide 62You may note that this is a “trick”question: it is intended to be an openquestion, but is framed as a closedquestion. It begins with “Can you . . . ,”which suggests that the answer mustbe yes or no; however, when asked inthis way, this type of question effectivelyfunctions as an open question.98©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 63Introduce the second of the OARSskills: Affirmations, as distinct fromoffering praise to clients.©2012 CAMH/TEACH 99

Motivational Interviewing in Respiratory Health Careslide 64The difference between praising andaffirming can be subtle and sometimesdifficult for practitioners tograsp. In general, praise refers toour (practitioners’) approval of theperson or the behaviour. Affirmationsare more neutral and focused on theclient—they acknowledge the personand their struggle with changing.This illustration can help:You ask a client about her longestperiod of abstinence from smoking,and she tells you that once she wasable to quit for three months. Yourespond: “Three months! That isreally great.” The client then states,“Actually, they were the most miserablethree months of my life!”Clearly, in this instance, praise didnot enhance the person’s motivation—infact it was actually demotivating.An example of affirmingwould have been to say: “You weredetermined to try to quit, and youwere successful for three monthseven though it was hard.”100©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 65This slide illustrates the “perils ofpraising” and how affirming can bemore helpful in enhancing motivation(see next slide).However, note to participants that weare not suggesting that praising is inall cases wrong or bad. Many clientsseek our approval and appreciatepraise for their efforts. But if our goalis to enhance a person’s intrinsicmotivation for change, praising is aless effective strategy than affirming.©2012 CAMH/TEACH 101

Motivational Interviewing in Respiratory Health Careslide 66Notice how the patient’s “inside”voice is uncertain, and she feelsconstrained from disclosing thisuncertainty or ambivalence to thepractitioner.102©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 67In this example the practitioneraffirms the patient for just thinkingabout changing a challenging behaviour(like smoking).©2012 CAMH/TEACH 103

Motivational Interviewing in Respiratory Health Careslide 68And the practitioner’s affirmationelicits change talk from the client.104©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 69Another illustration of praising thatmany practitioners can identify with.©2012 CAMH/TEACH 105

Motivational Interviewing in Respiratory Health Careslide 70But again we see the “inside voice”of the patient.106©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 71This affirmation acknowledges theperson’s effort and struggle along hisjourney of change and recovery . . .©2012 CAMH/TEACH 107

Motivational Interviewing in Respiratory Health Careslide 72. . . and again elicits change talk fromthe patient, as well as enhancingmotivation.108©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 73Take a couple of minutes to elicitquestions or comments from thegroup.©2012 CAMH/TEACH 109

Motivational Interviewing in Respiratory Health Careslide 74Introduce the next OARS skill—oftenthe most challenging skill for practitionersto learn and practise withease: Reflective listening.110©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 75Reflective listening is the most centralof the OARS skills, and can alsobe the most challenging to learn andpractise effectively. Many counsellorsassume that they already knowand practise reflective listening, yetwhen their interviews are recordedand reviewed, it becomes clear thatmany counsellors default to somecombination of questioning, advisingand affirming. For example, goback to the self-assessment at thebeginning of this chapter: did eitherof your responses to the challengingclient statements include a reflectiveresponse? Done well, reflective listening,on its own, can help open upnew ground with clients and conveyunderstanding and empathy.There are two types of reflectiveresponses:1. Simple reflections essentiallyrepeat back to clients the contentof something they have said.2. Complex reflections include theunspoken meaning, feeling, intentionsor experiences that a clienthas.In general, complex reflections aremore effective at continuing anddeepening the conversation. One wayto understand the difference betweenthese two types of reflections is toimagine a picture of an iceberg. Thetip of the iceberg, above the water,represents the content, or the wordsthe client actually speaks; a simplereflection focuses on the tip of theiceberg. The huge mass of the icebergbelow the water represents all ofthe thoughts, feelings, meanings, etc.,that lie behind the client’s words; acomplex reflection focuses below thewaterline.©2012 CAMH/TEACH 111

Motivational Interviewing in Respiratory Health Careslide 76Introduce this example, and explainthat the following slides will illustratedifferent simple and complex reflections.The purpose of these illustrations isto demonstrate how there are countlessreflections that can be offered inresponse to a single client statement.How we use reflective listening tostrategically guide the conversation isup to our own clinical judgment andskill; what we reflect subtly steers theconversation in a particular direction.112©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 77Call attention to the differencebetween simple and complex reflectionsin the example, and notice howthe complex reflection goes “belowthe waterline” in reflecting the person’sunderlying feelings.Ask participants to see how a personmay actually feel more understoodand acknowledged by a complex(versus a simple) reflection.Practitioners often get stuck on howto continue the conversation afteroffering a reflective response, especiallyif the client is not especiallyvocal or forthcoming. Each of theseslides has an example of a follow-upstatement or question from the practitioner,but note that these are allrepresentative of OARS skills.Follow up with: “What are some ofthe other things that you have beenconsidering changing?” (openquestion)©2012 CAMH/TEACH 113

Motivational Interviewing in Respiratory Health Careslide 78In this example, the practitioner takesa risk by naming and making explicitthe client’s ambivalence about changing.Follow up with: “It sounds like youmight have some other generalhealth behaviours or concerns asidefrom smoking.” (complex reflection)114©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 79This complex reflection moves theconversation towards the social support(or lack thereof) in the client’slife.Follow up with: “What are someof the concerns that people haveexpressed to you about yoursmoking?” (open question)©2012 CAMH/TEACH 115

Motivational Interviewing in Respiratory Health Careslide 80Tell participants that now they willhave a chance to practise formingreflections, and to compare noteswith colleagues. If you are short ontime, you can choose to have participantsgo directly into small groupsand say: “This is a reflective listeningcontest: the first table with one simpleand one complex reflection, raiseyour hands! Ready . . . set . . . go!”This can also raise the energy in theroom, and illustrates to participantsthat reflective listening is a skill thattakes practice to achieve fluency andproficiency.Individual exercise: 3–4 minutesSmall group exercise: 10 minutesLarge group sharing: 10 minutes116©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 81Read the statement, then go to thenext slide. . . .©2012 CAMH/TEACH 117

Motivational Interviewing in Respiratory Health Careslide 82Leave this slide up for the individual,small group and large group sectionsof the exercise.First elicit examples from the group,then reveal the sample responses onthe next slide and compare with whatthe groups came up with.Note to the group the diversity ofreflective responses, and how whatwe reflect steers the conversation ina particular direction, so we can usereflective listening strategically tosteer the conversation in the directionthat we think will be most productiveand likely to lead to increasedchange talk.118©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 83Let the group know that these are notnecessarily the best reflective examples—infact, the groups often comeup with better examples.©2012 CAMH/TEACH 119

Motivational Interviewing in Respiratory Health Careslide 84Optional, if there is time: you canchoose to do this as a large groupnow that they have some practice.Note to the group that this is a skillthat takes practice, and this illustratesthe axiom that MI is “simplebut not easy.”120©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 85Again, leave this slide up while thegroup generates examples of simpleand complex reflections . . .©2012 CAMH/TEACH 121

Motivational Interviewing in Respiratory Health Careslide 86. . . then compare the group’s exampleswith these ones.122©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 87Introduce the final OARS skill:Summary statements.Note that these are a form of reflectivelistening. We are pulling togetherand reflecting a number of differentcontent areas that a personhas discussed during the interview.Optimally, a summary statementfocuses on summarizing and offeringback to the client the examples of clientchange talk that we have heard.©2012 CAMH/TEACH 123

Motivational Interviewing in Respiratory Health Careslide 88Outline the rationale for offeringsummary statements, and explainthat you will be showing a videoexample that illustrates all of theOARS skills, with an example of howa summary statement can be integratedin the conversation with thepatient.124©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 89Ask participants to watch for all ofthe OARS skills in the video, payingparticular attention to the therapist’suse of a summary statement.After showing the video, ask participantswhat examples of the OARSskills they noticed, what the therapistdid well, and what she could do differently.It is important when showingvideo examples not to presentthem as “perfect” illustrations ofMI; explain that we are all striving toimprove, and there are always thingsthat we can do differently or better.Note that a transcript of this videois available in the “ParticipantResources” section of the toolkit(p. 273). It includes coding thatidentifies the therapist’s use of specificMI skills. You may want to providethe transcript to practitionersas a handout, so that they can followalong with the video and refer to itlater.©2012 CAMH/TEACH 125

Motivational Interviewing in Respiratory Health Careslide 90Briefly summarize the skills coveredin this section, and ask if there areany questions or comments from thegroup.This may also be an opportunity toincorporate an integrative role playor practice exercise. For example,you could ask for a volunteer fromthe group to come up to the frontof the room to engage in a role playof about five minutes, with you inthe role of the practitioner and thevolunteer, as the “client,” sharingsomething that they are consideringchanging. Afterwards, debrief withthe volunteer and then with the largegroup.Some suggested debriefing questions:For the “client”:• What was this conversation like foryou?• What was helpful or unhelpful?• What effect—if any—did this conversationhave on your motivationfor change?For the audience:• What OARS skills did you notice?• What would you have done differently?• What seemed to work well withthe “client,” and what seemed lesseffective?126©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 91If you are doing a full-day workshop,this may be the optimal time fora lunch break. However, you canextend or shorten the allotted timeof any of the preceding activitiesand exercises, based on the group’sneeds and your own agenda for thesession.©2012 CAMH/TEACH 127

Motivational Interviewing in Respiratory Health Careslide 92Introduce the MI skills covered inthis new section: Recognizing andresponding to change talk.128©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 93Here are some additional examplesof change talk versus sustain talk:• “I really need to quit smokingbecause of the bad example I amsetting for my kids . . . but I love tosmoke, it is so much a part of mylife.”• “I have started this exercise program,and things are going well . . .but I know I will go back to myold ways once the cold weathercomes.”• “My gambling is totally out of control. . . but betting is the only wayI can de-stress and forget all myproblems for awhile.”• “I know I should take my medicationevery day . . . it’s just that Iam worried about the possible sideeffects.”Expanding our understanding of whatconstitutes change talk can help usto know that we are on track. If wehear change talk, that means thatwe are headed in the right direction.Reflecting change talk—and avoidinga focus on sustain talk—keepsthe momentum of the conversationdirected towards enhancing motivationfor change.©2012 CAMH/TEACH 129

Motivational Interviewing in Respiratory Health Careslide 94Sustain talk is normal and expected—itis simply the flip side ofchange talk!130©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 95Outline the acronym DARN CAT,which summarizes different kinds ofchange talk. Here are some examplesyou can share, or you can elicit examplesfrom the group:• Desire: “Sure I want to be a goodparent.”• Ability: “I can quit any time I want.”• Reasons: “I think I’m getting tooold for this lifestyle.”• Need: “They will take away my kidsunless I go to this program.”• Commitment: “I am going to gethelp with my drug problem.”• Action: “I’ve erased the dealers’phone numbers from my contactlist, and I am getting a new phonenumber so they can’t call me anmore.”• Taking steps: “I’ve started taking afitness class at the community centretwice a week in the evenings.”©2012 CAMH/TEACH 131

Motivational Interviewing in Respiratory Health Careslide 96Note that “DARN” statements canstill reflect ambivalence towardschanging, and can be heard frompeople in the pre-contemplation orcontemplation stages of the changeprocess.“CAT” statements represent commitmentlanguage, and are often heardduring the preparation, action andmaintenance stages of change. Millerhas divided the two type of changetalk into the categories of “preparatorychange talk” and “mobilizingchange talk” or commitment language.132©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 97Even the most highly skilled andseasoned clinicians encounter resistanceand sustain talk. It helps if weregard these as feedback, pointing toa need to change strategies. In MI,resistance and sustain talk have distinctmeanings. Resistance refers toclient statements about the therapeuticrelationship (for example, “Youdon’t understand what I’m goingthrough”), while sustain talk focuseson the client’s behaviour and representsthe opposite side of changetalk (for example, “I don’t have aproblem with drugs”). Resistance isa normal, human response to feelingpressured or challenged to do somethingabout which a person is ambivalent.As well, sustain talk is simplypart of a person’s ambivalence aboutchanging. Both resistance and sustaintalk can be by-products of howwe engage the client.Resistance or sustain talk indicatethat we need to walk carefully andbe on our best “motivational behaviour.”The good news is that werespond to both resistance and sustaintalk in the same way, and threeparticular types of reflective listeningcan be especially helpful ways to rollwith resistance and ride the wave ofsustain talk. The following strategiescan open the door to a more productiveconversation—that is, dancing asopposed to wrestling.©2012 CAMH/TEACH 133

Motivational Interviewing in Respiratory Health Careslide 98Set up the exercise by letting participantsknow that you will be showinga number of slides, each with a clientstatement. Note that there maybe some disagreement about exactlywhich category a statement falls into.The key is to better hone our hearing,to listen carefully for examples of clientchange talk.Snap fingers = DARNClap = CATSilence = no change talk134©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 99DESIREREASONS©2012 CAMH/TEACH 135

Motivational Interviewing in Respiratory Health Careslide 100ABILITYNote that people often do not recognizethis as change talk, yet itprovides a wonderful opportunity toelicit even more change talk if we followup with:“If you did decide to change, howwould you go about it?”136©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 101ACTIONTAKING STEPS©2012 CAMH/TEACH 137

Motivational Interviewing in Respiratory Health Careslide 102REASONNEED138©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 103COMMITMENTACTIONTAKING STEPS©2012 CAMH/TEACH 139

Motivational Interviewing in Respiratory Health Careslide 104The OARS strategies are a way torespond to, and elicit more, changetalk. Use the content on this slide tooutline how these strategies can beused, and explain that you will sharesome concrete examples on the nextslide.140©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 105Read the example aloud (or ask aparticipant to do so), and then askthe group to “vote” on what kind ofchange talk this represents (see nextslide).DARN statement (Need)©2012 CAMH/TEACH 141

Motivational Interviewing in Respiratory Health Careslide 106DARN statement (Need)142©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 107Now, using the same client changestatement, demonstrate how eachof the OARS skills could be used torespond. Note that you are not suggestingthe use of all of the OARSskills at once, or in order; you areoffering participants a “menu” ofstrategies to respond to change talkin a way that will evoke more changetalk.©2012 CAMH/TEACH 143

Motivational Interviewing in Respiratory Health Careslide 108Tell the group that now it is their turnto practise. As in the previous example,read the client statement andask the group to vote on what type ofchange talk it is (see next slide).Commitment language (CAT—takingsteps)144©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 109Commitment language (CAT—takingsteps)©2012 CAMH/TEACH 145

Motivational Interviewing in Respiratory Health Careslide 110Leave the slide up and ask people tocomplete this exercise: individually(5 mins), in small groups (10–15mins), or individually followed bysharing notes in small groups (20mins).Then debrief and ask individualsand/or groups to share what theycame up with. Sample responses areon the following slide.146©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 111Show the sample responses after youhave debriefed the activity.Ask if anyone in the group has questionsor comments to share.©2012 CAMH/TEACH 147

Motivational Interviewing in Respiratory Health Careslide 112Introduce the skill of Agenda-settingin this section of the workshop.When a client has multiple, cooccurringproblems, it can beoverwhelming for both client andpractitioner to know where to start.Agenda-setting is a useful way toprioritize behaviour change goals ina way that supports client autonomyand collaboration.148©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 113An agenda-setting conversation putsall of the issues on the table andinvites the client to consider wherehis or her priorities are. Just namingan issue does not mean the clienthas to address it. The client isin charge of planning where he orshe would like to go with respect tohealth behaviour change.©2012 CAMH/TEACH 149

Motivational Interviewing in Respiratory Health Careslide 114Outline these tips for practitioners.You may choose to hide this slideand just share this content verballywith the group.150©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 115You may choose to hide this slideand just share this content verballywith the group.©2012 CAMH/TEACH 151

Motivational Interviewing in Respiratory Health Careslide 116These are useful approaches in holdingan agenda-setting conversationwith your client. In general, as a practitioner,you will want to focus onwhere the person is at, and acknowledgethat he or she is the expert inhis or her life.Outline the points on the slide, andask for any questions or comments.152©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 117Also called a “bubble sheet”, anagenda-setting worksheet is a pieceof paper on which you, the practitioner,draw a series of circles and invitethe client to work with you to fillthem in with possible issues or areasfor change.(Adapted from Rollnick et al., 2008,p. 55)©2012 CAMH/TEACH 153

Motivational Interviewing in Respiratory Health Careslide 118You and the client can start with ablank sheet, or you can “prepopulate”the sheet based on assessmentfindings.154©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 119Clients often add areas that we aspractitioners may not have considered,but that are important to them.©2012 CAMH/TEACH 155

Motivational Interviewing in Respiratory Health Careslide 120This is a way to put some boundariesaround the scope of the consultation.Another way to frame this question isto ask:“What would we need to cover inorder for you to leave here feeling likeyou got what you came for?”156©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 121Invite the client to share his or herpriorities. Even if you and the clientdo not agree, he or she can be reassuredthat small, incremental changesin one area can lead to changes inother areas as well.©2012 CAMH/TEACH 157

Motivational Interviewing in Respiratory Health Careslide 122Show the video (approximately fourminutes) illustrating an agendasettingconversation with a clientwho is having difficulty managing hisasthma, but is also struggling withnumerous other issues:• www.youtube.com/watch?v=klnHJ4coG8oAfter the video, debrief by asking:• What did you like about this example?What did you dislike, or whatwould you want to do differently?• How realistic is it for you to useagenda-setting with your own clients?• How could you adapt this approachto clients with literacy issues or languagebarriers? (e.g., you could dothis verbally, or use pictures, etc.)Note that a transcript of this videois available in the “ParticipantResources” section of the toolkit(p. 277). It includes coding that identifiesthe therapist’s use of specificMI skills. You may want to providethe transcript to practitioners asa handout, so that they can followalong with the video and refer tolater.158©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 123At the end of the consultation, it canbe helpful to check the client’s importance,confidence and readiness ratingson the “Readiness Ruler.”Follow up by asking:“Why are you at (current score) andnot zero? What would it take foryou to get from (current score) to(higher score)? What would you needthat would support you in makinga change, if you chose to do so?”(Adapted from Miller and Rollnick,2002)A useful follow-up to the ReadinessRuler is asking a key question to helpfacilitate the client’s explicit commitmentto making a change. Thekey question invites the client to talkabout what will come next. Differentways to ask a key question include:• Given what we have talked about,what do you think you will do?• Where would you like to go fromhere?• What is your next step?©2012 CAMH/TEACH 159

Motivational Interviewing in Respiratory Health Careslide 124Briefly summarize the skills coveredin this section and ask if there areany areas needing further clarificationor elaboration.Invite any additional comments fromthe group.160©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 125This is the suggested time to holda break (usually 15 minutes), but itis more important to pay attentionto the energy level of the group, andpropose a break when it seems likepeople are tired or losing focus.©2012 CAMH/TEACH 161

Motivational Interviewing in Respiratory Health Careslide 126Explain that you will show two videosthat illustrate MI-inconsistent andMI-consistent approaches with a clientwho is ambivalent about change(approximately 5 minutes per video).Let participants know that all ofthese videos are freely available onthe TEACH YouTube channel, whichalso includes a number of otherclinical demonstration videos (withboth individual clients and groups),as well as some informational videosby TEACH faculty (“A Minuteof TEACH”) on a variety of topicsrelated to Motivational Interviewingand tobacco cessation.Show the first video (the ineffectivepractitioner). Depending on howmuch time you have, you can ask theparticipants to code one or both ofthe videos, using the coding sheetin the next slide. Make sure that participantshave copies of the codingsheets in their handouts.Note that a transcript of this videois available in the “ParticipantResources” section of the toolkit(page 284). It includes coding thatidentifies the therapist’s use of specificMI skills. You may want to providethe transcript to practitionersas a handout, so that they can followalong with the video and refer to itlater.www.youtube.com/watch?v=kN7T-cmb_l0www.youtube.com/watch?v=-RXy8Li3ZaE162©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 127After participants have viewed andcoded the two videos, go throughthe scoring, asking people to call outtheir scores for each item. Then youcan share the coding scores provided(see Slide 130). Note that it can takea great deal of practice for MI codingteams to achieve high inter-raterreliability, so it is expected that therewill be variability. The point of theexercise is to help people to analyzemotivational consultations, with aneye to recognizing the specific microskillsbeing used.©2012 CAMH/TEACH 163

Motivational Interviewing in Respiratory Health Careslide 128Ask participants to watch for all ofthe OARS skills in the video, payingparticular attention to the therapist’suse of a summary statement.Make sure that participants havecopies of the coding sheets in theirhandouts.Note that a transcript of this videois available in the “ParticipantResources” section of the toolkit(page 281). It includes coding thatidentifies the therapist’s use of specificMI skills. You may want to providethe transcript to practitionersas a handout, so that they can followalong with the video and refer to itlater.www.youtube.com/watch?v=-RXy8Li3ZaE&feature=related164©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 129After participants have viewed andcoded the two videos, go throughthe scoring, asking people to call outtheir scores for each item. Then, youcan share the coding scores provided(see next slide) Note that it can takea great deal of practice for MI codingteams to achieve high inter-raterreliability, so it is expected that therewill be variability. The point of theexercise is to help people to analyzemotivational consultations with aneye to recognizing specific microskillsbeing used.©2012 CAMH/TEACH 165

Motivational Interviewing in Respiratory Health Careslide 130Invite participants to compare theircoding with the answers on thisslide, then invite people to reflect onthe overall spirit of MI for ineffectiveand effective practitioner examples.166©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 131This is an opportunity for participantsto consolidate their learningover the course of the one-day workshop.You can make it optional for participantsto use the coding sheets,if you wish. An advantage of havingparticipants use the coding sheets(see following slide) and follow theinstructions on the slide is that theywill receive more specific feedback,providing them with a personalized“road map” for further developingtheir skills in MI. This is important,because MI is not something thatcan be learned in a one-day workshop;the workshop introduces theskills and the approach, but proficiencycomes with practice.Make sure that you keep track oftime in facilitating this exercise: call“time” after each five-minute interval,so that people can switch roles andeveryone has an opportunity to practice.Remind the groups to hold theirfeedback until the very end. This isimportant, as people will be temptedto start debriefing right after eachinterval. Explain that you want toensure that everyone has equal timeto practise and receive high-qualityfeedback.©2012 CAMH/TEACH 167

Motivational Interviewing in Respiratory Health Careslide 132Make sure that participants havecopies of the coding sheets in theirhandouts to score each other. Itmay be helpful to keep this slide up,so that participants who are in therole of “counsellor” can refer to thescreen as a prompt for the skills theyneed to practise and use in theirinterview.Once everyone has had a chance topractise in their triad (5 mins each,15 mins total), call “time” and askpeople to share their feedback witheach other. As this is a relativelychallenging activity, make sure thatpeople have enough time to debriefin their small group and hear feedback—about10–15 mins.After the triads have debriefed, bringthe large group back together andgo on to the next slide, inviting comments,questions and reflections onthe activity and the skills.168©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 133Keep this slide up for debriefing thesmall-group practice activity.©2012 CAMH/TEACH 169

Motivational Interviewing in Respiratory Health Careslide 134The end of each workshop, whateverits duration, is an opportunity forparticipants to reflect on what theyhave learned, set concrete goals forpractice, and identify avenues forcontinuing professional development.Emphasize that MI is not somethingthat can be learned in a one-day,half-day or one-hour workshop; theworkshop introduces the skills andthe approach, but proficiency comeswith practice.170©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 135Invite participants to complete this“Readiness Ruler” with respect totheir self-assessed importance, confidenceand readiness to begin actuallypracticing the MI skills that they havelearned in their own setting. Allowa couple of minutes for this activity,then go on to the next slide.©2012 CAMH/TEACH 171

Motivational Interviewing in Respiratory Health Careslide 136Now, ask participants to write downmore concrete skills that they willcommit to practising in the comingweek. Ask them to think of this asa kind of contract with themselves.Remind them that the true valueof the workshop lies in bringingthe knowledge and skills they havelearned to their clinical practice.Provide a couple of minutes for thisactivity, and then invite people toshare (if they wish) what they wrotedown. It can be motivating for othersin the group to hear some of thepractice goals that their colleagueshave set. Also highlight the additionalresources that they can access (seenext slide).This is also an opportunity to inviteany additional comments or reflections.Conclude by thanking the group fortheir attendance and participation,and reminding participants to completethe workshop evaluation (seeAppendix). You may wish to includea slide with your contact information.An energizing way to end the day isto hold a raffle for a MI book or otherprize, if your budget permits.172©2012 CAMH/TEACH

Section 2: Facilitator resourcesslide 137Leave this slide up at the end of thesession as people are leaving, as areminder of the additional resourcesand readings that are available onMI. Again remind participants tocomplete the workshop evaluation(see Appendix).©2012 CAMH/TEACH 173

Motivational Interviewing in Respiratory Health CareInteractive learning activitiesInteractive and experiential learning is key to constructing and integrating newknowledge and skills. The facilitators’ notes in this toolkit contain a variety of practiceactivities for each of the skills; however, each facilitator and group have theirown learning styles and preferences. This section has some alternative activities thatyou can use in your workshops to support participants in developing their MI skills.You can select activities based on your audience and your understanding of theirpractice context and the kinds of presenting issues they commonly encounter, as wellas on the particular skills you would like the group to practise. Note that the resourcesin this toolkit emphasize your autonomy as a trainer in substituting or expandingon learning activities. The activities in this section provide a menu of options andinstructional strategies to help you to customize the learning experience for diversesettings and learners.The activities are presented in the order of the course learning objectives.Learning objective1. Define MI andits relevance torespiratory healthcare and healthbehaviour change2. Operationalizethe “spirit” of MIin conversationswith clients3. Review and practisefoundationskills in MI4. Listen for andrespond to clientchange talkLearning activityCommunication styles exercise: Team JengaThis exercise illustrates how the MI style (guiding)differs from other counselling styles (following ordirecting).Storytelling to promote empathyThis exercise helps participants to develop empathyand enhanced understanding of another’s point ofview and struggle with ambivalence. Empathy andcompassion are fundamental to the spirit of MI.Card game: Practising the skills of MIThis exercises facilitates participants’ active practiceof some of the key skills of MI (OARS skills, agendasettingand listening for/responding to change talk).Tuning in to clients’ change talkThis exercise helps participants to sharpen their skillsin listening for change talk.174©2012 CAMH/TEACH

Section 2: Facilitator resources5. Apply agendasettingas a strategyfor workingwith clients withcomplex, cooccurringissues6. Recognize andintegrate MI spiritand skills in practice.Agenda-setting (when there are too many things tochange!)This exercise allows participants to practise using anagenda-setting worksheet, and to hold an agendasettingconversation.Teach-back cardsThis exercise helps participants to consolidate theirlearning of the skills covered in the workshop.learning objective 1: define mi and its relevanceto respiratory health care and healthbehaviour changeCommunication styles exercise: Team JengaThis exercise illustrates how the MI style (guiding) differs from other counsellingstyles (following or directing).Approximate time: 45 mins total30 mins to play (average time it takes for the Jenga tower to fall, which signalsthe end of the game)5 mins for both teams to debrief at their tables with their observers andeach other5–10 mins discussion as large group, with all teams, about the exerciseJenga is a game of skill and precision, played with 54 wooden blocks. A tower ofblocks is set up, and players take turns removing blocks one at a time from anylevel of the tower except the top level, and placing each block on the top level of thetower. The traditional Jenga game is slightly modified for this activity, in that peopleplay on teams rather than playing as individuals. This is an engaging and interactiveway for participants to gain insight into their own communication styles, and toexperience the communication styles of following, guiding and directing.setupYou will need 1 Jenga game for approximately every 8–10 participants. Divide eachgroup of 8–10 participants into two equal teams.©2012 CAMH/TEACH 175

Motivational Interviewing in Respiratory Health CareJenga needs to be played on a flat surface, ideally the centre of a tabletop. It’s bestto set up the Jenga games on the tables in advance, as this can take about 5–10 minutesper game, and 4 or 5 Jenga games may be required to accommodate a large group.Prior to playing the game, briefly introduce the three communication styles indifferent counselling approaches: Following—Guiding—Directing.All three styles are equally valid, and a skilled MI clinician will transition in andout of these styles seamlessly in conversation with a client.Next, introduce the Jenga exercise and its purpose. Inform the participants thatthey will be divided up into teams of 4–5 players. Tell them that during the course ofthe game, one member of each team will be assigned the role of observer, to noticethe communication styles being used.Please note that participants are not given instructions with regards to how tocommunicate with each other. The idea is for them to interact with each other asthey would normally while they play this game.Observer role: The observer will not participate in the playing of the game; hisor her role will be to look for the different communication styles used, to pay attentionto the styles of following, guiding and directing, and to write down statementsthe others make that illustrate any or all of these three communication styles. Theobserver will need paper and a pen to record the communication styles.Ask the participants about their familiarity with this game; perhaps one of theparticipants will be able to explain the objectives and rules of this game to the rest ofthe group.Jenga rules• Establish two teams of four or five people around each Jenga game; the participantsdecide which team will go first.• Players from each team take alternating turns, so if Team A goes first, then thenext move is a player from Team B, then Team A and so on.• A move consists of taking one (and only one) block from any level (except thetop level) of the tower, and placing it on the topmost level.• Only one hand may be used when taking blocks from the tower.• Blocks may be nudged to find a loose block that can be removed without disturbingthe rest of the tower. Any block that is moved out of place must bereturned to its original position before another block is removed.• A turn ends when the next player to move touches the tower, or 10 seconds aftera block has been removed and restacked, whichever occurs first.176©2012 CAMH/TEACH

Section 2: Facilitator resources• The game ends when the tower falls, in even a minor way—in other words,when any piece falls from the tower, other than the piece beingknocked out tomove to the top.• The winning team is the last one to successfully remove and place a block withoutcausing the tower to fall.post-game debriefOnce the tower falls the game is over. Ask the pairs of teams who played against eachother to debrief together at their tables for five minutes. Ask the observers and theplayers to share their experience and observations around communication styles,both verbal and non-verbal.large group debriefOnce all of the teams have finished playing and have debriefed in their small groupsfor approximately five minutes, facilitate a discussion with the entire group abouttheir experience of this exercise. What did they learn about their own communicationstyle, and what did they observe about the other participants’ communicationstyles? Ask them to provide examples of the communication styles of following,guiding and directing.learning objective 2: operationalize the “spirit”of mi in conversations with clientsStorytelling to promote empathyThis exercise helps participants to develop empathy and enhanced understandingof another’s point of view and struggle with ambivalence. Empathy and compassionare fundamental to the spirit of MI.Approximate time: 15–60 mins (depending on size of group)To construct one’s story is to make meaning of it. This meaning-making throughwriting or sharing allows for trust-building through the feeling of being heard andunderstood, as well as connection through the similarity of experiences. Empathyis developed through witnessing this expression of memory, emotion and internalexperience, and the bravery it takes to share.Sitting or standing in a circle, ask the group, “What is your relationship to respiratoryhealth?” (You can also choose an alternative topic). Let the group know thatthere is no prescribed way to answer the question; however they choose to interpretthe question is fine. Participants may wish to share a chronology, one poignantpersonal story, or an experience in their current workplace that affected them, for©2012 CAMH/TEACH 177

Motivational Interviewing in Respiratory Health Careinstance. Try to get the ball rolling by sharing your own story, then continue on withthe person to your left. People may wish to pass, but allow everyone the opportunityto share. At the end of the circle, thank everyone for sharing and acknowledge thecourage it took to do so. Debrief by highlighting similarities and patterns in the stories,and encourage the group to identify these.Note: Sometimes someone’s story may trigger emotions. If this happens, do notignore it; have someone co-facilitate with you for moments like these, or be preparedto manage the situation yourself.facilitator tips if you have less time or a larger group• Ask for four volunteers.Say: “You can interpret the question, ‘What is your relationship to respiratoryhealth?’ any way you want.”• Let each person know they can speak for approximately two minutes.• After each of the four volunteers has shared, ask the large group,“What commonthemes, patterns or experiences did you hear in these four stories?”• Engage the group in a discussion of the different perspectives and experiences relatedto respiratory health that we all bring to our work.• In closing, reinforce the key point of the activity: A better understanding of a person’sunique point of view, in the context of broader themes, patterns and experiences,can help promote therapist empathy—which is at the heart of MI.learning objective 3: review and practise foundationskills in miCard game: Practising the skills of MIThis exercises facilitates participants’ active practice of some of the key skills ofMI (OARS skills, agenda-setting and listening for/responding to change talk).Approximate time: 45 minsA deck of cards has been prepared for this activity. (A template of the cards is providedon the included CD, with printing instruction. The cards are also illustrated inthe Appendix.). On one side of each card is a concept from MI; on the other side areinstructions for the practice activity. Participants should be broken into dyads, triadsor small groups. Provide one set of cards per group.Each participant in the group chooses a card and must demonstrate the skill onside one, following the instructions given on side two.178©2012 CAMH/TEACH

Section 2: Facilitator resourcescard 1Side 1: Open questionsSide 2: Have a conversation about any topic, asking several questions. Rememberthat for every closed question, you should ask two or three open ones.card 2Side 1: AffirmationSide 2: Affirmations are a way of highlighting something positive or a strength theclient demonstrates. They are not the same as praise. Turn to the person next to youand give them an affirmation, based on what you have observed of their behaviourand participation in this workshop.card 3Side 1: ReflectionsSide 2: You can use a simple or complex reflection, or both! Ask the person next toyou, “What is your favourite food, and why?” Then reflect back to them what youhave heard.card 4Side 1: Summary statementsSide 2: Have a brief conversation with a partner about their commitment to practiseMotivational Interviewing after this workshop, and when you think it’s appropriate,summarize what they have said. Don’t forget to check in with them to see if you gotit right!card 5Side 1: Agenda settingSide 2: Ask a partner to discuss various issues that they would like to change oraddress. Help them identify what those issues are and how they might prioritizethem.card 6Side 1: Recognizing and responding to change talkSide 2: While a partner is discussing an issue they are considering changing, listencarefully for change talk and reflect it back to them.©2012 CAMH/TEACH 179

Motivational Interviewing in Respiratory Health Carelearning objective 4: listen for and respond toclient change talkTuning in to clients’ change talkThis exercise helps participants to sharpen their skills in listening for change talk.Approximate time: 15 minsIn triads: Choose one of the client statements below as a starting point for a conversationbetween client and counsellor. One person is the client, one person is thecounsellor and one person is the observer. The counsellor engages the client in aconversation based on the case.instructions for clientsChoose one of the statements below and use it as a jumping-off point to role playa client. Try to make the role play as realistic as you can, but avoid being the mostchallenging and resistant client you have ever seen in your practice! The objectiveis to give the counsellor an opportunity to practise the skill of recognizing andresponding to change talk.Sample client statements:• “I know that this job is not the best for my lungs, but I love it and can’t give up themoney.”• “I know I need to quit smoking, but right now, with the wife sick, I’ve got a lot onmy mind. I can’t even think about taking one more thing on.”• “I am not going to get rid of my cat even though I am allergic to him.”• “It’s my home and no one can tell me what to do! I have enough fans and air purifiersto smoke in my room and not affect anyone else.”• “If smoking doesn’t kill me something else will. My lungs are already shot.”instructions for counsellorsIn your conversation with the client, listen for any examples of change talk. If yourecognize change talk, provide a reflective response that would reinforce the changetalk. If you don’t hear any change talk, think of a question that might elicit change talk.instructions for observersObservers identify the change talk. The observer can use a sheet listing the differenttypes of change talk, and tick off each one they hear.180©2012 CAMH/TEACH

Section 2: Facilitator resourceslearning objective 5: apply agenda-setting as astrategy for working with clients with complex,co-occurring issuesAgenda-setting (when there are too many things to change!)This exercise allows participants to practise using an agenda-setting worksheet,and to hold an agenda-setting conversation.Approximate time: 10 minspart 1In dyads, one participant will be the client and one the counsellor. Ask the client todiscuss some things they would like to change. Using an agenda-setting worksheet,the counsellor will help create a menu of issues that the client has identified as areasthat need change.part 2In the same dyads, the counsellor will now help the client prioritize an issue that theywould like to start with. Then, together, they will negotiate a change plan.learning objective 6: recognize and integratemi spirit and skills in practiceTeach-back cardsThis exercise helps participants to consolidate their learning of the skills coveredin the workshop.Approximate time: 15–45 mins, depending on how many Teach-back cards areused. Allow about 5 mins per card.The teach-back can be a useful activity towards the end of a workshop, when all ormost of the content has been covered and you would like to help participants consolidatewhat they have learned.A set of cards has been prepared for this activity. (A template is provided onthe included CD, with printing instructions. The cards are also illustrated in theAppendix.) Each card in the set has a skill or conceptcovered in the workshop. Provide a complete set of cards to each participant.Participants pair off, and partners take turns “teaching” each other the skillor concept on one of the cards. Allow 5 minutes per card, then have the pairs break©2012 CAMH/TEACH 181

Motivational Interviewing in Respiratory Health Careup and the participants move on to new partners. Repeat until all of the cards havebeen “taught.”Note: If you are short on time, you may choose to ask participants to chooseonly one, two, or three cards to “teach back.”contents of teach-back cardsA template for printing is provided on the included CD. The cards are also illustratedin the Appendix.1. Spirit of Motivational Interviewing2. A-C-E3. The righting reflex4. OARS5. Open questions6. Affirmations7. Reflective listening8. Simple reflection9. Complex reflection10. Summary statement11. Agenda setting12. DARN CAT13. Preparatory change talk14. How to respond to change talkCase-based learning activities and caseexamplesThe case examples on the following pages were contributed by members of the curriculumplanning group for this toolkit. These cases are based on actual clients seenin a variety of clinical practice settings, but names and identifying information havebeen changed to preserve client anonymity.how to use the casesCase examples can be a very helpful way to engage groups and individual practitioners.They ground the material being covered in a workshop by demonstrating:• the relevance of MI as a practice approach, especially with people who are ambivalentabout changing their behaviour• avenues for reflection on specific micro-skills or the overall spirit of MI• ways to practise the skills with diverse clients, and problem areas for intervention.182©2012 CAMH/TEACH

Section 2: Facilitator resourcesYou can select cases based on your audience and your understanding of theirpractice context and the kinds of presenting issues they commonly encounter, andon the particular skills you would like the group to practise. Note that the resourcesin this toolkit emphasize your autonomy as a trainer to substitute or expand onlearning activities. These cases provide a menu of options and instructional strategiesto help you to customize the learning experience for diverse settings and learners.All of the cases lend themselves to a variety of instructional strategies. Below is alist of suggested activities that you can incorporate in your own trainings and workshops,using one or more of the cases. In addition, we encourage you to adapt thesecases and/or to use your own case examples to illustrate and augment the workshopsyou facilitate.suggested activities for use with case examplesStart out with a case: Introduce a section or a skillStarting the workshop or a specific section of the workshop with a case is a nice wayto capture the group’s interest and attention. You can use the brief description of theclient on a slide as a jumping-off point for discussion and learning.Enhancing practitioner empathyThe following exercise can be a powerful way for participants to directly experiencethe spirit of MI, and can be done as an individual reflective activity or in pairs,dyads, triads or small groups. Have the participants re-write the case from the perspectiveof the client, then ask them to reflect on how the exercise of re-writing thecase impacted their empathic understanding of the person’s unique situation andconcerns. Debrief by asking the group to reflect on how they would respond to theperson and work to engage them in treatment with this new and enhanced understanding.Emphasize that this empathic understanding and compassionate stance isat the heart of the MI approach.Case discussionAsk the group to reflect on the case and discuss the following questions. Note thatyou can do this activity in dyads, triads, small groups or a large group.• How might Motivational Interviewing be useful with this client?• What are the barriers to change? What are the strengths or enablers of change forthis person?• What specific skills could you try (for example, OARS skills, agenda-setting)?• What kind of treatment plan might be optimal for this person? How could youintroduce this in a way that is consistent with MI spirit?©2012 CAMH/TEACH 183

Motivational Interviewing in Respiratory Health CareClinical demonstrationSelect a case and ask for a volunteer from the audience to play the role of the client.The facilitator takes the role of the practitioner, demonstrating MI skills to thegroup. Note that this can be a “high-risk” activity for facilitators (e.g., “What if I doa poor job demonstrating the skills?” “What if the ‘client’ is too resistant or challenging?”“What if I choke and don’t know what to say next?”). Here are some tips tohelp the demonstration go more smoothly and reduce your performance anxiety inthe practitioner role:• Emphasize that there is no such thing as a perfect motivational interview—we areall learning and striving to improve, and that includes MI trainers!• Periodically stop the role play and ask the group what they see as possible avenuesfor intervention, or possible skills to try.• Ask the group for help if the “client” is extremely difficult or resistant, by stoppingthe role play and inviting feedback (“If you were in my seat, what might you saynext? OK—let’s try that and see what happens”).• Encourage an atmosphere of experimentation: “We are going to try different strategiesand approaches, and the client’s response will be feedback as to whether weare on the right track.”• Beware of the “Righting Reflex.” If you find yourself struggling, it may be becauseyou have stepped out of the spirit of MI, and are trying to get the person to change.If you notice this happening, mentally regroup and remember that MI is a guiding(not directing) style to explore ambivalence and facilitate change.• Remember A-C-E: Autonomy, Collaboration, Evocation. This means emphasizingthat the client alone must decide to make this change or not, and you are there tohelp regardless of what he or she decides. Evoke the person’s reasons for change aswell as roadblocks or barriers.• Try to use all of the OARS skills (Open questions, Affirmations, Reflective listeningand Summary statements). Sometimes when we’re anxious we tend to default tothe skill that feels most comfortable for us, which is often questioning. Rememberto use affirmations, reflections and summary statements.• Finally, if all else fails, don’t be afraid to admit defeat and clearly state that MI isnot a panacea—this approach is neither appropriate nor effective with every client,and the reality is that some people will decide not to change, despite our bestefforts to assist them. However, if we can establish rapport and engagement, thenthe person may be more likely to return when he or she is ready to make a change.In debriefing the clinical demonstration, start by asking the “client” what theconversation was like for him or her, and what was helpful or less helpful. Theninvite the large group to comment and give feedback. The value in clinical demonstrations—asidefrom their utility as a group learning activity—is that they modelrisk-taking and willingness to practise, and make it more likely that participants willalso be willing to take risks, experiment, and practise MI skills in the workshop.184©2012 CAMH/TEACH

Section 2: Facilitator resourcesPractising specific MI skillsChoose one or more cases and provide them as handouts to participants. Usethe case example(s) as a starting point for asking participants to practise specificMI skills. Ask participants to read the case and respond to the challenging clientstatement(s) with:• an open-ended question• an affirmation• a simple reflection• a complex reflection• a summary statement.This is a lower-risk activity than a role play, as participants have some time toreflect and formulate their response rather than having to come up with a responsein the moment. Yet this exercise still provides a valuable opportunity to practise theskills. Participants can also be given one of the more complex cases and asked topractise agenda-setting, using the agenda-setting worksheet in the PowerPoint slides.Group role play and practiceAsk participants to form dyads, triads or small groups. Provide the case you havechosen as a handout, and ask one person to volunteer to be the client, and anotherperson to volunteer to be the practitioner. Other group members may act as coaches,or you can ask group members to “tag team” as practitioners (i.e., to take turnsresponding to the client).This exercise works best if you ask the “client” to start by reading the “challengingclient statement” included with the case description as a prompt for the practitionerto respond. It is also useful to instruct the “clients” to not role-play the mostresistant and difficult person that they have ever encountered in their practice career.The objective is to provide an opportunity to practise.After the groups have had a chance to complete the role play, debrief as a largegroup.We hope that these suggestions are helpful, and encourage you to adapt and addto the many possible ways to integrate case examples and practical learning activitiesinto your workshops. The cases can be found on the following pages, arranged byage (in descending order).©2012 CAMH/TEACH 185

Motivational Interviewing in Respiratory Health Carecase examplesAllan (male, 70)brief description of the patientAllan is a 70-year-old man discharged from the hospital two weeks ago after hisfirst admission with Acute Exacerbation of Chronic Obstructive Pulmonary Disease(AECOPD). He is retired, married and living with his wife, and is a long time heavysmoker (50 pack years). Allan’s wife has never smoked.presenting issues• Allan has never had spirometry screening to diagnose COPD.• He has symptoms of shortness of breath on exertion (SOBOE) and chronic productivecough.• As a result of his SOBOE, he has decreased his activity level.• He has been newly prescribed albuterol, fluticasone and salmeterol, and tiotropiumbromide capsules for inhalation; he may have issues with medication compliance.motivational issues• What is Allan’s understanding of his COPD diagnosis? Until very recently, he hadnever even heard of COPD.• Is medication compliance an issue? Does he know how to take his new medications?• Allan is still smoking, but has reduced the number of cigarettes per day.• Allan is motivated to change his smoking; still, he is ambivalent about a goal oftotal abstinence. He would like to be able to smoke just 1 or 2 cigarettes per day.a challenging statement to the practitioner“I can’t believe this has happened to me so suddenly. I was fine until last month, andnow the doctor tells me I have a chronic lung disease that is going to kill me.”186©2012 CAMH/TEACH

Section 2: Facilitator resourcesBilly and Betty (male, 64, and female, 68)brief description of the patientBilly and Betty, 64 and 68 years old respectively, are a retired couple who have cometo the clinic for smoking cessation counseling. Both are long-time smokers (40-plusyears). Spirometry screening reveals that Betty has very severe cardio-obstructivepulmonary disease (COPD) with 27% lung function. Billy reports a hacking coughwith a lot of phlegm. They both know they need to quit, and they say, “We reallywant to quit.” Neither has ever tried to quit before. They do quite well at beingsmoke-free when they are apart, but are struggling when together; both tend tosmoke when around each other.presenting issues• Betty and Billy are two heavily nicotine-dependent people with lengthy smokinghistories.• When together as a couple, they act as “triggers” for each other; they tend to haveless success abstaining from smoking when together.• Betty has severe COPD—poor lung function.• Billy also has respiratory symptoms.• This is the first quit attempt for both individuals.motivational issues• Billy and Betty are motivated by their respiratory symptoms (COPD diagnosis,impact of smoking on their health).• Their goals are aligned; they both “want” and “desire” to be smoke-free.• What is their level of understanding around the impact of second-hand smoke onCOPD?• How can their support of each other be enhanced?challenging statement to the practitioner“We do fine not smoking when we’re busy and not together, but we smoke wheneverwe’re together.”(Then, during their second visit, with sighs of relief:“We were afraid you were going to give us heck for not doing well, since we haven’tquit yet.”)©2012 CAMH/TEACH 187

Motivational Interviewing in Respiratory Health CareKhalid (male, 65)brief description of the patientA 65-year-old male, Khalid has smoked since age 19. He has tried to quit,but relapsed. He is depressed and has little hope. Medical Research CouncilBreathlessness Scale of 4 (“Stops for breath after walking about 100 yards, or after afew minutes on level ground”). Recent pulmonary function tests show severe cardioobstructivepulmonary disease (COPD). He lives with his wife; she is a non-smokerbut he smokes in their home. Khalid was recently prescribed oxygen 24 hours a day;however, he wears it only 6–8 hrs a day, when he is really short of breath.presenting issues• Khalid is smoking in his home with oxygen (a safety issue).• He has a history of depression, but is not taking meds.• His limitation of his activities has led to increased dyspnea (“air hunger”).• He has compliance issues.motivational issues• Khalid is smoking in his home with oxygen due to a lack of education and information.• Khalid feels quitting smoking now is pointless, no longer a relevant issue. His lungdamage is done already, and his disease is progressive—so why bother?• His beliefs and understanding around medications present issues. He does not likethe idea of taking more medications, such as meds for depression; he feels that he is“on too many medications already.”challenging statements to the practitioner“My lung disease is going to worsen, no matter what I do! I have little to enjoy now,so I am going to enjoy my cigarettes.”“I don’t wear my oxygen when I smoke.”188©2012 CAMH/TEACH

Section 2: Facilitator resourcesBob (male, 65)brief description of the patientBob is a 65-year-old client with cardio-obstructive pulmonary disease (COPD). Hisprimary care practitioner has recommended that he attend the Pulmonary RehabProgram. Bob is quite sedentary but is fairly adherent to his medication regime. Hehas had two exacerbations in the last year, one of which hospitalized him for threedays.presenting issues• Bob sits in his apartment for days on end. His wife cannot get him to accompanyher on outings—shopping, visiting or socializing.• He is becoming weaker, with decreased muscle mass. His shortness of breath (SOB)is increasing, which makes him more anxious, leading to more SOB (vicious cycle).• Bob is becoming increasingly depressed as he grows more dependent on his wife todo things for him.motivational issues• Bob realizes that his isolation is increasing his loneliness.• He realizes that each hospitalization leaves him weaker (decreased lung function).• He realizes that the less active he is, the more he suffers from SOB.challenging statement to the practitioner“You want me to attend the Pulmonary Rehabilitation Program? Do you have anyidea how difficult it is for me to leave my apartment, with my breathing problems?”©2012 CAMH/TEACH 189

Motivational Interviewing in Respiratory Health CareCase example: Tommy (male, 54)brief description of the patientTommy is a 54-year-old male with severe shortness of breath (SOB) and cough. Heis married, has a 16-year-old daughter, and owns his own construction company.He has no pets, smokes 30–40 cigarettes per day, and drinks one bottle of wine (fivestandard drinks) per day. He started smoking at age 12. His last visit for health carewas three years earlier, for pneumonia.presenting issues• Tommy wants to know if he has pneumonia again.• He is a long term, heavy smoker, and has undiagnosed SOB and cough.• Alcohol use is an issue—he is drinking more than safe drinking guidelines recommend.• There may be a relationship between his alcohol use and his smoking.• He is under business and financial stress.motivational issues• Tommy has never made a quit attempt or considered quitting smoking.• He does not believe smoking is related to his symptoms, or at least believes it is notan “important” factor.• He says he smokes and drinks to “wind down” and deal with stress.• It is unknown how he feels about his present alcohol use.• What are the good things, and are there any “not-so good” things, about his dailydrinking?• His wife and daughter’s respect and love are important to him. He does not smokein the home out of respect for his family.challenging statement to the practitioner“The only reason I would stop smoking is if you told me it was life or death.”190©2012 CAMH/TEACH

Section 2: Facilitator resourcesCarly (female, 52)brief description of the patientCarly is a 52-year-old woman with a diagnosis of anxiety and severe cardioobstructivepulmonary disease (COPD)/asthma. She is unable to work because ofher COPD/disability. She has smoked 1.5 packs per day (30 cigarettes per day) forover 40 years. Her recent pulmonary function tests (PFT) show severe deterioration(forced expiratory volume 29%). PFT comments include that she may now needarterial blood gas measurements (ABGs) to determine oxygen criteria. Her partneralso smokes in the home.presenting issues• Carly has an anxiety disorder.• Her COPD is severe and deteriorating.• She has a lengthy smoking history and is heavily nicotine dependent (30+ cigarettesper day).• She is unable to work.• Her partner smokes in the home and has no plans to quit.motivational issues• Carly does not want oxygen.• Her COPD medication has been maximized.• She is highly ambivalent about quitting smoking; she has been told by healthcare practitioners that she needs to quit smoking for her breathing prognosis toimprove, but she worries that quitting smoking will worsen her anxiety symptomsand it will be too difficult.• Her partner has no plans to quit, and Carly does not feel comfortable telling herpartner that she must smoke outside of their home.challenging statement to the practitioner“Can’t you just give me more breathing medicine?”“Trying to quit smoking will make me more stressed.”©2012 CAMH/TEACH 191

Motivational Interviewing in Respiratory Health CareHelen (female, 49)brief description of the patientHelen is a 49-year-old widowed female who sees you during a community visit. Shetells you that she wishes she had never started smoking as a teenager. She states thatshe has tried to quit a few times over the years but has never even been able to lastmore than one day without cigarettes; on her most recent try, she only lasted untillunchtime. She is currently taking the following medications: tiotropium bromide18 micrograms once daily; fluticasone plus salmeterol 250/50 micrograms twicedaily; ventolin 1–2 puffs eavery 4 to 6 hours as needed; venlafaxine 150 mg; vitamin D400 IU per day; lorazepam 1.0 mg every night as needed.presenting issues• Helen is a foster parent to her two grandchildren, as her daughter is in treatmentfor alcohol addiction. Her cardio-obstructive pulmonary disease (COPD) is gettingworse, making it harder to cope with the demands of caring for her grandchildren.• She is on social assistance and stays home all day.• She suffers from depression. It took many trials to find the current combination ofantidepressants that is working for her.• She smokes 40 cigarettes per day and starts smoking before she gets out of bedin the morning. She smokes in the house, despite knowing that it will affect hergrandchildren; no one else can watch her grandchildren if she smokes outside.• Her cravings are so strong that she smokes constantly, all day long. She said thatshe tried stopping “cold turkey” but got “very cranky and irritable” after not smokingfor half the day, so she resumed.motivational issues• Helen is compliant with her current medication regime.• She has very low self-confidence around her ability to quit smoking and is unsure ifshe is willing to try again.• She is ambivalent about quitting; she knows it’s important, but doubts it’s possible.• She has little information about or understanding of smoking cessation medicationoptions, how they work, access, other treatment options, and accessing support.• She loves caring for her grandchildren, but is very concerned about her ability todo this much longer because of her health and breathing difficulties.• What are some of the motivating factors that could lead to Helen making healthbehaviour changes?challenging statement to the practitioner“In a perfect world I would be a non-smoker, but it’s just too hard, I’ve tried to quita thousand times and I guess I just don’t have the will power that some people do.”192©2012 CAMH/TEACH

Section 2: Facilitator resourcesTodd (male, 48)brief description of the patientTodd is a 48-year-old male, single with no girlfriend, never married, and an eldestchild. He lives with his parents and younger siblings on a rural farm. He admits hefeels depressed. He has never been in hospital for respiratory problems. He admits heis very short of breath, and states he wants to die of “natural causes” so the insurancewill pay off the farm. Todd says he wants to speed up his inevitable death from cardio-obstructivepulmonary disease (COPD) so he has increased number of cigarettessmoked; when questioned, he says that he will not (cannot) commit suicide due toreligious beliefs. Spirometry screening shows moderate COPD. Todd reports extremefinancial pressure and works seven days a week on the farm.presenting issues• Todd’s COPD is undertreated.• His smoking has increased from 25 to 35 cigarettes per day.• He has financial stressors.• He shows signs of depression and hopelessness.motivational issues• Todd has become increasingly depressed since he was diagnosed with COPD lastyear.• He has not told his doctor about his increasing feelings of depression or soughttreatment for it.• He works seven days a week on the farm to support his family; his father suffereda serious injury a few years ago and is now unable to run the farm, and Todd’smother also has poor health.• Todd does not go out socially; he is too broke and too exhausted.challenging statement to the practitioner“Why would I want to take inhalers, or quit smoking? I have no life, I am trying todie sooner.”©2012 CAMH/TEACH 193

Motivational Interviewing in Respiratory Health CareJohn (male, 46)brief description of the patientJohn is a 46-year-old man with opioid addiction, depression and anger issues. He issingle, does not work, is on social assistance, has smoked since age 15, and lives ina rooming house with four other smokers. John smokes about 20–30 cigarettes perday, purchased in baggies from a contact; he pays $12 per baggie, and each baggiecontains 200 cigarettes.presenting issues• John has a hoarse voice and chronic bronchitis, and complains of chest pain andshortness of breath.• He attends a methadone program to manage his opioid addiction, and he is stable.motivational issues• John does not want to see a doctor, because he will just be told to quit smoking,and he is very resistant to this idea.• He shuts down the conversation when smoking is discussed.• There is a relationship between his smoking and his mental health. He smokesmore when he is stressed and/or angry; he uses cigarettes to help calm himselfdown.• There is also a relationship between his smoking and his opioid addiction andmethadone treatment. He says his favorite cigarette is the one that he has rightafter he drinks his methadone dose.challenging statement to the practitioner“Do not even talk to me about smoking. I love my cigarettes, they’re all I have.”194©2012 CAMH/TEACH

Section 2: Facilitator resourcesAnne (female, 26)brief description of the patientAnne is a 26-year-old woman who has been referred to a smoking cessation specialist.She is divorced with two young children, currently in custody of their father.Anne has been told by Child Protection Services that she has to stop marijuana usebefore she will be allowed access to her children. Anne smokes approximately 20cigarettes per day as well as one to two joints per day, typically in the evening beforebed.presenting issues• Anne’s smoking cessation counsellor has no particular expertise in cannabis addiction,and Anne’s tobacco use is not a priority for Anne.• Anne has a number of mental health diagnoses, including depression, anxiety, borderlinepersonality disorder, and posttraumatic stress disorder.• She reports having no community supports in place for her mental health concerns,and states that cannabis is the only thing that “keeps her sane.”motivational issues• She is willing to seek further support for her mental health issues.• She is ambivalent about changing cannabis use; she feels that she needs it to staysane, yet it prevents her from accessing her children.• She wants joint custody of her children.• She just got a new child protection worker; she is pleased with this change and shedescribes this worker as very supportive.challenging statements to the practitioner“The joints are medicinal—they help me sleep and cope with my anxiety. I don’tsmoke very much but I need them, nothing else works.”“Why should I have to quit completely when I know for a fact that my ex is stillsmoking up and the kids are with him?”©2012 CAMH/TEACH 195

Motivational Interviewing in Respiratory Health CareZach (male, 18)brief description of the patientZach is an 18-year-old male, brought to a primary care practitioner by his fatherbecause he is “blue” in the mornings around his mouth. Diagnosed with asthma atage 6, Zach is not using inhaled corticosteroids (ICS) therapy. He does not attendschool, sleeps until noon, smokes 3–4 joints per day, wants to be a tattoo artist anddoes tattooing out of the family basement with his parents’ support. He hopes tohave his own tattoo business one day.presenting issues• Zach has uncontrolled asthma and is not adherent to therapy.• He is a regular marijuana user and smokes in the home, in the basement.• The dyes and solvents he is exposed to when he does his tattooing may be an environmentaltrigger.• His irregular daily schedule is not structured to support regular twice-daily ICStherapy.motivational issues• Zach wants to have his own tattoo business one day.• He does not regard his daily marijuana use as harmful—he grows his own, it’sorganic, and he doesn’t roll it with tobacco.• Zach’s father was not initially concerned about Zach’s marijuana use; however, hewas not aware that it had increased from occasional use to 3–4 joints per day.challenging statement to the practitionerZach: “It’s no big deal. Mom and Dad worry too much.”196©2012 CAMH/TEACH

Section 2: Facilitator resourcesTyrone (male, 15) and his motherbrief description of the patientTyrone is a 15-year-old male who came to see the asthma educator with his mom.He was recently seen in the Emergency Room and put on prednisone. Accordingto his mother, Tyrone has not had any problems with his asthma since he was fiveyears old. (He has had no inhalers since.) Spirometry done at this visit showed severeobstruction, with minimal improvement post-bronchodilator. His mother is veryupset, as she thought he was fine for the past 10 years. She is visibly shaken. Tyronesays he “feels fine.”presenting issues• Tyrone’s chronically poor asthma control has led to fixed obstruction.• He is a poor perceiver of his asthma symptoms.• He treats acute episodes, but there are risks of poor control.• His mother feels intense guilt and distress.motivational issues• Tyrone reports feeling “fine” and having no real problems with asthma.• Tyrone and his mom are at very dissimilar stages in the change process. His momis upset, but is taking action—she brought him to see the asthma educator. Tyronefeels this issue is resolved, and no further action is required.• Tyrone was given no choice in attending this appointment with his mom. He ishesitant to engage in treatment. How can you increase his motivation around treatmentengagement?• In working to improve Tyrone’s management of asthma, self-care, and medicationcompliance, consider the developmental tasks of teenagers (developing autonomy,identity and role formation).challenging statements to the practitionerMother: “He’s been fine for 10 years! Now you are telling me he is not?”Tyrone: “I am fine now. I can do everything I want. It [the asthma] doesn’t stop mefrom doing anything.”©2012 CAMH/TEACH 197

Motivational Interviewing in Respiratory Health CareAndrew (male, 14)brief description of the patientAndrew, a 14-year-old Grade 9 student with a new group of friends, was diagnosedtwo years ago with asthma, but doesn’t like to take inhalers because “it’s not cool.”He has been experiencing worsening breathing, waking at night and feeling tiredduring the day. Andrew has a six-year-old sister who is very attached to the familydog. Andrew comes to the appointment with his mother, who is very concernedabout his worsening breathing. His mother is also concerned about the crowd he hasbeen hanging around with at school, as these youth have a reputation for using drugsand alcohol.presenting issues• Andrew’s non-compliance with medication is an issue. He used to be compliant oninhalers, but is not any more.• Andrew’s mother’s agenda is at odds with his own agenda.• There is a dog in his home, to which his six-year-old sister is very attached.• Andrew may be smoking cigarettes and/or marijuana.• He experienced one exacerbation of asthma symptoms two years ago, and neededhospitalization.• He has anaphylaxis to LTRA-montelukast (leukotriene receptor antagonist used formaintenance treatment of asthma).motivational issues• Teenage development involves mastering the task of autonomous decision making;at the same time, social acceptance by peers is of key importance.• Explore Andrew’s relationship with both his family and his peers, and the impactthis has on his self-care (medication compliance).• Explore Andrew’s understanding of his asthma and the recommended treatmentregime. Explore the same issue with his mother.• Does this case require primarily individual behaviour change, or is it potentiallya “whole-family” behaviour change issue? (For example, are there triggers in thehome, in addition to the dog?)• Are the parents also ready to look at making some changes related to this problem,or are they ambivalent themselves?challenging statements to the practitionerMother: “I need you to make Andrew take his medications because he won’t listen tome!”Andrew: “None of my friends need inhalers, why do I?”198©2012 CAMH/TEACH

Section 2: Facilitator resourcesCody (male, 11) and his motherbrief description of the patientCody is an 11-year-old male with moderate to severe asthma. His primary caregiveris his mother, who travels a lot for her job. His grandmother takes care of Codywhen his mom is not around. Grandma is a “cat lady” with 3 cats; she is a heavysmoker and lives in the basement of the family’s bungalow. Grandma loves to cookand smoke.presenting issues• Cody’s asthma is poorly managed.• His mother is in denial and doesn’t believe in inhaled corticosteroids (ICS) use,although Cody is becoming a “frequent flyer” (he has had over four emergencyroom visits for asthma attacks).• Asthma attacks mess up Cody’s hockey games. He loves hockey but it usually getsinterrupted.motivational issues• Cody’s goals and values motivate him. He would like to be able to progress beyondhouse league hockey to play “Triple A” one day.• Cody’s mom misses work every time Cody is sick.• Grandma has brought many triggers into the home environment.• Cody has little to no control over many factors that contribute to the managementof his asthma.• This case requires that the entire family engage in the change process. There is aneed to align the values and behaviour of Cody, his mother and his grandmotherto facilitate change.• How does the family’s current living situation—which permits and promotes manyenvironmental triggers—fit with the mother’s core values and her wish to changeCody’s asthma management?challenging statement to the practitionerCody’s mother: “Steroids will stunt my child’s growth!”©2012 CAMH/TEACH 199

Motivational Interviewing in Respiratory Health CarePaul (male, 8) and his fatherbrief description of the patientPaul is an eight-year-old boy diagnosed with asthma. He is atopic to many things:cats, dogs, dust mites, pollen. His parents are divorced, with shared custody. Paulstays with his mother during most of the week and his father on the weekends andMondays. His father smokes in the home and has a dog.presenting issues• Paul has had multiple, recent ER visits with uncontrolled asthma. He showsimprovement since he was put on an inhaled steroid; however, spirometry shows>12% & 200mL change in post bronchodilator spirometry, and he still has a nighttimecough.• Paul’s mother works on trigger avoidance and giving medication, but his fatherdoesn’t understand that he needs to do so as well. The two don’t get along or communicate.motivational issues• Paul, a child, has no control around presenting issues that require change.• His mother and father are at very different stages in the change process aroundPaul’s medication regime and trigger avoidance.• His father appears highly ambivalent about changing his smoking behaviour (i.e.,not smoking while Paul is in his care and home). It’s unclear if this issue is relatedto his motivation to change his smoking behaviour, or to his understanding ofthe importance of making this change. What is his understanding of the impact ofsecond-hand smoke on Paul’s asthma and on his children’s health in general?• The father has come in twice for separate visits, and seemed to be on board, butnow it seems nothing has changed. There is a discrepancy between his statementsduring his sessions with you, and his actions.challenging statement to the practitionerPaul’s father: “I don’t believe my son has any problem with his breathing.”200©2012 CAMH/TEACH

Section 2: Facilitator resourcesAhmed (male, 4) and Zarah, his motherbrief description of the patientAhmed is a four-year-old male who has asthma. Zarah is his young single mother.Ahmed has had two emergency room visits in the past six months and wakes up atnight occasionally because of his cough. He is on several puffers but Zarah is reluctantto give them consistently; she is concerned about side-effects. Zarah has missedwork on several occasions when Ahmed’s asthma flared up.presenting issues• Ahmed has had two recent emergency room visits.• He wakes up at night with a cough.• Zarah is not compliant around Ahmed’s medication, because of a steroid “phobia.”• Zarah faces financial implications if her repeated work absences due to Ahmed’scondition lead to the loss of her job.motivational issues• Ahmed’s symptoms are intermittent.• Zarah is highly ambivalent about the prescribed treatment regime because of herperceptions about the meds.• What are Zarah’s beliefs and values, and how do her current actions of not complyingwith Ahmed’s medication regime fit with these values and beliefs?• What are the pros and cons of treating Ahmed’s asthma intermittently with meds?challenging statements to the practitionerZarah: “The long term side-effects of steroids have not been well documented.”Zarah: “I’ve heard that steroids will stunt growth.”©2012 CAMH/TEACH 201

Motivational Interviewing in Respiratory Health CareCase-based video demonstrations of MIskillsThe Participant Resources section (page 273) includes transcripts from the followingvideo interviews conducted by Marilyn Herie, PhD, RSW:• Motivational Interviewing: An angry client (“Angry Bob”)(Available on YouTube: www.youtube.com/watch?v=79YTuZUFRIc)• Motivational Interviewing: Agenda-setting conversation with “Sal”(Available on YouTube: www.youtube.com/watch?v=klnHJ4coG8o)• Motivational Interviewing: A conversation with “Sal” about managing his asthma(Available on YouTube: www.youtube.com/watch?v=-RXy8Li3ZaE)• How NOT to do Motivational Interviewing: A conversation with “Sal” about managinghis asthma(Available on YouTube: www.youtube.com/watch?v=kN7T-cmb_l0)202©2012 CAMH/TEACH

Section 3:Participantresources

Section 3: Participant resourcesPre-reading for participantsevidence base for motivational interviewingin respiratory health care: a brief summaryby karina czyzewski, marilyn herie, stephaniecohen and peter selbyWhat is Motivational Interviewing?Health care systems are placing increasing emphasis on client-centered care, participatoryor shared decision making, and improved clinician-patient relationships—allwithin the context of evidence-based and brief interventions. One approach thatis consistent with these principles is Motivational Interviewing (MI), defined as “acollaborative, person-centered form of guiding to elicit and strengthen motivationfor change.” 1 MI was first developed beginning in the 1980s to address addictions,and is now well-researched across a variety of health behaviour domains. 2 It is “anempirically supported, theoretically consistent and rapidly diffusing approach whichimproves the quality of the clinician-patient interaction.” 2 Over the last 30 years,more than 1,000 articles have been published and over 200 randomized clinical trialshave been conducted, contributing to a robust evidence base to inform practice. 3This document provides a brief overview of the MI counselling approach as wellas research support for MI applications in respiratory health care.Foundation skills of MIO – Open-ended questionsA – AffirmationsR – Reflective listeningS – Summary statementsWhy practise MI?Evidence for the effectiveness of MI has been shown for a diversity of health behaviours4 including sexual health, dietary change, physical activity, diabetes, mentalhealth, addictions, chronic pain, self-care, smoking cessation and child health, aswell as criminal justice. 5,6 Of course, MI (like other psychosocial interventions) isnot a panacea; the effects of MI diminish over time and the meta-analyses reveal anoverall small to medium-size effect. Moreover, the outcomes of any intervention areimpacted by practitioners’ skills and client-related factors. 7 When compared withother interventions, MI tends to be effective about 75% of the time, a treatment©2012 CAMH/TEACH 205

Motivational Interviewing in Respiratory Health Careoutcome rate consistent with outcomes for other clinical interventions. 3 In addition,studies on MI have found that MI interventions take, on average, 100 fewer minutesto produce the same results as other talk-therapy interventions (such as cognitivebehaviourtherapy or psychoeducation). 4 The evidence base and efficiency of MIinterventions make this approach a good fit within the context of busy health-careenvironments.What makes MI effective?“change talk”MI has been shown to enhance treatment engagement and retention, client goalsettingand behaviour change, motivation, and client-practitioner collaboration,leading to more durable treatment outcomes. In one study using ProjectMATCH data, Moyers et al. 8 analyzed video recordings of MI therapist-clientinteractions using a validated MI coding instrument (Motivational InterviewingTreatment Integrity code [MITI 9 ]). The authors found that therapists’ skillful use ofMI-consistent statements led to significantly increased levels of clients’ “change talk”;whereas therapists with a greater proportion of MI-inconsistent statements evokedincreased counter-change, or “sustain,” talk from their clients. Perhaps most important,clients who expressed significantly more change talk demonstrated significantlybetter treatment outcomes at follow-ups two years later. Specifically, change talk atthe end of the session is predictive of change. Moyers’ hypothesized causal chain forMI can be expressed as:Therapist MI-consistent speech Increased client change talk Improved treatmentoutcomes 3Whereas:Therapist MI-inconsistent speech Increased client sustain talk Maintainingstatus quo or client counter-change 3What is client “change talk”?The acronym “DARN CAT” captures two categories of change talk:• Preparatory change talk is reflected in statements expressing a person’s Desire,Ability, Reasons or Need for change.• Commitment language is reflected in statements expressing Commitment,Action or Taking steps toward change.206©2012 CAMH/TEACH

Section 3: Participant resourcesWhat are MI-inconsistent statements by practitioners?The following behaviours tend to evoke sustain talk (and should be avoidedif the goal is to enhance motivation):• directing• informing (without asking permission)• warning or threatening• reassuring or praising• confronting.the “spirit” of miThe “spirit” of MI is expressed by the acronym ACE:• Autonomy• Collaboration• Evocation.At the heart of the MI approach is a core philosophy or “spirit.” This spirit can bereliably measured and can predict client responsiveness and treatment outcome. 2Therefore, it is important that practitioners understand and behave in a way that isconsistent with patient autonomy, patient-practitioner collaboration, and practitionerevocation of a patient’s goals, concerns, hopes and priorities for change. Accurateempathy, compassion and a willingness to work with the client—wherever he or sheis at—are hallmarks of MI spirit.MI-consistent practitioner targets• two reflective statements for each question asked• at least 50% complex (vs. simple) reflections• no more than 50% of therapist talk timereflective listeningReflective listening on the part of the practitioner helps patients to explore and clarifytheir ambivalence about changing. 10 Reflective listening is the most central of the©2012 CAMH/TEACH 207

Motivational Interviewing in Respiratory Health CareMI microskills, and can be the most challenging to practice fluently and effectively.However, with practice it is learnable and can positively impact therapeutic alliance,trust and rapport.What does this mean for respiratory care?Research suggests a number of ways to consider and apply MI microskills in respiratoryhealth settings:• Clients with chronic illnesses such as asthma or chronic obstructive pulmonarydisease (COPD) often experience a loss of control. Exploring personal change goalsand goal-setting can contribute to restoring that sense of control. 11 Promotingclients’ autonomy and acknowledging that they have choices makes clients activeparticipants in their health care (as opposed to passive recipients of treatmentinterventions and practitioner advice).• Treatment plans need to be tailored to the needs of each client. 12 Individuals havediverse needs and therefore require personalized support and care, including individualizedfeedback. 13• Patients’ perceptions about their respiratory illness or treatment plans often impairmotivation. 14 However, motivation is malleable and can be influenced by the practitioner—client“denial” or “resistance” is often directly related to how the practitionerinteracts with the client 13,15 and can actually serve to reinforce unhealthybehaviour. 14• A strong rapport with clients is the foundation of an effective therapeutic relationship.16 In this context, rapport is developed through practitioners’ non-judgmentalwarmth, empathy and respect, as well as humility, curiosity and low investment—that is, a “shift from expert advice and admonition” towards promoting clients’ownership of their health issues and behavioural choices or strategies. 13 The use of anMI-consistent approach can help transform a client’s negative beliefs and attitudesabout his or her health, leading to goal attainment and maintenance of change. 11• Some authors suggest that “compliance” or “adherence” are problematic terms anddo not resonate with the collaborative approach so characteristic of MI. Lask suggeststhe use of the term concordance, while Naar-King and Suarez emphasize theimportance of self-management in supporting and promoting autonomy. 14,17Evidence for the effectiveness of MI in respiratory careAs a counselling style, MI seeks to help patients explore and resolve their ambivalenceabout behaviour change. 18 In respiratory health care, three main themesemerged from an Ontario-based curriculum planning group of respiratory healthcare practitioners who provided guidance and expertise in developing materialsfor the Centre for Addiction and Mental Health’s Motivational Interviewing inRespiratory Health Care trainers’ toolkit. 19 The themes from the curriculum planninggroup included: (1) asthma and youth, (2) medication concordance and self-efficacy,208©2012 CAMH/TEACH

Section 3: Participant resourcesand (3) respiratory health and common concurrent concerns (smoking, substance use,and mental health concerns). Although further research is needed in MI specific torespiratory care settings and practice, the results of studies relevant to each of thesethree key themes are summarized below.(1) asthma and youthAsthma management with younger clients is a significant clinical practice concern.Some research supports MI for asthma management and medication concordancethrough regular school nurse visits, 20 text messaging, 20 and at-home visits by a healthcare professional. 22 These studies highlight the creative use of MI in various settingstoward the goal of increasing self-monitoring and client self-care. They also underscorethe complexity of the dimensions surrounding younger clients’ health concerns,as well as the need to understand the context in which a respiratory conditionlike asthma is aggravated or alleviated.A number of behaviour change areas relevant to youth with asthma derive fromthe many environmental factors that can exacerbate asthma, such as dust, danderand exposure to environmental tobacco smoke. Asthma triggers may come in theform of:• smoke from fire• road dust• an undusted home• a poorly ventilated, small space that has accumulated items that collect dust• the presence of pets• second-hand tobacco smoke and third-hand smoke.Younger clients and their families may benefit from brief motivational interventionstargeting these environmental triggers. For example, interventions focused onaddressing environmental smoke, dust or pets need to involve and engage the wholefamily, including parents or caregivers.In addition, some factors are more psychosocial: a youth may avoid taking hermedication because she sees stepping out of class or taking meds as potentially jeopardizingher social inclusion and sense of herself as “normal.” Moreover, a youth’sparents may believe that the prescribed treatment is actually harmful (for example,the belief that steroids will stunt growth). It is important for health care professionalsto understand the broader environmental, social and emotional context in whichhealth is affected and health decisions are made, so as to collaborate in the developmentof the most appropriate treatment plan for that individual and family.Family-focused approachThe client’s home environment and family dynamics are critical. Family-centeredcare is essential, as parents or caregivers play a major role in helping to manage this©2012 CAMH/TEACH 209

Motivational Interviewing in Respiratory Health Carechronic condition. Channon and Rubak, in MI with Adolescents and Young Adults,note that the family is actually key to the process of change. 17 For example, familyfunctioning and parents’ beliefs about the seriousness of the illness can create realbarriers toward treatment. 16Some parents may have strong beliefs with regards to how the respiratory healthprofessional should intervene; 17 the latter may find himself/herself forced into amediator position between the child or youth and the caregiver. Neutrality in thissituation will facilitate an open-minded approach to a conversation exploring concernsand outcomes. 17Although meeting the expectations of a parent is a strong predictor of the parent’ssupport for the treatment plan, it is essential to empower youth to create theirown personal change goals; 13 youth may disengage if treatment focuses solely ontheir parents’ goals. However, if the parent and youth have similar questions, concernsor doubts about recommended treatment, it may be helpful to complete ashared list of the pros and cons of changing versus staying the same. 17Caregivers may have to adjust parenting techniques to reflect a child’s emergingneeds for independence, embracing the child’s growing autonomy. 17 The balance ofguiding with appropriate directing and following that characterizes MI also representsgood parenting. 17 MI reinforces parental motivation and practices that are supportiveof the child’s chronic condition by increasing monitoring and parent-childcommunication. 13 Furthermore, research suggests MI resonates well with teens dueto the brief duration of MI and its empathic approach. 17 Rarely can youth speak withan adult about drug use, for example, in a manner that is non-combative or nondidactic,17 especially if their substance use may be exacerbating a respiratory healthissue. In summary, family-based approaches are recommended, and briefing parentson the principles of MI may help them to support their child and participate intheir treatment. 14 In addition, MI is oriented toward harm reduction approaches tohealth risk behaviours, which may be more realistic and attainable for youth who areunwilling or unable to grasp the consequences of their behaviours.(2) medication concordance and self-efficacyAs a patient-centred approach, MI is associated with better patient retention andtreatment outcomes, with decreased time and cost. 10 Unlike other communicationor intervention styles, MI helps assess a patient’s intrinsic motivation for change.Addressing patients’ ambivalence about behaviour change, and level of readiness toembark on the journey towards change, involves weighing the costs and benefits ofchange versus staying the same. If the difficulty of adhering to medication or prescribedtreatments is perceived to be greater than that of maintaining the behaviour,a patient may be inclined to remain “non-adherent.” Regardless of the health careprofessional’s advice, concern or recommendations, clients will ultimately decidewhat is best and will act accordingly. Therefore, the first step to behaviour change is210©2012 CAMH/TEACH

Section 3: Participant resourcesaffirming the client’s feelings and seeking to better understand the barriers to changeand perceived costs and benefits of change. 14 MI has been shown to impact patients’beliefs about illness and medication, known determinants for adherence to medication. 23Dealing with non-adherence requires patient-centred care characterizedby concordance, i.e., shared decision-making about therapyby doctors and patients. 19A number of studies support the efficacy of MI in increasing patients’ level ofreadiness toward medication adherence. 10,24,25 In one study, 12 the use of MI withpatients with COPD decreased the number of hospital admissions, unscheduledphysician visits and emergency room visits, and the average length of hospital stay.Overall, MI helped decrease health care utilization costs for these individuals, andalso increased patients’ self-efficacy and quality of life in general. For people livingwith chronic conditions, part of fostering a sense of optimism involves collaboratingto establish individualized treatment that is “explicit, time-contingent and adjustable,”11 and in some cases providing written guidelines. 12 By working together toidentify personal goals that are Specific, Measurable, Attainable, Realistic and withina known Timeline (“SMART” goals), client and practitioner can better track progressand work together to adjust strategies that are less effective. In summary, practitionersadopting an MI style and approach can improve the quality of care withoutincreased time, and can also decrease adverse patient events. 10Motivational interviewing practice tips1. Avoid the trap of “premature focus” (i.e., avoid directing the patient to focuson a behaviour he or she is not ready to change). Premature focus can provokepatient resistance, negatively impact the therapeutic alliance, and leadto feelings of disempowerment for the patient (and the practitioner!) 172. Sample MI-consistent opening statement: “Our meeting today may be differentfrom some of your other medical visits, in that I am not here to tellyou what to do or how to do it. Rather, I want to find out what you might beinterested in changing and what might help.”(3) respiratory care and concurrent tobacco use,other drug and mental health issuesThere is a robust evidence base for MI with clients who smoke and who have mentalhealth and/or substance use disorders. Although this literature is not specific toclients with concurrent disorders presenting in respiratory health care contexts, thefindings can guide respiratory health practitioners in adopting an MI approach withthese client populations.©2012 CAMH/TEACH 211

Motivational Interviewing in Respiratory Health CareTobacco useTobacco addiction is a chronic condition and a significant respiratory health concern.Tobacco smoke can also interact with medications through pharmacodynamicand pharmacokinetic mechanisms (for example, people who smoke may have lessresponse to inhaled corticosteroids). 26 This makes tobacco interventions a criticalelement of respiratory health care practice.A meta-analysis of clinical trials has shown Motivational Interviewing to beeffective in significantly increasing smoking quit rates. 27 MI has also proven effectivein decreasing household or passive smoke exposure by guiding caregivers to resolvetheir ambivalence toward changing behaviours that can affect their dependents’health. Emmons et al. 28 demonstrated that health care professionals can help parentswork toward reducing environmental and second-hand smoke even if they are notready to quit. Borrelli et al. 29 explored motivating parents to quit in homes where achild lives with asthma. The authors found the use of MI to be effective at reducingpassive smoke exposure in the home. Their approach compared MI-consistent goalsettingand skill-building to strictly increased risk perception and biomarker feedback.29 Health care professionals should always inquire about the smoking status of aclient, as outlined in the CAN-ADAPTT 30 guidelines, and especially with caregiverswhose child has asthma (and, more broadly, with every client with dependents). 31Other drug usePeople who misuse other drugs, including alcohol, are more likely to smoke and toexperience tobacco-related diseases than the general population. 32 Managing withdrawalamong hospital inpatients can be framed as a precursor to engagement in alongitudinal process of disease management. 32 When a client is empowered to set herown agenda or vocalize realistic and specific goals, research shows that the strengthof this commitment language can predict subsequent health behaviour change. 2,33,34Amrhein et al. 35 found that an MI approach to working with clients who used illicitdrugs was associated with increased client commitment language and significantlybetter treatment outcomes. Clients with addictions often experience stigma, and thenon-judgmental and non-confrontational style of MI make this approach particularlywell-suited to this population.With gentle yet tailored discussions about use, discrepancy can beexplored between actual use and current values or future aspirations.Common topic areas for developing discrepancy include money spenton [the substance], social support, and future goals. 17The eliciting style of MI, centered on the person’s perspectives, serves to buildrapport and trust, and in the process allows and reinforces the client’s feelings thathe or she is a worthwhile individual. 17212©2012 CAMH/TEACH

Section 3: Participant resourcesMental healthThere is a strong relationship between mental illness and tobacco use, and numerousbarriers impede clients with psychiatric conditions from receiving tobaccointerventions despite high prevalence, increased morbidity, cost and desire to quit. 32Identifying smoking status and assessing motivation to quit (such as the use of aLikert scale to determine readiness, importance and confidence in quitting) at eachclinical visit is recommended. 32 In addition to cessation medications, clients maybenefit from refusal and coping-skills training to address cravings, boredom, anxiety,symptoms and side effects. 32For individuals with cognitive impairments—such as the impairments thatoften accompany severe psychiatric illness—a number of adaptations have been proposed.36 These include:• simplifying reflective statements and open-ended questions• using metaphors to anchor abstract material in reality (for example, using themetaphor of a three-legged stool to illustrate the importance of three key areas offocus in recovery from concurrent mental health and substance use problems: (1)maintaining abstinence, (2) taking prescribed medications, and (3) participating ina concurrent disorders treatment program)• integrating strategies of repetition, simple verbal and visual illustrations, and breakswithin sessions• reducing reflective statements that focus explicitly on disturbing life experiences• using a decisional balance addressing the positives and negatives of being abstinentfrom problematic substances, and the positives and negatives of attending concurrentdisorders treatment• assessing the need for other interventions to promote psychiatric stability, logicalreasoning or safety.Motivational interviewing may also be a useful approach with people withacquired brain injury (ABI). 37 In particular, the spirit and techniques of MI can helppromote clients’ self-awareness, goal-setting and engagement in treatment and rehabilitation.ConclusionThere is a still a lack of comprehensive research within the field of MI and respiratoryhealth, and of studies that examine the use of MI interventions focused onbehaviour change issues specific to respiratory care. Furthermore, there is no singleapproach that is best for all clients. However, MI strategies have been shown to beeffective with clients facing various chronic health concerns, and MI interventionsmay take less time than other psychosocial approaches. Respiratory health care professionalscan utilize MI as an effective channel for developing strong therapeuticalliance, trust and rapport with clients, and to help guide clients in the direction ofpositive change.©2012 CAMH/TEACH 213

Motivational Interviewing in Respiratory Health CareReferences1. Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing isnot. Behavioural and Cognitive Psychothotherapy, 37, 129–140.2. Anstiss, T. (2009). Motivational Interviewing in primary care. Journal of ClinicalPsychology in Medical Settings, 16, 87–93.3. Herie, M. & Skinner, W. Motivational Interviewing. (In press) In M. Herie & W.Skinner (Eds.), Alcohol and Drug Problems: A Practical Guide for Counsellors (4th ed.)Toronto: CAMH.4. Rollnick, M., Butler, C., Kinnersley, P., Gregory, J. & Mash, B. (2010).Motivational Interviewing. British Medical Journal, 340, c1900.5. Lundahl , B.W., Kunz, C., Brownell, C., Tollefson, D. & Burke, B.L. (2010). Ameta-analysis of Motivation Interviewing: Twenty-five years of empirical studies.Research on Social Work Practice, 20(2), 137–160.6. Lundahl, B. & Burke, B.L. (2009). The effectiveness and applicability ofMotivational Interviewing: A practice-friendly review of four meta-analyses. Journalof Clinical Psychology, 65(11), 1232–1245.7. Prochaska, J.O. & Norcross, J.C. (2007). Systems of Psychotherapy: A TranstheoreticalAnalysis (6th ed.) Belmont: Thompson Brooks/Cole.8. Moyers, T.B., Martin, T., Houck, J.M., Christopher, P.J. & Tonigan, J.S. (2009).From in-session behaviours to drinking outcomes: A causal chain for MotivationalInterviewing. Journal of Consulting and Clinical Psychology, 77(6), 1113–1124.9. Moyers, T., Martin, T., Catley, D., Harris, K. & Ahluwalia, J.S. (2003). Assessingthe integrity of Motivational Interviewing interventions: Reliability of theMotivational Interviewing skills code. Behavioural and Cognitive Psychotherapy, 31,177–184.10. Borrelli, B., Riekert, K.A., Weinstein, A. & Rathier, L. (2007). Brief motivationalinterviewing as a clinical strategy to promote asthma medication adherence. Journalof Allergy and Clinical Immunology, 120(5), 1023–1030.11. Chavannes, N., Grijsen, M., van den Akker, M., Huub, S., Nijdam, M., Tiep, B.& Muris, J. (2009). Integrated disease management improves one-year quality of lifein primary care COPD patients: A controlled clinical trial. Primary Care RespiratoryJournal 18(3), 171–176.12. Khdour, M., Kidney, J., Smyth, B. & McElnay, J. (2009). Clinical pharmacy-leddisease and medicine management programme for patients with COPD. BritishJournal of Clinical Pharmacology 68(4), 588–598.214©2012 CAMH/TEACH

Section 3: Participant resources13. Sindelar, H., Abrantes, A., Hart, C., Lewander, W. & Spirito, A. (2004).Motivational Interviewing in pediatric practice. Current Problems in Pediatric andAdolescent Health Care, 34, 322–339.14. Lask, B. (2003). Motivating children and adolescents to improve adherence.Journal of Pediatrics, October: 430–433.15. Miller, W., Benefield, R. & Tonigan, J. (1993). Enhancing motivation for changein problem drinking: A controlled comparison of two therapist styles. Journal ofConsulting and Clinical Psychology, 61, 455–461.16. Taddeo, D., Egedy, M. & Frappier, J.-Y. (2008). Adherence to treatment in adolescents.Paediatrics & Child Health, 13(1), 19–24.17. Naar-King, S. & Suarez, M. (2011). Motivational Interviewing with Adolescentsand Young Adults. New York: Guilford Press.18. Knight, K.M., McGowan, L., Dickens, C. & Bundy, C. (2006). A systematicreview of motivational interviewing in physical health care settings. British Journal ofHealth Psychology, 11(2), 319–332.19. Training Enhancement in Applied Cessation Counselling and Health (TEACH)& The Ontario Lung Association (OLA). (2012). Motivational Interviewing inRespiratory Health Care: A Knowledge Translation Initiative. Toronto: CAMH.20. Halterman, J.S., Riekert, K., Bayer, A., Fagnano, M., Tremblay, P., Blaakman, S.& Borrelli, B. (2011). A pilot study to enhance preventive asthma care among urbanadolescents with asthma. Journal of Asthma, 48(5), 523–530.21. Seid, M., D’Amico, E.J., Varni, J.W., Munafo, J.K., Britto, et al. (2011). The invivo adherence intervention for at risk adolescents with asthma: Report of a randomizedpilot trial. Journal of Pediatric Psychology, 37(4), 390–403.22. Riekert, K.A., Borrelli, B., Bilderback, A. & Rand, C.S. (2011). The developmentof a motivational interviewing intervention to promote medication adherenceamong inner-city, African-American adolescents with asthma. Patient Education andCounseling, 82(1), 117–122.23. Klok, T., Sulkers, E., Kaptein, A., Duiverman, E. & Brand, P. (2009). Adherencein the case of chronic diseases: Patient-centred approach is needed. NederlandsTijdschrift voor Geneeskunde, 153.24. Cooperman, N., Parsons, J., Chabon, B., Berg, K. & Arnsten, J. (2007). The developmentand feasibility of an intervention to improve HAART adherence amongHIV-positive patients receiving primary care in methadone clinics. Journal of HIV/AIDS and Social Services, 6, 101–120.©2012 CAMH/TEACH 215

Motivational Interviewing in Respiratory Health Care25. Schmaling, K., Blume, A. & Afari, N. (2001). A randomized controlled pilot studyof motivational interviewing to change attitudes about adherence to medications forasthma. Journal of Clinical Psychology in Medical Settings, 8(3), 167–172.26. Rx for Change. (1999–2009). The Regents of the University of California.27. Lai, D.T.C, Cahill, K., Qin, Y. & Tang, JL. (2010). Motivational interviewing forsmoking cessation. Cochrane Database of Systematic Reviews, (1), 40.28. Emmons, K.M., Hammond, S.K., Fava, J.L., Velicer, W.F., Evans, J.L. & Monroe,A.D. (2001). A randomized trial to reduce passive smoke exposure in low-incomehouseholds with young children. Pediatrics, 108(1), 18–24.29. Borrelli, B., McQuaid, E., Berker, B., Hammond, K., Papandonatos, G., Fritz, G.& Abrams, D. (2001). Motivating parents of kids with asthma to quit smoking: ThePAQS Project. Health Education Research, 17(5), 656–669.30. The Canadian Action Network for the Advancement, Dissemination andAdoption of Practice-informed Tobacco Treatment (CAN-ADAPTT). (2012). CAN-ADAPTT Clinical Practice Guidelines for Smoking Cessation. Toronto: CAMH.31. McQuaid, E.L., Walders, N. & Borrelli, B. (2003). Environmental tobacco smokeexposure in pediatric asthma: Overview and recommendations for practice. ClinicalPediatrics, 42, 775–787.32. TEACH. (2012). Tobacco Interventions for Patients with Mental Health and/orAddiction Disorders. Toronto: CAMH.33. Chiasson, A., Park, D. & Schwarz, N. (2001). Implementation intentions andfacilitation of prospective memory. Psychological Science, 12, 457–461.34. Gollwitzer, P. (1999). Implementation intentions: Simple effects of simple plans.American Psychologist, 54, 493–503.35. Amrhein, P., Miller, W., Yahne, C., Palmer, M. & Fulcher, L. (2003). Client commitmentlanguage during motivational interviewing predicts drug use outcomes.Journal of Consulting and Clinical Psychology, 71, 862–878.36. Martino, S., Carroll, K., Kostas, D., Perkins, J. & Rounsaville, B. (2002). DualDiagnosis Motivational Interviewing: a modification of Motivational Interviewingfor substance-abusing patients with psychotic disorders. Journal of Substance AbuseTreatment, 23, 297–308.37. Medley, A.R. & Powell, T. (2010). Motivational Interviewing to promote selfawarenessand engagement in rehabilitation following acquired brain injury: A conceptualreview. Neuropsychological Rehabilitation, 20(4), 481–508.216©2012 CAMH/TEACH

Section 3: Participant resourcesWorkshop overviewsone-day workshopSummaryMotivational Interviewing (MI) is a “collaborative, person-centered form of guidingto elicit and strengthen motivation for change” (Miller and Rollnick, 2009). MIhas a robust evidence base across a range of health behaviours, including respiratoryhealth care. This workshop addresses the foundation skills and underlying philosophyof MI using case-based learning, hands-on practice and take-away resources.Learning objectivesAt the end of this workshop you will be able to:• define MI and its relevance to respiratory health care and health behaviour change• operationalize the “spirit” of MI in conversations with clients• review and practice foundation skills in MI• listen for and respond to client change talk• apply agenda-setting as a strategy for working with clients with complex, cooccurringissues• recognize and integrate MI spirit and skills in practise• set objectives and access resources for continuing professional development inMI skills.Workshop agendaSuggested time9:00–9:15(15 mins)9:15–9:30(15 mins)9:30–9:50(20 mins)Topic/activityWelcome and IntroductionsAcknowledgementsDisclosuresLearning objectives and workshop overviewLearning objective #1:Define MI and its relevance to respiratory health careand health behaviour changeWhat is MI?Evidence base for MI©2012 CAMH/TEACH 217

Motivational Interviewing in Respiratory Health CareSuggested time9:50–10:30(40 mins)10:30–10:45(15 mins)10:45–12:00(75 mins)Topic/activityLearning objective #2:Operationalize the “spirit” of MI in conversationswith clientsThe “spirit” of Motivational InterviewingBREAKLearning objective #3:Review and practise foundation skills in MIFoundation skills: OARSOpen questionsAffirmations12:00–1:00 LUNCH1:00–1:40(40 mins)1:40–2:15(35 mins)2:15–2:30(15 mins)Reflective listeningSummary statementsLearning objective #4:Listen for and respond to client change talkRecognizing and responding to change talkLearning Objective #5:Apply agenda-setting as a strategy for working withclients with complex, co-occurring issuesAgenda-settingBREAK2:30–3:45(75 mins)Learning objective #6:Recognize and integrate MI spirit and skills in practicePulling it all together3:45–4:00 Learning objective #7:Set objectives and access resources for continuingprofessional development in MI skillsContinuing professional development in MotivationalInterviewing218©2012 CAMH/TEACH

Section 3: Participant resourceshalf-day workshopSummaryMotivational Interviewing (MI) is a “collaborative, person-centered form of guidingto elicit and strengthen motivation for change” (Miller and Rollnick, 2009). MIhas a robust evidence base across a range of health behaviours, including respiratoryhealth care. This workshop addresses the foundation skills and underlying philosophyof MI using case-based learning, hands-on practice and take-away resources.Learning objectivesAt the end of this workshop you will be able to:• define MI and its relevance to respiratory health care and health behaviour change• operationalize the “spirit” of MI in conversations with clients• review and practise foundation skills in MI• set objectives and access resources for continuing professional development in MIskills.Workshop agendaTime9:00–9:15(15 mins)9:15–9:35(20 mins)9:35–10:15(40 mins)10:15–10:30(15 mins)Topic/activityWelcome and IntroductionsAcknowledgementsDisclosuresLearning objectives and workshop overviewLearning Objective #1:Define MI and its relevance to respiratory health careand health behaviour changeWhat is MI?Evidence base for MILearning Objective #2:Operationalize the “spirit” of MI in conversationswith clientsThe “spirit” of Motivational InterviewingBREAK©2012 CAMH/TEACH 219

Motivational Interviewing in Respiratory Health CareTime10:30–11:45(75 mins)Topic/activityLearning Objective #3:Review and practise foundation skills in MIFoundation skills: OARSOpen questionsAffirmationsReflective listeningSummary statements11:45–12:00(75 mins)Learning Objective #4:Set objectives and access resources for continuingprofessional development in MI skillsContinuing professional development in MotivationalInterviewingone-hour workshopSummaryMotivational Interviewing (MI) is a “collaborative, person-centered form of guidingto elicit and strengthen motivation for change” (Miller and Rollnick, 2009). MIhas a robust evidence base across a range of health behaviours, including respiratoryhealth care. This workshop addresses the philosophy of MI in an experiential way,and includes take-away resources.Learning objectivesAt the end of this workshop you will be able to:• define MI and its relevance to respiratory health care and health behaviour change• operationalize the “spirit” of MI in conversations with clients• set objectives and access resources for continuing professional development inMI skills.220©2012 CAMH/TEACH

Section 3: Participant resourcesWorkshop agendaTime9:00–9:05(5 mins)Topic/activityWelcome and IntroductionsLearning objectives and workshop overview9:05v9:15(10 mins)9:15 – 9:55(40 mins)9:55 – 10:00(5 mins)Learning Objective #1:Define MI and its relevance to respiratory health careand health behaviour changeWhat is MI?Evidence base for MILearning Objective #2:Operationalize the “spirit” of MI in conversationswith clientsThe “spirit” of Motivational InterviewingLearning Objective #4:Set objectives and access resources for continuingprofessional development in MI skillsContinuing professional development in MotivationalInterviewing©2012 CAMH/TEACH 221

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Section 3: Participant resourcesCase-based video demonstrations of MIskillsThe following transcripts are from video interviews conducted by Marilyn Herie,PhD, RSW.motivational interviewing: an angry client(“angry bob”)(Available on YouTube: www.youtube.com/watch?v=79YTuZUFRIc)Speaker Content SkillPractitionerPatientPractitionerPatientPractitionerPatientPractitionerPatientSo what brings you here, Bob? What can I do tohelp?Yeah, yeah well the only reason I’m here is'cause my wife thinks I got a problem with smoking.I’ve been smoking all my life and six monthsago she thought, she got onto this health kick,right, and now everyone who smokes is evil! Andso that’s why I’m here so it’s just to please her,get her off my back. . . .So you’re not too happy to be here. This is thelast thing that you want to be doing this afternoon.Yeah that’s an understatement. I mean I’m supposedto be at work right now too, right?So you’ve taken time off; it’s costing you timeand money to be here.Yeah, yeah. I’m only here because my wife forcedme to come, you know. Like this has come to ahead. Six months of just nagging me relentlessevery day because she was able to quit smokingand now I have to quit.So let me ask you this Bob: what are some ofyour wife’s concerns about your smoking?Well she’s concerned about my health, and shecuts out all these articles from the paper aboutsecond-hand smoke and. . . .OpenquestionsComplexreflectionComplexreflectionAskingpermissionOpenquestion©2012 CAMH/TEACH 273

Motivational Interviewing in Respiratory Health CareSpeaker Content SkillPractitionerPatientWow, that she’s been showing you and makingyou read. . . .Yeah I got to read this! That’s my reading assignmentfor breakfast! And I want to go out andhave, we used to go out and have a cigarettetogether at the table. Now I have to go outside inthis weather, you know. What’s that about? Andshe used to smoke more than me and now she’slike, “holier than thou.”SimplereflectionPractitioner So you’re pretty angry about it. ComplexreflectionPatientPractitionerPatientPractitionerPatientPractitionerPatientYeah.It’s pretty enraging that you’re forced to changeyour whole life because of a decision she madesix months ago.And she’s got my kids on this against me, youknow my son and my daughter they’re up, it’slike they’re ganging up on me, you know what Imean?So from your perspective do you see any consequencesto your smoking?Well the big one of course is how it’s affectingmy wife and I and the family. But, like, my dad’seighty-five and he still smokes! I mean, yeah, youknow sometimes I’ve thought of quitting but Imean, I don’t know if I can quit.So let me make sure I understand kind of thewhole scenario, because there’s a lot of piecesto it. Your wife is on your case and your kids areganging up too, so you’re sort of isolated, you’reput in a corner, and you’re being told this issomething you have to do, you have no choice inthe matter.Yeah.ComplexreflectionClosedquestionSummarystatement274©2012 CAMH/TEACH

Section 3: Participant resourcesSpeaker Content SkillPractitionerPatientPractitionerPatientPractitionerPatientPractitionerYou have a few concerns about your health, butthat’s not really the driving force. It sounds likeit’s most of all that it would be nice if things justwent back to the way they were before she quitsmoking and that all of this stuff wasn’t somethingthat you had to deal with anymore. Doesthat pretty much sum up?Yeah, I’m just, I don’t want to lose her or myfamily over smoking.I get the feeling that your relationship is reallyimportant to you, that you would do anything.Well yeah, I mean we’ve been married overtwenty-five years and we’ve never had any majorproblems. Like this is a real, this is the first problem,and I don’t even really see it’s a problemcause we used to both smoke! And I was tryingto accommodate them by smoking outside, butit’s feeling like we’re going like this [gestures,hands moving apart in two directions] and I’mjust concerned, like if this keeps going. . . .So it strikes me that the way that we’re talkingabout it, it’s like it’s all or nothing. Either youkeep smoking the way you are, things continueto go downhill and get worse, your wife getsmore and more on your case—or you put yourcigarettes down starting the moment you walk inthe door tonight, and never pick them up again.It’s almost like one or the other. It strikes methat as well there might be some middle groundhere . . . that it took you a long time to learnhow to be a smoker and maybe it’s going to takesome time to learn how to stop smoking.So I can actually do it that way? Like gradualtaper?There are some medications and some differentapproaches that we can use that aren’t soabrupt, recognizing that it’s going to take sometime and practice to get to where you mightwant to be.Summarystatement(cont’d)ClosedquestionComplexreflectionProvidinginformationProvidinginformation©2012 CAMH/TEACH 275

Motivational Interviewing in Respiratory Health CareSpeaker Content SkillPatientPractitionerPatientPractitionerPatientPractitionerPatientWell I wish my wife could have come today‘cause she feels I have to, like, just stop like rightaway. So do you think she could come with meat a future appointment or something and she’dhear that message?If you wanted to bring your wife along, I’d bemore than happy to talk with both of you.Yeah okay. I’ll have to talk to her just about,cause her schedule changes from week to weekcause she works shifts. So I’ll call you backtomorrow and we’ll set something up?Okay that sounds good.Alright.Thanks for coming in.Okay thanks.276©2012 CAMH/TEACH

Section 3: Participant resourcesmotivational interviewing: agenda-settingconversation with “sal”(Available on YouTube: www.youtube.com/watch?v=klnHJ4coG8o)Speaker Content SkillPractitionerPatientPractitionerPatientPractitionerPatientPractitionerPatientHi Sal. Thanks for coming in today.No problem.I saw that your doctor made the referral and Ireally appreciate you taking the time to comeand make that appointment.Yeah it’s, it’s a bit of an inconvenience I’d saybut I’m here though.So you made it in here—and do you have asense of what some of the doctor’s concernswere that led her to refer you?I don’t know. Something about changing my lifeeven more . . . you know the smoking’s beenchanged, and now it’s, you know, “cut down thedrinking,” “get rid of those extra smokes,” “getrid of my dog.” I don’t know what else I have todo!So your asthma’s been acting up and there’s alot of stuff, not just the asthma, going on.Yeah there’s a lot of stress too. My wife’s stillon maternity leave. She’s not getting paid, she’swith the baby right now, and I’m the only personthat’s working right now. And plus I got tochange all these things that are going on in mylife! Yeah it’s a lot.AffirmationSimplereflectionClosedquestionComplexreflectionPractitioner Almost overwhelming, it sounds like. ComplexreflectionPatientPractitionerYeah, yeah it is overwhelming, it is.Well we have about, I guess, fifteen or twentyminutes together, and I wonder would it be okayif we took a couple of minutes and just kind oflooked at all of the different things that are goingon for you and maybe you can let me know whatwould be the most helpful to spend some timeon?ProvidinginformationAskingpermissionClosedquestion©2012 CAMH/TEACH 277

Motivational Interviewing in Respiratory Health CareSpeaker Content SkillPatientPractitionerYeah, it just feels like everything is all over theplace. But I guess we got to start somewhere.Okay.PatientPractitionerPatientPractitionerPatientPractitionerPatientPractitionerPatientYeah.Well one of the things that that we use are these. . . it’s kind of like a worksheet, and it’s an agendasetting worksheet, basically.So if you were to list all of the different thingsthat people around you are saying that you needto work on or you need to change, what wouldsome of those things be?And Sal, just because we write them down here,it doesn’t mean that you have to change them.Okay.You’re in the driver’s seat, so it’s just to kind of“put all the cards on the table” so to speak.Okay, okay that sounds good, as long as I’m notchanging anything and we’re just kind of putting,I guess, pen to paper or something?Yep.Okay, so: my asthma.Okay so asthma is one. [writes on agenda-settingworksheet]Yeah.ProvidinginformationOpenquestionEmphasizingautonomyEmphasizingautonomySimplereflectionPractitioner What else? OpenquestionPatientThe fact that they want me to get rid of Oscar.That’s my dog.Practitioner So your dog and the doctor is saying the dog’s. . . . SimplereflectionPatientWell she’s, yeah, she’s saying it’s, well it’s amain contributor to my asthma problems—which I don’t, I don’t, I don’t buy it! And I justcan’t get rid of him, like that. But it’s somethingthat’s there.278©2012 CAMH/TEACH

Section 3: Participant resourcesSpeaker Content SkillPractitionerPatientThat’s pretty shocking to be told that you have toget rid of your dog, your—[interjects] Yeah the, the dog’s been there beforemy wife! I know I’ve had him [Oscar] longer [thanmy wife].ComplexreflectionPractitioner So that’s a huge stress right now. [writes] ComplexreflectionPatientPractitionerPatientYeah it’s a big stress. It’s like my best friend sothat’s one of the important things. Also I guesscutting down on these last cigarettes I’ve beenworking on.Okay so smoking and working towards quittingcompletely—it sounds like that’s a goal for you.[writes]Finances is a problem right now too.SimplereflectionPractitioner Okay, so money. [writes] SimplereflectionPatientPractitionerTime. I got to come to all these appointmentsand I’m taking time off work—which obviously isthe money factor right?Right, right, so the appointments and time.[writes]And some of these things are kind of related toeach other, I think we’re already seeing.Patient Yeah there’s something going on, and also I . . .my drinking. I got to cut down on my drinkingtoo.PractitionerPatientOkay, wow, so there’s a lot happening right nowSal.Yeah.SimplereflectionProvidinginformationSimplereflectionPractitioner Anything else that’s concerning you? ClosedquestionPatientPractitionerPatientNo, it’s just overwhelming when you see them—Right.—everything there you know.©2012 CAMH/TEACH 279

Motivational Interviewing in Respiratory Health CareSpeaker Content SkillPractitionerPatientPractitionerPatientPractitioner[Shows agenda-setting worksheet] Well, so if youhad to pick somewhere, one or two kind of highpriorities or things to talk about in our time thismorning, where would you want to start?I think, I don’t know, I think the thoughts aboutthe dog has been definitely bothering me. That’sbeen one . . .Okay.. . . and my asthma is out of control too. Somaybe those two.Okay and it, those are ones that are pretty relatedto each other it sounds like.[Voices fade out in video . . . Video end.]ClosedquestionProvidinginformation280©2012 CAMH/TEACH

Section 3: Participant resourcesmotivational interviewing: a conversationwith “sal” about managing his asthma(Available on YouTube: www.youtube.com/watch?v=-RXy8Li3ZaE)Speaker Content SkillPractitionerPatientSo where you said you’d like to start Sal is talkingabout asthma . . . and specifically about yourdog and how one is affecting the other.Yeah my asthma’s just been out of control latelyand my doctor says it might be connected toOscar.Practitioner So can you let me know. . .PatientPractitionerPatientPractitionerPatientWhat do you know about your asthma and thethings that affect it or might make it worse?I’ve got allergy testing. It’s just the dust makesit bad. I thought the smoking was the mainthing—that’s cut down, and then they said thedrinking might contribute to it too, so I’ve got alot of different things I’m working on, so that’swhat I know. The drinking, the smoking and thedust that I got the scratch test for—and that’swhat I know and that I take the medicine for it.Okay and that your pet has never been mentionedas a concern.No, I’ve had it for twelve years and now it’s aconcern. I don’t understand.Yeah and I can see that you’ve already workedhard to make some changes.You’ve almost quit smoking. You’re just downto your last couple of cigarettes—and you’re noteven smoking those in the house, so your houseis totally smoke-free. Just [smoking] at work withthe boys. And you have also thought about cuttingback on alcohol and I think you mentioneddone a little bit towards that.I’m a little, I’m a couple down. I used to drinkfour a night and now I’m down to three at least.SimplereflectionStarts a closedquestionOpenquestionAmplifiedreflectionAffirmationSummarystatement©2012 CAMH/TEACH 281

Motivational Interviewing in Respiratory Health CareSpeaker Content SkillPractitionerPatientPractitionerPatientPractitionerPatientPractitionerPatientPractitionerPatientOkay, so now almost like “that’s not goodenough,” like “now you have to, now it’s thedog,”—and if, now, what’s next?!What’s next?! Yeah! Yeah!Right, okay, so I mean there is certainly a lot ofevidence that pets in the home and the danderfrom their fur can make asthma worse. . . .But I wonder what are your experiences withOscar, you know, when he’s in the house, ormaybe sleeping near you, or you’re around him?What happens with your asthma symptoms?Well we keep him clean, like he’s clean, so allthe dander doesn’t really make sense. But I havebeen noticing sometimes when he comes on thebed or just beside I wheeze a little bit, but I thinkit has to do with the hair, the . . . in my lungscleaning itself out from the smoking. So I don’tknow if it’s. . . . That’s where I’m confused. Idon’t know how this could be happening.So it doesn’t make total sense to you that thatit’s all Oscar’s fault and that that’s the only solution.But, but the wheezing is something that I’ve definitelynoticed a little bit.I guess I also wonder whether regardless of ifyour asthma symptoms are connected to Oscar,that maybe part of you feels like it’s worth itbecause he’s been such a big part of your life forso long.M’hmm, M’hmm. I just want some medicine[laughs] and I want to keep Oscar and I want tofeel better about myself because I’m making allthese changes in my life and it, it honestly feelslike my nose is just above the water.Yeah.Yeah.ComplexreflectionProvidinginformationOpenquestionOpenquestionSimplereflectionComplexreflection282©2012 CAMH/TEACH

Section 3: Participant resourcesSpeaker Content SkillPractitionerPatientPractitionerPatientPractitionerPatientPractitionerPatientAnd in the end you know whatever you do aboutOscar, about your asthma, about all the otherthings that we talked about on that agenda settingworksheet . . . I mean you are in the driver’sseat, Sal it really is your choice.Yeah I know, that feels good that you know that atleast it is my choice. I just feel like just about. . . .I’m not feeling happy about just all these differentthings that are coming up and I’m kind ofsad about things, and I don’t know, I don’t knowwhat to do.There’s a lot of decisions and a lot of changewith your wife, with the new baby and now thinkingabout, looking after your health and wantingto be healthy for your wife and your baby.I want, I want Jean-Carlos to grow up with Oscarso he has his friend, when he’s young too, andI just . . . it’s a lot of stress and a lot of thingsyou got to think about and I’m not feeling goodabout it.So what would need to happen or how wouldyou know when or if you ever did have to make adecision about whether to keep Oscar with youor not?Man! Oh how would I know? I don’t know, Ithink if my asthma got really bad and the medicine,and she [doctor] gave me the strongestmedicine and it wasn’t working—that would bethe way right now cause I can’t see, I don’t knowhow I’m going to give this dog up.Yeah, and I get the feeling that it’s somethingthat you want to think about. That this is a reallybig decision and it’s not one you’re going tomake in a hurry.No, no it’s something . . . I got to just sit thereand, and kind of put the pros and the cons onthe table about, but—something’s going on . . .[Voices fade out in video . . . Video end.]EmphasizingautonomyComplexreflectionOpenquestionComplexreflection©2012 CAMH/TEACH 283

Motivational Interviewing in Respiratory Health Carehow not to do motivational interviewing: aconversation with “sal” about managing hisasthma(Available on YouTube: http://www.youtube.com/watch?v=kN7T-cmb_l0)Speaker Content ApproachPractitionerPatientPractitionerPatientPractitionerPatientPractitionerPractitionerI understand that your asthma symptoms havebeen just really out of control so we need to lookat some of the ways you can get healthy and notbe back here again.I definitely don’t want to come back here butthe doc said Oscar, my dog, is connected to myasthma symptoms—but the ridiculous part isI’ve had him for [laughs] 12 years before and nowit’s a problem!Well you sound a bit surprised by that but I’msure that you’ve seen some of the material thatthe clinic gave you about asthma symptoms, andmanaging your asthma and pets are a really bigsource of problems in that respect.Yeah but hold on, let me just clarify. I’ve seenthe materials. I have them. I haven’t read them.All I’ve been doing is taking the medicine so Idon’t know that much about this.Well, wait a second Sal . . . what do you meanyou, you have . . . you know, to be informed . . .[stuttering] I’m just really taken aback by that,because I understand from your chart that youhave a young baby—a new baby?Jean-Carlos, yeah.—and you are very concerned about your health,you want to be there for your baby and thatyou’ve already taken some steps, you’ve, you’vealmost quit smoking——which is fantastic!So the next step is to really deal with the dog,deal with the pet. I know it’s, it’s going to behard to do that but there are always people whowill adopt animals. I am sure that you havefriends or family members.DirectingProvidinginformationClosedquestionSummarystatementPraisingDirecting284©2012 CAMH/TEACH

Section 3: Participant resourcesSpeaker Content ApproachPatientPractitionerPatientPractitionerPatientPractitionerPatientThis is a little bit too much for me now. First ofall Jean-Carlos is taken care of. That’s fine, hedoesn’t have no asthma from the dog. It’s justme I don’t have—[Interrupting] It’s you that I’m worried about, Sal.It’s you that I’m worried about, okay the symptomsare worse, you’ve had two or three majorasthma attacks, and do you appreciate how, thisis a risk to your life? That there are some adultswith severe asthma who actually can die as aresult of their symptoms. It truly is something totake very, very seriously. I can’t emphasize thatenough.So Oscar [laughs] is going to make me die? Hehasn’t made me die in 12 years and the doctoris saying “oh I don’t know if it’s the stress, thefinances, the drinking” so what are we doing sayingOscar could make me die? I’ve had him for12 years.Sal, you understand that what happened sixyears ago or ten years ago, your asthma is progressivelygetting worse. You know very wellthat the puffers, the strength of the medication,is getting higher and higher and there’s only somuch that can be done with medication alone,you know this.Well they can keep giving me more medicine andgive me the strongest one and I’ll keep Oscar.Sal, you’re almost on the strongest one and ifOscar is that important to you, then do you putOscar higher than your baby, than your wife?Like, that makes no sense to me. Do you understandhow important this is?I understand, but I don’t think you get my situation.I’ve had this dog for twelve years so I’m notjust going to up and get him out of my housewhen I don’t even know if that’s the main thing.Practitioner [Sighs] Okay well. . . .[Voices fade out in video . . . Video end.]WarningThreateningDirectingProvidinginformationProvidinginformationConfronting©2012 CAMH/TEACH 285

Section 3: Participant resourcesResourcesmotivational interviewing resourcesRecommended resourcesHohman, M. (2012) Motivational Interviewing in Social Work Practice. New York:The Guilford Press.Martino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentino,C., Hamilton, J., and Hausotter, W. (2006). Motivational Interviewing Assessment:Supervisory Tools for Enhancing Proficiency (MIA STEP). Salem, OR: NorthwestFrontier Addiction Technology Transfer Center, Oregon Health and ScienceUniversity. Available: www.motivationalinterview.org/Documents/MIA-STEP.pdfMatulich, B. (2011). How to Do Motivational Interviewing: A Guidebook for Beginners.E-book available: web.mac.com/billmatulich/MIT/ebook.htmlMiller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing isnot. Behavioural and Cognitive Psychotherapy, 37, 129–140. journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in HealthCare: Helping Patients Change Behavior. New York: Guilford Press. First chapter andtable of contents available: www.motivationalinterview.orgRosengren, D.B. (2009). Building Motivational Interviewing Skills: A PractitionerWorkbook. New York: Guildford Press.Useful websitesMotivational Interviewing website:www.motivationalinterview.orgMotivational Interviewing Network of Trainers (MINT) website:www.motivationalinterviewing.orgExamples of Motivational Interviewing videos on YouTube:www.youtube.com/user/teachproject#p/u©2012 CAMH/TEACH 287

Motivational Interviewing in Respiratory Health Careadditional readings and resources on mi inrespiratory careAmrhein, P., Miller, W., Yahne, C., Palmer, M. & Fulcher, L. (2003). Client commitmentlanguage during motivational interviewing predicts drug use outcomes. Journalof Consulting and Clinical Psychology, 71, 862–878.Anstiss, T. (2009). Motivational Interviewing in primary care. Journal of ClinicalPsychology in Medical Settings, 16, 87–93.Borrelli, B., McQuaid, E., Berker, B., Hammond, K., Papandonatos, G., Fritz, G. &Abrams, D. (2001). Motivating parents of kids with asthma to quit smoking: thePAQS Project. Health Education Research, 17(5), 656–669.Borrelli, B., Riekert, K.A., Weinstein, A. & Rathier, L. (2007). Brief motivationalinterviewing as a clinical strategy to promote asthma medication adherence. Journalof Allergy and Clinical Immunology, 120(5), 1023–1030.Chiasson, A., Park, D. & Schwarz, N. (2001). Implementation intentions and facilitationof prospective memory. Psychological Science, 12, 457–461.Cooperman, N., Parsons, J., Chabon, B., Berg, K. & Arnsten, J. (2007). The developmentand feasibility of an intervention to improve HAART adherence among HIVpositivepatients receiving primary care in methadone clinics. Journal of HIV/AIDSand Social Services, 6, 101–120.Emmons, K.M., Hammond, S.K., Fava, J.L., Velicer, W.F., Evans, J.L. & Monroe,A.D. (2001). A randomized trial to reduce passive smoke exposure in low-incomehouseholds with young children. Pediatrics, 108(1), 18–24.Erickson, S.J., Gerstle, M. & Feldstein, S.W. (2005). Brief interventions and motivationalinterviewing with children, adolescents, and their parents in pediatric healthcare settings: a review. Archives of Pediatrics and Adolescent Medicine, 159(12), 1173–180.Gollwitzer, P. (1999). Implementation intentions: Simple effects of simple plans.American Psychologist, 54, 493–503.Halterman, J.S., Riekert, K., Bayer, A., Fagnano, M., Tremblay, P., Blaakman, S. &Borrelli, B. (2011). A pilot study to enhance preventive asthma care among urbanadolescents with asthma. Journal of Asthma, 48(5), 523–530.Klok, T., Sulkers, E., Kaptein, A., Duiverman, E. & Brand, P. (2009). Adherencein the case of chronic diseases: Patient-centred approach is needed. NederlandsTijdschrift voor Geneeskunde, 153.Knight, K.M., McGowan, L., Dickens, C. & Bundy, C. (2006). A systematic review ofmotivational interviewing in physical health care settings. British Journal of HealthPsychology, 11(2), 319–332.288©2012 CAMH/TEACH

Section 3: Participant resourcesLai, D.T.C, Cahill, K., Qin, Y. & Tang, JL. (2010). Motivational interviewing forsmoking cessation. Cochrane Database of Systematic Reviews, (1),40.Lozano, P., McPhillips, H.A., Hartzler, B., Robertson, A.S., Runkle, C., Scholz, K.A.,Stout, J.W. & Kieckhefer G.M. (2010). Randomized trial of teaching brief motivationalinterviewing to pediatric trainees to promote healthy behaviors in families.Archives of Pediatrics and Adolescent Medicine, 164(6), 561–566.Lundahl, B. & Burke, B.L. (2009). The effectiveness and applicability of motivationalinterviewing: A practice-friendly review of four meta-analyses. Journal of ClinicalPsychology, 65(11), 1232–1245.Lundahl, B.W., Kunz, C., Brownell, C., Tollefson, D. & Burke, B.L. (2010). A metaanalysisof motivation interviewing: Twenty-five years of empirical studies. Researchon Social Work Practice, 20(2), 137–160.Martin-Lujan, F., Piñol-Moreso, J., Martin-Vergara, N., Basora-Gallisa, J., Pascual-Palacios, I., Sagarra-Alamo, R., Llopis, E., Basora-Gallisa, M., Pedret-Llaberia, R.;ESPITAP Study Group investigators. (2011). Effectiveness of a structured motivationalintervention including smoking cessation advice and spirometry informationin the primary care setting: The ESPITAP study. BMC Public Health, 11, 859.McQuaid, E.L., Walders, N. & Borrelli, B. (2003). Environmental tobacco smokeexposure in pediatric asthma: Overview and recommendations for practice. ClinicalPediatrics, 42, 775–787.Powell, C. & Brazier, A. (2004). Psychological approaches to the management ofrespiratory symptoms in children and adolescents. Paediatric Respiratory Reviews,5(3), 214–224.Riekert, K.A., Borrelli, B., Bilderback, A. & Rand, C.S. (2011). The development ofa motivational interviewing intervention to promote medication adherence amonginner-city, African-American adolescents with asthma. Patient Education andCounseling, 82(1), 117–122.Schmaling, K., Blume, A., & Afari, N. (2001). A randomized controlled pilot studyof motivational interviewing to change attitudes about adherence to medications forasthma. Journal of Clinical Psychology in Medical Settings, 8(3), 167–172.Seid, M., D’Amico, E.J., Varni, J.W., Munafo, J.K., Britto, M.T., Kercsmar, C.M.,Drotar, D., King, E.C. & Darbie, L. (2011). The in vivo adherence intervention for atrisk adolescents with asthma: Report of a randomized pilot trial. Journal of PediatricPsychology 37(4), 390–403. First published online December 13, 2011.Weinstein, A.G. (2011). The potential of asthma adherence management to enhanceasthma guidelines. Annals of Allergy, Asthma and Immunology, 106(4), 283–291.©2012 CAMH/TEACH 289

Appendix

AppendixFacilitator evaluation of curriculummaterials and participant responsesWe would like to continue to enhance the “Motivational Interviewing in RespiratoryHealth Care” toolkit, so your candid feedback is critical. Please take a few minutes tocomplete and return this brief evaluation form every time you hold a training usingthe Motivational Interviewing in Respiratory Health Care curriculum materials. Thiswill also help us to track the frequency and locations of training events using thesematerials. We will communicate this information with our funders and stakeholders,but no personal, identifying information will be shared without your consent (pleasesee below).Name:Organization:Street Address:City: Province: Postal Code:Telephone (Work): ( ) Telephone (Home): ( )Job title or position:Which discipline do you belong to? General practitioners and family physicians Specialist physicians Registered nurses Licensed practical nurses Dietitians and nutritionistsSocial workers Psychologists Respiratory therapists, asthma educators Dentists Physiotherapists Pharmacists Chiropractors Dental hygienists and dental therapists Occupational therapists Dental assistants Other:What area of Ontario are you from? Midwives / Practitioners of natural healing South-west area (i.e., Windsor, Elgin-St.Thomas, Grey Bruce, Perth, Oxford,London) Central-west area (i.e., Waterloo, Brant, Niagara, Wellington, Guelph,Haldimand-Norfolk) Central-east area (i.e., Peterborough, Haliburton, Simcoe, Peel, York Region)©2012 CAMH/TEACH 293

Motivational Interviewing in Respiratory Health Care Eastern area (i.e., Ottawa, Kingston, Renfrew, Hastings, Prince Edward) North-east area (i.e., Porcupine, Sudbury, Algoma, Timiskaming, North Bay) Toronto area (i.e., GTA) Other:Date of workshop:Name and credentials of faculty teaching course:Duration of workshop (please circle):One hour Half day One day Other:Approximate number of participants attending:For each statement, please check the box that best describes your assessment of theMotivational Interviewing Trainers’ Toolkit.Strongly disagreeDisagreeNeutralAgreeStrongly agree1. The planning tips and facilitatorresources in the toolkit helped me prepareto facilitate this workshop.2. The facilitators’ notes for the slideshelped me speak to the content on theslides.3. I was able to incorporate interactiveexercises into my presentation.4. The audience seemed interested inthe interactive learning activities.5. I was able to tailor the content of myworkshop to address the learning needsof my audience (i.e., I could find theinformation I wanted on the slides providedin the toolkit).6. The information on the slides reflectscurrent, evidence-based informationabout Motivational Interviewing.294©2012 CAMH/TEACH

Appendix7. I am planning to hold another workshopin the future, and will use the toolkitagain.8. I would recommend the toolkit as aresource to others who are planning MItraining sessions.9. I supplemented the slide content withmy own materials/resources. (Pleasecircle the approximate % of materialsused that were your own, and describeon the back of this sheet what youincluded.)10. I supplemented the suggested interactiveactivities with my own activities.(Please circle the approximate % ofactivities used that were your own, anddescribe on the back of this sheet whatyou included.)11. Overall, I would rate the MotivationalInterviewing in Respiratory Health Caretoolkit as:0% 25% 50% 75% 100%0% 25% 50% 75% 100%Poor1 2 3 4 5(OPTIONAL: Print first and last name and discipline/profession/credentials)ExcellentI, ,agree to allow the TEACH Project to publish my written comments both in printmaterials and on the TEACH website.Please check the appropriate box: I agree that my first and last name and my discipline/profession/credentials maybe published with my comments. I agree that only my first name may be published with my comments. I request that my comments remain anonymous.Signature:Date:Thank you for taking the time to complete this evaluation form.Please fax to: 416 599-3802 or e-mail to teach@camh.ca.©2012 CAMH/TEACH 295

AppendixWorkshop evaluation for participantsPlease check the box that best describes your feeling about the workshop you justattended.Strongly disagreeDisagreeNeutralAgreeStrongly agree1. The facilitator presented materialclearly.2. The information provided wasrelevant to my work.3. Time provided for learning in thissession was adequate.4. At least 25% of the content involvedinteractive teaching methods.5. I would recommend this workshop toothers.6. My professional practice will beimproved by what I have learned fromthis workshop.7. I am confident that I have learned andunderstood the workshop content.8. I will begin to use the concepts andinterventions from this workshop in myday-to-day practice.9. Interaction with peers enriched mylearning experience.10. Overall, I would rate this workshopas:Comments:Poor1 2 3 4 5ExcellentThank you for taking the time to complete this evaluation form.©2012 CAMH/TEACH 297

AppendixPractising MI skills cardsFull-sized copies of these cards forprinting and duplication are availableon the included CD.©2012 CAMH/TEACH 299

AppendixTeach-back cardsFull-sized copies of these cards forprinting and duplication are availableon the included CD.©2012 CAMH/TEACH 301

This Trainers’ Toolkit addresses the need and demand for Motivational Interviewing(MI) training among people working in respiratory health care. MI is an evidencebasedintervention used across a wide range of health behaviours, including patientself-care for asthma, adherence to asthma management treatment plans, tobaccocessation and general health behaviour change.The toolkit provides resources for both facilitators and participants, and includes:• facilitation tips• learning objectives and lesson plans for full-day, half-day and one-hourworkshops• presentation slides with facilitators’ notes• coded video transcripts• interactive exercises and case examples.The tools may be used in the format provided or may be adapted as needed.The toolkit will be an invaluable guide for MI champions and trainers in the fieldof respiratory health. It will allow you to guide colleagues through key componentsof an MI approach, showing them how to enhance communication with theirpatients and improve patients’ engagement, treatment retention and outcomes.This toolkit is the result of a collaborative partnership between the Ontario LungAssociation’s Smoke-Free Homes and Asthma Program and the Centre for Addictionand Mental Health’s TEACH Project. Since 2006, the Smoke-Free Homes andAsthma Program has reviewed research and conducted a pilot study to determinethe effectiveness of addressing asthma and second-hand smoke exposure amongchildren. Over the same period, TEACH (Training Enhancement in Applied CessationCounselling and Health) has developed and offered accredited continuingprofessional education to health and allied health practitioners in tobacco cessationinterventions and health behaviour change. MI is the foundational psychosocialapproach used in TEACH.This publication may be available in other formats. For information aboutalternative formats or other CAMH publications, or to place an order, pleasecontact Sales and Distribution:Toll-free: 1 800 661-1111Toronto: 416 595-6059E-mail: publications@camh.caOnline store: http://store.camh.netWebsite: www.camh.caA Pan American Health Organization /World Health Organization Collaborating Centre4626 / 10-2012 / PZ171