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Herie advanced groups 2013 final pub
1. Advanced Practice in Group
Facilitation
Integrating Motivational Skills and Strategies
Dr. Marilyn Herie PhD, RSW
Brain Tumour Support Group Facilitator and Convenor Workshop
April 13, 2013
Brain Tumour Foundation of Canada
5. What do you most want to take away from today?
• Turn to the person next to you and
share your responses
• One or more key things you would
like to take away from this workshop?
• We will check in as a large group in 5
minutes
6.
7. Learning Objectives
At the end of this session, you will be able to…
1. Resist the “righting reflex” in favour of “PACE”
(Partnership, Acceptance, Compassion, Evocation)
2. Practice the foundation skills of Motivational Interviewing
(Open questions, Affirmations, Reflections, Summaries,
Information)
3. Apply the foundation skills in shaping group conversation
and engaging with challenging group members
4. Adapt motivational group activities for your own groups
5. Identify your preferred facilitation style, and increase
flexibility in incorporating other styles.
12. Content versus
Process
A person will not always
remember what you said
or did, but they will always
remember how you made
them feel.
13. Some challenging issues…
• A member monopolizes the conversation
• A member discloses she is having small
seizures but has not told her doctor because
she wants to retain her driver’s license
• A member starts to disclose childhood abuse
or trauma
• A member repeatedly talks about how much
he loved injecting opioids and this is upsetting
to other group members
14. Examples of Group Norms
• Making sure that everyone has a voice (“Is
it OK if I sometimes interrupt or redirect the
group to keep us on track?”)
• Mutual respect
• Being on time
• Missing a session
• What this group can and cannot do
• “Taboo subjects”
• How we support ourselves and each other
when difficult feelings come up
15. Some challenging issues
(revisited)
• A member monopolizes the conversation… Making
sure we all have a voice in this group/ Mutual
respect and inclusion
• A member discloses she is having small seizures
but has not told her doctor because she wants to
retain her driver’s license… Confidentiality & Duty
to Report
• A member starts to disclose childhood abuse or
trauma… What this group can and cannot do
• A member repeatedly talks about how much he
loved injecting opioids and this is upsetting to other
group members… Taboo subjects and how we talk
about/handle them
17. The Art of Counselling
• Attending to process and content
• Adapting materials to the needs of the
client and group
• Eliciting and integrating client feedback
• An ongoing development process…
18.
19. Easier More Difficult
Format Support Psychoeducational Psychotherapeutic
Structure Structured Semistructured Unstructured
Composition Homogenous Heterogeneous
Size 5 15
Session
Length
60 minutes 120 minutes
Admission Staggered Closed Open
Wagner & Ingersoll (2013) p.103
25. What is MI?
Motivational interviewing is a
collaborative conversation to
strengthen a person’s own
motivation for and commitment to
change.
Miller & Rollnick, 2013
38. “People are most able to
change when they feel
free not to.”
- Carl Rogers
39. Compassion
Guide me to be a patient companion,
to listen with a heart as open as the
sky. Grant me vision to see through
his eyes, and eager ears to hear his
story…Let me honour and respect his
choosing of his own path.
Adapted from Miller, 2013, “A Meditative Preparation” (p.24)
41. “A Psychological Law”
I learn what I believe
as I hear myself speak.
Bill Miller (Based on D. Bem, 1967, “Self-Perception: An
alternative interpretation of cognitive dissonance
phenomena”)
43. Four Processes in MI
1. Engaging: The relational foundation
2. Focusing: Clarify directions: What is the
horizon?
3. Evoking: The person’s own arguments for
change
4. Planning: Developing commitment to
change + formulating a plan of action
Miller and Rollnick, 2013
44. Engaging
• Opening check-in
• Attention to content
(e.g. what people
say) and process
(e.g. how they say it
& others’
responses)
• Openness and
flexibility – what
does the group
want or need?
45. Focusing
• What are we
covering in this
session?
• Therapist session
checklist and
group input
62. Open versus Closed Questions
• CLOSED questions invite a “yes/no”,
one- word or very limited answer
• OPEN questions encourage elaboration –
they evoke the group’s ideas, opinions,
hopes, concerns, etc.
64. a. Open question
b. Closed question
“Would you say you are looking forward
to these group sessions?”
65. a. Open question
b. Closed question
“Would you say you are looking forward
to these group sessions?”
66. a. Open question
b. Closed question
“Tell me some of your thoughts about
coming to these group sessions?”
67. a. Open question
b. Closed question
“Tell me some of your thoughts about
coming to these group sessions?”
68. “What made you decide to sign up for
this group?”
a. Open question
b. Closed question
69. a. Open question
b. Closed question
“What made you decide to sign up for
this group?”
70. How severe would you rate your
symptoms right now?
a. Open question
b. Closed question
71. a. Open question
b. Closed question
How severe would you rate your
symptoms right now?
72. Can you describe some of the
adjustments you’ve had to make?
a. Open question
b. Closed question
73. a. Open question
b. Closed question
Can you describe some of the
adjustments you’ve had to make?
74. If you were me…
1. Formulate two open questions to a
participant:
One focused on content
One focused on process
2. Formulate two open questions to the
group:
One focused on content
One focused on process
78. Allusions = To what has been said…
• That sounds like a good idea...
• I think that could work...
• I think you’re right about that...
• It’s important to you to be a good parent…
• I can see how that would concern you…
Andréasson, Farbring, Miller & Resnicow (2002)
http://www.motivationalinterviewing.org/sites/default/files/MINT9_2.pdf
79. Attributions = To make someone feel noticed
and “seen” as a person…
• You are a bit of a philosopher really. You are reflecting
on some really deep issues here…
• You are the kind of person who cares a lot for other
people…
• You are a very creative person. It reflects a lot in your
personality…
• You have what it takes to be a leader. Other people
listen to you…
• You are the kind of person who does not like to talk
behind the backs of other people. You have a lot of
integrity…
Andréasson, Farbring, Miller & Resnicow (2002)
http://www.motivationalinterviewing.org/sites/default/files/MINT9_2.pdf
90. Simple Reflection
Complex Reflection
They are really on your case
about coming to this group.
It wasn’t your idea to come
to group, and you’re not
sure this is going to be at all
helpful to you.
“I’m only coming to group today because my doctor and my
wife are both pressuring me.”
91. Practicing Reflective
Listening
Individually, take a moment to write
down an example of a simple and a
complex reflection for the following
statement (coming up – next slide).
Then compare what you wrote with
others at your table. As a group,
choose the best examples to share with
the larger group.
92. Practicing Reflective Listening (1)
Individual Simple & Complex
“I’ve been told I can’t return to my
job, and now they are taking away
my driver’s license!”
94. Individual Simple Reflection:
First one thing, and then another!
Individual Complex Reflection:
You’re feeling like pieces of your life are
being taken away, one by one.
“I’ve been told I can’t return to my job, and now they
are taking away my driver’s license!”
96. Individual Reflection
Group Reflection
“I’m only coming to group today because my doctor and my
wife are both pressuring me.”
Some people are here
because they chose to
come, while others have
been “mandated” to attend.
It wasn’t your idea to come
to group, and you’re not
sure this is going to be at all
helpful to you.
97. Practicing Reflective Listening (2)
Individual & Group Reflections
“I’ve been told I can’t return to my
job, and now they are taking away
my driver’s license!”
99. Individual Reflection:
You’re feeling like pieces of your life are
being taken away, one by one.
Group Reflection:
These are major losses, and it’s hard to
imagine how to cope with all of the
changes that people are experiencing.
“I’ve been told I can’t return to my job, and now they
are taking away my driver’s license!”
101. Group Simple Reflection:
Everyone is experiencing major losses
and change.
Group Complex Reflection:
These are major losses, and it’s hard to
imagine how to cope with all of the
changes that people are experiencing.
“I’ve been told I can’t return to my job, and now they
are taking away my driver’s license!”
103. Content Reflection
Process Reflection
Whatever your reason for
coming to group, ultimately
everyone would like to get
something of value for the
time spent here.
Some people are here
because they chose to
come, while others have
been “mandated” to attend.
“I’m only coming to group today because my doctor and my
wife are both pressuring me.”
104. Practicing Reflective Listening (3)
Group Content & Group Process
“I’ve been told I can’t return to my
job, and now they are taking away
my driver’s license!”
106. Content Reflection:
These are major losses, and it’s hard to
imagine how to cope with all of the
changes that people are experiencing.
Process Reflection:
We’ve heard about a lot of loss in the
group today, and it’s not always easy to
hear that or talk about it and still feel
hopeful.
“I’ve been told I can’t return to my job, and now they
are taking away my driver’s license!”
112. Reflecting Panel Instructions
1. Group: Each share one thing that you find
irritating or annoying
2. Panel: Take turns offering a single reflection
3. Group: After ALL Panel members are done,
talk to your coach about which reflection
resonates most for you and why
4. Group: Offer this feedback to the panel, and
continue the paragraph
122. The 5th Foundation Skill:
Providing Information in a
Motivational Way
Elicit
Provide
Elicit
123. Elicit/Provide/Elicit
• Elicit: What ideas do you (group) have
about coping with…?
• Provide: Can I offer some other
suggestions? You might consider…
• Elicit: How does this fit for you
(group)?
124. Mark Twain
Habit is habit, and not to be
flung out of the window by any
[one], but coaxed down the
stairs a step at a time.
127. A Strategy for “Taming”
Skeptical/Hostile Participants:
• Thank the person asking
• Acknowledge their experience/
commitment/willingness to take a risk
• Mirror the question or comment back
• Extrapolate to a broader context or
principle
• Respond to the question or comment
• See what others think and check back
TAMERS
132. What are some compassionate
possibilities in how we respond?
133. What strategy could you use?
• Open question
• Affirmation
• Reflection
Individual content reflection
Individual process reflection
Group content reflection
Group process reflection
135. What strategy could you use?
• Open question
• Affirmation
• Reflection
Individual content reflection
Individual process reflection
Group content reflection
Group process reflection
137. What strategy could you use?
• Open question
• Affirmation
• Reflection
Individual content reflection
Individual process reflection
Group content reflection
Group process reflection
139. What strategy could you use?
• Open question
• Affirmation
• Reflection
Individual content reflection
Individual process reflection
Group content reflection
Group process reflection
141. What strategy could you use?
• Open question
• Affirmation
• Reflection
Individual content reflection
Individual process reflection
Group content reflection
Group process reflection
142. Basic MI Conversational
Shaping Strategies
• Establishing, developing, holding focus
• Changing focus
• Accelerating and Decelerating
• Broadening and Narrowing
• Deepening and Lightening
148. Four Group members:
• Something about yourself that you
want to change
need to change
should change
have been thinking about changing
but you haven’t changed yet
i.e. – something you’re ambivalent about
Putting it all together…
149
149. Facilitator
150
• Listen carefully with a goal of understanding the
dilemmas you hear from group members
• AVOID giving advice unless you are explicitly asked
• Ask these four open questions of the group, follow with
reflective listening/affirmations…and listen with interest:
1. Why would you want to make this change?
2. How might you go about it, in order to succeed?
3. What are the three best reasons to do it?
4. On a scale from 0 to 10, how important would you say it
is for you to make this change?
Follow-up: And why are you at __ and not zero?
• Give a short summary/reflection of the group’s
motivations for change
• Then ask: “So what do you think you’ll do?” and just
listen
154. What are your next steps?
• What will you commit to doing to continue to
develop your facilitation skills?
Some ideas…
– Start or continue a peer supervision group focused on
the issues and topics we’ve discussed
– Observe colleagues’ group facilitation and spend time
debriefing with them before and after
– Ask clients for their feedback about what went well and
what you could do differently as a facilitator
– Buy a book on presentation, teaching or facilitation
skills and/or surf the web
– Set concrete goals and check back
– Others?
158. Summary
Quick review of group dynamics and
practice implications
Overview and practice: Resist the Righting
Reflex and evidence base for MI
Integrating MI best practice skills (MI Spirit,
Four Processes & OARS skills)
Agenda Mapping and providing information
Critical issues in group
What is your style: Guide, Follow or Direct?
Implementation planning & next steps
159. Recommended Resources
Martino, S., Ball, S.A., Gallon, S.L., Hall, D., Garcia, M., Ceperich, S., Farentinos, C., Hamilton,
J., and Hausotter, W. (2006). Motivational Interviewing Assessment: Supervisory Tools for
Enhancing Proficiency (MIA STEP). Salem, OR: Northwest Frontier Addiction Technology
Transfer Center, Oregon Health and Science University.
http://www.motivationalinterview.org/Documents//MIA-STEP.pdf
Miller, W.R. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (Third
Edition). New York: Guilford.
Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural
and Cognitive Psychotherapy, 37, 129-140.
http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=5318416
Rollnick, S., Miller, W.R., & Butler, C.C. (2008). Motivational Interviewing in Health Care: Helping
Patients Change Behavior. New York: The Guildford Press.
First chapter and table of contents available at www.motivationalinterview.org
Rosengren, D.B. (2009). Building Motivational Interviewing Skills: A Practitioner Workbook. New
York: Guilford.
Wagner, C.C. & Ingersoll, K.S. (2013). Motivational Interviewing in Groups. New York: Guilford
Useful Websites
Motivational Interviewing Website
http://www.motivationalinterview.net/
Motivational Interviewing Network of Trainers (MINT) Website
www.motivationalinterviewing.org
Examples of Motivational Interviewing Videos on YouTube
http://www.youtube.com/user/teachproject#p/u
160. Engaging
Focusing
Evoking
Planning
Motivational Interviewing: Practice Tips
MI Spirit: The Essential Foundation
Partnership: You and the client are equal
experts
Acceptance: Absolute worth, accurate empathy,
autonomy support, affirmation
Compassion: Beneficence, caring, focus on the
other
Evocation: The client’s wisdom is most
important
OARS: Key Skills
Open Questions: What are your reasons for
change? How might you go about it in order to
succeed?
Affirmation: You have worked hard to make this
happen. I can see that you’ve given this a lot of
thought.
Reflections: You wish that… You would like to…
Summary Statements: Let me make sure I
understand how this all fits together…
Diagnosis
Treatment
Plan
Symptoms
Benefits
Finances
Stress
Relationship
Agenda-Mapping
Can we take a few minutes to talk about the different issues or
concerns that you or others have? Just to get a “big picture” view of
what you are coping with right now…
Given all of these possible areas for change, what are your priorities?
Where would be the most helpful place for us to start?
0 1 2 3 4 5 6 7 8 9 10
People usually have multiple or competing priorities. On a
scale of zero-to-ten, how important is it to change…? How
confident are you that you could make this change?
Readiness Ruler
Why did you say [lower number] and not [higher number]?
What would it take to go from [lower number] to [higher number]?
Elicit: What do you already know about…?
Provide information: Be brief!
Elicit: How does that fit for you? What do
you make of that?
Listen for Change Talk: DARN CAT
Desire, Ability, Reasons, Need
Commitment, Activation, Taking Steps
Reference: Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change (3rd Edition). New York: Guilford.
2013 Marilyn Herie, PhD RSW marilyn.herie@utoronto.ca
Four MI Processes
161. “When people are ready to, they change.
They never do it before then, and
sometimes they die before they get
around to it. You can't make them change
if they don't want to, just like when they do
want to, you can't stop them.”
― Andy Warhol, Andy Warhol in His Own Words
http://en.wikipedia.org/wiki/File:Warhol-Campbell_Soup-1-screenprint-1968.jpg
165. If you have built castles in the air, your
work need not be lost. That is where
they should be. Now put the
foundation under them.
Henry David Thoreau
Castles in the air?
