Okay, we're going to get started. Good afternoon, everyone. I'm Dr. David Stifler on behalf of the American Academy of Addiction Psychiatry. Welcome to today's webinar. This is the first in a monthly series that we've put together focused on evidence-based intensive psychotherapy training for addiction psychiatry fellows and faculty. This is hosted in partnership with Oregon Health and Science University, as well as University of California, San Diego. Today we're excited you can join us to offer you this live training that will be held monthly on the second Wednesday of each month from 530 to 7 on the East Coast and 230 to 4 on the West Coast. We've put this together, Dr. Blazes will introduce himself in a moment. We've put together this curriculum, which is going to cover at least one to two years with different crucial psychotherapy topics where we're hoping to kind of fill in some of the gap in psychotherapy training, not only for addiction psychiatry fellows, but any addiction psychiatrist out there who might want to learn more, sharpen their skills, or become a better educator. So what better topic to start with than motivational interviewing, a crucial and fun topic, and to hear from an expert in the field. So that's why we're starting with motivational interviewing today. Just to let you know, our next presentation will be September 14th. It will be on cognitive behavioral therapy with Dr. Donna Sudak. And just please check the AAAP website for updates on the upcoming speakers. Thanks, David. I am Christopher Blazes from OHSU. We're just going to cover a couple other housekeeping items. But so before we begin, just recognize, please feel free to ask questions by clicking the question tab in the lower portion of your control panel and typing in your question there. You can submit questions at any point during the presentation, and we will reserve time at the end of the presentation to cover a lot of these questions. Following the session, you'll receive an email with information on how to obtain your CME and certificates for participation. And this is, of course, free of charge through AAAP. So to claim credit for this event, you have to log into your AAAP account and access the course. And then, of course, complete the course evaluation and follow prompts provided to claim the credit. So additional courses are being added all the time. This is going to be an ongoing course. So while you're in there and signed in, just click and sign on to the future courses so that you'll automatically get the email prompts to add them to your schedule in the future. So today, we're lucky enough to be joined by Dr. Brian Borsari. He has been a health behavioral coordinator and psychologist, as well as a clinician investigator at the San Francisco VA and is a professor in residence in the Department of Psychiatry at the University of California, San Francisco. His work is published in over 150 peer-reviewed articles over the past 22 years on topics such as the assessment and treatment of addictive behaviors, in-session processes of motivational interviewing that are related to behavioral change, the development and implementation of brief motivational interviewing, addressing a variety of target behaviors in a number of different populations, as well as the development and evaluation of motivational interviewing using mobile technology. So I myself was lucky enough to have exposure to Dr. Borsari's teaching in my time at UCSF, and I learned a great deal from him myself. I've also been a part of multiple other of his trainings, and each time I hear him speak, I learn something new. I think he has a remarkable in-depth understanding of the spirit of motivational interviewing and is able to kind of capture and communicate and embody the spirit of this really important tool. So without further ado, I will pass it on to Dr. Borsari. All right. Thank you so much for that wonderful introduction, Chris. Really appreciate it. Glad to be here at the inaugural seminar. And so let me just fire up my slides. I'll be talking for a bit, and then we'll show you. And I just want to disclose that I have no financial relationships within eligible companies. And today, what I want to talk about, we're going to cover motivational interviewing, the definition. Really, especially at this point, I really want to talk about the four processes of MI, which are a roadmap for you, when you're doing MI, when it's appropriate, kind of where am I going. I'm going to talk about specific things that you have control over, which is your MI consistent behaviors when you're having a conversation with a client, and also listening for client change language. And that's really what makes MI unique is the theory that what the client says regarding change really does mean something. And then I'm going to compress 20 years of process coding literature into four strategies that you can use immediately in your practice when you're working with clients and having a conversation about substance use. And then I plan on talking till about 3.30 my time, and then I'd like to spend a half an hour or so questions and also show you some videos of MI in practice. That's what we have planned for the day. And these are the specific learning objectives. When you finish up today, you'll be able to define motivational interviewing, maybe understand the four processes of MI. You'll be able to identify two MI consistent therapist behaviors. And then also, you'll be able to define change talk and sustain talk. So that's what we're hoping that you can leave with today. Dr. Versari, I just wanted to make sure if you're ready for the slides to be shown. They're not showing? No, no. All right. So that's not good. All right. So are you sharing screen? Yeah, I should. Yeah. Let's try this. Do people see that? There we go. Okay. And then I'm going to put it in the beginning. Can you see that? Perfect. Yeah. All right. All right. Sorry about the drama there. So we've just, once again, no disclosures. Here's the definition for processes, the overview of what we're going to be talking about today. Here are your learning objectives that I've covered. And, you know, I'll be talking about research that I've done and experiences, but I just want to acknowledge all of the colleagues and co-investigators that I've worked with over the past 25, 30 years. It's a tremendous number of people that have really helped me learn, not only MI, but clinical research. And I'm on the way doing funded projects, either as principal investigator or co-investigator. I've worked with tremendous staff. And most importantly, you know, staffing volunteers and interventionists or coders, people that either deliver the interventions or subsequently code and look at the processes. And so I just want to just acknowledge just the sheer amount of people and hours that have gone into these talks of myself and other people in the field to really look at mechanisms of change. And my own experience with MI started back in the mid-90s when I was a graduate student at Syracuse University, working with Kate Carey, and was looking at interventions for college students and looking at a way that you could have a conversation about alcohol use and risk in a way that would be received and not rejected. And this is where MI I was very valuable and was still in its first edition back then. And I used that in my master's and dissertation. Since then, it really started just this real interest in how can we have effective conversations with clients about their substance use in a way that can facilitate insight and change rather than resistance and argument. And so that's what led me to MI. And then I did my internship at the Boston VA. I started working with veterans. And then I went to the Center for Alcohol Addiction Studies at Brown University, where I met Tim Apodaca, who trained with Bill Miller. And he was really interested in process coding, the idea of quantifying what is said by the therapist and client during the sessions and linking that to outcomes. So that really got my interest into how do we actually look inside the black box of a motivational interviewing session and look at what's actually going on. And since then, I've been able to work with a number of collaborators enlisted in looking at MI, how to design interventions, how to facilitate change, and better yet, how to understand the mechanisms. So that's my own experience with MI. I just want to back up a little bit about what is motivational interviewing. That's the picture of the book. And I really encourage you, if you're interested in doing motivational interviewing, to buy the book. That is the book. It's in its third iteration. And it's really a wonderful, wonderful description of the process. A brief background. It really originated in Carl Rogers' client-centered therapy. There's been a large body of MI behavior change research, hundreds of studies looking at a variety of different target behaviors. But the origins was in substance abuse, substance use treatment. And it was a real response to the confrontational approach to substance use disorders. And really adapted. It was not going to be confrontational. It was going to actually be much more humanistic, evoking. And since then, since the initial iterations of MI in the early 80s, there's been a number of different adaptations of motivational interviewing to a number of different areas. The key is really to facilitate behavior change. And it's continuing to evolve. And I believe there's going to be another edition of MI coming out. But MI, we call MI 3, the third edition. That's been out since 2012. And it's a great addition to your library if you're going to do this work. So there's several definitions in the book. But I just want to share with you the technical definition of motivational interviewing. Because it covers really all aspects of this communication style. But MI is a collaborative, goal-oriented style of communication with particular attention to the language of change. It's designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person's own reasons for change within an atmosphere of acceptance and compassion. So we're going to piece apart, we're going to take apart different aspects of this definition. But this really gets everything that is important and really key to motivational interviewing. It's not a technique. It's not a trick. It's not a therapy. But it's a style of communication. And really focused on acceptance and compassion. And really strengthening and invoking the person's own argument for change. One aspect of motivational interviewing is the relational aspect. In MI theory, it tends to break down into the relational component and the technical component. The relational component is MI spirit. And this is the overlap of partnership. Genuine partnership with the client. Compassion where you have the client's best interest at heart. Acceptance of the clients across from you. Really respecting their absolute worth. Experiencing empathy. The ability to understand the experience of the person. Their autonomy. And also an affirmation of the person in their current state challenges. And then the other aspect of MI spirit, this overlap, is evocation. And a desire to uncover the client's own reasons for and against changing the behavior. So MI spirit is extremely important when you're trying to do MI. And it has to be genuine. Because clients will quickly determine if it's not. And this is also really helpful to determine the appropriate context of using MI. And that's what we're going to talk a little bit about the processes as well. So this is MI spirit. Now, often with MI, to do it well, you need a clear target. And this is very important. Because as we talk later, we're going to talk about change language. And it's impossible to determine change language without a target behavior that the person is referencing. So often when someone says, well, I did MI. And I'm like, what was the behavior you talked about? Oh, a bunch of different ones. Generally with MI, you need a clear target. And the way that you really identify that is through the four processes of MI. So when you're doing motivational interviewing, you've decided to do it, if you feel that the situation is appropriate, you're going to be moving through the four processes. This is your roadmap. First of all, you're going to engage. Establish a relational foundation to do MI. And I'll go into details with these a little bit later. The next part is the focusing. And this is the strategic centering of what the behavior is going to be that you're going to discuss. What is the target behavior? Then, and only then, can you transition to evoking. And this is really where MI becomes MI. Because you're going to be working to evoke change talk and sustain talk about that target behavior. And through this process, you can evoke and strengthen the client's own argument for change, which will lead to planning, bridging for change. So with MI, think about where you are in these processes. And the time that they can take will vary. For example, engaging, if you're establishing a helpful connection and working relationship, that can take time. It may happen immediately. If you're seeing someone repeatedly, engagement, they know why they're there. They trust you. You trust them. There's a therapeutic alliance established. Engaging may not need to take a long time. A client that's not, that may have had negative, you know, connections with previous providers, it is suspicious, distrustful, engaging may take, or is agitated, engaging may take longer. The focusing is really where collaboratively with the client, you're developing and maintaining a specific direction in the conversation about change. What are we going to talk about? We'll talk a little bit about how to do that. And then you're going to be evoking. If you try to evoke before engagement, it's not going to be effective. If you try to evoke before focusing, you may be talking about different things. You may be really interested in one behavior. The client may be interested in another behavior. That's going to lead to confusion. And then evoking is really where you develop the argument for change that can lead to planning. And you're going to hear different strategies. You're going to hear different things that could be useful. You're going to hear different things that information that they may lack that could be useful that can really facilitate effective planning for change. So this is the roadmap. And it may be if you rush through these, you may go backwards. If you start to evoke before you focus, it may be that you have to go back to focusing to say, what are we talking about? What are we going to focus on? So when I'm doing motivational interviewing, these are the processes, where am I? Focusing can be very different in different contexts. So think about your own context, session by session, clinic by clinic, what your rotation may be, what your experience may be, to think about what focusing may look like. It may be if you're meeting someone in a smoking cessation clinic and they're coming in, chances are you're going to be focusing and talking about smoking behaviors. There may be another setting where in primary care or something like that, there's a number of different behaviors that are of interest. Some may be of interest to you, some may be of interest to the client. And there's a lot of options we need to decide. And that can be agenda mapping, that can be really prioritizing the time we have, what can we focus on before you move into evoking doing motivational interviewing. And then also in other settings, it may be really open-ended or unclear what the focus is and we need to explore. And that's more of kind of like orientation in certain contexts. So think about when you're working with clients, what is the setting and how you can focus to lead to evoking. The next part, those are the processes, that's the roadmap. Let's talk a little bit about the actual clinical skills of motivational interviewing. These are things, these are the technical, what we call the technical hypothesis or technical component of motivational interviewing. And you can remember these by ORs. And these are open-ended questions, affirmations, my personal favorite, reflections, and summaries, summary statements. So ORs, open-ended questions, affirmations, reflections, and summaries. Open-ended questions. These are questions that can't be answered with yes or no, a number, an address, a thing, or any real single word, right? They really request elaboration. Tell me more. Do you drink is a yes, no, is a closed-ended question when we call it. Tell me about your drinking is an open-ended question. Does your drinking cause you problems is a closed-ended question, yes. What are some of the problems you've experienced as a result of your drinking? Open-ended. And these questions can be very valuable in establishing the evoking nature of motivational interviewing. A series of closed-ended questions can really lead to kind of a stilted or interrogative style of communication. Whereas open-ended questions, you can use to explore the patient's needs, their values, their expectations about treatment, about your work together, the importance, all of these wonderful things. An open-ended question can provide them the latitude of what they want to share with you, which in itself can really facilitate alliance and understanding of the client's situation. And when these questions are asked, in a certain way, the answer is going to be changed, right? So do you want to quit smoking? Yes, no, that's a closed-ended question. What would be some of the benefits of quitting smoking for you? Well, I would spend less money. I wouldn't stink. My wife would stop bugging me. All of that is change language, and we're going to talk about that. So really, you can use these open-ended questions very strategically to not only learn about the client's experiences, but also to guide the overall session towards planning for change and evoking and strengthening client change language. So a very important tool. Affirmations. This is a special form of a reflection or statement that emphasizes strength. Affirmations can be used to really show appreciation, recognize personal strengths, really can be used to build self-efficacy and orient people to their resources. They must be personal and genuine. These are a way of honoring and acknowledging the client's strengths, what they've done, what they've overcome, abilities that they could have, that they do have to facilitate change. And so really with affirmations and work that I did with Tim Apodaca, that was the one behavior that we found that was significantly more likely to get change language or language towards change, and significantly less likely to get sustained talk, which is language against change. And I think in a lot of the work where in my own work where I'm saying, quote unquote, unmotivated clients, which is a term I don't agree with because everyone's motivated to do something. It's just usually when it's something against the provider or the therapist's own interests or hopes for the client that they're called unmotivated. I really listen for things to affirm. And I really listen for things to affirm and feedback in detail to the client and really can facilitate a sense of what you're listening for, a sense of understanding of their own experiences. But also when it's fed back accurately, it demonstrates that you're listening. And also it demonstrates that you're recognizing or aware of a strength that they may be aware of and unsure of, or they're not really aware of until you tie it together. Both can really facilitate alliance and communication. The other part, the other therapist skill, and it's really core to motivational interviewing are reflections. And these are statements. And so your voice will go down. A question, your voice goes up, right? You want to quit smoking? A reflection, your voice goes down. You want to quit smoking. And they are a way of you reflecting back, holding up the mirror to the client to really demonstrate your knowledge and understanding of their own experience. And these can be two different types. It can be simple where you're basically repeating back what the client says. And the client says, you know, smoking really bugs you. Smoking bugs you. That's a simple reflection. A complex reflection can really reflect feeling, ambivalence, underlying meaning that you glean from your interaction with the client and your knowledge or your hunch or your guess about what they're going through or what their experiences are. And they can reflect values and goals. And these can be an incredibly valuable skill for you to move the conversation forward, to guide it towards a discussion of change and ambivalence, and really to demonstrate that you're listening and that you understand what the client is going through, which is really the definition of empathy, right? So yeah, my smoking really bugs you. You know, it's really something that you want to change. You're sick of it. That's a complex reflection, right? And you're guiding it towards change. You're guiding it toward wanting to talk. And the wonderful thing about reflections is that if you're wrong, it's a win-win. If you're accurate, it really facilitates communication. If you're wrong, the client will often correct you. And how you respond to that correction is key, right? You know, my smoking really bugs you. It's something that you want to quit. You've had enough. Well, I don't want to quit yet, but it's bugging me. I get it. Yeah, you're not ready to quit yet, but there's just stuff that's starting to irritate you about it. That can facilitate you've learned something. And it's also just demonstrated the partnership and the collaborative spirit of motivational interviewing, because you're not arguing, right? You're understanding and you're moving forward. So reflections, often when people start to learn MI, they're afraid of getting them wrong. I view that as a win-win. You get them right, or you get them wrong, you get corrected, you learn more, and you're facilitating that conversational topic. And summaries are basically a special form of reflective listening. You're really pulling together your knowledge of the client into a summary, tying the threads together. And you can note ambivalence if that's appropriate. And you really want to, I use them as either a summary or a transition. If there's a lot of information, I want to tie it together strategically to renew or to strengthen focus, or it can be really done to transition to another part of the processes. Sometimes it can transition to planning. You're pulling together what you've heard from the client about interest and change to use that as a transition towards planning, or what we call a key question, where does this leave you? So those can be selected. The one thing that often people that are starting to learn MI do is they include everything. And the summaries go on way, way, way too long. And so as you're learning and you're all this wonderful information that you're getting, you want to be strategic and concise in a summary statement, if you decide to use them. Once again, these orders can be used selectively. And this is the real beauty of motivational interviewing is that people have different styles. I myself, I like affirmations. Other people aren't as comfortable with them, but they do wonderful, concise summary reflection. This is where you can really make MI your own. So we've talked a little bit about the processes. We've talked a little bit about MI consistent skills that you can use. The thing that really makes MI MI is the focus on client change language, client change talk. As you read the three editions of motivational interviewing, this is something that really emerged over editions one through three, is the process coding. And we'll talk about that field of literature developed, and really looking at change talk. And what change talk is, is when you've engaged and you focused and you have a target behavior, you're talking about a specific changeable behavior using MI to do so. Change language reflects an inclination towards changing that behavior. There's a number of different subtypes of change talk. There's no need to get into that today, but really about reasons, desire, commitment to change. And here's some examples of change language. I spend a ton of money on cigarettes. I need that money for other things like food, right? That's change language about smoking. Smoking is a target behavior. That's desire to change smoking. Now I'm worried about getting arrested again. I don't want to go to jail on another drug charge, right? Change language, target behavior, drug use. I try to hide my drinking from my kids. I don't want them to see me when I've been drinking a lot. I want to be a better role model for them. Change language, target behavior is drinking. If I stopped, I stopped using drugs before it was hard, but I did it. Maybe I could do it again. Change language, you're using drugs, right? So these are the things as you evoke, they're going to pop up at any time. You know, when you're engaging with a client, it can pop up on focusing. Yeah, I really want to talk about my drinking. That's the number one thing that's, you know, really an issue in my life. So you're going to hear change language pop up as well as sustained talk. These are the things that you, you know, listen for. The flip side of the coin for change talk is sustained talk. And this reflects an inclination away from changing or to stay the same. And again, you can have reasons, desire, commitment, taking steps, all of these subtypes, all of these reasons for staying the same. An example is a sustained talk, right? My friends drink as much as me. It's not a big deal. That's sustained talk. I want to stay the same. I don't want to change it about drinking. I tried so many times to quit. It's just never worked. I can't do it again. It could be smoking. I'm not sure what the exact target behavior is, but that's sustained talk for, for smoking, let's say. All my friends smoke pot. It would be weird if I didn't. That's sustained talk. The target behavior is smoking cannabis, smoking marijuana. And then drinking is how I relax. And I read that it's good for you, right? Sustained talk for drinking. As a clinician, you're hearing these, and these often will pop up at different times. You'll get what we call a change talk sandwich, right? The client will say, I want to quit, but I really like this part, but it's still driving me, you know, my wife crazy. So all of these different pieces will come together. As a clinician, you're hearing them. I just want to make one, a couple of clarifications. The difference between sustained talk and discord. Sustained talk is about the target behavior and it will naturally be evoked and should be evoked when you're talking about change. Sustained talk by itself is not evil or bad, right? It's the person's other side of ambivalence. Ambivalence is feeling two ways about something. Discord is about your relationship. It's about what's going on between you and the client, right? That's wrestling. And so both are really responsive to counselor style, right? You can use your MI skills to evoke, strengthen, change language, to soften, sustain talk. And then also discord can be really addressed by affirmations, acknowledgement of partnership, clarification that it's their own responsibility to change. So there's a number of ways you can deal with it, but you want to be diagnostic. And I think one of the unanticipated kind of events or consequences of the change talk and sustained talk theory is that people started to see sustained talk as bad. And it's not, there's no moral value to it. It's just language about staying the same. And if you start to ignore it, it can lead to discord because then the client may not feel heard. So I'm always kind of thinking about sustained talk versus discord. You will get both. So like putting this all together is the theory of motivational interviewing. Okay. And I'm sorry, the slide is not coming up as well as I'd like on my screen. So here, training in MI, we're starting this, you know, today about the theory, um, the spirit, the emotional connection, the, the, the MI spirit, the collaboration is the, is the relational component of MI. The therapist use of MI consistent methods. So the ORS is the technical component of motivational interviewing theory. Both are hypothesized to lead to client change language, which then in turn leads to behavior change. So that's the theory of MI. And there's been a lot of focus in looking at therapist MI skills and client change language. And in general, the literature is showing that it's really the MI skills lead to change language. Um, but the, the literature on process coding is, is limited that it's been done primarily by coding trials where the clinicians got extensive MI training and fidelity monitoring and feedback. So there's been a lot of, you know, good MI analyzed, but right now it looks like the skills are really key. The MI spirit is important, but the skills are really key in evoking and deepening change language. And now I just want to shift a little bit to, to cover process coding and process coding is started about 20, 25 years ago. And there was a wonderful article, um, by Paul Ambrine back in 2003 that was published right when I was a postdoctoral fellow at the center for alcohol addiction studies and looking at client language in sessions, change talk and linking it to outcomes. And from that, there have been several versions and several different approaches to coding and motivational interviewing sessions. One of which is the manual for the motivational interviewing skills code. That's been through a number of different versions that really break down not only the relational aspects of motivational interviewing, but also the technical aspects. And since then, there's been a number of different studies that have been done by a number of different coding groups, many of which I've had the pleasure of collaborating with. And then the field is grown large enough now that there's actually been able to be meta-analyses of these coding grants, these coding manuscripts, pulling together the data to look at, you know, across 15, 20 studies, what facilitates change. I'm not going to get in the details of that literature. I will stress that for each hour of MI session takes about 20 hours for it to be recorded, transcribed, parsed, which is breaking the session transcripts into codable utterances, coded, and then double-coded for reliability. So there have been, you know, all the people that I listed early on, that's just a smattering of the coding groups that have done this painstaking research on analyzing what is said by the therapist, what is said by the client, how it influences each other, and how it relates to outcomes. So a tremendous amount of work has gone into these different coding studies. And I'd like to distill that into four strategies that hopefully you can use in your own work. So two decades. As I alluded to earlier, both change talking and sustained talk predicts outcome. And the meta-analysis that Molly McGill, and she conducted it, I was a co-investigator on that project. Sustained talk is predictive of worse outcomes. So if you're doing a session, you're hearing sustained talk. That does predict worse outcomes. So you want to be aware of it. But it's the balance. What they did find is the balance of change talks to sustained talk is associated with change. So again, it makes sense when you think about it, is the balance that you're looking for in your sessions. If the balance is tilted more towards change language than sustained talk, in total, those are the sessions that tend to be followed by behavior change. If there's a large amount of sustained talk, those are the ones that tend to be followed by lack of behavior change or maintaining the status quo. Again, it's important to listen to what your clients are saying. And it also makes sense that sustained talk alone is predictive of outcomes. Because remember, a lot of these process studies have been done with really good MI therapists. So in that context with MI spirit, if someone says, I'm not going to change, they mean it. Where you can have excellent MI, be doing excellent MI, but they're saying, I'm not going to quit smoking. That tends to be predictive. So the overall strategy for you is don't ignore sustained talk. You want to reflect and acknowledge it. Because you want to say, really, the strategy I use, if I hear sustained talk, I'm going to reflect it simply. But often from clients, you're going to be hearing change language. That's where I'm going to use my oars to evoke, deepen, and strengthen. If in maintaining MI spirit, you will get sustained talk genuinely if it's still there. But this is a way that in the sessions, you can guide. The session is towards focusing about the advantages of change linked to personal values and goals that can be so important. If you ignore sustained talk, you'll either hear it again, or you probably will generate what we call face talk, which is basically the clients telling you what they think you want to hear. Yeah, yeah, I'll change. Yeah, yeah, I'll quit. How long does this last? Really, you want to be listening to both sides. Number two, you get what you ask for and you reflect. Just with your open-ended questions and reflections about the benefits of change will elicit change language and vice versa. If you ask about the benefits of staying the same, if you reflect the benefits of staying the same, that's what you're going to get. MI consistent skills, they evoke more change language, but they also evoke sustained talk. You'll get both sides of the ambivalence, and that's okay. Use your skills to shift, evoke, and strengthen the change language. That's where MI is strategic. So really, the strategy I would recommend is using double-sided reflections. It can be one of the most valuable tools to keep the focus and momentum on change. Now, you want to reflect sustained talk first, simply connect it with an and, and then reflect change talk with a complex reflection. This is a way, as a clinician, that you can acknowledge the benefits of changing the sustained talk. I hear you, and not but, because but tends to negate the double-sided reflection, and you can reflect a deeper reflection, a complex reflection about the desire to change. If you reverse them, same content, if you reverse them and end on sustained talk, especially in a session with MI spirit, and the client is moving with you, that's going to be the focus of the conversation. It's like pumping the brakes on an effective session. So, clinically, if you're interested, and in the context of your work with your clients, most likely you are interested in trying to facilitate a personal argument for change, end on sustained talk. Ask questions to evoke change language. Number three from the process coding is not asking or chatting doesn't lead to change talk and often doesn't lead to change and one of the things you know that really I worked with Ann Fernandez and she's developed this wonderful intervention to use motivational interviewing with pre-surgical patients because even small amounts of alcohol use can really lead to poor outcomes following surgery and so she did some qualitative research with patients that were going in for surgery and we found that often patients weren't even asked about alcohol use and one of the patients took that last lack of asking about alcohol use is I figured if it was something really dire they would tell me ahead of time if it was really going to be a dangerous situation they would give you warnings about and we found in a lot of practice in surgical people didn't even ask and people were just assuming that things were fine because it wasn't asked so when your own work about substance use asks the question not asking the question can lead can may lead to an assumption of tacit approval or a tacit it's not that big a deal open-ended question can be very very helpful tell me a little bit about your drinking the other thing is that we see in the coding literature is that when the client when the therapist goes off topic the client will follow along and vice versa the client goes on off topic the therapist will go off topic as well they'll chat they'll be talking about non-behavior change you know non-target behavior topics I would recommend you avoid that and the way to keep the four processes in mind engagement can be can be where chatting or talk about you know talk about other topics can be valuable to facilitate that but when you go through engagement and focusing into evocation you want to stay focused on the target behavior because through the engagement and focusing collaboratively you've established what we're going to talk about evocation can be painful evoking and talking about personal substance use and its consequences and it's and how it conflicts with your personal goals and values can be uncomfortable and stressing stay focused on that distress that pain can lead to interest and change which can lead to planning but this is where am I is really focusing the evoking is to stay on topic and then also when change language occurs is important there's been some work showing that language at the end of sessions is predictive of subsequent behavior change so as you're going through the processes as you're going through using motivational interviewing I think that you want to end the session on change language on focusing of change one thing that often I hear in coaching calls is wonderful am I in at the end but when there's four minutes left so what are some of the barriers that could keep you from quitting what are some of the challenges you could face over the next until I see you again those are open-ended questions that are pulling sustained talk that are lessening efficacy so I think the motivational interviewing be strategic it may not be a plan for change it may not necessarily go that far although it may but you're ending on a note of focus efficacy interest in change and that can carry momentum out that can be seen behaviorally or if it's repeated sessions where you can start again some key takeaways inquiring about alcohol use or substance use just asking about it can start an important conversation that and I have the veteran the client the patient whatever your population is waiting to have systematically engage focus and then when you're evoking stay focused on alcohol use of the substance use don't be afraid of sustained talk acknowledge it but don't deepen and dwell on it sustained talk doesn't mean that you're doing a poor job sustained talk you're just uncovering and evoking one side of ambivalence it's so important to understand it and to evoke it to move forward into planning but you don't want to spend a ton of time you know you want to I think you'll know from your patients about how much time you want to spend on it and then you're also going to evoke the change language the reasons for change and then over the course of the session evoke and deepen change language and try to end on it remember your processes remember those aspects and then end on that note you're all have different degrees of experience with motivational interviewing these you know are generally the stages of learning motivational interviewing first learning the spirit of mi and the processes recognizing oars clients and their skills that's really what we've talked about today moving forward as you get more training and moving forward as you get more training and are more familiar and many of you on this call may be the skills that are more challenging is kind of recognizing and reinforcing change language hearing it you know having your ears perk up when you hear change language and then really being able to strengthen it and elicit it later on responding to sustain talk and discord is a skill we can talk more about that because that's one of the things that mi is is really excellent for and then really negotiating change plans getting specific and ideally incorporating what you've heard already in the conversation or systematically and strategically evoking not only knowledge but deficits knowledge is another skill solidifying and then really shifting between mi and other approaches this is really with cbt and other approaches you can learn during the seminar series is that mi can be really valuable when there's a behavior or a strategy that someone's ambivalent about so for example when i'm doing cognitive behavioral therapy for insomnia i'll use a lot of mi for completing the diaries the weekly diaries and wanting to do that what to record so you know you can really use the skill to identify through the process want to talk about and there's a number of additional resources that are available to you there are more and more books becoming available at this website that they have is wonderful and also there's for those of you in va there's va training courses and that's about all i have for today i'm really interested in hearing your questions and you know we can talk about showing some videos to show some actual mi skills well thank you dr borsari again once once again a really enlightening description of a really complicated subject that is something that i continue to want to learn more about so we'll start with a question from uh dr hills dunlap and she said for those of us working in the hospital setting where a medical crisis related to substance use can often serve as a facilitator to change how do you recommend we very quickly establish that connection that underlies mi and do you have recommendations about how to use the hospital setting medical crisis to help the client right so this is a great example like when when the client's in medical crisis right you want to get them care that's not an appropriate time for motivational interviewing but there's been some wonderful work done by peter monti tony spirido and others looking at using motivational interviewing in the emergency department and so once they're stabilized and safe use your mi to a evoke response to the specific medical crisis the involvement of substances involvement of significant others if they're there has been done there's a whole you know there's there's a whole body of literature looking at the advantages of incorporating significant others or when it's not recommended but really using that a lot of the work i've done is with mandated college students and patients and really looking at the situation that may have had significant consequences for themselves and others and how that links to kind of their own ideals and goals and values of how they want to live their life and the discrepancy between those and look at even the incident itself kind of evoking for them what plans or commitment or even taking steps that they want to take to change and then so if you're doing you know immediate or a one or two session that that's really a great place to focus i'm always linking the event concerns about it and how that event impacted their own values right how did it conflict with them did they let people down did putting other people or themselves in danger really disappoint themselves that's the springboard towards that target behavior but here you know with that also think about the processes the engagement chances are if they're in there for they may have been lectured they might have not had a very empathic interaction with family or other providers so engagement is important then systematic focusing there may be a variety of things that are going on that they that may be of more importance to them and then but once you get to the point of evoking you've got a lot of information you can evoke the incident what led to it their response to it is kind of a bridge of understanding the role of i'll just say substance use in their life but i think the hospital setting when i do cnl i'm using mi a lot i want to get a sense of and also in the hospital setting i think it's really important and mi is a great way to diagnose knowledge deficits and but also knowledge and where information skills strategies that you may have may be really relevant to them and they need you to provide them or better yet they already know them and you can uncover that in a firm thank you i'll present the next question this is from dr rodriguez do you think that ignoring sustained talk increases it due to the mi spirit you were describing earlier yeah for example if you don't reflect and acknowledge it the patient doesn't feel heard and then they are working to convince you and this is actually oh i was gonna say this is also um this is a more specific kind of tweak you're presenting compared to what i kind of thought before which is you you don't want to focus on sustained talk but i think that's much different than just simply ignoring it so absolutely yeah that's a great point in the end my dad's my dad's a uh a therapist right you know so i grew up you know and you know he had the practice in the home so i grew up with him seeing clients you know i would see him on the hour i'll never get you know what he said to me he says you know bry don't worry if you miss something that the client says because if it's important they're going to say it again you know if you have a relationship they're going to remind and it you know the question about sustained talk totally reminds me of that so if you ignore it they're going to say it again they may say it louder they may you know or they may feel unheard so i i really i think strategically i want to acknowledge and make sure that i understand the sustained talk i may miss it may have misheard or misunderstood it and then elaboration on their part is totally appropriate i want to learn that but i don't want to dwell on it and dig into it and really solidify it i don't want to spend a ton of time so to your point want to make sure i understand it but i really want to evoke and strengthen and learn more and and have the client explore and learn more and dwell on the change language and the benefits of change unapologetically when i work with clients i want to say we're going to be having conversations about change not conversations about staying the same not conversations about how change is bad but conversations about change so so once again that's part of the engagement piece and the other thing i'll just mention you know with that engagement is so important to clearly define who you are and what you're going to be doing and the amount of time that you're going to have session by session the more work i've done just a brief description of yourself how long you're going to have with somebody what you would like to get out of the session or collaboratively is so vital in reducing anxiety fear and assumptions it can often lead to discord so with that you know to loop it back to the sustained talk i'm unapologetically in the context i'm working about is focused on change improving your life right so that that you know is consistent with simply reflecting sustained talk acknowledging understanding it but not really going to be digging into it and if i miss it they'll tell me again so dr herschler asked what aspect of mi counters the demoralization that so many patients present with for example the hardcore smoker who has failed many times attempts to quit right first of all what what about it is i strategically if they've tried many times to quit i'm not going to ask immediately what made you go back to it i'm going to say what was it like when you weren't smoking how did you do that how was the week day hours right i really want to evoke with them with open ended questions and reflections what was it like when they did accomplish that behavior that i assume is consistent with their values and goals because they're talking about it we can get into what caused the relapse later but i want them to teach me about why they wanted to do it in in that brief moment it could be years months weeks days or hours that they were able to accomplish what did that feel like to not smell to not you know i mean you know not smell like smoke or things like that or to not drink to not you know all of those things so that's the real strategic evocation especially with behaviors that have been repeatedly you know relapsed quitting you know smoking again right they're used to being shamed and being less than but to genuinely evoke their abilities to do in the past what was that like and you know acknowledge that can really change the tone for them and that's really where with am i using those reflections and that's really where i like affirmations working with quote-unquote unmotivated patients that you know that kind of leeches into the the conversations they may have had but genuinely understanding and affirming interest in that even you know desire to quit can really change the tone and again you're evoking you're not instilling right i'm not instilling in them what they need to do to quit i'm we're together uncovering what they know they could maybe do strategies have been may work in the past and through that there may be strategies knowledge approaches that i might be able to provide that could especially through the vocation identifying that genuinely putting that puzzle piece in can you know really be effective the whole approach as a clinician is learning understanding reflecting getting them right feels good getting them wrong and being corrected can really teach you a lot it changes the whole tone of the conversation with the overall genuine communication of what you do is up to you i genuinely respect the decision but i want to have a conversation i can't make you change but i can have a conversation about you're changing and the good thing about that is that they own not only their i don't want to use the word failures or failures but challenges they own it but they also own their successes and that is so key can you just respond quickly from your experience on is there like a cadence in terms of the proportion of affirmations to reflections to summaries that you found to be most effective in my you know generally outside of engagement right and focusing i don't ask a question that i have a good hunch i have a hunch that i know the answer to so i want my reflection to question ratio to be um you know three four five to one right so if i'm meeting someone they're coming to talk with smoking you know smoking is a real challenge you know quitting smoking is a challenge for you reflection so quitting smoking has been tough for you question right so i want to start um through reflections getting into the cadence of this is what i hear you say i don't use that phrase and i i think um the best reflections start with you for a couple of reasons it cuts to the it cuts to the chase because often when people are learning in life they're like what i hear you saying or so what i hit you know what i think i hear you saying or what i think you're saying to me get rid of that scaffolding i like to go you feel you think you're aware you've been challenged that keeps the focus on them it holds up the mirror to them and it gets into a process of them talking about and me evoking their ambivalence once you say i think you're saying i'm entering me into it and i'm not really talking about me i'm reflecting what i what my understanding of their experiences and this is really important because when it's distressing when the pain of exploring the ambivalence comes out it's going to be directed at themselves and not at you right and this is really where am i reflect you can reflect back incredibly painful information but if you've evoked it and it's theirs then they start wrestling with themselves and that pain that wrestling can lead to the interest in changing to alleviate that right when the behavior conflicts with higher held values and goals and that's what mi is really good at evoking where the behavior of the target behavior is conflicting with or you know rubbing up against what they value more that's distressing and painful you can either change the value and goal or you can change the behavior to relieve that distress it's often simpler to change the behavior and that's i want to reflect that back using you you feel you're disappointed you're scared you're proud you were able you know that the that's that's what i like to do to keep it focused on them yeah i felt yeah you're right i you know i i never thought i could do that that's the language that's that's the cadence that's the that's the process okay um dr tran asked will you speak a little bit about the concept of rolling with resistance okay great question rolling with resistance so resistance is a term that came out of mi2 so really you know resistance you can you can conceptualize as discord right there's something going on in the relationship and someone's getting frustrated so i'm usually looking for you know it can be them getting quiet it could be them arguing it could be them you know kind of saying i don't want to change the way to melt away the the resistance or when that's happening is you can either kind of go back to clarification of focusing or even all the way back to engagement right genuine genuine generally the resistance and it's not sustained talk it's really where there's a fracture in the therapeutic relationship sometimes i'll back up to make sure that um we're on the same page in the immediate, the thing that I think works the best, emphasizing personal choice and control, making it clear that it's your choice whether or not to change, right? If you're in a coercive situation, that's not, you're not using MI, right? But really, you want to clarify that, because people will, resistance or discord will start to creep in when people feel pushed, ignored, or that you're trying to get them or make them do something, and then they're going to push back. So just kind of relieve that tension and say it's completely up to you whether or not you quit smoking, right? And that's like, can do that. But this is really where engagement and focusing, those are really important stages as you kind of ease into it, because I think if you do MI well, the evocation stage is going to cause distress, but you want them to wrestle with themselves and not wrestle with you. And that's what's often will happen is the second that MI spirit is dropped and they sense a whiff of judgment, confrontation, criticism, you know, that's when, in a way, they're relieved because then they can go after you, right? It's like they've got this distress, and then it's like, oh, you're judging me, screw you, I'm not going to do it. Instead, you want them to be, you know, the disappointment, gosh, you know, I could do this, and you're just reflecting it, and it's not coming at you. So that's the way to do that. Again, in engagement, set the structure, we're going to have a conversation, but I'm not going to tell you what to do. And as a clinician, don't tell them what to do, unless they explicitly ask, what do you think would be helpful? And that can often happen, right? If you do MI well, they will actually solicit information or thoughts about change. I really don't like to do that. I will consistently say, well, we've talked about a lot, what do you think would be the best strategy, right? But that's what can happen, and that, you know, that can lead you into planning. Here's a question that's near and dear to my heart. Can you give some examples of the difference between affirmation and simply offering praise? I find in my practice, I give too many compliments. Right. So think about when we code, right? So I'm, right now, I'm doing some wonderful work with Jen Manuel and Ben Ladd, and these are just great coders, and I've been, you know, I've worked with and trained the best. Think of initially, when MI coding first started, supportive statements, right? Quitting is hard, you know, change, you know, changing is difficult. Those were seen as MI consistent, and they aren't anymore, because they don't really lead to change language. They're really, in a way, seen as giving permission to continue the behavior. So I view, like, praise and support is like a hug, whereas an affirmation is like a pat on the back. So when I'm doing affirmations, I want to think, what am I honoring? In the, what intrinsic strength, awareness, behavior that this client has done? What is it? And I want to be specific about it, right? That was really tough, right? It's kind of a supportive statement. That was tough for you to go to your daughter's wedding and not drink, because you knew you had to stand up for her and give a speech, and you wanted to do it well. Affirmation. Yeah, you know, I mean, I just, the drinking, it just can't interfere with my, the quality of my life. Changed off, right? So that was tough, vague, that's good, that's okay. They're vague. I like to drill down and explicitly state what I'm honoring. And if I can't do it, then an affirmation, to your point, Chris, about how many of you do it, what? If I have a tough time doing that, I need to evoke a bit more. But I think what I like is just the rejuvenation and just the nature of listening for affirmative strengths, behaviors, awareness of a problem, puts me in a different mindset. And when they're done well, I think they can be incredibly powerful. And just enhancing their own confidence and ability and awareness. And having that being honored is not an experience that many people have, especially from a provider, that I think can be really powerful. So I'm always thinking of this, you know, the hug versus the pat on the back, I tend to go for, and we've maintained affirmations to be MI consistent. Because as we know, you know, from the coding work is that, you know, they do tend to lead to change language when they're done well, and they're less likely to sustain. And you'll find general ones are batted away. That was tough. Well, I could have done better sustained. Right? Whereas a genuine, you know, like a specific one, you know, veterans I work with are so good at batting away any generous. So they've really kind of trained me to really be good with my affirmations, because they got to be accurate to get through that armor. And they can't bat them away as easy. Right? So that that's been I've had a lot of them batted away, that was really tough. Boy, you know, you needed to do that, you know, now. So that's, that's kind of what I want to get through. And if you're looking at it from like a psychoanalytic framework, you know, if you, if you tell somebody that they're doing a great job, then they might feel like they're done, right? Right. The compliment itself might actually inhibit the change talk. Okay, next question. Do you find that MI can be less effective for people with lower motivation, for example, somebody suffering from depression? The, the lower motivation part is I'm trying to, I'm trying to uncover what they're motivated to, you know, what, what they're motivated for, right? What is their motivation? And so it's always kind of the, you know, just the assumption that the behaviors or lack of behavior is getting a certain need met, right? And just kind of working with that, and to kind of understand, all right, what did you do or in action, I see as an action as well. What were the benefits? And really gets, you know, especially someone, you know, with depression, anhedonia and stuff really have to work on my evoking skills to kind of clarify and then do a lot of like goals and values clarification, but that's the focus. And the other thing with MI that I found really valuable is the focus on change to be great because it scares away people or drives people with ulterior motives away because, and this is the point about chatting, you know, going into VA, you know, 15 years ago, there was a large cohort of veterans that, you know, just thought therapy was chatting, checking in, chatting, and not really focusing on change and improvement. And, you know, so really the other thing with the MI skills was the, you know, unending focus on how are you, what are you doing well, what change can we facilitate, right? Not that crass, right? It's not like change, change, change, change, but overall the focus on enhancing and improvement, the trajectory of continued improvement. There's going to be dips, there's going to be plateaus, but really using MI to get to and to the depression, we have manuals on our shelves. We have techniques within our EBPs that we've learned using MI to guide to the techniques, strategies, or the manuals was just a way to really help me envision a continued focus on, you know, moving forward and improvement. So there's another question. Can you speak to instances in which the change talk is abundant in sessions, but there is minimal behavioral change after several sessions? Some patients are prone to people please, or say that they think they want to hear, say that what they think you want to hear, how might you approach this? That's a great point. And I think that it's like, we call it face talk or we call it disingenuous change talk. And that's one thing I, you know, I'm doing some work with some researchers at USC now, because I'm really interested. Remember that all the process coding that we've done has been done on transcripts or on real content. And I would love to look at actually the verbal, the tonage, the prosody, the nonverbal aspects of that, because I think there's a difference predictably in, yeah, I'm going to quit versus, yeah, yeah, I'll quit. Right. Same content, but different prosody and tone. So I think as a clinician, what I do with regular is I chart behaviors. There can, I think the other thing you can have telling us what we want to hear, we can have people that are overconfident or putting together plans. It may not be feasible, but they're not aware of that. Or, you know, so I think that there's a lot of evoking in questions and tracking that can, that can identify that, but also, and this is really on the burden of the providers is detailed planning and tracking, right? Smart goals. Are there specific behaviors that they're wanting to change that they actually change that we do the work of tracking? That's why I love doing cognitive behavioral therapy for insomnia, because you have this incredibly rich data of sleep, but also if you incorporate alcohol use, it's one of the best, you know, everyone wants to improve their sleep. They may not want to address their substance use, but if I'm grabbing that on their diaries, geez, they're noticing that their sleep is being affected by drinking and vice versa. So I get, I kind of roll up my sleeves and get, is it too ambitious? Is it not ambitious enough? Are they telling me what I want to hear? Then we want to get back to engagement and focusing about what's the purpose of the sessions and what's of interest to them. Is there other things they want to talk about? So there's a lot, there's a long list of strategies that I can use to try to identify, you know, what, what's the change language, what's the target behavior, what's the plan. And in that process, that can exhaust someone that's there just to tell you what you want to hear if there's an ulterior motive. Right. Like, so that kind of rolling up the sleeves and doing that is absolutely exhausting for someone that's, that may not be, you know, genuinely interested in changing specific behaviors, but it's rare to get to that point. Usually it's, it's, you know, they're, let's just kind of back it up. What are the plans? What's the change? What's the target behavior? You know, what are the outcomes of the one that helps with depression? Uh, here's another one. Do you ever find yourself working with patients where it's very hard to identify areas of strength? How do you go about providing affirmations in these situations? Yeah. I mean that, I mean, that is to me, it's really rare to have someone with no strengths. Then I'm not really evoking enough. Right. So, I mean, I can, I can affirm even an awareness of a problem. Um, so I think once again, that could be setting and, you know, for example, I once had to do on the spot role play for people on probation and there was kind of in this training that, you know, there was kind of like, well, you know, they're lying to you or things like that. So they just said, said, can you do a role play of MI? So I did a role play and just uncovered from the person, the benefits of adhering to parole for his kids and not only modeling, but not having parole be revoked and sent back. And he was trying to be like a tough guy, but went after values and goals. So if you're, if there's really not identifying strengths, I want to kind of, and this is back towards the general orientation, kind of have an understanding of what are their goals and values? What are the behaviors that are conflicting or consistent with that? Right. This is often where we get, we understand motivation better. Um, so that that's really where I lean back and I want to identify what is it, what is admirable about the human being? And this gets the humanistic part in the MI spirit of MI, there's a belief that there's inherent worth in the person across from you. And if as a clinician, I can't find that or identify that, boy, that's, um, I, boy, that'd be a challenge. You know, um, we all have clients that we fluctuate and how well we work together or not, but generally the most effective way of me working with quote unquote, unmotivated patients that get referred to me is really working to understand their perspective and their strengths and abilities and what they will become. So I find that MI is such a great intervention that I want to use it in all circumstances, but I find that it's in some circumstances not very effective and in others, perhaps not even appropriate. Can you talk a little bit about that? To me with, with motivational interviewing, I mean, it's, it's the shift of, um, is this an appropriate, first of all, target behavior, right? Is it a behavior that someone can change? Someone can't change their kids or their wife's behavior, right? Everyone jokes like you do MI with your daughter. I have a 14, 11 year old daughter. It's like, Oh, you must do MI with them all the time. I'm like, no, they're my kids. So, but you really am, I'm thinking about, is this a changeable behavior, right? I can't physically fly, right? Chris, you could do wonderful motivational interviewing with me about physically flying. I'm never going to be able to do it. Right. Um, you know, Jen Manuel, you know, has a great example of like skydiving. She does not want to skydive in any way, shape or form. I could do wonderful MI with her about skydiving. She's never going to want to skydive. So this is, is it a target behavior that they have control over, right? And also, is it a target behavior that they're ambivalent about? Once again, to the MI point of, if there's a gap between the behavior and values or goals that the person holds more dear, that's MI has room to work. If there's not, MI is not appropriate. So that's always my rule of thumb. And then, you know, there's times when I need to be directed. We talked about, you know, in medical care, someone genuinely wants to quit smoking and is ready to go and wants to, you know, get on shantix. I'm not going to use MI when I'm going to get them on shantix. I'm going to go with it. You know, I might kick the tires a little bit on the language, but I'm going to get out of the way. It's really when someone feels two ways about a changeable behavior that I'm thinking MI might be appropriate. It looks like, and I know we're going to be running out of time shortly. Someone wanted you to just tell a brief story of yours about the success of a very difficult patient using MI. Um, so I worked with a veteran who was a heavy smoker, uh, PTSD smoked. And so we worked on, and he didn't want to quit smoking, but he wanted to reduce smoking. So did a lot of MI with him. We were addressing, you know, PTSD. So it was really kind of, first of all, in our work together, specific focusing on, um, you know, cigarette smoking and, you know, how are we doing? We want to focus on. So over time, over my work with him, he started saving money. The plan that he put up was, and he was getting like cheap cigarettes, but he was going to save, we figured out each cigarette at that time was about 10 or 15 cents per cigarette. So he was originally smoking about three, three packs a day. When I started working with him, he whittled it down to about six a day, but save the money. And he ended up going to Florida with money that he saved over the course of our work together. So there was a significant reduction, but he was still smoking. And, you know, I would check in with him when we were doing, you know, other treatment would work with depression, PTSD. And, um, I ended up when I transferred to San Francisco to Providence. So he had gotten down from, from 46, you know, about two packs a day, you know, 40 to 50 cigarettes to six, but he was really content with that. I, you know, so I, you know, using him, I once again, not making him quit that I would have been my ideal goal, but it wasn't his. Um, and then, you know, touch base with him. And then in our work together, he ended up quitting completely. And what did it was he was, um, watching over a six-year-old who was in the apartment building. And he really developed a relationship with her. It was really protective. And, um, and he would, he would babysitter and he was, and he went out to smoke a cigarette while he was babysitting. And he just realized what am I doing? Smoking a cigarette out on a porch when I'm babysitting the six-year-old and something could be going on any quick, quick, cold Turkey from that. And it was a great example of like us, me doing the planning and working together significant reductions, but the smoking conflicted with his value of a babysitter and someone who in his words was a protector. And that got him to zero, which, you know, we had talked about, but it's just a way that under the rock, you know, kind of under the water, there's all these potential, really strong motivators for change. So that's one that I think of, you know, with, with MI working with him, grafting a plan, adapting it, and then getting it done eventually and quitting by something that we had discussed, but, you know, didn't formulate it into a plan. So one last question, I had a psychiatric mentor who always used to tell me, follow your curiosity and you will learn what you need to know about a patient. And I'm just curious as to why that, that term or idea isn't kind of so prominent in the MI kind of verbiage. I, I think, you know, MI is a conversation about target behavior. It's, you know, that, and this is, that's really, you know, engagement and focusing are not unique to MI, neither is planning. The real thing that's unique to MI is the evoking about the target behavior because to hinge change language, you need the target behavior. So it's really a focused approach. Your curiosity and within that, and this is where chatting or going to non, you know, target behavior related conversations, this is where another reason why you as reflections is incredibly useful as a clinician, because you can get them back to talking about themselves if they're talking about something else. But I think your curiosity within the target behavior is well served. And that's where you can just get a tremendous amount of rich information. But MI is a collaborative conversation about change. So it is calibered as opposed to a much broader therapeutic approach that would be much more food ranging that would use many of the same MI skills, right? Open-ended questions, reflections, summaries are not unique to MI. It's what makes it MI is focusing on a target behavior, evoking, reflecting, monitoring change language, sustained talk, and then leading it to planning. Well, I think we're pretty much out of time. So I wanted to thank Dr. Borsari for taking the time to do this. I think motivational interviewing is so critical in what we do. And down the road, perhaps, you know, a year from now, after we get through other parts of our curriculum, perhaps we'll do some intensives on motivational interviewing in this area, because I think it's so important. I'd love to, and that would be great. It's been, thank you again, thank you for the invitation to talk with everybody. I really appreciate it. People know where to find me. I'm at the San Francisco VA. My name at VA or my name at UCSF.edu. Feel free to follow up and maybe someday we can do another seminar on MI4 and what they took out and what they left in. So. Well, thank you again, Dr. Borsari. And again, everybody, so this will be the second Wednesday of each month at 530 Eastern time. We have an excellent group of lecturers, just like Dr. Borsari planned for the next year. So we look forward to kind of, you know, enhancing everyone's understanding and knowledge on psychotherapeutic modalities. So thank you all for joining. Take care, everyone. Thank you. Bye, everybody.

motivational interviewing

addiction psychiatry

engaging

focusing

evoking

planning

open-ended questions

affirmations

reflections

summaries

listening

change talk