Motivational Interviewing - Lesson 3A: Video Exercise 2

Instructions

  1. Download this Observer Sheet to document what you observed of Dr. Selby demonstrating the Spirit of MI and the use of the OARS in the video link below.
  2. Watch this short video of B. Alan Lyme demonstrating MI skills and complete your observer sheet.
  3. Response to reflection question using the comment board below. Note: You must post your response by 5 PM ET the day before the next  live webinar session to earn your certificate of completion.

Discussion Question: How did Alan express empathy to his clients during his interaction? Please provide examples of verbal and non verbal communications. Were there any missed opportunities to use Motivational Interviewing skills?
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15 comments on “Motivational Interviewing - Lesson 3A: Video Exercise 2

  1. Alan’s calm and non-judgmental demeanor around the client’s concerned seemed to put her at ease and was a way for him to express empathy. I believe he missed a few opportunities to explore what was causing her stress and anxiety. He seemed to very focused on her drinking although she mentioned many times that she had consulted the doctor to find ways, including medication, to relieve and control stress and anxiety. He never questioned what were the sources of stress.

    He did show empathy by recognizing past successes with behavior modification and looked at her level of motivation for change. He did also show genuine interest and was very supportive by explaining various resources available to her. He also expressed confidence that she would be able to succeed given what she had shared with him. I just wonder if this was received as supportive and empathetic by the client or if it would add pressure as she would not want to disappoint him.

    Although he was empathetic, he seems caught up in the details of the drinking, in the "how-to" of the interventions which made it less natural than Dr. Selby's interventions in the last video.

  2. Initial signs of empathy demonstrated by Alan are his posture, leaning forward and turned towards client, keeping eye contact, expressing genuine interest of understanding the issue of the client beginning by an open ended question. He also has a non-judgmental simple reflection when the client brings up the issues, and simply summarises the issues. I appreciated that he checked in with the client and asked for permission with the question “If ok it’s with you?” to review information on the pink sheet.
    Through the discussion, he used prompts to maintain an empathetic connection “So I hear you”…

    Again in a non-judgmental manner he reviews the information and offers a reality check, and asks “what do you make of all that?” this shows empathy as is allows the client to own the issue without negative connotation. He talks about the conflicting information and summarize “One the one hand, on the other”, asking open ended questions “What do you make of that”, “what have you though of that”.
    He expresses concern for the client’s health and affirms her previous successes. He checks in with how important the issues is it to the client. His use of scale the scale and follow up questions such as why choose 7 and not 5 or 4 showed interest in learning about the clients perspective- also exploring the gap between lowest scores and possibly a high score again showing curiosity in a non-judgemental manner.

    He showed empathy by acknowledging the challenges that the client faces with statement such as “A lot riding on your decision, “given your responsibilities” and being curious while exploring her motivation “How confident are you?”, “How ready are you?” and then summarising this “Sounds like you are pretty motivated”. Empathy is shown at the end by reflecting to the client “So you would be willing to” and by suggestions for help by engage the client by offering an appointment before she leaves.

    He does ask a closed question “what type of drinks” that would have generated more information if it had been an open ended questions and does not explore the stressors that lead to increased drinking.

  3. Alan showed empathy through both his non-verbal and verbal interactions with the client. Non-verbally his body language showed he was interested in what she had to say. He was sitting facing her with good eye contact. He both nodded and used verbal confirmation such as “okay”, “yes”, “mhm”, and “thank-you”.

    Alan used open ended questions to explore deeper why the client drank, what she liked about drinking, and how she perceived it helped her anxiety. He used reflective listening when she mentioned exercising in the past, however, he did not really delve deeper into it or when she talked about understanding the cost that has taken a toll. He could have worked to acknowledge these things better. He did summarize things she mentioned, and utilized assessment tools she had filled out.

    I feel he was very by the book and may have hindered his ability to delve deeper into what was causing her stress and anxiety. He seemed to be focused more on her drinking and did not ask many questions to explore what was going on with her.

  4. Alan presents as a very calm and supportive therapist. He established a therapeutic alliance by presenting as a non-judgemental listener. He leans towards the client and makes eye contact indicating interest. I thought the time he spent reviewing the client’s alcohol use and the guidelines demonstrated patience and again, no judgement. He did a very good job towards the end of video in evoking the client’s motivation for change. He also collaborated with the client on strategies to help reduce her stress which is helpful for her to achieve her overall goal of drinking less. I thought at times Alan was overly focused on his notes.

  5. Alan did not show much empathy to his client. He did not try to build rapport and seemed to lead the interaction in a “by the books” way. He did not maintain full eye contact throughout and looked down often at his papers. He did make hand gestures, paraphrazed, summarized and used both open and closed questions for exploration and perspective, such as asking how often she drank, how much and what she drank. He included “mmhmm” a lot to gently probe the dialogue. He spoke a bit about her stress and let her guide the conversation in terms of the changes she would be ready to make and offered resources. Missed opportunities for Motivational Interviewing skills would be to delve into why she has been drinking more, in order for her to gain healthier perspectives, rather than her wanting to take medication. Also building rapport/adding in affirmations in the beginning would have made things smoother, as an emotional connection would have made her feel less hopeless and excited to change.

  6. Dr. Lyme demonstrated empathy non-verbally by providing eye contact, nodding, and leaning in towards his client. Verbally, he asked some open-ended questions that allowed his client to share her perspective of the pros and cons of continuing to drink and cutting down/stopping the use of alcohol, and provided some simple and complex reflections and summaries to demonstrate his understanding to her.

    In my opinion, Dr. Lyme missed opportunities for affirmations of the client’s strengths re: her strength in showing up to the appointment and engaging in a conversation about changing her behaviours, despite the “pros” that drinking offers her in terms of stress management. Open-ended questions regarding the stressors she is experiencing may have provided rich opportunities to further demonstrate understanding of her experience, validate her strength, and potentially uncover other means of coping with the stress. He did ask some close-ended questions when completing the questionnaire re: drinking behaviours and spend some time providing psychoeducation about “normal” drinking habits, and it may have been more in the spirit of MI to follow-up on those with more open-ended questions about her reactions to the questionnaires (which may have had less of a judgmental tone). There may also have been opportunities for double-sided reflections near the end of the session, to highlight her resistance to change and further explore that, and affective reflections to draw out her apparent anxiety re: the prospect of cutting down or stopping her use of alcohol.

  7. Alan demonstrated good non verbal communication for the majority of the session: eye contact, diagonal positioning (less threatening than head on, face to face), nodding, hand gestures. He also made an effort to turn the informational materials towards the client when explaining. I do think he spent some time looking down for extended periods while the client was speaking and I felt she trailed off at one point because of this.

    Alan asked open ended questions (i.e., what do you make of all that?') and acknowledged the client's position/perspective on drinking. He also demonstrated reflective listening (i.e., on the one hand.. on the other hand..).

    I personally feel as though Alan was focused on a goal he may have 'decided' was the right goal for reasons that did not align fully with the client. He did not delve into her stress, anxiety, and overwhelm although this was repeated frequently during the session (other than a focus on financial stress). He seemed to be focused on addressing the surface level, presenting issue (i.e., drinking) and not the possible causes (i.e., her stressors).

  8. Alan had good non verbal communication with his client he was sitting up straight, making good eye contact, leaning in when asking questions, giving good facial expressions that coincide with what she is expressing.

    He expressed empathy through his verbal communication by asking lots of open ended questions and helping her to understand where she fell on the scale of wanting to change.

    I think he could have asked more questions about the fact that she seemed really set on having a prescription medication. I would have like to see him ask more questions about stress vs anxiety. She seemed to be using them interchangeably.

  9. First off, Allan is using non-verbal cues such as facing the client, making eye contact, head nods and he also uses lots of "mmhmm" and "okay" "thank you" "yeah" encouraging cues to keep the client engaged and talking.

    Allan uses simple reflections: "He asked you to see me ..." "So it is starting to increase and you drink a little more" "It seems like a little less than what you've been drinking." "You like the taste of it and it helps to lower the stress." "So your financial stress is increasing with drinking."

    He uses a double sided complex reflection: "On the one hand it lowers and it's increasing."

    He uses a metaphor too "see-saw"

    He demonstrates partnership by asking before proceeding, "If it's okay with you..." "What is it that you like about alcohol."

    He asks open-ended questions: "What do you make of all that?"

    I feel like there were a few things missing such as affirmations, effective use summarizing, and not much focus on the emotion. The affirmation in particular could have been helpful. Certainly lots of focus on the issue but not the strengths that are there to build up and encourage the client.

  10. Alan was able to utilize several ways to show empathy to his client. He summarized why he was asked to see her and allowed her to describe why she thought she was there. He asked open ended questions to allow the client to engage in the conversation and express her thoughts about the situation. He used visuals to help her understand the impact that her drinking had on her. He explored further reasons for why she might be drinking more alcohol than she had originally indicated.
    His non verbal techniques were appropriate, he maintained some eye contact, he established rapport with his client by sitting with her, at her level and creating a calm environment.
    A missed opportunity may be the approach he took for addressing her reasons for the increased alcohol consumption. She indicated that she had financial stress but he didn't seem to explore that with her and connect it to the alcohol consumption and increased use of alcohol. I feel that if he spent a bit of time here with her, building her confidence, he would have been more effective.
    Alan didn't seem to be a good fit for her in my opinion as he relied on his scales and visuals to guide the conversation where the client needed affirmation and some planning of next steps in a more concrete way.

  11. Alan did support the client during the session by offering open-ended questions to explore her concerns. Verbally, he did offer lots of opportunities for evocative questions and showed reflective listening often by summarizing this client's concerns succinctly and seeking clarification. He did extrapolate her change behaviours and went deeper into her willingness to engage in change to identify her readiness.

    Non-verbally, Alan did lean in, provide eye contact and nod to indicate he was listening actively.

    I do think that although Alan did summarize her behaviours, he did miss provide affirmations and validation quite often. He did provide strategies and support and acknowledged client's drinking patterns but he did not provide statements of support or validation for the stressors in her life. At times, the conversation did feel somewhat judgmental about drinking behaviours and "normal/appropriate" behaviours for average women, which may have helped the client to understand there may be an issue, but may also cause her to feel guilty or judged, which can potentially harm the therapeutic relationship. It would be worth exploring if there are further stressors beyond financial that are causing the client anxiety. More empathy during this session would probably have been evocative and establish trust.

  12. Dr. Lyme used some verbal and non-verbal communication strategies that were important in the session for the client. Some of the verbal strategies he utilized were re-affirmation on why the client was there to seek help – the significance of people and situations that can benefit the client – in this case financial and family. He also asked for permission when requesting to review the charts. He expressed compassion, when asking the client of what she likes and does not like, and what is important to her. I think these are important strategies to use when developing partnership / relationship and progressing for the client to be able to open up.

    Dr. Lyme used some non-verbal strategies by being patient throughout the session and going step by step in each area for the client to focus on. He also had the session in an area as the sofas without any desks, which makes the conversations more personable, I feel. He also used a lot of eye-contact which is helpful.

    In terms of missed opportunities, perhaps a bit more information on the drinking scale and types for the client would be helpful. I felt it may be a bit intimidating for a client if this were an initial session, and some may have a hard time with sharing some of the details. I think in some cases, especially in a complex case where the client is asking for some medications, that can make the case even more complex, it is important to have more information and further sessions that can help the client decide whether or not it is suitable to offer medications. I am curious to know some further strategies that may assist when there are additional perhaps complex situations such as in this case.

  13. There were a few ways that Alan Lyme expressed empathy:

    Non-verbally he was able to maintain some eye contact with the client, showing that he was attentively listening to the client and was focused on her as she spoke. His tone of voice was also respectful and understanding towards the client. He used a lot of hand gestures to show his understanding and empathy towards the client.

    Alan asked a lot of open-ended questions to get a better understanding of the client's back story. Once the client shared her story, he was able to show more empathy towards the client's current situation at home. For example, by asking open-ended questions he was able to understand some of the clients stressors which included the stress of family responsibility and financial burdens.

    He used visual cues and scales to identify the client's readiness or motivation to change, once again it provided him with a better understanding of where the client stands in terms of their goal. I think through this scaling he was able to form a better rapport with the client, because she started to open up more as the conversation progressed and was better able to empathize with the client's current situation and struggle.

    He expressed empathy through double sided reflective listening. He identified on one hand drinking helps reduce the stress but it can only increase other stressors in their life.

    I think some missed opportunities with MI that Alan missed during his interaction was, I felt like he could have been more compassionate towards the client. Personally, I feel like he could have shown more support for the client and what she wanted. She seemed to be leaning more towards one option over the other, but I could not tell if he was being judgmental about that option. Also, he briefly touched up on her past strengths or successes with drinking and handling stress. He could have put more emphasis on those strengths and more affirmative to further motivate her maybe.

  14. Alan used non-verbal cues effectively to express his compassion and empathy for his client's circumstances by sitting forward on the couch, leaning in and using verbal cues like 'uhm' throughout their conversation to let her know he was listening.

    He used open ended questions throughout to gather information to understand why the client had chosen to drink to manage her stress and how her choice impacted her. Questions like: 'What is it you like about alcohol?' and 'What are the not so good things about it?'. This interest in her motivation for drinking helps to demonstrate empathy. He also used the generic open-ended question a few times 'What do you make of that?', presumably to get the client to reflect the data he was sharing and to gain clarification on how she was feeling in learning about the risks of drinking.

    I thought Alan could have demonstrated more empathy by probing into the types of stresses (beyond financial) that were causing her to drink and why she wasn't able to exercise to help with her stress, although perhaps that was not the goal of this session.

    Alan was collaborative in his approach asking the client how important change was for her and what factors would increase her willingness for change.

    Alan used affirmations like "I am pretty confident that you can make changes' demonstrating that he believes his client has the intrinsic motivation. I think he missed an opportunity however, to ask about prior change or draw out her strengths that might have made his vote of confidence more meaningful.

  15. During the session, Alan expressed empathy to his client when she was surprised to learn that the limit of alcohol consumption for females was seven drinks a week or less.

    Verbally, Alan expressed empathy by acknowledging the client's perspective; Alan stated "it seems less than what you consider healthy drinking". Alan goes on to state that there is conflicting information "out there" regarding the upper limits of weekly recommended drink average. Alan also stated how he understands that an increase in stress can make someone turn to this habit, empathizing with her life situation.

    Non-verbally, Alan was sitting up right, leaning towards the client and making eye contact. Alan waited for his client to finish speaking before beginning to speak.

    Perhaps one missed opportunity to use Motivational Interviewing skills that Alan missed was not utilizing affirmations. Alan could have raised his client's confidence and opened up discussions by recognizing the amount of work his client does and stating this to her directly.

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