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Using Motivational Interviewing to Help Your Patients Make Behavioral Changes

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Title: Using Motivational Interviewing to Help Your Patients Make Behavioral Changes


1
Using Motivational Interviewing to Help Your
Patients Make Behavioral Changes
2
Why Should We Be Interested In Patients
Motivation For Behavior Change?
3
Beliefs About Motivation (True or False?)
  • Until a person is motivated to change, there is
    not much we can do.
  • It usually takes a significant crisis (hitting
    bottom) to motivate a person to change.
  • Motivation is influenced by human connections.
  • Resistance to change arises from deep-seated
    defense mechanisms.

4
Beliefs About Motivation (True or False?)
  1. People choose whether or not they will change.
  2. Readiness for change involves a balancing of
    pros and cons.
  3. Creating motivation for change usually requires
    confrontation.
  4. Denial is not a client problem, it is a therapist
    skill problem.

5
Learning Objectives
  • At the end of the workshop, you will be able to
  • Define multiple MI techniques to help clients to
    change
  • Describe the Stages of Change
  • Complete a Stage of Change Assessment
  • Define the 4 principles of MI
  • Demonstrate skill with OARS
  • Demonstrate at least 2 methods to elicit change
    talk
  • Utilize a Readiness Ruler
  • Complete a Decisional Balance
  • Complete a Change Plan
  • Describe MI strategies to deal with resistance to
    change

6
MI is
  • A theory
  • A set of skills
  • A way of thinking
  • A way of relating

7
Experiential Exercise 1
8
Why Do People Change?
  1. ?
  2. ?
  3. ?
  4. ?
  5. ?
  6. ?

9
Why Dont People Change?
  1. ?
  2. ?
  3. ?
  4. ?
  5. ?
  6. ?

10
Sound Familiar?
  • I tell them what to do, but they wont do it.
  • Its my job just to give them the facts, and
    thats all I can do.
  • These people lead very difficult lives, and I
    understand why they _______.
  • Some of my patients are in complete denial.

Rollnick, Miller and Butler. Motivational
Interviewing in Healthcare. 2008.
11
Or Should We?
  • Explain what patients could do differently in the
    interest of their health?
  • Advise and persuade them to change their
    behavior?
  • Warn them what will happen if they dont change
    their ways?
  • Take time to counsel them about how to change
    their behavior?
  • Refer them to a specialist?

Rollnick, Miller and Butler. Motivational
Interviewing in Healthcare. 2008.
12
The Righting ReflexThe Best Intentions Can
Backfire
  • Most patients are ambivalent about unhealthy
    behaviors.
  • When we (providers) see an unhealthy/risky
    behavior, our natural instinct is to point it out
    advise change.
  • The patients natural response is to defend the
    opposite (no change) side of the ambivalence
    coin.

13
Avoid Righting ReflexTaking Sides Trap
  • PROVIDER
  • You must change
  • Youll be better off
  • You can do it!!
  • Youll die
  • PATIENT
  • I dont want to change
  • Things arent half bad.
  • No I cant!!
  • Uncle Fred is 89 and healthy as can be.

14
Experiential Exercise 2 The Change Exercise
15
Exercise The Change Exercise
  • Stand up and turn to stand face to face in pairs.
  • Silently observe your partner for 15 seconds.
  • Now turn back to back and change 3 things about
    yourself.
  • When you are done, turn back to face your
    partner.
  • Each person should take a minute to name the 3
    things your partner has changed.

16
Change Exercise Questions
  • What was your comfort level during this exercise?
  • What made you comfortable or uncomfortable?
  • How hard was it to change things?
  • How did you decide what things to change about
    yourself?
  • What does this exercise tell us about change?
  • Look around you did you notice how quickly people
    changed back to the way they started as soon as
    they sat down?
  • What implications might this have about change
    for people and ourselves?

17
Change Exercise Key Points
  • Change is difficult
  • Change is not always comfortable
  • Change requires creativity
  • We tend to go back to old ways
  • It is easier to stay the same
  • We like our comfort zones
  • Change requires an open mind
  • Change has emotional and cognitive components

18
Change Exercise Key Points
  • Change is a process
  • Change happens over time
  • The process is as important as the result
  • Watch out for measuring success only if a change
    occurred
  • Often there is a difference between what someone
    knows they should do and there readiness to do
    it.
  • Greatest chance to impact change is pacing it to
    the specific stage of change

19
Why Are Health Care Professionals (Outside
Behavioral Health) Interested In MI?
  • Behavioral/lifestyle factors in health issues
  • Exercise
  • Smoking
  • Weight control
  • Treatment adherence
  • Diet/nutrition
  • Conceptual consistency with patient-centered
    approaches
  • Positive and promising results from research on
    outcomes

20
Definition of Motivational Interviewing
  • A patient-centered, yet directive method for
    enhancing intrinsic motivation for positive
    behavior change by exploring and resolving
    ambivalence.

Miller, W.R. Rollnick, S.(2002)
21
Motivation is viewed as
  • multidimensional
  • a state, which is dynamic and fluctuating
  • modifiable
  • influenced by communication style

Our job is to elicit and reinforce patient
motivation for change.
22
Rapid Diffusion Into Health CareSettings
23
Motivational Interviewing Practice Basics
  • Spirit, Principles, Micro-skills

24
MI Spirit
  • A way of being with patients which is
  • Collaborative
  • Evocative
  • Respectful of autonomy

25
Collaboration(not confrontation)
  • Developing a partnership in which the patients
    expertise, perspectives, and input is central to
    the consultation
  • Fostering and encouraging power sharing in the
    interaction

26
Evocation(not education)
  • The resources and motivation for change reside
    within the patient
  • Motivation is enhanced by eliciting and drawing
    on the patients own perceptions, experiences,
    and goals
  • Ask key open ended questions

27
Autonomy(not authority)
  • Respecting the patients right to make informed
    choices facilitates change
  • The patient is charge of his/her choices, and,
    thus, is responsible for the outcomes
  • Emphasize patient control and choice

28
Spirit of Motivational Interviewing
  • Motivations to change are elicited from within
    the client, not imposed from outside.
  • It is the client's task, not the counselor's, to
    articulate and resolve his or her ambivalence.
  • Direct persuasion is not an effective method for
    resolving ambivalence.
  • Readiness to change is not a client trait, but
    fluctuating product of interpersonal interaction.

29
Spirit of Motivational Interviewing
  • The therapeutic relationship is more like a
    partnership or companionship than
    expert/recipient roles.
  • Positive atmosphere that is conducive but not
    coercive for change.
  • The counselor is directive in helping the client
    to examine and resolve ambivalence.

30
What MI is Not
  • A way of tricking people into doing what you want
    them to do
  • A specific technique
  • Problem solving or skill building
  • Just client-centered therapy
  • Easy to learn
  • A panacea for every clinical challenge
  • Source Miller Rollnick (2009)

31
Four Guiding MI Principles
  • Resist the righting reflex
  • If a patient is ambivalent about change and the
    clinician champions the side of change

32
Four Guiding MI Principles
  • Understand your patients motivations
  • With limited consultation time, it is more
    productive asking patients what or how they would
    make a change rather than telling them that they
    should.

33
Four Guiding MI Principles
  • Listen to your patient
  • When it comes to behavior change, the answers
    most likely lie within the patient, and finding
    them requires some listening

34
Four Guiding MI Principles
  • Empower your patient
  • A patient who is active in the consultation,
    thinking aloud about the what and how of change,
    is more likely to do something about it.

35
Core MI Skills (OARS)
  • Asking
  • Listening
  • Affirming

36
Asking
  • Use of open ended questions allows the patient to
    convey more information
  • Encourages engagement
  • Opens the door for exploration

37
Closed Ended Question ? Open Ended Question
  • Are you having any pain today?
  • Is there anything that is worrying you right now?
  • Are you short of breath?
  • Are you doing okay?
  • Why havent you tried this exercise?
  • Are you refusing treatment?
  • Do you have a follow up appointment scheduled?

38
Open-Ended Questions
  • What are open-ended questions?
  • Gather broad descriptive information
  • Require more of a response than a simple yes/no
    or fill in the blank
  • Often start with words like
  • How
  • What
  • Tell me about
  • Usually go from general to specific

OARS
39
Open-Ended Questions
  • Exercise
  • Turning closed-ended questions into
  • open-ended ones

40
Open-Ended Questions
  • Why open-ended questions?
  • Avoid the question-answer trap
  • Puts client in a passive role
  • No opportunity for client to explore ambivalence

OARS
41
Affirmations
  • What is an affirmation?
  • Compliments, statements of appreciation and
    understanding
  • Praise positive behaviors
  • Support the person as they describe difficult
    situations

OARS
42
Affirmations
  • Examples
  • I appreciate how hard it must have been for you
    to decide to come here. You took a big step.
  • Ive enjoyed talking with you today, and getting
    to know you a bit.
  • You seem to be a very giving person. You are
    always helping your friends.

43
Affirmations
  • Why affirm?
  • Supports and promotes self-efficacy, prevents
    discouragement
  • Builds rapport
  • Reinforces open exploration (client talk)
  • Caveat
  • Must be done sincerely

OARS
44
Express Empathy
  • What is empathy?
  • Reflects an accurate understanding
  • Assume the persons perspectives are
    understandable, comprehensible, and valid
  • Seek to understand the persons feelings and
    perspectives without judging

45
Express Empathy
  • Empathy is distinct from
  • Agreement
  • Warmth
  • Approval or praise
  • Reassurance, sympathy, or consolation
  • Advocacy

46
Express Empathy
  • Why is empathy important in MI and IDDT?
  • Communicates acceptance which facilitates change
  • Encourages a collaborative alliance which also
    promotes change
  • Leads to an understanding of each persons unique
    perspective, feelings, and values which make up
    the material we need to facilitate change

47
Express Empathy
  • Tips
  • Good eye contact
  • Responsive facial expression
  • Body orientation
  • Verbal and non-verbal encouragers
  • Reflective listening/asking clarifying questions
  • Avoid expressing doubt/passing judgment

48
Empathy is NOT
  • The sharing of common past experiences
  • Giving advice, making suggestions, or providing
    solutions
  • Demonstrated through a flurry of questions
  • Demonstrated through self-disclosure

49
The Bottom Line on Empathy
  • Ambivalence is normal
  • Our acceptance facilitates change
  • Skillful reflective listening is fundamental to
    expressing empathy
  • - Miller and Rollnick, 2002

50
Reflective Listening
OARS
51
Listening
  • Clinician accurate empathy is a robust predictor
    of behavior change
  • Involves careful listening with the goal of
    understanding the meaning of what the patient
    says
  • Skillful reflective listening looks easy, but
    its a complex skill

52
Reflective Listening
  • Reflective listening is a way of checking rather
    than assuming that you know what is meant.
  • (Miller and Rollnick, 2002)

OARS
53
Reflective Listening
  • Why listen reflectively?
  • Demonstrates that you have accurately heard and
    understood the client
  • Strengthens the empathic relationship
  • Encourages further exploration of problems and
    feelings
  • Avoid the premature-focus trap
  • Can be used strategically to facilitate change

54
Reflective Listening
  • In motivational interviewing,
  • About half of all practitioner responses are
    reflections
  • 2-3 reflections are offered per question asked
  • In ordinary counseling,
  • Reflections constitute a small proportion of all
    responses
  • Questions outnumber reflections 10 to 1

55
Learning Reflective Listening
  • Reflective listening begins with thinking
    reflectively
  • Thinking reflectively requires a continual
    awareness that what you think people mean may not
    be what they really mean

56
Thinking Reflectively
  • Exercise
  • Split up into triads (1-speaker) (2-listeners).
  • Each person will take a turn being a speaker.
  • Each person will share a personal statement
  • One thing I like about myself is
  • (e.g., I am organized. I am creative.)
  • The listeners respond with Do you mean that..
    (generate at least 5 for each).
  • The speaker responds with only yes/no.

57
Reflective Listening
  • A reflection is two things
  • A hypothesis as to what the speaker means
  • A statement
  • Statements are less likely than questions to
    evoke resistance

OARS
58
Reflections Are Statements
  • DO YOU MEAN?
  • Use a statement to reflect your understanding
  • Inflection turns down at the end
  • You... So you... Its... Its
    like... You feel...

59
Reflections Are Statements
  • Question
  • Youre thinking about stopping? (inflection goes
    up)
  • Versus a statement
  • Youre thinking about stopping. (inflection goes
    down)

60
Reflective Listening
  • Exercise
  • Split up into triads (1-speaker) (2-listeners).
  • Each person will take a turn being a speaker.
  • Each person will share a personal statement
  • One thing I like about myself is
  • OR
  • One thing about myself Id like to change is
  • The listeners respond with reflections only.
  • The speaker can respond with yes/no and
    elaboration.

61
Levels of Reflection
  • Simple Reflection stays close
  • Repeating
  • Rephrasing (substitutes synonyms)
  • Complex Reflection makes a guess
  • Paraphrasing major restatement, infers meaning,
    continuing the paragraph
  • Reflection of feeling - deepest

OARS
62
Not Reflective Listening
  • Communication Roadblocks
  • Ordering, directing, commanding
  • Warning, cautioning, threatening
  • Giving advice, making suggestions, providing
    solutions
  • Persuading with logic, arguing, lecturing
  • Telling what to do preaching
  • Disagreeing, judging, criticizing, blaming

63
Not Reflective Listening
  1. Agreeing, approving, praising
  2. Shaming, ridiculing, blaming
  3. Interpreting or analyzing, also labeling
  4. Reassuring, sympathizing, consoling
  5. Questioning, probing
  6. Withdrawing, distracting, humoring, changing the
    subject

64
Summaries
  • Pull together what has transpired thus far in a
    session
  • Strategic use practitioner selects what
    information should be included what can be
    minimized or left out
  • Additional information can also be incorporated
    into summary e.g., past conversations,
    assessment results, collateral reports etc.

OARS
65
Summarizing
  • Exercise 3(part 1)
  • Choose a partner.
  • Speaker for 90 seconds talk about a habit,
    behavior, situation you are thinking about
    changing.
  • Listener listen only and then give a summary of
    what youve been told.
  • Change roles and repeat.

66
Summarizing
  • Exercise (part 2)
  • Change partners.
  • Speaker once again tell your story for 90
    seconds w/out interruption.
  • Listener listen only and then give a summary,
    but this time include what you think is the
    underlying meaning, feeling, dilemma in the
    story.
  • Change roles and repeat.

67
Listen For Change Talk
  • D?A?R?N?C?A?T Change
  • Desire I want/wish/prefer to
  • Ability I can, could, able, possible
  • Reason why do it? what would be good?
  • Need important, have to, matter, got to
  • Commitment I will/am going to signals behavior
    change
  • Activations I am ready to do this
  • Taking Steps I am taking steps

68
Affirming
  • Supports patient self-efficacy
  • Emphasize patient strengths
  • Notice and appreciate positive action
  • Genuineness is critical

69
Affirmations May Include
  • Commenting positively on an attribute
  • (You are determined to get your health back.)
  • A statement of appreciation
  • (I appreciate your efforts despite the discomfort
    youre in.)
  • A compliment
  • (Thank you for all your hard work today.)

70
Theoretical Framework ofMotivational Interviewing
  • Readiness to Change
  • 1. Precontemplation not yet considering change
  • 2. Contemplation evaluating reasons for and
    against change
  • 3. Preparation planning for change
  • 4. Action making the identified change
  • 5. Maintenance working to sustain changes

71
Experiential Exercise 4 The Persuasion Exercise
72
How Do We Assist Others to Change?
  • Exercise has 2 parts
  • Use Persuasion
  • Use Motivational Interviewing
  • Reverse roles answer same questions

73
Lets see if it worksPersuasion Exercise
  • Ask your partner about a behavior that they have
    considered changing?
  • Explain why participant should make a change
  • List at least 3 specific benefits of making this
    change
  • Tell the participant how to change
  • Emphasize how important it is for them to make
    the change
  • Tell the person to do it!

74
Exercise Part 3 Now Lets TryUsing MI
  1. Ask you partner to select a personal change
    theyve have made in the past
  2. What change did you make?
  3. How did you decide to make this change?
  4. What people or events influenced your decision?
  5. What steps did you take to make the change?
  6. What did you learn from the process?

75
Exercise Part 3 Now Lets TryUsing MI
  1. Now, whats a new change youre considered now?
  2. What prompted you to look _at_ this issue now?
  3. How might you go about it in order to it,
    succeed?
  4. What are the 3 reasons to do it now?
  5. Summarize what you heard.
  6. Close by asking, what will you do next?

76
Stages of Change
Precontemplation
Maintenance
Relapse
Contemplation
Action
Preparation - Determination
77
Stages of Change Model
CONCEPT DEFINITION APPLICATION
PRE-CONTEMPLATION Not considering possibility of change. Does not feel there is a Problem. Goal Raise awareness. Task Inform and encourage. Validate lack of readiness.
CONTEMPLATION Thinking about change, in the near future. Goal Build motivation and Confidence. Task Explore ambivalence. Evaluate pros and cons.
PREPARATION Making a plan to change, setting gradual goals. Goal Negotiate a plan. Task Facilitate decision making.
ACTION Implementation of specific action steps, behavioral changes. Goal Implement the plan. Task Support self-efficacy.
MAINTENANCE Continuation of desirable actions, or repeating periodic recommended step(s). Goal Maintain change or new status quo. Task Identify strategies to prevent relapse.
78
RememberReadiness to change is a state, not
a trait.
79
Readiness Rulers
  • A Precontemplation Stage Tool

80
Readiness Rulers I-C-R
  • Importance The willingness to change
  • Confidence In ones ability to change
  • Readiness A matter of priorities

Confidence
Readiness
Importance
81
Importance Ruler
  • On a scale of 1 to 10, how important is it for
    you to make a change?

1 2 3 4 5 6 7 8 9 10
Not at all important Somewhat important Extremely Important

82
Importance to Change Readiness Ruler
  • We show the patient the Importance Readiness
    Ruler ask
  • On a scale of 1 to 10, how important is it to you
    to make a change in . . . ?
  • Example, If you are a 5, why are you a 5 and not
    a 3?
  • Or if you are a 5, what need to happen for you to
    go to a 7?
  • How could I assist you in getting to a 7?

83
Confidence Ruler
  • On a scale of 1 to 10, how confident are you that
    you could make a change if you wanted to?

1 2 3 4 5 6 7 8 9 10
Not at all confident Somewhat confident Extremely confident

84
Confidence to Change Readiness Ruler
  • We show the patient the Confidence Readiness
    Ruler ask
  • On a scale of 1 to 10, how confident are you to
    make a change in . . . ?
  • Example, If you are a 5, why are you a 5 and not
    a 3?
  • Or if you are a 5, what need to happen for you to
    go to a 7?
  • How could I assist you in getting to a 7?

85
Strategies to Enhance Confidence
  • Review past successes
  • Define small steps that can lead to success
  • Problem solve to address barriers
  • Hypothetical change (If you were able to quit
    smoking tomorrow, how do you think things would
    be different?)
  • Attend to the progress and use slips as occasions
    to further problem-solve rather than failure

86
Simplified Motivational Categories
Importance of Change Importance of Change
Confidence in Ability Low High
Low Group 1 Little interest in change dont think they could even if they wanted to. Group 2 Want to change, but dont think they are able.
High Group 3 Believe they could change, but not interested right now. Group 4 Want to change and believe they have the ability.
87
Readiness Ruler
  • On a scale of 1 to 10, how ready are you to make
    a change?

1 2 3 4 5 6 7 8 9 10
Not at all ready Somewhat ready Extremely Ready

88
Readiness to Change Readiness Ruler
  • We show the patient the Readiness Ruler ask
  • On a scale of 1 to 10, how ready are you to make
    a change in . . . ?
  • Example, If you are a 5, why are you a 5 and not
    a 3?
  • Or if you are a 5, what need to happen for you to
    go to a 7?
  • How could I assist you in getting to a 7?

89
Exercise 4 The Readiness Ruler Exercise
90
Exercise 4Lets Try Using Readiness Rulers
  • How important is it for you to learn about MI?
  • What are the challenges at your agency that makes
    this MI training important ?
  • How confident are you that you can begin to use
    utilizing what youve learned about MI in the
    next week?
  • How ready are you to start utilizing what youve
    learned about MI in the next week

91
Exercise 4 Utilizing Readiness Rulers
  • You will be working with your partner in both the
    role of helper helpee utilizing Readiness
    Rulers
  • Start off by using the 3 questions from
    previous slide with your partner
  • Then utilize importance, confidence importance
    rulers
  • Summarize outcome

92
Decisional Balance
  • A Contemplation Stage Tool

93
Decisional BalanceAn Explanatory Model Of
Behavior Change
  • Highlights the individuals ambivalence regarding
    maintaining vs changing a behavior
  • it is a balancing of the costs of status quo with
    the costs of change
  • and the benefits of change with the benefits of
    the status quo.

94
Decisional Balance
Decisional Balance Worksheet (Fill in what you
are considering changing)
Good things about behavior Not so good things about behavior
Not so good things about changing behavior Good things about changing behavior
95
Decisional Balance Sheet
Reasons for staying the same Reasons for making
a change
  • Good things about
  • 1.
  • 2.
  • 3.

Not so good things about 1. 2. 3.
Not so good things about changing 1. 2. 3.
Good things about changing 1. 2. 3.
96
Decisional BalancingBenefits and Costs Worksheet
  • Continuing Behavior
  • Stopping Behavior

Costs Benefits
1. 1.
2. 2.
3. 3.
4. 4.
Costs Benefits
1. 1.
2. 2.
3. 3.
4. 4.
97
Conducting a Decisional Balance Discussion
  • Accept all answers. (Dont argue with answers
    given by patient.)
  • Explore answers.
  • Be sure to note both the benefits and costs of
    current behavior and change.
  • Explore costs/benefits with respect to clients
    goals and values.
  • Review the costs and benefits.

98
Exercise 5 The Decisional Balance Exercise
99
Exercise 5 Decisional Balance
  • Partners will take turns as helper helpee.
  • Helper begins by asking helpee to identify
    either
  • something I know I need to change am
    considering or
  • something I feel 2 ways about
  • Helper assists helpee in completing a decisional
    balance
  • Helper processes decisional balance with helpee
    using OARS

100
Exercise 5 Decisional Balance
  • Ask your partner to think of an area of their
    life in which they have been contemplating making
    a change.
  • For example
  • Starting a diet or exercise program
  • Going back to school
  • Moving to a new home.

101
Negotiating a Change Plan
  • Patient sets a goal
  • Have patient develop a menu of strategiesbrainsto
    rm.
  • Have patient decide on a specific plan
    summarize it.
  • Elicit commitment
  • Have patient restate what they intend to do.
  • Involve others the more the patient verbalizes
    the plan to others, the more commitment is
    strengthened (no going back now concept)

102
Summary Benefits of Using MI
  • Evidence-based
  • Patient Centered
  • Provides structure to the consultation
  • Readily adaptable to health care settings

103
What Do You Think?
  1. On a scale of 1 to 10, how important is it for
    you to start using motivational interviewing in
    your practice?
  2. On a scale of 1 to 10, how confident are you to
    start using motivational interviewing in your
    practice?
  3. On a scale of 1 to 10,how ready are you to start
    using motivational interviewing in your practice?

104
Thank You For Coming Learning About MI!Any
Questions?
105
More Information on Motivational Interviewing
  • Literature on MI www.motivationalinterview.org
  • Miller and Rollnick. Motivational Interviewing
    Preparing People for Change. Guilford Press. New
    York and London. 2002
  • Rollnick, Miller and Butler. Motivational
    Interviewing in Health Care Helping Patients
    Change Behavior. Guilford Press. New York and
    London. 2008

106
Other Experiential Exercises
107
Imagine Extremes
  • What is the worst that can happen if you
    continued?
  • What do you think would have to happen to make
    you decide to tell yourself, ok thats enough?

108
Looking Back
  • When was the last time things were going well
    for you and what was it like for you?
  • What do you think could have prevented this
    setback?
  • What was your life like before this happened?
  • As you step back and look at all this, what do
    you make of it?

109
Looking Forward
  • What would you like your life to be like in 2
    years?
  • How does what you are doing now make that
    difficult?
  • What would it be like if you continue with the
    way things are now?
  • Suppose things dont change, how do think your
    life will look?

110
Motivation for Change
  • Motivation is an intrinsic process
  • Ambivalence
  • Alternative behaviors have pluses and minuses
  • Motivation arises out of discrepancy
  • Values/goals conflict with current behavior
  • Ambivalence ? discrepancy ? change
  • Change Talk facilitates change

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Strengthening Commitment
  • Summarize patients own perception of problem,
    ambivalence, desire/intention to change, and can
    include your own assessment.
  • Ask a key question, i.e. What is the next
    step?
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