The Four Processes: Evoking

By Mia Croyle, MA

In the third edition of Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013), we are introduced to the four processes. In previous newsletters, we discussed the first two of these, engaging and focusing. The third process is evoking. This process is where our method becomes distinctly motivational interviewing.  Our objective in this process is to evoke the other person’s own motivations (or plans) for change.   The evoking process pays special attention to “change talk” or the other person’s arguments for change.  In the evoking process, we work on three specific practitioner skills dealing with change talk:

01. Recognizing change talk: If you listen closely enough,people often tell you their own motivations for change.  One of the challenges in recognizing change talk is that it often comes intertwined with its opposite – sustain talk (a person’s arguments for not changing).  A patient statement that includes that ambivalence might sound like: “I know my health would get a whole lot better if I quit smoking, and I’d save money, too, but I just don’t think I can do it right now.”  The part that’s underlined is the change talk!

02. Responding to change talk:  When we hear change talk, we want to affirm it, reflect it back, and ask the other person to elaborate so we can continue to encourage their internal motivation and help them build their own case for change.  Using the statement from above, it’s pretty tempting to start addressing the sustain talk part of that ambivalence by convincing the patient that he can indeed do it.  A response that is more likely to evoke more change talk would be to reflect the change talk and ask for elaboration.  That might sounds like: “So, quitting smoking would help your health and your wallet.  What aspect of your health in particular would you expect to see improve?”

03. Evoking change talk: Sometimes we have to work a little harder to get patients to offer up their arguments for change.  This requires the practitioner to be strategic and intentional with the questions asked and the ways the other person’s statements are reflected back.  One of the most straightforward ways to get change talk is simply to ask for it.  “What would be the best thing about being an ex-smoker?” or “If you did decided to quit, what would you hope to get out of it?”

Evoking is at the heart of Motivational interviewing.  When we stand on the secure foundation of an engaged and collaborative relationship and have a shared focus, we can effectively partner with our patients to help them give voice to their motivation for change and then help support them while they put that motivation into action in the planning process.


The Four Processes: Focusing

By Mia Croyle, MA

In the third edition of Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013), we are introduced to the four processes. In our newsletter, we discussed the first of these, engaging. The second of the four processes is focusing. Our objective in this process is the collaborative, ongoing process of seeking and maintaining direction. 

In Motivational Interviewing. there are three main sources of focus, and in almost every instance. we rely on some combination of them all:

01. The other person (the “patient”): people generally have concerns, preferences, ideas, and values that influence our focusing process. For example, in BSI, if a patient screens positive for potential risk in the areas of tobacco use and depression, the patient will have some ideas about where he or she would like to start, and we certainly give priority to those ideas.

02. The setting: in BSI, we are in a healthcare context and generally, our health educators have a pre-established list of behaviors that they are trained and sanctioned to address. If patients have concerns that fall outside these areas, the health educator can refer patients to other resources.

03. The helping professional’s clinical expertise: in BSI, this is informed by the results of the screen and brief assessment. Other members of the healthcare team, such as the physician, may also have clinical expertise that informs our focusing process.

Like each of the four processes, focusing is an ongoing process. Once we have established a focus, we continue to attend to focusing throughout our interaction. We may need to revisit our focus at times to make sure we are still on the same page with the other person.


Q+A With Gundersen Health System’s Health Education Team

Today, we’re interviewing Rachael Garbers and Lindsay Seccombe to hear more about their real-world experiences implementing SBIRT (Screening, Brief Intervention and Referral to Treatment).

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Rachael currently is employed as a Wellness Specialist at Gundersen Health System Trauma services department. Lindsay is completing her preceptorship with Gundersen this semester. As preceptee (teacher) and preceptor (student intern), they work together to screen incoming trauma patients for behavioral risks, utilizing behavioral screening and intervention (SBIRT) practices.

To start, tell us about what you do and how you came to work as Wellness Specialists in Gundersen’s Trauma services department.

Rachael: For almost four years, I have worked as a Wellness Specialist at Gundersen Health System. I received motivational interviewing training under WIPHL’s previous grant and worked in family medicine before starting in trauma services. Here, I service all inpatients admitted with positive screens for at-risk alcohol consumption, tobacco, and/or illicit drug use.

Lindsay: I am a Wellness Specialist preceptee and work with Rachael to ensure maximum screening and intervention for Gundersen’s trauma patients. On a personal level, I am currently finishing my bachelor’s degree at University of Wisconsin-La Crosse. I have been accepted into a Master’s program for Public Health, and plan to continue on for medical school after that. Gundersen was an opportune facility to both gain experience and valuable one-on-one time with patients, which will make me a better doctor.

What is a typical day like in trauma services?

Rachael: Every morning, I begin my day running a screening report, which gives me a list of patients still needing to be screened and seen for the day. I also follow-up with patients via phone. Patients usually receive one-week, one-month, six-month, and one-year follow-up calls to provide them with additional assistance in making healthy lifestyle choices.

As a Wellness Specialist, you cannot directly prescribe medicine. What are some things you provide for patients?

Rachael: I am able to provide patients with compassionate care, opportunities for follow-up, and resources for help. This includes providing patients with recommendations and ways in which to promote their own health. Being that extra resource and support for patients is the one of the things I enjoy most about my job. Encouraging patients to take an active role in pursuing a healthy lifestyle is very rewarding.

How does Motivational interviewing (MI) fit in with what you do? Can you tell me a little more about what MI is?

Rachael: Motivational interviewing is the foundation for meeting with my patients. Being in a hospital bed can pose as a vulnerable time for people. It is often unexpected and can be life changing, that being said I do my best to put myself in the patient’s shoes.

Lindsay: Motivational interviewing provides us the opportunity to talk with patients about sensitive topics. Rachael and I use MI because it allows us to listen to patients. Many times in the health care field patients are told what to do and how to do it, without personalizing it. This often leaves patients frustrated and unsure about making changes. We collaborate with patients to meet them where they’re at. Giving patients the opportunity to actively participate in their own care can build confidence and promote change if the patient decides they are ready.

Is it difficult to work with patients who may need help but don’t necessarily want help?

Lindsay: I think that MI is especially important in these circumstances because again, our job is not to change people or force them to change. Learning MI has taught me to appreciate where people are at in their lives and that change doesn’t happen for everyone at the same time. With this mind set we are able to provide appropriate resources while respecting their autonomy.

Recently, the Wall Street Journal published an article about the benefit of using MI in clinical settings. What do you think of MI and its use in behavioral screening and intervention?

Rachael: MI is an efficient way to implement behavioral screenings and interventions in both clinical and inpatient settings, because it provides the opportunity to make a plan of action with the patient. My job helps bridge the gap between the provider and the patient. Being that the patients immediate needs are met by the providers, time can often be a barrier. As part of the healthcare team, I am able to help patients make further plans for change.

Lindsay: Taking the time to sit down with patients and engage in a conversation using MI gives us the opportunity to understand where the patient is at in regards to a healthy lifestyle. Rachael and I use MI to promote wellness without forcing information on the patients. By understanding what the patient is going through and where they are at in regards to making changes, or not, in their life helps us provide the most relevant information to benefit the patient.

Behavioral risks, like binge drinking, are extremely common in Wisconsin. How do you think BSI has the potential to change these common behaviors?

Lindsay: Being that Wisconsin has a high prevalence of at-risk alcohol consumption, we often see a significant amount of alcohol related traumas. Here at Gundersen we are taking those opportunities to educate, should the patient be open to it, about healthier lifestyle choices in an effort to prevent something worse from happening.

Rachael: Providing SBIRT services does help change the culture of risky drinking – it really just ties in beautifully to what we do and hope to continue doing.


The Four Processes of MI: Engaging

By Mia Croyle, MA

In the third edition of Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013), we are introduced to the four processes.  The first of these is engaging.  Our goal in this process is to establish and maintain a collaborative working relationship with the other person.

Ways to promote engagement:

  • Ask for and listen to what the other person wants
  • Seek an understanding of how important the topic at hand may be to the other person
  • Look for what you can genuinely appreciate and comment positively about
  • Provide the person with some sense of what to expect
  • Offer hope – explain how what you do may help

Ways to promote disengagement:

  • Assume an expert role
  • Move too quickly into an assessment process
  • Prematurely focus on one specific problem
  • Use language that indicates labeling or blaming


Partnership Between UW-La Crosse and WIPHL Is A Model For Health Educator Training Programs

By Laura Saunders, MSSW

When behavioral screening and intervention (BSI) becomes routine in healthcare settings, where will the new workforce of trained health educators come from to provide these services? Luckily, Dr. Gary Gilmore is helping take care of just that.

At the University of Wisconsin – La Crosse (UW-L), Dr. Gilmore and his colleagues are preparing the university’s community health education students for the future task of delivering BSI in general healthcare settings.

With help from WIPHL and funding from the UW School of Medicine and Public Health’s Wisconsin Partnership Program, UW-L faculty developed the curriculum for the initial course and was trained in Motivational interviewing (MI). MI is an evidence-based approach to facilitating conversations that help people recognize and take action upon their internal motivation for change. The MI approach provides  us with a method of communication that serves as a solid foundation for BSI.

Last semester, 10 students completed a 16-week, 3-credit course on a MI approach to delivering BSI. Feedback from the health education students indicates that this course is indeed a step in the right direction.

  • “This (course) is an innovative and highly effective evidence-based technique that is applicable to almost every health topic.  It is one of the best tools I’ve added to my professional toolkit.”
  • “I believe this class is something that I can take with me no matter what I end up doing in my professional career.  We have the opportunity to interact with people on a daily basis, having active listening skills are a valuable practice that not many people do well.”
  • “This is exactly what we need as health educators.  It teaches us that we can’t just fix people with education.  I think this should be a mandatory class.”
  • “I believe everyone working in health professions should learn MI.”

This semester, those students are delivering BSI in a 16-week preceptorship at various clinical sites.  WIPHL’s Dr. Rich Brown and Laura Saunders are consulting with the sites about modifying patient flow to maximize BSI delivery.  The UW-L faculty are conducting regular case teleconferences with their students, and reviewing and giving feedback on audiotapes of interviews between the students and actual patients.

The two-semester program will be revised, based on evaluation data, and offered to more students in the 2013-2014 academic year.


What’s New in Motivational Interviewing: The Four Processes

By Mia Croyle, MA

The third edition of Motivational Interviewing: Helping People Change (Miller & Rollnick, 2013) is the authoritative presentation of Motivational interviewing (MI).  This edition represents the latest in what is known about this powerful approach to facilitating change after 30 years of research and clinical experience.

One of the newest ideas introduced in this edition is that of the four processes which occur in a generally sequential, yet overlapping and recurring, fashion in the motivational conversation.

These four processes are:

  • Engaging – building the relational foundation for a collaborative working relationship.
  • Focusing – developing and maintaining a specific agenda.
  • Evoking – drawing out the other person’s own motivation for change and his or her ideas about whether and why to make a change.
  • Planning – partnering with the person to consider their thoughts about when and how they might want to go about making a change.

To be clear, MI is much more than a simple four-step checklist.  It is a complex intersection of these four processes with our core set of skills and a specific style that helps us engage in purposeful conversations that can help people change.

For more information, buy the book here or contact us at info@wiphl.org to learn more about motivational interviewing.


Three Ways to Support Your Patient’s Autonomy While Sharing Information

By Mia Croyle, MA

During the behavior change process, a skillful practitioner does not rely solely on his or her authority, expertise and knowledge to provide the motivation for a patient to make changes. Rather, the practitioner holds back on theirown expertise, using it strategically and not before the patient is ready to receive it.

Here are some tips on how you, the practitioner, can tell when a patient is ready to receive information that you have to share and how to make sure the patient stays engaged and empowered while you share it.

  1. The person asks for the information – if the patient asks you for information, that is usually a clear and obvious sign that he/she is interested in hearing what you know. Be sure to provide the information in small, digestible bites and check in with the patient for his/her understanding and reactions to the information.
  2. You ask permission to share the information – permission asking allows us the check in with the patient in a transparent way and shows that you respect their autonomy. You’ll rarely get a “No,” but be prepared to respect it if you hear it.
    Can I share some information with you?
    Is it okay with you if I tell you what we know?
  3. You reinforce the patient’s autonomy in regards to how to respond to the information
    This may or may not work for you….
    What you decide to do with this information is up to you…