1 MOTIVATIONAL INTERVIEWING FOCUSING

MOTIVATIONAL INTERVIEWING FOCUSING INSTRUMENT (MI-‐FI) version 1.0 Nina Gobat, Lauren Copeland, Judith Carpenter, Theresa B Moyers Introduction and rationale Motivational Interviewing (MI) is a collaborative, person-‐centred style of communication to elicit and strengthen a person’s motivation to change [1]. The most recent iteration of MI describes four processes through which MI is delivered, namely: engaging, focusing, evoking and planning [1]. Evoking represents the heart of MI where practitioners pay attention to the language of a client and selectively reinforce language and motivations that might move the client toward change. Skilful evoking requires a relational foundation of partnership, empathic connection and acceptance. This foundation is established through the engaging process and practitioners will attend to it throughout an MI interaction. Skilful evoking also requires a focus or direction to have been established so that practitioners are able to recognise client language that moves them toward change (change talk). The four processes are sequential in that each process builds on the previous one. MI was initially developed in the context of alcohol treatment but has since expanded into many different settings including but not limited to healthcare, criminal justice, education, sexual health, maternal and child health and social care. While behaviour change is often a core component of programmes in these setting, practitioners may also be required to enact several different tasks with conversations about change being just one of these. How best can MI be integrated into such programmes? In many instances, MI is added to programmes with well-‐developed materials and content as a method of delivering programme materials. The aspiration is for MI to inform an overall style of communicating with clients that is person-‐centred and collaborative. However, research on the mechanisms of action of MI would suggest that this is insufficient to effect behaviour change. Rather, practitioners should establish a focus on a change and then spend some time speaking about this change while moving into the evoking process. Existing measures may not adequately capture when and how this is done which limits our ability to consider how well MI has been integrated into such programmes. This observation led to the development of MIFI, a mini-‐measure of the focusing process in MI. The aim of this measures is to capture the focusing process in MI so that we can start to evaluate MI-‐informed interventions more robustly and clarify the essential elements of MI that need to be included in such a programme for it to have the best chance of impacting client outcomes. What is focusing in MI? The focusing process involves giving attention to the direction of a conversation (ref). Practitioners need to establish the focus of their conversation and may need to re-‐focus if the topic shifts into other areas. In the context of Motivational Interviewing, focusing should be a collaborative process that follows high quality engaging, through which practitioner and client goals are aligned. Alignment of goals may involve a negotiation or prioritising of different potential directions for the conversation. Alternately, it may simply involve raising a subject explicitly to ensure transparency and collaboration. The topic of conversation in MI serves as an anchor for the practitioner against which they might elicit and reinforce change talk and move into evoking. MI focusing instrument v1.0

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We have used the analogy of navigating to different islands as a way of describing the process of focusing. If each island represents a different topic of conversation, the focusing process involves consciously navigating from one island to another. When arriving at the island the practitioner and client should both be clear that they are landing on the island (i.e. will spend time on that conversation topic). When on the island, the practitioner should aim to stay on the island and make progress. In other words, the focus of the conversation should remain in one area allowing for exploration of that topic in a way that is meaningful and purposeful and developing a sense of momentum, forward movement or progress when discussing that topic. Oftentimes we notice that practitioners inadvertently shift to other discussion topics. Skilful focusing would involve practitioners noticing this shift for themselves and finding a way to return to island so that progress might be made. The concept of navigation captures a dual ability to maintain a clear directional course, while being sufficiently flexible to accommodate unexpected events arising in the interaction. The outcome of skilful focusing is efficiency in that both parties can travel further (i.e. make progress) in a briefer period of time. What makes focusing difficult? Focusing itself may not be difficult for many practitioners, particularly those who are comfortable taking the expert role or working in the directing style. The challenge for these practitioners may to ensure focusing is collaborative and that they have engaged enough with their client’s agenda. Studies have shown how practitioners who neglect their client’s agenda may need more consultation time when they realise that the topics they have been working on are not in fact their client’s priority concerns [2-‐5]. When learning to work in a more person centred style, these practitioners often worry that their client’s agenda may overwhelm them, take the conversation in directions that they are unfamiliar with or unable to address, or absorb more consultation time than they have available. At other times the focusing challenge looks different. Practitioners working in a person-‐centred way often focus on building a quality rapport with a client as a top priority, so much so that they worry about damaging that rapport by raising subjects that clients may not want to speak about. This was beautifully captured by a practitioner working with young psychotic client who said, “how can I build a good relation ship with this client while at the same time being the medication police?” The practitioner’s concern was that by raising the issue of adherence to medication they would rupture the relationship with the young client, which would inhibit their ability to work together. Consequently practitioners may avoid raising subjects, particularly if they feel a topic is sensitive or is an expression of their own agenda rather than the client’s agenda. Some examples include speaking with a pregnant woman about smoking or with a parent about their child’s weight. In social work settings, practitioners have expressed concerns with asking parents to see their child, particularly when they have spent time working on engaging that parent. A key concern for practitioners is how clients might respond. They anticipate that clients might be reluctant or ambivalent about speaking about a topic and they lack confidence in how to respond to the client so that the relationship isn’t affected. As a result practitioners may avoid raising the subject, try and raise it in a round about way or raise it but quickly back off from speaking further about it. Focusing can also be challenging when practitioners aren’t confident in their role. They may raise a topic, speak about it for a bit but wonder how much more there is to say about the topic especially if they are relying on giving of information as a way to discuss a topic. They may also get distracted by other tasks that they need to do and may decide, prematurely, that the topic has been fully explored. Practitioners who maintain focus for longer usually do so by exploring the client’s experience of the topic, asking questions about the topic and getting some context to it. This sustained attention allows the client to explore the topic further and lays the foundation for moving into the evoking process of MI. MI focusing instrument v1.0

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At times however it is the client who appears distracted or unwilling to talk about the agreed topic. Practitioners may then shift to a new topic and either return or not to the original topic. It can take some confidence on the part of the practitioner to risk re-‐establishing focus on a topic that the client seems unwilling to talk about and some practitioners worry that they are violating person-‐centeredness by doing so. Consider the following exchanges between a diabetes nurse and a client in a Diabetes clinic: Scenario 1: P One of the things the doctor wanted me to talk to you about was your weight C Hmm, everyone goes on about my weight in this clinic! P Ok, [thinks let’s talk about something else then] Are you taking the new medication we prescribed for your diabetes last time?

Scenario 2: P One of the things the doctor wanted me to talk to you about was your weight C Hmm, everyone goes on about my weight in this clinic! P It’s like people only see that about you C It really is …I mean I know I’ve got a weight problem P And you would do something about it if you could C Of course, but its not that easy P What sorts of things have worked for you in the past in terms of weight loss?

In the first scenario the diabetes nurse sensed the client’s reluctance to talk about her weight and changed the focus to a “safer” topic. In doing so, however, she was unable to fulfil the referral request, which was to discuss weight loss. In second scenario, the diabetes nurse persevered by expressing empathy with the client, allowing her to stay on topic. In doing so she was able to gently continue the conversation without forcing the client to talk about something she didn’t want to. Measures of focusing Several measures of MI are available for researchers seeking to assess fidelity to MI in their studies or to isolate elements of MI when examining its impact on outcomes. Many of these measures may also be used to train and supervise practitioners or interventionists to deliver MI. These measures offer a way of assessing both the relational and technical dimensions of an MI-‐informed interaction. However, to date, there are few measures that capture the focusing process as it unfolds throughout an MI-‐informed conversation, despite that it is a core element of an MI interaction and surprisingly difficult to perform well. Existing measures have included focusing in items direction (MITI3), guiding (MICA) or structure (MISC), however these measures do not couple practitioner skill with topic specification as are unable therefore to offer insight into the challenges we have observed with integrating MI into programmes. The measurement of focusing involves attending to what practitioners are doing explicitly. As a result scores are assigned based on evidence from practitioners verbal and non-‐verbal behaviours. This can create frustration for coders who may want to assign scores based on their perception of the practitioner’s intention. We have listed some verbal anchors for each of the global measures and assigning behaviour counts can also help coders keep their attention on what a practitioner actually does. This is important for measurement to be both reliable and valid. MI focusing instrument v1.0

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When to use the measure The measure is designed to capture the focusing process of MI and is useful if this is the process you want to assess. It may be particularly helpful for interventions with multiple foci or for single focus interventions that include multiple topic areas within them. The measure captures two dimensions of focusing: whether a practitioner can establish focus on a topic and whether they can take advantage of having established that focus to make some progress, developing depth and momentum toward change. The measure links skill with topic and coders will need to identify and define their topics in order to use the measure. The design of the MIFI mirrors MITI4.1 [6, 7] and 2 global measures from that measure are included in MIFI (partnership and empathy). This should make it easier for coders who are familiar with MITI to use this measure. However MIFI measures a different process to MITI and captures just one element of MI. It is not therefore a stand-‐alone measure of MI and should not be used as such. What this measure does not do • The measure is not designed to measure agenda mapping and currently does not capture the process of establishing focus when the purpose of a session is unclear or to be defined. • The measure does not incorporate the evoking process and is not designed to capture currently hypothesised mechanisms of action in MI (i.e. differential attention to client speech that is captured in evoking). Rather MIFI can be used as one of a number of measures when considering MI fidelity or other aspects of process research. How to use MIFI 1. Identify your topic areas 2. Randomly select a 20minute segment of an audio recording to listen to 3. Listen to the audio-‐recording and complete the behaviour count ratings (page xx) 4. Listen to the audio recording and complete the global measures (page xx) 1. Identifying topic areas The topic(s) of focus will vary across programmes and institutions and a key decision before using this measure is to decide what topics you are interested in. This will then allow you to use the measure strategically. The aim of the measure is to assess how practitioners establish and maintain focus on the topic areas that are of most interest to you and your programme’s goals. A few considerations when selecting topics: • What is the goal of the programme? Public health and healthcare interventions are generally designed with a clear purpose. This purpose will guide your selection of relevant topic areas. It will also guide your description of the topic, which is critical for reliable measurement. See appendix A for an example of a topic descriptor. • How many topic areas are you interested in? Some interventions have a single focus e.g. breastfeeding support programmes, whereas others may include multiple behavioural foci. Interventions with a single focus or goal may involve discussion of MI focusing instrument v1.0

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multiple sub-‐topics, for example, weight loss (diet, exercise etc.) and some discussions may start therefore with talk about a broad topic area and then narrow to a more specific focus. You will need to decide the level you are interested in coding to, however we recommend identifying no more than 5 topics. One way of prioritising topics would be to consider the way in which the programme anticipates MI to effect change and in what area. •

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To what extent do your topics fit the context? The “focus” of the conversation is the “work” that will be done in an interaction. There is some expectation that this will be congruent with the nature of that interaction. Therefore it would be inappropriate, for example, for the focus of an interaction aimed at encouraging breastfeeding to revolve around discussion of a neighbour’s pet. We might say that discussion about the neighbour’s pet adds to engagement, but could not in good conscience say it constituted an appropriate focus for the interaction. Note: It is completely acceptable that a certain about of informal chat would be observed in a session and we are not looking to penalise practitioners for chatting with clients. But we are looking to see that a greater proportion of the session time is focused on the agreed topic. Different programmes also have different tolerance for integrating and addressing unanticipated topics that are raised by clients. You will need to decide whether or not your practitioner could work with these and how you will code them. For example, you might assign a topic category of “client topic” to identify if and when one was raised and how the practitioner responded to it. If you are looking for MI to effect change, could a practitioner recognise change talk in relation to your topic? In MI-‐informed interventions, topic areas are framed as areas where change is desired or anticipated. These may be behaviours, for example diet, exercise, smoking or breastfeeding, but may also be less clearly framed as behaviours e.g. acceptance of loss or choosing a vocational pathway. Topics that are too broad or vague e.g. “improving well-‐being” or “hypertension management” may be more difficult to identify change talk against. Given that the focusing process sets a stage for evoking, it is worth considering ease with which practitioners might be able to move into that process. Note: you may wish to track how practitioners focus on topic areas where you do not anticipate MI being used e.g. “discussion of programme materials.” Clearly there is no need here to consider whether a practitioner could identify change talk in relation to such a topic. How to identify a random 20min sample Note how long your audio-‐recording is for. If the recording is 20minutes, simply listen to the full audio. If the audio recording is more than 20minutes: (a) subtract 20minutes from your total, (b) use a random number chart to tell you which number to start at; (c) start your recording from that number for 20minutes. For example, if you have an audio-‐recording that is 60minutes long. You would subtract 20 (60-‐20=40) and then identify a random number between 1 and 40. You would start listening to your audio from that number.

MI focusing instrument v1.0

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GLOBAL MEASURES These subscales capture a gestalt or overall impression of different dimensions of focusing. To assign a rating, you will listen through to the audio recording and allocate a number that best fits with your overall impression. Please use the manual at all times to make your judgment. The rating procedure is as follows: • Look at the verbal anchor chart for each global measure. • Start at the mid-‐point of the scale, which assumes a neutral position • Decide if, based on what you have heard the practitioner do, they would move up or down the scale. • Identify a number range, for example, you might think a practitioner is somewhere between a 1 and a 3. • Read the detailed verbal anchors with examples to help decide which number you would allocate. Four global measures: 1. Holding focus: the extent to which a practitioner is able to sustain ongoing attention on an agreed topic area. 2. Developing depth and momentum: the extent to which sustained attention on a topic allows for momentum and depth of topic exploration to develop 3. Partnership1: the extent to which the practitioner conveys an understanding that expertise and wisdom reside mostly within the client. 4. Empathy2: the extent to which the practitioner understands or makes an effort to grasp the client’s perspective and experience

1 From MITI4.17. Moyers, T.B., J.K. Manuel, and D. Ernst, Motivational Interviewing Treatment Integrity Coding Manual 4.2. 2014. MI focusing instrument v1.0

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Holding focus This sub scale captures the extent to which a practitioner is able to take advantage of the focus that they have established and to hold attention on the topic, using skills to do so. The practitioner aims to maintain continuity of focus on the discussion topic by framing the client’s narrative in the context of the topic being discussed. Practitioners may allow the conversation to expand around the topic or to narrow into a specific part of the topic, but in doing so they do not allow the conversation to drift to a new topic. To use the island analogy, this global is concerned with being on the island and staying there. For example, if the practitioner notices they are falling off the island, they will course correct back onto the island and re-‐frame their responses in the context of the agreed topic. 1

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Practitioner is unable to hold focus on the topic for sufficient periods

Practitioner may hold focus for brief periods, but these are Insufficient for progress to be made.

Practitioner is generally able to hold focus on a topic and frame questions or reflections in context to make progress.

Practitioner is able to hold focus on a topic with some consistency. May miss opportunities to do so.

Practitioner strategically using skill to stay on topic and consistently frames responses in context of the topic.

The global rating here relates to the times when practitioners are holding focus on one topic at a time. Behaviour counts will give you some steer as to where in the interaction you will find evidence of a practitioner doing this. In some interactions you may have very little evidence to base your judgment on. You should nevertheless base your judgments on the evidence available from that section of the audio recording. Higher scores are allocated to practitioners whose use of skill results in sustained attention on the topic being discussed. They may allow the discussion to expand around the topic being discussed but will explicitly link other topic areas to the primary topic and will maintain continuity of focus in this way. For example, when talking about alcohol reduction practitioners will allow the discussion to develop in other related areas such as the person’s social network but will consider such discussion in the context of their alcohol use. In this way practitioners use their skills to shape the conversation allowing the topic of conversation to act as a frame for discussion about it. Practitioners who receive low scores on this scale fail to take advantage of the focus that they have established with the client. They may become scattered or distracted once they have established a focus, allow the conversation to move off topic or inadvertently move the conversation off topic themselves. Practitioner responses may reinforce other aspects of the clinical interaction so that they fail to attend to what the client is saying that relates to the topic that they have established focus on. Verbal anchors 1. Practitioner is unable to hold focus on the topic for sufficient periods. Examples • May establish focus on a topic but not discuss it for any period of time • May briefly provide information and then shift to a new topic. • Does not use skill to frame client responses to the agreed topic. • Conversation may appear disorganised with lack of structure 2. Practitioner may hold focus for brief periods, but these are Insufficient for progress to be made. MI focusing instrument v1.0

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Examples • Focus is not sufficiently sustained that topic can be explored in any depth. • May be rapid movement across conversation topics. 3.

Practitioner is generally able to hold focus on a topic and frame questions or reflections in context to make progress.

Examples • Use of skill usually able to ensure focus on topic is maintained. • Frames responses in the context of the agreed topic • Misses opportunities for holding focus. • Some evidence of practitioner “course correcting” but using skill to maintain focus on discussion topic. 4. Practitioner is able to hold focus on a topic with some consistency. May miss opportunities to do so. Examples • Use of skill mostly allows practitioner to hold focus on topic. Conversation may wander off topic but practitioner notices that and brings it back on topic. • May be some instances where practitioner’s response is inflexible when conversation addresses linked, but potentially tangential content related to the topic. In this way the practitioners’ inflexibility does not allow the conversation to expand around the topic so that progress might be made.

5. Practitioner uses skill strategically to stay on topic and consistently frames responses in context of the topic. Examples • Use of skill consistently frames the conversation in the context of the agreed topic. • When goes off topic, able to link client statements back to re-‐focus on topic without inhibiting the conversational flow • Remains sufficiently responsive that there is flexibility in the conversation for it to move toward other areas, but the practitioner’s response maintains sustained attention on the topic. P: what would that be like for you if you didn’t drink around them? C: What do you do for a living? P: I’m a psychologist C: What would that be like for you if you couldn’t be a psychologist? P: And that’s what its like for you with drinking, you can’t even imagine. (note how this statement explicitly links the focus back to drinking, the target behaviour)


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Developing depth and momentum This sub scale captures the extent to which a practitioner is able to take advantage of the focus that they have established to make progress in understanding the client’s perspective about that topic and develop depth and momentum toward change. This requires the practitioner to hold attention on the topic, using skills to explore the topic and develop momentum toward change and/ or strengthening commitment to a particular course of action (e.g. maintaining breastfeeding). To use the island analogy, this global is concerned with being on the island and making progress. 1 Practitioner is unable to develop depth or momentum. .

2 Practitioner responses are Insufficient for depth or momentum to develop.

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Practitioner responses allow some exploration of the topic but struggles to move beyond superficial exploration so no real momentum develops.

Practitioner is able to develop some depth of discussion with some momentum. May miss opportunities to explore topic in this way.

Practitioner strategically using skill to explore topic such that depth and momentum can develop.

The global rating here relates to the times when practitioners are holding focus on one topic at a time. Behaviour counts will give you some steer as to where in the interaction you will find evidence of a practitioner doing this. In some interactions you may have very little evidence to base your judgment on. You should nevertheless base your judgments on the evidence available from that section of the audio recording. Higher scores are allocated to practitioners whose use of skill results in the topic being explored and new perspectives may be introduced. Practitioners who do this well will ‘dig in’ to the topic, getting a detailed picture of the client’s experience of that topic and deepening exploration of it such that momentum toward change is developed or commitment to a positive behavior is deepened. Deeping involves exploring how the topic has meaning and relevance to the patient. Momentum refers to a future orientated perspective such that the client and practitioner might consider moment or change. Explicit reference to congruence between values and behavior or affirmation of clients may also develop depth and momentum. Practitioners who receive low scores on this scale fail to take advantage of the focus that they have established with the client. They may struggle to move beyond superficial discussion or may rely heavily on providing information, self disclosure of praise to make progress. Verbal anchors 1. Practitioner is unable to develop depth or momentum. Examples • May keep discussion at superficial level • No attempts to deepen the discussion. • Has no curiosity about the topic. • Unable to respond in a way that might be meaningful for the client. • Consistently shuts down client contributions to the discussion that would lend depth. 2. Practitioner responses are Insufficient for depth or momentum to develop. MI focusing instrument v1.0

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Examples • Discussion remains superficial or with a strong reliance on information provision. • May rely on self-‐disclosure or offering opinions about the topic. • May offer praise (e.g. “good job”) that serve to keep discussion at superficial level • Has little curiosity about the topic. • Weak attempts to deepen discussion or at client centred listening. • May shut down client contributions to the discussion that would lend depth. 3. Practitioner responses allow some exploration of the topic but struggles to move beyond superficial exploration so no real momentum develops. Examples • Mixed efforts at demonstrating curiosity about the topic. • Evidence of client-‐centred listening, which allow some topic exploration. • Focus may centre on understanding the history of the topic or past experience of it. • May rely on information provision, which prevents depth and momentum to develop. • Responds inconsistently to client contributions that would lend depth and momentum to the discussion. 4. Practitioner is able to develop some depth of discussion with some momentum. May miss opportunities to explore topic in this way. Examples • Use of skill allows practitioner to hold focus on topic such that deeper exploration, momentum and depth start to develop. • Demonstrates some curiosity about the topic • May consider congruence between client’s values and behaviour regarding topic, e.g. by asking about this or by affirming values consistent with positive behaviour. • Practitioner responses usually encourage a future orientated perspective, e.g. questions that encourage forward thinking or envisaging. • Good efforts to develop depth and momentum but may miss opportunities for developing this further. • Usually responds pro-‐actively to client contributions that would lend depth and momentum to the discussion 5. Practitioner strategically using skill to explore topic such that depth and momentum can develop. Examples • There is a sense of forward movement, or momentum developing in the conversation and that progress is being made toward making a decision or taking action. • Consistently demonstrates curiosity about the topic • Explicitly considers how change may be consistent with client’s values or affirms congruence. • Consistently phrases questions such that they allow the client to envisage change, e.g. “what would it be like for you if you were able to ….?” • Consistently responds pro-‐actively to client contributions that would lend depth and momentum to the discussion MI focusing instrument v1.0

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Partnership2 This scale is intended to measure the extent to which the practitioner conveys an understanding that expertise and wisdom reside within the client.

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Practitioner actively assumes the expert role for the majority of the interaction with the client. Collaboration or partnership is absent.

Practitioner superficially responds to opportunities to collaborate.

3 Practitioner incorporates client’s contributions but does so in a lukewarm or erratic fashion.

4 Practitioner fosters collaboration and power sharing so that client’s contributions impact the session in ways that they otherwise would not.

5 Practitioner actively fosters and encourages power sharing in the interaction in such a way that client’s contributions substantially influence the nature of the session.

Practitioners high on this scale behave as if the interview is occurring between two equal partners, both of whom have knowledge that might be useful in solving the change under consideration. Practitioners low on the scale assume the expert role for a majority of the interaction and have a high degree of influence in the nature of the interaction. Verbal Anchors 1. Practitioner actively assumes the expert role for the majority of the interaction with the client. Collaboration or partnership is absent. Examples: • Explicitly takes the expert role by defining the problem, prescribing the goals, or laying out the plan of action • Practitioner actively forces a particular agenda for the majority of the interaction with the client Follows their agenda, moving swiftly across topic areas such that topic shifts may seem sudden or unexpected. • Denies or minimizes client ideas • Dominates conversation • Argues when client offers alternative approach • Often exhibits the righting reflex 2. Practitioner superficially responds to opportunities to collaborate. Examples: • Practitioner rarely surrenders the expert role • Minimal or superficial querying of client input • Often sacrifices opportunities for mutual problem solving in favour of supplying knowledge or expertise 2 . From Moyers, T.B., J.K. Manuel, and D. Ernst, Motivational Interviewing Treatment Integrity Coding Manual 4.2. 2014, with permsission. MI focusing instrument v1.0

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• • •

May be an over-‐reliance on giving information without opportunity for the client to consider interpretation. May use self-‐disclosure and information in an effort to persuade or convince the client. Minimal or superficial responses to clients potential agenda items, knowledge, idea, and /or concerns Occasionally may correct the client or disagree with what the client has said

• 3. Practitioner incorporates client s contributions but does so in a lukewarm or erratic fashion. Examples: • May take advantage of opportunities to collaborate, but does not structure interaction to solicit this. • May seem passive in interaction – not making efforts to work in partnership directly but not obstructing that either. • Misses some opportunities to collaborate when initiated by the client • The righting reflex is largely absent • Sacrifices some opportunities for mutual problem solving in favour of supplying knowledge or advice • Seems to be in a standoff with the client; not wrestling and not dancing 4. Practitioner fosters collaboration and power sharing so that client s contributions impact the session in ways that they otherwise would not. Examples: • Some structuring of session to ensure client input -‐ may offer options or choice about focus. • Demonstrates sensitivity to client preferences when establishing focus. • May invite participation or ask permission to raise a topic • May directly solicit focus from client. • Engages client in problem solving or brainstorming • Does not attempt to educate or direct if client “pushes back” with not wanting to focus on topic. 5. Practitioner actively fosters and encourages power sharing in the interaction in such a way that client s contributions substantially influence the nature of the session. Examples: • Genuinely negotiates the agenda and goals for the session. For example ,may elicit client’s view on the focus of the conversation and explicitly consider alternate directions. • Indicates curiosity about client ideas through querying and listening • Consistently demonstrates and retains sensitivity to whether the client is willing to address a focus, for example, by offering choice or seeking to understand. • Facilitates client evaluation of options • Explicitly identifies client as the expert and decision maker • Tempers advice giving and expertise depending on client input • Practitioner favours discussion of client s strengths and resources rather than probing for deficits


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Empathy3 This scale measures the extent to which the practitioner understands or makes an effort to grasp the client’s perspective and experience (i.e., how much the practitioner attempts to “try on” what the client feels or thinks). Empathy should not be confused with sympathy, warmth, acceptance, genuineness, support, or client advocacy; these are independent of the Empathy rating. Reflective listening is an important part of this characteristic, but this global rating is intended to capture all efforts that the practitioner makes to understand the client s perspective and convey that understanding to the client. This scale measures the extent to which the practitioner understands or makes an effort to grasp the client s perspective and experience (i.e., how much the practitioner attempts to “try on” what the client feels or thinks). 1 2 3 4 5 Practitioner gives little or no attention to the client s perspective.

Practitioner makes sporadic efforts to explore the client’s perspective. Practitioner ’s understanding may be inaccurate or may detract from the client’s true meaning.

Practitioner is actively trying to understand the client’s perspective, with modest success.

Practitioner makes active and repeated efforts to understand the client’s point of view. Shows evidence of accurate understanding of the client’s worldview, although mostly limited to explicit content.

Practitioner shows evidence of deep understanding of client’s point of view, not just for what has been explicitly stated but what the client means but has not yet said.

Practitioner s high on the Empathy scale show evidence of understanding the client’s worldview in a variety of ways including complex reflections that seem to anticipate what clients mean but have not said, insightful questions based on previous listening and accurate appreciation for the client s emotional state. Practitioner s low on the Empathy scale does not appear interested in the client s viewpoint. Verbal Anchors 1. Practitioner gives little or no attention to the client s perspective. Examples: • Asking only information seeking questions • •

Probing for factual information with no attempt to understand the client’s perspective

2. Practitioner makes sporadic efforts to explore the client s perspective. Practitioner ’s understanding may be inaccurate or may detract from the client s true meaning. Examples: • Offers reflections but they often misinterpret what the client had said • Displays shallow attempts to understand the client • May seek to educate or correct client’s reluctance to talk about a topic. 3

From Moyers, T.B., J.K. Manuel, and D. Ernst, Motivational Interviewing Treatment Integrity Coding Manual 4.2. 2014, with permission. MI focusing instrument v1.0

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3. Practitioner is actively trying to understand the client s perspective, with modest success. Examples: • May offer a few accurate reflections, but may miss the client s point • Makes an attempt to grasp the client s meaning throughout the session 4. Practitioner makes active and repeated efforts to understand the client s point of view. Shows evidence of accurate understanding of the client s worldview, although mostly limited to explicit content. Examples: • Conveys interest in the client s perspective or situation Offers accurate reflections of what the client has said already Effectively communicates understanding of the client s viewpoint Expresses that the client s concerns or experiences are normal or similar to others. May explore client’s reluctance to talk about a topic, seeking to understand. 5. Practitioner shows evidence of deep understanding of client s point of view, not just for what has been explicitly stated but what the client means and has not said. Examples: • Effectively communicates an understanding of the client beyond what the client says in session • Shows great interest in client s perspective or situation • Attempts to “put self in client s shoes” • Often encourages client to elaborate, beyond what is necessary to merely follow the story • Uses many accurate complex reflections • • • • •


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BEHAVIOUR COUNTS One of the following behaviour counts is assigned each time the practitioner speaks: • Establishing focus (EF) • Holding focus (HF) • Off topic (OT)

Usually a single code is assigned. The exception to this is for the EF code where more than one EF code may be assigned. Establishing focus (EF) The EF code is assigned to practitioner behaviours that serve to establish focus. Focus might be established in the following ways: 1. Topic raised by client or patient. The practitioner responds to client cue that then draws attention to the topic. 2. Topic raised by practitioner who may establish focus in a number of ways: • Questioning, e.g. “ How are you getting on with …?” • Permission asking, e.g. “Could we spend some time talking about …?” • Signposting, e.g. “Lets spend a bit of time thinking about…” • Providing Information Therefore the establishing focus code is also assigned one of four skills: Meta statement (EF-‐meta), cue (EF-‐ cue), question (EF-‐Q), and inform (EF-‐I). Meta-‐statement (EF-‐meta) Practitioners may use signposting statements to indicate a focus on a particular topic. These statements have a quality of being one step removed from the conversation, pointing to what is happening in the conversation. They may include phrases such as “lets talk about” or “lets think about.” Signposting can take the form of questions (e.g. “how about we spend some time talking about this?”) or statements (e.g. “lets talk about this”). Responding to client cues (EF-‐Cue) Practitioner responds to client cues, thereby drawing attention to a particular topic. Client cues may be verbal or visual, and may vary in their degree of subtlety or directness. For example, a client may ask a question, make a request, or describe an experience e.g. “I’m struggling with…”. Practitioners may also pick up client cues from the patient’s story, particularly where a topic may not have been that clearly formulated from the outset. The EF-‐Cue code is usually assigned where practitioner respond to client using reflective listening statements. They may also be assigned to observations made by practitioners, e.g. “from here it looks as though baby is feeding well” MI focusing instrument v1.0

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Questioning (EF-‐Q) Practitioners may simply ask about a particular topic or may ask permission to discuss it. § Practitioner asks question, “ How are you getting on with …?” § Practitioner asks permission, “Could we spend some time talking about…?” Inform (EF-‐I) Providing information on a particular topic establishes focus on that topic. Where practitioners offer an opinion or self-‐disclose this is also coded as EF-‐information (e.g. “I would have preferred if you had come tonight”). To capture the different ways practitioners might respond to establish focus, EF codes are qualified in the following way: Box 1: EF behaviour counts summary Meta-‐statement – structuring statement that explicitly draws attention to a particular focus. E.g. “Lets just step back for a moment and spend some time talking about that in more detail” (NOTE: EF-‐meta will trump all) Cue-‐ the client raises the identified topic either through a question to the practitioner, by telling a story or taking about a problem/success they are having. EF-‐cues are usually assigned when the practitioner responds using a listening statement or by making an observation. Questions that are also cues are coded as EF-‐Q. Question – questions raised by practitioner which could be broad: e.g. “tell me about (topic)?” or specific: e.g. “what concerns you most about….?” Inform -‐ practitioner provides information to the client about the identified topic. Personal opinion or self-‐disclosure is also coded as information.

EF-‐meta

EF-‐Cue

EF-‐Q EF -‐ I

Where a combination of EF behaviours is used to establish focus, all EF behaviours are coded in one interaction. Note: EF-‐meta will trump both EF-‐Q and EF-‐info. Example 1: Practitioner draws on what has been said to signpost an emerging topic: “You’ve mentioned that a few times now (EF-‐Cue). Would it be helpful if we spent some time talking about …? (EF-‐meta)” Example 2: Practitioner makes a reflection to steer the conversation in the direction of a topic and then follows this up with permission. “You might consider doing something about smoking, if it would make a difference to your fitness (EF-‐ Cue). How do you really feel about smoking? (EF-‐question)” Example 3: Practitioner makes an observation and follows this up with a question, e.g. breastfeeding support: “From here it looks as though she is feeding well (EF-‐Cue). How are you getting on with feeding baby generally? (EF-‐Q)” Once 3 interactional exchanges (i.e. a client statement and practitioner response) have been completed, resulting in 3 EF codes in a row, we assume the practitioner has established focus and HF codes are then assigned to track the extent to which focus is then maintained. For example: MI focusing instrument v1.0

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Practitioner: You’ve mentioned that a few times now (EF-‐Cue). Would it be helpful if we spent some time talking about smoking? (EF-‐meta) Patient: I thought this might come up today. I know I need to do something. Practitioner: Ok, so lets allocate some time to speaking abut this. (EF-‐meta) Patient: ok, why not. Practitioner: So how do you really feel about smoking? (EF-‐Q) Patient: It drives me crazy. Practitioner: How so? (HF) Patient: ……

Holding focus (HF) Aim of the holding focus code is to capture practitioner responses that influence the direction of the conversation so that it stays focused on the agreed topic of change. These behaviour counts are assigned to the response practitioners make after an agreed focus has been established. Note: you may start coding with an HF code if at the point you start listening on the audio recording it is clear that the conversational focus has been established. Holding focus may take the following forms: holding focus (HF), holding focus neutrally (HF-‐N), holding focus plus (HF+), holding focus minus (HF-‐). Holding focus (HF) Practitioner Holding focus neutrally (HF-‐N) This code is allocated when the practitioner’s response neither moves the conversation forward not blocks it. It is usually allocated when the coder has a sense that the practitioner may be forwarding the conversation because of the continuity of discussion that has developed but is unclear based on the content of what they have said whether they are still on topic or not. In this case we give the practitioner the “benefit of the doubt”. For example, practitioners may offer encouragement “you’re doing so well” or information that might relate to the topic under discussion, but might also be taking it in another direction. These codes are allocated sparingly and usually after 2 or 3 utterances it becomes clear whether the conversation is moving off topic or whether focus on the topic is held. Holding focus plus (HF+) This code is allocated when a practitioner acts clearly and unequivocally to move the conversation forward, developing depth or momentum toward change. These codes are usually allocated when practitioners ask questions that allow the client to contribute meaningfully, to reflect more deeply or to consider the actualities of change in their lives. Holding focus minus (HF-‐) This code is allocated when a practitioner acts clearly to prevent the conversation from developing depth or momentum toward change. These codes are usually allocated when practitioners revert to providing information, personal opinion or self-‐disclosure from an expert position. MI focusing instrument v1.0

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Box 2: HF behaviour counts summary On topic – the Practitioner’s response serves to further the discussion about the agreed topic such that the client continues talking about that same topic: e.g. “how do you feel about smoking?”; “you’ve done this before and know how much effort it takes” Neutral – the Practitioner’s response neither furthers the discussion nor takes it off course. This code may also be allocated if the rater is unclear whether a practitioner statement maintains the focus or takes it off topic (benefit of the doubt rule) Plus – this HF is coded for practitioner statements clearly designed to develop depth or momentum. For example, questions that encourage the client to think deeply, envisage change or those that emphasise and encourage choice about the change at hand. Minus – an HF code that clearly obstructs forward movement, usually self-‐disclosure or unsolicited advice or information.

HF

HF-‐N

HF+

HF-‐

Other topic (OT) Any discussion that is not related to the pre-‐determined topics is coded as other topic (OT). Other topics include: • Topics that are relevant to the programme or intervention but not ones we are interested in measuring. For example, programme tasks unrelated to the intervention being discussed, or other topics of interest or relevance but that don’t further the aim of the programme being evaluated (e.g. discussion of birth experience in a breastfeeding intervention) • Chat – informal, friendly discussion that helps establish relationship and can set an informal, relaxed tone to the interaction that follows. Chat can be heard at any stage of an interaction, e.g. “gosh, does that dog bark all day long?” • Salutations – greetings or closings. These serve an important function in developing relationship, but are coded here as other topic. No code Client statements such as “yeah” or “right” that do not interrupt the practitioner sequence are considered facilitative statements, and should not interrupt the practitioner utterance. Practitioner statements such as “yeah” or “right” that do not interrupt the clients sequence are considered facilitative statements and are not coded. Behaviour count coding conventions In order to follow the pattern of focusing during the session, one behaviour count is assigned to each practitioner response. • Establishing focus is assigned the first time an identified topic is mentioned. Identify which topic is raised at the start of an EF sequence. For example, EF-‐ breastfeeding. This allows you to track how the focus shifts in sessions where multiple topics might be raised. • Once there have been 3 establishing focus codes assigned then the practitioner is holding focus (HF) and an HF code is assigned thereafter. Note: HF is only assigned once there have been 3 EF codes in a row. HF-‐N, HF+ and HF-‐ all perpetuate the HF string.


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•

•

An OT code is assigned when the practitioner response is no longer directed at the behaviour change. 3 OT codes in a row will break the HF chain but one or two codes will not and are flickers in the holding focus chain. If other topic (OT) is assigned 3 times then the practitioner is said to be no longer focusing on the agreed topic. Any efforts to re-‐establish focus will receive a new EF code.


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FINAL SCORING Summarising global scores • Global measures are assigned a score from 1-‐5 Summarising behaviour counts • Summarise behaviour counts to show a string of counts. • We are interested in the sequence of counts as this offers insight into focus being established on a topic and then maintained. Therefore add your behaviour counts together making sure you can still follow the pattern of discussion. • When stringing together HF codes, include HF-‐N and HF+ or HF-‐ in your string. You can ignore any OT codes provided they don’t break the string of HF codes. Add the OT codes for a total HF string in brackets. • Where an OT code breaks an EF cluster, you should report this as it offers some insight into why focus was not established. For example: OT OT EF-‐smoking-‐ info EF-‐info EF-‐question HF HF-‐N OT HF HF+ HF+ EF-‐smoking-‐cue EF-‐meta EF-‐Q HF OT OT OT OT

2OT 3EF-‐smoking

5HF (1OT)

3EF-‐ smoking

1HF

5OT

How much discussion was on-‐topic – your behaviour counts will guide this judgment A score is allocated for how much discussion was observed for each topic of interest and on other topics, as follows: 1 Hardly, if at all – may be a few exchanges but no more.

2 A little – about a quarter of the time (roughly 5 mins)

3

4

About half of the time (roughly 10mins)

Much of the time – less than three quarters of the time (roughly 15 mins)

5 Most of the time – at least three quarters if not all of the time.

How often did the practitioner establish focus – your behaviour counts will guide this judgment For each topic of interest, note how many times the practitioner established focus on a topic, i.e. the number of times you have 3 in a row EF counts MI focusing instrument v1.0

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MIFI Coding sheet AUDIO-‐RECORDING ID CODER ID TOPIC(S):

Topic 1 2 3 4 5

Proportion score

Other topic

Number of times EF n/a

GLOBAL MEASURES Holding focus Depth & momentum Partnership Empathy

1

2

3

4

5

Coding notes

BEHAVOUR COUNT SUMMARY:


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MIFI TOPIC DESCRIPTION STUDY STUDY AIM TOPIC 1: …………………………………………………………………………………………………………………………………………… Description: TOPIC 2: …………………………………………………………………………………………………………………………………………… Description: TOPIC 3: …………………………………………………………………………………………………………………………………………… Description: TOPIC 4: …………………………………………………………………………………………………………………………………………… Description:


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APPENDIX A: TOPIC DESCRIPTOR EXAMPLE MIFI TOPIC DESCRIPTION STUDY MAM-‐KIND STUDY AIM To promote breastfeeding maintenance among women who choose to breastfeed TOPIC 1: Feeding baby………………………………………………………………………………………………………………… Description: Any talk of breastfeeding or bottle or formula feeding, including: • Intention to breast/ bottle feed or experience of breast/ bottle feeding • Early breastfeeding experiences, e.g. cluster feeding • How to breastfeed, techniques, positioning, feeding in public • Size of breast liked with feeding, maternity bras etc. • Benefits of feeding (e.g. loosing weight, uterus contracting, protection from cancer etc). • Drawbacks of feeding (e.g. partner feeling excluded) • Support for feeding baby from partner, family, friends, and social network, peer support groups. • Discomfort when feeding, e.g. painful or cracked nipples • Signs that baby is feeding well – e.g. baby poo, wet nappies, weight gain • Sleep linked with breastfeeding, for example, baby waking more often for a feed, or mum struggling with sleep because of feeding. • Discussion of co-‐sleeping to promote breastfeeding • Antenatal care and what they have been told about breastfeeding • Skin-‐to-‐skin in context of breastfeeding – so not all discussion of skin-‐to-‐skin is relevant. • Strategies for continuing to breastfeed when back at work, e.g. expressing milk TOPIC 2: MAM-‐KIND programme discussion …………………………………………………………………………………… Description: Any talk of the Mam-‐kind programme including peer supporter role, visits, logistical and practical arrangements for these, purpose of the programme and/ or information they may already have received, e.g. during study recruitment. • Discussion of peer supporter role • What mum can expect in terms of the programme, e.g. regularity of visits or contact; different forms of being contacted e.g. texts • What mum knows about the programme. • Timeline – when peer supporter will visits – practitioner might use visual chart • Arrangements for how to notify when baby born • Arrangements to meet peer supporter MI focusing instrument v1.0

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References 1. Miller, W.R. and S. Rollnick, Motivational Interviewing (3rd edition): Helping people change. 2012, USA: Guilford Press. 2. Gobat, N., et al., What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation. Patient Educ Couns, 2015. 98(7): p. 822-‐9. 3. Beckman, H.B. and R.M. Frankel, The effect of physician behavior on the collection of data. Annals of Internal Medicine, 1984. 101(5): p. 692-‐6. 4. Mauksch, L.B., et al., Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Archives of Internal Medicine, 2008. 168(13): p. 1387-‐95. 5. Marvel, M.K., et al., Soliciting the patient's agenda: Have we improved? Journal of the American Medical Association, 1999. 281(3): p. 283-‐287. 6. Moyers, T.B., et al., The Motivational Interviewing Treatment Integrity Code (MITI 4): Rationale, Preliminary Reliability and Validity. J Subst Abuse Treat, 2016. 65: p. 36-‐42. 7. Moyers, T.B., J.K. Manuel, and D. Ernst, Motivational Interviewing Treatment Integrity Coding Manual 4.2. 2014.


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