Hi, everybody. My name is Antoine Ndwehi. I'm going to be presenting on Motivation to Viewing, which I'm going to call it M.I. Israel, the whole presentation, Practices from the Heart, and I will specifically mention what I'm referring to when I say Practices from the Heart. I'm at the University of Pittsburgh School of Medicine. These are my disclosures and research funding, and I will be mentioning them also at the end, and also including the royalties for academic books, as well as royalties from Oakstone CME. All right, so this is the first slide that shows really the progression of Motivation to Viewing over the course of the years. Originally, Motivation to Viewing was conceptualized back in the late 80s, and the first book that came out summarizing the articles and the literature at that time about Motivation to Viewing was in 91, which was the first edition of Motivational Interviewing. Here, I wanted to show you how really the Motivation to Viewing has evolved and really progressed over the course of years. We're in the fourth edition at this point in time, and originally, Motivation to Viewing was conceptualized as the approach to really help people strengthen their motivation for change, addressing the ambivalence, and also strengthening people's commitment to change through eliciting more change talk. But here, I wanted to show you from that slide also that we have really, over the course of the years, in a way, learned so much about the processes and the mechanisms involving Motivation to Viewing and how it has really progressed from back in 91 to now 24. In fact, the last edition came out, which is the fourth edition in 2023, and that edition that has been published by the co-founders of Motivation to Viewing, Dr. Bill Miller and Dr. Stephen Rohnig, and really conceptualized Motivation to Viewing across the whole system. What I'm referring to is that not really particularly just in the context of behavioral medicine, but also in the context of medicine in general, also in the context of any sort of interpersonal connections. I'm going to talk a little bit more later on about the applications of Motivation to Viewing over the course of the years and how all these applications have really evolved with a significant science base, as well as really keeping and maintaining the core, the humanizing aspect of really the practice of Motivation to Viewing. So the question is that what have we been learning? And I'll tell you that we've learned a lot over the course of the years, and we keep learning. This is how we look at it, and we have an open mind to really still look at different ways to better understand how Motivation to Viewing works, and the mechanisms, and really the different aspects of it, and how we could really improve its application in the real world, whether we're talking about clinical care, or different aspects of counseling, or with different populations, with a lot of diverse populations particularly, and also how Motivation to Viewing fits in very well with social justice, within the social justice, and within really the ability for us to really be there for the patients, regardless of what their background is, and where they are coming from. And I will discuss that in details later on about also the cross-cultural applications of Motivation to Viewing that continues to be evolving over the course of the years. So again, we are still learning, and we're going to continue learning here, and with the hope that we will bring these learning experiences to the practitioners across the healthcare system, as well as different areas in life. This is really a slide that I wanted to show you that is really very, to me, was very much inspiring and fundamental, and it was in the first edition of my Motivation to Viewing book in 1991. At that time, the first edition was focusing on addictive behaviors. And in the preface, Dr. Bill Miller and Dr. Steve Rolnick talk about the people that they were really training, mentioning about a word of informed consent. And what are they referring to is basically that, look, this approach that you're going to be learning, this style of Motivation to Viewing, and this clinical presence that you're going to have with patients is very likely to change you. So we're talking about really a very powerful statement, and they talked about really what Motivation to Viewing is about, how it approaches people who are struggling with behavioral change. Fundamentally also, it really emphasizes that its purpose is not to change people's style and who they are. At the same time, through the practice of Motivation to Viewing, people also realize that the approach itself changes the way they look at themselves, they look at the life, they approach patients in their care in a different way. A different way is really a transformative way, a way that is really very much related to learning how to grow and how to really be more aware of your own value system. And this is what they are referring to about the approach likely to change you and change how you look at real life in general. And my journey with Motivation to Viewing is fascinating because I've started learning Motivation to Viewing back in 91, when I had a great mentor at that time who introduced me to the approach, which I had no idea of what it was, and introduced me to the first edition of the book Motivation to Viewing. And really at that time, this coincided with my interest in working with people who have addictive disorders. And as a result of that, I've started really practicing it with that population, and I've seen an amazing response to my approach of really listening and being present, listening to people's stories and being present there with them and meeting them where they are. And my path, you know, and my journey towards really that clinical transformation happened while I was really in training at that time. And you're talking about back in 92, 93. And the clinical transformation was really accompanied by that personal transformation, my approach to how I work with patients, but also my own self-reflections on what I really do and how I do it. And clearly, as you can tell, and I've talked about really briefly about that, and I'm going to go into details about what Motivation to Viewing is about, and remember, you know, the title I mentioned about practices from the heart, is it gives a lot of that compelling argument and framework for integrating a humanistic approach of really the being present with person, the unconditioned positive regard, the genuineness, and I'm going to talk about the accurate empathy, as well as it is grounded in really empirically validated practices. So we talk about really science that has merged within that humanistic approach. And as you can see here, that my really evolution throughout the years in learning MI and being transformed, you know, led to a few publications, one publication back in 2014, Motivation to Viewing, a guide for medical trainees, which was a collaboration with medical trainees who have learned MI and practiced MI. And then I talked about really my approach to addiction practice and how to humanize it, and MI has been a huge part of it. And the Motivation to Viewing in HIV care that we published back in 2020, about specifically how Motivation to Viewing can be used in HIV care. And most recently, we published the second edition of the Motivation to Viewing, a guide for medical trainees back in 2023, which was really very much more, in a way, expended on really the application of MI across the healthcare system. And in fact, you know, a lot of medical trainees have been involved in the writing, you know, process. So what is the context and roots of MI when we talk about that? First and foremost is the accurate empathy. And what I'm referring to the accurate empathy is that ability for people to, ability for the practitioners to really transpose themselves into people's world and really understand where they are coming from and what they are struggling with. And this is really very crucial because the accurate empathy has been developed very early on by Carl Rogers, the person-centered approach back in the 50s, and talks about, you know, that the importance of being present with the patient, being clinically present, the listening. Obviously, the accurate empathy is really fundamentally about the deep, mindful listening. And without that, you know, it would not be really called like reflective listening, you know, and reflective, empathic listening. And I'll talk about it in details here. And interestingly enough, that there has been a lot of studies that have demonstrated that even one session of MI can have a significant impact. So the unexpected impact of one really MI session, and it can be done alone. And what really guides that is what they call the relational piece. The relational piece of MI is that spirit that I'm going to talk about in details what it means. But most importantly here, when we're talking about the medical practitioner and therapist, the style that they have matters the most. And I'm going to discuss how it matters the most and what sort of a style, whether we're talking about an empathic style versus confrontational style, authoritarian style. When we talk about the empathy skills, you know, that I mentioned the accurate empathy, which is really a big part of the relational component of MI, the person-centered approach, you know, and that Rogers has conceptualized, which is based on the genuineness, unconditional positive regard and accurate empathy. And that is really founded in really the deep and mindful listening. As really Steve Rolnick will mention, when you're really with a patient, you have, you present yourself with that curious and itchy mind that you want to know more about the person. You want to know more about the patients. You want to dig deeper and understand better what they are really going through, which is really very much tied to that accurate empathy that I was describing. And it is not identification with the patient. The accurate empathy is really about the ability to understand what people are going through and be present with them while they are going through these struggles, not to identify or over-identify with the patients. I want to share with you here a very old study that has been done and that is a landmark study from my perspective. And that study was at the time working with patients who have alcohol use disorders and they identified nine therapists that delivered the same manualized guided behavior therapy. At that time, therapies were not very well developed when it comes to addictive disorders as they are now, but behavior therapy was really the fundamental therapy that has been utilized in people who have alcohol use disorders to help them change their behaviors and reduce their drinking. And these nine therapists are trained in behavior therapy as well as accurate empathy, how they can be really empathic with patients as I described based on the Carl Rogers model. And the sessions, their sessions were rated for accurate empathy using a scale. The scale is a TOAX and CARC-HALF scale, which sometimes we still use it now, you know, to measure, you know, the accurate empathy. And they were ranked, ordered from one to nine for empathic skills from, you know, the lowest to the highest empathic skills while delivering behavior therapy. So they were doing behavior therapy. They were doing it in a way that is very empathic. And what they looked at is basically a six months client outcomes that were measured. And the client outcomes I'm talking about really reducing the drinking. That is fundamentally the outcome. What did they find? Take a look at the therapist empathy. So the therapists that have the highest level of empathy, like for example, look at the hundred, you know, in the 175, they are correlated with the highest percent of positive outcomes. So the therapist who were delivering the behavior therapy have the highest empathic skills, produced the best outcomes. And you look at, for example, 25, 25, which is really low on the empathy scale, produced very low percent of positive outcomes. And the 60, as you can see in the green, is basically a combination of accurate empathy skills at the same time, what we call bibliotherapy, which means patients were giving some sort of really readings that they reflect on and all this. In fact, it did help. It did really help produce, you know, some positive outcomes. But this is really fascinating. Which means, you know, that it doesn't matter what therapy you're delivering, if it's delivered with empathic skills in an empathic way, it's going to produce positive outcomes. And it might not be the behavior therapy that did that, you know, it is probably the fact that it was delivered with empathic skills. So interestingly enough, these drinking outcomes accounted for by the therapist empathy, you know, there was really a predictive relationship that was consistent over the course of two years. You can see the first six months, 67%. The first year goes down, but still high, 52%. In two years, still 26%. So the effects are sustained and significant. And we're talking about, again, a study from back in 83, you know, which I believe is really so crucial to help us really understand, you know, that really that if the behavior therapy was delivered with that empathic approach, you know, that really it has a sustained impact on the positive outcomes on the drinking outcomes. So the bottom line here is that how you deliver a treatment matters. You remember I said at the beginning, the practitioner, the medical practitioner style matters. How you deliver the treatment matters. It doesn't matter, same counselor, same therapist, same practitioners, same treatment, different styles. So here, you know, this is kind of from the study that looked at, you know, confrontive versus, you know, the motivation interviewing approach. And yet they look at what we call the client behavior count, like change talk, you know, when clients, you know, make, you know, patients make these kind of a change talk saying that I want to stop drinking. I want to stop using drugs. I need to lose weight. These are the reasons I don't want to smoke anymore. You know, I feel like I'm capable of really taking my medication consistently. This is a change talk and I'll talk about it in details in a little while. The resistance piece is that what we call the sustained talk when people say, well, I know that I need to quit smoking, but I'm not going to do it right now. So the issue is that they look at measuring the correlation between change talk, sustained talk, which is the resistance. You know, this is all terminology and the client behavior count, whether if you use NMI, the motivation interviewing approach or confrontative approach. And interestingly enough, you see more change talk if you use the NMI approach and less change talk if you use the confrontative approach and you use less sustained talk if you use the motivation interviewing approach and more sustained talk with confrontative approach. So here, the point is that, you know, that what style you use, whether you use a confrontation versus really the motivation interviewing empathic style, it really dictates how patients are going to respond and how your patient's going to respond by expressing change talk if you're approaching them using motivation interviewing and they're going to be approached by expressing more sustained talk and not wanting to change if you approach them using a confrontational style and approach. So how it all started. So this is the historical context. So where did this NMI come about? This is an interesting article back in the 80s in behavioral psychotherapy that was published by Bill Miller, you know, the co-founder of motivation interviewing. At that time, he didn't want to publish that paper because it was not a data paper, it was more of a discussion paper, and he called it motivation interviewing for problem drinkers. At that time, they used to call the problem drinker people who have alcohol use disorder. So how he conceptualized what we call motivation interviewing. He kind of put a lot of principles of experimental, social psychology, cognitive dissonance, self-efficacy, confidence, and he conceptualized motivation as more of an interaction, you know, an interpersonal process, not a trait. And it emphasizes on de-labeling people and it emphasizes on really, really creating that cognitive dissonance. Like what people are really doing is not really correlating with who they are and then helping people see that. And empathic responses are based on really the approach itself, which is really the Carl Rogers approach. And so the whole point of it is that how can we, what sort of an approach like motivation reviewer can help people change their behaviors rather than be changed. So it's up to the patients to come up with the reasons why they want to really change and their own arguments, why they want to do it, not your own arguments. So, and what did he, and this is really kind of, you know, very much of a new concept here when it comes to working with people who have addictive disorders. And what did he call it? He called it motivational interviewing. Okay. So what are the basic concept of it? It's a person-centered, Rogerian-based counseling style. The patient should articulate the argument and the reasons for change. And what we do, we evoke, we bring from within all the way out the person's own motivation. We listen with empathy and genuineness and unconditioned positive regard. What do we do to minimize the resistance or to really minimize the sustained talk is by not hitting the head on, not hitting the resistance head on, which means not attacking, not confronting. And this approach fosters hope and optimism. People start feeling better about changes they want to make. And he called it motivation interviewing. Most of the time, MI is really used, you know, as a prelude for treatment. For example, people present with severe depression. They don't want to engage in any sort of a treatment. You use the motivation interviewing session, one to two sessions to enhance that motivation to get, really to help them get to a point where they are motivated enough to engage, for example, in interpersonal therapy and cognitive behavior. So again, this is not a data paper, discussion paper and back published in the 80s. How did MI evolve? You know, it evolved through four admissions, through since 91. This is really the first book that I had on motivation interviewing, preparing people to change addictive behavior in 91, and then moved to really 2002 about motivation interviewing, how we prepare people for change in general. Then in 2013, motivation interviewing, helping people change, modified version. And most recently, the fourth version and edition of MI is about helping people change and grow. This is really crucial. You know, so it's kind of going beyond just really people changing particular behaviors. Take a look at the special applications of MI, and this is just a sample for you, just a sample. In schools, in health care, with adolescent young adults, in groups, in nutrition and fitness, in sports, there's a book in sports, in HIV care, with CBT, and social work, and diabetes care, and dentistry, across everything, everything you can ever imagine. And I don't have really the time to really go through all these kind of applications, but just gives you an idea about how really the field has exploded from that aspect. All right. So now, let's start with that spirit that I talked about the relational piece of MI. MI is a way of being. It's not a way necessarily of doing, you know, it's a way of first being with the person. So, it has that relational and technical components. The relation component is really the spirit. So, how do we define motivation to viewing? Motivation to viewing is defined if you look at the lay person's definition. It's a collaboration, conversational style to strengthen a person's own motivation and commitment to change. So, what is it for? From the practitioner point of view, the focus is on helping the patient really see how ambivalent they are about change, help them explore that, and help them resolve it. They are, it's up to them to resolve that ambivalence about change. Ambivalence about change is a totally normal process. You're always conflicted about part of you wants to change, the other part of you doesn't want to change. For different reasons, you're conflicted. But this is a totally normal process, and we want to accept it and work with it as a normal process. In terms of the technical piece, this is the more elaborate, like how does it work? And this took years to really kind of conceptualize. It's a collaborative goal-oriented style of communication with particular emphasis to the language of change, to the natural language of change. And I'll talk about what I mean by that. So, the whole point of it is to strengthen person motivation for and commitment to a specific behavior by eliciting and exploring the person's own reasons for change. You provide them with that safe atmosphere, as well as atmosphere of acceptance for who they are, not accepting their behaviors, and compassion. You show them how much you care, you're listening, you're there, and then you start kind of exploring with them the reasons why they would want to change. So, what is that relational piece? Remember, a way of being us. It's the underlying spirit. And I showed this picture, you know, just gives you an idea about how the spirit is really not easy to define, you know, at the same time, it has that kind of really serene type of really approach, you know, that I'm meeting people where they are, I really am compassionate with people, I care about people, you know, about my patients, you know, I want to work with my patients, I accept that my patients are capable of change, I want the bottom line, empower my patients to really change. So, what are the elements of really the spirit of MI? The spirit of MI converges here into four elements. First element is the collaboration, is the partnership, working together. You do MI with patients, not on patients or to patients. You work with patients. The second one is basically acceptance. You accept people for who they are, not their behaviors. You accept that people are capable of change. You believe in people's worth, you know, people are really worth it, you know, and you support their autonomy, that it's up to the people, you know, to really decide what they really want to do. You respect that and you support that. And at the same time, you also really kind of strengthen their self-determination. You know, people are going to do whatever they believe is right for them, not what you tell them is right for them. And this is something very important to keep in mind. And what we provide as an atmosphere is an atmosphere of compassion. So, which means really kind of being there present and really kind of being empathic with the suffering of people, what they are really going through. The compassion has been sometimes misused from different kind of ways. You know, we're talking about really the compassion that we have towards patients, you know, kind of also correlates a lot with the self-compassion, which is really very crucial because if you're not self-compassionate, it's going to be very hard for you to be there, compassionate to other patients. But fundamentally, the bottom line here is how do we empower people. That's a big part of the spirit of MI is about empowering people really be themselves, to make the changes, and you want to present them with that safe atmosphere to be able to do that. And this is a huge kind of a component of the spirit of MI that has been introduced in the fourth edition. So, when you think about the coaching style, just reading very briefly here, you know, MI is a guiding style, you know, which means, you know, that you really kind of, in a way, you walk along with the patient. You don't direct patients. You don't follow patients. In any kind of a sort of an interaction with a patient, there's going to be some situations where you would have to direct the session. You have to do some of the following, but fundamentally, the MI style is a guiding style, is really working together, collaboration. Okay, so now, you know, we talked about the style, which is the presence, way of being with the patients. So, what does, what happens in that plan of really, once the spirit is established there, and I'm with the patient, is what we call like four foundational tasks. The tasks are really how to conduct really that MI session. And the tasks start with, first and foremost, the engaging piece. Engaging piece is establishing the therapeutic relationship, being there with the patient, listening to the patient, and then moving into what we call the strategic focus. A MI is directional, not directed, you know, or it's directional, which means that you know where you're going. There is an intentionality to it, you know, and at the same time, you're not controlling, you know, the patient here. And the strategic focusing is called strategic centering, which is really very crucial, you know. And once this is established, let's say that they want to really work on the fact that they are having a hard time adhering to medications, you know, for their ideas. Then you start moving into really what is fundamentally and very specific to MI, which is the evoking, which means evoking, bringing it from within all the way out, evoking motivation for change, getting a better understanding, you know, what's keeping them stuck, what's keeping them really ambivalent, at the same time, also what they want to do to get unstuck. So, you want to be very careful here what you're doing. You're eliciting more changed talk and softening, you know, the sustained talk. And once this is established in terms of their commitment to change and wanting to change and wanting to proceed with it, we go to the planning. The planning task is really when you're solidifying really that commitment that they have so they can start really thinking about the plan of action. Let me tell you, even though it really shows that this is the kind of really the trend from engaging, focusing, evoking, planning, but some people, this is not totally linear, which means, you know, sometimes you end up with the evoking process, but then the patient disengages, you know, in the session for different reasons, you know, then you would have to re-engage to make sure the therapeutic relationship is there to be able to get the person on track and to avoid what we call like a discord. You don't want to have any kind of discord in that relationship. You want that relationship to be very much harmonious, you know, so harmony versus really discord. So, again, just briefly to go through this, the engaging, which is the relational foundation person-centered approach. It's based on listening and really being present with the person there, displaying, you know, that spirit and understanding the dilemmas and values. It's very important. People change for different reasons, but also fundamentally people change because what they are really doing, it goes against what their value system is. And what we use in that kind of a process is what we call the ORS, which is really the core skills that I'm going to talk about it, which is using open questions, affirmations, not cheerleading, reflecting, and summarizing. Reflecting is based on, you know, the reflective listening. So, the focusing, as I told you, this is strategic centering. It's the directional piece. Change goal. What is the agenda setting? They come to you and tell you that I have pain, I cannot take my medication. You need to be very careful. They can come up with a few things, you know, on their agenda, but you don't want to address, you can't address a few things, but even though some of these things are very much interlinked. So, you want to figure out and finding a focus and finding a center here. You know, and the information and advice that you're going to give in the context of MI is minimal usually, but you have to do it in a way that uses what we call, you know, the exchange of information. First of all, asking always really permission. Is it okay with you if I share with you about what worked for people that I had the chance to really have as patients, you know, in terms of their ideas to medication? They tell you yes, and then that you want to continue, you want to elicit from the patients what they know, you want to provide them what you think would be helpful for them, and then you elicit from them what they think about what you're providing them. It's what we call elicit, provide, elicit. This is the exchange of information or ask, tell, ask, you know. So, we need to make sure, you know, the advice we're really giving is a motivational way, not telling people you should, you need to, you have to, if you don't do this, this is what's going to happen to you. That is totally the opposite of the guiding style of motivation interviewing. This is really the third step and task, you know, which is the evoke. This is where we're transitioning to the core of motivation interviewing, which is really selecting, you know, like the approach of eliciting the motivation, eliciting the reasons they want to change, how to respond to it, responding by eliciting more change talk, reducing the sustained talk, and really summarizing and getting a better understanding of what they are going through. So, evoking, bringing from within all the way out, which is really very fundamental to MI, and this is the only way that will help us get to know them, get to know where they are stuck, let's say, in terms of being ambivalent. The planning, so again, we're really kind of here, they are already committed to the change, they expressed a significant change talk, and then you were bridging to the change, negotiating a change plan, consolidating commitment, what they think, you know, they want to do it. How do they think they want to do it? They want to quit using drugs or quit smoking. How are they going to do it? You know, what are they thinking about? You know, so MI stops at really consolidating that commitment. The other rest of it in terms of learning skills is not an MI. Learning skills becomes more cognitive behavioral therapy, dialectical behavioral therapy, interpersonal therapy. But again, as I mentioned also, these are really not linear that people can move really from one task to another that you need to really always make sure that the therapeutic relationship is never really, you know, lost in the sense, you know, it's really strengthened to be able to keep the patient engaged with you. So remember I talked about change talk versus sustained talk, how we can elicit, evoke more of the stress, because change talk is predictive of change. If I'm going to hear myself saying that I want to quit smoking, quit drinking, taking my medication, following my diet, I'm going to most likely do it. You know, and people talk themselves into doing things. And so any change talk is a change that is in favor of the direction of change. And it shows up as natural language. And there are different types that I'm going to talk about. The sustained talk, not that there's anything wrong with a sustained talk, the sustained talk is more indicative of the fact that there is a status quo that people are stuck, you know, and then sometimes you hear in the same sentence, change talk and sustained talk, well, I want to quit smoking, you know, and, but I'm not going to do it right now because I'm so stressed out now, you know, and smoking helped me with my stress. You see, like you even hear within one sentence, a part of a change talk, the other part of a sustained talk. What is the change talk? What is the definition of change talk? There are two types. There is a preparatory talk and mobilizing talk. The preparatory talk is really, we use it under the acronym of DAWN, which is really first the desire to change. I want, I wish, I hope you hear more of that ability to change. You know, I can do it. You know, I have the capacity to do it. You know, I have done it before and I could do it again. The reason for change, I don't want to keep really kind of smoking because if I smoke, I'm going to end up with medical issues, but also I would not be able to be physically fit so I can be with my grandkids to really kind of play with them and hang out with them. The need to change, I have to do it. I got to do it. And if I don't do it, you know, I'm going to end up with very serious consequences. This is what we call preparatory talk. Preparatory talk can lead to what we call mobilizing change talk, more of a commitment. So you can say that I want to quit really smoking and I will do it is different than I want to. I will do it. I'm going to follow through. I said, I'm going to really quit drinking and I'm going to follow through with that. This is a commitment to change. Activation means, you know, I am preparing. I'm already, I'm ready to do it. You know, for example, you know, people who wanted to really kind of start getting more physically active, you know, and they said to the, you know, well, I really kind of want to get more active and I've stopped preparing for that. And you ask, you know, how you've been able to prepare for that. And they are taking steps where I already bought new running shoes that I'm going to be using. So the taking steps is I already took that kind of a step towards really, you know, making it happen. Remember I mentioned, you know, that patient in session speech predicts behavior change. So you want to tilt the balance towards more change talk, the ratio of change talk to sustained talk predicts change. You want to see more change talk than sustained talk. And what does the MI practitioner do? It's basically recognize change talk, paying attention. This is related to the reflective listening, proactively elicit it, bring it from within all the way out, get more change talk and strategically respond to it. So it will continue. You'll continue hearing change talk because it's going to more predictive of change, change talk, commitment, language, activation, all this. How is it done? And these are the skills, you know, so we talk about that kind of processes and tasks, you know, and how we do it, what sort of skills we use. We use open questions, how and what, how did you think about that? What made you decide this? You know, and then we use, I mean, I'm not saying that close questions are really not demonizing close questions, but close questions really can really shut the person in a sense, you know, or shut the person down totally, you know, or they are forced to answer by yes or no, you know, and you have to be very careful with that. So you want to ask more open questions, open-ended questions and really close-ended questions. Affirmation is really basically not cheerleading. Affirmation is basically acknowledging the effort that they made, you know, about opening up, about making changes, about making changes before and how they're going to make the changes now. So again, affirmation versus cheerleading. Reflective listening is exactly, you know, that the most difficult task, sorry, the most difficult skill of motivation interviewing, how to listen using the accurate empathy. And when you listen very attentively and deeply and mindfully, you have the ability to respond. And the reflections could be reflections of emotions, reflections of, you know, meaning, and they are 50% right, 50% wrong. It's a testing hypothesis. This is what reflection, and let's say you're not really accurate about what you said, then the patients, you know, would respond to you and tell you, well, you know, no, this is not exactly how I feel, you know, and then it continues the conversation, which is really fine, which is really great. This is what we're looking for. And the summary, summarization is more of a bouquet of reflections, you know, that would help you get a better understanding of what they've gone through, what they've already shared, and ask them whether there's an accurate, what you reflected on was an accurate description of what they shared, and there is more that they think they would want to share. So this is really kind of something that happens a lot in medical settings, what we call the writing reflex. Now we don't call it writing, we call it the fixing reflex, the desire to fix. Well, you know, you have this problem, you don't take your medication, I'm going to tell you what you should do, and this is how you should do it, and then everything is going to go great. So what ends up happening with that fixing reflex is it's very kind of really backfires in a way. Let's put it this way, it backfires. People start being invalidated, not respected, disengaged, not being attentive, feeling ashamed, you know, that you're really basically not respecting their autonomy and how they feel and what they want to do, what they don't want to do, and they end up resisting, arguing, discounting, being defensive, and they will never come back to see you basically, you know, and so you lose these people. Versus the MI approach, which is listening, evoking, and being there and with the patient, being in this kind of egalitarian approach to collaboration, people are going to feel affirmed, understood, they are respected, they felt engaged, they felt heard, they felt empowered, this is crucial, and hopeful and able to change, and they're going to be accepting more of the, you know, your motivational advice, they're going to be on defensive, interested, and activated, and they're going to come back to see you, you know. So, what are some of the elements of MI that are crucial? The spirit of MI, you talked about that, but could MI be without engaging, focusing, and evoking? So, if there is no focus, how could MI be used? But you remember the MI, I said at the beginning, it's a guiding style. MI can be used in any particular situation where you need to really stay neutral, like it's what we call the equipoise, counseling with neutrality. For example, you know, you have a couple who comes to see you, she wants to have a kid, he doesn't want to have a kid, and you want to stay neutral there and help them figure out how they can really kind of manage that whole situation. Or, for example, you know, a family member who wants to donate a kidney to his, let's say, son, you know, and he's very ambivalent about that. You want to be extremely careful about not really taking side or pushing that father to the donor to really kind of give the kidney to the recipient because, you know, that could be really potentially very much damaging. So, here there are some situations as what we call like equipoise situations, situations where you use motivation to viewing as a part of really more counseling with neutrality, staying neutral, and helping using, you know, the guiding style of motivation to viewing as a way to help them sort things out. So, does it really work? You know, and there is an explosion of MI outcome research, and the data tells us a lot over the course of these 30 years. And an example is the application in different settings. You have a ton of really controlled trials involving MI, a lot of meta-analyses, systematic reviews. If you look at Google search, 11,000 new citations per year now, more than 100,000, 173,000 total citations, substance use, addiction, psychotic disorder, chronic medical illness, nutrition, HIV, public health, sports, health promotion, preventative dentistry, social work, nursing, correction facilities, vaccine hesitancy, everything you can ever imagine. About two-third of the trials have shown a beneficial effect, one-third did not. The impact on wide behavior change is sustainable over the course of even a year. So, obviously, the effect size is small to medium, but it still kind of goes on for quite a while. Where do we have the strongest evidence of efficacy? Alcohol and cannabis use and as well as problem with drug use too, you know, smoking cessation, that's what originally started with, but also chronic disease management, the self-management of medical illnesses, medication adherence, dietary change, weight loss, increased physical activity, promoting health screening, improving oral health care and adults and children via parents. Now we have a lot of studies that have looked at working with parents using the MI approach to help kids change their, for example, diet behaviors, change, you know, their ability to take medications, you know, and particularly younger kids, you're talking about 10, 11, 12 years old, promoting treatment adherence and self-care in asthma, cancer, chronic pain, diabetes, heart disease, and hypertension. Cross-cultural, remember I mentioned at the beginning, you know, it's been practiced and taught in more than 50 languages. A ton of clinical trials published from North and South Africa, Europe, Oceania, as well as Asian, African, Arabic, and Native American nations. I would like you to really watch that video. I mean, we're going to share with you these slides, you know, about the social dominance that Bill Miller really posted, you know, about really how MI fits into the evolutionary perspective. And this paper is really fascinating by, you need to, you know, about the evolutionary perspective of motivation to view. MI is learnable. Insight from the MI training research, it's simple, but not easy. You know, I know it comes across as really simple, but not easy. And self-perceived practice does correlate with actual practice. There are some people who say, oh, I've been practicing MI and everything, not necessarily correlating with proficiency in practicing. Obviously, some people go to just workshops or like, for example, this lecture is more of a taste, barely a taste of MI. They had a good start, but they do not promote learning basic MI proficiency. And it has nothing to do, honestly, with educational attainment degree. You don't need to be a PhD or an MD or something to learn really motivation to viewing and to become competent with MI. What is crucial about how people improve is through feedback and in vivo coaching. And you're observing the practice significantly, you know, via really taping the sessions or something, or even, you know, in, you know, in-person presence. And this is would help significantly with acquisition as well as maintenance of the skills. You do not need to be a specialist to effectively promote behavior change. And joining what we call the network of trainers, that motivation to view network of trainers, the Mint, there are now 4,000 trainers in more than 50 languages. We always really kind of promote and really kind of encourage people to apply to become trainers and then train other people. So you remember that always, always remember that the patient's language in any sort of a therapy you're going to consider predicts treatment outcome. The change talk and commitment language associated with better outcomes with predictive of change, in a sense, the ratio is very crucial of the sustained thought of the change thought versus sustained talk. And it predicts the outcome, that ratio, in different type of therapies, CBT, 12-step facilitation, any sort of therapies. So the ultimate beneficiaries, you know, of the motivation approach is our patients. So you get the MI training, you get the feedback and in vivo coaching, it increases the MI fidelity. And what it increases of high fidelity, you're doing it in a very competent way, very adherent way, you increase patient change talk, and this leads to behavioral change. This is the definition of putting all together, putting everything together here, from MI, the first edition, from being to behaving. Remember way of being, which is the spirit of partnership, collaboration, acceptance, compassion, empowerment, the processes, engaging, focusing, evoking, planning, which we discussed, to the skills, how it is done through open question, affirmation, reflection, summaries, and particularly eliciting and responding to change talk. So I want to also kind of, we're going to show you that, you know, we're going to share with you, you know, the slides. I would recommend that you go and really watch that YouTube. It kind of illustrates all the MI, really skills as well as tasks, and gives you kind of a better sense of what I'm really referring to here. Okay. MI, as a conclusion, is based on decades of research, evidence-based approach, empirically grounded practices with a humanistic approach, relatively brief, verifiable, specific mechanism of actions. You remember that is the relational component, technical component. Relational component, the spirit, technical component, you know, is basically the skills and the strategies. Generalizable across conditions, including psychiatric and medical condition and behaviors, culturally adaptable, complementary, and integrates very well with other treatment approaches, such as DBT, CBT, mindfulness, and learnable by a broad range of practitioners. This is something I thought, you know, this is a card that we did, you know, we made that card, you know, about really the do's and don'ts of motivation interviewing. How can I be adherent? You know, I would suggest that you can print it out and laminate it. It's really very, very helpful. This is my information. I'm a professor, as I mentioned, of psychiatry and medicine, senior academic director of addiction medicine services. One of my basically area of research and specialty and interest is the psychology of change, as well as obviously addiction. That's my email for any questions and my disclosures that I mentioned earlier. And these are the references. And that's it. Thank you very much for listening. Thank you.

Motivational Interviewing

Collaborative Conversational Style

Person-Centered Counseling

Therapeutic Relationship

Change Plan

Open Questions

Reflective Listening

Behavioral Changes

Fidelity and Feedback