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Motivational interviewing for employment: An exploration of practitioner skill and client change talk

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Motivational interviewing (MI) is an evidenced-based approach for building and strengthening motivation for change. Eileen Britt discusses the effect of MI training on practitioner conversations with unemployed clients

Image courtesy of interviewee. August 15, 2024

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This video discusses motivational interviewing (MI), a conversational approach designed to enhance motivation for change, which originated in the context of alcohol abuse and has expanded to various areas including healthcare and employment support. A study was conducted to assess the use of MI in a government agency focused on helping unemployed individuals secure employment while providing financial support.

The approach consists of two key components: a relational aspect that emphasizes empathy and partnership, and a technical aspect that focuses on eliciting "change talk," or language that expresses motivation for change, while reducing "sustained talk," which expresses resistance to change. Effective MI practice requires recognizing and fostering change talk during conversations with clients.

The study involved five staff from a government agency who received training in MI, followed by ongoing coaching. Conversations were recorded to analyze the staff's communication styles and shifts in client language before and after MI training. Before training, staff demonstrated low relational and technical skills, focusing more on sustained talk. After training, their relational and technical skills improved significantly, leading to a notable increase in client change talk.

The results indicated that MI led to more motivational conversations, potentially increasing clients' motivation to seek employment. Suggestions for future research include linking MI practices to actual employment outcomes, exploring the effectiveness of MI training in broader organizational settings, and assessing the applicability of MI in other government services such as housing support.

Overall, the study shows the promise of MI as a beneficial tool in supporting unemployed individuals and suggests that training in MI could enhance outcomes in employment services.

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So motivational interviewing is a style of conversation

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to help build and strengthen motivation for change.

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And it's been, it was originally developed

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for the use in alcohol abuse

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and then moved out to other areas of behavior change

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and addictions and then health behavior change.

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And has since then been moving out more broadly.

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And it's generally found

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to be effective wherever it's been used in the different

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context it's been used.

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And so the study was actually looking about motivational

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interviewing used in a different context

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using in the context of people who are unemployed

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in a government or agency called Work and Income where,

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and their task is to support people into employment as well

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as provide financial assistance in the meantime.

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So motivational intervene is two key components to it.

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One is what we call the relational component.

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And so that's about working in partnership

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and working in a way to convey empathy,

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understanding of the person.

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And we know from research that

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that relational component is really important in terms

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of outcome on its own.

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It's not enough. The other component is

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the technical component.

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And that is where, in motivational interviewing

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what we do is we listen for what we call change talk,

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change talk as natural markers,

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that we have in our language about

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that showing our motivation for change.

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So we might talk about our reasons for change or our ability

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or our desire for change.

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And there is the opposite to that,

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which we call sustained talk.

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And sustained talk might be saying, I don't wanna do that,

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or there's not enough good reasons to do it.

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And so what we, the technical aspect

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of motivational interviewing is to ask questions

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or to guide the conversation in a way to bring out

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and strengthen that change talk

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and soften that sustained talk.

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And we know that shift and balance with more

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and stronger change talk and less

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and softer soft sustained talk is enough

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to help move people towards change.

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They're natural markers for change.

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And so it can emerge in our conversations naturally.

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And so we would listen

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for them when they're coming out naturally.

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And we also guide the conversation

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and how we might ask questions like,

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what would be,

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what would things look like in five years time

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if things stay the same?

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If you don't change, that's gonna

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to invite change talk coming out

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because people are gonna recognize the negative consequences

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or the risks of not making a change.

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So we can deliberately, aim to bring out change talk

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as well as I mentioned that we know

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that motivational interviewing is found

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to be effective in quite a broad range of contexts

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and moving out of those kind

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of clinical contexts into context.

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More general context like the employment context.

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However, the work in the employment context

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is relatively new.

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So there's the studies

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that we do have typically have been with people

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with health issues or,

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after post-injury, mental health issues

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and not with the general unemployed.

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And the other thing is that most

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of those studies have also tended to include,

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other interventions alongside that like behavioral

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contracting or, cognitive behavior therapy.

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So it's hard to know what the actual contribution to MI was.

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Motivational interviewing was in those, interventions

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and so they weren't looking at motivational interviewing

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as a standalone intervention.

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And the other issue with the past studies, most

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of the past studies is that they don't often

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give a lot of information about the, well,

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very little information about the skillfulness of

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the practitioners providing motivational interviewing

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and also the training that was provided.

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So motivational interviewing when it's done wow,

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seems like a very natural, easygoing conversation

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and people don't realize the level of training

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that's required to actually build up to that level

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to be able to achieve that.

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And these other, the studies really haven't given enough

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information for us to have much confidence in the level

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of skillfulness that was actually,

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and whether it even was motivational

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interviewing that was being tested.

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The study that

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this New Zealand study looked specifically

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with a general population in this government agency

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and with everyday staff.

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So that's another key thing

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that's different about those other studies

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that they often used.

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Um, people who were therapists or counselors already

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and so had came in with some sort of level of skillfulness

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and, and those kind of what we call the micro counseling,

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the core counseling skills.

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Whereas in this study, the staff were the staff

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that were already employed in the work and income service.

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And so the study involved

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five staff from work

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and income who volunteered to be in this study

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and their clients, the people they were speaking with.

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And so there were two parts to the study.

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The first part was where we audio recorded

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with the client's permission conversations

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that the staff were having with the clients

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so we could find out what, what style

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of conversations communication they were having

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before they were introduced to motivational interviewing.

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And what were the clients,

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what was the client's language like in terms of

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that change talk and sustained talk.

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Before the staff had any training in motivational

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interviewing, then the staff had, training

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and motivational interviewing, which was consistent

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with best practice.

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And so they had a series of workshop-based training

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and then ongoing coaching

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and feedback on their skills to continue

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to develop their skills.

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'cause what we know from class research is that without

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that ongoing training,

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after a workshop training, people

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so often just go back to their old habits.

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And so to really help that get implemented, and

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and integrated into their work,

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then their ongoing coaching is important.

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And that's what was also unique about the study.

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So they had that

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and soon as they finished the workshop training,

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they were again invited to ask their clients.

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And this was, so this was different clients to the ones

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that they saw before, still clients who are unemployed,

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and ask them if they could record their conversations then.

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And so we had their conversations recorded before and

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after they had MI training

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and during the process of receiving

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that coaching and feedback.

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So we could also see how their skills developed over time

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with that coaching and feedback as well.

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Some pretty remarkable, differences in the,

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the conversations before and

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after the motivational interviewing training.

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So before the training, their conversations, they,

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were actually really low in the relational component.

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They scored really low in the partnership and empathy

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and they didn't score at all on the technical component.

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Um, that I, I got to actually listen to those conversations

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and I, I could hear the change talk that was happening,

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but it was almost like it was invisible to the staff.

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They didn't hear it. And

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what they noticed was the sustained talk

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and that's what they tended to focus on and bring out

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and strengthen that rather than,

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anything about the change talk they used

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mostly asked questions.

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So it was a question and answer style.

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Um, really like an interview rather than a cap conversation.

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There was, very little reflections being used.

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And another thing that we try

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and do in motivational interviewing as well

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as use reflections to show our understanding

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and to be able to guide the conversation, we also use

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what we call complex reflections.

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Ones that, capture the, the meaning

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that the unspoken, the, the, that,

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and by using those kind of reflections,

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it really shows deep listening, deep understanding.

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Some conversations actually had no change talk at all.

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And some conversations actually had

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quite a lot of change talk.

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So it varied quite a lot.

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Um, before they had the training, so

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after they had the training, there was an increase in their,

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both their relational skills and their technical skills.

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And in particular they were, met criteria.

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We have an instrument,

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to measure those called the motivational interviewing

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Treatment integrity scale.

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The current version is 4.2 0.1

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and we use that to measure their skillfulness.

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And that scale also has some sort of overall scores

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that people are generated

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and some guidelines in terms of what's a fair

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and good level of skillfulness.

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And after the training, the staff, met

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all but one staff met fear

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or good skillfulness in the relational at some point over

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that follow up period in terms of the technical skills,

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that made a big change as well,

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although it took longer to change.

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So the relational skills all bumped up immediately

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after that workshop based training.

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And it was, so it kind

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of indicated they already had some level of skill in

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that area anyway, which you would expect

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with people working with people.

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Um, and then

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after the workshop based training, the, the,

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it took some time with the coaching, ongoing coaching

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and feedback for their technical skills to increase.

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And still we got to all five of the staff

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demonstrated a fair or good level of skill

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and all their audios except two.

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So they, they did do pretty well with that as well.

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They also showed a much greater use of reflective listening.

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Um, and so they reached a their or good level

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and more than half of their audios on, on that measure,

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they also showed a greater use

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of those complex reflections showing

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that really deep understanding.

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And that was actually shown on most audios.

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If we look at the client's language,

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what was different then?

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So ne there was nearly twice as much change talk

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in the conversations that were with the well

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after the staff that had the

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motivational interviewing training.

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And that was statistically significantly different.

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So there was differences in both the staff behavior

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consistent with mi

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and there was difference in the language

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that the clients engaged in change talk,

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which was be consistent with what we predict training

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and motivational interviewing did make a difference

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and the staff's behavior and in the client's behavior

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and that the, the, the clients spoke more.

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Change talk, change talk is a marker

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of motivation for change.

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And so it tells us that these clients, as a result

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of the way they were having the conversations

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with the staff, were becoming more motivated towards

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employment or doing what they needed

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that might have helped them towards employment.

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So in terms of future research, it would be good to link

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with actual outcome, you know,

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was there actually a difference in the employment rates

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or them doing other activities.

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Like some people needed to seek some counseling or alcohol

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and drug treatment before they could

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get even into employment.

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So actually connecting with actual outcome would be helpful.

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In terms of future research, I also mentioned

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that the staff were volunteers,

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so it would also be interesting

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to look at if this motivation interviewing was introduced

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into a, broader organization,

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an employment organization, would the same response happen

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for staff who weren't so keen to learn?

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Because obviously the staff were pretty motivated

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to put themselves forward For a study like this,

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it's pretty exposing being recorded

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and having, you know,

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having your practice put out there like that.

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So would it happen, would we get similar results

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for non volunteers?

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And also there's other studies

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that show that there's suggest

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that motivational interviewing produces good outcome

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for employment as well.

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As I mentioned, there's some other caveats

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'cause it's other contexts and so on.

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But given that,

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and given these results, it would suggest

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that motivational interviewing might be useful to

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be implemented within employment services,

13:59.955 --> 14:02.265
especially government general employment services.

14:02.405 --> 14:05.385
So the next question is, you know, the training

14:05.445 --> 14:07.105
as I described, was pretty intensive

14:07.765 --> 14:09.145
for it to be used that well.

14:09.765 --> 14:13.185
So in order for it to be implemented in government services,

14:13.295 --> 14:16.545
it's probably not reasonable to expect everyone to get

14:16.545 --> 14:17.545
that level of training.

14:18.205 --> 14:22.445
So another question would be, is there a level of skill,

14:23.065 --> 14:26.405
and maybe it's more about the relational is my hypothesis,

14:26.955 --> 14:29.885
that could be introduced to staff in general

14:30.425 --> 14:31.605
within those services.

14:32.985 --> 14:37.245
And then there might be other staff who work with,

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people who are struggling more with employment,

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which is the, the, the case in this study,

14:44.145 --> 14:46.845
who are more like case managers really helping people

14:47.505 --> 14:50.885
who aren't able to readily get into employment. Maybe

14:51.005 --> 14:53.165
They're the ones that need the full

14:53.165 --> 14:54.885
motivational interviewing training.

14:56.405 --> 14:58.505
And then the last, so the different levels

14:58.565 --> 15:01.105
of training might be, a thing

15:01.105 --> 15:02.505
to look at for future research.

15:03.005 --> 15:06.655
And the last thing is that, actually

15:07.625 --> 15:10.335
maybe motivational interviewing would be helpful in other

15:10.335 --> 15:11.735
government services as well.

15:12.315 --> 15:13.855
For example, housing support

15:13.955 --> 15:15.415
and trying to get people into housing.

15:16.315 --> 15:18.975
Um, the motivational might.

"Exploring the Effectiveness of Motivational Interviewing in Employment Contexts: A Study on Relational and Technical Components"

00:00:00 - So motivational interviewing is a style of conversation to help build and strengthen motivation for change. And it's been, it was originally developed for the use in alcohol abuse and then moved out to other areas of behavior change and addictions and then health behavior change. And has since then been moving out more broadly. And it's generally found to be effective wherever it's been used in the different context it's been used. And so the study was actually looking about motivational interviewing used in a different context using in the context of people who are unemployed in a government or agency called Work and Income where,
00:00:46 - as provide financial assistance in the meantime. So motivational intervene is two key components to it. One is what we call the relational component. And so that's about working in partnership and working in a way to convey empathy, understanding of the person. And we know from research that that relational component is really important in terms of outcome on its own. It's not enough. The other component is the technical component. And that is where, in motivational interviewing what we do is we listen for what we call change talk,
00:01:26 - that we have in our language about that showing our motivation for change. So we might talk about our reasons for change or our ability or our desire for change. And there is the opposite to that, which we call sustained talk. And sustained talk might be saying, I don't wanna do that, or there's not enough good reasons to do it. And so what we, the technical aspect of motivational interviewing is to ask questions or to guide the conversation in a way to bring out and strengthen that change talk and soften that sustained talk.
00:02:07 - and stronger change talk and less and softer soft sustained talk is enough to help move people towards change. They're natural markers for change. And so it can emerge in our conversations naturally. And so we would listen for them when they're coming out naturally. And we also guide the conversation and how we might ask questions like, what would be, what would things look like in five years time if things stay the same? If you don't change, that's gonna to invite change talk coming out because people are gonna recognize the negative consequences or the risks of not making a change.
00:02:49 - as well as I mentioned that we know that motivational interviewing is found to be effective in quite a broad range of contexts and moving out of those kind of clinical contexts into context. More general context like the employment context. However, the work in the employment context is relatively new. So there's the studies that we do have typically have been with people with health issues or, after post-injury, mental health issues and not with the general unemployed. And the other thing is that most
00:03:31 - other interventions alongside that like behavioral contracting or, cognitive behavior therapy. So it's hard to know what the actual contribution to MI was. Motivational interviewing was in those, interventions and so they weren't looking at motivational interviewing as a standalone intervention. And the other issue with the past studies, most of the past studies is that they don't often give a lot of information about the, well, very little information about the skillfulness of

"Unveiling the Impact of Training on Motivational Interviewing: Insights from a New Zealand Study"

00:04:12 - and also the training that was provided. So motivational interviewing when it's done wow, seems like a very natural, easygoing conversation and people don't realize the level of training that's required to actually build up to that level to be able to achieve that. And these other, the studies really haven't given enough information for us to have much confidence in the level of skillfulness that was actually, and whether it even was motivational interviewing that was being tested. The study that this New Zealand study looked specifically
00:04:54 - and with everyday staff. So that's another key thing that's different about those other studies that they often used. people who were therapists or counselors already and so had came in with some sort of level of skillfulness and, and those kind of what we call the micro counseling, the core counseling skills. Whereas in this study, the staff were the staff that were already employed in the work and income service. And so the study involved five staff from work and income who volunteered to be in this study
00:05:38 - And so there were two parts to the study. The first part was where we audio recorded with the client's permission conversations that the staff were having with the clients so we could find out what, what style of conversations communication they were having before they were introduced to motivational interviewing. And what were the clients, what was the client's language like in terms of that change talk and sustained talk. Before the staff had any training in motivational interviewing, then the staff had, training
00:06:18 - with best practice. And so they had a series of workshop-based training and then ongoing coaching and feedback on their skills to continue to develop their skills. 'cause what we know from class research is that without that ongoing training, after a workshop training, people so often just go back to their old habits. And so to really help that get implemented, and and integrated into their work, then their ongoing coaching is important. And that's what was also unique about the study. So they had that and soon as they finished the workshop training,
00:07:01 - And this was, so this was different clients to the ones that they saw before, still clients who are unemployed, and ask them if they could record their conversations then. And so we had their conversations recorded before and after they had MI training and during the process of receiving that coaching and feedback. So we could also see how their skills developed over time with that coaching and feedback as well. Some pretty remarkable, differences in the, the conversations before and after the motivational interviewing training. So before the training, their conversations, they,
00:07:42 - They scored really low in the partnership and empathy and they didn't score at all on the technical component. that I, I got to actually listen to those conversations and I, I could hear the change talk that was happening, but it was almost like it was invisible to the staff. They didn't hear it. And what they noticed was the sustained talk and that's what they tended to focus on and bring out and strengthen that rather than, anything about the change talk they used mostly asked questions. So it was a question and answer style.

"Improving Reflective Skills and Change Talk Through Motivational Interviewing Training"

00:08:26 - There was, very little reflections being used. And another thing that we try and do in motivational interviewing as well as use reflections to show our understanding and to be able to guide the conversation, we also use what we call complex reflections. Ones that, capture the, the meaning that the unspoken, the, the, that, and by using those kind of reflections, it really shows deep listening, deep understanding. Some conversations actually had no change talk at all.
00:09:05 - quite a lot of change talk. So it varied quite a lot. before they had the training, so after they had the training, there was an increase in their, both their relational skills and their technical skills. And in particular they were, met criteria. We have an instrument, to measure those called the motivational interviewing Treatment integrity scale. The current version is 4.2 0.1 and we use that to measure their skillfulness. And that scale also has some sort of overall scores that people are generated
00:09:46 - and good level of skillfulness. And after the training, the staff, met all but one staff met fear or good skillfulness in the relational at some point over that follow up period in terms of the technical skills, that made a big change as well, although it took longer to change. So the relational skills all bumped up immediately after that workshop based training. And it was, so it kind of indicated they already had some level of skill in that area anyway, which you would expect with people working with people.
00:10:27 - after the workshop based training, the, the, it took some time with the coaching, ongoing coaching and feedback for their technical skills to increase. And still we got to all five of the staff demonstrated a fair or good level of skill and all their audios except two. So they, they did do pretty well with that as well. They also showed a much greater use of reflective listening. and so they reached a their or good level and more than half of their audios on, on that measure,
00:11:10 - of those complex reflections showing that really deep understanding. And that was actually shown on most audios. If we look at the client's language, what was different then? So ne there was nearly twice as much change talk in the conversations that were with the well after the staff that had the motivational interviewing training. And that was statistically significantly different. So there was differences in both the staff behavior consistent with mi and there was difference in the language that the clients engaged in change talk,
00:11:52 - and motivational interviewing did make a difference and the staff's behavior and in the client's behavior and that the, the, the clients spoke more. Change talk, change talk is a marker of motivation for change. And so it tells us that these clients, as a result of the way they were having the conversations with the staff, were becoming more motivated towards employment or doing what they needed that might have helped them towards employment. So in terms of future research, it would be good to link

Exploring the Impact and Implementation of Motivational Interviewing in Employment Services**

00:12:33 - was there actually a difference in the employment rates or them doing other activities. Like some people needed to seek some counseling or alcohol and drug treatment before they could get even into employment. So actually connecting with actual outcome would be helpful. In terms of future research, I also mentioned that the staff were volunteers, so it would also be interesting to look at if this motivation interviewing was introduced into a, broader organization, an employment organization, would the same response happen
00:13:13 - Because obviously the staff were pretty motivated to put themselves forward For a study like this, it's pretty exposing being recorded and having, you know, having your practice put out there like that. So would it happen, would we get similar results for non volunteers? And also there's other studies that show that there's suggest that motivational interviewing produces good outcome for employment as well. As I mentioned, there's some other caveats 'cause it's other contexts and so on. But given that, and given these results, it would suggest
00:13:55 - be implemented within employment services, especially government general employment services. So the next question is, you know, the training as I described, was pretty intensive for it to be used that well. So in order for it to be implemented in government services, it's probably not reasonable to expect everyone to get that level of training. So another question would be, is there a level of skill, and maybe it's more about the relational is my hypothesis, that could be introduced to staff in general within those services.
00:14:37 - people who are struggling more with employment, which is the, the, the case in this study, who are more like case managers really helping people who aren't able to readily get into employment. Maybe They're the ones that need the full motivational interviewing training. And then the last, so the different levels of training might be, a thing to look at for future research. And the last thing is that, actually maybe motivational interviewing would be helpful in other government services as well. For example, housing support
00:15:16 - the motivational might.

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