Problemática social o familiar en el entorno del paciente

Abstract: During practice exercises or demonstration, participants are assigned a structured role as observers, using specific guidelines to encode the communication process.

Overview: It is very easy, in watching a demonstration or videotape, or even when engaged in a role play, to get caught up in the story, in the content of communication. Structured observation focuses the participant’s attention on the process of what is happening. It also gives observers an active rather than passive role during demonstrations and exercises.

Guidelines: Provide very clear instruction in exactly what is to be observed, and how. Provide a printed coding sheet and guidelines for more complex tasks. There is a temptation for observers to stop tracking and get caught up in the content, so use procedures designed to keep observers on task. Circulate and watch the coding process, stop action and ask observers for their observations, etc.

Observer Tracking Example 1: Wrestling-Dancing. Define two extremes of interaction style. In dancing the two parties are working together, with a heightened sensitivity to each other, listening, responding, making progress, and, most importantly, cooperating. In wrestling the two parties are grappling in a struggle of power or adroitness, each endeavoring to throw the other by tripping or overbalancing. Use a scale from -5 (maximum wrestling) to +5 (maximum dancing). In between is a zero point, which is a kind of neutral zone characterized by neither strife nor harmony. Observers rate the state of interaction early in a demonstration or practice, and then give a new rating whenever they perceive a shift in the interaction in one direction or the other.

Whenever a new rating is given, make notes as to what happened to make a difference. What was said, by whom, etc.

Thanks to: Jeff Allison

Observer Tracking Example 2: Readiness Level. Using a readiness ruler (0 to 10), the observer judges the level of client readiness throughout an interaction. Based on the client’s first few

responses, an initial rating is given. Then whenever the observer perceives a change in the level of client readiness during the interaction, a new rating is given and the observer notes what the

counselor was doing just before the change. Thanks to: Steve Rollnick

Observer Tracking Example 3: Reflection. The observer focuses on reflective listening

statements. Each response from the interviewer is coded as a reflection (R), question (Q), or other (O). Interviewer responses are recorded sequentially. When a reflection is coded, it is further rated as a simple, complex, or summary reflection.

Observer Tracking Example 4: Client Commitment Language. Here the observer attends to five categories of client speech that constitute change talk, with specific attention to Commitment

Notes: Explain fully and carefully how the coding system works, and what categories mean. It is helpful to

have a practice tape segment of a few minutes, and then give your own codes, or at least compare codes. Avoid detailed discussions of which is the “right” answer. Attaining high reliability of coders takes quite a while. The point is not perfection, but attending to process rather than content. When you assign an observer task, be sure to use the information during the exercise or debriefing. It’s frustrating to keep observational notes and then have them unused. That communicates a low importance of observational tracking.

Still more detailed coding systems are used in research (MISC, MITI), but something of this complexity is not recommended for use by untrained observers. They may be useful in advanced training.

Observer  Sheet  1:  Wrestling  or  Dancing?  

As you follow the interview, determine where you think the interaction is on a continuum ranging from 1 (total Wrestling; struggling with each other for control) to 6 (total Dancing; moving together smoothly and cooperatively). When you perceive a change in the interaction, note what happened at the point of change.

Wrestling Dancing What happened at the point of change? 1 2 3 4 5 6 _{Level of interaction at the beginning of the interview}

1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6

Observer  Sheet  2:  Client  Readiness  Level  

As you follow the interview, determine where you think the client is in readiness to change the target behavior, from 1 (not at all ready) to 7 (very ready for change) When you perceive a change in the client’s level of readiness for change, note what the counselor did just before it happened.

Not at all Very Ready What did the counselor do before this change?

1 2 3 4 5 6 7 Level of client readiness for change at the beginning of the interview 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7 1 2 3 4 5 6 7

Observer  Sheet  3:  Reflections  

Listen for counselor Reflections, and count them. Rate each Reflection as:

A. Simple Reflection - essentially a repetition or slight rewording of what the client said B. Complex Reflection - the counselor moves beyond what the client said, by paraphrasing meaning, continuing the paragraph, or otherwise reflecting a level of content or feeling beyond that which the client voiced

C. Summary Reflection - the counselor pulled together two or more client statements into a summary (bouquet), including material that had not been voiced by the client immediately before Make note of particularly good examples of each kind of reflection.

Type Count (hash marks) Good example(s) A. Simple

B. Complex

Observer  Sheet  4:  Client  Change  Talk  

Listen for examples of the five kinds of client change talk. As you hear them, place a hash mark (/) in the appropriate row. Make notes of examples of each type of change talk that you heard.

Type of Change Talk Count (hash marks) Example(s) Desire to change

Ability to change

Reasons to change

Need to change

Observer  Sheet  5:  OARS  

Listen for examples of the counselor’s use of each of the OARS responses. As you hear them, place a hash mark (/) in the appropriate row. Make notes of examples of each type of OARS response that you heard. Counselor Response Count (hash marks) Good Example(s)

O

A

R

S

Personalizing

Abstract: The trainer helps participants relate MI processes to personal experience, as way of

breathing life into to-be-learned material.

Overview: Participants share personal experiences in dyads, small groups, or the large group. Guidelines: Material to be shared shouldn’t be so personal that they the participant feels

uncomfortable revealing it, especially if there are co-workers present.

Examples:

The “Persuasion Exercise” (under Negative Practice) is a good example of personalizing, in that it

asks the speaker to use personal ambivalence as the subject matter, and to experience responses to a particular counseling style.

A personalizing experience that is often quite effective is the “Favorite Teacher” exercise. Ask participants to think of their favorite teacher from school or college - the teacher in whose class they felt particularly alive, interested, motivated, engaged. Invite participants to name their favorite teacher aloud, and then ask the participant to describe [teacher’s name]. What was it about that teacher that was different from the others? What was it about her or him that brought out the best in you? [Thanks to Carolina Yahne for this one]

Another personalizing exercise can be used to enhance empathic understanding among clinicians. Ask the trainees to think of a change they have been considering, or one they’ve been struggling to make. Reassure them that they will not be asked to share this with the group. Ask them to raise their hands when they have their issue in mind. After receiving this signal, tell them to imagine that you (the trainer) have the power to force them to stay in the room until they resolve the following command: “You must make a decision about whether you will make this change before you can leave the room today, and this decision to change or not will be permanent.” Allow a moment to absorb this, state that there are often a variety of reaction, and ask them to share their reaction. In debriefing, focus on different responses to the “intervention,” including decisions to change, decisions to avoid change, and decisions to lie to the facilitator in order to be let out of the room! To debrief, point out that these reactions illustrate the effects of pressuring someone who’s ambivalent, as well as illustrating aspects of the stages of change (those who were further along in readiness may be more willing to decide “permanently”). You may also wish to discuss Brehm’s concept of reactance and other social psychology principles. Cap off the exercise by stating that even with “normal” changes that may not involve stigmatized behaviors such as drug use, unsafe sex, excessive drinking, etc., people are not always fully ready to change, and when pressured, the majority resist the pressure and either retreat from the idea of change, or “lie” about their intentions, while a minority report that the persuasion was helpful. This can be particularly useful in increasing empathy for mandated client populations. [Thanks to Tore Børtveit for this one.]

Notes: You can do more prefacing, if you like, about why you are using a personal example. This

would reinforce that people get the clearest sense of how MI might work by experiencing it themselves with something that is meaningful to him or her. A little bit of levity (e.g., about “deepest, darkest secret”) keeps the tone about right and helps people feel like the request is not too intrusive.