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What is the MISC?

It stands for Motivational Interviewing Skill Code. The MISC was originally developed in 1997 as a method for evaluating the quality of motivational interviewing (MI) from audiotapes and videotapes of individual counseling sessions.

What are good use cases for the Motivational Interviewing Skill Code (MISC)

The possible uses of MISC include: * Documenting counselor adherence to MI within clinical trial protocols * Providing detailed session feedback for counselors in the process of learning MI, including specific goals for improved skillfulness * Evaluating the effectiveness of training in MI by comparing counselor skills before and after training * Conducting psychotherapy process research to examine relationships among counselor and client responses * Predicting treatment outcome from psychotherapy process measures * Generating new knowledge about MI and its underlying processes of efficacy

According to the theory of motivational interviewing what predicts behavior change?

Paul Amrhein's study found that only client commitment language predicted behavior change. Other client behaviors like desire, ability, reasons, and need predicted the occurrence of subsequent committing language, and thus influenced behavior change indirectly but did not predict the actual change.

During a counseling session which part is most predictive of behavior change.

The end of a session. Amrhein found that the strongest prediction of behavioral outcomes came from client speech toward the end of the session, when the client’s plan for change was the primary topic. Client commitment level at the beginning of an MI session, when clients discussed their reasons for presenting for treatment, did not predict the probability of behavior change

What are Motivational Interviewing (MI) adherent behaviors?

MI adherent behaviors are behaviors that a counselor expressees toward a client that are consistent with a motivational interviewing approach. They are, advising with permission, affirming the client, emphasizing control, support, reflecting, and open questions.

What are Motivational Interviewing (MI) non adherent behaviors?

MI non-adherent behaviors are behaviors are inconsistent with a motivational interviewing approach. In general they are perceived as less empathetic. They are, advising without permission, directing, confronting, and closed questions.

What is the definition of Advise according to the MISC

The counselor gives advice, makes a suggestion, or offers a solution or possible action. These will usually contain language that indicates that advice is being given: should, why don't you, consider, try, suggest, advise, you could, etc. Advise requires sub classification for whether the advice was given with or without prior permission from the client. Prior permission can be in the form of a request from the client, or in the counselor asking the client's permission to offer it. Indirect forms of permission asking may also occur, such as a counselor statement that gives the client permission to disregard the advice as in "This may or may not make sense to you").

Give two examples of advise with permission.

"Would it be all right if I suggested something?" "We could try brainstorming to come up with ideas about quitting if you like."

Give three examples of advise without permission.

"Consider buying more fruits and vegetables when you shop." "You could ask your friends not to drink at your house" "You should really stop playing so many video games."

What is the definition of Affirm according to the MISC

The counselor says something positive or complimentary to the client. It may be in the form of expressed appreciation, confidence or reinforcement. The counselor comments on the client’s strengths or efforts. It is not necessary to subclassify Affirm responses.

As a counselor practicing motivational interviewing how would you define appreciation?

Appreciation is when a counselor compliments the client on a trait, attribute, or strength. The reference can be to a "stable, internal" characteristic of the client, something positive that refers to an aspect of the client that would endure across time or situations (smart, resourceful, patient, strong, etc.). It may also be for effort.

Give four examples of a counselor demonstrating appreciation.

"You’re a very resourceful person." "Thank you for coming today." "You’ve made a huge cut in your smoking." "I’ve enjoyed talking with you today."

How would a psychologist practicing motivational interviewing demonstrate confidence in a client?

The counselor would make a remark that bespeaks confidence in the client's ability to do something, to make a change; it predicts success, or otherwise supports client self-efficacy. These are related to a particular task, goal, or change. Ane example would be: Client: "I don’t think I can do it." Counselor: "You’ve succeeded through some difficult changes in the past."

How would a psychologist practicing motivational interviewing demonstrate reinforce a client?

Reinforcements are general encouraging or applause statements even if they do not directly comment on a client's nature, and do not speak directly to self-efficacy. They tend to be short. For example a counselor might say something like: "That's a good idea" "Good for you!" "That's good".

When coding an affirmation what codes is it often confused with?

Support and Emphasize Control. Support takes on a sympathetic or agreeing quality, while affirm comments favorably on a client characteristic, bespeaks confidence, congratulates or encourages.

How would a psychologist practicing motivational interviewing reinforce a client?

Reinforcements are general encouraging or applause statements even if they do not directly comment on a client's nature, and do not speak directly to self-efficacy. They tend to be short. For example a counselor might say something like: "That's a good idea" "Good for you!" "That's good".

Which of these two statements by a psychologist is an affirmation and which is support and why?

"That must have been difficult." "You’ve accomplished a difficult task."

"That must have been difficult." is support because it is sympathetic to the patient but not appreciative. "You’ve accomplished a difficult task." is an affirmation because it highlights the effort a client has made and reinforces that behavior positively.

Which of these two statements by a counselor is an affirmation and which is emphasize control and why?

"Thank you for coming today." "It was your decision to come here today."

"Thank you for coming today." is an affirmation because it demonstrates appreciation of the patient's effort and action. "It was your decision to come here today." demonstrates the emphasize control code because it highlights the client's autonomy to make that decision but doesn't reinforce, demonstrate confidence, or show appreciation.

As a psychologist practicing motivational interviewing how would you define Direct?

Direct is when the counselor gives an order, command, or direction. The language is imperative. Some examples are: "Don't say that." or "Get out there and find a job."

What are some imperative stems which are directive?

"You need to ..." "I want you to ..." "You have to ..." "You must ..." "You can't ..."

Please list three examples of Direct.

"I want you to watch this video." "You’ve got to stop drinking." "You must have more respect for yourself."

When coding direct what codes is it often confused with?

Direct is often confused with Affirm, Advise or Confront.

Which of these three statements is Direct and why?

"You could try looking for a job this week." "I want you to try to find a job." "There’s no reason for you not to be working."

"I want you to try to find a job." is direct because it is a command. It tells the client to do something instead of just suggesting it. "You could try looking for a job this week." is advise without permission because it suggests a course of action without demanding it. "There’s no reason for you not to be working." is a confront because it has a negative quality that exudes judgement and ridicules the client.

Which of these statements is Direct and why?

"You should be proud of yourself for finding a job." "Now get out there and get a job!"

"Now get out there and get a job!" is direct because it is a direct order. "You should be proud of yourself for finding a job." is an affirmation because it is positive and complimentary. It highlights the clients effort in a positive way.

What is emphasizing control?

When someone directly acknowledges, honors, or emphasizes the another person's freedom of choice, autonomy, personal responsibility, etc. It highlights a person's autonomy and ability to enact changes in their life. This may also be stated in the negative, as in "Nobody can make you change." There is no tone of blaming or faultfinding.

What is emphasizing control?

When someone directly acknowledges, honors, or emphasizes the another person's freedom of choice, autonomy, personal responsibility, etc. It highlights a person's autonomy and ability to enact changes in their life. This may also be stated in the negative, as in "Nobody can make you change." There is no tone of blaming or faultfinding. Statements acknowledging the client’s autonomy in an accomplishment are coded as Emphasize Control rather than Affirm.

When coding an utterance as emphasize control what codes is it often confused with?

Affirm, Confront, or Reflect.

According to the MISC what is Facilitate?

These are simple utterances that function as keep going acknowledgments. "Mm Hmm." "OK." "Tell me more." "I see." Facilitate responses are stand alone utterances. They do not usually occur with other counselor responses in the same volley. Do not code as Facilitate if the vocal sound is a preface to some other counselor response like a Question or a Reflect. In these combinations, code only the second response.

According to the MISC what is Filler?

This is a code for the few responses that are not codeable elsewhere: pleasantries, etc. It should not be used often. If these exceed 5% of Counselor responses, they are probably being over-coded. Examples are things like "Good morning John.", "Nice Weather we're having".

What is a conversational reflection?

A reflection is a reflective listening statement where the speaker repeats back something the other person said. They can be more complicated where they mirror the ideas of the speaker through metaphor or analogy as well. In essence they capture and return something the other person said.

How many types of conversational reflections are there?

There are two. Simple Reflections and Complex Reflections.

What is the definition of a simple reflection?

Simple Reflections add little or no meaning or emphasis to what someone has said. Simple reflections merely convey understanding or facilitate further exchanges. Simply repeating or rephrasing what the someone has said qualifies as a Simple Reflection. Simple reflections might identify important of intense ideas but don't go far beyond the initial overt content.

What is the definition of a complex reflection?

Complex Reflections typically add substantial meaning or emphasis to what the someone has said. They convey a deeper or richer picture of the someone's statement where a simple reflection usually just parrots it. Usually they contain significantly more or different content from what the person actually said. The following are almost always complex reflections: * Analogy, metaphor and simile. * Exaggeration or amplification by understating or overstating * “Continuing the paragraph” by anticipation of what the client might reasonably say next * Double-sided reflection containing both sides of ambivalence in a single Reflect * Summaries are usually coded as Complex Reflections when they add content or meaning to client statements.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yes on occasion. therapist: And sometimes you feel guilty after you drink. client: Sometimes I just don't like how much I drink. I sometimes finish a bottle in one night. therapist: So you're not proud of finishing a bottle? client: No, it's not like I get crazy or anything but I just don't like the amount that I'm drinking.

Right. By the way, binge drinking is defined for women as having more than, uh, three drinks and there are about five drinks in a bottle. So, you enjoy drinking wine because it helps make things, uh, a little bit more interesting when you're feeling down but at the same time you don't like drinking when you have more than you want it to and then the depression returns after you drink.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: I'd say an eight. therapist: Okay. Why do you think it's not something less like a six? client: Well, I'm more ready than a six because I'm ready to cut back on my drinking and I don't wanna make my depression any worse. therapist: What would help you cut back to two drinks? client: Maybe having less wine in the house.

Having less wine in the house will help?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Maybe having less wine in the house. therapist: Having less wine in the house will help? client: Yes. therapist: What else besides drinking helps you relax and unwind in the evenings? client: Well, I like to watch movies, read a book, and take a bath but sometimes I drink when I take a bath.

So, it's not just wine that helps you relax. Um, there's reading a book, watching a movie, and taking a hot bath too.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Sure. therapist: Great. So, let's see how well you're doing with these new meds. client: Okay. therapist: And before you leave, uh, is it okay if we go over this screening form that you filled out today on your alcohol use? client: Sure.

Okay. Uh, thanks for filling this out. Uh, looks like you use alcohol two to three days a week?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Okay. therapist: And before you leave, uh, is it okay if we go over this screening form that you filled out today on your alcohol use? client: Sure. therapist: Okay. Uh, thanks for filling this out. Uh, looks like you use alcohol two to three days a week? client: Yeah, but only on the weekend.

Okay. And then when you do drink alcohol, you typically have five or six drinks.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: So, uh, are you saying I drink too much? therapist: How would you define drinking too much? client: Well, I-- If-if I was getting fallen down drunk or if I drink every night. Um, it's not like I get sloppy drunk or anything. therapist: Mm-hmm. Well, in this country, the guidelines are men can drink up to 14 drinks a week or up to four on one occasion and still be low risk. client: So I'm already at the week limit. And then I have four beers a night. Are you sure?

So a limit of four a night doesn't feel right to you?

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Well, I-- If-if I was getting fallen down drunk or if I drink every night. Um, it's not like I get sloppy drunk or anything. therapist: Mm-hmm. Well, in this country, the guidelines are men can drink up to 14 drinks a week or up to four on one occasion and still be low risk. client: So I'm already at the week limit. And then I have four beers a night. Are you sure? therapist: So a limit of four a night doesn't feel right to you? client: I have five or six beers when I go out with friends to a bar. It's not a problem for me.

You're not alone in feeling that way. Uh, binge drinking can feel normal to some people.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Well, I didn't know about those things. therapist: Can I ask you, uh, what do you like about drinking alcohol? client: Well, I-I like beer. I like the way it tastes, I like the way it makes me feel. Uh, like when I'm around friends and it's not a problem for me. therapist: And so what about your drinking do you not like or is there anything that worries you about your drinking? client: Well, that was fine until I came here, uh, but now that I know about the health risk, uh, I have something I gotta think about.

So, on one hand, you like how beer tastes, uh, it's part of your social life to some extent, um, but on the other hand, you don't like the idea of it posing risks to your health over the long term?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: E-exactly. therapist: So weighing those things, you know, what you like about your drinking, what you don't like about your drinking, uh, where do you wanna go from here? Uh, what would you like to change about your drinking? client: Hmm, I'm not sure. Uh, something I have to think about. therapist: Well, how about hypothetically if I were to ask you, how would your drinking have to impact your life in order for you to be ready to change your drinking? client: Uh, I don't know. Maybe if I got sick or something, uh, maybe I'd wanna change things then.

So if you experienced a negative consequence from your drinking, uh, that would feel meaningful to you?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

therapist: Okay, great. See you next time. therapist: Hi, John. Nice to see you again. So, tell me, how are things going? client: Well, doc, I know you told me that I need to lose weight. And even though the scale didn't show today, I was able to lose about 5 pounds, but then I gained it right back. therapist: Well, I appreciate you bringing your weight to the forefront. Do you mind if we explore this issue further? client: No, by all means. I know we have to discuss it.

All right. Uh, well, it sounds like you've been struggling with your weight recently. And I understand how difficult it is to lose the weight and then have it come back again. So, tell me what you did to lose that initial 5 pounds.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Well, doc, I know you told me that I need to lose weight. And even though the scale didn't show today, I was able to lose about 5 pounds, but then I gained it right back. therapist: Well, I appreciate you bringing your weight to the forefront. Do you mind if we explore this issue further? client: No, by all means. I know we have to discuss it. therapist: All right. Uh, well, it sounds like you've been struggling with your weight recently. And I understand how difficult it is to lose the weight and then have it come back again. So, tell me what you did to lose that initial 5 pounds. client: I started watching what I ate and I ate less. I've been eating more fruits and vegetables. I've also been walking a lot. I'm walking up to 20 minutes a day now. I saw the weight come slowly off, um, and I felt better. But then when I watched it come back on again, you know, I gave up.

But you did have some success. Tell me how you felt when you lost the weight.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: No, by all means. I know we have to discuss it. therapist: All right. Uh, well, it sounds like you've been struggling with your weight recently. And I understand how difficult it is to lose the weight and then have it come back again. So, tell me what you did to lose that initial 5 pounds. client: I started watching what I ate and I ate less. I've been eating more fruits and vegetables. I've also been walking a lot. I'm walking up to 20 minutes a day now. I saw the weight come slowly off, um, and I felt better. But then when I watched it come back on again, you know, I gave up. therapist: But you did have some success. Tell me how you felt when you lost the weight. client: I felt great and I felt really proud of myself. I thought that this was something that I could do.

Okay. Well, it sounds like you realized that when you lost the weight you feel better and that it's gonna affect your overall health. So, tell me what you think changed that caused you to gain the weight back.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Obviously, I need to cut back on the fruit juice. But boy, do I love that OJ. therapist: Oh, I understand. Let me ask you this, on a scale from 0 to 10, 0 meaning that there's no way you can do it, and 10 meaning that you're 100% confident that you can do it, how confident are you that you'll be able to reduce the amount of juice you're currently taking in. client: Um, six or seven. therapist: All right. So, you're not a zero. So, that tells me that you've got some confidence that this is doable, this is something you certainly can do it. Why are you not a zero? client: I guess it's because I know that I need to do it to lose the weight.

So, you realize, again, that if you decrease the amount of juice you're taking in, you're gonna decrease your weight, you're gonna feel better, and you're gonna impact your po- health positively?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yes. therapist: But you're also not a 10, and that tells me that there may be some obstacles to your success. What would it take for you to be a 10 or even an 8 or 9? client: Getting the fruit juice of the house because I know if it's there I'll drink it. My wife does the shopping for us, so maybe if I ask her not to get the juice, that would solve it. therapist: Okay. Now, if the juice was still there, can you think of anything else you could do? client: I suppose I could replace it with, um, a low-calorie drink or drink more water.

Excellent. John, I get the impression that you want to stay in course with weight reduction. And the best way to do this will be to decrease the amount of juice that you're currently taking in. So if I saw you in two weeks and I asked you how much juice you're t- drinking and how you did it, what would you tell me?

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

therapist: I agree. All right. Well, you-you know what? I'm not gonna start any medications today. Your levels were a little bit off, but I think we can handle this from a purely lifestyle standpoint. What do you think? client: Great. It sounds good to me. therapist: Excellent. I'll see you in two weeks. client: Okay. client: Well see, my-my wife's been getting on me a lot lately about trying to improve my health habits, and I really don't see what the big problem is. I mean, I've been working real hard. Sometimes I can't come home for dinner, so I'm having to go out to eat at Applebee's or something like that, so-- but she seems to have a bigger problem, I really don't see what the big deal is.

Okay, and so what I'm hearing is that you don't feel like your health is concerning you right now, or anything like that?

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Well, a little bit, but nothing too-- you know. I'm not blo- I'm not bloated or anything. therapist: Okay. Okay. And how about going to see the doctor? Have you gone to-- for a visit or anything recently? client: Well, yeah, I've been to the doctor about maybe last year for a physical, but-- I mean, everything showed up to be fine, so— therapist: Okay. But you feel that you feel good? client: Yeah.

Okay. Um, and so what I hear is that you're-- you feel like your wife might be, uh, overreacting to this?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

therapist: Okay. Good. therapist: Hi, Emily. client: Hi. therapist: It's been a while. client: Yeah, it's been a while.

This is something new.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Mm-hmm. therapist: Um, so that's one-one thing, and the other is, um, I do see fair amount of chipped teeth- client: Oh, yeah. therapist: -just from contact with it. I wonder what are your thoughts about that? client: Well, I definitely don't want it mess with my teeth. I know I kinda already have low gums to begin with, like you've been telling me for a while, and I have to flo-floss, which I-

Yes, flossing.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Oh, yeah. therapist: -just from contact with it. I wonder what are your thoughts about that? client: Well, I definitely don't want it mess with my teeth. I know I kinda already have low gums to begin with, like you've been telling me for a while, and I have to flo-floss, which I- therapist: Yes, flossing. client: Um, which I'm not doing but, um, yeah, I guess, I don't really wanna wreck my teeth 'cause-- Yeah, I didn't really notice any of the chipping.

There's nothing yet.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Well, I definitely don't want it mess with my teeth. I know I kinda already have low gums to begin with, like you've been telling me for a while, and I have to flo-floss, which I- therapist: Yes, flossing. client: Um, which I'm not doing but, um, yeah, I guess, I don't really wanna wreck my teeth 'cause-- Yeah, I didn't really notice any of the chipping. therapist: There's nothing yet. client: I guess I'm not paying attention to it.

Yeah. There's certainly been-- There's no problems and you, as you said, only have had it for a short time.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah. I guess if I really start to see a problem-- I mean, this might not last forever, but my teeth, I'm hoping- therapist: Mm-hmm. client: -will kind of stick [unintelligible 00:02:30] therapist: Emily, you said it so well it- client: Yeah.

-the-the piercing might not last forever, but your teeth really are-

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Um, well, I said I went to the polytech and stuff- therapist: Mm. client: -and I went back there and got another form and stuff, and just helping me with that. therapist: Mm-hmm. client: Yeah.

Yeah. And, get-getting to the polytech and getting the forms, that's a pretty big deal.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Yeah. therapist: Okay. So, where did you get to in terms of telling her that, uh, reading and writing is not that [unintelligible 00:27:23] for you? client: Just-- I-I asked her to fill that out for me because I said I'd be too messy. therapist: Mm-hmm. client: Yeah.

So, I was thinking about how that stuff about not feeling confident around reading and writing has, um, really got in the way for you.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Well, um-- Well, I don't know. Hopefully, there's not so much of that stuff. Um, oh, well, I don't know. I could find out maybe someone who can help you, like, at the school, at the polytech, maybe somebody can help you out and stuff, or there might be computers there or something. therapist: Mm. Yeah? client: Yeah. therapist: So, all these changes that you've- that you've made, um, Billy, where-where is the offending fitting into all of that now? client: Not really fitting in. It kind of just gets in the way.

So, offending gets in the way of the life that you're starting to lead?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Not really fitting in. It kind of just gets in the way. therapist: So, offending gets in the way of the life that you're starting to lead? client: Yeah. therapist: Yeah? So, what temptations have you had to, kind of, go back to offending? client: Like like getting on the piss, but with Donna, there kind of keeps me busy.

Mm. So the drinking is something that we talked about can make it easier for you to offend.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah. I just wanna have a bit of a laugh and like go smash some windows or go and nick a car or something, but yeah. It's kind of harder to think straight. therapist: It's harder to think straight when you've been drinking? client: Yeah. therapist: Yeah. Yeah. And so you've got Donna around at the moment? client: Yeah.

And that's helping keep you in check, as you said?

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Yeah. therapist: And that's helping keep you in check, as you said? client: Yeah. therapist: Yeah. What would happen if she wasn't around say or at a party or? client: I'd probably just go be stupid with my mates.

Okay. So Donna at the moment who kind of being there is like a strength?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah. 'Cause if there's just like if a mate said they're gonna go out and pick a car or something, she just bumps them out and then-then I don't know. She say that's stupid and stuff. And I don't know. It gives me something to do. therapist: Mm. What do you think? client: Just kind of stupid. Well, it's pointless, but still a bit of a laugh. therapist: Mm. Yeah. 'Cause I was thinking about that dream that you've got about the job and a life with Donna and- client: Mm.

-kids and stuff like that and how you were saying that the offending doesn't fit in with that dream or that idea.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Just kind of stupid. Well, it's pointless, but still a bit of a laugh. therapist: Mm. Yeah. 'Cause I was thinking about that dream that you've got about the job and a life with Donna and- client: Mm. therapist: -kids and stuff like that and how you were saying that the offending doesn't fit in with that dream or that idea. client: No.

So there's that on the one hand, but on the other hand, there's the kind of immediate, um, feeling when you've had a few to drink and you're with your mates and it feels like it would be a bit of a laugh?

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: No. therapist: So there's that on the one hand, but on the other hand, there's the kind of immediate, um, feeling when you've had a few to drink and you're with your mates and it feels like it would be a bit of a laugh? client: Yeah. therapist: So you've got-got those two things going on at the same time. Yeah? client: Mm.

And it sounds like sometimes when you're in there with your mates and had a few drinks, it's hard to hold on to that vision of the future.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: No. Just, like, it's not normally my idea, like someone else would just suggest it and you kind of just, yeah. therapist: So it's not your idea. And you also go along with it? client: Yeah. You can't really be like, "Oh no," just give me shit. therapist: Mm-hmm. What would happen if you say no? client: Just like, it can be shit and I still do it. They just-just call me a pussy or whatever and I don't know. And they'd talk me into it probably.

Mm-hmm. So it's hard to actually say no to your friends-

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Yeah. You can't really be like, "Oh no," just give me shit. therapist: Mm-hmm. What would happen if you say no? client: Just like, it can be shit and I still do it. They just-just call me a pussy or whatever and I don't know. And they'd talk me into it probably. therapist: Mm-hmm. So it's hard to actually say no to your friends- client: Yeah.

-'cause of what they- what they thought of you.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: They don't lead me into trouble. But- therapist: Okay. So tell me- tell me what it is that they do so I get a better understanding of it. client: Uh, like it's my choice though, they don't make me. therapist: Yeah. client: Yeah. I know it's just having grown up with, it's just what we've always done.

Okay. So that's just what you've always done.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Uh, like it's my choice though, they don't make me. therapist: Yeah. client: Yeah. I know it's just having grown up with, it's just what we've always done. therapist: Okay. So that's just what you've always done. client: Yeah.

But we're also talking about this idea that it doesn't fit with what your goals are or what your hopes are?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: So just hang out instead of go and do stuff, like stupid stuff. therapist: Okay. So-so Donna's helped calm you down and you'd like, um, them to calm down too? client: Yeah, 'cause then we could hang out together and stuff- therapist: Mm. client: -with our girlfriends and stuff.

So am I hearing that it's tricky in some ways to hang out with them sometimes-

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: -yes, someone who's got my back. therapist: So, someone who's loyal, someone who's got your back, yeah? What else? What else is really your definition of a really good mate? client: That's about it. It's-- yeah. therapist: Hmm. client: Someone who'll stand up for you.

Oh, so, someone who'll stand up for you?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: I mean, support me. therapist: Yeah. How-how would you wanna be supported, Billy? client: Just don't give me shit about, I don't know. Um, yeah, just, if I- if I don't wanna go do something, don't, like, don't give me shit about it. therapist: Mm. Okay, so that's-that's the kind of support that a really good mate would give you? It sounds- client: Yeah.

-like these guys have been around for you-

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Just don't give me shit about, I don't know. Um, yeah, just, if I- if I don't wanna go do something, don't, like, don't give me shit about it. therapist: Mm. Okay, so that's-that's the kind of support that a really good mate would give you? It sounds- client: Yeah. therapist: -like these guys have been around for you- client: Yeah, yeah, they [unintelligible 00:36:38]

-for quite some time, and they're really important to you.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: I guess, like, if they actually know I'm going to polytech and stuff that they might understand. therapist: Okay. client: But, like I feel guilty if they wanna go and have fun, and I'm not with them. therapist: Okay. That's the second time you've used that word 'guilty'. client: Yeah.

Yeah? So, it sounds like it's a really-- something's really important to you about that.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Yeah. therapist: Yeah? So, it sounds like it's a really-- something's really important to you about that. client: Yeah. Like, just going out with them or spending some times with them-- time with them, but, like, I really wanna spend time with Donna too- therapist: Mm. client: -so, it'd be cool if we could spend time together, like, with Donna and my mates.

Okay. So, it's almost as if you feel a bit torn because you wanna be with Donna, but you also wanna be with your-

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Yeah. Like, just going out with them or spending some times with them-- time with them, but, like, I really wanna spend time with Donna too- therapist: Mm. client: -so, it'd be cool if we could spend time together, like, with Donna and my mates. therapist: Okay. So, it's almost as if you feel a bit torn because you wanna be with Donna, but you also wanna be with your- client: Yeah.

-with your mates?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah. therapist: -with your mates? client: Yeah, like-- Well, I know I get into trouble with them, but they're still my mates, and I- therapist: Mm. client: -feel--

Yeah, so they're still important to you?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah, like-- Well, I know I get into trouble with them, but they're still my mates, and I- therapist: Mm. client: -feel-- therapist: Yeah, so they're still important to you? client: Yeah.

Hmm. I also am hearing that you don't wanna get into trouble anymore.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

therapist: Mm. Yeah. therapist: Hi, Sal. Thanks for coming in today. client: No problem. therapist: I saw that your doctor made the referral and, um, and I really appreciate you taking the time to come and make that appointment. client: Yeah, it's-it's a bit of an inconvenience I'd say, but I'm here though.

So you made it in here-

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Yeah, it's-it's a bit of an inconvenience I'd say, but I'm here though. therapist: So you made it in here- client: Mm-hmm. therapist: - and do you have a sense of-of what some of the doctor's concerns were that led her to refer you? client: I don't know, something about changing my life even more. You know, the smoking's been changed, and now it's, you know, cut down the drinking, get rid of those extra smokes, get rid of my dog. I don't know what else have to do.

So your asthma has been acting up and there's a lot of stuff, not just the asthma going on?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Mm-hmm. therapist: - and do you have a sense of-of what some of the doctor's concerns were that led her to refer you? client: I don't know, something about changing my life even more. You know, the smoking's been changed, and now it's, you know, cut down the drinking, get rid of those extra smokes, get rid of my dog. I don't know what else have to do. therapist: So your asthma has been acting up and there's a lot of stuff, not just the asthma going on? client: Yeah, there's a lot of stress too. My wife's still on maternity leave, she's not getting paid, she's with the baby right now. And I'm the only person that's working right now, and plus I got to change all these things that are going on in my life.

Mm-hmm. Almost—

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: I don't know, something about changing my life even more. You know, the smoking's been changed, and now it's, you know, cut down the drinking, get rid of those extra smokes, get rid of my dog. I don't know what else have to do. therapist: So your asthma has been acting up and there's a lot of stuff, not just the asthma going on? client: Yeah, there's a lot of stress too. My wife's still on maternity leave, she's not getting paid, she's with the baby right now. And I'm the only person that's working right now, and plus I got to change all these things that are going on in my life. therapist: Mm-hmm. Almost— client: Yeah, it's a lot.

Almost overwhelming it sounds like.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Okay. therapist: It really-- You're in the driver's seat, so it's just to kind of put all the cards on the table, so to speak. client: Okay. Um, okay, that sounds good. As long as I'm not changing anything and we're just kind of putting, um, I guess, pen to paper or something. therapist: Yep. client: Um, okay, so my asthma.

Okay, so asthma is one.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Um, okay, so my asthma. therapist: Okay, so asthma is one. client: Yeah. therapist: What else? client: Um, the fact that they want me to get rid of Oscar, that's-that's my dog.

So your dog, and-and the doctor's saying the dog's—

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Um, the fact that they want me to get rid of Oscar, that's-that's my dog. therapist: So your dog, and-and the doctor's saying the dog's— client: Well, he's-- Yeah, he's saying it's a main-- It's a main contributor to my asthma problems. therapist: Okay. client: Which I don't- I don't- I don't- I don't buy it and I can't just get rid of him like that, but it's something that's there.

That's pretty shocking to be told that you have to get rid of your dog.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Well, he's-- Yeah, he's saying it's a main-- It's a main contributor to my asthma problems. therapist: Okay. client: Which I don't- I don't- I don't- I don't buy it and I can't just get rid of him like that, but it's something that's there. therapist: That's pretty shocking to be told that you have to get rid of your dog. client: Yeah. The dog has been there before my wife. I know I've had him longer.

Hmm. So that's a huge stress right now?

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah. The dog has been there before my wife. I know I've had him longer. therapist: Hmm. So that's a huge stress right now? client: Yeah. Yeah, it's- it's a big stress, it's like my best friend, so that's one of the important things. Also, I guess, cutting down these last cigarettes I've been working on. therapist: Okay, so smoking and-and I'm working towards quitting completely sounds like that's a goal for you? client: Um, finances is a problem right now too.

Okay, so money.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah. Yeah, it's- it's a big stress, it's like my best friend, so that's one of the important things. Also, I guess, cutting down these last cigarettes I've been working on. therapist: Okay, so smoking and-and I'm working towards quitting completely sounds like that's a goal for you? client: Um, finances is a problem right now too. therapist: Okay, so money. client: Time, I got to come to all these appointments and I'm taking time off work, which obviously is the money factor, right?

Right. Right, right. So the appointments and time.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Um, finances is a problem right now too. therapist: Okay, so money. client: Time, I got to come to all these appointments and I'm taking time off work, which obviously is the money factor, right? therapist: Right. Right, right. So the appointments and time. client: Mm-hmm.

Um, and some of these things are kind of related to each other I think we're already seeing.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: No. It's just overwhelming when you see them everything they're, you know? therapist: Right. Well, so where would you-- I mean, if you-you had to pick somewhere, one or two kind of high priorities or-or things to talk about in our time this morning, where would you wanna start? client: I think- I think the thoughts about the dog has been definitely bothering me, that's been one. therapist: Okay. client: And, um, my-my asthma is out of control too. So maybe those two.

Okay, and those are ones that are pretty related to each other-

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing.

Sounds like a wild night.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. therapist: Sounds like a wild night.

Sounds like a wild night.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. therapist: Sounds like a wild night. therapist: Sounds like a wild night.

Sounds like a wild night.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night.

Sounds like a wild night.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Um, it's really stupid. Uh, I was at a pub crawl last night and you know how pub crawls are. You have a few drinks and then I thought it was a really good idea to catch up with my friends who are, yeah, they're in front of me. So I just like jumped off the stairs of the bus and I was wearing these like stilettos 'cause it was a 90s-themed pub crawl. Anyway, and then I just like fell on my ankle. It was really embarrassing. therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night.

Sounds like a wild night.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night.

Sounds like a wild night.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night. therapist: Sounds like a wild night.

Sounds like a wild night.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Yeah. therapist: Yeah. therapist: Yeah. therapist: Yeah. therapist: Yeah.

Yeah.

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

therapist: Yeah. therapist: Yeah. therapist: Yeah. therapist: Yeah. therapist: Yeah.

Yeah.

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little—

You're still feeling the effects of-

Pretend you are a therapist and provide a simple reflection for what the client is experiencing.

client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— therapist: You're still feeling the effects of-

You're still feeling the effects of-

Pretend you are a therapist and provide a complex reflection for what the client is experiencing.

client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— client: Uh, sure, uh, as long as we don't talk too much about like vodka 'cause I'm still, ugh, a little— therapist: You're still feeling the effects of- therapist: You're still feeling the effects of-

You're still feeling the effects of-