MICA (Motivational Interviewing Competency Assessment) was designed to provide practitioners with easily digestible, structured and specific feedback regarding their efforts to use the motivational interviewing approach with their clients.
A Quick Overview of the MICA
by Ali Hall
MICA Musings (12)
by Ali Hall
“Evoking” measures the extent to which the practitioner elicits the client’s perspective on their own thoughts, barriers, knowledge, feelings, ideas, motivators, goals, values and solutions regarding the target behavior and change. The practitioner operates both from a place of genuine curiosity and from a belief that the motivation for change and the ability to change exists within the client. The practitioner skillfully elicits, explores and expands these client perspectives on change. At the lower end of rating, the practitioner never or rarely expresses interest in the client’s perspective—or even that they HAVE one! The practitioner is more interested in telling or installing, in interrogating or fact-finding. At the higher end, the practitioner demonstrates interest and curiosity about the client’s perspective and respects their point of view.
“Partnering” measures the extent to which the practitioner fosters a collaborative process with the client as two equal partners who are working together towards the client’s goals. The client is the acknowledged decision-maker regarding their life and is supported in the lead role. The MI practitioner is the key consultant who provides relevant knowledge, expertise, insights and observations at the right time and in the right dose that support and advance the client outcomes. At the lower end of rating, the practitioner never or rarely removes their “expert hat,” and they come across as not trusting the client to make good decisions. At the higher end, we hear what sounds like an effortless working together for the client’s own goals.
Early learners may begin to offer content- or surface-level reflections. This is the beginning of good news, as the learner can be encouraged to write down some of the client’s statements and the simple reflection they offered. Then, they can form several deeper reflections. Invite them to write 3-5 different reflections they can think of, that land plausibly at a deeper level.
What to do with sustain talk?
When encountering sustain talk, the learner may be unsure—they know it will not be helpful to continue embracing sustain talk yet be unsure how to leverage forward to where change talk might live. Invite them to consider the constraint the client faces and reflect it “inside-out,” as an opportunity or the seed of a solution the client has already identified. “I want to move around more but I don’t have much energy.” We take the “I don’t have much energy” as the constraint…so we know that “to move around more,” whatever the client chooses has to fit within that. So, the reflection might become “You’re trying to find something to help you move around that suits your energy level.”
“Forward reflections” can help a client feel heard for the water that’s already starting to move in the creek, even if a trickle. “You’re already thinking about…” “You’re starting to wonder about…” “You’ve begun to be curious about…” are examples of reflection starters that notice the water is moving even if it’s running fast just yet ☺
A key way to support autonomy and activation is to reflect or affirm by connecting the client’s efforts to outcomes they are already beginning to notice, even if they client isn’t all the way to their goal just yet. “You’ve begun winding down earlier in the evening and are already noticing your sleep is improving.” “Your efforts at ‘x’ are already starting to pay off.”
When the practitioner has an agenda that’s different from their client, the practitioner can be tempted to impose their agenda or try to “get the client around to it.” We think of this as a secondary agenda, which can cause harm or distrust. It can feel like “directing” or “manipulating” to the client. The practitioner instead can be transparent about it. “Before you go, I’d like to make sure we address ‘x,’ but let’s start with what’s important to you” can be a skillful way to guide the conversation.
When the practitioner hears little bubblings of change talk, they can encourage the client by reflecting it and asking for more of the same kind or a different kind of change talk. Noticing when there is some importance and confidence talk gives the practitioner a signal to summarize and ask for some mobilizing talk. For example, “you’ve said this is something you really want and you have some important reasons already for it such as ‘a, b and c,’ you’ve got some strengths like ‘x, y and z’ that have helped you in other situations. What do you think might a step toward putting all that into action?”
While we don’t track closed and open questions as such in the MICA, we consider the kinds of questions the practitioner asks as we decide how to rate the conversation. Fact finding or history gathering kinds of questions do not usually help the client describe their point of view or perspective. And, in the strongest conversations, the client has an opportunity to express their perspective and self-explore in such a way that their perspective shifts by the end of the session. This is how our clients speak their way to change. In the MICA, the microskills we code include reflections and questions. These microskills are basic communication skills that practitioners intentionally apply when working with clients. Miller and Rollnick in 2002 found that clinicians asked questions significantly more than they used reflective statements in traditional therapy sessions. Reflections were markedly outnumbered by questions with a ratio of one to ten (1:10). They found a notable contrast with clinicians skilled in MI who tend to reflect more often than ask questions! Those skilled in MI had a reflection to question ratio of 3:1.
It can be hard to hear the difference between affirmation (which we don’t “count” but take into account with our overall ratings) and reflections (which we count). If we too often mistake reflections and affirmations, it can influence the accuracy of our ratings. Affirmations convey a positive observation about the person and address self-efficacy or personal agency, whereas reflections convey our understanding of the person’s perspective – something related to what they have said or meant. Skillful complex reflections capture deep, significant meaning and, as such, elicit insights from the client that can come across as uplifting and supportive. Therefore, it can be tempting to hear that utterance as an affirmation; i.e., because it feels weightier than a simple reflection a coder may want to “prize” it more. But when a coder erroneously counts affirmations as reflections, it skews both the total reflection count and the reflection-to-question ratio. Moreover, mistaken identification also negatively impacts inter-rater reliability (IRR), so an utterance (or verbal intervention) cannot be assessed as both a reflection and affirmation. The rule in coding is that if the statement does not clearly stand out as an affirmation, it should be coded as a reflection.
The MICA allows us to calculate a total or aggregate score. This is a sum of the average of the two strategies and the average of the five intentions. An aggregate, total or composite score helps the learner and any key administrators see at a glance where the conversation landed, with some nuance not available from scoring with other coding instruments. A 6.1 composite score would be considered Client-Centered. The total aggregate score range is from 2-10. You can consider a composite score between 2 and 4 to be between “Fundamentally Inconsistent” and “Inconsistent” skill, from 4.1-6.1 to be somewhere in between “Inconsistent” and “Client-Centered” skill, from 6.1-8 to be somewhere in between “Client-Centered” and “Competent” skill and from 8.1-10 to between “Competent” and “Proficient” skill.
The Expressing Empathy scale measures the practitioner’s Intention to actively listen without judgment; grasp the client’s thoughts, feelings, experiences, and perspective; and to convey that understanding to the client. Strategies include reflective listening, validation of the client’s reality, and all of the efforts the practitioner makes to accurately understand the client’s inner experience and effectively communicate that to the client. A conversation that sounds like “5” in this dimension (“skillfully conveys a multifaceted understanding of client perspective”) is one where it feels like the practitioner saw deep into the client’s soul and was able to convey that depth of understanding. The client feels seen and heard at a deep and meaningful level.
