Adaptations to various issues Groups_ Slides... · MI in Groups [email protected] Wagner, C.C....

MI in Groups

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Wagner, C.C. & Ingersoll, K.S.

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Based on C.C. Wagner & K.S. Ingersoll (2013). Motivational Interviewing in Groups. New York: Guilford Press.

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Adaptations to various issues �  Dual Psychological-Addiction Disorders (Martino & Santa Ana) � Managing Chronic Health Conditions (Lane, Butterworth, Speck) � Weight Management (Dunn, Hecht, Krejci) �  Intimate Partner Violence (Carden & Farrell) �  Sexual Offenses (Prescott & Ross) �  Adolescents and Young Adults (Feldstein-Ewing, Walters, Baer) � Mandated Substance Abuse Treatment (Johnson & Downey) �  Integrating MI and TTM for Cocaine Abuse (Velasquez,

Stephens, Drenner) �  Integrating Motivational Interviewing into Empowerment

Groups for Women with Addictions (Jasiura & Hunt)

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Expanding awareness from individual to group focus

•  We are most familiar with thinking of ourselves as individuals •  Our traits/characteristics •  Our interests/hobbies •  Our professions/

•  We are all members of groups ▫  Different friend groups, families, work colleagues, activity

groups such as sports/book club/yoga/church/ ▫  Describe different styles/norms of 2-3 groups ▫  Describe how you may think/feel/act differently across

groups

Therapeutic Groups

n More effective than no-treatment or minimal treatment

n Equally effective to individual for many problems n Potentially more cost-efficient n Lower dropout rate n Fewer empty timeslots n Serve more people at once

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Groups - Relationships

•  Exponential increase in complexity in groups ▫  Dyad = 1 relationship ▫  Triad = 3 1-to-1 relationships, 3 1-to-2 relationships, 1 3-

way relationships = 7 relationships/subgroups ▫  Four group = 27 relationships/subgroups

Individual and Group MI Similarities

•  Enhance motivation for change through resolving ambivalence

•  Balance client-centered/empathic and directive elements

•  Incorporate MI spirit(partnership, acceptance, compassion, evocation)

•  Strategically use OARS communication pattern • Use MI Strategies •  Avoid MI Non-adherent clinician behaviors •  Balance focusing and staying open

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Individual and Group MI Differences •  Facilitating vs. interviewing • Group dynamics ▫  Managing floor time ▫  Managing different styles and beliefs across members ▫  Eliciting group energy for change ▫  Working with group members’“righting reflexes”

•  Role of Change Talk ▫  Less prominent in group (due to lower floor time) ▫  Promote implicit/internal change talk through linking

Blending MI and Group Practice n Integrating MI concepts, strategies, and techniques

into MI groups n The challenge of being person-centered in a group of

people with competing needs/interests n Balancing acceptance and change n Rolling with resistance in groups n Using MI techniques in MI groups: OARS, providing

information, giving advice, etc. n Using group therapy techniques in MI groups:

n Facilitating, linking, redirecting, protecting, modeling, rounds, dyads, written exercises, group exercises

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Evidence about MI Groups – Processes

•  Increase perceived autonomy and promote recognition of ambivalence

•  Increase self-efficacy, behavioral intentions, readiness to change

•  Increase treatment engagement, attendance, completion

•  Increase participation in aftercare •  Promote recognition of problems •  Reduce iatrogenic effects in groups

Evidence about MI Groups – Outcomes

• Reduce alcohol use and binge drinking • Reduce drug use frequency and consequences •  Increase smoking cessation •  Improve risk reduction and disease coping

• Overall, just beginning, although process research ahead of curve

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Why offer MI groups?

• Help clients resolve ambivalence and move toward better future

•  Increase engagement and reduce dropout, leading to improved outcomes

• Clients benefit from support and guidance of other group members

•  Increase efficiency of services

Leader floor time 0-20% of the session

Linking Leader consistently links members’ experiences, interests, goals, themes or change processes, facilitating strong connections between

Framing Leader guides the group to discuss issues from within members’ perspectives; professional perspectives are used primarily to elicit members’ reactions (if at all)

Time orientation

Leader consistently guides the group to focus on the present and future; Any focus on the past is used to identify strengths, successes or lessons learned that can be applied to goals

General Group Leadership

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Empathy Leader shows deep understanding of nearly all members’ perspectives, including elements they have not explicitly communicated

Autonomy Leader strongly supports members’ autonomy, encouraging members to express their personal values, perceptions, goals or choices, even when they differ from others’

Strengths Leader consistently focuses on members’ strengths or competencies, and rarely focuses on deficits or inabilities

Engaging Leader consistently nearly all members involved in the group process, even when they are not speaking

Focusing Leader consistently keeps the group focused and on-task

Evoking Leader consistently elicits members’ own motivation, goals or plans, rarely if ever suggesting goals/reasons members should change

Progress Leader consistently focuses on members’ positive progress or growth. Problems are discussed only as obstacles to be overcome, or to gain context for setting goals

MI Group Leadership

Climate Members are highly supportive and affirming of one another regardless of topic of discussion or perspective or experiences shared

Openness Members actively share perspectives and feelings; initiate sharing, and share deeply; willing to share even unpopular opinions or vulnerabilities not regularly revealed

Cohesion Members appear to have strong and deep bonds with one another, a strong sense of solidarity and belonging

Altruism While not ignoring their own issues or progress, members consistently focus on helping others in the group

Hope While not ignoring potential challenges, members strongly focus on their hope that they can make things better, and rarely get bogged down by fears or concerns

MI Group Processes

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EXERCISE: Rate Yourself! Common Skills of Group Leaders

Skills 1= lower, 4= acceptable, 7= strong

1.  Comfort with anger, moodiness, talkativeness and silence

2.  Able to take a step back during conflict or sympathetic stories

3.  Able to understand others’ perspectives while maintaining some objectivity

4.  Able to maintain boundaries without being rigid

5.  Ability to help members connect to one another

6.  Can provide structure or be spontaneous as needed

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

Structuring MI Groups

n Structured to unstructured n Structured groups are predictable, include topics and

timelines, scheduled exercises, allow tight time management

n Semi-structured groups have identified topics, and some points to cover

n Unstructured groups build upon what clients bring to session

n Homogeneity vs. heterogeneity n Homogeneous groups are more quickly cohesive, allow

quicker focusing, and work on similar goals n Heterogeneous groups require more engagement and

creativity in focusing, yet can allow broader goal-setting and deeper processing

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Time span

•  Time-limited: ▫  Easy to sequence, ▫  Predictable flow ▫  Good for mandated # of sessions ▫  Good for research, intertwined services

• Open-ended: ▫  Good for those waiting for unpredictable treatment

start date ▫  Good for those uncertain as to whether other

treatment is needed or wanted ▫  More difficult to track participation over sessions

Admission: Open vs. closed membership

•  Open: no waiting period, changing dynamics, lower trust/depth

•  Closed: greater member familiarity, continuity of experience, numbers tend to diminish

•  Staggered: admit new members every X sessions; balances between two

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Format 1: Support groups

•  Focused on life transition or ongoing maintenance (adjusting to illness, divorce, death of loved one, caregiving)

• Often led by professionals without formal counseling training, sometimes by peers or paraprofessionals

•  Discussion-oriented or combination didactic-discussion •  Focus on adjustment vs. identified change •  MI strategies have change “built in” - helpful even with

inexperienced leaders

Format 2: Psycho-educational Groups

� Combine didactic information with personalizing and interpersonal interaction

� Facilitator shares content, followed by group discussion focused on personalizing material, group training or practicing a new skill.

� Size between 8 /12 members can remain interactive; larger groups tend to become strictly educational

� Typically structured or semi-structured � Issues when using worksheets: literacy issues,

attentional issues, engagement issues, avoiding strict educational format

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Format 3: Psychotherapeutic Groups

�  Interpersonal processes used strategically to achieve therapeutic goals for multiple individuals

� Perhaps between 6 and 10 members � Diversity of problems and demographic characteristics of

group members may be desirable � Typically unstructured approach � May teach participants basic MI communication skills (e.g.,

reflecting, affirming) � Closest to individual MI therapeutic processes; probably

most difficult

Template for Design of MI Groups SUPPORT PSYCHO-ED THERAPEUTIC

OBJECTIVES Engagement Any Behavior change

COMPOSITION Any Semi-structured Unstructured

SIZE Up to 15 8-12 6-10

DURATION Either Time-limited Open-ended

SESSION LENGTH 45-60 minutes 60-90 90-120

ADMISSION Open Closed or open Staggered

LEADER PREP Low Medium High

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Four Phase Model

n Engaging the Group

n Exploring Perspectives

n Broadening Perspectives & Building Momentum

n Moving into Action

ENGAGING EXPLORING BROADENING / MOMENTUM

MOVING INTO ACTION

Pre-group social time

Exploring lifestyles

Heuristic model (specify) Goal-setting

Group overview Typical day Assessment feedback Importance review

Differentiating group Ambivalence Envisioning Confidence review

Group guidelines Exploring values Exploring importance Hypothetical change

Orientation to session Looking back Exploring confidence Change planning

Warm-up exercise Reexamining expectations

Eliciting commitment

Eliciting member goals Decisional balance Initiation strategies

Past success stories Progress review Exploring strengths Challenges

MI Group Strategies by Phase

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Four Phase Model

•  Engaging the Group ▫  Setting the group environment ▫  Decontaminating the referral process ▫  Developing working relationships and norms within

the group ▫  Developing group guidelines ▫  What else?

(1) Engaging Exercise

• Goal is simply to develop basic familiarity and comfort in interacting

•  Brief introductions ▫  Personal, but not too threatening ▫  Something positive about lives - interests, something

that’s important, something passionate about

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(1) Engaging Exercise

•  Leader: ▫  Relax ▫  Breathe ▫  Be friendly ▫  Don’t rush ▫  Make people comfortable ▫  Keep your comments brief ▫  Shape into ongoing conversation with interaction ▫  Make some links as you go along

Group Climate n Overall atmosphere of group n Established at first contact

n Members n Care about each other n Try to understand self and others n Disclose personal information and feelings n Feel that the group is worth participating in n Support/challenge one another to make progress

n Group leaders who focus too much on tasks vs. relationships diminish outcomes

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CLIMATE

1 2 3 4 5 Members are regularly or highly critical of one another, dismissing one another’s opinions and

challenging perspectives

Members are somewhat uninvolved with one

another, generally not extending support,

occasionally criticizing, dismissing or avoiding

interaction with one another

Members are generally neutral in regard to one another, or there is an

even balance of supportive and

affirming comments with critical or

dismissive comments

Members are fairly supportive and

affirming of one another, with limits

when certain topics or perspectives are being

discussed

Members are highly supportive and

affirming of one another regardless of topic of discussion or

perspective or experiences shared

(2a) Identifying Focus and Establishing Group Guidelines

• Orient group (OPEN) ▫  Overview purpose: learning about members’ goals,

concerns, choices ▫  Personal choice and autonomy is emphasized ▫  Environment is respect and encouragement for all ▫  Non-confrontational nature of group

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(2b) Identifying Focus and Establishing Group Guidelines

•  Explore issues of focus for today ▫  Some way you’d like life to be better ▫  Something you might want to change but haven’t

started ▫  Something you’ve started but gotten stuck ▫  Something someone else suggests you change and

you’re not sure ▫  Some way you could live closer to your ideal

(2c) Identifying Focus and Establishing Group Guidelines

•  Brainstorm Group Guidelines ▫  Go around the circle ▫  Identify both what should be done and what would be

better not to do ▫  Establish realistic agreement on confidentiality (of

this group in this setting) ▫  Review and “boil down” guidelines, writing down if

desired (if any are not consensus, decide what to try “for now”)

•  Summarize and Elicit Reactions “so far”

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(2) Identifying Focus and Establishing Group Guidelines

• Orient group (OPEN) •  Explore possible issues of focus for today •  Brainstorm group guidelines •  Summarize and elicit reactions “so far”

•  LEADER – •  REMEMBER TO INVOLVE ALL MEMBERS; •  ASK OPEN QUESTIONS ABOUT THEIR FOCUS •  REFLECT THEIR INTERESTS AND CONCERNS;

CLIMATE

1 2 3 4 5 Members are regularly or highly critical of one another, dismissing one another’s opinions and

challenging perspectives

Members are somewhat uninvolved with one

another, generally not extending support,

occasionally criticizing, dismissing or avoiding

interaction with one another

Members are generally neutral in regard to one another, or there is an

even balance of supportive and

affirming comments with critical or

dismissive comments

Members are fairly supportive and

affirming of one another, with limits

when certain topics or perspectives are being

discussed

Members are highly supportive and

affirming of one another regardless of topic of discussion or

perspective or experiences shared

EMPATHY

1 2 3 4 5

Leader makes little attempt to understand

members’ perspectives, only attempts to do so with a few members to the exclusion of the rest of the group, or fails to understand members’

perspectives

Leader makes efforts to understand members, but fails to understand

several members’ perspectives

Leader shows understanding of many members’ perspectives, mostly limited to what

members have explicitly

communicated

Leader shows understanding of most

members’ perspectives, including some of what

members’ mean but have not explicitly

communicated

Leader shows deep understanding of nearly

all members’ perspectives, including

much of what members’ mean but have not explicitly

communicated

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Shaping Conversational Focus Aims When is this most

appropriate? What conversational methods?

Establishing, Developing and Holding Focus

-During initial session -Opening additional sessions -When conversation is productive

-Introductory framing -Evocative open questions -Simple reflections -Emphasizing personal control

Changing Focus

-When members focus on unproductive stories, details, or concepts

-Transitional summary -Shifting focus -Amplified reflection -Agreement with a twist

Four Phase Model

•  Exploring Perspectives ▫  Exploring members’ perspectives on their lives and

issues �  Exploring lifestyles �  Exploring ambivalence �  Exploring values

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Exploring Perspectives Principles •  Take a client-centered perspective •  Focus on the positives •  Bring the group into the moment •  Focus on the present •  Acknowledge suffering but don’t elicit grievances

Group facilitation

Series of one to one communications!

Facilitator!

Facilitate intragroup communications!

Facilitator!

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Group facilitation

Facilitator! Facilitator!

Group facilitation

Facilitator!

Intragroup communications!

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Cohesion ¡ Positive interactions between members ÷ Immature cohesion = superficial agreement and

false sense of unity ÷ Mature cohesion = True intimacy, allows

divergence and health conflict

Cohesion Positive Influence Negative Influence

Leader •  Encourage sharing •  Provide non-judgmental

feedback •  Warmth & eye-contact •  Ownership of mistakes •  Able to face anger •  Immediate

acknowledgement of unexpected moments

•  Fail to encourage interaction •  Defensiveness •  Anxious/avoidant attachment style •  Judgmental/competitive attitudes •  Unable to share warmth •  Fail to screen out toxic members •  Allow scapegoating and

subgrouping without exploration •  Fail to address absences and

tardiness •  Disallow negative emotions

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Cohesion Positive Influence Negative Influence

Members •  Turn-taking •  Support/acceptance •  Self-disclosing •  Psychological-

mindedness or higher educational experience

•  Willingness to experience emotions

•  Judgmental/evaluative responses •  Interpersonal problems such as non-

assertive, vindictive, intrusive •  Anxious or avoidant attachment

styles •  Inaccurate perceptions of others •  Lack of disclosure/risk-taking •  Easily overwhelmed by emotions •  Lateness or missing sessions

(3) Exploring Perspectives - Lifestyles

•  Define the term Lifestyles as the way we typically live, the things we typically do, how we spend our time, and the people we spend time with ▫ “Let’s talk a little about lifestyles. How do you

spend your time? What kinds of patterns are there in your daily life?” ▫  What about some of your habits, like your (insert

shared problematic habit here, such as: overeating, use of drugs, etc.)? How does that fit in?”

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(5) Exploring Perspectives – Values

� Define ¡ Ideals: what is important, meaningful, or good in life, such

as family, honesty, or contributing to the world. Others think in religious or spiritual terms.

¡ Preferences: Experiences we like, such as relaxation, excitement, joy or peacefulness

� What are one or two personal values that relate to issue?

� Explore how values could help in moving forward

LEADER FLOOR TIME – approximately what percentage of time is the leader speaking?

1 2 3 4 5

81-100% of the session 61-80 % of the session 41-60% of the session 21-40% of the session 0-20% of the session

LINKING

1 2 3 4 5 Leader does not connect or link

members’ experiences, interests, goals, themes

or change processes; focusing instead on

them as discrete individuals

Leader occasionally links members’

experiences, interests, goals, themes or change

processes

Leader links some members’ experiences, interests, goals, themes

or change processes

Leader often links members’ experiences, interests, goals, themes

or change processes, facilitating connections

between members

Leader consistently links members’

experiences, interests, goals, themes or change processes, facilitating a

strong web of connections between

members

COHESION

1 2 3 4 5

Members appear to be a collection of isolated individuals, with no sense of bonding or

solidarity

Members appear to have occasional

connections with one another and occasional sense of being “in it”

together

Members appear to have moderate, ongoing

sense of interconnectivity, and

moments of recognizable,

meaningful bonding

Members appear reasonably close and

connected, with a sense that they are part of a

group, and that the bonds between them

are valuable

Members appear to have strong and deep

bonds with one another, a strong sense of

solidarity and belonging

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Four Phase Model

n Broadening Perspectives & Building Momentum n Envisioning a more satisfying future n Considering options for change n Exploring and enhancing confidence n Heuristic models (Ready-Willing-Able, Stages of change,

chronic illness adapt) n Assessment Feedback n Looking Forward / Envisioning n Importance/Confidence n Strengths / Supports

Broadening Perspectives Principles

n Focus on positives n Focus on the future n Develop discrepancy n Accept defensiveness

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Working with a Co-leader

� Model MI Spirit with each other � Content & Process � One leader focus on content; individual exploration � Other focus on group process and linking

� Rolling with resistance in pairs �  If group member becomes defensive with one leader,

other can neutrally explore without “taking sides” � Mutual session review � Co-facilitators can compare impressions, brainstorm

together, consider strengths and needs of members

(6) Broadening Perspectives – Heuristic Models

•  Define - model to provide a lens to look at issues through •  Stages of Change ▫  Explore past significant change; how long it took to move from

considering it to starting change; how long to finish and put it behind (LINK SIMILARITIES; EXPLORE DIFFERENCES) ▫  Overview SOC ▫  Ask members where they are, what might help them move

forward (if they wish to) •  Ready-Willing-Able ▫  Elicit ideas about RWA; Explore examples; Explore

fit with current issue

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Dyads / Small Groups � Break members into small groups to work on issue, then “report out” and have large group discussion

� Make sure that dyads inform partner of things they wouldn’t want shared with large group

(7) Broadening Perspectives – Past Successes (Dyads) ▫  What past successes they have had in making some

change �  How they identified desire/need to change �  How they went about changing �  How others reacted �  Challenges/setbacks �  How today is different for having changed �  How can they build on past successes and avoid

quitting their current change attempt ▫  Large group debrief and link together on content,

motivation to change, experiences

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Conversational Shaping

Developing Breadth: • Broadening and Narrowing

Developing Depth: • Deepening and Lightening

Developing Momentum: • Accelerating and Decelerating

(Wagner & Ingersoll, 2013, Motivational Interviewing in Groups. New York: Guilford)

Developing Breadth

Narrowing the conversation toward a specific issue or idea…

…vs. broadening the conversation

into more general themes

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Shaping Focus - Breadth Aims When is this most appropriate? What methods?

Broadening When members are too focused on details, limited perspectives

-Linking summaries -Open questions -Imagery reflections -E-P-E sequence

Narrowing -When focusing on one aspect of a multifaceted issue will help promote progress toward change -When members speak vaguely, or talk about principles or values without tying them to change

-Closed questions - Selective reflection

Developing Depth

Focusing conversation on daily events, factual matters, or lighthearted discussion…

…vs. deeper conversations about

values, identity, vulnerabilities or

emotions

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Surface level Daily occurrences,

challenges, conflicts, etc. I I I I I I I

Deeper level Values, identity,

emotions, beliefs, vulnerabilities

Shaping Focus - Depth Aims When is this most appropriate? What methods?

Deepening

-When members are ready to share more vulnerable issues -When members are too focused on surface details, intellectualizing, or stuck in unresolvable ambivalence

- Reflections of emotions, values -Affirmations

Lightening -When closing sessions or ending group -When mood becomes too intense or heavy or conflict emerges

-Closing summary -Shifting focus -Linking reflections -Use of humor

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Developing Momentum Accelerating the conversation toward some conclusion or commitment to action…

…vs. slowing the conversation down to

more carefully consider an issue with no

particular movement toward a conclusion

Shaping Focus - Momentum Aims When is this most

appropriate? What methods?

Accelerating -After initial exploration of perspectives -When members focus on the past or “stop short” of tying ideas/values to choices or behaviors

-Open questions about change -“Continuing the paragraph” refs -Affirmations -Group brainstorming of change possibilities

Decelerating -When members skip or race through difficult issues -When members seem to have “false high confidence” about a complex, risky change

-Suggest slowing down -Explore a secondary theme -Incorporate a written exercise or work in pairs or small groups -Use linking reflections -Explore potential obstacles to change and backup plans

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STRENGTHS

1 2 3 4 5

Leader consistently focuses on members’ deficits or inabilities,

and rarely if ever focuses on their

strengths or competencies

Leader mostly focuses on members’ deficits or

inabilities, but sometimes focuses on

their strengths or competencies

Leader equally focuses on members’ strengths or competencies as well

as on their deficits or inabilities

Leader mostly focuses on members’ strengths or competencies, but sometimes focuses on

their deficits or inabilities

Leader consistently focuses on members’

strengths or competencies, and

rarely if ever focuses on their deficits or

inabilities

OPENNESS

1 2 3 4 5

Members appear highly guarded; actively avoid

or resist sharing perspective and feelings

Members appear fairly guarded; sharing

surface perspectives and feelings upon direct request or in exercises

intended to prompt sharing, but not

initiating sharing otherwise

Members appear neutral; willing to share if conditions are right, but do not regularly

initiate sharing beyond surface level

Members actively share their perspectives and

feelings to a large degree; possibly

holding back some deep vulnerabilities or

unpopular opinions, but open about most other

elements

Members actively share perspectives and feelings; initiate

sharing, and share deeply; willing to share

even unpopular opinions or

vulnerabilities not regularly revealed

▫ Share a vision for how things might be different in the future. ▫  Link together on content, motivation to

change, specific visions.

(8) Broadening Perspectives – Looking Forward Envisioning

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(9a) Broadening Perspectives – Importance and Confidence ▫  Scale Importance �  How important is this change on scale of 0 – 10 �  Line up in space �  Starting with top subgroup (8-10), what makes it

important? Mid-group (4-7), why X and not 0? �  Low group (0-3), why is it a little important? What might

make it more important? ▫  Scale Confidence �  Top group – What provides confidence? Mid-group, what

makes it X, not 0? What would boost confidence? �  Low-group, how can group help you gain more confidence?

(9b) Broadening Perspectives – Strengths

▫  Identify a few personal strengths / things you’re good at ▫  (Identify how one of those strengths helped in the

past or helps now in challenging situations where it might be more difficult if you didn’t have the strength)

▫  How might those strengths help moving forward on the issue at hand?

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Four Phase Model

n Moving into Action n Defining, planning and implementing changes that

participants believe will improve their lives n Importance/Confidence review n Hypothetical change n Change planning n Strengthening commitment to change n Getting started n Dealing with challenges and setbacks

Moving Into Action - Principles

n Focus on actions n Guide members to ask for what they need n Encourage attention to group processes n Focus on the immediate future n Support self-efficacy

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(10) Moving Into Action – Change Planning

•  Can work individually on plans; in dyads, or as large group

•  Can discuss person-by-person, or step-by-step •  After finished with each round, ask members ideas

they got from others that they might incorporate into their own plan

•  If members are stuck, see if they’d like group ideas, then offer several before asking member if any of those might fit for them

(10) Moving Into Action – Change Planning

• The changes I want to make (or continue making) are:

• The reasons I want to make these changes are: • The steps I plan to take in changing are: • The ways other people can help me are: •  I will know that my plan is working if: • Some things that could interfere with plan are: • What I will do if the plan isn’t working:

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(11) Moving Into Action – Commitment & Getting Started

•  Elicit commitment to take a specific action (and strength of commitment) ▫  Action can be “think more about” or “discuss with

others” ▫  Ask members to be realistic on strength (definitely,

probably) and specific on when/how they’ll take next step ▫  If divided between ready and not-quite-ready, consider

dyads of like pairs to develop commitment statements

(12) Moving Into Action – Termination

•  Explore experiences in group, what group has meant to members, what ideas/inspirations they’ll take away

•  Explore any future steps, alone or together (both on individual issues as well as using MI strategies/groups/etc.)

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HOPE

1 2 3 4 5

Members focus almost entirely on their fears or

concerns about being able to make things

better, and rarely if ever focus on their hope of

doing so

Members focus mostly on their fears and

concerns about being able to make things

better, and only somewhat on their hope

of doing so

Members have a nearly even balance in

focusing on their hope that they can make things better and on

their fears or concerns

Members mostly focus on their hope that they can make things better,

but sometimes get bogged down by fears

or concerns

While not ignoring potential challenges,

members strongly focus on their hope that they can make things better, and rarely get bogged

down by fears or concerns

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