MOTIVATIONAL INTERVIEWING: MOVING PARENTS TOWARDS

CHANGE Presented by Dr. Dianne Maing

May 5 & 6, 2015

Sault. Ste. Marie

Objectives

• Engage in a conversation about Motivational Interviewing (MI)

• Become familiar with the basic concepts of MI: Spirit, Process, Communication Skills

• Gain an awareness of potential MI strategies to apply to Triple P

Agenda

• MI and the ambivalent client

• MI Spirit: Partnership, Acceptance, Compassion, Evocation

• MI processes: Engaging, Focusing, Evoking, Planning

• Communication skills: OARS

• MI within a Triple P context

Your Objectives

Triple P Context: Common Obstacles to Change

Handout 1

Ambivalence

• Wanting and not wanting something or wanting 2 incompatible things

• People on the road to change often become stuck in ambivalence

• Staying put: Sustain talk

• Moving forward: Change talk

Ambivalence

Procrastination?

Decisional inability?

Stubbornness?

MI: What Is It? • Type of conversation to move individual

towards change when person is ambivalent

• Conversation is: (1) collaborative – person-centred, honours

autonomy; non-expert interaction (2) evocative – seeks to elicit person’s own

motivation and commitment to change when there’s ambivalence

(3) based on person’s values and interests

MI Values • Carl Rogers’ Client/Person-Centred Therapy :

– Unconditional positive regard for the client

• Ryan and Deci’s Self-Determination Theory:

– Each individual has a right to make his/her own choice

– Each person can achieve his/her goals

– Intrinsic motivation associated with greater persistence in achieving goals vs being extrinsically motivated

Evidence of Efficacy

• William R. Miller (1983): Treatment of problem drinkers

• Extensively studied in healthcare and wellness studies:

– Drug and alcohol addiction; Weight loss program, medication regime; Correctional settings; Mental health

• > 1500 publications

• > 200 randomized trials; 10 multisite trials

• Research supports MI as an evidence-based intervention when client is ambivalent about change

• Compatible with other interventions, e.g., CBT

What MI Is NOT

• Argument with clients about what the problem is

• Imposing a diagnostic label on clients or trying to convince clients of what the problem is

• Telling clients what they “must” do

• A way to manipulate people into doing what you want them to do

• A cure or fix-it-all

Miller & Rollnick’s 2013 Definition

“A collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and

compassion.”

Movere

MI Concepts: Spirit

P – Partnership: Collaborate or partner with the client, using the client’s expertise

A – Acceptance: Demonstrate empathy, support the person’s autonomy, and value and affirm the person’s worth and potential

C – Compassion: Act kindly in order to promote the client’s well-being and welfare, and give priority to the client’s needs

E - Evocation: Draw out the client’s own perspectives and motivation

MI Concepts: Processes

E – Engaging: Process of establishing trust

F – Focusing: Process of clarifying the particular goal(s) and the direction for change

E – Evoking: Process of eliciting the person’s motivation to change

P – Planning: Process of developing a change plan and supporting change

MI Concepts: Core Communication Skills

• OARSI

O – Open-ended questions

A – Affirmations

R – Reflections

S – Summary

I – Informing and advising

Having A Conversation About Change When Ambivalence is Present

Handout #2: Scenario A C: I try to get my son to put his dishes in the sink, but he just doesn’t listen.

After about five times of saying the same thing to him, I’m raising my voice and we’re into an argument.

T: It sounds like you’re really upset after repeating yourself. How often are you arguing with him?

C: Well, nearly every day.

T: What do the arguments look like? Are they really loud, with neither of you backing down? Are you able to control things?

C: Well, at times it can get loud, he’s swearing and I’m threatening to remove his videogames.

T: If you ignored him, what do you think will happen?

C: I’ve tried doing that to, but it doesn’t work. He still doesn’t put his dishes in the sink.

Handout #2: Scenario B

C: I try to get my son to put his dishes in the sink, but he just doesn’t listen. After about five times of saying the same thing to him, I’m raising my voice and we’re into an argument.

T: You’re having a really difficult time getting him to comply.

C: Yes, it’s so frustrating! It doesn’t seem to matter what I do. Even if I threaten to remove his videogames, he doesn’t care. I don’t know what to do anymore.

T: It seems like you’ve run out of ideas about what might work. If we take a step back for a moment, how do you understand what is happening between the two of you at those times?

C: I guess we’re both getting each other going. He’s not listening and I’m getting angry. But I don’t understand why he doesn’t care if I threaten to take away his videogames because that’s all he does.

T: Do you mind if I share my knowledge about situations like these?

Our Expectations of Ourselves and Our Clients

Therapist

Expert

Guide

Listener

Client

Expert

Guide

Listener

Engaging Process • Therapist style has been shown to be

predictive of client change

• Motivational-reflective style more predictive of longer-term change than confrontational-directive style

• Promotes change without being coercive

Engagement/Communication Style: A Continuum

Active, persuading, directing

Guiding

Supporting, facilitating, following

When To Guide and When To Direct

• DIRECTING: When factual information is required

• GUIDING: When change is being considered or being sought

• … And when to do both

“When the ambivalent client meets a fixer.”

Fixer:

• Tendency for helpers to use the “righting reflex”

• Want the person to follow the right course of action and tries to persuade by giving the good reasons for change

Ambivalent client:

• The more the therapist argues for change, the more the client argues against the change

• The more I hear myself talking about something, the more I believe it

Common Therapist Pitfalls

• The “righting reflex”

• “I have the expertise that I dispense.”

• “I collect information about problems & I’ll tell you what’s wrong.”

• “I correct gaps in your information.”

• “Frightening information may change behaviour.”

Miller & Rollnick, 2013

MI Consistent Language

• “The client is the expert on him/herself. I have some expertise.”

• “I find out what information clients want and need.”

• “I match information to clients’ needs and strengths.”

Elicit-Provide-Elicit (Handout #3)

• Elicit: Set an agenda with the client to discuss one of the concerns (include client’s agenda)

• Ask permission

• Provide information about particular concern

• Elicit: Invite client to express his/her perspective, concerns

– “How does this sound to you?’

Intake Conversation

How Engaging Am l?

• How comfortable is person in talking with me?

• How supportive and helpful am I being?

• Do I understand the person’s concerns and perspectives?

• Does this feel like a collaborative partnership?

• How comfortable do I feel in this conversation?

Miller and Rollnick (2013)

Focusing: Goal Setting

• Finding the client’s direction especially when it is unclear

• Agreeing together on a common direction or objective

• Exploring client’s values

The MI Language of Conversation

• Strategic communication skills:

–O – Open-ended questions

–A – Affirmations

–R – Reflections

– S – Summaries

– I – Informing & advising

Open-ended Questions

• Open-ended questions

– Seek to elicit a broad amount of information

– Allow for a range of responses

– Don’t limit the responder’s answers to “Yes” or “No”

• Closed-ended questions:

– Seek specific information

– Aren’t necessarily wrong, but limit how much information the responder may share

Open vs Close-Ended Questions

• Begin with “What,” “How,” “Tell me about,” “Describe,” etc.

• “What do you think will be some of the things that will prevent you from getting here on time?”

• Begin with “Have/Had/Has,” “Which,” “How many,” “Did/Do/ Does,” “Is/Are,” “When”

• “Have you used time outs before?”

OARS - Affirmations

• Statements that acknowledge and convey respect or appreciation for a client, and for his/her struggles and achievements

• Different from praise

• Examples: – “Thank you for being on time today.”

– ”I appreciate you being honest about this.”

– “You’ve been struggling with this behaviour for a while, but you’ve hung in there.”

Affirmations • An emotional response to what the client is

saying about his/her feelings, experiences, or values – “I am touched by your concern for your children and really

wanting to do this for them.”

• Reframe of a situation in a positive light – “You’re blaming yourself for your child’s behaviour, but it

seems to me that you’ve been attempting to use the behavioural charts.”

Communication Skills: Reflections

• Reflection is a statement intended to mirror the other person’s meaning, either explicit or implied

• Reflective or active listening involves the interviewer trying to understand the speaker’s subjective experience, offering reflections as guesses about the person’s meaning

Simple vs Complex Reflections

• Simple reflections: Can be one or two words

• Don’t add too much to the conversation

• Basically repeat or paraphrase

• Client: I’m depressed

• Staff: You’re feeling down; You’re feeling depressed.

Complex Reflections

• Convey a deeper understanding of where the client is at

• Adds emphasis or meaning in order to move the dialogue forward

• Includes making a guess … sometimes though, your guess may be wrong and can backfire – it’s a judgment call

• Client: I’m feeling down today.

• Staff: You look like you don’t have much energy

1. Client: I don’t really like having to talk in group. I know you said we learn from one another but it’s embarrassing. I feel as if the other parents are looking at me thinking how can she always be so strict with her kids rather than being supportive.

– Simple: Group can be helpful, but you get embarrassed.

– Complex: You’re feeling as if you’re under a microscope and being judged by the other parents. Plus, maybe you’re not sure you’re being the type of parent you want to be.

Communication Skills: Summaries

• Restatement or rephrasing of three or more concepts that the client has said

• Purpose of summarizing: Getting client to clarify a point or to see what he/she has said in a new way

• May be short or long,

• But must contain at least three ideas that the client has said; otherwise, they are reflections, not summarizations

OARS Skills Practice Handout #4:

Scenario C – Jed Choose any 2 of the

OARS skills to arrive at a goal

Scenario C - Jed Jed, a 10 year old, has been refusing to complete his chores, follow his parents’ rules regarding bedtime, and leaves the house without permission. His parents have tried to remove computer privileges in an effort to gain compliance, but with little to no success. Jed’s school has suggested the Triple P program. Jed’s parents arrive for the initial interview.

Reflection Questions

• Which OARS skill do you think you are using now?

• Which skills do you think you would like to enhance/use more?

Who Wants To Be A Millionaire?

Change occurs when the pain of keeping the status quo is greater

than the pain of change. Saunders

Evoking Change

• MI holds the view that clients already have what they need in them: Resources, motivation

• Strengths- based model rather than deficit-based

• Process of evoking is

– (1) to convey to the client the message that “You have what you need, and together we will find it.”

– (2) resolve ambivalence

• Focus on understanding the person’s strengths and resources rather than weaknesses

Ambivalence

• Approach-Approach: Both options are positive – least stressful ambivalent state

• Avoidance-Avoidance: Choice between 2 unpleasant situations

• Approach-Avoidance: Only one option is considered – but it has both positive and negative aspects

• Double Approach-Avoidance: Both alternatives have significant positive and negative aspects

Evoking Change Talk With The Ambivalent Client

• Listening for and responding to change talk

• Strengthening client’s change talk or commitment

• Developing discrepancy between client’s values and behaviour (“why is this important?”)

• Offer hope and confidence in person’s skills

Preparatory Change Talk: Not Getting Ahead of the Client

• Preparatory change talk:

–Desire: I want, I would like to, I hope

–Ability: I think I can

–Reason: No more fighting

–Need: Things can’t keep on like this

Handout

#5

Responding to Change Talk

• Use evocative questions to elaborate, affirm, reflect and summarize change talk

• Examine the pros and cons

• Change ruler: Importance of change; confidence, readiness

Miller & Rollnick, 2013

Importance of Change

Handout #6:

Heather - Read and circle the

various change talk & OARS techniques

Discord

• Client: How old are you? Do you have kids? How can you possibly understand me?

• Therapist: You’ve told me reasons why you want to make a change. What is your plan to actually do it? Why haven’t you done it?

Unimportant?

Lack of

confidence?

Insufficient buy-in to

model/framework?

Difficulty in therapeutic

relationship?

Sustain Talk & Discord

• “I will…” but “ I really won’t.”

• Sustain talk has to have a focus (behaviour/attitude) that client wants to move away from

• Debunking “resistance” in favour of “discord”

• Discord = Interpersonal disturbance

Riding the Wave of Discord

• Discord likely to sound like arguing, interrupting, disengagement, defensiveness

• Listen empathically

• Come along side

Responding to Sustain Talk • Reflective strategies:

– Simple reflection: “You resent having to be here.”

– Amplified reflection: “Things have hit rock bottom”

– Double-sided reflection: “You resent being here, and you want your child to argue less.”

• Exchange information: What have you heard?

• Explore others’ concerns for client

Miller & Rollnick, 2013

Examples

• “What did you take from the parenting classes? Can I check with you regarding the accuracy of this information?

• Knowing yourself as well as you do, how do you think you might handle scheduling h-w?”

• “What ideas do you have about this?”

• “Some parents have said they’ve found this to be difficult, what would work for you?”

Scenario – Harry – Use DARN

1. “By the time I get home from work, I’m tired and I still have to make supper, help with homework, and get ready for tomorrow. I know spending time with Harry is important but I’m just too tired to do it. Besides he would rather watch videogames.”

2. “We want to get Harry’s behaviour under control but we’ve taken so many parenting programs before but they haven’t helped.”

Moving Towards Change

• Preparatory change talk is insufficient

• Language of commitment: I swear, I guarantee

• Activation: “I’m willing to try planned ignoring”

• Specific actions: “I used planned ignoring”

Commitment Language

• Strength of commitment language:

– Low commitment: I mean to, I hope to, I will try

–Medium commitment: I look forward to, I plan to, I resolve to, I expect to

–High commitment: I guarantee, I will, I promise, I dedicate myself, I shall

MI Specific Change Variables • Osilla et al. (2015): 110 male and female at-risk

youth, aged 14-18 yrs, juvenile deferment

– 1st time offence; marijuana and alcohol use

– 6 group sessions: Evaluation of session content & subtypes of change talk (DARN, Commitment, Taking Steps) – in relation to decrease in drug use

– Results: Commitment and Reasons for change were more associated with decreased drug use

– Comment: CT may be enhanced through the use of exercises such as change rulers & decisional balance

Am I Evoking Change?

• What are this person’s reasons for change?

• Is the reluctance more about confidence or importance of change?

• What change talk am I hearing?

• Am I steering too fast or too far in one direction?

• Is the righting reflex pulling me to be the one arguing for change?

“I’m the kind of father who would let his kids stand in the rain while he chased a drug.”

Developing A Change Plan

• “What is a next reasonable step you might take?”

• Steps need to be specific

• Therapist behaviours may take more of a directing quality: Offering helpful solutions with permission, psychoeducation

• Maintain empathy and reflective listening

• Continue to be attentive to ambivalence

MI Summary

• Therapist behaviours: Developing an empathic relationship

• Technique: Becoming good at getting the client to give the reasons for change and minimizing sustain talk

Who Wants To Be A Millionaire?

MI Summary Reflection Questions

• How well do I understand the client’s experience? Am I listening and reflecting?

• Is there a clear sense of the goal?

• Am I hearing change talk? What am I deliberately doing to evoke change talk?

• Is it premature to talk about a plan? If I am offering advice, is it with permission?

Application Reflections

• What does MI bring to my work?

• How can I honour ambivalence and discord in order to guide, at times direct and/or follow, my client to make a change?

• Which one aspect of MI would I like to know or do more?

ALL CHANGE IS SELF-CHANGE, TO WHICH CLINICIANS ARE SOMETIMES PRIVILEGED

WITNESSES AND FACILITATORS.

Miller & Rollnick, 2013

References and Resources

• Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S., Moring, J., O’Brien, R., Schofield, N., & McGovern, J. (2001). Randomized Controlled Trial of Motivational Interviewing, Cognitive Behavior Therapy, and Family Intervention for Patients With Comorbid Schizophrenia and Substance Use Disorders. Amer. J. of Psychiatry, 58(10), 1708-1713.

• Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change. NY: Guilford Press. www.guilford.com/p/miller2

• Moyers, T., Martin, T., Houck, J., Christopher, P., & Tonigan, J. (2009). From in-session behaviors to drinking outcomes: A causal chain for motivational interviewing. J. Consulting and Clinical Psychology, 77(6), 1113-1124.

• Osilla, K., Ortiz, J.A., Miles, J., Pedersen, E., Houck, J. & D’Amico, E. (2015). How Group Factors Affect Adolescent Change Talk and Substance Use Outcomes: Implications for Motivational Interviewing Training. J. Counselling Psychology, 62(1), 79-86.

• Westra, H., Aviram, A. & Doell, F. (2011). Extending motivational interviewing to the treatment of major mental health problems: Current directions and evidence. Can. J. Psychiatry, 56(11), 643-650.

• www.motivationalinterviewing.org

• www.motivationalinterview.org