Motivational Interviewing (MI) in Children’s Services

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Presented by: Matt Wofsy, LCSW

Brian Mundy, LCSWThe Institute For Community Living, Inc.

2012 Clinical Lunch & Learn Webinar Series

Objectives

Develop an understanding of Motivational Interviewing (MI) & how it may be used in clinic settings

Review the fundamental principles of MI & the Stages of Change Model

Acquire an understanding of basic MI techniques

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Brief history of MI

Founded by William Miller and Stephen Rollnick in the substance abuse field

Based on research involving recorded conversations

Has been found efficacious in dozens of other areas, including lifestyle changes, medication adherence, child obesity, diabetes, treatment adherence, etc.

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What is MI? – 3 Goals

1. To support the enhancement of intrinsic motivation

2. To support the client’s self-efficacy

3. To assist the client to resolve ambivalence

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What Is MI?

Ambivalence: Feeling two ways about something

Examples of feeling ambivalent every day

Ambivalence is natural and an essential part of being human

Oftentimes ambivalence for clients is regarding big life changes

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What Is MI?

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Ambivalence is a bit like a see-saw …

Part of the person that

does not want to change

Part of person that

wants to make

changes

What Is MI?

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Part of the person that does not want to change

Part of person that wants to make changes

Ambivalence is a bit like a see-saw …

What is MI? The working assumption is that intrinsic

motivation is a necessary and often sufficient factor in instigating change.

Intrinsic vs. Extrinsic motivation Examples of extrinsic motivation:

◦ Child protective services◦ School principal/guidance counselor◦ Parole officer◦ Family court

Examples of intrinsic motivation◦ Desire for healthy relationships◦ Increased independence◦ Freedom

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Stages of Change

Stages of Change Precontemplation – Not ready to make a change; sees no real

problem in need of treatment◦ Example intervention: provide feedback, emphasize client responsibility

Contemplation – Unsure whether or not he/she has a problem ◦ Decisional balancing (pros/cons)

Determination/Preparation – Recognizes there is a problem and is ready to make a change in near future

◦ Explore expectations around change process Action – Not only recognizes the problem, but is already trying to

change◦ Troubleshoot barriers; Normalize that things might be harder

Maintenance – Has already made changes and is now working to hold onto those gains & not slip back into old patterns

◦ Relapse prevention Recurrence – Common, expectable, & likely to happen several times;

can occur at any point◦ Emphasize learning from the recurrence

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Stages of Change

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The stages of change are more accurately portrayed as a wheel …

Pre-contemplation

Contemplation

Preparation

Action

Maintenance

Recurrence

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Stages of ChangeTrue or False? A person with clinical depression can be

in the action stage around attempting behavior change but in pre-contemplation around re-visiting the psychiatrist TRUE

True or False? A person can be in action regarding

improving parenting skills one week but in pre-contemplation the following week TRUE

Stages of Change

Which stage of change is indicated?

a) Pre-contemplation

b) Contemplationc) Preparationd) Actione) Maintenance

In Pre-contemplation

“I can’t believe that my parents dragged me here. I mean so what if I cut school a few times? Everyone cuts class once in a while. I don’t need therapy, my parents are the ones who need therapy.”

“I can’t believe that my parents dragged me here. I mean so what if I cut school a few times? Everyone cuts class once in a while. I don’t need therapy, my parents are the ones who need therapy.”

Stages of Change

Which stage of change is indicated?

a) Pre-contemplation

b) Contemplationc) Preparationd) Actione) Maintenance

In Preparation

“The other night we got into a fight again. My boyfriend took it too far this time. I was really close to packing a bag and calling my sister about bringing the kids so we can stay with her. This has been going on for too long.”

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Four Principles of MI

E.D.R.S ● Express Empathy ● Develop Discrepancy ● Roll with Resistance ● Support Self-Efficacy

Four Principles of MI

1. Express Empathy –The MI therapist seeks to communicate great respect for the consumer:• Avoid communication that implies a

superior/inferior relationship• Client’s freedom of choice & self-direction are

respected• Listen, rather than tell.• Gentle, non-aggressive persuasion.• We communicate an acceptance of clients as

they are,while also supporting them in the process of change.

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Four Principles of MI

2. Develop Discrepancy - motivation for change occurs when people perceive a discrepancy between where they are and where they want to be.◦ Focus the consumer’s attention of these

discrepancies. ◦ Precontemplators don’t have this this

discrepancy – we have to help create it by exploring the consequences of current behavior.

◦ Move the consumer along the stages of change.

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Four Principles of MI

3. Rolling with Resistance -- ambivalence is normal; resistance is expected. ◦ Explore the ambivalence with the consumer in

a supportive, unthreatening way. ◦ Avoid Arguments – attacking the consumer’s

behavior tends to evoke defensiveness, opposition & resistance.

◦ No attempt is made to get the consumer to ‘admit’ there is a problem

◦ When MI is done well, it is the consumer and not the counselor who voices the arguments for change!

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Four Principles of MI

4. Support Self-efficacy – the consumer’s specific belief that he or she can change. • If one has little hope that things could

change, there is little reason to face the problem.

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Four Techniques

O.A.R.S.Open-ended Questions AffirmationsReflective ListeningSummaries

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Four Techniques: OARS

Open Questions: How many children do you have? Vs. Tell me about your family.

Did you get in trouble at school today? Vs. Tell me about your day at school.

How often do you visit with friends? Vs. Tell me a little about your friends.

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Four Techniques: OARS

Affirmations: Statements that recognize consumer

strengths. Help consumers feel change is possible.

(Hope is really important!) Can be used in response to resistance Must be genuine

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Four Techniques: OARS

Reflective Listening: This is the Key Focus on ‘change talk’ Reflect affect Tone of voice is important Keep momentum flowing through

reflections Validate where client is coming from

before launching into problem-solving.

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Four Techniques: OARS

Reflective Listening: Level 1 | Simple Reflection

Simply repeat or rephrase.

Consumer: I don’t want to go to school, that teacher is wack!

Counselor: You don’t like the teacher, so you feel like school is a waste of time

Consumer: Therapy sucks; I don’t want to be here right now.

Counselor: You really don’t want to be here.24

Four Techniques: OARS

Reflective Listening: Level 2 | Reframe Reflection

Listen for client’s “best perceived self” in the statement

and reframe it back to client. Consumer: I don’t want to go to school, that

teacher is wack! Counselor: So school is not meeting your needs

right now, and you want to exercise your ability to choose not to go

Consumer: Therapy sucks; I don’t want to be here right now.

Counselor: You really value your time and you don’t think that this is the best use of it.

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Four Techniques: OARS

Reflective Listening: Level 3 | Affective Reflection

Listen for the emotion behind the statement and reflect it

back to client. Consumer: I don’t want to go to school, that

teacher is wack! Counselor: You’re not getting anything from this

teacher and this whole conversation about school is getting you frustrated

Consumer: Therapy sucks; I don’t want to be here right now.

Counselor: You’re angry that you are here and resent even having to talk about it

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Four Techniques: OARS

Summarizing: Just a special form of reflective listening

where you reflect back what the consumer has been telling you

Summarizing presents an opportunity to begin mapping out the client’s ambivalence

Builds rapport Do frequently

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Four Techniques: OARS

Summarizing “Let me stop and see if I have this right. You

clearly don’t want to be here right now and you think that it’s a waste of time. Your foster parents have made you go to therapy in the past, and it really hasn’t gotten you anywhere. You feel like you can call your own shots, and you know what’s best for you. At the same time, you’re tired of getting grounded and fighting with your foster mother. You worry that, if this is left untouched, life in your current foster home will remain stuck and you’ll continue to feel bored and angry most of the time. Did I get that right?” 28

The FRAMES Approach Six elements of effective MI have been

identified and were presented in brief clinical trials, and the acronym FRAMES was coined to summarize them:◦ Feedback regarding personal risk or impairment us

given to the client following assessment of behavioral patterns and associated problems

◦ Responsibility for change is placed squarely and explicitly on the client

◦ Advice about changing, reducing, or stopping problematic behaviors is clearly given to the client by provider in non-judgmental manner

◦ Menu of Options is developed toward self-directed change

◦ Empathic counseling – showing warmth, respect, and understanding – is emphasized

◦ Self-efficacy or optimistic empowerment is engendered in the client to encourage change 29

MI, Documentation, and the Real World

We clinicians often get activated by felt lack of progress and personal responsibility

We feel like we have to do something!

Sometimes this drives us to over-function and take the reins of the change agenda

Documentation provides a useful framework for slowing the process down and crystalizing clinicians on-the-ground efforts◦ Client remains in pre-contemplation around

substance use◦ Clinician provided feedback, emphasized

client’s responsibility, and rolled with resistance in the service of maintaining a non-argumentative position with the client

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In Summary The technical aspects of MI – such as decisional

balancing, reflective listening, rolling with resistance, feedback, emphasis on natural consequences, and developing discrepancy – are mostly designed to put the argument for change inside the individual

As long as the clinician is not sending the client to the hospital, he/she needs to be able to sit with client choices so that his/her change agenda does not get in the way of the development of an internal argument and natural, sustained change on the part of the client

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Resources http://www.motivationalinterview.org/ http://www.motivationalinterview.org/Documents/1%20A%20MI

%20Definition%20Principles%20&%20Approach%20V4%20012911.pdf

Motivational Interviewing as a counseling style: http://kap.samhsa.gov/products/manuals/tipcurriculum/pdf/pmodule05.pdf

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. (2nd ed.). New York: Guilford.

Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2008). Motivational interviewing: In the treatment of psychological problems. New York: Guilford.

Narr-King, Sylvie & Suarez, Mariann. (2011) Motivational Interviewing with Adolescents and Young Adults. New York: Guilford.

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Wrap-up Q&A Next Webinar: Visit www.ctacny.com July 13, 2012-Trauma Part 1:

Assessment with Elizabeth Meeker, Ph.D.

And, email us with any questions/ concerns:

Kara.dean-assael@mssm.edu

THANK YOU FOR JOINING US!!

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