Motivational Interviewing ( MI) in Children’s Services

1. Motivational Interviewing (MI) in Children’s Services Presented by: Matt Wofsy, LCSW Brian Mundy, LCSW The Institute For Community Living, Inc. 2012 Clinical Lunch & Learn Webinar Series

2. 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

3. 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.

4. 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

5. 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

6. What Is MI? 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

7. What Is MI? 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

8. 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

9. Stages of Change

10. 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

11. Stages of Change The stages of change are more accurately portrayed as a wheel …

12. Stages of Change True 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 12

13. Stages of Change “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.” • Which stage of change is indicated? • Pre-contemplation • Contemplation • Preparation • Action • Maintenance  In Pre-contemplation

14. Stages of Change • Which stage of change is indicated? • Pre-contemplation • Contemplation • Preparation • Action • Maintenance “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.”  In Preparation

15. Four Principles of MI E.D.R.S ●Express Empathy ● Develop Discrepancy ● Roll with Resistance ● Support Self-Efficacy 15

16. 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.

17. 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.

18. 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!

19. 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.

20. Four Techniques O.A.R.S. • Open-ended Questions • Affirmations • Reflective Listening • Summaries

21. 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.

22. 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

23. 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.

24. 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.

25. 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.

26. 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

27. 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

28. 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?”

29. 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

30. 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

31. 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

32. 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.

33. 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!!