1 presented by: matt wofsy, lcsw brian mundy, lcsw the institute for community living, inc. 2012...
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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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