MOTIVATIONAL INTERVIEWING: MOVING PARENTS TOWARDS CHANGE Presented by Dr. Dianne Maing May 5 & 6, 2015 Sault. Ste. Marie

Transcription

1 MOTIVATIONAL INTERVIEWING: MOVING PARENTS TOWARDS CHANGE Presented by Dr. Dianne Maing May 5 & 6, 2015 Sault. Ste. Marie

2

3 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

4 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

5 Your Objectives

6 Triple P Context: Common Obstacles to Change Handout 1

7 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

8 Ambivalence Procrastination? Decisional inability? Stubbornness?

9 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

10 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

11 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

12 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

13 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.

14 Movere

15 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

16 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

17 MI Concepts: Core Communication OARSI Skills O Open-ended questions A Affirmations R Reflections S Summary I Informing and advising

18 Having A Conversation About Change When Ambivalence is Present

19

20 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.

21 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?

22 Our Expectations of Ourselves and Our Clients Therapist Expert Guide Listener Client Expert Guide Listener

23 Engaging Process Therapist style has been shown to be predictive of client change Motivational-reflective style more predictive of longer-term change than confrontationaldirective style Promotes change without being coercive

24 Engagement/Communication Style: A Continuum Active, persuading, directing Guiding Supporting, facilitating, following

25 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

26 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

27 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

28 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.

29 Elicit-Provide-Elicit (Handout #3)

30 Intake Conversation 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?

31 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)

32 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

33 The MI Language of Conversation Strategic communication skills: O Open-ended questions A Affirmations R Reflections S Summaries I Informing & advising

34 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

35 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?

36 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.

37 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.

38 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

39 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.

40 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

41 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.

42 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

43 OARS Skills Practice Handout #4: Scenario C Jed Choose any 2 of the OARS skills to arrive at a goal

44 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.

45 Reflection Questions Which OARS skill do you think you are using now? Which skills do you think you would like to enhance/use more?

46 Who Wants To Be A Millionaire?

47 Change occurs when the pain of keeping the status quo is greater than the pain of change. Saunders

48 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

49 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

50 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

51 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

52 Handout #5

53 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

54 Importance of Change

55 Handout #6: Heather - Read and circle the various change talk & OARS techniques

56 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?

57 Insufficient buy-in to model/framework? Unimportant? Lack of confidence? Difficulty in therapeutic relationship?

58 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

59 Riding the Wave of Discord Discord likely to sound like arguing, interrupting, disengagement, defensiveness Listen empathically Come along side

60 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

61 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?

62

63 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.

64 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

65 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

66 MI Specific Change Variables Osilla et al. (2015): 110 male and female at-risk youth, aged yrs, juvenile deferment 1 st 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

67 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?

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

69 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

70 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

71 Who Wants To Be A Millionaire?

72 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?

73 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?

74 ALL CHANGE IS SELF-CHANGE, TO WHICH CLINICIANS ARE SOMETIMES PRIVILEGED WITNESSES AND FACILITATORS. Miller & Rollnick, 2013

75 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), Miller, W. & Rollnick, S. (2013). Motivational Interviewing: Helping People Change. NY: Guilford Press. 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), 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), 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),