Community Care Live Motivational Interviewing in Social Care Wendy Weal

11/05/2016

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Who are Interface? We are a national provider of specialist expertise on effective approaches to support vulnerable families. • • • •

Specialist expertise and Support Training Information and Resources Evaluation and Monitoring

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Our experience and knowledge… Over the last five years our team have been responsible for the following: Providing training for over 6,500 front-line workers and managers Implementation and support of 371 Family Support Services Support service redesign and transformation programmes Facilitating a programme of evidence-based training for 617 parenting practitioners Embedding Think Family reforms in every LA School improvement and leadership development

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Our experience and knowledge… Supporting development of ‘system leadership’ across the early years sector Evaluating projects and services and developing business cases National coverage – innovative practice, what works well, up to date Early Help – Troubled Families – Family Support – Statutory Services Consultancy support – enhance, deepen understanding

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Tools, Toolkits Training/embedding resources ELearning • • • •

Tools to Support Work with Children and Families Practitioner Skills in Early Help Practitioner Skills in Reflective Practice Motivational Interviewing

New Level 4 qualification ‘Working with Children, Individuals and Families’. 3 Units • •

Professional Guidance Workbook/Reflective log

School Vulnerability Audit tool Interactive video clips Outcome tool 5

This session… How and where MI applies in a social care setting Why it is important to understand people’s motivations to change How they need to think about the cycle of change How MI works with what we traditionally see as ‘resistance’ What working in a different way looks like in practice – a new language and engaging individuals/families Swift overview of MI style and principles The challenges in using MI on social care

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Hertfordshire - Innovation Fund In 2012 HCC Children Services launched a programme of Motivational Interviewing (MI) Training. The adoption of this approach was influenced by the Munro report and research by Donald Forrester which indicated that a difference is made in a family’s life when the worker has confidence in their own ability, uses a framework or methodology that they believe in and has the trust of those they are working with. Having a workforce that is highly skilled in Motivational Interviewing techniques is essential to bringing about better engagement with families. Aimed at workers in Safeguarding & Specialist Services, and Education & Early Intervention Services.

Hertfordshire - Innovation Fund Successful in securing Department for Education funding for an Innovation Programme entitled ‘Family Safeguarding’. Twenty-two Multi-disciplinary Family Safeguarding Teams established during 2015-16. Teams = Team Leader, Social Workers, Community Psychiatric Nurse (substance misuse/mental health), Domestic Abuse Specialist and a Children’s Professional. First 6 teams live in April 2015.

Hertfordshire - Innovation Fund Workforce highly skilled in Motivational Interviewing is integral to this new programme.

Part of the change of culture - workers approach families with a different language and a different attitude, designed to empower parents to accept the help on offer to over their challenges and achieve better outcomes for their children. Classroom Based Motivational Interviewing Training Programme Practice Based Motivational Interviewing Workshops Programme

What is Motivational Interviewing?

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What is Motivational Interviewing? Several MI programmes throughout the field of substance misuse (where it originated) describe it as a client-centered, empathetic and yet directive interaction designed to explore and reduce inherent ambivalence and resistance, and to encourage selfmotivation for positive change in people. Miller and Rollnick (2013), who are widely recognised as the founders of the technique state that MI is a “collaborative conversation style for strengthening a persons own motivation and commitment to change”.

Confrontation MI leaders found that many services still use the confrontational approach and that this rarely worked.

They saw that the more people were told to keep an appointments, told they had to get work, told they had to change their behaviour, the more they resisted, challenged and stayed the same. But when they gained rapport, genuinely tried to understand, focussed on self determination and developed self motivation, changed was more likely to occur. They state that self motivation cannot be given to someone, it occurs from within. Without you will see compliance or resistance.

The limitations When not to use MI:

Where there is immediate danger to the child/parent. Where a client is very upset/distraught/in distress. When a client is responding well to other methods. When a client is actively changing already. If a client starts to increase the frequency and strength of resistance talk at each interaction. If there is a poor relationship between yourself and the client. If the worker has a lack of understanding or commitment to use the whole MI approach and only uses skills in isolation.

Motivational Interviewing Style Motivational Interviewing in a sense is not a technique but rather a style; a facilitative way of being with people. COLLABORATION - MI requires the worker to relate to the client in a nonjudgmental, collaborative manner. The client’s experience and personal perspectives provide the context and the content within which change is facilitated rather than coerced. EVOCATION - The workers stance is not one of imparting wisdom, insight or reality, but rather of eliciting the client’s internal viewpoint. The worker draws out ideas and feeling from the client. Finding intrinsic motivation for change and bringing it to the surface for discussion.

Motivational Interviewing Style AUTONOMY: Responsibility for change is left totally with the client. Individual client autonomy is respected. MI style communicates safety and support, first through an absence of confrontation or persuasion and second, by acceptance of the client.

ROLLING WITH RESISTANCE: Reluctance and ambivalence are not opposed but are acknowledged to be natural and understandable. The worker does not impose new views or goals, but invites the client to consider new information and offers new perspectives. The worker does not feel obliged to answer a client’s objection or resistance. Resistance is just a signal for the worker to shift approach.

MI Basic Principles In MI you provide low-key feedback, roll with resistance (e.g., avoiding arguments, shifting focus), and use a supportive, warm, non- judgmental, collaborative approach. You convey empathic sensitivity through words and tone of voice, and you demonstrate genuine concern and an awareness of the client’s experiences. You follow the client’s lead in the discussion instead of structuring the discussion according to your agenda. There are four principles of MI which underpin all aspects of the approach: Express Empathy Develop Discrepancy Roll with Resistance Support Self-Efficacy

Four Stages of MI Engage – Understanding a clients view Focus – Creating a shared agenda and priorities Evoke – Explorative conversation about change Plan – Change plan and SMART goals

MI in Practice – What does it look like? Two examples of MI in practice – one very skilful and one just practising and not always getting it right!!

https://youtu.be/bTRRNWrwRCo https://youtu.be/zlJMZGaL8SY

MI Basic Principles EXPRESS EMPATHY. Empathy has been called the defining principle of MI. One definition of empathy is: the capacity for participation in another’s feelings or ideas. Another way of thinking about empathy comes from Carl Rogers who popularized the term as one of the three essential pillars of client-centered therapy. Empathy means acceptance and understanding another’s perspective and feelings neutrally, without judging or evaluating in any way. Neutrality is key because acceptance does not necessarily mean approval or agreement. Typically, the word “listening” is associated with empathy, because one has to truly listen and hear another in order to be able to understand, accept, and empathize with him.

MI Basic Principles DEVELOP DISCREPANCY - develop the desire to change

Developing discrepancy is where MI departs from a straight client-centered or humanistic approach because it is specifically directive. The discrepancy that a worker using MI wants to build is that between the way things currently are and the way a person would like things to be. One of the purposes of using an MI approach is to help a person get “unstuck” from their ambivalent feelings that keeps them in the same behaviour patterns. By developing the discrepancy between where a person is now in their life and where s/he wants to be, the worker is helping the client determine how important a change could be.

MI Basic Principles ROLL WITH RESISTANCE – avoid argument

Can you think of examples where you are continually pointing out reasone to change, and they argue why things should stay the same? You could label them as ‘resistant’? Arguing for change with a client will likely trigger the client to argue against it, which the worker may feel (or think of ) as “resistance.” In MI, “resistance” is thought of as a signal, a red light, and a time to do something else.

When you feel what has traditionally been called resistance – the client sounds uninterested in or unmotivated or unprepared for change – in MI terms, you “roll” with it. Taking a stance where you just acknowledge it and move on rather than challenging it.

MI Basic Principles SUPPORT SELF-EFFICACY – support self belief Self-efficacy is a term popularized by Albert Bandura in the 1980’s as a cornerstone of his Social Learning Theory. It means a person’s belief in his or her ability to carry out a specific act or behaviour. It is similar to self confidence but is more specific and tied to a particular activity or behaviour. Self-efficacy is critical in MI because it reflects the “can do” or “can’t do” attitude that can make or break an effort for change. If one feels that making a change is very important but has no idea of how to go about making the change, one’s low self efficacy for making the change is likely to jeopardize the change attempt. Increasing self-efficacy means that change is more likely to be initiated and maintained.

MI Skills – OARS OARS stands for: Open questions Affirmations Reflective listening Summaries

MI Skills – Open Questions Asking open versus closed questions helps clients get started talking. An open question is one that does not invite one-word responses but rather encourages the client to take control of the direction of the reply, which can help the client feel more safe and able to express oneself. When a worker starts off with several closed questions, it is likely to cause the client to answer in short phrases and fall into a passive role waiting for the worker to ask for information. Instead, with open questions, a worker sets an interested, open, collaborative tone. A client is then likely to provide more information, explore issues of concern, and reveal what is most important.

Exercise

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Affirmations Think about something that you might want to change? Losing weight Giving up smoking Attending the gym regularly

Do you ever doubt that you can do it? or stick at it? What happens if your doubts grow? Do you find that you doubt you wanted to change in the first place?

What happens if you become more confident? Do you find that you desire increases?

This is a normal rationalizing experience

MI Skills – Affirmations Client centred therapy suggests that people are more likely to change if they feel good about themselves and are affirmed. To affirm will build their self confidence. They will feel valued. Its really important at the beginning of a relationship. How you greet them, use their name, gain rapport, respect them, make them feel welcomed and listened to. Trotter found that for every criticism you need to hear 5 positive affirmations. But many clients have had the opposite of that.

MI Skills – Reflective listening This is demonstrated by listening respectfully and actively to genuinely understand what the client is trying to say. You can demonstrate that you hear and understand another person by making reflective statements or reflections. Empathy can be felt when one is listened to reflectively and hears reflections of both meaning and content. The first step in using reflective listening is to listen carefully and think reflectively. The key to doing this is to think in terms of hypotheses. This means that when you hear someone say something, you form a hypothesis or a best guess about what the client means. The second step is the action that results from the listening: forming reflections. You try out your guess by reflecting back what you think you heard. It is like asking, “Do you mean….?” but without putting your words in question form.

MI Skills – Reflective listening This requires differentiating a statement from a question. It may feel odd to form a statement rather than a question when you are listening to someone and want to try out a hypothesis. However, reflective statements work better than questions in conveying empathy and increase how much a client talks. A question begs a response. When a client feels the need to answer a question, it has a slight distancing effect. A statement does not require a response. The speaker can go right on with his or her speech or can simply sit and think about what they have just had reflected to them. Reflections can be used strategically to emphasise aspects of the client’s view, emotion, ambivalence, and change talk.

Reflection circle – as a group take turns in giving simple and complex reflections back to the person talking. See how much information you can elicit without asking them any questions.

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MI Skills – Summaries Summaries serve several purposes: 1. Communicate that you have tracked what the client said and that you have an understanding of the big picture. 2. Help structure a session so that neither client nor worker gets too far away from important issues and can help you link what a client just said to something he/she offered earlier. 3. Provide an opportunity to emphasize certain elements of what the client has said. For example, providing summaries of the positive statements a client has made about change (change talk) gives the client another opportunity to hear what she or he has said in the context provided by the worker.

Stages of Change The Stages of Change model, part of the Transtheoretical Model of Change (Prochaska & DiClemente, 1984), depicts the process that people go through when they successfully make changes in their lives.

Stages of Change Pre-contemplation - the person does not see any problem in their current behaviours and has not considered there might be some better alternatives. Contemplation - the person is ambivalent; they are in two minds about what they want to do. Should they stay with their existing behaviours and attitudes or should they try changing to something new? Preparation - the person is taking steps to change usually in the next month or so. Action - they have made the change and living the new set of behaviours is an all-consuming activity. Maintenance - the change has been integrated into the person’s life, they are now more consistent and flexible. Relapse - a full return to the old behaviour. This is not inevitable, but is likely and should not be seen as failure. Often people will Relapse several times before they finally succeed in making a (more or less) permanent to a new set of behaviours.

MI Skills - Eliciting Preparatory Change Talk DARN: Desire: – –

Worker asks: “Why do you want to make this change?” Client uses words like “want, like, wish”

Ability: –

Worker asks: “How might you be able to do it?”

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Client uses words like “can, could”

Reasons: –

Worker asks: “What is one reason for making this change?”

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Client uses words like “if, then”

Need: Worker asks: “How important is it, and why?” Client uses words like “need, must”

MI Skills - Eliciting Implementing Change talk CAT: Commitment: –

Worker asks: “What do you intend to do?”

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Client uses words like “will, intend, ready, going to”

Activation –

Worker asks: “What are you ready or willing to do?”

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Client uses statements showing readiness and preparation

Taking Steps: –

Worker asks: “What have you already done?”

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Client reports and evidences change steps

Applying MI to Practice - Scaling Techniques Using scaling techniques such as readiness rulers on importance and confidence can give you an idea of the position of the client for each area of change. For example: “You have said that you really want to lose weight, how important is that to you on a scale of 1-10, with 10 being really important.” “Ok so you’ve scored that a 9 so we can see that’s definitely important to you.” “Now, how confident do you feel about losing weight, again on a scale of 1-10, with 10 being really important.” “Ok so this time its only a 3. So what makes it a 3 and not a 2?” “What things will you need in order to make it a 4 or a 5?”

MI Skills – Exploring Ambivalence and Developing Discrepancy

What is likely to happen when you push or argue with the part of a client that wants to change, encouraging him to change the behaviour and pointing out all the reasons for change? Typically, the client will feel compelled to talk about the other side—the side that does not want to change.

Decision Balance Worksheet What are you considering changing

Good things about behaviour

Good things about changing behaviour

Not so good things about behaviour

Not so good things about changing behaviour

MI Skills - Rolling with Resistance “Rolling with Resistance" involves a number of different possible approaches. They share some common features: Avoid a direct head-on argument: Don’t ever be viewed as challenging by the person whose behaviour you would like to see change. Show that you have heard what the other person has said: Using this key listening skill is a way of getting alongside them even if you don't agree and may help to defuse or prevent some of their instinctive defensiveness. Encourage the other person to come up with possible solutions or alternative behaviours themselves: This can help them to feel empowered rather than attacked.

Applying MI to Practice – Making a Plan Once you have explored a clients ambivalence, assessed their stage of change and readiness to change then you can make a plan and set some SMART goals The plan needs to be driven by their motivations for change and be focussed around the goals for change that you have elicited from them There can be negotiated goals on the plan but their origins have to be noted, i.e. you have to state what the family is concerned and about and also what the professional network is concerned about.

MI Change Plan Outline The changes I want to make are: List specific areas or ways in which you want to change Include positive goals (beginning, increasing, improving behaviour)

The most important reasons why I want to make these changes are: What are some likely consequences of action and inaction?

The ways other people can help me are: List specific ways that others can help support you in your change attempt How will you go about eliciting others’ support? I will know that my plan is working if: What do you hope will happen as a result of the change?

What benefits can you expect from the change?

Which motivations for change seem most important to you? Some things that could interfere with my plan are: The steps I plan to take in changing are: How do you plan to achieve the goals? Within the general plan, what are some specific first steps you might take? When, where and how will these steps be taken?

Anticipate situations or changes that could undermine the plan. What could go wrong? How might you stick with the plan despite the changes or setbacks?

How will I know if my plan is ‘SMART’? 1. 2. 3. 4. 5. 6. 7.

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It reads as a stand alone document. It’s written in language the family will understand and is free from ambiguous terms or social work jargon. The needs and risks are well understood and named. It shows what it will look like when the need is met or risk reduced. It details what the family is going to do to make the desired changes. It details what each professional agency is doing to help the family. There are details of not just the frequency of but also how each goal will be evaluated. The timeliness and actions are proportionate to the needs/risks.

MI Skills - Checking your position in relation to MI During Case Supervision there are some key questions you should ALWAYS be able to answer if you are truly using an MI approach: - Can I describe the situation from the clients perspective and really understand why this has happened? - What does the client need to talk about? What do I need to talk about? - Can I say why change is important for the client using the clients perspective and words? - Is the client ready to change? If yes then how do they intend to get there? You shouldn’t move onto the next question if you cant adequately answer the one that comes before it.

MI - What does this look like in practice? Case recordings reflect both the family and professional perspective In depth follow up of referrals out to other services, ensuring that the right help has reached the family in a timely manner to address their needs Language used about the family in both informal and formal situations Presentation of the family's needs/issues/progress in case supervision Feedback from families about making changes and their ‘relationship to help’ Outcomes and impact of social care interventions show change in families Less families in a revolving door scenario

Working in a different way New language – See different language and terms used in reports, supervision notes and in records Different types of statements made– Describing individuals and families in terms of their own concerns/goals and their stage of change around those Engaging in a way that demonstrates their motivation – Knowing that clients are engaged in the work are motivated to do it as they have investment in their plan

Working in a different way Outcomes that can be evidenced in terms of impact – Having clearer smarter goals (helps to show that not only has a referral been made but the individual or family are accessing the help and it is having an impact on the child) Capacity can be more easily evidenced – e.g. for safeguarding plans with clear goals that have not been met despite support being in place can be used as evidence of limited progression and an inability to change

How MI links to wider training Almost all interventions and approaches used within social care can be delivered in an MI way – this can also be applied across training, supervision and meetings. Embedding MI into an organisation involves approaching the delivery from several different angles. For example, mandatory training could be approached in an MI way by getting participants to assess their own knowledge at the start and setting their own goals. Integrating MI language across organisations – partnerships agency working and multidisciplinary working all helps with this but sharing a common language across agencies working with the families is key to a clear and evidenced based approach to the work. The delivery of the MI approach does not just apply to working with the families; it also applies to working with each other as colleagues. Being able to enhance someone's supervision by reflecting back and summarising rather than questioning is key to staff development and better family work.

The limitations When not to use MI:

Where there is immediate danger to the child/parent. Where a client is very upset/distraught/in distress. When a client is responding well to other methods. When a client is actively changing already. If a client starts to increase the frequency and strength of resistance talk at each interaction. If there is a poor relationship between yourself and the client. If the worker has a lack of understanding or commitment to use the whole MI approach and only uses skills in isolation.

The challenge Motivational Interviewing needs to be practiced and applied consistently and over a long period of time It needs good quality, intelligent and sensitive supervision in order to help the worker to embed “The difference being doing MI and being MI is about 10 years” (Steven Rollnick, 2001)

What do we mean by ‘conscious’? Unconscious Competence Auto-pilot – Doing it without thinking

Conscious Competence Deliberately thinking about it whilst doing it

Conscious Incompetence Uh oh – something might be wrong here

Unconscious Incompetence Not knowing what you don’t know

This session… How and where MI applies in a social care setting Why it is important to understand people’s motivations to change How they need to think about the cycle of change How MI works with what we traditionally see as ‘resistance’ What working in a different way looks like in practice – a new language and engaging individuals/families Swift overview of MI style and principles The challenges in using MI on social care

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