People not Problems - Motivational Interviewing in Practice

People not Problems: Motivational Interviewing in Practice.

Rhoda Emlyn-Jones

Where it began • 1970’s • Community based counselling services

• In the 80’s working within the local authority. • Counselling • Social work • homelessness

The early context • Building accessible community services • Emphasising personal choice • Acknowledging the expertise of the individual • Choosing their own path • MI built on the observations of best practise and provided the framework for best practise ,

What helped • Understanding ambivalence ! • Exploring helpful aspects of current behaviour first ! • Knowing what you were doing if you weren’t asking questions or giving advice. • Reflect , reflect , reflect. • Not to pathologise normal behaviour • Not challenging behaviour head on

principles • • • •

Express empathy: best relationship Develop Discrepancy: most difficult conversation Avoid argumentation: its not about what we think Roll with resistance: It’s a normal response but if raised will get in the way of change

•

Support self-efficacy :Its peoples belief in their own strategies and skills that leads to sustained change.

Effective services • • • • •

Skills Methodology Design MI consistent Consistently scrutinise and support all three

New service areas Early 90’s

• Criminal justice services • Child protection services • Fear of risk • Fear of perceived collusion • “doing good with a vengeance”

The context • People noticed more for the problems they cause than the problems they faced • Dominated increasingly by assessment • Care planning and monitoring. • Deficit models • Poor engagement • Little focus on outcomes

Spirit • Assess

• Engage listen /Evoke

• Plan

• Collaborate, with . not do to •

• Monitor

Firm platform not scaffolding.

• Autonomy : focus on sustainable outcomes

MI concepts that helped • Judges and family courts • Importance and confidence ! • The wider system not just the support service • Child protection social workers • “If we have no models to work with ambivalence we end up being too nice or too nasty “! • Listen engage :lower resistance increase disclosure

Family focussed work • Homebuilders and MI • MI and Option 2 • Evaluation and research what works in high risk/complex families • Being MI consistent !

Support the skills • OARS

• • • •

Open questions Affirmations Reflective listening summary

Focus on outcomes • 4 to 6 week intervention • 5.5 year follow up small sample • Parents considerably reduced or stopped their substance use 98% to 58% • Parental stress and risk of psychological problems 44% to 85% • Families had significantly more cohesion • Only 8% of option 2 children entered care compared to 44% • None in care permanently compared to 38%

IFSS • Underpinned by the spirit the principles and the skills • Supported by legislation: Child and family measure (Wales)2010 • Building a platform for integration: • A centre for workforce development: • A catalyst for transformational change: • Real commitment from Ministers and Officers.

Support Worker

Support Worker Admin Support Adult Worker Social Worker

Children's social worker

Substance Mis-use Worker Mental Health Worker

Designated IFSS Prac

Health Visitor

Family Adult Services

Children’s Service Case Management

Primary Care

The Wider Workforce

Independent Sector

Education

Health

Local Authorities

Community Safety Partnerships

IFSS Team: Core skills, Models & Approaches Organisational Development: The Skilled Workforce Wider Workforce Training

Training in the IFSS Model of Family Intervention: 4-days Principles: All team members Shared ideologies Skill set Understanding

The IFSS Model of Family Intervention: 4-Day Training • • • •

Day 1: Introduction to the Model: Overview of Model & Training Key Components of the Model: The Process of Behaviour Change Key Components of the Model: Outcome Focussed Work

• • •

Day 2: Core Skills: Motivational Interviewing, Engagement, Collaboration & Outcomes Beginning the Intervention: Reducing Resistance & Increasing Safety

• • •

Day 3: Working through the Intervention: Enhancing Motivation to Change Building Action Plans: Consolidating Change Behaviour & Inviting in Support

• • •

Day 4: Beyond the Intensive Intervention: Maintaining Change The Working Context: Our Team, Clarity of Role & Function

Training for other MI Congruent IFSS Team Roles • Consultation in the IFSS • Supervising in the IFSS • IFSS Trainers – IFSS services and wider workforce development

Integrated Family Support Service: Workforce Development Modules Module 1: Enhancing Motivation •

TV Game, Stages of change, 4 statements, Good teacher/bad, Principles of MI, OARS practice

Module 2: Lowering Resistance •

Persuasion exercise, Resistant behaviour, Road blocks & traps, 3-in-a-row, Palm push/shameful secret, Batting practice, Hot seat reflections OARS

Module 3: Goal Centred Interventions •

Why Goals? Case study focus SMART goals, Knowing when you’ve got there, Negotiating goals with families & professionals

Module 4: Promoting Family Change •

Process of change, Engagement, Motivational tasks at each stage, Miracle Question, Values, Strengths & Goals

Module 5: Care Pathways: Maximizing Multi-agency Planning •

Case study, Brainstorm what’s available, Identify goals, High, medium & low importance, Short, medium, long term, Engaging services around the family

Module 6: Substance Misuse •

What you know quiz, Knowledge, Attitudes, Impact on family life, Risk and resilience, Lifestyle impact

Feedback from training • • • •

I will listen rather than tell I will reflect meanings and feelings I will resist rescuing or fixing I will empathise and work with the person not the presenting behaviour • I will affirm rather than praise • I will not rob them of their own internal argument for change • I will try and help my agency to change

Feedback regarding the impact of training • Found myself offering to take a mother to her counselling appointment. Thank GOODNESS she knows the model builds autonomy & said "Thanks but no thanks, I can get a bus for my kids. I'll text you later"…! O2 worker in NW England • My new best friends are content, meaning and feeling reflections. Been rolling with resistance all morning. Saw it happen though, the moment the thought was provoked. Dad made a great argument for his change. So brave. SW in Wales

The focus of my work behaviour • Avoiding appointments • Blaming others • Hostility • Compliance • Refusal to engage • Minimising problems • Diverting the focus

feelings • Shame • Fear of judgement • Fear of consequences • Lack of trust • Lack of confidence • Lack of hope • Avoiding pain.

Accreditation: Assessing consolidating Learning; • IFSS Model of Family Interventions: Underpinning Knowledge & Skills for IFSS (Level 2), Implementing IFSS (Level 3), Managing the Delivery of Family Focussed Interventions (Level 6)

• • • • •

Consultation Skills in the IFSS Supervising in the IFSS Training the IFSS Trainers All 6 of the wider workforce modules Hundreds of staff across Wales describing MI practise

The current context and beyond • A real opportunity !!

• Risks

• Maximizing potential to change • Building on strengths competency models • Greater integration • Reclaiming social work • Workforce development

• Increased blame and punishment • Less hope and opportunity • Less provision supporting the core conditions for change.

Create Shared Platform Across All Disciplines There is a government vision

• Legitimacy • Adequacy • Support • IFFS ,Family first :Adult services: Criminal justice • Communities first.

 Shared Values  Shared Skills  Shared Language

2012 transformational change imbued with MI spirit, principles and skills • Remain purposeful and intentional • Be clear about what needs to change • See things through to the desired outcomes • Bring clarity to the system • Notice what's working and build on it • Its high challenge it needs high support it needs commitment • Skilled conversations, working together, release potential for autonomy.

And then there’s the future, the next 21 years