Resistance or Discord: Motivating Unhappy Clients

So I’d like to introduce our speaker this morning Mindy Hohman is a professor at the School of Social Work San Diego State University in San Diego, so she’s not really enjoying the weather here very much But -neither are we I don’t think anybody else is either Doctor Hohman teaches courses in substance abuse treatment research, motivation interviewing and social work practice She’s published numerous articles on the topics of substance abuse assessment and treatment services and women’s issues in the area And she’s been a trainer in motivational interviewing since 1999, training communities, social workers, child protective services workers, probation officers and addiction counselors She’s also author of the book “Motivational Interviewing in Social Work” which I actually have in my office If any of you are interested in taking a look at that too So I’m very excited that she’s agreed to come here and talk with us today, I know this is a topic that many of you have expressed a lot of interest in And I hope that this is a good morning for getting energized for your practice, so welcome *Mindy* Thank you, thank you it’s great to be here *applause* As Ellen was saying I teach motivational interviewing and right now I have two sections We teach a full semester course in it Oh he told me not to stand in front of the- Uh, right now I have undergraduates students, I also teach it as an elective for graduate students So as I looked out on my sea of students on Tuesday, I said I would be certain to tell them- tell you all about them and they all said to say hello to you Their counterparts in Wisconsin So I’m fairly happy to be here today Can I have a show of hands, who here are students? Just about everybody or- Okay And you’re all in the Title IV-E? Okay, wonderful So to start off with, and I’m hoping my clicker works here I wanted to go over the agenda and tell you a little bit about some of my ideas for what I thought we would discuss today But also to find out what kinds of things that you’re interested in hearing Related to the topic And Ellen had asked me to speak on the topic of working with resisting clients Or the term we now use in the motivational interviewing is when we have discord with our clients And so that’s kind of the general topic but, you know, if you have something specific related to that, we can get to that But we’re gonna start off with my defining motivational interviewing I’m gonna ask you about what you already know about it What you’ve learned about it in school, what you’ve heard about it Any trainings that you’ve been through And then we’ll start talking about what is it that actually makes clients resistant And really there’s actually a lot of knowledge in this room My background is I worked in juvenile probation and I worked in juvenile addiction treatment Had a lot of crossover, worked with the child welfare system and I’ve enjoyed training social workers in the child welfare system But in many ways your knowledge about your job helps me think about ways- how does motivational interviewing fit into this So I see it as a collaborative process Where we come together to kind of think out loud about how does this all work And then on the other hand we have a whole piece about looking at what makes us resistant What pushes our buttons, what kinds of things happen When clients do certain kinds of things Because, you know, at the end of the day, it is a human interaction And so we are humans, we, you know, we do have emotions and responses to our clients Particularly the difficult clients that you see And I, say my hat is always off to you in terms of The types of clients that you see are very, very difficult at many times, and probably some of the most difficult that social workers work with in this setting It was interesting, I had a long delayed flight to get here on Wednesday And ended up sitting with a judge Talking with him and he was like a real friendly guy, just kind of talked my ear off and he was on his way to Oklahoma City, I don’t know if he ever made it either but He talked about it- one point in his career he was a, I think He was a prosecutor and then he was a judge when he heard cases around child trafficking, child pornography And he said “You tell those social workers that if it weren’t for them, you know, that somebody has to be out there looking out for these kids” And how he talked about how grateful he was for the work that you do So I just had to pass that along, it was like a really nice message The other thing we’ll talk about, when we have resistance or discord with our clients What does that look like and where does it come from? Which gets us to the whole notion of communication traps and we’ll look at how does MI fit with resistance and how we work with client resistance And then the last part is helping clients thrive How can we make the best out of this situation where you’re working with clients who don’t want you in their lives Don’t want you to be involved with them And would be happy if you went away That you can best help them thrive and that’s what this judge talked about How he was on his way to work as a judge on a military base, he was in the reserves And he talked about how the best thing is is when their clients don’t come back to us So not only do we want them not coming back to us, but I think we’re all here because we want to see people change and grow and have happy lives And have children be safe So just thinking about that What other kinds of ideas do you have about maybe questions that you have or some topics that you would like to discuss this morning Because this is really your time To, you know, we can kind of pick each others brains here So what other ideas or thoughts come up? Any questions? *I guess I’d be interested in hearing you talk, it was pretty similar to what you already mentioned, but how to do this knowing that you have a different power than your clients, your authority *Because of the position that you have and how you can work with that in these types of role* *Mindy* Okay and it’s kind of that whole notion of the dual role You’re there as a social worker and you’re also there as a law and protect the child And so you already have that power differential, so how does that fit it all together, okay What other questions, comments do you have? Anything at all, I mean, burning questions about how do I work with the kind of clients, certain kind of clients *I guess also, we- if there are ways to use, like kind of some of the techniques and motivational interviewing while we’re working with other professionals to enhance that relationship *Mindy* Okay, so resist in professionals? Yeah You think? Okay I’m gonna make a note of some of these Okay so “power” and what I’m calling “dual role” Okay, other ideas or thoughts, questions? *How to bring it to the organization or anyone who might not be on board with it, so some agency culture that you might have to shift or take a leadership role on *Mindy* So, kind of some implementation And actually I was quite fortunate, we have a guy in San Diego County Whose name is Bill James and he is a supervisor of a unit that works with all the adolescents who are in residential care in San Diego County In the socially, emotionally disturbed units And so he works with his social workers and he’s worked real hard to implement MI, just kind of almost As part of the job But just within his own unit and I approached him and he wrote a section on that in my book, I have a chapter in implementations so It’s basically getting that straight from the horse’s mouth about how he, I wouldn’t say he goes as far as to say he’s changing the culture of the whole agency but he’s certainly changed the culture within his unit, he talks about that and I was also approached a woman who is an agency director in Cardiff, Wales Who, of a big child services, they call it there And she wrote more about then the whole changing the whole culture, so there’s some good ideas there too, but we’ll certainly talk about some of those things, thank you *I guess I’d like to hear more about- I think the biggest barrier in working with families and children is they really think social workers have an ulterior motive with their kids No matter what, you know, they say *Mindy* The old baby snatcher, yeah okay *How do you get over that barrier “I really want to leave your kids here” and get them to believe that *Mindy* Okay so, is that kind of like suspicion or lack of trust or what would you call it? Okay Sus-pic-ion, oh I’m running out of works, spelling here Suspicion A teacher should know how to spell Alright Anything else? Any other comments, ideas *Can you talk about the differences in motivating somebody and forcing them? *Mindy* Okay *Like when are we forcing rather than trying to motivate someone *Mindy* Forcing Okay *How does motivational interviewing fit into mandates services? *Mindy* Okay, mhmm And that kind of gets at this, I think And what’s very interesting is that and I probably shouldn’t say this on tape but in some ways social work has been kind of late to the party when it comes to embracing MI and really looking at this in this role Child welfare services, I should say And, Jan who’s If you want to put your hand up, Jan sitting over here is involved in motivational training as well We talked about that at a- how at our national meeting, our international meeting that we had this fall Jan and I were like about the only people there really that were doing child welfare And yet I went to a meeting that was probably, ehh, 35 people from corrections and criminal justice in the room So it’s very interesting right now to see how the criminal justice system Has really embraced MI and taken this on and bringing in MI coaches, there’s some work being done out of North Caroline however I should say Where their using MI coaches to go out with social workers on their home visits Observe the interaction, help them out, coach them along in the skills So that’s kind of neat to see So probation is definitely working on this whole issue of the mandated and how to work across both of those kinds of roles So there’s a lot of interest there Okay, well that gives us a start If you think of anything else, our dialogue, or my presentation today is gonna be a dialogue It’s not gonna be so much me talking, it’s gonna be- I wanna hear your thoughts, your ideas, thinking how this all fits together So I’m gonna be asking a lot more questions What do you already know about motivational interviewing ? Who here’s taken it in class? It’s gone over in class Okay So you’ve had a little bit of content in class or a lot of content would you say or? What would you-? *I actually worked with Cross County Human Services and we actually had motivational interviewing training and we actually have a session coming up for coaches who are coming to train us and take us out into the field *Mindy* And will they go with you? and- *Supposed to have a 3 day session And then all of our supervisors and management are being trained intensively and they’re supposed to be going out into the field with- *Mindy* Wonderful, wonderful that’s very progressive, that’s a great implementation tool Model of how to do that So you’ve already had some training, so what do you, what’s kind of your take away about how would you describe motivational interviewing *I think motivational interviewing is allowing the families that you’re getting to know the opportunity to tell you their story The reason why they were kind of brought in to, or why they were referred to your system Open-ended questions, letting them get out some of their frustrations I think it’s leading them- it’s you asking them questions, kind of guiding them to kind of See different insights into why they might be involved *Mindy* Okay so use of different kinds of skills, like you’re saying, open-ended questions Uh as well as guiding in terms of moving them in a certain kind of direction and getting To understand from their perspective One of the things we call evocation which we work to draw it out of them To understand their perspective, very good, you’re trainer was, did a good job *laughs* Who else? Who else wants to talk about their knowledge of MI or even if you’ve used it and how it’s worked? Or is this new for most of you? Okay, so some people this is a new for *I was gonna say, several classes, we’ve had like a day where we talk about it and maybe practice it a little bit With teachers in class but… *Mindy* What strikes you about it? When you heard it? *Um, I think it takes a lot of work and a lot of forethought and once you get into the habit of it, I think it’s easier, but when you first start out I think it’s kind of overwhelming like “okay” like listening to their answers but also thinking about how I’m gonna ask the question Where I’m gonna take this, there’s a lot of higher processes that happen along stuff like that *Mindy* And, when you see somebody doing MI, it looks like that’s what they’re doing Sitting there having this nice, calm chat And yet you’re describing it perfectly, your mind’s just going like a thousand miles an hour in terms of thinking about what are they talking about And how am I gonna respond to that *Is motivational interviewing also like collaborating? *Mindy* Mhmm, do you wanna say more about that or no? *laughs* Not really Yes, okay, so a collaborative kind of stance Not the, you know, I’m the expert I’m gonna come in here and tell you what to do with the collaborative stance is we’re gonna work on this together You, and in MI we talk about how there’s two experts in the room There’s you with your knowledge, your expertise, as well as the client, who’s an expert on his or her life And it’s bringing that two expertise together to try to figure out what is the situation here and what’s the best way to address it Okay back here *So with professionals in the community, I work with senior adult who are 60 and over We find that we use this constantly because, well there is the age difference it’s like how- that when you try to get them to see we experts, and then they also reach the point, ah, maybe changes are very difficult at that age So we’re just constantly using motivational interviewing to help guide and collaborate to find better options for our seniors *Mindy* What kinds of things are you guiding them towards, what’s kind of the focus? *Oh gosh, we do like everything To be honest *I think just the connecting- trying to encourage them to be open to connecting with certain services and programs that could really benefit them But you know, they might have a mindset like “Well I really don’t need that” or you know, “I can’t do that” that kind of thing *Mindy* Okay so motivating them to accept services? Okay perfect, good use of MI Very much so And in terms of when you use it, what kind of strikes you about MI? Or what do you like about it? *Like she said, the collaboration, it’s- you know, I can walk in and have some ideas of what would benefit them But if they’re not really willing to be there yet, then I have to walk with them but I have to walk with them in a way that we can’t get the best options and services for them so they can continue to maintain their independence *Mindy* Okay, very interesting yeah I don’t know much about working with older adults, um, I had a student in a couple years ago who was placed at a hospice and came in with this incredible story about how she used MI to help guide her client to think about not feeding her husband when he was on end of life support and how dangerous that was to him And, it was such an incredible story, I encouraged her to write it up and she did have it published so if you’re interested in anything like that, I have my email at the end I can send it to you But, I know it makes my mind just go, I’m thinking about all the issues of older adults and wanting to stay independent and yet, the need for services that you’re dealing with okay Other comments? About MI? Or uses of MI? *I’m involved in facilitating kind of organizational change and one of the, in the child welfare area, but one of the kind of consequences I think of equipping workers in the skills to do this, related to the opportunities is that it really conflicts, you know, requires organizations to confront The fact that they’re not necessarily organized to allow this work to be done And so it’s- I’m just really interested in how- and really I think I use MI skills in doing these larger conversations with the organization to figure out how- if this then is the work, the skills that really do need to get done That are needed, how then do they need to look organizationally to allow for that to happen *Mindy* Mhmm, the *So this is really a cultural thing, a routine, that’s being introduced to the front end Have reverberations *Mindy* It does end up having a cultural shift A few years back Bill Miller, who was the founder of MI did a large training study and one of the anecdotal stories that came out of it was that when people went back to their agencies And tried to practice using MI they couldn’t And they quit their jobs, now on this economy that couldn’t happen Of course, but there does have to be cultural shifts And a number of years ago I did a training with child welfare supervisors And it really became clear to me that we got the supervisors- and I’m not hoping that nobody here’s a supervisor and thinks that I’m picking on them but the way they talked, it was like, Telling your worker you go do this and you go do that And yet, you know, then the worker would kind of turn around and start doing the same thing with the family so You’re right, it becomes this whole culture about it, is this a system that’s gonna support interacting with clients differently Alrighty, well let’s look at our definition Okay, and this is the newest definition of motivational interviewing Bill Miller and Steve Rollnick are psychologists. Bil Miller developed motivational interviewing And what’s interesting in how he developed it is that it really came out of his work with clients He was originally sent, uh I believe it was in the 80s Maybe no Earlier than that? Early 80s perhaps to do an internship for psychology on an alcohol treatment ward and he in his program, had never studied addiction treatment And, so he was placed on the ward and he figured out “I just do what I know how to do” which was a lot of Carl Rogers, humanistic types of therapy And he treated the clients with respect, he started listening to them And he came away thinking about “You know, they’re really not that much different than anybody else” Which was kind of a profound thought at the time My internship as a MSW student was in an adolescent drug treatment unit And I was taught that the highly confrontational method And that’s what was popular at the time And so when he was kind of going, was in a whole different direction In fact, he went back to New Mexico where he was- ended up getting a job and they had an alcohol treatment clinic And they started doing some more behavioristic studies, he was a behaviorist And they started noticing that some clients had better outcomes than others Like what’s going on here, we’re all training these people to do the same types of behavioral intervention Why are some clients improving more and they looked at what the counselors were doing or the therapists And started realizing that the therapists that had a more empathic style within this tended to have better outcomes and so they did a study of that And raised and lowered the level of empathy So some clients randomly received highly confrontational methods and some clients received the empathetic methods and then they followed them down the road to look at their drinking rates And about a year later, they found out those that had received the empathy Had the best outcomes, they had reduced their drinking the most That was counter intuitive to what I was being taught, what other people were being taught at the time And, so part of that was he started changing the work And developing his work and developing the model and Steve Rollnick is a psychologist in Wales And he started then going around the UK and teaching this and so together they wrote a book and they’re now on their third edition that just came out On motivational interviewing so if you’re interested This would be basically our Bible In terms of what is MI to go pick that up, but this is their newest definition And as treatments change and as they learn more about MI Of course, sometimes definitions and the thoughts of how it worked changes as well And partly thats because there’s been an incredible body of research to support it, it’s started out in alcohol and drug treatment and has since progressed Greatly into other areas of medicine Particularly diet, exercise, health, all kind of health behavior change Diabetes, medication adherence, those kinds of things So like you were saying back here, it is collaborative, it’s a collaborative goal-oriented style of communcation It’s a communication method, it’s not a therapy It can be a therapy, it can be used by therapists But it can also be a method of communication that is used by social workers who don’t consider themselves therapists, by probation officers who aren’t therapists by physicians and there’s a big thrust to get therapists in medical training now To have physicians start to understand what motivates people and part of that’s coming out of the new Affordable Care Act Where physicians are gonna be much more accountable and working in a partnership with their client But it has a goal in the conversation In MI, we always talk about what is our goal, what is your target behavior, which I was asking you back there What you said was getting them to accept services, that’s the goal of the conversation With a particular attention to the language of change Anybody know what that means? The language of change? Is that ringing a bell for anybody? You remember that from your training? Okay And that’s because sometimes people say “Oh” when I go do trainings “MI, I had this in graduate school 20 years ago, this is nothing new” You know “this is just reflective listening, I haven’t learned anything new here And yet one of the pieces that makes MI very distinct is this whole focus on the language of change and how that’s come about is through having a researcher who’s, what’s called a psycholinguist, look at transcripts of clients Sessions in this alcohol treatment center And they found that clients talk about certain change in certain kinds of ways And we’ll look at what those are in a few slides down But that’s, in training, we train people to listen for that Coming from California, I use the metaphor “It’s like panning for gold” And I ask my students “Who here has panned gold?” And like a lot of hands go up I think, really people still do that? I guess they do there Maybe at one of the amusement parks or something like that but it’s really, you know, you’re shifting through and all the sand and all the dirt And all those kinds of things fall through but the gold is what stays and that’s what’s called change talk When you start to hear a client talk about change It’s what you do with that and you take and you reflect it and ask about it and work on them It is designed to strengthen personal motivation So this kind of gets at that in this question When you’re made to do something how invested in it are you? Who here’s gone to traffic school? *laughter* Okay Last time I went it was like kicking and screaming, it was right at the end of my semester, I had to grade papers, I had so much I had to do, my husband who had already been there a few times I said to him “Can I take my papers and sit and grade them” he said “absolutely not, that instructor will never allow that” Okay, I was not invested in that, I- it was just like I wanted to show up and just sit there and be a body So when we’re made to do things, and sometimes it works You know, I mean you sit there and you listen and you hear a few things and you know, okay I’ll slow down And I’ll pay more attention to the speed But when we start to look for peoples personal motivations Your clients are gonna be more likely to follow through If they’re doing this because they see some benefit in it for them They realize they’re gonna get something out of it So, their personal motiv- strengthening that, finding out what that personal motivation is strengthening it and then getting a commitment to a specific goal by eliciting and exploring the person’s own reasons for change Why would they find this important? Why would they want a change? In an atmosphere of acceptance and compassion And this, this word of compassion is new to the definition that Bill Miller has added in And I think part of it was he was doing some reading about some sales literature in business Cause you can do a lot of this kind of stuff in selling cars Right? What do you like about this car? What are you looking for in a new car? What’s important to you in a new car? But the compassion’s not there, the bottom line is It’s in the salespersons best interest to have you buy But the compassion part is that we’re always at the bottom line of our clients best interest And that’s what makes it unique, one of the things that makes it unique and different,bless you So that’s a big long, technical definition Alrighty, lemme just see where I am on my notes here Alright, well let’s just get you moving here for a minute, everybody stand up and find themselves a partner Please and then I’ll give you just a quick instruction And if you don’t have a partner lemme know *awkward laughter* Everybody have a partner? Everybody have a partner? Everybody have a partner? Everybody okay? Cause I could use one, alright Oh, alrighty, alright everybody raise your right hand Put it against your partner’s right hand Push as hard as you can *laughter* Okay, you can let go now, thank you alright have a seat *laughter* Alright, nobody fell over that’s good Does this look familiar? Here we go, so let’s talk about the push You just did the push You pushed and what did your partner do? Pushed back, partly because I told you to alright What’s the push look like from clients? What happens when you get resistance from your clients? And lemme back this up a minute The reason the resistance is in quotes is because Miller’s using- moving away from using this language Cause resistance gets caught up in the old psychoanalytic theories and- that’s not what we’re talking about What are we talking about here, what’s the push look like? When you get the push back from clients? *No acknowledgement of a change *Mindy* Okay, so no change Or no acknowledgement of it, okay don’t need change, what else does a push back look like? *Maybe acknowledgement of a needed change, but not following through with it so it- *Mindy* Okay *This is less clinical but it sort of is like, “I don’t wanna, you can’t make me” *Mindy* Okay, okay so kind of challenging you What else do clients do? *Not giving up control *Mindy*Okay so what does that look like? *You can’t tell me what to do… *Mindy* Okay Okay, you can’t tell me what to do, it’s my life okay *This is a little more behavioral but not answering phone calls *Mindy* Alright, okay *On the more aggressive side, like “Get the flake out of my house” *Mindy* Okay, okay so yell, swear Make you think about going to work at Starbucks right, yeah okay Course you might get that there too, so *Telling you what you want to hear but then not following through *Mindy* Okay Okay, not follow through, no compliance *Maybe not raise their hand at all for the push, just be passive *Mindy* Okay So kind of that “okay, you’re right, alright I’ll do it” and then not following through Okay *Maybe being disinterested and kind of dismissing the process *Mindy* okay Disinterest When we worked with adolescents we used to call that the “lights out, nobody’s home” look yeah, okay *Uh, no communication of any positive feelings towards the other person *Mindy* Okay, so it’s all anger Kind of, or? *Just nothing positive coming *Mindy* no positive in the interaction you mean or? *No sense that the intended client feels something positive about the work *Mindy* okay, kind of back to the disinterested or alright, or worse, angry What else? What else do you see, why the push? *think it could be threatening *Mindy* Giving you a threat?Okay, what other kinds of things? *Sarcastic *Mindy* So threaten, sarcastic Anything we’ve missed here? Okay so here’s the next question, kind of gets to what we were talking about, why do they act that way? *Maybe they’re afraid of the change *Mindy* What could clients be afraid of? Lots of things, like what? The change Okay, like what kind of change? For instance Losing your kids, that’s the ultimate one Okay, what might- what other things might they be afraid of? *Just maybe- finding a new place to live, finding a new comunity *Mindy* Maybe, being clean, being sober? Okay *Relationships *Mindy* Relationships, maybe having to move away for this bad boyfriend That she loves, okay *I think change can be overwhelming, like thinking about what they have to do to make a change so huge *Mindy* It’s so overwhelming And so the idea with the overwhelmingness by pushing Okay *I mean the failure itself, knowing that if they acknowledge it and try to overcome it they can’t do it *Mindy* Yeah, so a sense of shame And stigma, in the article that you have there by Donald Forester he talks about that *I think a lot of times, people feel like if they begin to cooperate with you, they’re giving up their authority and they don’t want that *Mindy* Okay, absolutely okay *I think sometimes they think they’re not qualified by virtue of like age or child or- you have no idea, I’m the expert on my own life and they are, in a lot of ways so they don’t need you They don’t respect that you may have other insights *Mindy* okay, so they, that’s the pushback you get, okay about “Who are you to be telling me what to do, you have no kids, do you have kids?” Or you’re the wrong, you know, wrong race, wrong gender, wrong class, wrong something *The unknown, if I change I don’t know what that looks like, it’s not familiar to me and so it’s the unknown *Mindy* okay, fear of the unknown, big one *And then, how would you truly emphasize with my situation, do you really have compassion, do you really want what’s best for me? I think is an underlying feeling *Mindy* The suspicion , okay And that it’s really all about “You’re gonna take my kid” Okay *I think sometimes the environment and their resources and relationships that either can sometimes be the why, you know if you- or the how, that they won’t- just their surroundings And all of that, it makes it difficult sometimes to make any changes *Mindy* It does, okay You know, what if I were to ask you to say “I think you should come and live in California” Okay Just pick up and move to California Okay *laughter* Well I guess that was a bad example, right *laughter* Yeah, okay yeah there we go okay I’m saying that thinking dollar signs, dollar signs, you know, cost of housings probably four times as much Okay so- but the idea, what I’m enjoying hearing about you is you get your clients You’re getting them You’re getting what they’re dealing with and you’re getting what they’re grappling with and how scary it is to make change To do something different, you know, and thinking about, you know, just use myself as an example To pick up and move and go somewhere else and I have resources, I have family, I have support, I have you know, many of the kinds of things that your families don’t have So change is very scary and it’s very intimidating So really I’m excited to hear how much you get them Okay, doesn’t mean it make sit easier to deal with necessarily, but you’re getting them So what have you found that works to- when they get unhappy and I started using that work instead of resistance because I think that’s just part of it, the fear and the unhappiness So what works, what are you finding that works *I think we can find ways- things that they may be able to do and like, involve them to make choices and, like more control over- *inaudible* *Mindy* okay so giving choices *I think also, we kind of talked about this earlier in talking about how important empathy is, and I think it really helps people calm down and just acknowledge why they’re upset and that makes sense *Mindy* okay so, I’m sorry I don’t have more room to write this stuff bigger, so really acknowledging, like can you give an example of what you might say to somebody? *That it can be a really hard situation or if I was in that situation I’d probably be really upset *Mindy* Okay, so you’re really- this is really a tough time for you Something like that okay What else do you do? I’m sorry, back here *Just finding common ground while keeping the focus on, for instance, if you’re doing an initial assessment and can’t really remember what you called it but Focusing on we’re really just talking about the safety of your child, without talking about *inaudible* and being clear about the safety *Mindy* So really having that focus on that child and what’s best for your child And somehow conveying that to them that you care about this child Okay, what else? *I think being available, that’s something that I *inaudible* like I made sure that I’m available for them And I’m collaborating with them *Mindy* Okay so you answer- you return your phone calls, you get back to them Okay *inaudible* certain times a week like Monday, I’ll leave like one client in particular Monday are his days at 9 o’clock he can call me and we can go through whatever it is that he needs to for the week *Mindy* So it’s not only that your available, but you have time set aside specific for that client That makes him special Okay *Helping them recognize their own strengths *Mindy* How do you do that? *You ask them when they did not *inaudible* problem *Mindy* Okay, so tell me about a time when things were going well for you What other kinds of strengths-based questions can you ask? *Like what is going on, what’s going through *Mindy* What is going really well Other strengths-based questions you ask? Anybody say like “What do you like about being a mom?” “What are some of the happy times” Cause it all kind of fits into the same types of things you’re talking about What are your dreams? Okay there’s a I don’t know if you’ve ever met him or not, but Jan might know him, he and I- he’s written about this, I think it’s so interesting, his name is Carl Ockifarbring And he’s a psychologist in the Swedish prison system Now that’s a little bit different setting So he talks about how clients come in, or the inmates come in to meet with him and they sit there and Their, you know, expecting him to talk about why they were arrested, you know, what their offense was, why they were sent to prison, like that kind of thing And he starts off with them by saying “Tell me a little bit about you, what makes you, you?” “What do you do thats special or different?” And they just look at him in astonishment because they’re so used to thinking about being a probem And I just think that’s such a lovely way that he works to try to shift the focus of the conversation so he can work at engaging them Other ideas, or other methods that you use to reduce their unhappiness? *Listening well And I guess sort of mentioned earlier, the reflective listening we learned. The importance of not only being able to hear but to reflect that to the person that you are hearing And if there’s some understanding there, some empathy, some compassion, some appreciation for their situation, their feelings, their thoughts *Mindy* So kind of what you’re talking about is about what happens in reflective listening And I always tell my students there’s two parts to reflective listening, you’re hearing it And then you are reflecting it back to your clients So they know that you know But I really- you know you really added in this whole other piece that Miller talks about that’s so important Which is that what happens when somebody listens to you and gets you I mean surely you’ve all had friends that “get you” When you’ve had a problem What’s that like to have somebody that listens to you and understands what you’re talking about? *You feel less isolated *Mindy* Okay, you start to feel connected and he talks about how there seems to be this healing process in that And when you think about how isolated most of your clients are Maybe isolated from family members, isolated from positive people in their lives Making that connection is just critical So that’s why reflective listening is a key in motivational interviewing Well let’s just move on here a little bit Now, I call this the eye glazers As soon I bring up theory in class it goes lights out, nobody’s home okay The eye glazer And typically social work students And myself included as a student, we do not study social psychology And theories, does anybody have a background in social psychology, take a social psych course? Okay, so you have a little? Okay I’m new to that material and I absolutely love it It is incredible about how it explains human behavior to me And I picked two theories, and like I said Miller and then with Rollnick, worked to develop it from the ground up, what is motivational interviewing, what seems to work and they’ve refined it through the research process But then they started looking at what theories seem to fit with this typically when you have an intervention, you have the theory first And then the behavior that goes with it This has worked the opposite way And one of the first ones they’ve talked about is what’s called psychological reactance theory and I had never heard of that And what this theory says and its Brehm and Brehm are the authors of this Is that humans will react to protect their autonomy Humans, and there’s more to it, but this is like the key issue, key piece in it Then humans have a need for autonomy and We push when it gets threatened Okay, so like, women in the room, when you were teenagers And your mother said to you “Are you gonna wear that?” What did you say back? “You bet” alright? You got the push back You know, teenagers are great at wanting to preserve their autonomy When somebody gives you advice that you haven’t asked for, what do you say? *laughs* mind your own business Okay, typically thats a push back A little less blunt way might be “yes, but” Don’t you have friends that as soon as you tell them your problem they start saying “Well you need to do this and you should do this and you should just go tell her-” And um, Even with all the problems I had with my airline on Wednesday my husband starts telling me “You need to call them, and-” you know, okay What do we all say when we start getting that? “Yeah, but” Yeah, buts, and that is According to these guys A normal human reaction to just wanna push back So what you’re seeing your clients doing, and you guys are getting it Is that it’s normal It’s normal for them to be suspicious of you It’s normal of them to Discount you or act disinterested in you, I mean the push back is a normal part of the process Because typically you’re showing up in client’s lives When they haven’t asked for it Right? *I was just gonna say the hardest clients to work with are clients that says “You’re right” and they don’t want autonomy, they are just at a place of total dependence and feeling stuck And it’s really hard to move them forward so you kind of almost have to get them to a point where they feel strong enough to be able to push back *Mindy* okay, yeah and I’m almost wondering if you’re getting the push back but it’s just done in a different kind of way The way they know how so you’re maybe Looking for some healthy assertion kinds of skills, kind of skills but maybe they’re doing it in a whole different way and a lot of that conversation we had yesterday When I trained over at the county office, was about clients that talk incessantly I don’t know if that’s the push, but my guess is somethings going on there that their not being heard Or they feel like, “I’m not being heard so I gotta keep telling you what my problem is over and over and over again because you’re not getting it” Just a guess, I don’t know So there’s different ways that we get the push back but what psychological reactance theory tells us it’s normal for people to react, it’s normal for you to react If I would’ve said, you know “Make everybody change their seats and do something different” Some of you would’ve just sat there and said “I’m not doing it” Okay, that is normal Okay here’s our second one And love self-determination theory I feel like it explained so much behavior Comes out of, I think it’s Deci, Deci? I don’t know how to say his name Ryan and Deci, a lot of its coming out of like Montreal Toronto area, Syracruse, those kind of Northeastern Universities But they say, among other things, that in order to thrive humans need three things supported The first one is their autonomy People need to make their own decisions The second thing is being competent, people need to be seen as competent And the last one is relatedness, being in a relationship And what’s been real interesting is I’ve looked a little bit, they’ve applied self-determination theory to the work setting So here we’re talking about being interested in work culture and that organizational setting and again, I’m a micro kind of gal, I’m not a macro kind of person but just looking at what they’ve done think about that, if you’re in a work setting Where you’re allowed to be autonomous and make your own decisions The second one is to be in a work setting where you have a boss or a supervisor who acknowledges that you’re smart and know what you’re doing Or supports you when you don’t In a way, makes you feel competent And the last one is to have relationships in a place, perhaps there’s communication, you know, you hear- your boss tells you what’s going on With the powers that be, those kinds of things And what they’re finding is that people that have, in a work setting, have those kinds of needs met Tend to thrive, stay longer, do well, be happy employees So that’s very interesting because it all, pertains to us in different kinds of ways You know, for us, working for me, working you know and Ellen, people that work in a large bureaucratic university but also working for a large bureaucratic social service agency And there has been a lot of work done on cultures in agencies But lets go back to these and think about How does this affect our clients? What’s happening to our client’s autonomy? You were saying something about loss of control So what’s happen- what’s going on with their autonomy? When they’re working with the social service agency? Such as yours Where they are forced to take services *Maybe monitor and every step they take is being assessed and judged *Mindy* Wow yeah, so *I also feel especially when the child is removed that’s like a complete removal of control *Mindy* So all their behaviors, all their actions as well as the whole possibility they’ve lost their child or they have lost their child Okay so they’ve lost their child And, I always talk about how, well this is kind of more related to competence But I believe that one of the most cross cultural roles that we have for women is that women, if they are mothers, wanna be good mothers Somewhere in there is this whole notion about “We want to be good mothers” And have that recognized And so when you lose control of that, that’s incredible How else do they lose their autonomy? Being told to go to drug testing, being told to go to parenting classes Court, okay Well that happens to you to when you go to court, right? You start losing your autonomy and judge starts telling you what to do and how to do it And what’s, you know, the expectations are *With the seniors that we work with, a lot of them are dealing with loss of their autonomy in a number of different ways, you know losing independence as far as not driving Not being able to do things for themselves that they were able to do all their lives and so, thats a huge issue *Mindy* So if we go back to reactance theory It’s easy to see why, as an older person, you start pushing harder Whereas a client, you start pushing back harder Because you’re losing more and more because what happens is the systems pushing on you If you don’t push back equally as hard, what’s gonna happen to the other person? They crash, okay, so the harder Life problems, or the harder system problems push on the person The harder they’re gonna push back because otherwise they’re gonna fall over What about competence? We start telling somebody that she’s not- you know, not is these words, but she feels like it, “You’re not a good mother” And for men I believe it’s- most men are socialized to be providers You know, and that’s,you know, talk about unemployment problems and all that and why there’s depression with unemployment, particularly among men You know, you’re losing all that control, but your competence *You get a real sense of not only embarrassment but shame *Mindy* Mhmm, so how do you push back on shame? You start to tell your worker they don’t know what they’re talking about Or use drugs or Okay, check out more yeah Oh I’m sorry I thought you had your hand- okay I used to- when I first started training motivational interviewing, I worked with another trainer who was a psychology professor He’s moved onto a different university, but he ran the Counseling clinic on campus and oversaw the PhD students And he used to tell the story of a client Of a student who had a client who, again, somebody who talked incessantly and never quite seemed to think that the counselor was getting her And not really acknowledging her And he said to him “Why don’t you try an affirmation?” Which is partly what we do in MI to really affirm what we see happening and underscore their strengths and skills And so he’s “Alright I’ll try it but she’s driving me crazy” so he went in And as this woman talked and talked and talked, finally he said to her “Wow you are really a survivor, you’ve been through so much” And she stopped dead in her tracks, is what he said, and started crying And said “No ones ever told me that before” And so there’s something about seeing the competence in people and acknowledging it and commenting on it that’s very, very powerful And it- there’s some other related theories to that that talk about how when we do that It just changes, I mean think about when somebody has told you you’ve done something well How do you feel? Like woo! Yeah? And, you know, for me as an instructor I try to find that in students and really affirm when they’re doing things well to really encourage them to keep going Okay, and then the last thing is the relatedness, the relationship What is the relationship with the social worker And this kind of gets back to the question about the power and the role differential and the dual diagnosis So how does the relationship get affected in the sense of being related to other people Sometimes by social workers What do social workers do sometimes that pushes? I can guess but I can guess what you’re seeing *Um, I think they continue to assess their power differential They’re always assessing *Mindy*Okay, asking a lot of questions okay *I feel like sometimes they can put the focus in front of the wrong thing, like in initial assessment or emergency response Like focusing on whether a specific event happened isn’t so necessary as focusing on, like, the big picture and whether it will happen again If a social worker is kind of fixated on determining whether it happened which is more like a police man’s role, kind of like that It can really lose sight and continue to push *Mindy* Mhmm, and it doesn’t build the relationship There really hasn’t been any research on how the use of MI affects burn out But there’s a lot of anecdotes on it The people talk about once they start using MI and go to work because When I worked in drug treatment I was kind of had that cop mentality You know, I did intake assessments “You will tell me about what drugs you’re using” So help me, you know That gets old And so what people talk about when they’re using MI is they start to approach clients differently Clients are gonna do what they’re gonna do You have no control over that, you can try to influence them but they’re gonna do what they wanna do anyway I think everybody knows that It’s just sometimes because you have a judge back here telling you “You gotta get this family fixed” “within 12 months” That it starts to become, you know, the pressure of, you know “I gotta move you, I gotta motivate you, I gotta push you” And yet then you’re pushing, pushing, pushing, and what are they gonna do? They’re gonna push back Exert their control And so people talk about, is they start to use MI and realize that clients are gonna do what they’re gonna do anyway, I can try to guide the conversation, I can try to be collaborative, I can try to work with them It’s freeing In many ways That it’s really all about you, it has nothing to do with me Even though I’m working real hard in my head to make this a good relationship So it’s kind of like, the question there I think we’ve already answered about what makes clients push when you think about Peoples autonomy, their control Just the space over what goes on in their daily lives They’re being told that there’s something wrong with them, that they need these services, that they need to get help That they’re not being a good parent, that they’re doing something wrong, the relationship- all those kinds of messages Makes clients wanna push And then, we’re human, we start to push back What does that look like, what’s the social work push look like? I know my colleague in San Diego talks about- he starts hearing arguments over the phone with parents. Talks about how that’s gone down a lot since they’ve been using MI What do social workers do to push back? *Telling them you have to do it now and they need to see results now *Mindy*They- I’m sorry *Like the now effect, like *Mindy* You have to do it now? Okay Because maybe you’re getting the push again, that 12 month deadline or something So then you turn around and start pushing them or your supervisor’s pushing you. “You gotta do it, you gotta do it now” *Maybe the type of over managing where you call them every day, I’m taking them to their appointments, I’m doing almost everything for them And then when it comes to that point where I give them a little leverage to go they fall flat You can’t understand that you were the one pushing the whole time *Mindy* Yeah, it’s that frantic feel that I have to help you, yeah *So you might start giving them ultimatums like “Well if you can’t be these certain roles, you know, we’re gonna have to take action” *Mindy* Okay, so start to um Is it a threaten or is it more just like this is the? This is what it is okay Yeah, okay And particularly- there’s some really good literature written for the criminal justice field about probation plans and your Complimentary thing would be a parenting plan About how to handle that MI style, to talk about, you know, “What are your goals, what are your ideas” but also about you know, these are the kinds of things that we need to accomplish You know, that I need to see you need to accomplish so it is possible But there’s also times when people threaten “If you don’t do this, this is what’s gonna happen” So hopefully I didn’t glaze you over too much there Alright here we go So Miller and Rollnick talk about how we fall into, as part of our push back or trying to have our own competence or have our own autonomy, we fall into these communication traps And the first one he talks about is the expert trap That “I need to be in charge here, I need to make the decisions about this case, I need to fix this family. You need to do what I say” And again, I think some of that, in your line of work, probably comes from the pressures that you’re under And having a judge or a supervisor or somebody pushing you, telling you that you have to get these things done And there’s also, again, Forester talks about it in this article, the pressure of child safety And I think there’s another pressure in maybe you talk about it and maybe you don’t But there are times for some of you, you wonder “Would I ever get my name in the newspaper?” You know, when you see that something happens to a child and every time I see it and you know, I get the Los Angeles Times and you see something And you know, once in a blue moon And it starts talking about the social worker gone out and something- had missed something or whatever the situation was I think “ohh, that poor person” you know? Because people aren’t, aren’t doing this You know, voluntarily in terms of making a bad decision, it’s just, maybe it’s the nature of the work sometimes But you know, also that fear about “Am I gonna make a wrong call here on this child’s safety?” So there’s all those kinds of pressures that people start to feel like they have to become the expert and being the expert gets tiresome The second one is the question and answer trap which was kind of what you were talking about About ongoing assessment That if I ask you enough questions or if I get enough information then I will get all the answers which makes me then become the expert And so we tend to ask a lot of questions And social workers love questions and I swear We love knowing about peoples background, we go into this line of work, there has to be a piece of all of us that’s just inherently nosey We wanna know- because we like people We enjoy peoples stories And if you didn’t, you know, again, you’d be at Starbucks or something you know, if you’re -Don’t tell me your problems But we enjoy it And so many times, and I have to work around- with my students around, you only ask for the information that you need It might be interesting, you know, might be curious but if it doesn’t pertain to the presenting problem and what you’re looking at You don’t need to know that kind of information And yet we tend to ask a lot of questions One of the things they do for people who are really wanting to learn MI and Jan here would be your expert To help you with this And I have my students do it is you tape your conversations And I train them in coding and they go back and they code their questions- or code their statements and questions with clients Looking for certain kinds of things that would make it adherent to MI And there is some- there are several different coding methods out there that have been validated and typically they’re used in research studies Because you’d wanna know if this person’s- if the intervention is MI are they really doing MI? So there is coding manuals and I teach my students how to code And one of the things that you do in MI is you look at your ratio of your reflective listening to your questions And for people starting out, you wanna have at least one to one So you ask a question Client responds, you make a reflection And maybe they ask- then they say something and then maybe ask another question But to really get proficient in MI you wanna have maybe two-three-four reflections for every question To get away from the questions What’s the problem with questions? Can have good open-ended questions, but overall what’s the problem with questions do you think? *Asking questions, there’s the perception of that that person’s in control, it’s not a mutually beneficial conversation *Mindy* Absolutely, and you’re the one, I mean you are guiding a conversation, but when you ask a lot of questions, it’s all about your agenda Instead of really allowing the client to talk and reflecting back what they’re saying *It’s an interruption to the flow of communication *Mindy* Yeah, and I was sharing with Ellen, I do a pre test Using a validated measure with my undergraduates students and I’ve been looking at what kinds of things, its a video where the client talks and then they write a response Then the client, clock ticks down And then the client talks again and they write a response and there’s a coding book and there’s about 18 items on it That goes with it And you go back and you code it and you look at, were they doing things that engendered resistance they call it And typically those are things about being very confrontational, about giving advice Telling the person what to do, trying to solve their problem or warning or threatening them And it- or it could be things that really don’t further the conversation like asking another question or doing a reflection that really has nothing to do with what they’re talking about that’s real off target And the number one response I found, it baseline of my students, when they’re just coming into social work school as a junior and just starting is Anybody guess? Advice, yes Okay, so 20-21 year olds are full of advice about, for people how to live their lives okay? And we were kind of talking about whats the reason for that, well why do you go into social work? You’re nosey and you wanna help people And how are we acculturated to help people in our culture? You try to give them ideas, try to think about things and so it’s a normal kind of response to wanna give advice And we’ve already talked about what happens when you give advice to people The reactance theory People wanna be autonomous , they don’t wanna be told what to do so they push back, “Yes, but” So it’s really a very, it can be, I don’t know if giving advice can be damaging but giving advice can certainly say confrontational statements or threats You know, you’re really damaging and you’re damaging that relationship so not only are you taking away their autonomy then you’re destroying the relationship So questions have a time and a place and actually in motivational interviewing we talk about how advice can be given But you do it with permission first Would you be interested in hearing my thoughts on your situation? Would you be interested in hearing what other clients have done in your situation And then, you give them choices, in MI speak we call that a menu of options Sometimes my clients do this, sometimes my clients have done that Sometimes my clients have done that So you’re not even telling them what you think they should do but what other people have done Do any of those fit for you? So again, that’s a way of really acknowledging their autonomy And also supporting their competence that they’re an adult that can make a good decision for themselves And as you do those kinds of things, your relationship’s gonna build And hopefully your client starts to thrive And when we talk about thriving in child welfare services that’s the kind of thing you have to define what that looks like What does that mean for you Another trap people get into is the labeling trap So if I come up with a label And I heard a lot of personality disorders terms thrown around yesterday Well when you have a client with personality disorder, okay Or I mean there’s just all kind of labels that we use in our culture And how labels can become very dangerous In terms of they become a category that we put people in And they stop the communication So I- never forget, I was doing a role play, I was doing training with some probation supervisors And it was about how to use MI and giving feedback on a risk assessment tool And they had a category called criminal personality Which I wasn’t quite sure what that meant but I think it means like thoughts about, “Well her purse was just sitting there, she wasn’t watching it, I should help myself” You know, like antisocial thinking or something like that And so I was trying to demonstrate how to give feedback and the guy that was my client went “What?” “Criminal personality, what are you talking about?” And was really offended by it as a client In a client role And that’s just another example of a label, when we start to use labels “Well you’re an alcoholic” “You have a drug addiction problem” Those kinds of things, it just gets in the way of communication So clearly if they were gonna take this risk assessment tool and use it for feedback they had to give some other kind of name to that category To talk to the person about where they fell into And the last one they talk about is the premature focus trap Which is where we’re starting to move too far, too fast for the client Have you all studied about stages of change? Okay So the client still in precontemplation, they’re not even thinking they have a problem and because we know that clock is ticking We’re into the action stage and so we start pushing them and again, the conversation Again, because it’s pushing against their autonomy and their competence Starts to become very difficult And not be very productive so these are things that keep us from having productive conversations with our clients *Just throw one thing in the side, in the question, answer trap And that is, I think lots of times that comes up because we’re so uncomfortable with silence And so there’s a momentary silence and then it’s like “Oh I better ask another question” To keep this thing going, cause, especially early on, getting through the interview is sometimes just the goal It’s like, then I can go home I made it through that one, I never had any times where everyone was sitting there, nothing to say I ask them questions *Mindy* And that’s a, kind of a cultural norm Yeah, that we don’t like silence So what I tell my students is if you’re uncomfortable with silence what’s your client gonna be? Their gonna be uncomfortable too so let them be the one to start talking again Cause they’re gonna be starting to tell you something *There’s a lot going on in peoples thoughts, you gotta give them some time to think before *Mindy* Yup, for sure So- but questions or comments about that, before I move on *Um, so I’m not sure if you’re gonna go into this, you very well may but So I know that deadlines push things, but like, in initial assessment we have 60 days to determine where something should go so how do you work around that? You don’t wanna push someone too much to make a change too quickly in the first stage, but at the same time, you know you really want the family to succeed and that’s your goal, to make a safe environment *Mindy* Well, just from what you’ve heard so far, what would be your thought? In terms of what might be productive that’s gonna support them *The problem that I’m having is like when I’m thinking about getting services in place for example, there are certain- you can suggest to a client You know, these are services, options that people have used in the past but the problem is if you’re gonna end up requiring them to do it anyways It seems fake to first offer it as an option and then say “Well actually, regardless you’re gonna have to do it” So, which is sometimes just the reality *Mindy* Right, right and that might not be the place to give options Okay, unless there is a place within that So, what I’ve heard social workers talk about is they try to find those places as much as possible, where there are options Can it be residential versus outpatient drug treatment? Like those kinds of things, so at least there’s some, some choice Yeah Did you have a comment? Okay, so part of it is to, in using a motivational style is to acknowledge everything that’s going on To talk about, get them to talk about it- may be upset, those kinds of things to have that conversation and then the other piece is to provide them information about your role and what kinds of things that you need to do And then start looking- and maybe even having a conversation about- but I want you to have as much choice in this process because it’s -this is about you, it’s not about me telling the judge that you did these things This is about you and your child So, part of it is having those conversations that maybe sometimes don’t get said Or to talk about the relationship Yeah, other comments? questions? Okay, well this kind of leads us then to the next kind of place Talking about some of the behaviors that we’ve seen in clients and the things that they say Miller and Rollnick distinguished between what’s called sustain talk and discord and they’re two different things Sustain talk, anytime you have a change is very, very normal So lemme ask you this, who here has bought memberships to gyms? Okay and who here’s actually used them? Mmkay, well some hands go up But many times there are people that buy memberships to gyms and then what happens? Never go Okay, maybe you go out and buy like a really great outfit to wear to the gym and then what kind of gets in the way? Get some great shoes Life gets in the way, I’m too busy Okay, yeah, too many skinny people there Yeah, alright what else gets in the way? Kids, work schedule Don’t- you don’t wanna be there, and I know I’ve had people say to me “Well I don’t like to sweat” Um, that could be the problem All those kinds of things are what’s called sustain talk And that is talk about why you need to keep the status quo And it- the flip side of what we’ll look at is change talk so desire for the status quo I really don’t want things to change, I need to I need to use drugs because they give me energy and I need them to keep up You know, I don’t wanna quit using Inability to change, I’ve tried to quit before and it hasn’t worked Or I’ve tried to go to the gym before and I just lost interest So why bother? Why beat myself up over it? Reasons for sustaining, well you know, I need to use drugs cause I have three kids And if I don’t use cocaine or methamphetamine I can’t keep up with them And I need all the energy I can get, I work two jobs Okay, you’re getting the idea? All the reasons why people need to maintain the behavior Or just say to you and I’m not gonna quit And I think it’s always very interesting when I talk to smokers, when I do trainings or in class You can go through and they can say “I know it’s gonna kill me someday, I know I’m gonna have health problems, I know, but I’m not ready to quit” Tell me all the reasons why and then say I’m not ready to quit That’s all sustain talk and it’s very normal to talk about the behavior that way Now that’s different than what they used to call discord Or resistance, it’s now calling it discord And thats like some of these kinds of things that you’re getting So that’s when “Who are you to tell me what to do, do you have kids?” “You don’t have kids, you’re too young, you’re too middle class” Okay, “You’re the wrong race” You can’t tell me about my life Or “You’re always picking on me or you’re really out to get me” Discord is when you’re getting that push back Okay the push that you get from sustain talk is more, they’re pushing at the behavior, they don’t want to change, you know that whole thing about control but discord is when they’re pushing at you Okay, so lets stand up again if you could find your partner again Okay, get you moving again, one more time Alright, raise- oh one of you decide who is the social worker and who is the client Okay, alright, raise your right hands Okay, push your hands together, push, push, push, push, social worker drop your hand *laughter* okay Okay thank you have a seat okay What’s the takeaway message from that If you don’t push back what’s gonna happen They’ll fall okay, or not fall over You stop getting the push, you stop getting the push Okay, so what Miller talks about is that when you get the push, when they’re coming after you and saying things about you or perhaps Some of these things I would see more as sustain talk, just in a different direction You know, I know she’s gonna ask me about if I went to the parenting meeting and I didn’t go so I’m not gonna answer my phone That’s all sustain talk The discord is the challenging, the yelling, and I didn’t really do those as- threatening, as really discrete columns as they should be But he talks about how it’s interpersonal relationship Something is going on in that relationship and he uses the metaphor of a smoke detector That when you start seeing the smoke, when you start feeling the push The idea is to think about “Okay, what am I doing here thats getting that reaction?” And to change your- the way that you approach it Now that being said, there are gonna be times when just you showing up is enough It has nothing to do with you personally, it’s the last worker or whatever Okay so again, when we start to get that push back though, to think about maybe what’s going on with this client What’s going on with all this autonomy and relatedness and competence And maybe what do I need to do differently, can I do something differently That’s gonna make them respond in a different kind of way Other metaphors they use is are you wrestling or are you dancing? And I think everybody knows exactly what the wrestle looks like What does the dance look like? The flip side of all of this, what’s the dance look like? Working together, how do you get a sense that you’re dancing with a client? Okay, they’re acting interested, they’re asking you questions okay They seem engaged with you, I think that was some of the way that you talked about when clients aren’t engaged okay How else do you know you’re dancing? Okay, the comply, they’re following through, they seem invested in it So it’s finding out that what’s their personal motivation and getting them To hopefully do it for that Now obviously there’s a whole lot of steps in the process of MI And that’s not what today’s about, it’s exactly what is MI and how do you get it moving But my guess is, and just listening to you, you already know a lot of these things You’re already doing a lot of it Some of the things that you talked about But you know when the dance happens and what Miller talks about is if you’re getting the dance, keep doing what you’re doing You’re doing something that’s making that person engage with you, respond to you, if you’re getting the wrestle, step back and think about what’s going on and maybe what do I need to do differently What do you think, does this make sense? Or is this different way of looking at it? Because it’s easy to start to label and pathologize our clients as we used to do when I worked in drug treatment, if they didn’t want to change And were full of, what we didn’t know then was called sustain talk, we would say “Oh they’re in denial” You know, they need to go out and use some words till they hurt bad enough to change And fortunately a lot of that thinking’s changed, that that’s really not what it’s about But Miller talks about how of course they’re in denial because what would happen, you confront, confront, confront and you push They’re just pushing back, they’re doing what’s normal And it’s normal that have a lot of sustain talk about changing a behavior because it’s hard to change Question, comment *Just a comment, I was also like training with parenting training *inaudible* so a lot of this reminds me of the stuff we should be teaching our parents to do with their children As well, like that restful, giving choices and stuff That a lot of it is good modeling for them as well if you’re doing that with them *Mindy* Yeah, it’s funny you should say that because my very first job as a juvenile probation officer I worked in a foster care unit For adolescents and we, again it’s a 21 year old teaching parenting skills Love it, but we were given Thomas Gordon’s book “Parent Effectiveness Training” And Miller took a lot of that for MI Like the communication traps and reflect- some of the reflective listening stuff and communication blockers Comes out of all the parenting skill stuff That being said, they all talk about how MI, as a communication method, really cannot be used with children Because there’s a lot of abstract thinking in it The conceptualization that kids can’t do It’s better- it’s good with teenagers and on up However, we can do reflective listening, we can do the choices, we can do some of the different kinds of skills *I had just a general question that was especially brought to my attention during the sustain talk But I think it’s for the *inaudible* Does motivational interviewing have any work it has done beyond one client at a time? The assumption that clients means one person, certainly in social work and I think in most fields, there are couples Whole families, many times and I was thinking about how sustain talk is really group like, one foster kid in a family, group home of seven There’s all kinds of other peer influences and pressures and whether there’s any work here that can be applied to the worker dealing with both parents or a whole family Or is it mostly verified only on one end point? *Mindy* That’s a great question thank you MI started off as an individual intervention, it has been taken more recently, a lot of it’s still kind of in the last decade There has been a book that came out this year on MI with groups In group setting, in group work There’s some people that have taken the brief intervention part of MI when it’s used that way and applied it with parents in the school setting I believe so, yes I’d have to look and see about family work or couples work *Cause the MI in groups is really people working individually in group settings *Mindy* Mhmm, are you familiar with anything around marital work? yea *Even when- well, even when I’m working In a system I’m still working with individuals. One of the things I need to acknowledge is it can be very different places in terms of thinking about change And that their issues can be different from *inaudible* and that’s really where the MI piece fits It’s not a systems approach I mean it is in that for any individual you’re right, it’s influence of peers and all that, can be like what are my losses? In terms of relationship But it’s, it’s not a peer MI application What you find- there’s lots in MI- once you learn MI you take pieces of it and use them in different kinds of settings and different kinds of ways But I have a hard time seeing a peer MI application when you’re working with a couple *Mindy* I don’t know, there could be research that’s being used with- typically a lot of the couples, their abuse tends to be more cognitive behavioral Yeah, yeah, you mean family? Yeah I know there’s I think his name is Dischion, his work is called “The Family Check up” But I haven’t read it in a long time so there is If you would google “Family Check up” I think that’s where you’d find it I think it’s in his work Thank you So just to kind of pull it all together here, MI helps us in many ways to avoid those traps and again this is kind of like MI in a nutshell To really train in this would be like two or three days some of you have had that already But there’s this whole thing called the MI spirit which is the whole collaborative, evocative, evoking, pulling it out of the client And not me telling you what you need to do but like, really listening to what your thoughts are, pulling it out of you by your ideas about how you might make a change Or what the change needs to be About what’s important to you, pulling out from you your goals and your values And really then tying those together about the changing behavior And using reflective listening gets us away then from, and the OARS skills I should tell you first Is open-ends, affirmations, reflections and summaries And a summary is really a long reflection where you’re pooling together everything the client’s talking about But in MI you’re listening for important values and things that you can connect to making a change, abilities to make change All those kinds of things and then reflecting it back to the client so they’re hearing themselves think Out loud. A labeling gets us – I mean, using focusing on change talk gets away from labeling And the change talk is the opposite of the sustain talk and it’s the desire to change I want to be a good mother, I want things to work for my child and it’s the ability Tell me about when you’ve been able to stay clean before Tell me about when you’ve been, you know, had a really positive interaction with your child And starting to learn about the abilities or the values of that person and reflecting them back The reasons for change Why might you want to make this change? And we kind of couch it in those kinds of words If you were to stop using drugs, how might that affect your relationship with your child? How might things be different in your life? You know, if you were to do these kinds of things, not telling them if you did, you know if you were to And then the need for change Why might this change be important to you but really pulling it out of the person And the last thing that’s been integrated in Miller’s and Rollnick’s new book, the newest edition and it’s on your reference list Is this whole idea of thinking about, there’s four processes within an interview And Rollnick’s next starting to call the engagement stage giving it the 20% rule Even with physicians when they train them, that you’re using at least 20% of your time to engage that parent, even if you already know them, but just spending time talking to them What makes you you? What, you know, tell me about the positives that happened in your week? What’s been going on in your life? And then taking that and finding the focus, like what’s the goal of the interview? Is it to talk about going to your parenting classes Is it to talk about some problems that your child’s had at school. What is the focus of the interview? And then the evocation is pulling it out of them, what do you think happened, what’s- you know, what’s your take on it? What are you thinking you need to do, what are- you know, all those kinds of questions that then you’re reflecting back on them and if possible would it get to some sort of plan? Where do you go from here? What kinds of things do you need to do? Again, this is MI in a nutshell , just explained like in 5 minutes very, very quickly that would take probably several days to train in and because it’s a skill But what’s interesting about it is that it is a different way of communicating and interacting And many times social workers, and this is what happened to me As soon as we see it we know it This fits so nicely with social work and the values about empowering our clients And about self determination And it was almost like, when I first learned about it, it was like this breath of fresh air after working in this environment Where I had to be highly confrontational, I went from being a probation officer to a drug counselor You know, talk about being highly confrontational And yet, this is like a whole different way to interact with people Not that necessarily people are always confrontational But like my students, you know just normal ways of talking is to give advice and to ask a lot of questions And to kind of do things that just don’t really take us in a positive direction Okay let me just check my notes here Okay what I would like you to do again is to find a partner Maybe find somebody you don’t know And if everybody could get together as partners, I mean you can just move your chairs around Then I’m gonna give you your next instruction, we’re just gonna do a little exercise before we wrap up Okay, what I would like you to do is one person is kind of the client, I want you to think about a behavior maybe That you might think about changing Typical American ones would be diet, exercise, spending Those are just some hints Smoking, drinking, okay but some kind of- procrastination that’s the one my students always talk about Think about a behavior that you need to change, the other person’s gonna be the social worker You need to tell that, when I give you the go sign, you need to tell your social worker what the behavior is Then I’m gonna put a script on the board and social workers, I want you to follow the script This is very scripted social work but it’s called a taste of MI Okay so here are your questions Okay everybody, here are your questions Ask them once you know what the change is, why they might wanna make this change What- how might you go about it, what are the three best reasons to do it? Provide a summary about what you heard and ask them where they go next so take about 5 minutes to have this conversation if you would Okay, well I sure felt the energy in the room go up with- put the social in social work, right? What was it like to be the client? “Client” What was that like? It- not bad “laughter* Alright, okay *It was affirming *Mindy* Okay, because… *Well particularly around the reflection and then A, you felt heard *Mindy* And it’s nice to be listened to, yeah. Somebody gets us. How else was it to be the client? You were a chatty bunch so don’t go dead on me here now What was it like to be the client, to actually feel a little bit of what MI feels like? What was it like? *Somebody was really wanting to hear from me Like there was a genuine feeling they want to hear * You’re coming up with your own solutions so that was things that in your mind you might say to yourself “I could manage that” Cause I’m coming up with it *Mindy* Okay so your ideas… anybody come up with things that surprised themselves? Solution wise Okay, cause sometimes that happens, people will say “I never even knew I had that in me” To think about Okay *Well I just… I lost my thought *Mindy* I’m sorry. When it comes back to you So what was it like to receive an MI interview? A little bit of one *It’s like, it says a client, it’s like this little gift of time that was all about me And really I just, we did it with just the script and afterwards I thought, you know I really did not know much about him at all He didn’t talk about himself, it was about me. I mean that *inaudible* *Mindy* Doesn’t happen all that often Did you- did, you know, at least with my friends I’ll say everybody shares their story and somebody else can’t wait to share their story And then- you know, and then that happened to me too… Yeah *I think I was a little the opposite of that cause I’m uncomfortable sharing, so I was like Didn’t, I’d rather find out about her, I’d rather be asking the question I’m a bit of a control freak I guess *Mindy* Okay, so that’s something to think about too. Maybe- many clients find it as a gift or find it freeing or something But maybe other people it’s kinda a little intimidating or whatever reason You have that, okay. What was it like to be the social worker * We talk about this in Ellen’s class a lot and it’s something I definitely have a hard time with, you wanna have a solution to that Right and this, the script really helps you help to stay away from that. And it really has to come out of her She they do a great job thinking about what his strengths were and how she should tackle the tasks that he has And that was really interesting to see how- the thing in my head she was saying a couple minutes later So if you just wait on it a little bit and do some of the stuff it will come out *Mindy* Okay, it will come that they have it in them And that’s- one of the other things is Miller uses a lot of humanistic theory Says that, you know, humans have the resources and the knowledge And it’s, part of it is the belief that they do Okay? *I think connected to that, it almost takes the pressure off of you to feel like you have to fix their problem because if you just give them a moment they can fix it themself Like, like I don’t know, when we did it. When I asked her the first time like what do you think you need to succeed She was like “Well I don’t know that’s why I’m here” But then when I like allowed her to talk more about like why she wanted to do it and then I asked her again Like what do you think you’ll do, then she had a plan *Mindy* Good for you, you didn’t let her try to put it back on you and tell her what to do cause then you’d be getting the “yes but” s It’s about what works for that person *Yeah like I found myself not spending too much time in my head, like “Oh I should ask him this or I should ask him this” It was more just being able to like release myself and actually hear what he was saying And kind of devote my thinking to what she’s actually telling me Instead of trying to race to the next thing *Mindy* And think what’s my next question But, you had to remember it all for the summary, that’s hard That’s hard to pull it all together Miller uses the metaphors of a bouquet You’re pulling the different change talk flowers, this was all change talk The reasons to do it, the ways to do it, but you’re pulling it together and your handing it back to them So they’re hearing themselves, it’s how you pull it together, it’s a very strategic part of MI *I noticed it was kind of nice to have a script to refer to for a change Kind of what you are doing is reflective listening and taking all of that in So that’s kind of nice to defer- default to something and then you really then engage in listening to what they have to say And sort of that was kind of easier to hold that all in and then reflect it back to her, having something to default to *I thought it was nice to have, you know, I might during an interview ask “well why do you wanna make that change?” But I wouldn’t ask what are the three best reasons for it and I think that gives the person a sense of you know, real focus on the importance of their goal *Mindy* Mhmm, you’re really exploring that with them, it’s really taking that conversation and exploring it more Other comments? Well I’m happy you liked it, it sounds like you got a lot- I wish I could take credit for it, this is Bill Miller Exercise, but it really is a nice way to give you a sense of what is it feel like to give an interview And what is it feel like, you were kind of talking about being a literal freed up To be the social worker in that So going back to some of the questions at the beginning You know, specifically I don’t know if I was able to address some of those, but thinking about you know the power differential, how might MI impact that? That was a question that was asked Just from what you’ve learned today, how might that impact that *I think it really helps even the playing field because you’re really putting the ball in their court, like really they’re the ones that have the power Like the reasons, what’s gonna work with them, all that so it really helps level that out *Mindy* So putting the ball in their court and helping them figure it out Kind of reduce- you’re always gonna have that power differential Any time you’re an officer of the court you do But, again, it’s starting to put it in more of a collaborative relationship We talked about working with other professionals Now you’re not gonna have an MI with a target behavior interview, for the most part, with other professionals What do you think you could take to work with other professionals? What might be a skill or something that you’ve learned? When you’re getting the wrestle with them? *I think just really that like listening to that like where they’re coming from. That could be part of it. Cause sometimes they’re not cooperating with you because they have a different opinion about the case or they think that things aren’t going the way they should be So actually listening to that and acknowledging that, they’ll be more willing to address also how you’re feeling *Mindy* And they wouldn’t have that need necessarily to keep telling you what that is Okay? That you’re at least trying to hear it and listen to it, and you may not come to an agreement but you’re giving them a good listening to Okay, implementation. What do you think it takes to learn MI? Practice, practice, practice, yeah. And Miller compares it to learning how to play the piano Or a sport. Think about it, any time you learned a new skill, you just, like, sit down and play the piano No, you know, you peck out Mary Had a Little Lamb And then you get- yeah script, we have our script But it is, it’s about practice, practice, practice But implementation, there’s some different models on implementation but- and there’s a whole implementation science That looks at taking evidence based practice and how do you get people to change their behavior But one of the key pieces is this whole notion of practice And one of the things we’re trying to get going in San Diego County is what are called Communities of Practice Where people come together voluntarily just to practice their skills with each other And give each other some coaching and feedback I mean if you have money it’s nice to hire somebody like Jan Who can work- I’m not saying you wouldn’t do something for free too, but a lot of times people who are MI coaches People send them tapes and pay them for their time to code their tape and get them feedback So communities of practice where people come together and work on their skills is a cost effective way of doing that And they’ve started that where, because we brought five instructors into the MI class last summer And they’ve been meeting once a once since then to work together and their- ones like a school social worker, they’re all in different settings *I think that person who asked the question originally was asking about- they’ve learned this and how to now get it back into their agency *Mindy* Typically when agencies are interested in it, such as San Diego probation right now they- it’s a top down kind of thing, comes from the top and there’s mandated- Making it bottom up I don’t know as much about But if there’s implementation models But certainly bringing it to peoples attention that this is an evidence based practice when it’s done with fidelity, there’s much research to show that it’s effective We’re getting some better research now on child welfare but there’s certainly, you know, hundreds and hundreds of studies in other areas of practice to support it so … And then you get also, you know, mandates from other places that are wanting evidence based practices implemented so it’s, I would say Thinking about how to motivate the decision makers Using some of these skills *And that’s a really important issue and another thing to think about is in everyone’s practice the place that you have the most control In your own practice is how you talk to the person across the table from you, how you talk to someone when you’re in their living room That’s the place in your practice that you have the most control There’s an enormous amount individuals can do in their own practice when they decide I wanna change how I talk to people Even if everything around them doesn’t *Mindy* Yup, I guess as Betty Hannah, you know Betty Hannah, says, another MI trainer “You gotta talk to them” so might as well make it productive The batteries maybe going kaput Okay it went, Alright well I’m just gonna go onto the next slide because it’s time for us to finish up This is a quote from Miller from his book And Rollnick, in arguing for the status quo or sustain talk, or expressing discord, the client is probably rehearsing a script that has been played out many times before There is an expected role for you to play, one that is acted out by others in the past. Your lines are predictable, if you speak these same lines as others have done The script will come to the same conclusion as before But you can rewrite your own role Your part in the play need not be the dry predictable lines the client is expecting Responding well to sustain talk and discord is a key to successful communication. If you can recognize it for what it is an opportunity And I thought this is such a lovely refrain when we get these kinds of negative behaviors from our clients To be able to say “Aha”, here’s an opportunity for me to be different So I thank you all, you’ve been great. I’ll have to tell the students in social work in San Diego state that I had some wonderful students at Madison And I really appreciate your interest and the questions and the discussion and I wish you a happy spring *laugther* *applause*

5 comments

  1. I think I actually understood and learned something new which was actually helpful today. Thank you kindly.

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