190815 understanding the diversity of az families and ... · mi spirit: evocation • evoking...
TRANSCRIPT
8/27/2019
1
Understanding the diversity of Arizona families & using Motivational Interviewing to engage them
Dr. Judy Krysik, PhD Stephanie Miller, LMSW
Research & Training Specialist
First Things Firstearly childhood summit 2019
instructors
Dr. Judy Krysik, PhDDirector, Center for Child Well Being & Associate Professor
School of Social Work
Stephanie Miller, LMSWResearch & Training Specialist
Arizona State University
Center for Applied Behavioral Health Policy
Motivational Interviewing Coding Lab
8/27/2019
2
learning objectives
1. Understand diverse populations of infants and toddlers across AZ.
2. Learn about risk factors associated with the
families who encounter the home visiting services
and child welfare system.
3. Learn and practice Motivational Interviewing to
engage families.
agenda
• demographics in Arizona
• risk factors for families
• challenges with engaging families
• Motivational Interviewing introduction & application
8/27/2019
3
group agreements
• what helps us maintain a safe learning space?
• how can we support one another in our discussion and learning?
• what are your needs for ensuring an enjoyable, productive experience?
part I: families in AZ
8/27/2019
4
children in AZ
• In recent post-recession years, Arizona experienced the greatest birth rate decline in the nation.
• The birth rate fell sharply from 16.4 per 1,000 population in 2006 to 13.0 per 1,000 in 2014.1
• This difference has resulted in approximately 20,000 fewer births per year. For example, in 2007 there were 102,687 births compared to approximately 81,000 in 2017.2
1Arizona Department of Health Services. (n.d.). Table 5B-2. Birth rates by county of residence, Arizona, 2006-2016. https://pub. azdhs.gov/health-stats/menu/info/trend/index.php?pg=births2 Arizona Department of Health Services. (n.d.). Table 5B-2. Birth rates by county of residence, Arizona, 2006-2016. https://pub. azdhs.gov/health-stats/menu/info/trend/index.php?pg=births
reasons for the decline• One contributor to the decline is a reduction in
teen pregnancies in AZ. • Teen pregnancies decreased by 55.3% from
15,038 in 2007 to 6,724 in 2016. The teen pregnancy rate declined from 34.4 pregnancies per 1,000 girls 10-19 years of age in 2007, to 14.9 in 2016 (still above national average of 9 per 1,000)
• Teen pregnancies are of concern as babies born to teen mothers are more likely to be born preterm and low birthweight, and are more likely to live in poverty, which creates other forms of disadvantage.
8/27/2019
5
increasing diversity
• Hispanic children have surpassed white, non-Hispanic children as the largest ethnic category since 2010.
• The proportion of white, non-Hispanic children continues to fall over time from 43% in 2008 to 39% in 2017, whereas other groups including mixed race children have increased.
• As non-white children tend to be overrepresented on a number of risk factors including economic, health, education and safety this points to a more diverse population in need.
Data Source: Population Division, U.S. Census Bureau.
infants & toddlers (2010 – 2017 N = 13,963)
• From 2010 through 2015 there was a 67.4% increase in the number of children less than three years of age from Maricopa County who experienced a first removal for reasons of maltreatment.
• The number of removals has declined consistently from 2016 through 2017. In 2017 they were closest to that experienced in 2011; a 28.9% decline from the peak in 2015.
2010 2015 2016 2017
+67.4%-28.9%
8/27/2019
6
• In 2010, 52.8% of children removed for the first time in their lives were birth to one year of age at the time of removal, compared to 61.8% in 2017.
• The primary driver of this change has been the growth in children removed from birth to 30 days.
infants & toddlers (2010 – 2017 N = 13,963)
48
50
52
54
56
58
60
62
64
2010 2017
children removed for the first time in their lives
children removed for the first time in their lives(0-1 year of age at time of removal)
diversity among children removed• African American and American Indian children
under three years of age were overrepresented among first time removals compared to their representation in the population of children under five years of age in Maricopa County.
• In 2015, 5.8% of the child population under five years of age in Maricopa County was identified as African American, and 2.5% American Indian and Alaska Native. In contrast, 12.6% of children under three years of age with first time removals in Maricopa County were identified as African American and 5.7% American Indian (2010 –2017).
• 80% single parent, majority (85% English as primary language)
Source. U. S. Census Bureau: American Community Survey (Tables B01001 B, C, D, E, F, G, H & I, B09001).
8/27/2019
7
group discussion
• What are some ways that we build rapport with families?
• What are the perspectives of parents we work with and how do we honor their experiences/perceptions?
• How do we engage in their case plans?• How do we support parents and caregivers in ownership of their case plans?
part II: why MI?
8/27/2019
8
What is one of the strongest predictors of
success in a helping relationship?
YOU(the “working alliance”)
(the “working relationship”)
8/27/2019
9
why would we need to foster a working alliance?
participation in services
parents support
attendance
child remains
interested
why MI? Parents…
• often the ones initiating referral for treatment
• must provide legal consent, transportation, and payment for treatment
• play a key role in managing their children’s adherence both in sessions and between clinic visits
“Thus, in child therapy, although the focus is often on modifying the child’s behavior, it is the parent who must manage treatment attendance and adherence. This is particularly true of treatments that make use of parent training as a component of the treatment or as the sole
source of treatment.”Nock, M.K. & Kazdin, A.E. (2005). Randomized controlled trial of a brief intervention for increasing participation in parent management training. Journal of Consulting and Clinical Psychology, 73 (5), pp. 872-879.
8/27/2019
10
>1,200 publications
on the MI model since 1990
>200 randomized clinical trials
reflecting a wide array of problems, professions, and practice settings
Miller & Rollnick, 2013
Bernstein et al., 2005; Nock & Kazdin, 2005; Rubak et al., 2005; Soria, Legido, Escolano,
Lopez Yeste, & Montoya, 2006
effective in even very brief interventions
8/27/2019
11
MI was 2-3 times more effective with ethnic
minorities
Hettema, J., Steele, J. & Miller, W. (2005). A meta-analysis of research on motivational interviewing treatment effectiveness (MARMITE). Annual Review of Clinical Psychology, 1, 91-111.
“We know of no evidence, however, that directing-style interventions are more effective than MI when time is brief. If patient behavior change is what’s needed and time is short, MI is likely to be more effective than telling people what to do and why.”
-Bill Miller & Steve Rollnick
8/27/2019
12
key MI factors
increased change talk
improved working relationship
part III: MI fundamentals
8/27/2019
13
communication styles
• following• directing• guiding
“righting reflex”• our innate tendency to ‘correct’ other people’s behavior
•premise: “I have the answer, if you just do things this way, things will get better for you.”
• this is well-intended, the intent is to help
• in MI we try to repress this reflex
8/27/2019
14
directing style results in…
disengagement
pessimismhostility
defensiveness
breakdown in relationship
tension
hostility
frustration
anger
no-shows
guiding styleThink Bill Miller…
8/27/2019
15
guiding style results in…
likelihood of returning optimism
engagementempowerment
trust
talkativeness
good rapport
receptiveness
communication styles
all 3 are valid…
• helping professionals typically rely on directing
• following is best when support is needed
• guiding is the best tool for behavior change and enhancing motivation
8/27/2019
16
MI definition
“Motivational Interviewing is a collaborative conversation style for strengthening a person’s own motivation and commitment to change.”(Miller & Rollnick, 2013)
the MI Spirit
Partnership
Acceptance
Compassion
Evocation
A
P
C
E
8/27/2019
17
• collaborating• working as equals• remaining outside of the ‘expert’ role
MI Spirit: partnership
MI Spirit: acceptance
• accepting the person without judgment (without condoning their behavior)
• avoiding confrontation
8/27/2019
18
MI Spirit: compassion
• ≠ sympathy• advocating for the person• empathizing with the person
MI Spirit: evocation
• evoking change talk • eliciting the person’s reasons for
change
8/27/2019
19
where are we on the hill?
where is the client?
part IV: 4 processes
8/27/2019
20
Engaging: use OARS to accurately understand their perspective, meet them where they are, change is their choice, assess and stage match
Focusing: what are their goals? how can utilizing services be of use? assess and stage match
Evoking: be curious, reflect meaning, use a guiding style, assess and stage match
Planning: their plan, their goals, next steps, support systems, assess and stage match
Miller & Rollnick, 2013 . Adapted by R.B.Colgan 2016
4 overlapping processes of MI• each step builds upon the one before it
ENGAGEMENT is the foundation
• they can be repeated indefinitely
8/27/2019
21
engagement
Gordon’s communication roadblocks
1) ridiculing/shaming (even jokingly)2) criticizing/judging/blaming3) warning/threatening4) preaching/moralizing5) directing/ordering/commanding6) lecturing/instructing7) diagnosing/analyzing/interpreting 8) interrogating/questioning/probing 9) unsolicited advice/suggestions 10) distracting/diverting/withdrawing11) praising/approving/being agreeable12) sympathizing/reassuring
Gordon, T. (2000). Parent effectiveness training: The proven program for raising responsible children (3rd ed.). New York, NY: Harmony.
8/27/2019
22
do more… do less…listening
reflecting
acting curious
focusing on strengths
empathizing
talking
question asking
advice giving
focusing on weakness/deficits
information seeking
focusing
8/27/2019
23
focusing: the strategic direction
“In order to be an effective guide you need to know where you’re going…Without a focus MI can’t get off the ground.”
(Miller & Rollnick, 2013)
target behaviors/change goals
• measurable• How would we know this is happening?
• related to a specific behavior• health or behavioral health goals
• reconcile the client’s and the provider’s goals
• maintain the therapeutic alliance
8/27/2019
24
identifying & refining the target behavior
ask permission
explore desiredoutcome
measurable target
behavior
target behavior examples
• obtaining employment
• taking child/ren for immunizations
• improving diet for the family
• ensuring school attendance (reducing truancy)
• improving safety (i.e. wearing seat belts, reducing smoking in the home/car)
• reading to child(ren)
• ensuring child(ren) get all necessary medical screenings
• reduce/stop substance use
8/27/2019
25
how do we get to the target behavior?
change talk can be increased by using open questions and reflections
1. increasing Change Talk2. decreasing Sustain Talk
evocation
8/27/2019
26
evoking: going “fishing” for
motivation
interviewer stylepredicts change
talk
change talk is strongly
correlated with change
8/27/2019
27
the key to MI
•we believe what we say, not what we hear
•our job is to arrange conversations so the person talks themselves into changing
•we do this by bringing out more “change talk” and cutting out “sustain talk”
where are we on the hill?
where is the family?
8/27/2019
28
OARS
open questions
8/27/2019
29
open vs. closed questions
open questions = require a longer answer
Ex: Tell me about your hometown.Ex: What is your family like?Ex: Tell me about the role alcohol has played in your life.
closed questions = can be answered “yes,” “no,” or in a few words
Ex: Where are you from? Ex: Are you married?Ex: When was the last time you drank?
• leave the person waiting for the next question
• feel more like an interrogation• do not expand the conversation• if you don’t ask the right question, you might
miss something
the impact of closed-ended questions
8/27/2019
30
affirmations
affirmations• praising or affirming the person• support autonomy & empathy• build the therapeutic
relationship
examples:• “I’m proud of you. You’ve been
working really hard to cut back.” • “You don’t really want to be here,
but you’re following through on your obligations. I respect that.”
• “You feel like you have a ways to go, but you’ve come a long way so far!”
8/27/2019
31
reflections
simple reflections - defined
• responding to resistance with non-resistance
• acknowledge and validate
• can elicit opposite response
• emphasize change talk
• encourage more change talk - person opens up
• enhance collaboration, trust, and rapport
• clarifies points of confusion
8/27/2019
32
simple reflections (cont’d)
Individual says: “My kids are important to me, but sometimes I don’t know how to talk with them.”
Helper says: “Your relationships with your children are important to you and you want to find ways to connect.”
complex reflections
8/27/2019
33
complex reflections
Individual says: “Being a single parent is so hard, and I can’t see how I will be able to continue doing this alone.”
Helper says: “You have been managing a lot on your own, and you are open to getting the support you need to continue taking care of your family.”
8/27/2019
34
summaries
8/27/2019
35
summaries & key questions• summarize key points (snippets of change talk)
from the conversation (this is akin to a long reflection)
• use the summary to direct the session toward the target behavior or transition
• end with a key question (open) that evokes change talk and moves the person into a planning phase
example: “Learning to co-parent after the separation has been difficult. Your children’s success is very important to you and you’re committed to finding ways to work together with your ex-spouse in order to meet the needs of your children. What are some ways that you would like to better communicate in order to ensure your children get to their appointments?”
OARS recap
Open-ended questions (50-70%)Affirmations (@ least 1x)Reflections (2:1)Summaries (1-2x)
8/27/2019
36
planning
indications of readiness
• ↑ change talk
• ↓ sustain talk
• categories of change talk: steps, commitment
• “resolve”
• imagining the future with the change enacted
• asking questions about the change or methods for change
8/27/2019
37
temptation: reverting back to a directing
style during the planning stage
part V: next steps
8/27/2019
38
MI learning continuum
intermediate MI training
giving feedback on MI skills
(coaching others)
introductory MI training
receiving coaching on MI
skills
MI coachingWithout feedback, it’s
natural to think we’re doing a good job.
Studies show people rate their MI skills higher
than they really are.
Coders provide the benefit of feedback to improve
one’s skills.
8/27/2019
39
part VI: wrap-up & resources
review: a formula for MI
• increase reflections ↑• focus on complex reflections
• decrease questions ↓• use 2x’s as many reflections as questions • eradicate closed-ended questions
• reflect change talk; deflect sustain talk
• ask permission to provide information
• express empathy through affirmations and reflections
• step out of the expert role; avoid advice giving
8/27/2019
40
additional resources
Miller & Rollnick
Motivational Interviewing: Helping People Change (3rd edition, 2012)
Thank you!Dr. Judy Krysik, PhD
Director, Center for Child Well Being
Associate Professor ASU School of Social Work
602.496.0086
Stephanie Miller, LMSW
Research and Training Specialist
520.884.5507x20605