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    Motivational Interviewing: An Evidence-Based Approach to Working with Families

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    Motivational Interviewing (MI) is a form of strengths-based counseling originally developed by Miller and Rollnick with the aim of helping people to change. Miller and Rollnick defined motivational interviewing as “a collaborative, person-centered form of guiding to elicit and strengthen motivation for change”.

    Proponents of MI tend to argue that it is more than a set of techniques to help strengthen a person’s motivation for change as it also encompasses a particular ‘way of being’ as a practitioner, based on collaboration rather than confrontation, evocation rather than the provision of advice, and on the promotion of individual autonomy rather than a reliance on authority. In the field of substance and alcohol misuse, MI has a good evidence base as being an effective way to help and there has been in recent years an increasing interest in the use of MI techniques and principles in the field of child protection social work, particularly in the UK.

    In addition, MI has many philosophical similarities with strengths-based approaches more generally. A recent systematic comparison between MI and strengths-based practice found that MI practitioners tend to focus on the goals to be achieved (rather than on any problems that may exist), on service users’ current strengths and how to utilise these for future change, on the employment of service users’ own resources, on the development of a positive and collaborative relationship between the practitioner and the service user, and on the provision of meaningful choices.

    As such, in my view, MI is both potentially of practical use for social workers in many different fields, wherever the aim is to help people to change, but it also fits well with the broader value base of the social work profession in its’ recognition of autonomy, of expertise by experience and its’ focus on collaboration.

    In practice, MI involves changing the way we speak to service users as a way of putting these principles into practice. For example, by asking the permission of the service user to either discuss certain topics or before giving advice, affirming the control of the service user and their ability to make choices, by supporting and encouraging their efforts so far and by asking open questions and reflecting on what they have said.

    One would also seek to avoid confronting the service user or directing them as to what they should do. Rollnick, one of the principal founders and developers of MI, provides the following examples of how one might engage with someone about smoking, with the first being an example of ‘the righting reflex’ (the desire to advise and direct solutions) and the second being an example of a more MI-consistent approach. I’ve added some comments in brackets to highlight where the doctor in these examples is either using or failing to use the principles of MI:

    EXAMPLE 1:

    You: Are you a smoker? (closed question)

    Patient: Well, sort of yes.

    You: How much do you smoke each day? (closed question)

    Patient: I don’t know, about 15-20 years?

    You: With that chest, I must tell you, it’s going to get worse if you smoke like this (confronting)

    Patient: Yes, I know but you see it helps with the stress, if you knew what I go through with that truck and the long roads, it’s enough just to get through the day.

    You: But if you carry on like this you might lose even more time at work (confronting and not listening to the patient’s reasons for smoking)

    Patient: yes, I am cutting back you see.

    You: Well we’ve got some good aids to quitting if you are interested? (advising, directing)

    Patient: yes thanks, I’ll give it some thought thank you doctor.

    EXAMPLE 2:

    You: would you mind if we talked about your smoking? (asking permission)

    Patient: Well, OK.

    You: How do you really feel about it? (open question)

    Patient: I’m trying to cut back, but I can’t say it’s easy with my job, you know it’s stressful driving a truck.

    You: It’s not easy for you yet you’d like to smoke less (reflecting, highlighting the patient’s possible motivation to change)

    Patient: Oh if I could, definitely, I know it’s not good for my chest for a start.

    You: You can feel the effect for yourself and it’s not pleasant (reflecting, highlighting the patient’s possible motivation to change)

    Patient: That right, but it’s such a stress reliever it’s hard to let go.

    You: It’s difficult for you to imagine being without smoking (reflecting)

    Patient: yes, that’s exactly right, you got me.

    You: I don’t want to give you a lecture or hassle you about this, but I’m wondering what would be helpful for you? (emphasising patient’s control, seeking their opinion on what might help)

    Patient: I just don’t know Doc.

    You: Tell me, deep down, how important is this for you right now? (open question, emphasising the patient’s option to seek help or not)

    Patient: I feel sick and I’m tired, and this smoking wears me down…

    The difference between these two conversations is quite stark and I can easily imagine how the patient in the first example might leave feeling under pressure but without any real motivation to change, whereas in the second example, the patient would (hopefully) feel listened to and may leave thinking about why they do actually smoke and perhaps even thinking about what it might be like if they could stop.

    I would suggest, and there is evidence to support this, that the patient in the second example is much more likely to come back to the doctor for further help and support, whereas the patient in the first example may not and may even actively avoid getting into a discussion about smoking again with their doctor.

    One very simple technique for seeing how well one can put these ideas and principles into practice – of asking open questions, seeking permission, emphasising the service user’s control and choice, reflecting on what has been said and seeking to highlight potential ambiguity regarding the possibility of change – is to record a conversation with a service user (with their permission, of course) and simply listen back, noting down when you have asked open or closed questions, when you have advised without permission, confronted or directed and where you have been able to reflect and emphasise the service user’s autonomy.

    Personally, I have found this to be a powerful learning technique in my own practice and this, in turn, has allowed me to develop my own skills of MI, which I believe has made a difference for how productive my conversations and discussions are with services users.

    For More Information

    Miller, W. and Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change. Second edition. London: The Guilford Press.

    Miller, W. and Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37(2), 129-140.

    Forrester, D., Westlake, D. and Glynn, G. (2012). Parental resistance and social worker skills: towards a theory of motivational social work. Child and Family Social Work, 17(2), 118-129.

    Manthey, T., Knowles, B., Asher, D. and Wahab, S. (2011). Strengths-Based Practice and Motivational Interviewing. Advances in Social Work, 12(2), 126-151.

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    David Wilkins is a Qualified Social Worker and has worked primarily in the fields of child protection and with disabled children in North London. He graduated from Middlesex University in 2007 with a Master's in Social Work. David is currently undertaking a PhD in Social Work at the University of Kent and has written books on Child Abuse and Critical Analysis Skills for Social Workers. David has also written a number of book chapters and articles in a range of areas including: attachment theory and children with autism, disorganized attachment and related caregiver characteristics, direct work tools for children, ethical dilemmas in social work, analysis and decision making, effective case recording and better care planning and the analysis of risk and protective factors for children. You can follow David on twitter @david82wilkins. 

    Mental Health

    When Giving Thanks, Don’t Forget Yourself

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    As we give thanks at the holidays, it’s easy to overlook someone important: your past self.

    While it’s well documented that gratitude toward others can improve wellbeing, two University of Florida scientists find that gratitude toward your past self also has benefits.

    Does thanking yourself seem a bit…selfish? The researchers, UF psychology professor Matt Baldwin, Ph.D., and undergraduate student Samantha Zaw, think not.

    “Despite the fact that past gratitude is self-focused, it reminds people that they’re part of a bigger story and that they have the power to grow,” Baldwin said. “It’s possible this promotes a pay-it-forward type of mentality.”

    Gratitude is what psychologists call a self-transcendent emotion, one that lifts us out of the everyday and expands our perspective, which can help us get along with each other better. In a recent experiment, Baldwin and Zaw asked participants to write brief gratitude letters. The first group thanked someone else, the second thanked themselves, while a third, the control condition, wrote about a positive experience they’d had. Zaw and Baldwin then surveyed the participants about their self-perception after writing the letter. Although the results are not yet published, early analysis shows that the exercise gave the other- and self-focused gratitude groups a sense of redemption and helped them feel they were morally good people. However, the group that wrote to themselves scored higher on both measures.

    The past-self group also saw a benefit the others didn’t: an increase in the self-awareness measures of clarity, authenticity and connectedness.

    “Unlike gratitude toward others, being appreciative of ourselves carries an added benefit of truly understanding who we are and feeling connected to ourselves,” said Zaw, a McNair Scholar who has been working with Baldwin since her freshman year as part of UF’s Emerging Scholars Program.

    Zaw and Baldwin’s research — the first known data gathered on past-self gratitude — was inspired by a Reese’s cup. When Baldwin’s co-worker, boredom researcher Erin Westgate, returned to the office after pandemic lockdown, she was delighted to discover a peanut butter cup she had squirreled away in her desk.

    “She texted me like, ‘Oh my gosh, my past self left my future self a Reese’s,’” Baldwin recalled. “I was like, ‘Wait a second. You’re expressing gratitude towards something your past self had done. We have to study this.’”

    As Zaw and Baldwin dug into previous studies, they found plenty on gratitude toward others and a few on self-compassion, but nothing on past-self gratitude. They designed the letter-writing experiment to test its effects, presenting their findings at the Society of Southeastern Social Psychologists in October and at the upcoming meeting of the Society for Personality and Social Psychology in February.

    If you’re curious about the benefits of self-gratitude, Zaw offered a way to try the experiment at home, maybe as a new Thanksgiving tradition. Take a few minutes to write a thank you message to someone else, and another to yourself for something you did in the past. Sharing what you wrote could foster connections between loved ones, she said, but the exercise can also pay dividends if you try it on your own.

    “At Thanksgiving and Christmas, we focus on other people, but self-care is really needed too, especially if we want to feel more clear about ourselves,” she said. “Maybe it can even lead to a better vision for ourselves for the next year.”

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    Mental Health

    A Lifeline for Primary Care Amid a Crisis in Youth Mental Health

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    Most mental health care in America doesn’t happen in psychiatrists’ offices – especially when it comes to children, teens and young adults.

    Instead, young people with depression, anxiety and more turn to the same people they already go to for all kinds of other health issues: their pediatricians, family doctors, school-based clinics and other primary care providers.

    But where do those providers turn when they need more help in handling the mental health concerns of their patients – especially more serious issues that they’re not trained to handle?

    If they’re anywhere in Michigan, they can turn to the team at MC3.

    For nearly a decade, the MC3 program has helped thousands of primary care providers throughout the state care for the mental health needs of young people up to age 26. It also aids providers caring for pregnant women and new mothers of any age who have mental health needs.

    More than 16,000 times since 2012, MC3’s psychiatrists and pediatric behavior specialists from the University of Michigan have connected directly with more than 1,800 primary care providers by phone, for consultations about their patients.

    Together, they’ve mapped out plans for handling ADHD in young children, suicide-prevention safety planning for teens and symptoms that might signal schizophrenia in young adults.

    There’s no charge to providers or their patients, thanks to the program’s funding from state and federal grants.

    For providers whose patients recently had a mental health emergency or are waiting for an appointment with a child psychiatrist or a psychiatric inpatient bed, the service can literally be a lifeline: one in five of the consults involve a patient who has expressed suicidal thoughts or harmed themselves.

    How it Works

    MC3 also offers video-based telehealth appointments to connect patients of participating providers with psychiatrists. U-M and Michigan State University experts have also created a wide range of training options for professionals available on the MC3 website.

    Though the demand has grown in recent years thanks to the pandemic, the program has room for more Michigan providers to join the network and get access to its services.

    Each connection starts by contacting one of the trained professionals in MC3’s network of Behavioral Health Consultants, located throughout the state. MC3 also works closely with the state-funded Community Mental Health agencies across the state.

    “Only about 3% of the children, teens, young adults and moms that our participating providers have consulted with us about are in treatment with a psychiatrist. We’re providing access to specialist-informed care to young people who wouldn’t otherwise have it,” said Sheila Marcus, M.D., who heads the pediatric component of MC3 and is a professor of psychiatry at Michigan Medicine, the University of Michigan’s academic medical center.

    “The reality is that no matter where they live and no matter what their family’s income level, most of these patients would not have easy access to a specialist because of the critical shortage of such providers,” she added. “In some counties, there are no local providers trained to provide this level of care.”

    Primary care providers inside and outside Michigan can also access MC3’s free online resources, even if they’re not enrolled in the program.

    These include prescribing guides for mental health medications and online provider education, to equip them to provide diagnosis and care that might not have been part of their formal professional training. Much of that training offers continuing education credits that can help physicians, nurse practitioners, physician assistants and certified nurse midwives keep up their license.

    “For me, MC3 has been a game changer,” said Lia Gaggino, M.D., who first interacted with the MC3 team through her pediatrics practice in Portage, Michigan and now is the team’s consulting pediatrician. “Since its inception I have used their services for children and teens who presented with very complicated mental health concerns. I wished I had had a psychiatrist to help me and then MC3 appeared and offered me a lifeline. Their services changed my prescribing practices and improved my skills and I am so grateful for their advice and support. I encourage my colleagues to sign up and call –MC3 is there to help us!”

    Local Care Amid a National Emergency

    As the nation grapples with a national emergency of rising mental health concerns among young people, MC3 and similar programs in other states are expanding access to critical psychiatric services at a time when demand is soaring.

    The national organizations that declared that emergency in October called for more support of mental health care in primary care settings, as well as efforts to overcome the national shortage of mental health specialists for young people, especially in rural and low-income areas.

    That shortage is what drove the creation of MC3 in the first place.

    Michigan is third from the bottom among all states in supply of mental health professionals for young people. Only Washtenaw County, where the University of Michigan is located, meets national population-based criteria for having enough mental health providers specializing in children and teens.

    The pandemic has made matters worse across Michigan and the United States. A national report from November 2020 showed that anxiety and depression in pregnant women have more than doubled, and emergency department visits for mental health concerns in children had risen by double digits since the pandemic began.

    Joanna Quigley, M.D., another MC3 consulting psychiatrist from Michigan Medicine, recently presented data at a national meeting showing that 30% of MC3 consults during 2020 focused on pandemic-related concerns.  

    The pandemic has prompted MC3’s team to plan to offer extra training to help providers identify the needs and handle the concerns of children traumatized by experiences they or their families have had during COVID-19.

    Trauma-informed care is also important for children who even before the pandemic experienced very disruptive life events.

    Terri Rosel, NP-C, a nurse practitioner at Cherry Health in northern Michigan, wrote to the MC3 team: “I work in a small student health center in Cedar Springs and am the sole provider in the office. Since starting this job four years ago I have had the pleasure of seeing so many students with mental health concerns. I felt ill-equipped at times to help them with my degree as a family practice nurse practitioner. I would utilize MC3 often to help with treatment plans for these wonderful kids who needed help but could not get into psychiatric services soon enough.”

    As the program continues to grow, it will partner more with schools through a direct connection with the TRAILS program that offers mental health awareness and support services.

    Positive Feedback from Providers

    The MC3 team has surveyed participating providers and found that 99% agreed with the statement that “following phone consultation(s) I felt more confident that I could effectively treat patients’ behavioral health problems.”

    The team published other findings from its survey of providers, and responded to feedback by making changes.

    The quotes they received from providers are equally compelling.

    “This service has been absolutely ‘practice- changing’,” said one. “As we have more and more patients with mental health issues and limited local resources- we are essentially the only option for these kids. Having MC3 support helps us make good treatment decisions and is also ‘on the job training’ which we can apply to future patients.”

    In fact, MC3 data show that 25% of the interactions help the patient avoid a higher-level of care that may be difficult to access, such as a psychiatric hospital bed or emergency psychiatric visit.

    One of the maternal health providers who joined MC3 recently said, “I can’t even express how this service has enhanced the care I can provide. In the past, we’d screen and diagnose and then send moms out. We’d place referrals and hope that folks could navigate the complex system. Now, with MC3, I can collaborate with psychiatry, start meds or treatment, and access community resources that I am confident they will be able to access. It’s really been invaluable.”

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    Culture

    America Has an Anger Problem – Can Better “Mental Nutrition” Fix It?

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    America is a pretty angry place these days. Formerly respectful spaces like school board meetings have become bitter battlegrounds. Some people are harassing healthcare workers and threatening restaurant staff for enforcing COVID protocols. Others are openly furious with the vaccine-hesitant. Everyone, wherever they stand on the (deeply divided) political playing field, is outraged about something.

    Sure, anger is part of the human condition, but have things always been this bad? Elaine Parke thinks not—and she has a plan to get America the anger management tools it needs.

    “We’ve stopped listening to one another because we’ve become addicted to our own narrow and sometimes selfish points of view,” says Parke, author of “The Habits of Unity: 12 Months to a Stronger America…one citizen at a time” (Outskirts Press, 2021, ISBN: 978-1-9772-4276-1, $21.95, www.12habits4allofus.org). “And we seem to have lost sight of the notion that we’re personally responsible for our own behavior.

    “It’s way past time for us to take a collective deep breath and treat others with dignity, respect, and civility—and listen to them—whether we agree or not,” she adds. “It’s urgent that we make this shift now.”

    Dialing down our ire is easier said than done. We are living in extraordinarily stressful times. But there’s more at play. Parke says we are shaped by the messages we consistently consume—and in today’s connected world, a lot of those messages come from our digital diet.

    “Social media isn’t solely to blame for stoking our emotional flames—in fact, it was designed to be a source of information and to bring people together,” Parke clarifies. “But if your newsfeed is making you an angrier person, it’s on you to either log off for a few days or reassess the kind of content you’re engaging with. When we choose to focus on stories that are positive and nourishing, we go a long way toward resetting our emotional equilibrium.”

    Parke’s “The Habits of Unity” is her attempt to help people take charge of what she calls their “Mental Nutrition.” Much in the same way that we (hopefully) approach the food we eat, we need to develop the discipline to make more nutritious mental choices every day. Her book’s 365 “one-magic-minute-a-day” motivationals make it easy to hardwire these choices into habit.

    With her simple, doable framework for uplifting ourselves, boosting our mental health, and practicing unity, Parke hopes to get everyone focused on the same branded behavior each month. The idea is that the sheer force of all that concentrated positive energy sparks a unity revolution that rises from the ground up and sweeps the nation.

    Yet, until that happens, we can leverage the power of  “The Habits of Unity” on a personal level by forming one good habit per month:

    January: Help Others

    February: You Count

    March: Resolve Conflicts

    April: Take Care of Our Environment

    May: Be Grateful

    June: Reach Higher

    July: Become Involved

    August: Know Who You Are

    September: Do Your Best

    October: Be Patient and Listen

    November: Show a Positive Attitude

    December: Celebrate Community, Family, and Friends

    Those who’ve tried it say the plan is easy to put into practice. It feels good, so you’ll want to keep doing it. And there’s a ripple effect. As you become more positive, centered, and respectful, others will be drawn to you and your relationships will improve.

    “As these ripples expand, they will improve the emotional climate in our country and make it easier to seek common ground, instead of lashing out,” says Parke. “But we can’t sit around waiting for others to take action. Each American must recommit to making our country a welcoming, affirming melting pot—instead of a stewing pot.”

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