HCD8186 - SECTION 5: INTERVENTIONS WITH HIGH-CONFLICT PARENTS
Reality therapy for divorced parents:
No matter what clinical approach you take with HCD clients, here are a number of points that must be reinforced many times. It is wise to print out these statements on a handout and continually refer to them. Consider this part of cognitive therapy whenever a parent gets caught up in his or her emotions.
Note that several of the statements below deal with clarifying the roles of domiciliary and non-domiciliary parents.
- The legal divorce ends a marriage, but it does not end co-parenting responsibilities.
- Children really do need both parents, no matter what one ex-spouse may think of another.
- Re-marriage does not provide substitute parents, no matter how wonderful the step-parents are; only the primary parents (adoptive or biological) can provide certain things the children need.
- In joint custody arrangements, the domiciliary parent is generally supposed to foster a good relationship between the children and the other parent.
- The domiciliary parent does not have the right to change visitation dates or times arbitrarily, nor can he or she withhold vital information about the children, such as which schools they attend or which doctors they see.
- The non-domiciliary parent is responsible for getting school information from the school, not from the domiciliary parent, making his or her own school conference plans, etc.
- The court does not equate domiciliary and non-domiciliary status with “superior” and “inferior” parenting.
- Disagreements or non-cooperation about finances (child support) are separate issues from the parenting plan. The child needs time with both parents no matter what the financial arrangement is.
- Young children should not be allowed to “choose” whether or not they follow the parenting plan. The parent whom the child is leaving is responsible for preparing the child for a pleasant time in the other parent’s home.
- Children’s needs over time may require changes in parenting plans.
- Changes of time-sharing and/or domiciliary status are common, even
in low-conflict divorces. However, they occur in low-conflict divorces because the parents are able to collaborate about the children’s needs; they often occur in high-conflict divorce as a sort of “win/lose” battle between the parents.
Clarifying vague legal language and misperceptions
The first session is also a vital time to check on the parent’s understanding of certain legal terms. Many times, parents have misperceptions about how much decision-making power they have. For example, domiciliary mothers sometimes believe they have the right to refuse visitation because of a late child support payment.
Also, many non-domiciliary parents believe they are “not allowed” to contact the children’s schools or doctors. It is helpful to give your clients a handout explaining these legal roles in simple language. (This is not legal advice; it is education about parenting roles.)
Another important consideration is about visitation terminology. If the judgment uses vague language (such as “reasonable visitation” or “share the holidays equally,”) you may ask the parents to work this out in a more precise fashion. This will cut down conflict considerably.
“Reasonable visitation” is a phrase sure to cause trouble. It allows the domiciliary parent to determine what “reasonable” is, and does not protect the relationship between the children and other parent.
“Sharing the holidays equally” does not address the exact dates and times of exchanges. A common solution is the odd-year/even year split. For example, in 2006, the father would have Easter and the mother would have Thanksgiving; in 2007 these would be reversed. In 2008, the father would have Easter and the mother would have Thanksgiving again.
Parents can get over-emotional about wanting to be with their children on “the” holiday—particularly a religious or family-oriented one. This often leads to arrangements in which the children spend half of “the” day with one parent, with an exchange for the latter half of “the day.”
Many grown children now look back on this arrangement with anger, feeling their happiness was sacrificed to the parents’ needs. These adult children report they would have preferred to alternate “the day” so they could have enjoyed it fully with one side of the family in alternative years.
It may be necessary to help the parent grieve the loss of the fantasized “perfect holiday.” You can help normalize this by pointing out that almost all step-families or families with shift-working parents regularly miss celebrating on “THE day.”
Be sure to help the parent prepare for spending holiday time without the children—and prepare the parent to make the child’s leave-taking guilt-free.
Normalize when possible
Reassure parents that many of their family dynamics would also be operating in non-divorced families. For example, adolescents rebel against parents all over the world, and two-year olds throw tantrums. Young children experience separation anxiety and need to be addressed confidently and lovingly that the separation is temporary and both the child and the separated parent will have fun until they are reunited.
It’s also normal to grieve the loss of the marriage, to be jealous of an ex-spouse’s new marriage or better economic situation. However, these feelings must be handled in a mature way, and therapy is an excellent resource for these situations.
Many oversensitive people will interpret an event not to their liking as “terrible” or “traumatic.” For example, if a parent is late to pick up a child at school, this is not “traumatic.” It may be inconvenient for the child, and possibly for the school staff.
However, such a problem can be handled with a few phone calls. Unfortunately, parents with poor reality-testing, histrionic or sociopathic traits may interpret this event as a sign of the late parent’s serious neglect of the child. Taken by itself, this one incident is NOT serious enough to call “neglect” and could happen in any family.
Overly sensitive parents need help with cognitive therapy, particularly to learn not to “awfulize” or “catastrophize” events. Parents with sociopathic traits, who wish to manipulate even slightly questionable events to their own advantage, need a rational rebuttal and reframing of the event as falling within normal parenting. (Of course, if the event IS questionable, you must pursue further questioning, albeit in an even-handed way.)
Separation Anxiety in High-Conflict Divorce
Mothers’ innate biology as well as cultural shaping encourages them to believe that the children belong with them. America’s cultural norm is still that mothers tend to do most of the child care, particularly with infants. Whereas the divorce laws used to be based on “maternal preference,” this is no longer true.
Many judges will award a 50/50 split of time between households, even for very young children. Divorcing mothers are often shocked to learn that they may be separated from even young children for considerable periods of time.
Separation anxiety is the major problem for mothers of young children. The research is clear that fragile mothers are likely to have behaviors that instill anxiety in their children during parting. For example, the mother may cry, clutch at the baby, or even reject the baby in the attempt to not feel the pain of separation. A small child will be very vulnerable to these triggers.
Toddler and preschool children will react to mother’s distress by mirroring it. A link is then made between the father’s arrival, the mother’s distress, and the child’s pain. The father’s arrival then becomes the “trigger” for the child’s bad feelings, and it is then easy for the mother to believe that the child is afraid of leaving with the father.
A major focus of counseling in these cases is to help mothers break their part in the cycle for the child’s sake. Since fragile mothers may have a hard time separating the children’s needs from their own, this may require extensive therapy time.
Of course, fragile fathers may also exhibit this unhealthy behavior, but since only 14% of fathers are the residential parents, it is not as common a problem among men.
Techniques to teach anxious parents:
- Preparing for the exchange with a happy ritual, such as packing the child’s favorite teddy bear in a special knapsack.
- Talking to the child about what a good time he or she will have at the other parent’s house. (“You’ll get to see Mommy and Granny,” or “I know Daddy’s going to help you learn to ride your bike.”)
- Telling the child that the anxious parent will be okay while the child is gone. (“I’m going to see a movie and then the next day when you come back, I’ll tell you all about it.”)
- Having the child’s belongings (and medicines) all packed so that the transition takes places quickly and smoothly.
- Acknowledging the child’s other parent at the time of the exchange with a pleasant greeting but keeping other conversation for later. No new information should be exchanged at this time lest it start up a conflict.
- If one parents attempts to start up a new topic, the other parent should be prepared with a deferring statement such as “I will call you as soon as I get home to discuss this, but for now, let’s just get Tommy settled in with you.”
- Phone calls to “check on the child” should be kept to a minimum. The very young child has no concept of telephone conversations; this is to soothe the parent’s anxiety but may raise the child’s. Furthermore, the other parent will likely resent the intrusion on his or her time. Phone calls to 5-year olds and above can be limited to once a day, and should be upbeat and brief. In very hostile cases, older children are often given “secret cell phones” to keep in touch with one parent.
Helping the over-emotive parent:
Histrionic or borderline traits in parents often put the “high-conflict” in high-conflict divorce. These over-emotive people cannot regulate their emotions well and have difficulty accessing their rational and objective side. As therapists, we can help them best by cultivating their cognitive skills and decreasing their emotional outbursts.
Obviously, the over-emotive person has a great deal of difficulty moving through divorce and letting go. People with histrionic and/or borderline traits are erratic in their parenting. They may dote on their children one minute and reject or ignore them the next. They are very prone to wanting to be the children’s “favorite parent.” Two such parents turn the parent-child relationship upside-down, with the two parents vying for favors to be bestowed by the children.
Example of an avoidant-histrionic pairing:
Mel is a 40-year old math professor at the local college. Lisa is a 38-year old stay-at-home mom who has domiciliary custody of their two daughters, Gina, age 5, and Hester, age 7. The couple was married for 15 years and just divorced 6 months ago. Lisa had filed for divorce after having a short-lived affair. Mel moved out of the house and into an apartment near campus. He has his daughters every other weekend and takes them to dinner on the alternate Wednesday evenings.
Lisa comes to your office with her primary complaint being that “Mel doesn’t care about the children.” She cites his declining the last two Wednesday dinner opportunities, and says that he never calls the girls.
She is very angry that he does not return her phone calls and gives only minimal responses to her long emails. She made this appointment because Mel showed up at the last exchange with a woman in his car. Lisa thought this was inappropriate and refused to allow the girls to go to with their father.
When Mel arrives for his first appointment, he states, “I love my girls, I just don’t want to have to deal with their mother anymore.” He states that Lisa’s affair was “a total surprise” and “broke his heart.” He didn’t file for divorce, but was rather relieved when she did.
The woman who accompanied him was a colleague whom he brought along because he was afraid of another one of Lisa’s outbursts when he picked up the children. He doesn’t understand why Lisa has the nerve to yell at him when the divorce is “all her fault.” He admitted that he has started dating his colleague, but has no plans to “get serious” so soon.
In this example, the avoidant parent’s defense of detachment increases the anxiety level of the histrionic parent. Her demands for confrontation - and to be listened to - then prompt more attempts at withdrawal by the avoidant parent.
Dealing with allegations of mental illness, drug abuse or physical/sexual abuse
If you choose to work with high-conflict divorce, you will certainly face the issue of allegations of mental illness or abuse. Depending on what role you are playing—child therapist, adult therapist, court-appointed parenting coordinator, or evaluator, you will have different legal and ethical responsibilities.
Be sure you understand the requirement of the jurisdiction for reporting allegation, either to the police department or the social service agency. You are responsible for complying with the laws and ethical code of your profession.
These parents may well have histories of domestic violence, drug abuse, or mental illness. However, you must stay focused on the present. Parents are likely to bring up past allegations or documented instances of abuse, or tell you about an incident which would legally be considered hearsay.
High-Conflict Divorce Factoid:
If a parent’s allegation of child sexual abuse is deemed credible by Child Protection, the parent accused of the abuse loses all visitation rights for an indefinite period.
Parental Mental Illness and/or Substance Abuse
- What is the nature of the alleged disorder? What symptoms and behaviors have been documented? What is the frequency of duration of the illness or substance abuse?
- Is the parent in question currently in treatment? With whom, and for how long? What is the nature and effectiveness of this treatment? Is the parent in question now in remission? For how long? How has this affected the parent’s parenting skills?
- How well does the accusing parent understand the illness or substance abuse problem? Does the accusing parent have a history of such a problem? Does the accusing parent understand whether this will have an impact on the parenting arrangement?
- Are the children capable of being educated about the signs and nature of the illness? What has been the impact of this disorder on the children? (Baris & Coates, 269-270)
Allegations of Physical/Sexual Abuse
A crucial point with allegations is whether they also occurred pre- rather than only post-divorce. The person alleging that the abuse was chronic and occurred pre-divorce will need to provide reasonable documentation in order for the Court to consider the complaints valid.
In order to sort out legitimate concerns from emotionalism or manipulations by a vindictive parent, consider the following when listening to the allegations.
- How do you know of this event?
- Were there any witnesses?
- If you were present, what was your behavior?
- Is this a violation of a restraining order? If so, check the restraining order to be sure it is valid.
- Has anyone reported this event to a pediatrician, the police or social service agency?
As therapists, we must balance our desire to help with our need to remain objective. We must remember that fragile or personality-disordered parents may be perceiving events through a faulty lens—and that fragile or personality-disorder parents are capable of abusive behavior as well.
Unfortunately, many abuse allegations are unsubstantiated and are ploys to punish the ex-partner or keep him or her from being able to see the children.
There are thousands of internet sites devoted to teaching such manipulative techniques to angry parents.
When the threats are deemed valid by the appropriate agency, you may be given recommendations by the agency or the Court regarding your scope of practice with the family. For example, you may be requested to do anger-management or reconciliation work with a parent.
High-Conflict Divorce Factoid:
The National Committee for the Prevention of Child Abuse (1993) estimated that about 3 million abuse and neglect reports are made each year, but only one-third are substantiated after an investigation.
High-Conflict Divorce Factoid:
There is a sharp spike in statistics when you correlate the time around divorce with the reporting of alleged abuse. When custody is in dispute, over 83% of abuse and neglect allegations turn out to be false. Dr. Melvin Greyer, Family Law Project of the University of Michigan, in Watnik, p. 272
Stages of Change, Motivational Interviewing, Vision Statements
In prior times, high conflict divorce clients, who seemed stuck in dysfunctional behavioral patterns, were often described as being “unmotivated.” This perspective on “unmotivated clients” over the past couple of decades has undergone a significant evolution, as a number of newer motivational models of treatment, such as Motivational Interviewing, suggest that individuals initiate change when the perceived costs of the maladaptive behaviors outweigh the perceived benefits of doing something different, and when they can anticipate some benefits from behavior change. People do bring various levels of motivation and resistance to treatment, but they do so while they engage in a complex kind of risk-reward evaluation, in order to select the choices with more benefits and fewer risks.
There are some important elements to consider here that are relevant to high conflict divorce. David Burns has suggested that there are two kinds of resistance to change involved in this complex evaluation effort: process resistance and outcome resistance. Process resistance is the perceived amount of work that is going to be involved in making a change, while outcome resistance is related to worries about what the changed state is going to consist of, and whether the changed state will be too difficult for the client to handle from a psychological perspective.
Many of the people who engage in high conflict divorces have significant mental health problems that may have been significant contributors to the unraveling of their marriages and may contribute to the presence of conflict in their divorces. This means that they may have significant drains on their available emotional energy for change, with a resulting amplification of the process resistance. They may also be limited in their ability to envision other ways of acting and/or have emotional obstacles to seeing the changed state of being as a positive experience, with a resulting amplification of the outcome resistance. This combination can keep them trapped in behavioral approaches that do not serve the purposes of successful co-parenting. It can also make it difficult for the clinician to find a way to re-arrange the risk-reward formula in a constructive way.
The newer approaches to addressing motivation in treatment suggest that there are some key facts, principles, and approaches that will need to be applied. First, the process of moving clients towards positive change will likely need to be viewed as a multi-part process with different steps and stages. There is a very well-developed and empirically supported model for this change process, established by Carlo DiClemente in some of his seminal work on this subject. In his formulation, there are five stages of change: precontemplation, contemplation, preparation, action, and maintenance. The goal at each of the early three stages is to engage in the correct therapeutic action to facilitate movement towards the next stage of the process until the client has successfully readied him/herself to take active steps of change in the fourth stage, which is the action stage.
Movement towards the action stage will involve efforts on the part of the clinician to address the motivational landscape that the client is wrestling with, and to help the client make a more realistic appraisal of the positive and negative consequences of their behavioral choices and offer them a vision of a way to have better control over the results of their choices – in alignment with motivational elements that are important to them.
Because we are in an area of clinical work that is oriented towards motivation, it may be helpful here to bring in a widely accepted model of motivational design that can address the concepts related to this change process: the ARCS Model of Motivational Design. The ARCS Model was developed by John Keller. Dr. Keller is an adult learning specialist, and his work has influenced the way that trainers and teachers approach the design of learning environments that will maximize motivation to learn. It is part of a field of study called Motivational Design.
Adaptive work represents a kind of learning: making changes to cognitive structures, emotional structures, conscious structures and unconscious structures. This learning takes place in an environment with various elements and components that have effects on the client’s motivation to change and success in learning.
A key feature in shaping successful adaptive work has to do with how well the facilitator for the adaptive work structures and directs that learning environment. The ARCS model is concerned with defining the key focal points for enhancing motivation for the kinds of learning that occur in adaptive work.
Motivational design is concerned with:
- Knowing and identifying the elements of human motivation
- Analyzing audience characteristics to determine motivational requirements
- Identifying characteristics of instructional materials and processes that stimulate motivation
- Selecting appropriate motivational tactics
- Applying and evaluating appropriate tactics
The ARCS model contains a very clear and concise reminder for clinicians of what to focus on as they work to continuously shape and reshape the environment in which change interventions are occurring. It helps to center intervention strategies on the most important few elements that keep clients engaged in the change process.
It is also a very useful concept to teach to clients who are themselves in teaching roles. For instance, parents who are attempting to teach their children the important lessons in life will be directed towards more effective learning strategies through the use of these concepts. It will also be useful as a psychoeducational tool to teach to high-conflict divorce clients as they attempt to sort through the conflicts with their ex-spouses and teach their children.
Because the concepts are cognitive in nature – as well as quite simple and straightforward - they can help the client to stay in a more cognitively focused approach towards teaching and learning. This can help combat resistance that might arise from emotional sources. For instance, parents who struggle with maintaining emotional control while engaging in attempts to re-direct and discipline their children get some support for staying focused on the child’s learning experience instead of their own emotional reactions.
However, when teaching the ARCS model to clients, it is very important to remember the difference between the knowledge base of someone with experience in the helping professions and a lay person who lacks such a background. Many of the components of the ARCS model will seem simple and familiar to a professional; the core understandings will fit easily into the structures of what we already know. It is important not to project this level of learning onto the client, not to assume that because it is obvious to us that it will be obvious to them.
For the lay person, the concepts offered by the model may be wholly unfamiliar, ideas that will be considered for the very first time. They will serve only as a lead-in to the adaptive work that your target audience may need to do to re-conceptualize how they lead others. These concepts may require much additional instruction before the client is willing to adopt them and use them.
The ARCS Model is an acronym for four key areas of learning motivation: Attention, Relevance, Confidence, and Satisfaction. Let’s examine what is involved in each of these areas, with some explanation of how this applies to work with clients.
In order for learning to occur, the target audience must pay attention to the attempts to impart new information. If the teacher cannot get the target audience to pay attention to the material, then the learner will not engage his/her cognitive resources in the process of receiving and processing new information.
The best learning environments will be those in which generate good focus and attention. Keller outlines three areas that are important for this aspect of learning:
A1 Perceptual arousal
A2 Inquiry arousal
Perceptual arousal is generated by presenting to the target audience the learning material in a way that is interesting and stimulating to the client. In adult learning situations, this can frequently be accomplished by introducing information in unusual or surprising ways that grab the target audience’s attention.
Inquiry arousal is concerned with introducing information in ways that generate a motivation for the learner to explore and engage in the learning process, either by generating curiosity or wonder, or by posing challenging questions or problems that the learner is motivated to try to answer or solve. Motivation for learning is increased, in other words, when the learner is persuaded to take ownership of the learning material.
Variability is concerned with the need to continuously modify and upgrade the learning environment to prevent boredom and complacency from setting in.
As helping professionals, there are several key concepts to take away from this part of the ARCS Model. First is the importance of continuously remaining aware of and attuned to the client’s degree of focus and attention as they interact with us. This is not always as simple as it looks.
In order for attention to be sustained long enough for learning to occur, the learning material must be relevant to the target audience, and efforts must be made that help and invite the target audience to grasp and understand that relevance. Keller outlines three areas that make up the relevance aspect of learning motivation:
R1 Goal orientation
R2 Motive matching
In order to sustain the attention of the target audience, the material being presented must have relevance for the goals, wants, needs, motives and aspirations of the target audience. This implies that our assessment efforts are needed in order to gather good information in these areas. Additionally, when engaging in difficult adaptive work with clients, it is important to help them maintain focus on how moving to a new position aligns with their most important goals and purposes.
Additionally, the change material must also be relevant in terms of how it relates to and connects with the knowledge base and core understandings already held by the target audience. In other words, there must not be too great a cognitive gap between what the target audience already knows and the new material that is being presented.
Learning and change carry risks to the emotional well being of the target audience. This is particularly true if the high-conflict divorce client is emotionally fragile. Relevance, and the next factor to be studied, satisfaction, are concerned with the risks that the changed state will be unhelpful and unwanted by the target audience. Confidence is most directly concerned with the risk of failure, of the worry that the necessary changes are not within the adaptive capacities of the person engaged in the learning process.
Keller outlines three factors that are involved in addressing the issue of confidence within a learning environment:
C1 Learning requirements
C2 Success opportunities
C3 Personal control
In the helping professions, there are several elements that contribute to creating an atmosphere of confidence in adaptive work. First, the competence and professional authority of the helping professional establishes a foundation of support for the holding environment in this area. Two other foundation elements include the confidence expressed by the helping professional in his/her own skill sets and confidence shown and expressed about the capabilities of the client to make the necessary change efforts.
In addition to expressing confidence in the client’s ability to change through non-verbal means – a stable, calm and positive presentation of self in interaction with the client – it is always helpful to verbalize your belief and confidence in the client’s adaptive capacities. This need for implied confidence is an essential feature of appropriate dependency on the part of the client, and one of the key features of the holding environment that a therapeutic relationship creates.
However, confidence also needs to be created in the way in which learning and change material is presented to the client. Confidence is most successfully created through experiential success, and this means that we must design our change work in a manner that creates learning successes and a sense of mastery. We need to build in some opportunities for small victories within the design of our intervention approaches.
Keller discusses the importance of breaking the learning work down into small, incremental steps, with continuous feedback that supports the perception of success. This is very much in keeping with concepts related to the stage of change and how to move the client through these stages, using procedures such as personalized feedback and asking people to identify their own concerns, encouraging the responsibility of the client and presenting a menu of options to help promote a sense of autonomy and build mastery motivation. In motivational terms, this is called increasing self-efficacy.
Because self-efficacy and confidence are such important factors in preparing the ground for change, clinicians should be prepared to address and have solutions for practical barriers to change, such as resource development, such as child care, mental health providers, etc.
A very helpful tool for building self-efficacy and helping the client formulate their idea of what is relevant to his/her goals and purposes is the use of a vision statement. This very simple tool, used first in the business community to oriented organizations around a single core purpose, can be extremely helpful to the clinician in terms of learning what is relevant to the client within the context of the ARCS model. It can also be very helpful to the client in terms of describing the ideal end state towards which the therapeutic efforts are oriented. Because it is the client’s description of their vision for themselves, it has intrinsic motivational power and can serve as a focus to facilitate movement through the stages of change.
For clinicians who have never created or used a vision state for themselves or their clients, it is a short, concise document with three parts: 1) My vision is . . . 2) Supported by the following core values, beliefs, and perspectives . . . 3) Put into effect by the following action steps.
When working with high-conflict divorce cases, clinicians may direct the client towards the best vision of themselves - as a parent to their children, as a healthy, loving adult, as the best self that they can be. Simply putting down on paper their most secret and hopeful aspirations for themselves and their lives can be a profound experience, and will serve as a reference point for everything else that follows in the treatment process.
The use of this tool also aligns with the other important aspect of treatment with high-conflict divorce cases that bears mention here: the use of motivation-driven approaches to change. The most well-know of these is an approach called motivational interviewing.
The final element of Keller’s model is concerned with assuring that the learning creates rewards, or satisfaction, for the person undertaking the effort of change. Satisfaction can include both the increased sense of mastery from successful adaptation and learning, as well as rewards given from external sources to reinforce the behavioral changes engaged in to learn.
Keller highlights three components of this part of his model.
S1 Intrinsic reinforcement
S2 Extrinsic rewards
One of the key understandings of this part of the ARCS model is that satisfaction, like relevance, needs to be targeted to the unique individual to whom the learning process is directed. What is highly satisfying or rewarding to one person may have very little reward capacity for another person.
As we instruct others in the use of the ARCS model, this can be a very difficult concept for some people to grasp. As helping professional, we are exposed early and often to the concepts of seeing others as unique individuals, with different motivations, needs, goals, values and purposes. Through experience, we become quite skilled at envisioning the experience of others.
For many people with whom we interact, this can be a novel and difficult concept to grasp. In utilizing this part of the ARCS model, too, there can be created a point of entry for conversations about the advantages of using more flexible perspectives in interacting with people in learning environments.
Two visionary clinicians developed in the early 2000s an approach to working with highly resistant substance abuse clients, based largely upon the person-centered work of Carl Rogers. This approach, called motivational interviewing (MI), proved to be very successful, and its use has been expanded to other groups of clients for whom resistance has been a problem. Motivational interviewing has been described as a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.
Motivational interviewing is concerned with the creation in therapy of appropriate conditions to foster fostering growth and change. There are believed to be three counselor attributes that help to create a growth-promoting context that supports movement towards positive change: 1) congruence (genuineness or realness), 2) unconditional positive regard (acceptance and caring), and 3) accurate empathic understanding (an ability to grasp the subjective world of another person).
The principles of Motivational Interviewing extended Rogers’ perspective and created an orientation to client interaction that can be summarized in the following way:
- Change occurs naturally
- Motivation can be influenced by many naturally occurring interpersonal and intrapersonal factors as well as formal interventions
- What happens during and after formal interventions (treatment, counseling, education, etc.) mirrors natural change, rather than being a unique form of change
- The likelihood that change will occur is strongly influenced by interpersonal interactions
- When behavior change occurs within a course of treatment, much of it happens within the first few sessions, and, on average, the total dose of treatment does not make all that much difference
- The counselor, therapist, or treatment person is a significant determinant of treatment dropout, retention, adherence, and outcome
- People who believe that they are likely to change do so and people whose counselor believe that they are likely to change do so
- What people say about change is important, in that, statements that reflect motivation for, and commitment to change, do predict subsequent behavior change (Miller & Rollnick, 2002)
Additionally, there are four guiding principles that underlie motivational interviewing:
- Expressing empathy by respectfully listening to people with a desire to understanding their perspectives
- Creating and amplifying, from the person’s perspective, a discrepancy between present behavior and broader goals and values
- Rolling with resistance by actively involving the person in the process of problem solving
- Supporting self-efficacy by enhancing people’s belief in their ability to carry out and succeed with their plan for change.
Developing an empathic relationship with the client creates the precondition for the client to trust the clinician enough to examine the discrepancy between their ideal vision for themselves, their parenting efforts, and the behavioral choices that interfere with that ideal vision. Change is facilitated by helping the client’s formulate their own reasons for - and benefits of – change. This is presented to the client with full awareness of the ARCS model: securing the client’s attention, establishing the relevance of looking at and addressing the discrepancy, supporting and building confidence in their ability to make the necessary changes, and celebrating and highlighting the positive results from the different choices of behavior.
Motivational interviewing has also posited the core principle that clinicians should be prepared to roll with the resistance presented by clients. Resistance is not the client trying to frustrate or seize control from the clinician, in the view of motivational interviewing. It is the client in conflict with different needs for themselves, working out the complex risk-reward equations we have been discussing in this section. If the clinician takes too strong a position on behalf of one side of that conflict, when the client is not ready to resolve the discrepancy, the clinician should be prepared to back off and move back to a position of allowing the client to engage in that argument with him/herself.
Rather than challenging or directly confronting the resistance, the counselor can move back to a position of helping the client to explore the reasons for the resistance. Clients will always have some reasons for the position they are taking; it just may be they are not quite ready to resolve the conflict that is created with that position. They may also not even be quite ready to acknowledge where one of the sides of the conflict is coming from. This is perhaps better described as ambivalence, rather than resistance. The concept of “rolling with the resistance” involves accepting as a reality of treatment that clients may be reluctant or ambivalent.
Motivational interviewing focuses on helping to motivate individuals toward making changes using such strategies or techniques such as:
- Normalizing client uncertainties
- Rolling with resistance
- Asking open-ended questions
- Discovering client’s beliefs
- Reflective listing
- Conducting empathetic assessments
- Amplifying client doubts
- Developing discrepancy between person goals and problem behavior
- Conveying confidence in client’s abilities to change
- Supporting client choice and self-efficacy
- Reviewing past treatment experiences
- Working with client to develop a treatment plan
- Providing relevant feedback
- Summarizing and reviewing potential sources of non-adherence
- Negotiating proximal goals
- Discovering potential roadblocks
- Displaying optimism
- Involving supportive significant others
A skilled practitioner in the use of motivational interviewing will adopt a stance of curiosity to examine with the client the complex motivational conflicts they are experiencing, making reference to the information provided by the client about their vision for their life, and looking with the client at what small steps they feel comfortable to make. This may occur to help move the client from one stage of change to the next, or to take realistic actions steps to move closer to their goals and vision.
The developers of motivational interviewing are quick to point out that MI is more of an attitude than a technique. However, it is an attitude that also suggests techniques, one of the most common of which is the many questions to evoke the client’s sense of the direction they want to move towards. In addition to more specific questions, motivational interviewing is a strong proponent of well-formed open-ended questions.
Examples of Open-Ended Questions to Evoke Change Talk
Disadvantage of the status quo
In what way does this concern you?
How has this stopped you from doing what you want to do in life?
What do you think will happen if you don’t stop or change anything?
How do your friends and family feel about it?
What difficulties have you had in relationship to your _____?
Advantages of change
How would you like things to be different?
What would be the advantages of making this change?
What would be the good things about _____?
If you were to wake up tomorrow and everything would be the way you wanted it to be, what would it look like?
What would you like to be doing 5 or 10 years from now?
Optimism about change
If you decided to change, what do you think would be a good first step?
How confident are you that you can make this change?
What personal strengths do you have that will help you succeed?
Are there people in your life that could support you in making this change?
What encourages you to think that you can change if you wanted to?
Intention to change
Right now, how important is this to you?
What do you think you might do first?
Of the options we have discussed, which one sounds like it would work best for you?
I can see that you’re feeling kind of stuck at the moment. What’s going to need to happen to get you unstuck?
Is there anything that I can do, or your friends or family can do, to you help you? (Miller & Rollnick, 2002).