Motivational Interviewing

Motivational Interviewing

The goal of coaching in home-based therapy is to support caregivers in prioritizing therapy and learning how to deliver therapy. This requires behaviour change. One evidence-based approach to coach behaviour change is motivational interviewing. Motivational interviewing may be useful during conversations with caregivers.

This section provides a brief introduction to motivational interviewing. 

Key Concepts

Motivational interviewing (MI) is way of communicating that is client-centred and engages by following (active listening) and directing (giving instruction/advice). The conversation is a balance between sharing and learning. The clinician is the expert in therapy, and the caregiver is the expert in their child.

Using an MI approach, the clinician is respectful and curious. The goal is to empower caregivers to learn to help their child in a way that is meaningful and feasible for them. This requires learning about the caregiver and their child and honouring their autonomy as agents of change.

Principles of Motivational Interviewing

The four guiding principles of MI are represented by the RULE acronym:

• R: Resist the “righting reflex”, which is the urge to “fix” the caregiver and tell them how to create change.
• U: Understand the caregiver and child. The caregiver’s reasons and capacity to prioritize and deliver therapy are most important because these will most likely trigger behaviour change.
• L: Listen to the caregiver. MI involves as much listening as informing.
• E: Empower the caregiver. Convey hope around the possibility of change and support patients’ choice and autonomy.

Skills

Following the OARS acronym facilitates getting started with MI. 

• O: Open-ended questions encourage the caregiver to elaborate. For example:
  • How does your child use the assisting arm now?
  • How would you like your child to use the assisting arm?
  • What are your child’s favourite toys?
  • When is your child most calm and ready to engage?
  • What activities/tasks are most exciting/fun for your child?
  • How do you like to play with your child?
  • What do you notice helps encourage your child to use the assisting arm?
  • What are some things that might help/hinder doing therapy for the assisting arm?
  • When do you think this might fit in your day?
• A: Affirmations promote optimism and acknowledge the caregiver’s expertise, efforts, and experience. Acknowledge beneficial practices when they happen regardless of if it is inconsistent. Note: affirmations are not about your approval of the caregiver. For example:
  • Wow, I know there was a lot going on at the beginning of the session with siblings and doorbells, but you somehow juggled all of that and then had some focused play time with your son.
  • You follow his nonverbal cues really well. Switching to a different toy when he started looking away and ignoring it was a good strategy.
  • Wow, you found the magic motivator. Finding and pointing to dad in the photo album was something it seemed like she would do all day.
  • I like how you rotated the stick to present it vertically, so she needed to turn her forearm to grab it.
  • I like your thought about the Velcro food. It’s a great bimanual activity and easier to put together and pull apart than Duplo.
  • You have a great sense of how far you can make him reach without frustrating him; it’s still fun even though he’s working hard.
• R: Reflections use accurate empathy. 
  • Simple reflections involve paraphrasing and repeating what the caregiver said. For example:
    • You’re disappointed that she didn’t want to play today.
    • The activity was too hard, but it can be tweaked for the just-right challenge.
    • It was difficult to get him to do the target activity and make it fun.
  • Complex reflections involve reflecting on what the caregiver has said as well as what he or she is experiencing but has not yet verbalized (the meaning beneath the words). For example:
    • This kind of therapy puts a lot of responsibility on you and that’s a lot to balance with also being a dad.
    • Your daughter was clearly super excited when she was able to pull apart the Duplo for the first time. That is really satisfying and rewarding for a parent because it shows a bit of what is possible for her long term.
• S: Summaries that are targeted and succinct synopses of what the caregiver said, with a focus on elements that are solution focused. The goal is to help the caregiver organize his or her experience. For example:
  • Your son was having fun today, but it was hard to get focused practice with distractions that kept popping up. You mentioned that the bedroom had less family traffic and visual distractions along with a door that closes. Maybe that would be something to try next time.
  • Squishing playdough for pinch lost its appeal today. He was telling us he was ready to play so it makes sense to switch up the activity. He was really interested when you pulled the pen out to take notes. Maybe he is ready for a bigger challenge, and we can try removing and replacing a pen or marker lid?
  • I agree; reaching and grabbing an object in one motion was too hard for your daughter. You mentioned she can grasp and reaches to knock her cup off the tray. Maybe we can work on those movements separately. Interesting objects can be presented close to her trunk. We can try a Velcro mitt or cuff and lightweight objects and encourage her to reach. She also likes to knock things off the tray; we can use that to our advantage!