working motivationally with individuals with intellectual disabilities

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					2011 OVRS InService ∙ Using MI with Individuals with Intellectual Disabilities



MI Spirit- “way of being” emphasizing:

    1. Collaboration

        Collaborative rather than hierarchical approach between VRC and participant.

    2. Evocation

        Curious, neutral communication style used to help weigh the risks and benefits of change.
        Acceptance- provides a context in which an individual can express concerns and develop goals.

    3. Autonomy

        Facilitate engagement in the discussion in the benefits and concerns of work- it is important an
        individual’s motivation be assessed and not assumed.



Principles underlying Motivational Interviewing Counseling Style:

    1. Express empathy

        Uses an empathetic response to the individual’s exploration of his or her emotional and
        cognitive ambivalence about work

    2. Develop discrepancy

        Is the participant OK with the status quo, or is there a disconnect between their goals and not
        working?

    3. Roll with resistance

        Ability to shift flexibly between strategies. Is this working for the participant?

    4. Support self efficacy

        Promotes the individual’s self efficacy regarding change- provides individuals with specific skills
        clearly connected to identified goals.
2011 OVRS InService ∙ Using MI with Individuals with Intellectual Disabilities



Critical thinking points for working with an individual with an intellectual disability:

Family attitudes- likely to have a learning history in which expressing ambivalence, reluctance and
resistance is punished. Verbal expression of motivation is reinforced. Helpful to spend time at the
beginning exploring and assessing motivation through listening, reflecting and accepting ambivalence.

Slower processing speed-simplicity and clarity throughout the interview. Inquire about small chunks of
info in a straightforward manner. Slower pace with more pauses for questions and clarifications. (one
concept at a time). Visual aids such as graphs or charts or drawings. Use of thermometer- like scales to
prompt discussions about levels of commitment to work may help them talk about their level of
motivation and what might raise or strengthen their commitment to change.

Problems with attention and concentration-may have difficulty tracking what is asked or said or holding
in balance combined and competing motivation to change. Provide a degree of structure to the
interview. Provide prompts or questions more frequently than might be necessary at other times
(reflection), repeat important concepts. Question, reflect and summarize in clear and concise terms.
Liberally use successive reflections and summaries help someone attend to, remember and logically
organize the conversation. Offer feedback across multiple, brief sessions so that it is delivered in small,
assimilated units- “chunk”. If you are using the Decisional Balance Process, PMI and CAF could be
difficult, so you do what is a simple guided DB with the four quadrants labeled as “Don’t do it” /”Do it”
and then, “good”/”bad” and you could ask them to weight each issue by simply telling you how good
each point is and then you can tally up the two sides.

Problems with mental flexibility and lack of insight- difficulty with self reflection, appraising the
consequences of problem behavior. Illustrate concrete concepts (more visual, less verbal). Develop
discrepancy by asking them to identify up to three goals that they would like to accomplish. For each
identified goal, ask the person “How will working affect each goal? OK to prompt them on goals if they
have difficulty coming up with then. Next is a cost-benefit discussion.

Deficits in word generation – not sure what to say or how to respond, may not be able to identify future
goals without considerable assistance- more structured and directed- find out which area is most
important- may mean identifying the domains that are most dissatisfying “how will working in the
community help you be able to get a car so you can have more freedom?” Doing a traditional DB might
result in low production- research their situation ahead of time- bring in things specific to ask because
they might not come up with them without prompting. Write on a board (pros and cons list). Simplify DB
by focusing only on the positive and negative consequences of changing behavior. Or, discuss the
reasons for not changing and the reasons for changing. Another option: stack blocks into two piles (both
sets of reasons- for changing or not changing) and review “which has more?”.
Problems with working memory- memory aids for use in session or outside of sessions. Environmental
modifications (could be involvement of caregivers). Use colored cards (red for reasons to stop/green for
reasons to go) as external cues.

Problems with abstract reasoning- focus on familiar problems and personal goals and not abstract
concepts. Focus on the consequences of not working for the person and his/her goals. Focus on 1-2
negative consequences that strongly impact the client then focus on these significant drawbacks in
motivating the person. Use a sequence of specific, concrete questions to help ID goals: How do you
spend your time during the day?; What do you like about what you do?; Are there things that you don’t
like about what you do?; Is there something that you would rather do?, or Is this something that you
would like to change?; Is this something that you would like to work on now? Do you want to make this
a goal? Is this goal very important or just a little important? (prioritize).

IN CONCLUSION:

 MI is by no means a “one size fits all” paradigm, and customization is especially necessary when
communication barriers are present. It is not to be used as a way of dissuading individuals or deselecting
them, but is used as a tool to help the individual decide for themselves the benefits and importance of
work in their life. Know when to use MI and how to adopt strategies to accommodate an individual’s
challenges. While clinicians may continue to employ the underlying empathic and collaborative MI
counseling style in the client’s overall work, or formally use MI as needed to systematically resolve
recurring or new motivational dilemmas, skilled clinicians flexibly shift between targeted motivational,
skill-building, supportive and crisis interventions to address the individual’s VR needs. Best practice- Is it
OK for the participant?


Compiled and Presented by Heather Lynch, VRC Bend Branch and member of MI Support Team
REFERENCES:



Motivational Interviewing – Preparing People for Change by William R. Miller and Stephen Rollnick,
Second Edition (2002)

Motivational Interviewing in the Treatment of Psychological Problems Ed. by Hal Arkowitz, Henny A.
Westra, William R. Miller and Stephen Rollnick (2008)



ALTERNATIVE APPROACHES:

Person-Centered Planning is a process-orientated approach to empowering people with disability labels.
It focuses on the people and their needs by putting them in charge of defining the direction for their
lives, not on the systems that may or may not be available to serve them. The perceived difference from
MI is consensus with a group or, common vision of the “circle of support”.

http://rtc.umn.edu/docs/pcpmanual1.pdf

http://www.ilr.cornell.edu/edi/pcp/



The Employment First Policy requires that employment in integrated work settings be the first and
priority option explored in service planning for working age adults with intellectual and other
developmental disabilities. The document entitled “An Employment Guide to Planning” addresses
motivation. If an individual indicates general satisfaction with their current situation then the focus of
this path is to maintain or improve the outcomes of their current situation. If the individual indicates
dissatisfaction with their current situation, but clearly wants change, go on to the next step (assess clear
desire or lack of clarity) which tells you how to work with the person based on what stage of change
they are in.

http://www.dhs.state.or.us/dd/supp_emp/initiative.html

				
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