Motivational Interviewing: Fostering Behavioral Change in Older Clients

Motivational Interviewing is about helping people overcome ambivalence in making important life decisions. Advisors are in a position to guide their clients through the process.

One of the most common conditions to the human experience is ambivalence, the experience of having “mixed feelings.” Ambivalence is often the root of difficulty that
people have in committing to a decision. Any commitment we make has consequences, both good and bad. Think of many of the thoughts you have had, and the commitments you have wanted to make in your lifetime. These could include losing weight, financial
planning, calling or writing that friend you’ve been thinking about. Losing weight sounds lovely, but it also comes with hard work and sacrifice, as does financial planning. Chances are, you know intimately the experience of ambivalence. You also likely know the
frustration of working with an ambivalent person. We all have an internal pull to resolve the ambivalence of others, to push a little harder or to justify a little more the reason for change in the face of statements like “yes, but,” and “well, I’m not really sure.” 

As a therapist, I work with a lot of ambivalence, and as advisors, I am sure that you do as well. There is a tool we use in my industry known as Motivational Interviewing (MI). Initially developed by Dr. William Miller (1983) as a method of aiding people with addictions in resolving their ambivalence around sobriety, MI has developed into one of the most productive and widely used set of clinical tools in the world of healthcare. MI is founded on the belief that all people are more ambivalent than they seem about a particular thought or anticipatory commitment. It also assumes that people have motivation for these thoughts and commitments that we, as advocates, can aid them in understanding, fostering, and eventually transmitting into action. MI is a collaborative conversation that strengthens someone’s own motivation for and commitment to change
(Miller 1983). 

The mission of the Society of Certified Senior Advisors (SCSA) is to “improve the lives of seniors by providing an integrated approach to working with senior clients.” (SCSA 2014.) One of the foundational aspects of this mission is building relationships with seniors and their support networks. Relationships foster the mutual trust, commitment, and willingness necessary to participate in the reciprocal nature of the advisor-client contract. Embedded within these professional relationships is the belief that the advisor knows the needs and motivations of the client, and aspires to act in the best interest of the client. MI is a phenomenal method of fostering relationships through understanding motivation for change and aiding the client’s goal setting. 

You do not need to be a clinician to use MI. It does not require years of training or specialized certification. But it does take a shift in mindset and a degree of patience and self-control that is often a new experience for practitioners. This starts by understanding the “Spirit of Motivational Interviewing” (Miller 1983) and then using the tools of the method. Rollnick and Miller (1995) describe the “spirit of MI” as: 

• collaborative (versus confrontational or authoritative), 
• evoking the client’s own motivation (rather than trying to bestow it),
• honoring the clients’ independence and autonomy in making decisions in their own lives.

The Spirit of MI

 
Collaboration. MI is a partnership. This is an occasion where you step down from the role as “expert” and step into the role of partner and guide to the ultimate viewpoint and experiences of the client. It really doesn’t matter what you think about the change or
your idea of how to enact it. It matters what the client thinks, wants, and is willing and able to do. 

Evoking the client’s own motivation. Motivation comes in many shapes, sizes, and forms. We often use the terms intrinsic (coming from within, like an aspiration to do something due to a desire to be a “better person”), or extrinsic (an outside motivator, like money, fame, or acknowledgement). Try not to judge motivators; they all serve the same purpose, and don’t be quick to assume that one size fits all. Motivation is often deeply personal and individual. Your task is to discover what motivates your client.

Honoring the client’s autonomy. We must never forget that the true power for change is within the client. Clients have a right to their thoughts, feelings and decisions. They’re the ones who are going to do the work and live with the outcomes. That means we
respect where they are coming from, what they are thinking, what they want and are willing to do to get it, even if we disagree (within legal and ethical boundaries,
of course).

Now that you understand the spirit of the method, let’s talk about the tools you will use to help your clients achieve the change they hope for and often need. The “Principles of MI” (Motivationalinterview.org 2014; Miller 1983) are overarching concepts, which
each has a set of tools that will guide your work with your clients. These principles are thematic for a reason. You already have your own innate personality styles, methods of communication, and advocacy. Be guided by the principles, while maintaining your own authenticity in interacting with your clients. Remember the principles are not necessarily sequential. You can use all of the principles each time you interact with your client or just one if the situation serves. 

The Principles of MI

 
Empathy. Change is hard and conflicting. You have to do different things, give things up, and it stresses the status quo of your life. Begin first with acknowledging this for your clients and really trying to see the world from their viewpoint. Why is this particular decision hard for them? What are they feeling conflicted about? Express that empathy. Join, reflect, summarize, and affirm. Show them that you’re listening, you care, and
you understand.

Example:

Client: I just never thought we would reach this point. I never thought I would have to make decisions for my dad. 

Advisor: What a hard place to be in. You want to respect your father’s right to make decisions for himself, but you also want to help him and make sure he gets what he needs. I think this is a difficult position for all adult children.

Foster self-efficacy. In the end, it is the client who has to follow through with the commitment. This means that clients need to believe they are capable of achieving the changes hoped for. In MI, we support this self-efficacy by reminding them of previous successes: “I remember when I first met you, you told me about how you…” and highlighting abilities the client already has. “I’ve always been impressed by your ability to….”

Example:

Client: I just don’t know if I can do it. Downsizing, selling my things, moving to a new home. It all feels so overwhelming.

Advisor: I think it would feel overwhelming for everyone. Tell me about another time in your life when you felt overwhelmed. What did you do then? 

Roll with resistance. This is perhaps the hardest and easiest part of MI. Hard in the beginning, and so much easier as time goes by. You are just there to support the client. If you start getting the “yes, buts…,”its time to back off and change tactic. Go back to empathy. You’re pushing too hard. The more the client fights against you, the more they are justifying the reasons not to change. Your actions in MI should always move the client in the direction of the positive change they originally expressed to you.

Example:

 
Client: Yes, but I don’t know if I need to get a living will now. I mean it’s not like I’m going to die tomorrow.  

Advisor: I understand. You feel that you don’t need to draft a living will until you know you’re going to need it. Let’s talk about that. What will things look like when you’re ready to draft a living will? 

Develop discrepancy. This may feel like the most counterintuitive principle of MI, but it is perhaps the most powerful. People do not like ambivalence. It is uncomfortable, and they can only take it for so long. They are compelled to anchor. Fostering this discrepancy
in your clients between their values, who they want to be, what they want to do, and where they are now is key. It is the proverbial fire underneath the frying pan. Discrepancy should be gradual—that is, don’t lose your supportive, empathic style in the process
of heating things up. Move slowly in the direction of helping your clients see that their current actions are actually inhibiting, rather than supporting their end goals. These tools are fun to use, and can foster amazing results, but remember you need your clients
to know first that you are on their side, you believe they can do it, and you’re willing to be flexible and roll with their concerns. Once you have this foundation, give some of these tools to aid in developing discrepancy a try:

Using the ruler as a tool: Ask your client, “On a scale of 0-10 with zero being “it’s not going to happen” to ten being ’I’m going to follow through right after we’re done!’ where are you right now?” Suppose the client responds with a three. “Okay, what would it take for you to move one step closer to a ten?” Remember, there is no wrong point on the ruler, and ALWAYS ask what it would take to move closer to the goal. Never reinforce
the reasons not to. 

Query extremes: Ask your client, “What is the worst part about the way things are now?” What is the best?” What if you chose not to….” Notice the emotion and discomfort behind these questions. That’s healthy. Remember you’re targeting the current behavior (what the client is already doing) to elicit a desire to change to the goal behavior.
 

Query values and the congruence of current behavior: Ask you client, “If I were to ask, what your top three values are, what would you say?” “Where does your current behavior fit in with these values?” 

In the beginning, MI can feel like more work, because it is often hard to hold back on all of that insight and knowledge we have. However, think back to those times in your life when you were ambivalent. Did you need someone to tell you why what you wanted
was important to you? Did you need someone to tell you how and when to enact this change in your busy schedule? Chances are, you were already aware of these things, but you weren’t as aware of the true values and reasons for wanting to commit to this goal. You weren’t aware of that spark that you needed to move forward with the commitment. This is the foundation you are providing for your clients through the use of MI—increasing
their awareness of what they truly value and motivates them to achieve their goals.
 

Once this foundation is established, your expertise can truly shine and will be sought out and appreciated due to its contribution to their already strong motivation and commitment. As advisors to older adults, you have the knowledge they and their families need to make decisions, commitments, and achieve goals. The skill of motivational interviewing will aid you in working with clients with clearer focus and stronger commitment to the use of your services in achieving their goals. •CSA

Carilyn Ellis is a psychology intern at the Salt Lake VA Medical Center, specializing in Palliative Care,Geriatric Home-Based Primary Care, OutpatientMental Health and Neuropsychology. She has a master’s degree in clinical psychology and is a Psy.D. (doctor of psychology) candidate at George Fox University in Newberg, Oregon. She can be reached at cellisalaska@yahoo.com.

Motivational Interviewing: Fostering Behavioral Change in Older Clients was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors 

www.csa.us

Headed for the Future: A Boomer's Guide to Returning to College

It’s never too late to return to academic life, and the wave of baby boomers flooding college campuses proves it. They are pursuing new and advanced degrees for encore careers, updating professional skills, and indulging their love of learning. Going back to school has never been more exciting. 

At seventy-eight million strong, baby boomers continue to change the world, obliterating the notion that age is a meaningful variable in the decision about going back to college. According to Hunt (2012), “Adults returning to college today make up almost 20 percent of enrollments, which is double what it used to be when they were the young eighteen-year-old demographic.”

Older adults engage in higher education for many reasons. Some go back to fulfill “dreams deferred” and transition into encore careers. Others, who may have lost retirement savings during the recession, go back to update existing skills and maintain employability; and some return to class for mental stimulation, to remain socially engaged, and indulge a love of learning. Regardless of motivation, it is useful for advisors and their clients to discuss both the benefits and challenges of going back in order for this new cohort of college students to fulfill their personal and professional goals.

Hollywood and Beyond
With the motto, Curiosity Never Retires, the Osher Lifelong Learning Institute (OLLI) conducts scholarly courses for individuals ages fifty and older at 117 colleges and universities across the country, with 113,000 members paying annual dues from two to six hundred dollars a year (Hasson 2013). Osher offers a wide variety of classes with topics tasty enough to satisfy any intellectual appetite, from “The Hollywood Novel,” “Current Research Topics in Astronomy,” and “American Environmental History.” Online examples of lifelong learning opportunities without tuition include those provided by the Emeritus Program through Continuing Education at the San Diego Community College District and by the State of Ohio, where “under Ohio law, residents sixty and older can audit classes for free at thirteen public universities and twenty-three community colleges, space permitting, with the professor’s approval.” (Brown 2011.)

While the benefits of lifelong learning have been well documented, a recent study suggests that the well-being of entire communities is based, in part, on the extent to which their older citizens participate in formal and informal learning activities (Merriam and Kee 2014). Further, and with a wider perspective, higher education among older adults impacts the economy and welfare of the national and global community as well, as explained in a Lumina Foundation report (Pusser et al. 2007), “Returning to Learning: Adults' Success in College is Key to America’s Future.” The study notes that fifty-four million adults lack a college degree and thirty-four million have no college experience at all, suggesting insufficient preparation among the nation’s adults to compete in a dynamic global economy.

The New Currency
The urgency for adults to pursue higher education has also been addressed by President Obama, as reported by U.S. Secretary of Education Arne Duncan in the Adult College Completion Tool Kit (Tolbert 2012) who notes, “Shortly after taking office, President Obama set a bold goal: By 2020, the U.S. will once again have the most highly educated, best-prepared workforce in the world. In order to meet this goal, the President challenged every adult to complete at least one year of postsecondary education. In today’s knowledge economy, education is the new currency. Put simply, we must dramatically increase overall rates of educational attainment to ensure the success of individuals in the workplace and safeguard our country’s prosperity in the global economy. To do this, adult learners across America must enter and succeed in postsecondary education in ever greater numbers.

Researchers Kelly and Strawn (2011) add that the country needs to graduate 10.1 million students between the ages of twenty-five and sixty-four with Associate and Bachelor degrees by 2020 in order to match the best performing countries throughout the world in college attainment.

A major, nationwide program addressing this issue is the Plus 50 Initiative. In 2008, the project started with ten community colleges across the country to encourage creative curricula designed to address the needs of baby boomers to remain “active, healthy and engaged in careers and projects that matter to them” (AACC 2014). Examples of projects from early grants include retraining experienced nurses to mentor new nursing students, training individuals to become seasonal guides at national parks, and providing business education through online classes in tax preparation and medical transcription. 

But this was just the beginning. In 2010, the Plus 50 Completion Initiative was launched for eighteen community colleges throughout the nation to focus on degree and certificate completion for adults over age fifty. The three-year evaluation report released in August 2013 demonstrates the success of the program and the desire of boomers to participate in workforce education. With a goal of serving nine thousand students, instead it enrolled 16,507 participants earning 7,192 professional credentials in the fields of accounting, agriculture, business, health, human services, culinary arts, early childhood education, and many others (Learning for Action 2013). 

The most recent iteration of Plus 50 began in 2012 as the Plus 50 Encore Completion Program. This initiative is designed to help ten thousand baby boomers complete degrees or certificates in the high demand fields of education, health care, and social services (AACC 2014). Training in these areas is intended to provide pathways to employment as well as a means for boomers to give back to their communities and to the world. 

When Life and Learning Collide

But nobody said it would be easy. At age fifty, Erik Amerikaner had held executive positions at companies across the country. But when asked to relocate in China, the vice-president and former CEO opted instead to pursue a teaching credential at Chapman University in San Luis Obispo, California. Today at age sixty-two, he has been teaching information technology for twelve years and has been honored as a Certified Educator by the National Board for Professional Teaching Standards. Although he loved going back to college, he notes, “The hardest part was working full time during the day while going to school at night.”

Although Amerikaner had the tenacity to push through to completion, most do not. Data from the National Center for Educational Statistics show that just slightly more than a quarter (28 percent) of fulltime, and a mere 5 percent of part-time older students go on to finish their college studies (Schepp 2013). In discussing the explanation behind their poor completion rate, Schepp reports findings from the Apollo Research Institute indicating several reasons why adults drop out. Examples include anxiety over college-related expenses, guilt about spending too little time with loved ones, and concern over their ability to succeed.

While the cost of higher education is an understandable stressor, new online tools can help potential students select an educational program that best fits their finances. They include the United States Department of Education College Affordability and Transparency Center (2014), and the College Navigator (2014) produced by the Institute of Educational Sciences of the National Center for Educational Statistics. In addition, potential students need to apply for federal financial aid, as well as the myriad of scholarships available each year. A comprehensive resource addressing the cost of education is 501 Ways for Adults Students to Pay for College, by Tanabe and Tanabe (2013), underscores the value of spending serious time seeking out scholarships that support adults. 

In addressing the guilt stemming from spending less time with family and friends, advisors can help clients learn to clearly communicate their needs by using “I messages.” An example is for the student to replace angry, accusatory statements such as “Don’t make me feel guilty all the time” with “I care about you and I’m sorry that I can’t go to the family picnic on Sunday. But at this time in my life, I’m choosing to attend college and I need to study. This is important to me, and I hope you’ll understand.” 

Finally, potential students need to consider whether colleges that run by semesters, quarters, or rapid-fire, month-long terms will best fit into their lives. Online education with classes that are generally asynchronous and can be accessed any time of the day or night, continue to grow in popularity. Although some believe that online education is less demanding than traditional classes, this is false. Online offerings are obligated to demonstrate the same rigor as their classroom counterparts. However, for online students to be successful, they must be comfortable with technology, exceptionally motivated, and have enough self-discipline to persevere without the commitment of classroom attendance. In her book, The Adult Student: An Insider’s Guide to Going Back to School, Dani Babb, Ph.D. (2012) discusses online learning, including considerations about attending public versus private programs, and an explanation of the issues regarding a college’s accreditation and the potential impact on a student’s career choices.

While college degrees and professional certificates generally result in lower unemployment and better paying jobs, job hunting is rarely easy at any age. However, a wide variety of resources are available to assist older adults in their job search. “New Trends in Retirement Jobs” is a CSA online article providing job seekers and advisors with extensive, practical suggestions for a successful outcome. Lastly, they should visit the websites of their local state employment offices, to inquire about workshops designed specifically for those seeking encore jobs or careers. 

Mindfulness
When baby boomer Tamara Sprigel started college, her youngest of four children was twelve. She was going through a divorce and anxious to complete a degree in psychology. “At one point I carried twenty-three units. The toughest part was keeping the family going while I was in school, but I loved college.” She now has a Ph.D. in clinical psychology and is a licensed marriage and family therapist. Gail Smith also went back to college after her children were grown. She earned a bachelor’s degree in behavioral psychology, but not for specific career aspirations. Her goal was to feed something deeper—a validation of her ability to succeed. “As a result, I now have an ‘I can’ attitude rather than ‘maybe not me.’” 

To prove it’s never too late, this year, at age sixty-four, Susan Miedzianowski proudly earned her Ph.D. in Human Services and Gerontology. After obtaining a master’s degree on her fortieth birthday, she returned to school to reach the ultimate academic milestone. Now an adjunct professor at multiple universities, she hopes her perseverance will inspire other older adults to pursue their lifelong dreams. 

It is not uncommon among adult learners to express a sense of pleasure about their college experience. Professors enjoy having older adults in class and often observe that they’re among the most engaged. Mary Lange, Supervisor of Programs for Older Adults at Mt. San Antonio College in Walnut, California, and Chair of the California Community of College Educators of Older Adults adds, “As an educator, embracing the fact that older adult learners bring to the classroom a rich background of real-world experiences that add to the academic setting is very empowering for both students and faculty. Therefore, uniting faculty and students to foster knowledge that encourages student participation, mentoring, and personal education goals is a synergistic approach that is beneficial to all generations.”

Accordingly, with support from policy makers and leaders like Lange, along with colleges and universities across the country, the new “senior class” is changing the paradigm of higher education as an institution for young adults. Kanter (2006) recommends the term even higher education to describe the college experience for older adults. She explains, “This isn’t going back to school. It’s using school to move forward.”

Thus, as boomers use college to move forward, they exemplify the concept of “mindfulness,” described by researcher Ellen Langer (2014) as “the process of actively noticing new things. It is the essence of engagement.” CSAs and other professionals who work with older adults can support their clients’ mindful engagement in higher education by:

1. Helping clients define their goals and then locating appropriate educational programs to fulfill those goals. 

2. Exploring all avenues for financial aid.

3. Researching a wide variety of instructional delivery options.

4. Facilitating clients’ use of effective communication skills.

5. Teaching clients simple methods for time management, memorization, note taking and expository writing.

6. Encouraging clients to utilize college and university tutoring services, as well as study groups to solidify academic skills.

With support from advisors, family, and friends, older adults will continue going back to school for both lifelong learning and professional development fully engaged, and headed for the future. •CSA


Karen Gorback earned a Ph.D. in education from the University of California, Santa Barbara. She is currently a commissioner on the Council on Aging for the City of Thousand Oaks, California. She recently published her debut novel titled Freshman Mom, a contemporary story about a divorced mother who goes back to college. Contact her at Karen@karengorback.com, or visit her website at www.karengorback.com. 

Headed for the Future: A Boomer's Guide to Returning to College was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors 

www.csa.us