Using Motivational Interviewing Techniques to More Effectively Partner with Parents

Using Motivational Interviewing Techniques to More Effectively Partner with Parents webinar

Kelly Towey: Hello and welcome. Thank you for joining us today for our webinar, "Using Motivational Interviewing Techniques to More Effectively Partner with Parents." This webinar is sponsored by the Office of Head Start National Center on Health. My name is Kelly Towey and I'm a consultant for the National Center on Health.

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At this point, I'd like to introduce our speakers for today's webinar. Dr. Neal Horen is a clinical psychologist who has focused on community-based work for the last 15 years. He is co-director of training and technical assistance for the Georgetown University Center for Child and Human Development, and serves as deputy director of the early childhood team. In addition, Dr. Horen continues to spend time working in direct clinical care, including development of social skills, interventions for young children, working in his fussy baby clinic, and is director of a clinic which offers therapeutic and assessment services for young children and families.

Amy Hunter is an assistant professor at Georgetown University Center for Child and Human Development. Currently, Amy oversees the mental health section of the Head Start National Center on Health. Previously Amy served in many positions at ZERO TO THREE, including director of program operations for Early Head Start National Resource Center, and the project director for the infant/toddler portion of the Center on the Socially Emotional Foundations for Early Learning project.

For 20 years, Amy has been involved in early childhood mental health, including providing training and technical assistance on early childhood mental health to individuals and groups around the country.

Amy also maintains a small private practice on Capitol Hill in Washington, D.C. At this point, I'm going to turn the presentation over to Dr. Neal Horen.

Dr. Neal Horen: Thanks Kelly, and welcome everybody. We're excited to spend the next almost hour with you all. We're going to talk as best we can about something that's a much more involved, lengthy topic. So, this is not a training on motivational interviewing. This is just sort of a brief overview of how some of the strategies of motivational interviewing can be really helpful. And we are going to make the PowerPoint available to folks and really looking forward to the next little bit of time with you all. In terms of what we're hoping to do, we're hoping that all of you just get a little bit more familiar with strategies to enhance conversations with others, meaning we're pretty sure that most of you are able to have a conversation with another person. This is really about some strategies that can make that go a little bit better at times.

There are a number of resources and training materials that we've worked on, that others have worked on that we're planning on getting to, and we really want to talk about some of the specific techniques of motivational interviewing: Reflective listening, seeking permission, asking open-ended questions. And because it's a webinar, it's not going to be quite as interactive as we would like it to be, where you really get to practice those skills, but it's a good start and we hope that it will draw enough interest that you'll want to pursue a little bit more around this topic.

We're going to start with a little poll just to get a sense. Because, if all 1,100 of you say that you know this, this is going to go really fast. But we're assuming that some of you are familiar with it, some of you are not, and we have a little poll about how many of you had training in motivational interviewing. So I'm going to ask that the poll come out, thanks, and we'll just give you a little bit of time. It's a very complex poll so we want to give you time to answer yes or no. It'll give us a sense of who here has sort of done training on this, things like that. Okay.

So, let's see what the results of that are. And it looks like, if I can read this -- I'm a child psychologist, I don't really do graphs -- it looks like a great number. Amy, if I'm looking at this right, about 67 percent no training, and 32 percent have had some training on this. So, we're going to go back to our slides.

So, when we talk about motivational interviewing, we just want to be clear on a couple of things. Motivational interviewing is a technique, an evidence-based practice. It really came out of the substance abuse world, and things like smoking cessation and working with folks who are dealing with substance abuse. That's where this technique really started. It certainly has expanded well beyond that. We're really excited about that.

And it really is about the conversation that people have, where you're trying to help an individual be motivated to change their behavior.

Not to force somebody to do something, but to work about strengthening that individual's motivation. It can help parents, it can help staff, it really can help anyone sort through when they have mixed feelings. And I think many of us in this work have encountered folks -- parents, coworkers, other folks in the field

-- who may have mixed feelings and are not sure about making a change. And Amy and I oftentimes talk about with folks, think about yourself. Have you ever been uncertain about making a change? As somebody who has a painter in his house right now with 55 rooms being painted -- I don't have 55 rooms,

I just thought that would be impressive but -- having all those rooms changed, the decisions to make -- actually, I have some mixed feelings. Not quite as complex as some of the ones that we're going to talk about when we do our work in Head Start and Early Head Start, but motivational interviewing can really help folks sort through that.

One of the things to really keep in mind, and hopefully all of you know about the fantastic PFCE, the Parent Family Community Engagement Center and the National TA Center for Head Start and a lot of the good work around family involvement, family engagement, this concept of how we really effectively partner with families that come out of that center. When we talk about this, obviously Head Start and Early Head Start have a huge focus on involving parents and working with parents. We really like this distinction between what family involvement is and family engagement. And certainly you want families to be involved. You want them to show up, to have interactions and things like that, but we really want families as our partners and we want families who are engaged. When there's engagement, that is a different qualitative feel in terms of how we work with families.

I was trained -- I'm a child psychologist, so I was trained 20 years ago. I know you look at that picture and like, "No, there's no way he's been doing this for 20 years," but 20 years ago I was trained. You sit in a room; you pretend an hour lasts for 50 minutes and you tell a family what to do. And that is not family engagement in any way, shape, or form.

And so what we think about is how, in Early Head Start and Head Start and certainly the work that the National Center on Parent, Family, and Community Engagement has done, they really, really shifted this emphasis to engagement and how we use some strategies to work with families. Not to make them do what we want them to do, but to work with them more effectively. And the key to that really is about engagement. And it's relational.

Certainly, on the mental health side of things, that's all we talk about is the importance of relationships. And there are -- if you think about relationships that you have in your life -- when you're really engaged in a relationship, there's safety and there's trust and there's respect and caring and hope. So, when we can foster that kind of relationship, that really can help, in terms of engagement. And that engagement in turn can lead to changes in attitudes or a sense of what's possible.

And that really is what we're going to be talking about today is working with some of these techniques to help families make the decisions that they'd like to make. And when we do that, everyone benefits. I think all of us are obviously interested in children being healthy and more ready for kindergarten. But we really want families more engaged in our program and then ultimately in the school system. And when that happens, programs have a higher quality and communities are oftentimes better for that.

When we engage families, we have a much better shot at doing what it is that we've set out to do in doing this work. They feel supported; they're willing to make those kinds of changes that are going to support their children and themselves.

We're guessing that most of you are familiar with this, this sense of strength-based attitudes and the idea that families are the first and most important teachers of their children. When we really follow through on an attitude like that, that's when we really are engaging families, and that's when we're working together to help make decisions, not trying to force somebody to do something. All families have something valuable to contribute and they have the expertise about their child.

As a child psychologist, I say this all the time: I could see your child for an hour a week. You're going to see them for the other 140 hours of a week. I don't really like to do math in public but I think that's about right. And if you're going to see them for 140 hours a week, you have a lot of influence on them. And because of that, you have the ability to really give us the kinds of observations and the kinds of information that, as a team, will help us make much better decisions for that child. So, we're going to change up here and Amy's going to take over.

Amy Hunter: Hello everyone. It's a pleasure to be with you. I hear we have over 2,000 participants, which is very exciting. So, we're transitioning a little bit. Neal's been talking about the value of really engaging families and the wonderful work of PFCE, and there's kind of a funny picture on your screen. And those of you who have been to the eye doctor may recognize it. And we put this up here to be an analogy for the different types of lenses that we can use when we work with families.

This picture, the technical term is phoropter -- it's a new term to me. But you can see that there's many, many different lenses and if you, again, been to the eye doctor, you recognize that they ask, "What does it look like now? What does it look like now?" And so we can think about all of the different lenses that we bring to the work with families, the lens of our own beliefs, our own values, our own culture, gender, the experiences that we've had. And the ability to sort of shift our lens and really put ourself in the shoes of a family really brings us to have closer engagement with families and more authentic relationships with families. And when we're able to put ourself in the family's shoes and really see the world the way that they see it, we're better able to support them through their own journey.

This next picture -- some of you may see as you look at this picture, is a picture of an old woman. Others of you may see the picture of a young woman. So, take a minute to look at this picture and see what you see, and see if you can see the other side. So again, some of you may see a picture of an elderly woman and some of you may see a picture of a young woman.

And see how hard it is or how easy it is for you to be able to shift back and forth. And again, that's just a very simple, fun reminder of the intentionality that we really need to bring to be shifting our lens and moving from different ways of viewing a situation or viewing the experience the way the family does. Some of the really critical principles that we are adopting or borrowing from the motivational interviewing work or they call it the spirit of the motivational interviewing work, is this idea of collaboration. And Neal mentioned true partnerships with families where we're not viewing ourselves as an expert or that we have all kinds of knowledge or wisdom to impart or to be an expert but really understanding where the family is coming from, what they want to know and learn, what kinds of information they may need, what kinds of things they want to work on.

As Neal mentioned, they are the experts not only in the lives of their children but in their own lives, in terms of the kinds of things that they want to focus on, where they want to go with their goals, and then ultimately this sense of autonomy, that it's their choice. We may have lots of ideas and experience that we bring to the work. We certainly, many of us, have had years of education and again training, experience. It can be very easy to think we know what they need, we have ideas about what would be helpful. But in fact, it's really up to them to decide what is best for their situation and their circumstances at that time. And the more able we are to ensure that they have the autonomy and that we're valuing their autonomy to make those decisions, the better we are able to partner with families.

So, three strategies that we're going to focus on during our time this afternoon is reflective listening, soliciting permission, that's also the same as developing a collaborative agenda -- what are we going to work on together? And open-ended questions. This is a quote actually from Miller and Rollnick. Miller and Rollnick are the original authors and creators of the motivational interviewing work. And I'm not going to read the slide to you, but what I will say is I love this last piece of it where they say, "When you're in doubt about what to do." And I think when we think about it, we've all been there at some point in time, where someone said something – whether it's a parent or a staff member or a colleague -- and you are flummoxed about what to say or you don't really know what to do with that or where to go with it. And that's natural and it's important to pay attention to.

And they say the best thing to do is just listen. And in fact, it's amazing. If you do just listen without trying to rush in to fill the space or offer a solution or say something, often colleagues, parents, people we're working with come up with their own answers. And really that's what this work is all about. The more that people share and talk out loud about what it is that they might be struggling with or thinking about, they often have the answers that then is our job to support.

So, talking about reflective listening, we're really thinking about the kind of listening that's, as it says here, other-directed, non-defensive. It can be very easy in the work we do in our Early Head Start and Head Start to get our back up or to get put on the defensive if someone's questioning where we're coming from or questioning what we know or, frankly, has a really different perspective.

But being reflective or being empathic -- it's again stepping in their shoes, seeing the world from their lens and their experiences. We, in being empathic or reflective, are really thinking about receiving the information and trying to understand what the other person is saying, rather than paying attentionto what we're going to say next or what we want to offer.

So, some of the phrases that we often use when we're thinking about being a reflective listener or being an empathic listener would be phrases like this: "So you feel," and then paraphrase what they're saying; or, "It sounds like you're saying," that you're having a hard time with X; or often one of my favorite phrases if, "You're wondering about," or, "We wonder what's happening here." It helps to use the phrase "wondering" because then you're looking at something together. You're avoiding that expert stance.

When we do live training, we often engage in a listening exercise, which would be very difficult to do as a webinar. But we wanted to leave this in here; so for those of you who do training, you can think about doing an exercise like this. It can be very informative to how difficult it is to listen. And so, what we do in this exercise is we have one person in teams of two be a listener and one person bea talker, and then they switch after about 90 seconds. And each time the person is listening, the other person is talking about something that they want to change in their life.

And we talk about don't pick the most upsetting thing that you want to change in your life but pick something that's more meaningful than maybe switching your bedspread or, as Neal mentioned, your paint color in your house. Just something that's meaningful. And then have the listener just listen without offering any response, not saying anything at all. And then after both pairs have had a chance to be the listener, you can talk in an audience about what that experience is like. And it's often enlightening I think for all of us to really try to focus on listening to what the other person has to say for over a minute, and how many times your own thoughts drift or you find yourself incredibly compelled to want to say something back in that short period of time. So, it's just a good exercise to remind us that this work seems so simple but is actually quite complex when we want to do it right.

So, thinking about a collaborative agenda and seeking permission, here are a couple examples of how you might seek permission to develop the agenda. And we actually encourage no matter what kind of a meeting that you're having with parents or with staff or with colleagues to think about how you create that agenda together. So, you could say to a staff member that you might be supervising, "What do you have for the agenda today?" or "What kinds of things are on your mind?" In this example, it's asking permission to share information. So, whatever the topic may be -- whether it's about smoking cessation, whether it's about nutrition or oral health or behavior issues -- you certainly want to get buy-in about that conversation. And now we are switching it over to Neal.

Dr. Horen: So, the question we get asked a lot is, "So, what if a parent says no?" You know, it doesn't happen quite as often if you really are seeking permission. So, if you say to somebody, "Would it be okay if we put this on the agenda?" is vastly different than, "We need to talk about Johnny's behavior." So, it doesn't happen very often but it does. And it's important to keep in mind: A parent may not be ready. And one of the most important lessons I ever learned was from a group of elders -- Yupik Eskimo elders -- that I was privileged to work with who said it's about being ready when you talk about child development and things like that. Sometimes, a parent may not be ready.

And you have to be okay saying, "All right. Maybe, we'll circle back to this," and not try to hammer home, "It has to be right now. We have to discuss this right now." And when you meet a parent where he or she is, in terms of addressing the concerns and priorities, you have a much better relationship, because that parent is going to see you as somebody who respects their opinion and doesn't try and force them to do something.

Another one of the strategies that we like folks to become more familiar with is open-ended questions and the idea that when you ask someone a question that is a closed question, it really in some ways can be a conversation stopper. So, "Has anything happened since the last time we talked?" "No." And then the conversation could be over. As opposed to, "Tell me a little bit about what's been happening since we last talked." That's much more open-ended. It sort of suggests, "Just tell me what you want to tell me." You see a couple of other examples there, and we'll sort of go through these a little bit more quickly. "Do you want things to be different?" is a closed question. "No," or "Yes." Even if I said yes, there's not much there.

But if I said to you, "How would you like things to be different?" it sort of opens it up for Amy to say, "Here's how I'd like things to be different." Oftentimes, I've had someone say to me, "Well I've tried everything." And I'll say, "Well, what if anything have you tried before related to this that's been helpful or not helpful? What's been the least helpful? What's been the most helpful?" Asking open-ended questions really changes the nature of that conversation. And what it does is it sort of facilitates more parent engagement.

So, we've given you here 12-14 examples of this. But the idea is that they don't have a yes or no question. It's an opportunity for the other person to do more talking and share their thoughts and their experiences. And it's really to engage the parent in a dialogue. So, when I say to somebody, "What do you think would happen if you made this change?" It really opens it up for that parent to say, "Well I don't think that would work because we tried to do that one time and here's what happened." Or they might say, "I'm not sure." And that keeps the conversation open as opposed to, "Do you want to make this change?" "No," or "Yes." So, those are a couple of different examples of open-ended questions.

For me, this probably one of the harder things for us, because most of us have gotten into this field because we want to help people. I know we all got in for the money too -- but most of us got into this field because we want to help people. And yet what we're going to tell you to do is to give that up.

Don't give advice. Don't try and solve the problem. And certainly don't be the expert. I remember the first time I was working with a parent and I came out and met with my supervisor, and my supervisor said, "So what do you think?" And I said, "This is easy." And she's like, "What?" I said, "Yeah, this is easy. I know exactly what they're supposed to do." And she said, "You're way wrong. And you don't even understand why you're wrong, but you'll come to understand," and I did come to understand it.

When you sort of believe this person ought to change or needs to change or that if they don't, they've done something wrong, you're not really working with that person. You're not engaged with that person. You're not relating to that person. You're trying to be the expert. And so, when we're working with others, what we want to do is try and help them decide what they want to change and how they want to make that change.

So, when we think about ourselves and changes that we've had to make and how we go about that, it's not a simple process. And as Amy pointed out, the range of things from relatively simple things to the more complex questions that get posed to us about wanting to make change, in all of them there is a process to that. And when we dig deeper into change and allow the other person that we're speaking with -- when we're working with a parent -- we allow them to work towards a solution, as opposed to trying to give them a solution or tell them what we think they need to do; then, they're much more likely to be willing to make a change.

One of the other ways to do that is to roll with resistance. So, our guess is that there are a number of you in the audience who've experienced resistance when working with families. The truth is that if we asked the question of families, "Have you ever encountered resistance from the folks you're working with?" They'd probably, an equal number, would raise their hands. We experience resistance in all aspects of our work.

And resistance is really a sort of -- you have to think of it almost like a clue. If that person's being resistant, maybe I'm missing something, or maybe we're not on the same -- we're not aligned in the way that we're thinking. And instead of saying, "So there must be something wrong with them or they must not be thinking the right way," it's a real opportunity to say, "Let's stop for a second. There's something going on here." And when somebody's resistant, they need someone or something to be resistant against. And that's you.

And so, sometimes there's good reasons to exhibit resistance. I remember working with a family once where the mom was very resistant. She wouldn't come in for meetings. And no one ever took the time to find out that she had -- her own mother was very ill and she had to go take care of her mother. Not anyone tried to figure out what was the resistance -- I'm putting up air quotes but it's a phone call so you can't see me. Amy can see me though, so it's really going well. But had somebody taken the time to figure out what's the resistance about, they might've been able to help that parent be more engaged and more willing to discuss this. So, things to avoid are try not to argue for the change. "Well you really should make this change because if you don't, here's what's going to happen to your child," or, "You really need to make this change because we don't know what else to do."

Try to offer different perspectives without imposing that on someone else. And you have to be coming from a place where you see the family as the primary decision maker as the resource for finding answers and solutions. When you see resistance, a couple things to think about is try and understand that resistance by exploring why the person feels that way. Don't oppose it.

Get a sense of: "So, what is it that makes you feel that way?" So, somebody says, "Well, I don't really want to do the particular change that you're suggesting for my child." Instead of saying, "Well, we really think we have to. We don't know any other way to do it," is to say, "Well, what makes you," right? Ask an open-ended question: "What makes you think that that might not work? Is there something about previous experience? Is there something about the way your family handles things? Is there something about the way culturally that we're approaching this that has not worked for you?" And so when you do that, you're rolling with resistance. It doesn't mean to just let the other person do whatever they want. It means to be aware of the process. There's sort of a spirit to this, this idea of using these strategies and techniques. And that spirit is that the two of you are in it together, and that when you're in it together, instead of saying, "Well you're being resistant, so this conversation is over," or, "You're being resistant and you just need to do this," it's to roll with that resistance.

See the resistance for what it is, which is an opportunity to maintain engagement and not say -- well we have a couple videos that we're going to get to in a sec -- but in there you'll see that instead of seeing resistance as the end, see it as the opening for another part of the conversation. And with that in mind is to think about that when people are making changes -- and Amy and I urge you to think about any changes that you've made for yourselves -- there are stages to this. There's pre-contemplation, right?

When you're not really ready. You're just thinking about the change that you want to make. You're not even necessarily aware of the need to make a change. And so that then is followed by contemplation, which is sort of a getting ready, where you're becoming aware of a desire to change in the near future.

Then, there's preparation. I don't think I need to explain it. At this point, if you've been able to make it onto the webinar, you probably know what preparation means. Then, there's action. So, the individual's begun to change their behavior and they're engaging in that plan of action and they're committed. And then there's maintenance. Right?

There's this idea that you're maintaining the change for a while and working to maintain that change without relapse, without going back to what you were doing before. And in those stages of change, you also have to be aware of where is the other person. If we're talking about engaging with families, where is the family in terms of making a particular change? And if you're aware of that and you're aware of the things like using open-ended questions and rolling with resistance and suspending judgment and helping to set that agenda collaboratively, you have a much better chance than having that conversation lead to some sort of a change. It may not always be the change that you would like to see, you personally, but it is going to be the change that the family needs to make. And they'll be much more willing to make that kind of change.

That was pretty dramatic right? That was pretty good. All right, so I'm going to turn it over to Amy. We have a couple of videos we're going to watch. Amy: I also want to say that if you're interested in this, certainly there are a wealth of resources on motivational interviewing. Clearly we're just highlighting some of the main concepts from this work.

The EHSNRC has done a webinar also a few years ago on motivational interviewing. You might want to check that out. It's available on the ECLKC. And I believe we have some videos to show. The technology, how do I show the videos?

Dr. Horan: Somebody's going to help us. I feel it.

Amy: I feel someone is going to put up a video. Is that right? Yes, I got confirmation that someone is going to show a video.

Dr. Horan: Just bear with us.

Amy: So, when the video comes up, what I'd like you to do is watch for some of the strategies that we've been talking about. Watch for the reflective listening. Watch for the rolling with resistance.See how that's handled.

[Video begins]

Narrator: A Head Start teacher, Ms. Jefferson, is meeting with a parent, Mary, at the Head Start program where her four-year-old son Joe attends. Their previous conversations have included discussions about Joe's strengths, as well as some concerns about his behavior in the classroom. Joe's concerning behaviors include frequent hitting and biting other children, yelling and screaming when he becomes angry, and having trouble following his teacher's directions. Ms. Jefferson has invited Mary to come to provide her perspective on how things are going for Joe in the program.

Ms. Jefferson: Mary, thank you so much for coming in today to talk about how things are going with Joe.

Mary: I had to rearrange my work schedule and my boss is giving me a hard time about it, but you said it was important.

Ms. Jefferson: I know it can be hard to rearrange your work schedule, and it sounds like it wasn't easy with your boss. I know you are very committed to Joe. I know I called you for this meeting, but before we get started, I wanted to see if there were any topics or concerns that you wanted to address. What should we put on the agenda?

Mary: I'm here because you asked me to come in and because Joe is everything to me. I was concerned that you wanted to have a meeting about it, and I want to hear what was so important that I had to take off work.

Ms. Jefferson: Sure. Well, the main reason I called this meeting was to talk more about Joe's behavior in class and see if we can put our heads together to come up with some solution.

Mary: That's fine. But honestly, I don't think that there's anything wrong with Joe. I think that the problem is the classroom. No offense, but it seems out of control in there. And Joe doesn't have any of these behaviors at home. Maybe, he acts up at school because the other kids are constantly bugging him and because it's so crazy.

Ms. Jefferson: So, you've had more success at home than we have with his behavior in the classroom. As you've mentioned, what we have been doing doesn't seem to be working as well as we hoped. And it sounds like you have some concerns about the classroom environment. Tell me more about that.

Mary: Well, I've seen other kids pushing Joe and I think that he should stand up for himself. I don't want him to be a wimp and get picked on his whole life. Those kids don't have any respect. and they shouldn't get away with calling Joe names and getting in his face all the time. It's loud in the class and I don't know if you or Ms. Rita sees the things that Joe tells me about.

Ms. Jefferson: You feel like you're hearing about and seeing a lot in the classroom that we might not be aware of. I really appreciate you sharing these concerns with me. Of course, you want Joe to be able to stand up for himself if other kids are bothering him. Tell me more about what's happening that we don't see and how the other kids are treating Joe.

Mary: It's mostly that kid Alex. All Joe talks about is how Alex is always pushing him and telling him what to do. I've seen that kid and he does not know how to behave. Maybe, Joe is just defending himself. I don't know. I don't know if there's anything else that I can do. I think that the school has to figure this out.

Ms. Jefferson: It sounds like maybe we can look more closely at interactions between Alex and Joe. I also hear that you want us to figure out what we can do in the program to help the situation.

Mary: Exactly. You guys need to figure something out.

Ms. Jefferson: Sounds good. Would it be okay if we talked about Joe's progress and what we've been doing?

Mary: Sure.

Ms. Jefferson: First, let me say Joe is a great kid. He has many strengths. He is always eager to help out. He is really learning his letters quickly. However, we are concerned that the hitting and biting have not improved since our last meeting, despite some of the things that we've tried already.

Mary: Does he mostly just hit Alex?

Ms. Jefferson: That is certainly something we will take a look at. We'll observe to see if there's some pattern with Alex. Would it be okay if I shared another idea that we've been thinking about?

Mary: Sure, I guess.

Ms. Jefferson: We would like to have our mental health consultant Ms. Gibson come in and observe Joe in the class. She will observe how Joe and the other kids interact. We can even give her your suggestion of paying close attention to Joe's interactions with Alex. Her job is to give us her perspective or ideas on what might be contributing to Joe's behaviors.

Mary: I'm not sure about that. I don't think so. That is not necessary. Like I said, Joe doesn't act this way at home. He's not mental or something. Doesn't the mental health person see crazy kids?

Ms. Jefferson: I hear your hesitation to have Ms. Gibson observe Joe. Let me assure you, we do not think Joe is mental or something. It sounds like maybe her title, mental health consultant, might have put you off.

Mary: He isn't crazy. I don't want someone in our business judging me and my son. I've got enough of that. I think you're making it seem like this is his problem. We didn't have any of these behaviors before he came here, and I don't have any of this at home. You've always been straight with me, Ms. Jefferson, and I appreciate that, and I like how you treat Joe. But I don't like this. Maybe, he should go to a different school or stay home with my mother, if you can't handle him.

Ms. Jefferson: You're right. Joe isn't crazy. This is not just Joe's problem. In fact, really, we need help trying to figure out what we can do to support Joe. I hear you that you're not comfortable at this point with Ms. Gibson coming in to focus on Joe right now. That's okay. I respect that. You're his parent and you know what is best for your family. These are hard conversations to have.

You know, I realized you haven't met Ms. Gibson and this may be the first time you've heard about her role here. Would it be okay if I told you a little bit about what she does here?

Mary: Go ahead.

Ms. Jefferson: This is a lot of information to take in. She's here at our center one day a week. You may have even met with her without realizing it. She's tall with sort of spiky gray hair. She's often in the classrooms playing with the kids, talking to us, and sometimes even doing some lessons with the kids about feelings and things like sharing.

Mary: I've seen that lady. I thought she was one of those grandparent volunteers.

Ms. Jefferson: It seems you're still unsure. You are worried about being judged and us focused on something being wrong with Joe. I can understand that. You know, you may or may not be interested in just meeting with Ms. Gibson. You could get a sense of her for yourself, not just taking my word for it.

Mary: I'm not sure. Maybe.

Ms. Jefferson: You're unsure and that makes sense. We've talked about a lot today. Maybe, it would be helpful to let this all sink in. What if we talked on the phone tomorrow just to see how you're thinking about it.

Mary: You can call me tomorrow and I'll think about it, but I still don't know. Maybe, this lady should be looking at other kids.

Ms. Jefferson: Ms. Gibson does look at other children. I promise you that Joe is not the only child we suggest Ms. Gibson help us with. She offers us a lot of help with many children, so that we can teach them in different ways. Thanks, for even considering a meeting with her and being open to us talking some more about this. I'll call you tomorrow to see what your thoughts are, after you've had more time to mull it over. What time is the best time to call you?

Mary: Noon is fine.

Ms. Jefferson: Sounds good. I want to thank you for coming in and I really appreciate your willingness to listen to our thoughts. And I'll talk to you tomorrow.

[Video ends]

Amy: Okay. Hopefully, you all were able to see that video. That is one of two videos that the National Center on Health has created to illustrate some of the concepts that we've been talking about related to reflective listening, developing a collaborative agenda; and I think you heard many instances of the teacher reflecting back to the parent to make sure she really understood what the parent was saying and to help the parent feel that the teacher really heard her. She heard her words; she heard the message behind her words. You heard phrases like, "It sounds like you're saying," or, "I hear you saying this," "Do I have that right?" You heard many times the teacher soliciting permission: "Would it be okay if I asked about this? Would it be okay if we talked about your child's behavior?" You also heard the teacher really illustrating that idea of you know what's best for your child.

Now, this video, along with another that we have developed -- the other one is about a home visitor talking to the parent about a positive depression screen, and they both are not perfect interactions. They both are rich for discussion, and so we encourage those of you who are trainers to use these videos and really have it be an opportunity to have dialogue with the people that you work with, to say, "What felt helpful about this conversation? Where in this conversation do you feel like it could've been improved?" One of the most positive things, I think, about this conversation is that we have heard from others that we've shown it to that it's fairly realistic in terms of the parent having the concerns that she has about concerns being in the classroom. And then, at the end of the conversation, the teacher did not convince the parent to go along with her idea, which was to engage the mental health consultant, but that they're still open to talking.

That the most important thing here is that the relationship is preserved and that they have an ongoing relationship. And I think that's the part that we want to communicate most is that the relationship is far more important than having some kind of specific set agenda.

We have about 10 more minutes. I'm going to show you one or two very quick debriefs is what we call them. And this is where the parent or the teacher -- we have clips of both -- have talked about how this interaction went for them. So, they're doing what we consider to be a very important aspect of working with families, and it's that reflective piece. So, asking the teachers or asking the parent, "What was that like for you?" And so, if Addy you could go ahead and show --

[Video begins]

Narrator: As a parent, how do you feel your opinions were respected in this conversation with Ms. Jefferson?

Mary: You know, even though I don't agree with Ms. Jefferson's suggestion to have the mental health consultant observe Joe, in the end, I do think Ms. Jefferson listened to my perspective and is going to follow through on my concerns. I know that Ms. Jefferson cares for Joe and I know she wants what's best for him. I trust her, and I know that she's not going to try to force me to do anything.

Amy: And let's go ahead and show a couple more.

Narrator: Would you do anything differently if you could do it over?

Ms. Jefferson: You know actually, I might try to stay with Mary's concerns about the classroom even more. I might try to elicit more information about her concerns or how things are different at home compared to our classroom. I think if I had done that, I might have been able to explore and invoke more of her ideas about what she believes needs to change. I do think it is important for me to share our ideas with Mary and offer her information about consultation in our program.But, I also think I could've done a better job exploring her thoughts and ideas about what needed to change.

[Video ends]

Amy: And we're going to show one more debrief. Thank you, Addy for putting these up. [Video begins]

Narrator: It seems both of you are willing to continue this conversation at another time. What allowed this conversation to continue without ending poorly?

Ms. Jefferson: Well, I do think conversations like this can be challenging, especially when we have an idea about what we think would be helpful and a parent doesn't agree or has other ideas. I think conversations like this can end badly when a parent doesn't trust us or when we try to convince a parent to do something or somehow force them to try to agree with us. The truth is: I do think having the mental health consultant observe is helpful. But it's far more important to have Mary on board and for us to work together to try to figure out how to better meet Joe's needs in the class.

Mary: At first I thought that Ms. Jefferson was going to blame me or blame Joe for what was going on in the classroom. And that would've been a deal breaker. As much as I like Ms. Jefferson, I would not have continued to talk with her if she had tried to force me to do something or judge me. I've had enough conversations like that. I know we don't totally agree on what would help, but I'm just not sure that I agree with the mental health consultant. I feel like Ms. Jefferson really heard my concerns and is willing to work with me. She knows I want what's best for him.

[Video ends]

Amy: Great, thank you Addy for helping us do the technology to show those, it looks like we have a few questions. Bear with us. Kelly, do you want us to go ahead and read them or did you want to read them?

Kelly: Sure, we do have a few questions. One of them is: What strategies apart from engagement skills can we use to work with resistant parents?

Dr. Horen: So, I'll take a shot at this one. I think that part of -- again as we said at the beginning, we can't cover everything today but -- hopefully you heard a couple strategies, and one was about rolling with resistance. And when I hear resistant, I always think to myself, "What's really happening?" So, is it something I'm doing? That's that reflective practice that we really want staff to engage in, which is: If there's resistance, it's not just because a parent's being resistant. It's about there's resistance, and there's two parties involved.

So, what can I do? I can continue to push and see if the resistance increases or decreases -- we're pretty sure we know what's going to happen if we continue to push -- or we can stop for a second and say, "Boy, it doesn't feel like this is something you're ready to address. What do you think we should do?" So, what I've done is I've rolled with the resistance, I've asked an open-ended question, and I've acknowledged that the two of us are not really aligned and we need to stop and figure out how we're going to keep moving forward. And then these videos hopefully show that, that what happened at the end is the parent didn't agree to do what Ms. Jefferson thought would be most helpful, and yet was not stomping out of the office taking her child with her. She was saying, "Yeah, we'll talk tomorrow at noon." And you hear in these debrief video clips, "I like the way she handled it, because she didn't make me do something I wasn't ready to do." Anything else Amy?

Amy: Well I guess I'm probably going to reiterate what Neal said. The term itself, "resistant parent," gives us a clue about a mindset in some ways. And if we think about that as we have gotten -- and I heard Neal say earlier -- if we feel the resistance, we've gotten out of alignment. So, we're no longer alongside the parents, taking their journey with them, or we're no longer behind the parents, supporting them in the decisions and the road that they want to go on, but we're now in opposition to them. And so, what Neal has said is a great strategy is thinking about, "Why are we in opposition? And how do I align myself next to the parent so that we're walking together? Or, how do I get behind the parent to support the goals that they have, the decisions they want to make, the values that they're bringing?" So, I guess that would be our answer to that question.

Dr. Horen: Okay, Kelly, we have maybe one more question, or two.

Kelly: Yeah. I think the next question is: What can we do if parents ask for advice?

Dr. Horen: Well, so the first thing is to say, "Oh, good. They want my advice," meaning that they actually trust my opinion. I don't think it's bad to give advice. I think that part of what we've been talking about today is not to avoid giving advice ever.

It's to avoid giving advice if there's some change that a parent's not ready to make and you're trying to help them make that decision. And so giving advice is not a bad thing at all, it's a very good thing, particularly when a parent says, "I'd like your opinion. I'd like your advice." Hopefully, these videos illustrate sometimes that doesn't happen and, in fact, a parent disagrees with our best thinking. And so in this situation, had Ms. Jefferson said, "Well let me give you some advice. I think it's critical for Joe to be able to stay here that we have the mental health consultant take a look," that would not be advice that's very helpful. It would really further distance them, parent and staff, from one another. And so giving advice about a bad thing is just, what's the context in which that's happening?

Amy: Well, and I think sometimes people ask for advice and it doesn't always go so well, even if they've asked for it. So, I think one of the best things we can do is help parents or help whoever it is that we're working with come to their own decisions. And then if they come to their own decisions or even if they give themself advice, that's going to be much, much more meaningful than anything we could probably offer. So, I would agree with Neal that if someone is asking for advice it's not that you would never offer an opinion; however, I think sometimes when that is offered, it can be something to resist against. I think if we put ourselves in the shoes of when we've made our own changes or when we've taken a different direction in our life, it hasn't so often been because someone gave us advice to do that. And that when we come to our own decisions with support of others, those kinds of changes and those kinds of decisions are going to be most meaningful.

Kelly: Well, thank you, Neal and Amy, for sharing this wealth of information on motivational interviewing and partnering with parents. We do know that we have other questions that we have not had time to answer on the webinar. We'll be answering those questions via email over the next few weeks. And if you have other questions that come up, you can always contact the office of Head Start National Center on Health at nchinfo@aap.org. Again the email is nchinfo@aap.org.

And just a reminder, when the webinar ends, there will be a survey poll that can be taken immediately. There will also be an email sent to everyone who watched live with instructions to share the survey link to everyone in their group who watched today's webinar. Remember, you need to take the survey in order to get your certificate of completion of attending. And thanks again, for joining us for this webinar and we look forward to seeing you on further events. Thank you.

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