Presentation on theme: "Motivational Interviewing in Action: Integrating MI Across Your Agency"— Presentation transcript:
1 Motivational Interviewing in Action: Integrating MI Across Your Agency Buddy Garfinkle and Nancy Schneeloch,Bridgeway Rehabilitation Services,Elizabeth, New Jersey
2 Bridgeway Rehabilitation Services OUR MISSION:Bridgeway provides psychiatric rehabilitation services to adults who have serious mental illnesses to help them live as independently as possible in the community. Bridgeway is on the cutting edge of improving service interventions and expanding resources that have helped individuals receiving mental health services with their journeys toward recovery.
3 Bridgeway Rehabilitation Services Our Services – Eight counties, 1500 IndividualsPACTSupportive HousingResidential Intensive Support TeamsPATH: Homeless Outreach ServicesJustice-Involved ServicesCareer Development ServicesCommunity Support Team
4 Beginning with MI Why start with Motivational interviewing? MI integrates principles, spirit, and methods for working with individuals servedAll staff have the capacity for learning and using MI methodsIn an expanding agency, it helped us to integrate a method for speaking a common languageHelped staff to focus on a specific skill setProvide clinical interventions based on an individual’s stage of change
5 Beginning with MIRecognition that staff was uncomfortable with person served’s ambivalence or lack of insight.Instilled confidence in staff in areas where they previously experienced frustrationEvidence base for Motivational InterviewingSAMSHA’s evidence-based practices require MI and CBT interventions.Decision made to focus on MI and CBT before implementing IMR
6 Senior Management Involvement How was Senior Management Involved with the Process?Executive Director and Program Directors discussed applicability of MI to psychiatric rehabilitationAgreement on all staff to be trained simultaneouslyFeasibility of agency-wide implementationDeveloped an MI steering CommitteeIdentified an expert trainerMI Steering Committee members attend additional Integrated Dual Disorder Treatment Trainings
7 Going Agency wideSupervisory Staff and staff with MI experience were first trainedRegional Workgroups were established for group supervisionMet every two weeks to practice skills and review sessions with persons servedEvery staff person needed to identify a person served who demonstrated ambivalenceFilled out an MI skills sheet to talk about the sessionRole play in group supervision
8 Going Agency wide Identify skills to be practiced Groups met for four months before agency roll outMeetings with program elements to discuss integration of MI into practiceCurriculum developed by three agency trainersAll staff trained (2 day training) with practice exercisesCommittees continued to meet monthly for six months
9 Benefits of Learning about Motivational Interviewing More realistic expectationsGreater recognition of small accomplishmentsGreater success over timeLess frustration and burnoutEffective across populations and culturesActively involves the person in his/her own careImproves adherence and retentionInstills hopeConsistent with Recovery TransformationSource: Retrieved July 18, 2008 from ahec.allconet.org/newrihp/powerpoint/
10 MI TRAINING GOALS for STAFF To provide an introduction to the spirit of MITo learn about MI principles to use with individuals on behavior changeTo assess motivation for readiness to changeTo provide a foundation to build skills
11 What Is Motivational Interviewing? Directive, person centered counseling style that aims to help people explore and resolve their ambivalence about behavior changeSource: Michael Wiles and Cross Country Education, Inc. 2005Mi is a counseling style rather than a set of techniques. It is not a method for tricking people in to doing things they do not want to do. It is a style for eliciting from the person their own motivations for change. It is a way of interacting with people to assess their readiness to change and to help them move through different stages of change. MI focuses on creating a comfortable atmosphere without pressure or coercion to change. It is called interviewing because it involves careful listening and strategic questioning rather than teaching to help people overcome their ambivalence to change. Any change that will happen will come from within the client and not imposed upon them by some outside force. It is the role of the client to be able to articulate and resolve his or her own ambivalence to change. Ambivalence is the I want to but I don’t want to state of mind – feeling 2 ways about something. Direct persuasion is rarely effective at resolving ambivalence.First Developed in 1983 by William Miller in the treatment of problem drinkers and further concepts were elaborated by Bill Miller and Stephen Rollnick in 1991.MI has been used in many health settings . Clinical trials of MI have shown that persons are more likely to enter, stay in and complete treatment; to participate in follow-up visits; to adhere to glucose monitoring and to improve glycemic control; to increase exercise and fruit and vegetable intake; to reduce stress, to improve medication adherence; to decrease alcohol and drug use; to quit smoking; and to have fewer subsequent injuries and hospitalizations.
12 Three Components of MI Spirit CollaborationWorking in partnershipEvocationDraw out ideas and solutions from individualsAutonomyDecision making left to the person
13 Spirit of MIMotivation to change is elicited from the person, not externallyIt is the person’s task, not the counselor’s, to articulate and resolve ambivalenceDirect persuasion is not an effective method for resolving ambivalenceThe counselor’s style is generally a quiet and eliciting oneThe counselor is directive only in helping the person to examine and resolve ambivalenceReadiness to change is a fluctuating product of interpersonal interaction.The therapeutic relationship is more like a partnership or collaboration than expert/recipient role.
14 Characteristics of Motivational Interviewing Guiding, more than directingDancing, rather than wrestlingListening, as much as tellingCollaborative conversationEvokes from a person what he/she already hasHonoring of a person’s autonomySource: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care, 2008.Motivation for change can be shaped and is particularly formed in the concept of relationships. No one is completely unmotivated. We all have hopes and aspirations. The way in which we talk to people can influence their motivation for change.With MI it is a partnership instead of an uneven power relationship where the helping person or health care provider is the expert.Instead of giving people what they lack be it medication, knowledge, skills or insight, MI seeks to evoke the person’s own motivations and resources for change. Even though the person may not be motivated in the direction you would like, every person has personal goals, values, aspirations and dreams. Part of the art of MI is connecting behavioral health change with the persons values and concerns. This can only be done by understanding the person’s perspectives and evoking their own good reasons and arguments for change.There needs to be a certain detachment from outcomes – not an absence of caring but an acceptance that people can an do make decisions about the course of their lives. By acknowledging the person’s freedom not to change, it makes change possible. With MI there is an acceptance that people make choices and despite what helpers may tell them, they ultimately make the decision.
15 What do we know about Motivation? It is fundamental to changeIt fluctuatesIt can be modifiedIt is influenced by external factors and social interactionsIt is very sensitive to interpersonal styleThere are internal and external sourcesWe want to increase the probability of the person engaging in change behaviorMotivating is an inherent part of our job
16 What is Ambivalence? I want to, but I don’t want to Natural phase in the process of changeNormal aspect of human nature, not pathologicalAmbivalence is key issue to resolve for change to occurIt is our friend
17 Changing Extrinsic to Intrinsic Motivation Changing because I want to Know and explore valuesCore value discrepancy motivates changeExplore life goals; discrepancy between where the person is and where he/she wants to beChoice/Self DeterminationReframing the person’s negative statements
18 D- DEVELOP DISCREPANCY S- SUPPORT SELF EFFICACY PRINCIPLES OF MOTIVATIONALINTERVIEWING…“AREDS”A- Avoid ArguingR- ROLL WITH RESISTANCEE- EXPRESS EMPATHYD- DEVELOP DISCREPANCYS- SUPPORT SELF EFFICACY
19 REVIEW RESISTANCE It is normal 4 types: arguing; denying; ignoring; interruptingThe more one talks about non-change behaviors, the more a person is likely to do them.It is determined by therapist styleMay mean the therapist is ahead of the person in the change processResistance often stems from fear of change
20 Develop DiscrepancyDifference between the person’s core values and life goals and their health behaviorDifference between where the person is now and where he/she would like to be in the futureElicit client goals & values.Evaluate client’s current state with regard to those goals & values.Emphasize the discrepancy between them.Best if the individual makes the argument for change.No discrepancy = No ambivalence…Ambivalence makes change possible.
21 Assessment Tools…Stage of ChangePayoff MatrixICR ScalesValue Cards
22 STAGES OF CHANGE CONCEPT DEFINITION METHODS OF TX. PRE-CONTEMPLATION Unaware of the problem, hasn’t thought about changeEngagement skills, develop trust, assertive outreach, accept client where they are at, provide concrete careCONTEMPLATIONThinking about change, in the near future (usually w/in the next 6mos)Instill hope, positive reinforcement for harm reduction, discuss consequences, raise ambivalence, motivational interviewingPREPARATIONMaking a plan to change plans, setting gradual goals (w/in 1 mo)Assist in developing concrete action, problem solve w/ obstacles, build skills, encourage small steps, tx planningACTIONSpecific changes to life style has been made w/in past 6 mosCombat feelings of loss and emphasize long term benefits, enhance coping skills, teach how to use self help, tx. Planning, develop healthy living skills, teach to avoid high risk situationsMAINTENANCEContinuation of desirable actions, or repeating periodic recommended step'sAssist in coping, reminders, finding alternatives, relapse preventionRELAPSEPART OF THE PROCESSDetermine the triggers and plan for future prevention
23 PAYOFF MATRIX about Drinking Drinking as beforeAbstainingBenefitsHelps me relaxEnjoy drinking with friendsEases boredomFeel better physicallyHave more $Less conflict with family, workCostsHard on my healthSpending too much $Might lose my jobI’d miss getting highWhat to do about friendsHow to deal with stress
24 The ICR Scales : IMPORTANCE How important is it for you to change right now?CONFIDENCEIf you decide to change, how confident are you that you could do it?READINESSHow ready are you to change right now?
25 Value Cards Sort them into important/not important categories Have person pick out the five most important values and share what it means to him\her
26 MI Skills “AROSE” AFFIRMATIONS REFLECTIVE LISTENING OPEN ENDED QUESTIONSSUMMARIESELICIT CHANGE TALK
27 Reflective Listening Allows individual to feel heard Allows you to confirm perceptionsSimple declarative statement:-”It wasn’t your idea to come to see me today”-”You feel pretty discouraged right now”-”You have mixed feelings about your drug use”
28 Examples of Reflective Listening “It sounds like . . .”“It seems as if . . .”“What I hear you saying . . .”“I get a sense that . . .”“It feels as though . . .”“Help me to understand. On the one hand you and on the other hand . . .”Handout exercise 3.4
29 Strategies To Elicit Change Talk Asking Evocative QuestionsUsing Readiness RulersExploring the Decisional BalanceLooking Back/Looking ForwardUsing hypotheticalsKey QuestionsSource: S. Rollnick, W. Miller and C. Butler, Motivational Interviewing in Health Care, 2008.Ask questions that can be answered with change talk.Why might you want to make this change?If you did decide to make this change, how would you do it?Use a ruler – rating scale from 1 to 10. Ask “How strongly do you want to . . .How important is it for you to? How ready to do you feel to make this change?How confident are you in your ability to make this change?Then ask – you rated it a 5. Why not a 3? The answer gives you change talk.Decisional balance – looking at the pros and cons of change. This helps to explore ambivalence. Mention attached formsWhat are the three most important benefits you see in making this change? What are some good things about what you are doing? What are some not so good things?Hypotheticals – Suppose you did decide to quit? How would your life be different? What would it take for you to go from a 5 to an 8Looking forward – 5 years down the road, where do you want to be?Looking back – are there times in your life when things were going well? How was your behavior then?Key Question – tests the level of commitmentWhat do you make of all this? What do you think you will do? What would be the first step for you?
30 Training on MI Skills Review the definition Practice the skills right after definitionUtilize the OARS worksheetUtilize the MI workbook
31 MI-Training of StaffProvide training on MI for employees twice a year for core clinical skillsBeginner MI – offered for all new employees and anyone who wants\needs a refresherAdvanced MI – for those staff wanting to take MI to a deeper levelMI for non-clinical staff, i.e.: administrative assistants, finance office, data entry, etc
32 Supervision with MIFormal supervision with supervisor in session practiceStaff required to complete MI Skills formIndividual Recovery Plans and Progress Notes templates created to cue staffMI skills as a response to ambivalenceIn the field, in vivo supervisionObservation, supervisor feedbackGroup supervision focused on MI in every session, utilizing skills checklistConsistent supervisory feedback in “teaching moments”
33 Recovery Plan/Progress Note OVERALL REHAB/RECOVERY GOAL #1:_____________________________ STAGES OF CHANGE (PLEASE CHECK THE APPROPRIATE BOX) PRE- CONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE STAGES OF TREATMENT (PLEASE CHECK THE APPROPRIATE BOX) PRE-ENGAGEMENT ENGAGEMENT EARLY PERSUASION LATE PERSUASION EARLY ACTIVE TX LATE ACTIVE TX RELAPSE PREVENTION OVERALL REHAB/RECOVERY GOAL #2: ______________________________ EARLY ACTIVE TX LATE ACTIVE TX RELAPSE PREVENTION
34 Progress Note Menu (CBT) Cognitive Behavioral Skills Motivational Interventions(CBT)Cognitive Behavioral Skills(IM/R) Illness Management and RecoveryPromote hope & positive expectationsReinforcementRecovery StrategiesConnect info and skills with personal goalsRole PlayingReducing RelapsesExplore pros and cons of changeShapingPractical Facts about Mental IllnessRe-frame experiences in positive lightCognitive RestructuringCoping with StressReflection, Affirmation, Open-ended Questions, SummarizeModelingStress VulnerabilityElicit Change TalkRelaxation TrainingCoping w/symptoms & problemsLooking Back/Looking ForwardRelapse PreventionSocial SupportDeveloping DiscrepancyMental Health System.Explore ambivalenceMedication EducationStrengthening commitment to changeSubstance AbuseHealthy Lifestyles
35 Path Team and MIEmbracing Spirit of MI = engagement of homeless individualTailor strategies and interventions towards stage of change and readinessUtilize tools of MI, payoff matrix, Importance Confidence Readiness scalesTeam supervision and Individual supervisionReview trainings twice a year
36 Program OutcomesSuccess of MI implementation leads to Cognitive Behavioral Interventions method of training and supervision.The change process for persons served is the focusStaff matches intervention/skill to person’s stage of changeDistinguish process outcomes from persons served outcome measuresIntegrated Dual Disorder Treatment ImplementationCapture number of persons served moving from pre-contemplation/contemplation to action/relapse prevention
37 Program OutcomesCapture number of persons served completing the Illness Management and Recovery ToolkitCapture number of people completing a readiness assessment for employment and education who followed through on their plansMotivational Interviewing is integral to helping programs meet outcome measures
38 Training ResourcesMotivation Interviewing Resources for clinicians, researchers and trainers
39 ResourcesB. Borrelli, “Using Motivation Interviewing to Promote Patient Behavior Change and Enhance Health”S. Rollnick, P. Mason and C. Butler Health Behavior change: A Guide for Practitioners. Churchill Livingstone 1999S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. Guilford Press 2008C. Field, D. Hungerford and C. Dunn “Brief Motivational Interventions: An Introduction. J Trauma 2005; 59:S21-S26M. Wiles Motivational Interviewing: Overcoming Client Resistance to Change Cross Country Education
40 Q & ABuddy Garfinkle, Associate Executive Director, Bridgeway Rehabilitation ServicesNancy Schneeloch, Program Director, Bridgeway Rehabilitation ServicesPlease type your questions into the Chat Box. We will field as many questions as we can.The presentation slides and recording will be available on the HRC and PATH websites within three days.