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Motivational Interviewing in Action: Integrating MI Across Your Agency

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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 Individuals PACT Supportive Housing Residential Intensive Support Teams PATH: Homeless Outreach Services Justice-Involved Services Career Development Services Community Support Team

4 Beginning with MI Why start with Motivational interviewing?
MI integrates principles, spirit, and methods for working with individuals served All staff have the capacity for learning and using MI methods In an expanding agency, it helped us to integrate a method for speaking a common language Helped staff to focus on a specific skill set Provide clinical interventions based on an individual’s stage of change

5 Beginning with MI Recognition that staff was uncomfortable with person served’s ambivalence or lack of insight. Instilled confidence in staff in areas where they previously experienced frustration Evidence base for Motivational Interviewing SAMSHA’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 rehabilitation Agreement on all staff to be trained simultaneously Feasibility of agency-wide implementation Developed an MI steering Committee Identified an expert trainer MI Steering Committee members attend additional Integrated Dual Disorder Treatment Trainings

7 Going Agency wide Supervisory Staff and staff with MI experience were first trained Regional Workgroups were established for group supervision Met every two weeks to practice skills and review sessions with persons served Every staff person needed to identify a person served who demonstrated ambivalence Filled out an MI skills sheet to talk about the session Role play in group supervision

8 Going Agency wide Identify skills to be practiced
Groups met for four months before agency roll out Meetings with program elements to discuss integration of MI into practice Curriculum developed by three agency trainers All staff trained (2 day training) with practice exercises Committees continued to meet monthly for six months

9 Benefits of Learning about Motivational Interviewing
More realistic expectations Greater recognition of small accomplishments Greater success over time Less frustration and burnout Effective across populations and cultures Actively involves the person in his/her own care Improves adherence and retention Instills hope Consistent with Recovery Transformation Source: Retrieved July 18, 2008 from

To provide an introduction to the spirit of MI To learn about MI principles to use with individuals on behavior change To assess motivation for readiness to change To 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 change Source: Michael Wiles and Cross Country Education, Inc. 2005 Mi 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
Collaboration Working in partnership Evocation Draw out ideas and solutions from individuals Autonomy Decision making left to the person

13 Spirit of MI Motivation to change is elicited from the person, not externally It is the person’s task, not the counselor’s, to articulate and resolve ambivalence Direct persuasion is not an effective method for resolving ambivalence The counselor’s style is generally a quiet and eliciting one The counselor is directive only in helping the person to examine and resolve ambivalence Readiness 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 directing Dancing, rather than wrestling Listening, as much as telling Collaborative conversation Evokes from a person what he/she already has Honoring of a person’s autonomy Source: 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 change It fluctuates It can be modified It is influenced by external factors and social interactions It is very sensitive to interpersonal style There are internal and external sources We want to increase the probability of the person engaging in change behavior Motivating 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 change Normal aspect of human nature, not pathological Ambivalence is key issue to resolve for change to occur It is our friend

17 Changing Extrinsic to Intrinsic Motivation Changing because I want to
Know and explore values Core value discrepancy motivates change Explore life goals; discrepancy between where the person is and where he/she wants to be Choice/Self Determination Reframing the person’s negative statements


4 types: arguing; denying; ignoring; interrupting The more one talks about non-change behaviors, the more a person is likely to do them. It is determined by therapist style May mean the therapist is ahead of the person in the change process Resistance often stems from fear of change

20 Develop Discrepancy Difference between the person’s core values and life goals and their health behavior Difference between where the person is now and where he/she would like to be in the future Elicit 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 Change Payoff Matrix ICR Scales Value Cards

Unaware of the problem, hasn’t thought about change Engagement skills, develop trust, assertive outreach, accept client where they are at, provide concrete care CONTEMPLATION Thinking about change, in the near future (usually w/in the next 6mos) Instill hope, positive reinforcement for harm reduction, discuss consequences, raise ambivalence, motivational interviewing PREPARATION Making 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 planning ACTION Specific changes to life style has been made w/in past 6 mos Combat 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 situations MAINTENANCE Continuation of desirable actions, or repeating periodic recommended step's Assist in coping, reminders, finding alternatives, relapse prevention RELAPSE PART OF THE PROCESS Determine the triggers and plan for future prevention

23 PAYOFF MATRIX about Drinking
Drinking as before Abstaining Benefits Helps me relax Enjoy drinking with friends Eases boredom Feel better physically Have more $ Less conflict with family, work Costs Hard on my health Spending too much $ Might lose my job I’d miss getting high What to do about friends How to deal with stress

24 The ICR Scales : IMPORTANCE
How important is it for you to change right now? CONFIDENCE If you decide to change, how confident are you that you could do it? READINESS How 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


27 Reflective Listening Allows individual to feel heard
Allows you to confirm perceptions Simple 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 Questions Using Readiness Rulers Exploring the Decisional Balance Looking Back/Looking Forward Using hypotheticals Key Questions Source: 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 forms What 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 8 Looking 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 commitment What 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 definition Utilize the OARS worksheet Utilize the MI workbook

31 MI-Training of Staff Provide training on MI for employees twice a year for core clinical skills Beginner MI – offered for all new employees and anyone who wants\needs a refresher Advanced MI – for those staff wanting to take MI to a deeper level MI for non-clinical staff, i.e.: administrative assistants, finance office, data entry, etc

32 Supervision with MI Formal supervision with supervisor in session practice Staff required to complete MI Skills form Individual Recovery Plans and Progress Notes templates created to cue staff MI skills as a response to ambivalence In the field, in vivo supervision Observation, supervisor feedback Group supervision focused on MI in every session, utilizing skills checklist Consistent supervisory feedback in “teaching moments”

33 Recovery Plan/Progress Note

34 Progress Note Menu (CBT) Cognitive Behavioral Skills
Motivational Interventions (CBT) Cognitive Behavioral Skills (IM/R) Illness Management and Recovery Promote hope & positive expectations Reinforcement Recovery Strategies Connect info and skills with personal goals Role Playing Reducing Relapses Explore pros and cons of change Shaping Practical Facts about Mental Illness Re-frame experiences in positive light Cognitive Restructuring Coping with Stress Reflection, Affirmation, Open-ended Questions, Summarize Modeling Stress Vulnerability Elicit Change Talk Relaxation Training Coping w/symptoms & problems Looking Back/Looking Forward Relapse Prevention Social Support Developing Discrepancy Mental Health System. Explore ambivalence Medication Education Strengthening commitment to change Substance Abuse Healthy Lifestyles

35 Path Team and MI Embracing Spirit of MI = engagement of homeless individual Tailor strategies and interventions towards stage of change and readiness Utilize tools of MI, payoff matrix, Importance Confidence Readiness scales Team supervision and Individual supervision Review trainings twice a year

36 Program Outcomes Success of MI implementation leads to Cognitive Behavioral Interventions method of training and supervision. The change process for persons served is the focus Staff matches intervention/skill to person’s stage of change Distinguish process outcomes from persons served outcome measures Integrated Dual Disorder Treatment Implementation Capture number of persons served moving from pre-contemplation/contemplation to action/relapse prevention

37 Program Outcomes Capture number of persons served completing the Illness Management and Recovery Toolkit Capture number of people completing a readiness assessment for employment and education who followed through on their plans Motivational Interviewing is integral to helping programs meet outcome measures

38 Training Resources Motivation Interviewing Resources for clinicians, researchers and trainers

39 Resources B. 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 1999 S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care. Guilford Press 2008 C. Field, D. Hungerford and C. Dunn “Brief Motivational Interventions: An Introduction. J Trauma 2005; 59:S21-S26 M. Wiles Motivational Interviewing: Overcoming Client Resistance to Change Cross Country Education

40 Q & A Buddy Garfinkle, Associate Executive Director, Bridgeway Rehabilitation Services Nancy Schneeloch, Program Director, Bridgeway Rehabilitation Services Please 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.

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