Buddy Garfinkle and Nancy Schneeloch, Bridgeway Rehabilitation Services,

Elizabeth, New Jerseybuddy.garfinkle@bridgeway.com

nancy.schneeloch@bridgeway.com

Bridgeway Rehabilitation ServicesOUR 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.

Bridgeway Rehabilitation ServicesOur Services – Eight counties, 1500

IndividualsPACTSupportive HousingResidential Intensive Support TeamsPATH: Homeless Outreach ServicesJustice-Involved ServicesCareer Development ServicesCommunity Support Team

Beginning with MIWhy 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 language

Helped staff to focus on a specific skill setProvide clinical interventions based on an

individual’s stage of change

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 frustration

Evidence base for Motivational InterviewingSAMSHA’s evidence-based practices require

MI and CBT interventions.Decision made to focus on MI and CBT before

implementing IMR

Senior Management InvolvementHow 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 CommitteeIdentified an expert trainer

MI Steering Committee members attend additional Integrated Dual Disorder Treatment Trainings

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

Going Agency wideIdentify skills to be practicedGroups met for four months before agency roll

outMeetings with program elements to discuss

integration of MI into practice Curriculum developed by three agency trainersAll staff trained (2 day training) with practice

exercisesCommittees continued to meet monthly for six

months

Benefits of Learning about Motivational InterviewingMore realistic expectations Greater 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 Transformation

Source: Retrieved July 18, 2008 from ahec.allconet.org/newrihp/powerpoint/

MI TRAINING GOALS for STAFFTo 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

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

Three Components of MI Spirit

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.

Characteristics of Motivational InterviewingGuiding, more than directingDancing, rather than wrestlingListening, as much as tellingCollaborative conversationEvokes from a person what he/she already

hasHonoring of a person’s autonomy

Source: S. Rollnick, W. Miller and C. Butler Motivational Interviewing in Health Care, 2008.

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

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

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

PRINCIPLES OF MOTIVATIONAL INTERVIEWING…

“AREDS”

A- Avoid Arguing

R- ROLL WITH RESISTANCE

E- EXPRESS EMPATHY

D- DEVELOP DISCREPANCY

S- SUPPORT SELF EFFICACY

REVIEW RESISTANCEIt is normal4 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

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 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.

Assessment Tools…

1. Stage of Change2. Payoff Matrix 3. ICR Scales4. Value Cards

CONCEPT DEFINITION METHODS OF TX.

PRE-CONTEMPLATION

Unaware of the problem, hasn’t thought about change

Engagement skills, develop trust, assertive outreach, accept client

where they are at, provide concrete care

CONTEMPLATIONThinking 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

PREPARATIONMaking 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

MAINTENANCEContinuation of desirable actions,

or repeating periodic recommended step's

Assist in coping, reminders, finding alternatives, relapse prevention

RELAPSE PART OF THE PROCESSDetermine the triggers and plan for future prevention

STAGES OF CHANGE

PAYOFF MATRIX about Drinking

Drinking as Drinking as beforebefore

AbstainingAbstaining

BenefitsBenefits Helps me relaxHelps me relax

Enjoy drinking with Enjoy drinking with friendsfriends

Eases boredomEases boredom

Feel better physicallyFeel better physically

Have more $Have more $

Less conflict with Less conflict with family, workfamily, work

CostsCosts Hard on my healthHard on my health

Spending too much $Spending too much $

Might lose my jobMight lose my job

I’d miss getting highI’d miss getting high

What to do about What to do about friendsfriends

How to deal with How to deal with stressstress

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?

Value CardsSort them into important/not important

categoriesHave person pick out the five most important

values and share what it means to him\her

http://www.motivationalinterview.org/library/valuescardsort.pdf

MI Skills

“AROSE”

AFFIRMATIONS

REFLECTIVE LISTENING

OPEN ENDED QUESTIONS

SUMMARIES

ELICIT CHANGE TALK

Reflective ListeningAllows individual to feel heardAllows 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”

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

Strategies To Elicit Change Talk Asking Evocative Questions Using Readiness RulersExploring the Decisional Balance Looking Back/Looking Forward Using hypotheticalsKey Questions

Source: S. Rollnick, W. Miller and C. Butler, Motivational Interviewing in Health Care, 2008.

Training on MI SkillsReview the definitionPractice the skills right after definitionUtilize the OARS worksheetUtilize the MI workbook

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

Supervision with MIFormal supervision with supervisor in session practiceStaff required to complete MI Skills form Individual Recovery Plans and Progress Notes

templates created to cue staffMI skills as a response to ambivalenceIn the field, in vivo supervision

• Observation, supervisor feedbackGroup supervision focused on MI in every session,

utilizing skills checklistConsistent supervisory feedback in “teaching

moments”

Recovery Plan/Progress Note     OVERALL REHAB/RECOVERY GOAL #1:_____________________________     STAGES OF CHANGE (PLEASE CHECK THE APPROPRIATE BOX) PRE- CONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCESTAGES 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: ______________________________     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

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 ambivalenceMedication Education

Strengthening commitment to changeSubstance Abuse

Healthy Lifestyles

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

Program OutcomesSuccess 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

Program OutcomesCapture 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

Training Resources

Motivation Interviewing Resources for clinicians, researchers and trainers

http://www.motivationalinterview.org/

ResourcesB. Borrelli, “Using Motivation Interviewing to Promote Patient

Behavior Change and Enhance Health” http://www.medscape.com/viewprogram/5757

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

www.CrossCountryEducation.com

Q & ABuddy Garfinkle, Associate Executive

Director, Bridgeway Rehabilitation ServicesNancy 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.