Buddy Garfinkle and Nancy Schneeloch, Bridgeway Rehabilitation Services, Elizabeth, New Jersey [email protected] [email protected] 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. 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 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 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 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 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 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 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 ahec.allconet.org/newrihp/powerpoint/ MI TRAINING GOALS for STAFF  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 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 Collaboration • Working in partnership Evocation • Draw out ideas and solutions from individuals Autonomy • Decision making left to the person 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. 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. 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 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 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 PRINCIPLES OF MOTIVATIONAL INTERVIEWING… “AREDS” A- Avoid Arguing R- ROLL WITH RESISTANCE E- EXPRESS EMPATHY D- DEVELOP DISCREPANCY S- SUPPORT SELF EFFICACY REVIEW RESISTANCE  It is normal  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 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. Assessment Tools… 1. Stage of Change 2. Payoff Matrix 3. ICR Scales 4. Value Cards STAGES OF CHANGE CONCEPT DEFINITION METHODS OF TX. 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 PRECONTEMPLATION ACTION Specific changes to life style has been made w/in past 6 mos MAINTENANCE Continuation of desirable actions, or repeating periodic recommended step's RELAPSE PART OF THE PROCESS 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 Assist in coping, reminders, finding alternatives, relapse prevention Determine the triggers and plan for future prevention 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 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 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 http://www.motivationalinterview.org/library/valuescar dsort.pdf MI Skills “AROSE” AFFIRMATIONS REFLECTIVE LISTENING OPEN ENDED QUESTIONS SUMMARIES ELICIT CHANGE TALK 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” 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 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. Training on MI Skills  Review the definition  Practice the skills right after definition  Utilize the OARS worksheet  Utilize the MI workbook 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 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” 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: ______________________________ 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 Progress Note Menu Motivational Interventions Promote hope & positive expectations Connect info and skills with personal goals Explore pros and cons of change Re-frame experiences in positive light Reflection, Affirmation, Open-ended Questions, Summarize (CBT) Cognitive Behavioral Skills (IM/R) Illness Management and Recovery Reinforcement Recovery Strategies Role Playing Reducing Relapses Shaping Practical Facts about Mental Illness Cognitive Restructuring Coping with Stress Modeling Stress Vulnerability Elicit Change Talk Relaxation Training Coping w/symptoms & problems Looking Back/Looking Forward Relapse Prevention Social Support Developing Discrepancy Explore ambivalence Strengthening commitment to change Mental Health System. Medication Education Substance Abuse Healthy Lifestyles 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 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 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 Training Resources  Motivation Interviewing Resources for clinicians, researchers and trainers http://www.motivationalinterview.org/ Resources B. 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&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.