buddy garfinkle and nancy schneeloch, bridgeway rehabilitation services, elizabeth, new jersey...
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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.
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