Motivation and it is in action

1. Buddy Garfinkle and Nancy Schneeloch,
Bridgeway Rehabilitation Services,
Elizabeth, New Jersey
buddy.garfinkle@bridgeway.com
nancy.schneeloch@bridgeway.com

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 ahec.allconet.org/newrihp/powerpoint/

10. 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

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

12. Three Components of MI Spirit

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.

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

18. PRINCIPLES OF MOTIVATIONAL
INTERVIEWING…
“AREDS”
A- Avoid Arguing
R- ROLL WITH RESISTANCE
E- EXPRESS EMPATHY
D- DEVELOP DISCREPANCY
S- SUPPORT SELF EFFICACY

19. 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

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…
1. Stage of Change
2. Payoff Matrix
3. ICR Scales
4. Value Cards

22. 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
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
STAGES OF CHANGE

23. PAYOFF MATRIX
about Drinking
Drinking as beforeDrinking as before AbstainingAbstaining
BenefitsBenefits Helps me relaxHelps me relax
Enjoy drinking with friendsEnjoy drinking with friends
Eases boredomEases boredom
Feel better physicallyFeel better physically
Have more $Have more $
Less conflict with family,Less conflict with family,
workwork
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 friendsWhat to do about friends
How to deal with stressHow 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 himher
http://www.motivationalinterview.org/library/valuescar
dsort.pdf

26. MI Skills
“AROSE”
AFFIRMATIONS
REFLECTIVE LISTENING
OPEN ENDED QUESTIONS
SUMMARIES
ELICIT CHANGE TALK

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.

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 wantsneeds 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
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

34. 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
http://www.motivationalinterview.org/

39. 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

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.