Communities of Practice and Motivational Interviewing

1. Communities of Practiceand Motivational Interviewing Melinda Hohman, Ph.D. mhohman@mail.sdsu.edu

2. Today’s Agenda • Motivational Interviewing (MI): A brief overview • Beyond “Train and Hope”:EBP Implementation Science model • Applying the Implementation model to MI • Coaching: Formal and Informal systems and examples • The role of Communities of Practice (CoP) • Sustaining CoP • Summary and Wrap-Up

3. What is MI? “MI is a collaborative, goal-oriented style of communication with a particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” (Miller & Rollnick, 2013, p.29 )

4. MI Spirit: The speaker demonstrates: • Partnership/collaboration • Acceptance • Absolute worth • Accurate empathy • Autonomy support • Affirmation • Evocation • Compassion (Miller & Rollnick, 2013)

5. MI Skills: The speaker utilizes: • Open-ended questions • Affirmations and supportive statements • Reflective listening • Summaries

6. With a focus on: Change Talk • Desire to change • Ability to make changes • Reasons for change • Need for change and • Commitment to Change • Taking Steps

7. Four Foundational Processes in MI

8. MI as an EBP • NREPP from SAMSHA: http://www.nrepp.samhsa.gov/ViewIntervention.aspx?id=130 • California Clearinghouse for EBP for CW: http://www.cebc4cw.org/program/motivational-interviewing/ • Numerous RCTs and meta-analyses (Hohman, 2012)

9. Questions about MI?

10. How is MI Implemented?Moving Beyond “Train and Hope”Or Helping People to Change Their Behaviors Using Implementation Science and other research as a guide

11. Implementation Science: Successful Implementation (Fixsen et al., 2005)

12. Core Implementation Components (Fixsen et al., 2005)

13. Core Implementation Components (Fixsen et al., 2005)

14. Administrative Supports • Top down: Agency administrator decides that specific EBPs will be implemented • Bottom up: Agency is supportive of practitioner-initiated change • Provides training • Provides space for on-going practice, learning

15. Core Implementation Components (Fixsen et al., 2005)

16. Selection • Staff selection: Voluntary or Involuntary? • Practitioners; New hires • Organizational staff • Administrators • Evaluators • Trainer selection • Outside trainers • In-house trainers

17. Core Implementation Components (Fixsen et al., 2005)

18. Training • Release time away from tasks of work, clients • Content is meaningful, useful, contextualized • Consists of: • Knowledge • Demonstrations of Skills • Opportunities to Practice Skills • For Motivational Interviewing, 2-4 days gives a good foundation

19. Learning MI: EMMEE Trial* • 140 social workers, counselors assigned to: • Workshop only (2 days) • Workshop with coaching • Workshop with feedback • Workshop with feedback and coaching • Waitlist with manual and videotapes All provided an audiotape of a session with a client at baseline, post-training (standardized client), 4, 8, 12 months, which were coded. *Evaluating Methods for Motivational Enhancement Education, (Miller et al., 2004)

20. Outcomes • All groups improved relative to the waitlist • Marginal gains were made by workshop only but lost at 4 month FU • Other 3 groups made significant gains which were maintained; MI inconsistent responses decreased • No gains made at all by waitlist group at FU • Only those who received workshop/feedback/ coaching showed differences in client response

21. Implications • Self-guided training doesn’t work • Self-report is not valid; Need for objective observer • Mandated versus Voluntary trainees—may need to spend time with increasing motivation to learn • Skill gain can be made after 2-days of training but need for on-going support/coaching to make an impact on clients

22. Why is MI be so hard to utilize? Miller: “Simple, but not easy.” Common communication methods that become communication traps: • Question-Answer • Expert • Premature Focus • Taking Sides • Labeling Miller & Rollnick, 2013

23. Questions about MI training and implementation?

24. Core Implementation Components (Fixsen et al., 2005)

25. Put Me in Coach… When you think of coaching, what comes to mind? What is it like to learn a new skill or refine an old one?

26. Too often, after a training, practitioners… “return home to an isolated practice with no one to witness and support tentative stabs at applying the learning.” (Paré, 2009, p. 99)

27. Coaching • Behavior change is difficult for most people • Skills can be somewhat basic after initial training • Removing old skills can be difficult • Reactions from colleagues, etc. may not be supportive • Skills need to be shaped in the service setting • Personal support can be helpful (Fixsen et al., 2005)

28. MI and Coaching • May involve hiring trained coaches • Use of audiotaped sessions that are coded for fidelity or real-time observations • Feedback of scores and coaching to improve skills • Telephone-based • Group-based • Coaching relationships can be started during training • Ongoing nature

29. MI Coaching: Formal Models • Alamance County, NC CWS • San Diego Probation

30. Alamance County CWS Coaches used in • Office visits • Home visits • Community settings Immediacy of skill practice & feedback • Direct observation • Feedback for one change • Practiced in immediate next visit • Fidelity scores provided (Daye, McGinty, Nagy, & Snyder, 2013)

31. San Diego Probation • Implementation Team • Training in MI for admin, all staff • Selected Senior staff training in Coaching and Feedback: modeling MI • Provided 3-6 tapes to trainers • Paired with 4 mentees • Work in field to give feedback; also tapes

32. MI Coaching: Informal Model Communities of Practice Or Learning Circles Or Reflective Counseling Groups Or MI Peer Support Group

33. Communities of Practice “Communities of Practice (CoP) are groups of people who share a concern or passion for something they do and learn how to do it better as they interact regularly.” (Wenger, 2006)

34. Communities of Practice • Developed initially in education, then management; into health care, mental health work • Meet regularly over time • No manager or supervisor to report to • Goal is to increase skills, fidelity to MI • Focus is on practice of skills with feedback • Application of MI to contexts of practice • Atmosphere of learning, support, collaboration, practice, mutuality of expertise

35. Elements of CoP • A domain of knowledge • Common ground, sense of identity, purpose, ownership • A community of people • Care about the domain, interested in learning, sharing, trust and involvement, partnering • Shared practice • Framework, language, skills (Barwick, Peters, & Boydell, 2009)

36. Characteristics of CoP • Membership is informal & fluctuates • May cross agency boundaries, disciplines • Members set their own agenda & methods (Moore, 2008) • Activities can be formal or informal or both • Based on interpersonal relationships to develop skills • Emphasis on “learning, practice, and process”

37. Potential Benefits Qualitative study of 25 occupational therapists who participated in a 12 month CoP:  Able to critically examine their practice and consider ways to improve it  Increased confidence in their practice and passion for their work (Wilding, Curtin, & Whiteford, 2012)

38. Potential Benefits Randomized control trial: Children’s mental health social workers assigned to CoP or PAU • N=18; Met 6 times over 12 months, facilitated by trainer • Focus was on implementing standardized assessment/outcome measure • Outcome: Greater use of tool in practice, better knowledge, and satisfaction with supports • (Barwick, Peters, & Boydell, 2009)

39. Suggestions for MI CoP Meetings • Focus on a particular skill in your context • Real vs role play • Use short increments—5 minutes • Keep observers busy; give a task • Debrief: Social worker, then client, then observers: What was good or MI adherent about the interview? • ONE suggestion for improvement from ONE person (Miller & Rollnick, 2013)

40. Other Tips • Prerequisite for joining the group? • Make a commitment to scheduling it, 1 or 2x month • Review client tapes (consented) • Affirm those who take a risk • Use a structured coding method, such as counting OARS skills, change talk • Indicate target of change before listening or role play • Focus on positive, one suggestion • Keep focus on MI skills • Avoid being the “expert” if you are one • Food is fun!

41. CoP Examples • San Diego CWS: Clinical Supervision Group run by Bill James, MSW (bill@billjamestraining.com) or see Hohman (2012) • San Diego SDSU Field Instructors: • http://mipracticesd.spruz.com/ • “In case conferences, practitioners typically talk about their work, but most do not show the work or do the work in the room,” (Paré, 2009, p. 99)

42. Sustaining CoP • Little research in social services work • Anecdotal experiences; Paré (2009) • Solicit feedback on members’ experiences • Focus on shared values, collaboration • Voluntary nature • Outreach, outreach, outreach

43. Questions about Coaching, Formal or Informal or Communities of Practice?

44. Core Implementation Components (Fixsen et al., 2005)

45. Individual Evaluation:Why all the bother? • Practitioners recognize and embrace MI • See differential response from clients • Understand that fidelity is related to effectiveness (Gaume, Gmel, Faouzi, & Daeppen, 2008) • Realize that communication traps are difficult to overcome/Skill drift • Formal: Administrators may want to change agency culture

46. Core Implementation Components (Fixsen et al., 2005)

47. Program Evaluation • Agencies need to be at Full Implementation before a system-wide evaluation of the intervention’s impacts can be evaluated.

48. Summary & Wrap-Up • MI is described as simple but not easy to learn • Old skills can impact effectiveness • Fidelity to the model is critical • Coaching and on-going evaluation is how practice improves • Communities of Practice can be a low-cost way to improve skills • Sustaining CoP can be difficult but do-able

49. Summary & Wrap-Up • Implementation with focus on Coaching and Communities of Practice • For consultation on implementation: • www.motivationalinterviewing.org • List of MI trainers who have experience in system-wide implementation and/or individual coaching services

50. “For me, the skills that I feel comfortable with within this group and I see in everybody, are around connecting. So they’re about sharing; they are about collaborating; they’re about building on each other’s ideas, they’re about giving space…those are the skills that I treasure, and that I want to develop more and more.” (CoP member, as quoted by Paré, 2009, p. 100)