Communities of Practice and Motivational Interviewing Melinda Hohman, Ph.D.

Communities of Practice
and
Motivational Interviewing
Melinda Hohman, Ph.D.
mhohman@mail.sdsu.edu
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
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 )
MI Spirit:
The speaker demonstrates:
• Partnership/collaboration
• Acceptance
– Absolute worth
– Accurate empathy
– Autonomy support
– Affirmation
• Evocation
• Compassion
(Miller & Rollnick, 2013)
MI Skills:
The speaker utilizes:
•
•
•
•
Open-ended questions
Affirmations and supportive statements
Reflective listening
Summaries
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
Four Foundational Processes in MI
Planning
Evoking
Focusing
Engaging
MI as an EBP
• NREPP from SAMSHA:
http://www.nrepp.samhsa.gov/ViewInterventi
on.aspx?id=130
• California Clearinghouse for EBP for CW:
http://www.cebc4cw.org/program/motivation
al-interviewing/
• Numerous RCTs and meta-analyses
(Hohman, 2012)
Questions about MI?
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
Implementation Science:
Successful Implementation
Core
Implementation
Components
Organizational
Components
Influence
Factors
(Fixsen et al., 2005)
Core Implementation Components
Coaching
Individual
Training
Evaluation
Program
Selection
Evaluation
Administrative
Supports
(Fixsen et al., 2005)
Core Implementation Components
Coaching
Individual
Training
Evaluation
Program
Selection
Evaluation
Administrative
Supports
(Fixsen et al., 2005)
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
Core Implementation Components
Coaching
Individual
Training
Evaluation
Program
Selection
Evaluation
Administrative
Supports
(Fixsen et al., 2005)
Selection
• Staff selection: Voluntary or Involuntary?
– Practitioners; New hires
– Organizational staff
– Administrators
– Evaluators
• Trainer selection
– Outside trainers
– In-house trainers
Core Implementation Components
Coaching
Individual
Training
Evaluation
Program
Selection
Evaluation
Administrative
Supports
(Fixsen et al., 2005)
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
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)
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
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
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
Questions about MI training and implementation?
Core Implementation Components
Coaching
Individual
Training
Evaluation
Program
Selection
Evaluation
Administrative
Supports
(Fixsen et al., 2005)
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?
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)
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)
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
MI Coaching: Formal Models
• Alamance County, NC CWS
• San Diego Probation
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)
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
MI Coaching: Informal Model
Communities of Practice
Or
Learning Circles
Or
Reflective Counseling Groups
Or
MI Peer Support Group
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)
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
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)
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”
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)
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)
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)
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!
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)
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
Questions about Coaching, Formal or Informal
or Communities of Practice?
Core Implementation Components
Coaching
Individual
Training
Evaluation
Program
Selection
Evaluation
Administrative
Supports
(Fixsen et al., 2005)
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
Core Implementation Components
Coaching
Individual
Training
Evaluation
Program
Selection
Evaluation
Administrative
Supports
(Fixsen et al., 2005)
Program Evaluation
• Agencies need to be at Full Implementation
before a system-wide evaluation of the
intervention’s impacts can be evaluated.
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
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 systemwide implementation and/or individual coaching
services
“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)
Final Thoughts and/or Questions
References
Barwick, M. A., Peters, J., & Boydell, K. (2009). Getting to uptake: Do Communities of
Practice support the implementation of evidence-based practice? Journal of the
Canadian Academy of Child and Adolescent Psychiatry, 18 (1), 16-29.
Bennett, G. A., Moore, J., Vaughan, T., Rouse, L., Gibbins, J. A., Thomas, P., James,
K., & Gower, P. (2007a). Strengthening motivational interviewing skills following
initial training: A randomized trial of workplace-based reflective practice. Addictive
Behaviors, 32, 2963-2975.
Daye, A.,, McGinty, M., Nagy, P., & Snyder, L. (2013). Comprehesive family
assessment: A collaborative model for improving caseworkers’ clinical assessment
and engagement skills. Paper presented at PCA-NC Summit. Raleigh, NC.
Fixsen, D. L., Naoom, S. F., Blase, K. A., Friedman, R. M., & Wallace, F. (2005).
Implementation research: A synthesis of the literature. Tampa, FL: The National
Implementation Research Network (FMHI Publication #231).
Gaume, J., Gmel, G., Faouzi, M., & Daeppen, J. B. (2009). Counselor skill influences
outcomes of brief motivational interventions. Journal of Substance Abuse
Treatment, 37 (2), 151-159.
Hohman, M. (2012). Motivational interviewing in social work practice. New York:
Guilford Press.
References
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change. (3rd
Ed.). New York: Guilford Press.
Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A
randomized trial of methods to help clinicians learning motivational interviewing.
Journal of Consulting and Clinical Psychology, 72 (8), 1050-1062.
Moore, B. (2008). Using technology to promote communities of practice (CoP) in social
work education. Social Work Education, 27 (6), 592-600.
Paré, D. (2009). Notes from the basement: Developing therapist communities through
collaborative practice groups. Journal of Systemic Therapies, 28 (3), 89-102.
Wenger, E. (2006). Communities of practice: A brief introduction. Accessed at
http:/www.ewenger.com/theory.
Wilding, C., Curtin, M., & Whiteford, G. (2012). Enhancing occupational therapists’
confidence and professional development through a community of practice scholars.
Australian Occupational Therapy Journal, 59, 312-318.
Other articles/books
Bennett, G. A., Moore, J., Vaughan, T., Rouse, L., Gibbins, J. A., Thomas, P.,
James, K., & Gower, P. (2007). Strengthening motivational
interviewing skills following initial training: A randomized trial of
workplace-based reflective practice. Addictive Behaviors, 32, 29632975.
Cook-Craig, P. G., & Sabah, Y. (2009). The role of virtual communities of
practice in supporting collaborative learning among social workers.
British Social Work Journal, 39, 725-739.
Lowencamp, M., Robinson, C. R., Koutsenok, I., Lowencamp, C. T., & Pearl, N.
(2012).The importance of coaching: A brief survey of probation officers.
Federal Probation, 72 (2).
Wenger, E., McDermott, R., & Snyder, W. M. (2002). Cultivating communities
of practice. Boston: Harvard Business School Press.