Research Associate, Northwest Addiction Technology Transfer Center

Transcription

1 DEVELOPING MOTIVATIONAL INTERVIEWING SKILLS THE ROLE OF CLINICAL SUPERVISION Wendy Hausotter, MPH Research Associate, Northwest Addiction Technology Transfer Center You are a clinical supervisor in a behavioral health treatment agency, and you take pride in the fact that the counselors you supervise are well- versed in the use of various evidence- based practices, including Motivational Interviewing (MI). You support their training needs and have sent them to extensive workshops; you have followed up by asking them, during supervision sessions, if and how they are using MI. Most of them report that, in fact, they are using MI routinely and are having good success with it among their clients. Those who are struggling with MI are offered additional training. Periodically you revisit this conversation in your supervision sessions so you can support the ongoing use of MI. Sounds like a pretty good implementation strategy, right? Maybe not. Workshop training is often the primary way counseling skills such as MI are imparted, but research shows that workshops alone don t appear to adequately equip counselors to consistently deliver evidence- based practices to their clients (Walters et al., 2005). Research on MI in particular has shown that counselors demonstrated small increases in skills after a workshop, but quickly reverted to pre- workshop levels after several weeks (Baer et al., 2004; Miller et al., 2004; Mitcheson et al., 2009). While workshop- type training can improve counselors attitudes, knowledge, and confidence, supervised practice is where true skill development occurs. In Strategies for Training Counselors in Evidence- Based Treatments, Martino (2010) noted that competency- based clinical supervision has been shown to improve counselor skills. Further, clinicians who received a combination of written feedback, telephone coaching, or both, following participation in an MI workshop, demonstrated more proficiency than those who attended training without follow up, as reported in Miller and colleagues (2004). Notably, only when counselors received the most intensive level of supervisory input both feedback and coaching did their clients exhibit significant improvements in motivation for change within their sessions (Martino, 2010). MI skill acquisition How does one obtain the skills needed for effective use of MI? According to Miller and Moyers, MI practitioners acquire expertise in this method through a sequence of eight stages: (1)

2 2 openness to collaboration with clients' own expertise; (2) proficiency in client- centered counseling, including accurate empathy; (3) recognition of key aspects of client speech that guide the practice of MI; (4) eliciting and strengthening client change talk; (5) rolling with resistance; (6) negotiating change plans; (7) consolidating client commitment; and (8) switching flexibly between MI and other intervention styles. This succession occurs roughly in order, with earlier steps representing logical prerequisites to advanced skill acquisition. (Miller et al., 2010). While these stages may seem straightforward, research on MI skills in action would seem to indicate that many clinicians do not successfully complete all of these stages (Ball et al., 2002). While many counselors say and think they are doing MI, observation reveals they are not using MI appropriately, effectively, or consistently (Miller, 2004). Forsberg (2010) found that it took two- and- one- half years for clinicians to achieve the recommended threshold for beginning proficiency in the MI spirit variables alone. Practitioners do not necessarily learn MI easily. Forsberg and colleagues note, Any successful implementation in a naturalistic clinical setting requires ongoing supervision of counselors, including feedback and monitoring clinical practice. This strategy is consistent with Fixsen s research on the elements ( implementation drivers ) that have been found in successful adoption of evidence- based practices, including not only staff selection, pre- service and in- service training, but also ongoing coaching and consultation, and staff performance evaluation, among other aspects (Fixsen, 2005). If clinical supervision, feedback, and observation are key components in MI skill development, is it happening? The ATTC Network s Vital Signs: Taking the Pulse of the Addiction Treatment Workforce, a 2012 study on the addiction treatment workforce, provides some indication of the degree to which clinical supervision is occurring, and whether it typically includes observation of, and supervised practice with, particular counseling skills. Results of the Vital Signs study indicate that, during supervision sessions, clinical directors focus relatively little time on improving specific counseling skills (16%) and giving feedback on observed performance (15%). Instead, the most time is spent discussing counselor problems and challenges, listening to counselors present cases, and reviewing treatment discharge plans. The graph below, from the study, illustrates the time actually spent on activities during supervision sessions:

3 3 Source: Ryan et al., 2012 in Vital Signs If observation and supervised practice are essential to MI (and other evidence- based practice) skill acquisition, it is no wonder that a gap exists between self- reported and demonstrated skill levels when counselors are observed using MI assessment tools (Miller et al. 2004). Use MI TO support MI Although research on evidence- based supervision is sparse (Ellis et al., 1996; Holloway & Neufeldt, 1995), various studies, articles, and analyses have addressed ways through which clinical supervisors can impart MI skill development in particular. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency, (Martino et al. 2006) emphasizes the role of the supervisor in how well a clinician implements MI. Strategies such as eliciting the counselor s perspective on areas of strength and challenge in MI performance first, and then guiding the discussion toward progress and options for clinical direction with a particular client, tend to yield rich conversations. Accounting both for the efficacy of MI in promoting behavior change and the value of modeling desired behavior, it makes intuitive sense that if a clinical supervisor is seeking to cultivate MI skills within their staff members, employing MI as a supervision style would be an effective approach. To view contrasting examples illustrating MI- consistent and MI- inconsistent supervision sessions, visit using- motivational- interviewing- style from Mental Health Systems. As you watch the videos, note the differences in who owns the realizations in both scenarios. The MI- consistent conversation seems to empower and motivate the counselor far more than the session that is more focused on problems. Interestingly, MI- based clinical supervision has been found to decrease counselor resistance to the supervision process itself, especially when a discrepancy exists between observed and self- assessed skills. In one study, the recommended procedure of using written self- critiques of audiotaped therapy sessions, based on MI principles, was used to facilitate acceptance of

4 4 feedback for doctoral clinical psychology students. According to the authors, The self- critiques were evaluated very positively by trainees as helping them accept critical feedback and allowing them to provide suggestions for their own clinical skill development (Sobell et al., 2008). In addition to clinical supervision, agency context and organizational support for training (Baer et al., 2009; Bruns et al., 2008), as well as specific training methods used (Herschell et al., 2010), appear to have an impact on how counselors approach proficiency. Despite the influence of other variables, clinical supervision remains a key factor. Several helpful resources can be used to improve that part of the skill development process. MI resources for clinical supervisors A variety of tools exist to support clinical supervisors in guiding counselors along the path to competent MI practice. A few of tem are highlighted below: ATTC trainings Keep an eye out for trainings in clinical supervision offered by many of the regional ATTCs; go to for information on training opportunities. Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) This toolkit (available at is a collection of resources for mentoring counselors in the use of MI skills during clinical assessments. It includes a training package for clinical supervisors and practical tools they can use to enhance treatment providers MI skills. Motivational Interviewing Website: This resource hub for all things Motivational Interviewing also includes specific pages that focus on the needs of clinical supervisors. It can be accessed at: National Implementation Science Research Network Information and resources on what works in implementation of innovative and evidence- based practices, including training, supervision, coaching and performance assessment tools. SAMHSA TIP 35: This in- service training manual introduces substance abuse treatment counselors, clinicians, and other professionals to basic concepts and techniques of motivational enhancement interventions. TIP 35 includes modules with overheads and handouts: Motivation- for- Change- Inservice- Training/SMA Video demonstrating clinical supervision in MI style: using- motivational- interviewing- style

5 5 Conclusion MI is an evidence- based strategy with deep roots in helping clients with substance use disorders. Given the research emphasizing the critical role of coaching and feedback in fidelity to the model, clinical supervisors are in a unique position to influence MI skill acquisition in counselors, which in turn significantly impacts client change. Herschell et al., in a review of 55 studies evaluating EBP training methods, sums up the relative contributions of various aspects of skill development with the following apt statement: Essentially, there does not seem to be a substitute for expert consultation, supervision, and feedback for improving skills and increasing adoption. Training alone is clearly not enough, and the tools and resources outlined in this article can help clinical supervisors ensure that MI is used in the maximally helpful way for the client. References Baer JS, Rosengren DB, Dunn CW, Wells EA, Ogle RL. (2004). An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians. Drug and Alcohol Dependence. 73: Baer JS, Wells EA, Rosengren DB, Hartzler B, Beadnell B, Dunn C. (2009). Agency context and tailored training in technology transfer: A pilot evaluation of motivational interviewing training for community counselors. Journal of Substance Abuse Treatment 37: Ball, S. A., Bachrach, K., DeCarlo, J., Farentinos, C., Keen, M., McSherry, T., Polcin, D., Snead, N., Sockriter, R., Wrigley, P., Zammarelli, L., & Carroll, K. M. (2002). Characteristics, beliefs, and practices of community clinicians trained to provide manual- guided therapy for substance abusers. Journal of Substance Abuse Treatment. 23(4): Bruns EJ, Hoagwood KE, Rivard JC, Wotring J, Marsenich L, Carter B. (2008). State implementation of evidence- based practice for youths, part II: Recommendations for research and policy. Journal of the American Academy for Child and Adolescent Psychiatry 47(5): Center for Substance Abuse Treatment (2007). Competencies for Substance Abuse Treatment Clinical Supervisors. Technical Assistance Publication (TAP) Series 21- A. DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Center for Substance Abuse Treatment. Enhancing Motivation for Change Inservice Training. (2006). DHHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration. Ellis MV, Ladany N, Krengel M, Schult D. (1996). Clinical supervision research from 1981 to 1993: A methodological critique. Journal of Counseling Psychology 43:35 50.

6 6 Fixsen, D. L., & Blase, K. A. (2009, January). Implementation: The missing link between research and practice. NIRN Implementation Brief #1. Chapel Hill: The University of North Carolina, FPG, NIRN. Forsberg, L, Forsberg, LG, Lindqvist, H and Helgason, A (2010). Clinician acquisition and retention of Motivational Interviewing skills: a two- and- a- half- year exploratory study. Substance Abuse Treatment, Prevention, and Policy 5:8. Herschell A, Kolko D, Baumann B, Davis A. (2010). The role of therapist training in the implementation of psychosocial treatments: A review and critique with recommendations. Clinical Psychology Review. 30(4): Holloway EL, Neufeldt SA. (1995). Supervision: Its contributions to treatment efficacy. Journal of Consulting and Clinical Psychology 63: Martino, S. (2010). Strategies for Training Counselors in Evidence- Based Treatments. Addiction Science and Clinical Practice. 5(2): Martino, S, Ball, SA, Gallon, SL, Hall, D, Garcia, M, Ceperich, S, Farentinos, C, Hamilton, J, and Hausotter, W (2006). Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA:STEP). Salem, OR: NW Frontier ATTC, Oregon Health and Science University. Miller, W.R., et al. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology 72(6): Miller WR, Mount KA. (2001). A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioural and Cognitive Psychotherapy 29: Miller, WR, Moyer, TB. (2010). Eight Stages in Learning Motivational Interviewing. Clin Psychol. 17(1): Mitcheson L, Bhavsar K, McCambridge J. (2009). Randomized trial of training and supervision in motivational interviewing with adolescent drug treatment practitioners. Journal of Substance Abuse Treatment 37(1):73-8. Ryan, O., Murphy, D., Krom, L. (2012). Vital Signs: Taking the Pulse of the Addiction Treatment Workforce,A National Report, Version 1. Kansas City, MO: Addiction Technology Transfer Center National Office in residence at the University of Missouri- Kansas City. Sobell, LC, Manor, L., Sobell, MB, Dum, M. (2008). Self- critiques of audiotaped therapy sessions: A motivational procedure for facilitating feedback during supervision. Training and Education in Professional Psychology 2(3): Walters ST, Matson SA, Baer JS, Ziedonis DM. (2005). Effectiveness of workshop training for psychosocial addiction treatments: A systematic review. Journal of Substance Abuse Treatment 29: