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Communities of Practice and Motivational Interviewing

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Title: Communities of Practice and Motivational Interviewing


1
Communities of Practice and Motivational
Interviewing
  • Melinda Hohman, Ph.D.
  • mhohman_at_mail.sdsu.edu

2
Todays Agenda
  • Motivational Interviewing (MI) A brief overview
  • Beyond Train and HopeEBP 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
    persons 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
Planning
Evoking Evoking
Focusing Focusing Focusing
Engaging Engaging Engaging Engaging
8
MI as an EBP
  • NREPP from SAMSHA http//www.nrepp.samhsa.gov/Vie
    wIntervention.aspx?id130
  • California Clearinghouse for EBP for CW
    http//www.cebc4cw.org/program/motivational-interv
    iewing/
  • 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 doesnt work
  • Self-report is not valid Need for objective
    observer
  • Mandated versus Voluntary traineesmay 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 Childrens mental
    health social workers assigned to CoP or PAU
  • N18 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 increments5 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_at_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 interventions
    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 theyre about sharing they
are about collaborating theyre about building
on each others ideas, theyre about giving
spacethose are the skills that I treasure, and
that I want to develop more and more. (CoP
member, as quoted by Paré, 2009, p. 100)
51
Final Thoughts and/or Questions
52
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.
53
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.

54
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,
2963- 2975. 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.
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