Gateway to Recovery
Success
Connecting the Mission and Improving Recovery Outcomes
Through Staff Supervision and Professional Development for
Counselors and Case Managers in Addiction Treatment
KIMBERLY R. BECK, M.ED., LPC,CRAADC,CCJP, CCDP-D
CONNECTING TO MISSION
• MEET HUMAN NEED:
“While women weep, as they do now,
I'll fight
While little children go hungry, as they do now,
I'll fight
While men go to prison, in and out, in and out, as they do now,
I'll fight
While there is a drunkard left,
While there is a poor lost girl upon the streets,
While there remains one dark soul without the light of God,
I'll fight-I'll fight to the very end!”
― William Booth
EQUIPPING TO SERVE
• And it was He who gave some to be apostles, some to be prophets, some to
be evangelists, and some to be pastors and teachers, 12to equip the saints
for works of ministry, to build up the body of Christ,
• EPHESIANS 4:11-12
INSTITUTE OBJECTIVES
• LEARN BEST PRACTICE INTERVENTIONS
• PRACTICE BEST PRACTICE INTERVENTIONS
• RECEIVE AND LEARN HOW TO PROVIDE EFFECTIVE SUPERVISORY
INTERVENTION
OBJECTIVE ONE-LEARN BEST PRACTICES
• Motivational Interviewing
WHAT IS EVIDENCE BASED PRACTICE
• Adherence to psychological approaches and techniques that are based on
scientific evidence is referred to as "Evidence-based Practice" (EBP). ... The
most commonly used evidence-based practice approaches for
the treatment of psychological symptoms involve cognitive and
behavior therapies (CBT).
WHERE TO FIND EVIDENCE BASED
PRACTICES
http://www.nrepp.samhsa.gov/landing.aspx
What We Know from Research
• ● Many people leave treatment before it has a chance to work.
• ● Whether or not a client stays in treatment depends on:
• – Motivation to change
• – Degree of support
• – External pressure (such as Criminal Justice System)
MOTIVATIONAL INTERVIEWING-AN
EVIDENCE BASED PRACTICE
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Motivational Interviewing (MI) is an evidence-based treatment that addresses ambivalence to change. MI is a
conversational approach designed to help people with the following:
Discover their own interest in considering and/or making a change in their life (e.g., diet, exercise, managing symptoms of
physical or mental illness, reducing and eliminating the use of alcohol, tobacco, and other drugs)
Express in their own words their desire for change (i.e., "change-talk")
Examine their ambivalence about the change
Plan for and begin the process of change
Elicit and strengthen change-talk
Enhance their confidence in taking action and noticing that even small, incremental changes are important
Strengthen their commitment to change
MULTIPLE DISCIPLINES
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MI is one of the core components of a variety of interventions used by direct-service providers,
supervisors, team leaders, and organizations in the following service areas:
Substance abuse (addiction services)
Mental health
Psychiatry
Primary healthcare
Nursing
Supported employment
Tobacco cessation & recovery
Vocational rehabilitation
Residential
Housing
Healthcare
Criminal justice
BENEFITS OF MI
• MI is especially useful for engaging and retaining people in treatment.
• ● MI is well developed and researched.
• ● Effects of MI are significant and durable.
BENEFITS OF MI
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Increase
Positive treatment outcomes
Consumer quality-of-life
Consumer engagement and retention
Staff recruitment, satisfaction, and retention
Decrease
Staff burn-out and attrition
Confrontations with consumers
Consumer no-show and drop-out
FREE TRAINING RESOURCES
MOTIVATIONAL INTERVIEWING AS A STYLE AND
SPIRIT
• a. Person-centered versus disorder-centered approach
• b. Motivation as a state or stage, not a fixed character trait
• c. Client defensiveness or resistance as a therapeutic process
• d. Effect of therapist style on client behavior
• e. Collaboration, not confrontation
• f. Resistance and change talk: opposite sides of ambivalence
• g. Respect for client autonomy and choice
UNDERLYING PRINCIPLES OF
MOTIVATIONAL INTERVIEWING
• a. Express empathy
• b. Develop discrepancy
• c. Roll with resistance, avoiding argumentation
• d. Support self-efficacy
DEVELOPING DISCREPANCY
• Part of developing discrepancy is eliciting statements from clients about the
importance of attaining future goals or making changes to the status quo.
When a current behavior is in conflict with overall life goals such as being
healthy, living a productive existence, and providing for one’s family,
focusing on the discrepancy can provide motivation for change.
EXPRESS EMPATHY
• An empathic style Communicates respect for and acceptance of clients
and their feelings
• Encourages a nonjudgmental, collaborative relationship
• Allows you to be a supportive and knowledgeable consultant
• Sincerely compliments rather than denigrates
• Listens rather than tells
• Gently persuades, with the understanding that the decision to change is
the client’s
• Provides support throughout the recovery process
DEVELOP DISCREPANCY
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1) asking the client to look into the future and imagined a changed life under
certain conditions (e.g., absence of drug abuse, if married with children)
. 2) asking the client to look back and recall periods of better functioning in
contrast to the present circumstances, and
3) asking the client to consider the worst possible scenario resulting from their use
or the best possible consequences resulting from trying to change. Sometime
double-sided reflections that bring together previously unrecognized discrepant
client statements are examples of your attempt to heighten discrepancies.
ROLL WITH RESISTANCE
• Resistance is a signal to you to change direction or listen more carefully.
Resistance actually offers you an opportunity to respond in a new, perhaps
surprising, way and to take advantage of the situation without being
confrontational. Adjusting to resistance is similar to avoiding argument in that
it offers another chance to express empathy by remaining nonjudgmental and
respectful, encouraging the client to talk and stay involved. Try to avoid evoking
resistance whenever possible, and divert or deflect the energy the client is
investing in resistance toward positive change.
SUPPORT SELF-EFFICACY
• Belief in the possibility of change is an important motivator.
• The client is responsible for choosing and carrying out personal change.
• There is hope in the range of alternative approaches available.
STAGES OF CHANGE
• a. Pre-contemplation
• b. Contemplation
• c. Preparation
• d. Action
• e. Maintenance
• f. Relapse
STAGES OF CHANGE READINES MODEL
THE CLIENT AND STAGES OF CHANGE
KEY POINTS ABOUT THE USE OF MI WITH
CLIENTS IN THE EARLY STAGES OF CHANGE
• : Precontemplation and Contemplation: Application of MI in precontemplation is a response to resistance. The counselor follows the clients
lead. The counselor stays with the client in whatever stage of change s/he
might be in. Examples work well in the early stages as concrete thinking
may prevail. Estimates put 80% of people in either contemplation or
precontemplation.
KEY POINTS ABOUT THE USE OF MI IN LATER
STAGES OF CHANGE
• Preparation, Action and Maintenance: Motivation to continue the change
process fluctuates, as does ambivalence MI is used to facilitate change talk
in the preparation, action and maintenance stages. MI is woven throughout
the skill building process in order to maintain the client’s readiness to
change. MI is used as clients transition through the stages and embark on
changing other addictive behaviors.
AMBIVALENCE
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MAKING THE CASE
Ambivalence is a natural state of uncertainty that each of us experiences throughout most
change processes (e.g., dieting; exercising; maintaining health; restructuring an
organization). Ambivalence occurs because of conflicting feelings about the process and
outcomes of change.
Although ambivalence is natural, many of us are not aware of it. In addition, many service
providers have not been trained to respond to people who are ambivalent about change,
and most service programs are not designed to accept and work with people who are
ambivalent. Yet, there is a solution. Change your service approach and the culture of your
organization with Motivational Interviewing:
DECISIONAL BALANCE –EXPLORING
AMBIVALENCE
• In MI, success in treatment is largely determined by the ability of the
counselor to help the client explore and resolve his or her ambivalence in
favor of change.
MI MICRO-SKILLS: OARS
• a. Open-ended questions
• b. Affirmations
• c. Reflective listening
• d. Summaries
OBJECTIVE TWO
•PRACTICE EVIDENCE BASED PRACTICE
OPEN-ENDED QUESTIONS
• Open-ended examples:
• What types of things would you like us to talk about?
• How did you first get started drinking?
• What would change in your life if you stopped using?
• How do you think smoking pot is related to the problems you talk about in
your marriage?
OARS PRACTICE, ESPECIALLY IN FORMING
REFLECTIONS
• a. Types of reflections
• i. Simple
• ii. Amplified
• iii. Double-sided
• b. Levels of reflection
• i. Repeat
• ii. Rephrase
• iii. Paraphrase
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Affirm the Client
In MI, affirmations are genuine, direct statements of support during the
counseling sessions that are usually directed at something specific and
change oriented that the client has done.
• These statements demonstrate that the counselor understands and
appreciates at least part of what the client is dealing with and is supportive
of the client as a person.
• For example: I appreciate your honesty (if you know she is being honest).
• I can see that caring for your children is important to you.
• It shows commitment to come back to therapy.
• You have good ideas.
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The point of affirmations is to notice and acknowledge client effort and strength.
LEVEL OF REFLECTIONS
• 1. Repeating – The first or closest to the surface level of reflection is simply
repeating what someone has just said.
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2. Rephrasing –The next level of reflection is to rephrase what a person has
just said with a few word substitutions that may slightly change the
emphasis.
3. Paraphrasing – Here you make a fairly major restatement of what the
person has said. This typically involves the listener inferring the meaning of
what was said and stating that back to the listener. It can be thought of as
stating the next sentence the speaker is likely to say. This is not the same
as finishing someone’s sentence.
4. Reflecting feeling – This is a special kind of paraphrase as it achieves the
deepest level of reflection because you are not necessarily reflecting
content, but the feeling or emotion underneath what the person is saying.
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Provide Summaries
Summaries serve several purposes:
1. Communicate that you have tracked what the client said and that you have an
understanding of the big picture.
2. Help structure a session so that neither client nor counselor gets too far away
from important issues and can help you link what a client just said to something
he offered earlier.
3. Provide an opportunity to emphasize certain elements of what the client has
said. For example, providing summaries of the positive statements a client has
made about change (change talk) gives the client another opportunity to hear
what she or he has said in the context provided by the counselor.
Summaries represent change talk statements (statements that people make that
are in the direction of change) linked together by counselor reflection.
OBJECTIVE TWO- PRACTICE EVIDENCE
BASED PRACTICE
• PRACTICE OARS
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EXERCISE ONE: PARTNER UP WITH
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THINK OF A CLIENT THAT HAS BEEN DIFFICULT TO ENGAGE AND ACT AS IF YOU ARE
THAT CLIENT YOUR PARTNER WILL PRACTICE OARS –DISCUSS WITH YOUR PARTNER
WHAT IT WAS LIKE TO EXPERIENCE THE OARS …CHANGE ROLES
GOOD NEWS BAD NEWS
• Good News: A substantial number of counselors in the US are being trained
in MI and report that they are “doing MI” in their sessions.
• Bad News:
• ● Research demonstrates that most counselors who say they are doing MI
really are not.
• ● Unless counselors record sessions that can later be rated, it is not possible
to know if they are really doing MI (or adhering to any type of practice).
WHY COUNSELOR SUPERVISON ?
• F.1. Counselor Supervision and Client Welfare
• F.1.a. Client Welfare A primary obligation of counseling supervisors is to
monitor the services provided by supervisees. Counseling supervisors
monitor client welfare and supervisee performance and professional
development. To fulfill these obligations, supervisors meet regularly with
supervisees to review the supervisees’ work and help them become
prepared to serve a range of diverse clients. Supervisees have a
responsibility to understand and follow the ACA Code of Ethics.
THE RESPONSIBILITY OF THE SUPERVISOR
• F.2. Counselor Supervision Competence
• F.2.a. Supervisor Preparation Prior to offering supervision services,
counselors are trained in supervision methods and techniques. Counselors
who offer supervision services regularly pursue continuing education
activities, including both counseling and supervision topics and skills.
THE SUPERVISORS ETHICAL RESPONSIBLITY
• Ethics in supervision is as essential as it is all other aspects of the counseling
profession. Although ethical behavior is essential as a counseling
professional, it may carry an even more significant burden when serving as a
supervisor. Everything we say and do serves as modeling behavior for
supervisees. If our professional behavior and decisions are not following the
highest ethical standards with our supervisors, we are giving them
permission to not hold themselves to the highest standards in working with
their clients. We have a ripple effect on the supervisee and each of the
clients to be served.
CHALLENGES TO PROVIDING SUPERVISON
• TIME
• STAFF RESISTANCE
• SUPERVISORY STYLE
• INTRUSION
• EVALUATION
ACTIVITY
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DIVIDE INTO GROUPS OF 3- EACH OF YOU SHARE WITH THE GROUP THE
FOLLOLOW:
LIST THE TOP 3 THINGS COUNSELORS/CASE MANAGERS SHOULD EXPECT
FROM YOU IN SUPERVISON
SHARE WITH YOUR GROUP YOUR NEGATIVE EXPERIENCES AS A SUPERVISEE
SHARE WITH YOUR GROUP YOUR NEGATIVE EXPERIENCES AS A SUPERVISOR
HOW TO GET STARTED
• Introduce MI into one assessment interview
• ● Train counselors and supervisors in MI
• ● Provide ongoing supervision of MI
• ● Tape counseling sessions
• ● Train supervisors in a simple tape rating system
• ● Rate counseling sessions on a regular basis
• ● Use information from tapes and ratings to guide supervision to increase
adherence and competency in MI
• ● If possible, use an MI style in supervision (not tested by what we think)
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SHARING SUPERVISORY FEEDBACK
UTILIZING MI PRINICPLES IN PROVIDING SUPERVISORY FEEDBACK
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SET AN AGENDA
PROVIDE A COPY OF AND REVIEW DATA FROM OBSERVATION
PRACTICE OARS
SANDWICH TECHNIQUE FOCUS FIRST ON WHAT IS WORKING WELL, ALLOW
THERAPIST TO IDENTIFY TOP TWO OR THREE AREAS THEY WANT TO WORK ON,
UTILIZE AFFIRMING AND ACKNOWLEDMENT OF INSIGHT AND OTHER POSTIVE
STRIDES (IDENTIFIED STRENGTHS) TO HELP THERAPIST DEVELOP A PLAN FOR
INCREASING USE OF MI TECHNIQUES
PROVIDE HOMEWORK
ASK HOW THEY FEEL ABOUT THE SUPERVISON
FOLLOW-UP IN NEXT SESSION
REMEMBER THE PRINCIPLES OF MI:
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b. Develop discrepancy
c. Roll with resistance, avoiding argumentation
d. Support self-efficacy
OBJECTIVE THREE
• GIVE AND RECEIVE SUPERVISORY FEEDBACK
Activity
• Part 2: Track use of MI Techniques
• Person 1: Talks about something they probably should change, want to
change or need to change but have not yet started to change Person
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2: Uses OARS in an empathetic manner to focus primarily on sustain talk
and help person 1 feel heard. Person
• 3: Observes person 2 and uses Counselor MI Assessment Form
• Person 3 gives person 2 feedback utilizing MI principles
Activity
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Part 1: Track Change Talk in Speaker
Person 1: Talks about something they probably should change, want to change or
need to change but have not yet started to change Person
2: Uses OARS in an empathetic manner to focus primarily on sustain talk and help
person 1 feel heard. Person
3: Observes person 1 and uses Change Talk Tracker to track types of change
talk/sustain talk.
Discussion Points - What did it feel like as the speaker? As the listener? - What types
of change talk did you notice? Sustain talk? - When might this be useful? When is it
not useful?
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The cognitive-behavioral model is based upon the assumption that our thoughts and beliefs
influence our behavior, emotions, and physiology. In the supervisory relationship, a cognitivebehavioral supervisor would attempt to correction faulty thinking or misconceptions of the
supervisee's conceptualization of a case. Supervision sessions are structured, focuses, and
educational in nature. Both the supervisor and the supervisee assume responsibility for the flow and
content of the supervision session. The goal of supervision is to assist the supervisee in examining
cognitions related to his or her skills and to understand how those cognitions influence the work with
the client. As the supervisee participated in cognitive-behavioral supervision, he or she is also
learning how to utilize the model with clients. There are distinct steps in a cognitive behavioral
session as detailed by Liese and Beck (1997).
Check-in: greeting and getting an assessment of how the supervisee is feeling
Agenda setting: determining what will be accomplished in the session. This also encourages the
supervisee to come to the session prepared to work.
Bridge for previous session: a review of what was learned or accomplished in the last supervision
session
Inquiry about previously supervised therapy cases: update on the progress of cases
Review of homework since previous supervision session: discussion of any assigned readings or
research, utilization of newly learned techniques, etc.
Prioritization and discussion of agenda items: Review of taped-recorded sessions, role-playing or
teaching of new techniques
Assignment of new homework: assign activities to further develop knowledge and skills
Supervisor's capsule summaries: reflection on the work of the session with emphasis on important
elements
Elicit feedback from supervisee: elicit feedback from supervisee on the session and what was learned
INCORPORATING TECHNOLOGY INTO
SUPERVISION
WE MUST INVEST IN THE TRAINING AND
SUPERVSION OF OUR STAFF TO IMPROVE
OUTCOME
Internet Resources
http://www.motivationalinterviewing.org/sites/default/files/mia-step.pdf
• http://www.intrinsicchange.com
• https://store.samhsa.gov/shin/content/SMA13-4212/SMA13-4212.pdf
http://www.pachiefprobationofficers.org/docs/Motivational_Interviewing_Manual_2015.pdf