Supporting the “MI Spirit” Through an Intensive TA Process: Clinical Supervisory Staff Improve Their Communication Skills For Use with Clients and Each Other

Laura Cooley
Northwest ATTC Technology Transfer Specialist

How would you rate your skill level in motivational interviewing (MI)?
On the first day of a two-day MI workshop, 35 behavior analysts were asked this question about their perceived skill and confidence level in using MI. The behavior analysts, all of whom work as clinical supervisors at a Washington-based organization, proceeded to line themselves up in the training room according to self-ratings on a 0-10 scale (from ”not at all ready” to ”extremely ready”). One small group thought they had a very low level of ability in this area, two placed themselves in the intermediate to high range, and the rest ranked themselves somewhere in the middle.

The workshop was the start to an intensive technical assistance (TA) process led by the Northwest ATTC in partnership with Connections Behavior Planning and Intervention, LLC. The results of this TA process, which relied on use of an adapted EPIS (Explore-Prepare-Implement-Sustain) model, proved to be impressive:

By the end of the intensive TA process in MI, 96% of survey respondents reported intermediate or better confidence that they would be able to maintain use of the techniques they had learned after more than half a year of sustained technical support.

Today, an internal implementation team at the organization is busy putting the “MI spirit” into action by using their MI skills with clients, on-boarding new staff, or coaching their colleagues.

Getting the “buy-in” to take on this intensive TA was the easy part; Connections’ senior leadership team, James Kidwell and Paul Mullan, recognized MI’s value and wanted to improve staff satisfaction. They saw MI as a core skill that could “…both improve their staff-client interactions and be helpful in improving staff interactions with other staff,” said Mullan.

Dusty Dixon, director of continuing education, added, “From the start, we were committed to doing this because we recognized that ongoing practice and feedback are in line with our understanding of best practices.”

A real strength of this project has been the plan for sustained support from a highly skilled MI trainer, Dr. Ann Marie Roepke, who supported Connections on two levels:

  1. Virtual sessions focused on specific MI skill development and practice, and
  2. Creation of an internal implementation team to lead and sustain the improved MI capacity.
Commitment of senior leadership has been crucial. Senior leadership actively took part in the TA process and further demonstrated their buy-in by freeing up staff time. They committed the organization to the effort over the long haul and dedicated time normally allocated for administrative duties to further MI coaching.

IMPLEMENT The 5 main phases of this TA process consisted of:
  1. A two-day, in-person training on motivational interviewing;
  2. A series of videoconference calls over a 7-month period focused on further MI skill development and practice;
  3. Targeted observation of staff who volunteered to be observed as they practiced their MI skills, and some observation of senior management communication styles;
  4. TA coaching and support to an internal sustainability implementation committee; and
  5. Creation of a set of recommendations for sustaining MI skills at the organization.

Flexibility was intentionally built into the intensive TA process to ensure staff would have ample opportunity to practice their skills. They also received personalized, expert feedback from Dr. Roepke.

Coaching was offered through targeted observation of staff who volunteered to demonstrate their skills and discuss strengths and areas for further development. For the implementation team, this ongoing support proved to be “immensely beneficial,” according to Dixon.

Using videoconferencing helped meet the needs of the organization’s co-located staff. Sustained coaching of MI skills over several months led to implementation team members learning the basics of how to code MI skills. They can now coach new employees through on-boarding and model MI skills for others.

Keeping development and refinement of MI skills in-house is an organizational priority. As part of the sustainability plan moving forward, Connections staff have been revising some of their policies and procedures. These have “…shifted to align better with the ‘MI Spirit,’” says Dixon, who has been an in-house champion and key to facilitating the entire process. Another key in-house champion, David Cole, who directs their training programs, worked with the implementation team to promote MI’s use organizationally. MI is now being used to refine the training and coaching offered during the onboarding process.

Another sign of the “MI spirit” in action? The last of the regular virtual sessions was entirely run by the internal sustainability team.

Next steps for the Northwest ATTC team include working with Connections staff to identify recommendations for ongoing sustainability of MI support and training to staff.

NIATx: Promising Practices to Increase Engagement in Treatment

Maureen Fitzgerald
Great Lakes ATTC/NIATx

NIATx Principle 1, "Understand and Involve the Customer," comes alive when a change team conducts a walk-through of their agency or one of its processes.  For many change teams, the first walk-through focuses on the customer's first contact with the agency: the intake and admission processes.

A walk-through of first contact can start with a member of the change team can pose as a customer calling the agency for information.  This simple activity can uncover previously unnoticed barriers:

  • an out-of-service phone line
  • an endless loop of voicemail prompts
  • a grumpy phone receptionist 
The walk-through can also bring attention to the agency's physical environment. 
  • Is the entrance marked?
  • Are clients welcomed by a friendly staff person or a uniformed security guard?
  • Is the waiting area comfortable and inviting? 
Waiting area, Above and Beyond Family Recovery Center
A welcoming environment that reflects clients' cultures and interests can have a big impact on engagement in treatment. Mark Sanders, LCSW, CACD, cites Above and Beyond Family Recovery Center in Chicago as a great example of an agency that's committed to creating a welcoming environment, as part of a strategy to improve engagement for all of its clients, but in particular for African Americans seeking treatment. Mark recently interviewed Dan Hostetler, executive director of Above and Beyond, for more insights on this agency's commitment to its diverse client population. Read the full story here

Mark will discuss the importance of the agency environment and other strategies to engage African American clients in treatment in the upcoming Great Lakes ATTC webinar:

Engaging African Americans in Substance Use Disorder Treatment
Wednesday, February 5, 2020
11:00am CST

The webinar will be recorded and available for viewing on the Great Lakes ATTC website after the live event. 

Read about other NIATx Promising Practices 

Has your agency conducted a walk-through of one of your processes? What did you discover? Share your story in the comments section below. 

ATTC Region 2: Increasing Capacity for the Drug Courts in Puerto Rico

Tech Transfer in Action

The Institute of Research, Education and Services in Addiction at the Universidad Central del Caribe, School of Medicine has been providing various trainings to the Drug Courts of Puerto Rico. Drug Courts is a program that seeks the recovery of people with substance use disorders through a continuous and intensive judicial follow up. It applies the Therapeutic Justice Model, which is the use of social science to study the extent to which legal rule, or practice promotes the psychological and physical wellbeing of the people it affects. Drug Courts goals are the recovery of the participants, their reintegration to society, and decrease recidivism or commission of new offense. All training opportunities delivered to the Drug Courts personnel have been requested by the Judicial Academy of Puerto Rico. The Academy took the initiative to provide training to all there staff from the Department of Correction and Rehabilitation (e.g., prosecutors, police, officials, social workers, judges, assistants, and program coordinators) who are directly or indirectly involved in Program. This was with the intention that all areas receive the same training (based on evidence and best practices), share the same knowledge and understanding on how to provide adequate and needed services for all Program’s participants.

All trainings provided to Drug Courts staff during past year included the following topics:
  • application and management of incentives and sanctions in specialized courts for controlled substances;
  • access to justice and the treatment of substance use disorders for vulnerable populations
  • trauma management in people with substance use and mental health disorders and the vicarious trauma;
  • instruments for screening and assessment evaluation for substance use disorders; and
  • the effect of opioids on human behavior and its impact on the justice system.

These topics considered the specific capacity building needs from criminal justice personnel. The delivery encompassed increasing knowledge and providing necessary skills for this particular workforce, thus they are able to understand substance use disorders, screening and assessment strategies, connection between substance use and mental health disorders, as well as its treatment alternatives. Raising awareness and capacity building in these professionals will decrease stigma on persons with substance use disorders, while helping them receive needed services and treatment to recover their lives and return to the community with the tools they need to be a productive citizens. It is our goal that we do not only influence the workforce but to create a cascade of actions to reduce health disparities among the population they serve. These professionals now have the skills to assist participants with particular situations while in receiving their services. The Drug Courts program has been in Puerto Rico for 23 years and the NeC ATTC has been providing them with training and technical assistance. This year we delivered a total of 15 trainings and impacted 442 providers. We look forward to continue providing the Drug Courts program with all the trainings they need in order for participants to receive quality and responsive services.

2020 Vision: What Will You Improve in the New Year?

Mat Roosa, LCSW-R
NIATx Coach

With the start of a new year, many organizations resolve to tackle long-standing issues, such as high no-show rates. In this post, NIATx coach Mat Roosa shares his vision for reducing no-shows: Offer walk-in hours.

“The best way to get rid of no-shows for appointments is to get rid of appointments.”
As a coach, I often work with behavioral health organizations that are struggling with low show rates. The result is low staff productivity, reduced revenue generation, client turnover, increased costs associated with higher discharge and admission rates, and a felt failure to perform the core service mission of supporting individuals through the recovery process.

Programs often choose to work on a range of strategies designed to increase show rates. They use incentives for clients and staff, reminder calls, and transportation supports to get more clients to the door at the designated hour. But too often these efforts yield only modest results. That is when I often make the bold assertion above, and usually couple it with the following question:

Why do we think that appointments will work when we are serving people who do not schedule appointments for any other service that they receive?
The introduction of developing a walk-in approach often yields a great deal of anxiety…

  • But we won’t be able to plan our day?
  • We will have no way of knowing who will show up?
  • How will we staff for this?

In response to these concerns, I typically ask a question or two:

  • How do emergency rooms do it?
  • How do grocery stores do it?

This is the moment when many teams began to shift their thinking toward a new paradigm: Maybe we could find ways to reorganize ourselves with walk-ins. Perhaps we could do some short walk-in periods during the week to explore the model. Maybe this will create better service access. If a grocery store can do, we can too.

Walk-ins don’t work for everybody, but they do work for many. And they are a great way for traditional programs to rethink how they deliver care.

See the NIATx Promising Practice: Establish Walk-in Hours

About our Guest Blogger Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in the areas of quality improvement, organizational development, and planning, evidence-based practice implementation. He also serves as a local government planner in behavioral health in New York State. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat at


By The New England ATTC and Stephen Andrew, LCSW, LADC, CCS, CGP 

The New England ATTC is collaborating with the Health Education & Training Institute in an effort to implement Motivational Interviewing (MI) systems-wide throughout Tri-County Mental Health Services of Maine. Tri-County Mental Health Services provides integrated behavioral health care for clients with substance use and mental health problems, and they are seeking to integrate MI across their entire continuum of care. MI is a client-centered, evidence-based method for enhancing clients’ intrinsic motivation to change. It was selected as the focal intervention because of its potential to improve client engagement, retention, and substance-related treatment outcomes. The goal of this MI initiative is to optimize sustainability within the organization by creating an internal group of trainers and coaches who will learn to use and teach/coach MI.

The intensive technical assistance (TA) initiative is targeted towards counselors, supervisors and community workers with varying levels of experience in MI and will ultimately be delivered across 5 Tri-County locations in Maine. It begins with three days of face-to-face instruction followed by a virtual MI Master Class using Zoom conferencing. The Master Class provides continued coaching and skill building. Additionally, there are on-going monthly Zoom calls for core staff over a 12-month period and assigned MI activities to practice concepts during existing staff meetings.

On-site trainings are conducted by Stephen Andrew, LCSW, LADC, CCS, an internationally renowned MI and MIA-STEP (Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency) trainer, and long-standing member of the International Motivational Interviewing Network of Trainers (MINT). Stephen has been a consultant and trainer for the New England ATTC since 2007.

During the first two days of face-to-face training, Stephen provides an introduction to the clinical method of MI with a focus on intervention basics. Participants have the opportunity to explore creative ways of integrating MI techniques and skills. After orientation to the underlying spirit, structure, and principles of MI, application of practical exercises helps participants strengthen their empathy skills, recognize and elicit change talk, and roll with resistance.

The third day of training is titled Advancing the Practice using MIA-STEP. MIA-STEP is a training for those that supervise or mentor treatment providers in a clinical setting whose roles involve providing feedback and coaching to help practitioners improve their skills and effectiveness. This training provides clinical supervisors practical tools to enhance treatment providers' MI skills. To date, 25 Tri County Mental Health Services staff have completed the two-day MI basics training and 16 staff have participated in the MIA-STEP one-day training at the first location in Lewiston, ME.

Participants have referred to the in-person trainings, and Stephen, as “amazing” saying, “the whole audience loved it.” When asked which training aspects were most useful, staff indicated they now had “a better way to work with clients who are ambivalent about sobriety,” and “insightful … tools for [their] work ‘tool box’ Further, staff reported feeling better equipped to understand their own “personal shortcomings and … to normalize ambivalence,” ,” to “meet clients where they dream,” and to “sit with clients ambivalence and suffering” until the client felt ready to move forward.

The monthly virtual Master Class is conducted by Kathryn Hartileb, PhD, RDN, an Assistant Professor at Florida International University’s Herbert Wertheim College of Medicine. Kathryn is an expert in health communication and behavior change. Like Stephen, she is a long-standing member of the MINT network. Kathryn’s main goal when leading the Master Class is to build participants’ MI skills through exploration of Bill Miller's "Master Class" exercises and practice diving into the Four Processes of Engaging, Focusing, Evoking, and Planning. The Zoom Master Class is designed to provide the opportunity for participants to practice MI Spirit and skills alongside a supportive network of peers facing similar professional challenges as well as the opportunity to consult about clients who struggle with substance-related concerns. The first Master Class was launched on October 9, 2019, with seven participants in attendance. Classes will continue through September 2020.

The New England ATTC is excited to partner with the Health Education & Training Institute to offer this intensive TA initiative to Tri-County Mental Health Services of Maine!