Motivational Interviewing Training at a State Psychiatric Hospital

This report describes an initiative at a state psychiatric hospital to provide training in motivational interviewing to staff. Motivational interviewing is a person-centered, directive therapy designed to reduce ambivalence and increase motivation to change. It involves a collaborative approach that respects patients' autonomy, which is in contrast to the more traditional prescriptive, paternalistic approach. There are four general guiding principles of motivational interviewing: express empathy, develop discrepancy, roll with resistance, and support self-efficacy.

Although motivational interviewing was initially developed within the addictions field, its uses and applications have become more widespread and diverse over the past ten years. It has been used with patients with schizophrenia or other severe mental illnesses to strive for outcomes such as adherence to medications and reduction of substance use. The results have been promising. However, thus far few studies have examined the use of motivational interviewing in psychiatric inpatient units or by nonprofessional direct care staff, such as therapy aides. There are several reasons why training direct care mental health staff in this approach may be helpful: motivational interviewing provides a method to improve staff communication skills, it may be useful in improving treatment adherence, and it provides an integrated approach to co-occurring mental and substance use disorders, which are common on inpatient units.

The Rockland Psychiatric Center (RPC) is a New York State psychiatric hospital with 475 inpatient beds and 2,500 outpatients for a catchment area of five counties, including Manhattan. Focus groups with direct care staff (therapy aides) and their union at RPC revealed a desire for additional training on effective methods in communicating therapeutically with patients. An RPC grand rounds presentation on motivational interviewing by Mary Rosedale, Ph.D., from the New York University College of Nursing, and the successful application of motivational interviewing by psychologists at RPC led to a pilot training program in an inpatient unit. Administrative coverage was organized for the involved inpatient unit so that staff could attend training sessions. Given limited financial resources, internal RPC staff experienced in the motivational interviewing approach, rather than outside consultants, provided the training. A motivational interviewing project planning committee was formed and consisted of RPC psychologists, senior clinical nurses, and psychiatrists.

The inpatient unit staff that received training included therapy aides, social workers, nurses, psychologists, psychiatrists, rehabilitation staff, and the unit team leader. The training had the support of the inpatient unit leadership, an important factor in conducting the training and enabling staff to attend.

Training consisted of an introduction to the motivational interviewing approach and ten weekly one-hour sessions that involved both didactic material and interactive learning via case examples generated by the trainees. The training focused on the basic principles, techniques, and spirit of motivational interviewing. Some patients volunteered to be interviewed by the motivational interviewing trainer in front of the participants to demonstrate the techniques. Videos demonstrating the motivational interviewing approach were also utilized. In-person consultation on the inpatient units was provided by motivational interviewing project team members to demonstrate motivational interviewing and to give feedback and guidance to trainees implementing it. The initial response of unit staff to the motivational interviewing approach was positive, and there were fewer violent incidents on the unit during the motivational interviewing training, decreasing from 3.5 to 2.2 incidents per month.

Given the initial positive response, the training program was expanded. An instrument was developed to survey both clients and staff about the motivational interviewing approach and its fit with the RPC mission statement "to provide hope, respect, and recovery to people with mental illness." This survey will be provided to clients and staff before initiating the training and then again one month after training. Another outcome measure will be the number of violent incidents on each unit.

Challenges have been encountered in providing the training. Some staff members were skeptical that motivational interviewing would be effective in an inpatient setting. Some staff missed training sessions because of schedule conflicts, which interfered with the continuity of the learning experience. The trainees provided valuable feedback that future training should involve more role-play scenarios and more demonstration interviews with patients. There are also plans to provide on-the-unit supervision and consultation on motivational interviewing and to provide training refreshers. This current initiative at RPC is ongoing, and the motivational interviewing project committee is continuing to work to improve the training experience. The plan is to train all inpatient and residential staff over the next two years. We hope that this training effort will result in a more collaborative approach to care and improved communication between staff and patients.