An episode of “Changing the Conversation” podcast
Tory Morgan and Ali Hall discuss strategies for supervising people using Motivational Interviewing (MI) and creating a MI culture with host Jeff Olivet.
November 23, 2020
Jeff Olivet, Host: [00:05] This is Jeff Olivet with “Changing the Conversation.” And today is another installment in our ongoing conversation about Motivational Interviewing (MI). And today we’re focusing on supervision of people who are learning and embodying and practicing Motivational Interviewing in their clinical work. And I am very pleased to be joined by Tory Morgan and Ali Hall. Tory Morgan is based in Arnold, Maryland, and has almost a decade of experience treating adults, couples, families, and adolescents. She’s worked with ADHD, oppositional defiant disorder, adolescent issues, depression, anxiety, trauma, just about anything you can name, Tory has seen it and has brought Motivational Interviewing to bear on those very difficult issues that people are facing. Ali Hall, who many of our listeners have met previously is an independent trainer consultant, coach in MI and member and board member of the Motivational Interviewing Network of Trainers. And Ali, it seems to be is always in a different place every time we talk. So, Ali, I don’t know where you’re calling in from today.
Ali Hall, Guest: [1:06] I’m calling in today from San Francisco, California.
Jeff: [1:09] Ali, it’s great to have you again.
Ali: [1:11] Thank you, Jeff. And it’s really good to be here today with you and Tory.
Jeff: [1:15] And Tory, it’s nice to have you on the program. We would love to hear more about your journey to Motivational Interviewing. I know you’re a very seasoned clinician and have been doing this work for a long time. How did you come to MI? How did it come to you? How did you and Ali get to know one another? Where is your starting point?
Tory Morgan, Guest: [1:33] I actually found Ali through a training that was with our local health department. I’m an LTWC. So, coming out of grad school, I was an LMSW… Excuse me. I was an LGSW, used to be. Now it’s identified as LMSW. And I was in a position at our local detention center. I was there for about six years providing clinical services to an incarcerated population. And our local health department offered a, I believe it was a four day intensive MI training. And at that time, MI was not something that I had been taught from more than one class out of a grad school education, which they have improved that with the MSW program now, but it wasn’t something that was familiar to me.
Tory: [2:21] And I asked to be able to attend the training. I showed up. And basically from day one, I was hooked to what Ali had to say. So, that training I don’t exaggerate I think when I tell people that I’m supervising. When I tell interns and graduate-level clinicians, that that training changed my trajectory. Partially, because of the effect that I was able to see. And partially, because specifically as a clinician in a forensic setting with a very challenging and severely ill population, it absolutely changed the way that I practice and the way I felt when I went home at night.
Jeff: [3:02] Talk more about the effect that you saw. You said it changed your trajectory, not only because of, you feel like you’ve got a new skill set or you’re better at your job, but you actually saw a difference in the lives of the people that you were talking with every day. What did that look like?
Tory: [3:19] I was specifically in a detention center setting. So, it is individuals who are primarily pretrial, primarily people who are awaiting charges or waiting trial for whatever they… Charges from trespassing to first-degree murder. I will admit that going into that population, I was… I didn’t understand exactly what I was getting myself into. And it was a little bit eye-opening in terms of the challenges I was faced with. But it allowed me to truly meet people where they were and allowed me to embrace people’s reasons for change, as opposed to walking in as this fresh faced social worker.
Tory: [4:01] And I was all of 24 walking into the doors of that detention center. And I had a determination that I was going to be able to significantly reduce the incarceration and that I was going to be able to treat people and see improvement despite the setting in which they were functioning in that moment. And I was truly able to see people working with their own change and not working with mine. It really helped me to reset in terms of embracing other people, their purpose and motivation for change, and being able to actually see that play out even within a detention setting.
Jeff: [4:39] You talked also about how it made you feel better when you went home. And I know the process of therapy or connection or conversation is not about the clinician or about the provider, it’s about the life change that’s happening within the person themselves. But it is also a, it’s a dance and it’s a conversation and it’s dialogue, and it does affect all of us. And I know in my early days of direct service work as a street outreach worker and working in shelters and also in carceral settings of various kinds, you carry it home with you. It’s tough, it’s hard. These are painful stories. You’re walking through some of people’s darkest days with them. How did Motivational Interviewing shape your thinking when you punched out? Not that you actually punch out anymore, but when you were done with your day and went home, what was different?
Tory: [5:30] I stopped fighting with people. I stopped looking at that righting reflex. I was able to say, “Okay, you don’t want to make that change.” And be okay with that, truly okay with that. As opposed to, “Okay, I’m saying this, but I’m going to circle back tomorrow, and I’m going to talk this guy into it.” I truly was able to go home and say, “Okay, I did my end and that person didn’t want to make that change. And that’s their choice. Their truly their choice.”
Jeff: [6:07] Letting go of the outcome a little bit. I’d like to draw Ali Hall into this conversation. Ali, you’re a friend of this podcast and certainly a champion of Motivational Interviewing. You have done many years of MI training. Did you have any idea your work was having such a shaping impact on new social workers and others?
Ali: [6:28] Well, yeah, it’s great to hear you and Tory talking about this. I suppose I’m not really surprised, although I don’t really feel it has anything particular to do with me. I just think that MI is so incredibly profound and powerful as a way of engaging and helping others move from where they are to where they want to be. When we embrace those skills and set ourselves aside and stand alongside someone in their perspective, something really truly magical happens. I know I felt it and experienced it, and I am certainly not surprised to know that others have, too.
Jeff: [7:08] Thank you, Ali. Tory, we’ve talked about your own personal experiences with MI and how it has really shaped your practice. Now you find yourself in the position of supervising others. How does Motivational Interviewing play into that? How do you think about supervising in the context of Motivational Interviewing? And that could be with interns or students or new clinicians who are recently graduated. What is your supervisory approach? How does MI shape that? How does that all play out?
Tory: [7:38] Of course, we see some level of difference in terms of which of those populations I’m providing supervision to. Whether clinicians who are independently licensed, clinicians who are on the verge of things. So, or sometimes folks who have just walked out of undergrad and just started a master’s program. And again, have not really heard of Motivational Interviewing. And I think that part of the way that I introduced that in a supervisory relationship is, one, by modeling it. Specifically, in my language and the language that I use when I am supporting the interns’ and clinicians’ own process toward change. So, for example, someone that I have been in a supervisory relationship for a long period of time is probably going to roll their eyes every time I say, “And yet,” because I never say that in the supervisory relationship. And someone that I’m in a supervisor relationship within the course of the supervision, they are going to hear different styles of reflections and many more reflections than they’re going to hear questions.
Tory: [8:54] I also have the opportunity with my students of getting line-by-line process recordings from them. They don’t typically do the recorded sessions the way they do in some programs. But in those line-by-line process recordings, I’m actually able to see written language and be able to work with them, to pick it apart and say, “Oh gosh, you missed this opportunity. There was the change talk right there. And these are the steps we could have taken. Remember this acronym that we’ve been working on?” And sometimes that is going to be students who are very familiar and have a basis for Motivational Interviewing. And sometimes we’re going to start with, “Hey, this is why giving advice is dangerous. And this isn’t what we’re going to do. We’re not going to advise.” And, “Hey, this is how you use a reflection. This is even what a reflection is.” And even for folks who are in a master’s program, sometimes starting with that foundation is incredibly changing for how they look at a conversation.
Jeff: [10:00] It sounds like you’re operating on a couple of levels at the same time. On the one hand, you are teaching about Motivational Interviewing. And on the other hand, you are all of these maybe aren’t two hands at the same time, and yet you are also practicing Motivational Interviewing as a supervisor. You are offering amplified reflections, you’re asking good open questions. You’re looking for change talk in the conversation of the people you’re supervising. Are you thinking on those two planes at the same time? Is it just so ingrained at this point that you’re not self-conscious about doing that? How does that experience play out for you as a supervisor when you are both practicing the thing and teaching about the same thing that you’re practicing?
Tory: [10:38] Well, I think there is the element of trying to maintain a connection with the person and keeping those two balls in the air in terms of both practicing MI with on together with the supervisee. And actually, teaching and modeling those MI skills. Because most of the time they will have developed a good supervisory relationship with those individuals, there’s actually, there’s fun to it. Whereas we are talking about the change language that they’re evoking and the persons served. They can catch me. They can catch me using the MI file, they can catch me using some language changes.
Tory: [11:24] And towards the end of the supervisory relationship, it’s almost like they can put a little tally point in the course of a supervision and they can see some of those clinical skills and specifically the MI skills modeled. And I can tell that they are absorbing the style and the spirit, because they’re starting to be like, “Oh, you know what? Did you just use LLB? Did you… Oh, Mm-hmm (affirmative).” And that allows us to… Yes, be operating on those two planes, but not in a way where I have to feel self-conscious or like I’m therapizing people that I’m supposed to be providing supervision for.
Jeff: [12:05] I am curious at the end of a long week, if sometimes your students or interns or new clinicians think, “I wish she just stopped doing MI on me and tell me what I should do in this situation.” Ali, you have seen supervision play out a lot in clinical settings in non-clinical settings, all over the country, all over the world. What do you see around the domain of supervision? What does good MI supervision look like?
Ali: [12:29] I think the agencies that I have seen be the most successful are the ones that have a healthy climate of supervision in the first place. Where even if a new clinician isn’t so sure about what it’s going to be like, feels it’s collaborative, feels accepted, feels that their supervisor is on a treasure hunt for their skills and strengths and just supporting them. And another thing, as Tory is talking about, not only modeling MI and her interactions with those she supervises, but also helping them… And at the same time is helping them develop their MI skills.
Ali: [13:10] So, really two things are happening, demonstrating it and using MI as a supervision style as well as helping people develop their own skills. I guess what it comes down to really, the organizations that are the most successful are where MI is in the air. And others are experiencing it, they’re breathing it, they’re living it, they’re growing, it’s nourishing them. They hear it all around them. And I feel like they’re more inspired to strengthen their own skills in that direction.
Jeff: [13:43] Ali, there’s sometimes resistance to this. Not only among the people that we’re serving, but among the providers doing the work. And I can see how resistance might be a little diminished in a place where MI is in the air as you described it. But even then, there may be reasons that a very seasoned clinician who has been working in a certain way for many years is resistant to change, or that a new staff person who is trained in a certain way is kind of reluctant to take a new step in that direction. In the spirit of Motivational Interviewing and the practice of it, I’ve heard people talk a lot over the years about rolling with resistance. And I know that you can sort of start breaking down the terms here. But Ali, I’m curious what you see around resistance on the part of staff people, or reluctance on the part of staff people to want to take on a new way of working.
Ali: [14:39] Yeah, always is a challenge. I mean, each clinician may have a different way of seeing things or how they… What they learned in school or what they’ve learned on the job. While some of us come from places where business as usual didn’t sound like MI, it feels like if part of the mission statement of the organization is to use best practices, to do things that we know work. Similarly, we don’t really get a choice to decide to use CPR or first aid or to comply with HIPAA or confidentiality requirements. These are all best practices and we learn them… And on the job, we’re expected to use these things. I’m not saying as an enforcement style, but really as an aspirational tool. If that’s the shared agenda to do what’s best, and we know when people are viewed in this way and spoken with in this way, they’re more likely to be successful.
Ali: [15:31] I think the shared agenda is to help the person we’re serving be successful. And by the way, at the same time to be releasing our own blood pressure and stress cortisol. It’s like giving MI a try if it’s a shared expectation to do our best for that person. Whatever reason the clinician has to go along with that. Again, everybody has their own reasons for change. And if we’re all trying to do our best, and that’s part of our mission. I think it’s a little bit more successful way of collaborating than trying to convince people or persuade them that it’s a better way.
Jeff: [16:06] Tory, I’m curious how you’ve seen this play out and let’s start with new clinicians and then maybe we can shift to more kind of seasoned longer-term folks. How do you see reluctance, resistance, ambivalence even, playing out among the people that you’re supervising?
Tory: [16:25] Actually, at any level, some of the reluctance or ambivalence tends to be centered around, “Okay, you’re teaching me this, but not with my people.” You don’t understand that stuff… Yeah, that can work for that client that you’re identifying. Oh yeah, sure. Evidence-based, yeah, that practices. Sure. But that’s not going to work with my caseload. And I think that there is so much value in being able to sit with that, right? And again, we’re using, MI skills in the course of supervision and say, “Okay, I hear that that’s not going to work with your caseload.” And yet we’re acknowledging that statistically, it is an evidence-based style that we are bringing that brings change to individuals globally. Being able to work with those individuals. And this is where I find role play in supervision to be very, very beneficial.
Tory: [17:29] And that’s the time where I do, “Gosh, you got to be on your MI game if you are in supervision with somebody.” And say, “Okay. Hey, you, you’re your hardest client, be the person that who’s challenging you the most right now.” And let’s practice the use of some of MI skills in that session, in the role-play session. And sometimes if the person is able to be able to hear some of those skills being brought to the table with… Although not actually with their person in the room, but with the person that they’re identifying as a person so to… With whom they’re really struggling in that moment, that can go a long way in trying to move with that reluctance. Because, typically, it’s not that the individual is opposed to helping or even opposed to change, but they don’t see it as something that will help their caseload.
Jeff: [18:31] Tory, I wonder if you could also speak to the question of more experienced staff who may be a little more fixed in their way of operating a little less in learning mode. I mean, not everyone certainly, but how do you see some of these issues play out with someone who has been operating maybe in a way that’s not? So, am I consistent for years, decades? How does a change process happen within them? How do you support people in that process?
Tory: [19:01] So, I think with veteran clinicians or veteran direct care staff who may have been in the field for an extended period of time. Our expectations of change have to move at a pace that’s commensurate with how long we’ve been in the field. That kind of change is going to happen slowly. That we aren’t going to walk into supervisory relationship and make the assumption that, “Oh, hey, I brought you this, I brought you this goodie bag MI,” and “Oh, now, oh, I’m going to go implement that tomorrow.” And instead we are going to be… I love the way that Ali describes the treasure hunt.
Tory: [19:38] We are going to be finding those little nuggets of, “Gosh, I actually heard you. I heard you’re using this there.” I’m wondering how that felt. I’m wondering how the person served reacted to that. And being able to find those nuggets and build on them as opposed to going from a deficit approach of, “Hey, listen, that intervention style you’re using is not okay, or it’s not evidence-based, or it’s not best practice and just stop it.” And instead coming from that place of gradual change. And I think that what Ali said about building a, MI in the air, but almost a culture of MI within the agency. To me, the agency-wide training are really, really valuable in that it just starts everyone using the same language. And then when the supervisors are enforcing the MI principles and the MI skills over and over and over in their individual sit-downs, I think that has the most dramatic effect that repeated reinforcement of the MI principles and skills.
Jeff: [20:53] And what you’re talking about does not just apply to the licensed clinicians, but to an entire staff. And I know my background is working in homeless programs for the most part, as I mentioned earlier, where the vast majority of staff have not been formally trained or licensed. I think it’s true in jails and prisons. It’s true in many community settings where the preponderance of staff does not have a lot of letters behind their names or in my case just had the wrong letters that were kind of irrelevant for the job they were doing. Ali, when you think about training a staff, when you think about supervisors who are supervising non-licensed people, what are the implications of instilling MI as an overarching way of working among those staff?
Ali: [21:40] Well, a few things, and one is that, when Tory is talking about the value of an agency-wide training, we’re all serving the same person. We’re just maybe serving at different touchpoints or from different angles or approaches. Maybe we have more or less time with the person. Maybe our task with them is a little bit more specific or less general. But here I’m thinking… And in Tory’s agency, I know this is one of the… Some of the evidence I have for how effective MI and agency-wide training can be. Her key leaders, her supervisors, everyone at every level, everyone from every perspective in the organization is sitting there together and learning together and contributing. And I think there’s a real disconnect when administrators or key leaders say, “I don’t want to take the time. I don’t want to bother, but you need to do this.”
Ali: [22:31] Here we’re all in it together. Now, someone who has very tangential contact with the person being served, maybe if an initial phone call or an engagement may not need the whole encyclopedia, but if the heart-set and mindset is being expressed, then that first contact with that agency is something that the person being served is going to feel good and positive about. And retention engagement is going to lead to retention and retention is going to lead to more meaningful outcomes for that person. Or, the person may walk away saying maybe not today. But they’re going to walk away feeling respected, feeling their dignity and absolute worth was honored. And the door is open for them to seek services maybe at that agency or maybe somewhere else. I think it really makes a difference for the person’s experience. So, I am one to speak to the broad and wide effects of MI when it’s done well, like in an organization that Tory’s with.
Jeff: [23:30] Ali, one final question for you. I’m curious what advice you would have for supervisors who are trying to instill MI in the people they are supervising.
Ali: [23:38] I’m not so sure that when we encounter a commission with reluctance to MI. I’m not sure that it is an important issue. It might be a confidence issue. The person may feel their expertise is threatened. “I studied all these years. This is what I just graduated with. This is what I need to do.” They may have a zeal for it, not so sure that it may… It may be a confidence thing. It may be, “I’m not sure I can. I’m not sure I’m as good at this new thing as I am with what I know.” So, the willingness to try something on may come out as an important concern. “I don’t think that’s going to work. That won’t work here. These people are too difficult.” Well, what we know about the more challenging the person’s experience has been, the more likely MI is to be successful with them. So, we can make modifications with that. So elective clinician we can help them with that. We can also support their confidence to be just as good as this as the other things that they bring in to the context that they’re strong at.
Jeff: [24:43] Tory, same question for you. What advice do you have for other supervisors?
Tory: [24:46] I think that what we’ve said before about creating the culture of MI or the MI in the air is really critical. Because as the supervisor, you are one voice and this individual is surrounded by other voices. In a good agency, you are going to have group supervision. You’re going to have individual supervision. You’re going to have, hey people checking in with their peers, “Hey gosh, this really challenging thing just happened to me. And I’m walking out of a session or I’m walking out of the visit and I’m feeling blindsided.” And I think creating that kind of overarching culture of, “Hey, this is how we speak to people. This is how we work toward change.” Is really critical in terms of developing that.
Jeff: [25:35] Thank you for that, Tory. Ali, anything you’d like to add in response to that?
Ali: [25:39] Well, I’m so glad that Tory just spoke to group supervision and to team consult. And the idea here is really pointing toward developing a community of practice or a learning community. Which can come be generated from the supervisor can also be from key champions in MI around the organization. So that there’s space set aside. That says, this is valuable. We don’t have to take a lot of time in the staff meeting, but we’re going to take a little bit to look at this difficult or challenging thing, and maybe come up with five to 10 MI consistent solutions that might be helpful here. And really look to each other, rely on each other, brainstorm together. And with humility, we’re always going to keep learning. I’m just liking this community of practice idea quite a lot.
Jeff: [26:26] With humility, we’re always going to keep learning. Ali Hall, thank you for being back with us as always.
Ali: [26:31] Thank you, Jeff and Tory. Thank you so much.
Jeff: [26:33] And Tory Morgan, thank you so much for joining us. Good luck with your work and keep fighting the good fight.
Tory: [26:39] It was absolutely my pleasure. Thank you guys so much for having me. I loved talking about this.
Jeff: [26:44] And to our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer: [26:48] Visit C4innovates.com and follow us on Twitter, Facebook, and LinkedIn, for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on “Changing the Conversation.”
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