David Jefferson, MSW
Director of Training and Technical Assistance
Northwest ATTC

Over the past three years, in collaboration with the Northwest ATTC, I have led a large technical assistance project to support implementation of Motivational Interviewing (MI) for 200+ members of the behavioral health workforce employed at social service agencies in Whatcom County, Washington. During the course of this targeted technical assistance project, workforce members participated in basic and intermediate MI training workshops and received individualized, skills-focused coaching. In March 2020, when I became the Director of Training and Technical Assistance at the Northwest ATTC and we found ourselves in the midst of the pandemic, with providers being asked to quickly pivot to telehealth, it seemed like the perfect opportunity to build on their MI skills.

In mid-March, local programs discontinued face-to-face sessions and their workforce started providing all services virtually (i.e. phone, video-conferencing). Knowing we had a robust number of MI-trained workforce members, we thought this would be an opportune time to offer them individualized coaching in applying MI in their telehealth services. We speculated workforce members needed to increase their confidence in providing care, needed skills in this new medium, and could use guidance on how to be more effective with MI. We also knew many programs would be overwhelmed with administrative and programs complications related to Covid-19.

In response to this need, the Northwest ATTC developed a MI telehealth coaching protocol and by early April started delivering individualized coaching sessions to 41 workforce members. The coaching sessions were 30 minutes in length and delivered via Zoom. Prior to each coaching session, workforce members filled out a skill development form, which included identifying skills they were interested in developing, and writing out a case scenario. During the sessions, the coach role-played the client and the workforce member practiced his or her skills. The sessions ended with a debrief about what worked well, what were the challenges, and what skills to improve. Workforce members were offered up to four individual coaching sessions, and most completed at least three. In all, we completed 99 coaching sessions through the end of May.

The coaching revealed a depth of dedication and commitment by workforce members, who signed up to advance their skills during a time when their stress was peaking, workloads were more complicated and certainty in their day-to-day lives, hard to find. Workforce isolation prompted us to invite all participants to a one-hour Zoom session with the goal of sharing lessons learned and strengthening community. We asked the 25 attendees to answer three questions in small groups and report their top impressions. Here are the questions and responses.

What have you learned to improve your Telehealth services?
  • Workforce members benefit from setting up a workspace, being prepared to provide guidance and structure for the call and taking responsibility for setting the tone.
  • It is important to start calls by checking in about the basics. Asking the client initial questions like: “is this still a good time?”, “are you in an appropriate location?”, and “do you have privacy?” was critical, prior to exploring their comfort and skill level around using the phone and/or computer for services.
  • Acknowledge the common awkwardness, empathize with your shared dilemma of this new medium, and use humor to defuse the situation.
  • Adjust to shifting goals and respect the silence, not all clients like to talk on the phone.

What MI skills have been most useful?
  • The Four Processes of MI; Engagement, Focusing, Eliciting and Planning are helpful for structuring the call and guiding the conversation.
  • Slowing down helps clients make faster connections
  • Moving away from my “to-do list” and developing an agenda with the client.
  • Open-ended questions and reflection keep the conversation going but the reflections need to be deeper and lean toward what is possible, what is helpful, and what is hopeful.
  • Meaningful and well-crafted affirmations shine a light on clients’ skills and abilities especially during these times when they feel desperate and stagnant. Affirming that they have the resources to go forward helps them identify their self-efficacy.
  • Summaries help start and end the conversations and add structure. They create a story or narrative about the client’s life that is difficult to capture in these two-dimensional settings.
  • Explore the discord, as it helps increase engagement.

What are your pending challenges to strengthen services?
  • Building rapport and making genuine connections over the phone is the hardest part. Not all clients are comfortable with using phones for counseling sessions and do not see the value.
  • Maintaining connections via virtual sessions is hard and must be attended to each time.
  • Ambivalence is on the increase. Everything seems to be put on hold. Encouraging change talk is a bit harder as clients are hesitant to move on, due to fear, etc. (e.g., some have chronic diseases are afraid to go to healthcare providers).
  • They want Covid-19 information, which is limited, so it triggers the desire to fix clients and leaves workforce members feeling like they did not help.
  • Hard to move people to the eliciting phase. Need to make use of looking forward strategies to build hope and rekindle dreams.

Offering this cohort an opportunity to practice their MI skills with mock client role-plays, seemed well timed, and many expressed their appreciation and gratitude. The success of the project led the Northwest ATTC to offer the same opportunity starting in late May to the Idaho behavioral health workforce and we are exploring the possibility of expanding in other areas in region Ten.


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