Barriers to implementing motivational interviewing in addiction treatment: A nominal group technique process evaluation

Lack of staff time. MI implementation, particularly practicing MI skills, was viewed as overly time-consuming. Staff had large caseloads, meetings, and other job requirements, and these other time constraints took precedence over implementing MI in their sessions. Clinics that were not fully staffed required current employees to take on multiple day-to-day jobs just to maintain viability, and therefore, MI implementation could not be prioritized (e.g., “We were so horribly short-staffed I don’t know how I kept my doors open”). When new counselors were finally hired, these clinics remained in a state of “rebound” as all staff were behind on their regular work tasks. As a result, staff were both overworked and burned out, causing MI to be forgotten about or “put on the backburner.” One leader summarized this concern: “This would be something that they would probably have to take home with them to read up on and practice [outside of work hours] and come back in, but can I ask them to do that without paying them?”

Resistance. Certain staff were unwilling to use MI and/or engage in the MI feedback process because it was new and different than their regular routines, a sentiment amplified if a staff member already held general closed-mindedness and reticence toward any culture change. This was most common among the more seasoned counselors who had already developed a pattern of clinical practice over time (e.g., “[One of my staff members] was definitely one of the old school style of counselors, not very touchy feely for sure”) and among counselors who were less invested in their work (e.g., “I had conversations with my other counselor but it was just taken as ‘Yeah, okay. Whatever. I did my job.’”). As a whole, staff resistance to change dissipated over the course of the study.

Lack of confidence. Some staff lacked confidence in their ability to deliver MI with fidelity and therefore avoided using MI or participating in the MI feedback process all together. At times, this phenomenon occurred among staff who displayed sufficient competency in MI but did not realize their skill level (e.g., “A lot of times counselors feel like they really have to think about doing MI when they were actually already doing MI without even thinking about it”). Leaders stated that counselor confidence in MI improved with encouragement and practice and was higher among staff by the end of the study (e.g., “Not being good at something because it’s new and ‘I don’t know how to do it’ kind of deters them from partaking, in really having fidelity to the recording, so it kind of made them seem like they were not cooperative at first. But now that I feel like because they’ve gotten some really good feedback . . . their confidence has increased as they have learned.”).

Competency. Some staff lacked a general understanding of MI. For example, one leader stated that his staff became preoccupied with adhering to the MI model (e.g., how and when to use exact MI techniques), rather than the overall purpose and spirit of MI, which resulted in less effective therapy sessions. In addition, counselors varied in level of experience and training in MI implementation; some counselors had been trained in MI before the study whereas others had little to no exposure to the EBP. As a result, staff varied widely in their need for support and supervision, which complicated first-level clinic leaders’ plans for overall MI implementation.

Staff apprehension. Related to lack of confidence, certain staff were concerned about taking risks and trying something new, and subsequently avoided the MI feedback process. Rather than ask for help, staff made excuses about why they were not able to fully engage with MI (e.g., “Some of these people were so worried about how they might look and then they would make excuses like, ‘Oh, the clients don’t want to sign the waiver’”). Apprehension was frequently expressed at the beginning of the study, though one leader commented that this concern dissipated over time as counselors became more comfortable with the EBP.

Lack of staff buy-in to MI. A few staff discredited the value of and evidence behind MI and therefore did not accept agency efforts to implement MI (e.g., “If the counselors don’t see it as being significant, they’re not going to go in that direction [of putting time and energy into the MI feedback process]”). Despite first-level clinic leaders’ various efforts to increase the appeal of MI to their staff, some staff lacked interest in adopting MI because they did not understand how it could help their clients. Support from upper management and the provision of incentives sometimes helped mitigate these struggles: “Sometimes, you’ve really got to take the upper management and kind of come down and say, ‘Hey, you’ve got to get behind this.’” Unlike other staff-level barriers that dissipated with time, leaders stated that the level of staff buy-in fluctuated throughout the course of the study.

Leaders’ time. Participants felt that they, as first-level clinic leaders, were unable to dedicate the time, focus, and energy they felt necessary to adequately follow up on the initial MI training. Although they expressed a desire to provide education and supervision to their staff, leaders were diverted by their regular day-to-day workload, as well as abrupt clinic disruptions such as staff turnover and being short staffed, that required them to take on additional work (e.g., “It has been extremely difficult for me to fit the time commitments that were necessary to do an excellent job with this . . . Unfortunately, other kind of things trumped my attention”).

Staffing. Staffing concerns occurred at all levels in the agency, from counselors to executives. Agencies were short-staffed, either permanently or temporarily, due to a cycle of staff turnover. Participants were affected by turnover at levels above them (i.e., executive leadership) and below them (i.e., staff). Executive leadership turnover particularly affected MI implementation when executives recruited onto the LOCI study and who championed strategic development around MI, later left the agency with little transition to their replacement. Staff turnover required leaders to consider how newly hired staff differed from those who had left; leaders reported some new staff were less confident, less trained, and held different attitudes toward EBPs.

External contractual constraints. Participants’ agencies were funded by external contracts that demanded specific documentation and clinical service provision to maintain funding. As new external contracts were adopted by the agency, new mandates required extensive preparation, which interfered with the delivery of EBP services. When newer contracts were signed, there were competing demands agency-wide that staff, leaders, and executives had to focus on. This was in addition to their own deadlines that were high priority. In extreme cases, entire clinics closed when they were unable to keep up with their external contracts and get renewed funding. Within this study, a new waiver was introduced in California that diverted much of the attention of both leaders and staff away from MI implementation to new waiver-mandated requirements: “July 1st everything goes to drug MediCal, so we need all the time we have in case conference and other meetings to work on what needs to change by July 1st, so I think this kind of took a backseat to that.”

Support from other levels. Although leaders saw the value in adapting a new EBP model, other members of the leadership team, such as executives and clinical supervisors, offered limited support and/or resisted these strategic efforts (e.g., “We have to come together as an agency and [implementation] has to go all the way up, you know? Because I can set goals for my people that are under me, but I don’t have anybody above me who has ever like one time asked me about, ‘Hey, how is the MI going?’”). Leaders felt that executives did not provide sufficient guidance, support, or attention to reinforcing the importance of EBP implementation (e.g., “The hardest thing about this whole process is you know each program [within the agency] has kind of had to come up with its own way of doing this, and the support that we’ve received from corporate from the agency itself has been pretty low”).

Financial resources. As part of the LOCI intervention, the LOCI trainers introduced the benefits of establishing rewards and incentives to maintain motivation for new EBP initiatives. Although first-level clinic leaders were enthusiastic about this suggestion, their agencies lacked the financial resources to designate funds for this purpose. Therefore, some leaders were not able to provide rewards or incentives, while others paid for rewards out of their own pocket (e.g., “I could never justify gift card incentives for staff . . . I’d get in big trouble for that. So do you take it out of your own pocket? Um okay, seeing what non-profit people make . . .”). Leaders also discussed the need for financial resources to support provision of additional MI trainings, including refresher trainings for previously trained staff or full trainings for new staff members.

Leadership turnover (at the LOCI leader level). In addition to mentioning turnover at other levels in the organization, participants also highlighted the effects of LOCI leader turnover. Throughout the study, LOCI leaders left their clinic, were promoted to other positions, or stepped down from leadership positions. Replacement LOCI leaders came from positions both internal and external to agencies. Within the NGT, those replacement leaders commented on how difficult it was to enter in the LOCI leader role partway through the study.

Clients’ apprehension and resistance to being recorded. Leaders and staff reported that many clients refused to have their sessions recorded. These clients, especially those in forensic or probation systems, may have been uncomfortable with any potential breaches in confidentiality or privacy. However, this barrier may also have been confounded with other barriers, as some leaders noted that clients’ reactions were based on staff’s introduction to recordings (e.g., “I think a lot of [clients’ resistance] was how the counselor presented the recording itself”) and staff’s perceptions (e.g., “[My staff] didn’t think their clients were going to want to do it”). In addition, one leader commented that clients’ concern with being recorded may change the nature of sessions: “[Some patients] take on a different role, they’re not themselves really . . . They want to be politically right . . . The patient won’t put down the barrier because the recorder.”

Staff’s apprehension and resistance to recording. Related to aforementioned staff-level issues, staff expressed discomfort around recording their sessions that would then be scored and reviewed in the feedback process. Counselors expressed concern regarding how they would be perceived after others listened to their recordings, how they would be graded or judged, and ultimately if they would face punitive action around their performance. This resistance was so prevalent that despite input from and problem-solving with higher-level executives, first-level clinic leaders struggled to motivate their staff to record sessions for upload.

Technology issues. Staff had difficulty using the technological equipment provided by the study team (e.g., audio recorders) and at their own agencies (e.g., computers, internet issues) that were necessary to record and upload MI sessions. As a result, staff required more training and/or additional help from their information technology support staff or LOCI staff to navigate these issues, which resulted in more time and coordination than anticipated. One leader remarked, “If we would get past [the technology issues], then we would have focused more on the [MI/clinical] issues.”