Motivational Motivational Interviewing in Mental Interviewing in Mental Health TreatmentHealth Treatment

Michael P. Giantini, PhD, MA, LPC, MINTMichael P. Giantini, PhD, MA, LPC, MINT

Training & Consultation SpecialistTraining & Consultation Specialist

UMDNJ-UBHC-BRTI-Technical Assistance CenterUMDNJ-UBHC-BRTI-Technical Assistance Center

Ph: 732-235-9286. E-mail: giantimp@umdnj.eduPh: 732-235-9286. E-mail: giantimp@umdnj.edu

ReferencesReferences

‘‘Motivational Interviewing’ Motivational Interviewing’ 22ndnd Edition, Miller & Rollnick, 2002, Edition, Miller & Rollnick, 2002, Guilford PressGuilford Press

‘‘Evidence-based Mental Health Evidence-based Mental Health Practice’, Practice’, Drake et.al.,Drake et.al., 2005, Norton2005, Norton

Ohio Substance Abuse & Mental Ohio Substance Abuse & Mental Health Coordinating Center of Health Coordinating Center of Excellence:Excellence:

http://www.ohiosamiccoe.cwru.edu/http://www.ohiosamiccoe.cwru.edu/about/aboutus.htmlabout/aboutus.html

OutlineOutline

Core IDDT & MI principlesCore IDDT & MI principles Implementation:Implementation:

– Evaluating implementation and Evaluating implementation and obstaclesobstacles

– Learning IDDT & MILearning IDDT & MI– Evaluating fidelity and outcomesEvaluating fidelity and outcomes

Motivational Motivational InterventionsInterventions Specific approaches are designed to Specific approaches are designed to

treat consumers in pre-action stagestreat consumers in pre-action stages Motivational interventions:Motivational interventions:

– Pre-contemplationPre-contemplation– ContemplationContemplation– PreparationPreparation– Action = Counseling stage. Attempts to Action = Counseling stage. Attempts to

do counseling with clients who are do counseling with clients who are pre/contemplators leads to poor resultspre/contemplators leads to poor results

MI Spirit & its MirrorMI Spirit & its Mirror

CollaborationCollaboration

EvocationEvocation AutonomyAutonomy

ConfrontatioConfrontation &/or n &/or DirectiveDirective

EducationEducation AuthorityAuthority

Principles of MIPrinciples of MI

RRoll with ‘resistance’oll with ‘resistance’ EExpress accurate empathy – xpress accurate empathy –

particularly through reflective particularly through reflective listeninglistening

DDevelop discrepancyevelop discrepancy SSupport self-efficacyupport self-efficacy

MI ‘micro-skills’MI ‘micro-skills’

AAffirmationsffirmations RReflective listeningeflective listening OOpen-ended questions pen-ended questions SSummarizingummarizing EElicit change talklicit change talk

– OARSOARS = open-ended questions, = open-ended questions, affirmations, reflective listening & affirmations, reflective listening & summarizingsummarizing

Rogerian Skill and Client Rogerian Skill and Client OutcomesOutcomesValle (1981) Valle (1981) J Studies on Alcohol 42J Studies on Alcohol 42: 783-: 783-790790

20

29

3538

13

1923 24

5

1115

18

0

5

10

15

20

25

30

35

40

6 Months 12 Months 18 Months 24 Months

Follow-up Points

Client Relapse Rates

LowMediumHigh

Summary of 26 Co-Summary of 26 Co-occurring SPMI & SU occurring SPMI & SU Research Studies Research Studies Drake et.al, Psychosocial Rehab. 12/2004Drake et.al, Psychosocial Rehab. 12/2004 Integration of treatment is essential:Integration of treatment is essential:

– Non-integrated = <5% stable remission/year Non-integrated = <5% stable remission/year – Integrated = 10-20% stable remission/yearIntegrated = 10-20% stable remission/year

Programs studied show positive outcomes:Programs studied show positive outcomes:– < Substance abuse, psychiatric symptoms, < Substance abuse, psychiatric symptoms,

hospitalizations & arrestshospitalizations & arrests– > Housing, functional status and quality of life> Housing, functional status and quality of life

Critical components across programs Critical components across programs identifiedidentified

Currently 36 controlled studies provide Currently 36 controlled studies provide empirical evidence for approachempirical evidence for approach

Critical components:Critical components:1. Integrated 1. Integrated treatmenttreatment The same clinicians or team of The same clinicians or team of

clinicians provide treatment for clinicians provide treatment for symptoms of mental illness and symptoms of mental illness and substance use disorders at the substance use disorders at the same time. The team integrates same time. The team integrates all aspects of the treatment and all aspects of the treatment and has the same philosophy and has the same philosophy and clinical approach to treatment.clinical approach to treatment.

Critical components: Critical components: 2. Assertive Outreach2. Assertive Outreach Clients have difficulty linking with Clients have difficulty linking with

services and treatmentservices and treatment Engages clients & members of their Engages clients & members of their

support systemsupport system Without assertive outreach, non-Without assertive outreach, non-

compliance and dropout rates are highcompliance and dropout rates are high Part of Engagement Stage of Part of Engagement Stage of

TreatmentTreatment

Critical components: Critical components: 3. Counseling3. Counseling Multiple modalities:Multiple modalities:

– Use of Motivational Interviewing & Cognitive Use of Motivational Interviewing & Cognitive Behavioral TherapyBehavioral Therapy

– IndividualIndividual– GroupGroup

Persuasion and Active/Relapse PreventionPersuasion and Active/Relapse Prevention Social Skills and Skills trainingSocial Skills and Skills training Co-occurring disorders specific groupsCo-occurring disorders specific groups

– FamilyFamily Family Psycho-education for Co-DOsFamily Psycho-education for Co-DOs Behavioral Family Therapy Behavioral Family Therapy

CounselingCounseling

– Motivational Interviewing is integrated into all Motivational Interviewing is integrated into all the different counseling approaches before the different counseling approaches before and during counseling sessionsand during counseling sessions

– Specific substance abuse counselingSpecific substance abuse counseling– Interventions to reduce negative Interventions to reduce negative

consequencesconsequences– Secondary interventions for substance abuse Secondary interventions for substance abuse

treatment ‘non-responders’treatment ‘non-responders’– Social support interventions:Social support interventions:

Strengthening of immediate social environmentStrengthening of immediate social environment Includes social network as well as family Includes social network as well as family

interventionsinterventions May include abstinent/sober and/or overall recovery May include abstinent/sober and/or overall recovery

supportssupports

Critical components: Critical components: 4. Long-term 4. Long-term PerspectivePerspective Long-term community based perspective Long-term community based perspective

that includes (re)-habilitation perspectivethat includes (re)-habilitation perspective Consumers tend to NOT develop stability Consumers tend to NOT develop stability

and functional improvements even in and functional improvements even in intensive treatment programs unless they intensive treatment programs unless they enter treatment at an active stage (active enter treatment at an active stage (active treatment and motivated)treatment and motivated)

10%-20% maximum remission/year10%-20% maximum remission/year Longitudinal studies indicate 1 to 8 yearsLongitudinal studies indicate 1 to 8 years

Critical components: Critical components: 5. Comprehensiveness5. Comprehensiveness Attention to substance use and mental Attention to substance use and mental

illness is integrated into all aspects of illness is integrated into all aspects of existing mental health program existing mental health program including:including:– Inpatient hospitalization, all outpatient and Inpatient hospitalization, all outpatient and

assertive community treatments, residential assertive community treatments, residential services, medical care, assessment, crises services, medical care, assessment, crises intervention, medication management, intervention, medication management, money management, laboratory screening, money management, laboratory screening, housing & vocational rehabilitation.housing & vocational rehabilitation.

ComprehensivenessComprehensiveness

Inclusion of other EBPsInclusion of other EBPs– Assertive community treatment or Assertive community treatment or

Integrated Case ManagementIntegrated Case Management– Residential servicesResidential services– Illness management and recoveryIllness management and recovery– Supported employmentSupported employment– Family PsychoeducationFamily Psychoeducation

Critical components: Critical components: 6. Cultural Competence6. Cultural Competence Need for tailoring of programs to Need for tailoring of programs to

address under-served groupsaddress under-served groups Model program generalization:Model program generalization:

– Local solutions are not necessarily Local solutions are not necessarily superiorsuperior

– Cultural and local considerations are Cultural and local considerations are important but critical program important but critical program components components need toneed to be replicated to be replicated to achieve good outcomesachieve good outcomes

Critical components:Critical components:7. Staged 7. Staged InterventionsInterventions Intensive treatment approaches do not work Intensive treatment approaches do not work

for the majority of consumersfor the majority of consumers High drop out rates related to mismatch in High drop out rates related to mismatch in

stage of changestage of change Stages of Treatment & ChangeStages of Treatment & Change

– EngagementEngagement ->-> Pre-contemplationPre-contemplation– PersuasionPersuasion ->-> Contemplation &Contemplation &

PreparationPreparation– Active treatmentActive treatment ->-> ActionAction– Relapse preventionRelapse prevention ->-> MaintenanceMaintenance

Past Year Perceived Need for Specialty Past Year Perceived Need for Specialty Treatment among Persons Aged 12 or Treatment among Persons Aged 12 or Older Needing Treatment for Older Needing Treatment for Alcohol/Illicit DrugsAlcohol/Illicit Drugs:: 2003 National Survey 2003 National Survey on Drug Use & Healthon Drug Use & Health

Treated(1.9 Million Receiving

Treatment)

Not Treated and Did Not Feel They Needed

Treatment(19.3 Million)

Not Treated andDid Feel They

Needed Treatment(1.0 Million)

(26% Made Effortto Get Treatment)

22.2 Million Needing Treatment for Illicit Drugs or Alcohol

87% 5%

8%

Past Year Receipt of and Perceived Past Year Receipt of and Perceived Need for Treatment for Need for Treatment for Mental Health Mental Health ProblemsProblems among Persons Aged 18 or among Persons Aged 18 or Older with SMI: 2003 NSDU&HOlder with SMI: 2003 NSDU&H

Not Treated, No Perceived Unmet Need(7.8 Million)

Treated(9.2 Million)

Not Treated, Perceived

Unmet Need(2.5 Million)

19.6 Million with SMI

47%13%

40%

Past Year Treatment among Adults Past Year Treatment among Adults Aged 18 or Older with Aged 18 or Older with Co-Occurring Co-Occurring SMI and a Substance UseSMI and a Substance Use Disorder: Disorder: 2003 NSDU&H2003 NSDU&H

Substance Use Treatment Only

(4.2) Million Adults with Active Co-Occurring SMI and Substance Use Disorder

Treatment for Both Mental Health and Substance Use Problems

No Treatment

39.8%

49.0%

7.5%

3.7%

Treatment Only for Mental Health Problems

PrecontemplationPrecontemplation

ContemplationContemplation

MaintenanceMaintenance

Preparation/PlanningPreparation/Planning

ActionAction

Transtheoretical Change Process

HOW PEOPLE CHANGE

Matching Stage of Change, SATS & Types of Matching Stage of Change, SATS & Types of InterventionsInterventions

Pre-contemplation

Engagement Outreach, practical health, crisis intervention, relationship building, assessment

CRS; SATS, Longitudinal Assessment; Contextual Assessment; Payoff Matrix/Functional Analysis; Motivational Interviewing

Contemplation & preparation

Persuasion Education, goal setting, increase awareness of problems practical skills training, family support, peer support

Motivational interviewing (expressing empathy, developing discrepancy, eliciting change talk, rolling with resistance, supporting self-efficacy)

Action Active Substance abuse counseling, medications treatment, skills training, self-help, groups, family therapy

Functional analysis, skills training

Maintenance Relapse prevention

Relapse prevention plan, continuing skill training, expanding recovery to other areas

Continuation of functional analysis, skills training, specific relapse prevention plans

Stage of Change SATS Interventions IDDT methods

Critical components:Critical components:8. Motivational 8. Motivational InterventionsInterventions Most consumers initially have low Most consumers initially have low

motivation for abstinence-oriented motivation for abstinence-oriented treatment and/or management of treatment and/or management of psychiatric illness and other functional psychiatric illness and other functional goalsgoals

Elicit clients own goals and support for Elicit clients own goals and support for them. Consumers in pre-action stage them. Consumers in pre-action stage are identifiableare identifiable

MI is an EBP (> 105 clinical trials)MI is an EBP (> 105 clinical trials)

Practical Practical considerations considerations exerciseexercise Form groups of similar roles:Form groups of similar roles:

– AdministrativeAdministrative– SupervisorySupervisory– Clinical/case managementClinical/case management– Consumer/family memberConsumer/family member

Consider:Consider:– Core EBP (intervention) principlesCore EBP (intervention) principles– What would be the pros and cons for your What would be the pros and cons for your

agency to implement one of these practices agency to implement one of these practices (time, QI, costs, staff & agency stages of (time, QI, costs, staff & agency stages of change)?change)?

– What would you see as necessary to What would you see as necessary to implement the practice?implement the practice?