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

Issues in the mental Issues in the mental health systemhealth system Persons suffering from severe and Persons suffering from severe and

persistent mental illness persistent mental illness MI associated with at least four EBP’s: MI associated with at least four EBP’s:

IDDT, IMR, SE and ACTIDDT, IMR, SE and ACT MI as an EBP muted by complex set of core MI as an EBP muted by complex set of core

principles associated with these EBPsprinciples associated with these EBPs MI vs MH EBP fidelityMI vs MH EBP fidelity

– Individual clinician vs programmaticIndividual clinician vs programmatic– Valuation of fidelity anchor points:Valuation of fidelity anchor points:

MI – yes, as much as discernableMI – yes, as much as discernable MH EBPs – not at this timeMH EBPs – not at this time

Issues in the mental Issues in the mental health systemhealth system Wide variations in substance use Wide variations in substance use

approaches and philosophyapproaches and philosophy Multiple co-occurring serious Multiple co-occurring serious

illnesses, especially:illnesses, especially:– Mental healthMental health– Substance useSubstance use– Chronic & acute medical conditionsChronic & acute medical conditions– Cognitive impairmentCognitive impairment– Active MH & SU symptomsActive MH & SU symptoms

Issues in the mental Issues in the mental health systemhealth system Less overall knowledge regarding Less overall knowledge regarding

substance use issues and the higher substance use issues and the higher vulnerability those with SPMI have to vulnerability those with SPMI have to substances in generalsubstances in general

History of a strong medical model History of a strong medical model Treatment system funded to Treatment system funded to

address acute versus chronic illness address acute versus chronic illness (~65% of budget IP care & 24 hour (~65% of budget IP care & 24 hour servicesservices

MI & mental health wellness & MI & mental health wellness & recovery:recovery:the good, the bad & the uglythe good, the bad & the ugly

MI good – client centered, respectful, MI good – client centered, respectful, fits with core wellness and recovery fits with core wellness and recovery values and philosophyvalues and philosophy

MI bad – use pay off matrix cons as MI bad – use pay off matrix cons as ammunition to establish substance use ammunition to establish substance use as no goodas no good

MI ugly – a manipulative technique MI ugly – a manipulative technique clinicians use to get the client to carry clinicians use to get the client to carry out the clinician’s goals/treatment planout the clinician’s goals/treatment plan

Implementation: NIRNImplementation: NIRN

Consideration for the specific evidence Consideration for the specific evidence based intervention(s)based intervention(s)

The implementation process & The implementation process & strategies to put the intervention in strategies to put the intervention in placeplace

Effective Effective interventionintervention practices + practices +

Effective Effective implementationimplementation practices = practices =

Good outcomes for consumersGood outcomes for consumersNo other combination of factors reliablyNo other combination of factors reliably

produces desired outcomes of consumersproduces desired outcomes of consumers

An effective An effective implementation implementation strategystrategy1.1. Active & qualified PurveyorActive & qualified Purveyor

2.2. Systemic use of Implementation Systemic use of Implementation DriversDrivers

3.3. Vertical integration to create Vertical integration to create aligned systemsaligned systems

4.4. Attention to Stages of Attention to Stages of ImplementationImplementation

1.1. Active & qualified Active & qualified PurveyorPurveyor An individual or group representing a An individual or group representing a

program or practice who actively work to program or practice who actively work to help others implement that practice or help others implement that practice or program with fidelity & good effectprogram with fidelity & good effect

Accumulates data & experiential knowledge, Accumulates data & experiential knowledge, more effective & efficient over timemore effective & efficient over time

– Supervisors – can become purveyors over time, Supervisors – can become purveyors over time, but it is difficult to develop & maintain that rolebut it is difficult to develop & maintain that role

Active & qualified Active & qualified PurveyorPurveyor Purveyor interface:Purveyor interface:

– PractitionersPractitioners– Organization:Organization:

Management (leadership, policy, QI)Management (leadership, policy, QI) Administration (HR, structure)Administration (HR, structure) Supervision (nature, content)Supervision (nature, content)

– System of careSystem of care– State policiesState policies

2.2. Systemic use of Systemic use of Implementation Implementation DriversDrivers Implementation Drivers are Implementation Drivers are

mechanisms that help to develop, mechanisms that help to develop, improve and sustain practitioners’ improve and sustain practitioners’ ability to implement an ability to implement an intervention or innovation for intervention or innovation for consumer benefitconsumer benefit

They move programs closer to They move programs closer to ideal practiceideal practice

Implementation DriversImplementation DriversFacilitative Administrative

Supports

Consultation & Coaching

Staff/Program Performance Evaluation

Systems Interventions

Recruitment & Selection

Pre-service Training

Decision SupportData Systems

Why focus on Why focus on practitioner behavior?practitioner behavior? The The Practitioner Practitioner is is the the

interventionintervention– Doing the right thing for the right reason Doing the right thing for the right reason

at the right time with the right person to at the right time with the right person to maximize progressmaximize progress

– Wide ranging inputs (practitioner history Wide ranging inputs (practitioner history & current realities)& current realities)

– Challenge & promise of EBP’s – Be Challenge & promise of EBP’s – Be effective consistentlyeffective consistently

LearningLearning

Outcomes of new classroom skillsOutcomes of new classroom skills

TrainingTraining Knowledge Knowledge Skill Skill Use inUse in ComponentsComponents Demonstration Demonstration

ClassroomClassroom

Theory & DiscussionTheory & Discussion 10% 10% 5% 5% 0% 0%

… … + Demonstration in+ Demonstration in 30% 30% 20% 20% 0% 0%trainingtraining

… … + Practice & feedback 60%+ Practice & feedback 60% 60% 60% 5% 5%in trainingin training

… … + Coaching in+ Coaching in 95% 95% 95% 95% 95%95%the classroomthe classroom

LearningLearning

Dissemination of information by Dissemination of information by itself does not lead to successful itself does not lead to successful implementationimplementation

Training alone, no matter how Training alone, no matter how well done, does not lead to well done, does not lead to successful implementationsuccessful implementation

MI FidelityMI Fidelity

Minimum MI fidelity (MITI)Minimum MI fidelity (MITI)– Accurate empathyAccurate empathy– SpiritSpirit– MI adherentMI adherent

Asking permission, affirming, emphasizing Asking permission, affirming, emphasizing personal control, supportpersonal control, support

– MI non-adherent behaviorsMI non-adherent behaviors Advise, confront, directAdvise, confront, direct

– Open ended questionsOpen ended questions– Complex vs simple reflectionsComplex vs simple reflections

IDDT Fidelity: SAMHSAIDDT Fidelity: SAMHSA

Multidisciplinary Multidisciplinary teamteam

Integrated substance Integrated substance abuse specialistabuse specialist

Stage wise Stage wise interventionsinterventions

Client access to Client access to comprehensive comprehensive servicesservices

Time unlimited Time unlimited servicesservices

Assertive outreachAssertive outreach MIMI

Substance abuse Substance abuse counseling (CBT)counseling (CBT)

Group DD treatmentGroup DD treatment Fam Psych Ed for Fam Psych Ed for

CODCOD D & A self help groupsD & A self help groups Pharmacological Pharmacological

interventionsinterventions Interventions to Interventions to

promote healthpromote health Secondary Secondary

interventions for non-interventions for non-respondersresponders

IDDT Fidelity: SAMHSAIDDT Fidelity: SAMHSA

SAMHSA measures of fidelity are SAMHSA measures of fidelity are predominantly programmatic vs predominantly programmatic vs individual clinician basedindividual clinician based

Fidelity will include observation of Fidelity will include observation of the practitioner andthe practitioner and– Documentation, treatment plansDocumentation, treatment plans– Supervision and team meetingsSupervision and team meetings– Stage of change, MI and CBT Stage of change, MI and CBT

approachesapproaches

3.3. Vertical Integration Vertical Integration to create aligned to create aligned systemssystems Will the practice seriously conflict Will the practice seriously conflict

when interfaced with current when interfaced with current agency, county, state and federal agency, county, state and federal system?system?

If so, can the interface conflict be If so, can the interface conflict be removed or reduced?removed or reduced?

4.4. Attention to Stages Attention to Stages of Implementationof Implementation ExplorationExploration InstallationInstallation 2 – 4 2 – 4 Initial implementationInitial implementation years years Full implementationFull implementation InnovationInnovation SustainabilitySustainability

Purveyor activities Purveyor activities during stages of during stages of implementationimplementation

Purveyor Activities Purveyor Activities (N=577)(N=577) Implementation Implementation StagesStages

ExploreExplore Install Install Initial Initial ImplementationImplementation

AssessmentAssessment 97%97% 1%1% 2%2%

PlanningPlanning 20%20% 32%32% 48%48%

TrainingTraining 3%3% 31%31% 66%66%

CoachingCoaching 8%8% 6%6% 86%86%

EvaluationEvaluation 3%3% 23%23% 73%73%

Organizational DevelopmentOrganizational Development 11%11% 16%16% 73%73%

System InterventionSystem Intervention 37%37% 30%30% 33%33%

Practical Practical considerationsconsiderations Has your agency:Has your agency:

– Understood the key principles of the EBP?Understood the key principles of the EBP?– Weighed the pros/cons of a given practice?Weighed the pros/cons of a given practice?– Weighed the pros/cons of implementing the practice?Weighed the pros/cons of implementing the practice?– Consider the impact of implementing the practice?Consider the impact of implementing the practice?– Discussed its plans in detail with a purveyor – before Discussed its plans in detail with a purveyor – before

initiating an action plan?initiating an action plan?– Discussed implementation with all agency stake Discussed implementation with all agency stake

holders represented?holders represented? CEO/PresidentCEO/President QIQI SupervisorsSupervisors StaffStaff ConsumersConsumers Family membersFamily members

Practical Practical considerationsconsiderations

– Considered the stage of change of the staff, Considered the stage of change of the staff, supervisors and programs in the agency in relation to supervisors and programs in the agency in relation to the practice under consideration?the practice under consideration?

– Where to begin? – better small and with those Where to begin? – better small and with those interested. Is there a clear plan for implementation?interested. Is there a clear plan for implementation?

– Does the agency understand all of what Does the agency understand all of what implementation involves: training, coaching, ongoing implementation involves: training, coaching, ongoing supervision, conflicts with the current internal and supervision, conflicts with the current internal and external system of care and outcome measures?external system of care and outcome measures?

– What outcomes do you expect from implementation of What outcomes do you expect from implementation of the evidence based intervention?the evidence based intervention?

– How will you monitor that outcome?How will you monitor that outcome?

ReferencesReferences

MI: www.motivationalinterview.org/MI: www.motivationalinterview.org/ National Survey on Drug Use & Health: National Survey on Drug Use & Health:

http://oas.samhsa.gov/nhsda.htm#NHSDAinfohttp://oas.samhsa.gov/nhsda.htm#NHSDAinfo SAMHSA IDDT Toolkit:SAMHSA IDDT Toolkit:

– http://www.mentalhealth.samhsa.gov/http://www.mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/cmhs/communitysupport/toolkits/cooccurring/cooccurring/

‘‘Integrated treatment for dual disordersIntegrated treatment for dual disorders.’.’ Mueser et.al. 2003, Guilford PressMueser et.al. 2003, Guilford Press

ReferencesReferences

National Implementation Research National Implementation Research Network:Network:http://nirn.fmhi.usf.edu/aboutus/01_whatisnirn.cfm http://nirn.fmhi.usf.edu/aboutus/01_whatisnirn.cfm

TIPS 35 & 42:TIPS 35 & 42:– www.treatment.org/backup7-6-04/www.treatment.org/backup7-6-04/

Externals/tipsExternals/tips Co-occurring Center for Excellence:Co-occurring Center for Excellence:

– http://http://coce.samhsa.gov/audience/coce.samhsa.gov/audience/index.htmlindex.html

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