1. Motivational Interviewing in Mental Health Treatment
Michael P. Giantini, PhD, MA, LPC, MINT
Training & Consultation Specialist
UMDNJ-UBHC-BRTI-Technical Assistance Center
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2. References
‘Motivational Interviewing’ 2nd Edition, Miller & Rollnick, 2002, Guilford Press
‘Evidence-based Mental Health Practice’, Drake et.al., 2005, Norton
Ohio Substance Abuse & Mental Health Coordinating Center of Excellence:

3. Outline Core IDDT & MI principles Implementation:
Evaluating implementation and obstacles
Learning IDDT & MI
Evaluating fidelity and outcomes

4. Motivational Interventions
Specific approaches are designed to treat consumers in pre-action stages
Motivational interventions:
Pre-contemplation
Contemplation
Preparation
Action = Counseling stage. Attempts to do counseling with clients who are pre/contemplators leads to poor results

5. MI Spirit & its Mirror Collaboration Evocation Autonomy
Confrontation &/or Directive
Education
Authority

6. Principles of MI Roll with ‘resistance’
Express accurate empathy – particularly through reflective listening
Develop discrepancy
Support self-efficacy

7. MI ‘micro-skills’ Affirmations Reflective listening
Open-ended questions
Summarizing
Elicit change talk
OARS = open-ended questions, affirmations, reflective listening & summarizing

8. Rogerian Skill and Client Outcomes Valle (1981) J Studies on Alcohol 42: 783-790

9. Summary of 26 Co-occurring SPMI & SU Research Studies Drake et
Summary of 26 Co-occurring SPMI & SU Research Studies Drake et.al, Psychosocial Rehab. 12/2004
Integration of treatment is essential:
Non-integrated = <5% stable remission/year
Integrated = 10-20% stable remission/year
Programs studied show positive outcomes:
< Substance abuse, psychiatric symptoms, hospitalizations & arrests
> Housing, functional status and quality of life
Critical components across programs identified
Currently 36 controlled studies provide empirical evidence for approach

10. Critical components: 1. Integrated treatment
The same clinicians or team of clinicians provide treatment for symptoms of mental illness and substance use disorders at the same time. The team integrates all aspects of the treatment and has the same philosophy and clinical approach to treatment.

11. Critical components: 2. Assertive Outreach
Clients have difficulty linking with services and treatment
Engages clients & members of their support system
Without assertive outreach, non-compliance and dropout rates are high
Part of Engagement Stage of Treatment

12. Critical components: 3. Counseling
Multiple modalities:
Use of Motivational Interviewing & Cognitive Behavioral Therapy
Individual
Group
Persuasion and Active/Relapse Prevention
Social Skills and Skills training
Co-occurring disorders specific groups
Family
Family Psycho-education for Co-DOs
Behavioral Family Therapy

13. Counseling
Motivational Interviewing is integrated into all the different counseling approaches before and during counseling sessions
Specific substance abuse counseling
Interventions to reduce negative consequences
Secondary interventions for substance abuse treatment ‘non-responders’
Social support interventions:
Strengthening of immediate social environment
Includes social network as well as family interventions
May include abstinent/sober and/or overall recovery supports

14. Critical components: 4. Long-term Perspective
Long-term community based perspective that includes (re)-habilitation perspective
Consumers tend to NOT develop stability and functional improvements even in intensive treatment programs unless they enter treatment at an active stage (active treatment and motivated)
10%-20% maximum remission/year
Longitudinal studies indicate 1 to 8 years

15. Critical components: 5. Comprehensiveness
Attention to substance use and mental illness is integrated into all aspects of existing mental health program including:
Inpatient hospitalization, all outpatient and assertive community treatments, residential services, medical care, assessment, crises intervention, medication management, money management, laboratory screening, housing & vocational rehabilitation.

16. Comprehensiveness Inclusion of other EBPs
Assertive community treatment or Integrated Case Management
Residential services
Illness management and recovery
Supported employment
Family Psychoeducation

17. Critical components: 6. Cultural Competence
Need for tailoring of programs to address under-served groups
Model program generalization:
Local solutions are not necessarily superior
Cultural and local considerations are important but critical program components need to be replicated to achieve good outcomes

18. Critical components: 7. Staged Interventions
Intensive treatment approaches do not work for the majority of consumers
High drop out rates related to mismatch in stage of change
Stages of Treatment & Change
Engagement -> Pre-contemplation
Persuasion -> Contemplation &
Preparation
Active treatment -> Action
Relapse prevention -> Maintenance

19. Past Year Perceived Need for Specialty Treatment among Persons Aged 12 or Older Needing Treatment for Alcohol/Illicit Drugs: 2003 National Survey on Drug Use & Health
Not Treated and
Did Feel They
Needed Treatment
(1.0 Million)
(26% Made Effort
to Get Treatment)
Not Treated and Did Not Feel They Needed Treatment
(19.3 Million) 5%
87% 8%
Treated
(1.9 Million Receiving Treatment)
22.2 Million Needing Treatment for Illicit Drugs or Alcohol

20. No Perceived Unmet Need
Past Year Receipt of and Perceived Need for Treatment for Mental Health Problems among Persons Aged 18 or Older with SMI: 2003 NSDU&H
Not Treated,
Perceived
Unmet Need
(2.5 Million)
13%
Treated
(9.2 Million)
47%
Not Treated,
No Perceived Unmet Need
(7.8 Million)
40%
19.6 Million with SMI

21. Past Year Treatment among Adults Aged 18 or Older with Co-Occurring SMI and a Substance Use Disorder: 2003 NSDU&H
Treatment Only for Mental Health Problems
Treatment for Both Mental Health and Substance Use Problems
39.8%
7.5%
3.7%
Substance Use Treatment Only
No Treatment
49.0%
(4.2) Million Adults with Active Co-Occurring SMI and Substance Use Disorder

22. Transtheoretical Change Process Preparation/Planning
HOW PEOPLE CHANGE
Precontemplation
Maintenance
Action
Contemplation
Preparation/Planning

23. Matching Stage of Change, SATS & Types of Interventions
Stage of Change SATS Interventions IDDT methods
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

24. Critical components: 8. Motivational Interventions
Most consumers initially have low motivation for abstinence-oriented treatment and/or management of psychiatric illness and other functional goals
Elicit clients own goals and support for them. Consumers in pre-action stage are identifiable
MI is an EBP (> 105 clinical trials)

25. Practical considerations exercise
Form groups of similar roles:
Administrative
Supervisory
Clinical/case management
Consumer/family member
Consider:
Core EBP (intervention) principles
What would be the pros and cons for your agency to implement one of these practices (time, QI, costs, staff & agency stages of change)?
What would you see as necessary to implement the practice?