Motivational Interviewing in Mental Health Treatment Michael P

Motivational Interviewing in Mental Health Treatment Michael P. Giantini, Ph. D, MA, LPC, MINT Training & Consultation Specialist UMDNJ-UBHC-BRTI-Technical Assistance Center Ph: 732 -235 -9286. E-mail: giantimp@umdnj. edu

Issues in the mental health system n n Persons suffering from severe and persistent mental illness MI associated with at least four EBP’s: IDDT, IMR, SE and ACT MI as an EBP muted by complex set of core principles associated with these EBPs MI vs MH EBP fidelity – Individual clinician vs programmatic – Valuation of fidelity anchor points: n n MI – yes, as much as discernable MH EBPs – not at this time

Issues in the mental health system Wide variations in substance use approaches and philosophy n Multiple co-occurring serious illnesses, especially: n – Mental health – Substance use – Chronic & acute medical conditions – Cognitive impairment – Active MH & SU symptoms

Issues in the mental health system Less overall knowledge regarding substance use issues and the higher vulnerability those with SPMI have to substances in general n History of a strong medical model n Treatment system funded to address acute versus chronic illness (~65% of budget IP care & 24 hour services n

MI & mental health wellness & recovery: the good, the bad & the ugly n n n MI good – client centered, respectful, fits with core wellness and recovery values and philosophy MI bad – use pay off matrix cons as ammunition to establish substance use as no good MI ugly – a manipulative technique clinicians use to get the client to carry out the clinician’s goals/treatment plan

Implementation: NIRN n n n Consideration for the specific evidence based intervention(s) The implementation process & strategies to put the intervention in place Effective intervention practices + Effective implementation practices = Good outcomes for consumers No other combination of factors reliably produces desired outcomes of consumers

An effective implementation strategy 1. 2. 3. 4. Active & qualified Purveyor Systemic use of Implementation Drivers Vertical integration to create aligned systems Attention to Stages of Implementation

1. Active & qualified Purveyor n n An individual or group representing a program or practice who actively work to help others implement that practice or program with fidelity & good effect Accumulates data & experiential knowledge, more effective & efficient over time – Supervisors – can become purveyors over time, but it is difficult to develop & maintain that role

Active & qualified Purveyor n Purveyor interface: – Practitioners – Organization: n Management (leadership, policy, QI) n Administration (HR, structure) n Supervision (nature, content) – System of care – State policies

2. Systemic use of Implementation Drivers are mechanisms that help to develop, improve and sustain practitioners’ ability to implement an intervention or innovation for consumer benefit n They move programs closer to ideal practice n

Implementation Drivers Decision Support Data Systems Staff/Program Performance Evaluation Consultation & Coaching Facilitative Administrative Supports Systems Interventions Recruitment & Selection Pre-service Training

Why focus on practitioner behavior? n The Practitioner is the intervention – Doing the right thing for the right reason at the right time with the right person to maximize progress – Wide ranging inputs (practitioner history & current realities) – Challenge & promise of EBP’s – Be effective consistently

Learning Outcomes of new classroom skills Training Components Knowledge Skill Use in Demonstration Classroom Theory & Discussion 10% 5% 0% … + Demonstration in training 30% 20% 0% … + Practice & feedback 60% in training 60% 5% … + Coaching in the classroom 95% 95%

Learning Dissemination of information by itself does not lead to successful implementation n Training alone, no matter how well done, does not lead to successful implementation n

MI Fidelity n Minimum MI fidelity (MITI) – Accurate empathy – Spirit – MI adherent n Asking permission, affirming, emphasizing personal control, support – MI non-adherent behaviors n Advise, confront, direct – Open ended questions – Complex vs simple reflections

IDDT Fidelity: SAMHSA n n n n Multidisciplinary team Integrated substance abuse specialist Stage wise interventions Client access to comprehensive services Time unlimited services Assertive outreach MI n n n n Substance abuse counseling (CBT) Group DD treatment Fam Psych Ed for COD D & A self help groups Pharmacological interventions Interventions to promote health Secondary interventions for nonresponders

IDDT Fidelity: SAMHSA measures of fidelity are predominantly programmatic vs individual clinician based n Fidelity will include observation of the practitioner and n – Documentation, treatment plans – Supervision and team meetings – Stage of change, MI and CBT approaches

3. Vertical Integration to create aligned systems Will the practice seriously conflict when interfaced with current agency, county, state and federal system? n If so, can the interface conflict be removed or reduced? n

4. Attention to Stages of Implementation Exploration n Installation n Initial implementation n Full implementation n Innovation n Sustainability n 2– 4 years

Purveyor activities during stages of implementation Purveyor Activities (N=577) Implementation Stages Assessment Planning Training Coaching Evaluation Organizational Development System Intervention Explore Install Initial Implementation 97% 1% 2% 20% 32% 48% 3% 31% 66% 8% 6% 86% 3% 23% 73% 11% 16% 73% 37% 30% 33%

Practical considerations n Has your agency: – – – Understood the key principles of the EBP? Weighed the pros/cons of a given practice? Weighed the pros/cons of implementing the practice? Consider the impact of implementing the practice? Discussed its plans in detail with a purveyor – before initiating an action plan? – Discussed implementation with all agency stake holders represented? n n n CEO/President QI Supervisors Staff Consumers Family members

Practical considerations – Considered the stage of change of the staff, supervisors and programs in the agency in relation to the practice under consideration? – Where to begin? – better small and with those interested. Is there a clear plan for implementation? – Does the agency understand all of what implementation involves: training, coaching, ongoing supervision, conflicts with the current internal and external system of care and outcome measures? – What outcomes do you expect from implementation of the evidence based intervention? – How will you monitor that outcome?

References MI: www. motivationalinterview. org/ n National Survey on Drug Use & Health: n http: //oas. samhsa. gov/nhsda. htm#NHSDAinfo n SAMHSA IDDT Toolkit: – http: //www. mentalhealth. samhsa. gov/cmhs/ communitysupport/toolkits/cooccurring/ n ‘Integrated treatment for dual disorders. ’ Mueser et. al. 2003, Guilford Press

References n National Implementation Research Network: http: //nirn. fmhi. usf. edu/aboutus/01_whatisnirn. cfm n TIPS 35 & 42: – www. treatment. org/backup 7 -604/Externals/tips n Co-occurring Center for Excellence: – http: //coce. samhsa. gov/audience/index. html

References n ‘Motivational Interviewing’ 2 nd Edition, Miller & Rollnick, 2002, Guilford Press n ‘Evidence-based Mental Health Practice’, Drake et. al. , 2005, Norton n Ohio Substance Abuse & Mental Health Coordinating Center of Excellence: http: //www. ohiosamiccoe. cwru. edu/about/abo utus. html