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Motivational Interviewing in Mental Health Treatment Michael P. Giantini, PhD, MA, LPC, MINT Training & Consultation Specialist UMDNJ-UBHC-BRTI-Technical.

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Presentation on theme: "Motivational Interviewing in Mental Health Treatment Michael P. Giantini, PhD, MA, LPC, MINT Training & Consultation Specialist UMDNJ-UBHC-BRTI-Technical."— Presentation transcript:

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

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

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

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

5 MI & mental health wellness & recovery: the good, the bad & the ugly MI good – client centered, respectful, fits with core wellness and recovery values and philosophy 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 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 MI ugly – a manipulative technique clinicians use to get the client to carry out the clinician’s goals/treatment plan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

20 Purveyor activities during stages of implementation Purveyor Activities (N=577) Implementation Stages ExploreInstall Initial Implementation Assessment97%1%2% Planning20%32%48% Training3%31%66% Coaching8%6%86% Evaluation3%23%73% Organizational Development11%16%73% System Intervention37%30%33%

21 Practical considerations Has your agency: 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? CEO/President CEO/President QI QI Supervisors Supervisors Staff Staff Consumers Consumers Family members Family members

22 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?

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

24 References National Implementation Research Network: National Implementation Research Network: http://nirn.fmhi.usf.edu/aboutus/01_whatisnirn.cfm TIPS 35 & 42: TIPS 35 & 42: –www.treatment.org/backup7-6- 04/Externals/tips Co-occurring Center for Excellence: Co-occurring Center for Excellence: –http://coce.samhsa.gov/audience/index.html http://coce.samhsa.gov/audience/index.htmhttp://coce.samhsa.gov/audience/index.htm

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


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