1. EVIDENCE BASED CARE IN BEHAVIORAL HEALTH MEDIATORS OF OUTCOME CONTEXTCONTEXT PROCESSPROCESS TOOLSTOOLS RELATIONSHIPRELATIONSHIP CLINICIANCLINICIAN CLIENTCLIENT ++ THERAPYTHERAPY OUTCOMESOUTCOMES

2. BEHAVIOR KNOWLEDGE SKILLS + + PERSONALITY + + OPPORTUNITY + + ATTITUDES + BELIEFS VALUES CULTURAL MORES CONSEQUENCES EVIDENCE BASED CARE IN BEHAVIORAL HEALTH WHAT DRIVES BEHAVIOR?

3. MEDIATORS OF OUTCOME CLIENT FACTORS PROBLEMS Bio-Psycho-Social Consideration Bio-Psycho-Social Consideration Types & Number Types & Number Duration & Severity Duration & Severity ATTITUDES & BELIEFS RESOURCES Personal competencies Personal competencies Support Systems Support SystemsPROBLEMS Bio-Psycho-Social Consideration Bio-Psycho-Social Consideration Types & Number Types & Number Duration & Severity Duration & Severity ATTITUDES & BELIEFS RESOURCES Personal competencies Personal competencies Support Systems Support Systems

4. MEDIATORS OF OUTCOME CLINICIAN FACTORS PROFESSIONAL BACKGROUND Training & Philosophy Training & Philosophy Professional competencies Professional competencies Knowledge & Skills Knowledge & Skills Clinical Experience Clinical Experience PERSONAL CHARACTERISTICS ATTITUDES & BELIEFS PROFESSIONAL BACKGROUND Training & Philosophy Training & Philosophy Professional competencies Professional competencies Knowledge & Skills Knowledge & Skills Clinical Experience Clinical Experience PERSONAL CHARACTERISTICS ATTITUDES & BELIEFS

5. MEDIATORS OF OUTCOME CLINICAL RELATIONSHIP THERAPEUTIC ALLIANCE Openness Openness Trust & Confidence Trust & Confidence Empathy Empathy THERAPEUTIC CLIMATE DECISION-MAKING MODEL Directive-Shared-Autonomous Directive-Shared-Autonomous THERAPEUTIC ALLIANCE Openness Openness Trust & Confidence Trust & Confidence Empathy Empathy THERAPEUTIC CLIMATE DECISION-MAKING MODEL Directive-Shared-Autonomous Directive-Shared-Autonomous

6. MEDIATORS OF OUTCOME CLINICAL TOOLS SCREENING, ASSESSMENT & DIAGNOSIS Instruments Instruments Procedures ProceduresINTERVENTION Case management Case management Psychotherapy Psychotherapy Pharmacotherapy Pharmacotherapy Combination therapy Combination therapy SCREENING, ASSESSMENT & DIAGNOSIS Instruments Instruments Procedures ProceduresINTERVENTION Case management Case management Psychotherapy Psychotherapy Pharmacotherapy Pharmacotherapy Combination therapy Combination therapy

7. MEDIATORS OF OUTCOME THERAPEUTIC PROCESS ACCESS & AVAILABILITY Regular, stable schedule On-demand Unfettered by distance, time etc. LOCUS OF CONTROL Client v. Clinician Centered SAFE & SECURE

8. MEDIATORS OF OUTCOME CONTEXT OF TREATMENT CLINIC POLICIES & PROCEDURES Service eligibility Service eligibility Services provided Services provided Clinician-Clinic Clinician-Clinic Clinician compensation Clinician compensation AGENCY, MCO & STATE POLICIES Service mandates Service mandates Funding - Levels & Streams Funding - Levels & Streams CLINIC POLICIES & PROCEDURES Service eligibility Service eligibility Services provided Services provided Clinician-Clinic Clinician-Clinic Clinician compensation Clinician compensation AGENCY, MCO & STATE POLICIES Service mandates Service mandates Funding - Levels & Streams Funding - Levels & Streams

9. EVIDENCE BASED CARE IN BEHAVIORAL HEALTH DESIRED OUTCOMES ADHERENCE TO PLAN Participation in Tx Participation in Tx Meds used as prescribed Meds used as prescribed No substance abuse No substance abuseASYMPTOMATIC Reduced frequency/severity Reduced frequency/severity IMPROVED LIFE FUNCTION Family & Friends Family & Friends Work & Recreation Work & Recreation ADHERENCE TO PLAN Participation in Tx Participation in Tx Meds used as prescribed Meds used as prescribed No substance abuse No substance abuseASYMPTOMATIC Reduced frequency/severity Reduced frequency/severity IMPROVED LIFE FUNCTION Family & Friends Family & Friends Work & Recreation Work & Recreation

10. Motivationally-Based Integrated Treatment for Mentally Ill Substance Abusing Patients Sponsored by The Ethel and James Flinn Family Foundation Sponsored by The Ethel and James Flinn Family Foundation EP Schoener, MJ Henderson, SJ Ondersma & CL Madeja Departments of Psychiatry & Psychology Wayne State University EP Schoener, MJ Henderson, SJ Ondersma & CL Madeja Departments of Psychiatry & Psychology Wayne State University

11.  more severe psychiatric morbidity,  greater treatment resistance,  poorer compliance & psycho-social adjustment,  greater utilization of social and health care services,  more frequent hospitalization,  more severe psychiatric morbidity,  greater treatment resistance,  poorer compliance & psycho-social adjustment,  greater utilization of social and health care services,  more frequent hospitalization, NATURE OF THE PROBLEM People with co-existing MI and SA manifest: compared to those with MI alone.

12. Motivationally Based Integrated Treatment for Mentally Ill Substance Abusing Patients HYPOTHESESHYPOTHESES Employ MBIT with fidelity and competenceEmploy MBIT with fidelity and competence Engender a stronger therapeutic allianceEngender a stronger therapeutic alliance Encourage greater client retention and adherenceEncourage greater client retention and adherence Realize more positive and enduring treatment outcomesRealize more positive and enduring treatment outcomes Employ MBIT with fidelity and competenceEmploy MBIT with fidelity and competence Engender a stronger therapeutic allianceEngender a stronger therapeutic alliance Encourage greater client retention and adherenceEncourage greater client retention and adherence Realize more positive and enduring treatment outcomesRealize more positive and enduring treatment outcomes In this effectiveness study, therapists trained in MBIT will:

13. METHODS/PROCEDURESMETHODS/PROCEDURES  Enroll clinicians  Assess patients at baseline  Monitor participants (6-12 sessions)  Train clinicians in MBIT  Monitor participants (8 sessions)  Follow-up patients (3 & 6 months)  Enroll clinicians  Assess patients at baseline  Monitor participants (6-12 sessions)  Train clinicians in MBIT  Monitor participants (8 sessions)  Follow-up patients (3 & 6 months) Motivationally Based Integrated Treatment for Mentally Ill Substance Abusing Patients

14. INSTRUMENTSINSTRUMENTS SCID, BSI, ASI, DTCQ, SF-36, QOLI, RTC, WAI MISC coding of individual therapy sessions SCID, BSI, ASI, DTCQ, SF-36, QOLI, RTC, WAI MISC coding of individual therapy sessions TRAININGTRAINING Two day workshop + biweekly supervisionTwo day workshop + biweekly supervision Manualized experiential + didactic learningManualized experiential + didactic learning Focus on MI skills and their applicationsFocus on MI skills and their applications Two day workshop + biweekly supervisionTwo day workshop + biweekly supervision Manualized experiential + didactic learningManualized experiential + didactic learning Focus on MI skills and their applicationsFocus on MI skills and their applications Motivationally Based Integrated Treatment for Mentally Ill Substance Abusing Patients

15. OUTCOME VARIABLES REFLECTIONS total # of paraphrased and rephrased statements EMPATHY global rating of therapist SPIRIT global rating of therapist Open:Total Questions (Ratio) # open Q’s /# open + closed Q’s ADVISE # of advise statements without permission SMS self-motivational statements or “change talk” (the only outcome measure of client behavior) REFLECTIONS total # of paraphrased and rephrased statements EMPATHY global rating of therapist SPIRIT global rating of therapist Open:Total Questions (Ratio) # open Q’s /# open + closed Q’s ADVISE # of advise statements without permission SMS self-motivational statements or “change talk” (the only outcome measure of client behavior) Motivationally Based Integrated Treatment for Mentally Ill Substance Abusing Patients

16. OVERALL FINDING FOR TIME, THERAPIST AND INTERACTION EFFECTS (N =196) Wilks’ Lambda df F Time (pre/post).84 6, 166 5.26*** Therapist.2560, 875 4.47*** Time X Therapist.6260, 8751.42* Note. *p <.05; ***p <.001. Motivationally Based Integrated Treatment for Mentally Ill Substance Abusing Patients

17. MISC Scores Pre- and Post- Training

18. Very Good Response: Pre- & Post- Training MISC Scores, Therapist #13

19. No Response: Pre- and Post-Training MISC Scores, Therapist # 4

20. CLINICIAN VARIABLES Therapists differ in:  Experience  Approach  Openness to new methods  Skill  Commitment to manual Therapists differ in:  Experience  Approach  Openness to new methods  Skill  Commitment to manual And thus, their ability to conduct MBIT

21. EVIDENCE BASED CARE IN BEHAVIORAL HEALTH MEDIATORS OF OUTCOME CONTEXTCONTEXT PROCESSPROCESS TOOLSTOOLS RELATIONSHIPRELATIONSHIP CLINICIANCLINICIAN CLIENTCLIENT ++ THERAPYTHERAPY OUTCOMESOUTCOMES