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
References
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‘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:
http://www.ohiosamiccoe.cwru.edu/about/abo
utus.html
Outline
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Core IDDT & MI principles
Implementation:
– Evaluating implementation and obstacles
– Learning IDDT & MI
– Evaluating fidelity and outcomes
Motivational Interventions

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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
MI Spirit & its Mirror
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Collaboration
Evocation
Autonomy

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Confrontation
&/or Directive
Education
Authority
Principles of MI
Roll with ‘resistance’
 Express accurate empathy –
particularly through reflective
listening
 Develop discrepancy
 Support self-efficacy

MI ‘micro-skills’
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Affirmations
Reflective listening
Open-ended questions
Summarizing
Elicit change talk
– OARS = open-ended questions, affirmations,
reflective listening & summarizing
Rogerian Skill and Client
Outcomes
Valle (1981) J Studies on Alcohol 42: 783-790
40
35
30
25
Client Relapse
20
Rates
15
10
5
0
38
35
29
24
23
20
19
15
13
18
11
5
6 Months 12 Months 18 Months 24 Months
Follow-up Points
Low
Medium
High
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

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Critical components across programs identified
Currently 36 controlled studies provide
empirical evidence for approach
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.
Critical components:
2. Assertive Outreach

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Clients have difficulty linking with
services and treatment
Engages clients & members of their
support system
Without assertive outreach, noncompliance and dropout rates are high
Part of Engagement Stage of Treatment
Critical components:
3. Counseling

Multiple modalities:
– Use of Motivational Interviewing & Cognitive
Behavioral Therapy
– Individual
– Group
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Persuasion and Active/Relapse Prevention
Social Skills and Skills training
Co-occurring disorders specific groups
– Family
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Family Psycho-education for Co-DOs
Behavioral Family Therapy
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:
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Strengthening of immediate social environment
Includes social network as well as family interventions
May include abstinent/sober and/or overall recovery
supports
Critical components:
4. Long-term Perspective

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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
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.
Comprehensiveness

Inclusion of other EBPs
– Assertive community treatment or
Integrated Case Management
– Residential services
– Illness management and recovery
– Supported employment
– Family Psychoeducation
Critical components:
6. Cultural Competence
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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
Critical components:
7. Staged Interventions
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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
– Persuasion
->
->
– Active treatment
– Relapse prevention
->
->
Pre-contemplation
Contemplation &
Preparation
Action
Maintenance
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 Not Feel
They Needed
Treatment
(19.3 Million)
87%
5%
Not Treated and
Did Feel They
Needed Treatment
(1.0 Million)
(26% Made Effort
to Get Treatment)
8%
Treated
(1.9 Million
Receiving
Treatment)
22.2 Million Needing Treatment for Illicit Drugs or Alcohol
Past Year Receipt of and Perceived Need
for Treatment for Mental Health Problems
among Persons Aged 18 or Older with SMI:
2003 NSDU&H
Treated
(9.2 Million)
47%
13%
40%
19.6 Million with SMI
Not Treated,
Perceived
Unmet Need
(2.5 Million)
Not Treated,
No Perceived
Unmet Need
(7.8 Million)
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%
No Treatment
Substance Use
Treatment Only
49.0%
(4.2) Million Adults with Active Co-Occurring SMI
and Substance Use Disorder
Transtheoretical Change Process
HOW PEOPLE CHANGE
Maintenance
Precontemplation
Action
Contemplation
Preparation/Planning
Matching Stage of Change, SATS & Types of Interventions
Stage of Change
Precontemplation
SATS
Engagement
Interventions
IDDT methods
Outreach, practical health,
crisis intervention,
relationship building,
assessment
CRS; SATS, Longitudinal
Assessment; Contextual
Assessment; Payoff
Matrix/Functional
Analysis; Motivational
Interviewing
Contemplation Persuasion
& preparation
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
Critical components:
8. Motivational Interventions

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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)
Practical considerations
exercise

Form groups of similar roles:
–
–
–
–
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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?