Motivational Interviewing & Severe & Persistent Mental Illness

1. Motivational Interviewing&Severe & Persistent Mental Illness MINT Forum 2008 Susan Littrell, ML Ruef & Michael P. Giantini

2. Overview • Intent of the session • How does published information potentially influence MI training of persons working with clients having severe & persistent mental illness? • Potentially establish ongoing dialogue among interested MINTies • Current MI information in relation to SPMI • Themes • Discussion

3. Effective therapist behaviors Rogers et.al. 1 • Study: The relationship of congruence, empathy & unconditional positive regard to ‘movement’ in therapy • Results: • “Schizophrenic clients” perceive low levels of these therapist behaviors and may increase slowly over time • “Schizophrenic clients” tend to perceive positive regard and congruence, i.e. relationship formation characteristics, more so than empathy, related to self-exploration

4. Effective therapist behaviors • Unbiased raters and “schizophrenic clients” had similar evaluations of the three conditions • Therapist ratings of their own conditions were so discrepant, they were negatively associated • Some small improvement in client functional outcomes noted • Martino et al: MI (+) for cocaine & SPMI, Std. Psychiatric Interview (+) for marijuana & SPMI. MI effectiveness symptom related? 2

5. Medication adherenceMcCracken & Corrigan 3 • Research literature (primarily Schizophrenia Spectrum Disorders): 3 • Combined educational, behavioral, affective, long-term interventions and positive alliance with providers along with concrete problem solving and motivational strategies 4 • Expect recurrence of adherence issues 5 • Compliance therapy (motivation related positive effect 6 , no effect 7)

6. Medication adherence • Interview context: • Client with severe symptoms: • Primary focus – develop trusting relationship • Express empathy • Client stable with cognitive impairments: • Identify goals using a structured format of client’s life areas (e.g. living circumstances, social, money) • Prioritize goals & link to medication adherence • Use MI and costs/benefits

7. Medication adherence • Recommendations: • Interview context influences how MI conducted • MI integrated into all components of treatment • Motivation continually assessed • Link medication adherence to client goals • Base MI interventions on type of resistance to change: • Rationalizing • Rebellious • Reluctant • Resigned

8. Illness Management & Recovery 8 • Compilation of CBT research based interventions demonstrating improved outcomes in five areas: • Broad based psycho-education on mental illness • Medication focused programs (including adherence & shaping) • Relapse prevention (skills focused) • Coping skills training & comprehensive programs • CBT treatment for psychotic symptoms

9. Illness Management & Recovery • Clinical consensus: • Motivational strategies critical and integral to all aspects of IMR delivery & outcomes • Ongoing need to link client goals to motivation towards specific skills • No specific research on MI to date • In public health domains – group format

10. Integrated Dual Diagnosis Treatment 9 • Specific to severe & persistent mental illness • MI generally supported for decreased substance use 10 • Graeber et al controlled study - Positive 11 • Mixed results in individual sessions 12 • Majority of interventions delivered in group format

11. Integrated Dual Diagnosis Treatment • Integral to treatment: • Functional assessments & analyses integral to treatment planning and skills development • Long term perspective • Staged interventions based on substance abuse treatment scale • Presupposes implementation within programs already delivering high quality psychiatric rehabilitation services (www.uspra.org)

12. Co-occurring DisordersHandmaker, Packard & Conforti 13 • Transitioning IP to OP, treatment adherence & medication adherence • Staged match treatment services • Change: • talking about • tools for • practicing • maintaining • Need for skills development in addition to motivational considerations

13. Dual Disorders & Treatment AdherenceZweben & Zuckoff 14 • Treatment adherence framework: • Improve problem acceptance: • Sources of non-adherence • Strategies • Improve treatment acceptance: • Sources of non-adherence • Strategies • Feedback

14. Co-occurring DisordersMartino & Moyers 15 • Some MI modifications necessary due to • Multiple interacting behavioral targets • D & A, MH, medication and treatment adherence • Cognitive impairments • MI simplified, clarity and conciseness, successive reflections and summaries, concrete materials for eliciting change talk • Positive symptoms • Paraphrase to maintain reality-based and organized dialogue, use of metaphors and similes, caution regarding negative events/emotions, summarize ambivalence & quickly move to elicit change talk to resolve ambivalence

15. Co-occurring DisordersMartino & Moyers • Negative symptoms • Paraphrase to stimulate discussion, time for client response, affirm participation, use of personalized & structured feedback • Non-MI interventions • Skill building and supportive interventions in addition to dual diagnosis issues, MI use or crisis interventions from ongoing assessment/monitoring of client symptoms • “It may be that MI makes its impact with dually diagnosed patients only when clinicians perform at the highest levels to accommodate the marked symptom & social impairments posed by psychotic illness.”

16. Dialectical Behavioral TherapyLinehan 16 • Dialectical behavioral therapy conceptual framework: • Acceptance, reflective and validation approaches balanced with CBT skills development • Similar considerations for SPMI and co-occurring substance use • Similar clinical skill sets: • Therapist flexibility in providing both high quality validation and change strategies • Detailed description of treatment dynamics and balancing of acceptance, change & skills development

17. Other areas • Physical health: • Persons with SPMI mortality rate 25 years below national average • Medical issues a major contributor • Criminal justice: • Jail diversion • Parole/probation involvement

18. Themes • Relationship with provider essential • MI adaptations based on (psychotic) symptom severity • Recognition and support for long-term perspective • Client-centered versus MI • Simultaneous client goal and skill development identified via functional assessment & analysis • MI group skills • Possible need for high quality MI for effectiveness

19. References 1. The Therapeutic Relationship & Its Impact: A Study of Psychotherapy with Schizophrenics, 1967, Ed. Carl R. Rogers, University of Wisconsin Press • Martino, S. et al., 2006, Addiction, 101, 1479-1492 • MI for Medication Adherence in Individuals with Schizophrenia, 2008, McCracken & Corrigan, in, MI in the Treatment of Psychological Problems, Eds. Arkowitz, Westra, Miller & Rollnick, Guilford Press • Dolder, C.R. et al., 2003, J. Clinical Psychopharmacology, 23, 389-399 • Zygmunt, A. et al., 2002, American Journal of Psychiatry, 159, 1653- 1664

20. References • Kemp, R. et al., 1998, British Journal of Psychiatry, 172, 413-419. • O’Donnell, C. et al., 2003, British Medical Journal, 327, 834-837 • Mueser, K.T. et al., 2002, Psychiatric Services, 55 (10), 1272-1284 • Drake, RE et al., 2001, Psychiatric Services, 52, 469-476 • Drake, R.E. et al., 2004, Psychiatric Rehabilitation Journal, 27(4), 360-374 • Graeber, D.A. et al. 2003, Community Mental Health Journal, 39, 189-202

21. References • Drake, R.E. et al., 2008, J. Substance Abuse Treatment, 34, 123-138 • Handmaker, N., Packard, M. & Conforti, K., 2002, MI in the Treatment of Dual Disorders, in, MI 2nd Edition, Miller & Rollnick, Guilford Press • Zweben, A. & Zuckoff, A., 2002, MI in the Treatment of Dual Disorders, in, MI 2nd Edition, Miller & Rollnick, Guilford Press • Martino, S. & Moyers, T.B. 2008, MI with Dually Diagnosed Patients in, MI in the Treatment of Psychological Problems, Eds. Arkowitz, Westra, Miller & Rollnick, Guilford Press • Linehan, M. M., CBT of Borderline Personality Disorder, 1993 Guilford Press