Transcript Document

Motivational Interviewing
&
Severe & Persistent Mental
Illness
MINT Forum 2008
Susan Littrell, ML Ruef & Michael P. Giantini
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
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 selfexploration
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
Medication adherence
McCracken & 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)
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
Medication adherence
Recommendations:
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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
Illness Management & Recovery 8
Compilation of CBT research based
interventions demonstrating improved outcomes
in five areas:
1. Broad based psycho-education on mental illness
2. Medication focused programs (including adherence &
shaping)
3. Relapse prevention (skills focused)
4. Coping skills training & comprehensive programs
5. CBT treatment for psychotic symptoms
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
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
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)
Co-occurring Disorders
Handmaker, 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
Dual Disorders & Treatment Adherence
Zweben & Zuckoff 14
Treatment adherence framework:
– Improve problem acceptance:
Sources of non-adherence
Strategies
– Improve treatment acceptance:
Sources of non-adherence
Strategies
– Feedback
Co-occurring Disorders
Martino & 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
Co-occurring Disorders
Martino & 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.”
Dialectical Behavioral Therapy
Linehan 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
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
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
References
1.
2.
3.
4.
5.
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
References
Kemp, R. et al., 1998, British Journal of Psychiatry, 172,
413-419.
7. O’Donnell, C. et al., 2003, British Medical Journal, 327,
834-837
8. Mueser, K.T. et al., 2002, Psychiatric Services, 55 (10),
1272-1284
9. Drake, RE et al., 2001, Psychiatric Services, 52, 469-476
10. Drake, R.E. et al., 2004, Psychiatric Rehabilitation
Journal, 27(4), 360-374
11. Graeber, D.A. et al. 2003, Community Mental Health
Journal, 39, 189-202
6.
References
12. Drake, R.E. et al., 2008, J. Substance Abuse
13.
14.
15.
16.
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