Effects of motivational interviewing training on mental health therapist behavior

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Abstract

This study examined the effectiveness of training community mental health therapists in motivational interviewing (MI) adapted to treat clients with co-occurring disorders. Ten therapists with high caseloads of culturally diverse clients in two different community mental health settings fulfilled all study requirements. MI training consisted of a two-day didactic and experiential workshop followed by eight biweekly small group supervision (coaching) sessions. Using an interrupted time series design, 156 randomly selected therapy sessions involving 28 clients were coded for assessment of therapist fidelity to MI at multiple points in time, both pre- and post-training. Employing hierarchical linear modeling analysis, significant improvement in MI skill was observed after training on five of six key therapist ratings, and on the sole client rating (client change talk) that was examined. Importantly, the present study demonstrates training-related proficiency in motivational interviewing using: (a) a representative sample of mental health therapists from the community; (b) a protocol emphasizing adherence to a mental health treatment regimen as well as management of substance use behavior for clients with co-occurring disorders; (c) repeated random observations of therapy sessions; (d) measurement of training-related changes in clinician skills and self motivational statements by clients. Findings of this effectiveness study compared favorably with efficacy literature on MI training.

Introduction

People with co-occurring mental health and substance use disorder (COD) manifest more severe psychiatric morbidity, poorer psycho-social adjustment and ability to manage their lives, lower compliance with clinical recommendations, greater utilization of social and health care services, and more frequent hospitalization compared to those with only one of the conditions. Because CODs are complex, it has been suggested that integrated treatment approaches would be most effective, and studies of such protocols have been encouraging (Hellerstein et al., 1995, Herman et al., 1997, Jerrell, 1996, Jerrell and Ridgely, 1995a, Jerrell and Ridgely, 1995b, Mueser et al., 1996). In addition, recent studies have found Motivational Interviewing (MI) promising for COD populations (Bellack and Gearon, 1998, Carey et al., 2002, Caroll, 2004, Daley et al., 1998, Graeber et al., 2003, Martino et al., 2000, Martino et al., 2002, Swanson et al., 1999). Taken together, these reports offer persuasive evidence that integrated MI treatment can improve general functioning and increase abstinence rates of COD clients. However, dissemination of motivationally based integrated treatment for people with COD is daunting because few therapists today are prepared to deliver such care. Indeed, the ability of active practitioners to achieve proficiency in such therapy using a conventional model of continuing education is unknown at this time. The present effort is informed by the efficacy studies of Miller et al. (2004) and Baer et al. (2004). Miller et al. (2004) conducted a randomized trial comparing a conventional two-day workshop alone with the addition of feedback, coaching (supervision) and combinations thereof on MI-skills of their trainees. They noted that only those in the enhanced conditions (feedback and/or coaching) exceeded the 95% proficiency standard for MI-consistent behavior at four month follow-up. This finding underscores the value of supervision to achieve skill proficiency.

Baer et al. (2004) also evaluated the impact of a two-day MI workshop and retention of MI skills over two months by 22 local therapists; however, they employed “standardized patients” rather than real clients for skill assessment. They found that less than half of their trainees achieved and sustained the proficiency standards recommended by Miller (2000). Indeed, almost the same number came to the study with prior knowledge and/or training in MI as reflected in their high baseline skill levels. There was no ongoing supervision in this study and MI proficiency declined from post-workshop assessment to follow-up.

The purpose of the present study was to determine if practicing therapists at community mental health clinics could demonstrate proficiency in MI modified for clients with co-occurring disorders following a two-day workshop and regular supervision (coaching).

Section snippets

Participants

Fifteen therapists at three mental health clinics in urban and suburban middle class communities originally enrolled in this study along with 35 of their eligible clients. Of those 15 therapists and 35 clients, ultimately 10 therapists and 28 clients at two clinics completed all requirements of the study. Of the five therapists lost to the study, one terminated employment early on and four others were unable to enroll a sufficient number of eligible client-participants. Clients were included in

Results

The global indices of therapist Empathy and MI Spirit demonstrated normal symmetrical distributions for both the pre- and post-intervention time periods. In contrast, values for certain specific MI skill variables, including therapist Reflective Listening Statements, Closed- and Open-Ended Questions, and Advising Without Permission, were skewed positively for both the pre- and post-intervention time periods. That is, performance of more clinicians fell below the mean than above it for these

Discussion

Results of this study demonstrate that active community mental health clinicians with numerous demands on their time and caseloads of 80–100 severely mentally ill clients can improve MI-consistent behaviors and diminish MI-inconsistent ones following two days of training plus ongoing supervision. Importantly, the change in therapist proficiency on MI skills from the pre- to post-training period was accompanied by an increase in Client Change Talk, a key variable associated with commitment

Acknowledgements

The authors wish to acknowledge the generous support of the Ethel and James Flinn Family Foundation as well as the enthusiastic collaboration of the treatment staff at Community Care Services (CCS) and the Sinai-Grace Outpatient Psychiatry (SG) Clinic, without which the study could not have been accomplished. William Walsh (CCS) and Ellen Portnoy (SG) in their roles as Site/Clinic Administrators championed this effort from start to finish. We would also like to thank our very able Research

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