EVIDENCE BASED CARE IN BEHAVIORAL HEALTH

1
EVIDENCE BASED CARE IN BEHAVIORAL HEALTH
MEDIATORS OF OUTCOME
RELATIONSHIP
TOOLS
CLIENT
THERAPY
OUTCOMES

CLINICIAN
PROCESS
CONTEXT
2
EVIDENCE BASED CARE IN BEHAVIORAL HEALTH
WHAT DRIVES BEHAVIOR?
CULTURAL MORES
VALUES
OPPORTUNITY
ATTITUDES BELIEFS
PERSONALITY

SKILLS

BEHAVIOR
KNOWLEDGE

CONSEQUENCES
3
MEDIATORS OF OUTCOME
CLIENT FACTORS
PROBLEMS Bio-Psycho-Social Consideration
Types Number Duration
Severity ATTITUDES BELIEFS RESOURCES
Personal competencies Support Systems
4
MEDIATORS OF OUTCOME
CLINICIAN FACTORS
PROFESSIONAL BACKGROUND Training
Philosophy Professional competencies
Knowledge Skills Clinical
Experience PERSONAL CHARACTERISTICS ATTITUDES
BELIEFS
5
MEDIATORS OF OUTCOME
CLINICAL RELATIONSHIP
THERAPEUTIC ALLIANCE Openness Trust
Confidence Empathy THERAPEUTIC
CLIMATE DECISION-MAKING MODEL
Directive-Shared-Autonomous
6
MEDIATORS OF OUTCOME
CLINICAL TOOLS
SCREENING, ASSESSMENT DIAGNOSIS
Instruments Procedures INTERVENTION Case
management Psychotherapy Pharmacotherapy
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 Services provided
Clinician-Clinic Clinician compensation AGENCY
, MCO STATE POLICIES Service mandates
Funding - Levels Streams
9
EVIDENCE BASED CARE IN BEHAVIORAL HEALTH
DESIRED OUTCOMES
ADHERENCE TO PLAN Participation in Tx
Meds used as prescribed No substance
abuse ASYMPTOMATIC Reduced frequency/severity
IMPROVED LIFE FUNCTION Family Friends
Work Recreation
10
Motivationally-Based Integrated Treatment for
Mentally Ill Substance Abusing Patients
EP Schoener, MJ Henderson, SJ Ondersma CL
Madeja Departments of Psychiatry
Psychology Wayne State University
Sponsored by The Ethel and James Flinn Family
Foundation
11
NATURE OF THE PROBLEM
People with co-existing MI and SA manifest

• more severe psychiatric morbidity,
• greater treatment resistance,
• poorer compliance psycho-social adjustment,
• greater utilization of social and health care
  services,
• more frequent hospitalization,

compared to those with MI alone.
12
Motivationally Based Integrated Treatment for
Mentally Ill Substance Abusing Patients
HYPOTHESES
In this effectiveness study, therapists trained
in MBIT will

• Employ MBIT with fidelity and competence
• Engender a stronger therapeutic alliance
• Encourage greater client retention and adherence
• Realize more positive and enduring treatment
  outcomes

13
Motivationally Based Integrated Treatment for
Mentally Ill Substance Abusing Patients
METHODS/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)

14
Motivationally Based Integrated Treatment for
Mentally Ill Substance Abusing Patients
15
Motivationally Based Integrated Treatment for
Mentally Ill Substance Abusing Patients
OUTCOME VARIABLES
REFLECTIONS total of paraphrased and
rephrased statements EMPATHY global rating of
therapist SPIRIT global rating of
therapist OpenTotal Questions (Ratio) open
Qs / open closed Qs ADVISE of advise
statements without permission SMS
self-motivational statements or change talk
(the only outcome
measure of client behavior)
16
Motivationally Based Integrated Treatment for
Mentally Ill Substance Abusing Patients
OVERALL FINDING FOR TIME, THERAPIST AND
INTERACTION EFFECTS (N 196)
Wilks Lambda df F
Time (pre/post) .84 6, 166 5.26
Therapist .25 60, 875 4.47
Time X Therapist .62 60, 875 1.42
Note. p lt .05 p lt .001.
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

And thus, their ability to conduct MBIT
21
EVIDENCE BASED CARE IN BEHAVIORAL HEALTH
MEDIATORS OF OUTCOME
RELATIONSHIP
TOOLS
CLIENT
THERAPY
OUTCOMES

CLINICIAN
PROCESS
CONTEXT