The International Journal of Psychosocial Rehabilitation

Motivational Interviewing and Assertive Community Treatment:

A Case for Training ACT Teams

 

Trevor J. Manthey, LMSW

Office of Mental Health Research and Training
University of Kansas School of Social Welfare

1545 Lilac Lane,  Lawrence, KS  66044-3184

 

Shannon Blajeski, MSW

Maria Monroe-DeVita, Ph.D.

Washington Institute for Mental Health Research and Training
University of Washington Department of Psychiatry and Behavioral Sciences

2815 Eastlake Avenue East, Suite 200,  Seattle, WA  98102

Citation:
Manthey TJ, Blajeski S & Monroe-DeVita M. (2012). Motivational Interviewing and Assertive Community 
Treatment: A Case for Training ACT Teams
.  International Journal of Psychosocial Rehabilitation. Vol 16(1) 5-16




All Correspondence can be sent to Trevor J. Manthey at trevormanthey@gmail.com


Abstract
Motivational Interviewing (MI) is an evidence-based clinical intervention that has shown positive outcomes for individuals with co-occurring serious mental illness and substance use disorders.  Many of these individuals are similar to those served by Assertive Community Treatment (ACT) teams, highlighting that MI is an important intervention and a beneficial modality to be used within ACT teams.  This article examines areas of treatment (assertive engagement, Integrated Dual Disorder Treatment and person-centered planning) which both utilize MI techniques and are considered an integral part of ACT services.  These three areas of treatment are also assessed within the Tool for Measurement of Assertive Community Treatment (TMACT), an instrument used to assess fidelity to the ACT model. Lessons learned from the implementation, training and fidelity measurement of ACT teams in Washington State and recommendations for future MI implementation within ACT teams are described.

Keywords:  Assertive Community Treatment, Motivational Interviewing, assertive engagement, person centered planning, Integrated Dual Disorder Treatment.


Introduction
Assertive Community Treatment (ACT) is a transdisciplinary team approach to providing treatment and rehabilitation to adults with severe and persistent mental illness, major functional impairments, and continuous high service needs within their community.  It is the most widely studied evidence-based practice for this population and has consistently shown positive outcomes in the areas of decreased psychiatric hospitalization, improved housing stability, retention in treatment, and consumer and family satisfaction with services (Bond, Drake, Mueser, & Latimer, 2001).  

Areas of service provision that are not always fully implemented by ACT teams include assertive engagement, Integrated Dual Disorder Treatment (IDDT) and person-centered planning.  Based on IDDT research (Drake, Mueser, Burnette, & McHugo, 2004) and promising work in these areas with similar populations (e.g., Adams & Grieder, 2005; Tondora, Pocklington, Gorges, Osher, & Davidson, 2005) these three specific service areas are hypothesized to have additional positive outcomes within ACT, thereby improving the quality of ACT treatment and rehabilitation.  The authors have utilized the Tool for Measurement of Assertive Community Treatment (TMACT), an instrument used to assess fidelity to the ACT model (Monroe-DeVita, Teague, & Moser, in press) in the implementation and ongoing training and technical assistance to ACT teams in Washington State.  In addition to measuring other core elements of ACT, the TMACT encourages the acquisition and application of Motivational Interviewing (MI) skills, particularly in the areas of assertive engagement, IDDT, and person-centered planning.  This article reviews the evidence base for utilization of MI within ACT teams across these three treatment areas and makes recommendations for ongoing training in MI within ACT.

The Evidence Base for MI in ACT
Motivational Interviewing, listed on the National Registry of Evidence-based Programs and Practices as an EBP (2009), has been included in over 200 published outcome studies (Wagner & Conners, 2010).  In addition, many separate meta-analyses have reported an overall significant effect (Hettema, Steele, & Miller, 2005; Rubak, Sandboek, Lauritzen, & Christensen, 2005; Burke, Arkowitz, and Menchola, 2003; Lundahl, Tollefson, Gambles, Brownell & Burke, 2010).  Based on these findings it has been suggested that MI outperforms traditional interventions in the treatment of a variety of behavior change issues.  These behavior change issues are similar if not identical to those addressed by areas of ACT teams’ service provision and include treatment of dual disorders  (Martino, Carroll, Kostas, Perkins, & Rounsaville, 2002), mental health (Arkowitz, Westra, Miller, & Rollnick, 2007), physical health (Rollnick, Miller, & Butler, 2008), medication adherence (McCracken & Corrigan, 2008), prevention programming (Bennett, Stoops, Call, & Flett, 2007), homelessness (Fisk, Sells, & Rowe, 2007), HIV risk reduction (Koblin, Chesney, Coates, et al., 2004), probation (Harper & Hardy, 2002) criminal justice (McMurran, 2009), supported employment (Larson, 2008), and vocational rehabilitation (Lloyd, 2008; Manthey, 2009).  

Findings further support using MI to decrease substance use with individuals who experience co-occurring schizophrenia or schizoaffective disorders and most substance abuse disorders (e.g. Barrowclough, Haddock, Tarrier, Lewis et al., 2001; Bellack & DiClemente, 1999; Graeber, Moyers, Griffith, Guajardo, & Tonnigan, 2003; Ziedonis & Trudeau, 1997; Martino et al., 2002; Handmaker, Packard, & Conforti, 2002, Steinberg, Ziedonis, Krejci, & Brandon, 2004; Carey, Purnine, Maisto, & Carey, 2001).  Motivational Interviewing has also been found to help individuals with a psychiatric disability transition from inpatient to outpatient settings (Swanson, Pantalon, & Cohen, 1999), and to improve attendance and involvement in dual diagnosis treatment (Martino, Carroll, O’Malley, & Rounsaville, 2000). In addition, most consumers with a psychiatric disability who receive MI respond positively regarding its value and helpfulness (e.g. Franklin, Murphy, Cameron, Ramirez, et al., 1999).

A meta-analysis conducted by Hettema (2005) found that the effects of MI appear to persist or increase over time when added to an active treatment. This was termed the additive effect. The additive effect appeared to have more potency and effectiveness over time than either MI or the active treatment when delivered alone.  This finding lends further credibility to the idea that adding MI to ACT teams (an active treatment model) could increase the effectiveness of ACT team intervention.    

ACT Treatment Areas Utilizing MI
Kortrijk, Mulder, Roosenschoon, and Wiersma (2009) recommend utilizing MI for addressing problems of motivation for individuals within ACT.  The following section expands on this recommendation by outlining three distinct areas of ACT treatment outlined within the TMACT where MI is recommended as a beneficial modality: assertive engagement, Integrated Dual Disorder Treatment, and person-centered planning.   

Assertive Engagement
Individuals with a dual diagnosis (severe mental illness and co-occurring substance use disorders) often lack motivation to manage psychiatric symptoms and pursue employment or other functional goals (Drake, Essock, Shaner, Carey, Minkoff, et al., 2001).  Therefore, ACT teams sometimes need to do some additional work to engage consumers to be an active participant in services.  Further, to meet fidelity to the ACT model, teams are required to utilize assertive engagement techniques for the purpose of retaining consumers, engaging them in treatment and fostering therapeutic relationships (Monroe-DeVita, Teague, & Moser, in press). According to the TMACT fidelity protocol, the team should use an array of techniques including (a) collaborative, motivational interventions to engage consumers and build intrinsic motivation for receiving services from the team (b) when necessary, therapeutic limit-setting interventions to create extrinsic motivation for receiving services deemed necessary to prevent harm to the consumer or to others (when therapeutic limit-setting interventions are used, there is a focus on instilling autonomy as quickly as possible) and (c) thoughtful processes for measuring effectiveness of engagement techniques and adjusting them appropriately.

Helping individuals tap into intrinsic motivation can create long-term behavior change, while using external or compliance-based motivation often creates only short-term behavior change (Miller & Rollnick, 2002).  Unfortunately, sometimes practitioners on ACT teams may sacrifice long term behavior change for short term compliance.  Therefore, it is important for ACT teams to utilize MI to gain understanding of individuals’ goals, wishes and values in order to facilitate engagement; rather than immediately jumping to therapeutic-limit setting techniques (such as outpatient involuntary commitment, payeeship, etc).  Using MI allows the practitioner to both directly involve the individual in their treatment and retain them in the program.  

Integrated Dual Disorder Treatment
Approximately 50 % of individuals with a psychiatric disability are affected by substance use disorders (Essock, Mueser, Drake, Covell, McHugo, et al., 2006).  Further, Morrissey, Meyer, & Cuddeback (2007) found no significant reduction in substance abuse or jail days for individuals with co-occurring disorders when using the ACT model as a sole intervention.  Implementing Integrated Dual Disorder Treatment (IDDT) within the structure of ACT teams has been necessary to meet the needs of individuals who experience co-occurring substance use disorders and severe mental illness.  

The IDDT model (Mueser, Noordsy, Drake & Fox, 2003) suggests that consumers with co-occurring disorders be treated from a stage-wise treatment approach integrating the Transtheoretical stages-of-change model (Prochaska & Diclemente, 1992) with stages of treatment (see Table 1 for a description of how consumers in different stages can receive different treatment approaches). Specifically, the IDDT model proposes that consumers who are assessed to be in early stages of treatment, based on their early stages of change, be engaged utilizing MI to help them resolve their ambivalence and discover their own motivations for decreasing and/or abstaining from substances.  This differs from a traditional chemical dependency treatment approach in that confrontation is not used when an individual is perceived as resistant.

Table 1

Examples of Stage-Wise Substance Abuse Treatment Interventions*

Early Stages of Change Readiness

Later Stages of Change Readiness

Pre-Contemplation

Contemplation and Preparation

Action

Maintenance

The consumer does not recognize that s/he has a problem with substance use or has no interest in modifying use at this time. 

 

Focus of treatment is outreach, assessment, and building a working alliance.  Services are provided regardless of ongoing use. 

 

The consumer recognizes that substance use is causing some problems and is considering a change. In the contemplation stage, the consumer is more aware about the pros & cons, but ambivalent about change; whereas in the preparation stage, the consumer is planning for change.

 

Focus of treatment is education about substances, mental illness, and their interactions, and identifying pros & cons of use. 

Motivational interviewing techniques are essential:

     express empathy

     offer reflective listening

     assist with goal-setting

     develop discrepancy  between goals and substance use

     conduct decision balance (pros & cons)

     roll with resistance to

change

     emphasize personal choice

The consumer is committed to reducing or discontinuing substance use. 

 

Focus of treatment is helping her/him make change & sustain it:

     cognitive-behavioral therapy

     managing social

environments

     identifying & managing triggers and cravings

     relaxation/coping skills

     money management to avoid using

     problem solving to  

reduce stress

 

 

The consumer has abstained from substance use for at least 6 months. 

 

Focus of treatment is maintaining abstinence:

     develop a relapse

     prevention plan

     help consumer attend

     self-help groups

     help build and maintain social supports for

sobriety

     maintain awareness of

vulnerability to relapse

     help expand recovery to other areas of life (parent group, vocational supports)

 

*Adapted from the TMACT Protocol (Monroe-DeVita, Teague, & Moser, in press)

Given that research on consumer populations with co-occurring schizophrenia and substance use disorders cite that low motivation is often an explanation for poor outcomes in treatment (Drake et al., 2001) and that ACT teams are developing capacity to provide IDDT, it is beneficial that ACT clinicians become skilled in MI techniques.  

Person-Centered Planning
In addition to utilizing motivational interventions to engage consumers in their treatment, it is necessary that ACT teams have a person-centered perspective (e.g., able to see a participant as a person with normative needs and desires, rather than a ‘mentally ill person.’).  Outcomes associated with a shift from traditional mental health treatment planning to person-centered planning include improved access to treatment, better retention in treatment and improved personal outcomes that are important to the client (Adams & Grieder, 2005). Motivational interviewing has been suggested as a means to help individuals with a psychiatric disability explore and develop individualized goals and attempt to achieve them (Corrigan, McCracken, & Holmes, 2001).  

Inherent to the MI skill set is attending to an individual’s goals and values.  The MI practitioner attempts to evoke from within the individual how they envision themselves reaching their goals and determining how their current behavior fits or conflicts with what has been identified (Miller & Rollnick, 2002).  Therefore, the process of training an ACT team in MI may assist clinicians in becoming more person-centered or more recovery-oriented in their framework.  In this way, MI can add to or enhance a team’s recovery orientation and their person-centered planning ability, helping them to better engage consumers in the treatment and rehabilitation process.

Measuring Fidelity for Performance Improvement
To assess program fidelity is to evaluate the extent to which a program adheres to the intended implementation model.  Fidelity measures may assess program elements such as the population to be served, staffing and staff roles, and specific program processes and interventions.  This is important because high fidelity is tied to better outcomes across many evidence-based practices, including ACT (McHugo et al., 1999; Becker et al., 2001).

The Tool for Measurement of Assertive Community Treatment (TMACT) (Monroe-DeVita, Teague, & Moser, in press) is an enhanced version of the original ACT fidelity scale, the Dartmouth Assertive Community Treatment Scale (DACTS) (Teague, Bond, Drake, 1998). The TMACT contains 47 items, grouped into six subscales, including:  (1) Operations & Structure, (2) Core Team, (3) Specialist Team, (4) Core Practices, (5) Evidence-Based Practices, and (6) Person-Centered Planning and Practices.  It was designed, in part, to capture not only the structural components of an ACT team, but how core services such as assertive engagement, IDDT and/or person-centered planning are carried out by a team.

The organization of the TMACT and the DACTS is very similar; each item is rated on a five-point behaviorally-anchored scale, ranging from one (not implemented) to five (fully implemented) and ratings are based on the current structure and activities of the team (i.e., not future plans). Among the many changes from the DACTS, the TMACT expands the DACTS fidelity measurement by rating ACT teams’ use of other evidenced-based clinical modalities including MI and IDDT.  To date, the TMACT has been adopted and piloted in five states as well as in Japan and Norway, and is being used by several teams in other states.  A recent study using the TMACT to evaluate ten Washington State ACT teams found that teams scored significantly lower on the TMACT than on the DACTS at baseline, six, and 12 months, while also demonstrating greater improvement over time in comparison, suggesting that the TMACT is a more sensitive measure of ACT (Monroe-DeVita, Teague, & Moser, in press).  Teams also consistently scored lower in the areas of specialist roles, integration of other EBPs, and person-centered practices--areas not assessed by the DACTS--suggesting the need for ACT teams to better implement specialist roles and apply specific strategies to improve clinical, functional, and recovery outcomes.

In 2007, 10 ACT teams were concurrently implemented in Washington State (Bjorklund, Monroe-DeVita, Reed, Toulon, & Morse, 2009).  All 10 teams received a TMACT fidelity review at six month intervals for a total of four reviews per team over a two-year period.  Thereafter, TMACT fidelity reviews continued on a yearly basis.  

At start-up, all 10 newly-implemented ACT teams were provided a one-day ACT overview followed by a variety of core skills trainings including an MI training meant as an exposure to basic skills.  In fall 2008 and spring 2009, a Motivational Interviewing Network of Trainers (MINT) trainer also skilled in the TMACT fidelity scale provided two MI training sessions scheduled one month apart on-site to each of the 10 teams. The month lag time in between the MI training was purposefully scheduled in order to allow trainees the opportunity to practice their MI skills.  The practitioners were then able to report to the trainers where they felt they needed added skill development and support.  The follow-up training and consultations were then focused on these individualized areas.  

A summary of TMACT items assessing for the use of MI and a Stage-wise Treatment approach is noted in Table 2.  Performance improvement is one of the primary foci of a fidelity scale.  The TMACT showed sensitivity to the needs of teams when their scores dropped on the items illustrated in Table 2.  The need for continued MI training and consultation was noted and generally TMACT fidelity review feedback sessions often included recommendations for continued MI training.

Table 2

TMACT Fidelity Scale Items Assessing either Motivational Interviewing or Stage-Wise Treatment

Assertive Engagement

(Core Practices)

 (CP2)

Integrated Dual Disorder Treatment

 (Evidenced-Based Practices) (EP7)

Person-Centered Planning

(Person-Centered Practices) (PP2)

Team uses an array of techniques to engage consumers, including (1) collaborative, motivational interventions to engage consumers and build intrinsic motivation for receiving services from team and where necessary, (2) therapeutic limit-setting interventions to create extrinsic motivation for receiving services deemed necessary to prevent harm to consumer or others. (3) the team has a thoughtful process for identifying the need for assertive engagement, measuring the effectiveness of these techniques, and modifying approach where necessary.

Program uses a stage-wise treatment model that is non-confrontational and the FULL TEAM (1) considers interactions between mental illness and substance abuse; (2) follows cognitive-behavioral principles; (3) does not have absolute expectations of abstinence and supports harm reduction; (4) understands and applies stages of change readiness in treatment; and (5) is skilled in motivational interviewing.

 

The team conducts person-centered planning: (1) development of formative treatment plan ideas based on discussion with the consumer; (2) conducting regularly scheduled treatment planning meetings; (3) attendance by key staff, the consumer, and anyone else she/he prefers (e.g. family), (4) meeting driven by the consumer’s goals and preferences; and (5) provision of coaching and support to promote self-direction and leadership within the meeting, as needed. 

 

The substance abuse specialist provides integrated dual disorder treatment to PACT consumers who have a substance use problem.  Core services include:  (1) systematic and integrated screening and assessment; interventions tailored to those in (2) early stages of change readiness (e.g., outreach, motivational interviewing) and (3) later stages of change readiness (e.g., CBT, relapse-prevention).

 

 

Full Responsibility for Dual Disorders Treatment: These include services provided by the substance abuse specialist as well as other team members well-versed in integrated, stage-wise treatment for co-occurring disorders.  Core services include:  (1) systematic and integrated screening and assessment and interventions tailored to those in (2) early stages of change readiness (e.g., outreach, motivational interviewing) and (3) later stages of change readiness (e.g., CBT, relapse-prevention).

 

 

Substance Abuse Specialist on Team: The team has at least 1.0 FTE staff member designated as a substance abuse specialist. Preferably this specialist has training or experience in integrated dual disorder treatment.

 

 

*Adapted from TMACT fidelity instrument (Monroe-DeVita, Teague, & Moser, in press)

Training Motivational Interviewing
Performance improvement on ACT teams cannot be obtained without adequate training and some agencies have not fully appreciated the intricacy involved in learning MI (Cahill, 2008).  Many agencies have begun training practitioners in MI through one day single shot workshops, the results of which have been mixed (Baer, Rosengren, Dunn, Wells, Ogle, & Hartzler, 2004).  In addition, some agencies have tried to have their staff build MI skills through self directed learning, which is ineffective (Miller, Yahne, Moyers, Martinez, & Purritano, 2004).  Recent training research has shown evidence that the typical one or two day workshop may not be the best way to learn MI (Miller & Mount, 2001; Walters, Matson, Baer, & Ziedonis, 2005), and that MI skills are not retained without added supervision (Heaven, Clegg, & Maguire, 2006).  A more effective form of learning MI after initial training has been shown to be continued supervision in the form of feedback and coaching (Bennett, Moore, Vaughan, Rouse, et al., 2007; Miller et al., 2004).  One of the benefits of using the TMACT fidelity scale is that it assesses for indicators to determine when continued supervision and coaching in MI is needed.

    In the spirit of helping to facilitate effective trainings for performance improvement, suggestions are provided based on concerns verbalized during the training of MI in Washington State.  These suggestions are depicted in Table 3.  Some of the concerns described were originally detailed in a newsletter for an organization of motivational interviewing trainers in the context of vocational rehabilitation (Manthey, 2009) and are repeated here with some adaptations and additions for the ACT context.

Table 3

Suggestions for responding to selected concerns expressed by individuals learning MI.

Concern:

Potential Response:

“What if they’re symptomatic?”

It can sometimes be difficult to use MI with individuals with a psychiatric disorder who are experiencing symptoms.

        Emphasize that one can still function within the spirit of MI even if circumstances don’t always permit using MI in its pure intervention form.

        Emphasize that there are adaptations of MI made specifically for individuals with psychiatric disabilities. (See the following for further information on this topic, Carey, Leontieva, Dimmock, Maisto, & Batki, 2007; Corrigan, McCracken, & Holmes, 2001; Martino, Carroll, Kostas, Perkins, & Rounsaville, 2002; and, Rusch & Corrigan, 2002).

“Not all of us are therapists!”

Not all ACT team practitioners are mental health clinicians (e.g. nurses, housing specialists, supported employment specialists, peer counselors etc) and for some there may be a desire to avoid interactions that could be construed as therapy.

        Emphasize that MI is a way of being with people.

        Emphasize that MI has helped people make diverse behavior changes in a wide variety of settings, not just therapy.

        Spend more time helping people grasp the spirit of MI.

 

“What if they don’t change?”

If an individual decides not to change or fails at their attempt to change than the practitioner may feel as if they have failed or done a poor job.

        Emphasize that within MI choosing not to change is a legitimate option (even though the likelihood that someone will change is increased).

        Discuss the importance of not getting attached to an individual outcome. It is more helpful to improve/develop one’s own skill set than to try to control the result for each participant.

 

“I already do this stuff.”

Some trainees report that they already posses the skills described in the MI training. 

        Try to avoid confronting these statements, rather utilize analogies or conduct activities which develop discrepancy between what participants state they do and what they are actually doing.

“I need lots more practice.”

Some ACT team practitioners report a lack of confidence in their ability to do MI, even if they understand MI concepts.

        Adding monthly feedback and supervision portions to the training workshop series increases confidence and skill development (See Heaven et al., 2006; Miller & Mount, 2001; Miller et al., 2006).

“If they would just listen.”

Assuming the expert role is a common issue faced by practitioners when learning MI. Once in this role practitioners will offer unsolicited solutions or advice about how to fix an individual’s problems.

        There are several behaviors that can help with this issue discussed by Rollnick et al. (2008): Avoid arguing for change when the service user is not ready, do not assume practitioners have to offer all the solutions for change, do not assume the consumer ought to change, wants to change or that recovery is the prime motivator for them to change.

        Emphasize that giving information to consumers can be beneficial and can occur in MI consistent ways: such as asking permission before giving advice and providing a menu of opjtions (See Miller & Rollnick, 2002).

“There isn’t enough time!”

Some ACT teams consistently function in a state of crisis. Meaning the team is reactive, moving from crisis to crisis without believing they are able to slow down and conduct proactive or preventative interventions. When this occurs teams often spend a lot of time trying to push people into behavior changes rather than drawing out behavior change from within the person.

        Discuss avoiding the premature focus trap (See Miller & Rollnick, 2002).

        Emphasize that MI has been used successfully in very brief settings such as healthcare and therefore can be a very short intervention if needed.


Recommendations
Although further research needs to be conducted to more fully assess the effectiveness and implementation of MI within an ACT model; this article clearly lays out the treatment areas where MI skills are necessary to meet fidelity to the ACT model. Utilization of fidelity scales are meant to be a continual process and not a one-time assessment. Therefore, utilizing the TMACT fidelity scale not only allows assessment of a team’s adherence to the ACT model but also can provide information such as whether to implement further technical assistance in other evidence-based practices.  Based on the information described here, recommendations for future implementation of MI into ACT teams include utilization of the TMACT fidelity protocol because of its ability to track the use of MI.   It is also recommended that future efforts to implement MI within ACT teams include additional follow along supports such as supervision and coaching.  This would provide practitioners continued support in implementing the practice as well as increasing their confidence and skills.  Supervision and coaching would also allow for consultation with team leaders and staff around using MI to build relationships with difficult-to-engage participants.  Most importantly, implementing MI provides practitioners on ACT teams with practical skills that increase their ability to engage consumers into services, provide Integrated Dual Disorder Treatment, conduct person-centered planning, and generally increase consumer motivation for behavior change and recovery.    


 

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