ORIGINAL PAPER

Combining Evidence-based Practices for Improved BehavioralOutcomes: A Demonstration Project

Thomas J. Blakely • Susan Bruggink •

Gregory M. Dziadosz • Margaret Rose

Received: 25 August 2010 / Accepted: 18 September 2012 / Published online: 30 September 2012

� Springer Science+Business Media New York 2012

Abstract This article describes a demonstration project

carried out by a special team at a mental health agency

serving adults with a serious psychiatric condition. The

project consisted of combining the evidence-based practices

of cognitive therapy, Motivational Interviewing and Stages

of Change with Social Role Theory and the Chronic Care

Model that were the organizing concepts of the agency’s

assessment and treatment program. Measures of the results

of clients’ improved mental health and social functioning

indicated the successful use of this combination.

Keywords Combination � Evidence-based practices �Demonstration

Introduction

This narrative reports a demonstration by a special team of

staff that used a combination of Cognitive Therapy (CT)

(Beck 1995), Motivational Interviewing (MI) (Miller and

Rollnick 2002 and Stages of Change (SOC) (Prochaska et al.

1992) with the Chronic Care Model (CCM) (Wagner et al.

2001) and Social Role Theory (SRT) (Thomas and Feldman

1964). The latter two were the organizing concepts of the

agency’s established assessment and treatment program

serving adults with a serious psychiatric condition entitled

community treatment and rehabilitation (CT&R) (Blakely

and Dziadosz 2003). The purpose of the demonstration was

to determine whether the agency’s staff use of this combi-

nation was effective in increasing clients’ social functioning.

An IRB application was submitted. The response was that

IRB approval was not necessary since this was a program

evaluation.

Agency administrative staff decided to adopt CT about

6 months before the demonstration based on recognition of

its being an effective treatment model for psychiatric

conditions (Beck 1976; NAMI 2011). Some clinical

supervisors were sent to the Beck Institute in Philadelphia.

As part of the training these staff completed a program of

expert review of their taped sessions with clients to become

adept practitioners of cognitive therapy. CT was the central

practice concept for this demonstration as it is a process of

collaborating with clients to identify and examine their

patterns of learned beliefs, interpretations, and automatic

thoughts about themselves and others. Clients were guided

to consider possible alternative interpretations of situations

in their lives based on evidence. An increased awareness

about how thoughts have a direct impact on emotions,

along with behavioral experiments, led to an increase in

clients’ adaptation and social functioning.

Literature reviews by agency personnel led to adopting

Motivational Interviewing also before this project began

(see for example: Barkhof et al. 2006). A MINT (Motiva-

tional Interviewing Network of Trainers) member trained

several agency clinical supervisors in this model. Listening,

recognizing, and resolving the client’s ambivalence and

internal motivation to change occurred through using the

MI micro skills, OARS (open ended questions, affirmation,

reflective listening and summary). Staff learned to assess a

client’s level of ambivalence and stage of change.

The Spirit of MI meant respecting the client’s right to

choose change or no change, honoring and respecting the

At the time of the initial submission of this article the authors were

with Touchstone innovare’ that merged with Cherry Street Services

on October 1, 2011.

T. J. Blakely (&) � S. Bruggink � G. M. Dziadosz � M. Rose

Cherry Street Health Services, 100 Cherry St. S.E.,

Grand Rapids, MI 49503, USA

e-mail: thomas.blakely@wmich.edu

123

Community Ment Health J (2013) 49:396–400

DOI 10.1007/s10597-012-9550-x

client’s autonomy about where they will start their change

process and what techniques will work best for them. It was

a way of being with a client. Collaborating with compas-

sion enhanced the connection between the clinician and the

client. As the level of fear decreased, change talk occurred.

Agency clinicians that practiced the integration of the

MI micro skills reported they experienced less frustration

in their work. They related how listening to a client in the

Spirit, even one who is psychotic and delusional, led to a

connection never thought possible.

SOC was adopted as an assessment tool for understanding

how change occurs and assessing the clients’ level of readi-

ness for change. Initially it was part of the agency’s co-

occurring disorders program (Blakely and Dziadosz 2007a).

SOC was a significant guide to delivering services to this

population as it provided clinicians with a focus for deter-

mining the implementation of appropriate interventions.

Through the application of this theory clinicians became

proficient in matching interventions to a client’s readiness for

change. For example, clinicians learned not to implement an

action stage intervention if the client was in a pre-contem-

plation stage. Such a focus also helped clients as behavior

change was achieved, and maintained more readily, when the

clinician and client were able to analyze readiness for change.

Combining these three models was the essence of the

demonstration. CT was the primary intervention theory,

supported by MI and SOC. CT and MI have been linked

previously with successful outcomes. For example, Bar-

rowclough et al. (2001) conducted an integrated treatment

program with persons with co-morbid schizophrenia and

substance abuse that resulted in significant improvement in

subjects’ general functioning. Haddock et al. (2003) and

Arkowitz and Westra (2004) had the same results. Bar-

rowclough et al. (2010) did not have similar positive results

from integrating motivational interviewing and cognitive

therapy compared to their earlier study in 2001. They sug-

gested that the differing results might be related to a much

higher relapse in the control group in the initial study plus

improvements in care for persons with a dual diagnosis due

to policy changes enacted in 2001. Britton et al. (2011)

combined MI and CT to reduce suicidal behavior. Crooks

et al. (2006) integrated MI and CT in relation to father’s

care for their children. Burke (2011) wrote encouragingly

about MI combined with CT as a general treatment strategy.

Abou-Saleh (2004) successfully employed motivational

interviewing and cognitive therapy in the treatment of co-

morbid severe mental illness and substance abuse. Tomlin

and Richardson (2004) authored a book on using MI with

SOC. The project team’s use of the three frameworks that

was successful in the treatment of our clients with a serious

psychiatric condition adds to the literature. A literature

review did not yield any publications describing the com-

bination of these frameworks with the CCM and SRT.

The CCM and SRT were the organizing concepts of

CT&R before this project began. The project team’s estab-

lishing targets for behavioral change toward normative

adaptation and social functioning through combining CT,

MI, SOC, CCM and SRT in creating interventions made a

contribution toward recovery defined as achieving the

agency’s product of psychiatric wellbeing (PWB). This

product was achieved when all a client needed from the

mental health system was a place to obtain psychotropic

medication, a place to go for short term counseling or a place

to go when symptoms returned. Agency staff had developed

a valid, reliable and internally consistent PWB scale to

measure these outcomes (Blakely and Dziadosz 2007b).

Applying the CCM became clearer as clinicians wrestled

with combining it with SRT. Social functioning, a central

concept of SRT, became a primary focus of assessment and

treatment. The various ascribed or achieved social positions

in which a client had exhibited adaptive behaviors were

identified as strengths and used to encourage clients.

Weaknesses were established as targets for behavior change.

The Demonstration

The demonstration team consisted of eighteen staff and a

clinical supervisor from a previously existing team. The

supervisor had received primary source training in CT at

the Beck Institute and is a member of the MINT. She

supervised project team members in CT and MI. A MI

training consultant came to the agency to train team

members. Agency administrative staff provided training in

SOC and CCM. A consultant and a clinical supervisor

provided training in SRT. The team became proficient in

the practice of these theories and combined them into a

holistic model to assess and treat clients.

The client population of the team was similar to the

agency’s general population. The 213 clients involved in

the demonstration were randomly selected from among the

team members’ previous caseloads. Clients ranged in age

from 21 to 64 years. Fifty-two percent were male and

forty-eight percent female. They were 69 % white, 24 %

African American, 2 % Hispanic and 5 % other. Diag-

nostically they presented with schizoaffective or schizo-

phrenia (39 %), bi-polar (16 %), major depression (11 %),

substance dependent (18 %) or other (16 %).

The program evaluation of the demonstration used a

pre-/post-test quasi experimental design. Pre-test scores

were collected within the first month of assignment to the

team and post-test data were collected 12 months later. The

evaluation used the Brief Symptom Inventory (BSI), Beck

Depression Inventory (BDI), Beck Anxiety Inventory

(BAI) and the Psychiatric Wellbeing Scale. Data were

analyzed using a mixed model Analysis of Variance

Community Ment Health J (2013) 49:396–400 397

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(ANOVA) with Time as the within-subjects and Diagnosis

as the between-subjects variables.

Results

The results of this demonstration project suggest that the

combined use of CT. MI, and SOC with the program’s

organizing concepts of the CCM and SRT contributed

significantly to client increased social functioning and that

staff should continue to use this combination. The team

was successful in assisting clients to manage the symptoms

of their illness and increase social functioning as indicated

by statistically significant reductions on each of the three

major subscales of the Brief Symptom Inventory (BSI);

Global Severity, Positive Symptom Total and Positive

Symptom Distress scores over the 1 year period of the

project. There also was an increase in social functioning as

measured by the PWB scale. An analysis of variance was

used. The results are presented in Table 1.

Combining MI and CT proved to be quite effective with

symptoms of anxiety and depression, despite the underlying

presence of a serious psychiatric condition. SOC was

effective in the timing of interventions. This is important

because these symptoms are prevalent among this popula-

tion and are often treated with medication alone, sometimes

because of the belief that psychotherapeutic techniques

would not be effective with people who have a serious

psychiatric condition. Of the team’s clients included in the

Beck Depression Inventory (BDI) and Beck Anxiety

Inventory (BAI) results in Table 1, 101 (47 %) exhibited

moderate to severe depression on their pre-test on the BDI.

A total of 87 (41 %) exhibited moderate to severe anxiety

on their pre-test on the BAI. Sixty-four clients (63 % of

those with depression and 74 % of those with anxiety)

presented with moderate to severe symptoms of both.

Within this subset, there was a significant improvement

on both the BDI and BAI over 1 year. An analysis of

variance showed a significant effect for the pre- post-test

comparison (p \ .001 for Depression and p = .003 for

Anxiety). Of those with depression, 37 % improved to the

mild to asymptomatic range on the post-test. There was no

significant difference in outcome related to Diagnosis or

the Diagnosis by Time interaction (schizoaffective,

schizophrenia, bipolar, major depressive disorder, or sub-

stance dependence). These data are displayed in Table 2.

Staff Reaction and Cost

A study of the reaction of members of the integration team

to the implementation of the evidence-based practices was

completed. The analysis of the data suggested that there

were facilitating and impeding factors in the process of the

team’s implementation of the practice theories involved.

The facilitating conditions related to reduction of caseloads

for team members, consistent supervision, sufficient time

for training, administrative interest and support, and rec-

ognition of positive client outcomes. The impeding con-

ditions related to the opposite of these issues such as the

unavailability of administrators, too much time spent in

training, the lack of consistent supervision and differing

practice styles from the identified practices (Gioia and

Dziadosz 2008). Reassignment of some clients in order to

facilitate the study resulted in a small increase in caseloads

of other agency staff. Costs of training were covered by

budgeted staff development funds.

Table 1 Pre- and post-test

comparisons of BSI and PWB

scores

Outcome measure Pre-test

mean

Post-test

mean

Degrees of

freedom

F Sig.

Brief Symptom Inventory (BSI)

BSI Global Severity 48.4 46.5 257 11.06 p \ .001

BSI Positive Symptom Total 47.4 45.2 257 9.47 p \ .01

BSI Positive Symptom Distress 49.6 48.4 257 3.85 p \ .05

Psychiatric Wellbeing 108.6 117 384 121.12 p \ .001

Table 2 Pre- and post-test

comparisons of BDI and BAI

scores

Outcome measure Pre-test

mean

Standard

deviation

Post-test

mean

Standard

deviation

F Sig.

Beck Depression Inventory 31.7 9.54 23.6 11.8 39.57 p \ .001

Beck Anxiety Inventory 25.9 7.6 20.5 11.4 9.39 p = .003

398 Community Ment Health J (2013) 49:396–400

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Case Example

The following disguised case example illustrates the use of

the practice combination model. The characteristics of this

client are typical of the clients involved in this study.

Tony is a 38 year old African American man who pre-

sented with a Diagnosis of Major Depressive Disorder. He

was chronically suicidal and often talked of his wish to

drive his car off the road into a tree to end his life. He was

able to maintain a part time job to supplement his Social

Security Disability Payments although he reported contin-

ued concerns that he would be ‘‘let go’’ due to poor per-

formance issues. This caused a great deal of anxiety for

him and he reported many nights of poor sleep resulting

from bad dreams and inability to relax and stop his

relentless thoughts of self-harm. He agreed to see his cli-

nician weekly to learn some cognitive therapy skills to help

him find some relief from his reported unrelenting

depression and anxiety. He completed the Beck Depression

Inventory, the Beck Anxiety Inventory and the Beck

Optimism/Hopeless Scale each week.

As he talked about his scores with his clinician it was

discovered that Tony was also a gay man. This was a

source of great anxiety and shame for him as he believed it

would not be accepted in his family or his church. He

perceived himself to be worthless, unlovable and certain to

face eternal damnation for his unforgivable sin of homo-

sexuality. He also desperately desired a relationship and

would connect with men that would often ‘‘use me for sex

but didn’t want nothin’ else to do with me’’ thereby com-

pounding his feelings of shame and worthlessness.

Tony initially worked with his clinician to learn about

automatic thoughts and how to evaluate them. He worked

on developing a list of activities for both mastery and

pleasure to help activate fighting his depression. Although

he would participate in these activities with his clinician

and agree to homework, he would not follow through

during the week. He also would continue to report the same

intensity of distress from week to week as well. Tony had

struggled in school and also thought of himself as a ‘‘slow

learner, stupid’’ so the idea of homework was discovered to

be adding to his distress.

After several weeks of using cognitive strategies to try

and alleviate distress with very limited reported success

from Tony, the question of his stage of change was raised.

Although he was committed to his appointments, and

reported that his clinician was important to him and that he

wanted to keep seeing her, he was not reporting the

expected relief. Perhaps he really was not in as much of an

‘‘action’’ stage as first thought. It was decided that stepping

out of the action orientation of cognitive therapy and

spending time exploring Tony’s ambivalence and feelings

of hopelessness may be more helpful in supporting him to

find his own intrinsic motivation to change. His clinician

moved into using Motivational Interviewing. She reflected

his feelings of hopelessness without trying to move him

away from them. They talked about his ambivalence, his

desire to love and be loved and his fear and shame about

his sexual orientation. As Tony was finally able to explore

and ultimately accept the negative side of change he began

to discover his own reasons for living. It was as though he

had to go through the negative side rather than around it.

Then with cognitive therapy his depression began to lift

and he developed a relationship that was based on friend-

ship rather than physical desires and in time he told his

clinician that ‘‘I just don’t think the way I used to. I don’t

know why I thought like that anyway.’’

Limitations

This was a demonstration project and not a research study.

In the absence of a comparison or control group, one

cannot exclude the possibility that the positive outcomes

may have been the result of factors other than the combi-

nation of the clinical interventions. The demonstration took

place in an organization that had already invested in pri-

mary source CT and MI training for staff and it may be

difficult to replicate in settings that cannot make the

commitment of resources needed to train staff to profi-

ciency in these interventions. Sustainability is dependent

on reimbursement for psychotherapy which may be limited

in scope or duration by third party payers or restricted to

professionals with certain licenses.

Conclusions

This project report adds to the literature on combining

practices. Our literature review clarified the existing rela-

tionship among the practices used in this study (Beck 1967,

1976, 1995; Beck et al. 1993; McNamara 2002; Weissman

2007). Velicer et al. (1998) wrote that MI is a model of

emotion, cognition and behavior, concepts related to CT.

Prochaska et al. (1992) described SOC as an integrative

model of behavior change that may be used with other

theories for interventions as a means of determining cli-

ents’ level of readiness for change. This review also

revealed that the combination of practices as reported in

this article has been employed by other agencies with

similar results. The study results, based on the Beck BAI

and BDI measures, suggest that CT in combination with

other practices does result in improved social functioning.

MI, as a major practice in the combination, was very much

responsible for positive outcomes as Britt et al. (2004)

discussed.

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Miller and Rollnick (2002) have made the connection

between MI and SOC. Prochaska et al. (1992) wrote about

the relationship between MI and SOC although Wilson and

Schlam (2004) wrote that there is no theoretical connection

between them. This demonstration project did not suggest a

theory but it did confirm the relationship. Burke (2011)

wrote about the combination of MI and CT. These con-

nections suggest the combination of the three of these

practices is potentially realistic and the results of this study

support that contention as the combination was successful

in decreasing anxiety and depression and improving social

functioning in clients with a serious psychiatric condition.

Largely as a result of this demonstration the county

funding source has agreed to fund a new team in a local

Federally Qualified Health Center to provide integrated

behavioral and physical health services to eligible clients.

References

Abou-Saleh, M. (2004). Dual diagnosis: management within a psycho-

social context. Advances in Psychiatric Treatment, 10, 352–360.

Arkowitz, H., & Westra, H. A. (2004). Integrating motivational

interviewing and cognitive behavioral therapy in the treatment of

depression and anxiety. Journal of Cognitive Psychotherapy, 18,

337–350.

Barkhof, H., Haan, L., Meijer, C., Fouwels, A. J., Keet, I., Hulstijn,

K., et al. (2006). Motivational interviewing in psychotic

disorders. Current Psychiatry Reviews, 2(2), 207–213.

Barrowclough, C., Haddock, G., Tarrier, N., Lewis, S. W., Moring, J.,

O’Brian, R., et al. (2001). Randomized control trial of motivational

interviewing, cognitive behavior therapy, and family intervention

for patients with comorbid schjizophrenia and substance use

disorders. American Journal of Psychiatry, 158(10), 1706–1713.

Barrowclough, C., Haddock, G., Wykes, T., Beardmore, R., Conrod,

P., Craig, T., et al. (2010). Integrated motivational interviewing

ad cognitive behavioural therapy for people with psychosis and

comorbid substance misuse: Randomized controlled trial. BMJ,

341, c6325.

Beck, A. (1967). Depression: Chemical, experimental, and emotional

aspects. New York: Harper & Row.

Beck, A. (1976). Cognitive therapy and the emotional disorders. New

York: International Universities Press.

Beck, J. (1995). Cognitive theory: Basics and beyond. New York:

Guilford Press.

Beck, A., Wright, C., Newman, B., & Liese, B. (1993). Cognitive

therapy of substance abuse. New York: The Guilford Press.

Blakely, T., & Dziadosz, G. (2003). Community treatment and

rehabilitation: One agency’s model of case management. Care

Management Journals., 4(3), 129–135.

Blakely, T., & Dziadosz, G. (2007a). Creating an agency integrated

treatment program for co-occurring disorders. American Journal

of Psychiatric Rehabilitation., 10(1), 1–18.

Blakely, T., & Dziadosz, G. (2007b). An agency generated outcome

measure. Care Management Journals., 15(1), 113–119.

Britt, E., Hudson, S., & Blampied, N. (2004). Motivational inter-

viewing in health settings: A review. Patient Education and

Counseling, 53, 147–156.

Britton, P., Patrick, H., Wenzel, A., & Williams, G. (2011).

Integrating Motivational interviewing and self-determnation

theory with cognitive behavioral theory to prevent suidice.

Cognitive and Behavioral Practice, 18, 16–27.

Burke, B. (2011). What can motivational interviewing do for you?

Cognitive and Behavioral Practice, 18, 74–81.

Crooks, C., Scott, K., Francis, K., Kelly, T., & Reid, M. (2006).

Eliciting change in maltreating fathers: goals, processes, and

desired outcomes. Cognitive and Behavioral Practice, 13,

71–81.

Gioia, D., & Dziadosz, G. (2008). Adoption of evidence-based

practices in community mental health: A mixed-method study of

practitioner experience. Community Mental Health Journal, 44,

347–357.

Haddock, G., Barrowclough, C., Tarrier, N., Moring, J., O’Brien, R.,

Schofield, N., et al. (2003). Cognitive-behavioural therapy and

motivational interviewing for schizophrenia and substance

misuse. 18-month outcomes of a randomised controlled trial.

British Journal of Psychiatry, 183, 418–426.

McNamara, Eddie. (2002). Motivational interviewing and cognitive

intervention. In P. Gray (Ed.), Working with emotions (pp.

77–98). New York: Routledge-Falmer.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing:

Preparing people for change. New York: Guilford Press.

Nami (2011) NAMI Cognitive Behavioral Therapy [Web page]

accessed 11/21/11)).

Prochaska, J. O., DiClemente, C. C., & Norcross, J. C. (1992). In

search of how people change: Applications to addictive behav-

iors. American Psychologist, 47, 1102–1114.

Thomas, E. J., & Feldman, R. A. (1964). Concepts of role theory: An

introduction through programmed instruction and programmed

case analysis. Ann Arbor: Campus Publishers.

Tomlin, K., & Richardson, H. (2004). Motivational interviewing and

stages of change. Center City, MN: Hazelden Publishers.

Velicer, W. F., Prochaska, J. O., Fava, J. L., Norman, G. J., &

Redding, C. A. (1998). Smoking cessation and stress manage-

ment: Applications of the Transtheoretical Model of behavior

change. Homeostasis, 38, 216–233.

Wagner, E. H., Austin, B. T., Davis, C., Hindmarsh, M., Schaefer, J.,

& Bonomi, A. (2001). Improving chronic illness care: Translat-

ing evidence into action. Health Affairs, 90(6), 64–78.

Weissman, M. (2007). Cognitive therapy and interpersonal psycho-

therapy: 30 years later. American Journal of Psychiatry, 164(5),

693–696.

Wilson, G. T., & Schlam, T. R. (2004). The transtheoretical model

and motivational interviewing in the treatment of eating and

weight disorders. Clinical Psychology Review, 24, 361–378.

400 Community Ment Health J (2013) 49:396–400

123