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The current study aimed to (a) evaluate the effectiveness of motivational interviewing, as applied by a community mental health team (CMHT) based in Singapore; (b) reduce hospital admissions and length of hospital stay; and (c) im-prove global functioning and satisfaction of individuals with mental illness. The current study used a quasi-experimental method. A convenience sample of 120 participants was selected from the caseload of the CMHT. Participants re-ceived motivational interviewing sessions at least once every month for 1 year. Data on the number of hospital admissions, length of hospitalization, Global Assessment

of Functioning, and patient satisfaction were collected at baseline and 6 and 12 months. Participants who underwent the CMHT services with motivational interviewing were more compliant to treatment, resulting in significant reduc-tion in hospitalization and improvement in functionality. Motivational interviewing is effective in facilitating better ill-ness management for patients in the community. Adoption of the motivational interviewing approach may potentially provide significant benefits for psychiatric support services in the community. [Journal of Psychosocial Nursing and Men-tal Health Services, 53(12), 28-37.]

ABSTRACT

Motivational Interviewing Approach Used by a Community Mental Health TeamSharon Chay Huang Tan, BSN; Mindy Wen Hui Lee, BPsych; Gentatsu Tan Xiong Lim, BPsych; Joseph Jern-Yi Leong, MMed; and Cheng Lee, MMed

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The importance of motivation in behavior change within the mental health care setting has

garnered increasing research attention in recent years. In particular, motivational interviewing is an approach that has gained popularity in its use as a brief, long-term, and supplementary intervention. Motivational interviewing is a “collaborative, person-centered form of guiding to elicit and strengthen mo-tivation for change” (Miller & Rollnick, 2002, p. 130).

Motivational interviewing attempts to increase patients’ awareness of potential problems caused by their behavior, consequences experienced from it, and risks faced as a result. Patients may also try to envision a better future when the behavior is changed and thus become increasingly motivated to achieve it. In doing so, the community mental health team (CMHT), psychiatric nurses, and allied health workers use non-didactic coun-seling skills, such as asking open-ended questions and using reflective listening, and direct the discussion to focus on ambivalence and its resolution (Miller & Rollnick, 1991).

The current study aimed to investi-gate the effectiveness of motivational interviewing used together with CMHT services administered to patients with mental health problems during home visits (each session lasting 1 hour). In supporting CMHT services, motiva-tional interviewing was the technique provided to enhance family support and psychoeducation and follow up given by psychiatric nurses and allied health workers. It is likely for patients to expe-rience relapses, high readmission rates, and defaulting follow up if the service approach is not improved. Knowing about these consequences prevents dis-tress for patients and family members, and reduces health care costs. Hence, a vicious cycle is seen if service approach is not improved as patients are currently

stabilized in the hospital, but unable to reintegrate into the community due to a lack of change in behaviors and com-pliance to treatment. The interven-tion lasted more than 1 year prior to discharge from CMHT services. Evalu-ation was based on patients’ number of readmissions to psychiatric hospi-tals, their length of stay (if any), and global functioning, as well as their (and their caregivers’) level of satisfaction regarding the services delivered using motivational interviewing. The cur-rent study is the first to investigate the usefulness and applicability of motiva-tional interviewing on mental health patients in Singapore.

MOTIVATIONAL INTERVIEWINGThe spirit of motivational

interviewing is to encourage col-laboration, evocation, and autonomy between patients and professionals (Hettema, Steele, & Miller, 2005). Collaboration, as opposed to confron-tation, allows a patient-centered part-nership between patients and profes-sionals. Instead of directing action, professionals aim to draw out patients’ own motivation and commitment toward change. This is done by using motivational interviewing strategies of resolving ambivalence and asking evoc-ative questions that elicit change talk. Autonomy is embraced throughout the process as patients are allowed to form ideas and make decisions.

Professionals practicing motivational interviewing are guided by four main principles of evoking change: (a) ex-pressing empathy, (b) developing discrep-ancies, (c) rolling with resistance, and (d) supporting self-efficacy (Miller & Rollnick, 1991). Empathy is mostly expressed through reflective listening and by exhibiting characteristics similar to Rogerian therapy (Emmons & Rollnick, 2001). Developing discrep-ancy involves reflection of incongruity between patients’ current behavior and

their values or future goals. For this purpose, the motivational interviewing approach emphasizes giving feedback in a nonjudgmental way and asking patients’ permission to explore issues. Ideally, practitioners should give feed-back that involves a number of objec-tive parameters, such as physiological, neurological, and psychosocial charac-teristics, that aim to enhance motiva-tion for change. Professionals provide facts, but making those facts personally meaningful remains a task for patients.

Hesitancy toward change is common among individuals seeking treatment or changing behavior; they are ambivalent—they want and do not want it (Hettema et al., 2005). Moti-vational interviewing acknowledges this ambivalence and advocates rolling with the resistance rather than directly challenging it. Rolling with resistance encourages professionals and patients to work together to explore and resolve ambivalence (Levensky, Forcehimes, O’Donohue, & Beitz, 2007). This reso-lution is achieved through a variety of reflective listening techniques. One such technique is amplified reflection, which works on the assumption that the oppositional tendency of the patient will lead to a withdrawal because his/her resistance and negative position is overstated (i.e., the patient will rethink his/her extreme behavior and negotiate for a reason to change) (Treasure, 2004). Double-sided reflection high-lights the contradiction between what patients are currently stating and con-trary statements that they have made previously (Markland, Ryan, Tobin, & Rollnick, 2005). The goal is to heighten patients’ awareness and emphasize their autonomy in the matter of change. The therapeutic relationship elicits hope and optimism in the feasibility of accomplishing change by uncovering patients’ own strengths and resources. This self-efficacy is essential in realizing sustained behavior change.

29Journal of Psychosocial nursing • Vol. 53, no. 12, 2015

BACKGROUNDMiller (1983) first explored the use

of motivational interviewing as a treat-ment for problem drinking. Since then, use and effectiveness of motivational interviewing as an intervention for other addictions has been extensively studied. Lai, Cahill, Qin, and Tang (2010) found that motivational inter-viewing was an effective tool in helping individuals stop smoking and its effec-tiveness was more significant when multiple sessions (≥20 minutes) were

conducted. Other studies have targeted behavioral outcomes, including reduc-tion in substance abuse (Forsberg, Ernst, Sundgvist, & Farbring, 2011) and gam-bling (Carlbring, Jonsson, Josephson, & Forsberg, 2010), and changes in health-related behaviors (e.g., diet, exercise, safe sex) (Bowen et al., 2002; Brodie & Inoue, 2005; Van Wormer & Boucher, 2004). Meta-analyses of studies that examined the effects of motivational interviewing on behavioral outcomes found the strongest relationships to engagement in treatment for substance abuse and addiction behaviors, whereas the impact on other behaviors showed conflicting results (Lundahl, Kunz, Brownell, Tollefson, & Burke, 2010).

Use of motivational interviewing can be extended to promoting gen-eral health (Shinitzky & Kub, 2001). Research showed that if motivational interviewing was offered as a stand-alone intervention, its long-term effects may be enhanced by booster sessions or stepped care (Swanson, Pantalon, & Cohen, 1999). Stepped care refers to interventions that start with the

least intensity, but are likely effec-tive. With monitoring, interventions either increase or decrease in intensity depending on the needs of the patient (Bower & Gilbody, 2005). When used as a prelude to treatment, the effects of motivational interviewing appeared to endure over time, suggesting efficacy persisted in conjunction with other treatment procedures (Hettema et al., 2005).

Application of motivational inter-viewing for individuals with psychiatric

disorders was examined by Swanson et al. (1999) as an adjunct to standard treatment (e.g., pharmacotherapy, individual/group psychotherapy, activities therapy, milieu treatment, discharge planning) during hospital-ization. Their results showed signifi-cantly higher outpatient appointment attendance for individuals with dual diagnoses of psychiatric disorders and addiction. However, little research exists on the impact of motivational interviewing for individuals who are diagnosed with psychiatric disorder and do not have comorbid addictions.

Use of motivational interviewing on patients with mental illness can be complicated because of severe lack of insight, as noted by Rüsch and Corrigan (2002). They explored use of motivational interviewing to improve insight and treatment adherence and found that use of the intervention can improve insight and adherence of clients with schizophrenia who were concurrently treated by specific psychotropic medications (Rüsch & Corrigan, 2002). As Jaspers (1963)

explained, mere awareness of the ill-ness is a feeling of being ill, whereas insight involves an “objectively correct estimate of the severity of the illness and an objectively correct judgment of its particular type” (p. 419). As such, insight can be seen as the internal and subjective perspective of one’s illness. Hence, it stands to reason that when patients were allowed to explore their own goals and share decision in their treatment, insight would improve, resulting in better adherence (Rüsch & Corrigan, 2002).

Nevertheless, although individuals who are diagnosed with severe mental health problems may lack insight and have cognitive deficits, motivational interviewing recognizes that change occurs at different rates for different individuals (Swanson et al., 1999). Therefore, for change to occur and be sustained, especially for individuals with chronic and recurring mental disorders (e.g., schizophrenia), patient collabora-tion and self-responsibility is crucial in managing their own lives with greater autonomy (Corrigan, McCracken, & Holmes, 2001). To achieve this, clini-cians and professionals must first help clients identify their goals. Goal assess-ment assures that the focus of treatment is driven by clients’ own perceptions of important needs (Noordsy et al., 2002). Following goal assessment, Dades et al. (2005) described the important role clinicians play in helping indi-viduals identify the cost and benefits of specific existing behaviors as well as planned behaviors. Benefits detail rea-sons why the individual should pursue a goal; costs define barriers to achieving that goal (Noordsy et al., 2002). The motivational interviewing framework seemed to support the current study and suggests a promising method to moti-vate change behaviors in individuals with mental health issues.

The CMHT at Singapore’s Institute of Mental Health has been providing services and treatment support to individuals living in the community for many years. The program is approved by the National Mental Health Blueprint—a ministerial initiative that

Motivational interviewing attempts to increase patients’ awareness of potential problems caused by their behavior, consequences experienced from it, and risks faced as a result.


aims to improve treatment and quality of life of individuals who are diagnosed with mental illness. A primary goal of the CMHT is to improve patients’ illness self-management and treat-ment adherence. This goal is achieved when the team (i.e., psychiatric nurses, medical social workers, and occupa-tional therapists) conduct home visits, medication counseling, depot injec-tion, social skills training, occupational therapy, family therapy, recovery interventions, and motivational interviewing.

METHODThe current study used descriptive

and inferential statistics to evaluate the effectiveness of motivational interviewing in modifying patients’ behaviors in managing their illness in the community. Over a 12-month period, nurses and allied health workers (e.g., medical social workers, occupa-tional therapists) from the CMHT vis-ited a convenience sample of 120 par-ticipants (59% female and 41% male) and used the motivational interviewing technique in their interventions. Effects of motivational interviewing techniques on the number of readmis-sions to psychiatric hospitals, length of stay in psychiatric hospitals, global functioning, and level of satisfaction were evaluated.

ParticipantsOne hundred twenty participants

newly recruited to the CMHT pro-grams comprised the study sample.

Inclusion criteria for participants were: community-dwelling adults ages 18 to 65; diagnosis according to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Asso-ciation [APA], 2013) of severe mental illness (e.g., schizophrenia, delusional disorder, bipolar disorder); presence of symptoms and impairment that pro-duce distress and disability in daily function; significant disability caused by severe mental illnesses that is not helped by traditional outpatient man-agement services; and having three or

more admissions and/or duration of hospitalizations of >30 days in the past year.

Exclusion criteria were organic brain disorder, acute exacerbation of symptoms, concurrent alcohol or substance abuse problems, residence in chronic wards of the Institute of Mental Health, being homeless, and other medical problems. Family was not present during the home interven-tions as most were working.

Individuals who declined to par-ticipate were those who also declined home visits; hence, they were not accepted to CMHT services. No data were available for dropouts.

ProceduresPatients who consented to the cur-

rent study were selected from a CMHT case worker’s caseload. In the following 12 months, 32 case workers visited participants’ homes once or twice per month to provide family support, psy-choeducation, and medication educa-tion using motivational interviewing. The number of visits was determined by participants’ medical or mental con-dition as well as the support required by family members, including financial capabilities. A structured questionnaire designed for the study was administered at baseline and 6 and 12 months.

During the initial session, the case worker provided information about the study and gave detailed explana-tions of the nature and purpose of the interview. After obtaining consent, a 15-minute interview with the partici-pant was conducted in a private room at the participant’s home to complete the questionnaire. Data collected were then entered into an electronic work-sheet saved on a laptop brought by the case worker. Any questions or queries were clarified.

Data CollectionData were collected using a struc-

tured questionnaire. Case workers were briefed on the use of the instru-ment and trained to adopt a uniformed approach to ensure consistency in the interviewing process. An interrater

reliability test of the case workers for using components of the question-naire yielded 0.981 for the Global Assessment of Functioning (GAF) scale (APA, 2000).

Measurement ToolsThe structured questionnaire used

for data collection comprised four sec-tions. Section A was a demographic profile designed by case workers, including participants’ age, sex, ethnicity, and education. Section B tracked the number of hospital admis-sions and length of hospital stays over a period of 1 year before and after the study began. Section C comprised the GAF scale to measure level of impairment or dysfunction associated with emotional disturbance. Based on DSM-IV (APA, 2000) criteria, the GAF scale has been widely used and reported to have good reliability and validity, including correlations with measures of overall severity of illness and relationship to rehospitalization. The GAF scale is a clinical tool that enables a rating of participants’ general functionality on a hypothetical con-tinuum of mental health illness. The rating takes into account functionality in the psychological, social, and occu-pational dimensions. Scores range from 1 to 100, where 1 represents persistent danger of severely hurting oneself or others (e.g., recurrent violence), per-sistent inability to maintain minimal personal hygiene, or serious suicidal act with clear expectation of death; 100 represents superior functioning in a wide range of activities (APA, 2000). Section D comprised the Patient’s Sat-isfaction Questionnaire (PSQ; Larsen, Attkisson, Hargreaves, & Nguyen, 1979). This questionnaire comprises eight 4-point Likert scale questions targeted at measuring participants’ sat-isfaction level on various aspects of the program. Total scores were converted into a scale with a possible score of 100.

Cronbach’s alphas for internal reli-ability for the scale were 0.86 (after 6 months) and 0.91 (after 12 months). Factor analyses also supported that all eight items loaded on one panel


for data collected at 6 (factor loading range = 0.68 to 0.77) and 12 (factor loading range = 0.71 to 0.88) months when a rule of thumb of an eigenvalue >1 was used.

Permission to use the GAF and PSQ scales was sought with the current authors by the administrators of the Institute of Mental Health.

Motivational Interviewing InterventionThe motivational interviewing

approach was used by case workers visiting participants and their families during the course of the current study to implement interventions such as psychoeducation and therapy. One or two visits per month were sched-uled according to participants’ prefer-ences. Each visit lasted approximately 1 hour. Case worker–participant inter-actions revolved around healthy life-style, medication issues, relationships, education, and work. Motivational interviewing was used to acknowledge and reflect participants’ concerns, encouraging them to share more and use their own abilities to solve prob-lems. Other motivational interviewing strategies (e.g., the change ruler…0-10 [Hesse, 2006]) were used to identify the level of importance, confidence,

and readiness toward change. Option menus or evoke-change statements were used to elicit change talk. Mo-tivational interviewing strategies commonly used during these home visits included open-ended questions, reflections, double reflections, ampli-fied reflections, roll with resistance, avoid argumentation, affirmations, evoke-change statements, action reflections, and summaries. Double reflection was defined as having state-ments meant to capture both sides of an individual’s ambivalence; it is a reflection of the pros and cons of change that the participant has said or hinted at saying. Typically, the two sides are joined by the phrase, “On the other hand.” Amplified reflection was defined as a reflection of what the participant said in a slightly amplified or exaggerated form. It is important to be genuine and not sarcastic. Often the amplified reflection will cause the participant to clarify or elaborate on an important aspect of what was said, especially when what was amplified revealed resistance (Miller & Roll-nick, 2002).

Motivational Interviewing TrainingStaff were trained in motiva-

tional interviewing by a local trainer who is a member of the Motivational Interviewing Network of Trainers (MINT) and an overseas motivational interviewing trainer. Local trainers included a doctor (L.J.-Y.J.) and nurse clinician (T.C.H.S.). Regular prac-tices and supervision were conducted according to weekly and monthly schedules. Assessment of staff com-petency was conducted using One Pass coding as advised by the MINT instructor.

The current study and ethical issues were approved by the Project Director of the CMHT. Ethical issues were guided according to the hospital ethic review committee and guidelines. All participants were informed of the pur-pose and nature of the current study and consent was sought prior to initial assessment. Anonymity of participants was preserved.

Data AnalysisAll collected data were analyzed

with SPSS version 21.0. Three-way mixed design analyses of variance were computed to identify the effects of motivational interviewing, gender, and age (i.e., younger versus older; patients were divided into two groups using a mean age of 45 as a split point) on participants’ number of hospital admissions, length of hospital stay, functioning ability, and satisfaction level. Huynh–Feldt correction was used to avoid violation of assumption of sphericity.

RESULTSDemographic Characteristics

A total of 120 participants (59.2% female and 40.8% male) were interviewed at their respective homes. Table 1 summarizes characteristics of participants.

Number of Hospital AdmissionsResults showed that motivational

interviewing significantly influenced the number of hospital admissions at a 0.05 level (F [1, 119] = 84.11, p < 0.001, ηp2 = 0.42) (Table 2). Number of hos-pital admissions before motivational interviewing (mean = 1.47, SD = 1.19) were found to be improved compared to post-intervention (mean = 0.37, SD = 0.83). From the interaction graph shown in Figure 1, it was con-cluded that male participants showed better improvement than female par-ticipants in terms of number of hospital admissions (F [1, 119] = 6.52, p = 0.01, ηp2 = 0.05).

Length of Hospital StayMotivational interviewing was found

to be significant in predicting length of hospital stay (F [1, 119] = 25.82), p < 0.001, ηp2 = 0.18) (Table 3). Length of hospital stay post-intervention (mean = 8.96, SD = 22.82) reduced from pre-intervention (mean = 71.14, SD = 152.49). Male participants were found to have better improvement than female participants (F [1, 119] = 5.48, p = 0.02, ηp2 = 0.05). Older participants were also found to

TABLE 1PATIENT DEMOGRAPHICS (N = 120)

Variable n (%)Gender

Male 71 (59.2)

Female 49 (40.8)

Age (years)a

≤20 1 (0.8)

21 to 30 10 (8.3)

31 to 40 28 (23.3)

41 to 50 44 (36.7)

51 to 60 30 (25)

≥61 7 (5.8)

a Mean (SD) = 45.04 (10.30), range = 20 to 65.


have better improvement than younger participants (F [1, 119] = 4.01, p = 0.05, ηp2 = 0.03) (Figures 2 and 3).

Global Assessment of FunctioningIn this section, two variables were

found to be significant in predicting GAF, namely motivational interviewing (F [2, 119] = 3.62, p = 0.03, ηp2 = 0.03) and age (F [1, 119] = 5.62, p = 0.02, ηp2 = 0.05) at the 0.05 level (Table 4). GAF scores collected at baseline (mean = 64.26, SD = 9.76) were significantly lower than those collected 6 (mean = 66.43, SD = 8.63) and 12 (mean = 66.72, SD = 8.14) months after the interven-tion. Older participants (mean = 66.99, SD = 7.51) were also found to have better functioning scores compared to younger participants (mean = 64.54, SD = 6.58).

Patient’s Satisfaction QuestionnaireMotivational interviewing had

a marginally significant effect on PSQ scores (F [1, 98] = 3.23), p = 0.08, ηp2 = 0.03). Satisfaction scores 12 months after the program (mean = 81.06, SD = 8.89) were higher than the 6-month scores (mean = 78.98, SD = 7.95).

DISCUSSIONThe aim of the current study was

to investigate whether motivational interviewing could reduce patients’ number of hospital admissions and length of hospital stay, as well as improve their GAF score. The current authors wanted to evaluate whether clients were generally satisfied with the motivational interviewing inter-vention and sought to understand how gender and age could potentially influ-ence these outcome variables. Pre- and post-intervention comparisons with the addition of demographic informa-tion were performed to answer these research questions.

Findings demonstrated the effec-tiveness of motivational interviewing in improving outcomes for all areas of measurement. In terms of hospital admissions, results showed a significant reduction after 1 year of motivational

interviewing. As a directive, person-centered approach, a principle of motivational interviewing is the reso-lution of ambivalence toward desired behavior—in this case, treatment adherence (Miller & Rollnick, 2009). Motivational interviewing strategies encouraged participants to weigh the pros and cons of treatment adherence and take charge of their own illness

management. The approach effectively helped psychiatric patients living in the community to be more treatment adherent, thereby lowering their need for hospital admissions. Similarly, in the length of hospital stay, reduction was significantly profound. Participants had better insight and adopted better coping strategies so that they were more ready to stay in the community. For the

TABLE 2NUMBER OF HOSPITAL ADMISSIONS (N = 120)

Source df FBetween-patient effects

Gender 1 0.95

Age 1 2.76

Gender × age 1 0.05

Error 116

Within-patient effects

MI 1 84.11***

MI × gender 1 6.52**

MI × age 1 0.01

MI × gender × age 1 0.5

Error 116

Note. df = degrees of freedom; MI = motivational interviewing. **p < 0.01; ***p < 0.001.

Figure 1. Interaction effect between motivational interviewing and gender on number of hospital admissions.


same reason, participants’ functioning status improved slowly and their goals were met. Although participant sat-isfaction was not highly rated, many complimenting letters were received (Amrhein, Miller, Yahne, Palmer, & Fulcher, 2003; Gollwitzer, 1999).

However, analysis of interaction effect suggested that the motivational interviewing intervention was more effective for male than female par-

ticipants. Women may be less willing to change when they are stressed or frustrated by unexpected life circum-stances (Hosseinpoor et al., 2012). Similarly, Spivey et al. (2009) noted that women’s resistance levels may potentially increase when they feel emotionally stressed.

Results also showed a significant reduction in participants’ overall length of hospital stay. Again, motivational

interviewing strategies of increasing awareness and ambivalence resolution likely caused an improvement in par-ticipants’ treatment adherence. Most psychiatric patients, when asked, would readily voice their preference for staying in the community than admission into a hospital. The approach adopted by motivational interviewing effec-tively challenges participants to think through the consequences of poor health and illness management behav-iors (Gourlan, Sarrazin, & Trouilloud, 2013). By increasing participants’ awareness of the consequences of poor management, they were thus motivated to improve self-management and stay longer in the community.

Male participants demonstrated a more significant reduction in the length of hospital stay than female par-ticipants. Recent evidence indicates women have higher rates of morbidity than men (Bird & Rieker, 1999). Wom-en also experience higher levels of psy-chological distress (Gove, 1984). This is largely a result of their social role as nurturers. It has been argued that men, having highly structured or fixed roles, tend to be causally related to better health and lower rates of morbidity. In contrast, women’s roles as nurtur-ers tend to add strain on their abilities, leading to poorer health and more ill-nesses (Gove, 1984; Jaspers, 1963; Van de Velde, Bracke, & Levecque, 2010).

Although the current study found motivational interviewing to be ef-ficacious across all age groups, older participants were shown to benefit more from the approach than younger participants. This finding suggests a higher resistance among younger par-ticipants toward treatment adherence (Patel, Flisher, Hetrick, & McGorry, 2007). Older participants, being ill for a longer period of time, may have been ambivalent about treatment for a long time. Motivational interview-ing, in emphasizing awareness and self-efficacy, may be more effective for older participants because it provokes an acknowledgement of the need for adherence. In addition, older partici-pants may also have greater familiar-

TABLE 3LENGTH OF HOSPITAL STAY (N = 120)


Gender 1 2.34

Age 1 2.1


Error 116


MI 1 25.82***

MI × gender 1 5.48**

MI × age 1 4.01*


Error 116

Note. df = degrees of freedom; MI = motivational interviewing. * p < 0.05; ** p < 0.01, *** p < 0.001.

Figure 2. Interaction effect between motivational interviewing and gender on length of hospital stay.


ity with treatment and therapeutic requirement, and are therefore in a better position to self-manage. Find-ings are consistent in the categories of length of hospital stay and functioning capability.

For GAF, two main effects were found to be significant: motivational interviewing intervention and age. GAF scores collected at baseline were significantly lower than those collected at 6 and 12 months, indicat-ing motivational interviewing strate-gies help in improving participants’ illness management behavior. Older participants were also found to have better functioning scores when com-pared to their younger counterparts. This finding suggests that as psychi-atric patients get older, they become more competent in managing their condition. It may be a result of greater familiarity with treatment and meth-ods of illness management or from having learned from experience the adverse effects of treatment nonad-herence. Similarly, Callaghan (2004) found that older adults had better attitudes and more contributions to society than their younger counter-parts. Younger participants may have unrealistic and untried expectations of the illness condition and its manage-ment, which may explain their poorer GAF scores.

Poor mental health is strongly related to other health and develop-ment concerns in young individuals, affecting them in many ways. The effectiveness of some interventions for individuals experiencing many mental illnesses in this age group has been well-established. However, more needs to be done to improve the range of affordable and feasible interventions. As noted by Patel et al. (2007), most mental health needs of young individuals are unmet, even in high-income coun-tries. Young individuals may be more resistant to psychiatric treatment and are higher risk takers than older adults. Some younger individuals have better support, especially those who have a higher educational background. How-ever, in the current study, they were

comparable to older participants in terms of functioning status even though the overall results still showed a signifi-cant improvement. The overall effect of motivational interviewing strategies on this age group may be to move them slowly toward better health behaviors (Callaghan, 2004).

Improvement in patient satis-faction during the study was ob-

served to be marginally significant. Satisfaction scores at 12 months were higher than those at 6 months. Al-though only marginally significant, participants were noted to be verbally happy and had written compliments for case workers after 6 months of motivational interviewing interven-tion. Recovery stories were collected and published previously as success

TABLE 4GLOBAL ASSESSMENT OF FUNCTIONING (N = 120)


Gender 1 2.08

Age 1 5.62*


Error 116


MI 2 3.62*

MI × gender 2 0.98

MI × age 2 1.04


Error 232

Note. df = degrees of freedom; MI = motivational interviewing. * p < 0.05.

Figure 3. Interaction effect between motivational interviewing and age on length of hospital stay.


stories to be shared with others. Us-ing feedback in a nonjudgmental way and eliciting participants’ permission are principle motivational interview-ing strategies. Such an approach demonstrates respect for participants’ opinions and empowers them to make choices that work well for them. Hence, practitioners may provide facts, but the personal implications of those facts should be elicited from participants.

Evaluation of the intervention during home visits found that partici-pants who receive motivational inter-viewing sessions are more compliant to treatment. Findings showed significant reduction in readmission and increased global functioning.

LIMITATIONS AND RECOMMENDATIONS

The current study was conducted to evaluate the preliminary program and is limited to only 1 year of the program. A longer study of 3 or 5 years may yield more observations about the sustain-ability of positive outcomes.

It is also recommended that fur-ther study be performed to compare different modes of interventions, such as using motivational interviewing with cognitive-behavioral therapy or another recovery intervention. Thera-pists’ competency has been found to

be a significant factor in determining the effectiveness of motivational interviewing; studies attempted in this vein will contribute to achieving better outcomes in the future. All case workers, including nurses and allied health workers, were trained in motivational interviewing; hence, no control group was possible within the team. Future studies may be conducted to compare a control group in another department or other agency.

CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE

The current study demonstrated the potential of the motivational interviewing approach in reducing hospitalization and improving global functioning for individuals with mental illnesses in Singapore. Findings sug-gest community psychiatric nurses and allied health workers of a CMHT, while working with patients with mental ill-ness, could incorporate motivational interviewing to enhance effectiveness in providing psychoeducation, medica-tion counseling, and family support. The staff’s engaging style has made patients feel respected and reflections have cre-ated the understanding of their prob-lems. Developing the discrepancy of participants’ noncompliance behavior and what they want to achieve is com-mendable because it helps them become

aware of what they want versus what they do. This discrepancy usually shifts these individuals to change their be-havior of noncompliance to treatment compliance. As a result, individuals have improved wellness statuses to the extent of reduced hospital stays and also improved functioning ability.

Motivational interviewing is an effective technique to be used for mental health settings in supporting all services, whether in the inpatient set-ting or with a CMHT.

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KEYPOINTSTan, S.T.C., Lee, M.W.H., Lim, G.L.X., Leong, J.J.-Y., & Lee, C. (2015). Motivational Inter-viewing Approach Used by a Community Mental Health Team. Journal of Psychosocial Nursing and Mental Health Services, 53(12), 28-37.

1. Motivational interviewing has shown positive intervention outcomes with patients who have severe mental illnesses and are living in the community.

2. Motivational interviewing focuses on eliciting change, particularly through reflections and rolling with resistance.

3. Motivational interviewing demonstrated better engagement with individuals who have poor insight in their illness or problems.

4. The current study found improved compliance to treatment and overall functioning and reduced hospitalizations for individuals who received motivational interviewing interventions.

Do you agree with this article? Disagree? Have a comment or questions?Send an e-mail to the Journal at [email protected].


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Ms. Tan is Nurse Clinician, Researcher, and Trainer, Ms. Lee is Counselor, Dr. Leong is Psychia-trist, Consultant, and Deputy Director of Com-munity Mental Health Team, and Dr. Lee is Vice Chairman Medical Board (Clinical) and Director of Community Mental Health Team, Institute of Mental Health, Buangkok; and Mr. Lim is Research Analyst, Nanyang Technological University, Singa-pore.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Sharon Chay Huang Tan, BSN, Nurse Clinician, Researcher, and Trainer, Institute of Mental Health, 10 Buangkok View, Singapore 539747; e-mail: [email protected].

Received: April 16, 2015Accepted: August 21, 2015doi:10.3928/02793695-20151020-03


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