Motivational Interviewing: Participant Characteristics and Early Retention in Community Clinics

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Motivational InterviewingParticipant
Characteristics and Early Retention in Community
Clinics

• Samuel A. Ball Kathleen M. Carroll
• Training Director Principal Investigator
• Yale University School of Medicine
• CTN New England Node

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BRIDGING THE GAP IN THE CLINICAL TRIALS
NETWORK (CTN)

• First CTN psychotherapy protocol to involve front
  line addiction counselors
• Goal of effecting and sustaining changes in
  clinical practice
• First examination of treatment-as-usual
• Local variation to enhance buy-in
• Treatment Providers as true partners with
  Researchers in bidirectional process
• First randomized clinical trial for all but two
  of the 11 sites

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COMMUNITY TREATMENT PROGRAMS (CTPs)

• NEW ENGLAND
• Connecticut Renaissance
• Liberation Meridian Guenster
• PACIFIC REGION
• Haight Ashbury Free Clinic
• Tarzana Treatment Center
• NEW YORK
• Lower East Side Service Center

• OREGON NODE
• ChangePoint
• Willamette Family Treatment Services
• ADAPT
• DELAWARE VALLEY
• Northeast Treatment Center
• Rehab After Work
• MID-ATLANTIC NODE
• Chesterfield County CSB

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PROTOCOL DESIGN TEAM

• Delaware Valley George Woody
• Paul Crits-Christoph
• Thomas McLellan
• New England Kathleen Carroll
• Samuel Ball
• New York Jon Morgenstern
• Pacific Region Jeanne Obert
• Douglas Polcin
• Oregon Chris Farentinos
• NIDA Ivan Montoya
• Lisa Onken

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TREATMENT RESEARCH PARTNERSHIP

• Protocol Development
• Local and national survey
• Development of two protocols
• Manual Development
• Definition of Standard Care for Ratings
• Therapist Training
• Local Experts attend national training
• Local Supervisor to enhance sustainability
• Protocol Implementation

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STUDY RATIONALE

• Attrition is a major issue in
• substance abuse treatment
• The bulk of attrition occurs very early in
  treatment
• Retention linked to better outcome in several
  studies

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STUDY RATIONALE

• Brief, motivational approaches have strong
  empirical support among alcohol cigarette using
  populations
• Effects are clinically significant and durable
• More data needed on effectiveness in more
  heterogeneous population of substance abusers and
  real world settings

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MOTIVATIONAL INTERVIEWINGPrinciples

• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Support self-efficacy

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MOTIVATIONAL INTERVIEWINGTechniques

• Open-ended questions
• Affirmation
• Reflective listening
• Summary Statements
• Personal feedback
• Decision balance
• Eliciting self-motivational statement
• Develop alternatives and options

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STUDY PRIMARY AIMS

• To evaluate the efficacy of MI-style assessment,
  relative to Standard Care assessment in real
  world community treatment programs
• To evaluate the durability of MI effects and
  practice relative to standard care through a
  3-month follow-up

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STUDY DESIGN

• Multisite randomized clinical trial in five
  community-based drug treatment programs (CTPs)
• Single (2-hour) clinical evaluation session
  comparing Motivational Interviewing (MI) with
  Standard Care (SC)
• Clinician characteristics and skill acquisition
  assessed
• Treatment fidelity and discriminability monitored
• Training plan designed to facilitate sustained
  changes in practice and dissemination

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LEVELS OF TRAINING

• MET/MI Expert Trainer
• MET/MI Supervisor
• MET/MI Therapist

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EXPERT TRAINER

• Study site representative(s) who is research
  investigator/collaborator or trainer
• Attended two-day train-the-trainer meeting in
  Albuquerque (Drs. Miller and Moyers)
• Provided training to supervisors and therapists
  within each clinic performance site
• Reviewed session audiotapes for supervisory
  feedback and therapist credentialing
• Provided face-to-face or phone supervisory
  meeting with each MI supervisor monthly

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SUPERVISOR

• Preferably clinical or assistant director and
  higher in clinic hierarchy than the therapists
• Attended two-day therapist/supervisor training
  provided by the MI expert trainer
• Reviewed therapist audiotapes for supervision
  purposes and consultation with Expert Trainer
• Meet weekly with therapists (indiv. or group)

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THERAPIST

• No formal MI training in past 3 months or
  experience providing manualized MI in prior
  clinical trial
• Assessed, randomized to MI or Standard Care,
  trained, audiotaped and supervised to follow
  treatment manual
• Completed brief research assessments and pre- and
  post-protocol tapes
• Certified by MI expert and supervised by MI
  supervisor

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ADHERENCE COMPETENCE MONITORING SYSTEM

• Guided supervision/training process between
  expert-trainer and supervisor and supervisor and
  therapist
• Adaptation of the Yale Adherence Competence
  Scale (Carroll et al., 2000) used in several
  prior clinical trial studies

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ADHERENCE COMPETENCE ITEMS

• 39 items rated on two 7-point Likert dimensions
• (frequency/extensiveness and skill level)

• MI-Consistent sample items
• Open-ended Qs
• Reflections
• Affirmations
• Pros/Cons
• Discrepancies
• MI Style

• MI-Inconsistent sample items
• Confrontation
• Skills Training
• Asserting Authority
• Psychodynamic
• Invoking Spirituality
• Total Abstinence

• Standard Care sample items
• Psychosocial Assess
• Program Orientation
• Case Management
• SA Psychoeducation
• Assessing Sub. Use
• Treatment Planning

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STUDY PARTICIPANTSCounselors (n32)

• Predominantly Caucasian (81), female (66), with
  average age of 42.2
• Experienced group of clinicians with mean of 7.3
  years of counseling experience and mean of 4.1
  years working for current agency
• 56 of sample had masters degrees
• 66 certified in drug and alcohol counseling or
  licensed (social work marriage and family
  therapy counseling)
• 56 of sample self-identified as being in
  recovery

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STUDY PARTICIPANTSCounselor Orientation and
Techniques

• Range of common theoretical orientations used for
  addiction counseling with most frequent being
  Relapse Prevention/Cognitive-Behavioral (75) and
  least frequent being Gestalt/Experiential (9)
•  
• When describing their treatment of a typical
  client seen prior to training, clinicians scored
  themselves highest on use of motivational
  interviewing items
•  
• Relatively few clinicians reported reliance on
  one dominant theoretical orientation for
  counseling

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STUDY PARTICIPANTSPatients (n423)

• Adults seeking outpatient treatment for any type
  of substance abuse
• Not seeking or requiring methadone maintenance,
  detoxification only, or inpatient treatment
• Sufficiently medically and psychiatrically stable
• Randomly assigned to MI (n209) versus Standard
  Care session (n214)

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STUDY PARTICIPANTSPatient Characteristics

• Gender 57 Male
• 43 Female
• Ethnicity 72 Caucasian
• 9 African American
• 4 Hispanic/Latin American
• 14 Multi-racial
• Marital 20 Married/cohabitating
• 33 Separated/Divorced/Widowed
• 47 Single
• Age 32.9 Years
• Education 12. 2 Years

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STUDY PARTICIPANTSPatient Characteristics

• Employment 63 Unemployed
• Legal 24 Criminal Justice Referred/Mandated
  36 No Legal Problems
• Primary Substance 48 Alcohol
• 21 Marijuana
• 19 Methamphetamine
• 6 Cocaine
• 5 Opiates
• 1 Benzodiazepine
• Past 28 Days
• Primary Use 9.7 Days

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PRIMARY HYPOTHESES

• During first 28 days of treatment and at a
  3-month follow-up, MI gt Standard Care session
• 1) Retaining patients (proportion still enrolled
  in treatment at CTP)
• 2) Decreasing substance use (days of use of
  primary substance)

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PRELIMINARY ANALYSESEffects on Retention

• Patients assigned to MI subsequently completed
  more counseling sessions (mean5.02, sd5.15)
  than Standard Care patients (mean4.03, sd4.21)
  during 28 days after randomization (plt.05)
• MI patients more likely (84) to still be
  enrolled at the program after one month than
  Standard Care patients (75) (plt.04)

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FUTURE ANALYSESOutcomes

• Primary
• Retention in the clinic (attendance)
• Days of substance use (SUC, urines, breath)
• Secondary
• Motivation (URICA)
• Psychosocial functioning (ASI)
• HIV risk behaviors (HRBS)
• Treatment utilization (TSR)
• Participant satisfaction

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FUTURE ANALYSESMatching and Process

• Evaluate types of participants who respond best
  to motivational approaches
• Evaluate the ability of unselected clinicians to
  implement motivational approaches effectively
• Evaluate the discriminability of motivational
  approaches from standard care