MOTIVATIONAL INTERVIEWING: Theory, Treatment, Training, and Targeting Special Populations

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MOTIVATIONAL INTERVIEWINGTheory, Treatment,
Training, and TargetingSpecial Populations

• Samuel A. Ball, Ph.D.
• Yale University School of Medicine
• Department of Psychiatry
• Division of Substance
• Presentation at NHSN 4th Annual Conference
  10/14/04

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BACKGROUNDTheory and Research

• Experimental Social Psychology
• Motivational Stages of Change
• Humanistic Psychology

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BACKGROUNDExperimental Social Psychology

• Causal Attributions
• Cognitive Dissonance
• Psychological Reactance
• Self-Efficacy

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BACKGROUNDMotivational Stages of Changes

• Precontemplation
• Contemplation
• Determination/Preparation
• Action
• Maintenance
• Prochaska DiClemente (1984)

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BACKGROUNDHumanistic Psychology

• Individual, not Label
• Empathy, not Direction
• Client-centered, not Therapist-Driven
• Acceptance, not Confrontation

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MOTIVATIONAL INTERVIEWINGPrinciples

• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Support self-efficacy
• Miller Rollnick (1991)

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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
• Miller Rollnick (2002)

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MODEL DEVELOPMENT TESTINGStages of Research

• Stage I (Development)
• -1960s Supportive referral encouragement
  (Chafetz)
• -1970s Simple advice and referral (Edwards)
• Stage II (Efficacy)
• -1980s Motivational Interviewing (Miller
  Rollnick)
• Drinkers Check-up (Miller
  Sovereign)
• Stage III (Effectiveness/Multisite)
• -1990s Motivational Enhancement Therapy (MATCH
  Miller et al)
• -2000s WHO, Marijuana Treatment, Clinical Trials
  Network

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EFFICACY EFFECTIVENESS Subpopulations

• Heavy or Problem Drinkers
• Alcohol Abuse or Dependence Patients
• Heroin, Cocaine, Methamphetamine, Marijuana, and
  Polydrug Patients
• Dually Diagnosed Patients
• Other Health Risk Behavior Groups

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MI TRAINING RESEARCHCurrent Projects

• Motivational Interviewing Network of Trainers
  (MINT)
• University of New Mexico Center on Alcoholism,
  Substance Abuse and Addictions (CASAA)
• NIDA Behavioral Therapy Training Projects
• NIDA Clinical Trials Network Protocols
• Therapy Training Integrity Procedures

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MI TRAINING RESEARCHCurrent State of Knowledge

• Two-day training results in increased knowledge
  of MI and satisfaction with training procedures
• Training improves MI skills better than it
  suppresses non-MI skills
• MI skills learned are lost over time unless
  intensive and/or ongoing supervision provided
• (Baer et al, 2003
  Miller Mount, 2001 Rubel et al, 2000)

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Motivation Interviewing (MI) and Enhancement
Therapy (MET)Clinical Trials Network

• Motivational Interviewing (one session)
• Motivational Enhancement (three sessions)
• MET for Pregnant Women (ongoing)
• MET for Spanish Speaking Clients (ongoing)
• MET for African American Clients (proposed)

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MET/MI CTN STUDY DESIGN

• Multisite randomized clinical trial in 11
  community-based drug treatment programs
• Clinician characteristics and skill acquisition
  assessed
• Treatment fidelity and discriminability monitored
• Training plan designed to facilitate sustained
  changes in practice and dissemination
• Participants assigned to Motivational
  Intervention vs. Standard Care evaluation/counseli
  ng followed by regular outpatient treatment

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Did clients assigned to MI complete more sessions
than those in standard assessment?
YES
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Did MI retain more participants in treatment at
the 1-month point?
YES
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Abstinence Rates at 1 Month by Site
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MET for Spanish Speaking ClientsNIDA Clinical
Trials Networks

• Jose Szapocznik, Ph.D., Lead Investigator
• Lourdes Suarez, Ph.D., Study Coordinator
• University of Miami
• Kathleen Carroll, Ph.D., Lead Investigator
• Julie Matthews, Study Coordinator
• Samuel Ball, Ph.D., Training Director
• Yale University

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MET for Spanish Speaking ClientsStudy Rationale

• Little known about outpatient drug abuse
  treatment outcomes for Hispanic/Latino
  populations
• Spanish speaking clients typically excluded from
  clinical research studies and underserved in most
  programs
• Perceived need for treatment, motivation to
  change, use of denial, and drop out appear to be
  especially problematic in Hispanic/Latino groups
  (Longshore et al 1992, 1993, 1997)
• MET/MI most widely studied and disseminated, but
  very limited attention to Spanish speaking
  populations despite its relevance and promise for
  this group

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MET for Spanish Speaking ClientsKey Design
Implementation Features

• Treatments conducted in Spanish
• Independent determination of counselor
  bilingualism
• MET manual and handouts translated
• Bilingual national expert trainers and
  supervisors
• Translation of standard research assessments and
  inclusion of Bicultural Involvement Questionnaire

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CONCLUSIONSKey Effectiveness Research Questions

• Efficacy in Subpopulations (ethnicity, gender,
  treatment circumstances, psychopathology, drugs)
• Clinician Attributes (for learning and fidelity)
• Optimal Training and Disssemination Strategies
  (to ensure sustained changes in practice)
• Mechanisms of Action (change talk, motivational
  stages, empathy)