MOTIVATIONAL INTERVIEWING Theory, Treatment, Training, and

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					MOTIVATIONAL INTERVIEWING:
Theory, Treatment, Training, and Targeting
           Special 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
    BACKGROUND
   Theory and Research

• Experimental Social Psychology

• Motivational Stages of Change

• Humanistic Psychology
      BACKGROUND
Experimental Social Psychology

     • Causal Attributions

     • Cognitive Dissonance

     • Psychological Reactance

     • Self-Efficacy
       BACKGROUND
Motivational Stages of Changes

   •   Precontemplation
   •   Contemplation
   •   Determination/Preparation
   •   Action
   •   Maintenance

              Prochaska & DiClemente (1984)
    BACKGROUND
  Humanistic Psychology

• Individual, not Label

• Empathy, not Direction

• Client-centered, not Therapist-Driven

• Acceptance, not Confrontation
MOTIVATIONAL INTERVIEWING
              Principles

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

                  Miller & Rollnick (1991)
MOTIVATIONAL INTERVIEWING
                Techniques
    •   Open-ended questions
    •   Affirmation
    •   Reflective listening
    •   Summary Statements

    •   Personal feedback
    •   Decision balance
    •   Eliciting self-motivational statement
    •   Develop alternatives and options
                              Miller & Rollnick (2002)
MODEL DEVELOPMENT & TESTING
                   Stages of Research
                  Stage I (Development)
-1960’s Supportive referral encouragement (Chafetz)
-1970’s Simple advice and referral (Edwards)
                  Stage II (Efficacy)
-1980’s Motivational Interviewing (Miller & Rollnick)
        Drinker’s Check-up (Miller & Sovereign)
                  Stage III (Effectiveness/Multisite)
-1990’s Motivational Enhancement Therapy (MATCH; Miller et al)
-2000’s WHO, Marijuana Treatment, Clinical Trials Network
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
        MI TRAINING RESEARCH
                   Current 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
    MI TRAINING RESEARCH
      Current 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)
 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)
  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/counseling followed by
  regular outpatient treatment
 Did clients assigned to MI complete more
sessions than those in standard assessment?
 Number of
sessions/ 28 6
   days
                    5.02                YES
             5
                                 4.03
            4

            3
                                         MI
            2
                                         Standard

            1

            0
                 Treatment condition
         Did MI retain more participants in
          treatment at the 1-month point?
100.00
                    84                       YES
                                        74




                                                   MI
                                                   Standard




  0.00
                  Treatment condition
    Abstinence Rates at 1 Month by Site
% abstinent/ 100
  primary
              90
substance
              80

              70

              60

              50
                                    MI
              40                    Standard
              30

              20
                   1   2   3   4
MET for Spanish Speaking Clients
     NIDA 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
 MET for Spanish Speaking Clients
                    Study 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
MET for Spanish Speaking Clients
    Key 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
                 CONCLUSIONS
  Key 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)