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

1. MOTIVATIONAL INTERVIEWING:Theory, 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

2. BACKGROUNDTheory and Research • Experimental Social Psychology • Motivational Stages of Change • Humanistic Psychology

3. BACKGROUNDExperimental Social Psychology • Causal Attributions • Cognitive Dissonance • Psychological Reactance • Self-Efficacy

4. BACKGROUNDMotivational Stages of Changes • Precontemplation • Contemplation • Determination/Preparation • Action • Maintenance Prochaska & DiClemente (1984)

5. BACKGROUNDHumanistic Psychology • Individual, not Label • Empathy, not Direction • Client-centered, not Therapist-Driven • Acceptance, not Confrontation

6. MOTIVATIONAL INTERVIEWINGPrinciples • Express empathy • Develop discrepancy • Avoid argumentation • Roll with resistance • Support self-efficacy Miller & Rollnick (1991)

7. 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)

8. MODEL DEVELOPMENT & TESTINGStages 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

9. 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

10. 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

11. 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)

12. 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)

13. 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

14. Did clients assigned to MI complete more sessions than those in standard assessment? YES

15. Did MI retain more participants in treatment at the 1-month point? YES

16. Abstinence Rates at 1 Month by Site

17. 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

18. 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

19. 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

20. 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)