Motivational interviewing in community-based research: Experiences from the field

Motivational Interviewing (MI) has been established as an effective psychotherapeutic treatment for problem drinking in clinical settings. Consequently, there is a growing interest in applying MI to facilitate change across other health behaviors, such as tobacco use, eating habits, and physical activity in a variety of community-based research settings. These extended applications pose new challenges regarding implementation and evaluation. For instance, investigators must consider how best to train intervention counselors; implement strategies for preserving the MI spirit, despite limited client contact time; incorporate adjunctive strategies that support brief MI sessions; and develop a plan for monitoring and evaluating MI treatment fidelity. This article highlights specific examples of how several behavior change research projects applied MI across a variety of settings and populations, provides lessons learned from our experience as a collaborative workgroup, and offers strategies for consideration in future community-based research. Funding for this multisite project was provided by RO1 HL62165, 1AR01 45901, 5M01 RR00334, 1 R01 HD37368-01, 1 R01 DE13093-01, 1 R01 MH59594-01 We express our appreciation of the contributions made by the MI workgroup of the BCC, with specific assistance from Judy Salkeld. Special thanks go to Karen Emmons, Diane Elliot, Esther Moe, and Patricia Jordan who offered substantive comments and guidance on earlier drafts of this article.     

Overcoming barriers to disseminating exposure therapies for anxiety disorders: a pilot randomized controlled trial of training methods

The present study evaluated methods for training mental health providers (N = 46) in exposure therapies (ETs) for anxiety disorders. A pilot randomized controlled trial compared: (1) an interactive, multimedia online training (ET OLT), (2) the ET OLT plus a brief Motivational Interviewing-based intervention (ET OLT + MI), and (3) a placebo control OLT. Assessments were completed at baseline, post-training, and one-week following training. Both ET OLT and ET OLT + MI received high satisfaction ratings and were comparably effective at increasing knowledge of ETs as well as clinicians’ overt efforts to learn and use the treatment. ET OLT + MI was the most effective method for improving clinicians’ attitudes toward ETs. Results indicate that OLT is effective for disseminating knowledge about ETs to clinicians, and suggest that supplementing OLT with a brief MI-based intervention may be a promising direction to address potential attitudinal barriers to adopting these highly efficacious treatments.     

Motivational Interviewing to prevent dropout from an education and employment program for young adults: A randomized controlled trial

This study tested the efficacy of Motivational Interviewing for improving retention at a “second chance” program in the United States for unemployed young adults who had not graduated high school (ages 18–24; 60% male). We investigated how Motivational Interviewing effects might be mediated by change talk (i.e., arguments for change) and moderated by preference for consistency (PFC). Participants (N = 100) were randomly assigned to (1) Motivational Interviewing designed to elicit change talk, (2) placebo counseling designed not to elicit change talk, or (3) no additional treatment. Motivational Interviewing sessions increased change talk, but did not increase program retention or diploma earning. PFC was a significant moderator of Motivational Interviewing's impact on program retention; Motivational Interviewing was most effective at increasing 8 week retention for high PFC participants, and least effective for low PFC participants. These results suggest that Motivational Interviewing could be a useful tool for improving retention in education and employment programs, but clinicians should be attentive to how participant characteristics might enhance or diminish Motivational Interviewing effects.     

Extended nortriptyline and psychological treatment for cigarette smoking

OBJECTIVE: Accepted treatments for cigarette smoking rarely achieve abstinence rates of >35% at 1 year. Low rates may reflect failure to provide extended and multifocal treatment for this complex and chronic addiction. Using a chronic disease model of smoking, the authors undertook a study to determine the effects of long-term antidepressant and psychological treatment. METHOD: One hundred sixty smokers of > or =10 cigarettes/day were randomly assigned to one of four treatment conditions in a two-by-two (nortriptyline versus placebo by brief versus extended treatment) design. All subjects received 8 weeks of a transdermal nicotine patch, five group counseling sessions, and active or placebo treatment. Interventions for subjects in brief treatment ended at this point. Subjects in extended treatment continued taking drug or placebo to week 52 and received an additional 9 monthly counseling sessions, with checkup telephone calls midway through each session. Subjects were assessed at baseline and weeks 12, 24, 36, and 52. The principal outcome variables were repeated abstinence at each assessment after the first over a 1-year period and a point prevalence of 7 days of abstinence. RESULTS: At week 52, point-prevalence abstinence rates with missing subjects imputed as smokers were 30% for placebo brief treatment, 42% for placebo extended treatment, 18% for active brief treatment, and 50% for active extended treatment. With missing subjects omitted, these rates were 32%, 57%, 21%, and 56%, respectively. CONCLUSIONS: Comprehensive extended treatments that combine drug and psychological interventions can produce consistent abstinence rates that are substantially higher than those in the literature.     

Interventions to improve adherence to antipsychotic medication in patients with schizophrenia–A review of the past decade

ObjectiveNonadherence to antipsychotic medication is highly prevalent in patients with schizophrenia and has a deleterious impact on the course of the illness. This review seeks to determine the interventions that were examined in the past decade to improve adherence rates.MethodThe literature between 2000 and 2009 was searched for randomized controlled trials which compared a psychosocial intervention with another intervention or with treatment as usual in patients with schizophrenia.ResultsFifteen studies were identified, with a large heterogeneity in design, adherence measures and outcome variables. Interventions that offered more sessions during a longer period of time, and especially those with a continuous focus on adherence, seem most likely to be successful, as well as pragmatic interventions that focus on attention and memory problems. The positive effects of adapted forms of Motivational Interviewing found in earlier studies, such as compliance therapy, have not been confirmed.ConclusionNonadherence remains a challenging problem in schizophrenia. The heterogeneity of factors related to nonadherence calls for individually tailored approaches to promote adherence. More evidence is required to determine the effects of specific interventions.     

The Student Check-Up: effects of paraprofessional-delivered Motivational Interviewing on academic outcomes

Paraprofessionals and school volunteers increase the number of youth who receive academic and mental health interventions by providing services that were traditionally reserved for professional staff. However, the promise of these low-cost, high-volume non-professional services is tempered by the lack of experimental evidence documenting their effectiveness. In this study, we trained non-professionals to provide a brief school-based Motivational Interviewing (MI) intervention called the Student Check-Up (SCU) to middle school-students. In contrast with previous studies, we found no significant differences between treatment and control groups in post-treatment academic grades. However, following the SCU, participants randomly assigned to the treatment group rated the importance of in-class participation and academic effort self-efficacy significantly higher than those in the control group. Based on these results, we provide recommendations for improving the effectiveness of paraprofessionals’ use of the SCU and for improving future research methodology in this area.     

Randomized controlled trial of motivational interviewing, cognitive behavior therapy, and family intervention for patients with comorbid schizophrenia and substance use disorders

OBJECTIVE: Comorbidity of substance abuse disorders with schizophrenia is associated with a greater risk for serious illness complications and poorer outcome. Methodologically sound studies investigating treatment approaches for patients with these disorders are rare, although recommendations for integrated and comprehensive treatment programs abound. This study investigates the relative benefit of adding an integrated psychological and psychosocial treatment program to routine psychiatric care for patients with schizophrenia and substance use disorders. METHOD: The authors conducted a randomized, single-blind controlled comparison of routine care with a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family or caregiver intervention. RESULTS: The integrated treatment program resulted in significantly greater improvement in patients' general functioning than routine care alone at the end of treatment and 12 months after the beginning of the study. Other benefits of the program included a reduction in positive symptoms and in symptom exacerbations and an increase in the percent of days of abstinence from drugs or alcohol over the 12-month period from baseline to follow-up. CONCLUSIONS: These findings demonstrate the effectiveness of a program of routine care integrated with motivational interviewing, cognitive behavior therapy, and family intervention over routine psychiatric care alone for patients with comorbid schizophrenia and alcohol or drug abuse or dependence.     

The pharmacologic treatment of the alcohol dependence

The pharmacological intervention can play a crucial role in the reduction of craving and drinking and the maintenance of abstinence. This article reviews pharmacotherapy for alcohol dependence with an emphasis on the naltrexone, dissulfiram and acamprosate. The opioid antagonist naltrexone lowers relapse rate, reduces drinking days and prolongs periods of abstinence. Acamprosate restores the normal activity of glutamate and GABA systems. Disulfiram has been shown to be most effective for patients who believe in its efficacy and remain compliant with the treatment. Ondansetron, has shown promise in the early-onset alcohol dependence but needs more extensive study. Topiramate (up to 300 mg per day) was more efficacious than placebo in the treatment of alcohol dependence.     

Independent effects of tobacco abstinence and bupropion on cognitive function in schizophrenia

OBJECTIVE: The objective of this study was to examine the effects of tobacco abstinence and bupropion treatment on cognitive functioning in adult smokers with schizophrenia in the setting of a randomized, double-blind, placebo-controlled clinical trial of bupropion for smoking cessation. METHOD: Fifty-three adults with schizophrenia (DSM-IV) took part in a trial of bupropion for smoking cessation. Subjects were enrolled in the study from August 1999 to March 2003. Forty-five subjects remained in the trial at week 4; 41 subjects, 19 taking bupropion and 22 taking placebo, completed the baseline and week 4 cognitive assessments and were included in the analysis of adjusted effects of abstinence and bupropion treatment on cognitive function. RESULTS: Controlling for bupropion treatment and baseline performance, 7 days of tobacco abstinence was associated with slowed motor speed (finger tapping) but was not associated with worsening of performance on tests of attention (AX Continuous Performance Test [AX-CPT]), verbal learning and memory (California Verbal Learning Test [CVLT]), working memory (digit span), or executive function/inhibition (Stroop) and was not associated with worsening of any clinical measures. Controlling for abstinence status, bupropion was associated with reduction (improvement) in reaction time variability on the AX-CPT and with reduction in perseverative errors on the CVLT. CONCLUSION: We conclude that 1 week of tobacco abstinence is associated with slowed motor speed but is not associated with detectable worsening in performance on a range of neuropsychological tests or clinical symptoms in the subset of patients who were able to quit smoking. We also conclude that bupropion treatment may be associated with improvement in variability of attention.     

The First Step Series: Art therapy for early substance abuse treatment

The First Step Series (FSS) is a protocol of five art therapy directives designed for the initial stages of substance abuse treatment. These directives target denial to facilitate client identification of ambivalence and eventual acceptance of lifestyle changes necessary for recovery. Motivational Interviewing (MI) [Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people to change (2nd ed.). New York: Guilford Press] informs a conceptualization of denial as normal ambivalence that occurs during any change process. Normalizing ambivalence sets the stage for the related therapeutic tasks of matching the client's attitude toward treatment, promoting trust in the therapeutic relationship, and gently supporting the client's internal desire for change.