1 motivation and treatment interventions niaaa social work education module 6 (revised 3/04)

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Motivation and Motivation and Treatment InterventionsTreatment Interventions

NIAAA Social Work Education

Module 6(revised 3/04)

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OutlineOutline

Treatment Adherence Treatment Adherence Motivational InterviewingMotivational Interviewing Brief InterventionsBrief Interventions Motivational Enhancement Therapy (MET)Motivational Enhancement Therapy (MET) Cognitive Behavioral Therapy (CBT)Cognitive Behavioral Therapy (CBT) Relationship Enhancement Therapy (RET)Relationship Enhancement Therapy (RET) Limitations, MatchingLimitations, Matching Pharmacological Interventions Pharmacological Interventions Future and IssuesFuture and Issues

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Treatment AdherenceTreatment Adherence

Client beliefs and perceptions about the Client beliefs and perceptions about the problemproblemPerceptions about treatment Perceptions about treatment Ambivalence about changeAmbivalence about changeExpectanciesExpectancies about treatment outcomesabout treatment outcomes

Moving from assessment to Moving from assessment to treatment requires addressing the treatment requires addressing the sources of adherence problemssources of adherence problems

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Treatment Adherence Treatment Adherence (continued)(continued)

Individuals who do not believe that they have problems that need changing,

and are placed in a treatment that they do not believe will help,

are susceptible to adherence problems

• Level of self-efficacy• Barriers• Previous negative

treatment experiences

• Practitioner outcome expectancies

• Stigma

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Treatment Adherence Treatment Adherence (continued)(continued)

Client blaming and Client blaming and negative labeling negative labeling impede adherenceimpede adherence

Shift to interactional Shift to interactional perspectiveperspective

Root treatment Root treatment approaches in approaches in readiness to readiness to change/motivation change/motivation processes (e.g. MI)processes (e.g. MI)

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Motivational Interviewing Motivational Interviewing (MI)(MI)

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Motivational Interviewing Motivational Interviewing (continued)(continued)

Motivational Interviewing Motivational Interviewing (MI) ensures participation (MI) ensures participation in treatment by:in treatment by:Modifying unrealistic Modifying unrealistic treatment expectationstreatment expectations

Resolving client ambivalenceResolving client ambivalenceEnhancing client self-efficacyEnhancing client self-efficacy

©2002 Microsoft Corporation.

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Motivational Interviewing Motivational Interviewing (MI)(MI)

MI is a critical MI is a critical element in element in facilitating facilitating treatment treatment adherence and adherence and positive outcomespositive outcomes

MI is a style, not a MI is a style, not a specific techniquespecific technique

MI can be a stand MI can be a stand alone approach or alone approach or an add-on to other an add-on to other forms of treatmentforms of treatment


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Interviewing style Interviewing style elements:elements: Ask open-ended Ask open-ended

questionsquestions Conduct empathetic Conduct empathetic

assessmentsassessments Discover client’s Discover client’s

beliefsbeliefs Reflective listeningReflective listening ©2002 Microsoft Corporation.

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Motivating strategies:Motivating strategies: Normalize client Normalize client

doubtsdoubts Amplify client doubtsAmplify client doubts Deploy discrepancyDeploy discrepancy Support self-efficacySupport self-efficacy Review past treatment Review past treatment

experiencesexperiences



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Motivating strategies (continued):Motivating strategies (continued): Provide relevant feedbackProvide relevant feedback Summarize sources of non-Summarize sources of non-

adherenceadherence Negotiate proximal goalsNegotiate proximal goals Discover potential barriersDiscover potential barriers Display optimismDisplay optimism Involve supportive significant Involve supportive significant

othersothers



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Treatment is negotiatedTreatment is negotiated Incorporates:Incorporates:

– Client perceptions of Client perceptions of needsneeds

– Client preferencesClient preferences– Client outcome Client outcome

expectanciesexpectancies Requires: Requires:

– AssessmentAssessment– Assessment feedbackAssessment feedback



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Present menu of optionsPresent menu of options Client choice based on Client choice based on

need and capacitiesneed and capacities Possibly employ Possibly employ

incremental approachincremental approach Make long-term goals Make long-term goals

into “doable” unitsinto “doable” units Discuss “setback” issuesDiscuss “setback” issues



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Brief InterventionsBrief Interventions

Intended for at-risk Intended for at-risk drinkers or those in early drinkers or those in early stagesstages

Applied in a broad array of Applied in a broad array of settings outside traditional settings outside traditional alcohol treatment systems alcohol treatment systems (non-specialized treatment (non-specialized treatment settings)settings)

Effective and cost effectiveEffective and cost effective


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Brief Interventions Brief Interventions (continued)(continued)

Time-limited, structuredTime-limited, structuredSelf-helpSelf-helpPrevention strategyPrevention strategyNegotiated reduction in alcohol Negotiated reduction in alcohol

useuseNot teaching specific skillsNot teaching specific skillsNot changing social environmentNot changing social environment


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Steps:Steps:ScreeningScreening

AssessmentAssessment

Advice givingAdvice giving

Assessing motivation for changeAssessing motivation for change

Establishing drinking goalsEstablishing drinking goals


Conducting follow-upConducting follow-up

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Brief Interventions: Brief Interventions: ScreeningScreening

“On average, how many days a week do you drink?”

“On a day when you drink alcohol, how many drinks do you have?”

“What is the maximum number of drinks you consumed on any given occasion during the past month?”

•Positive screen = Women >7/week or >3/occasion, Men >14/week or >4/occasion

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Brief Interventions: Brief Interventions: AssessmentAssessment

Perform with anyone who drinks Perform with anyone who drinks above established cut-offsabove established cut-offs

Assess potential alcohol-related Assess potential alcohol-related problemsproblems

Assess for symptoms of Assess for symptoms of dependencedependence

Refer to specialist practitioner if Refer to specialist practitioner if evidence of alcohol dependenceevidence of alcohol dependence

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Brief Interventions: Advice Brief Interventions: Advice GivingGiving

Express concerns about Express concerns about the alcohol use patternthe alcohol use pattern

Provide personalized Provide personalized feedback about how feedback about how alcohol affects personalcohol affects person

Advise about need to Advise about need to change the drinking change the drinking behaviorbehavior


20Brief Interventions: Brief Interventions: Assessing Motivation to Assessing Motivation to ChangeChange

1.1. Not interested (precontemplation) Not interested (precontemplation)

2.2. Considering change Considering change (contemplation)(contemplation)

3.3. Ready for action (preparation) Ready for action (preparation)

4.4. Initiating action (action) Initiating action (action)

5.5. Already acting (maintenance) Already acting (maintenance)

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Brief Interventions: Brief Interventions: Establishing Drinking GoalsEstablishing Drinking Goals

Negotiate specific drinking Negotiate specific drinking amountsamounts

Establish specific datesEstablish specific dates Develop a written contractDevelop a written contract Offer resources, materials, Offer resources, materials,

information, workbook, information, workbook, exercises, drinking diaryexercises, drinking diary


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Brief Interventions: Brief Interventions: Conducting Follow-upConducting Follow-up

Review drinking goalsReview drinking goalsAssess ongoing problemsAssess ongoing problemsSupport ongoing efforts to Support ongoing efforts to

changechangeAssess new problems that Assess new problems that

might emergemight emerge

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Most trials found a Most trials found a greater reduction in greater reduction in alcohol use among alcohol use among intervention groups intervention groups compared to controlscompared to controls

Methodological Methodological limitations existlimitations exist


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Motivational Enhancement Motivational Enhancement Therapy (MET)Therapy (MET)

Derived from the Derived from the FRAMESFRAMES model model

FFeedbackeedback

RResponsibilityesponsibility

AAdvicedvice

MMenuenu

EEmpathympathy

SSelf-efficacyelf-efficacySource: Miller & Sanchez, 1994Source: Miller & Sanchez, 1994

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MET MET (continued)(continued)

Express empathyExpress empathyDevelop discrepancyDevelop discrepancyAvoid argumentationAvoid argumentationRoll with resistanceRoll with resistanceSupport self-efficacySupport self-efficacyEnsure client choiceEnsure client choiceConvey optimismConvey optimism


Choices

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Phase I:Phase I:– Establish rapportEstablish rapport– Provide personal feedbackProvide personal feedback– Build motivationBuild motivation

Phase II:Phase II:– Strengthen motivationStrengthen motivation– Develop specific change planDevelop specific change plan– CommitmentCommitment– Move to actionMove to action


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MET TSF CBT

Evidence Evidence suggests that suggests that MET is effectiveMET is effective

Evidence Evidence indicates that indicates that MET is cost-MET is cost-efficientefficient

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Client/Treatment MatchingClient/Treatment Matching Matching treatment toMatching treatment to

– Client characteristicsClient characteristics– Readiness to change to Readiness to change to

improve adherenceimprove adherence For clients with high anger For clients with high anger

levels, MET was superior tolevels, MET was superior to – Cognitive Behavioral Cognitive Behavioral

Therapy (CBT)Therapy (CBT)– Twelve-Step Facilitation (TSF)Twelve-Step Facilitation (TSF)


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Cognitive Behavioral Therapy Cognitive Behavioral Therapy (CBT)(CBT)

Skills building (not Skills building (not motivation) interventionsmotivation) interventions

Targets a wide range of Targets a wide range of objectives:objectives:– To improve social skillsTo improve social skills– To reduce psychiatric To reduce psychiatric

symptomssymptoms– To reduce angerTo reduce anger– To increase social supportTo increase social support– To facilitate job findingTo facilitate job finding ©2002 Microsoft Corporation.

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CBT CBT (continued)(continued)

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Effective when delivered Effective when delivered as part of comprehensive as part of comprehensive program, not as a stand-program, not as a stand-alonealone

Most effective at changing Most effective at changing social environment contextsocial environment context

More effective than other More effective than other treatments when added to treatments when added to pharmacotherapypharmacotherapy


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Client/Treatment Matching:Client/Treatment Matching: Aftercare with low alcohol dependence… Aftercare with low alcohol dependence…

Cognitive Behavioral Therapy better than Cognitive Behavioral Therapy better than Twelve-Step FacilitationTwelve-Step Facilitation

More alcohol dependence symptoms… Twelve-More alcohol dependence symptoms… Twelve-Step Facilitation betterStep Facilitation better

Higher degree of psychiatric severity… Higher degree of psychiatric severity… Cognitive Behavioral Therapy better than Cognitive Behavioral Therapy better than interactional therapyinteractional therapy

High drinking support environment… Cognitive High drinking support environment… Cognitive Behavioral Therapy better than Relationship Behavioral Therapy better than Relationship Enhancement TherapyEnhancement Therapy

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Relationship Enhancement Relationship Enhancement Therapy (RET)Therapy (RET)

Promotion and active involvement Promotion and active involvement of supportive significant others of supportive significant others (SSO)(SSO)

SSO may be child, parent, friend, SSO may be child, parent, friend, clergy, self-help group memberclergy, self-help group member

Examples: Examples: – marital or family therapymarital or family therapy– mutual help opportunitiesmutual help opportunities

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RET RET (continued)(continued)

BenefitsBenefits Increase awareness about problemIncrease awareness about problem Enable acceptance of responsibility Enable acceptance of responsibility

for changefor change Buttress motivational readinessButtress motivational readiness Improve interaction patterns that Improve interaction patterns that

promote and reinforce sobrietypromote and reinforce sobriety Reduce interaction patterns that Reduce interaction patterns that

trigger or reward problem drinkingtrigger or reward problem drinking Increase social networkingIncrease social networking


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Common goals include:Common goals include:– Compliance, motivation, Compliance, motivation,

promote sobriety, promote sobriety, emotional ties, abstinence emotional ties, abstinence networks, coping networks, coping capacities, spiritualitycapacities, spirituality

Ideal SSOs:Ideal SSOs:– Support sobriety, support Support sobriety, support

is valued by client, not is valued by client, not experiencing alcohol-experiencing alcohol-related hardshiprelated hardship ©2002 Microsoft Corporation.

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RET is superior to RET is superior to control groups on control groups on several outcome several outcome measures:measures:– DrinkingDrinking– Marital stabilityMarital stability– MotivationMotivation– ComplianceCompliance ©2002 Microsoft Corporation.

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LimitationsLimitations

Research requires Research requires “purity” for comparison; “purity” for comparison; reality requires blending reality requires blending and variability due to the and variability due to the differential needs and differential needs and capacities of capacities of heterogeneous heterogeneous populationspopulations

Need better, more Need better, more comprehensive theory of comprehensive theory of client-treatment matchingclient-treatment matching


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MatchingMatching

Phase Model of MatchingPhase Model of Matching How to deliver treatments How to deliver treatments

over time?over time? Change is a dynamic, Change is a dynamic,

contextualized processcontextualized process Client-treatment matching Client-treatment matching

effects are short-lived effects are short-lived unless therapeutic unless therapeutic ingredients interact with ingredients interact with circumstances, conditionscircumstances, conditions

Use of Decision TreesUse of Decision Trees Link specific modules Link specific modules

to stated preferences to stated preferences and assessed and assessed needs/capacitiesneeds/capacities

Flexible model with Flexible model with real-world applicabilityreal-world applicability

Clinical research tests Clinical research tests the principles the principles underlyingunderlying

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Pharmacological Pharmacological InterventionsInterventions

Important and revolutionary Important and revolutionary advances in pharmacological agents advances in pharmacological agents for treating alcohol problemsfor treating alcohol problemsNaltrexone = opioid antagonist, = opioid antagonist,

dealing with pleasure areas of brain dealing with pleasure areas of brain activityactivity

Acamprosate = glutamate antagonist, = glutamate antagonist, dealing with negative areas of braindealing with negative areas of brain

CombinationsCombinations©2002 Microsoft

Corporation.

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FUTURE: Combining FUTURE: Combining TreatmentsTreatments Pharmacology alone is not an answerPharmacology alone is not an answer As individuals start to feel better As individuals start to feel better

medically they need other social and medically they need other social and psychological treatments to support thempsychological treatments to support them

Extend benefits beyond 3-month drug Extend benefits beyond 3-month drug therapy period with other treatmentstherapy period with other treatments

Medications can enhance efficacy of other Medications can enhance efficacy of other treatments (e.g., Naltrexone + CBT)treatments (e.g., Naltrexone + CBT)

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Combining Treatments Combining Treatments (continued)(continued)

Cravings, urgesCravings, urges

Leisure–time Leisure–time counselingcounseling

Enhance network Enhance network supportsupport

Improve copingImprove coping

Enhance motivationEnhance motivation

PsychosocialPsychosocialMedicationMedicationBenefitsBenefits

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Combing Treatments Combing Treatments (continued)(continued)

Improving attitudesImproving attitudes

Changing beliefsChanging beliefs

Overcoming obstaclesOvercoming obstacles

Facilitate compliance Facilitate compliance (treatment, medication)(treatment, medication)

Priorities settingPriorities setting

Therapeutic allianceTherapeutic alliance

PsychosocialPsychosocialMedicationMedicationBenefitsBenefits

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Non-Treatment?Non-Treatment?

Change may or may Change may or may not require professional not require professional treatment to occurtreatment to occur

Natural history and Natural history and process of change is process of change is consistent either wayconsistent either way

Treatment may support Treatment may support natural change effortsnatural change efforts


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Appendix:Appendix:

Addressing Treatment Addressing Treatment Adherence ProblemsAdherence Problems

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Addressing AdherenceAddressing Adherence

For Problem Acceptance:For Problem Acceptance: Risk from client misperceptions, Risk from client misperceptions,

misunderstandings, uncertainties about misunderstandings, uncertainties about beliefs and/or problem seriousnessbeliefs and/or problem seriousness

Use empathic reflection, awareness Use empathic reflection, awareness building, deploy discrepancies, normalize building, deploy discrepancies, normalize unclarities, use open-ended questions, unclarities, use open-ended questions, elicit “change talk”, amplify doubtselicit “change talk”, amplify doubts

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Addressing Adherence Addressing Adherence (continued)(continued)

For Treatment Acceptance:For Treatment Acceptance: Risk from previous negative treatment Risk from previous negative treatment

experiences, misperceptions about experiences, misperceptions about need, negative therapist or treatment need, negative therapist or treatment outcome expectancies, barriers to care, outcome expectancies, barriers to care, ambivalence about change, low self-ambivalence about change, low self-efficacyefficacy

Use information, support self-efficacy, Use information, support self-efficacy, display optimism, decisional balancing, display optimism, decisional balancing, explore and address barriers, negotiate explore and address barriers, negotiate proximal goals, involve SSOproximal goals, involve SSO

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Phase I: Assess and understand Phase I: Assess and understand why the client may be unable or why the client may be unable or unwilling to participate in unwilling to participate in treatmenttreatment

Phase II: Aim at helping the client Phase II: Aim at helping the client to develop an adherence plan that to develop an adherence plan that is appropriate to his/her capacities, is appropriate to his/her capacities, resources, and treatmentresources, and treatment

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Phase IPhase I Conduct an empathic assessmentConduct an empathic assessment Review chain of events leading to programReview chain of events leading to program Discuss importance of events to changeDiscuss importance of events to change Detect early warning signs of nonadherenceDetect early warning signs of nonadherence Communicate understanding about Communicate understanding about

nonparticipationnonparticipation Help make client aware of, and sort out Help make client aware of, and sort out

reasons for, nonadherencereasons for, nonadherence

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Phase IPhase I (continued)(continued) Review past and current treatment Review past and current treatment

experiences related to nonadherenceexperiences related to nonadherence Ask about and re-discuss goals, Ask about and re-discuss goals,

therapist style factors, outcome therapist style factors, outcome expectanciesexpectancies

Make client sensitive to ongoing Make client sensitive to ongoing pattern of nonadherencepattern of nonadherence

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Phase IIPhase II Log negative feelings about the Log negative feelings about the

treatment processtreatment process Identify and involve significant Identify and involve significant

others for supportothers for support Break down large goals into Break down large goals into

manageable tasksmanageable tasks Present a menu of optionsPresent a menu of options

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Phase IIPhase II (continued)(continued) Review the pros/cons of optionsReview the pros/cons of options Address decisional balanceAddress decisional balance Do not negotiate with doubts or if Do not negotiate with doubts or if

conditions indicate you shouldconditions indicate you should State concerns about nonparticipationState concerns about nonparticipation Obtain agreement before opinionObtain agreement before opinion Summarize and plan for anticipated Summarize and plan for anticipated

sources of nonadherencesources of nonadherence Communicate non-perfection messageCommunicate non-perfection message

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Appendix:Appendix:

Using Reflective StrategiesUsing Reflective Strategies

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ReflectionReflection

Reflection is not a passive process, it is Reflection is not a passive process, it is a highly selective process involving:a highly selective process involving:

Direction (to draw attention)Direction (to draw attention) Reinforcement (to strengthen and build Reinforcement (to strengthen and build

up)up) Exaggeration (to elicit correction from the Exaggeration (to elicit correction from the

client)client) Amplification (to heighten effect)Amplification (to heighten effect) Increase awareness (linking pieces of Increase awareness (linking pieces of

information)information)

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ReflectionReflection

Multiple levels of reflection exist:Multiple levels of reflection exist: Simple reflectionSimple reflection Amplified reflectionAmplified reflection Double-sided reflectionDouble-sided reflection Reflection of expressed or inferred Reflection of expressed or inferred

feelings or affectfeelings or affect Reflection of meaningReflection of meaning

1 motivation and treatment interventions niaaa social work education module 6 (revised 3/04)

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treatment ambivalence

treatment outcomes

forms of treatment

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client doubts

client ambivalence

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adherence shift