institut für suchtforschung i.gr. an der fachhochschule frankfurt a.m. 60318 frankfurt a.m.tel.:(0...
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Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.60318 Frankfurt a.M. Tel.: (0 69) 1533 2819 [email protected] Nibelungenplatz 1 Fax: (0 69) 1533 2809 http://www.fh-frankfurt.de
Case Management and Motivational Interviewing in the
German Heroin Trial
Irmgard Vogt,
Martina Schu, Martin Schmid, Wilfried Görgen, Hans Oliva
Fachhochschule Frankfurt am Main/ FOGS, Köln
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational Interviewing in the Heroin Trial
Case Management and Motivational Interviewing is introduced into the Heroin Trial as one variation of psychosocial support of clients
Case Management emphasises structure and an organisational framework, networking and cooperation with other agencies; Motivational Interviewing embraces motivational factors, style of interaction, collaboration with clients
The two concepts blend well as both of them have a long history in individual counselling and are related to each other
To facilitate comparison of results in a multicenter setting, implementation and documentation are standardised, and coaching of counsellors during trial is part of the standard procedure
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management: Background
CM has a long history in individual counselling
CM is a variation of a “client-centred” approach in a well structured setting, designed specifically for the care of people with complex problems
CM is target-orientated
CM is designed for long term interventions and geared to solutions and sustained support in a continuum of care
Case Managers work "in the field” making use of clients resources as well as organisational networks; in cooperation with clients they plan, organise and coordinate a needs-based, comprehensive and efficient package of care, crossing institutional and professional boundaries.
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management: Techniques
CM is well structured and organised along „stages“ or steps of the helping process
CM asks for networking and cooperation of (welfare) agencies and organisations
CM includes re-assessment and evaluation of the helping process and of its outcome
CM blends well with MI. However, CM underlines structure, MI counselling style and techniques. Mixing both requires a delicate balancing of form and content, structure and style of interaction
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Model of Case Management and Motivational Interviewing
Admission/ First session
Assessment and Analysis of Problems
Care and treatment plan
Working along plan (and networking)
Monitoring and Re-Assessment
Evaluation and termination of counsellingt
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management
CM has been evaluated in the USA, within the framework of a control study of drug addicts with complex problems (cf.: Ball & Ross 1991, Mejta et al. 1997)
Result: CM is more successful than "treatment as usual”
CM has been implemented in Germany as well (cf. Oliva et al. 2002), but not yet in comparative studies
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Motivational Interviewing
MI has developed out of a client-centred counselling approach, integrating elements of motivational psychology and cognitive behaviour therapy
MI is based on the stages-of-change model
MI stresses the style of interaction between counsellor and client. Counselling techniques are tailored to facilitate the exploration of motivational conflicts of client and to support motivation to change
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Stages of Change
Stage 1 Precontemplation
Stage 2 Contemplation
Stage 3 Preparation
Stage 4 Action
Stage 5 Maintenance
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Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Motivational Interviewing, Stages of Change
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Motivational Interviewing: Basic Skills
Unconditional Acceptance - the counsellor accepts the client as a person regardless of his or her values, life-style or actual problems; he is respectful towards the client
Empathy - understanding another person‘s emotions and feelings from that persons frame of reference; the counsellor is warm, caring and interested in the client
Enhancing Self-efficacy in clients - the counsellor fosters hope and optimism in the clients’ capacities to change
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Motivational Interviewing: Techniques
Showing interest in client via reflective listening and open-ended questions
Developing discrepancies between client’s current situation and hi/her hopes for the future
Avoiding to argue, moralise, blame and label
Avoiding interpretations - client’s statements are taken as such and not analysed for hidden meanings
Roll with resistance - instead of confrontation shift perspectives and reframe statements
Supporting self-efficacy - strengthen client‘s belief in change
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Motivational Interviewing
MI was used and analysed in the USA in several efficacy studies, eg. in project MATCH (1998)
In the study, alcohol dependent clients were randomly assigned to 3 groups of intervention methods, one of it was MI. Results were monitored and treatment outcomes evaluated. Result: MI is an effective intervention method
MI is widely used in Germany, especially in counselling persons with alcohol problems (John et al. 1996, Kremer et al. 1999) and in short interventions
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational InterviewingSteps to Standardization
Development of guidelines to Case Management and Motivational Interviewing - Manual for counsellors
Development of questionnaires and fact sheets to facilitate assessment, treatment planning, minutes etc.
Training’s of Case Managers in the trial in methods, techniques and use of questionnaires
Re-training’s of Case Managers 3 and 6 months after start of the trial
Coaching of Case Managers at work place
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational Interviewing Steps to Standardization
Development of questionnaires and fact sheets General information sheet for clients regarding Case Management
and Motivational Interviewing contract to collaboration while in trial Client files and documents Documentation of daily work schedule of Case Managers Questionnaire of Generalised Competence Expectation Final evaluation assessment sheet
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management und Motivational InterviewingSteps to Standardization
Client files and documents Structured assessment forms regarding: patterns of drug use and
abuse, general aspects of health, relationship to family members and friends, education and employment, actual income and debts, problems with the police and the judicial system, self-reported problems
Checklist of regional support system (e.g. counselling organisations and welfare agencies) and establishing a network according to the needs of the client
Forms for treatment plans and for conferences to discuss treatment plans
Re-assessment forms Final evaluation form
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management und Motivational InterviewingSummary
The blending of CM and MI is suitable and offers a wide range of methods and techniques to psychosocial care for substance dependents
The combination of CM and MI is tailored to care for people with longstanding and complex problems including clients with dual diagnosis
Steps to standardise the helping process allow for a control of the number and type of interventions in multicenter settings
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational Interviewing
Content Motivationalstage
Techniques
Admission and first session, explanation of the concept, establishing collaborationand agreement to work together
Precontem-plation
Reflective listening, open-ended questions, explore and support clients needs, provide information of study, regional support system etc.
Assessment, start to network with counselling and other related agencies in the region and with personal resources of client
Contemplation Reflective listening, open-ended questions, evoke and work with discrepancies, affirm, give feedback, summarise.First assessment of clients‘ motivational stage in different areas of interest; mapping of counselling and welfare agencies in the region; if appropriate, introduce diagnostic results (triangulation); visit client at home.
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational Interviewing
Content Motivationalstage
Techniques
Assessment and definition of target problems. Outlining a treatment plan
ContemplationPreparation
Reflective listening, open-ended questions, evoke and work with discrepancies, elicit self-motivational statements, affirm, give feedback, summarise, planning of next step, reframe, explore alternatives and choices, support self-efficacy. If appropriate, organise conference on treatment plan with colleges of related agencies
Working along treatment plan PreparationAction
Reflective listening, open-ended questions, affirm, elicit self-motivational statements, reframe, advocacy, feedback, summarise. Introduce relapse prevention
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational Interviewing
Content Motivationalstage
Techniques
First preliminary evaluation of results.If necessary, Re-Assessment and re-arrangement of treatment plan. Strengthening collaboration with colleges of related agencies, networking with new actors
Contemplation,Praparation,
Action
Reflective listening, open-ended questions, affirm, elicit self-motivational statements, give feedback, reframe, explore alternatives and choices, support self-efficacy, intensify cooperation with other institutions
Working along treatment plan. Process evaluation
ActionMaintenance
Reflective listening, open-ended questions, affirm, elicit self-motivational statements, give feedback, explore alternatives and choices, support self-efficacy, increase level of clients self management
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational Interviewing
Content Motivationalstage
Techniques
Outcome evaluation and termination of counselling
MaintenanceTermination
Reflective listening, open-ended questions, affirm, feedback, summarise, support self-efficacy, increase level of clients self management, prepare to finish counselling
Institut für Suchtforschung i.Gr. an der Fachhochschule Frankfurt a.M.
Case Management and Motivational Interviewing
Content Motivationalstage
Techniques
Relapse prevention Relapse Relapse prevention package, crisis intervention, reflective listening, open-ended questions, provide information, planning of next step