‘Connection’ in the First Interview

Gilles Fleury MDUniversity of Montreal Health Center

May 5th 2005

Objectives

To formulate an understanding of Motivational Interviewing in order to increase treatment adherence

To discuss the concept of motivation as a self-regulatory function

To present a possible research project in Addiction Psychiatry

Introduction

Non-compliance and Treatment Resistance in general practice the ‘difficult’ patient

Treatment outcome and drop-out rate in substance abuse

Integration of Psychotherapy and Pharmacology to improve outcomes (Carroll, 1997)

A pill to increase men’s commitment?

Genetically modified moles become « commited to the female and like it »

The concept of Therapeutic Alliance

A « Working Relationship »: Goals Tasks Bond

- Bordin (1976, 1980)

Therapeutic Alliance

« Helping relationship »

- Petry NM, Bickel WK (1999)

How to improve the alliance?

Support patient’s wish to achieve his/her goals

Offer understanding and acceptance of patient

Develop a liking for the patient Convey a realistically hopeful attitude that the

treatment goals are likely to be achieved Recognize when appropriate that the patient

has made progress toward the goals - Luborsky (1984, 1993)

Motivational Interviewing (MI)

4 Principles: 1) Express Empathy

2) Develop Discrepancy 

3) Roll with Resistances

4) Support Self-Efficacy - Miller WR, Rollnick S (2002)

Strategies in the first session: Open Questions Reflective Listening Affirm Summarize

Motivational Interviewing

Mentalization:« My mother thinks of me as thinking, therefore I exist »

- Peter Fonagy

Motivational Interviewing

Use of Evocation Constructive behavior change seems to arise

when the person connects it with something of intrinsic value, something important, something cherished.

- Miller WR, Rollnick S (2002)

Motivation as Interpersonal Process Helps to resolve ambivalence

Summary

Usefulness of psychotherapeutic strategies to increase adherence

Specific ways to ‘connect’ with patient to promote reflection on new motivated behaviors

Neurobiology of Motivation

Definition: … brain activity that processes « input »

information about the internal state of the individual and external environment and determines behavioral « output ».

- Dorman and Gaudiano (1998)

Effective Self-Regulation: Higher-order processing designed to

organize behavior to maximize survival

CNS organization

Limbic SystemBrain stem

Thalamocortical system

AppetiteSex

Defense

CategorizationSophisticated

response

« value-category »Memory(salience)

- Gerald Edelman

EffectiveConnectivity

« Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period

of Addiction Vulnerability »- Chambers RA et al. (2003)

Impulsivity and Suboptimal Decision making: Normative traits of the developing brain May reflect the relative imbalance

between: Dopamine promotivational system 5-HT inhibitory system

Prefrontal cortex abnormalities associated with increased risk of developing Substance Use Disorder

Self-Regulation deficit ? vs Disconnectivity?

« Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period

of Addiction Vulnerability »- Chambers RA et al. (2003)

Research Project

A prospective study Population: ETOH or Cocaine

Dependence Goal:

Study the effect of the first session of Motivational Interviewing On Treatment Adherence On brain function (qEEG)

Research Project

Possible predictors of Treatment Adherence: Therapeutic Alliance ‘Brain dysfunction’ (disconnectivity?)

Hypothesis: Effective MI helps the patient switch to a

better self-regulatory state, with higher motivation and eventually higher adherence to treatment

Research Project

Method: Treatment group:

qEEG + MI + qEEG Control group:

Treatment as usual (no MI) and 2 qEEG

Main measures: qEEG patterns before and after MI Treatment adherence

« Prediction of treatment outcome in cocaine dependent males using quantitative EEG »

- Prichep et al. (1999)

N = 35 male subjects 20 min resting EEG, eyes closed

5 – 14 days after last cocaine use Length Of Stay in Treatment (LOST)

Do possible homogeneous EEG subtypes predict LOST?

Cluster 1: Increased relative beta activity

87,5% remained in Tx ≤ 21 weeks Cluster 2:

Siginificant excess of power in the alpha f 84,2% remained in Tx ≥ 21 weeks

« Prediction of treatment outcome in cocaine dependent males using quantitative EEG »

- Prichep et al. (1999)

Conclusion

References

Alper M. et al., « Electroencephalographic Analysis: A Methodology for Evaluating Psychotherapeutic Process », Psychiatry Research, 2, 323-329 (1980).

Carroll, K., « Integrating Psychotherapy and Pharmacotherapy to Improve Drug Abuse Outcomes », Addictive Behaviors, vol. 22, no 2, 233-245, 1997.

Chambers A et al., « Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period of Addiction Vulnerability », Am J Psychiatry 2003; 160: 1041-1052.

Hoffman DA et al., « Limitations of the American Academy of Neurology and American Clinical Neurophysiology Society Paper on QEEG », J Neuropsychiatry Clin Neurosci 11:3, Summer 1999.

Hughes JR et al., « Conventional and Quantitative EEG in Psychiatry », J Neuropsychiatry Clin Neurosci 11: 190-208, May 1999.

Lebeaux, D., « The Role of the Conscious Therapeutic Alliance in Davanloo’s Intensive Short-Term Dynamic Psychotherapy », Int. J. Intens. Short-Term Dynamic Psychoth, 14, 39-48 (2000).

Luborsky, L. and al., « Establishing a Therapeutic Alliance with Substance Abusers », NIDA Research Monograph, 165: 233-244, 1997.

References

Martino, S and al., « Dual Diagnosis Motivational Interviewing: a modification of Motivational Interviewing for substance-abusing patients with psychotic disorders », Journal of Substance Abuse Treatment 23 (2002) 297-308.

Miller, WR, Rollnick, S, Motivational Interviewing : preparing people for change, 2ième Édition, The Guilford Press, New York, 2002.

Petry, NM, Bickel, WK, « Therapeutic Alliance and Psychiatric Severity as Predictors of Completion of Treatment for Opioid Dependence », Psychiatric Services, February 1999, vol. 50, no.2 , 219-227.

Prichep, LS et al., « Prediction of Treatment Outcome in Cocaine Dependant Males Using Quantitative EEG », Drug and Alcohol Dependence 54, 35-43 (1999).

Takahashi, et al., « Changes in the EEG and Autonomic Nervous activity during meditation and their association with personality traits », Int. J. of Psychophysiology 55 (2005), 199-207.

Winterer, G et al., « Quantitative EEG predict relapse in patients with chronic alcoholim and points to a frontally pronounced cerebral disturbance », Psychiatry Research 78 (1998) 101-113.

Woody, GE and al., « Psychotherapy with Opioid-Dependant Patients », Psychiatric Times, Nov. 1998, vol 15, no 11.

Woody, and al., « Psychotherapy in community methadone programs: a validation study », American Journal of Psychiatry, vol 152, no 9, 1302 (1995).

References