Addiction and Motivation: What Works?

Rik BesCentre for Motivation and ChangeHilversum, the Netherlandswww.motivationalinterview.nlwww.motivationalinterviewing.org

Addiction and Motivation: What Works?

• Motivational Interviewing; evidence base• Practitioner’s competency• Implementation in organizations

Addiction and Motivation: What Works?

• Motivational Interviewing; evidence base• Practitioner’s competency• Implementation in organizations

MI Outcome Studies by Era

MI and evidence-based research

Meta-analysis

Hettema JM, et al. Annual Review of Clinical Psychology 2005;1:91–111

Hettema JM, et al.J of Cons Clin Psychol 2010;78(6):668–84

Mean combined effect size by problem area(N = 72 RCT’s)

0.14

0.04

0.78

0.14

0.26

0.41

0.72

0.42

0.29

0.44

0.3

0.51

0.29

0.51

0.53

0.71

0 0.2 0.4 0.6 0.8 1

Follow-up

3 Months

HIV riskDrug abuse

Public healthGambling

Treatment adherenceAlcohol

Diet / exerciseSmoking

HIV riskDrug abuse

Public healthGambling

Treatment adherenceAlcohol

Diet / exerciseSmoking

Adoption Curve for InnovationsN

umbe

r of

Ado

ptio

ns

Source: Everett M. Rogers Diffusion of Innovations

Number of MI Publications

050100150200250300350400450500550

83 84 85 86 8788 89 90 9192 93 94 95 96 97 98 99 0 1 2 3 4 5

Years

Num

ber of

Pub

licat

ions

Source: www.motivationalinterviewing.orgPublications double about every three years

Adoption Curve for MIN

umbe

r of

Ado

ptio

ns

If Rogers’ curve holds, approximately 30% of those who will ultimately adopt MI have done so

So, after 30 years of research we have a treatment method that is:

• Evidence-based >90 RCT’s• Relatively brief• Specifiable (but be careful with manuals)• Grounded in testable theory• With specifiable mechanisms of action• Generalizable across problem areas• Complementary to other treatment

methods• Learnable by a broad range of providers• Verifiable – Is it being delivered properly?

Addiction and Motivation: What Works?

• Motivational Interviewing; evidence base• Practitioner’s competency• Implementation in organizations

A continuum of styles

Directing Guiding Following

Informing Asking Reflective Listening

0

10

20

30

40

50

60

70

A working definition:

• Motivational interviewing is a collaborative,• person-centered• structured form of guiding• to elicit and strengthen• intrinsic motivation for change

Eight Stages in Learning MI

1. Getting the spirit of MI2. Using client-centered skills (OARS)3. Recognizing change talk4. Eliciting and reinforcing change talk5. Rolling with resistance6. Developing a change plan7. Consolidating client commitment8. Integrating MI with other intervention methods

Miller, W. R., & Moyers, T. B. (2006). Eight stages in learning motivational interviewing. Journal of Teaching in the Addictions

10 things that MI is . . .

1. A refined form of guiding2. in a conversation focused on change3. that evokes and strengthens personal motivation4. in a person-centered, autonomy-honoring way5. using specific methods in certain ways6. toward a particular change goal7. that is attuned to and guided by client speech8. and is relatively brief9. adaptable across people, cultures and problems10. and is specifiable and learnable

Where MI Clinicians Can Get Stuck

1. Letting go of the expert role (righting reflex)

2. Using complex reflections3. Missing opportunities for MI4. Giving insufficient direction 5. Opposing resistance6. (Not) moving on to focusing and

planning7. (Not) attending to commitment

language8. (Not) letting go of MI

MITI (Motivational Interviewing Treatment Integrity)

• Therapist behavior counts• Global markers– Empathy– Collaboration– Evocation– Autonomy– Direction/focus

Learning MISome findings

• Reading about MI doesn’t affect competency

• 2-3 day workshops will raise awareness and interest; they won’t increase competency enough to score ‘competency’ on MITI

• Advanced workshops help to get ‘un-stuck’

• Continued coaching and observed practice lead – over time – to full competency

Addiction and Motivation: What Works?

• Motivational Interviewing; evidence base• Practitioner’s competency• Implementation in organizations

Examples from MI implementation

• Addiction services in the Netherlands (mid 90’s)

• Various hospitals (2007 ->)• Criminal Justice systems (Netherlands,

Sweden, UK) (2000 ->)• Health Care standards (f.i. diabetes care,

smoking cessation)

Implementation challenges

• MI is not ‘easy’ to do for a practitioner, neither for the organisation to implement

• Need for longer term planning• Sustainability of competency:• Professional peer support• Intervision/supervision/coaching• Life-long-learning

• More than what happens between patient and therapist

Some helpful resources

• Monitoring and research• Tailor-made:• Teaching tools• Peer-support solutions

• E-Learing and blended learning• Webinars• Online coaching

Addiction and Motivation: What Works?

Rik BesCentre for Motivation and ChangeHilversum, the Netherlandswww.motivationalinterview.nlwww.motivationalinterviewing.org