institut für suchtforschung i.gr. an der fachhochschule frankfurt a.m. 60318 frankfurt a.m.tel.:(0...

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


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.


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


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


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


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


Stages of Change

Stage 1 Precontemplation

Stage 2 Contemplation

Stage 3 Preparation

Stage 4 Action

Stage 5 Maintenance

R

E

L

A

P

S

E


Motivational Interviewing, Stages of Change


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


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


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


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


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


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


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


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.




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




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




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




Techniques

Relapse prevention Relapse Relapse prevention package, crisis intervention, reflective listening, open-ended questions, provide information, planning of next step

institut für suchtforschung i.gr. an der fachhochschule frankfurt a.m. 60318 frankfurt a.m.tel.:(0...

Documents

institut fr suchtforschung

motivational interviewing

stages of change slide

motivational factors

style of interaction

kln slide

model of case management

heroin trial case management