motivational interviewing: participant characteristics and early retention in community clinics...
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Motivational Interviewing:Motivational Interviewing:Participant Characteristics and Early Participant Characteristics and Early
Retention in Community ClinicsRetention in Community Clinics
Samuel A. Ball Kathleen M. CarrollTraining Director Principal Investigator
Yale University School of Medicine
CTN New England Node
“BRIDGING THE GAP” IN THE CLINICAL TRIALS NETWORK (CTN)
• First CTN psychotherapy protocol to involve front line addiction counselors
• Goal of effecting and sustaining changes in clinical practice
• First examination of ‘treatment-as-usual’• Local variation to enhance buy-in • Treatment Providers as true partners with
Researchers in bidirectional process• First randomized clinical trial for all but two of
the 11 sites
COMMUNITY TREATMENT COMMUNITY TREATMENT PROGRAMS PROGRAMS (CTPs)(CTPs)
NEW ENGLANDConnecticut Renaissance
Liberation Meridian Guenster
PACIFIC REGIONHaight Ashbury Free Clinic
Tarzana Treatment Center
NEW YORKLower East Side Service Center
OREGON NODEChangePoint
Willamette Family Treatment Services
ADAPT
DELAWARE VALLEY
Northeast Treatment Center Rehab After Work
MID-ATLANTIC NODE Chesterfield County CSB
PROTOCOL DESIGN TEAMPROTOCOL DESIGN TEAMDelaware Valley: George Woody
Paul Crits-ChristophThomas McLellan
New England: Kathleen CarrollSamuel Ball
New York: Jon MorgensternPacific Region: Jeanne Obert
Douglas PolcinOregon: Chris FarentinosNIDA Ivan Montoya
Lisa Onken
TREATMENT – RESEARCH TREATMENT – RESEARCH PARTNERSHIPPARTNERSHIP
• Protocol Development– Local and national survey
– Development of two protocols
• Manual Development• Definition of Standard Care for Ratings• Therapist Training
– Local Experts attend national training
– Local Supervisor to enhance sustainability
• Protocol Implementation
STUDY RATIONALESTUDY RATIONALE
Attrition is a major issue in
substance abuse treatment
The bulk of attrition occurs very early in treatment
Retention linked to better outcome in several studies
STUDY RATIONALESTUDY RATIONALE
• Brief, motivational approaches have strong empirical support among alcohol & cigarette using populations
• Effects are clinically significant and durable
• More data needed on effectiveness in more heterogeneous population of substance abusers and “real world” settings
MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWINGPrinciplesPrinciples
• Express empathy
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Support self-efficacy
MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWINGTechniquesTechniques
• Open-ended questions • Affirmation• Reflective listening• Summary Statements
• Personal feedback• Decision balance• Eliciting self-motivational statement• Develop alternatives and options
STUDY PRIMARY AIMSSTUDY PRIMARY AIMS
• To evaluate the efficacy of MI-style assessment, relative to Standard Care assessment in “real world” community treatment programs
• To evaluate the durability of MI effects and practice relative to standard care through a 3-month follow-up
STUDY DESIGNSTUDY DESIGN
• Multisite randomized clinical trial in five community-based drug treatment programs (CTPs)
• Single (2-hour) clinical evaluation session comparing Motivational Interviewing (MI) with Standard Care (SC)
• Clinician characteristics and skill acquisition assessed• Treatment fidelity and discriminability monitored• Training plan designed to facilitate sustained changes in
practice and dissemination
LEVELS OF TRAININGLEVELS OF TRAINING
• MET/MI Expert Trainer
• MET/MI Supervisor
• MET/MI Therapist
EXPERT TRAINEREXPERT TRAINER
• Study site representative(s) who is research investigator/collaborator or trainer
• Attended two-day “train-the-trainer” meeting in Albuquerque (Drs. Miller and Moyers)
• Provided training to supervisors and therapists within each clinic performance site
• Reviewed session audiotapes for supervisory feedback and therapist credentialing
• Provided face-to-face or phone supervisory meeting with each MI supervisor monthly
SUPERVISORSUPERVISOR
• Preferably clinical or assistant director and higher in clinic hierarchy than the therapists
• Attended two-day therapist/supervisor training provided by the MI expert trainer
• Reviewed therapist audiotapes for supervision purposes and consultation with Expert Trainer
• Meet weekly with therapists (indiv. or group)
THERAPISTTHERAPIST• No formal MI training in past 3 months or
experience providing manualized MI in prior clinical trial
• Assessed, randomized to MI or Standard Care, trained, audiotaped and supervised to follow treatment manual
• Completed brief research assessments and pre- and post-protocol tapes
• Certified by MI expert and supervised by MI supervisor
ADHERENCE & COMPETENCE ADHERENCE & COMPETENCE MONITORING SYSTEMMONITORING SYSTEM
• Guided supervision/training process between expert-trainer and supervisor and supervisor and therapist
• Adaptation of the Yale Adherence & Competence Scale (Carroll et al., 2000) used in several prior clinical trial studies
ADHERENCE & COMPETENCE ITEMSADHERENCE & COMPETENCE ITEMS
39 items rated on two 7-point Likert dimensions(frequency/extensiveness and skill level)
MI-Consistent sample items:
•Open-ended Qs
•Reflections
•Affirmations
•Pros/Cons
• Discrepancies
•MI Style
MI-Inconsistent sample items:
•Confrontation
•Skills Training
•Asserting Authority
•Psychodynamic
•Invoking Spirituality
•Total Abstinence
Standard Care sample items:
•Psychosocial Assess
•Program Orientation
•Case Management
•SA Psychoeducation
•Assessing Sub. Use
•Treatment Planning
STUDY PARTICIPANTSSTUDY PARTICIPANTSCounselorsCounselors (n=32)
• Predominantly Caucasian (81%), female (66%), with average age of 42.2
• Experienced group of clinicians with mean of 7.3 years of counseling experience and mean of 4.1 years working for current agency
• 56% of sample had masters degrees • 66% certified in drug and alcohol counseling or licensed
(social work; marriage and family therapy; counseling) • 56% of sample self-identified as being in recovery
STUDY PARTICIPANTSSTUDY PARTICIPANTSCounselor Counselor Orientation and Techniques
• Range of common theoretical orientations used for addiction counseling with most frequent being Relapse Prevention/Cognitive-Behavioral (75%) and least frequent being Gestalt/Experiential (9%)
• When describing their treatment of a typical client seen
prior to training, clinicians scored themselves highest on use of motivational interviewing items
• Relatively few clinicians reported reliance on one
dominant theoretical orientation for counseling
STUDY PARTICIPANTSSTUDY PARTICIPANTSPatients (Patients (nn=423)=423)
• Adults seeking outpatient treatment for any type of substance abuse
• Not seeking or requiring methadone maintenance, detoxification only, or inpatient treatment
• Sufficiently medically and psychiatrically stable
• Randomly assigned to MI (n=209) versus Standard Care session (n=214)
STUDY PARTICIPANTSSTUDY PARTICIPANTSPatient CharacteristicsPatient Characteristics
Gender 57% Male
43% Female
Ethnicity 72% Caucasian
9% African American
4% Hispanic/Latin American
14% Multi-racial
Marital 20% Married/cohabitating
33% Separated/Divorced/Widowed
47% Single
Age 32.9 Years
Education 12. 2 Years
STUDY PARTICIPANTSSTUDY PARTICIPANTSPatient CharacteristicsPatient Characteristics
Employment 63% Unemployed
Legal 24% Criminal Justice Referred/Mandated 36% No Legal Problems
Primary Substance 48% Alcohol
21% Marijuana
19% Methamphetamine
6% Cocaine
5% Opiates
1% Benzodiazepine
Past 28 Days
Primary Use 9.7 Days
PRIMARY HYPOTHESESPRIMARY HYPOTHESES
During first 28 days of treatment and at a 3-month follow-up, MI > Standard Care session:
1) Retaining patients (proportion still enrolled in treatment at CTP)
2) Decreasing substance use (days of use of primary substance)
PRELIMINARY ANALYSESPRELIMINARY ANALYSESEffects on RetentionEffects on Retention
• Patients assigned to MI subsequently completed more counseling sessions (mean=5.02, sd=5.15) than Standard Care patients (mean=4.03, sd=4.21) during 28 days after randomization (p<.05)
• MI patients more likely (84%) to still be enrolled at the program after one month than Standard Care patients (75%) (p<.04)
FUTURE ANALYSESFUTURE ANALYSESOutcomesOutcomes
Primary– Retention in the clinic (attendance)
– Days of substance use (SUC, urines, breath)
Secondary– Motivation (URICA)– Psychosocial functioning (ASI)– HIV risk behaviors (HRBS)– Treatment utilization (TSR)– Participant satisfaction
FUTURE ANALYSESFUTURE ANALYSESMatching and ProcessMatching and Process
• Evaluate types of participants who respond best to motivational approaches
• Evaluate the ability of unselected clinicians to implement motivational approaches effectively
• Evaluate the discriminability of motivational approaches from standard care