Motivational Interviewing: Participant Characteristics and Early Retention in Community Clinics Samuel A. Ball Kathleen M. Carroll Training 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 PROGRAMS (CTPs) NEW ENGLAND Connecticut Renaissance Liberation Meridian Guenster PACIFIC REGION Haight Ashbury Free Clinic Tarzana Treatment Center NEW YORK Lower East Side Service Center OREGON NODE ChangePoint Willamette Family Treatment Services ADAPT DELAWARE VALLEY Northeast Treatment Center Rehab After Work MID-ATLANTIC NODE Chesterfield County CSB

PROTOCOL DESIGN TEAM Delaware Valley: George Woody Paul Crits-Christoph Thomas McLellan New England:Kathleen Carroll Samuel Ball New York:Jon Morgenstern Pacific Region:Jeanne Obert Douglas Polcin Oregon:Chris Farentinos NIDAIvan Montoya Lisa Onken

TREATMENT – RESEARCH PARTNERSHIP 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 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 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 INTERVIEWING Principles Express empathy Develop discrepancy Avoid argumentation Roll with resistance Support self-efficacy

MOTIVATIONAL INTERVIEWING Techniques Open-ended questions Affirmation Reflective listening Summary Statements Personal feedback Decision balance Eliciting self-motivational statement Develop alternatives and options

STUDY 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 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 TRAINING MET/MI Expert Trainer MET/MI Supervisor MET/MI Therapist

EXPERT 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

SUPERVISOR 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)

THERAPIST 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 MONITORING 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 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 PARTICIPANTS Counselors STUDY PARTICIPANTS Counselors (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 PARTICIPANTS Counselor STUDY PARTICIPANTS 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 PARTICIPANTS Patients (n=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 PARTICIPANTS Patient 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 Years

STUDY PARTICIPANTS Patient 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 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 ANALYSES Effects 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 ANALYSES Outcomes 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 ANALYSES Matching 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