Brief Interventions and Motivational Interviewing
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Brief Interventions and Motivational Interviewing Page 1 of 21 PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All Rights Reserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in Oxford Handbooks Online for personal use (for details see Privacy Policy ). Subscriber: University of New Mexico; date: 16 October 2014 Subject: Psychology, Clinical Psychology Online Publication Date: Oct 2014 DOI: 10.1093/oxfordhb/9780199381708.013.007 Brief Interventions and Motivational Interviewing Jennifer Hettema, Christopher C. Wagner, Karen S. Ingersoll, and Jennifer M. Russo The Oxford Handbook of Substance Use Disorders, Volume 2 (Forthcoming) Edited by Kenneth J. Sher Oxford Handbooks Online Abstract and Keywords This chapter focuses on the use of brief interventions for the treatment of alcohol and other substance use disorders and risky use. The authors provide definitions of brief interventions and a rationale for their use. They review the evidence base for brief interventions across primary care, emergency medical, college, and correctional settings, and include analysis of the impact of brief intervention on drinking and drug use and the relative costs of such services. They also describe several widely used frameworks or organizing structures for brief interventions including FRAMES (provide feedback, emphasize responsibility, give advice, menu of options, express empathy, support self-efficacy), SBIRT (screening, brief intervention, and referral to treatment), and the five As (ask, assess, advise, assist, arrange). Finally, the authors discuss the therapeutic approach of motivational interviewing as an interaction style that can be used within the context of many brief intervention structures. Keywords: brief intervention, brief treatment, motivational interviewing Introduction Brief interventions provide a viable means to prevent the development and progression of substance use problems, treat a range of severities of use, and facilitate referral-making for those for whom more intensive treatment may be appropriate. Alcohol use disorders occur among more than 76 million people internationally (WHO, 2004) and rates of illicit substance use reach similar numbers (UNODC, 2009), indicating that the need for effective, efficient treatment is profound. Alcohol and substance use increase the risk for physical, mental health, and social problems (Rehm, 2003) and brief interventions within opportunistic settings promote significant, long- term reductions in use, associated problems, and cost (Fleming, 2002). Motivational interviewing (MI) is an evidence-based practice that is highly applicable to brief interventions and compatible with many recommended brief intervention approaches. This chapter provides an overview of the rationale, definition, and evidence base of brief interventions within different settings, and describes the MI model and its applicability to brief intervention approaches. Overview of Brief Interventions Definition Many terms are used to describe brief interventions, including “simple advice,” “minimal interventions,” “brief counseling,” or “short-term counseling” (Barry, 1999). The definition of “brief” varies widely across settings and even within the context of empirical research. On the continuum of substance abuse care, brief interventions can fill the gap between primary prevention and intensive or specialized treatment and can be implemented with a variety of settings and populations by specialists and nonspecialists. Although brief interventions are often
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Transcript of Brief Interventions and Motivational Interviewing
Brief Interventions and Motivational Interviewing
Page 1 of 21PRINTED FROM OXFORD HANDBOOKS ONLINE (www.oxfordhandbooks.com). (c) Oxford University Press, 2014. All RightsReserved. Under the terms of the licence agreement, an individual user may print out a PDF of a single chapter of a title in OxfordHandbooks Online for personal use (for details see Privacy Policy).Subscriber: University of New Mexico; date: 16 October 2014
Subject: Psychology,ClinicalPsychologyOnlinePublicationDate: Oct2014
DOI: 10.1093/oxfordhb/9780199381708.013.007
BriefInterventionsandMotivationalInterviewingJenniferHettema,ChristopherC.Wagner,KarenS.Ingersoll,andJenniferM.RussoTheOxfordHandbookofSubstanceUseDisorders,Volume2(Forthcoming)EditedbyKennethJ.Sher
OxfordHandbooksOnline
AbstractandKeywords
Thischapterfocusesontheuseofbriefinterventionsforthetreatmentofalcoholandothersubstanceusedisordersandriskyuse.Theauthorsprovidedefinitionsofbriefinterventionsandarationalefortheiruse.Theyreviewtheevidencebaseforbriefinterventionsacrossprimarycare,emergencymedical,college,andcorrectionalsettings,andincludeanalysisoftheimpactofbriefinterventionondrinkinganddruguseandtherelativecostsofsuchservices.TheyalsodescribeseveralwidelyusedframeworksororganizingstructuresforbriefinterventionsincludingFRAMES(providefeedback,emphasizeresponsibility,giveadvice,menuofoptions,expressempathy,supportself-efficacy),SBIRT(screening,briefintervention,andreferraltotreatment),andthefiveAs(ask,assess,advise,assist,arrange).Finally,theauthorsdiscussthetherapeuticapproachofmotivationalinterviewingasaninteractionstylethatcanbeusedwithinthecontextofmanybriefinterventionstructures.Keywords:briefintervention,brieftreatment,motivationalinterviewing
IntroductionBriefinterventionsprovideaviablemeanstopreventthedevelopmentandprogressionofsubstanceuseproblems,treatarangeofseveritiesofuse,andfacilitatereferral-makingforthoseforwhommoreintensivetreatmentmaybeappropriate.Alcoholusedisordersoccuramongmorethan76millionpeopleinternationally(WHO,2004)andratesofillicitsubstanceusereachsimilarnumbers(UNODC,2009),indicatingthattheneedforeffective,efficienttreatmentisprofound.Alcoholandsubstanceuseincreasetheriskforphysical,mentalhealth,andsocialproblems(Rehm,2003)andbriefinterventionswithinopportunisticsettingspromotesignificant,long-termreductionsinuse,associatedproblems,andcost(Fleming,2002).Motivationalinterviewing(MI)isanevidence-basedpracticethatishighlyapplicabletobriefinterventionsandcompatiblewithmanyrecommendedbriefinterventionapproaches.Thischapterprovidesanoverviewoftherationale,definition,andevidencebaseofbriefinterventionswithindifferentsettings,anddescribestheMImodelanditsapplicabilitytobriefinterventionapproaches.
OverviewofBriefInterventions
DefinitionManytermsareusedtodescribebriefinterventions,including“simpleadvice,”“minimalinterventions,”“briefcounseling,”or“short-termcounseling”(Barry,1999).Thedefinitionof“brief”varieswidelyacrosssettingsandevenwithinthecontextofempiricalresearch.Onthecontinuumofsubstanceabusecare,briefinterventionscanfillthegapbetweenprimarypreventionandintensiveorspecializedtreatmentandcanbeimplementedwithavarietyofsettingsandpopulationsbyspecialistsandnonspecialists.Althoughbriefinterventionsareoften
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associatedwithopportunisticsettingslikeprimarycare,theycanalsobeimplementedinspecialtytreatmentsettingsforalcoholandsubstanceusedisorders.Furthermore,briefinterventionscanbeappliedtothefullrangeofseveritiesofuse,fromriskytodependent,thoughevidenceseemstosuggestthattheymaybemosteffectivewithlessseverepopulations.Targetedbehavioraloutcomesofbriefinterventionsvaryfromtreatmentengagementtodirectreductionofuse.Somehavedifferentiatedbriefinterventionsfrombrieftherapies.Fromthisperspective,briefinterventionsareapproachestohelpclientschangeoneparticularbehaviororaction,suchastreatmentattendance,whilebrieftherapiesaddresslargergoals,suchasmaintainingabstinenceorlonger-termtreatmentadherence(Barry,1999).Briefinterventionsmayalsovaryconsiderablyinthecommunicationstyleandunderlyingmodalityortheorybeingusedtoencouragechange.Inmanyways,briefinterventionscanbeseenasshellsthatcanholdavarietyoftreatmentmodalities.Althoughbriefinterventiontypesvary,manyhaveanemphasisontargetingandincreasingmotivationandrelyontheprinciplesandtechniquesofMI(Libby,2008).Whileformaldefinitionsvarywidely,mostagreethatbriefinterventionsareabodyofpracticesthatsharethecommonelementsofbeingtime-limited,structured,andgoal-oriented.Inaddition,briefinterventionsoftensharecertaincharacteristics,including(a)afocusonreduceddrinkingorharmreductionversusabstinence,(b)deliverybysomeonewhoisnotanaddictionsspecialist,(c)beingdirectedatriskyornondependentversusdependentsubstanceusers,and(d)attentiontotheconstructofmotivation(Moyeretal.,2002).Whilethediversityofbriefinterventionformatsincreasesavailabilityandaccessibility,variabilityindefinitionscreatesamethodologicalchallengetosummarizingtheliterature.
RationaleSeveralfactorsprovidearationaleforcontinuingtodevelop,investigateandimplementbriefinterventionsintheareaofsubstanceuse(Saitz,2005).Forone,whileratesofalcoholandothersubstancemisuseanddiagnosesarehigh,mostindividualsdonotreceivespecialtytreatment.TheNIAAA(2005)estimatesthat16%(40million)ofadultsintheUnitedStatesaredrinkingatriskylevelsand7.5%(19million)meetcriteriaforalcoholabuseordependence.TheseresultsaresimilartothosereportedintheNationalSurveyonDrugUseandHealth(SAMHSA,2010),whichestimatesthatover23millionAmericansmeetcriteriaforasubstanceusedisorder.Despitethesehighrates,theNSDUHreportsthatonly2.3millionAmericanswithanalcoholordrugusediagnosishavereceivedspecialtytreatmentfortheirsubstanceusedisorderinthelastyear.Thislowrateofparticipationinspecialtytreatmentrelatestomanyfactors.Mostimportant,perhaps,isthefactthatmanyindividualsarenotinterestedinreceivingsuchservices.Ofthenearly21millionpeoplewithadiagnosablesubstanceusedisorderwhodidnotreceivespecialtytreatmentin2008,fewerthan5%indicatedaperceivedneedfortreatment(SAMHSA,2010).Individualsreportdisinterestinspecialtytreatmentbecauseofmanyfactors,includingnotbeingreadytostopusing,nothavinghealthcoverageorabilitytopay,possiblenegativeeffectsonworkoremployment,andlackofinformationaboutwheretogofortreatment(SAMHSA,2010).Stigmaalsocontributestodisinterestinspecialtytreatment.Individualsareconcernedthatreceivingsuchtreatmentmightcausetheirneighborsorcommunitytohaveanegativeopinionofthem(Copeland,1997).Muchofthisfearofstigmatizationiswellgrounded,assomeformsoftreatmentsuchasmethadonemaintenancehavebeenlinkedtodiscrimination(Hettemaetal.,2009).Briefinterventionsinnon-specialtysettingsmayprovideaviablealternativeforindividualswhoarenotinterestedinparticipatinginspecialtytreatment.Suchtreatmentsarealsomoreacceptabletoindividuals,particularlythosewithlesssevereuselevelsorconsequences(Moyeretal.,2002).Inadditiontoindividualbarriersthatreduceparticipationinspecialtytreatment,systemicfactorsalsoplayarole.Forone,specialtysubstanceabusetreatmentprogramshavelimitedcapacityandareonlyabletoaccommodateafractionofthoseindividualswithsubstanceusedisorderdiagnoses.Whilethecapacityofoutpatienttreatmentprogramsishardtoestimate,residentialandinpatientsubstanceabuseprogramshavealimitedcapacityofbarely100,000bedsandexceeda90%utilizationrate,leavinglittleroomforadditionalpatients(SAMHSA,2006).Infact,longwaitinglistsarecommonlycitedasabarriertotreatmententryforsubstanceusedisorders(MacMasteretal.,2005).Limitedcapacityalsoappearstoaffectsomegroupsmorethanothers.Forexample,accesstospecialtytreatmentmaybeespeciallyproblematicforthoseindividualslivinginruralareas(Fortney&Booth2001).Professionalsinhealthcareencounteralargenumberofindividualswhoareusingsubstancesinariskymanneror
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whomeetcriteriaforsubstanceusedisorders.Withratesofriskyuseapproaching16%ofthegeneralpopulation(NIAAA,2005),aprimarycarephysicianwithapatientpanelsizeof2000encounters320patientswithpotentiallyharmfulalcoholuseannually.Theserateswouldbeevenhigherwhenincludingindividualswithriskydruguse.Whileopportunistictreatmentwithinmedicalsettingsmaybeaviablealternativetospecialtytreatment,lessthan16%reporteverydiscussingalcoholusewithahealthprofessional(McKnight-Eilyetal.,2014)and,unfortunately,problematicuseoftengoesundetectedinthesesettings.Forexample,primarycarephysiciansmayinterveneinonlyoneof10casesofalcoholdependence(McGlynnetal.,2003)andmaybeevenlesslikelytointervenewithriskyusers.Despitehighratesofalcoholandsubstancemisuseinternationally,andevidencetosupporttheeffectivenessofbriefinterventions,mostprovidersdonotusebriefinterventions.Alcoholandsubstanceusecontributetomanyotherproblemsthatarecommonlyencounteredwithinsettingsinwhichbriefinterventionscanbeadministered,increasingthebenefitsthatcanberealizedbyaddressingthisimportantneed.Forexample,inmedicalsettings,healthproblemssuchaslivercirrhosis,coronaryarterydisease,cancer,injury,suicide,andpsychiatricproblemscanbenegativelyaffectedbyorevencausedbyalcoholandsubstancemisuse.Providinginterventionsindifferenttimelimitedprofessionalsettingstoindividualswhowouldnototherwiseparticipateinspecializedtreatmentcouldhavesignificantpublichealthbenefits.
EvidenceBaseAlthoughtheconceptofbriefinterventionsisincreasinginpopularity,thisapproachisnotanewideainthetreatmentofalcoholandsubstanceusedisorders.Bienetal.(1993)citeanearlysalientexampleofthepromiseofbriefinterventioninastudyfromEdwardsetal.(1983),inwhichasinglesessionof“sympatheticandconstructive”advicewasfoundtobecomparabletoanextensivetreatmentpackageconsistingofAlcoholicsAnonymousfacilitation,medications,andextensivetreatmentthatcouldincludeinpatienttreatmentfornon-responders.Sincethattime,briefinterventionshavebeenthefocusofconsiderableresearchefforts,particularlyintheareaofalcoholuseinhealthcaresettings.Overall,researchsupportstheeffectivenessofbriefinterventions,whichgenerallyoutperformcomparisonconditionsandperformequallyaswellasextendedtreatment.
EvidencefromPrimaryCareSettingsTheWorldHealthOrganizationconductedalargeinternationaltrialintotheeffectivenessofbriefinterventionsinprimarycaresettings(Babor&Grant,1992).Investigatorsrandomlyassignedat-riskdrinkerstoacontrolcondition,a5-minuteadvicecondition,oraconditionthatincludedadviceplus15minutesofcounselingandaself-helpmanual.Bothinterventionconditionsledtosignificantreductionsinalcoholusecomparedwiththecontrolcondition.Severalrecentmeta-analyseshavefoundsimilarresultsregardingbriefinterventionswithinprimarycaresettings.Inameta-analysisof56studies,briefinterventions(fourorfewersessions)producedsignificanteffectsizesforalcoholconsumptionandotherdrinking-relatedoutcomevariablesamongnon–treatment-seekingpopulationsforupto1year(Moyeretal.,2002).Whitlocketal.(2004)foundthatbriefinterventionsinprimarycarereducedalcoholconsumptionanywherefromthreetoninedrinksperweek,oranoverallreductioninconsumptionof13%to34%.Inameta-analysisof22randomizedcontrolledtrialswithmorestringentacceptancecriteria,Kanerandcolleagues(2009)foundareductioninconsumptionbytwotofourdrinksat1-yearfollow-up,withgreatereffectsonmenthanwomen.Alsousingfairlynarrowselectioncriteria,Jonasetal.(2012)foundthatamongbriefinterventionsconductedwithnondependentalcoholmisusers,consumptiondecreasedby2.4to4.8drinksperweek.Briefinterventionsoftenhavebenefitsthatexceedreductioninconsumption.Onerecentmeta-analysisofbriefinterventionsforproblemdrinkingfoundadecreaseintherelativeriskofmortalitybyabouthalfcomparedwithcontrolconditions(Cuijpersetal.,2004).Maciosek(2006)foundthatthepracticeofalcoholscreeningandbriefinterventionwasaseffectiveaswidelyacceptedpreventionpracticessuchascervicalandcolorectalscreeningandinfluenzaimmunizationinreducingclinicallypreventableburden(CPB).CPBestimateshowmuchdisease,injury,anddeathwouldbepreventedifservicesweredeliveredtoalltargetedindividuals.Inanotherreview,Solbergetal.(2008)foundthatscreeningandbriefinterventionforalcoholdisorderswereamongthehighestrankedpreventiveservicesincost-effectiveness,returnoninvestment,andhowmanydollarswouldbesavedfor
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eachdollarspent.Infact,briefinterventionsforalcoholdisordersweremorecost-effectivethancervicalandcolorectalscreening,influenzaimmunization,andevenhypertensionscreeningandtreatment.Overall,briefinterventionsforriskydrinkinginprimarycaremaysave$4incostforevery$1invested(Fleming,2002).Whiletheevidenceinfavorofbriefinterventionsforalcoholuseisstrong,briefinterventionsforsubstanceusewithinprimarycaresettingshaveasmaller,butgrowing,evidencebase.Forexample,Bernsteinetal.(2005)foundthataone-sessionpeer-ledinterventionforcocaineandheroinusersidentifiedbyscreeningduringroutinemedicalcareproducedincreasedabstinenceforbothsubstancesat6-monthfollow-uppoint.Similarresultshavebeenfoundwithregularmarijuanausers(Copelandetal.,2001;Stephensetal.,2000).Anothergeneralfindingisthat,whenitcomestosubstanceabusetreatment,moreisnotnecessarilybetter,andeffectsdiminishovertime.IntheMoyerreview(2002),differencesbetweenbriefinterventionsandmoreextendedtreatmentsintreatmentseekingwerenegligible.Wutzkeetal.(2002)andKaneretal.(2009)similarlyfoundthattheintensityoftheinterventionwasnotrelatedtooutcome.Intheirreview,Bienetal.(1993)alsoconcludedthatextensivetreatmentsdonottendtooutperformbriefinterventions.WhiletheabovestudiessupporttheeffectivenessofBIcomparedwithmoreextensivetreatments,someevidencesuggeststhatlongertreatmentdurationisbeneficialinsomecases,particularlywheninvestigatedusingcommunityornoncontrolledtrials(Hubbardetal.,2003;McKay,2005).Asisthecasewithmanysubstanceuseinterventions,effectsofbriefinterventionstendtodiminishovertime.Anotherbriefinterventionstudyfoundthatparticipantswhoshowedsignificantreductionsinalcoholconsumptionatearlyfollow-uppointsnolongerdifferedfromcomparisonparticipantsonalcoholconsumption,mortality,oralcohol-relateddiagnosesafter10years(Wutzkeetal.,2002).
ClicktoviewlargerFigure1 .Thespectrumofalcoholuse.
Whenthinkingaboutbriefinterventions,itishelpfultohighlightthatthereisaspectrumofseveritywhenitcomestoalcoholandsubstancemisuse.Whilethealcoholorsubstancedependentindividualisperhapsthefirsttocometomind,thisgroupactuallyconstitutesasmallminorityofthepopulationofsubstanceusers.Thereisamuchlargerproportionofindividualswhoaredrinkingatriskylevels(seeFigure1).Briefinterventionwiththeseriskydrinkerscouldperhapsproducesomeofthelargestpayoffsbyreducingpersonalandsocietalcostsofsubstancemisuse.Evidencefrommeta-analysisalsosuggeststhattheeffectsofbriefinterventionmaybestrongerforthosewithriskyuseorlessseverealcoholproblems(Moyer,2002).
EvidencefromEmergencySettingsOfthe115millionvisitstoU.S.emergencydepartments(EDs)andtraumacentersannually(USDHHS,2007),anestimated29%arealcoholrelated(McDonald,2004)andasmanyas50%ofpresentingpatientsaredrinkingatriskylevels(Desy,2010).ThesesettingscreategreatpromiseforSBIRTimplementationbecauseofthehighbaserateofriskydrinkers,thepresenceofapotential“teachablemoment”thatmayresultfromalcohol-relatedinjuriesormedicalcomplications,andthepresenceofhighlyskilledmedicalprofessionalsaspotentialinterventionists.Somestudiessuggestthatbriefinterventionsconductedinemergencysettingshavebeneficialeffects;theyreducereinjuryratesbyasmuchas50%(Gentilelloetal.,1999),preventoneDWIarrestforeveryninebrief
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interventionsadministered(Schermeretal.,2006),andsavefourtimestheircostinsubsequenthealthcareexpenses(Gentilelloetal.,2005).Inresponsetotheseimpressivestatisticsandthecontrastingevidencethatemergencyphysiciansdonotroutinelyofferbriefinterventionstopatientspresentingwithalcohol-relatedinjuries(Lowensteinetal.,1990),in2005theAmericanCollegeofSurgeons(theprimaryorganizationresponsiblefordevelopingtraumacenterrequirements)enactedalandmarkresolutionthatmandatesLevelItraumacentersscreeninjuredpatientsforanalcoholusedisorderandprovidebriefinterventionstothosewhoscreenpositive.Morerecently,theAmericanCollegeofEmergencyPhysicians(ACEP)hasendorsedtheuseofSBIRTinEDsettings(ACEP,2011).Despitetheenthusiasm,someworrythatardencyoverEDSBIRThasoutpacedtheevidence(Saitz,2009).WhilethereisstrongevidencethatSBIRTtargetingriskyalcoholuseiseffectiveinprimarycaresettings(Moyer,2002;Whitlock,2004)evidencespecificallyfromEDsettingsismoremixed(Saitz,2009).Meta-analysesrevealthattherehavebeenseveralnegativetrialsofSBIRTinEDsettings(Nilsen,2008)resultinginquestionableevidenceoftheimpactofSBIRTonconsumption(Havard,2008).Criticspointout(Saitz,2009)thatthemostmethodologicallysoundofavailablecontrolledtrialsdonotfindsignificantbetween-groupdifferencesfavoringSBIRTovercontrol(Daeppenetal.,2007;D’Onofrio,2008).OfthepositivetrialsofSBIRTinEDsettings,manyhavemethodologicallimitationsincludinghighratesoffollow-upattrition(Gentilello,1999),debatableanalytictechniques(Schermeretal.,2006),orlackofacontrolgroup(Vaca,2011).Severalofthesesinglearmstudieshavefoundsignificantdrinkingimprovements,includingasix-sitenationalsinglearmstudythatfound50%reductionsinconsumption(Madras,2009),butitisdifficulttomakecausalinferenceswithoutacontrolgroup.A14-sitenationwideassessmentofreal-worldEDSBIRTimplementationconsidering3-,6-,and12-montheffectsshowedshort-termreductionsofat-riskdrinkingbutinsignificantdifferencesbetweensubjectsandcontrolpatientsat6and12months(Bernstein&Bernstein,2010).AdditionalmethodologicallysoundcontrolledtrialsofSBIRTwithEDpopulationsaredesperatelyneeded.
EvidencefromCollegeSettingsRatesofriskydrinkingandnegativeconsequencesarehighincollegepopulations(Larimeretal.,2004).Collegecampuseshaveseveralopportunisticsettingsinwhichbriefinterventionsforsubstanceabusecanoccur,includingstudenthealthclinics,studentorganizations,andjudicialsystemsthatdealwithalcoholanddrug-relatedpolicyviolations.Overall,effortstoscreenandprovidebriefinterventionwithcollegesampleshaveproducedpositiveresults(Larimeretal.,2004).Forexample,Schaus(2009)foundthatuptoonequarterofcollegestudentsseeninaprimarycareclinicatapublicuniversityweredrinkingatriskylevelsandthatatwosessioninterventionbasedonmotivationalinterviewingsignificantlyreduceddrinkingwithinthispopulation.Althoughtheevidenceisfairlystrongformanycollegebriefinterventions,thereismixedevidenceformandatedcollegesamples.Forexample,Ciminietal.(2009),foundnosignificantpre-postdifferencesindrinkingvariablesamongpublicuniversitystudentsmandatedtoparticipateintreatmentbecauseofaschoolalcoholpolicyviolation.Resultswerepoorforallthreeinterventionstyles,includingsmallmotivationalinterviewingclasses,interactive-educationalgroups,andpeer-facilitatedbriefinterventions.Similarly,Amaroetal.(2009)foundthatcollegestudentsmandatedtoparticipateinabriefinterventionbasedonemployeeassistanceprogrammodelsshowedfewimprovementsinprimarydrinkingoutcomesrelativetocontrolparticipants.However,anotherseriesofstudiesfoundimprovementsindrinkingamongcollegestudentsadjudicatedfordrinkingoffenseswhentheyunderwentbriefmotivationalinterventionsinsmall,interactivegroups(LaBrie,Lamb,Pedersen,&Quinlan,2006;Labrie,Thompson,Huchting,Lac,&Buckley,2007).Anotherfactorimpactingtheeffectivenessofbriefinterventionsamongcollegestudentsisinterventionstyle.Allbriefinterventionstylesdonotappeartohaveequivalenteffects.Forexample,educationalstrategieshavegenerallybeenfoundtobeineffectiveatreducingriskyalcoholuseamongcollegesamples;incontrast,briefmotivationalinterventionstendtohavefavorableresults(Larimer&Cronce;2002).Specifically,motivationalenhancementtherapysessions,combiningassessmentfeedbackandMI,haveshownpromiseamongcollegeindividuals(Baeretal.,2001;Marlattetal.,1998;Murphyetal.,2001)andgroups(LaBrieetal.,2008;LaBrie,Pedersen,Lamb,&Quinlan,2007).Assessmentandfeedbackresultsmayalsobeaparticularlyeffectivecomponentofotherbriefinterventionsfor
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collegestudentsamples,andseveralstudiesindicatethatnormativefeedbackalone,evenwhengivenbymail,maybeaneffectiveinterventionamongthispopulation(Murphyetal.,2004).Butler&Correia(2009)foundthatsuchfeedbackmaybeequallyeffectivewhenadministeredelectronicallyversusfacetoface.Infact,evenassessmentwithoutnormativefeedbackhasbeenfoundtosignificantlyaffectsomeaspectsofriskydrinking(Waltersetal.,2009).
EvidencefromCorrectionalSettingsAlcoholandsubstanceuseareassociatedwithcriminalbehavior,andasignificantproportionofthecriminaljusticepopulationhavehistoriesofalcoholordrugabuse(Lapham,2004).Thisfact,incombinationwiththeregularityandfrequencywithwhichcorrectionsstaffandofficerstypicallyinteractwithindividualsinvolvedinthecorrectionalsystem,hasledthesubstanceabusefieldtofocusonthefeasibilityofconductingbriefinterventionswithinsuchsettings.Whilemoststatesrequirescreeningofindividualsconvictedfordrivingwhileintoxicated,screeningofindividualswhocommittedothercrimesismuchmorevariable,despitegenerallyhighratesofuseamongthispopulation(Lapham,2004).However,criminaljusticesettingsoftenreferoffenderstospecializedtreatmentprograms.Infact,alargeproportionofpublicsystemreferralsforsubstanceabusetreatmentcomefromcriminaljusticesettings.Whilebriefinterventionswithincorrectionalsettingsseempromising,evidenceoftheeffectivenessofbriefinterventionswiththispopulationissparse.Davisetal.(2003)foundthatbriefMIincreasedthetreatmentengagementrateofsubstanceabusingveteransfollowingincarceration.However,Wells-ParkerandWilliams(2002)foundlessfavorableresultswhentestingtheimpactofagroupdiscussioninterventiononrecidivismforDWI.
FrameworksandOrganizingStructuresforDeliveringBriefInterventionsSeveralframeworksandorganizingstructuresareavailableforthedeliveryofbriefinterventions.Mostoftheseframeworksrecommendspecificstepsthatcanbeseenasshellsfilledwithdifferentinteractiontechniquesorstyles.Thissectionwillprovideanoverviewoftherationale,procedures,andevidencebaseforavarietyofbriefinterventionframeworks,includingscreening,briefintervention,andreferraltotreatment(SBIRT),FRAMES,the5As,andtheStagesofChange.
Screening,BriefIntervention,andReferraltoTreatmentSBIRTisapublichealthinitiativedesignedtoscreenindividualsforriskysubstanceuseorsubstanceusedisorders,conductbriefinterventionsthattargetindividualswithriskyalcoholusewhodonotneedspecializedtreatment,andreferthosewithmoresevereusetospecializedtreatment(http://sbirt.samhsa.gov/about.htm).SBIRTtypicallytakesplaceincommunityormedicalsettingswhereprofessionalshaveopportunitiestoscreenindividualsforsubstanceusedisordersanddeterminetheappropriatelevelofintervention.ThefirststepinSBIRTinvolvesscreeningindividualsforriskyorproblematicuse.Positivescreensmaythenbefollowedwithmoreintensiveassessmenttodeterminethepresenceofsubstanceusedisordersorotherrelevantsubstance-relatedconsequences.AscanbeseeninFigure1,substanceuseandrelatedconsequencesamongindividualsoccuronacontinuum,rangingfromabstinencetodependence.Epidemiologicresearchsuggeststhatmenwhoregularlydrinkmorethanfourstandarddrinksinaday(ormorethan14perweek)andwomenwhoregularlydrinkmorethanthreeinaday(ormorethansevenperweek)areatincreasedriskforalcohol-relatedproblems(Dawsonetal.,2005).Becauseofthis,theNIAAArecommendsasinglescreeningquestionqueryingthepresenceofusethatexceedstheselevelstoidentifyindividualswhoareatriskforalcohol-relatedproblems(NIAAA,2005).Otherscreeninginstrumentsforalcoholanddrugusearealsoavailableandeachhasitsownindividualbenefitsanddrawbacksintermsofsensitivity,specificity,andeaseofadministration.Forexample,theCAGEquestionnaire(Ewingetal.,1984)isafour-questionscreeningtoolthatiseasytouseandrememberbecauseofitsacronym:Haveyoueverfeltyoushouldcutdownonyourdrinking?Havepeopleannoyedyoubycriticizingyourdrinking?Haveyoueverfeltbadorguiltyaboutyourdrinking?Haveyoueverhadadrinkfirstthinginthemorningtosteadyyournervesortogetridofahangover(eye–opener)?Theinstrumentgenerallyhasgoodpsychometriccharacteristics(Fiellin,2000)includinginternalconsistencyreliability(Mischke&Venneri,1987).Endorsementof
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threeormoreitemshasbeenfoundtobestronglypredictiveofanalcoholusedisorder,withgoodlevelsofsensitivityandspecificity,butthecut-offscoreof1foridentificationofriskydrinkershasbeencriticizedforpoorsensitivityorhighratesoffalsepositives(MacKenzieetal.,1996).TheAlcoholUseDisordersIdentificationTest(AUDIT;Saundersetal.,1993)screensforthequantityandfrequencyofalcoholuse,bingedrinking,symptomsofdependence,andalcohol-relatedconsequences.Theinstrumentcanbeself-administeredandmaybeparticularlyappropriateforbriefinterventionstudiesbecauseofitsabilitytoidentifypeoplewhohaveproblemswithalcoholbutwhomaynotbedependent(Feillin,2000).TheMichiganAlcoholismScreeningTest(MAST;Selzer,1971)includesquestionsaboutdrinkingandalcohol-relatedproblems.Thisinstrumentcanbeparticularlyhelpfulinidentifyingalcoholdependence(Reidetal.,1999).TheDrugAbuseScreeningTest(DAST;Gavin,Ross,&Skinner,1989)isasimilarinstrumentthatisavailablefordetectingdrugusedisorders.Additionally,theWorldHealthOrganization(WHO)developedtheAlcohol,SmokingandSubstanceInvolvementScreeningTest(ASSIST)toscreenforproblematicorriskyuse(WHO,2008:http://www.who.int/substance_abuse/activities/assist_technicalreport_phase3_final.pdf).Theinstrumentyieldsariskcategoryfornicotine,alcohol,andarangeofdrugsthatcanbeusedtoinformtheappropriatelevelofbriefintervention.WhileNIAAArecommendsuniversalscreeningofallpatientsseeninprimarycaresettings,theapproachmaybeparticularlyapplicableorimportantduringphysicalexaminations,whenprescribingamedicationthatinteractswithalcohol,withwomenwhoarepregnantortryingtoconceive,withpatientswhoarelikelytodrinkheavily(suchassmokers,adolescents,andyoungadultsandthosewhohavehealthproblemsthatmightbealcoholrelated),orpatientswhohavechronicillnessesthatarenotrespondingtotreatmentasexpected(NIAAA,2005).WithintheSBIRTmodel,followingscreening,providersdeterminethelevelofinterventionthatmaybeappropriateforaparticularindividual.Severaltoolsandprocessescanbeusedtomakethisdetermination.ForproviderswhousetheASSIST,theinstrumentyieldsariskcategoryof“low,”“moderate,”or“high”thatcorrespondstorecommendedinterventiontypes,includingnointervention,briefintervention,orbriefinterventionplusreferral(WHO,2008).Forindividualswithnouseorlowriskuse,reinforcementofhealthybehaviorsistypicallyrecommended,butinterventionisnot.Forthosewhoscreenpositiveforat-riskuse,additionalassessmenttodeterminethepresenceofdependence,degreeofnegativeconsequences,orpresenceoffamilyhistorymaybeappropriate.Basedontheseresponses,individualswithriskydrinkingalonemaybeappropriateforbriefintervention,whilethosewithsignsofdependenceorapositivefamilyhistoryofdependencemaybemostappropriateforbrieftreatment(treatmentorintervention?)withreferraltospecialtytreatment.Providerscontinueworkingandinterveningwithpeoplewhoarenotinitiallyinterestedinreferraltotreatment.OneexampleofanSBIRTprotocolwasdevelopedbytheNIAAA(2005)asaguideforhealthcarepractitionerstoscreenandintervenewithpatientsatriskforalcoholproblems.Theguideincludesfoursteps.Thefirststepinvolvesaskingaboutalcoholuse,includingthepresenceorabsenceofuseand,inthepresenceofuse,thepresenceofheavydrinking(fiveormoredrinksformen;fourormoredrinksforwomen)oranelevatedAUDITscore(8orhigherformen;4orhigherforwomen).Forthosewhoareatrisk,steptwoinvolvesamorethoroughassessmentofalcoholuse,includingthediagnosisofalcoholabuseordependence.Stepthreeinvolvesgivingadviceandassistancebasedonthedrinkinglevelsofthepatient.Thisadvicemayincludeabstinenceandspecialtytreatmentforthosewithalcoholusedisordersandcuttingdownforthosewithriskyuse.NIAAArecommendsthatthenatureofassistanceorbriefinterventionshouldbedependentonthereadinesslevelofthepatient.Forthosewithlowreadinesstochange,providersareencouragedtohelppatientsexploreambivalencetochange,whilethosewhoarehighinreadinessmaybenefitfromsettingagoal,developingachangeplan,andreceivingeducationalresources.Atstepfour,providersareencouragedtoacknowledgethatchangeisdifficultandsupportanypositivechangesinthosewhowereunabletoreducedrinking,aswellasreinforceprogressinthosewhowereabletoeliminateriskyuse.Rescreeningatleastannuallyisencouraged.TheSBIRTmodelhasastrongevidencebaseforreducingratesofalcoholandsubstanceusewithinmedicalsettings.Forexample,theSubstanceAbuseandMentalHealthAdministration(SAMHSA)implementedandevaluatedanSBIRTinitiativeacrossavarietyofinpatient,outpatient,andemergencymedicalsettings(Madrasetal.,2009).ThesixsitesinthestudyhadsomeflexibilityregardingthespecificcomponentsoftheirSBIRTprotocol,butgenerallyscreenedpatientsusingtheDAST,AUDIT,quantity/frequencymeasuresofconsumptionorsomecombinationoftheabove.Nearly460,000individualswerescreenedwithinthetrial.Riskyuse,definedasdrinkingmorethanfivedrinksinonesittingorusingillicitsubstancesinthepast30days,wasidentifiedin23%ofpatients
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andtheseindividualswereprovidedwithbriefinterventionsthatincludedsite-customizedadaptationsoffeedback,FRAMES(seedescriptionlater),andMI.Inaddition,3%ofindividualswithhigherlevelsofusereceivedmoreintensivebrieftreatmentrangingfromonetoeightsessionsacrosssitesand4%ofindividualswhoindicatedsymptomsofsubstancedependencewerereferredforspecialtytreatment.Overall,thestudyrevealedverypositiveresultsfortheeffectsofSBIRT;thosewhoreceivedbriefinterventionreducedtheirdruguseby67.7%andtheiralcoholuseby38.6%.
FRAMESInareviewofbrieftreatmentforalcoholinterventions,MillerandSanchez(1993)identifiedseveralkeycharacteristicsofeffectivebriefinterventions(Bienetal.,1993).ThesecomponentscorrespondedtotheacronymFRAMES,whichreferstofeedbackofpersonalrisks,emphasizingthatresponsibilityforchangelieswiththeindividual,advice-giving,providingamenuofchangeoptions,anempathicinteractionstyle,andtheenhancementofself-efficacy.Whilemanyofthesecomponents,suchastheemphasisonempathyandenhancementofself-efficacy,areconsistentwithMI(Miller&Rollnick,2002),others,suchasadvicegiving,arenot.Feedbackofpersonalrisksinvolvesprovidingindividualswithobjectivefeedbackabouttheiralcoholorsubstanceuse.Thiscouldtaketheformofnormativefeedbackonstandardizedassessmentresults,asisdoneinmotivationalenhancementtherapy,orsimplyprovidinginformationaboutthepresenceorabsenceofriskyordependentuseortheimpactofuseonothermedicalorpsychosocialissues.Cliniciansemphasizetheimportanceofpersonalresponsibilitytoencouragetheindividual’ssenseofdegreeofpersonalcontrolandinterestininitiatingbehavioralchange.Advicetochangeinvolvesrecommendingthatindividualsstoporreduceuse,withclearguidanceabouthowtogetstarted,andwithanofferofsupport.Providingamenuofoptionsgivesindividualschoicesondrinkingorsubstanceusegoalsorspecifictreatmentoptions.Forexample,thepersonmaybepresentedwiththechoiceofwhethertocutdownoreliminatetheiruse,orofferedvarioustreatmentoptionssuchasself-change,communitysupportgroups,orformaltreatment.Usinganempathicandreflectiveinteractionstylehasbeenempiricallydemonstratedtobemoreeffectivethanconfrontationalapproaches(Miller&Rollnick,2002)andishighlyconsistentwiththeMIstyle.Finally,thevalueofenhancingself-efficacyisbasedondecadesofresearchonsocialcognitivetheory(Bandura,1986)thatindividuals’beliefsthattheycaneffectivelychangeincreasestheprobabilitythattheywillattempttoandsucceedatchange.Fortunately,self-efficacycanbedramaticallyinfluencedbyclinicians’actions,andclinicians’beliefintheirclients’abilitytochangehasbeenfoundtobepredictiveoftreatmentengagementandultimateoutcome(Leake&King,1977).
FiveAsThe5Asisaninterventionstrategy,drawnoriginallyfromthesmokingcessationliterature,thatprovidesrecommendedsequentialstepsforinterventionistsworkingwithbehavioralhealthissuessuchassubstanceuse(Fioreetal.,2000).Withinthemodel,providersareencouragedto:askaboutuse,assessseverityandreadinesstochange,advisecuttingdownorabstinence,assistingoalsettingandfurthertreatmentifnecessary,arrangetomonitorprogress,and,inarecentadditionofasixthA,assurecross-culturalefficacyofpractices(NIAAA,2005).Otherversionsofthemodelvaryslightly.Forexample,Whitlocketal.(2002)usetheformat:assess,advise,agree,assist,arrange.Assessinvolvescompletingvalidatedscreeningorassessmentinstrumentsandquestionstodeterminethepresenceorabsenceofaproblem.Assesscanalsoinvolvedetermininganindividual’sknowledgeaboutsubstanceusebehaviorandrelatedconsequences,motivationstochange,andperceivedbarriers.Withinthismodel,assessmentresultsareusedtoinforminterventionsandareoftenrelayedbacktotheindividualintheformoffeedback.Adviseinvolvesprovidingtheindividualwithpersonallyrelevantandspecificinformationaboutrecommendationsforchange.Theinterpersonalstylewithwhichadviceisgivencanvarydramaticallyacrossinterventionists.Agreereferstotheuseofcollaborativediscussionanddecision-makingtohelptheindividualdevelopagoal.Here,too,interventionistsareoftenencouragedtoprovideamenuofoptionsforindividuals,involvesignificantothers,anddevelopagoalthatisspecificandmeasurable.Assistinvolveshelpingtheindividualtodevelopaspecificchangeplanorstrategiestoachievetheirgoal.Suchstrategiesmayincludereferraltospecializedtreatment.Last,arrangeinvolvesfollow-uptoreinforcechange,assurecross-culturalappropriateness,revisegoals,oraddressbarriers.The5Ashaveastrongevidencebaseacrossavarietyofhealthbehaviors,includingsubstanceuse,andare
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consistentwithinterventionelementsfoundtobeassociatedwithimprovedoutcomesinreviewandmeta-analyses(Goldsteinetal.,2004).Inaddition,providersreportsatisfactionwiththe5Asapproach,whichtheyperceiveasrequiringlittletraining,havingastrongevidencebase,andbeingsimpleandflexible(Grandesetal.,2008).
TheTranstheoreticalModelThetranstheoreticalmodel(TTM;DiClementeetal.,1985;Prochaska&DiClemente,2005)isamodelofbehavioralchangethatfocusesonhowpeoplemakedeliberate,purposefulchanges.Themodellargelyfocusesonbehavioralchangesthatinvolveeliminatingproblembehaviorsandbeginningnew,healthierbehaviors.Themostwell-knownaspectoftheTTMisthe“stagesofchange”(SOC)model,whichviewsbehaviorchangeasaprocessthatprogressesfromlowproblemawarenessandreadinesstochangethroughhighawarenessandactiveeffortstoinitiateormaintainchange.Themodelhasfivestages:precontemplation(individualsmaynotrecognizetheirbehaviorasproblematicandarenotplanningtochange),contemplation(individualsareconsideringchangebutremainambivalentaboutwhetherthebenefitsofbehaviorchangeoutweighthecosts),preparation(individualshavedecidedtomakeachangeandaremakingplanstochange),action(individualsareactivelytakingstepstochange),andmaintenance(individualsareintegratingbehaviorchangeintotheirongoinglifestyle).Whileprogressionthroughthestagesofchangeissometimeslinear,thedevelopersemphasizethatindividualscanmovefromanystagetoanotherandcyclethroughthestagesmultipletimesbeforeachievingsustainedchange.Inadditiontothestagesofchange,theTTMmodelfocusesonchangeprocesses.Differentexperiencesandactivitiesarehypothesizedtofacilitateprogressionthroughthevariousstagesofchange,withsomeevidencesupportingthesehypotheses(DiClemente,2003;Perz,DiClemente,&Carbonari,1996).Experientialprocessesmaybemostrelevanttoprogressingthroughtheprecontemplationandcontemplationstages.Consciousnessraisingabouttheproblembehaviorandsolutions,becomingmoreattunedtoemotionalaspectsofchange,consideringhowtheproblemaffectsothers,andclarificationofvaluesinrelationtothebehaviorareallthoughttocontributetoprogressthroughtheearlystages.Behavioralprocessesarebelievedtofacilitateprogressthroughactionandmaintenancestages.Theseincludemakingachoiceandcommitmenttochange,controllingtemptationsandtriggers,avoidingrisks,substitutingandreinforcingalternativebehaviors,andusingavailablesupportstohelpachieveandmaintainchange.TheTTMrecognizesthataperson’sbeliefsaboutthebenefitsanddrawbacksofchange,self-efficacyintheabilitytochange,environmentaltemptations,andindividualbiopsychosocialcharacteristicscaninfluenceprogressiontowardchange(Prochaska&DiClemente,2005).Themodelhasbeenusedtohelpmatchindividualstoappropriatelevelsandstylesoftreatmentandsuchapplicationshavebeenfoundtolowerrelapseratesandimprovetreatmentengagementamongindividuals(Dempsey,2008).ItshouldbenotedthattheSOCmodelhasreceivedsomecriticismasaninappropriateassessmentofreadiness(West,2005)andashavinglimitedapplicationtoaddictioningeneral(Sutton,2001).However,itisaninfluentialmodelofthestagesandprocessesofchange.
BriefInterventionsandInteractionStyleAsBienetal.(1993)describeintheirreviewofbriefinterventionsforalcoholproblems,theclinician’sinteractionstylecanhaveasignificantimpactonoutcome.TheseauthorsciteearlystudiesbyChafetz(1961,1962,1968),whichdemonstratetheimportanceofinteractionstylewhenmakingreferralstospecialtytreatment.Inthesestudies,standardreferralproceduresusedtoencouragespecialtytreatmentforpatientspresentingtoemergencydepartmentswithalcohol-relatedproblemswerecomparedwithastandardizedbriefinterventionthatusedanempathiccommunicationstyle.Theempathicapproachimprovedattendanceratesatasubsequentappointmentforspecialtytreatmentbyupto72%.Incontrast,aninterventionfocusedonadvicegiving,persuasiveness,andtheauthorityofthephysician,designedtoincreaseengagementinspecialtytreatmentforactivelydrinkingpatientswithgastrointestinaldisease,didnotincreaseratesoffollow-upcarebeyondthoseofthecontrolcondition(Kuchipudietal.,1990).Severaltherapeuticstylesorinterventiontechniquescanbeusedtoformthebasisofbriefinterventions.However,wewillfocusontheuseofmotivationalinterviewingasaninteractionstylethatcanbeusedinisolationortofillthestepsintheframeworksdescribedabove.
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MotivationalInterviewing
OverviewoftheApproachMIisatherapeuticapproachusedtoexploreandresolveambivalenceaboutbehaviorchange.MIhasastrongevidencebaseforreducingsubstanceuseandrelatedproblemsandhasbeenappliedextensivelyinbriefinteractionswithinmedicalandotheropportunisticsettings(Hettemaetal.,2009).Theapproachhasbeendefinedas“aperson-centeredcounselingstyleforaddressingthecommonproblemofambivalenceaboutchange”(Miller&Rollnick,2013,p.21),as“aclient-centered,directivemethodforenhancingintrinsicmotivationtochangebyexploringandresolvingambivalence”(Miller&Rollnick,2002)or,similarly,asa“collaborative,person-centeredformofguidingtoelicitandstrengthenmotivationforchange”(Rollnicketal.,2008).Theperson-centeredaspectoftheapproachreferstotheassumptionthattheperceptionsandgoalsoftheindividualversusthoseoftheinterventionistsshouldbeattheforefrontoftheinteraction.Person-centeredapproachesalsotendtofocusontheexpressionofempathyandacceptancethroughtechniquessuchasreflectivelistening.However,inadditiontotheperson-centeredaspectsofMI,cliniciansusedirectiveorguidingstrategiestointentionallypursuetheresolutionofambivalence,elicitandstrengthenmotivationtochange,andreducesubstanceuseorrelatedconsequences.Thus,whilefocusingonandelicitingtheclient’sperceptions,theMIinterventioniststrategicallyseekstohelptheclientdevelopanawarenessofanydiscrepancybetweensubstanceuseandpersonalgoalsandvalues.MIwasfirstdescribedasanapproachtohelppeoplewithdrinkingproblems(Miller,1983)andhasbeenmostcommonlyusedwithsubstanceusingpopulations,includingtobacco,alcohol,andotherillicitsubstancessuchascocaine,marijuana,andopiates(Hettemaetal.,2009).Ambivalenceiscommonamongpeoplewithsubstanceuseproblemsanddisorders,astheyoftenhavemixedfeelingsabouttheiruse.Forexample,whileanindividualmayperceivesomenegativeconsequencesoftheiruse,suchashangovers,work,orrelationshipproblems,heorshemayalsoenjoysomeofthepositiveoutcomesofusesuchasintoxication,reductionofnegativeemotions,orassociatedsocialization.Apersoninthisambivalentstateislikelytoremainconflictedandrefrainfromchangeunlessthebalanceoftheprosandconsofcontinueduseshifts.MIpractitionersviewthespiritoftheunderlyingapproachasnecessaryforthesuccessfulimplementationofspecificskills.MIpractitionersassumethatindividualshavewithinthemprosocialandhealthyvaluesandthattheyshouldbetreatedaspartnersinthechangeexplorationprocessversusrecipientsofexpertadvice(Miller&Rollnick,2005).TheMIspiritencouragescollaboration,wheretheindividualisseenasanexpertonhisorherowncircumstancesandtheinterventionististheexpertonskillsforeffectivelymanagingaconstructiveconversationaboutchange.Therelationalstanceofcollaborationassumesthatindividualsarecapableofmakingsounddecisionsandoftenhavetheresourcesandinformationnecessarytoimplementthem.Infact,manyindividualsusingsubstanceuseatriskylevelsareoftenawareofthepotentialrisksoftheirbehavior,effectivestrategiestoreduceuse,andresourcestoassistthem,andmerelistingofthesefactsisunlikelytopromotechange.Rather,MIinterventionistsavoidprovidingunneededorunwantedinformation,andelicitmoreinformationthantheyprovide.FromtheMIperspective,itismoreimportantthattheinterventionistdevelopasupportiverelationshipwiththeindividualanddrawouttheperson’sownmotivationsthangiveinformation,educate,orpersuade,allofwhichmayleadtoresistanceandpotentiallydecreasetheperson’swillingnesstochange.ThespiritofMIisalsobasedonanimplicitandexplicitrespectoftheclient’sautonomy.Itencouragestheacknowledgementandsupportoftheindividual’sabilityandresponsibilitytoconsideroptions,makedecisions,andtakeaction.However,whilethespiritofMIisevocative,italsoallowsandevenencouragesinterventioniststoprovideopportunitiesforindividualstogainnewperspectivesontheirsubstanceusebehaviorsbythinkingaboutanddiscussingissuesrelatedtotheirbehaviorinanorganizedandsupportiveenvironment.
CoreSkillsMIpracticebuildsonitsspiritusingasetofkeyskillsthatcanbesummarizedusingtheacronymOARS:open-endedquestionsthatelicitthatindividual’sperspectiveorconsiderationofatopic,affirmationswhichcanhelptodeveloprapportandreinforcestrengthsorpositivechanges,reflectionsthatindicateinterest,acceptance,andunderstandingoftheclient,andsummariesthatcanbeusedtocapturethemeswithininteractionsandtransitionbetweentopics.Thesetechniquesareusedtobuildrapportandtherapeuticalliance,encourageconsiderationandexplorationofchange,andincreasecommitmenttochange.
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TherapeuticProcessesInadditiontotheemphasisonusingOARSasabasiccommunicationstyle,theMItherapistusesbroadertherapeuticprocesses:engaging,focusing,evokingandplanning(Miller&Rollnick,2013).Thefirstkeyprocessisengaging.EngagementinMIinvolvesdevelopingadeeptrustbetweenpractitionerandclientthatallowsforthedevelopmentofclient-centeredgoals.Whenclientsarenotdeeplyengaged,theytendtobemorepassive.WhileMIpractitionersmayhaveaclinicalinvestmentinaparticulardirectionforclientchange(suchasreducinguseorharm),MIdevelopsacollaborativerelationshipbetweenclientandpractitioner,asitisnotfocusedonknowledgeorskilldevelopment.Thesecondkeyprocessisfocusing.Onceclientsaresufficientlyengagedintherapeuticconversation,MIpractitionersbegintonarrowthefocustotheissueofclientchange.Whatdoestheclientnotlikeabouthisorherlife?Whatmightbedifferent,better?Whatmighttheclientliketokeepwhilemovingforward,andwhatcanbeleftbehind?ThethirdcentralMIprocessisevokingclientperspectivesandideasaboutchangeratherthanprovidingideasandperspectives.Atitscore,MIisbasedontheideathatpeoplemotivatethemselvestochange,andthataneffectivewaytoelicitclientchangeistostructureconversationssothatclientsidentifyanddiscussthereasons,desiresandneedstheyhavetomakechanges.Thisisdistinctfromamorepersuasiveapproach,inwhichtheinterventionistpersuadesortellstheindividualhowandwhyheorsheshouldchange.InMI,discrepanciesthoughttomotivatebehavioralchangearedevelopedbydrawingouttheindividual’sownideasandfeelingsaboutsubstanceuseandperceptionsabouthowthebehaviorfitsinwithpersonalgoalsandvalues.Giventhatambivalentpeoplehavebothsidesoftheargumentaboutmakingchangesvs.holdingtothecurrentcoursealreadyinternalized,MIpractitionersevokeclients’ownthoughtsaboutchangeandarecarefultoavoidextollingthevirtuesofchangeduetotheriskofmotivatingclientstomake“yes,but”argumentsdefendingthestatusquo.Thefourththerapeuticprocessisplanning.Atsomepoint,clients’focusofattentionshiftsfromwhetherandwhytochangetohow.Theshiftmaybesudden,withaclientwhohasbeenponderingpossibilitieswhodeclares“I’vegottochange”or“Ican’tgoonlikethisanymore.”Othertimes,theshiftmaybegradual,almostunnoticeable,astheclientgoesbackandforthbetweenchangingonewayoranother,orstayingthesame,consideringhypotheticalpossibilities,thentalkingabouthoweachpossibilitymightworkandwhathecoulddotowardthatend.Buthowevertheconversationoccurs,whenclientstilttowardfavoringchange,MIpractitionersshifttohelpingclientsdevelopchangeplansandputthemintoaction.
StrategiesofMIThecoreskillsandprinciplesofMIformthebasisformanyspecificstrategiesorinterventiontechniquesthatcanbeusedtoimplementmotivationalinterviewinginpractice.Whereasthecoreskillsaremicro-levelinteractionaltechniques,andtheprinciplesaremacro-levelguides,MIstrategiesareintermediatemethodstostructureconversationstomaximizetheemergenceofmotivationforchange.SeveralofthesestrategiesthatareparticularlyapplicabletobriefapplicationsofMIandexamplesofhowtousethemfollow.
1.Agendasettinginvolvesprioritizingtasksandtopicsforaninteraction.Examplesinclude:Howwouldyouliketospendourtimetogethertoday?Or,Whichoftheseissueswouldyouliketodiscussfirst?Or,I’dliketofigureoutwhat’sgoingonwithyoursorethroatandthenspendafewminutesfollowingupondiscussionofalcoholusefromlasttime.2.Importanceandconfidencescalingcanbeusedtoassessmotivationandalsoasatooltoelicittalkaboutchange.I’dliketounderstandmoreabouthowyouviewyourdrinking.Onascaleof0to10,with0beingnotatallimportant,and10beingextremelyimportant,howimportantisitforyoutochangeyourdrinkingnow?Thisquestion(andthesimilarquestionaboutconfidence)canbefollowedbyaskingtheindividualwhytheirscorewasnotsomethinglowerthanwhattheyindicatedandwhatitwouldtaketomovetoahighernumber,bothofwhichstrategicallyelicittalkaboutchange.3.ProvidinginformationinanMIconsistentwaycaninvolveaskingpermissionorprovidingamenuofoptions.Ihavesomeinformationaboutstrategiesforreducingdrinking.WoulditbeallrightifIsharedthemwithyou?Or,Youtalkedaboutwantingtogetsomemoreinformationaboutmanagingyourdrinking.Weofferseveraloptionshereincludingmeetingwithatherapisttodoakindof“checkup”aboutdrinking,enrollinginourdrinkers’supportgroup,ordiscussingyourhealthfurtherwiththenurseorwithme.ThereareadditionalresourcesIcanpointyouto,includingwrittenmaterialsandinteractiveprogramsontheinternet.Which,ifanyofthese,areofinteresttoyou?4.Elicit-Provide-Elicitinvolvesincreasingthecollaborativenatureofinformationprovisionbyelicitingwhatan
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individualalreadyknowsaboutatopic,providingadditionalorcorrectiveinformationinatailoredway,andthenelicitingaresponsetotheinformation.Whatdoyouknowaboutlevelsofsafedrinking?…Ithasbeenfoundthatwomenwhodrinkmorethan3drinksadayor7drinksinaweekareatanincreasedriskforavarietyofhealthandotherproblems.Whatdoyoumakeofthat?5.Exploringstrengthscanbeusedtohelpidentifyresourcesanddevelopplansaswellasincreaseself-efficacy.Whataresomepersonalqualitiesthatyouareproudof?Or,Whichstrengthsdidyouusetoovercomethatchallenge?6.Exploringvaluescanbeusedtohelpindividualsdevelopadiscrepancybetweenharmfulsubstanceuseandwhatismostimportanttothem.Whatthingsaremostimportanttoyouinyourliferightnow?Or,Takealookatthislistofvalues.Takeaminutetopickyourtopthreeandtellmewhattheymeantoyou.Or,You’vementionedhowimportantyourchildrenaretoyou.Whatimpact,ifany,doesyourmarijuanausehaveonyourchildren?7.Lookingbackwardgivesindividualsanopportunitytothinkaboutatimeintheirliveswhensubstanceusewasnotanissueandidentifybenefitsofthiswayofbeingandalsoeffectivestrategiesformaintainingthisbehavior.Let’stalkaboutatimebeforeyoustartedusing.Whatwereyoudoingthen?Howdidyoufeel?8.Lookingforwardinvolvesaskingindividualstothinkabouttheirlifedowntheroadconsideringiftheywereorweren’tabletomakechanges.Avariationistoaskindividualstoenvisionafuturethattheydesire.Wheredoyouthinkyou’regoingwithyourdrinkingifyoulookaheadafewyears?Whataresomeoftheworstthingsthatwilllikelyhappenifyoumaintainyourcurrenthabits?Whataresomeofthebestthingsthatmighthappenifyoumadesomechanges?9.Consideringhypotheticalchangeshelpsindividualstoidentifyimportantstepstowardschangeandgivesthemanopportunitytoforeseeadifferentfuturewithoutbeingforcedtomakeacommitment.Ifyouweretomakeachangeinyourdrinking,howmightyougoaboutitinordertosucceed?Whatwouldbechallenging?Whatwouldberewarding?
InadditiontodefiningwhatstrategiesMIincludes,itisalsousefultodefinewhatitdoesnotinclude.Forexample,unsolicitedadviceisnotofferedwithoutfirstobtainingpermissionfromtheindividual.Similarly,practitionersavoidconfrontingorwarningclientswiththeirownconcernsaboutdrinkingordrugusechoices.MIstrategiesortechniquesarenotsimplyaddedintointeractionsthatarehierarchicalinnature;rather,theMIstyleprescribesthatthetherapeuticrelationshipisinherentlynonhierarchicalandcollaborative.
EvidenceBaseSomeofthefirstempiricalevidenceinsupportoftheMImodelcamefromanearlystudyofMIinaDrinker’sCheck-upthatinvolvedassessingindividualsfordrinkingbehaviorandrelatedconsequencesandprovidingthemwithfeedbackinanMIconsistentmanner(Milleretal.,1988).Thisstudyshowedearlypositivefindingsthatbriefinterventionscouldsignificantlyreducedrinkingforupto1yearandafollow-upstudyfurtherdemonstratedthatMI-consistentinteractionstylepredictedthedegreeofclientsuccess(Milleretal.,1993).Followingthesestudies,afour-sessionadaptationofMIthatincludedpersonalizedfeedbackcalledMotivationalEnhancementTherapy(MET)wastestedwithinProjectMATCH,alargemulti-siterandomizedclinicaltrial,andwasfoundtoperformequallywellatreducingdrinkingasmoreextensivecognitivebehavioraltherapyand12-Stepfacilitationapproaches(ProjectMATCHResearchGroup,1997).Sincetheseearlystudies,therehasbeenanexplosionofinterestinandstudiesofMI,withmorethan200clinicaltrialsconductedtodate,andthesubsequentdevelopmentofanascentmodelofsomeofthemechanismsofMI(Miller&Rose,2009).MIanditsmostcommonadaptation,MET,havebeenlistedasevidence-basedpracticesontheNationalRegistryofEvidence-basedProgramsandPractices,whichisanorganizationthatfacilitatesthereviewandratingofsubstanceabusetreatmentmodalities.Severalmeta-analysesofMIhavebeenconductedtodate.Inoneearlyreview,30randomizedcontrolledtrialsofadaptationsofmotivationalinterviewing(AMIs)wereincluded(Burkeetal.,2003).ThemajorityofincludedstudiesinvestigatedtheimpactofMIonalcoholordruguse.Themeandoseoftheinterventionisgenerallyconsideredtobebriefinnature,rangingfrom15to240minutes,andaveraging99minutes.Theauthorsfoundsmalltomediumbetweengroupeffectsizesfordrinkingandmediumeffectsizesfordruguse.Intheseareas,AMIsdoubledabstinenceratesfrom1:5to2:5.OveralltheauthorsconcludedthatAMIsareeffectiveandefficient,astheycan
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producesimilarresultsintwosessionstothoseachievedbyotherinterventionsstylesin8sessions.Amorerecent,largermeta-analysisofMIincluded72studiescoveringarangeofproblembehaviors.Again,themajorityofstudiesfocusedonalcoholordruguseorengagementinsubstanceusetreatment.Hettemaandcolleagues(2005)foundsmalltomediumeffectsizesforalcoholanddruguseandmuchlargereffectsforengagementinsubstanceabusetreatment.Thismeta-analysisalsofoundthat,similartootherbehavioraltreatments,effectsofMIappearearlyandtendtodiminishsomewhatovertime,exceptinstudiesinwhichMIisaddedtosomeotherformoftreatment.TheyfoundthattheaverageeffectsizeofMIwasd=0.77atpost-treatment,d=0.31at4to6months,andd=0.30at6to12months.Anothermeta-analysiscomparedtheeffectivenessofMItobriefadviceonavarietyofhealthbehaviors(Rubak,2005).Seventy-twotrialswereincludedandthoseaddressingalcoholusefoundthatMIoutperformedbriefadvice-basedinterventiononobjectiveoutcomevariablessuchasbloodalcoholconcentrationandstandardethanolcontent.MIdemonstratedaneffectin74%oftheRCTsassessedandlikelihoodofaneffectincreasedwithincreasesinthenumberofminutespersessionandthenumberofencountersperpatient.TheauthorsconcludedthatMIismorebeneficialthanbriefadviceforabroadrangeoftargetbehaviors,includingsubstanceuse.Mostrecently,Lundahletal(2009)conductedameta-analysisof119experimentalandquasi-experimentalstudiesacrosssubstanceuse,healthbehaviors,andtreatmentengagementdomains.LundahlestimatedaneffectsizeforMIofg=0.28againstweakcomparisongroupsandanonsignificanteffectofg=0.09againstcompetingactivetreatments.WhiletheyquestiontheresultsoftheHettemaandMiller(2005)meta-analysisduetoinclusionofastronglypositiveoutliersample,theiranalysismaybeundulyinfluencedbyseveralnegativestudiesofMIforsmoking.Incontrast,theyreportthatapproximately75%ofallparticipantsinMIstudiesexperiencepositivegains,withapproximately25%experiencingmoderatetolargegains.Lundahlandcolleaguesofferanswerstoseveralcomponentquestionsinsecondaryanalyses,including:—DoesMIwork?(Yes)
-ShouldI,ormyagency,considerlearningoradoptingMI?(Yes)IsMIonlyindicatedforsubstanceuseproblems?(No)IsMIsuccessfulinmotivatingclientstochange?(Yes)
-IsMIsuccessfulonlywithclientswhohaveminorproblems?(No)-IsMIassuccessfulasotherinterventions?(Yes,exceptwithtobaccouseandsomemiscellaneousdrugproblems,andoftenMIisassuccessfulinlesserdoses)
AreMIeffectsdurable?(Yes,atleastupto1to2years)
-Shouldpractitionerslearn“basicMI”or“MET”?(LearnMItointegratewithotherapproaches;learnMETtotargetspecificbehaviorchanges)
Ismanual-guidedMIsuperiortothealternative?(No)
-DoestheformatofMIinfluenceoutcomes?(No)-DoesprofessionalbackgroundinfluencesuccessofMI?(No)-DoesMIdosagematter?(Yes—indiscretedeliveryforms,moreMIisrelatedtobettereffects)-DoesMIworkformostclients?(Uncertain)-DoesMIworkingroupformats?(Uncertain).WenotethatthemostrecentreviewoftheevidenceforMIingroupformatsindicatesthattheyshowconsiderablepromise(Wagner&Ingersoll,2013).
Intheareaofsubstanceabuse,abroadrangeofpopulationshavebeentreatedwithMIinclinicalandresearchsettings.Treatedpopulationsrangefromyouthexperimentingwithdrinkingthroughadultswithseverealcoholanddrugdependenceproblems,includingthosewhoseaddictionproblemshaveresultedincriminaljusticesysteminvolvement.StudieshaveshowntheefficacyofMItoreducedrinking,increaseabstinencefromdrinking,reduceheavydrinkingdays,facilitateparticipationinharmreductionstrategiessuchasusingneedleexchangeprograms,
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andreducedruguse.Inaddition,MIhasbeenusedtohelppatientswithanumberofmedicaldiagnosesandrelatedhealthconditions,someofwhichhavelessobviousrelationshipswithsubstanceabuse.Inthedomainofmentalhealth,thereismuchgrowthinapplicationsofMI(Arkowitzetal.,2008).Relatingtosubstanceuseproblems,MIhasbeenusedclinicallyandtestedinresearchasadualdisorderintervention,targetingbothsubstanceuseandmentalillness.TheU.S.DepartmentofJusticehasadoptedMIasapreferredpracticeforthosewhoareimprisonedorinvolvedincommunitycorrectionssettingsrelatedtosubstanceabuseissues.ApplicationsinchildprotectiveservicesanddomesticviolencepreventionandtreatmentservicesprovidefurtheropportunitytouseMIwiththoseinvolvedinthelegalsystem.Additionally,MIisbeingincreasinglyappliedtosimultaneousbehaviorchangeinitiatives.Forexample,promisingprojectsshowbenefitsofMIreducingtheriskofalcohol-exposedpregnancybytargetingbothdrinkingandcontraception(Floydetal.,2007).TherearemanypossiblebehavioraltargetsofMIandavarietyofsettingsinwhichtheinterventioncanbedelivered.ThoughMIbeganasanoutpatientinterventionforalcoholproblems,involvingmeetingwithatherapistforuptoanhour,applicationsinbriefermedicalconsultationsarebecomingincreasinglycommon.
Summary&ConclusionsOverall,briefinterventionsshowagreatdealofpromiseforaddressingalcoholandsubstanceabuseissues.Theycanbeeffectivelyappliedwithinavarietyofsettingsthroughseveralframeworksdevelopedtoguidetheirapplications.WhilemanyoftheseframeworksrecommendMI-consistentstrategies,avarietyoftherapeuticinteractiontechniquescouldbeusedtopopulatethem.Forexample,theadvisestrategythatispresentinbothFRAMESandthe5Aswouldpresentdifferentlydependingontheinterventionists’interactionstyle.AspectsofMIthatinvolveattemptingtoelicittheindividual’sperspectiveonanadvisablecourseofaction,suchasaskingpermissionbeforegivingadviceandemphasizingpersonalchoice,mayormaynotbeusedtoenhancethisstepwithintheseframeworks,makingthemmoreorlessconsistentwiththeMImodel.Similarly,whiledistinct,theSOCmodelandMI“grewuptogether”andcomplementoneanother(DiClemente&Velasquez,2002).DevelopersoftheSOCmodelciteMIasavaluableapproachtousewhenpeopleareintheearlierstagesofchange,tobuildinterestinandmotivationforchange.However,withinMItheconceptofstagesisseenmoreasaheuristicthanasareflectionofreality.MIemphasizesthatreadinesstochangeisabyproductofinterpersonalinteractionsandcanfluctuatefrommomenttomoment.Whenconsideringinteractiontechniquesthatmaybeusedwithinbriefinterventionframeworks,MIseemstobealogicalfirstchoiceand,withintheliterature,MIskillsandprinciplesarecommonlyoverlaidonframeworkssuchasSBIRTandthe5As.MIisanefficaciousmethodtofacilitatebehaviorchangewithstrongevidenceforitspositiveimpactonaddictivebehavior.Itoftenachievesgoodoutcomeswithfewersessionsandinlesstimethanothersubstanceabusetreatmentmethods.Ithasbecomeapopularapproachandisusedaroundtheworldforthetreatmentofsubstanceabuseaswellasotherbehavioralchangechallenges.Whiletheclinicalmethodshavebeendetailedthoroughly,usingMIinvariousbriefinterventionframeworkshasnotbeenthoroughlyresearched.Rollnickandcolleagues(2008)advisethatMIshouldonlybeappliedwhenthereisaprimaryfocusonincreasingreadinessforchangeandtheprinciplesandspiritdescribedabovehavebeenintentionallyimplemented.However,theynotethatitisstillunresolvedwhetherthespiritofmotivationalinterviewingcan,infact,becapturedinbriefinteractionsofaslittleas5to10minutes.AsMIexpandsintonewareasofapplicationbeyonditsindividualsubstanceabusecounselingroots,suchasbriefinterventioninprimarycare,thereisaneedtodevelopinnovativemethodsofdelivery,measureoutcomes,andprovideeffectivetrainingforpractitioners,agencies,andtrainers.
PrioritiesforFutureResearchWhileresearchhasshownpromisingresultsthroughapplicationofSBIRT,furtherresearchisneededinanumberofareas.Tostart,briefinterventionsshouldbestudiedinadditionalcaresettingsandwithotherpatientgroups.Asnoted,theenthusiasmforSBIRTthatpromptedtheAmericanCollegeofSurgeonstomandateLevelItraumacenterstoscreeninjuredpatientsforanalcoholusedisorders,andprovidebriefinterventionstothosewhoscreenpositive,wasbasedlargelyonthestrengthofevidencecollectedinprimarycaresettings.FurtherstudyoftheefficacyofSBIRTspecificallyinemergencydepartmentsettingsisneeded(Saitz,2009).Additionally,thebulkofevidencesupportingtheuseofSBIRTsurroundsthescreeningandtreatmentofalcohol-relatedproblems;studiesaddressinghowbriefinterventionsmighteffectivelyimpactothersubstanceabusewouldbehelpful.
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ItshouldalsobenotedthattheBriefInterventioncomponentofSBIRTreferstoarangeofdifferenttherapies.Inotherstudies,differentapproachestotherapyyieldedverydifferentresults.TheefficacyofMotivationalInterviewinghasbeendemonstratedwithbothdrinkingandsubstance-usingpatients(Hettemaetal.,2005).AstudydistinguishingbetweenMIandotherbriefinterventions,suchassimpleadvice,couldofferguidanceonwhichapproach(es)wouldbemostusefulandeffective.TrainingineffectiveapplicationofSBIRTisanotherdirectionforfutureresearch.Whilebriefinterventionscanimprovepatients’reductioninalcoholandsubstanceuse,thereisaninvestmentinstafftrainingrequired.AstudyofhowthelengthofanSBIRTtrainingprogramimpactsimplementationcouldguideorganizationsonwhatamountoftimeandtrainingresourceswouldberequiredtoeffectachangeinpatientoutcomes.Forprimarycarephysicians,anassessmentoftheircurrentuseofscreeningtodetectalcoholorsubstanceuseinpatientscouldprovideaspringboardtocomparesuchpracticeswiththepotentialimprovementsindetectionandtreatmentthroughSBIRT.ItwouldalsobeinterestingtoapplyMIwithprimarycarephysicianstoassesswhatissuestheyfacewiththeimplementationofSBIRTandMIwiththeirpatients.AllowingthemtoexplorethechallengesandpotentialbenefitsofimplementingSBIRTinasupportivecounselingsessionmightilluminatetheobstaclesfacedbyotherpractitionersinavarietyofsettings.
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JenniferHettemaJenniferHettemaisPsychologyFellowatUniversityofCalifornia,SanFrancisco.ChristopherC.WagnerChristopherC.Wagner,VirginiaCommonwealthUniversityKarenS.IngersollKarenS.Ingersoll,UniversityofVirginiaJenniferM.RussoJenniferM.Russo,UniversityofVirginia
