Chapter 9 Integrating Motivational Approaches Into Treatment Programs

How do the motivational approaches discussed in this TIP fit into the real world of health care delivery? Although the demand for treatment of substance abuse continues to far exceed its availability, changes in health care economics are placing greater pressure on providers and their clients. Payors increasingly demand evidence that the services being provided are not only effective, but cost-effective.

Clinicians and programs are increasingly challenged if they do not use research-supported, current methods. Public funding is scarce, and third-party payors exert great pressure to provide treatment that is shorter, less costly, and more effective. In sum, clinicians are asked to do more with less.

The incorporation of motivational approaches and interventions into treatment programs may be a practical and efficacious response to many of these challenges. Recent research (Brown and Miller, 1993; Kolden et al., 1997; McCaul and Svikis, 1991) supports the integration of motivational interviewing modules into programs to reduce attrition, to enhance client participation in treatment, and to increase the achievement and maintenance of positive behavioral outcomes.

Other studies have shown brief interventions using motivational strategies and motivational interviewing to be more effective than no treatment or being placed on a waiting list, and not inferior to some types of more extensive care (Bien et al., 1993a, 1993b; Noonan and Moyers, 1997). A review of the cost-effectiveness of treatments for alcohol use disorders concluded that brief motivational counseling ranked among the most effective treatment modalities, based on weighted evidence from rigorous clinical trials (Holder et al., 1991).

Brief motivational counseling was also the least costly--making it the most cost-effective treatment modality of the 33 evaluated. Although cautioning that it was an approximation that requires refinement, the same study found a negative correlation between effectiveness and costs for the most traditional forms of treatment for alcohol use disorders and highlighted a growing trend to favor effective outpatient care over less effective or less studied--but far more expensive--inpatient, hospital-based, or residential care (Holder et al., 1991).

This chapter begins with a discussion of the treatment continuum into which motivational interventions must be incorporated and ends with descriptions of motivational approaches that have been used in specific treatment settings. Also discussed is the importance of involving a significant other to enhance a client's motivation for change.

The Treatment Continuum and Stepped Care

In 1990, the Institute of Medicine (IOM), in a special report to Congress, called for broadening the base of treatment for alcohol use disorders (IOM, 1990a). Both before and after that summons, modalities and special interventions to treat problems related to substance use have proliferated. In the year following the IOM report, Holder and associates reviewed the effectiveness and costs of 33 separate types of treatment for alcohol problems that had been subjected to controlled clinical trials (Holder et al., 1991).

The costs are much larger if specialized treatment services for substance-related problems are added to the base. However, these multiple modalities are not always used appropriately. Moreover, services are not always available to all who need or want them because of costs, lack of physical accessibility, and too few staff members.

The IOM report called attention to several important suppositions that underlie its efforts:

Substance use problems are not homogeneous--they differ in intensity, duration, effects, and other important dimensions.

Individuals who have problems with substance use are also diverse and have preferences about the treatments they will accept.

The magnitude of substance-related problems is too large to be handled by specialized treatment programs that are isolated from mainstream health care and other social services.

In an era of managed care and decreasing public funds for services that are demonstrated as not cost-effective, the provision of health care must necessarily be limited. However, funds can still be allocated in a rational, fair, and effective way if the most expensive treatments are reserved for the most serious cases and the least intensive interventions that have a reasonable chance of success are applied as a first response. This stepped care approach to delivering treatment services operates according to the following principles (Sobell and Sobell, 1999):

Both assessment and treatment should be individualized, with different types and intensities tailored to the presenting problem (or problems) and client characteristics.

The treatment initially recommended should be the least intensive and least costly treatment that is most likely--based on research, assessment findings, and clinical judgment--to resolve the identified problem.
More intensive and expensive treatments should be reserved for more serious problems and for clients who do not respond to less intensive interventions.

Where two interventions are equally effective for clients with certain characteristics, the less costly treatment should be tried first. This principle applies to the use of group treatment instead of individual care and to counseling by telephone, Internet, or mail instead of a personal meeting when these approaches are demonstrated to be equally effective.
All recommended treatments should be based on solid research or, in the absence of adequate data, peer-established best practice guidelines.

When making recommendations, clinicians should consider the client's preferences regarding treatment. "It makes little sense to refer clients to treatments that they believe are inappropriate and where the referrals are likely to result in those individuals dropping out of treatment" (Sobell and Sobell, 1999).

Both assessments and treatments should be ongoing, increasingly comprehensive processes, not one-time activities. That is, simple screening and brief interventions may be sufficient for excessive drinkers identified in opportunistic settings, but more comprehensive assessments and more intensive treatments should follow if clients do not respond satisfactorily to initial care based on empirically established outcome measures.

The need for additional treatment is based on both performance in the initial setting and another, more thorough assessment. Additional treatment may consist of more sessions in the original setting or referral to an alternative intervention, depending on clinical judgment, assessment findings, and client preferences.

The implications for motivational interventions of a stepped care approach to planning and service delivery are many. First, this model reflects many of the same principles underlying motivational approaches, including the importance of offering treatment options to clients and respecting their informed choice in treatment decisions.

Second, the stepped care model supports an increase in brief outpatient interventions that could effectively address mildly impaired persons without providing unnecessary services for them, while meeting public health objectives for reducing the high social costs of hazardous drinking and drug use.

Motivational approaches entailing an assessment and only a few clinical sessions have proven effective and could be offered in a wide range of health care settings, provided staff members are properly trained and agree with the method. Finally, since a stepped care approach to planning and allocating treatment services is performance-based and does not specify a hierarchy of interventions, motivational approaches can be applied in different formats.

For example, clinicians can experiment with the number, duration, or frequency of sessions to find the format that best meets individual needs.

Applications of Motivational Approaches In Specific Treatment Settings

No single method to incorporate motivational approaches into service delivery systems is superior to others. A few obvious opportunities present themselves, but applications have been and continue to be a matter of clinical creativity.

Some of the ways in which motivational interventions have been used are as

A means of rapid engagement in the general medical setting to facilitate referral to treatment

A first session to increase the likelihood that a client will return and to deliver a useful service if the client does not return

An empowering brief consultation when a client is placed on a waiting list, rather than telling a client just to wait for treatment

A preparation for treatment to increase retention and participation

A help to clients coerced into treatment to move beyond initial feelings of anger and resentment

A means to overcome client defensiveness and resistance

A stand-alone intervention in settings where there is only brief contact

A counseling style used throughout the process of change

Often, there is a relatively short period of time in which you, the clinician, can make a beneficial impact. This may be because length of service is restricted by reimbursement policies or by the nature of a program (e.g., an employee assistance program) or the setting may allow for only a single encounter, such as an emergency department. Moreover, the average length of stay in substance abuse treatment is very short. If you do not make an impact in the first session or two, you may make no impact at all. Thus, it is wise to make the best use of the first contact with a client.

However, this may conflict with the practical demands of a clinical setting in which paperwork must be done for admission, a waiting room is full of clients, or a treatment plan must be completed by the fourth session. Nevertheless, it is usually a mistake to start a session with filling out forms. Take some time at the very beginning just to listen to your client, to understand him, and enhance motivation for change. If one contact is all you get with this client, filling out a questionnaire alone is unlikely to help. Research shows that even a single session of motivational interviewing does make a difference.

The rest of this chapter describes creative ways in which the motivational approaches described in this TIP have been implemented.

In the Emergency Department

One of the first demonstrations of the power of brief interventions was implemented in the emergency department at Massachusetts General Hospital in the late 1950s. Morris Chafetz was concerned that many of the patients treated in the emergency department were there because of health problems and injuries related to their drinking. Yet nothing was being done about it. A resident might shake a finger at the patient and say, "You really have to quit drinking," but never follow up. In fact, less than 5 percent of these patients sought treatment for their alcohol problems.

Chafetz wondered what would happen if an empathic counselor were present to listen to these patients after they had been treated medically, encouraging them to come back for treatment. Thus, he conducted two studies in which patients coming into the emergency department with alcohol-related medical problems were assigned, at random, to meet with a counselor for a short conversation (15 to 20 minutes) following their medical treatment. In both studies (Chafetz et al., 1962, 1964), patients were 12 times more likely to return for treatment of their alcohol problems if they had talked with an empathic counselor (65 and 78 percent), compared with patients receiving only emergency department care (5 and 6 percent).

At Boston Medical Center's Emergency Department, doctors developed Project ASSERT (an acronym for Alcohol and Substance abuse Services and Educating providers to Refer patients to Treatment), originally funded by the Center for Substance Abuse Treatment. Project ASSERT employs health promotion advocates who screen emergency department patients for substance use, establish rapport, explore change issues, assess readiness to change using the readiness ruler, negotiate a plan, and facilitate access to the substance abuse treatment system.

The program also trains and involves the residents in emergency medicine. Published followup data show a 45-percent reduction in severity of drug problems, a 56-percent reduction in alcohol use, and a 64-percent reduction in frequency of binge drinking. Additionally, 50 percent of the patients reported keeping an appointment for treatment (Bernstein et al., 1997a).

In Obstetric Clinics

Another example of an effective motivational intervention is the pilot study conducted by Nancy Handmaker with pregnant women who attended obstetric clinics. Women who reported some drinking in the past month underwent a structured assessment and were assigned to receive either a motivational intervention or written materials informing them of the risks of drinking during pregnancy.

In the nonjudgmental personal interviews the women reported considerably more drinking than they did on screening questionnaires. Among women with higher estimated peak blood alcohol concentrations, motivational intervention was more effective in reducing consumption during the next 2 months of pregnancy (Handmaker et al., 1999).

In Medical Settings

Several studies have used motivational interventions in medical settings. Hospitalized teen smokers benefited from brief motivational interviews in their smoking dependence and number of days they smoked (Colby et al., 1998). Researchers determined the stage of change of patients in a primary care clinic who gave at least one positive response to the CAGE. Although the researchers had expected most of these individuals to be in the contemplation stage, the patients were found to be primarily in the action stage, and most were no longer using alcohol (Samet and O'Connor, 1998).

This implies that primary care physicians can perhaps contribute best to their patients' sobriety by providing positive feedback about remaining abstinent and using relapse prevention techniques. Primary care providers who received a brief training program on patient-centered alcohol counseling improved their counseling skills and were much better prepared to intervene with problem drinkers (Ockene et al., 1997).

Motivational Interviewing and the Marijuana Checkup

A study conducted at the University of Washington offered a two-session Marijuana Checkup, publicized through the local media with a telephone number for inquiries. In the initial weeks of the program, the staff noticed that 60 percent of eligible callers who scheduled an assessment session failed to keep their appointments. This rate was reduced by half when the initial telephone intake protocol was modified. The new approach involved a 3- to 5-minute dialog during which the staff person asked a series of open-ended questions and, using reflective listening, discussed the caller's reasons for being interested in the program.

The Matrix Model for Drug Users

In 1994, the National Institute on Drug Abuse funded the development of a model intensive outpatient treatment program that was to be constructed from research-supported elements (Rawson et al., 1995). The first version of this model, intended for persons with stimulant use disorders, contained specific instructions for therapists and an articulated philosophy of treatment that emphasized a motivational approach:

The therapist fosters a positive, healthy relationship with the patient and uses that relationship to reinforce positive behavior change. The interaction is realistic and direct but not confrontational or parental. Therapists are trained to view the treatment process as an exercise that will promote self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is a critical element for patient retention. (p. 120)

The basic motivation-enhancing philosophy that characterized the original Matrix model of outpatient treatment for stimulant users has since been broadened to include protocols for substances. The model continues to be evaluated and refined according to the results of ongoing outcome studies.