Motivational intervention is a relatively new, but favorably received, approach to encouraging positive behavioral change. The approach is derived from a variety of sources, including client-centered counseling, cognitive therapy, systems theory, and a transtheoretical model of change (Miller and Rollnick, 1991). To date, motivational interventions have been successfully used with a variety of problems, client populations, and settings (see Chapter 2), and the methodology appears to be generally applicable, although it was primarily developed for heavy alcohol drinkers and cigarette smokers. A number of controlled clinical trials of motivational interviewing and brief interventions that use a motivational approach have been conducted with promising results (Bien et al., 1993; Noonan and Moyers, 1997).
As with many innovative treatment approaches, however, there are still many unanswered questions about motivational interventions--especially as the concept has evolved over its comparatively short lifespan. Many of these questions are issues for an ongoing and broad research agenda; others are more practical problems pertaining to clinical applications. Many of the questions are also complex and interrelated so that untangling answers presents a challenge.
Some of the questions or issues that call for additional research include the following:
What are the active ingredients of motivational interventions? Although there has been some attempt to identify the common elements of brief interventions and to add more fundamental elements to motivational approaches, no structured research has yet parceled out the separate elements and determined which are most critical or which combinations are most useful. Reflective listening, structured feedback, discrepancy development, and decisional balances, for example, have each assumed some prominence in discussions of the approach. This question probably does not have a simple answer because some types of clients are likely to respond better to one aspect of the model than another and at different points in the change process.
Can motivational interventions be standardized? A corollary of the first question regarding active ingredients is whether motivational approaches can be successfully integrated into training manuals so that clinicians can be taught the basic elements and monitored to determine their adherence to the model. One example of such a program is already available, the Project MATCH manual published by the National Institute on Alcohol Abuse and Alcoholism (Miller et al., 1995c).
What types of clients benefit most--and least--from motivational interventions? There is a danger here that in the interest of health care cost containment, someone might conclude, "Why not give only motivational interventions?" Far too little is known at this time about who does and who does not respond to brief motivational counseling--and why. About half the studies of brief motivational interventions have been of heavy drinkers in medical settings who were not seeking treatment for alcohol problems. Other studies have shown that motivational intervention increases the effectiveness of subsequent treatment (Bien et al., 1993; Noonan and Moyers, 1997). Project MATCH tested a four-session motivational enhancement therapy against two 12-session outpatient treatment methods and found similar overall long-term outcomes, with some evidence that more severely dependent clients fared better in longer treatment (Project MATCH Research Group, 1997a). It is far too early to predict who needs only brief motivational counseling and who needs more intensive treatment.
What standard outcomes for motivational interventions can be defined and measured? Motivational approaches have been used to influence a variety of factors, including substance consumption patterns, successful referrals, compliance with treatment, and successful completion of the prescribed regimen. Research evaluations must specify what outcomes are expected and how these will be measured. One issue with motivational interventions is the variable effect sizes in the studies to date (Noonan and Moyers, 1997). Similarly, where the intervention is targeted at compliance with medical or treatment advice (e.g., taking medications as prescribed, participating regularly in exercise or rehabilitation programs), how large an effect is expected and how long will it last? Another related question is what, if any, proximal outcomes predict longer term outcomes.
What characteristics of clinicians influence the effectiveness of motivational interventions? Clinicians, as well as clients, have characteristics that negatively or positively influence how closely they can adhere to the model and what their expectancies are with regard to the potential effectiveness of motivational interventions. Clinicians who delivered brief advice with a medically authoritative voice or were not carefully trained may have compromised the spirit of motivational interviewing and negatively tainted research findings (Noonan and Moyers, 1997). Motivational interviewing is not an approach that is compatible with all clinicians.
Are stage-matched interventions appropriate? Some evidence indicates that when clients are at early stages of readiness, they are most likely to respond favorably to a motivationally focused intervention rather than one that focuses on behavioral change (Heather et al., 1996b). This suggests that different treatment strategies may be optimal at different stages of change. A different question is whether certain motivational strategies are appropriate only at certain stages of change (Perz et al., 1996), or with certain populations (Obert et al., 1997). Do action-oriented treatments work better for clients in the action stage? Two studies found that outcomes were similar for action-stage clients given motivational interviewing versus behavioral change treatment (Heather et al., 1996; Project MATCH Research Group, 1997a;). Which interventions are better at which stages or with which populations? There is still much to learn.
How effective and cost-efficient are motivational interventions in relation to other established and more extensive substance abuse treatments? At least one clinical trial has indicated that motivational interviewing was not inferior to a more extended support group in helping adult marijuana users reduce use or achieve and maintain abstinence (Noonan and Moyers, 1997). Similarly, in Project MATCH, a motivational enhancement approach yielded comparable overall outcomes at lower cost, compared with two longer treatment methods. Replications and refinements of this type of study must be conducted to ascertain whether motivational approaches are realistic and less costly alternative interventions for some clients.
How do culture and context influence the effectiveness of motivational interventions? Project MATCH found no differences in the treatment response of African-American, Hispanic, and non-Hispanic white outpatients to motivational enhancement therapy and two other treatment approaches (Project MATCH Research Group, 1997a). Yet ethnicity was defined simplistically here, as in most studies, as a self-identified label. More sophisticated analyses of ethnic influences are needed, because within-group heterogeneity is missed by such crude categorization, also called "ethnic gloss" (Longshore and Grills, 1998). Levels of acculturation, language, and counselor-client match can influence the process and outcome of motivational interventions.
What kinds of training and support are necessary to teach motivational interventions? The clinical approaches described in this TIP are more a motivational style of counseling, than a set of tricks or techniques. Clinicians differ in their effectiveness with motivational counseling (Project MATCH Research Group, 1998b). As the need to teach motivational interventions increases, questions to be considered will include the following: What are the "technology transfer" aspects of teaching this motivational approach? What training formats are most effective in changing counselor practice behavior to influence clients' responses during and after treatment? What aspects of motivational intervention are the most important to teach, and how is such teaching best done? It seems likely, though, that more than a single workshop presentation would be necessary to change established clinical practices. Perhaps most promising is the incorporation of this approach into the training of new addiction professionals.
Motivational Interviewing With Dually Diagnosed Inpatients
I became interested in motivational interviewing (MI) when my team and I were trying to improve the rate of attendance at aftercare appointments for dually diagnosed patients discharged from our psychiatric units. I was surprised to see that little had been written about the efficacy of motivational interventions with this population. So, my team and I decided to conduct a study of MI's effectiveness with dually diagnosed patients. We randomly assigned half of our patients to standard treatment (ST), in which they received standard inpatient psychiatric care, including standard discharge planning where the team would encourage and explain the importance of aftercare. The other half were assigned to ST but also received a motivational assessment, feedback on the results at admission, and a 1-hour motivational interview just before discharge.
We found that dually diagnosed patients in the MI group attended their first outpatient appointment at a rate that was two and a half times greater than the ST group (Swanson et al., in press), suggesting that MI, with virtually no modification, was effective. The intervention appeared to be particularly effective for patients with very low motivation. This could have been because these patients were more verbal about their ambivalence than others and because we viewed MI as a perfect way to resolve ambivalence. Another thing we learned was that asking patients about why they would not attend aftercare had surprise value and greatly enhanced the rapport between therapist and patient. It appeared to let patients know that we were not only going to tell them about the importance of aftercare, but that we were actually willing to discuss their ambivalence about it.
Patients were also surprised when we did not directly counter their reasons for not going to aftercare. For example, if a patient said, "I'm better now, I don't need aftercare," we would not say, "But in order to stay well, you need to continue your treatment." Instead, we used open-ended questions (e.g., "What do you think helped you get better?" or simply, "Tell me more about that") or amplified reflection (e.g., "So, you're saying you probably won't need any other treatment ever again" or, for more fragile patients, "It's hard for you to imagine a reason why you might continue to need treatment"). When patients offered specific disadvantages of pursuing aftercare, such as loss of time from work or negative reactions from family, we similarly responded with open-ended questions and reflective listening (e.g., "It sounds like your job is very important to you and that you wouldn't want anything to get in the way of that"). Frequently such questions and reflections would lead a patient to counter his own initially resistant statements. It turned out that even difficult patients could sell themselves on the idea of aftercare better than we ever could, and MI gave us the perfect method for facilitating this process. What was most important, however, was what we did not do, namely, argue with the patient or even attempt to therapeutically dispute his (sometimes) illogical ideas about aftercare. Instead, we waited for kernels of motivation and simply shaped them along until the patient finally heard himself arguing in favor of seeking further services.
Many different motivational approaches have been discussed in this TIP. Certainly, the evidence to date is very encouraging that even brief interventions can influence client motivation and trigger significant improvement. However, we are just beginning to understand how and why these approaches work, and how best to incorporate them into health care services with various populations. The use of these promising methods in the future will depend on the creativity of clinicians and researchers to adopt, adapt, and evaluate them to make them effective for clients.
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