8.5.1
Context
The most popular forms of less-intensive treatment currently available are based on the set of therapeutic principles and counselling techniques known as
motivational interviewing (Miller and Rollnick, 1991; 2002). Motivational interviewing is closely linked with the stages of change model described in chapter one.
This approach to treatment of alcohol problems fits with the following observations:
• Many people who present to agencies for treatment of
alcohol problems have not yet formed a definite commitment to change
• Even when an alcohol misuser seems convinced that
change is necessary, there is often a lingering attachment to heavy drinking and intoxication, and a deep ambivalence towards alcohol
• Conflict is an essential part of what we mean by
addiction or dependence (Orford, 2001). Motivational interviewing includes a collection of therapeutic principles, a set of counselling techniques and, more generally, a style of interaction. It is defined by Miller and Rollnick (2002, p25) as “a client-centred, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence.” The guiding principles of the therapist’s interaction with the service user are:
• Express empathy
• Develop discrepancy
• Roll with resistance
• Support self-efficacy.
A basic assumption of motivational interviewing, at least as a standalone treatment, is that, once motivated to change, service users can succeed in doing so by using their own change resources and without additional training in behaviour change skills. A full account of the theory, principles and techniques of motivational interviewing is given by Miller and Rollnick (2002). Motivational interviewing is contrasted with the traditional confrontational approach to alcoholism treatment in table 8a. Given the popularity of the confrontational approach, there is surprisingly little evidence to support it. Alcohol misusers at all levels of severity do not show more denial
Confrontational approach Motivational approach
Heavy emphasis on acceptance of self as “alcoholic”; acceptable of diagnosis seen as essential for change
De-emphasis on labels; acceptance of “alcoholism” label seen as unnecessary for change to occur
Emphasis on disease of alcoholism which reduces personal choice and control
Emphasis on personal choice regarding future use of alcohol and other drugs
Therapist presents perceived evidence of alcoholism in an attempt to convince the service user of diagnosis
Therapist conducts objective evaluation but focuses on eliciting the service user’s own concerns.
Resistance seen as “denial”, a trait characteristic of problem drinkers requiring confrontation
Resistance seen as an interpersonal behaviour pattern influenced by the therapist’s behaviour; resistance is met with reflection
and resistance than people without drinking problems. Those who accept the label of alcoholism do no better, and may actually do worse, than those who reject it (Miller and Rollnick, 1991). When compared to alternative approaches to counselling, confrontation has been found to be less effective in general and to be harmful for service users with low self-esteem (Annis and Chan, 1983). It is important to note here that the confrontational approach runs entirely counter to the spirit of the writings of Bill Wilson, the co-founder of Alcoholics Anonymous (AA World Services, 1980) and to the treatment philosophy underpinning the 12-Step method (see chapter 12).
Miller, Benefield and Tonigan (1993) provided strong support for an interactional view of service user
motivation. They randomly assigned alcohol misusers to receive confrontational counselling or a client-centred motivational counselling style. Service users in the confrontation group showed much higher level of resistance during counselling sessions than those in the other group. In addition, the more the counsellor had used a confrontational style during counselling, the greater the service user’s alcohol consumption at follow- up over a year later. This and other evidence (Miller and Rollnick, 2002) strongly suggests that confrontation is counterproductive in the attempt to motivate service users for treatment and that a non-confrontational approach should be preferred (see also chapter four).
8.5.2
Evidence
The category of motivational enhancement occupies second place in the Mesa Grande (see page 44), although many of the studies included there were of opportunistic brief interventions and were not carried out among treatment samples.
Five systematic reviews of research on the effectiveness of motivational interviewing (MI) for a range of addictive disorders have been published. Noonan and Moyers (1997) reviewed 11 clinical trials evaluating MI, nine with alcohol misusers and two with “drug abusers”. Their conclusion was that: “Most of these studies support MI as a useful clinical intervention. MI appears to be an effective, efficient and adaptive therapeutic style worthy of further development, application and research” (p8). Dunn, DeRoo and Rivara (2001) reported a systematic review of MI covering 29 randomised trials over the four behavioural domains of substance abuse, smoking, HIV
risk-taking, and diet and exercise. The authors
concluded: “There was substantial evidence that MI is an effective substance abuse intervention method when used by clinicians who are non-specialists in substance abuse treatment, particularly when enhancing entry to and engagement in more intensive substance abuse treatment-as-usual” (p1725). Therefore, MI can be used as a preparation for the more intensive forms of treatment discussed in the next chapter (chapter eight).
Three systematic reviews of MI have recently been published by Brian L Burke and colleagues. Burke, Arkowitz and Dunn (2002) began by noting that virtually all published research in this area involves the study of adaptations of MI (AMIs), rather than MI in its relatively pure form. AMIs refer to “packaged” versions of MI in which certain methods, such as feedback of assessment results, are used as a shortcut to elicit the service user’s reflections on the pros and cons of the behaviour in question, such as a drinker’s check-up (Miller, Sovereign and Krege,1988), motivational enhancement therapy (Miller et al., 1992) and brief motivational interviewing (Rollnick, Heather and Bell, 1992).
The reviewing method used by Burke and colleagues was based on the “box score” method developed by Miller et al. (1995) and, as noted in chapter three, this has been criticised by Finney (2000). However, the earlier review by Burke, Arkowitz and Dunn (2002) was superseded by later work by Burke, Arkowitz and Menchola (2003) that used quantitative meta-analysis in a technically
sophisticated manner. None of the conclusions reached by Burke, Arkowitz and Dunn were overturned by this later review.
The authors identified 30 controlled trials that met their inclusion criteria, of which 15 were in the area of alcohol problems:
• Two trials (Bien, Miller and Boroughs, 1993; Brown
and Miller, 1993) looked at AMI as a prelude to treatment among service users at the more severe end of the range of alcohol-related problems. Both found clear evidence of the effectiveness of AMI for this specific purpose
• Thirteen trials considered AMI as a standalone
intervention.
Clear interpretation of research on AMIs as a standalone intervention from this review is difficult, because this category of studies combines the separate domains of
opportunistic intervention in the non-treatment–seeking population and less-intensive treatment in the treatment- seeking population. Nevertheless, on balance, the evidence suggested MI-based interventions among a diverse range of groups were effective, including those with significant dependence seeking help for established alcohol problems. Effect sizes were in the small to medium range for comparisons of AMIs with placebo or no treatment conditions. There was no evidence that AMIs were superior to alternative forms of treatment for alcohol problems, but here the MI-based intervention was usually less intensive than the comparison treatment, suggesting that it may be more cost-effective. In the latest review by this team, Burke et al. (2004) updated the conclusions of their previous meta-analysis by including 38 studies of AMI. These conclusions were not substantially changed. The authors also provided answers to other questions regarding AMI:
• There was some evidence that MI achieves its effects
in the theoretically expected manner by increasing motivation or readiness to change. However, there was no current evidence that this mechanism of change was specific to AMIs as opposed to other forms of intervention
• With special regard to AMI as a prelude to other
treatment, there was a suggestion that it works by increasing treatment participation, but no firm
evidence of a mediating role for increased participation in linking AMI and treatment outcome
• There were methodological weaknesses in much of
the research reviewed. The greatest threats to internal validity arose from lack of proper treatment
specification, insufficient attention to treatment fidelity and the rarity of checks on treatment integrity. Finally, Burke et al. considered relationships between AMI and the other major and well-researched modality in the treatment of addictions, cognitive-behavioural skills training (see chapter eight). They concluded that very little is known about the relative effectiveness of these two forms of treatment, whether they are indicated for different types of service user or whether they could be profitably combined in treatment delivery.
The three government-sponsored reviews consulted for this document reached the following conclusions with respect to motivational interviewing:
• Among its post-detoxification population of interest,
the Scottish review (Slattery et al., 2003) concluded that MI was supported as an effective part of more extensive psychosocial treatment (p5–9)
• Based partly on its own meta-analysis, the Swedish
review (Berglund, Thelander and Jonsson, 2003) concluded that “motivational interviewing increases the effect of another treatment, but has not itself been subjected to randomised study” (p56)
• The Australian review (Shand et al., 2003) concluded
that: “The effectiveness of motivational interviewing delivered prior to treatment is unclear and there is a need for further studies to address this issue” (p50). The difference in conclusions between the Swedish and Scottish reviews, and the Australian review is that the Australian work highlighted the short, three-month follow- ups on which the favourable findings of the two studies of MI as a prelude to treatment proper (Bien, Miller and Boroughs, 1993; Brown and Miller, 1993) were based. Therefore, several important questions remain regarding the effective mechanisms of MI (and MET – see section 8.6), the duration of its effects and its possible
advantages and disadvantages compared to other forms of treatment. However, the relative brevity and cost- effectiveness of MI, combined with its growing popularity among treatment professionals, suggests that it should occupy a prominent place in modern treatment services.
8.5.3
Conclusions
• The non-confrontational principles and style of MI
should inform the conduct of specialist treatments for alcohol problems (IB)
• MI increases the effectiveness of more extensive
psychosocial treatment (IA)
• While there is no evidence at present of long-term
effects, MI and its adaptations can be effective as a preparation for more intensive treatment of different kinds (IA)
• Standalone adaptations of MI are no more effective
than other forms of psychosocial treatment but are usually less intensive and therefore potentially more cost-effective (IA).