Motivational Interviewing works, but no better than other treatments

Cochrane conducts a meta-analysis of motivational interviewing (MI) and concludes that it’s no more effective than other treatments.

More than 76 million people worldwide have alcohol problems, and another 15 million have drug problems. Motivational interviewing (MI) is a psychological treatment that aims to help people cut down or stop using drugs and alcohol. The drug abuser and counsellor typically meet between one and four times for about one hour each time. The counsellor expresses that he or she understands how the clients feel about their problem and supports the clients in making their own decisions. He or she does not try to convince the client to change anything, but discusses with the client possible consequences of changing or staying the same. Finally, they discuss the clients’ goals and where they are today relative to these goals. We searched for studies that had included people with alcohol or drug problems and that had divided them by chance into MI or a control group that either received nothing or some other treatment. We included only studies that had checked video or sound recordings of the therapies in order to be certain that what was given really was MI. The results in this review are based on 59 studies. The results show that people who have received MI have reduced their use of substances more than people who have not received any treatment. However, it seems that other active treatments, treatment as usual and being assessed and receiving feedback can be as effective as motivational interviewing. There was not enough data to conclude about the effects of MI on retention in treatment, readiness to change, or repeat convictions.The quality of the research forces us to be careful about our conclusions, and new research may change them.

This is a great example of a major flaw in research. There are so many assumptions in every study. One wrong assumption can lead to bad findings. For example, that motivational interviewing is an especially effective and sufficient intervention to treat alcoholism.

MI is being integrated into treatment for all sorts of medical problems, chronic health problems in particular, where part of treatment is recruiting the patient into participating in a treatment that is known to be effective but often suffers from low rates of patient compliance.

The difference here is that researchers seem to be interested in replacing existing treatments for addiction with MI.

One big problem here is that this inserts the assumption that alcoholism is resolved be increasing motivation to quit or reduce drinking.

I believe that these assumptions may be correct for low severity alcohol problems and that MI may be an effective intervention for these problems.

I also believe that MI is probably a valuable tool for more severe alcohol problems, but, in these cases, its proper use is to get patients to accept and participate in treatments that are known to be effective when patients comply. Twelve step facilitation, for example.

Why is there this push for MI as a replacement treatment rather than a treatment inducement tool? Does this constitute a bias on the part of researchers? I don’t know, but note that I’m not the one tossing out the baby with the bath water. I’m suggesting MI might be very important but that they are just asking the wrong questions. It’s also a little ironic that the push to use MI to replace other treatments actually weakens the case for MI having an important role in treating alcoholism.

Behavior Change

by Jeremy Brooks

Behavior change and motivation to change are interesting to me.  I have spent a lot of time thinking about how to maximize the likelihood that someone “gets it” (hope) while they are in treatment or detox and starts to take action.  When all of the stars line up it is a beautiful and rewarding thing to witness and be part of. We can help set the stage, but that there is so much that we cant see, predict or control.

This paper by Ken Resnicow and Roger Vaughan looks at behavior change through the lens of Chaos Theory. It nicely articulates many of the observations I have had over time and makes a lot of sense to me. It is full of gems, but I especially like this quote which focuses on what our role may be in helping our clients. It provides hope that even the most seemingly “tough” cases can get it. Our role may be to just do what we can to ensure that the ping pong balls keep spinning.

“In the complex system approach, the role of health communications may be analogous to the spinning of ping pong balls in a lottery machine. Say that each ping pong ball represents a chunk of knowledge, attitude, efficacy, or intention. On each ball lies a few strips of Velcro; the soft side. Inside the human psyche lies strips of the opposite, hard side of Velcro, which serve as potential motivational “receptors”. Some of the motivational ping pong balls may have resided in the system for years while others may have been more recently implanted through a health education program, clinical counseling encounter, or health communication campaign. Rather than attempting to predict which piece or pieces of motivation may “tip” the individual, from the chaotic perspective, the role of the health professional is to ensure the balls are kept spinning at various intervals and velocities to maximize the chances that they adhere to their receptors. When sufficient balls have adhered a tipping point may occur. Which balls or combination of balls may trip the motivational switch as well as when and why they may stick, are chaotic events that defy accurate prediction. From a non-linear perspective, the goal of health professionals may be to encourage wing flapping.”

The go-to way

From an interview with the author of a book on how peer pressure has the potential to transform the world in positive ways [emphasis mine]:

Why is there so much fear around connectedness? Some of the people in that group were afraid that other people would become busybodies and that they’d almost get too close for comfort.

I think there’s still a lot of resistance to the idea of solving problems in groups. Not with the idea of addiction anymore — I think those groups [like 12-step programs] have now become the go-to way of dealing with it — but with other problems [the resistance is still there]. America is still a very individualist society compared to most other places. We’ve structured a middle class suburban life that increases that sense of alienation. Your kids don’t play in a communal park — they go to the swing set in your backyard. But I think people are realizing that it’s not healthy to live that way, that we’d be happier if we were more connected.

Interesting…particularly for an approach to drug problems that takes so much flak.

This is especially interesting in the context of social contagion of drinking and other health problems.