THEMATIC REVIEW Theotivational motivationalhallo helloMANNERS MATTER PART 3 THE With its empathic style, motivational interviewing seems the ideal way to engage new clients in treatment, a psychological handshake which avoids gripping too tightly yet subtly steers the patient in the intended direction. And often it is, as long as we avoid deploying a mechanical arm. by Mike Ashton of THE MANNERS MATTER SERIES is about how services has been on reinforcing motivation, an amalgam of Thanks to Bill Miller, Jim can encourage clients to stay and do well by the acknowledging a problem, wanting help, and resolv- McCambridge, Dwayne Simpson, 5 Don Dansereau, Gerard Connors, manner in which they offer treatment. Parts one and ing that treatment is the help you need. and John Witton for their comments. two dealt with practical issues like reminders, trans- Once thought of as something the patient either Thanks also to Bill Miller, Janice port and childcare. Even at this level, more is in- did or did not have, motivation is now seen as a fluid Brown, Terri Moyers, Paul Amrhein, John Baer and Damaris Rohsenow volved: respect; treating people as individuals; state of mind susceptible to influence. Of the ways for help with obtaining and conveying concern and caring. to exert this influence, motivational interviewing is interpreting their work. Though they 6 have enriched it, none bear any From here on, relationship issues take centre by far the best known. It qualifies for this review responsibility for the final text. stage. Relegated by medicine to the bedside man- because it is more about how to relate to the client ners which lubricate the interaction while technical than what to say or do.8 treatments do the curing, in psychological therapies, We can see where it fits in through a model bedside manners are the treatment, or a large part of which encapsulates research on the processes under- it.1 2 3 We start with how to say hello, and specifi- lying effective treatment and the points where these cally with motivational interviewings role in prepar- could be promoted by interventions A model of ing clients for treatment (induction), the role for treatment, p. 24.9 Motivational interviewing is among which Bill Miller created it.4 the Readiness interventions in the top left hand corner. Its importance is that the more motivated the MOTIVATION CAN BE MOVED patient is, the deeper their initial participation. This Induction strategies aim to prime the client for is linked to staying longer which in turn is linked to treatment by telling them what to expect, addressing better outcomes.10 11 12 Via this chain, if motivational concerns, enlisting support, and strengthening interviewing does boost motivation, it should in- psychological resources. But most of all, the focus crease the effectiveness of subsequent treatment. Positive verdict from aggregated research Before analysing individual studies (numbered from enth and tenth in their league tables of evidence of 1 to 19i), well take what we can from analyses which effectiveness, outranking many treatments which have amalgamated these studies. Conclusively, these take longer and cost more. Other analyses have tell us there is something here worth investigating. confirmed this conclusion, and added that the ben- From diabetes to problem drinking, high blood efits were significantly greater when motivational pressure and poor diet, motivational approaches help approaches were an induction to substance misuse patients adhere to treatment and change their life- treatment rather than a standalone therapy.15 16 18 19 styles more effectively than usual clinical advice.13 A later analysis added two further observations.20 For drinking in particular, it has a better research First, that the gains from motivational induction are record than practically any other treatment.14 15 16 greater because they persist over at least the next 12 But these omnibus verdicts conflate very differ- months while those from standalone therapies de- ent scenarios. For current purposes, the ideal analy- cay. Second, and contrary to expectations, therapists sis would focus on people seeking treatment rather had less impact when they followed a manual. This than identified through screening, and then on findings far-reaching implications are explored later induction studies rather than studies of motivational Is it dangerous to follow the manual?, p. 28. interviewing as a treatment in its own right. It would The final analysis focused on turning up for and then assess whether treatment participation was sticking with treatment or aftercare.21 Most of the productively deepened by motivational preparation. studies it pooled were of substance misuse. On the None precisely fit the bill, but some come close. basis that 12 found significant advantages for moti- vational interviewing, five that it was as effective as STRONGEST RECORD IN INDUCTION STUDIES other approaches, and just four found no benefits, Two analyses take us part way there.14 17 Among the authors declared themselves cautiously optimis- drinkers known or presumed to be seeking treat- tic. Though the weight of the evidence was positive, ment, these ranked motivational approaches elev- in three of the substance misuse studies (3, 6 & 10) 2005 ISSUE 13 DRUG AND ALCOHOL 23 THEMATIC REVIEW and in another not in the review,25 motiva- duction approach would do as well or better, approaches,19 or that it improved outcomes tional induction had no impact on starting including feedback in another style. Then by enhancing engagement with treatment. or sticking with treatment. The reviewers there were the negative studies and, for To get more of a grip on these loose argued that retention was already so good some, no convincing explanations why ends, the individual studies in these analyses that there was little room for improvement, motivational interviewing failed in these but and several later studies were analysed in but in two studies (6 & 10) this does not not in others. Finally, we have greater confi- depth Get the full story, p. 26. What follows seem to have been the case. dence that one thing causes another when focuses on the patterns which emerged. we can see the levers connecting the two, yet Rather than definitive conclusions, the LOOSE ENDS the reviewers found little evidence that interpretations offered here are an attempt Of the loose ends left by these analyses, motivational interviewing actually did to make sense of these patterns and to rec- loosest of all was whether some other in- stimulate motivation more than alternative oncile seemingly inconsistent results Albuquerque air: the first studies of drinkers The earliest trials of motivational interview- (when the cap fitted) dubbing patients ened the profile of the therapists interper- ing were conducted by Bill Millers team at alcoholics. As expected, the empathic style sonal style, seeming to confirm that the style Albuquerque in New Mexico. While thera- did result in greater reductions in drinking, mandated by motivational interviewing was pists had the benefit of expert tuition and but the differences were small and fell short preferable to confrontation. The stage was oversight from the approachs originator, as of statistical significance. set for trials of the approach in its intended yet there was no manual for them to follow. The reason may have been that in prac- role as a prelude to further treatment. tice the therapists did not implement radi- PROMISING STANDALONE INTERVENTION cally distinct approaches. Only when the STARTLING IMPACT IN INDUCTION STUDIES First it was tried as a standalone brief inter- focus was shifted to how they and their In 1993 results were published from the first vention combined with feedback from the clients actually behaved did clear and signifi- trials of motivational interviewing as a prel- Drinkers Check-up, a battery of tests of cant relationships emerge. The more the ude to respectively in- and out-patient treat- alcohol use and related physical and social therapist had confronted (arguing, showing ment. In contrast to the check-up studies, problems. Though concerned enough to disbelief, being negative about the client), patients had arrived for treatment via nor- respond to ads for the check-up, participants the more the client drank a year later. The mal referral routes and were much heavier were not the highly dependent alcoholics same was true of resistant client behaviours drinkers and more severely dependent. normally seen at treatment services. like interrupting, arguing, or being negative In both trials, a non-directive, one-on- about their need to or prospects for change. one motivational session preceded consider- Comparing immediate against delayed These client and therapist behaviours ably more directive 12-step based group 1 motivational feedback suggested that were closely related. For motivational inter- therapy.21 There was a real chance one this approach could motivate reduced viewing, the favoured interpretation is that would undermine the other, but the oppo- drinking and treatment entry among this when therapists departed from its non- site happened. Given that it was a brief type of client.27 The non-stigmatising offer confrontational style, clients were provoked prelude to more extended treatment, moti- of a check-up seemed to enable many to in to hitting back or withdrawing. The vational feedback caused startlingly large take a first (if often incomplete) step towards pattern of results suggests this was at least reductions in post-treatment