Motivational Interviewing

Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve ambivalence (Rollnick & Miller,1995).

Defined by Miller and Rollnick (1991) motivational interviewing (MI) has become a standard counseling approach used in many different settings. The Motivational Interviewing website ( www.motivaionalinterview.org ) lists studies reviewing the efficacy of MI in areas as diverse as drug and alcohol abuse to diet and exercise or gambling. The core beliefs behind MI are that the motivation to change comes from the client. Motivation to change can not be imposed on client. Also, the client is the one who has to resolve any issues they have regarding change. The interview style is non-confrontational. The counselor does not try to persuade or coerce the client to change, instead expressing acceptance and affirmation. Throughout the process the clients’ freedom of choice and behavior is emphasized.

The literature regarding the effectiveness of MI or adaptations of MI (AMI) is vast. Burke et al (2003) performed a meta-analysis of 30 controlled clinical trials investigating MI and found that when compared with a placebo or no-treatment group, MI returned moderate effects. When compare with other active treatments the results were equivalent. The results did not support the use of MI’s or AMI’s for smoking or HIV-risk behaviors. The authors point out that the AMI’s evaluated were as effective as other treatments, but were conducted in much less time. AMI’s could very well be a cost-effective and successful model of counseling. Further research is needed to address that issue.

There are a number of articles that focus on the ability of MI or AMI techniques to increase access to and retention in alcohol and other drug abuse treatment. Saunders et al (1995) performed a controlled clinical trial with 122 drug users attending a methadone clinic. Patients were randomly assigned to the MI group or an educational (control) group. At the 6 month follow-up, 40% of patients had dropped out of the program, although they were more likely to be from the educational group than the MI group, 49% to 30%.

Carroll et al (2001) performed a study where 60 individuals referred to a substance abuse assessment were randomly assigned to a standard evaluation or an evaluation using MI techniques. Patients who attended the evaluation + MI were more likely to attend an additional treatment session, 59% to 29%. This study also supports the idea that MI techniques are a cost effective method for enhancing treatment as these effects were achieved through minor changes to the clinicians’ style.

Sinha et al (2003) found that a MI technique coupled with vouchers received for session attendance improved retention among young probation-referred marijuana users. The vouchers could potentially value $120 if patients attended all 3 sessions. The study found that 65% of patients attended all 3 sessions within 28 days which compares favorably with the engagement rate historically found for this population at this clinic, 49%. The authors point out that the population studied was probation-referred, which may experience a higher level of external motivation to attend treatment.

Mullins et al (2004) addressed this issue by performing a study to determine the efficacy of MI with coerced populations. The study focused on 71 women referred to treatment by child welfare due to prenatal drug use. The women were randomly assigned to receive either three MI sessions or receive educational materials which included a home visit. The results show that for both the MI and educational group, better treatment engagement and retention was related to the number of sessions attended. These results were consistent with the findings of Burke et al (2003) discussed earlier. The authors point out that with a legally coerced population, the effects of MI may be diminished and call for further research on this topic.

As shown by the research of Sinha et al (2003) the effect of providing incentives may have a positive impact on treatment engagement and retention. Higgins et al (1994) evaluated a study in which 40 cocaine abusing individuals were randomly entered into treatment by itself or treatment with a voucher program. Patients in the experimental group were eligible to receive vouchers exchangeable for retail items if they submitted cocaine-free urine specimens during weeks 1-12 of treatment. Both groups were treated the same during weeks 13-24 (no vouchers). 75% of the patients who received vouchers completed 24 weeks of treatment compared to a 40% completion rate for the control group. There have also been several studies performed that relate the use of voucher systems with increased cocaine abstinence but do not directly refer to increases in engagement and retention (Kirby et al, 1998; Silverman et al, 1996; Silverman et al, 1998).

The use of incentives is also discussed in the Outreach section of this report. Empirical evidence points to the effectiveness of using incentives like free treatment (Jackson et al, 1989; Sorensen et al, 1993; Maddux et al, 1994; Wells et al, 1994; Booth et al, 2004) or providing transportation to treatment (Friedmann et al, 2001; Booth et al, 2004).