‘Connection’ in the First Interview
Gilles Fleury MDUniversity of Montreal Health Center
May 5th 2005
Objectives
To formulate an understanding of Motivational Interviewing in order to increase treatment adherence
To discuss the concept of motivation as a self-regulatory function
To present a possible research project in Addiction Psychiatry
Introduction
Non-compliance and Treatment Resistance in general practice the ‘difficult’ patient
Treatment outcome and drop-out rate in substance abuse
Integration of Psychotherapy and Pharmacology to improve outcomes (Carroll, 1997)
A pill to increase men’s commitment?
Genetically modified moles become « commited to the female and like it »
The concept of Therapeutic Alliance
A « Working Relationship »: Goals Tasks Bond
- Bordin (1976, 1980)
Therapeutic Alliance
« Helping relationship »
- Petry NM, Bickel WK (1999)
How to improve the alliance?
Support patient’s wish to achieve his/her goals
Offer understanding and acceptance of patient
Develop a liking for the patient Convey a realistically hopeful attitude that the
treatment goals are likely to be achieved Recognize when appropriate that the patient
has made progress toward the goals - Luborsky (1984, 1993)
Motivational Interviewing (MI)
4 Principles: 1) Express Empathy
2) Develop Discrepancy
3) Roll with Resistances
4) Support Self-Efficacy - Miller WR, Rollnick S (2002)
Strategies in the first session: Open Questions Reflective Listening Affirm Summarize
Motivational Interviewing
Mentalization:« My mother thinks of me as thinking, therefore I exist »
- Peter Fonagy
Motivational Interviewing
Use of Evocation Constructive behavior change seems to arise
when the person connects it with something of intrinsic value, something important, something cherished.
- Miller WR, Rollnick S (2002)
Motivation as Interpersonal Process Helps to resolve ambivalence
Summary
Usefulness of psychotherapeutic strategies to increase adherence
Specific ways to ‘connect’ with patient to promote reflection on new motivated behaviors
Neurobiology of Motivation
Definition: … brain activity that processes « input »
information about the internal state of the individual and external environment and determines behavioral « output ».
- Dorman and Gaudiano (1998)
Effective Self-Regulation: Higher-order processing designed to
organize behavior to maximize survival
CNS organization
Limbic SystemBrain stem
Thalamocortical system
AppetiteSex
Defense
CategorizationSophisticated
response
« value-category »Memory(salience)
- Gerald Edelman
EffectiveConnectivity
« Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period
of Addiction Vulnerability »- Chambers RA et al. (2003)
Impulsivity and Suboptimal Decision making: Normative traits of the developing brain May reflect the relative imbalance
between: Dopamine promotivational system 5-HT inhibitory system
Prefrontal cortex abnormalities associated with increased risk of developing Substance Use Disorder
Self-Regulation deficit ? vs Disconnectivity?
« Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period
of Addiction Vulnerability »- Chambers RA et al. (2003)
Research Project
A prospective study Population: ETOH or Cocaine
Dependence Goal:
Study the effect of the first session of Motivational Interviewing On Treatment Adherence On brain function (qEEG)
Research Project
Possible predictors of Treatment Adherence: Therapeutic Alliance ‘Brain dysfunction’ (disconnectivity?)
Hypothesis: Effective MI helps the patient switch to a
better self-regulatory state, with higher motivation and eventually higher adherence to treatment
Research Project
Method: Treatment group:
qEEG + MI + qEEG Control group:
Treatment as usual (no MI) and 2 qEEG
Main measures: qEEG patterns before and after MI Treatment adherence
« Prediction of treatment outcome in cocaine dependent males using quantitative EEG »
- Prichep et al. (1999)
N = 35 male subjects 20 min resting EEG, eyes closed
5 – 14 days after last cocaine use Length Of Stay in Treatment (LOST)
Do possible homogeneous EEG subtypes predict LOST?
Cluster 1: Increased relative beta activity
87,5% remained in Tx ≤ 21 weeks Cluster 2:
Siginificant excess of power in the alpha f 84,2% remained in Tx ≥ 21 weeks
« Prediction of treatment outcome in cocaine dependent males using quantitative EEG »
- Prichep et al. (1999)
Conclusion
References
Alper M. et al., « Electroencephalographic Analysis: A Methodology for Evaluating Psychotherapeutic Process », Psychiatry Research, 2, 323-329 (1980).
Carroll, K., « Integrating Psychotherapy and Pharmacotherapy to Improve Drug Abuse Outcomes », Addictive Behaviors, vol. 22, no 2, 233-245, 1997.
Chambers A et al., « Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period of Addiction Vulnerability », Am J Psychiatry 2003; 160: 1041-1052.
Hoffman DA et al., « Limitations of the American Academy of Neurology and American Clinical Neurophysiology Society Paper on QEEG », J Neuropsychiatry Clin Neurosci 11:3, Summer 1999.
Hughes JR et al., « Conventional and Quantitative EEG in Psychiatry », J Neuropsychiatry Clin Neurosci 11: 190-208, May 1999.
Lebeaux, D., « The Role of the Conscious Therapeutic Alliance in Davanloo’s Intensive Short-Term Dynamic Psychotherapy », Int. J. Intens. Short-Term Dynamic Psychoth, 14, 39-48 (2000).
Luborsky, L. and al., « Establishing a Therapeutic Alliance with Substance Abusers », NIDA Research Monograph, 165: 233-244, 1997.
References
Martino, S and al., « Dual Diagnosis Motivational Interviewing: a modification of Motivational Interviewing for substance-abusing patients with psychotic disorders », Journal of Substance Abuse Treatment 23 (2002) 297-308.
Miller, WR, Rollnick, S, Motivational Interviewing : preparing people for change, 2ième Édition, The Guilford Press, New York, 2002.
Petry, NM, Bickel, WK, « Therapeutic Alliance and Psychiatric Severity as Predictors of Completion of Treatment for Opioid Dependence », Psychiatric Services, February 1999, vol. 50, no.2 , 219-227.
Prichep, LS et al., « Prediction of Treatment Outcome in Cocaine Dependant Males Using Quantitative EEG », Drug and Alcohol Dependence 54, 35-43 (1999).
Takahashi, et al., « Changes in the EEG and Autonomic Nervous activity during meditation and their association with personality traits », Int. J. of Psychophysiology 55 (2005), 199-207.
Winterer, G et al., « Quantitative EEG predict relapse in patients with chronic alcoholim and points to a frontally pronounced cerebral disturbance », Psychiatry Research 78 (1998) 101-113.
Woody, GE and al., « Psychotherapy with Opioid-Dependant Patients », Psychiatric Times, Nov. 1998, vol 15, no 11.
Woody, and al., « Psychotherapy in community methadone programs: a validation study », American Journal of Psychiatry, vol 152, no 9, 1302 (1995).
References
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