The futility of brief interventions for illicit and prescription drug addiction—or is it?

An interesting article in the online journal, Medscape (see http://www.medscape.com/viewarticle/829612) suggests that brief interventions with those addicted to illicit substances and prescription pain medications may be futile.  I found this interesting, especially in light of my long history providing “brief interventions” with college students regarding all manner of high-risk behavior, not the least of which was drinking and other drug use. 

As disheartening, at first glance, as the cited research studies may be, I am not too concerned about these results.  First, although both cite the use of Motivational Interviewing (MI), neither seems to have truly applied MI as designed and it is questionable how Screening-Brief Intervention, Referral to Treatment (S-BIRT)…or what is now being referred to as SBI, Screening and Brief Intervention…was employed.  There is a literature that suggests the role of the interviewer as opposed to the use of MI as a technique alone affects the likelihood of movement as the result of a sessions(s); no matter how adroit the practitioner in the application of MI technique, if the individual using MI is “stiff,” distant, or otherwise “unavailable” to the individual being counseled, that individual is not likely to engage in “change talk."  As there is little indication of the skill level of those conducting the single session MI interviews in the cited research articles—and admittedly I have yet to read either study in its original form—that could affect the reported (lack of) results as well.

Returning to my opening comment regarding a question about a true (accurate?) use of MI, it is clear in Miller and Rollnick’s newer 3rd Edition of their text, Motivational interviewing: Helping people change (2013, Guilford Press), MI is more about arranging conversations so individuals talk themselves into change than about actually motivating the desired change.  This suggests that a “single session” on MI, even if done correctly and by a practitioner who is both knowledgeable and effective, may not be sufficient to actually result in immediate reductions in use or arrests, etc.  MI is not an “action stage of readiness to change” (see http://www.uri.edu/research/cprc/TTM/StagesOfChange.htm) intervention so much as a means by which practitioners can increase the likelihood that “pre-contemplative” and “contemplative” changers move in the direction of readiness to change, AKA, towards taking “action.”  Assessing the stages of readiness to change of randomly selected individuals and then exposing them to MI and reassessing their readiness to change might produce a more meaningful measure of MI’s efficacy.

Miller & Rollnick acknowledge that MI does not change behavior so much as facilitate change talk in the individual being engaged.  They actually argue that practitioner do not change behavior, in that all change is internal and many individuals will actually change their behavior, w/o treatment, once having come to a point where the tipping point in their ambivalence is reached and continuing old behavior becomes more of a hassle than instigating new.  MI is about hastening the advent of this “tipping point” rather than getting folks to change their substance using behavior.

In short, these research studies are interesting, to me, but not because they disparage MI so much as underscore the importance of understanding the difference between the “spirit” of MI and its practice as well as recognizing that MI is not so much a “velvet club” by which a “motivate” resistant changers as a “shoe horn” that can facilitate the potential changer’s “easing into” change by recognizing that it is a personal choice resulting from a simple cost-benefit analysis of the facts regarding current patterns of behavior.

What do you think?

Dr. Robert