Case Management and Motivational Interviewing in the German Heroin Trial

1. Case Management and Motivational Interviewing in the German Heroin Trial Irmgard Vogt, Martina Schu, Martin Schmid, Wilfried Görgen, Hans Oliva Fachhochschule Frankfurt am Main/ FOGS, Köln

2. Case Management and Motivational Interviewing in the Heroin Trial • Case Management and Motivational Interviewing is introduced into the Heroin Trial as one variation of psychosocial support of clients • Case Management emphasises structure and an organisational framework, networking and cooperation with other agencies; Motivational Interviewing embraces motivational factors, style of interaction, collaboration with clients • The two concepts blend well as both of them have a long history in individual counselling and are related to each other • To facilitate comparison of results in a multicenter setting, implementation and documentation are standardised, and coaching of counsellors during trial is part of the standard procedure

3. Case Management: Background • CM has a long history in individual counselling • CM is a variation of a “client-centred” approach in a well structured setting, designed specifically for the care of people with complex problems • CM is target-orientated • CM is designed for long term interventions and geared to solutions and sustained support in a continuum of care • Case Managers work "in the field” making use of clients resources as well as organisational networks; in cooperation with clients they plan, organise and coordinate a needs-based, comprehensive and efficient package of care, crossing institutional and professional boundaries.

4. Case Management: Techniques • CM is well structured and organised along „stages“ or steps of the helping process • CM asks for networking and cooperation of (welfare) agencies and organisations • CM includes re-assessment and evaluation of the helping process and of its outcome • CM blends well with MI. However, CM underlines structure, MI counselling style and techniques. Mixing both requires a delicate balancing of form and content, structure and style of interaction

5. Model of Case Management and Motivational Interviewing

6. Case Management • CM has been evaluated in the USA, within the framework of a control study of drug addicts with complex problems (cf.: Ball & Ross 1991, Mejta et al. 1997) • Result: CM is more successful than "treatment as usual” • CM has been implemented in Germany as well (cf. Oliva et al. 2002), but not yet in comparative studies

7. Motivational Interviewing • MI has developed out of a client-centred counselling approach, integrating elements of motivational psychology and cognitive behaviour therapy • MI is based on the stages-of-change model • MI stresses the style of interaction between counsellor and client. Counselling techniques are tailored to facilitate the exploration of motivational conflicts of client and to support motivation to change

8. Stages of Change

9. Motivational Interviewing, Stages of Change

10. Motivational Interviewing: Basic Skills • Unconditional Acceptance - the counsellor accepts the client as a person regardless of his or her values, life-style or actual problems; he is respectful towards the client • Empathy - understanding another person‘s emotions and feelings from that persons frame of reference; the counsellor is warm, caring and interested in the client • Enhancing Self-efficacy in clients - the counsellor fosters hope and optimism in the clients’ capacities to change

11. Motivational Interviewing: Techniques • Showing interest in client via reflective listening and open-ended questions • Developing discrepancies between client’s current situation and hi/her hopes for the future • Avoiding to argue, moralise, blame and label • Avoiding interpretations - client’s statements are taken as such and not analysed for hidden meanings • Roll with resistance - instead of confrontation shift perspectives and reframe statements • Supporting self-efficacy - strengthen client‘s belief in change

12. Motivational Interviewing • MI was used and analysed in the USA in several efficacy studies, eg. in project MATCH (1998) • In the study, alcohol dependent clients were randomly assigned to 3 groups of intervention methods, one of it was MI. Results were monitored and treatment outcomes evaluated. Result: MI is an effective intervention method • MI is widely used in Germany, especially in counselling persons with alcohol problems (John et al. 1996, Kremer et al. 1999) and in short interventions

13. Case Management and Motivational InterviewingSteps to Standardization • Development of guidelines to Case Management and Motivational Interviewing - Manual for counsellors • Development of questionnaires and fact sheets to facilitate assessment, treatment planning, minutes etc. • Training’s of Case Managers in the trial in methods, techniques and use of questionnaires • Re-training’s of Case Managers 3 and 6 months after start of the trial • Coaching of Case Managers at work place

14. Case Management and Motivational Interviewing Steps to Standardization • Development of questionnaires and fact sheets • General information sheet for clients regarding Case Management and Motivational Interviewing • contract to collaboration while in trial • Client files and documents • Documentation of daily work schedule of Case Managers • Questionnaire of Generalised Competence Expectation • Final evaluation assessment sheet

15. Case Management und Motivational InterviewingSteps to Standardization • Client files and documents • Structured assessment forms regarding: patterns of drug use and abuse, general aspects of health, relationship to family members and friends, education and employment, actual income and debts, problems with the police and the judicial system, self-reported problems • Checklist of regional support system (e.g. counselling organisations and welfare agencies) and establishing a network according to the needs of the client • Forms for treatment plans and for conferences to discuss treatment plans • Re-assessment forms • Final evaluation form

16. Case Management und Motivational InterviewingSummary • The blending of CM and MI is suitable and offers a wide range of methods and techniques to psychosocial care for substance dependents • The combination of CM and MI is tailored to care for people with longstanding and complex problems including clients with dual diagnosis • Steps to standardise the helping process allow for a control of the number and type of interventions in multicenter settings

17. Content Motivational stage Techniques Admission and first session, explanation of the concept, establishing collaboration and agreement to work together Precontem-plation Reflective listening, open-ended questions, explore and support clients needs, provide information of study, regional support system etc. Assessment, start to network with counselling and other related agencies in the region and with personal resources of client Contemplation Reflective listening, open-ended questions, evoke and work with discrepancies, affirm, give feedback, summarise. First assessment of clients‘ motivational stage in different areas of interest; mapping of counselling and welfare agencies in the region; if appropriate, introduce diagnostic results (triangulation); visit client at home. Case Management and Motivational Interviewing

18. Content Motivational stage Techniques Assessment and definition of target problems. Outlining a treatment plan Contemplation Preparation Reflective listening, open-ended questions, evoke and work with discrepancies, elicit self-motivational statements, affirm, give feedback, summarise, planning of next step, reframe, explore alternatives and choices, support self-efficacy. If appropriate, organise conference on treatment plan with colleges of related agencies Working along treatment plan Preparation Action Reflective listening, open-ended questions, affirm, elicit self-motivational statements, reframe, advocacy, feedback, summarise. Introduce relapse prevention Case Management and Motivational Interviewing

19. Content Motivational stage Techniques First preliminary evaluation of results.If necessary, Re-Assessment and re-arrangement of treatment plan. Strengthening collaboration with colleges of related agencies, networking with new actors Contemplation,Praparation, Action Reflective listening, open-ended questions, affirm, elicit self-motivational statements, give feedback, reframe, explore alternatives and choices, support self-efficacy, intensify cooperation with other institutions Working along treatment plan. Process evaluation Action Maintenance Reflective listening, open-ended questions, affirm, elicit self-motivational statements, give feedback, explore alternatives and choices, support self-efficacy, increase level of clients self management Case Management and Motivational Interviewing

20. Content Motivational stage Techniques Outcome evaluation and termination of counselling Maintenance Termination Reflective listening, open-ended questions, affirm, feedback, summarise, support self-efficacy, increase level of clients self management, prepare to finish counselling Case Management and Motivational Interviewing

21. Content Motivational stage Techniques Relapse prevention Relapse Relapse prevention package, crisis intervention, reflective listening, open-ended questions, provide information, planning of next step Case Management and Motivational Interviewing