‘Connection’ in the First Interview

1. ‘Connection’ in the First Interview Gilles Fleury MD University of Montreal Health Center May 5th 2005

2. 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

3. 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)

4. A pill to increase men’s commitment? • Genetically modified moles become « commited to the female and like it »

5. The concept ofTherapeutic Alliance • A « Working Relationship »: • Goals • Tasks • Bond - Bordin (1976, 1980)

6. Therapeutic Alliance « Helping relationship » - Petry NM, Bickel WK (1999)

7. 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)

8. Motivational Interviewing (MI) 4 Principles: • Express Empathy • Develop Discrepancy • Roll with Resistances • Support Self-Efficacy - Miller WR, Rollnick S (2002)

9. Motivational Interviewing • Strategies in the first session: • Open Questions • Reflective Listening • Affirm • Summarize Mentalization: « My mother thinks of me as thinking, therefore I exist » - Peter Fonagy

10. 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

11. Summary • Usefulness of psychotherapeutic strategies to increase adherence • Specific ways to ‘connect’ with patient to promote reflection on new motivated behaviors

12. 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

13. CNS organization Categorization Sophisticated response Thalamocortical system « value-category » Memory (salience) Effective Connectivity Limbic System Brain stem Appetite Sex Defense - Gerald Edelman

14. « 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

15. « Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period of Addiction Vulnerability »- Chambers RA et al. (2003) • Prefrontal cortex abnormalities associated with increased risk of developing Substance Use Disorder • Self-Regulation deficit ? • vs Disconnectivity?

16. 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)

17. 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

18. 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

19. « 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?

20. « Prediction of treatment outcome in cocaine dependent males using quantitative EEG »- Prichep et al. (1999) • 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

21. Conclusion

22. 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.

23. References • Martino, S and al., « Dual Diagnosis Motivational Interviewing: a modification of Motivational Interviewing for substance-abusing patients with psychotic disorders », Journal of Substance AbuseTreatment 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.

24. References • 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).