1. ‘Connection’ in the First Interview Gilles Fleury MD University of Montreal Health Center May 5 th 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 of Therapeutic 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: 1)Express Empathy 2)Develop Discrepancy 3)Roll with Resistances 4)Support Self-Efficacy - Miller WR, Rollnick S (2002)

9. 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

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

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. 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)

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. 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)

21. Conclusion

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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 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.

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