‘Connection’ in the First Interview Gilles Fleury MD University of Montreal Health Center May 5 th 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 System Brain stem Thalamocortical system Appetite Sex Defense Categorization Sophisticated response « value-category » Memory (salience) - Gerald Edelman Effective Connectivity

« 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, (1980). Carroll, K., « Integrating Psychotherapy and Pharmacotherapy to Improve Drug Abuse Outcomes », Addictive Behaviors, vol. 22, no 2, , Chambers A et al., « Developmental Neurocircuitry of Motivation in Adolescence: A Critical Period of Addiction Vulnerability », Am J Psychiatry 2003; 160: 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 Hughes JR et al., « Conventional and Quantitative EEG in Psychiatry », J Neuropsychiatry Clin Neurosci 11: , May 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, (2000). Luborsky, L. and al., « Establishing a Therapeutic Alliance with Substance Abusers », NIDA Research Monograph, 165: , 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) Miller, WR, Rollnick, S, Motivational Interviewing : preparing people for change, 2ième Édition, The Guilford Press, New York, 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, Prichep, LS et al., « Prediction of Treatment Outcome in Cocaine Dependant Males Using Quantitative EEG », Drug and Alcohol Dependence 54, (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), 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)

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