1. Adoption of Motivational Interviewing/Motivational Enhancement Therapy Joseph Guydish PhD, Sarah Turcotte Manser MA, Martha A. Jessup RN PhD, Barbara Tajima EdM Institute for Health Policy Studies, University of California, San Francisco San Francisco This work was supported by National Institute on Drug Abuse (R01 DA-14470), by the California-Arizona research node of the NIDA Clinical Trials Network (U10 DA-105815), and by the NIDA San Francisco Treatment Research Center (P50 DA-09253) American Psychological Association August 18, 2007

2. MI/MET CTN Trials NIDA Clinical Trials Network (CTN) NIDA Clinical Trials Network (CTN) Randomized Clinical Trial of Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET) Randomized Clinical Trial of Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET) 11 sites (MI=5, MET=6) 11 sites (MI=5, MET=6) 884 participants (MI=423, MET=461) 884 participants (MI=423, MET=461) Data points: baseline, 28 day, 84 day Data points: baseline, 28 day, 84 day

3. MAP Study Methods Studied adoption of MI/MET in clinics where it was tested Studied adoption of MI/MET in clinics where it was tested 5 sites: MI=3, MET=2 5 sites: MI=3, MET=2 29 Key informant interviews 29 Key informant interviews Interviews on average 4.25 months after the treatment phase of the trials Interviews on average 4.25 months after the treatment phase of the trials

4. Organizational Change Organizational Structure and Culture De Smet (1998) Burke & Litwin (1992) Organizational Readiness for Change Backer (1995) Attitudes Towards Research Lamb et al. (1998) Perception of Intervention Backer (1991) Rogers (1995a) Resources Rogers (1995b) Dissemination of Study Results Sorensen et al (1998) Brown (1998)

5. LevelNumber (n=29) Intervention Developer1 Funder1 Lead Investigator3 Regional Investigator7* Clinic or Program Director5† Clinical Supervisor2 Clinician10 Multi Levels of Assessment * Includes project management, data management, and training activities † One clinic level supervisor could not be located and two also had the role of clinic director. Interviews were completed 4 -13 months after treatment phase completion

6. Data Analysis Organizational functioning Organizational functioning Theoretical framework informed key domains Theoretical framework informed key domains Closed coding developed using analytic categories Closed coding developed using analytic categories Concurrent data collection and analysis Concurrent data collection and analysis Analytic memos, team discussion, and on-going comparison of the data Analytic memos, team discussion, and on-going comparison of the data

7. Local Training Model [William Miller] has been doing this motivational interviewing network of trainer thing for years … once a year he offers this big training of trainers… it's a world-wide network. So, being able to tap into that made a huge difference… in terms of … sustainability... and then that trainer was available to train the... supervisor.... the idea [is] that it's a model that builds in sustainability if you've got somebody there who can supervise the treatment... MI/MET Elite

8. I never had heard the term ‘motivational interviewing’ until... a conference... we saw something...that fit our philosophy about how you treat people. And, we trained our staff... in [MI]. [We]... did a chapter a month, had different people leading the discussions each time we met, and assigned people reading time and reduced some of their workload in order to give them time to do it... and then challenged the staff... to operationalize it... and come up with a model for doing treatment that would work better than what we were doing... Clinic Director A Champion

9. ... I quite frankly did not foresee some of the problems that we would have getting this [trial] together. …I think clear messages [were needed] from high-level administrators…they needed to pull everyone together. Clinic Research Supervisor Difficulty Implementing the Trial

11. How is Adoption Measured ? You never really know how people practice, when they’re alone in a room. Clinic Director And at times, they may forget that that's a tool that they have... I hope when you talk to them, that the MI counselors are gonna say, "Yeah, that was a good thing for me. I got a lot out of that, and I use it."... Do I absolutely know that? Clinical Supervisor

12. A Range of Adoption Outcomes No Adoption IntentionToAdopt Tool box Adoption Partial Adoption Adoption Re-invention, Adaptation

13. NA * No Adoption IntentionToAdopt Tool box Adoption Partial Adoption Adoption Re-invention, Adaptation MI/MET Site 1 Site 2 Site 3 Site 4 Site 5 Adoption of MI/MET at Clinic Sites (n=5) * No opportunity to adopt

14. Adoption in Prior Studies Fals-Stewart study of Brief Couples Therapy (BCT) in 5 sites Fals-Stewart study of Brief Couples Therapy (BCT) in 5 sites  1 site adopted Study of Matrix adoption in 6 sites Study of Matrix adoption in 6 sites 1 site adopted  1 site adopted Study of MI/MET in 5 sites Study of MI/MET in 5 sites 2 sites adopted  2 sites adopted Rate of Adoption: 25% Rate of Adoption: 25%

15. Conclusions Post clinical trials rate of adoption is low Post clinical trials rate of adoption is low Need infrastructure to support adoption Need infrastructure to support adoption Determine what kind of implementation is wanted (toolbox, partial, full, adaptation) Determine what kind of implementation is wanted (toolbox, partial, full, adaptation) Determine method to measure adoption Determine method to measure adoption