Developing and evaluating collective motivational interviewing (CMI) with a social nexus paradigm for persons with drug addiction : a mixed methods case series study

Abstract

Concerned significant others (CSOs) typically play a supporting role for Persons with Drug Addiction (PDAs) in addiction counseling, which is well associated with better outcomes. Clinical strategies to prepare CSOs to better support PDAs in motivational interviewing (MI) have been overlooked. The present study had two core objectives to: (1) develop and evaluate a brief, collective motivation approach with low-hurdle to participate called Collective Motivational Interviewing (CMI), and (2) discern the active ingredients of its therapeutic effects. The CMI is based on the empirical approach of MI, extending the individual-focused practice to a social nexus paradigm. The PDAs can nominate CSOs to participate in the motivational process to reach achievable goals collectively. This doctoral study followed the guidelines of the Medical Research Council in the UK for developing and evaluating the CMI. The CMI consisted of three brief interview sessions including two sessions individually preparing the PDA and CSO for the third conjoint session. The outcome instruments went through a vigorous translation process according to the World Health Organization guidelines. The feasibility of the CMI was examined in the pilot study. The main study was a mixed-methods case series design to test the intervention in a cohort (N = 40) of 20 PDAs and their CSOs. The potential impacts of CMI were examined by measures at baseline, post-intervention, and 1-month and 3-month post-intervention. All clinical sessions were audio-recorded and four cases were randomly selected for fidelity review by two trained coders. The normality of data at the baseline was checked by Shapiro-Wilk test. Non-parametric Wilcoxon-signed-rank test and parametric ANOVA were employed for quantitative analysis, whereas a thematic analysis was conducted for the qualitative data. Impartiality of the findings was maintained through member checking, and data triangulation procedures. However, the small sample sizes, non-random sampling, and no control group may limit the generalizability and confirmation of the outcomes and the “real effects”. The results showed six PDAs had reduced drug use, and 10 maintained drug abstinence with the support of CSOs, whereas four PDAs remained unchanged or increased drug use. Overall, at the 3-month follow-up, drug use was reduced (p < .05), and social support was strengthened (p < .05), and PDAs motivation for change was enhanced (p < .01). Besides, PDAs (n = 12) and their CSOs provided feedback in the post-intervention interview, and six drug counselors as observers participated in the process evaluation using a nominal group technique. Four key therapeutic elements of CMI were identified: (1) guided exploratory process, (2) strengths perspective, (3) therapeutic alliance, and (4) collectiveness. This work contributes several new theoretical concepts: (1) modifying MI in a social nexus paradigm, (2) extending the four-process MI to the six-process CMI, (3) developing the Four-Quadrant Theory of Collective Motivation, and (4) expanding the Dual Process Cognitive Dissonance Theory to better describe the development of collective motivation. In summary, CMI is a promising therapeutic tool to motivate PDAs with the support of CSOs to achieve mutually agreed outcomes. Further development and evaluation with robust methodology are warranted. (499 words)