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Pragmatic case study analyses of Motivational Interviewing with depressed Latinos

Dissertation
Author: Ariana Prawda
Abstract:
Relatively little research has been conducted on improving adherence to treatment for Latino patients. Given the changing demands in the field of Latino mental health and the difficulties of treatment engagement and treatment retention with Latinos, finding effective mental health interventions is of utmost importance. The following study analyzes Motivational Interviewing (MI) techniques that have been used with depressed Latinos in an effort to increase their adherence to antidepressant medication and improve symptoms of depression. The analysis consists of a series of pragmatic case studies, which are intended to capture the contextual factors that contribute to either the success or failure of the MI intervention in facilitating medication compliance and that contribute to the manner in which psychological interventions can be adapted to special populations. The MI intervention involved two sessions delivered within a two-week time period and one booster session delivered approximately two months later. Throughout their participation in the study, participants were monitored with regard to their level of depression, motivation to adhere to their antidepressive medication treatment, and actual compliance in taking their antidepressant medication. In total, three subjects from the research study's database were selected for case study analysis: one who was found to have a positive outcome, one who was found to have a negative outcome, and one who was found to have mixed results with the MI intervention. The results suggest that while Motivational Interviewing has the potential to work as a treatment-enhancing intervention, its success in producing behavioral change largely depends on how well the techniques are adjusted to the individual's stage of change.

TABLE OF CONTENTS PAGE ABSTRACT...............................................................................................................ii ACKNOWLEDGEMENTS.......................................................................................iii LIST OF TABLES.....................................................................................................vi LIST OF FIGURES....................................................................................................vii CHAPTERS I. CASE CONTEXT AND METHOD..................................................1 The Rationale for Selecting These Particular Clients........................4 The Methodological Strategies Employed for Enhancing the Rigor of the Study........................................................................5 The Clinical Setting in Which the Case Took Place..........................7 Sources of Data Available Concerning the Client.............................7 Confidentiality...................................................................................8 II. THE CLIENTS..................................................................................9 Lupe, a Client with a Positive Outcome............................................9 Maria, a Client with a Negative Outcome..........................................9 Ana, a Client with a Mixed Outcome................................................10 III. GUIDING CONCEPTION, WITH RESEARCH AND CLINICAL EXPERIENCE................................................................11 Guiding Principles of Motivational Interviewing..............................12 Nuts and Bolts of Each Session.........................................................13

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Adaptations of Motivational Interviewing for a Latino Population...............................................................................16 Cultural Values......................................................................16 Outreach Efforts ....................................................................17 Dichos....................................................................................18 IV. ASSESSEMENT OF THE CLIENT’S PROBLEMS, GOALS, STRENGTHS, AND HISTORY........................................................19 Lupe...................................................................................................20 Background............................................................................20 History....................................................................................20 Status at Intake.......................................................................22 Maria..................................................................................................23 Background............................................................................23 History....................................................................................24 Status at Intake.......................................................................25 Ana.....................................................................................................27 Background............................................................................27 History....................................................................................28 Status at Intake.......................................................................28 Quantitative Data for the Three Clients.............................................30 V. FORMULATION AND INTERVENTION PLAN...........................31 General Formulation across the Three Clients...................................31 Specific Aspects of the Formulation for Each Client........................32

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Lupe.......................................................................................32 Maria......................................................................................32 Ana.........................................................................................33 Intervention Plan................................................................................33 VI. COURSE OF MOTIVATIONAL INTERVIEWING INTERVENTION..............................................................................35 Lupe...................................................................................................35 First Session...........................................................................35 Second Session.......................................................................38 Maria..................................................................................................42 First Session...........................................................................42 Second Session.......................................................................47 Endpoint Assessment.............................................................51 Booster Session......................................................................51 Ana.....................................................................................................54 First Session...........................................................................54 Second Session.......................................................................59 Booster Session......................................................................63 VII. THERAPY MONITORING AND USE OF FEEDBACK INFORMATION................................................................................68 Symptom Monitoring.........................................................................68 Feedback Delivery for the Patient......................................................68 Feedback Delivery for the Clinician..................................................69

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VIII. CONCLUDING EVALUATION OF THE THERAPY PROCESS AND OUTCOME............................................................70 Lupe’s Positive Outcome...................................................................70 Maria’s Negative Outcome................................................................71 Ana’s Mixed Outcome.......................................................................73 Cross Comparison of the Three Cases...............................................75 The Participant’s Readiness for Change................................75 Factors Associated with Medication Adherence and the Reduction of Depression........................................................77 Conclusion.........................................................................................78 REFERENCES..........................................................................................................85 APPENDIX A Specific Motivational Interviewing Techniques................................89

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LIST OF TABLES PAGE Table # 1Depression Scores across Assessment Periods for All Three Cases...........80 Table #2 Depression Means and Standard Deviations for Treatment Group Across Assessment Period..........................................................................80 Table #3 Percentage of Adherent Days for All Three Cases.....................................81 Table #4 Group Means and Standard Deviations for Treatment Condition at T2, T3, and Total Adherence.................................................81 Table #5 Motivational Interviewing Treatment Integrity (MITI) Scales for Participants across MI Sessions.................................................82 Table #6 Treatment Plan for MI Session 1: Motivational Enhancement Phase........82 Table #7 Treatment Plan for MI Session 2: Strengthening Commitment Phase.......83 Table #8 Importance, Confidence, and Readiness Ratings for Each Case Throughout the Study..................................................................................83

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LIST OF FIGURES PAGE Figure #1 Changes in Depression Scores across Assessment Periods.......................79 Figure # 2 Percentage of Adherent Days for All Three Cases...................................81 Figure #3 Participants Progression through the Randomized Controlled Trial.........84

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CHAPTER I Case Context and Method Major depressive disorder has become a significant public health problem. The National Comorbidity Survey Replication reports that its lifetime prevalence has reached 16.2% and 6.6% in a 12-month period (Kessler et al., 2003). The National Institute of Mental Health (NIMH) indicated that more than 14.8 million Americans experience some form of depression in a given year and that depression is the leading cause of disability for people ages 15-44 (NIMH, 2008). Keller and Boland (1998) estimate that by 2010, depression will be the most costly of all illnesses worldwide. While the effects of depression are wide-reaching, Latinos, have been identified as a particularly vulnerable population. They too carry high lifetime prevalence rates, with figures reaching as high as 14.8% for native-born Latinos, 5.2% for immigrant populations, 10.2% for urban populations and 6.3% for rural populations (Vega et al., 1998). Latinos face increased risk to mental health problems due to factors like alienation and isolation from their country of origin, acculturative stress, changes in lifestyle or environments, altered social support, fear of deportation, trauma due to immigration experience, discrimination, socioeconomic pressures, and increased likelihood to reside in communities with multiple risk factors for mental health problems (Miranda et al., 2003). Major depressive disorder, for Latinos, often co-occurs with other mental and physical problems like alcohol and substance use, domestic violence, anxiety, diabetes, and HIV infections (Rios-Ellis, 2005). Unfortunately, Latinos have difficulty

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treating depression as they tend to underutilize services, have limited access to culturally and linguistically appropriate treatment, and have high drop out rates in mental health care (Atdjian & Vega, 2005; Rios-Ellis, 2005). When it comes to the general treatment of depression, the American Psychological Association’s Division 12 (Society of Clinical Psychology) has proclaimed several approaches as “empirically supported” including, behavior therapy, cognitive therapy and interpersonal therapy (Chambless et al., 1998). Despite the empirical support that these treatments have received, medication is the initial and most frequently prescribed form of treatment for unipolar depression in the United States (Antonuccio et al., 1995; Olfosn, Marcus, & Druss, et al., 2002). Some treatment protocols, like the one issued by the American Psychiatric Association (1993), suggest that antidepressants are the only treatment for severe depression. Difficulty with treatment engagement and non-compliance with pharmacotherapy has been found to be a major problem in the treatment of depression amongst inner city Latinos. With regard to treatment engagement, depressed patients struggle with various obstacles including “time and hassle” factors, lack of mental health insurance benefits or resources to pay for care, lack of access to transportation, inability to find appropriate childcare, worry or embarrassment about the illness or the treatment, previous negative experiences with mental health services, and mismatches between treatment offered and that desired (Swartz, H. A. et al., 2007). If they are successful in engaging in treatment, adherence to their prescribed medication can often present as an additional battle. In a clinic serving the mental health needs of monolingual Latinos of New York City, compliance with psychotropic medication was found to be less than twenty percent

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(Opler, L. et al., 2004). Some of the reasons that led to poor compliance included lack of understanding as to why the medication was need and/or switched, lack of understanding of the medication’s side effects, too disorganized to take the medication, distrust of the medical professional, shame and stigma, and cultural differences in conceptualization of the illness (Opler, L et al., 2004). Fortunately, Motivational Interviewing (MI) has been effective in addressing difficulties with engagement and adherence to treatment. Originally developed by William Miller (1983), MI is a client-centered approach aimed to help people work through ambivalence and commit to change. The MI style is unique in that it is supportive and empathic, yet also directive (Miller & Rollnick, 2002). MI is brief in nature, can be delivered in one or two sessions, can be integrated into other therapeutic interventions, or serve as its own freestanding intervention. A meta-analysis conducted by Hettema et al. (2005), found a .72 effect size with regard to Motivational Interviewing techniques applied to treatment compliance. A large percentage of the sample population for the 5 studies that were reviewed in this meta- analysis was either African American or Latino. This suggests that MI has the potential to be a particularly effective technique in improving treatment compliance with ethnic minorities. Hettema’s meta-analysis also found that the effects of MI appeared to persist or increase over time when added to an active treatment, had a rapid impact within controlled trials, and had enduring effects when used as a prelude to treatment. Other studies have also made a case for the integration of MI techniques for engaging depressed patients in psychotherapy and improving treatment participation. Swartz et al., (2007), argue that MI allows for an exploration and resolution of ambivalence which

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ultimately facilitates treatment entry and adherence. It addresses both the patient-specific impediments to an alliance (i.e., ambivalence) as well as the clinician-specific barriers to treatment (bias). While there seems to be a strong rationale for using MI to engage depressed patients in treatment and to improve compliance with treatment, relatively little research has been devoted to determining the effectiveness of MI in improving adherence to antidepressant medication amongst depressed Latinos. Alejandro Interian, Ph.D. at the University of Medicine and Dentistry of New Jersey, is currently investigating this via a randomized controlled trial. While the results of this study will yield information on the efficacy of the MI amongst depressed Latinos, little will be known about the mechanisms of change and the factors that lead to positive of negative outcomes with the intervention. As such, three cases have been selected for a pragmatic case study to capture the contextual factors that contribute to either the success or failure of the treatment. The Rationale for Selecting These Particular Clients To qualify for the larger randomized controlled trial, participants were required to meet DSM -IV criteria for either Major Depressive Disorder or Dysthymic Disorder within the last year. Participants were allowed to have co-morbid conditions, like anxiety or psychosis. However, those who had co-morbid substance abuse, alcohol abuse, or manic episodes within the last year were excluded. Additionally, those who were pregnant were excluded from the study. The cases of “Lupe,” “Maria,” and “Ana,” were chosen for analysis because, respectively, they represented good examples of a positive outcome, negative outcome, and mixed outcome for the application of motivational interviewing to increase or sustain

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adherence to antidepressant medication. These cases were distinctive for several reasons. First, each subject demonstrated noteworthy change with regard to level of depression [as measured by depression scores on the Beck Depression Inventory- II (BDI; Beck et al., 1996)] while participating in the research study (see Table 1 and Figure 1). Specifically, Lupe’s scores very significantly subsided, Maria’s scores at first substantially decreased and then to some extent increased, and Ana’s scores did not significantly change. In addition, each case’s level of adherence to the antidepressant medication was noteworthy (see Table 3 and Figure 2). Lupe’s scores were high at the beginning of the study and remained high, Maria’s adherence scores fluctuated and lacked sustainability, and Ana’s adherence scores started high and diminished towards the end. Finally, each case was selected for analysis because there was availability of rich qualitative information, and with the consensus of the research team, it was determined that these cases would facilitate an exploration of moderating variables that affected treatment outcomes as well as provide a good basis for comparison to other cases with different outcomes. The Methodological Strategies Employed for Enhancing the Rigor of the Study Several steps were taken to enhance the rigor of the treatment and preserve its validity. First, all participants in the study were randomly assigned to either the control group or to the intervention group. Random assignment allowed for the researcher to preserve internal validity as it controlled for variables like income, gender, level of acculturation, severity of depression, previous discontinuations of antidepressant medication, additional health problems, etc. In addition, the study employed standardized and reliable measures to determine extent of psychopathology, measure

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severity of depression, measure change in attitudes toward antidepressant mediation, and measure level of adherence. These measures included the Beck Depression Inventory-II (Beck, 1996), Attitudes towards Antidepressant Medication (Lin, Von Korff, & Ludman, 2003), Rating of Medication Influences (ROMI) (Weiden et al., 1997), and the Structured Clinical Interview for DSM- IV (SCID, First, Spitzer, Gibbon & Williams, 2005). Data on adherence to antidepressant medication was collected via use of a MEMS bottle (an electronic bottle which records each time the bottle is opened). Finally, the research assistants conducting the pre, post, and follow-up assessments were blind to participant’s condition (either treatment or control). This minimized the amount of bias that could have occurred during the assessments. The rigor of the study was also enhanced through the type and extent of training and supervision that the MI clinicians received. To start, the clinicians who delivered the Motivational Interviewing intervention were either advanced doctoral students or licensed psychologists. Each clinician attended a multi-day, off-site, MI training delivered by a Motivational Interviewing Network of Trainers (MINT) trainer (a trainer who has participated in Dr. Miller and Dr. Rollnick’s training of trainers workshop). In addition, each clinician read Dr. Miller and Rollnick’s book Motivational Interviewing (2002) to familiarize herself with the principles of MI, watched several video tapes of clinicians performing MI, and engaged in many role-plays to prepare for the MI sessions. While delivering the intervention, the doctoral students received face-to-face supervision with a licensed psychologist trained in motivational interviewing before and after each motivational interviewing session. All MI sessions were audio-recorded, which were then evaluated by a licensed psychologist and an MI consultant. They were rated with

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the Motivational Interviewing Treatment Integrity scales (MITI), a measure of fidelity to the motivational interviewing approach (see Table 5). In addition, the clinicians received written feedback from the MI consultant as to how to improve on MI technique. The Clinical Setting in Which the Case Took Place The original research study was designed to recruit 60 Latino participants, ages 18 to 65. Participants were mostly monolingual Spanish speakers. A small minority of participants were English speaking or bilingual. Most of the participants were immigrants who came from disadvantaged backgrounds and who faced multiple psycho- social stressors. Typical stressors included unemployment, limited financial resources, history of abuse, neglect, or domestic violence, separation from family of origin and extended support network, lack of immigration documentation, and co-morbid psychiatric and medical illnesses. Participants were recruited from a local community mental health clinic and were primarily referred by their psychiatrist or mental health clinician. A small minority of participants were self-referred via fliers that were posted around the clinic. Prior to participating in the research study, the participants were required to sign a consent form that was approved by the IRB of the University of Medicine and Dentistry of New Jersey. Sources of Data Available Concerning the Client Data for the study was gathered by bilingual (Spanish/English) research assistants and therapists. In addition, all questionnaires were available in English and Spanish. Data on adherence to antidepressant medication was collected via use of MEMS bottle (an electronic bottle which records each time the bottle is opened). Participants also completed several self-reported assessment measures including the Beck Depression

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Inventory-II (Beck, 1996), a questionnaire about Attitudes towards Antidepressant Medication (Lin, Von Korff, & Ludman, 2003), Rating of Medication Influences (ROMI) (Weiden et al., 1997), and a self-reported medication-taking scale, and the Importance, Confidence, Readiness (ICR) ruler by Miller and Rollnick (2002). Motivational Interviewing Treatment Integrity scales (MITI) were used as a measure of fidelity to the motivational interviewing approach. Additional qualitative data was gathered from audio recordings of the narratives provided in the overview section, mood module, psychotic module, alcohol and substance use module of the Structured Clinical Interview for DSM- IV (SCID, First, Spitzer, Gibbon & Williams, 2005), as well as audio recordings of three motivational interviewing sessions. In addition, the researcher conducted an exit interview with the participant. The purpose of the exit interview was to obtain a detailed, phenomenological “picture” of what it was like for the subject to participate in the study and to learn what kind of impact the treatment had on the participant’s life. Finally, since the researcher was drawn into intensive contact with the each associated case, data was also gathered from her role as a participant observer. Confidentiality To ensure confidentiality, names, nationality, and other specific identifying information have been changed. Nonetheless, the clinical reality of these cases has been preserved.

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CHAPTER II The Clients Lupe, a Client with a Positive Outcome At the time of the study, Lupe was a 46 year-old, married, monolingual Spanish- speaking Ecuadorian female with two children aged 13 and 23. She had graduated high school and immigrated to the United States at age 34. Lupe’s first experience of depression occurred in her adolescence, at the age of 15, when she was raped. Shortly after this trauma, she attempted to burn herself by pouring alcohol on her body, but was found unharmed by her sister. Lupe’s depression went untreated, and twenty years later, at the age of 35, Lupe’s depression emerged again after emigrating from Ecuador to the United States. At intake into the study, Lupe met DSM-IV diagnostic criteria for a Major Depressive Episode with sub-threshold psychotic features (i.e., hearing her name being called, hearing doors open, hearing people talk when nobody is there). Maria, a Client with a Negative Outcome At the time of the study, Maria was a 30 year-old, monolingual Spanish-speaking Venezuelan female with a high school education. She had immigrated to the United States two and a half months prior to becoming a participant in the study. She was recently married and came to the United States to be with her husband, who was American. However, upon arriving in the United States, she learned that her husband had been having an affair and that he fathered another child. At the time of the study, Maria was living with friends and was unemployed. Maria met DSM-IV criteria for a Major

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Depressive Disorder, Recurrent with Psychotic features. Her depressive symptoms had been persisting for about 2 months and amounted to intense sadness, feeling like a failure, loss of interest in activities that she used to find pleasurable, feelings of guilt, blame, and uselessness, low self-esteem, suicidal ideation, low energy and fatigue, inability to make decisions, and changes in her sleep and appetite. Ana, a Client with a Mixed Outcome At the time of the study, Ana was a 27 year-old, monolingual Spanish speaking Guatemalan female who was living with her partner and their two children, ages 5 and 3. She had achieved a fifth grade equation before being pulled out of school so that she could work and contribute to the expenses of her family of origin. She had immigrated to the United States 8 years prior to her participation in the study. At intake, Ana met criteria for a diagnosis of chronic Major Depressive Disorder, complained of feeling depressed most of the day almost every day, wanting to be left alone to cry, loss of interest in spending time with her children, notable changes in sleep and appetite (i.e., gaining about a pound a week), low energy, psychomotor retardation, feelings of guilt and worthlessness, trouble concentrating, and suicidal ideation (i.e., thinking about walking into traffic with her children).

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CHAPTER III Guiding Conception with Research and Clinical Experience The therapeutic model employed in this case was an adaptation of Motivational Interviewing (MI). Miller and Rollnick (2002) define motivational interviewing as a client-centered, evidence-based, directive method for enhancing intrinsic motivation to change behavior by exploring and resolving ambivalence. Building from Prochaska & DiClemente’s (1984) transtheoretical model, MI rests on an assumption that ambivalence is normal; all clients are viewed as having reasons for and against wanting a particular behavior change. In addition, motivation for behavior change is not a dichotomous or linear process. It is a dynamic process in which individuals fluctuate through various stages of readiness for change (i.e., pre-contemplation, contemplation, preparation, action, and maintenance). MI was originally developed within the field of addictions (Miller & Rollnick, 2002). It proved successful in helping clients move beyond their ambivalence and change their patterns of substance use. Since then, MI has been applied to a variety of clinical problems with favorable results. While the efficacy of MI in its pure form has not been extensively studied, adaptations of MI, which retain its core principles, have received significant empirical support. Noonan and Moyers (as cited in Miller & Rollnick, 2002) reviewed 11 clinical trials of adaptations of MI with problem drinkers and drug abusers and were able to find that nine of the studies supported the efficacy of MI for addictive behaviors. Similarly, Dunn, DeRoo and Rivera (as cited in Miller & Rollnick, 2002)

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reviewed 29 randomized trials that incorporated MI interventions to affect substance abuse behavior, diet and exercise, HIV risk reduction, and smoking. They were able to find that 60% of the studies had at least one significant effect size for the adaptation of motivational interview. Furthermore, the effect sizes did not appear to decrease over time. Finally, as previously mentioned, when applied to improving treatment compliance, MI was noted to have a .72 effect size (Hettema et al., 2005). While MI demonstrated some effect across different problem areas, it continues to have the strongest effect with substance abusers. Nonetheless, these clinical findings suggest that MI carries great potential for successful adaptation to new domains like adherence to antidepressant medication and with different ethnic groups, such as Latinos. Guiding Principles of Motivational Interviewing

Collaboration, respect for the autonomy of the individual, and compassion are all important factors that contribute to the “spirit” of Motivational Interviewing. Motivational Interviewing recognizes that the resources of change reside within the individual and strives to create a counseling atmosphere where clients are apt to express their intrinsic motivation for change and be the ones to generate the solutions. Miller and Rollnick (2002) argue that what people say about change predict subsequent behavior. Therefore, the ultimate goal of Motivational Interviewing is to elicit change talk so that the client can move closer to achieving his or her personal goals. In general, Motivational Interviewing rests on four basic principles: 1. expressing empathy, 2. developing discrepancy, 3. rolling with resistance, and 4. supporting self- efficacy. The first principle, empathy, involves relating to the clients’ experiences from the client’s perspective, in contrast to relating to their experience from outside their

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perspective (judgment). Empathy can be achieved by respecting and understanding the client’s position. Once empathy is established and communicated, it is believed that the client will open up to the possibility of change. Miller and Rollnick (2002) advise that counseling in a reflective and supportive manner decreases resistance allowing for an increase in change talk. The second principle, developing discrepancy, refers to the belief that motivation for change emerges when clients’ feel dissonance between their current behavior and their goals, beliefs, or values. The third principle, rolling with resistance, offers a way of avoiding the arguing or confrontation that can result when one considers change. If one were to get resistant in the face of potential behavior change, Motivational Interviewing interventions would aim to reduce the resistance, not by confronting it, but by shifting the focus, reframing the issue, agreeing with the client in a way that changes the direction of the conversation, or emphasizing personal choice and control. Finally, the fourth principle, supporting self-efficacy, refers to the confidence that is needed for a client to make a change. Self-efficacy can be supported through an honest belief that the client is capable of behavioral change if he/she chooses and commits to do so. For specific motivational techniques that were used throughout the sessions refer to Appendix A. Nuts and Bolts of Each Session Figure 3 presents a time line of the study, including the T1 assessment session at entry; the two MI interviews one and two weeks later, respectively; the second T2 assessment session at 2 weeks after the second MI session; the MI Booster Session and at three months; and the final T3 assessment and Exit Interview session at 5-6 months into the study. Throughout the course of the study, participants continued to receive their

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“treatment as usual,” which for all participants included medication management. Some participants were also in concurrent individual therapy, with variation in the frequency and modality of the individual therapy. The MI intervention was delivered through two phases, the motivational enhancement phase (session 1) and the commitment strengthening phase (sessions 2 and 3). In the motivational enhancement phase (session 1), the primary focus was on enhancing the client’s motivation, getting the client to argue for change, and helping shift his/her decisional balance towards change. During this phase of treatment, there was very little discussion on specific action; rather the emphasis was on helping the client resolve his/her ambivalence. The clinician was instructed to meet the client at his/her stage of change and gradually work towards eliciting and reinforcing change talk. General tasks accomplished in Session 1 included: informing the client of what was going to be done in the session and providing him/her with the opportunity to choose how to proceed (agenda setting), understanding the participants’ depression, establishing the importance of solving the problem (i.e., improving depressive symptoms), determining the source of motivation for the client by understanding his/her values and goals, assessing motivation for use of antidepressant medication (by using the Importance/Confidence/Readiness Scale), exploring reasons for and against adherence by means of a decisional balance, collecting data on use of antidepressant medication (scanning MEMs container), providing feedback (i.e., reinforcement for days that medication was taken or exploration of reasons for days medication was not taken), and eliciting a preference to meet for a second MI session (see table 6).

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The work of strengthening commitment to improve adherence for antidepressant medication occurred once the client was ready to take action (typically in session 2). If the client was not ready to change, however, the MI clinician was instructed to remain in Phase 1, continue to meet the him/her at his/her stage of change, and work towards helping the client develop more reasons for change. If the client was ready to take action, session 2 proceeded towards strengthening the client’s commitment. In this case, session 2 focused on exchanging antidepressant information by 1. informally listening for/assessing antidepressant knowledge, 2. reinforcing what participants already knew, and 3. imparting information if necessary. Additional tasks included exploring experiences of non-adherence and relating those experiences to client’s current plan (use of ICR ruler), framing adherence to medication as one way of achieving the client’s goal, reflecting the other ways the client manages depression (i.e., attending therapy, accessing support network, positive thinking, exercise, behavioral activation, etc), eliciting self- efficacy for adherence, anticipating barriers to adherence and providing the client with a menu of options for addressing those barriers so that he/she can maintain the desired level of adherence, arriving at an adherence plan, and eliciting the client’s commitment toward the plan (see table 7). Finally, clients were offered a booster session (Session 3) which provided the opportunity for them to continue to strengthen their commitment, review progress toward their adherence plan, support follow-through with change, and problem solve any barriers to adherence that may have developed in the interim. If/when the client chose not to commit to taking the medication, the booster session shifted to reviewing his/her decision not to do so, considerations for taking medication in the future, providing information on

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relapse as a result of premature discontinuation, and exploring other ways of progressing toward achieving his/her goals. Adaptations of Motivational Interviewing for a Latino Population

There are a number of reasons which make MI an appealing intervention to use with ethnic minority populations, particularly Latinos. To start, its short term nature makes it a viable intervention for a population which experiences difficulty in accessing and engaging in treatment. In addition, MI can be considered appealing for Latinos because its use of empathy has the potential to reduce the stigma that many Latinos face. Finally, the treatment is tailored to one’s individual needs, allowing for greater understanding and the potential for stronger alliances. One way that the principal investigator of the randomized control trial adapted MI to the Latino population was by conducting a series of focus groups prior to the study. These focus groups allowed participants to share their experience with antidepressant medication and their experience with mental health services. Cultural Values. Through the focus group discussions, a series of important cultural values emerged that were helpful in informing the MI clinician about common sources of motivation. For example, several members of the focus group spoke about the importance of trabajando (working hard), luchando (fighting, forging ahead, surviving difficult times), and aprovechando (taking advantage of what is available). These values captured a theme of striving to improve the difficult circumstances encountered through migration stressors and poverty. Not only did

Full document contains 102 pages
Abstract: Relatively little research has been conducted on improving adherence to treatment for Latino patients. Given the changing demands in the field of Latino mental health and the difficulties of treatment engagement and treatment retention with Latinos, finding effective mental health interventions is of utmost importance. The following study analyzes Motivational Interviewing (MI) techniques that have been used with depressed Latinos in an effort to increase their adherence to antidepressant medication and improve symptoms of depression. The analysis consists of a series of pragmatic case studies, which are intended to capture the contextual factors that contribute to either the success or failure of the MI intervention in facilitating medication compliance and that contribute to the manner in which psychological interventions can be adapted to special populations. The MI intervention involved two sessions delivered within a two-week time period and one booster session delivered approximately two months later. Throughout their participation in the study, participants were monitored with regard to their level of depression, motivation to adhere to their antidepressive medication treatment, and actual compliance in taking their antidepressant medication. In total, three subjects from the research study's database were selected for case study analysis: one who was found to have a positive outcome, one who was found to have a negative outcome, and one who was found to have mixed results with the MI intervention. The results suggest that while Motivational Interviewing has the potential to work as a treatment-enhancing intervention, its success in producing behavioral change largely depends on how well the techniques are adjusted to the individual's stage of change.