Lora Hughes and Neil Lundberg, Recreation Management
Diseases related to aging, developmental disorders, mental illnesses, acquired physical disabilities, and traumatic events cause untold human suffering each year. Many professionals seek to alleviate such suffering, including the discipline of therapeutic recreation (TR), which uses a holistic process of targeted interventions, leisure education, recreation participation, and experiential learning to encourage positive change in clients. When working with clients, recreation therapists (RTs) need evidence and direction for using the best practices in therapeutic communication1. One such type of therapeutic communication, Motivational Interviewing (MI), has become popular since the 1970s, especially within mental health and substance abuse fields2. MI “helps clients explore and resolve ambivalence,” discuss “overcoming barriers to change,” recognize their own desires for improved outcomes, and make plans to change3 behavior(s). Drawing on the growing interdisciplinary evidence, this study explored the literature to compile “evidence tables” needed by practicing and academic RTs4 to improve the field and reduce human suffering.
The study utilized a literature review methodology; articles published in the last 5 years emphasizing the role of motivational interviewing in treating symptoms or syndromes often addressed by RTs were read and analyzed. Tables were constructed comparing samples, interventions, results, limitations, and study designs of relevant articles. Articles were pulled from peer-reviewed journals through the BYU library databases. Specifically, articles that explored use of MI outside of formal psychotherapy sessions, use of MI in group sessions, and use of MI by RTs were highlighted and emphasized in gathering data about how RTs can effectively utilize MI in their therapeutic process. While reviewing articles, areas of additional research as well as possible contraindications were noted to help protect clients receiving care at the hand of RTs that may adopt MI as part of their practice.
Overall, the literature shows statistically and practically significant benefits for the use of Motivational Interviewing in working with those changing behavior. When seeking to decrease smoking6, alcohol intake7, or drug use8, or consistently take depression medication9, change eating/weight loss habits10, meet probation goals2, manage video game or other addictive behavior11, reduce PTSD scores11, avoid negative peer pressure8, or engage in other behavior change, Motivational Interviewing was positively associated with making and maintaining change. Unfortunately, the literature on the use of MI in group settings continues to be limited12 and so the hypothesis about expanding MI use for group settings (where RTs often work) requires further investigation. The published research about group settings shows that use of MI by group facilitators can lead to increased “change talk”5 within group settings, but the actual changes in behavior have yet to be measured8, 12. Client outcomes throughout the research varied greatly depending on type of client, type and training of facilitator, setting of treatment (inpatient, outpatient, probation, etc.), and other variables.
The first hypothesis explored was how RTs could utilize MI to improve patient outcomes; measurable patient outcomes represent decreased suffering but also billable services to third-party payers. The trend noted throughout the literature was the need for thorough training of MI facilitators. In those studies where professionals received only a short, basic workshop in MI principles, the outcomes of MI utilization essentially mirrored control groups3. Not only is full training important, but so is regular practice and updating for professionals to maintain their skills as MI requires different communication strategies than Americans typically use2. All of this training requires time and funding that many practicing RTs may not currently be able to access. Additional research about the effectiveness of MI could help motivate health care organizations to see the value in funding such training sessions.
The second hypothesis explored research on MI in group settings. While the literature has grown slightly in the last couple years, it remains limited in funding and scope to the actual therapy sessions rather than following the participants’ outcomes. Additionally, another current limitation in the research is that it follows psychotherapy groups in relatively isolated scenarios, and additional research about more generalizable groups of people in healthcare systems could better inform TR practice. In order for MI style group interventions to fully qualify for “evidence-based practice” funding, such as from Medicare, additional research exploring patient outcomes of groups dealing with depression, substance abuse, or PTSD symptoms within outpatient settings would be needed.
Recreation therapists should seek out professional training in Motivational Interviewing in order to maximize results. Additionally, Motivational Interviewing should be used in conjunction with traditional methodologies of therapy, as a means of guiding verbal exchanges. While current evidence suggests MI can lead to positive outcomes individually or in group settings, RTs should evaluate the limited scope of research on group outcomes. Additional studies specifically following the behavior changes of group members will be needed before group MI can be considered fully “evidence-based practice.” As this project continues to grow throughout the researcher’s internship, it will seek to further address research needed by practicing RTs in order to maximize the effectiveness of MI within TR in order to help patients improve their lives and therapists utilize effective, meaningful communication.
- Stumbo, N. J., & Wardlaw, B. (Ed.). (2011) Facilitation of therapeutic recreation services: An evidence- based and best practice approach to techniques and processes. State College, PA: Venture.
- Watson, J. (2011). Resistance is futile? Exploring the potential of motivational interviewing. Journal of Social Work Practice, 25(4), 465-479. http://dx.doi.org/10.1080/02650533.2011.626653
- Rollnick, S., Miller, W.R., & Butler, C. C. (2008). Motivational Interviewing in healthcare: Helping patients change behavior. New York, NY: Guilford Press.
- Stumbo & Wardlaw, 2011, p. 118-122
- Rollnick, Miller, & Butler, 2008, p. 3
- Rohsenow, D. J., Tidey, J. W., Martin, R. A., Colby, S. M., Sirota, A. D., Swift, R. M., & Monti, P. M. (2015). Contingent vouchers and Motivational Interviewing for cigarette smokers in residential substance abuse treatment. Journal of Substance Abuse Treatment, 55, 29-38. http://dx.doi.org.erl.lib.byu.edu/10.1016/j.jsat.2015.02.010
- McDevitt-Murphy, M. E., Williams, J. L., Murphy, J. G., Monahan, C. J., & Bracken-Minor, K. L. (2015). Brief intervention to reduce hazardous drinking and enhance coping among OEF/OIF/OND veterans. Professional Psychology: Research and Practice, 46(2), 83-89. US: American Psychological Association.
- D’Amico, E. J., Houck, J. M., Hunter, S. B., Miles, J. N., Osilla, K. C., Ewing, B. A., (2015). Group Motivational Interviewing for adolescents: Change talk and alcohol and marijuana outcomes. Journal of Consulting and Clinical Psychology, 83(1), 68-80. http://dx.doi.org/10.1037/a0038155
- Keeley, R. D., Engel, M., Nordstrom, K., Dickinson, L. M., Brody, D. S., Burke, B. L., Morales, E., & Emsermann, C. (2016). Motivational Interviewing improves depression outcome in primary care: A cluster randomized trial. Journal of Consulting and Clinical Psychology, 84(11), 993-1007. http://dx.doi.org/10.1037/ccp0000124
- Gruhl, E. & Van Leuven, K. A., (2014). Motivational Interviewing for adolescents: Behavior counseling for diet and exercise. Journal for Nurse Practitioners, 10(7), 493-499. http://dx.doi.org.erl.lib.byu.edu/10.1016/j.nurpra.2014.04.006
- Campbell, M. S., Ryan, M., Wright, D., Devore, M. D., & Hoge, C. W. (2016) Postdeployment PTSD and addictive combat attachment behaviors in U.S. military service members. American Journal of Psychiatry, 173(12), 1171-1176. http://dx.doi.org/10.1176/appi.ajp.2015.15101297
- Houck, J. M., Hunter, S. B., Benson, J. G., Cochrum, L. L., Rowell, L. N., D’Amico, E. J. (2015). Temporal variation in facilitator and client behavior during group Motivational Interviewing sessions. Psychology of Addictive Behaviors 29(4), 941-949. 15 http://dx.doi.org/10.1037/adb0000107