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Stein M.D, Caviness C.M, Anderson B.J. et al.
Addiction: 2010, 105(3), p. 466–475.
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Could just two motivational interviewing sessions moderate the drinking of very heavy drinking US women prisoners? The surprise was not that there were few benefits, but that there were some, especially after the reinforcing session usually conducted after the prisoners' release.
Summary While in prison women drinking at hazardous levels can be identified by screening, and despite the high turnover of prison populations, the one or two short counselling sessions which characterise brief interventions can normally be completed. Especially if reinforced after leaving, these may prove of benefit.
This possibility was tested at the US Rhode Island prison complex by a study which recruited newly admitted female adult prisoners who on assessment by researchers were found They also had to have reported unprotected sex on at least three separate days in the three months before entering prison. to have drunk heavily (four or more US standard drinks or seven UK units) on at least three days in the previous three months, or who scored as hazardous drinkers (eight or more) on the AUDIT alcohol problem screening questionnaire.
On average the 245 women who joined the study were 34 years of age, had drunk heavily three days a week (each day consuming 25 UK units) in the three months before their imprisonment, and scored just over 20 Editor's note: considered to warrant further diagnostic evaluation for alcohol dependence. on the AUDIT questionnaire. Nine in 10 met criteria for being or having been dependent on alcohol.
They were randomly allocated to no intervention (the control A group of people, households, organisations, communities or other units who do not participate in the intervention(s) being evaluated. Instead, they receive no intervention or none relevant to the outcomes being assessed, carry on as usual, or receive an alternative intervention (for the latter the term comparison group may be preferable). Outcome measures taken from the controls form the benchmark against which changes in the intervention group(s) are compared to determine whether the intervention had an impact and whether this is statistically significant. Comparability between control and intervention groups is essential. Normally this is best achieved by randomly allocating research participants to the different groups. Alternatives include sequentially selecting participants for one then the other group(s), or deliberately selecting similar set of participants for each group. group), or to two 30–45-minute motivational interviewing sessions. The first session was conducted in prison immediately after the researchers had recruited the prisoners to the study. All the participants were to be re-assessed a month later. If they had been released, for those allocated to the brief intervention this was immediately followed by their second session. If they were still in prison, the session was delayed until they were released, with the proviso that in any event it was to be scheduled before the three-month follow-up. In practice about a quarter of the women did not attend the second session; of the remainder, three quarters attended it after release.
During the first session the specially trained female clinicians were to lead the prisoner to set goals for changing their drinking, and to explore strategies to deal with any obstacles. The second session focused on the participant's progress (or on setting a goal if none had been set before) and on developing concrete strategies for meeting new goals. Recovery strategies were also discussed, with an emphasis on identifying and coping with high-risk situations.
Sessions were audiotaped and reviewed in fortnightly supervision sessions.
Nearly 8 in 10 participants completed each of the follow-ups (one, three and six months after recruitment) and 91% completed at least one.
The following analyses ignored days when participants were not free to drink because they were in prison.
Generally the women continued to frequently drink heavily after release, but at the three-month follow-up, somewhat less frequently if they had been allocated to the two brief intervention sessions, which by then they would have completed or failed to attend.
At the three-month follow-up, on 68% of days since their baseline interview women offered the brief intervention had not drunk at all versus 57% of days among the control group, a statistically significant advantage for the intervention. This effect was much greater among the minority of women who had not been dependent on alcohol than among those who had been. Over the same period women offered brief intervention also recalled significantly fewer adverse consequences from their drinking.
These were, however, the only statistically significant results. There were no such differences at the one-month follow-up before the second session had been offered, and by the six-month follow-up the gap in the proportion of non-drinking days had narrowed to an insignificant 66% versus 62%.
Few women avoided drinking altogether (8% of controls and 9% offered brief intervention) and there was no evidence that the intervention restrained drinking on days when the women did drink; at the last two follow-ups they still averaged around 16–17 UK units on each drinking day. Neither did the intervention encourage significantly more women to start treatment for their drinking. Whether (as intended) the second motivational session had taken place after release rather than in prison made no difference to the findings, as did the time between the two sessions.
Among these heavy-drinking female prisoners, a two-session brief alcohol intervention increased the proportion of alcohol-free days over the three months after the initial session. It also resulted in a reduction in alcohol-related problems, suggesting the impacts on drinking were clinically meaningful. These effects did not last, and the brief intervention was not enough to produce consistent or prolonged abstinence, or to moderate the intensity of drinking on drinking days. In other words, though at three months the brief intervention led to fewer days when the women started drinking, once they had started, it did not restrain consumption.
These results should be seen in the context of the nature of the caseload. Nine in 10 of the women had a history of alcohol dependence, people often excluded from brief intervention trials on the basis that such minimal help could not be expected to work. They were also selected on the basis of their pre-prison risky sexual activity. This population may have needed more intensive care than two brief sessions. Also, these results were achieved with trained and supervised clinicians doing the motivational interviewing, not routine prison staff.
commentary For the UK the findings of this study will be of greatest relevance to the many short-term female prisoners for whom a full course of treatment (one of the main programmes runs over 20 two-hour sessions) is not feasible, especially since the cognitive-behavioural group therapy programmes common in UK prisons have so far gathered little evidence that they affect substance use or crime.
However the results offer little encouragement. In generally finding no significant positive impacts, the findings in one way accord with the major British trial of a brief alcohol intervention for heavy drinking offenders, in this case on probation. Where they differ is that the most noticeable impact in the featured study was among the less severe drinkers, while in the British study it was among the most severe. Outside a criminal justice context too, it is not unusual to find that severe drinkers, including those dependent on drinking, do benefit from brief interventions, in some cases more so than less severe drinkers.
The results presented above and the study focus on the difference the intervention made. Another way of looking at the results is the difference potentially made by the full package of research assessments, screening and intervention – an increase from 45% non-drinking days at baseline to 68% three months later and a drop from 21 UK units at a sitting to 18. This however is the maximum change the package might have made; some of this modest remission might have happened anyway.
For more on the application of motivational interviewing in criminal justice contexts see this Findings review.
Last revised 10 September 2013. First uploaded 04 September 2013
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REVIEW 2011 Motivational interviewing for substance abuse