Expand Motivational Interviewing for Pregnant People

Introductory Paragraph

Motivational Interviewing (MI) is an evidence-based practice that is effective in helping people make decisions to stop negative behaviors and start positive ones. MI is a therapeutic tool intended for use in conjunction with other forms of therapy or treatment. It has high potential to help pregnant people who are using substances. Since MI is designed to inspire change in clients who may otherwise feel reluctant to change, it supports incremental choices toward recovery.

Although MI is a technique which works across the continuum of care, it is placed within a harm reduction context, because it "meets people where they are at." While useful for all populations, it is particularly relevant during pregnancy, because of the choice-space it creates -- an immediate benefit in relieving the challenges associated with pregnancy and SUD.

Key Information

MI was founded by Dr. William Miller and Dr. Stephen Rollnick. It is a collaboration approach which is based on an interview process between the provider and the patient. MI patients are empowered to create their own goals, as opposed to goals imposed by a therapist, such as complete abstinence. When individuals in recovery feel as though they are in control of their own recovery, they take ownership of their success and move forward with their own goals. This encourages patient autonomy. When a patient feels responsible for their actions and is confident in their recovery, they are more likely to stay sober and to not relapse after treatment.

Motivational interviewing does not focus on the underlying causes of an addiction, such as past traumas or mental illnesses. It is intended to be used in addition to other forms of therapy, such as cognitive behavioral therapy. Although MI pulls from various therapeutic styles and theories, such as humanistic therapy, cognitive dissonance theory, therapeutic relationship building, and positive psychology, it is most effective when used in conjunction with one of these forms of treatment. MI is also an effective part of an inpatient treatment regimen, before seeking other recovery options.

Miller and Rollnick formulated four client-centered processes to help patients identify their goals and begin to work towards them. They are as follows:

• Engaging – Getting to know the client and establishing a trusting and respectful alliance.
• Focusing – Coming to a shared idea about the main focus of a client’s recovery.
• Evoking – Bringing out the client’s own arguments for change.
• Planning – The client is willing and able to envision change and how they will manifest it.

Relevant Research

This literature review is titled, "Psychosocial Interventions for Substance Use During Pregnancy." The author notes the limited amount of research that has been done on MI with this population and focuses on early investigations into the practicality and efficacy of contingency management, motivational support, and cognitive behavioral therapies adapted for pregnant people.

This article documents the results of MI training for obstetric healthcare professionals working with obese pregnant people. Participants made more interventions towards the principles of motivational interviewing and asked fewer closed and more open questions than they had before the training.

Impactful Federal, State, and Local Policies

SAMHSA identifies MI as as a model of change and indicates that it aligns to the five "stages for change:"

• Precontemplation — Individuals currently using substances are not thinking of making a change now or in the future.
• Contemplation — Individuals currently using substances are aware that they need to make a change.
• Preparation — Individuals currently using substances begin weighing the pros and cons of making a change and preparing for how to deal with urges and triggers.
• Action — Individuals currently using substances decide to change their behavior and successfully attempt to do so.
• Maintenance — Individuals who changed their substance use behaviors are engaged in efforts to continue doing so over the long term.

Available Tools and Resources

• SAMHSA has published a guide titled "Using Motivational Interviewing in Substance Use Treatment." One of the Addiction Technology Centers (ATTC) in the SAMHSA Network focuses on family-centered behavioral health of pregnant and postpartum people. It includes three videos on MI in an integrated care setting -- for nurse practitioners, counselors, and social workers.

• SAFE Project:
  • See the wiki titled "Reduce Stigma for Pregnant People with SUDs" for more detailed information on reducing stigma for substance use issues affecting pregnant populations and how the reduction of stigma will lead to better care.

• The Founders of MI provide a website that offers an instructional overview of the four MI processes, online trainings, and free resources.

• University of Arizona has a website dedicated to information on pregnant and post-partum people with SUDs. It includes a one-hour video training titled "Essentials of Motivational Interviewing."

• The National Harm Reduction Coalition has published "Pregnancy and Substance Use: A Harm Reduction Toolkit" that includes information on MI.

• SAFE Project has a dedicated website titled "Addiction and Mental Health Resources for Women." This includes various resources specifically r;evant for support during pregnancy.

Promising Practices

The Motivational Interviewing Network of Trainers (MINT) is an international organization of MI trainers. Trainers in MINT come to the non-profit from diverse backgrounds and apply MI in a variety of settings. Their central interest is to improve the quality and effectiveness of counseling and consultations with clients about behavior change. MINT was started in 1997 by a small group of trainers who were trained by Miller and Rollnick. The organization has since grown to represent 35 countries and more than 20 different languages.

Clinical Health Coach® Training provides online training through the Iowa Chronic Care Consortium (ICCC), a non-profit that specializes in population health consulting, training, and organization planning. Their mission is to build capacity with other organizations to deliver effective and personalized strategies for health improvement and chronic care. Clinical Health Coach Training Online is a flexible, 26-hour, self-paced, six to twelve week experience. It engages participants in an online learning platform for various topics, including MI.

An MI App. Steven Ondersma, Ph.D., at Michigan State University has a primary research interest in computer-delivered assessment and motivational interventions for substance use and other risk factors among pregnant and postpartum people. He developed an MI app that runs on tablets and smart phones that uses a 3-D animated guide to walk patients through an intervention specific to their responses. The guide asks questions such as “what do you like about opioid use, why do you use opioids, and what do they do for you?” The guide then reflects their answers. At the end of the session, if the patient indicates a need for change, the guide in the app can help them develop a plan to change, send tailored text messages after they leave the doctor’s office, and suggest treatment options in their area. This type of intervention has shown success in some communities and is currently being tested to address opioids. This intervention could be very successful for four reasons:

• Using an electronic based system to ask these difficult questions could remove stigma from the situation.
• Most people will have access to a mobile device.
• It automates follow-up.
• It does not require additional MI training for doctors and decreases their time for screening.