Culturally Tailored Motivational Interviewing and Community Reinforcement Approach (MICRA)

A culturally adapted combination of two evidence-based interventions (MI and CRA) was compared to treatment as usual

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MICRA is a combination of two evidenced-based outpatient treatments, motivational interviewing (MI) and Community Reinforcement Approach (CRA), which were culturally adapted for American Indians. Participants were randomly assigned to either treatment as usual or the MICRA condition; there was not a no-treatment control condition. MI is a client-centered approach to reduce ambivalence regarding changing alcohol use. CRA is a behavioral approach to find rewards/reinforcers that do not involve substance use and to displace substance use behaviors. The Tribal treatment as usual consisted of individual and group didactic style sessions including elements of 12-step, cognitive behavioral and relapse prevention along with referral to cultural educators. In the MICRA condition participants received between 16-20 individually administered sessions, with MI serving as a precursor to the CRA treatment approach.

Outcomes

Estimates of changes or differences in alcohol-related problems and the stability of those changes or differences. 

Low Level of Change

Both treatment groups improved on SUD outcomes, there was no benefit of MICRA over treatment as usual. 

Participants in both MICRA and treatment as usual conditions showed improvements in percent days abstinent, substance use disorder (SUD) severity, and negative consequences from baseline to the 12-month follow-up with no benefit of MICRA over treatment as usual. Supplementary analyses found no significant differences between MICRA and treatment as usual for heavy drinking days. However, participants did decrease frequency of past 30-day alcohol use from 13.75 days at baseline to 7.35 days at 12-month follow up. The researchers suggested the lack of differences between groups could be the result of poor counselor adherence to the MICRA protocol and/or overlap between the two treatment conditions, which shared culturally congruent components, as well as elements of behavioral therapy and 12-step programs.

Costs

Two domains estimating start-up and ongoing expenses. 

Mid-range start-up and ongoing costs for staff time, training, supervision, and assessments. 

Assuming some access to treatment infrastructure, including clinic space and community-based counselors who are already providing some related treatment services, both the start-up and ongoing costs are likely to be mid-range. Training counselors in both MI and CRA involves hiring experts who are able to provide at least 2 days of training. Initial MICRA costs would also include administration of assessments, the results of which are employed in the MICRA intervention. Medium ongoing costs include continued staff time to administer up to 20 MICRA sessions and expert training and supervision to ensure the treatment is delivered effectively.

Cultural Engagement

Two indicators of cultural and Tribal/community contributions. 

Tribal consultation and participation led to high level of cultural adaption of intervention. 

Culturally adapted MICRA was delivered in both English and Native language. Cultural adaptions included greeting the spirit of the client in their native language, traditional introductions using clan membership, incorporating spirituality and culturally relevant activities, exploration of traditional values, and including motivations for change that involved the family, extended family, religious, spirituality, and cultural identity. There was inclusion of Tribal research protocol preferences and approvals. The Tribe was awarded a sub award on the grant, requested cultural adaption of the EBTs, contributed to cultural adaptation and randomization processes and approved publications.

Tribal members seeking treatment for substance use disorder at an outpatient treatment facility on a rural reservation. 

Seventy-nine participants (68% male) American Indian/Alaska Native Tribal members seeking treatment and meeting criteria for substance use disorder (SUD) were recruited from an outpatient treatment facility located on a rural Southwest reservation. Mean age for the MICRA group was 32.16 years and 33.61 for the treatment as usual group.

Staffing Needs

Credentials and/or background of personnel who delivered the intervention. 

Certified Professional, Community Member

Bilingual community members were trained and certified to conduct the MICRA intervention. 

Bilingual counselors from the community, including a traditional male Tribal member and a bicultural female Tribal member, were certified to conduct MICRA after training in MI and CRA. MI and CRA experts provided biweekly supervision/coaching sessions to ensure treatment fidelity and enhance treatment effectiveness.

Research Design

Methods employed to gather research data. 

Randomized controlled experimental design

Developmental stage of research

Stage of development of the evidence supporting this intervention. 

Mid Stage

Research found MICRA to be effective in SUD treatment but unable to determine comparative benefit over treatment as usual. 

This open-pilot feasibility randomized control trial compares cultural adaptions of evidence-based interventions (MI and CRA) to a fairly robust treatment as usual. The null findings for benefit of MICRA over treatment as usual, lack of compliance with MICRA fidelity monitoring, plus the lack of a no-treatment control makes evidence for comparative efficacy of MICRA over treatment as usual inconclusive. Nevertheless, the research does provide evidence of overall effectiveness of MICRA in SUD treatment.

Potential

Narrative offered by expert reviewers providing overall comments or evaluations about the intervention. 

The study found a combination of two evidence-based interventions (MI and CRA) can be culturally adapted and successfully implemented in an AI/AN community. 

Motivational interviewing and Community Reinforcement Approach are evidence-based practices which have been integrated and culturally adapted to treat substance use disorders in one Southwest Tribal population. Both MICRA and Tribally based treatment as usual show promise in targeting substance use disorders. While there was a lack of significant differences in percent days abstinent between the MICRA and treatment as usual, there were reductions in frequency of drinking. The MICRA intervention would require further tailoring for other Tribal communities.

References

Primary 

Venner KL, Serier K, Sarafin R, et al. Culturally tailored evidence-based substance use disorder treatments are efficacious with an American Indian Southwest tribe: An open-label pilot-feasibility randomized controlled trial. Addiction . 2021;116(4):949-960. https://pubmed.ncbi.nlm.nih.gov/32667105 . https://doi.org/10.1111/add.15191 .

Secondary 

Venner KL, Greenfield BL, Hagler KJ, et al. Pilot outcome results of culturally adapted evidence-based substance use disorder treatment with a Southwest Tribe. Addict Behav Rep . 2016;3:21-27. https://pubmed.ncbi.nlm.nih.gov/26951788 . https://doi.org/10.1016/j.abrep.2015.11.002 .

Associated 

Hirchak KA, Hernandez-Vallant A, Herron J, et al. Aligning three substance use disorder interventions among a tribe in the Southwest United States: Pilot feasibility for cultural re-centering, dissemination, and implementation. J Ethn Subst Abuse . 2022;21(4):1219-1235. https://doi.org/10.1080/15332640.2020.1836701 .

Recommended Reading 

Venner KL, Feldstein SW, Tafoya N. Helping clients feel welcome: Principles of adapting treatment cross-culturally. Alcohol Treat Q . 2008;25(4):11-30. https://ohsu.pure.elsevier.com/en/publications/helping-clients-feel-welcome-principles-of-adapting-treatment-cro . https://doi.org/10.1300/j020v25n04_02 .

Venner KL, Feldstein SW, Tafoya N. Native American Motivational Interviewing: Weaving Native American and Western Practices . A Manual for Counselors in Native American Communities . Unpublished Treatment Manual. University of New Mexico, Center on Alcohol, Substance Use, and Addictions; 2006. https://casaa.unm.edu/assets/html/namitxt.html .

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