2010 icmi presenation apodaca june6

  • 657 views
Uploaded on

 

  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
No Downloads

Views

Total Views
657
On Slideshare
0
From Embeds
0
Number of Embeds
2

Actions

Shares
Downloads
0
Comments
0
Likes
1

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide
  • The purpose of the current review is to evaluate the existing evidence regarding potential within-session mechanisms of change in MI with alcohol or other drug use disorders. As conceptualized in the present review, a mechanism of change is a variable temporally intervening between assignment to MI treatment and measured substance abuse outcome and at least partially explaining the relationship. The central question we sought to answer in this review was: Which MI constructs and variables appear to be the most promising candidates for mechanisms of change?
  • Inclusion Criteria Studies were included if they met the following criteria: (1) clients received a therapeutic intervention for problematic alcohol use or any use of illegal substances; (2) the therapeutic intervention was referred to as 杜 otivational interviewing, � 杜 otivational enhancement, � 杜 otivational intervention, � or 澱 rief intervention � (and was described by the authors as being based upon the principles of motivational interviewing); (3) the intervention was delivered individually, and not in a group setting; (4) the potential mechanism was measured either during the intervention or immediately following.

Transcript

  • 1. Mechanisms of Change and Active Ingredients of Motivational Interviewing Timothy R. Apodaca International Conference on Motivational Interviewing June, 2010 ~ Stockholm, Sweden
  • 2. Overview
    • Why care about mechanisms
    • What do we know about how MI works
    • What’s next
  • 3. What is a “mechanism”?
    • How does treatment work?
    • Changes in attitudes, beliefs, or behaviors that patients are assumed to undergo according to a treatment theory
    T M O (Treatment) (Mechanism) (Outcome)
  • 4. Context
    • The call for most effective treatments
    • The everyday clinician needs to know:
    • How to be
    • What to do
    • What not to do
    • To answer the question of “How does treatment work?”
    • Identify mechanisms of change in patients
    • Identify active ingredients of treatment that lead to change
  • 5. Mechanisms Review Apodaca & Longabaugh (2009). Addiction
  • 6. Method
    • Criteria for studies to be included in review
      • Treatment of alcohol or drug problems
      • Individual (not group)
      • Potential mechanism measured either during the intervention or immediately following
  • 7. Steps in the model Therapist MI Client Outcome (Alcohol/Drug) Link 1a Link 2 Main effect Link 1b Link 3a Link 3b
  • 8. Effect Size Calculation
    • For each step in the model
    • Used correlation coefficient (r)
    • Guidelines for interpretation:
      • Small (r = .10)
      • Medium (r = .30)
      • Large (r = .50)
  • 9. Therapist
    • MI Spirit
    • MI-Consistent behaviors
    • MI-Inconsistent behaviors
    • Specific components
  • 10. Therapist MI Spirit MI Spirit MI Client Outcome .22 .36 .13
  • 11. Therapist MI-Consistent MICO MI .64 Client Outcome Guame et al. 2008 and Moyers et al., 2009; reported MICO  CT and CCT; Houck & Moyers 2008: MICO  CT;
  • 12. Therapist MI-Inconsistent MIIN MI Client .30 .49 .43 Outcome
  • 13. Therapist Specific Components Specific Components MI Client .52 .19* Outcome *Larger effect sizes for Feedback and Decisional Balance
  • 14. Client
    • Change talk/intention
    • Readiness to change
    • Involvement/engagement
    • Resistance
    • Experience discrepancy
  • 15. Client Change Talk/Intention Therapist MI Change Talk .29 * Outcome *Guame et al., 2008; Baer et al., 2008; Moyers et al., 2009 provide additional evidence for this link .25 (Longshore)
  • 16. Client Readiness Therapist MI Readiness Outcome
  • 17. Client Engagement/Involvement Therapist MI .31 Engagement/ Involvement Outcome .15 (Baird)
  • 18. Client Resistance Therapist MI Resistance Outcome .58 (Miller) .12 (Miller)
  • 19. Client Confidence Therapist MI .25 Confidence Outcome *Barnett (2010) adds suggestive evidence for this link *
  • 20. Client Experience Discrepancy Therapist MI .18 Experience Discrepancy Outcome *Walters (2009) adds suggestive evidence for this link .20* (McNally)
  • 21. Summary
    • Good evidence for:
      • MI-Inconsistent behavior (MIIN)
      • Change Talk
        • Robust predictor of outcome
        • Also important in CBT and 12-step
    • Promising:
      • Client Experience of Discrepancy
        • Internal condition for change talk?
    • Surprising:
      • Readiness and resistance
  • 22. Predictors of Change Plan Completion Magill, Apodaca, Barnett, Monti (2010). Journal of Substance Abuse Treatment
  • 23. Predictors of Change Plan
    • Aim: examine within-session predictors of patient completion of written Change Plan
    • Setting: hospital ER/trauma (N=291)
    • Transcribed and coded using the MISC
  • 24. Language Measurement
    • Therapist MICO
    • Therapist MIIN
    • Patient Change Talk
    • Patient Counter-Change Talk
    • Language measured in deciles 1-8
    • Change plan took place in deciles 9-10
  • 25. Predictors of Change Plan
    • Patient chose whether or not to complete at the end of the session
      • Written
      • Given to patient
    • Measurable goals, supports, specific actions toward change
    • 53% decided to complete a change plan
  • 26. Results: Therapist General Behavior
    • MI-Consistent, p < .001
    • MI-Inconsistent, ns
  • 27. Results: Therapist General Behavior
    • MI-Consistent
      • Affirm
      • Emphasize control
      • Open question
      • Advise/raise concern with permission
      • Simple reflection
      • Complex reflection
  • 28. Results: Therapist Specific Behavior
    • MI-Consistent
      • Affirm
      • Emphasize control
      • Open question, p = .034
      • Advise/raise concern with permission
      • Simple reflection
      • Complex reflection
  • 29. Results: Patient General Behavior
    • Change Talk, p < .001
    • Counter-Change Talk, p < .001
  • 30. Results: Patient Specific Behavior
    • Change Talk
      • Reason, Desire, Need, Taking Steps, Other
      • Ability, p < .001
      • Commitment, p < .001
      • Desire, p = .008
    • Counter-Change Talk
      • Need, Ability, Taking Steps, Commitment, Other
      • Desire, p = .05
      • Reason, p = .03
  • 31. Change Plan
  • 32. Change Plan No Change Plan
  • 33. Effect of a Significant-Other on Client Change Talk Apodaca, Magill, Longabaugh, Jackson, & Monti. Under Review
  • 34. Effect of Significant Other
    • One-session MI with active involvement of a significant other (partner, family, friend). N=157
    • Measured language of Therapist, Patient, and Significant Other
    • Focus on Therapist and SO behaviors predictive of within-session change talk
  • 35. Language Measurement
    • MICO, MIIN; Change Talk Counter-Change Talk
    • SO Support (encourage, ideas for change, acknowledge problem)
    • “ I know you can do this.”
    • “ I’d like him to have a better life, without drinking.”
    • “ Maybe you could start your hobby again.”
    • SO Against (direct, negative, criticize, lack of problem recognition)
    • “ Get your act together.”
    • “ He’s just a social drinker, no big deal.”
    • “ I don’t think he’ll change his friends.”
  • 36. Methods
    • Divided sessions into deciles
    • Calculated proportion of each category of language within each decile
    • Used Multi-level modeling to assess temporal relationships among variables
    Change Talk (CT + CCT + FN) Ex. Proportion change talk =
  • 37. Methods Decile 1 Decile 2 Decile 3 Therapist Significant Other Therapist Significant Other Therapist Significant Other Patient Change Talk (& CCT) Patient Change Talk (& CCT)
  • 38. Methods Decile 1 Decile 2 Decile 3 Therapist Significant Other Therapist Significant Other Therapist Significant Other Patient Change Talk (& CCT) Patient Change Talk (& CCT)
  • 39. Results Predicting Change Talk MICO MIIN SO Support SO Against Predicting Counter-Change Talk MICO MIIN SO Support SO Against
  • 40. Results Predicting Change Talk MICO ns MIIN ns SO Support p < .001 SO Against ns Predicting Counter-Change Talk MICO ns MIIN ns SO Support p < .001 SO Against ns
  • 41.  
  • 42.  
  • 43.  
  • 44. Implications
    • SO support for change is key when an SO is involved in MI
    • Impact of therapist on change talk is different when an SO is present
    • How to best elicit SO support?
  • 45. Next Steps
    • Our lab
      • Sequential data-collection and re-coding
      • Linking processes to outcomes
      • Component analyses
      • Advanced statistical analyses
      • Larger datasets (350, 450, 900)
  • 46. Next Steps
    • Do the subtypes of change talk matter?
    • Moderated mediation
      • Karno & Longabaugh
      • Stein
  • 47. Next Steps
    • Include nonverbal behavior
      • Mimicry: increases how much people empathize with and trust one another
      • Consistency: fluidity of speech can be perceived as expertise
      • Movement: can indicate interest and excitement
    Alex Pentland, Honest Signals: How They Shape our World. 2008. MIT Press
  • 48. What do you think? I’ll do it.
  • 49. What do you think? I’ll do it.
  • 50. Acknowledgements
    • Special thanks to
    • Richard Longabaugh
    • Terri Moyers
    • Bill Miller
    • Coding Lab
    • Collaborators: Molly Magill, Nancy Barnett, Peter Monti, Brian Borsari, Kristina Jackson
    • Coders: Heather Ross, Mariya Masyukova, Andrea Wolford, Lily Kanter
    • Transcribers: Jen Shurman, Ashley Aguilar, Eunice Hong, Erin Johnson
    Supported in part by grant K23AA015595 from the National Institute on Alcohol Abuse and Alcoholism Thank you to the patients and therapists.
  • 51. Thank You!
    • [email_address]
  • 52. Thank You!
    • [email_address]
  • 53. Multiple Mediators of MI Barnett, Apodaca, Magill, Colby, Gwaltney, Rohsenow, Monti (2010). Addiction
  • 54. Mediators of MI
    • Secondary analysis of clinical trial of MI conducted in emergency department
    • Aim: to identify mediators of MI
    • Compared MI to feedback-only (with no counselor involvement)
  • 55. Mediators of MI
    • Mediators measured between treatment and outcome (12-months)
    • Use of multiple mediator model
    • All four mediate; each one mediate; individual paths
    • Theoretically relevant variables
  • 56. Mediators Examined
    • Readiness to change
    • Experience discrepancy (shift in perceived benefits & risks of use)
    • Self-efficacy
    • Treatment-seeking
  • 57. The Original Study MI Vs. Feedback Alcohol use at 12-months
  • 58. Mediator study MI Vs. Feedback Readiness Alcohol use at 12-months Risk/Benefit Self-efficacy Treatment Seeking
  • 59. Results MI Vs. Feedback Readiness Alcohol use at 12-months Risk/Benefit Self-efficacy Treatment Seeking
  • 60. Implications
    • Mediation is difficult to “find”
    • Are we measuring often enough?
    • Are we measuring the right things?
  • 61. Context
    • The call for most effective treatments
    • The everyday clinician needs to know:
    • How to be
    • What to do
    • What not to do
    • To answer the question of “How does treatment work?”
    • Identify mechanisms of change in patients
    • Identify active ingredients of treatment that lead to change
  • 62. Context
    • After 20 years of RCTs, two conclusions:
    • Some treatments are more effective
    • Among effective treatments, they are all about equally effective
    • Possible explanations:
    • Effects equalized by factors outside of treatment
    • Common factors