Be careful what you hear: Increasing motivation for change by influencing client speech Theresa B. Moyers, Ph.D. Departmen...
Motivational Interviewing: An empirically based treatment with a secret
Motivational Interviewing A Definition <ul><li>Motivational interviewing is  </li></ul><ul><li>a person-centered,  </li></...
It is both person-centered and directive. How to do both? Person-centered  Directive
Engaging Person-centered  Directive
Person-centered Elements of MI: <ul><li>Importance of therapeutic empathy and relationship in client outcomes  </li></ul><...
Engaging Evoking Person-centered  Directive
Directive Element of MI: <ul><li>Recognize change talk </li></ul><ul><li>Respond to it contingently (reinforce or consequa...
What is change talk?* <ul><li>Client language in favor of change </li></ul><ul><ul><li>Desire  </li></ul></ul><ul><ul><li>...
When does change talk occur? <ul><li>Change talk occurs naturally and spontaneously when clients are ambivalent about chan...
Why would client language during treatment sessions facilitate change? <ul><li>Facilitates awareness and insight (Engle & ...
Smoke versus Fire <ul><li>Some explanations refer to an underlying process that is INDICATED by the presence of change tal...
How would we conceptualize such a relationship?
Does Client Change Talk Mediate MI and Drinking Outcome Relationship? Motivational Interviewing Client Change Talk Drinkin...
Does Client Change Talk Mediate MI and Drinking Outcome Relationship? Motivational Interviewing Client Change Talk Drinkin...
Evidence of Association Between MI and Client Change Talk  Motivational Interviewing Client Change Talk Intervention Test ...
Does Client Change Talk Mediate MI and Drinking Outcome Relationship? Client Change Talk Drinking Outcome Mediator and  Ch...
Can we move beyond association?
Can we move beyond association?
Three Conditions for Causation <ul><li>Covariation </li></ul><ul><li>Temporal order </li></ul><ul><li>Ruling out alternati...
Temporal order: the advantage of sequential coding <ul><li>Pr ocess  E xchanges in  M otivational  I nterviewing  R esearc...
Premir Project <ul><li>118 first session tapes; clients nested within therapists </li></ul><ul><li>Drinking outcomes match...
Premir Project <ul><li>Multilevel modeling* used to examine relationships between clinician MI practice and client change ...
Premir Results <ul><li>MI Consistent Behaviors (affirm, reflect, support autonomy, advise and inform only with permission)...
Premir Results <ul><li>Overall, this link accounts for about 3% of variance in client drinking outcomes </li></ul>
Now, that’s a nice causal chain <ul><li>Stronger argument for causation, but data is still examining associations </li></ul>
What would stronger evidence look like?
Experimental Manipulation of Change Talk <ul><li>Direct clinicians to “switch change talk on and off” in their clients? </...
<ul><li>If change talk from the client is under the influence of the clinician….. </li></ul><ul><li>Can frontline clinicia...
Project ELICIT: Evaluating Client Language in Interviewing Training <ul><li>Randomized Controlled Trial  </li></ul><ul><li...
Workshop Training (n=200) MI Standard  (MI) MI with Change Talk  Emphasis (MI Plus) Coaching and Feedback Standard Coachin...
MI Standard <ul><li>Plain Vanilla MI </li></ul><ul><li>Standardized Protocol used in EMMEE and AFTER studies </li></ul><ul...
MI Plus <ul><li>Same workshop, same trainers, same time, same place BUT 40% of curriculum specific to change talk </li></u...
Hypothesized Outcomes Change talk in Client Sessions Time MI Plus MI Only
Demographics: Elicit Wave One 38 (36.9%) In recovery 24.37 (9.64) Hours/week treating SA clients 82 (82.0%) White 9 (9.0%)...
Progress for Wave One <ul><li>Workshops held in November, 2008 </li></ul><ul><li>Mean number of consult calls was 3.41 (SD...
Clinician variables from coding SCOPE for Elicit Study <ul><li>Global </li></ul><ul><ul><li>Empathy </li></ul></ul><ul><ul...
Some very preliminary results from the Elicit Project
Post Training Between Groups Global measures <ul><li>Do the groups look different in their global approach to MI after tra...
Post Training Between Groups Global measures <ul><li>No differences between groups on individual global ratings </li></ul>
What about behavior counts? <ul><li>Often more psychometrically stable than globals </li></ul><ul><li>We hypothesized that...
Post Training Between Groups Behavior Counts <ul><li>MANOVA revealed a trend toward significance on specific counts of beh...
What does this look like after 3 months? <ul><li>Clinicians have now had up to 4 consult calls (mean = 3.8) with MI expert...
3 month work samples for  Wave One <ul><li>Globals completed for feedback </li></ul><ul><li>Behavior counts on the way, bu...
Let’s look at Globals <ul><li>Generally, globals should be the same for both groups (empathy, MI spirit) EXCEPT </li></ul>...
Elicit Results for 3 month work samples (Wave One) <ul><li>Repeated measures Manova </li></ul><ul><li>Empathy ( p  = .036)...
Elicit Results for 3 month work samples (Wave One) <ul><li>Evocation changed differently between the two training groups (...
Evocation
Conclusions <ul><li>Some evidence to indicate that clinicians can be trained to “choose” to evoke change talk, or not </li...
Conclusions <ul><li>If there is an impact on client outcomes of language shaping, regardless of other processes occurring ...
With thanks  <ul><li>Tim Martin </li></ul><ul><li>Jon Houck </li></ul><ul><li>Jennifer Manual </li></ul><ul><li>William Mi...
With Thanks to: Tim Martin Jon Houck Jennifer Manual William Miller Lisa Glynn Kevin Hallgren Erin Tooley
HLM Analysis Plan Project ELICIT Base Post 3-month 6-month 12-month Participants (n=200) Group (n=2) Wave (n=2)
Project ELICIT: 3 month follow up data for  Wave One
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Moyers june8-plenary

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ICMI 2010 Day 2: Be careful what you hear: Influencing client language - T Moyers

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  • These person centered elements of MI can be (and are) hypothesized to be causal mechanisms of this treatment, in and of themselves. Previous work in our lab shows a link between therapist interpersonal skills (including empathy) and client engagement in MI. sessions. New work by Pollack has shown a relationship between the therapist’s adherence to the spirit of MI and the client’s dietary outcomes (Pollack cite).
  • Aharonovich: cocaine, strength Hodgins: gambling, strength Baer: substance use, frequency Gaume: ER, alcohol and marijuana, frequency
  • Differences in upper-level variables lead to changes in lower-level variables. Differences in training group will (we hope) lead to changes in variables at the participant level. Differences within participants will lead to changes in MI skill across time. We don’t expect substantial differences based on wave (we hope), but have to include it in the model to detect any effects.
  • Hope to see something like this at the end of the study
  • This is ugly, but then it’s demographics…
  • Changes from post to 3 month probably represent effects of feedback and coaching
  • Changes from post to 3 month probably represent effects of feedback and coaching
  • Differences in upper-level variables lead to changes in lower-level variables. Differences in training group will (we hope) lead to changes in variables at the participant level. Differences within participants will lead to changes in MI skill across time. We don’t expect substantial differences based on wave (we hope), but have to include it in the model to detect any effects.
  • Transcript of "Moyers june8-plenary"

    1. 1. Be careful what you hear: Increasing motivation for change by influencing client speech Theresa B. Moyers, Ph.D. Department of Psychology Center on Alcoholism, Substance Abuse and Additions University of New Mexico
    2. 2. Motivational Interviewing: An empirically based treatment with a secret
    3. 3. Motivational Interviewing A Definition <ul><li>Motivational interviewing is </li></ul><ul><li>a person-centered, </li></ul><ul><li>directive </li></ul><ul><li>method of communication </li></ul><ul><li>for enhancing intrinsic motivation to change by exploring and resolving ambivalence. </li></ul>
    4. 4. It is both person-centered and directive. How to do both? Person-centered Directive
    5. 5. Engaging Person-centered Directive
    6. 6. Person-centered Elements of MI: <ul><li>Importance of therapeutic empathy and relationship in client outcomes </li></ul><ul><li>Focus on client strengths and reasons for optimism </li></ul><ul><li>Examining disconnect between client’s distressing behaviors and deeply held values and goals </li></ul><ul><li>Emphasis on collaboration and client choice to reduce resistance; therapist avoids prescribing change or offering expert advice about it </li></ul>
    7. 7. Engaging Evoking Person-centered Directive
    8. 8. Directive Element of MI: <ul><li>Recognize change talk </li></ul><ul><li>Respond to it contingently (reinforce or consequate) </li></ul><ul><li>Elicit change talk strategically </li></ul>
    9. 9. What is change talk?* <ul><li>Client language in favor of change </li></ul><ul><ul><li>Desire </li></ul></ul><ul><ul><li>Ability </li></ul></ul><ul><ul><li>Reasons </li></ul></ul><ul><ul><li>Need </li></ul></ul><ul><ul><li>Commitment </li></ul></ul><ul><ul><li>Taking Steps </li></ul></ul>* Really? Are we sure?
    10. 10. When does change talk occur? <ul><li>Change talk occurs naturally and spontaneously when clients are ambivalent about change </li></ul><ul><ul><li>“ I want it but I don’t” </li></ul></ul><ul><ul><li>“ Yes, but” </li></ul></ul><ul><li>It occurs much less, or not at all, when clients are not ambivalent about change </li></ul><ul><li>It is usually intertwined with counter change talk and resistance </li></ul><ul><li>It is the spontaneous emergence of this language within an empathic therapeutic context that is the marker of change talk, not simply repetition, lying or “chanting” </li></ul>
    11. 11. Why would client language during treatment sessions facilitate change? <ul><li>Facilitates awareness and insight (Engle & Arkowitz) </li></ul><ul><li>Enhances emotional salience (Wagner & Ingersoll) </li></ul><ul><li>Persuades speaker of what they believe when ambivalence is prominent (Miller & Rollnick via Bem) </li></ul><ul><li>Obligates listener through public commitment (Amrhein) </li></ul>
    12. 12. Smoke versus Fire <ul><li>Some explanations refer to an underlying process that is INDICATED by the presence of change talk (smoke) </li></ul><ul><li>Others indicate a more active role for the forming and speaking of language within a particular context as ITSELF being powerful </li></ul>
    13. 13. How would we conceptualize such a relationship?
    14. 14. Does Client Change Talk Mediate MI and Drinking Outcome Relationship? Motivational Interviewing Client Change Talk Drinking Outcome Using Baron & Kinney’s model for mediation
    15. 15. Does Client Change Talk Mediate MI and Drinking Outcome Relationship? Motivational Interviewing Client Change Talk Drinking Outcome d=.77 Hettema, Steele & Miller, 2005
    16. 16. Evidence of Association Between MI and Client Change Talk Motivational Interviewing Client Change Talk Intervention Test Catley, et al., 2006 Houck & Moyers, 2008
    17. 17. Does Client Change Talk Mediate MI and Drinking Outcome Relationship? Client Change Talk Drinking Outcome Mediator and Change Test Aharonovich et al., 2009 Amrhein et al., 2003 Baer, et al., 2008 Gaume, Gmel & Daeppen, 2008 Hodgins et al., 2009 Moyers, et al., 2007 Pollack et al., 2009 Strang & McCambridge, 2008
    18. 18. Can we move beyond association?
    19. 19. Can we move beyond association?
    20. 20. Three Conditions for Causation <ul><li>Covariation </li></ul><ul><li>Temporal order </li></ul><ul><li>Ruling out alternative explanations through experimental manipulation and control of extraneous variables </li></ul><ul><li>- J.S. Mill (in Cook & Campbell, 1979) </li></ul>
    21. 21. Temporal order: the advantage of sequential coding <ul><li>Pr ocess E xchanges in M otivational I nterviewing R esearch: Premir Project </li></ul><ul><li>Moyers, Martin, Houck, Christopher & Tonigan JCCP, 2009 </li></ul><ul><li>Used taped therapy sessions from Project MATCH in the MET condition </li></ul>
    22. 22. Premir Project <ul><li>118 first session tapes; clients nested within therapists </li></ul><ul><li>Drinking outcomes matched to client tapes </li></ul><ul><li>Tapes coded using a sequential coding system (SCOPE) </li></ul><ul><li>Preserves temporal order of interactions and allows generation of if-then relationships </li></ul>
    23. 23. Premir Project <ul><li>Multilevel modeling* used to examine relationships between clinician MI practice and client change talk and drinking outcomes </li></ul><ul><li>Both drinking severity (alcohol involvement) and self-efficacy (AASE) accounted for </li></ul>*thank you Reviewer 3
    24. 24. Premir Results <ul><li>MI Consistent Behaviors (affirm, reflect, support autonomy, advise and inform only with permission) predict client drinking </li></ul><ul><li>Change talk also predicts drinking </li></ul><ul><li>Change talk mediates between MICO and Drinks per week accounting for about 30% of this effect </li></ul>
    25. 25. Premir Results <ul><li>Overall, this link accounts for about 3% of variance in client drinking outcomes </li></ul>
    26. 26. Now, that’s a nice causal chain <ul><li>Stronger argument for causation, but data is still examining associations </li></ul>
    27. 27. What would stronger evidence look like?
    28. 28. Experimental Manipulation of Change Talk <ul><li>Direct clinicians to “switch change talk on and off” in their clients? </li></ul><ul><li>Talking About Drinking Study (Glynn & Moyers, 2010) </li></ul>
    29. 29. <ul><li>If change talk from the client is under the influence of the clinician….. </li></ul><ul><li>Can frontline clinicians be trained to influence change talk in actual substance abuse treatment sessions? </li></ul>Can we teach clinicians to do it?
    30. 30. Project ELICIT: Evaluating Client Language in Interviewing Training <ul><li>Randomized Controlled Trial </li></ul><ul><li>Two MI training conditions; standard and CT emphasis (called MI Plus) </li></ul><ul><li>Workshop training plus consult calls and feedback (specific to condition) </li></ul><ul><li>Clinicians submit actual therapy sessions at 3, 6 and 12 months after workshop training </li></ul><ul><li>Both clinician behaviors and client change talk rated by masked raters using objective behavioral rating system </li></ul>
    31. 31. Workshop Training (n=200) MI Standard (MI) MI with Change Talk Emphasis (MI Plus) Coaching and Feedback Standard Coaching and Feedback Specific to CT <ul><ul><li>3, 6 and 12 month Follow-Up </li></ul></ul><ul><ul><li>Percent Change Talk in Client Sessions </li></ul></ul>Evaluating Language in Clinician Interviewing Training: Project ELICIT NIDA 021227
    32. 32. MI Standard <ul><li>Plain Vanilla MI </li></ul><ul><li>Standardized Protocol used in EMMEE and AFTER studies </li></ul><ul><li>Two day workshop </li></ul><ul><ul><li>Burke, Miller, Manual, Moyers, Yahne </li></ul></ul>
    33. 33. MI Plus <ul><li>Same workshop, same trainers, same time, same place BUT 40% of curriculum specific to change talk </li></ul><ul><li>Recognize, reinforce and evoke client change talk </li></ul><ul><ul><li>More attention (asking questions, reflecting) to client language about changing </li></ul></ul><ul><ul><li>Less attention to client language about “downside” of changing </li></ul></ul><ul><ul><li>Strategically arranging conversations so that client more likely to offer change talk </li></ul></ul>
    34. 34. Hypothesized Outcomes Change talk in Client Sessions Time MI Plus MI Only
    35. 35. Demographics: Elicit Wave One 38 (36.9%) In recovery 24.37 (9.64) Hours/week treating SA clients 82 (82.0%) White 9 (9.0%) African American 4 (4.0%) Other 1 (1.0%) Asian American 4 (4.0%) American Indian/ Alaska Native Ethnicity 64 (63.4%) Female 37 (36.6%) Male Sex 44.45 (10.01) Age M (SD) / n (%) Variable
    36. 36. Progress for Wave One <ul><li>Workshops held in November, 2008 </li></ul><ul><li>Mean number of consult calls was 3.41 (SD = .91), with no significant difference between the groups ( t (1, 95) = 1.53, p = .219) </li></ul><ul><li>77% submitted 3 month work sample (actual substance abuse treatment session) </li></ul>
    37. 37. Clinician variables from coding SCOPE for Elicit Study <ul><li>Global </li></ul><ul><ul><li>Empathy </li></ul></ul><ul><ul><li>Acceptance </li></ul></ul><ul><ul><li>Collaboration </li></ul></ul><ul><ul><li>Autonomy Support </li></ul></ul><ul><ul><li>Direction </li></ul></ul><ul><ul><li>Evocation </li></ul></ul><ul><li>Behavior Counts </li></ul><ul><ul><li>Open Questions </li></ul></ul><ul><ul><li>Closed Questions </li></ul></ul><ul><ul><li>Simple and Complex Reflections </li></ul></ul><ul><ul><li>MI Consistent (affirm, support, emphasize control, ask permission) </li></ul></ul><ul><ul><li>MI Inconsistent (confront, direct, warn, advice without permission) </li></ul></ul>
    38. 38. Some very preliminary results from the Elicit Project
    39. 39. Post Training Between Groups Global measures <ul><li>Do the groups look different in their global approach to MI after training? (no consult calls or feedback yet) </li></ul>
    40. 40. Post Training Between Groups Global measures <ul><li>No differences between groups on individual global ratings </li></ul>
    41. 41. What about behavior counts? <ul><li>Often more psychometrically stable than globals </li></ul><ul><li>We hypothesized that MI Plus should be responding differentially to change talk </li></ul><ul><li>Preferentially reflecting Change Talk (this necessarily implies less responding to Sustain Talk) </li></ul>
    42. 42. Post Training Between Groups Behavior Counts <ul><li>MANOVA revealed a trend toward significance on specific counts of behaviors at post-training ( F (8,92) = 1.922, p = .066) </li></ul><ul><li>Univariate follow-up indicated group differences on two variables </li></ul><ul><ul><li>Reflections of counter-change talk ( p = .015) * MI Plus Condition reflecting less counter change talk </li></ul></ul><ul><ul><li>Questioning the negative aspects of the target behavior ( p = .046) *MI Plus Condition asking less about negative aspects of substance use </li></ul></ul>
    43. 43. What does this look like after 3 months? <ul><li>Clinicians have now had up to 4 consult calls (mean = 3.8) with MI experts* </li></ul><ul><li>These consult calls are specific to the MI condition in which they were trained </li></ul><ul><li>They have also received and discussed their feedback, which is also tailored to their training condition </li></ul>* The best in the business
    44. 44. 3 month work samples for Wave One <ul><li>Globals completed for feedback </li></ul><ul><li>Behavior counts on the way, but not ready yet </li></ul>
    45. 45. Let’s look at Globals <ul><li>Generally, globals should be the same for both groups (empathy, MI spirit) EXCEPT </li></ul><ul><li>Ideally we should see a difference in Evocation </li></ul><ul><ul><li>That is, MI Plus participants should be HIGHER in this global </li></ul></ul>
    46. 46. Elicit Results for 3 month work samples (Wave One) <ul><li>Repeated measures Manova </li></ul><ul><li>Empathy ( p = .036) and Acceptance ( p =.003) increased significantly from post-treatment session to three month session </li></ul><ul><li>Collaboration ( p = .085) trended toward significance </li></ul>* 77% submitted tapes at 3 month follow up; 39 MI and 38 MI Plus
    47. 47. Elicit Results for 3 month work samples (Wave One) <ul><li>Evocation changed differently between the two training groups ( p = .034) </li></ul><ul><ul><li>Significant increase in MI Plus group only </li></ul></ul>* 77% submitted tapes at 3 month follow up; 39 MI and 38 MI Plus
    48. 48. Evocation
    49. 49. Conclusions <ul><li>Some evidence to indicate that clinicians can be trained to “choose” to evoke change talk, or not </li></ul><ul><li>In other words, this looks to be a learn-able skill </li></ul><ul><li>If so, we are ready for a randomized, controlled trial to test the impact of this “evoking” on client outcomes </li></ul>
    50. 50. Conclusions <ul><li>If there is an impact on client outcomes of language shaping, regardless of other processes occurring within treatment, the argument for this as a causal mechanism is stronger </li></ul><ul><li>Would this be a good outcome? </li></ul>
    51. 51. With thanks <ul><li>Tim Martin </li></ul><ul><li>Jon Houck </li></ul><ul><li>Jennifer Manual </li></ul><ul><li>William Miller </li></ul><ul><li>Lisa Glynn </li></ul><ul><li>Kevin Hallgren </li></ul><ul><li>Erin Tooley </li></ul>
    52. 52. With Thanks to: Tim Martin Jon Houck Jennifer Manual William Miller Lisa Glynn Kevin Hallgren Erin Tooley
    53. 53. HLM Analysis Plan Project ELICIT Base Post 3-month 6-month 12-month Participants (n=200) Group (n=2) Wave (n=2)
    54. 54. Project ELICIT: 3 month follow up data for Wave One

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