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MI, Complexity and Chaos             Ken Resnicow, PhD           University of Michigan           School of Public Health ...
What do these concepts mean for MI ?       Sudden/Unplanned Change       Chaos Theory       Energy and Depletion      ...
Newtonian PrinciplesLinearity— simple relationship between inputs and   outputs. Small inputs have small effects, large   ...
Transtheoretical Model: Stage of Change                  (Prochaska)       Source: http://www.prochange.com/ttm
Implications for MI   Sudden/Unplanned Change   Chaos   Energy and Depletion   Autonomy Preferences   Why to How     ...
Random selection:           900 current smokers800 ex-smokers quit > 4 weeks but < 10 years
Which of these statements best describes how your    most recent quit attempt started?   I did not plan the quit attempt ...
  UNPLANNEDI did not plan the quit attempt in advance, I just did it  PLANNEDI planned the quit attempt for later the sa...
Odds of 6-month success
West, R. and T. Sohal (2006). "Catastrophic" pathwaysto smoking cessation: findings from a national survey.              B...
Sudden Gains: enduring reductionsin symptoms from one session tothe next.
Study Overview   60 moderately-to-severely depressed adult    outpatients who scored at least 20 on the 17-item    modifi...
Sudden Gains   7 BDI points (Beck Depression Inventory), between    Session n and Session n+1, and   At least 25% of the...
Response & Relapse   Responders: (a) 16-week HRSD <= 12 and either 14-week    HRSD <=14 or 10-week and 12-week HRSD < = 1...
RESULTS   24 of the 60 patients (40%) experienced    sudden gains (SG) during treatment.   8 patients experienced more t...
RESULTS        35 RespondersSudden Gain        No Sudden Gain  19/24                16/36  (79%)                (44%)
Non Relapse by Sudden-Gain Status     Responders only (n=35)                            73%                            34%
Quantum ChangeQuantum Change: When Epiphanies and Sudden Insights Transform  Ordinary Lives. William R. Miller and Janet C...
“Buried in the statement “I just decided”,  however can be another kind of experience  that has been confused with ordinar...
So what?   Is sudden, unplanned change simply a    curiosity, or can we elicit “epiphany”    clinically?                 ...
Some new/other concepts to   incorporate into MI   Sudden/Unplanned Change   Chaos   Energy and Depletion   Autonomy P...
Chaotic and Complex Systems   Sensitive to Initial Conditions   Outcomes are non-random, but difficult to    predict   ...
Chaotic and Complex Systems   Sensitive to Initial Conditions   Outcomes are non-random, but difficult to    predict   ...
Sensitivity to Initial ConditionsEdward Lorenz accidental discovery, in 1961, through his work on  weather prediction.Lore...
The Butterfly EffectThe flapping of a butterflys wings in Malaysia cancreate a tornado in Kansas.The butterfly flapping it...
Sensitivity to initial conditions                   Person 2                                Person 1        Success   Fail...
Chaos, Complexity, and                   Behavior Change    Behavior change is sensitive to initial conditions.    Behav...
Healthy Variability (chaos)Ary L. Goldberger. Proc Am Thorac . Vol 3. pp 467–472, 2006
A little Chaos is good/Correlated VariabilityToo Little         Optimal      Too MuchCHF                Healthy      V-fib...
Chaos and Complexity    Intervention and Assessment Implications       Moderators        Mediators   Tailoring Variables
Chaos and Complexity Intervention Implications       Moderators        Mediators   Tailoring Variables
Creating a Butterfly Effect   We help create the atmospheric conditions for a    perfect storm, although it is outside ou...
Creating a Butterfly Effect   Provide multiple opportunities for change   Vary Initial Conditions……    – How you counsel...
Chaos and Complexity Assessment Implications       Moderators        Mediators   Tailoring Variables
Assessing quantum vs.                     planned changeHow would you describe the process you used to change your (weight...
DESCISION-MAKING: TRAITWhen you make an important life decision, are you more likely to plan or to just do it?    PLAN    ...
Some new/other concepts to   incorporate into MI   Sudden/Unplanned Change   Chaos   Energy and Depletion   Autonomy P...
WHEN MI MAY NOT BE THE        PREFERRED METHODState:   Fully motivated clients   Some clinical situations warrant a more...
WHEN MI MAY NOT BE THE        PREFERRED METHODState:   Fully motivated clients   Some clinical situations warrant a more...
Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decisionmaking. A national study of public ...
Methods:US Population-based survey of adults conducted inIn 2002 General Social Survey (N = 2,765).GSS conducted by the Na...
Methods:Respondents rated preferences ranging from patient-  directed to physician directed styles on each of 3  aspects o...
ITEMS‘‘I prefer to rely on my doctor’s knowledge and not try to find outabout my condition on my own’’ (Knowledge)‘‘I pref...
Results:
• HIGHER SCORES = HIGHER PATIENT CENTERED                PREFERENCE
PATIENT COMMUNICATION         PREFERENCESSee Also•   Miller S, Khensani N, Beech B. Perceptions of Physical Activity and  ...
The role of AUTONOMY in patient counseling                               High State/                                  Trai...
Some new/other concepts to   incorporate into MI   Sudden/Unplanned Change   Chaos   Energy and Depletion   Autonomy P...
There is no improvement, Henry. Are you sure you’ve given up everything              you enjoy?                           ...
Depletion: Self-Regulation as Limited                Resource• Self-regulation requires energy• A single, domain-general r...
Depletion:   Self-Regulation as Limited Resource• Meta-analysis of 83 studies• Significant ego depletion effects:  – Task ...
RESISTANCE ENERGY CONSERVATION DREAD          DEPLETION                                       58
Some new/other concepts to   incorporate into MI   Sudden/Unplanned Change   Chaos   Energy and Depletion   Autonomy P...
MOVING FROM WHY TO HOW                      AUTONOMY SUPPORTIVE CHOOSINGWHY Change                  HOW to Change         ...
Build Discrepancy                    Listening                     Advising                     Informing                 ...
Explore          ChooseGuide                   62
4 Processes1-Engage2-Guide3-Evoke4-Plan                         63
Build Discrepancy                          Listening                           Advising                           Informin...
Three Phases of Consultation   Explore (WHAT/WHY/WHY NOT)     –   COMFORT THE AFFLICTED     –   Build Initial rapport & E...
Autonomy Supportive Choosing   Action Reflections   Elicit-Provide-Elicit   Provide Menu of Options for Change    – Usu...
Action Reflections• Imbed Solutions to Barriers• Imbed Action Plans• Undersell  – You might want to…  – You might want to ...
Action Reflections:              Soft Sell CBT• 1) Invert Barrier   – Sounds like we might want to address barrier a,b,c• ...
Action Reflections                     69
E-P-E   Elicit    –   What is your understanding of?    –   What have you heard about?    –   What do you want to know?  ...
E-P-E Is this normal ? Can I xxx?                     71
PAD54 year old female with PAD, diabetes mellitus,  hypertension, and difficulty walking.“I used to walk to the park with ...
A 12 year old went to WIC clinic, she    was asked about breastfeeding and    answered,   “Can I? I heard teenagers can’t...
   “Moms should stop    breastfeeding around 6 Months,    because breast milk is not good any    longer.”                ...
EPIPHANY ANYONE ?                    75
The RANDOM WALK
Random Walk   Stock prices (Health Behaviors)    tend to follow a random walk, i.e,    the best forecast of tomorrow’s   ...
METHODSOverweight adults (N=104) were randomly assigned to nondirective, directive, orminimal support.All received weekly ...
Resnicow2012icmiplenary
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  • In this comic, the physician is telling his patient: [Read slide.] Unfortunately, numerous studies have found that patients FREQUENTLY disagree with physicians’ prescribed treatment plans [like the guy in this cartoon probably does]. This—usually unspoken—disagreement then leads to unfilled and partially used prescriptions, lack of follow-up, and poor clinical outcomes. We often aren’t AWARE when patients disagree, but they do.
  • Sounds like you are interested in breastfeeding your baby, but you are not sure it is ok for teen moms… EPE/SPA What have you heard about teenagers breastfeeding their babies? Reflect – their knowledge Can I provide you some information about teenagers breastfeeding? Give info. What do you make of that?
  • You feel that your body cannot produce good milk after six months….. Optional E-P-E
  • Transcript of "Resnicow2012icmiplenary"

    1. 1. MI, Complexity and Chaos Ken Resnicow, PhD University of Michigan School of Public Health Department of Pediatrics Comprehensive Cancer Center Center for Health Communications Research Ann Arbor, MI Kresnic@umich.edu http://chcr.umich.edu
    2. 2. What do these concepts mean for MI ?  Sudden/Unplanned Change  Chaos Theory  Energy and Depletion  Autonomy Preferences – MI not for everyone?  Why to How transition 2
    3. 3. Newtonian PrinciplesLinearity— simple relationship between inputs and outputs. Small inputs have small effects, large inputs have large effects.Reductionism— systems can be understood by breaking them down into their component parts.Determinism—a system can be predicted.Rationalism---- Behavior can be formulated as the making of a rational choices between alternative means of achieving a known end. More information leads to more rational choices. Are these principles inherent to MI?
    4. 4. Transtheoretical Model: Stage of Change (Prochaska) Source: http://www.prochange.com/ttm
    5. 5. Implications for MI Sudden/Unplanned Change Chaos Energy and Depletion Autonomy Preferences Why to How 6
    6. 6. Random selection: 900 current smokers800 ex-smokers quit > 4 weeks but < 10 years
    7. 7. Which of these statements best describes how your most recent quit attempt started? I did not plan the quit attempt in advance, I just did it I planned the quit attempt for later the same day I planned the quit attempt the day beforehand I planned the quit attempt a few days beforehand I planned the quit attempt a few weeks beforehand I planned the quit attempt a few months beforehand
    8. 8.  UNPLANNEDI did not plan the quit attempt in advance, I just did it PLANNEDI planned the quit attempt for later the same dayI planned the quit attempt the day beforehandI planned the quit attempt a few days beforehandI planned the quit attempt a few weeks beforehandI planned the quit attempt a few months beforehand
    9. 9. Odds of 6-month success
    10. 10. West, R. and T. Sohal (2006). "Catastrophic" pathwaysto smoking cessation: findings from a national survey. BMJ 332(7539): 458-60.
    11. 11. Sudden Gains: enduring reductionsin symptoms from one session tothe next.
    12. 12. Study Overview 60 moderately-to-severely depressed adult outpatients who scored at least 20 on the 17-item modified HRSD. 16 weeks of CT A full course of CT usually produces about 12– 15 points of improvements in mean BDI scores
    13. 13. Sudden Gains 7 BDI points (Beck Depression Inventory), between Session n and Session n+1, and At least 25% of the pre-gain session’s BDI score (relative magnitude), and Difference between the mean BDI score of the three sessions before the gain (n 2, n 1, and n) and the three sessions after the gain (n 1, n 2, and n 3) was at least 2.78 times greater than the pooled standard deviations of these sessions’ BDI scores
    14. 14. Response & Relapse Responders: (a) 16-week HRSD <= 12 and either 14-week HRSD <=14 or 10-week and 12-week HRSD < = 12 or (b) 12-, 14-, and 18-week HRSD < = 12.3 Relapse: Responder (a) scored > = 14 on HRSD for 2 consecutive weeks or (b) met the diagnostic criteria for major depressive disorder for 2 consecutive weeks.
    15. 15. RESULTS 24 of the 60 patients (40%) experienced sudden gains (SG) during treatment. 8 patients experienced more than one sudden gain. Sudden gains averaged 11 BDI points Median SG was Session 5.
    16. 16. RESULTS 35 RespondersSudden Gain No Sudden Gain 19/24 16/36 (79%) (44%)
    17. 17. Non Relapse by Sudden-Gain Status Responders only (n=35) 73% 34%
    18. 18. Quantum ChangeQuantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives. William R. Miller and Janet C’de Baca, 2001“Quantum Change is a vivid, surprising, benevolent, and enduring personal transformation. Some quantum changes are insightful, an "aha!" that leaves a person breathless and confident of a new truth and a new way of thinking. Other quantum changes are mystical, like Saint Paul’s on the road to Damascus. Both kinds tend to impart a mysterious and enduring sense of peacefulness. Both mark the beginning of lasting and often pervasive changes in a person’s life. Both usually involve a significant alteration in how one perceives other people, the world, oneself, and the relationships among them. What differentiates the mystical type is the sense of being acted upon by something outside and greater than oneself. ” 21
    19. 19. “Buried in the statement “I just decided”, however can be another kind of experience that has been confused with ordinary decision making…..When people talk about such experiences….., they may say “it just happened” or “I just decided”.Inquire a little more closely, however, and it becomes apparent that the process is somewhat more complex.” (page37) Quantum Change: When Epiphanies and Sudden Insights Transform Ordinary Lives. William R. Miller and Janet C’de Baca, 2001
    20. 20. So what? Is sudden, unplanned change simply a curiosity, or can we elicit “epiphany” clinically? 23
    21. 21. Some new/other concepts to incorporate into MI Sudden/Unplanned Change Chaos Energy and Depletion Autonomy Preferences Why to How 24
    22. 22. Chaotic and Complex Systems Sensitive to Initial Conditions Outcomes are non-random, but difficult to predict Often non-linear pattern Exact patterns rarely repeat Greater than sum of their parts Multiple interactions
    23. 23. Chaotic and Complex Systems Sensitive to Initial Conditions Outcomes are non-random, but difficult to predict Often non-linear pattern Exact patterns rarely repeat Greater than sum of their parts Multiple interactions
    24. 24. Sensitivity to Initial ConditionsEdward Lorenz accidental discovery, in 1961, through his work on weather prediction.Lorenz was running computer simulations to predict weather. He wanted to repeat a prediction. To save time he started the simulation in the middle. He did so by beginning in the middle of the run, using output from the prior calculation.To his surprise the weather predicted was completely different than the weather calculated before.He discovered that he had rounded some variables off to a 3-digit number, but the computer originally worked with 5-digit numbers.This tiny difference produced large changes in the long, complex calculation which greatly altered the outcome.We call this the BUTTERFLY EFFECT.
    25. 25. The Butterfly EffectThe flapping of a butterflys wings in Malaysia cancreate a tornado in Kansas.The butterfly flapping its wings represents a "small"change in the initial condition of the system whichcauses a chain of events leading to large-scalephenomena like tornadoes. Had the butterfly notflapped its wings, the trajectory of the system mighthave been vastly different.
    26. 26. Sensitivity to initial conditions Person 2 Person 1 Success Failure
    27. 27. Chaos, Complexity, and Behavior Change Behavior change is sensitive to initial conditions. Behavior change is highly variable and difficult to predict. (non- deterministic). Behavior change is a complex dynamic system that involves multiple component parts that interact. Behavior change is often a quantum leap rather than a gradual linear event. (small input large output). • Many health decisions are transformational, not rational. Knowledge necessary but insufficient.5) Motivation may be greater than the sum of it parts (non-reductionistic).6) Chaos can be positive.
    28. 28. Healthy Variability (chaos)Ary L. Goldberger. Proc Am Thorac . Vol 3. pp 467–472, 2006
    29. 29. A little Chaos is good/Correlated VariabilityToo Little Optimal Too MuchCHF Healthy V-fibSleepGaitEpilepsyBreathingOCDBehavior Change?Grant Review?
    30. 30. Chaos and Complexity Intervention and Assessment Implications Moderators Mediators Tailoring Variables
    31. 31. Chaos and Complexity Intervention Implications Moderators Mediators Tailoring Variables
    32. 32. Creating a Butterfly Effect We help create the atmospheric conditions for a perfect storm, although it is outside our ability to cause. MI provides opportunities for epiphanies and sudden change. – Directive interventions inhibit them. Jump in change talk. – Motivational Orgasm. Accept linear change; strive for quantum change
    33. 33. Creating a Butterfly Effect Provide multiple opportunities for change Vary Initial Conditions…… – How you counsel – When you counsel  Client Mood – Where you counsel – What you recommend
    34. 34. Chaos and Complexity Assessment Implications Moderators Mediators Tailoring Variables
    35. 35. Assessing quantum vs. planned changeHow would you describe the process you used to change your (weight, eating, exercise)? 1 2 3 4 5 6 7 8 9 10 I planned it I just did it Intellectual Emotional Weighed Pros and Cons Just Decided Thought it through It just hit me
    36. 36. DESCISION-MAKING: TRAITWhen you make an important life decision, are you more likely to plan or to just do it? PLAN JUST DO ITWhen you make an important life decision, are you more likely to weigh the pros and cons or to just decide? WEIGH THE PROS AND CONS JUST DECIDEWhen you make an important life decision, are you more likely to think it through or to just let it hit you? THINK IT THROUGH LET IT HIT YOU
    37. 37. Some new/other concepts to incorporate into MI Sudden/Unplanned Change Chaos Energy and Depletion Autonomy Preferences – MI not for everyone? Why to How 41
    38. 38. WHEN MI MAY NOT BE THE PREFERRED METHODState: Fully motivated clients Some clinical situations warrant a more directive style, e.g., acute conditions, recent DxTrait: Some individuals prefer a directive style 42
    39. 39. WHEN MI MAY NOT BE THE PREFERRED METHODState: Fully motivated clients Some clinical situations warrant a more directive style, e.g., acute conditions, recent DxTrait: Some individuals prefer a directive style 45
    40. 40. Levinson W, Kao A, Kuby A, Thisted RA. Not all patients want to participate in decisionmaking. A national study of public preferences. J Gen Intern Med 2005;20(6):531-5.
    41. 41. Methods:US Population-based survey of adults conducted inIn 2002 General Social Survey (N = 2,765).GSS conducted by the National Opinion ResearchCenter (NORC).Largest sociology project funded since 1973 by theNational Science Foundation.In-home interview, 90 minutes
    42. 42. Methods:Respondents rated preferences ranging from patient- directed to physician directed styles on each of 3 aspects of decision making: 1) seeking information 2) discussing options 3) making the final decision
    43. 43. ITEMS‘‘I prefer to rely on my doctor’s knowledge and not try to find outabout my condition on my own’’ (Knowledge)‘‘I prefer that my doctor offers me choices and asks my opinion’’(Options) ITEM REVERSE CODED FOR MULTIVARIATE‘‘I prefer to leave decisions about my medical care up to my doctor’’(Decision).Responses: 6-point scale ranging from ‘‘strongly agree’’ (l) to ‘‘stronglydisagree’’ (6).
    44. 44. Results:
    45. 45. • HIGHER SCORES = HIGHER PATIENT CENTERED PREFERENCE
    46. 46. PATIENT COMMUNICATION PREFERENCESSee Also• Miller S, Khensani N, Beech B. Perceptions of Physical Activity and Motivational Interviewing Among Rural African-American Women with Type 2 Diabetes. Womens health issues 2009: 1–7.• Miller ST, Beech BM. Rural healthcare providers question the practicality of motivational interviewing and report varied physical activity counseling experience. Patient Education and Counseling 2009;76(2):279-282.
    47. 47. The role of AUTONOMY in patient counseling High State/ Trait Need Autonomy Autonomy Support Style Support Style Acute Condition Chronic Condition More Directive Style Autonomy Support Style Low State/Trait NeedLow State need, e.g., high arousal, anxiety or fear state or recent diagnosisLow Trait need, e.g., preference for expert recommendation, personality-culture
    48. 48. Some new/other concepts to incorporate into MI Sudden/Unplanned Change Chaos Energy and Depletion Autonomy Preferences – MI not for everyone? Why to How 54
    49. 49. There is no improvement, Henry. Are you sure you’ve given up everything you enjoy? 55
    50. 50. Depletion: Self-Regulation as Limited Resource• Self-regulation requires energy• A single, domain-general resource from which individuals draw every time they exert self- control (Muraven et al., 1998)• Ego-depletion: Each exertion can affect subsequent self-regulation• Resisting temptations, delaying gratification, monitoring impressions, controlling emotion
    51. 51. Depletion: Self-Regulation as Limited Resource• Meta-analysis of 83 studies• Significant ego depletion effects: – Task performance, effort, perceived difficulty, subjective fatigue, & blood glucose levels• Moderators of ego depletion effects: – Task duration & complexity – Motivation & self-control training (Hagger, Wood, Stiff, & Chatzisarantis, 2010)
    52. 52. RESISTANCE ENERGY CONSERVATION DREAD DEPLETION 58
    53. 53. Some new/other concepts to incorporate into MI Sudden/Unplanned Change Chaos Energy and Depletion Autonomy Preferences – MI not for everyone? Why to How 59
    54. 54. MOVING FROM WHY TO HOW AUTONOMY SUPPORTIVE CHOOSINGWHY Change HOW to Change MI Background PlatformMI Primary ModalityBuilding Motivation Building an Action Plan Self-Monitoring Shaping Contract Contingency Management Cognitive Restructuring 60
    55. 55. Build Discrepancy Listening Advising Informing Asking Explore Guide ChooseUnderstanding Deciding Acting 61
    56. 56. Explore ChooseGuide 62
    57. 57. 4 Processes1-Engage2-Guide3-Evoke4-Plan 63
    58. 58. Build Discrepancy Listening Advising Informing Asking Explore Guide ChooseUnderstanding Deciding Acting1-Engage 2-Guide 3-Evoke 4-Plan
    59. 59. Three Phases of Consultation Explore (WHAT/WHY/WHY NOT) – COMFORT THE AFFLICTED – Build Initial rapport & Express Empathy – Drain the swamp of negativity – Obtain a history – Collaborative agenda setting – Explore pros, cons, hopes and fears (Reasons) Guide (IF) – AFFLICT THE COMFORTBLE – Build Motivation & Discrepancy – Elicit change talk • 0-10 Readiness Rulers • Importance (Reasons/Desire/Need) • Confidence (Ability) • Values Clarification (Desire & Need) – SPIN THE BALLS • Where does that leave you? – Obtain COMMITMENT – Move toward a behavior decision Choose (if a decision/commitment has been made) (WHEN/HOW) – Taking STEPS – Establish a Goal – Provide Menu of Options – Set an Action Plan – Overcome/anticipate barriers – Make a contract & Discuss follow up 65
    60. 60. Autonomy Supportive Choosing Action Reflections Elicit-Provide-Elicit Provide Menu of Options for Change – Usually client helps populate the list Counselor Undersells Options Provide Choice – What to change – How much change – When – How Monitored 66 – Contingencies
    61. 61. Action Reflections• Imbed Solutions to Barriers• Imbed Action Plans• Undersell – You might want to… – You might want to consider… – Sounds like…..might be an option… – If we are to move forward you might want to address…. 67
    62. 62. Action Reflections: Soft Sell CBT• 1) Invert Barrier – Sounds like we might want to address barrier a,b,c• 2) General Behavior Fix – Sounds like doing something like x,y,z• 3) Specific Behavior Fix – Sounds like doing x may be a possibility• 4) Cognitive Fix – Sounds like you may have to think about x differently (make peace, no all or nothing thinking, giving credit) EXTENSION OF REFLECTING ON DARN CAT (Taking Steps) 68
    63. 63. Action Reflections 69
    64. 64. E-P-E Elicit – What is your understanding of? – What have you heard about? – What do you want to know? – What’s the most important thing you want to know about?  REFLECT AND AFFIRM THEIR KNOWLEDGE  ASK PERMISSION TO PROVIDE  GIVE CHOICE ABOUT WHAT AND HOW Provide – Information – Advice “Some of what I say may differ from what you have heard?” Elicit – What do you make of that? – Where does that leave you? – How does that compare to what you previously thought/heard? 70
    65. 65. E-P-E Is this normal ? Can I xxx? 71
    66. 66. PAD54 year old female with PAD, diabetes mellitus, hypertension, and difficulty walking.“I used to walk to the park with my nephews, but now I avoid walking more than a block because of the cramping in my right calf. I miss spending time with them. But I’m worried that the pain will make my leg worse. Is that true? ” E-P-E 72
    67. 67. A 12 year old went to WIC clinic, she was asked about breastfeeding and answered, “Can I? I heard teenagers can’t breastfeed.” E-P-E
    68. 68.  “Moms should stop breastfeeding around 6 Months, because breast milk is not good any longer.” E-P-E
    69. 69. EPIPHANY ANYONE ? 75
    70. 70. The RANDOM WALK
    71. 71. Random Walk Stock prices (Health Behaviors) tend to follow a random walk, i.e, the best forecast of tomorrow’s price (Behavior) is today’s price (Behavior/Intention) plus a random component (Our Interventions)
    72. 72. METHODSOverweight adults (N=104) were randomly assigned to nondirective, directive, orminimal support.All received weekly lessons and feedback graphs via email.Participants in the nondirective and directive support conditions received individualizednondirective or directive weight loss support.Participants attended an in-person baseline assessment, completed on-lineassessments at 4 and 8 weeks, and attended an in-person 12-week follow-upassessment

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