Preparing Challenging Clients for Treatment Mary McMurran Institute of Mental Health  Nottingham, UK A partnership of and
Plan <ul><li>Treatment non-completion  </li></ul><ul><ul><li>Treatments for offending </li></ul></ul><ul><ul><li>Treatment...
Acknowledgements <ul><li>Colleagues </li></ul><ul><ul><li>Professor Miles Cox Dr Jo Sellen </li></ul></ul><ul><ul><li>Dr E...
Treatment Non-Completion <ul><li>Problems -  </li></ul><ul><ul><li>Compromised service cost-efficiency </li></ul></ul><ul>...
Systematic Review –  Offenders <ul><li>McMurran, M., & Theodosi, E. (2007).  Is treatment non-completion associated with i...
Research Question <ul><li>Q. Is treatment non-completion associated with increased risk of reconviction over no treatment?...
Systematic Review <ul><li>Cognitive-behavioural treatment outcome studies </li></ul><ul><ul><li>Completers </li></ul></ul>...
Sample <ul><li>Identified 16 studies </li></ul><ul><li>Total  19,563  offenders </li></ul><ul><li>Location  </li></ul><ul>...
Non-Completion Rates <ul><ul><li>Total   Institution  Community </li></ul></ul><ul><ul><li>Completers  7744    6149   1595...
Non-Completion Rates <ul><ul><li>Total   Institution  Community </li></ul></ul><ul><ul><li>Completers  7744    6149   1595...
Non-Completion Rates <ul><ul><li>Total   Institution  Community </li></ul></ul><ul><ul><li>Completers  7744    6149   1595...
Non-Completion Rates <ul><ul><li>Total   Institution  Community </li></ul></ul><ul><ul><li>Completers  7744    6149   1595...
Effects of Non-Completion <ul><li>Comparing  Completers and Untreated  </li></ul><ul><ul><li>Shows a modest positive effec...
Effects of Non-Completion <ul><li>Non-completers may be complex cases </li></ul><ul><ul><li>Would do worse anyway? </li></...
Systematic Review –  Personality Disorder <ul><li>McMurran, M., Huband, N., & Overton, E. (2010).  Non-completion of perso...
Research Questions <ul><li>Q.  What are the correlates of treatment non-completion in PD treatments? </li></ul><ul><li>A. ...
PD Treatment Non-Completion  <ul><li>Inclusion criteria </li></ul><ul><ul><li>Empirical study </li></ul></ul><ul><ul><li>P...
Studies Identified
Rates of Non-Completion <ul><li>Median rate of non-completion - 37% </li></ul><ul><ul><li>Range 15% to 80% </li></ul></ul>...
Correlates of Non-Completion <ul><li>Framework for examining correlates  (Barrett et al, 2008) </li></ul><ul><ul><li>Patie...
Correlates of Non-Completion <ul><li>Researchers ignore client perspective, at least in PD engagement research </li></ul><...
Client Attributes <ul><li>Younger </li></ul><ul><li>Lower education </li></ul><ul><li>Lower occupation </li></ul><ul><li>U...
Client Needs <ul><ul><li>Complex PD  </li></ul></ul><ul><ul><li>Type of PD? Yes and no </li></ul></ul><ul><ul><li>Narcissi...
Correlates of Non-Completion <ul><li>A hit-and-miss approach </li></ul><ul><li>Need theories of engagement to drive resear...
Outcomes of Non-Completion <ul><li>Non-completers  versus  completers </li></ul><ul><li>4 studies </li></ul><ul><ul><li>Hi...
Interventions to Reduce Non-Completion <ul><li>Only 2 studies </li></ul><ul><li>Both pre-treatment preparation </li></ul><...
Conclusions so far… <ul><li>Non-completion of treatment is important because of association with poor outcomes </li></ul><...
Pre-Treatment Preparation <ul><li>Motivational interviewing for offenders </li></ul><ul><li>Goal-based motivational interv...
Motivational Interviewing with Offenders
Systematic review –  MI with Offenders <ul><li>McMurran, M. (2009).  Motivational interviewing with offenders: A systemati...
Research Question <ul><li>Q. Does MI work with offenders? </li></ul><ul><li>Depends what we mean by ‘work’ </li></ul><ul><...
MI with Offenders <ul><li>Inclusion criteria </li></ul><ul><ul><li>Empirical studies </li></ul></ul><ul><ul><li>MI or moti...
MI with Offenders <ul><li>Identified 19 evaluations of MI with offenders </li></ul><ul><li>Three aims: </li></ul><ul><ul><...
MI with Offenders <ul><li>The 19 studies focused on 2 areas: </li></ul><ul><ul><li>Substance-misuse  (N=10) </li></ul></ul...
Retention in Treatment <ul><li>MI appears  successful   at enhancing retention in treatment for  substance misuse </li></u...
Engagement in Treatment <ul><li>Single session MI no better than single session psycho-education for enhancing engagement ...
Motivation for Change <ul><li>In both substance misusers and domestic violence offenders,  MI improves </li></ul><ul><ul><...
Behaviour Change <ul><li>Substance misuse </li></ul><ul><ul><li>1 good quality study – RCT; N=135 </li></ul></ul><ul><ul><...
Behaviour Change <ul><li>Domestic violence </li></ul><ul><ul><li>1 good-quality study – RCT; N=33 </li></ul></ul><ul><ul><...
Behaviour Change <ul><li>Driving under the influence </li></ul><ul><li>#1 RCT; N=305 </li></ul><ul><li>MI approach to psyc...
Conclusions <ul><li>With offenders, MI appears to improve  </li></ul><ul><ul><li>Retention in treatment  </li></ul></ul><u...
Conclusions <ul><li>MI may be effective in reducing substance use, especially in conjunction with other treatment componen...
Conclusions <ul><li>Mixed evidence of effectiveness in changing offending behaviour </li></ul><ul><ul><li>Drink driving (w...
Conclusions <ul><li>“ What Works” evidence is that high-risk offenders need intensive treatments to reduce recidivism* </l...
Future Research <ul><li>What  types of offences  might MI reduce? </li></ul><ul><ul><li>Violence? Drink driving? </li></ul...
Currently, safe to say …… <ul><li>The goal of MI with offenders might be to help them decide to enter into and commit to o...
A Goal-Based Motivational Preparation
Goal-Based Motivational Preparation  <ul><li>Goals are a motivational construct (Chris Wagner) </li></ul><ul><li>Where mig...
What’s your concern?
Steve Rollnick: What shall we talk about? Diet Exercise Stress Drinking Drug use Smoking ?
Goals as a motivational construct <ul><li>People strive to attain valued goals </li></ul><ul><li>Different levels of goal ...
Goals are Important <ul><li>Goals are the concrete  expression of a person’s life purpose , they represent how people stru...
Good Lives Model  of Offender Rehabilitation <ul><li>Primary Human Goods </li></ul><ul><ul><ul><li>Life </li></ul></ul></u...
Theory of Current Concerns <ul><li>Miles Cox & Eric Klinger </li></ul><ul><li>Current concerns are active goals </li></ul>...
Life Areas <ul><li>Home and household </li></ul><ul><li>Employment and finance </li></ul><ul><li>Partner , family and rela...
Treatment as a means of  attaining valued goals <ul><li>Identifying valued goals indicates to people what will make their ...
Treatment as a means of  attaining valued goals <ul><li>Identifying obstacles to goal attainment can identify treatment ne...
Treatment as a means of  attaining valued goals <ul><li>Identifying obstacles to goal attainment can identify treatment ne...
Treatment as a means of  attaining valued goals <ul><li>Identifying valued goals indicates to people what will make their ...
Personal Concerns Inventory <ul><li>Interview </li></ul><ul><li>Ask client’s goals in life areas </li></ul><ul><li>Rate go...
 
 
Motivational ‘hook’ <ul><li>Elicit valued goals,  i.e., lead to happiness </li></ul><ul><li>Identify obstacles to goal att...
 
Does the PCI help prisoners engage? <ul><li>An adaptive motivational structure on the PCI (i.e., commitment to valued goal...
Does the PCI help prisoners engage? <ul><li>Of sex offenders who were refusing treatment, those who did the PCI interview ...
Does the PCI help prisoners engage? <ul><li>PCI as a motivational interview for a Thinking Skills programme </li></ul><ul>...
More research is needed …. <ul><li>Evidence so far is insufficient </li></ul><ul><li>Project using the PCI as a pre-treatm...
Why might the PCI work? <ul><li>Elicit the individual’s valued goals </li></ul><ul><li>Help the client explore obstacles t...
Tack så mycket [email_address]
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Mc murran june9-session-plenary

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Mc murran june9-session-plenary

  1. 1. Preparing Challenging Clients for Treatment Mary McMurran Institute of Mental Health Nottingham, UK A partnership of and
  2. 2. Plan <ul><li>Treatment non-completion </li></ul><ul><ul><li>Treatments for offending </li></ul></ul><ul><ul><li>Treatments for personality disorder </li></ul></ul><ul><li>Preparatory interventions </li></ul><ul><ul><li>Motivational interviewing with offenders </li></ul></ul><ul><ul><li>A goal-based approach with offenders and people in treatment for personality disorder    </li></ul></ul>
  3. 3. Acknowledgements <ul><li>Colleagues </li></ul><ul><ul><li>Professor Miles Cox Dr Jo Sellen </li></ul></ul><ul><ul><li>Dr Eleni Theodosi Eleanor Overton </li></ul></ul><ul><ul><li>Dr Nick Huband </li></ul></ul><ul><li>Funders </li></ul><ul><ul><li>National Programme for Forensic Mental Health R&D </li></ul></ul><ul><ul><li>National Institute for Health Research, Research for Patient Benefit Programme </li></ul></ul>
  4. 4. Treatment Non-Completion <ul><li>Problems - </li></ul><ul><ul><li>Compromised service cost-efficiency </li></ul></ul><ul><ul><li>Lowered staff morale </li></ul></ul><ul><ul><li>Opportunity costs for waiting list clients </li></ul></ul><ul><ul><li>Disruption of group therapy </li></ul></ul><ul><ul><li>Potential disadvantage to non-completers themselves? </li></ul></ul>
  5. 5. Systematic Review – Offenders <ul><li>McMurran, M., & Theodosi, E. (2007). Is treatment non-completion associated with increased reconviction over no treatment? Psychology, Crime and Law, 13, 333-343 . </li></ul>
  6. 6. Research Question <ul><li>Q. Is treatment non-completion associated with increased risk of reconviction over no treatment? </li></ul><ul><li>A. (The answer! </li></ul><ul><ul><li>Non-completers are more likely to be reconvicted than are untreated offenders </li></ul></ul><ul><ul><li>MI has an important role in engaging offenders in treatment) </li></ul></ul>
  7. 7. Systematic Review <ul><li>Cognitive-behavioural treatment outcome studies </li></ul><ul><ul><li>Completers </li></ul></ul><ul><ul><li>Non-Completers </li></ul></ul><ul><ul><li>Untreated </li></ul></ul><ul><li>Groups unlikely to differ on risk (randomly allocated, risk matched, waiting list control) </li></ul><ul><li>Reoffending or reconviction data </li></ul>
  8. 8. Sample <ul><li>Identified 16 studies </li></ul><ul><li>Total 19,563 offenders </li></ul><ul><li>Location </li></ul><ul><ul><li>Community - 8 studies </li></ul></ul><ul><ul><li>Detained – 9 studies </li></ul></ul>
  9. 9. Non-Completion Rates <ul><ul><li>Total Institution Community </li></ul></ul><ul><ul><li>Completers 7744 6149 1595 </li></ul></ul><ul><ul><li>Non-completers 2385 1056 1329 </li></ul></ul><ul><ul><li>Untreated 9434 5443 3991 </li></ul></ul><ul><ul><li>Percentage non-completion </li></ul></ul>
  10. 10. Non-Completion Rates <ul><ul><li>Total Institution Community </li></ul></ul><ul><ul><li>Completers 7744 6149 1595 </li></ul></ul><ul><ul><li>Non-completers 2385 1056 1329 </li></ul></ul><ul><ul><li>Untreated 9434 5443 3991 </li></ul></ul><ul><ul><li>Percentage non-completion </li></ul></ul><ul><ul><li>24% </li></ul></ul>
  11. 11. Non-Completion Rates <ul><ul><li>Total Institution Community </li></ul></ul><ul><ul><li>Completers 7744 6149 1595 </li></ul></ul><ul><ul><li>Non-completers 2385 1056 1329 </li></ul></ul><ul><ul><li>Untreated 9434 5443 3991 </li></ul></ul><ul><ul><li>Percentage non-completion </li></ul></ul><ul><ul><li>24% 15% </li></ul></ul>
  12. 12. Non-Completion Rates <ul><ul><li>Total Institution Community </li></ul></ul><ul><ul><li>Completers 7744 6149 1595 </li></ul></ul><ul><ul><li>Non-completers 2385 1056 1329 </li></ul></ul><ul><ul><li>Untreated 9434 5443 3991 </li></ul></ul><ul><ul><li>Percentage non-completion </li></ul></ul><ul><ul><li>24% 15% 45% </li></ul></ul>
  13. 13. Effects of Non-Completion <ul><li>Comparing Completers and Untreated </li></ul><ul><ul><li>Shows a modest positive effect in reducing recidivism ( d = 0.11 ) </li></ul></ul><ul><li>Comparing Non-completers and Untreated </li></ul><ul><ul><li>Shows a modest but negative effect ( d = - 0.16 ) </li></ul></ul><ul><li>Non-completers are more likely to be reconvicted than untreated </li></ul><ul><li>Effect more pronounced in the community ( d = -0.23 ) compared with secure settings ( d = -0.15 ) </li></ul>
  14. 14. Effects of Non-Completion <ul><li>Non-completers may be complex cases </li></ul><ul><ul><li>Would do worse anyway? </li></ul></ul><ul><li>Does non-completion make non-completers worse? </li></ul><ul><ul><ul><li>Dropout  feel unable to change </li></ul></ul></ul><ul><ul><ul><li>Removal  increase anti-authority attitudes </li></ul></ul></ul><ul><ul><ul><li>Interruption  problems raised but not solved </li></ul></ul></ul>
  15. 15. Systematic Review – Personality Disorder <ul><li>McMurran, M., Huband, N., & Overton, E. (2010). Non-completion of personality disorder treatments: A systematic review of correlates, consequences, and interventions. Clinical Psychology Review, 30, 277-287. DOI:10.1016/j.cpr.2009.12.002 </li></ul>
  16. 16. Research Questions <ul><li>Q. What are the correlates of treatment non-completion in PD treatments? </li></ul><ul><li>A. Researchers are looking for (stable) client attributes, not therapy or therapist attributes </li></ul><ul><li>Q. What are the outcomes of non-completion? </li></ul><ul><li>A. More use of health services than completers </li></ul><ul><li>Q. What are people doing to reduce non-completion? </li></ul><ul><li>A. Not much – or not evaluating it. Room for MI here! </li></ul>
  17. 17. PD Treatment Non-Completion <ul><li>Inclusion criteria </li></ul><ul><ul><li>Empirical study </li></ul></ul><ul><ul><li>Psychological treatment for personality disorder </li></ul></ul><ul><ul><li>Adults </li></ul></ul><ul><ul><li>Personality disorder diagnosed using a structured assessment </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><ul><li>Correlates of non-completion , OR </li></ul></ul><ul><ul><li>Outcomes of non-completion , OR </li></ul></ul><ul><ul><li>Evaluation of intervention to reduce non-completion </li></ul></ul>
  18. 18. Studies Identified
  19. 19. Rates of Non-Completion <ul><li>Median rate of non-completion - 37% </li></ul><ul><ul><li>Range 15% to 80% </li></ul></ul><ul><li>Comparable with non-completion rates in a psychotherapy generally - 47% (Wierzbiki & Pekarik, 1993) </li></ul>
  20. 20. Correlates of Non-Completion <ul><li>Framework for examining correlates (Barrett et al, 2008) </li></ul><ul><ul><li>Patient characteristics </li></ul></ul><ul><ul><li>Practical barriers to treatment </li></ul></ul><ul><ul><li>Need factors </li></ul></ul><ul><ul><li>Environmental factors </li></ul></ul><ul><ul><li>Client’s perception of problems </li></ul></ul><ul><ul><li>Client’s beliefs about treatment </li></ul></ul>
  21. 21. Correlates of Non-Completion <ul><li>Researchers ignore client perspective, at least in PD engagement research </li></ul><ul><ul><li>Practical barriers to treatment </li></ul></ul><ul><ul><li>Client’s perception of problems </li></ul></ul><ul><ul><li>Client’s beliefs about treatment </li></ul></ul><ul><li>Treatment non-completion studies focus on largely on what the client is or has and ignores how the client feels about his/her problem, and the treatment on offer </li></ul>
  22. 22. Client Attributes <ul><li>Younger </li></ul><ul><li>Lower education </li></ul><ul><li>Lower occupation </li></ul><ul><li>Unemployed </li></ul><ul><li>Juvenile conviction </li></ul><ul><li>Parents divorced before age 10 </li></ul><ul><li>Emotional neglect in childhood </li></ul><ul><li>Spending less time alone </li></ul><ul><li>Being in a new relationship </li></ul>
  23. 23. Client Needs <ul><ul><li>Complex PD </li></ul></ul><ul><ul><li>Type of PD? Yes and no </li></ul></ul><ul><ul><li>Narcissism </li></ul></ul><ul><ul><li>Impulsivity </li></ul></ul><ul><ul><li>Less depressed </li></ul></ul><ul><ul><li>Higher anxiety </li></ul></ul><ul><ul><li>Precontemplation </li></ul></ul><ul><ul><li>Low persistence </li></ul></ul><ul><ul><li>High avoidance </li></ul></ul><ul><ul><li>Poorer problem solving </li></ul></ul><ul><li>Poor ego structure </li></ul><ul><li>Less primitive defences </li></ul><ul><li>Lower level of functioning </li></ul><ul><li>Substance use </li></ul>
  24. 24. Correlates of Non-Completion <ul><li>A hit-and-miss approach </li></ul><ul><li>Need theories of engagement to drive research </li></ul>
  25. 25. Outcomes of Non-Completion <ul><li>Non-completers versus completers </li></ul><ul><li>4 studies </li></ul><ul><ul><li>Higher hospitalisation rates </li></ul></ul><ul><ul><li>More hospital days </li></ul></ul><ul><ul><li>Poorer functioning </li></ul></ul><ul><li>Evidence that non-completers fare worse than treated </li></ul>
  26. 26. Interventions to Reduce Non-Completion <ul><li>Only 2 studies </li></ul><ul><li>Both pre-treatment preparation </li></ul><ul><li>Both studies prepared people for TCs </li></ul><ul><ul><li>Introduce people to the community </li></ul></ul><ul><ul><li>Preparation group work </li></ul></ul><ul><ul><li>Appoint a buddy </li></ul></ul><ul><li>Both reduced dropout </li></ul>
  27. 27. Conclusions so far… <ul><li>Non-completion of treatment is important because of association with poor outcomes </li></ul><ul><li>Most research looks at stable attributes of the client </li></ul><ul><li>Need to investigate the client’s perspective </li></ul><ul><li>Correlates direct us to targets for improving engagement, BUT </li></ul><ul><li>Hypothesis-driven research is needed to develop theories of engagement </li></ul><ul><li>Pre-treatment preparation may help reduce dropout </li></ul>
  28. 28. Pre-Treatment Preparation <ul><li>Motivational interviewing for offenders </li></ul><ul><li>Goal-based motivational interview for people in treatment for personality disorder </li></ul>
  29. 29. Motivational Interviewing with Offenders
  30. 30. Systematic review – MI with Offenders <ul><li>McMurran, M. (2009). Motivational interviewing with offenders: A systematic review. Legal and Criminological Psychology, 14, 83-100. </li></ul>
  31. 31. Research Question <ul><li>Q. Does MI work with offenders? </li></ul><ul><li>Depends what we mean by ‘work’ </li></ul><ul><ul><li>MI helps improve motivation and engagement </li></ul></ul><ul><ul><li>MI helps reduce substance use in conjunction with other components </li></ul></ul><ul><ul><li>Not enough evidence that MI does – or does not – work to reduce offending </li></ul></ul>
  32. 32. MI with Offenders <ul><li>Inclusion criteria </li></ul><ul><ul><li>Empirical studies </li></ul></ul><ul><ul><li>MI or motivational enhancement therapy (MET) </li></ul></ul><ul><ul><li>Any type of offender (any offence; male/female; prisoner/probationer; any age) </li></ul></ul><ul><ul><li>Focus on any problem (e.g., substance use or offending) </li></ul></ul><ul><ul><li>Measure any outcome (e.g., treatment engagement; behaviour change; reconviction) </li></ul></ul>
  33. 33. MI with Offenders <ul><li>Identified 19 evaluations of MI with offenders </li></ul><ul><li>Three aims: </li></ul><ul><ul><li>To enhance retention in treatment </li></ul></ul><ul><ul><li>To improve motivation for change </li></ul></ul><ul><ul><li>To change behaviour </li></ul></ul>
  34. 34. MI with Offenders <ul><li>The 19 studies focused on 2 areas: </li></ul><ul><ul><li>Substance-misuse (N=10) </li></ul></ul><ul><ul><ul><li>Including substance use generally (3), marijuana use (2), alcohol or marijuana (2), alcohol only (3) </li></ul></ul></ul><ul><ul><li>Offending (N=9) </li></ul></ul><ul><ul><ul><li>Including domestic violence (3) and driving while intoxicated (5), and offending generally (1) </li></ul></ul></ul>
  35. 35. Retention in Treatment <ul><li>MI appears successful at enhancing retention in treatment for substance misuse </li></ul><ul><ul><li>3 good quality studies </li></ul></ul><ul><ul><li>Better attendance with MI versus no MI </li></ul></ul><ul><ul><li>Effect augmented by contingency management </li></ul></ul>
  36. 36. Engagement in Treatment <ul><li>Single session MI no better than single session psycho-education for enhancing engagement in treatment for perpetrators of domestic violence </li></ul><ul><ul><li>But only one study </li></ul></ul><ul><ul><li>… . and a very minimal intervention </li></ul></ul>
  37. 37. Motivation for Change <ul><li>In both substance misusers and domestic violence offenders, MI improves </li></ul><ul><ul><li>Problem recognition </li></ul></ul><ul><ul><li>Stage of change </li></ul></ul><ul><ul><li>Readiness to change </li></ul></ul><ul><ul><li>Confidence to change </li></ul></ul><ul><li>3 good-quality studies </li></ul>
  38. 38. Behaviour Change <ul><li>Substance misuse </li></ul><ul><ul><li>1 good quality study – RCT; N=135 </li></ul></ul><ul><ul><li>Marijuana use </li></ul></ul><ul><ul><li>MET or CBT or drug counselling (all 8 sessions), with or without contingency management (CM) </li></ul></ul><ul><ul><li>MET + CM attended more sessions </li></ul></ul><ul><ul><li>CM interventions reduce marijuana use at 1 month </li></ul></ul>
  39. 39. Behaviour Change <ul><li>Domestic violence </li></ul><ul><ul><li>1 good-quality study – RCT; N=33 </li></ul></ul><ul><ul><li>2 sessions of MI versus treatment-as-usual </li></ul></ul><ul><ul><li>No effect on recidivism </li></ul></ul><ul><li>General offending </li></ul><ul><ul><li>1 good-quality study – RCT; N=116 </li></ul></ul><ul><ul><li>MI versus treatment-as-usual </li></ul></ul><ul><ul><li>MI 21% lower reconviction and 17% lower imprisonment at 4 years </li></ul></ul>
  40. 40. Behaviour Change <ul><li>Driving under the influence </li></ul><ul><li>#1 RCT; N=305 </li></ul><ul><li>MI approach to psychoeducation + imprisonment versus imprisonment only (28 days) </li></ul><ul><li>At 24 months, MI had fewer drinking days </li></ul><ul><li>No differences in arrests </li></ul><ul><li>- 3 good-quality studies </li></ul><ul><li>#2 RCT; N=1309 </li></ul><ul><li>Interlock plus MI versus Interlock only </li></ul><ul><li>At 12 months, MI plus Interlock had fewer Interlock failures </li></ul><ul><li># 3 RCT; N=104 </li></ul><ul><li>MI versus relaxation training </li></ul><ul><li>MI self-reported less drink driving only for those low on depression </li></ul>
  41. 41. Conclusions <ul><li>With offenders, MI appears to improve </li></ul><ul><ul><li>Retention in treatment </li></ul></ul><ul><ul><li>Self-reported motivation to change </li></ul></ul><ul><li>Important, since non-completion may be associated with worse recidivism outcomes </li></ul>
  42. 42. Conclusions <ul><li>MI may be effective in reducing substance use, especially in conjunction with other treatment components (e.g., contingency management) </li></ul>
  43. 43. Conclusions <ul><li>Mixed evidence of effectiveness in changing offending behaviour </li></ul><ul><ul><li>Drink driving (with Interlock; if not depressed) </li></ul></ul><ul><ul><li>General offending </li></ul></ul><ul><li>No evidence of changing domestic violence </li></ul>
  44. 44. Conclusions <ul><li>“ What Works” evidence is that high-risk offenders need intensive treatments to reduce recidivism* </li></ul><ul><ul><li>Most intensive treatments include a motivational theme </li></ul></ul><ul><li>Briefer interventions not supported </li></ul><ul><li>BUT , MI might work </li></ul><ul><li>Need careful research in this area </li></ul>*Bourgon, G., & Armstrong, B. (2005). Transferring the principles of effective treatment into a “real world” prison setting. Criminal Justice and Behavior, 32, 3–25.
  45. 45. Future Research <ul><li>What types of offences might MI reduce? </li></ul><ul><ul><li>Violence? Drink driving? </li></ul></ul><ul><ul><li>Sexual? Acquisitive? </li></ul></ul><ul><li>In what types of offender ? </li></ul><ul><ul><li>Risk level? Age? </li></ul></ul><ul><ul><li>Gender? </li></ul></ul><ul><li>In what types of setting ? </li></ul><ul><ul><li>Community? Prison? </li></ul></ul>
  46. 46. Currently, safe to say …… <ul><li>The goal of MI with offenders might be to help them decide to enter into and commit to offending interventions </li></ul><ul><li>Offender treatments do work, BUT only if people complete them </li></ul><ul><li>Non-completion is associated with worse recidivism outcomes than untreated groups </li></ul>
  47. 47. A Goal-Based Motivational Preparation
  48. 48. Goal-Based Motivational Preparation <ul><li>Goals are a motivational construct (Chris Wagner) </li></ul><ul><li>Where might this fit with MI? </li></ul><ul><li>What if people are not ambivalent about change? </li></ul><ul><li>What if they are unfocused about change? </li></ul>
  49. 49. What’s your concern?
  50. 50. Steve Rollnick: What shall we talk about? Diet Exercise Stress Drinking Drug use Smoking ?
  51. 51. Goals as a motivational construct <ul><li>People strive to attain valued goals </li></ul><ul><li>Different levels of goal </li></ul><ul><li>Goal striving varies over time in relation to factors such as need, opportunities, alternative priorities, etc. </li></ul>
  52. 52. Goals are Important <ul><li>Goals are the concrete expression of a person’s life purpose , they represent how people structure their lives, and striving towards worthwhile goals is a key determinant of human health and happiness . In short, a person’s goals are synonymous with meaning in life , since they are the route by which the individual fulfils his or her needs for competence, relatedness, self-transcendence, and spirituality. </li></ul><ul><li>Emmons, 2005 </li></ul>Emmons, R.A. (2005). Striving for the sacred: Personal goals, life meaning, and religion. Journal of Social Issues, 61, 731-745.
  53. 53. Good Lives Model of Offender Rehabilitation <ul><li>Primary Human Goods </li></ul><ul><ul><ul><li>Life </li></ul></ul></ul><ul><ul><ul><li>Knowledge </li></ul></ul></ul><ul><ul><ul><li>Mastery </li></ul></ul></ul><ul><ul><ul><li>Autonomy </li></ul></ul></ul><ul><ul><ul><li>Peace </li></ul></ul></ul><ul><ul><ul><li>Relatedness </li></ul></ul></ul><ul><ul><ul><li>Meaning </li></ul></ul></ul><ul><ul><ul><li>Happiness </li></ul></ul></ul><ul><ul><ul><li>Creativity </li></ul></ul></ul><ul><li>Professor Tony Ward </li></ul>
  54. 54. Theory of Current Concerns <ul><li>Miles Cox & Eric Klinger </li></ul><ul><li>Current concerns are active goals </li></ul><ul><li>People strive for goals in a number of life areas ... </li></ul>
  55. 55. Life Areas <ul><li>Home and household </li></ul><ul><li>Employment and finance </li></ul><ul><li>Partner , family and relatives </li></ul><ul><li>Friends and acquaintances </li></ul><ul><li>Love, intimacy, and sex </li></ul><ul><li>Self-changes </li></ul><ul><li>Education and training </li></ul><ul><li>Health and medical matters </li></ul><ul><li>Substance use </li></ul><ul><li>Spiritual matters </li></ul><ul><li>Hobbies, pastimes and recreation </li></ul><ul><li>Other…. </li></ul>
  56. 56. Treatment as a means of attaining valued goals <ul><li>Identifying valued goals indicates to people what will make their lives happier and more fulfilling </li></ul>
  57. 57. Treatment as a means of attaining valued goals <ul><li>Identifying obstacles to goal attainment can identify treatment needs and highlight the value of treatment </li></ul>
  58. 58. Treatment as a means of attaining valued goals <ul><li>Identifying obstacles to goal attainment can identify treatment needs and highlight the value of treatment </li></ul>
  59. 59. Treatment as a means of attaining valued goals <ul><li>Identifying valued goals indicates to people what will make their lives happier and more fulfilling </li></ul><ul><li>Identifying obstacles to goal attainment can identify treatment needs and highlight the value of treatment </li></ul><ul><li>By highlighting this, treatment readiness and engagement may be enhanced </li></ul><ul><li>Recidivism outcomes are better for offenders who enter treatment voluntarily compared to those who are mandated or coerced </li></ul>
  60. 60. Personal Concerns Inventory <ul><li>Interview </li></ul><ul><li>Ask client’s goals in life areas </li></ul><ul><li>Rate goals on a number of scales </li></ul><ul><ul><li>Likelihood </li></ul></ul><ul><ul><li>Control </li></ul></ul><ul><ul><li>Knowledge </li></ul></ul><ul><ul><li>Happiness </li></ul></ul><ul><ul><li>Commitment </li></ul></ul><ul><li>Identify obstacles to goal attainment </li></ul>
  61. 63. Motivational ‘hook’ <ul><li>Elicit valued goals, i.e., lead to happiness </li></ul><ul><li>Identify obstacles to goal attainment, e.g., lack of resources to attain goals </li></ul><ul><li>Obstacles identify treatment need </li></ul><ul><ul><li>e.g., anger control, substance misuse, relationship problems </li></ul></ul><ul><li>Obstacles identify other social needs </li></ul><ul><ul><li>e.g., education/training, money management, accommodation </li></ul></ul>
  62. 65. Does the PCI help prisoners engage? <ul><li>An adaptive motivational structure on the PCI (i.e., commitment to valued goals) is associated with internal reasons for entering programmes </li></ul><ul><li>A maladaptive motivational structure on the PCI (i.e., commitment to non-valued goals or low commitment to valued goals) is associated with being in the precontemplation stage of change </li></ul>Sellen, J. et al. (2009). Validity of the offender version of the Personal Concerns Inventory with adult male prisoners. Psychology, Crime & Law 15 , 451-468.
  63. 66. Does the PCI help prisoners engage? <ul><li>Of sex offenders who were refusing treatment, those who did the PCI interview evidenced a slightly greater motivational shift towards treatment compared with those who did not do the PCI interview </li></ul>Theodosi, E., & McMurran, M. (2006). Motivating convicted sex offenders Into treatment: A pilot study. British Journal of Forensic Practice, 8, 28-35.
  64. 67. Does the PCI help prisoners engage? <ul><li>PCI as a motivational interview for a Thinking Skills programme </li></ul><ul><li>Prisoners - excluding sex offenders </li></ul><ul><li>Random assignment </li></ul><ul><ul><li>PCI (N=33) </li></ul></ul><ul><ul><li>No PCI (N=32) </li></ul></ul><ul><li>Combined staff- plus self-ratings of engagement </li></ul><ul><li>PCI group rated as significantly more engaged </li></ul>Campbell, J. (2010). Measuring and enhancing offender motivation to engage in treatment and change. Unpublished PhD thesis, UWIC, Cardiff:
  65. 68. More research is needed …. <ul><li>Evidence so far is insufficient </li></ul><ul><li>Project using the PCI as a pre-treatment preparation to improve engagement and reduce treatment non-completion in a sample of people with personality disorder </li></ul><ul><li>(see clinical trials.gov.uk) </li></ul>
  66. 69. Why might the PCI work? <ul><li>Elicit the individual’s valued goals </li></ul><ul><li>Help the client explore obstacles to attaining valued goals </li></ul><ul><li>Advise on treatment or other options to overcome obstacles </li></ul><ul><li>Positive approach – focus on approach goals, i.e., aim to achieve rather than eliminate </li></ul>McMurran, M., & Ward, T. (2004). Motivating offenders to engage in therapy: An organizing framework. Legal & Criminological Psychology, 9, 295-311.
  67. 70. Tack så mycket [email_address]

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