Post on 21-Mar-2018
Where does MI fit in the family of psychotherapies?
So far, most descriptions of MI practice and coding of MI sessions have used MI-specific instruments
Miller & Rose 2009 described relational and technical hypotheses for MI effects
Using both MI and general psychotherapy coding systems may better describe MI
Coding systems must be practical and useful
To explore the utility of a novel 2-pass coding system composed of existing, validated instruments that assess MI and psychotherapy concepts
To describe MI through the lens of traditional psychotherapy concepts
First pass: Psychotherapy Q Set (PQS): ranked top 13 of 100 Proportion Time Focus: past, present, near future,
far future Dimensional rating and CLOPT: Interpersonal
characteristics of therapist and client MITI- 3: MI Fidelity MISC-1/2 elements: selected therapist and client
behaviors MISTS: MI principle-based strategies
Second pass: Patient Change Talk tallies: importance,
confidence, commitment, taking steps, (plus/minus coding)
Working Alliance Inventory-O: Goal, task, bond
YACS and Strategies Checklist: Treatment-specific content and strategies
Client Centered Therapy and MI share: humanistic perspective, reflective listening
Cognitive Therapy and MI share: task orientation, planning and initiating behavior change
Can the coding system distinguish them? General Hypotheses
Relational elements: Client => MI > Cog
Technical/directive: Client <MI <= Cog
Demonstration Tapes used as exemplars of three methods
Client centered therapy: Carl Rogers “Gloria”
Motivational Interviewing: Bill Miller “Soccer Guy”
Cognitive therapy: Judith Beck “Depressed Mom”
5 raters experienced with MITI and other MI and psychotherapy coding, involved in larger projects
4 week training phase: raters coded other audio and videotapes until good agreement reached
Clarifications and reminders in weekly rater group meetings
Subsequent to reaching good agreement across raters, each rater independently coded all 3 full length videos
Raters each coded tapes twice (two passes) Final inter-rater agreement was calculated
for global, behavior count/ratio, and interactional variables using Shrout & Fleiss IntraClass Correlation Coefficients (ICCs)
Behavior count variables were divided by session length to create variables representing behaviors per minute
Therapist Global Variables
Intra-Class Correlation
Client Global Variables
Intra-Class Correlation
MITI Empathy .57 Client Self Exploration .49
MITI MI Spirit .80 Disclosure .57
MITI Direction .71 Engagement .80
Therapist affiliation (Friendly-Hostile) .05 Patient affiliation (F-H) .82
Therapist control (Dominance-Submission)
.92 Patient control (D-S) .90
MISTS Attends to change talk .88
MISTS Addresses ambivalence .87
MISTS Roll with resistance .80
MISTS Support self efficacy .76 N=3 samples, K=5 judges/raters
Therapist Count/Ratio Variables
Intra-Class Correlation
Client Count/Ratio Variables
Intra-Class Correlation
MI Adherent .90 Importance Plus & Minus .62
MI Non adherent .91 Confidence Plus & Minus .49
Provide information .92 Commitment Plus & Minus .29
Closed questions .98 Taking Steps Plus & Minus .67
Open questions .99
Simple reflections .98
Complex reflections .94
Interaction Global Variables Intra-Class Correlation
Interaction Proportional Variables
Intra-Class Correlation
Alliance goal .72 Time Focus Past .19
Alliance task .21 Time Focus Present .75
Alliance bond .89 Time Focus Near Future .49
Time Focus Far Future .66
Client-Centered
Therapist clarifies, restates, or rephrases
patient’s communication
Therapist adopts supportive stance
Patient seeks therapist’s approval, affection, or
sympathy
Self-image is a focus of discussion
Therapist conveys a sense of nonjudgmental
acceptance
MI
Therapist conveys a sense of nonjudgmental
acceptance
Therapist adopts supportive stance
Therapist asks for more information or
elaboration
Therapist clarifies, restates, or rephrases
patient’s communication
Dialogue has a specific focus
Cognitive Therapy
Patient’s interpersonal relationships are a major
theme
Discussion centers on ideas or belief systems
Therapist is sensitive to the patient’s feelings, attuned to
the patient; empathic
Therapist actively exerts control over the interaction
(e.g., structuring, and/or introducing new topics)
There is discussion of specific activities or tasks for the
patient to attempt outside of session
0
10
20
30
40
50
60
70
Past Present NearFuture
Far Future
Client Centered MI Cognitive
Interactant Circumplex
Friendly- Dominant
Dominant
Hostile- Dominant
Hostile
Hostile- Submissive
Submissive
Friendly- Submissive
Friendly
Interpersonal Ratings: Therapist
45
90
135
180
225
270
315
0
Client Centered
MI
Cognitive
0
10
20
30
40
50
60
70
Total Goal Task Bond
Client Centered MI Cognitive
0 1 2 3 4 5
PlanCommit
PlanBehaviors
Set Goals
SupportSystem
ExploreDenial
Feedback
Check In
SetAgenda
Cognitive MI Client CenteredX axis = n Raters who
endorsed the strategy
0 1 2 3 4 5
Task or HW
ChallengeAutothoughts
ID Thinking errors
ID Auto thoughts
Cognitive MI Client CenteredX axis = n Raters who endorsed
the strategy
Empathy
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Empathy Direction MI Spirit
Client Centered MI Cognitive
1
2
3
4
5
6
7
Attends to CT Address Ambivalence
RollwResist Support Self Efficacy
Client Centered MI Cognitive
0
2
4
6
8
10
12
14
16
MI Adherent MI NonAdherent
Client Centered MI Cognitive
Adherent= Asking Permission to Provide, Emphasize Choice/Control, Reframe
Non-adherent=Advice without Permission, Confront, Direct
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
Client MI Cognitive
Info
Questions
Reflections
1
2
3
4
5
6
7
Self-Exploration
Cooperation Disclosure Benefit
Client Centered MI Cognitive
Client Globals: Self-Exploration, Cooperation, Disclosure, Benefit
-0.2
-0.1
0
0.1
0.2
0.3
0.4
0.5
Client Centered MI Cognitive
(MI = Client Centered) > Cognitive on Empathy, MI Spirit
(MI =Cognitive) > Client Centered on Direction Client Centered < MI < Cognitive on
Interpersonal dominance All = on Working Alliance (MI = Cognitive) < Client-Centered in Client
Self-Exploration All = in Client Cooperation, Benefit,
Disclosure
Cognitive> MI > Client Centered in Questions and MI Adherent behaviors
MI > Client Centered > Cognitive on Reflections Cognitive > (Client Centered =MI) on MI-Non
Adherent behaviors MI > (Client Centered = Cognitive) on
Responding to change talk (MI > Client Centered) > Cognitive in
Addressing ambivalence, Rolling with resistance
(MI = Cognitive) > Client Centered in Supporting self efficacy
(MI = Cognitive) > Client Centered in Direction Client Centered < MI < Cognitive on number of
technical therapy strategies (Client Centered =MI) > Cognitive on net
Importance Change Talk (Client Centered = MI) > Cognitive on net
Confidence Sustain talk All = in and near zero in net Taking Steps and
Commitment talk (Cognitive =Client Centered) < MI on Focusing on
the Present and Future
Coding system distinguished MI from Cognitive and Client-Centered therapies
Coding system illuminated relational and technical qualities of MI through a psychotherapeutic lens
The specific combination of MI and other relational and technical processes in MI may be unique
Coding system is not reliable enough on time orientation, therapist interpersonal style, and net change talk in importance, confidence, and commitment areas
Objective coding of many important psychotherapy processes can be done in 2 passes
Using existing instruments in combination is a parsimonious method to gain information about MI’s characteristics from a psychotherapy perspective
The coding system should be refined to improve inter-rater agreement
Supported by NIH R01AA015930 Thanks to our Demonstration Video project
coding team: Amy Fansler, Leah Farrell, Kendall Plageman, Stefania Fabbri, and Jenny Hettema