OptimizingOptimizing effects effects in MIin MI ...farbring.com/downloads/Mint Forum 2011 download...

OptimizingOptimizing effectseffects in MIin MI––observations and observations and hypotheseshypotheses from from observations and observations and hypotheseshypotheses from from clinicalclinical practicepractice

Mi F Mi F 11

Mint Forum, Mint Forum, Sheffield 2011Sheffield 2011

Carl Åke Carl Åke FarbringFarbringwww.farbring.comwww.farbring.com

Focus on effective outcome Focus on effective outcome in MIin MI

1.1. ImplegrationImplegration222.2. Compass directionCompass direction3.3. ExpectanciesExpectancies44

224.4. AllianceAlliance5.5. AffirmationsAffirmations

WHAT WORKS: WHAT WORKS: ReducingReducing relapserelapse in in crimecrime and and drugdrug useuse --drugdrug useuse

”Therefore ”Therefore you must you must learn an artlearn an artlearn an art learn an art from from heaven,heaven,thou shalt thou shalt hate the hate the crime butcrime butcrime but crime but love the love the perpetrator”.perpetrator”.p pp p

33Carl Jonas Love Almqvist, famous Swedish author, 1793Carl Jonas Love Almqvist, famous Swedish author, 1793--18661866..

What Works; accredited programs; p g

Reasoning and RehabilitationReasoning and RehabilitationOne-to-OneARTART Offender Substance Abuse Program (OSAP)Brotts-BrytetEnhanced Thinking SkillsROS; sexual offendersDomestic Violence (IDAP)( )PRISMBSF(MI:5;semistructured MI in five sessions)

44

BSF(MI:5;semistructured MI in five sessions)RelapseRelapse Prevention/MIPrevention/MI

What Works 2006What Works 2006What Works 2006What Works 2006

”…”…resultsresults dodo not provide strong not provide strong evidenceevidenceof of treatmenttreatment effectivenesseffectiveness.”.”…”…”therethere is is limitedlimited evidenceevidence to to demonstratedemonstrate whatwhat impactimpact thesethesedemonstratedemonstrate whatwhat impactimpact thesetheseinterventions interventions actuallyactually havehave in in practicepractice.”.”””ThusThus, no outcome , no outcome evaluationevaluation in this report in this report providesprovides unequivocalunequivocal evidenceevidence of ”of ”whatwhatprovides provides unequivocalunequivocal evidenceevidence of of whatwhatworksworks” in ” in correctionscorrections.”.” Harper & Chitty (2005). The

Impact of corrections on re-offending. A review of What Works. Home Office Research Study 291

Greenlight ProjectGreenlight ProjectGreenlight ProjectGreenlight Project

A multidimensional reA multidimensional re--entry demonstration programme to entry demonstration programme to reduce recidivism in New Yorkreduce recidivism in New YorkRandomised designRandomised designSupervised by researchers, organisational supportSupervised by researchers, organisational supportEvidensbased programmes (R & R, Relapse Prevention, Evidensbased programmes (R & R, Relapse Prevention, Job preparation training, social counseling, social skills Job preparation training, social counseling, social skills training drug treatment prevention to avoidtraining drug treatment prevention to avoidtraining, drug treatment, prevention to avoid training, drug treatment, prevention to avoid homelessness, family reunion groups; action plan etc.)homelessness, family reunion groups; action plan etc.)Two control groupsTwo control groupsResults: ……..Results: ……..

66

GreenlightGreenlight Project:Project: resultsresultsGreenlightGreenlight Project: Project: resultsresultsO tO t G li htG li ht TSPTSP U t tU t t T t lT t l Si ifiSi ifiOutcome Outcome GreenlightGreenlight TSP TSP UpstateUpstate Total Total SignificanceSignificance

n=344 n=278 n=113 n=735n=344 n=278 n=113 n=735

AnyAny newnewarrest 44% 35% 32% 39% .02arrest 44% 35% 32% 39% .02

New New FelonyFelonyArrests 24% 19% 16% 21% NsArrests 24% 19% 16% 21% Ns

RevocationsRevocations 29% 25% 17% 25% .05 29% 25% 17% 25% .05

77Vera Institute of Justice

A 3A 3 year MIyear MI training projecttraining projectA 3A 3--year MIyear MI--training project training project W k h i MIW k h i MI ii 19981998Workshops in MI Workshops in MI sincesince 199819982500 2500 probationprobation officers and tutors and officers and tutors and clientclient

l t dl t d t fft ff ii ii t i dt i drelatedrelated staffstaff in in prisonprison werewere trainedtrainedduringduring 33--day workshops 2001day workshops 2001--2003.2003.G tG t tt ddGovernmentGovernment moneymoney to to reducereducesubstancesubstance abuseabuse in prions in prions ––approxapprox 80000 USD80000 USDExtremelyExtremely positive feedbackpositive feedbackBill and Steve Bill and Steve contributedcontributedGovernmentGovernment fundsfunds helpedhelped

88

GovernmentGovernment fundsfunds helpedhelped

MI in Swedish prison and probationMI in Swedish prison and probationMI in Swedish prison and probationMI in Swedish prison and probation

After After aboutabout 100 of 100 of thesethese 33--day workshops for day workshops for prisonprison staffstaff, the Swedish National Council for , the Swedish National Council for CrimeCrime Prevention Prevention reportedreported ” ” therethere is no is no evidenceevidencethat that therethere hadhad beenbeen anyany motivationalmotivational sessions sessions with with clientsclients” (2005).” (2005).Risk for negative perception of MI (Risk for negative perception of MI (typetype 3 3 errorerror))HypothesisHypothesis: The work situation : The work situation hadhad not not changedchangedforfor prisonprison officers andofficers and othersothersfor for prisonprison officers and officers and othersothers

99

An attempt to implement MI by a semi structured manual An attempt to implement MI by a semi structured manual with monitoring of integrity and peer group coachingwith monitoring of integrity and peer group coachingwith monitoring of integrity and peer group coaching with monitoring of integrity and peer group coaching ––A driverA driver´́ s guide through MIs guide through MI Metaphor: Learning by Metaphor: Learning by

driving in all sorts of MI driving in all sorts of MI traffictraffic

• A Pre-session followed by five(5) conversations about change

traffictraffic

• Clients also work in an exercise book ≈ alliance

• Manual follows change talk dimensions (and(and stagesstages ofofdimensions (and (and stagesstages of of changechange))

• Conversations are rooted in• Conversations are rooted in the client´s experience and reference of frame but directed Manual originallyManual originallyreference of frame but directedby the counselor compass

Manual, originally Manual, originally presented 2003presented 2003

The Implegration ReportThe Implegration ReportThe Implegration Report The Implegration Report ––

A D iA D i ´́ G id th h MIG id th h MI• 5 guided semi structured conversations about change with

A DriverA Driver s Guide through MIs Guide through MI

a work book for clients

• Advantage 1: Intentionally, g y,deliberately performed motivational sessions – not just ” h t” i”chat” sessions.

• Advantage 2: Sessions are visible to all, recorded, counted and evaluated.

Manual originallyManual originally

1111•

Manual, originally Manual, originally presented 2003presented 2003

TwoTwo objectivesobjectives of the MI/BSF of the MI/BSF implegrationimplegration

STRUCTURAL LEVELSTRUCTURAL LEVELSTRUCTURAL LEVELSTRUCTURAL LEVEL1. 1. MakingMaking MI MI moremore ””programmaticprogrammatic” ” mademadeit acceptable and later it acceptable and later accreditedaccredited by the by the scientificscientific accreditationaccreditation panel panel –– a a requisiterequisitepp qqfor national roll for national roll outout,,

2. It 2. It alsoalso mademade MI/BSF MI/BSF acceptedaccepted for for nationalnational statisticalstatistical and administrativeand administrativenational national statisticalstatistical and administrative and administrative support.support.

1212

Supervision and support in BSFSupervision and support in BSFSupervision and support in BSFSupervision and support in BSFG hi i tiG hi i tiGeographic organizationGeographic organizationPeer groups Peer groups –– peer review peer review every 5th week; peer every 5th week; peer

it i d f db kit i d f db kPL PL

PL

monitoring and feedback on monitoring and feedback on tapes (1 PASS)tapes (1 PASS)Certification Certification –– 3 audio tapes 3 audio tapes

PL

PL

PL

PHL

with feedback between with feedback between supervisor and tutor (program supervisor and tutor (program leader)leader)Supervisors meet in head Supervisors meet in head office 4 times a year office 4 times a year Positive feedback or lie! Make Positive feedback or lie! Make participants enjoy!participants enjoy!Local ownership! Important!Local ownership! Important!

1313

ONE PASS – monitoring, coaching and positive feedback in BSF/1

ONE PASS – monitoring, coaching and positive feedback in BSF/2

COMPLETIONSCOMPLETIONS l l kl l kCOMPLETIONS COMPLETIONS –– a closer looka closer lookProgrammeProgramme presentedpresented for the first time APRIL 2003for the first time APRIL 20032003: 175 2003: 175 completionscompletions2004: 568 = 79% 2004: 568 = 79% completioncompletion raterateBSF: 73% of BSF: 73% of increaseincrease of programs 2003of programs 2003--0404BSF: 36% av program BSF: 36% av program volumevolume 2004.2004.2005: 777 2005: 777 completionscompletions, 84% , 84% completioncompletion rate rate –– 64 % of 64 % of total programtotal program volumevolumetotal program total program volumevolume2006: 1011 2006: 1011 completionscompletions2007: 16982007: 1698 completionscompletions; 90 %; 90 % completioncompletion raterate2007: 1698 2007: 1698 completionscompletions; 90 % ; 90 % completioncompletion raterate2008: 2020; 93% 2008: 2020; 93% completioncompletion raterate20092009 –– 2010:2010: moremore thanthan 20002000 completions/yearcompletions/year

1616

2009 2009 2010: 2010: moremore thanthan 2000 2000 completions/yearcompletions/year

SOCRATES 8/DSOCRATES 8/DSOCRATES 8/DSOCRATES 8/D

N Probl recognition /Ambivalence/ StepsN Probl recognition /Ambivalence/ Steps--------------------------------------------------------------------------------------------------------------------------------950 0,36 950 0,36 -- 0,66 1,84 0,66 1,84

AverageAveragedifferencedifference

p<.03 p<.0001 p<.0001 p<.03 p<.0001 p<.0001 ----------------------------------------------------------------------------------------------------------------------------------

from prefrom pre-- to to post testpost test

Clinical observation: Just mentioning Clinical observation: Just mentioning ggchange ”inflates” ratings of intentions to change ”inflates” ratings of intentions to change.change.

SOCRATES 8/ASOCRATES 8/ASOCRATES 8/ASOCRATES 8/A

N Probl recognition /Ambivalence/ StepsN Probl recognition /Ambivalence/ StepsAA --------------------------------------------------------------------------------------------------------------------------------

304 0,63 304 0,63 -- 0,56 1,78 0,56 1,78 03 01 000103 01 0001

AverageAveragedifferencedifferencefrom prefrom pre toto p<.03 p<.01 p<.0001 p<.03 p<.01 p<.0001

----------------------------------------------------------------------------------------------------------------------------------


URICAURICAURICAURICA

N Pre C/ Contempl/ Action/ MaintenanceN Pre C/ Contempl/ Action/ Maintenance--------------------------------------------------------------------------------------------------------------------------------645 0,54 645 0,54 --0,83 1,69 0,83 1,69 --1,11 1,11

AverageAveragedifferencedifferenceff tt p<.004 p<0001 p<.0001 p<.0001 p<.004 p<0001 p<.0001 p<.0001

----------------------------------------------------------------------------------------------------------------------------------


The Change The Change QuestionnaireQuestionnaire –– a a motivationalmotivationalindexindex basedbased onon changechange talk (Millertalk (Miller MoyersMoyersindex index basedbased on on changechange talk (Miller, talk (Miller, MoyersMoyers, ,

AmrheinAmrhein, 2008, 2008))DIMENSIONSDIMENSIONSDIMENSIONS:DIMENSIONS:Problem recognition: p <.02 Problem recognition: p <.02 Need: p <.3Need: p <.3Desire: p <.0006Desire: p <.0006Confidence: p <.002Confidence: p <.002Commitment/Do: p <.02Commitment/Do: p <.02Commitment/Do: p .02Commitment/Do: p .02Taking Steps: p <.0009Taking Steps: p <.0009Total (N=88) p < 0005Total (N=88) p < 0005Total (N=88) p <.0005 Total (N=88) p <.0005 ________________________________________________________________________

Pearson r = .072 (2Pearson r = .072 (2--tailed) p<.0001 (N=78)tailed) p<.0001 (N=78)

Motivational factors (scales)Motivational factors (scales)Motivational factors (scales)Motivational factors (scales)D i 3 85 0001D i 3 85 0001Desire: 3,85; p<.0001Desire: 3,85; p<.0001Self Efficacy: 0,43; p<.0001Self Efficacy: 0,43; p<.0001P i it 0 83 0001P i it 0 83 0001

AverageAveragedifferencedifference

Priority; 0,83; p<.0001Priority; 0,83; p<.0001Inner motivation: 0,61; p<.0001Inner motivation: 0,61; p<.0001


Total;3,85; p<.0001Total;3,85; p<.0001pp

Th S l f B l E i Wh I h ll (ME)Th S l f B l E i Wh I h ll (ME)

MEME OTHERSOTHERS

The Scale of Balance Exercise: Why I want to change personally (ME) orThe Scale of Balance Exercise: Why I want to change personally (ME) orOther people or circumstances that influence me (OTHERS)Other people or circumstances that influence me (OTHERS)

Graphical position in TTMGraphical position in TTMGraphical position in TTMGraphical position in TTMSTAGES OF CHANGE; Where are you in the wheel? Put a mark in the figure!

The Transtheoretical Model according toProchaska- DiClemente

DATES AND DEGREESthe wheel? Put a mark in the figure!

/ - = °

/ - = °MAINTENANCE RELAPSE/DRUG USE

= continuation of change…! ”Now I might just as well ”once --always…” keep on - or…”

ACTION PRECONTEMPLATION What Works; accredited programs It doesn´t concern me at all

/ - = °

What Works; accredited programs, It doesn t concern me at all treatment ...

DECISION ”Now I have had enough CONTEMPLATION”Now I have had enough… CONTEMPLATION I really have do to something…” = I am ambivalent

beginning to see disadvantages...

PREPARATION beginning to think how… trying outtrying out...

I am asking others how they…

18

C. Åke Farbring, 2003

ResultsResultsResultsResults

N PrepN Prep--5th 5th5th 5th--laterlaterN PrepN Prep 5th 5th5th 5th laterlaterAverageAveragedifferencedifference

1368 43,82 24,511368 43,82 24,51P< 0001 P< 0001P< 0001 P< 0001

from prefrom pre-- to to post testpost test P<.0001 P<.0001P<.0001 P<.0001pp

Program counselors assessment of clientProgram counselors assessment of client´́s s d i i t tid i i t tiprogress during interventionprogress during intervention

Q tiQ ti NN %% %% %%QuestionQuestion NN %%yesyes

%%nono

%%no no answer answer

Does the client intend to go into more Does the client intend to go into more treatmenttreatment

15531553 52.5452.54 37.03 37.03 10.4310.43

Does the client want followDoes the client want follow--up sessions in up sessions in BSFBSF

15371537 44.1244.12 38.7138.71 17.1717.17

Have you noticed improvement in Have you noticed improvement in collaborationcollaboration

15411541 55.0955.09 38.6138.61 6.296.29

collaborationcollaboration

Have you noticed improvement in desire to Have you noticed improvement in desire to changechange

15501550 80.7180.71 15.5515.55 3.743.74

changechange

ClientClient´́s own assessment of the effect of the s own assessment of the effect of the program on their thinking about changeprogram on their thinking about change

StatementStatement NN % % AbsoluAbsolu

%%MayMay--

%%Yes toYes to

%%YesYes

%%NoNotely tely

NOTNOT

MayMaybebe

Yes, to Yes, to some some degreedegree

Yes, Yes, very very muchmuch

No No answeranswer

I am thinking more aboutI am thinking more about 306306 0.650.65 9.89.8 33.0133.01 46.4146.41 10.1310.13I am thinking more about I am thinking more about change now than I did change now than I did before the programmebefore the programme

I have already started to I have already started to make changesmake changes

305305 1.311.31 4.594.59 32.7932.79 51.851.8 3.743.74

make changesmake changes

IntegratedIntegrated implementationimplementation((implegrationimplegration) ≠ ) ≠ oneone sizesize fitsfits allall

ImplementationImplementation –– an an intentionalintentional processprocessB ttB tt titiBottomBottom--upup perspectiveperspectiveAn An exploringexploring and and listeninglistening attitudeattitude

(f(fLocalLocal ownershipownership (from the centrally (from the centrally decideddecided goalgoalorientationorientation) ) B lB l b tb t id liid li dd i dlii dliBalanceBalance betweenbetween guidelinesguidelines and and mindlinesmindlinesAdjustingAdjusting to to locallocal conditionsconditions = integration= integrationP iti tP iti t thth it iit i dd t lt lPositive support Positive support moremore thanthan monitoringmonitoring and and controlcontrol

2626

Evaluation of 38 programs in OhioEvaluation of 38 programs in OhioEvaluation of 38 programs in OhioEvaluation of 38 programs in Ohio

Group N Effect sizeGroup N Effect size

All 38 - 0.43

Completers 38 0.15

Lowenkamp, C. T., Latessa, E. J., & Smith, P. (2006). Does Correctional Program Quality Really Matter? Criminology & Public Policy, 5, 3, 201-220

2727

A closer lookA closer lookA closer lookA closer look

Correctional Program Assessment Inventory Correctional Program Assessment Inventory (CPAI)(CPAI) (Andrews & Gendreau, 2001)( )( )

Unsatisfactory level (24 programs):Unsatisfactory level (24 programs): 1 7%1 7%Unsatisfactory level (24 programs): Unsatisfactory level (24 programs): --1,7%1,7%Satisfactory but in need of improvement (13): Satisfactory but in need of improvement (13): -- 8,1% 8,1% S ti f t (1)S ti f t (1) 22%22%Satisfactory (1): Satisfactory (1): -- 22%22%Very satisfactory (0)Very satisfactory (0)

2828

But not always….But not always….

Valence of the Effect Size: the difference between Positive and Negative

70%

Positive Effect Size Negative Effect Size70%

Positive and Negative

60%

70%

40%e

60%

70%

40%e

40%

50% 40%r = .40

ism

Rat

e

40%

50% 40%r = -.40

sm R

ate

20%

30%

Rec

idiv

i

20%

30%

Rec

idiv

is

0 0%

10%

0 0%

10%R

2929DAA – Don Andrews 2929

0.0%

Control Treatment0.0%

Control Treatment

A MAJOR CHALLENGE: Programming in A MAJOR CHALLENGE: Programming in the “Real World of Corrections” versus thethe “Real World of Corrections” versus thethe Real World of Corrections versus the the Real World of Corrections versus the

“Small Demonstration” Project“Small Demonstration” Project

Mark LipseyMark Lipsey: effects from treatment in: effects from treatment inMark LipseyMark Lipsey: effects from treatment in : effects from treatment in demonstration projects are much higher demonstration projects are much higher than in the “real world” of regularthan in the “real world” of regularthan in the real world of regular than in the real world of regular programmingprogrammingReal world: Large samples; Evaluator not Real world: Large samples; Evaluator not involved in design and/or delivery ofinvolved in design and/or delivery ofinvolved in design and/or delivery of involved in design and/or delivery of serviceservice

3030

DAA (Don Andrews, 2007)30

Two Separate Worlds of PracticeTwo Separate Worlds of PracticeTwo Separate Worlds of PracticeTwo Separate Worlds of Practice“REAL WORLD” (k =209)“REAL WORLD” (k =209) “DEMO PROJECT” (k = 47)“DEMO PROJECT” (k = 47)“REAL WORLD” (k =209) “REAL WORLD” (k =209) “DEMO PROJECT” (k = 47)“DEMO PROJECT” (k = 47)

Any Human ServiceAny Human Service65%65% 98%98%

Mean RNR AdherenceMean RNR AdherenceMean RNR AdherenceMean RNR Adherence0.82 0.82 2.302.30

Mean BreadthMean Breadth0 060 06 2 112 110.060.06 2.112.11

Staff Selection, Training, Clinical SupervisionStaff Selection, Training, Clinical Supervision01%01% 28%28%

Sum Core Correctional PracticesSum Core Correctional Practices0.230.23 2.192.19

Sum of Integrity ScoresSum of Integrity Scores1.52 1.52 4.324.32

Mean ESMean ES0.03 0.03 0.290.29

3131DAA – Don Andrews 31

Dramatic NeedDramatic NeedDramatic NeedDramatic Need

***To make regular corrections more like***To make regular corrections more like***To make regular corrections more like ***To make regular corrections more like demonstration projects ***demonstration projects ***

3232DAA Don Andrews 32

ImplementationImplementation a new sciencea new scienceImplementation Implementation -- a new sciencea new science

Dean Fixsen etDean Fixsen etDean Fixsen et Dean Fixsen et al., 2005)al., 2005)

3333

Dean L Fixsen NIRNDean L Fixsen NIRNDean L. Fixsen, NIRNDean L. Fixsen, NIRN99% f b d t99% f b d t tt d t did t di ti l i dti l i d itiiti idid99% of budget 99% of budget goesgoes to to understandingunderstanding etiologi and etiologi and writingwriting evidenceevidencebasedbased treatmentstreatments; ; onlyonly 1% of the budget to make 1% of the budget to make themthem workworkPeople People cannotcannot benefitbenefit from from treatmenttreatment that that theythey dodo not not experienceexperience as as pp yy ppusefuluseful for for themthem!!ImplementionteamImplementionteam! 80% in 3 ! 80% in 3 yearsyears comparedcompared to 14% pin 17 to 14% pin 17 yearsyears..T t tT t t i t ti i t thi t ti i t th thithi i l t tii l t tiTreatmentTreatment intervention is not the same intervention is not the same thingthing as as implementationimplementation..

ImplementationImplementation

Effective NOT effectiveEffective Positive outcome Shortlived

/negativeTreatmentTreatment /negative outcome

NOT effective Negative outcome Negative or evenharmful outcome

TreatmentTreatment

harmful outcome

ICTAB 12, Santa FE, 2010ICTAB 12, Santa FE, 2010

A 4A 4--year year codingcoding projectproject of tapes of tapes (Timothy (Timothy ApodacaApodaca))

DistanceDistance coursecourse: : trainingtraining in the in the presencepresenceof of trainerstrainers, , followedfollowed by supervisors, by supervisors, ,, y p ,y p ,boosterbooster trainingtraining (MIA step) (MIA step) –– recordingrecording of of tapestapestapes.tapes.ResultResult: no : no increaseincrease of of reflectivereflective listeninglistening, ,

ii ff hh ii ff MIMIno no increaseincrease of of empathyempathy, no , no increaseincrease of of MIMI--spiritspirit. . OnlyOnly differencedifference –– increasedincreased useuse of of pp yyopenopen questionsquestions towardtoward the the endend of the of the projectproject..projectproject..

WhatWhat elseelseWhatWhat elseelsehappenedhappened in my in my i l ii l i ??implegrationimplegration??

3636

Forsberg L Ernst D & Farbring C Å (2010)Forsberg L Ernst D & Farbring C Å (2010)Forsberg, L., Ernst, D., & Farbring, C. Å. (2010) Forsberg, L., Ernst, D., & Farbring, C. Å. (2010) Learning motivational interviewing in a realLearning motivational interviewing in a real--life life setting: A setting: A randomisedrandomised controlled trial in the controlled trial in the S di h P i S iS di h P i S i C i i lC i i l B h iB h i ddSwedish Prison Service. Swedish Prison Service. Criminal Criminal BehaviourBehaviour and and Mental Health.Mental Health. (wileyonlinelibrary.com) DOI: (wileyonlinelibrary.com) DOI: 10 1002/cbm 79210 1002/cbm 79210.1002/cbm.79210.1002/cbm.792

ABSTRACT:ABSTRACT:ABSTRACT:ABSTRACT:BackgroundBackground Motivational interviewing (MI) is a Motivational interviewing (MI) is a

clientclient--centredcentred, directive , directive counsellingcounselling style for style for ,, gg yyhelping people to explore and resolve helping people to explore and resolve ambivalence about ambivalence about behaviourbehaviour change and change and shown to decrease drugshown to decrease drug and alcohol use A fiveand alcohol use A fiveshown to decrease drugshown to decrease drug and alcohol use. A fiveand alcohol use. A five--session semisession semi--structured MI intervention structured MI intervention ((BeteendeBeteende SamtalSamtal FörändringFörändring (BSF; (BSF; BehaviourBehaviour, , (( gg ( ;( ; ,,CounsellingCounselling, Change)) was implemented in , Change)) was implemented in Swedish prisons.Swedish prisons.

AimsAims To examine whether in a realTo examine whether in a real--life implementationlife implementationAims Aims To examine whether, in a realTo examine whether, in a real life implementation life implementation of semiof semi--structured MI, staff receiving ongoing MI structured MI, staff receiving ongoing MI training, based on audiotraining, based on audio--recorded feedback in peer recorded feedback in peer groups (BSF+) possess greater MI skill compared withgroups (BSF+) possess greater MI skill compared withgroups (BSF+) possess greater MI skill compared with groups (BSF+) possess greater MI skill compared with staff receiving workshopstaff receiving workshop--only MI training (BSF), and staff only MI training (BSF), and staff conducting usual prison planningconducting usual prison planning interviews (UPI).interviews (UPI).MethodsMethods Prisoners werePrisoners were randomisedrandomised to one of theto one of theMethods Methods Prisoners were Prisoners were randomisedrandomised to one of the to one of the

three interventions. The first sessions between staff and three interventions. The first sessions between staff and prisoner with complete data were assessed with the prisoner with complete data were assessed with the M ti ti lM ti ti l I t i iI t i i T t t I t it C d 3 0T t t I t it C d 3 0Motivational Motivational IntreviewingIntreviewing Treatment Integrity Code 3.0.Treatment Integrity Code 3.0.ResultsResults Content analysis of 45 staff: prisoner sessions Content analysis of 45 staff: prisoner sessions

revealed that revealed that counsellorscounsellors in the BSF+ group were in the BSF+ group were g pg psignificantly more competent in MI than those in the UPI significantly more competent in MI than those in the UPI group, but there was no difference in MI competency group, but there was no difference in MI competency between the BSF and the UPI groups.between the BSF and the UPI groups. Overall, staff Overall, staff g pg p ,,were rated as not having achieved beginning proficiency.were rated as not having achieved beginning proficiency.

ConclusionsConclusions Our findings suggest that staff Our findings suggest that staff delivering motivational interviewing programmes delivering motivational interviewing programmes g g p gg g p gfor substancefor substance--misusing prisoners in Sweden are misusing prisoners in Sweden are not being given sufficient training for the task. not being given sufficient training for the task. Previous literature has suggested that staff needPrevious literature has suggested that staff needPrevious literature has suggested that staff need Previous literature has suggested that staff need more than a basic 3more than a basic 3-- to 5to 5--day workshop training, day workshop training, but our findings suggest that they may need but our findings suggest that they may need g gg y yg gg y ylongerlonger--term continuing supervision and support term continuing supervision and support than previously recognised.than previously recognised.

Mean value of indices calculated on estimates of Mean value of indices calculated on estimates of behavioral measures and behavior counts for all behavioral measures and behavior counts for all intervention groupsintervention groups

Globalvariables

Reflec-tions/q

Complexr/r (%)

Open q/q (%)

MI adherent

MI non-adherent

Informa-tiongiving

intervention groupsintervention groups

givingRef valueUPI Mn=14 SD

M=1.0.4924

M=0.40.0912

M=0.50.2615

.1032

1.701 57

11.5010 57n=14 SD

BSF Mn=27 SDBSF+ M

.24

.53

.3256

.12

.21

.1627 *

.15

.28

.1133

.32

.86

.951 24 *

1.571.141.6652

10.5713.146.1614 62BSF+ M

n=42 SD.56.31

.27

.21.33.15

1.24 1.34

.521.12

14.625.43

BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI scores BSF > UPI but not significant Here BSF+ and evenscores BSF > UPI but not significant Here BSF+ and even if not significantlyif not significantly BSFBSF

4040

scores BSF > UPI but not significant. Here BSF+ and even scores BSF > UPI but not significant. Here BSF+ and even –– if not significantly if not significantly –– BSF BSF seems to matter. (Note no difference between BSF and BSF+) However suggested level of seems to matter. (Note no difference between BSF and BSF+) However suggested level of proficiency is not reached.proficiency is not reached.

Mean value for estimate of global measures in all Mean value for estimate of global measures in all intervention groupsintervention groups

Globalvariables

Empathy Evocation Collabor Autonom MI Spirit Direction

UPI M 2 30 2 10 2 40 2 20 2 23 4 20UPI Mn=10 SDBSF MN=14 SD

2.30.822.5085

2.10.742.431 02

2.40.972.5776

2.20.792.7182

2.23.742.5772

4.201.034.141 45N=14 SD

BSF+ MN=21 SD

.853.10 (*).89

1.023.10 *.89

.763.10.89

.823.14 *.79

.723.11 *.71

1.454.71.56

Analysis of variance: BSF+ > (s) UPI/BSF in empathy, evocation, autonomy and MI spirit. Analysis of variance: BSF+ > (s) UPI/BSF in empathy, evocation, autonomy and MI spirit. BSF+ scores > 3 on average (ref.value 3.5 (Moyers et al., 2007) No difference between BSF+ scores > 3 on average (ref.value 3.5 (Moyers et al., 2007) No difference between UPI and BSFUPI and BSFAdj t d (B f i t h t t ) i di t i ifi t diff i ti (Adj t d (B f i t h t t ) i di t i ifi t diff i ti (

4141

Adjusted (Bonferroni, post hoc tests) indicate significant differences in evocation : (mean Adjusted (Bonferroni, post hoc tests) indicate significant differences in evocation : (mean difference difference --.995, p = .019), autonomy (.995, p = .019), autonomy (--.943, p = .012), MI spirit: .943, p = .012), MI spirit: --878, p = .008)878, p = .008)

Mean value of indices calculated on estimates of Mean value of indices calculated on estimates of behavioral measures and behavior counts for all behavioral measures and behavior counts for all intervention groupsintervention groups

Globalvariables

Reflec-tions/q

Complexr/r (%)

Open q/q (%)

MI adherent

MI non-adherent

Informa-tiongiving

intervention groupsintervention groups

givingRef valueUPI Mn=14 SD

M=1.0.4924

M=0.40.0912

M=0.50.2615

.1032

1.701 57

11.5010 57n=14 SD

BSF Mn=27 SDBSF+ M

.24

.53

.3256

.12

.21

.1627 *

.15

.28

.1133

.32

.86

.951 24 *

1.571.141.6652

10.5713.146.1614 62BSF+ M

n=42 SD.56.31

.27

.21.33.15

1.24 1.34

.521.12

14.625.43

BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI scores BSF > UPI but not significant Here BSF+ and evenscores BSF > UPI but not significant Here BSF+ and even if not significantlyif not significantly BSFBSF

4242

scores BSF > UPI but not significant. Here BSF+ and even scores BSF > UPI but not significant. Here BSF+ and even –– if not significantly if not significantly –– BSF BSF seems to matter. (Note no difference between BSF and BSF+) However suggested level of seems to matter. (Note no difference between BSF and BSF+) However suggested level of proficiency is not reached.proficiency is not reached.

Forsberg, L. G., Ernst, D., Sundqvist, K., & Farbring, C. Å. (2011) Forsberg, L. G., Ernst, D., Sundqvist, K., & Farbring, C. Å. (2011) Motivational Interviewing Delivered by Existing Prison Staff: A Motivational Interviewing Delivered by Existing Prison Staff: A Randomized Controlled Study of Effectiveness on Substance Use AfterRandomized Controlled Study of Effectiveness on Substance Use AfterRandomized Controlled Study of Effectiveness on Substance Use After Randomized Controlled Study of Effectiveness on Substance Use After Release.Release. Substance Use & MisuseSubstance Use & Misuse. Informa Healthcare. DOI: . Informa Healthcare. DOI: 10.3109/10826084.2011.591880.10.3109/10826084.2011.591880.

Abstract: A Abstract: A samplesample of 296 of 296 drugdrug--usingusing inmatesinmates in 1 in 1 S di hS di h ii d i dd i d d id i 20042004 20062006 i ti tSwedish Swedish prisonsprisons waswas randomizedrandomized duringduring 20042004--2006 2006 intointothreethree intervention intervention groupsgroups; ; MotivationalMotivational interviewinginterviewingdeleviereddeleviered by by counselorscounselors with with workshopworkshop--onlyonly trainingtraining, or , or bb ll i h k hi h k h i ii i f ll df ll d bbby by counselorscounselors with workshop with workshop trainingtraining followedfollowed by by peerpeergroup supervision, and group supervision, and controlscontrols. . DrugDrug and and alcoholalcohol useusewaswas measuredmeasured by the by the AddictionAddiction SeveritySeverity Index (ASI) at Index (ASI) at yy yy ( )( )intageintage and at 10 and at 10 monthsmonths after release. after release. CompleteComplete data data from 114 from 114 clientsclients werewere analyzedanalyzed by a by a stepwisestepwise regression regression analysisanalysis. All . All threethree groupsgroups reducedreduced alcoholalcohol and and drugdrug useuse. . yy g pg p gg....

ThereThere werewere no no significantsignificant differencesdifferences betweenbetween the the groupsgroupsgroupsgroups..

Days with drug use in 30 days prior to arrest (preDays with drug use in 30 days prior to arrest (pre--y g y (y g y (ASI) and 30 days prior to postASI) and 30 days prior to post--ASI interview for ASI interview for subjects with complete data (n=114)subjects with complete data (n=114)

Intervention

Pre M(SD) PostM(SD)

t df pon M(SD)UPI (N=24) 21.8 (11.8) 6.5 (11,8) 5.63 23 <0.001

BSF ( 35) 23 1 (11 5) 6 5 (11 7) 6 30 34 <0 001BSF (n=35) 23.1 (11.5) 6.5 (11.7) 6.30 34 <0.001

BSF +(n=55)

19.9 (12.1) 7.2 (11,6) 6.07 54 <.001+(n=55)

Total (n=114)

21.3 (11.8) 6.8 (11.6) 10.23 113 <.001

Differencebetw. groups

F= .839 F= .045

p= .435 p= .956

Number of days of illegal activity in 30 days prior Number of days of illegal activity in 30 days prior y g y yy g y yto interviewto interview

Intervention

Pre M(SD) PostM(SD)

t df pon M(SD)UPI (N=23) 16.0 (13.8) 3.3 (9.0) 4.16 22 <0.001

BSF ( 33) 18 6 (13 5) 3 1 (8 8) 6 5 32 <0 001BSF (n=33) 18.6 (13.5) 3.1 (8.8) 6.5 32 <0.001

BSF +(n=47)

12.2 (13.2) 4.5 (9.5) 3.54 46 <.001+(n=47)

Total (n=103)

15.1 (13.6) 3.8 (9.1) 7.79 102 <.001

Differencebetw. Groups

F= 2.176 F=.083

p=.119 p=.920

Number of days working 30 days prior to Number of days working 30 days prior to y g yy g yinterviewinterview

Intervention

Pre M(SD) PostM(SD)

t df pon M(SD)UPI (N=24) 5.1 (9.1) 7.8 (11.0) -1.07 23 <.296

BSF ( 33) 2 0(5 9) 5 5 (9 9) 1 90 32 < 067BSF (n=33) 2.0(5.9) 5.5 (9.9) -1.90 32 <.067

BSF +(n=53)

2.1(6.1) 4.8 (8.8) - 2.13 52 <.038+(n=53)

Total (n=110)

2.73 (6.8) 5.7 (9.6) -2.99 109 <.003

Differencebetw. Groups

F= 2.049 F=.818

p=.134 p=.444

Observation # 1Observation # 1Observation # 1Observation # 1

MI MI implegrationimplegration has has beenbeen highlyhighly successfulsuccessful in in increasingincreasing clientclient motivation tomotivation to changechangeincreasingincreasing clientclient motivation to motivation to changechangeMI MI implegrationimplegration (MI+) (MI+) outperformsoutperforms significantlysignificantlyUPI inUPI in clinicalclinical excellenceexcellence EffectEffect isis probablyprobablyUPI in UPI in clinicalclinical excellenceexcellence. . EffectEffect is is probablyprobablyunderestimatedunderestimated, , sincesince the the studystudy waswas performedperformedveryvery earlyearlyveryvery earlyearly ……ThereThere is no is no evidenceevidence that MI that MI changeschanges offenderoffender´́ssbehaviorbehavior inin prisonprison contextscontexts (for(for manymany reasonsreasons))behaviorbehavior in in prisonprison contextscontexts (for (for manymany reasonsreasons).).TrainingTraining meansmeans veryvery littlelittle and and maymay be be overratedoverratedSo So herehere is is moremore empiricalempirical evidenceevidence for…for… 4747

McMurranMcMurran, M. (2009) , M. (2009) –– MI with MI with offendersoffenders: A : A systematicsystematic reviewreview. . Legal and Legal and CriminologicalCriminological PsychologyPsychology, 14, 83, 14, 83--100100

MI MI appearsappears to to improveimprove: : -- retention in retention in treatmenttreatment. (. (ImportantImportant: : NonNon--completerscompleters are are moremorelikelylikely to beto be reconvictedreconvicted thanthan areare untreateduntreated offendersoffenderslikelylikely to be to be reconvictedreconvicted thanthan are are untreateduntreated offendersoffenders..Q: Q: WhatWhat are are peoplepeople doingdoing to to reducereduce nonnon--completioncompletion..A: Not A: Not muchmuch. . RoomRoom for MI for MI herehere.).)

-- selfself reportedreported motivation to motivation to changechange-- MI MI maymay be effective in be effective in reducingreducing substancesubstance abuseabuse

especiallyespecially in in conjunctionconjunction with with otherother treatmenttreatmentcomponentscomponents..Mi dMi d idid ii h ih i ff diff di b h ib h i-- Mixed Mixed evidenceevidence in in changingchanging offendingoffending behaviorbehavior..McMurranMcMurran, M., & , M., & TheodosiTheodosi, E. (2007) Is , E. (2007) Is treatmenttreatment nonnon--completioncompletion associatedassociated with with increasedincreased reconvictionreconviction over no over no treatmenttreatment? ? PsychologyPsychology, , CrimeCrime and and LawLaw, 13, 333, 13, 333--343 343 16 studies, 19.563 16 studies, 19.563 offendersoffenders..

4848((McMurranMcMurran, ICMI 2, Stockholm, , ICMI 2, Stockholm, 2010)2010)

Smedslund, G., Berg, R. C., Smedslund, G., Berg, R. C., HammarstromHammarstrom, K. T., , K. T., SteiroSteiro, A., , A., LeiknesLeiknes, , K. A, Dahl, H. M., Karlsen, K. (2011) K. A, Dahl, H. M., Karlsen, K. (2011) MotivationalMotivational InterviewingInterviewing for for

SubstanceSubstance AbuseAbuse .. CochraneCochrane DatabaseDatabase of of SystematicSystematic Reviews 2011, Reviews 2011, IssueIssue55-- Art. No.: CD008063. DOI: 10.1002/14651858pub2.Art. No.: CD008063. DOI: 10.1002/14651858pub2.

B k dB k d 7676 illill ll hh l h ll h l bl 15bl 15 illillBackgroundBackground: 76 : 76 millmill peoplepeople havehave alcoholalcohol problems, 15 problems, 15 millmillpeoplepeople havehave otherother drugdrug problems. MI has problems. MI has shownshown goodgood resultsresultsin in manymany studies in studies in thesethese areas. areas. QuestionQuestion: Is MI on the : Is MI on the wholewholeff tiff ti i ff tii ff ti dd itit dd h ?h ?effective, effective, ineffectiveineffective or or doesdoes it it dodo harm?harm?

••59 studies (57 59 studies (57 RCTsRCTs), N= 13.342. ), N= 13.342. comparecompare MI with 1) no MI with 1) no treatmenttreatment 2) TAU 3)2) TAU 3) assessmentassessment and feedback and 4)and feedback and 4) otherothertreatmenttreatment 2) TAU 3) 2) TAU 3) assessmentassessment and feedback and 4) and feedback and 4) otherotheractiveactive treatmenttreatment..•• MI is MI is significantlysignificantly moremore effective effective comparedcompared to no to no treatmenttreatment, , strongeststrongest effecteffect immediatelyimmediately after the interventionafter the intervention weakerweakerstrongeststrongest effecteffect immediatelyimmediately after the intervention, after the intervention, weakerweakerafter that and not after that and not significantsignificant at at longerlonger followfollow--upup..•• No No differencedifference betweenbetween MI and TAU.MI and TAU.•• No No differencedifference betweenbetween MI and MI and otherother activeactive treatmenttreatment•• For medium For medium followfollow--upup the the effecteffect of MI of MI comparedcompared to to assessmentassessment andand treatmenttreatment waswas significantlysignificantly positive Not forpositive Not forassessmentassessment and and treatmenttreatment waswas significantlysignificantly positive. Not for positive. Not for shortshort or or longlong followfollow up.up. Standard medium Standard medium differencedifference: (medium mall SMD = 0.2; medium: 0.5; : (medium mall SMD = 0.2; medium: 0.5; largelarge

0.7; 0.7; ResultsResults: No : No treatmenttreatment: 0.79 (after); 0.17 (: 0.79 (after); 0.17 (shortshort 6 6 monthsmonths); 0.15 6); 0.15 6--12) 0.06= 12) 0.06= longlong >12 >12 monthsmonths..


SubstanceSubstance AbuseAbuse .. CochraneCochrane DatabaseDatabase of of SystematicSystematic Reviews 2011, Reviews 2011, IssueIssue55-- Art. No.: CD008063. DOI: 10.1002/14651858pub2. (Art. No.: CD008063. DOI: 10.1002/14651858pub2. (continuedcontinued))

ImplicationsImplications for for practicepractice: : IfIf thth ll f lf l f t blf t bl ithith kiki ithithIfIf the the counselorcounselor feelsfeels comfortablecomfortable with with workingworking with with MI, it MI, it worksworks betterbetter thanthan no no treatmenttreatment. . ThereThere is not is not enoughenough data todata to concludeconclude whetherwhether MI isMI is betterbetter thanthanenoughenough data to data to concludeconclude whetherwhether MI is MI is betterbetter thanthanCBT.CBT.ImplicationsImplications for research:for research:pp

WeWe havehave enoughenough of RCT studies that show that MI of RCT studies that show that MI cancan work. Time has come work. Time has come nownow to to findfind outout HOW and HOW and WHY MIWHY MI kk d dd d h th t i ti t R fR fWHY MI WHY MI worksworks and under and under whatwhat circumstancescircumstances –– Ref. Ref. to to ApodacaApodaca and and LongabaughLongabaugh (2009) (2009) –– aboutaboutcausalitycausality in MI.in MI.causalitycausality in MI.in MI.

GeneralGeneral conclusionsconclusions aboutabout effectseffectsGeneral General conclusionsconclusions aboutabout effectseffects

EffectsEffects from interventions from interventions varyvary from negative to from negative to positivepositiveTeachingTeaching meansmeans veryvery littlelittle. . LearningLearning is is whatwhat it is it is all all aboutabout. . MONTY ROBERTSMONTY ROBERTS

StyleStyle of of communicationcommunication meansmeans moremore thanthancontentcontent empathyempathy collaborationcollaboration engagementengagementcontentcontent –– empathyempathy--collaborationcollaboration--engagementengagementImplementation Implementation meansmeans moremore thanthan learninglearningth hth h (( ii litlit ) k h d) k h dthroughthrough ((eveneven superiorsuperior qualityquality) workshops and ) workshops and classesclasses: : ►► LearningLearning by by doingdoing!!VeryVery fewfew interventions interventions meetmeet thesethese criteriacriteria


SubstanceSubstance AbuseAbuse .. CochraneCochrane DatabaseDatabase of of SystematicSystematic Reviews 2011, Reviews 2011, IssueIssue55-- Art. No.: CD008063. DOI: 10.1002/14651858pub2. (forts.)Art. No.: CD008063. DOI: 10.1002/14651858pub2. (forts.)

C l iC l iEnd of End of implegrationimplegration

ConclusionsConclusions::

I li tiI li ti ff titi IfIf thth ll f lf lImplicationsImplications for for practicepractice: : IfIf the the counselorcounselor feelsfeelscomfortablecomfortable with MI it with MI it worksworks betterbetter thanthan no no treatmenttreatment. . ComparedCompared to CBTto CBT therethere is notis not enoughenough material tomaterial toComparedCompared to CBT to CBT therethere is not is not enoughenough material to material to make make conclusionsconclusions ifif oneone is is betterbetter thanthan the the otherother..

ImplicationsImplications for research: for research: ThereThere is no lack of is no lack of RCTsRCTsshowingshowing ifif MI MI worksworks or not. Time has come to or not. Time has come to findfind outouthh MIMI kk d dd d h th t dititidititi R fR fhowhow MI MI worksworks and under and under whatwhat condititionscondititions. . ReferenceReferenceto to ApodacaApodaca and and LongabaughLongabaugh (2009) (2009) –– aboutaboutcausalitycausality in MI.in MI.causalitycausality in MI.in MI.

Outcome Outcome variancevariance attributedattributed to to factorsfactors in in therapytherapy (%)(%)therapytherapy (%)(%)

MI as a MI as a communicationcommunication stylestyle is is uniqueunique in in itsits focusfocus on on yy qqgeneral general factorsfactors and and tryingtrying to to operationalizeoperationalize themthem !!!!

Unexpl varClient contribution 25%

relationmethodcounselor

25% Unexplained variance 45%

Interplay 5%

interplayclient

Method

p y

8%

John John NorcrossNorcross, ICTAB 11, 2006., ICTAB 11, 2006.

MoreMore lessonslessons learnedlearned

StrikingStriking and and largelarge variations in variations in gg ggoutcomesoutcomes of of treatmenttreatment (MI). (MI). WhyWhy??

MI is not a ”MI is not a ”methodmethod” not a set of ” not a set of skillsskills. Different . Different counselorscounselors willwill yieldyielddifferentdifferent qualityquality outcomeoutcome

John C. John C. NorcrossNorcrossICTAB ICTAB -- IIII

different different qualityquality outcome… outcome…

University University of Scranton, of Scranton, PennsylvaniaPennsylvania

COMPASS DIRECTIONCOMPASS DIRECTIONCOMPASS DIRECTION COMPASS DIRECTION

NoticeNotice -- RewardReward areas of the areas of the brainbrain

Frontal cortexFrontal cortex

AmygdalaAmygdala

Nucleus Nucleus accumbensaccumbens

AmygdalaAmygdala

LimbicLimbic systemsystem

HippocampusHippocampusHippocampusHippocampus

Mesolimbiska Mesolimbiska dopaminsystemetdopaminsystemet Ventrala tegmentumVentrala tegmentum

NeurobiologicalNeurobiological research in MI: research in MI: HowHow are are rewardrewardareas in the areas in the brainbrain affectedaffected by status quo or by status quo or changechangey qy q ggtalk in MI? talk in MI? ((FeldsteinFeldstein Ewing, S. W., Ewing, S. W., FilbeyFilbey, F. M., , F. M., SabbineniSabbineni, A., Chandler L. D., Hutchison, , A., Chandler L. D., Hutchison, K. E. (2011) K. E. (2011) HowHow PsychosocialPsychosocial AlcoholAlcohol Interventions Work: A Interventions Work: A preliminarypreliminary Look at Look at WhatWhat fMRIfMRI Can Tell Can Tell

Us.Us. AlcoholismAlcoholism: Clinical and: Clinical and ExperimentelExperimentel Research,Research, VolVol 35, No 4. April 2011)35, No 4. April 2011)Us. Us. AlcoholismAlcoholism: Clinical and : Clinical and ExperimentelExperimentel Research, Research, VolVol 35, No 4. April 2011)35, No 4. April 2011)

•• CCT CCT significanlysignificanly affectsaffects neurobiologicalneurobiologicalg yg y ggresponsesresponses of of alcoholalcohol signals/cuessignals/cues) ) ––orbitofrontalorbitofrontal cortex, cortex, nucleusnucleus accumbensaccumbens, , anterioranterior insulainsula posteriorposterior insulainsula caudatecaudate andandanterioranterior insulainsula, , posteriorposterior insulainsula, , caudatecaudate and and putamenputamen

•• No areas No areas werewere affectedaffected by CT!by CT!

•• PreliminaryPreliminary conclusionconclusion: CT in MI : CT in MI cancan preventpreventactivationactivation of the of the rewardreward areas in the areas in the brainbrain. (= . (= DontDont elicitelicit status quo talk)status quo talk)

To talk about change: Adaption of a nomenclature for client langugageTo talk about change: Adaption of a nomenclature for client langugageMiller, Moyers, Amrhein & Rollnick, 2006Miller, Moyers, Amrhein & Rollnick, 2006

------ corticalcortical ------ limbic systemlimbic systemC o m p a s s c o u r s e

Change talk Neutral Status quo-talk ResistanceDirected towards change directed away from change

Preparatory talk:

Reason

Commitment to changel

(do)

Direction towards l status quo

Inability

Interrupt

Disagree

Disregard

Neutral discussion that may contain

Desire

Self efficacy

Need

(do)

Take steps towards change

Inability

Reasons forl s q

Need forl s q

Disregard

Minimize

Argue

Change topic

contain different tracks

Commitment for s q

g p

””FollowingFollowing neutral is neutral is worseworse

Farbring, 2006. Adaption after Moyers, ICTAB 2006.

thanthan doingdoing nothingnothing at all” (at all” (AmrheinAmrhein & & Walker)Walker)

ResistanceResistance or status quo or status quo –– WhereWhere dodo you you wantwant to to go?go?

Clinical observation fromClinical observation from manymany of myof my drugdrug usingusing clientsclients::Clinical observation from Clinical observation from manymany of my of my drugdrug usingusing clientsclients::””WhyWhy shouldshould I I quitquit smoking… smoking… ItIt´́ss onlyonly becausebecause of of memeyouyou havehave aa jobjob InIn factfact youyou shouldshould bebe gratefulgrateful toto meme YouYouyou you havehave a a jobjob. In . In factfact you you shouldshould be be gratefulgrateful to to meme. You . You peoplepeople are not are not interestedinterested in in helpinghelping meme anywayanyway…”…”

Alt. 1. You Alt. 1. You dondon´́tt feelfeel like like quittingquitting and you and you feelfeel that that weweare not are not givinggiving the kind of the kind of helphelp that you that you deservedeserve from from usus..g gg g pp yy

WhatWhat happenshappens nextnext ►►Alt. 2. You Alt. 2. You reallyreally deservedeserve moremore helphelp thanthan you are getting you are getting yy pp y g gy g gright right nownow from from usus. This is not the kind of life you . This is not the kind of life you wantwant for for yourselfyourself and you are the kind of person who is and you are the kind of person who is willingwilling to to

kk h dh d tt hh it Sit S hh ii ffwork work hardhard to to changechange it. So it. So wherewhere are you are you goinggoing from from herehere? (? (RecencyRecency rulerule))

ResistanceResistance or status quo?or status quo?ResistanceResistance or status quo?or status quo?

ResistanceResistance is an is an emotionallyemotionally colouredcolouredreactionreaction with with rootsroots in the in the limbiclimbic systemsystemyyStatus quo is Status quo is whenwhen statementsstatements are are directeddirected awayaway fromfrom changechange butbut basicallybasicallydirecteddirected awayaway from from changechange butbut basicallybasicallylogicallogical and and conversationalconversational ((eveneven thoughthoughhh dd h ilh il )) dd iitheythey maymay sound sound hostilehostile) ) –– rootedrooted in in ((neoneo)cortex.)cortex.(( ))A A transcibedtranscibed statementstatement in in codingcoding cancan be be bothboth resistanceresistance or status quoor status quo dependingdependingbothboth resistanceresistance or status quo or status quo dependingdependingon on howhow it is it is saidsaid.. 6060

Tools to Tools to helphelp you you changechange or or staystay on on coursecoursetowardstowards changechange

DifferentialDifferential reflectivereflective listeninglisteningContinuingContinuing ––thethe-- paragraphparagraph-- reflectionsreflectionsContinuingContinuing ––thethe-- paragraphparagraph-- reflectionsreflectionsRecencyRecency rulerule ((conversationconversation mechanicsmechanics))Action Action reflectionsreflectionsAffirmations (Affirmations (SteeleSteele, 1989), 1989)

WrongWrong choicechoice of of wordswords in in conversationsconversations (in MI*) (in MI*) willwill triggertrigger limbiclimbic system system responsesresponses

WhatWhat and who isand who is importantimportant inin counselingcounseling?? SometimesSometimesWhatWhat and who is and who is importantimportant in in counselingcounseling? ? SometimesSometimesthe the counselorcounselor willwill express express his/herhis/her observations. observations. ((choosechoose youryour wordswords on theon the orientaloriental sideside ))((choosechoose your your wordswords on the on the orientaloriental sideside.) .) Pat. to his Pat. to his physiotherapistphysiotherapist (after (after rejectingrejecting an an exerciseexercise to to relieverelievepain for the 52nd time )pain for the 52nd time )pain for the 52nd time.)pain for the 52nd time.)TherapistTherapist: ”It : ”It seemsseems you are you are constantlyconstantly complainingcomplaining aboutabout your your painpain butbut still you arestill you are refusingrefusing toto dodo anythinganything aboutabout it ”it ”pain pain butbut still you are still you are refusingrefusing to to dodo anythinganything aboutabout it.it.BetterBetter suggestion…?suggestion…?TherapistTherapist: ”: ”FranklyFrankly with yourwith your unhealthyunhealthy overweightoverweight youryourTherapistTherapist: : FranklyFrankly, with your , with your unhealthyunhealthy overweightoverweight your your thoughtsthoughts aboutabout doingdoing somethingsomething aboutabout your your eatingeating habits habits seemsseems like the bestlike the best ideaidea II havehave heardheard from you so far.from you so far. ** InIn mostmostseemsseems like the best like the best ideaidea I I havehave heardheard from you so far. from you so far. In In mostmostreal life work situations MI is real life work situations MI is interweavedinterweaved with with otherother ((professionalprofessional) ) communicationcommunication..

DifferentialDifferential reflectivereflective listeninglistening towardstowards changechangeDifferential Differential reflectivereflective listeninglistening towardstowards changechange

Patient: ”Patient: ”TheseThese twotwo exercisesexercises that you that you wantedwantedmeme to to dodo simplysimply dondon´́tt work. I am just work. I am just wastingwastingtime with this. I time with this. I needneed to to functionfunction bothboth at work at work and at and at homehome and I and I needneed somethingsomething that that reallyreallyworksworks, a medicine that , a medicine that killskills the pain…the pain…PhysiotherapistPhysiotherapist: ….: ….


Patient: ”Patient: ”TheseThese twotwo exercisesexercises that you that you wantedwantedmeme to to dodo simplysimply dondon´́tt work. I am just work. I am just wastingwastingtime with this. I time with this. I needneed to to functionfunction bothboth at work at work and at and at homehome and I and I needneed somethingsomething that that reallyreallyworksworks, a medicine that , a medicine that killskills the pain…the pain…PhysiotherapistPhysiotherapist: You are : You are disappointeddisappointed with with whatwhatwewe havehave donedone so far and you so far and you wouldwould ratherrather havehavea medicine for your pain.a medicine for your pain.


Patient: ”Patient: ”TheseThese twotwo exercisesexercises that youthat you wantedwantedPatient: Patient: TheseThese twotwo exercisesexercises that you that you wantedwantedmeme to to dodo simplysimply dondon´́tt work. I am just work. I am just wastingwastingtime with this Itime with this I needneed toto functionfunction bothboth at workat worktime with this. I time with this. I needneed to to functionfunction bothboth at work at work and at and at homehome and I and I needneed somethingsomething that that reallyreallyworksworks a medicine thata medicine that killskills the painthe painworksworks, a medicine that , a medicine that killskills the pain…the pain…PhysiotherapistPhysiotherapist: … You are : … You are goinggoing throughthrough a a diffi ltdiffi lt ti i htti i ht ith i d tith i d tdifficultdifficult time right time right nownow with your pain … and at with your pain … and at the same time you are the kind of person who is the same time you are the kind of person who is

illiilli t t ll ti th tt t ll ti th t h lh l ttwillingwilling to try all options that to try all options that maymay helphelp you to go you to go to the to the rootsroots of the pain, for of the pain, for yourselfyourself, your work , your work

dd f ilf il SS h th t ii th htth htand your and your familyfamily. So . So whatwhat are your inner are your inner thoughtsthoughtsaboutabout this?this? EmpathicEmpathic reflectionreflection, , continuingcontinuing the the paragraphparagraph, ,

affirmation, affirmation, recencyrecency rulerule..

WhereWhere dodo you you wantwant to go with your to go with your reflectionsreflections? ? Risk for Risk for limbiclimbic system system responsesresponses… …

I i i l t ll th ti d II i i l t ll th ti d I b i ib i i ttI am in pain almost all the time and I am I am in pain almost all the time and I am beginningbeginning to to understandunderstand that this is that this is somethingsomething onlyonly a a skilledskilled physicianphysiciancancan understandunderstand –– and you are notand you are not oneone -- so I amso I amcancan understandunderstand and you are not and you are not oneone so I am so I am beginningbeginning to to wonderwonder -- whatwhat am I am I doingdoing herehere??((RejectingRejecting physicalphysical exerciseexercise) I just) I just cancan´́tt gogo intointo gyms orgyms or((RejectingRejecting physicalphysical exerciseexercise) I just ) I just cancan tt go go intointo gyms or gyms or placesplaces like that. People are so like that. People are so slimslim and and nicenice--lookinglooking, , theythey havehave expensiveexpensive trainingtraining suitssuits and I just and I just feelfeelashamedashamed of my of my bodybody. . WhenWhen you live in a you live in a familyfamily wherewhere everyoneeveryone loves loves foodfood and and

itit ff hh t tht th didi t bl it it bl it i tt hh t kt kcancan sitsit for for hourshours at the at the dinnerdinner table it is table it is tootoo muchmuch to ask to ask from from meme that I must not be part of that. I that I must not be part of that. I enjoyenjoy thosethosemoments Youmoments You peoplepeople are deskare desk therapiststherapists and youand you givegivemoments.Youmoments.You peoplepeople are desk are desk therapiststherapists and you and you givegiveadviceadvice that you that you havehave read from read from booksbooks butbut dondon´́tt work in work in the real world.the real world.

ChangingChanging neutralneutral coursecourseChangingChanging neutral neutral coursecoursePatient: Patient: YesYes, I am in as , I am in as muchmuch pain pain nownow as I as I waswas beforebefore. I . I hadhad to stop to stop doingdoing the the exercisesexercises becausebecause my dog my dog dieddiedand Iand I waswas soso depresseddepressed SheShe waswas aa familyfamily membermember forforand I and I waswas so so depresseddepressed. . SheShe waswas a a familyfamily membermember for for moremore thanthan 10 10 yearsyears. I . I cancan´́tt live live withoutwithout a dog. a dog. NowNow weweare are beginningbeginning to to thinkthink aboutabout buyingbuying a new a new oneone, , perhapsperhapsg gg g y gy g ,, p pp pa a smallersmaller oneone and not a and not a femalefemale this time. A dog is this time. A dog is moremoredaringdaring and easy and easy goinggoing in a in a wayway. I . I meanmean wewe dondon´́tt havehave

hh dd iito to watchwatch a dog a dog twicetwice a a yearyear......PhysiotherapistPhysiotherapist::

Paul Paul AmrheinAmrhein: : FollowingFollowing neutral is neutral is worseworse thanthandoingdoing nothingnothing at all. (at all. (AmrheinAmrhein, P., & Walker, D., P., & Walker, D.


hh dd iito to watchwatch a dog a dog twicetwice a a yearyear......PhysiotherapistPhysiotherapist: So you : So you reallyreally love dogs. love dogs. TheyThey are are

d f ld f l i Ii I hh t it iwonderfulwonderful companions…Icompanions…I cancan seesee howhow you must miss you must miss your dog.your dog.



hh dd iito to watchwatch a dog a dog twicetwice a a yearyear......PhysiotherapistPhysiotherapist: So you : So you reallyreally love dogs. So love dogs. So dodo I. In I. In factfactII hh tt A t liA t li Sh ltiSh lti thth j t l ilitj t l ilitI I havehave twotwo Australian Australian SheltiesShelties; ; theythey just love agility. just love agility.



hh dd iito to watchwatch a dog a dog twicetwice a a yearyear......PhysiotherapistPhysiotherapist: A dog is : A dog is reallyreally importantimportant to you and it to you and it

illill h lh l t b k tt b k t t i it i i ii A dA dwillwill helphelp you get back to your you get back to your trainingtraining exercisesexercises. And . And untiluntil thenthen you you wantwant to go back to to go back to exerciseexercise and and reducereduceyour pain so youyour pain so you cancan walk yourwalk your puppypuppy and play withand play with himhimyour pain so you your pain so you cancan walk your walk your puppypuppy and play with and play with himhimas as muchmuch as you as you wantwant whenwhen you get you get himhim..


Compass direction Compass direction –– continuingcontinuingpp ggthe the paragraphparagraph

ItIt´́ss notnot goinggoing to work forto work for meme ItIt seemsseemsItIt ss not not goinggoing to work for to work for meme. It . It seemsseemshopelesshopeless.... I .... I givegive up.up.

-- My My drinkingdrinking palpal, Charlie, , Charlie, hehe just just quitquit oneonedayday, just like that…, just like that…

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Compass direction Compass direction –– continuingcontinuingpp ggthe the paragraphparagraph

(Depression)(Depression) ItIt´́ss notnot goinggoing to work forto work for meme(Depression) (Depression) ItIt ss not not goinggoing to work for to work for meme. . It It seemsseems hopelesshopeless.... I .... I givegive up.up.-- And still you And still you knowknow that that therethere are are manymanyyy yygoodgood daysdays aheadahead of you of you ifif you you reallyreally wantwant. . HowHow wouldwould you you describedescribe oneone of of thosethose daysdays??

-- (Noticing and (Noticing and catchingcatching the the opportunityopportunity for for changechange talk) Mytalk) My drinkingdrinking palpal CharlieCharlie hehe justjustchangechange talk) My talk) My drinkingdrinking palpal, Charlie, , Charlie, hehe just just quitquit oneone dayday, just like that…, just like that…--AndAnd nownow you areyou are thinkingthinking itit couldcould happenhappen toto

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And And nownow you are you are thinkingthinking it it couldcould happenhappen to to you….Howyou….How wouldwould that be?that be?

Action Action reflectionreflection ((negligencenegligence or or InabilityInability to to movemove to to phasephase II from high motivation II from high motivation levelslevels maymay backfirebackfire) )

A suggestion for action A suggestion for action phrasedphrased as as listeninglistening. . (in (in steadstead of: ” is it ok of: ” is it ok ifif I…” )I…” )gg (( ))

Paves Paves wayway for for cognitionscognitions of of behaviorbehaviorbasedbased waysways toto movemove on fromon from increasedincreasedbasedbased waysways to to movemove on from on from increasedincreasedmotivation to the motivation to the nextnext practicalpractical stepstepCounselor: .. And Counselor: .. And nownow you are you are beginningbeginningtoto considerconsider whatwhat youyou cancan actuallyactually dodo tototo to considerconsider whatwhat you you cancan actuallyactually dodo to to improveimprove your your healthhealth, , e.ge.g. . cutcut downdown or stop or stop smokingsmoking removeremove ashash traystrays from yourfrom yoursmoking, smoking, removeremove ashash traystrays from your from your apartment or apartment or somethingsomething elseelse ……

Clinical observation # 2: Clinical observation # 2: ReflectionsReflections ((evenevencomplexcomplex)) reinforcereinforce thethe clientclient´́ss direction:direction: stayingstaying ononcomplexcomplex) ) reinforcereinforce the the clientclient ss direction: direction: stayingstaying on on

coursecourse towardstowards changechange is is importantimportant

ElicitElicit changechange talk on the talk on the stagestage wherewhere the the clientclient is is at (default: problemat (default: problem recognitionrecognition needneed wishingwishingat (default: problem at (default: problem recognitionrecognition, , needneed, , wishingwishing, , beingbeing ableable to, to, dodo))W hW h f d i if d i i dd i fi fWatch Watch outout for deviations, for deviations, dodo not not reinforcereinforcesustainsustain talk, neutral or talk, neutral or resistanceresistance; ; reflectingreflecting on on hh ii hh bb ll h lh l hhthosethose maymay impartimpart empathyempathy butbut alsoalso helphelp the the

clientclient to talk to talk himhim--/herself/herself intointo resistanceresistance and and d id i ii hh t lkt lkundermineundermine previousprevious changechange talk.talk.

Try to Try to endend on an up on an up slopeslope of of changechange talktalk

Repetition: Repetition: PhasePhase 1 or 1 or PhasePhase 2 0r2 0r4 4 processesprocesses. (. (thoughtsthoughts aboutabout structurestructure…)…)

PROCESSESPROCESSES –– Another Another wayway of of lookinglooking at it (Miller & at it (Miller & Rollnick, ICMI II, 2010):Rollnick, ICMI II, 2010):Rollnick, ICMI II, 2010): Rollnick, ICMI II, 2010):

A A forgottenforgotten phasephase (Steve R, 2010):(Steve R, 2010):

EngagingEngaging –– The The RelationalRelationalFoundationFoundation•• GuidingGuiding –– The The StrategicStrategic FocusFocus•• EvokingEvoking –– The The TransitionTransition to MI to MI •• PlanningPlanning –– The Bridge to ChangeThe Bridge to Change

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General General FactorsFactors in in treatmenttreatment explainexplain moremoreof of variancevariance of of changechange thanthan specificspecific factorsfactors

ExpectationsExpectationsppEmpathyEmpathyAllianceAllianceAllianceAllianceAffirmationsAffirmations

CanCan thesethese factorsfactors bebe moremore accentuatedaccentuated ininCan Can thesethese factorsfactors be be moremore accentuatedaccentuated in in MI?MI?

ExpectationsExpectations –– Is Is therethere a a rolerole for for ExpectationsExpectations Is Is therethere a a rolerole for for workingworking with with expectationsexpectations in MI? in MI?

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MINT FORUM, MINT FORUM, Sheffield, 2011Sheffield, 2011Carl Åke FarbringCarl Åke Farbring

Limitations in Limitations in treatmenttreatment((e.g.correctionse.g.corrections) ) -- expectationsexpectations

Negative Negative expectationsexpectations ((accountaccount for 15% of for 15% of outcome variation (Lambert, 1992) and outcome variation (Lambert, 1992) and ( , )( , )1515——40% of 40% of variancevariance in TA ratings.in TA ratings.OverlyOverly highhigh expectationsexpectations cancan alsoalso affectaffectOverlyOverly high high expectationsexpectations cancan alsoalso affectaffectoutcomeoutcomeRisk: Risk: repeatedrepeated relationshiprelationship terminationsterminations… … (”(”wastewaste of timeof time”” –– oror worseworse…)…)(( wastewaste of timeof time or or worseworse…)…)

The The naturenature of of expectationsexpectationsppLambert & Lambert & BartleyBartley (2002) (2002) ExpactationsExpactations the the thirdthird mostmost importantimportant factorfactor afterafter clientclient variablesvariablesthirdthird mostmost importantimportant factorfactor after after clientclient variables variables and relation: 15%.and relation: 15%.ProbablyProbably mediatedmediated by by allianceallianceExpectationsExpectations and motivation?and motivation? RelationshipRelationship??ExpectationsExpectations and motivation? and motivation? RelationshipRelationship??ClientsClients who who havehave high high expectationsexpectations willwill work work moremore activelyactively…. (Joyce at al., 2003)…. (Joyce at al., 2003)ThereThere isis somesome evidenceevidence thatthat clientsclients withwithThereThere is is somesome evidenceevidence that that clientsclients with with modest modest expectationsexpectations farefare betterbetter thanthan clientsclientswith highwith high expectationsexpectations cfcf basebase linelinewith high with high expectationsexpectations –– cf cf basebase linelinemotivationmotivation

ExpectationsExpectations ---- whatwhat doesdoes the research the research saysay??ConstantinoConstantino, M, J., , M, J., ArnkoffArnkoff, D. B., Glass, C. R., , D. B., Glass, C. R., AmetranoAmetrano, R. M., & Smith, J. Z (2011) , R. M., & Smith, J. Z (2011)

ExpectationsExpectations Journal of ClinicalJournal of Clinical PsychologyPsychology: In Session: In Session 67 (2) 18467 (2) 184--192 (2011)192 (2011) AdaptedAdaptedExpectationsExpectations. . Journal of Clinical Journal of Clinical PsychologyPsychology: In Session, : In Session, 67 (2), 18467 (2), 184--192 (2011) 192 (2011) AdaptedAdaptedfrom from chapterchapter in J. C. in J. C. NorcrossNorcross (ed) (2011) (ed) (2011) PsychotherapyPsychotherapy relationshipsrelationships that work (2nd that work (2nd

ed). New York: Oxford University Press.ed). New York: Oxford University Press.

E t tiE t ti kk i di ti di t ff f lf lExpectationsExpectations are a key are a key ingredientingredient of of successfulsuccessfulpsychotherapypsychotherapy ((GoldfriedGoldfried, 1980; , 1980; GoldsteinGoldstein, 1960; , 1960; RosenzweigRosenzweig, 1936), 1936)

”” bili tibili ti ff hh ff i ti t” a ” a mobilizationmobilization of of hopehope for for improvementimprovement (Frank, (Frank,

(1961) (1961) PersuasionPersuasion and Healing. and Healing. ””RestoringRestoring hopehope and positive and positive expectationexpectation is ais a powerfulpowerful changechange ingredientingredient””expectationexpectation is a is a powerfulpowerful changechange ingredientingredient ……””PsychotherapiesPsychotherapies are are inextricablyinextricably linked with linked with the manipulation and revision of patientsthe manipulation and revision of patients´́the manipulation and revision of patientsthe manipulation and revision of patientsexpectationsexpectations (Greenberg, (Greenberg, ConstantinoConstantino, & Bruce, 2006)., & Bruce, 2006).

ContinuumContinuum fromfrom benefitsbenefits ofof treatmenttreatment totoContinuumContinuum from from benefitsbenefits of of treatmenttreatment to to expectationsexpectations of positive outcome of positive outcome ExpectationsExpectations areare influencedinfluenced byby earlierearlier treatmenttreatmentExpectationsExpectations are are influencedinfluenced by by earlierearlier treatmenttreatmentand and contactscontacts with with therapiststherapists..

SomeSome usedused measuresmeasures in in littlelittle researchedresearchedareaarea

BriefBrief (4(4 itemsitems) and) and studystudy specificspecific andandBriefBrief (4 (4 itemsitems) and ) and studystudy--specificspecific and and sometimessometimes confoundedconfounded with with otherother constructsconstructs ––e.ge.g.. credibilitycredibility..e.ge.g. . credibilitycredibility..CommonCommon questionsquestions::

-- At this At this pointpoint, , howhow logicallogical doesdoes the the therapytherapy offeredoffered seemseem to you?to you?t t st t s po tpo t,, oo og caog ca doesdoes t et e t e apyt e apy o e edo e ed seesee to youto you-- HowHow successfulsuccessful dodo you you thinkthink this this treatmenttreatment willwill be in be in reducingreducing your your

symptoms?symptoms?-- By theBy the endend of theof the therapytherapy periodperiod howhow muchmuch improvementimprovement dodo youyou-- By the By the endend of the of the therapytherapy period, period, howhow muchmuch improvementimprovement dodo you you

thinkthink willwill occuroccur??

In In somesome analysesanalyses credibilitycredibility itemsitems hunghungyy yy ggtogethertogether whilewhile the the expectancyexpectancy itemsitems hunghungtogethertogether with with affectivelyaffectively--anchoredanchored itemsitems –– e.ge.g..

-- HowHow muchmuch dodo you you reallyreally feelfeel that that therapytherapy willwill helphelp you you reducereduce your your symptoms? symptoms? HowHow muchmuch improvementimprovement in your symptoms in your symptoms dodo you you feelfeelwillwill occuroccur??

MoreMore aboutabout measuresmeasures etcetcMoreMore aboutabout measuresmeasures etc.etc.

P i i tiP i i ti ititPessimisticPessimistic itemitem::-- ActuallyActually I am I am ratherrather skepticalskeptical aboutabout whetherwhether treatmenttreatment cancan helphelp

meme……meme… …

PrognosticPrognostic expectationsexpectations are are alsoalso affectedaffected by by contextcontext and and oneone´́ss ownown learninglearning experiencesexperiences. . gg ppOutcome Outcome expectationsexpectations and and treatmenttreatmentexpectationsexpectations probablyprobably interactinteract. . ((ConstantinoConstantino et al., 2011)et al., 2011)pp p yp y (( , ), )

Is Is knowledgeknowledge aboutabout patientspatients´́andand clientclient´́ssexpectationsexpectations usefuluseful forfor usus in MI?in MI?expectationsexpectations usefuluseful for for usus in MI? in MI?

MetaMeta--AnalyticAnalytic Review (Review (ConstantinoConstantino et al., 2011) et al., 2011) EffectsEffects of outcomeof outcome expectationsexpectations on outcomeon outcomeEffectsEffects of outcome of outcome expectationsexpectations on outcome.on outcome.

RESULTS:RESULTS:RESULTS:RESULTS:N= 8.016 patients N= 8.016 patients acrossacross 46 independent 46 independent samplessamplessamplessamples>80% >80% adultadult (18(18--65), > 60% White , > 60% 65), > 60% White , > 60% womenwomenwomenwomenOverall Overall weightedweighted effecteffect sizesize d d = .24, p< .001 = .24, p< .001

((CohenCohen´́ss (1988)(1988) d.), rd.), r = . 12, p< .001 (CI.= . 12, p< .001 (CI.9595 . 10 to .15). 10 to .15)((CohenCohen ss (1988) (1988) d.), r d.), r . 12, p .001 (CI. . 12, p .001 (CI.9595 . 10 to .15). 10 to .15)

Moderators andModerators and MediatorsMediatorsModerators and Moderators and MediatorsMediators

ThusThus: : therethere is a small is a small butbut significantsignificant association association betweenbetween outcome outcome expectationsexpectations and and treatmenttreatmentoutcome.outcome.HoweverHowever littlelittle is is knownknown aboutabout specificspecificmechanismsmechanisms throughthrough whichwhich theythey operateoperate ((ArnkoffArnkoff, , Glass &Glass & ShapiroShapiro 2002)2002)Glass, & Glass, & ShapiroShapiro, 2002), 2002)

Three studies Three studies havehave directlydirectly investigatedinvestigated the the putativeputative mediatormediator pathwaypathway (Meyer et al 2002; Joyce(Meyer et al 2002; Joyceputativeputative mediatormediator pathwaypathway (Meyer et al., 2002; Joyce, (Meyer et al., 2002; Joyce, OgrodniczukOgrodniczuk, Piper, & , Piper, & McCallumMcCallum, 2003; , 2003; AbouguendiaAbouguendia, Joyce, Piper, , Joyce, Piper, & & OgrodniczukOgrodniczuk, 2004) …, 2004) …iindicatingndicating that that therapeutictherapeuticalliancealliance is a robust is a robust mechanismmechanism..Patients with positive outcome Patients with positive outcome expectationsexpectations are are moremore likelylikely to to engageengage in a in a collaborativecollaborativerelationshiprelationship with the with the counselorcounselor..

WhatWhat aboutabout highhigh expectationsexpectations??WhatWhat aboutabout high high expectationsexpectations??

PrognosticPrognostic expectationsexpectations cancan sometimessometimes be be tootoohighhigh (like motivation) and (like motivation) and cancan endend in in disappointmentdisappointment, frustration and , frustration and eveneven anger anger b tb tbutbut……ExpectationsExpectations are are malleablemalleableSingleSingle assessmentassessment or or staticstatic understandingunderstanding of of expectationsexpectations at the start is not at the start is not productiveproductive..ExpectationsExpectations –– like motivation like motivation –– is is somethingsomethingthat the that the counselorcounselor needsneeds to to adress and work onadress and work on..

ImplicationsImplications for for practicepractice ((ConstantinoConstantino et al., et al., 2011)2011)

11 E li itlE li itl (( d t dd t d)) titi1.1. ExplicitlyExplicitly assessassess ((understandunderstand) ) prognosticprognosticexpectationsexpectations at the at the beginningbeginning of of treatmenttreatment..

22 B hB h ii th tth t t ht h thth ti tti t´́2.2. BehaveBehave in a in a wayway that that matchesmatches the the patientpatient´́sslevellevel of optimism and of optimism and useuse strategiesstrategies to to enhanceenhancea positive outcomea positive outcome looklook outout forfor unrealisticunrealistica positive outcome a positive outcome –– look look outout for for unrealisticunrealisticspeed or speed or degreedegree of of changechange

33 MakeMake hopehope inspiringinspiring statementsstatements: ”: ”WhatWhat you areyou are3.3. Make Make hopehope--inspiringinspiring statementsstatements: : WhatWhat you are you are dealingdealing with right with right nownow is is veryvery commoncommon and and cancanbebe changedchanged”; ”You are the kind of person who”; ”You are the kind of person whobe be changedchanged ; You are the kind of person who ; You are the kind of person who cancan reallyreally accomplishaccomplish thingsthings that you that you putput your your mind to”mind to”

4.4. NormalizeNormalize possiblepossible fluctuationsfluctuations towardstowardschangechange..

ImplicationsImplications forfor practicepracticeImplicationsImplications for for practicepractice

Make Make conversationconversation ((dondon´́tt read) and read) and adaptadapt to to your your ownown contextcontextyy

Carl Åke Farbring, 2009Carl Åke Farbring, 2009

The The EngagementEngagement RulerRuler -- an an allianceallianceg gg ginstrument (instrument (sideside A)A)

At the At the endend of the session (make of the session (make conversationconversation –– dondon´́tt read):read):

RegardlessRegardless of rating an of rating an importantimportant questionquestion willwillfollowfollow!!followfollow!!

Alliance Alliance –– WhatWhat is is alliancealliance in MI? A in MI? A d t ti f d t ti f titimodest suggestion for modest suggestion for practicepractice..

MINT FORUMMINT FORUM

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Carl Åke FarbringCarl Åke Farbring

New New phasesphases (Miller & Rollnick, (Miller & Rollnick, 2010 ICMI 2 2010 ICMI 2 conferenceconference))

EngagingEngaging –– thethe relationalrelational foundationfoundationEngagingEngaging –– the the relationalrelational foundationfoundation

GuidingGuiding –– thethe strategicstrategic focusfocusGuidingGuiding –– the the strategicstrategic focusfocus

EvokingEvoking –– thethe transitiontransition to MIto MIEvokingEvoking the the transitiontransition to MIto MI

PlanningPlanning –– the bridge tothe bridge to changechangePlanningPlanning the bridge to the bridge to changechange

((replacesreplaces priorprior PhasePhase I and III and II distinctiondistinction))9090

((replacesreplaces prior prior PhasePhase I and II I and II distinctiondistinction))

General General factorsfactors explainexplain moremore of the of the variancevariance of of hh hh i li l ff dd h dh dchangechange thanthan special special factorsfactors and and methodsmethods

Alliance (MI ≈ Alliance (MI ≈ empathyempathy, , collaborationcollaboration))

explainsexplains about7about7--8 % of the 8 % of the variancevariance of of changechangeweakenedweakened alliancealliance correlatescorrelates withwithweakenedweakened alliancealliance correlatescorrelates with with

unilateral unilateral terminationtermination..llilli ” t fi t” t fi t i hti ht ””alliancealliance ”at first ”at first sightsight ””

NoteNote: : clientsclients i CJ and i CJ and similarsimilar contextscontextsare are oftenoften defensive at the start (affirmations).defensive at the start (affirmations).

SUPERSHRINKSSUPERSHRINKS WhatWhat´́ss thethe secretsecret ofof

Miller, Hubble, & Duncan, 2008)Miller, Hubble, & Duncan, 2008)

SUPERSHRINKS. SUPERSHRINKS. WhatWhat ss the the secretsecret of of theirtheir successsuccess??

EnormousEnormous differencesdifferences in in successsuccessbetweenbetween therapiststherapists in the same in the same pporganizationorganization with same with same educationeducation and and workingworking with with similarsimilar patients. patients. WhatWhat are are supershrinkssupershrinks doingdoing that the that the othersothers are not are not doingdoing??Cf. Cf. TerriTerri MoyersMoyers´́ metaphormetaphor aboutabout the the surgeonsurgeon… and … and psychosocialpsychosocial

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counselorscounselors

What does the research say?What does the research say?What does the research say?What does the research say?

Working and therapeutic alliance is an Working and therapeutic alliance is an important predictor of behavior changeimportant predictor of behavior changep p gp p gHow it operates is little understoodHow it operates is little understoodP i d b ti tti k lP i d b ti tti k lPrison and probation settings make clear Prison and probation settings make clear obstacles for working alliance to emergeobstacles for working alliance to emergeIn fact systemic factors may even In fact systemic factors may even interveneintervene againstagainst allianceallianceintervene intervene againstagainst alliancealliance

What is alliance?What is alliance?What is alliance?What is alliance?B diB di ´́ thth (1979)(1979)BordinBordin s s theorytheory (1979):(1979):

11 AgreementAgreement on theon the goalsgoals thethe offenderoffender m stm st1.1. AgreementAgreement on the on the goalsgoals the the offenderoffender must must work onwork on

22 ClearClear collaborationcollaboration on the taskson the tasks2.2. Clear Clear collaborationcollaboration on the taskson the tasks3.3. BondBond betweenbetween clientclient and and counselorcounselor

((relationshiprelationship))((relationshiprelationship))

WAIWAI predictspredicts outcome (outcome (HorvathHorvath, 1994), 1994)WAI WAI predictspredicts outcome (outcome (HorvathHorvath, 1994) , 1994) BordinBordin, E. S. (1979) , E. S. (1979) PsychotherapyPsychotherapy: : TheoryTheory, , Research and Research and PracticePractice, 16, , 16, 252252--260260

New (2008) theory revision of BordinNew (2008) theory revision of BordinRoss, E. C., Polaschek, D. L. L. & Ward, T. (2008) The therapeutic Alliance: A Theoretical revision Ross, E. C., Polaschek, D. L. L. & Ward, T. (2008) The therapeutic Alliance: A Theoretical revision

for offender rehabilitation. for offender rehabilitation. Aggression and Violent Behavior, 13, 462Aggression and Violent Behavior, 13, 462--480480

1.Bond can predict change irrespective of 1.Bond can predict change irrespective of goals and tasks goals and tasks gg

2.Two factor model 2.Two factor model –– bond and goals/tasksbond and goals/tasks3 R i l i ti hi h di t3 R i l i ti hi h di t3. Reciprocal intimacy was a high predictor 3. Reciprocal intimacy was a high predictor

of session quality ratings and overall of session quality ratings and overall effectieness (Saunders, 1999)effectieness (Saunders, 1999)

4 Bond may be even more important in brief4 Bond may be even more important in brief4. Bond may be even more important in brief 4. Bond may be even more important in brief therapies.therapies.

FindingsFindings (1)(1)FindingsFindings (1)(1)

””SurprisinglySurprisingly, , professionalprofessional variables variables havehavedemonstrateddemonstrated littlelittle or no or no relationshiprelationship to the to the TA…. TA…. yearsyears of of professionalprofessional experienceexperience werewereunrelatedunrelated to the TA for to the TA for universityuniversity basedbasedtherapiststherapists. ”. ”DirectiveDirective behaviorsbehaviors reducereduce empathyempathy and and warmthwarmthNegative Negative expectationsexpectations ((previousprevious failurefailure etcetc) ) cancaninfluenceinfluence TA andTA and cancan becomebecome selfself--fulfillingfulfillinginfluenceinfluence TA and TA and cancan becomebecome selfself fulfillingfulfillingTA in MI: TA in MI: empathyempathy, , collaborationcollaboration……

Findings (2)Findings (2)g ( )g ( )Words like: psychopath, punishment, Words like: psychopath, punishment, aversiveness, obtrusive, rules, personality aversiveness, obtrusive, rules, personality disorder, distasteful, crimes…are often used.disorder, distasteful, crimes…are often used.Counselors in corrections routinely experience Counselors in corrections routinely experience challenges that threaten TA. How do you challenges that threaten TA. How do you d l TA ith li t th t l id l TA ith li t th t l idevelop TA with a client that you value in develop TA with a client that you value in negative termsnegative termsCli t ill t h ithi tiCli t ill t h ithi tiClients will not change within a negative Clients will not change within a negative counselorcounselor--client relationship client relationship -- alliance is a alliance is a prerequisiteprerequisiteprerequisiteprerequisiteClientClient´́s perception of the counselor as an s perception of the counselor as an empathic individual rather than actual counselorempathic individual rather than actual counselorempathic individual rather than actual counselor empathic individual rather than actual counselor behaviorbehavior

Skeem: Dual role; care and control Skeem: Dual role; care and control and resource oriented instrumentsand resource oriented instrumentsA validated TAA validated TA--instrument made for correctionsinstrument made for correctionsImprovement over WAI in correctionsImprovement over WAI in correctionsppIn stead of problem oriented instrumentes: Good In stead of problem oriented instrumentes: Good Lives ModelLives Model (Ward & Stewart, 2003)(Ward & Stewart, 2003)Lives Model Lives Model (Ward & Stewart, 2003)(Ward & Stewart, 2003)

Goal Matrix, motivational structure model (Cox, Goal Matrix, motivational structure model (Cox, Klinger 2002):Klinger 2002):Klinger, 2002):Klinger, 2002):Personal Concerns Inventory, OA, (Psychology, Personal Concerns Inventory, OA, (Psychology, Crime and Law )Crime and Law )Crime and Law.) Crime and Law.) (Sellen, McMurran, Theodosi, Cox, Klinger, in press)(Sellen, McMurran, Theodosi, Cox, Klinger, in press)

Alliance and feedbackAlliance and feedbackAlliance and feedbackAlliance and feedback

Lambert (2003) reports an ES of 0.39 on Lambert (2003) reports an ES of 0.39 on feedbackfeedback comparedcompared to a group to a group wherewherepp g pg pfeedback feedback waswas not given.not given.

In a recentIn a recent studystudy in Norway (2009) Ankerin Norway (2009) AnkerIn a recent In a recent studystudy in Norway (2009) Anker, in Norway (2009) Anker, Duncan & Sparks report a 4 Duncan & Sparks report a 4 timestimes biggerbiggerli i llli i ll i ifii ifi diffdiff hhclinicallyclinically significantsignificant differencedifference to the to the

advantageadvantage of the feedback group.of the feedback group.gg g pg p(JCCP, 2009, (JCCP, 2009, VolVol 77, No 4, 69377, No 4, 693--704.704.It i thIt i th li tli t´́ d t did t di ff llilli th tth t

Carl Åke Farbring, 2009Carl Åke Farbring, 2009It is the It is the clientclient ss understandingunderstanding of of alliancealliance that that

predictspredicts outcome outcome –– not the not the therapisttherapist´́ss

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LetLet the the clientclient investinvest in your in your collaborationcollaboration, , buildingbuilding alliancealliance

NoteNote: In : In conversationconversation –– not not assessmentassessment!!

-- IfIf youyou werewere toto givegive somesome adviceadvice onon howhow II couldcouldIfIf you you werewere to to givegive somesome adviceadvice on on howhow I I couldcouldbe be moremore helpfulhelpful to you to you –– whatwhat wouldwould you you suggest?suggest?suggest?suggest?

-- 1….1….22


-- 2….2….-- 3….3….

Activity moment Activity moment –– a small exercisea small exercise

1. You are 1. You are meetingmeeting a new a new clientclient and are and are askingasking aboutabout his/herhis/her expectationsexpectations as part as part ofof conversationconversation notnot assessmentassessment!!!!!!of of conversationconversation –– not not assessmentassessment!!!!!!2. 2. ImagineImagine that the session has passed.that the session has passed.3 Ask3 Ask ifif thethe collaborationcollaboration matchedmatched3. Ask 3. Ask ifif the the collaborationcollaboration matchedmatched

his/herhis/her expectationsexpectations..4 Ask4 Ask aboutabout his/herhis/her opinionopinion aboutabout you asyou as4. Ask 4. Ask aboutabout his/herhis/her opinion opinion aboutabout you as you as

a a counselorcounselor as part of as part of conversationconversation. Do . Do not read on the not read on the rulerruler!!!!!!5.Thank the 5.Thank the clientclient for for his/herhis/her

collaborationcollaboration. Ask for . Ask for adviceadvice on on howhow to be to be moremore helpfulhelpful

102102

moremore helpfulhelpful..

WorkingWorking with with expectationsexpectations in MI (1)in MI (1)--o go g tt e pectat o se pectat o s ( )( )adaptadapt to your to your ownown contextcontext

PractitionerPractitioner´́ss task: task: workingworking with with expectationsexpectations = = antecipatoryantecipatory socialisation socialisation –– ExpectationsExpectations must be must be metmet..


WorkingWorking withwith expectationsexpectations in MI (2)in MI (2)WorkingWorking with with expectationsexpectations in MI (2)in MI (2)

NowNow imagineimagine that you that you havehave beenbeen havinghavingyour session and it has your session and it has beenbeen comingcoming to an to an yy ggendend……

InviteInvite the the client/patientclient/patient to to assessassess YOU and YOU and YOUR performance!YOUR performance!

104104

The The EngagementEngagement RulerRuler -- an an allianceallianceg gg ginstrument (instrument (sideside A)A)

At thAt th dd f th i ( kf th i ( k titiAt the At the endend of the session (make of the session (make conversationconversation ––dondon´́tt read) Hand over the instrument to the read) Hand over the instrument to the client/patientclient/patient..

RegardlessRegardless of rating an of rating an importantimportant questionquestion willwillfollowfollow!!followfollow!!

The The EngagementEngagement RulerRulerg gg gAn An alliancealliance instrument (instrument (sideside B)B)

At the At the endend of the sessionof the session–– dondon´́ttread, make read, make conversationconversation::

R dlR dl f tif tiRegardlessRegardless of rating an of rating an importantimportant questionquestion willwill followfollow!!

InviteInvite the the clientclient to to investinvest in your in your collaborationcollaboration -- buildingbuilding alliancealliance

NoteNote: : conversationconversation –– not not assessmentassessment!!

-- IfIf youyou werewere toto givegive somesome adviceadvice onon howhow II couldcouldIfIf you you werewere to to givegive somesome adviceadvice on on howhow I I couldcouldbe be moremore helpfulhelpful to you to you –– whatwhat wouldwould you you suggest?suggest?suggest?suggest?

-- 1….1….22


-- 2….2….-- 33

InviteInvite the the clientclient to to investinvest in your in your collaborationcollaboration -- buildingbuilding allianceallianceNoteNote: : conversationconversation –– not not assessmentassessment!!

-- IfIf you you werewere to to givegive somesome adviceadvice on on howhow I I couldcouldbebe moremore helpfulhelpful to youto you whatwhat wouldwould youyoube be moremore helpfulhelpful to you to you –– whatwhat wouldwould you you suggest?suggest?11-- 1….1….

-- 2….2….-- 3….3….

Carl Åke Farbring, Carl Åke Farbring, 20112011

Making people feel seen as valuable Making people feel seen as valuable Making people feel seen as valuable Making people feel seen as valuable and unique persons.and unique persons.

Affirmations in MIAffirmations in MI”He made us feel”He made us feelHe made us feel He made us feel

greater than we were…”greater than we were…”

MINT FORUM, Sheffield, MINT FORUM, Sheffield, September 2011September 2011

Carl Åke Carl Åke farbringfarbring 20112011

The Use of Affirmations in MIThe Use of Affirmations in MIThe Use of Affirmations in MIThe Use of Affirmations in MI

AttributingAttributing interestinginteresting qualitiesqualities to a person (MINUET, to a person (MINUET, 2002)2002) –– makingmaking the personthe person feelfeel ””seenseen” as a person (not” as a person (not2002) 2002) makingmaking the person the person feelfeel seenseen as a person (not as a person (not just as a just as a client/patientclient/patient or ”problem or ”problem bearerbearer”).”).Bill Miller (2007): ” Bill Miller (2007): ” ”It seems clear that we have not enough understood or emphasized the importance ofenough understood or emphasized the importance of affirmations in MI.” (ref. (ref. LinehanLinehan, 2002), 2002)Self Affirmation Self Affirmation TheoryTheory ((SteeleSteele, 1988), 1988)yy (( ))ExtendsExtends and and elaborateselaborates on the present definition and on the present definition and practicepractice of affirmation in MIof affirmation in MISherman & Cohen (2006)Sherman & Cohen (2006) TheThe PsychologyPsychology ofof SelfSelfSherman & Cohen (2006) Sherman & Cohen (2006) –– The The PsychologyPsychology of of SelfSelf--DefenseDefense AdvancesAdvances in Experimental Social in Experimental Social PsychologyPsychology, 38, , 38, 183183--242.242.

Carl Åke farbring 2011Carl Åke farbring 2011

AFFIRM in MIAFFIRM in MI

Alluding and referring to what has been said or Alluding and referring to what has been said or g gg gdone earlier:done earlier:

-- I understand that it is hard for you to talk about this.I understand that it is hard for you to talk about this.-- You have lots of resources that will help you to deal with You have lots of resources that will help you to deal with

this problemthis problem-- It must have been difficult for you… and you made it!It must have been difficult for you… and you made it!

I i t th t ld h t dI i t th t ld h t d-- I appreciate that you could come here todayI appreciate that you could come here today-- I think that it is very good that you want to deal with this I think that it is very good that you want to deal with this

problemproblemproblemproblem-- You showed that you really could!You showed that you really could!


AFFIRM (cont.)AFFIRM (cont.)

AttributingAttributing interestinginteresting qualitiesqualities to a person; to a person; gg gg qq ppmakingmaking him/herhim/her seenseen as a (as a (--n) (n) (interestinginteresting) ) person:person:

-- You are a bit of a You are a bit of a philosopherphilosopher reallyreally. You are . You are sayingsayingllll d dd d hihi hhreallyreally advancedadvanced thingsthings herehere..

-- You You havehave the the qualitiesqualities of a of a leaderleader. People look up to . People look up to youyouyou.you.

-- You look almost like a You look almost like a professionalprofessional athleteathlete!!-- You are the kind of person whoYou are the kind of person who carescares aa lotlot forfor othersothersYou are the kind of person who You are the kind of person who carescares a a lotlot for for othersothers..-- You are a person with You are a person with veryvery high high integrityintegrity!!

(Farbring 2002)(Farbring 2002)


(Farbring, 2002)(Farbring, 2002)

PraisePraise and affirmationsand affirmationsPraisePraise and affirmationsand affirmations•• I am impressed by your progress!I am impressed by your progress!•• I think you did that really well! Congratulations!I think you did that really well! Congratulations!•• Now that was an intelligent statement!Now that was an intelligent statement!•• I know it was difficult for you to come today. You deserve credit for I know it was difficult for you to come today. You deserve credit for y yy ythat.that.=….. a perspective ”von oben” =….. a perspective ”von oben” –– mirroring a perspective of deficits mirroring a perspective of deficits

(”the deficit worldview”, Corbett, 2006)(”the deficit worldview”, Corbett, 2006)••Who is the main person there?Who is the main person there?

•• You are saying so many interesting things You are saying so many interesting things -- almost like a almost like a philosopher!philosopher!•• You are a person who really likes to help people in need.You are a person who really likes to help people in need.•• You understand different cultures better than most people because You understand different cultures better than most people because you can speak so many languages.you can speak so many languages.=….a perspective from a position ”under/below”. The competence =….a perspective from a position ”under/below”. The competence

ld i ”ld i ”worldview”.worldview”.•• Who is the main person here? Who is the main person here?

Basic tenets in Self Affirmation Basic tenets in Self Affirmation Theory (Steele, 1988)Theory (Steele, 1988)

People are strongly motivated to uphold self People are strongly motivated to uphold self integrity and self respect and a positive image of integrity and self respect and a positive image of g y p p gg y p p gthemselves on domains that are important!themselves on domains that are important!This motivation often results in defensive This motivation often results in defensive responses, more rationalizing than rational.responses, more rationalizing than rational.The self system is flexible. You compensate The self system is flexible. You compensate yyfailures in one domain by increasing the failures in one domain by increasing the importance in another one. (Your are fighting importance in another one. (Your are fighting

h d t h ld th i f lfh d t h ld th i f lfvery hard to uphold the image of yourself as a very hard to uphold the image of yourself as a positive person and upholding self worth.) positive person and upholding self worth.)


Defensive attitudesDefensive attitudesDefensive attitudes Defensive attitudes

Defensive Defensive attitudesattitudes are adaptive and are adaptive and naturalnatural. . TheyThey reducereduce threatthreat againstagainst positive positive selfself image image and and selfself worthworth..People People downplaydownplay threateningthreatening informationinformationpp p yp y ggTheyThey are are helpinghelping you to you to survivesurvive sometimessometimes..TheyThey are maladaptiveare maladaptive whenwhen changechange isisTheyThey are maladaptive are maladaptive whenwhen changechange is is necessarynecessary ((e.ge.g. to . to survivesurvive).).I itI it iblibl f th MIf th MI ll tt ddIs it Is it possiblepossible for the MI for the MI counselorcounselor to to decreasedecreasedefensive defensive attitudesattitudes in the in the clientclient to to increaseincrease

ti itti it tt t t tt t t??Carl Åke farbring 2011Carl Åke farbring 2011

receptivityreceptivity to to treatmenttreatment??

AFFIRMATIONS (Steele 1988)AFFIRMATIONS (Steele 1988)AFFIRMATIONS (Steele, 1988)AFFIRMATIONS (Steele, 1988)

P bl P lP bl P l ftft dd t t dt t dProblem: People Problem: People oftenoften dodo not accept and not accept and rejectreject information and information and resistresist treatmenttreatment (to (to protectprotect theirtheir ownown positive image of positive image of themselvesthemselves))Affirmations Affirmations cancan reducereduce defensive defensive attitudesattitudes and and increaseincrease willingnesswillingness from from a udesa udes a da d c easec ease g essg ess ooclientsclients to accept ”problem” and to accept ”problem” and treatmenttreatmentAffirmationsAffirmations strengthenstrengthen thethe psychologicalpsychologicalAffirmations Affirmations strengthenstrengthen the the psychologicalpsychologicalimmune systemimmune system (Sherman & Cohen, 2006)(Sherman & Cohen, 2006)


Effect of affirmationsEffect of affirmationsEffect of affirmationsEffect of affirmations

WhWh l b ll b l ff lflf i t iti t itWhenWhen global global measuresmeasures of of selfself integrityintegrity are are strengthenedstrengthened the the needneed to to upholduphold defensedefenseagainstagainst threateningthreatening information is information is reducedreduced, , sincesince it it cancan be be seenseen, , understoodunderstood and and dealtdealtwith in a with in a biggerbigger contextcontext..Self Self integrityintegrity cancan be be activelyactively upheldupheld, by , by SeSe eg yeg y caca bebe ac e yac e y up e dup e d, by, byengagingengaging in in activitiesactivities that that strengthenstrengthen your your conceptionconception of ”who you are” andof ”who you are” and whatwhat youyouconceptionconception of who you are and of who you are and whatwhat you you are are worthworth..


Th l b l lf i t itTh l b l lf i t itThe global self integrity The global self integrity (Karin)(Karin)

ATTRACTIVEATTRACTIVE+ 2+ 2GOOD GOOD

MUMMUM+ 3+ 3

BEINGBEING

+ 2+ 2

JOBJOB-- 33

DANCINGDANCING

BEING BEING POPULARPOPULAR

+3+3

PHYSICALPHYSICALSHAPESHAPE

+ 3+ 3 ALCOHOLALCOHOL

DANCINGDANCING+ 2+ 2

+ 3+ 3 ALCOHOLALCOHOL-- 33


My furious friend Peter hcp 13My furious friend Peter hcp 13My furious friend Peter, hcp 13My furious friend Peter, hcp 13

And after And after returning to thereturning to thereturning to the returning to the game:game:

-- You know I could You know I could run all this wayrun all this wayrun all this way run all this way without even without even losing my breathlosing my breathand…:and…:

-- (to himself) (to himself) At At least I am good at least I am good at saving moneysaving money


PhysicallyPhysically fitfit like alike a toptop athleteathletePhysicallyPhysically fitfit like a like a toptop athleteathlete

After losing a head position After losing a head position and being transferred to and being transferred to

th i tith i tianother organizationanother organization

•• I l d I hI l d I h•• I am glad I have a I am glad I have a family…family…•• Can we exercise duringCan we exercise during•• Can we exercise during Can we exercise during lunch?lunch?


Self affirmation theory (Steele, Self affirmation theory (Steele, 1988)1988)

Where is the evidence?Where is the evidence?Where is the evidence?Where is the evidence?Sherman, D.K., & Cohen, G. L. 2006. Sherman, D.K., & Cohen, G. L. 2006. The psychology of The psychology of SelfSelf--Defense: Self AffirmationTheory. Advances in Defense: Self AffirmationTheory. Advances in yyExperimental Social PsychologyExperimental Social Psychology, Vol 38. 183, Vol 38. 183--242242


Stress cortisol as a function of time and Stress cortisol as a function of time and status of affirmationstatus of affirmationstatus of affirmationstatus of affirmation

C ll W l h T l Sh G ld & M (2005)C ll W l h T l Sh G ld & M (2005)Cresswell, Welch, Taylor, Sherman, Gruenewald & Mann (2005). Cresswell, Welch, Taylor, Sherman, Gruenewald & Mann (2005). Psychological Science, 16, Psychological Science, 16, 846846--851. (The Tries Social Stress Task for job 851. (The Tries Social Stress Task for job applicants and an arithmetic task 2083 by 13applicants and an arithmetic task 2083 by 13´́s))s))

1 051,1

1,15 Affirmations Affirmations cancan bufferbuffer selfself

0,951

1,05 integrityintegrity not not onlyonly on on psychologicalpsychological

0 80,850,9

psychologicalpsychologicalmeasuresmeasures butbuton a on a

0,750,8

baslinje 20 min 30 min 45 min

psyshiologicalpsyshiologicallevellevel as as wellwell!!

YellowYellow = A= A


e oe oRed= Red= nonnon--AA

Steretypical threats and performanceSteretypical threats and performanceMartens Johns Greenberg & Schimel (2006) Combating Stereotype threat TheMartens Johns Greenberg & Schimel (2006) Combating Stereotype threat TheMartens, Johns, Greenberg & Schimel (2006). Combating Stereotype threat. The Martens, Johns, Greenberg & Schimel (2006). Combating Stereotype threat. The effect of self affirmation on womeneffect of self affirmation on women´́s intellectual performanced. s intellectual performanced. Journal of Journal of Experimental Social Psychology, 42, Experimental Social Psychology, 42, 236236--243.243.

•• Stereotype : ”Women do not perform as well as men in Stereotype : ”Women do not perform as well as men in th ti ” (t i t th t ill i fl fth ti ” (t i t th t ill i fl fmathematics” (triggers stress that will influence performance mathematics” (triggers stress that will influence performance

negatively)negatively)•• A test was presented as a) diagnosticA test was presented as a) diagnostic b) basis forb) basis for•• A test was presented as a) diagnostic A test was presented as a) diagnostic ------ b) basis for b) basis for researchresearch•• Result: Women in the diagnostic condition performedResult: Women in the diagnostic condition performedResult: Women in the diagnostic condition performed Result: Women in the diagnostic condition performed worse than the other women and clearly worse than men.worse than the other women and clearly worse than men.•• Women in the same category a) that were affirmed did just Women in the same category a) that were affirmed did just as well as women in the research group and just as well as as well as women in the research group and just as well as men also.men also.


Other aspects of affirmationsOther aspects of affirmationsOther aspects of affirmations…Other aspects of affirmations…

Affirmations on the focussed area may Affirmations on the focussed area may backfire!backfire!backfire! backfire! Affirmations must be unrelated to the domain Affirmations must be unrelated to the domain –– Act counterintuitively!Act counterintuitively!Affirmation theory offers a framework forAffirmation theory offers a framework forAffirmation theory offers a framework for Affirmation theory offers a framework for understanding and dealing with bias.understanding and dealing with bias.M di i f d d b iM di i f d d b iMediating factors are not understood; basis Mediating factors are not understood; basis for researchfor research


Affirmations and cognitive Affirmations and cognitive dissonancedissonance

Upholding self integrity rather than Upholding self integrity rather than balancebalanceLooking actively for information not just to Looking actively for information not just to gain balance but to restore self integritygain balance but to restore self integritygain balance but to restore self integritygain balance but to restore self integrityPurpose: to decrease feelings of unease Purpose: to decrease feelings of unease ––that value of the person does not depend that value of the person does not depend on the unfortunate event…on the unfortunate event…on the unfortunate event…on the unfortunate event…


What can we do as clinicans to reduce What can we do as clinicans to reduce defensive bias when change is important?defensive bias when change is important?

Reinforce and strengthen important Reinforce and strengthen important alternative domains of self integrity.alternative domains of self integrity.g yg yClinician behaves ”counterintuitively”!Clinician behaves ”counterintuitively”!Total concentration on the client!Total concentration on the client!Total concentration on the client!Total concentration on the client!Affirmations are a form of reflective Affirmations are a form of reflective

fflistening i.e. attributions of qualities are listening i.e. attributions of qualities are statements. statements. Avoid saying ”I think you are…”Avoid saying ”I think you are…”


Summary of effectsSummary of effectsSummary of effectsSummary of effectsAffi tiAffi tiAffirmations can …Affirmations can …reduce defensive bias with respect to attitudes, reduce defensive bias with respect to attitudes,

iti ti t d i liti ti t d i lcognitive receptiveness, stress and social cognitive receptiveness, stress and social perception. perception. Affi ti l i fl t tAffi ti l i fl t tAffirmations can also influence stereotypes, Affirmations can also influence stereotypes, prejudice and behaviorprejudice and behaviorR lt li bl h l l t f fi ldR lt li bl h l l t f fi ldResults are applicable over a whole lot of fields.Results are applicable over a whole lot of fields.Self protective strategies can be reduced and Self protective strategies can be reduced and

li i t d if th i t t d ili i t d if th i t t d ieven eliminated if other important domains even eliminated if other important domains unrelated to the threatened area are affirmed.unrelated to the threatened area are affirmed.


What happens if affirmations are What happens if affirmations are made conscious?made conscious?

People to which the domain in question is very People to which the domain in question is very important are more likely to have bias, but theyimportant are more likely to have bias, but theyimportant are more likely to have bias, but they important are more likely to have bias, but they are also the ones who have most to gain from are also the ones who have most to gain from affirmationsaffirmationsAffirmations work in a subtle way ”under the Affirmations work in a subtle way ”under the surface” without mediating role for the surface” without mediating role for the conscience.conscience.Affirmations that are made clearly conscious are Affirmations that are made clearly conscious are impotent.impotent.


Suggestion: be counterintuitive!Suggestion: be counterintuitive!Suggestion: be counterintuitive!Suggestion: be counterintuitive!

First two minutes: ”First I would be very First two minutes: ”First I would be very interested if you could tell who you are, what interested if you could tell who you are, what kind of a person you are. What is important in kind of a person you are. What is important in your life, what makes you feel really well,when your life, what makes you feel really well,when and what makes you feel that you have done and what makes you feel that you have done something really good…?something really good…?Listen reflectively and return at times in Listen reflectively and return at times in conversation and show that you know ”who this conversation and show that you know ”who this important person is…”important person is…”


Affirmations in clinical practiceAffirmations in clinical practiceAffirmations in clinical practiceAffirmations in clinical practiceMember of parish Member of parish

+2+2

Singing in a choir + 2Singing in a choir + 2

F tb ll t i fF tb ll t i fFootball trainer for young Football trainer for young boys + 3boys + 3

Family: relations close Family: relations close d ti 2d ti 2and supportive +2and supportive +2

ImportantImportantSafe private economy + 2Safe private economy + 2

Speaks Spanish +2Speaks Spanish +2

Important Important domains in domains in TomTom´́s lifes life


Affirmations in MI Affirmations in MI –– empiricalempiricalfinding (N=291)finding (N=291)

••8% of the variance of change talk is explained by 8% of the variance of change talk is explained by open ended questionsopen ended questions••7% of the variance is explained by complex 7% of the variance is explained by complex reflective listening.reflective listening.••4% is e plained b emphasi ing personal control4% is e plained b emphasi ing personal control••4% is explained by emphasizing personal control4% is explained by emphasizing personal control

19% of the variance is explained by 19% of the variance is explained by affirmations (standard)affirmations (standard)affirmations (standard).affirmations (standard).

(Apodaca, 2010)(Apodaca, 2010)

WhyWhy dodo affirmations (affirmations (SteeleSteele, , yy (( ,,1988) work1988) work

•• ItIt´́ss ”A ”A mysterymystery” (Sherman & Cohen, 2006)” (Sherman & Cohen, 2006)•• ExperienceExperience of love and of love and caringcaring for for othersothers.. (.. (CrockerCrocker, , pp gg ((NiiyaNiiya, , MischowskiMischowski, 2008), 2008)•• An An interestinginteresting hypothesishypothesis: : OxytocinOxytocin (Henry & Wang, (Henry & Wang, 2008)2008)2008)2008)••The The hormonehormone of of closenesscloseness ((UvnäsUvnäs Moberg, 2009)Moberg, 2009)

Affirmations and Affirmations and empathyempathy; non; non--verbal verbal communicationcommunication:: interestinginteresting threadsthreads forforcommunicationcommunication: : interestinginteresting threadsthreads for for

developmentdevelopment in MIin MI

1.1. Is Is makingmaking the person the person feelfeel seenseen as a person as a person ––accordingaccording to to selfself--affirmationaffirmation theorytheory ((SteeleSteele, , 1988) 1988) –– a a shortshort cutcut to to empathyempathy? ?

2.2. HowHow effectiveeffective is a is a smilesmile??


Thank you! Thank you! [email protected]@telia.com

Is it over? Is it over? Can Can wewe havehave lunch lunch nownow??

134134

nownow??

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