Motivational Interviewing Grows Up. William R. Miller, Ph.D.

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1 Motivational Interviewing Grows Up William R. Miller, Ph.D.

2 The Happenstance Beginning

4 A Second-Year Practicum (1972) Therapeutic Empathy

5 Milwaukee, 1973 Uncommon alcoholics

6 Eugene, Oregon 1975 Why did that control group get better?

7 Study Design Miller, Gribskov & Mortell, 1981 International Journal of the Addictions, 16: Counselor-Delivered Behavioral Self-Control Training (10 Weeks) or Self-Help Advice + Bibliotherapy (1 Session) Both groups self-monitored with weekly drinking diary How much better would clients fare with a counselor?

8 1976 Bibliotherapy 2013

9 Drinks per Week Drinking Outcomes Intake 3 months 6 months 12 months Therapist-Directed

10 Drinks per Week Drinking Outcomes Intake 3 months 6 months 12 months Therapist-Directed Self-Directed

11 Albuquerque 1976

12 Replicated in New Mexico:

13 Was it just an artifact of time or self-monitoring?

14 Study Design Psychology of Addictive Behaviors, 4, Counselor- Self-Help Waiting List Waiting List Delivered (10 Weeks) Book (1 Session) with Diary (10 Weeks) no Diary (10 Weeks)

15 Drinks per Week Drinking Outcomes Intake 10 weeks 20 weeks 15 Months Therapist-Directed Self-Directed Waiting List (2 groups)

17 Drinks per Week If that is so, why didn t the waiting list group change? Intake 10 weeks 20 weeks 15 Months Self-Directed Therapist-Directed Waiting List

18 And why do counselors clients have such different outcomes when receiving the same treatment?

20 All Nine Counselors: Miller, W. R., Taylor, C. A., & West, J. C. (1980). Focused versus broad spectrum behavior therapy for problem drinkers. Journal of Consulting and Clinical Psychology, 48,

21 Therapist Empathy Miller, Taylor & West (1980)

22 Therapist Empathy 60 Miller, Taylor & West (1980)

23 Client Drinking Outcomes Accounted for by Therapist Empathy 6 months 1 year 2 years r =.82 r =.71 r =.51 67% 52% 26% Miller & Baca (1983) Behavior Therapy 14:

Client Relapse Rates 40 35 30 25 20 15 10 5 0 35 38 29 23 24 20 19 15 13 11

24 Client Relapse Rates Months 12 Months 18 Months 24 Months Follow-up Points Low Medium High

25 A barbershop in Norway

27 Called it motivational interviewing Conceived of MI as preparation for treatment Miller, W. R. (1983). Motivational interviewing with problem drinkers. Behavioural Psychotherapy, 11,

29 Motivational Interviewing was originally designed for working with people who are less ready to change.

30 Back in New Mexico: The Drinker s Check-up

32 Problem drinkers receiving the drinker s check-up were randomly assigned to: Counselor delivers feedback in a confrontive-directive style or Counselor delivers feedback in a supportive-reflective style or a 6-week waiting list group The same counselors delivered both styles.

33 Drinks per Week Intake 6 Weeks 12 Weeks 12 Months MI Confrontive Waiting List

34 Correlation Coefficient Predicting 12-month drinking from actual in-session responses Therapist Behavior Client Behavior Confront Argue Interrupt Negative Off Task

35 Counselor Style and Client Response 45 43, Client Behavior Counts ,3 21,6 Change Talk ,7 Resistance 5 0 Directive Empathic

37 0,8 0,7 0,6 0,5 0,4 0,3 E1 D1 E2 D2

38 Sydney 1989

39 Some Contributions from Steve 1991

40 The Beginning of MINT Albuquerque 1993 Malta 1997

42 2002

44 44

45 Languages of MI Trainers (50) and Books (27) Arabic Bulgarian Cantonese Chinese (simplified) Croatian Czech Danish Dutch English Estonian French Gaelic Georgian German Greek Hebrew Hindi Icelandic Italian Japanese Korean Mandarin Norwegian Persian/Farsi Polish Portuguese Punjabi Romanian Russian Spanish Swedish Turkish

48 A Continuum of Styles Directing <=> Guiding <=> Following

49 2013

50 X

51 X

53 (What s it for?) Practitioner s definition (How would I use it?) Motivational interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change

54 (How does it work?)

55 The Underlying Spirit of MI

56 Collaboration Compassion MI Spirit Acceptance Evocation

57 Absolute Worth Accurate Empathy Acceptance Autonomy Support Affirmation

58 Four Fundamental Processes in Motivational Interviewing

59 Four Foundational Processes Evoking Planning Focusing Engaging

60 Can it be MI without... No No No Yes

61 Opposite Sides of a Coin Preparatory (DARN) Desire Ability Reasons Need Mobilizing (CATs) Commitment Activation Taking Steps

62 The other side of ambivalence

63 How Motivational Interviewing is Directional PS Carl Rogers did this

67 MI1 FA1 CT2 FA2

69 When decisional balance is a bad idea: ambivalence Miller, W. R., & Rose, G.S. (2015). Motivational interviewing and decisional balance: Contrasting responses to client ambivalence. Behavioural and Cognitive Psychotherapy, 43(2),

70 What about resistance?

71 Deconstructing Resistance Sustain Talk Discord

72 What MI Research Tells Us

74 Average Between-Group Effect Size (d) of MI Across All Reported Outcome Measures (N=72 trials) End of Treatment 4-6 Months 7-12 Months Hettema et al. 2005, Annual Review of Clinical Psychology, 1,

76 Mean Combined Effect Size by Problem Area (Hettema et al. 2005) Smoking Diet/Exercise Alcohol Adherence Gambling Public Health Drug Abuse HIV Risk 1-3 Months 4-12 Months

78 CBT MET TSF

79 BASELINE POST TX 3 MONTH 6 MONTH 9 MONTH 12 MONTH 36 MONTH % Days Abstinent CBT MET TSF Timeline Relative to Treatment Window

80 Percent Days Abstinent ,4 46,6 42,3 43,2 29,5 29,5 Baseline 3 Months 12 Months MI SBNT

83 Effect Size of MI Over Time (Hettema et al, 2005 meta-analysis) All Studies C1 C2 C3 Controlled Additive Comparative >1-3 >3-6 >6-12 >12 Follow-up Months

85 Client Outcomes by Therapist 120 All Clients received the same manual-guided treatment in the NIAAA COMBINE Study Mean PDA Baseline Mean PDA Week 4 Mean PDA Week 26 Mean PDA Week 52 Mean PDA Week 68

87 MI Desire Ability Reasons Need Commitment Change

88 ,8 0,6 0,4 0, Directive Empathic 0 MI1 FA1 MI2 FA2

89 Is MI Just Client-Centered Counseling? Sellman, J. D., Sullivan, P. F., Dore, G. M., Adamson, S. J., & MacEwan, I. (2001). A randomized controlled trial of motivational enhancement therapy (MET) for mild to moderate alcohol dependence. Journal of Studies on Alcohol, 62(3),

90 , ,9 OR=2.62 OR=2.95 % Patients Drinking Heavily MET NDRL Control

96 Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72,

97 Trained groups > control at 4 months p <.001 All enhanced training groups exceed criterion Due mostly to decreased MI-inconsistent responses

98 No significant increase except in Group WFT

100 Young children? Those who have already decided to change

101 MI Training Feedback + Coaching Increased MI Fidelity Change Client Change Talk

102

103 N umber of Adopt ions Adoption Curve for Innovations Source: Everett M. Rogers Diffusion of Innovations

104 Annual Cumulative

105

106 and still we re just getting started

107

These core elements are included in three increasingly detailed levels of definition:

These core elements are included in three increasingly detailed levels of definition: A Definition of Motivational Interviewing The definition of Motivational Interviewing (MI) has evolved and been refined since the original publications on its utility as an approach to behavior change.