Dr. William Miller, “Motivational Interviewing: Facilitating Change Across Boundaries”
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Oh
good morning okay so we’re going to the
light saying is appropriate for this
time okay it’s hard to follow a black
preacher and doctor fully love a
charismatic singer and social worker mr.
ozaki in and the gentle eloquent voice
of mr. Cruz I’m only 61 years old and
not having the seniority of dr. fuller
love and being a scientist I do have a
PowerPoint with with slides and some
data but fundamentally what I have to
tell you is the story and it’s the story
of motivational interviewing which
started out working with some of the
most despised and rejected members of
our society with those missing fathers
you’ve been hearing about or lost in the
world of alcohol and drugs and then with
the mentally ill chemically chemical
abusers and that awful name for people
Marcus with those with the HIV and at
risk of it and now has spread into the
fields of Public Health and probation
and parole and it’s a kind of
interesting winding story it’s not one
that that happened by forethought at all
but in sort of unexpected serendipitous
ways so I want to tell you how its
unfolded and where we are at the moment
and express my gratitude for a career
built on projects 25 years of funding
from the National Institute on Alcohol
Abuse and Alcoholism hands NIDA and the
thanks to my colleagues at the
University of New Mexico Center not all
ism substitutes and addictions who were
very instrumental in all the research
that you’re going to see the story
really begins in Milwaukee in 1973 when
I was on an internship and wandered into
an alcoholism treatment unit knowing
absolutely nothing about alcoholism the
director of the program said what do you
know about alcohol SMI sit up nothing
whether they teach you in graduate
school nothing I said well you’re going
to need to know about this because it’s
the second most common diagnosis you’re
going to see in your lifetime so you
learn about so I spent that summer
listening to people on the on the wards
I didn’t know anything and so I had
nothing to to to offer but I put on my
best Carl Rogers hat and listened to the
stories of these men primarily who were
who were there in this VA hospital and
how they’ve gotten there and where they
thought their lives were going and what
was happening what their hopes and
dreams were and I loved it others in the
immediate chemistry of working with with
people with alcohol problems for me and
then I went home and started reading the
literature on alcoholism and it said
alcoholics are in denial they’re
pathological liars can never get through
to them they’re huge walls of defensive
mnestheus a bulldozer to break down and
gosh those aren’t sane people I was
talking to it doesn’t it doesn’t doesn’t
sound like alcoholics in Milwaukee or
like that no well I went back to the
University of Oregon and decide to do my
dissertation working with with problems
ranking and one of the annoyances was
the control group seemed to work as well
as the intervention group in the study
that I did and specifically in a
follow-up study we randomly assigned
people who were who had drinking
problems to commit and see a counselor
who was doing behavior therapy for ten
weeks or to be randomly assigned to a
group that worked on their own with
materials that we gave them said take
this home and and follow directions and
we’ll be in touch with you in ten weeks
and see how you’re doing and the
self-help materials eventually were
published as as this book alcohol
controlling your drinking and those who
saw a therapist showed a nice decrease
in their drinking you see their alcohol
use is cut down by half and down to a
reasonably safer range but the
embarrassing thing was that the control
group working on their own didn’t know
any better and so they went ahead and
got better also even without the
assistance of a therapist and there and
there was no difference between these
groups over time so I moved to New
Mexico I thought the funding would go
away but
replicas in 1978 in 1979 in 1983 several
randomized trials talk about being in
denial and I finally decided I had a
real finding here that there was
something going on now was it just an
artifact when one thing we had people
doing was keeping records of their
drinking and what we asked people what
helped you one of the things they said
was well it was keeping on records that
you told me every time before tea I had
a drink I was supposed to write it down
and not get on my car ready to have a
drink kind of look at it and say well
now do I really want that drink enough I
think maybe I had enough and I put it
away that was really helpful or maybe
it’s just a passage of time maybe it’s
just that people come in and once they
come in to say I want help with my
drinking that they’re already done so we
designed another study with the same two
groups in it ten weeks of behavior
therapy self-help group with what we
came to call bibliotherapy that’s giving
people a book to take home and follow or
waiting lists where we told people will
we can’t see you now but we’ll see you
in ten weeks and one of them we said
meanwhile keep these diaries of your
drinking thinking that perhaps that was
the active ingredient and the other
group we said just just wait and we’ll
see you in 10 weeks and what we found
was once again the the group that work
with the therapists got their drinking
in half once again the group working on
their own who actually started somewhat
higher than the therapist group showed a
very nice reduction in drinking that
maintained well over time and the two
waiting list groups didn’t go anywhere
up until 10 weeks and then we treated
them a therapist saw them and then
they’re drinking came down after that so
it wasn’t just the passage of time and
it wasn’t the record-keeping in fact the
group that kept records there Ricky went
up a little bit over time you know so so
it wasn’t that day either and the lesson
seems to be that people seem to have an
impressive capacity to change themselves
if you believe in them if you tell them
that they can and give them some help
and
so they’re now over 30 randomized
clinical trials showing the same thing
that a relatively brief form of
counseling can bring about substantial
change in drinking then I got the
thinking about that waiting list control
because you would expect people to get
somewhat better I mean they walk into a
clinic fish that I have a drinking
problem I want to get some help with it
yeah and it’s absolutely flat it doesn’t
improve at all up to ten weeks and then
it hit me that that they were doing
exactly what we told them to do they
were waiting we put them on a waiting
list and the message is you’re not
expected to get better until we can
treat you and then it’s alright to get
better after that
and so they complied very nicely with
that with that instruction we have that
kind of power to communicate our
expectations to people about what will
and will not happen in their lives and
it becomes self-fulfilling prophecies I
also noticed something else I noticed
that our counselors have had quite
different outcomes that one of the one
of the things that seem to be
determining who is going to reduce their
drinking it was going to manage it well
was the counselor that they saw and
there were big differences and this
turns out to be true and in the alcohol
and drug treatment field more generally
that one of the big influences on the
outcome is the therapist you happen to
draw the person that happens to see you
well what’s that about so we did this
study quite a while ago as you can see
now having the one west there were nine
therapists in this study and then three
supervisors including myself and we were
is long enough ago we were sitting by in
one-way mirrors watching these
therapists do their work and reading
them on a variety of things including
using the Truex and kharkov scale of
accurate empathy right out of crow
Rogers laboratory to what extent are
these therapists listening well and
understanding and communicating back to
their clients what the client is
experiencing how good are their
reflective listening basically is what
the ski
Liz and we randomly assigned problem
drinkers to counselors so there wasn’t
any differential assortment there and we
agreed rather well who was the most
empathic we just rank ordered the
therapists and all three of us picked
the same person is most empathic
independently and all three of us two of
us had the same person as the the least
empathic and the other supervisor rated
that person is number eight so the
overall correlation of is 0.87 and in
rankings then we wind up our our
therapists from most empathic number one
to least empathic number nine and we
looked at their success rates when we
got the follow-up data and there they
are that’s a pretty good correlation
that’s a pretty good relationship it’s
not perfect but we got a couple
therapists where every one of their
clients are doing well numbers one three
and down at the bottom we got a
therapist with the 25% of their clients
doing well and in this study we also had
a group going home and working on their
own with a book and here’s their success
rate and if you average all the
therapists together you come to the
conclusion that therapists are no
different from self-help conditions but
that isn’t really true we’ve got five
therapists who are doing better than the
self-help conditioner and then we got a
few where the client would have been
better off going home with a good book
and and what’s that about it’s about
empathy we can predict client drinking
outcomes very behavioral stuff from
empathy how well the counselor is
listening to and interested in what the
client has to say and here are the
correlations if you like statistic
that’s six months the correlation
between therapists empathy and the
number of drinks per week is 0.82 which
is doggone good for psychology it
accounts for two-thirds of the variants
in client outcomes a year later we’re
still accounting for half the variance
in drinking two years later they can
hardly even remember the name of their
therapist you know we’re still
accounting for a quarter the bearings
and outcomes based on how good a
listener how good the therapist was at
Rogier
empathy accurately well I was that was
kind of regressive when it got here oh
this is another study done by Valen in
which he looked at therapists who were
high medium or low in Rogerian skills
and now that the vertical axis here is
relapse rate so you don’t want it to be
high alright and these are the these are
the counselors again randomly assigned
clients these are the counselors who
were low in Rogerian skillfulness these
are the clients who were medium in
Rogerian skillfulness and these were the
most empathic counselors and look at the
differences if you get two to four fold
differences in relapse rates based on
how well your counsel listens to you I
think the evidence is strong enough to
use empathy is a hiring criterion
addiction treatment programs this point
I think we ought to be doing that well
the loose data I went off of my first
sabbatical to Norway and I worked at in
alcoholism Hospital nestled right on the
edge of a few ER and they gave me this
nice corner office looking out into the
forest which I learned had been the
barbershop they ran the barber out of
there to make room for a visiting
professor and and in that barber shop I
had time for writing and in addition to
the lectures that I was giving on
behavioral treatment of alcohol problems
the director said would you meet with
these psychologists we have they’re
pretty green they’re just out of school
and just have a conversation every you
know a couple weeks or so and see what
comes of it I said sure and what they
wanted to do these young psychologist
was to roleplay cases they were seeing
that were their most difficult cases
that were particularly they were finding
resistant or difficult in some way and
essentially say okay smart guy what
would you do with this and we’re working
in English so they’re working in their
second language right although no
regions are pretty good in English so
they would bring in these these cases
and they would roleplay and I would do
my best to show what I was doing in
counselling and it would stop me very
often and say what what are you thinking
when what what’s going on your head
where are you going in this at this
moment you asked a question there why
did you ask that question and not some
other question or you reflect it what
why did you reflect instead of asking a
question or why did you reflect that
particulars
said why did you reflect that and they
caused me to verbalize a set of decision
rules that I was using unknowingly in
working with clients I haven’t been
aware of it and embarrassingly it wasn’t
a great deal like the what I was
lecturing about in the next room woman
on behavioral treatment and some of
those principles were that the person
rather than the clinician should be the
person who’s making the arguments for
change what you want is to evoke the
person’s own concerns and motivations
and to listen with empathy to use a lot
of reflective listening you want to do
what you can to minimize resistance and
for heaven sakes don’t push against it
because that tends to increase
resistance and you want to nurture hope
and optimism and so the things that I
was doing as they asked me for the
rationale tended to be along those kinds
of lines and I gave it this name
motivational interviewing if I called it
anything else that would have been
motivational conversation I think no and
I was thinking of this as a preparation
for treatment at that point is something
you would do up front to prepare the way
for treatment and as you’ll see in a bit
that’s that’s not an unreasonable way to
think about it I then went home and
designed something called the drinkers
checkup and we tried to get people out
of the community who were drinking too
much but hadn’t gone into treatment and
so we wanted a very low threshold Public
Health kind of
approach and what we did with the state
we have a free checkup available for
people who are drinkers who wonder
whether they’re drinking too much this
is not part of treatment you won’t be
diagnosed or you get health information
back and what you do with that
information is up to you and lots of
people gain people who wouldn’t go near
the door of a treatment center but 100%
of whom have had problems with drinking
every last one of them and we gave them
treatment referral a sheet of
information with the places they can go
for treatment well what we found was
nobody want the treatment but they have
the gall to get better without a
therapist you know they’re they’re
drinking decrease in a manner very
similar to what we had seen in the
previous studies that was interesting so
then we compare two styles of giving
feedback one of them more
confrontational because alcoholism
treatment at that time was pretty in
your face confrontational or a more
motivational interviewing style and we
randomly assigned people to different
counselors although both the same
counselor did both kinds of treatment
and we’ve we found with with
motivational interviewing a very large
reduction in in drinking from about 50
down to about 15 drinks a week on
average as the mean for the whole group
and less of a reduction with a confront
of feedback but nonetheless feedback was
was having some kind of effect and then
the then a waiting list group again
dutifully waited until we could see them
and then they decrease their drinking
when we give them a feedback but notice
in both of our waiting list conditions
they splash back also which we’re
finding if you make people wait for
treatment it doesn’t work as well you’re
better off doing something brief right
away then putting people on a Tanner
12-week waiting list because what you
deliver 10 or 12 weeks later doesn’t
seem to hold as well as what you could
have done right at the moment so that’s
intriguing but I knew that these
counselors some of them were really good
at gets empathy and some of them were
awful at empathy and some of them were
pretty good at getting in somebody’s
face and some of them weren’t so good at
that
than they were they were doing both
smiles of therapy so rather than the
assigned condition I said what did the
therapist really do you know before I do
that though let me let me show you this
effect of on client change talk what
what the clients are saying is very
different in these two conditions this
is the amount of of change talk which is
the client making arguments for change
and the amount of resistance which is
the client making arguments against
change and you see it’s about 50/50 in
the confrontational condition and here’s
the motivational interviewing condition
you get double the amount of client
change talk and you get half the amount
of client resistance and that’s just
with the assignment conditions here’s
another is I’m sorry about this one
there’s another study in which Gary
Patterson that counselors change their
style every 12 minutes within session
can you imagine that
directive and teaching and then Carl
Rogers listening in a panic and then
directive and teaching incra and here’s
client resistance it just goes up and
down in the step function
I mean resistance is not a client
problem it’s a counselor problem it’s
it’s a counselor skill issue you have
control over the amount of resistance
not the amount of resistance you get
when the person walked through the door
but what happens after that is up to you
okay now here I’m back to back to what
counselors really did so we listen to
the tapes this is the first study in
which we did tape coding and what the
camp what the counselor actually did in
this section not what we told them to do
what they actually did and then we got
drinking outcomes and we said can we
predict drinking outcomes from what the
council what the counselors saying
and from what the client said and it
turns out yes we could we had an almost
point-six correlation between one
counselor behavior and client drinking a
year later the more the counselor
confronted the more the client drank we
also have very good prediction from
climate resistance the more the client
resisted the more the client drank and
the model we have is the more you
confront the more the client resists in
the world
resists the less they change that
basically is the way it looks well next
we went to randomly assign people in
three different subtleties treatment
programs to receive or not receive a
single session of motivational
interviewing around intake early on and
the programs were at the VA hospital
program outpatient program or primarily
mail people with alcohol drug problems a
private insurance paid a residential
treatment program for four more well-off
predominately white people and a public
outpatient adolescent treatment program
where 100% of the kids are being brought
in and dragged by the ear when was the
last time an adolescent came in and said
I’d like some help with my stuff into
these problems please now they’re being
pushed to by the courts and by parents
and all sorts of folks so we wondered
whether motivation later would make a
difference well here’s the VA program
this is changing drinking before right
after a three months and six months
three months after discharge and you see
drinking isn’t really changing very much
in fact seems to go up a little bit with
the standard VA treatment program but an
a motivational interview to the front
end of the same program and there’s what
you see a huge difference if you like
abstinence rates there they are without
and with a motivational interview at the
front end of the same VA program almost
double not quite almost double the total
absence rate what about that private
higher socioeconomic status program well
there’s the change in drinking over the
three-month period with the program
itself as it was and add a motivational
interview and you get a much more
substantial reduction in drinking and
the abstinence rates again are about
doubled by simply adding a single
motivational interview it in there what
about the kids we thought this this is
where it won’t work on it well here’s a
reduction in percent days drug use with
the regular seven piece treatment
program and here’s the reduction with
motivationally of your upfront we
actually got the biggest effect size of
any
some are working with kids and in
retrospect what’s the population you
least want to get in their face and tell
them what to do it’s a blessin s’alright
it also made a difference in treatment
sessions attended kids coming without a
motivational have you attended on
average eight outpatient sessions those
who’ve got the initial motivational
interview attended on average 20
sessions randomly assigned so a big
difference in retention in the program
as well as in outcomes with that I went
on my second sabbatical to Sydney
Australia and there I met a fella named
Steve roling who South African but but
lives in Wales and we both haven’t be
there that year he said then we did the
guide about that article on motivational
interviewing I published a little
description of the clinical methods in a
out-of-the-way British Journal and I was
amazed anybody could even read it since
a young rabbit and he said oh you read
it
not only have I read it I can’t keep up
with the demand for training in this
motivational everything has become
standard treatment for addictions in the
UK I’m going all over the United Kingdom
training it how many sure if I’m doing
it right you got to write more about
this so I said well show me what you do
and it had the same heart he had exactly
the same same style I was talking about
Andy had brilliant ideas about how to
teach it so I said look let’s write a
book together and so we did the 1991
edition came out of that sabbatical and
by the time it was time for a second
edition it was no longer just about
addictions because motivation is being
spread so fast into healthcare and
corrections and mental health care and
public health and other fields that in
2002 it’s a book about preparing people
to change more generally here’s our
current working definition of
motivational interviewing it’s a
collaborative definitely a partnership
you know a collaborative person-centered
form of guiding to elicit and strengthen
a person’s motivation for change the
definitions evolve some over time but
it’s always rooted in Rogers it’s always
that person
approach it’s always a collaborative
partnership style not an expert one down
style as always focused on listing the
ohm they’re the person’s own reasons for
change most people who come into an
addiction treatment program and I find
also who come into family practice and
in primary care and probation and you
know lots of other settings are
ambivalent about changing their behavior
in some ways they see that they need to
do that it’s pretty clear that they’re
drinking too much or whatever and at the
same time they like their life the way
they’ve been doing it before so they
really feel two ways about making a
change and they come in and they meet a
helper like meeting who went it’s been a
bunch of years in school motivated by
the desire to help people and a desire
to fix things in the world and so we
become fixers sort of and when you see
somebody going down the road that’s
leaning in the wrong direction you want
to get out in front of them and say stop
go back don’t you see this is the wrong
way you know this is going to lead you
in the wrong direction then this is what
you should do instead now what happens
when an ambivalent person meets a fixer
the fixer makes the arguments for change
you’ve got a drinking problem and you
need to do something about it and that
leaves only one set of lines for the
client no I don’t it’s not that bad
which we label as denial in the
addiction field but very much a product
of the interpersonal relationship when
you take responsibility for the good
arguments you leave the client the other
side of the arguments not because
they’re pathological and having credible
defense mechanisms but because when you
need an ambivalent person and you
ordered for one side they’re going to
argue the other side there’s no question
about it and that might be fine except
that we believe ourselves so as I hear
myself arguing against change I’m
actually talking myself out of changing
while you’re trying to talk me into
changing it’s it’s a fascinating dynamic
whether Scott has focused very much on
what clients have to say and it turn
we can predict rather well from
counseling sessions whether clients are
going to quit using drugs or not and and
a psycho linguist watch my screen here
but just tag it
I’m captain but I tell you there’s
nothing to happen here but you know
while it’s still up there a psycho
linguist helped us to identify several
different forms of change talk these are
different things that people say that
reflect their style of motivation all
right do not know what happened there
I still haven’t recovered from 35
millimeter slides some things that
clients they reflect a desire to change
I want to I wish I could I’d like to you
know those those words in English which
would like want our desired language I
want to quit drinking
there’s ability language I could I can
quit drinking I’m able to you know so
that language tells you something about
the person’s perceived self-efficacy
then thank you very much then there are
reasons to change the person telling you
specifically slide juggling why they
would want to change and explaining the
reasons for it out here okay I’ll get
their cocaine then need for change I’ve
got to something has to change they will
say I must that has an imperative
quality to it not little boy wailing
we’re getting there and then finally
commitment to change
I will there we go I’m going to which is
a different kind of commitment a
different kind of motivational speech
it’s this one that tends to predict
behavior change by the way I’ll show you
a little bit more on that in just a
minute here so I want to I could I have
good reasons to I need to I’m going to
so that it’s the kind of speech who are
listening to and all that we call change
talk and you can also hear from clients
the same kinds of things on behalf of
not changing I don’t want to quit
drinking I don’t think I could I need to
do
it’s important to me all my business
rotates around drinking who would my who
would I have four friends and I’m not
quitting drinking and nobody’s going to
stop me
you know me those are those are the same
speeches but on the other side of the
ambivalence dimension so that will turn
out to be important in just a minute now
in 1995 Steve roling and I started
describing the spirit of motivational
interviewing precisely because we saw
counselors doing exactly what we taught
them to do and we were horrified
it just it was the words without the
music it didn’t didn’t quite understand
the the essence of it and so we said
well in addition there’s a certain heart
set or a certain mindset to what you’re
doing with motivational interviewing it
is collaborative it is a partnership
it’s not an expert recipient one down
kind of thing but rather we’re in this
together and collaborators and you know
we’re honest that we’re on the same path
together it’s evocative you’re
interested in the other person’s
perspective when you want to be able to
look through that person’s eyes in the
empathic way and see the world through
their eyes you’re trying to elicit from
them what’s already there so instead of
the message I have what you need the
message is you have what you need and
together we’re going to find it and then
honoring of autonomy that you don’t get
to make the choices for other people
they make the choices about their lives
and whether their behavior changes or
not and you need to know that in your
heart and it has to be ok it’s for two
to be able to do this well that this is
why I don’t do motivational with my own
kids I can’t sit with my son and say so
what so what are the good things about
cooking for you
I’m Jeff I’m just not detached enough
you know I’m really connected
where’s with the client I can do that
because I know in my heart it’s up to
them now we have all kinds of silly
things in the addiction field but you
can’t let alcoholics decide and so forth
but I mean what does that make us God
you know you can take away someone
else’s choice know that choice is always
there and you respect that autonomy of
the other person and just global ratings
of that evocative spirit collaborative
evocative autonomy unerring spirit are
good predictors of change as well so the
extents of which the therapist manifests
that predicted change well this is an
adoption curve that my colleague Everett
Rogers came up with for how almost
anything finds its way into practice
whether it’s a new technology or a new
widget or a new counseling method or
digital TV or whatever that there are
reluctant lots of reluctant people but
very early adopters and then more people
begin to adopt then it hits this steep
curve and starts climbing upward and
until finally gets to the place where
everybody who has adopted it is going to
and I’ve been tracking the number of
publications on motivational
interviewing and that red line is what
it looks like and that looks familiar to
me which says to me we’re somewhere
around where that little star is on this
curve which means we’re in the steep
part of the climb here and this thing is
spreading faster than then I can imagine
and certainly then we have quality
control for it at this point which is a
little bit scary we’re now at 16
languages with the book there are 10 of
the books published on motivational
interviewing besides ours there are now
over 200 randomised trials in the
literature including 10 multi-site
trials more than 800 publications and
that the number doubles every three
years we’ve got 1,200 trainers actually
more than that working in 36 different
languages and whole states and nations
are implementing motivational
interviewing it’s astonishing that’s
with virtually no marketing which is
intriguing I mean I would not they’re
trying to get people to adopt this I was
busy trying to understand how it works
these are the languages in which in
which we have motivational interviewing
trainers and translations all over the
world every continent except Antarctica
why it certainly wasn’t the evidence
base am i started disseminating fast
before we really had good evidence of
its efficacy and the best I can say as
clinicians seem to recognize it when
they hear me talk about it they say yeah
I know that I know that and they have a
sense of not learning something new but
learning something they already knew and
they say you’ve kind of put into words
for me what I’ve known but you’re
helping me do it more systematically
interestingly mi has particularly taken
root with the most despised and rejected
populations in our society that’s where
it was used first and that’s where it
seemed to work best by the way and now
that it’s an evidence-based treatment
then it’s getting picked up all the more
for for that reason but that wasn’t the
original reason for this incredible
spread well what is the evidence based
very quickly
lots of randomized clinical trials only
about 1/3 of them were with alcohol drug
problems now there are meta analyses out
there and the average effect size is a
medium effect size about 0.4 to 0.45 so
pretty good effect size with lots of
variability these are all the areas that
there are clinical trials in now and the
brown one is alcohol and the white one
just on top of this drugs and you can
see that applications are more outside
than inside the substance abuse field
now lust with chronic diseases in in
public health and family practice and
primary care this is our most recent
meta-analysis and one interesting thing
we found was that the effect size that
the motivation limonene goes down over
time that means the difference between
the group that gets mi and doesn’t get
mi decreases up to about a year but it’s
not because the mi group has relapsed
it’s because what it’s being compared
with is catching up and so it just seems
that mi is getting changed going quicker
but there’s one kind of study that green
line in which you get it continued 0.6
or so effect size over time and that’s
where mi is combined with another act of
treatment you’re not doing just mi but
you’re doing mi plus some other
evidence-based approach that helps um
some medication or a behavior therapy or
something that’s got a good track record
and they seem to be synergistic they
seem to be seems to be that motivational
moving works better in that condition
because there’s an active treatment and
you increase compliance with it and so
the active treatment works better and
the motivation may be much better both
so this is not something to you don’t
have to be converted to motivational
interviewing and give up everything else
you’re doing this is a tool to have in
your toolbox to use if and only if the
person doesn’t seem quite ready to make
the change that you’re hoping for if
they’re already ready to change don’t
waste your time with motivational
interviewing go right ahead we did what
many analysts do which is say what
predicted effect size and we found two
things one of them was whether or not
the therapist used a manual to guide
their use of motivational interviewing
are they following a book basically and
in studies where that was true the
effect size was 0.37 and the studies
without a manual it was double almost
one six five now flies right in the face
of what is commonly believed if you have
a therapist manually going to be doing
better work but I know from experience
now what’s going on here that if you’re
trying to follow a formula you’re not
doing good motivational interview this
is a method or a style that you learn
that’s very very responsive to what the
client is doing and it’s not fixed that
you do this in session one in this in
session two in this in session three
there’s an overall style that you adhere
to yes but don’t try to follow specific
directions in manual second for this
audience ethnicity was a predictor when
the population being studied was
primarily white the average effect size
was 0.39 when it was predominantly
minority which in the United States is
Hispanic and that for
American primarily again double the
effects of a large effect size on
average of almost point eight it’s quite
a quite a sizable effects of it that’s
intriguing and I’ll come back to maybe
why that’s the case
at the end of my talk the effects are
highly variable therapists really differ
and how how good they are motivational
interviewing so when you average across
people you don’t get as clear a picture
as looking at the differences among
therapists in their outcomes with
motivational interviewing in multi-site
trials you get sites where mi worked and
sites where it didn’t work which
probably has to do with the therapist
order we’re delivering it we haven’t
found any provider characteristics that
predict who’s going to be a good
motivational interviewer it’s not years
of education it’s not degrees it’s not
personality that we’ve been able to
measure we can’t find any trait about
the therapist and yet what they do in in
practice is a strong predictor of
outcome so we can predict just listening
to the tharros responses whether that
client is going to get better or not
just as launchers do that suggests we
need to understand how and why a mine
works you know get round to that in just
a sec but we’ve also done some research
on how to help people learn motivational
interviewing and we did a randomized
trial in which counselors who wanted to
learn how to do motivational
interviewing were randomly assigned to
different programs to help them do that
140 clinicians came into the study some
of them got just a two-day workshop with
with me in a couple of other very good
trainers so the standard two day
motivational eating workshop some of
them got that workshop plus we were
getting tapes from everybody and we sent
them feedback based on their tapes of
what they’re doing well and where they
could make some improvements some of
them got the workshop and the gut little
coaching so we had six follow-up calls
with people all over the country
about a half an hour call every call
involves some skill practice now why are
they doing this because how you learn
any complex field have you learned to
play the piano how do you learn to play
a sport when you have a coach who’s
giving you some
tips along the way and you’re getting
some feedback you know you can’t learn
without feedback very well and it’s
helps to have somebody who knows better
how to do it than you do to coach you
along the way
we had a group that got all of that they
got the workshop plus feedback plus
coaching and then we had our usual
waiting list control we sent them the
motivational interviewing book and our
videotape series and said watch this and
study it and do your best to learn this
style and we’ll see you in four months
and then we’ll give you the workshop did
they learn the treatment method well
this this is percent of my consistent
responses and it’s the direction is
generally up but you do see some things
you see that the waiting lists control
if anything got worse than their mi
skills over time so reading a book and
watching videotapes simply didn’t do it
then we gave them workshop feedback and
coaching and they come up to the to the
proficiency level of the other three
groups the three groups above the line
are those that either got feedback or
coaching or both and the group that just
got the workshop with me by the way
improve some but you know not as much as
those that got some individual attention
now what are their clients doing because
here’s the refuse where the rubber hits
the road we can predict really well from
client responses if the clients going to
change so now we’re listening to client
change talk and saying the clients the
real clients on the tapes with these
people who’ve been through training are
they showing more change talk and only
one group shows that it’s the group that
got workshop and feedback and coaching
and didn’t have to wait for it
interesting so it’s not easy to learn
this from reading a book and watching
videotapes it’s not easy to learn this
from coming to a workshop even if I’m
the teacher of it alone it’s it involves
as does learning musical instrument or a
sport having someone who can give you
some feedback and someone who could
coach you a bit and suggest once you try
a little bit of this next time see what
happens
well what’s going on here because one of
the questions in my mind is one is this
work at all I mean how can it be that
sitting down for one session with
somebody who’s had to be
it’s been going for a decade and has
been devastating their lives changes the
behavior after that session it doesn’t
make any sense to me in my training as a
psychotherapist was the longer you spend
with me the better you’re going to get
and and here’s something that replicated
over and over and over again in a
relatively short period of time it’s
showing medium the large effects on the
behaviors so what on earth is going on
here well we didn’t start with the
theory as I told you where it came from
it came through an intuitive practice
that I wasn’t even aware of doing so now
after all this time we’re kind of
getting to a theory that I think holds
water and it has two active ingredients
one is the relationship and one is
technical so let me just flesh those out
for you a little bit the relationship is
basically what Carl Rogers was talking
about and the technical is getting good
at causing clients to give you the
arguments for change and in minimizing
resistance we know that mi significantly
increases change doc I showed you a
study where it doubles it
we know that client change talk predicts
behavior change so the more client is
arguing for change during a session the
more likely they are to change we know
that mi significantly decreases
resistance and we know that resistance
predicts lack of change so those those
are all pretty solid findings at this
point so mi is changing to things that
are both relevant to outcome it’s
increasing clients arguments for change
and it’s decreasing clients resistance
to or arguments against change now along
to our department came Paul Omron a
psycho linguist who made a wonderful
contribution to motivational
interviewing in his job talk he talked
about the language of commitment and the
ways in which we make promises to each
other and how we elicit those promises
and as he talked my brain was going a
mile a minute and he was saying things
like when two people come together and
the level one of them wants have changed
to happen and the level of demand from
the one person is higher than the level
willingness of the other person it
doesn’t go well they both go away from
the interaction unhappy and nothing
changes but when the level of request or
demand is lower than the level of
willingness then you tend to see things
happen that’s what I’ve been trying to
teach clinicians don’t get ahead of your
client so Paul taught us what change
talk is we had a very vague notion of it
and these are what are called semantic
Universal they turn up in virtually
every language across cultures and you
can find them any any human language you
can find these things there and he
taught us to listen to the strength of
it so it’s not just desire but how
strong is the desire well I guess I want
to isn’t as strong as I absolutely want
to you know so clinicians know this you
know well I might do something about my
drinking
is not as strong as I promised you I’m
going to quit and they’re they’re even
nonverbal things so Paul Paul says if
you say I promise if you watch me now if
you say I promise and there’s a sort of
extension forward in American culture of
the hands I promise it’s a much stronger
commitment than if you say I promise and
shrug your shoulders so there are all
kinds of cues in language verbal and
nonverbal about how likely it is the
person going to do something and you
studied the pattern of language over
sessions which we hadn’t been doing
either we were just counting things and
here’s a study the first one where Paul
helped us and this is the two thirds of
our drug drug abusing drug dependent
population who did well so the first
thing we did was separate those who did
well from those who didn’t do well and
you can see drug use just about
disappear in this group I mean there’s
some use here and there but for the most
part these people who stand growing free
which is about as good as it gets if you
use perfection as your outcome you get
really depressed because people who
never ever use anything again is like a
percent
but but overall improvement is huge
so that group here’s what they’re here’s
their commitment language during the
session and what it’s doing is going up
rather steadily over time so the client
starts out in a negative range which is
actually arguing to continue using drugs
the beginning of the same they walk
through the door saying I don’t I’m not
sure I want to be here and I’m not sure
I’m going to do anything about this at
all in the other court said I have to be
here but you know and by the end of the
session 50 minutes later they’re making
strong committing language to changing
their drug use and and you saw the the
outcomes back there that they did in
fact do rather well now here’s the group
that didn’t do as well one-third of the
population and their drug use it down by
half still but nonetheless it’s enough
it’s 40 percent of days that we’re you
know we’re worried about and here’s
their commitment language over the
course of the session and it looks a
little different you know it goes up but
then it comes down again
then it goes up to just about where the
other group was and then it falls down
again at the end and Paul sim what are
you doing to these people
Yahtzee bounces around like that very
much what’s going on well about point
number two is where we start giving
people feedback about the severity of
their drug problem now for the 2/3 of
the sample that increased their
motivation but these people started
backpedaling
they weren’t responding well to the
feedback but the manual that I wrote
said always given the feedback and so we
might very read Ian’s therapist went
ahead and did that so then about five or
six they’re getting me to the end of the
feedback and they start doing
motivational interviewing again and look
what happens it lifts off and they get
the session nine and then the manual
that I wrote says now do a change plan
say what are you going to do and let’s
write down specifically what you’re
going to do and this group didn’t like
it
I wrote that manual so what we found is
early in motivational interviewing
sessions you see clients beginning to
express stronger desire stronger ability
stronger reasons and stronger need and
in motivational hearing we’re teaching
people to listen for and
ask for and reflect and summarize those
very things acronym darn you know
looking for the darn motivation there as
that goes up you begin to hear
commitment language increasing and it
starts out weak and then it gets
stronger over the course of the session
in its commitment language Paul found
that predicts actual changes other
people are finding direct relationships
between darn and outcome as well without
having to go through commitment by the
way so one thesis is motivationally
everything works because it elicits
change taught from people that that is
true I mean increasing client change
talk does predict strength of commitment
strength the commitment does predict
behavior change there’s a whole
literature on implementation intentions
that says that when you express a clear
intention to change it’s more likely to
happen client resistance fosters no
change so that seems to hold together
elicit and reinforce change talk and not
resistance would be the guideline and
yet do you think it’s actually saying
the words that makes the difference if
you have people come in and sit in a
chair and your office and chant 100
times I will stop smoking I will stop
smoking on will stop smoking do you
think it’s going to happen I don’t think
it’s the words I think the speaking of
the words is a signal that something
else is going on underneath and that
this naturally-occurring commitment
language is just telling you that things
are clicking into place inside the
person let me give you just an example
of this from from our book this is the
story from David Prima that made the
biographical he talks about having gone
down to the library Public Library to
get his kids and he was waiting for them
to come out and he was at the curb and
with his engine running and it’s raining
and he’s going through his pockets and
he’s looking under the seat he’s going
to go up in those cigarettes anywhere
and he really wants a cigarette so he
pulls away from the curb to go buy a
pack of cigarettes and that was his last
day of smoking what happened what
happened was he looked at his rearview
mirror and he saw his children coming
out of the library as he pulled away
from the curb and said to himself I
think I can get to the store and get
cigarettes and get back before they get
too wet and he said my god I’m a man who
would leave his children standing in the
rain to chase a drug ah fatherhood came
at the competition with smoking and
fatherhood one when anybody doing a
motivational interviewing with him in
the car you know something the same but
the same kind of thing is happening
inside of him something clicks and it’s
over so what is that underlying event
it’s kind of a decision in a way sort of
a shift in meaning meaning that smoker
now has a different meanings of this man
than it did before certainly an
emotional impact it’s not an unusual
people that get teary or a week during
motivational interviewing you could talk
about this increased readiness to change
you can talk about ambivalence being
resolved you can talk about it being the
last straw what Roy Baumeister calls the
crystallization of discontent that
suddenly it forms up like a crystal you
know what whatever whatever the metaphor
you use something is clicking and if
it’s some kind of underlying shift that
triggers change rather than just the
talk itself then surely that happens
most of the time not with somebody
sitting there selectively reinforcing it
but in other contexts
so what else seems to matter what the
relationship does the resolution of
ambivalence and movement toward change
is also facilitated by being with
someone who’s behind to you by someone
who cares about your perspective own
takes time to understand it and listen
to you and reflect meaning back to you
and treat you as a colleague and honors
you and respect your autonomy and offers
you hope if you don’t have any of your
own at the moment
right so there’s good evidence for that
too even before am i there was the work
of Rogers we know councils are a big
determinant of outcome no matter what
the treatment is we know that empathy
predicts client change in or outside of
motivational interviewing and we know
that even little acts of caring calling
somebody back up they miss a session as
a huge affect on whether they come back
or not just let you know little stuff
like that without teaching directed
motivational interviewing working
Alliance is a good predictor of outcome
we’re able to teach family members how
to do this and triple the rate of their
getting a loved one into treatment
counsellor puffy predicts change even in
behavior therapy and implementation
intentions predict behavior change so I
really think both things are going on I
think first and foremost manifest the
overall spirit of motivational
interviewing that compassionate
collaborative evocative honoring spirit
that that if gentle guidance in Steve
role mix language and at the same time
also help the client develop and
verbalize their own arguments for change
that further increases the likelihood of
change and when the client is ready and
not before help them to figure out what
they’re going to do and how to move
forward well one reason I was asked here
I think is that motivational everything
seems to cross cultures pretty well in
employees that why has it been adopted
all over the world long before there was
evidence long before there were local
trainers people are picking it up using
it in the African bush to promote water
purification technologies so that babies
don’t die of diarrhea you know I mean
just astonishing things that I would
never have bet on meta-analysis session
I showed you show larger double effect
size working with disadvantaged
populations than with majority white
populations and that’s with mostly
majority clinicians so we’re talking
cross-cultural counseling working better
than counseling your own kind here if
you’re white
kind of interesting and it appears to
rip to require from my experience around
the world relatively little adaptation
to use in different cultures the doggone
thing seems to communicate and take root
without needing to be really different
so it’s not like you have to do am i
different with black people and you do
with Hispanics than you do with white
people than you do with Norwegians but
it seems to be very much the same heart
well I think one reason is that it looks
is that empathy crosses cultures well
techno help yes
listening to people understanding their
perspective understanding who they are
and caring about how they look at the
world and wanting to know and making
them the expert on themselves is a very
good way to counsel people who are
different from you instead of I’m the
expert on you it kind of says I don’t
know anything about you
and I need you to tell me who you are
and what it is you want and where you’re
headed in life and what you care about
what you want for yourself and your
family a very good way to counsel across
differences of all kinds so does respect
for autonomy cross cultures pretty well
saying you’re in charge of your life I’m
not I don’t get to decide for you maybe
I’m your probation officer but if I say
you can’t leave the county I’m telling
you a life began I mean there may be
consequences to it but I don’t get to
decide that for you if if you have an
alcohol problem and I said you can’t
drink
I’m telling you lying mic lines have
been perfectly capable of drinking I
find and it’s really their choice so
that respect for autonomy also crosses
cultures well even in authoritarian
cultures where I’m told oh this will
never work with our clients it’s
actually the clinicians who think it
won’t work the clients love it in MI
clients are always the experts on
themselves
on their own line on the direct room
they’re going to take and there’s a very
strong focus on hearing and
understanding the clients meaning making
sure you got it and it works through
semantic universals desirability reasons
need commitment are things that you find
in all cultures the language is
different you have to understand the
language of local culture of course and
to know how people make promises to each
other in that culture but the phenomenon
is there and that crosses culture as
well so after 35 years of research we’ve
got a treatment now that’s
evidence-based that’s relatively brief I
mean we’re talking to session or do if
you want me to make an 8th session
motivational interview I don’t know how
to do it it’s not like over time you
wear people down this is relatively
brief it’s very specifiable and
verifiable we can listen to a tape and
say yes that’s that’s motivational
everything being done well or no it’s
not it’s grounded in the testable theory
it’s got specifiable Meccans mechanisms
of action we understand some things
about what makes it work so we know more
about how to teach you it seems to be
generalizable across all kinds of
problem areas it’s complementary to
other treatment methods it doesn’t
replace different approaches it’s cross
culturally adaptable and it can be
learned by a very broad range of
providers you don’t have to have a
degree after your name to learn how to
do this and I think we’re just getting
started
thanks very much
that was absolutely fantastic and I hope
that guys come up knowing um the three
1980 story so that we are you for being
the founder originator a motivation of
doing anything wrong make for anything
look your project going so less than
that improper perspective we like to
hire you with the war today and it’s
called Harriet Tubman freedom award
honoring weimar Miller PhD emeritus
distinguished professor of psychology
and psychiatry University of New Mexico
for outstanding global community action
and lifetime achievement by contributing
original theory research and writing and
thereby driving global movements to
improve physical emotional spiritual
health and specifically for
disseminating motivational interviewing
to facilitate change across boundaries
mark 7
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