Transcript downloads/Holland January 2012

Implementing MI in Criminal Justice
organizations - A Swedish
experience
Presentation for HQ
Dutch Prison Service,
the Netherlands 2012
Carl Åke Farbrin
1
www.farbring.com
 Effective treatment in Criminal Justice to
reduce recidivism in drugs and crime
Berman, A., & Farbring, C.Å.
800 pages
(2010) Criminal Justice in
practice. Strategies to reduce
relapse in crime and drug use.
Studentlitteratur. I boken
medverkar bl.a. James
McGuire, Don Andrews, Philip
Priestley, Joel Ginsburg,
Belinda Seagram, Johan
Franck, Sten Levander, Marie
Levander, Sten Rönnberg,
Johan Kakko, Björn Fries,
Agneta Öjehagen, Hans
Bergman, Helene Lööw, Siv
Nyström m. fl.
c åke farbring, 2008
MI - an explosion of knowledge
 > 1000 publikationer
 > 200 randomised






clinical studies
Dozens of books
10 Multisite clincal
trials
Coding system to
control quality
Research on how to
learn MI
MIA-STEP – Structure
as a help for trainers
And still we are only in
the beginning!!! We
know very little on how
MI works.
Motivational Interviewing; carl åke farbring, 2001- workshopmaterial
Recent book about this
implementation
Farbring, C. Å. &
Johnson, W.R. (2008). MI Corrections.
In Hal Arkowitz, Henny Westra, William
R. Miller & Steve Rollnick: Motivational
Interviewing in the Treatment of
Psychological Problems. New York:
Guilford
c åke farbring, 2008
What Works; accredited programs
 Reasoning and Rehabilitation
 One-to-One
 ART
 Offender Substance Abuse Program (OSAP)
 Brotts-Brytet
 Enhanced Thinking Skills
 ROS; sexual offenders
 Domestic Violence (IDAP)
 PRISM
 BSF(MI:5;semistructured MI in five sessions)
 Relapse Prevention/MI
5
What Works 2006
 ”…results do not provide strong evidence
of treatment effectiveness.”
 …”there is limited evidence to
demonstrate what impact these
interventions actually have in practice.”
 ”Thus, no outcome evaluation in this report
provides unequivocal evidence of ”what
works” in corrections.”
Harper & Chitty (2005). The
Impact of corrections on reoffending. A review of What
Works. Home Office Research
Study 291
Greenlight Project
 A multidimensional re-entry demonstration programme to





reduce recidivism in New York
Randomised design
Supervised by researchers, organisational support
Evidensbased programmes (R & R, Relapse Prevention,
Job preparation training, social counseling, social skills
training, drug treatment, prevention to avoid
homelessness, family reunion groups; action plan etc.)
Two control groups
Results: ……..
7
Greenlight Project: results
Outcome Greenlight
n=344
Any new
arrest
New Felony
Arrests
Revocations
44%
24%
29%
TSP
n=278
Upstate
n=113
Total
n=735
Significance
35%
32%
39%
.02
19%
16%
21%
Ns
25%
17%
25%
.05
Vera Institute of Justice
8
Effect Size of MI Over Time
1.4
1.2
1
A ll St ud ie s
0.8
C1
C2
0.6
C3
0.4
Controlled
Additive
Comparative
0.2
0
0-1
> 1-3
> 3-6
> 6-12
> 12
MARMITE
A 3-year MI-training project
 Workshops in MI since 1998
 2500 probation officers and tutors and client




related staff in prison were trained
during 3-day workshops 2001-2003.
Government money to reduce
substance abuse in prions –
approx 80000 USD
Extremely positive feedback
Bill and Steve contributed
Government funds helped
10
MI in Swedish prison and probation
 After about 100 of these 3-day workshops for
prison staff, the Swedish National Council for
Crime Prevention reported ” there is no evidence
that there had been any motivational sessions
with clients” (2005).
 Risk for negative perception of MI (type 3 error)
 Hypothesis: The work situation had not changed
for prison officers and others
11
The Implegration Report –
 A Driver´s Guide through MI
5 guided semi structured
conversations about change with
a work book for clients
•
• Advantage 1: Intentionally,
deliberately performed
motivational sessions – not just
”chat” sessions.
• Advantage 2: Sessions are
visible to all, recorded, counted
and evaluated.
•
Manual, originally
presented 2003
13
Supervision and support in BSF
 Geographic organization
 Peer groups – peer review




every 5th week; peer
monitoring and feedback on
tapes (1 PASS)
Certification – 3 audio tapes
with feedback between
supervisor and tutor (program
leader)
Supervisors meet in head
office 4 times a year
Positive feedback or lie! Make
participants enjoy!
Local ownership! Important!
PL
PL
PL
PHL
PL
PL
PL
15
ONE PASS – monitoring, coaching and positive feedback in BSF/1
ONE PASS – monitoring, coaching and positive feedback in BSF/2
COMPLETIONS – a closer look



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
Programme presented for the first time APRIL 2003
2003: 175 completions
2004: 568 = 79% completion rate
BSF: 73% of increase of programs 2003-04
BSF: 36% av program volume 2004.
2005: 777 completions, 84% completion rate – 64 % of
total program volume
2006: 1011 completions
2007: 1698 completions; 90 % completion rate
2008: 2020; 93% completion rate
2009 – 2011: more than 2000 completions/year
18
SOCRATES 8/D
N
Probl recognition /Ambivalence/ Steps
---------------------------------------------------------------Average
difference
950
0,36
- 0,66
1,84
from pre- to
p<.03
p<.0001
p<.0001
post test
-----------------------------------------------------------------
Clinical observation: Just mentioning
change ”inflates” ratings of intentions to
change.
SOCRATES 8/A
Average
difference
from pre- to
post test
N
Probl recognition /Ambivalence/ Steps
---------------------------------------------------------------304
0,63
- 0,56
1,78
p<.03
p<.01
p<.0001
-----------------------------------------------------------------
URICA
Average
difference
from pre- to
post test
N
Pre C/ Contempl/ Action/ Maintenance
---------------------------------------------------------------645
0,54
-0,83
1,69
-1,11
p<.004 p<0001 p<.0001 p<.0001
-----------------------------------------------------------------
The Change Questionnaire – a motivational
index based on change talk (Miller, Moyers,
Amrhein, 2008)
DIMENSIONS:
Problem recognition: p <.02
Need:
p <.3
Desire:
p <.0006
Confidence:
p <.002
Commitment/Do:
p <.02
Taking Steps:
p <.0009
Total (N=88)
p <.0005
____________________________________
 Pearson r = .072 (2-tailed) p<.0001 (N=78)
Motivational factors (scales)
Average
difference
from pre- to
post test
ME





Desire: 3,85; p<.0001
Self Efficacy: 0,43; p<.0001
Priority; 0,83; p<.0001
Inner motivation: 0,61; p<.0001
Total;3,85; p<.0001
OTHERS
The Scale of Balance Exercise: Why I want to change personally (ME) or
Other people or circumstances that influence me (OTHERS)
Graphical position in TTM
The Transtheoretical Model according to
STAGES OF CHANGE; Where are you in
the wheel? Put a mark in the figure!
MAINTENANCE
DATES AND DEGREES
/
-
=
°
/
-
=
°
/
-
=
°
RELAPSE/DRUG USE
= continuation of change…!
”once --always…”
ACTION
Prochaska- DiClemente
”Now I might just as well
keep on - or…”
PRECONTEMPLATION
What Works; accredited programs,
treatment ...
It doesn´t concern me at all
DECISION
”Now I have had enough…
I really have do to something…”
CONTEMPLATION
= I am ambivalent
beginning to see disadvantages...
PREPARATION
beginning to think how…
trying out...
I am asking others how they…
18
C. Åke Farbring, 2003
Results




Average
difference
from pre- to
post test
N
Prep-5th
1368 43,82
P<.0001
5th-later
24,51
P<.0001
Program counselors assessment of client´s
progress during intervention
Question
N
%
yes
%
no
%
no
answer
Does the client intend to go into more
treatment
1553
52.54
37.03
10.43
Does the client want follow-up sessions in
BSF
1537
44.12
38.71
17.17
Have you noticed improvement in
collaboration
1541
55.09
38.61
6.29
Have you noticed improvement in desire to
change
1550
80.71
15.55
3.74
Client´s own assessment of the effect of the
program on their thinking about change
N
%
%
Absolu
Maytely
be
NOT
%
Yes, to
some
degree
%
Yes,
very
much
%
No
answer
I am thinking more about
change now than I did
before the programme
306
0.65
9.8
33.01
46.41
10.13
I have already started to
make changes
305
1.31
4.59
32.79
51.8
3.74
Statement
What accounts for the effect?
1. MI?
2. The person doing MI? His
or her education? Or his or
her personal skill?
3. Something else?
28
Evaluation of 38 programs in Ohio
Group
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
29
A closer look
Correctional Program Assessment Inventory
(CPAI) (Andrews & Gendreau, 2001)
Unsatisfactory level (24 programs):
-1,7%
Satisfactory but in need of improvement (13): - 8,1%
Satisfactory (1):
- 22%
Very satisfactory (0)
30
 But not always….
Valence of the Effect Size:
the difference between
Positive and Negative
70%
70%
60%
60%
40%
r = .40
50%
40%
30%
20%
40%
30%
20%
10%
0.0%
0.0%
Treatment
40%
r = -.40
50%
10%
Control
31
Negative Effect Size
Recidivism Rate
Recidivism Rate
Positive Effect Size
DAA – Don Andrews
Control
Treatment
31
31
A MAJOR CHALLENGE: Programming in
the “Real World of Corrections” versus the
“Small Demonstration” Project
 Mark Lipsey: effects from treatment in
demonstration projects are much higher
than in the “real world” of regular
programming
 Real world: Large samples; Evaluator not
involved in design and/or delivery of
service
32
32
DAA (Don Andrews, 2007)
Two Separate Worlds of Practice
“REAL WORLD” (k =209)
“DEMO PROJECT” (k = 47)
Any Human Service
65%
98%
Mean RNR Adherence
0.82
2.30
Mean Breadth
0.06
2.11
Staff Selection, Training, Clinical Supervision
01%
28%
Sum Core Correctional Practices
0.23
2.19
Sum of Integrity Scores
1.52
4.32
Mean ES
0.03
0.29
DAA – Don Andrews
33
33
Integrated implementation
(implegration) ≠ one size fits all




Implementation – an intentional process
Bottom-up perspective
An exploring and listening attitude
Local ownership (from the centrally decided goal
orientation)
 Balance between guidelines and mindlines
 Adjusting to local conditions = integration
 Positive support more than monitoring and control
35
 Implegration - Integrated
implementation of Motivational
Interviewing, an evidence based treatment
in Swedish Corrections
Implegration –
a practitioner´s report
ICTAB 12, Santa Fe,
February 8-10, 2010
36
Carl Åke Farbring
Implementation - a new science
Dean Fixsen et
al., 2005)
37
Dean L. Fixsen, NIRN
 99% of budget goes to understanding etiologi and writing evidence
based treatments; only 1% of the budget to make them work
 People cannot benefit from treatment that they do not experience as
useful for them!
 Implementionteam! 80% in 3 years compared to 14% pin 17 years.
 Treatment intervention is not the same thing as implementation.
Implementation

Effective
NOT effective
Effective
Positive outcome
Shortlived
/negative
outcome
NOT effective
Negative outcome Negative or even
harmful outcome
Treatment
ICTAB 12, Santa FE, 2010
What is implementation?
 ”Implementation – the forgotten issue”
(Gendreau, 1999)
 E g. not just doing the ”right things”
(evidence based) but doing them ”right”.
 ”The implementation gap” (knowledge is
not disseminated)
 Not a clear discipline and too little
research…
39
Implementation: new demands from
politicians demand new perspectives
 Reduce relapse in crime, increase costeffectiveness from investments.
 Well posed hypothesis: Variations in
effects = variations in quality of
implementation…
 Eliminate risk for (typ III-errors)
 Use a deliberate implementation strategy
to increase effects from evidence based
knowledge and skills.
40
What is in play?
 Organization – problem and deficits on





organizational level cannot be corrected by
eduction (Fridell, 1996).
Teaching ≠ (learning) > courses, rules,
regulations…
Climate
Rethoric = reality
Requires “supervision” from the executive level,
but…more supportive than controlling and…
Not just contents (program integrity) but quality
in implementation
41
Implementation by rules
 Large byreaucratic organisations with large







distances between staff, high level of formal and
strict (hierarchical) ways of decisions;
Rules, (sanctions)
Top – down
Production ideology, selling in
Lack of collective view, lack of feeling of
collaboration, different motives
Insufficent analysis of employer´s situation
Risk for high levels of frustration
Risk for defensive attitudes
42
Implementation > decisions/orders
 Rationality is overestimated by heads and the need for
implementation is underestimated
 ”*That´s my decision (these are my orders)”
 Of 356 attempts to introduce changes in organisations
more than half failed. (Nutt, 1999)
 I most cases this was caused by using the wrong
strategy ; orders, rules, top-down
Nutt, 1999, citerad i Robert Holmbergs
rapport: Implementering av nya
behandlingsprogram i kriminalvården,
2006
43
Adjusted implementation
(implegration)




Implementation – an intentional process
Bottom-up perspective
An exploring and listening attitude
Local ownership (from the centrally decided goal
orientation)
 Balance between guidelines and mindlines
 Adjusting to local conditions = integration
 Positive monitoring and support
44
Is the organisation motivated for
working with programmes
 A validated instrument for assessing suitability
and readiness for organisations. Organizational
Readiness for change. (ORC)
Lehman, Greeener, Simpson (2002)
 Research at the Institute of Behavioral
Research, Texas Christian University.
 JSATs special issue October 2007: 10 articles
about implemation (only).
45
Positive correlations between
outcome and implementation:
• Experienced possibility for peer influence
• Organisation can with credibility impart ”a mission”
• Easy access to the Internet
• Feeling of need to get better in working with
programmes
• Generous possibilties for personal growth and
development
• A certain level of stress in the organisation (!?)
Fuller, Rieckmann, Nunes, Miller, Arfken, Edmundson, McCarty. (2007) Organizational
readiness for change and opinios toward treatment innovations. Journal of Substance
Abuse Treatment.
46
An implegration model for Swedish
Corrections (CIM)
Dimensioner:
A. Organisation
B. Program characteristics
C. Staff
D. Clinical skills
E. Integration, contextual factors
F. Clients
G. Evaluation
(Farbring, 2007)
47
An implegration model for Swedish
Corrections (KIM)
Goals:
1. Increase effectiveness from programmes
- reduce relapse
2. Assess need for support
3. Produce information for self assessment
4. Assess suitabilty for (further) programme
work
(Farbring, 2007)
48
KIM- exempel på schema för bedömningar
49
KIM - exempel på kodnyckel
50
RESEARCH ON THE
MI-IMPLEGATION IN
SWEDISH
CORRECTIONS
51
Forsberg, L., Ernst, D., & Farbring, C. Å. (2010)
Learning motivational interviewing in a real-life
setting: A randomised controlled trial in the
Swedish Prison Service. Criminal Behaviour and
Mental Health. (wileyonlinelibrary.com) DOI:
10.1002/cbm.792
ABSTRACT:
Background Motivational interviewing (MI) is a
client-centred, directive counselling style for
helping people to explore and resolve
ambivalence about behaviour change and
shown to decrease drug and alcohol use. A fivesession semi-structured MI intervention
(Beteende Samtal Förändring (BSF; Behaviour,
Counselling, Change)) was implemented in
Swedish prisons.
Aims To examine whether, in a real-life implementation
of semi-structured MI, staff receiving ongoing MI
training, based on audio-recorded feedback in peer
groups (BSF+) possess greater MI skill compared with
staff receiving workshop-only MI training (BSF), and staff
conducting usual prison planning interviews (UPI).
Methods Prisoners were randomised to one of the
three interventions. The first sessions between staff and
prisoner with complete data were assessed with the
Motivational Intreviewing Treatment Integrity Code 3.0.
Results Content analysis of 45 staff: prisoner sessions
revealed that counsellors in the BSF+ group were
significantly more competent in MI than those in the UPI
group, but there was no difference in MI competency
between the BSF and the UPI groups. Overall, staff
were rated as not having achieved beginning proficiency.
Conclusions Our findings suggest that staff
delivering motivational interviewing programmes
for substance-misusing prisoners in Sweden are
not being given sufficient training for the task.
Previous literature has suggested that staff need
more than a basic 3- to 5-day workshop training,
but our findings suggest that they may need
longer-term continuing supervision and support
than previously recognised.
Mean value of indices calculated on estimates of
behavioral measures and behavior counts for all
intervention groups
Global
variables
Reflections/q
Complex
r/r (%)
Open q/q
(%)
MI
adherent
MI nonadherent
Information
giving
Ref value
UPI M
n=14 SD
BSF M
n=27 SD
BSF+ M
n=42 SD
M=1.0
.49
.24
.53
.32
.56
.31
M=0.40
.09
.12
.21
.16
.27 *
.21
M=0.50
.26
.15
.28
.11
.33
.15
.10
.32
.86
.95
1.24 *
1.34
1.70
1.57
1.14
1.66
.52
1.12
11.50
10.57
13.14
6.16
14.62
5.43
BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI
scores BSF > UPI but not significant. Here BSF+ and even – if not significantly – BSF
seems to matter. (Note no difference between BSF and BSF+) However suggested level of
55
proficiency is not reached.
Mean value for estimate of global measures in all
intervention groups
Global
variables
Empathy
Evocation Collabor
Autonom
MI Spirit
Direction
UPI M
n=10 SD
BSF M
N=14 SD
BSF+ M
N=21 SD
2.30
.82
2.50
.85
3.10
.89
2.10
.74
2.43
1.02
3.10
.89
2.20
.79
2.71
.82
3.14 *
.79
2.23
.74
2.57
.72
3.11
.71
4.20
1.03
4.14
1.45
4.71
.56
(*)
*
2.40
.97
2.57
.76
3.10
.89
*
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
UPI and BSF
Adjusted (Bonferroni, post hoc tests) indicate significant differences in evocation : (mean
difference -.995, p = .019), autonomy (-.943, p = .012), MI spirit: -878, p = .008)
56
Mean value of indices calculated on estimates of
behavioral measures and behavior counts for all
intervention groups
Global
variables
Reflections/q
Complex
r/r (%)
Open q/q
(%)
MI
adherent
MI nonadherent
Information
giving
Ref value
UPI M
n=14 SD
BSF M
n=27 SD
BSF+ M
n=42 SD
M=1.0
.49
.24
.53
.32
.56
.31
M=0.40
.09
.12
.21
.16
.27 *
.21
M=0.50
.26
.15
.28
.11
.33
.15
.10
.32
.86
.95
1.24 *
1.34
1.70
1.57
1.14
1.66
.52
1.12
11.50
10.57
13.14
6.16
14.62
5.43
BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI
scores BSF > UPI but not significant. Here BSF+ and even – if not significantly – BSF
seems to matter. (Note no difference between BSF and BSF+) However suggested level of
57
proficiency is not reached.
Training or implementation?
 Basic training in MI BUT -- The effect is an effect from
implementation/implegration – not training.
58
Forsberg, L. G., Ernst, D., Sundqvist, K., & Farbring, C. Å. (2011)
Motivational Interviewing Delivered by Existing Prison Staff: A
Randomized Controlled Study of Effectiveness on Substance Use After
Release. Substance Use & Misuse. Informa Healthcare. DOI:
10.3109/10826084.2011.591880.
Abstract: A sample of 296 drug-using inmates in 1
Swedish prisons was randomized during 2004-2006 into
three intervention groups; Motivational interviewing
deleviered by counselors with workshop-only training, or
by counselors with workshop training followed by peer
group supervision, and controls. Drug and alcohol use
was measured by the Addiction Severity Index (ASI) at
intage and at 10 months after release. Complete data
from 114 clients were analyzed by a stepwise regression
analysis. All three groups reduced alcohol and drug use.
..
There were no significant differences between the
groups.
Days with drug use in 30 days prior to arrest (preASI) and 30 days prior to post-ASI interview for
subjects with complete data (n=114)
Interventi
on
Pre M(SD) Post
M(SD)
t
df
p
UPI (N=24)
21.8 (11.8)
6.5 (11,8)
5.63
23
<0.001
BSF (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
Total
(n=114)
21.3 (11.8)
6.8 (11.6)
10.23
113
<.001
Difference
betw.
groups
F= .839
F= .045
p= .435
p= .956
Number of days of illegal activity in 30 days prior
to interview
Interventi
on
Pre M(SD) Post
M(SD)
t
df
p
UPI (N=23)
16.0 (13.8)
3.3 (9.0)
4.16
22
<0.001
BSF (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
Total
(n=103)
15.1 (13.6)
3.8 (9.1)
7.79
102
<.001
Difference
betw.
Groups
F= 2.176
F=.083
p=.119
p=.920
Number of days working 30 days prior to
interview
Interventi
on
Pre M(SD) Post
M(SD)
t
df
p
UPI (N=24)
5.1 (9.1)
7.8 (11.0)
-1.07
23
<.296
BSF (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
Total
(n=110)
2.73 (6.8)
5.7 (9.6)
-2.99
109
<.003
Difference
betw.
Groups
F= 2.049
F=.818
p=.134
p=.444
Observation # 1
 MI implegration has been highly successful in




increasing client motivation to change
MI implegration (MI+) outperforms significantly
UPI in clinical excellence. Effect is probably
underestimated, since the study was performed
very early …
There is no evidence so far that MI changes
offender´s behavior in prison contexts (for many
reasons).
Training means very little and may be overrated
So here is more empirical evidence for…
63
So can MI help?
 McMurran (2009) * - 19 studies and McMurran




(offending – N=9; substance misuse – N=10), at
the ICMI 2 conference, Stockholm 2010:
Three aims with MI:
1. To enhance retention in treatment
2. To improve motivation to change
3. To change behaviour.
* Motivational interviewing with offenders: A systematic review. Legal and Criminological
Psychology (2009) 14, 83-100)
64
Retention in treatment
 Completers show a modest positive effect in
reducing recidivism (d = 0.11)
 Important to reduce drop out rates because
non-completers show a negative (d= - 0.16)
effect even compared to untreated controls.
”Non-completers are more likely to be
reconvicted than untreated.” *
 Conclusion: 3 good quality studies: MI appears
successful at enhancing retention in treatment
for substance misuse.
McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with increased reconviction
65
over no treatment? Psychology Crime and Law. 13. 333-343)
McMurran, M. (2009) – MI with offenders: A
systematic review. Legal and Criminological Psychology, 14, 83-100
 MI appears to improve:
 - retention in treatment. (Important: Non-completers are more
likely to be reconvicted than are untreated offenders.
 Q: What are people doing to reduce non-completion.
 A: Not much. Room for MI here.)
- self reported motivation to change
- MI may be effective in reducing substance abuse
especially in conjunction with other treatment
components.
- Mixed evidence in changing offending behavior.


McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with
increased reconviction over no treatment? Psychology, Crime and Law, 13, 333-343
16 studies, 19.563 offenders.
(McMurran, ICMI 2, Stockholm,
2010)
66
General conclusions about effects
 Effects from interventions vary from negative to positive
 Teaching means very little. Learning is what it is all




about. MONTY ROBERTS
Style of communication means more than content –
empathy-collaboration-engagement
Implementation means more than learning through
(even superior quality) workshops and classes: ►
Learning by doing!
Very few interventions meet these criteria
MI works better combined with other ”practical”
interventions – preferably structured in ”MI-style” – for
instance: (see next slide)
Vaccination against relapse – A scientifically accredited
relapse prevention program in MI style (2006,2011)
Smedslund, G., Berg, R. C., Hammarstrom, K. T., Steiro, A., Leiknes,
K. A, Dahl, H. M., Karlsen, K. (2011) Motivational Interviewing for
Substance Abuse . Cochrane Database of Systematic Reviews 2011, Issue
5- Art. No.: CD008063. DOI: 10.1002/14651858pub2. (forts.)
Conclusions:
Implications for practice: If the counselor feels
comfortable with MI it works better than no treatment.
Compared to CBT there is not enough material to
make conclusions if one is better than the other.
Implications for research: There is no lack of RCTs
showing if MI works or not. Time has come to find out
how MI works and under what condititions. Reference
to Apodaca and Longabaugh (2009) – about
causality in MI.
More lessons learned
Striking and large variations in
outcomes of treatment (MI). Why?
MI is not a ”method” not a set of
skills. Different counselors will yield
different quality outcome…
John C. Norcross
ICTAB - II
University of Scranton,
Pennsylvania
Outcome variance attributed to factors in
therapy (%)
MI as a communication style is unique in its focus on
general factors and trying to operationalize them !!
Client
contribution
25%
Interplay 5%
Method
8%
John Norcross, ICTAB 11, 2006.
Unexplained
variance 45%
Unexpl var
relation
method
counselor
interplay
client
General Factors in treatment explain more
of variance of change than specific factors
 Expectations
 Empathy
 Alliance
 Affirmations
Can these factors be more accentuated in
MI?
 Expectations – An important part of
MI
HQ Dutch Prison
Service
Netherlands, 2012
Carl Åke Farbring
73
Limitations in treatment
(e.g.corrections) - expectations
 Negative expectations (account for 15% of
outcome variation (Lambert, 1992) and
15—40% of variance in TA ratings.
 Overly high expectations can also affect
outcome
 Risk: repeated relationship terminations…
(”waste of time” – or worse…)
The nature of expectations
 Lambert & Bartley (2002) Expactations the




third most important factor after client variables
and relation: 15%.
Probably mediated by alliance
Expectations and motivation? Relationship?
Clients who have high expectations will work
more actively…. (Joyce at al., 2003)
There is some evidence that clients with
modest expectations fare better than clients
with high expectations – cf base line
motivation
Expectations -- what does the research say?
Constantino, M, J., Arnkoff, D. B., Glass, C. R., Ametrano, R. M., & Smith, J. Z (2011)
Expectations. Journal of Clinical Psychology: In Session, 67 (2), 184-192 (2011) Adapted
from chapter in J. C. Norcross (ed) (2011) Psychotherapy relationships that work (2nd
ed). New York: Oxford University Press.
 Expectations are a key ingredient of successful




psychotherapy (Goldfried, 1980; Goldstein, 1960; Rosenzweig, 1936)
” a mobilization of hope for improvement (Frank,
(1961) Persuasion and Healing. ”Restoring hope and positive
expectation is a powerful change ingredient”…
”Psychotherapies are inextricably linked with
the manipulation and revision of patients´
expectations (Greenberg, Constantino, & Bruce, 2006).
Continuum from benefits of treatment to
expectations of positive outcome
Expectations are influenced by earlier treatment
and contacts with therapists.
Some used measures in little researched
area
 Brief (4 items) and study-specific and
sometimes confounded with other constructs –
e.g. credibility.
 Common questions:
- At this point, how logical does the therapy offered seem to you?
- How successful do you think this treatment will be in reducing your
symptoms?
- By the end of the therapy period, how much improvement do you
think will occur?
 In some analyses credibility items hung
together while the expectancy items hung
together with affectively-anchored items – e.g.
-
How much do you really feel that therapy will help you reduce your
symptoms? How much improvement in your symptoms do you feel
will occur?
More about measures etc.
 Pessimistic item:
-
Actually I am rather skeptical about whether treatment can help
me…
 Prognostic expectations are also affected by
context and one´s own learning experiences.
 Outcome expectations and treatment
expectations probably interact. (Constantino et al., 2011)
 Is knowledge about patients´and client´s
expectations useful for us in MI?
Meta-Analytic Review (Constantino et al., 2011)
Effects of outcome expectations on outcome.
 RESULTS:
 N= 8.016 patients across 46 independent
samples
 >80% adult (18-65), > 60% White , > 60%
women
 Overall weighted effect size d = .24, p< .001
(Cohen´s (1988) d.), r = . 12, p< .001 (CI.95 . 10 to .15)
Moderators and Mediators
 Thus: there is a small but significant association
between outcome expectations and treatment
outcome.
 However little is known about specific
mechanisms through which they operate (Arnkoff,
Glass, & Shapiro, 2002)
 Three studies have directly investigated the
putative mediator pathway (Meyer et al., 2002; Joyce,
Ogrodniczuk, Piper, & McCallum, 2003; Abouguendia, Joyce, Piper,
& Ogrodniczuk, 2004) …indicating that therapeutic
alliance is a robust mechanism.
 Patients with positive outcome expectations are
more likely to engage in a collaborative
relationship with the counselor.
What about high expectations?
 Prognostic expectations can sometimes be too
high (like motivation) and can end in
disappointment, frustration and even anger
but…
 Expectations are malleable
 Single assessment or static understanding of
expectations at the start is not productive.
 Expectations – like motivation – is something
that the counselor needs to adress and work on.
Implications for practice (Constantino et al.,
2011)
1. Explicitly assess (understand) prognostic
expectations at the beginning of treatment.
2. Behave in a way that matches the patient´s
level of optimism and use strategies to enhance
a positive outcome – look out for unrealistic
speed or degree of change
3. Make hope-inspiring statements: ”What you are
dealing with right now is very common and can
be changed”; ”You are the kind of person who
can really accomplish things that you put your
mind to”
4. Normalize possible fluctuations towards
change.
Implications for practice
Make conversation (don´t read) and adapt to your own
context - Practitioner´s task: working with expectations =
antecipatory socialisation – Expectations must be met.
Carl Åke Farbring, 2009
 Alliance – Who is performing the
change? A suggestion for practice.
MI In Dutch
Prison Service
Netherlands 2012
Carl Åke Farbring
84
General factors explain more of the variance of
change than special factors and methods
 Alliance
(MI ≈ empathy, collaboration)
 explains about7-8 % of the variance of change
 weakened alliance correlates with
unilateral termination.
 alliance ”at first sight ”
 Note: clients i CJ and similar contexts
are often defensive at the start (affirmations).
Miller, Hubble, & Duncan, 2008)
SUPERSHRINKS. What´s the secret of
their success?
 Enormous differences in success
between therapists in the same
organization with same education and
working with similar patients.
 What are supershrinks doing that the
others are not doing?
 Cf. Terri Moyers´ metaphor about the
surgeon… and psychosocial
counselors
carl åke farbring, 2009 - www.farbring.com
What does the research say?
 Working and therapeutic alliance is an
important predictor of behavior change
 How it operates is little understood
 Prison and probation settings make clear
obstacles for working alliance to emerge
 In fact systemic factors may even
intervene against alliance
Findings (2)
 Words like: psychopath, punishment,
aversiveness, obtrusive, rules, personality
disorder, distasteful, crimes…are often used.
 Counselors in corrections routinely experience
challenges that threaten TA. How do you
develop TA with a client that you value in
negative terms
 Clients will not change within a negative
counselor-client relationship - alliance is a
prerequisite
 Client´s perception of the counselor as an
empathic individual rather than actual counselor
behavior
Skeem: Dual role; care and control
and resource oriented instruments
 A validated TA-instrument made for corrections
 Improvement over WAI in corrections
 In stead of problem oriented instrumentes: Good
Lives Model (Ward & Stewart, 2003)
 Goal Matrix, motivational structure model (Cox,
Klinger, 2002):
 Personal Concerns Inventory, OA, (Psychology,
Crime and Law.) (Sellen, McMurran, Theodosi, Cox, Klinger, in press)
What is alliance?

Bordin´ s theory (1979):
1. Agreement on the goals the offender must
work on
2. Clear collaboration on the tasks
3. Bond between client and counselor
(relationship)
WAI predicts outcome (Horvath, 1994)
Bordin, E. S. (1979) Psychotherapy: Theory,
Research and Practice, 16, 252-260
New (2008) theory revision of Bordin
Ross, E. C., Polaschek, D. L. L. & Ward, T. (2008) The therapeutic Alliance: A Theoretical revision
for offender rehabilitation. Aggression and Violent Behavior, 13, 462-480
1.Bond can predict change irrespective of
goals and tasks
2.Two factor model – bond and goals/tasks
3. Reciprocal intimacy was a high predictor
of session quality ratings and overall
effectieness (Saunders, 1999)
4. Bond may be even more important in brief
therapies.
Alliance and feedback
Lambert (2003) reports an ES of 0.39 on
feedback compared to a group where
feedback was not given.
In a recent study in Norway (2009) Anker,
Duncan & Sparks report a 4 times bigger
clinically significant difference to the
advantage of the feedback group.
(JCCP, 2009, Vol 77, No 4, 693-704.
It is the client´s understanding of alliance that
predicts outcome – not the therapist´s
Carl Åke Farbring, 2009
The Engagement Ruler - an alliance
instrument (side B)

Let the client invest in your
collaboration, building alliance
Note: In conversation – not assessment!
- If you were to give some advice on how I could
be more helpful to you – what would you
suggest?
- 1….
- 2….
- 3….
Carl Åke Farbring, 2009
The Engagement Ruler - an alliance
instrument (side A)
At the end of the session (make conversation –
don´t read) Hand over the instrument to the
client/patient.
Regardless of rating an important question will
follow!
MI as Walk and Talk
98
MI on the organizational level, part II.
Three styles –
• Taking MI from the therapy room into
the real world – corridors, kitchens
• Authored by Steve Rollnick in
collaboration with Carl Åke Farbring,
• An interactive product with
videorecorded ”situations”
• Three communication styles in
”short” and ”difficult” conversations –
telling (instruct), listening, guiding
► Primary focus on reducing stress
(stress cortisole) and secondly
► Creating a climate more conducive
for change (for clients)
99
The three styles intervention
relates to this recent book
The three styles further developed in:
Rollnick, S., Miller, W. R.,
& Butler, C. C. (2008)
Motivational Interviewing in
Health Care.
Helping Patients
Change Behavior.
Guilford Press.
 Swedish edition
100
RESULTS
(Forsberg, L., Lundberg, U., Theorell, T., Farbring, C. Å., Rollnick, S.
under preparation)
• Staff involved in non-therapeutic
communication with (e.g. prison officers,
staff in mental hospitals) rate applicability
higher than full scale MI: 8.2 on average.
• In a randomized trial, stress cortisol
among staff has been reduced – this
finding is not supported by psychological
questionnaires, burn out etc.
• It has been estimated to change work
climate by heads of organizations
101