Presentation for HQ Dutch Prison Service, the Netherlands 2012

11

Presentation for HQ Presentation for HQ Dutch Prison Service, Dutch Prison Service, the Netherlands 2012the Netherlands 2012

Carl Åke FarbringCarl Åke Farbring

www.farbring.comwww.farbring.com

Implementing MI in Criminal Implementing MI in Criminal Justice organizations - A Swedish Justice organizations - A Swedish experienceexperience

c åke farbring, 2008c åke farbring, 2008

Effective treatment in Criminal Justice to Effective treatment in Criminal Justice to reduce recidivism in drugs and crimereduce recidivism in drugs and crime

Berman, A., & Farbring, C.Å. Berman, A., & Farbring, C.Å. (2010)(2010) Criminal Justice in Criminal Justice in practice. Strategies to reduce practice. Strategies to reduce relapse in crime and drug use.relapse in crime and drug use. Studentlitteratur. Studentlitteratur. I boken I boken medverkar bl.a. James medverkar bl.a. James McGuire, Don Andrews, Philip McGuire, Don Andrews, Philip Priestley, Joel Ginsburg, Priestley, Joel Ginsburg, Belinda Seagram, Johan Belinda Seagram, Johan Franck, Sten Levander, Marie Franck, Sten Levander, Marie Levander, Sten Rönnberg, Levander, Sten Rönnberg, Johan Kakko, Björn Fries, Johan Kakko, Björn Fries, Agneta Öjehagen, Hans Agneta Öjehagen, Hans Bergman, Helene Lööw, Siv Bergman, Helene Lööw, Siv Nyström m. fl.Nyström m. fl.

800 pages800 pages

MI - an explosion of knowledgeMI - an explosion of knowledge

> 1000 publikationer> 1000 publikationer > 200 randomised > 200 randomised

clinical studies clinical studies Dozens of booksDozens of books 10 Multisite clincal 10 Multisite clincal

trialstrials Coding system to Coding system to

control qualitycontrol quality Research on how to Research on how to

learn MIlearn MI MIA-STEP – StructureMIA-STEP – Structure

as a help for trainersas a help for trainers And still we are only in And still we are only in

the beginning!!! We the beginning!!! We know very little on how know very little on how MI works.MI works. Motivational Interviewing; carl åke farbring, 2001- workshopmaterialMotivational Interviewing; carl åke farbring, 2001- workshopmaterial

c åke farbring, 2008c åke farbring, 2008

Recent book about this Recent book about this implementationimplementation

Farbring, C. Å. & Farbring, C. Å. &

Johnson, W.R. (2008). MI Corrections.Johnson, W.R. (2008). MI Corrections.

In Hal Arkowitz, Henny Westra, WilliamIn Hal Arkowitz, Henny Westra, William

R. Miller & Steve Rollnick: MotivationalR. Miller & Steve Rollnick: Motivational

Interviewing in the Treatment ofInterviewing in the Treatment of

Psychological Problems. New York:Psychological Problems. New York:

GuilfordGuilford

55

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/MIRelapse Prevention/MI

What Works 2006What Works 2006

”…”…results do not provide strong evidence results do not provide strong evidence of treatment effectiveness.”of treatment effectiveness.”

…”…”there is limited evidence to there is limited evidence to demonstrate what impact these demonstrate what impact these interventions actually have in practice.”interventions actually have in practice.”

””Thus, no outcome evaluation in this report Thus, no outcome evaluation in this report provides unequivocal evidence of ”what provides unequivocal evidence of ”what works” in corrections.”works” in corrections.” Harper & Chitty (2005). The

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

77

Greenlight ProjectGreenlight Project

A multidimensional re-entry demonstration programme to A multidimensional re-entry demonstration programme to reduce recidivism in New Yorkreduce recidivism in New York

Randomised designRandomised design Supervised by researchers, organisational supportSupervised by researchers, organisational support Evidensbased programmes (R & R, Relapse Prevention, Evidensbased programmes (R & R, Relapse Prevention,

Job preparation training, social counseling, social skills Job preparation training, social counseling, social skills training, drug treatment, prevention to avoid training, drug treatment, prevention to avoid homelessness, family reunion groups; action plan etc.)homelessness, family reunion groups; action plan etc.)

Two control groupsTwo control groups Results: ……..Results: ……..

88

Greenlight Project: resultsGreenlight Project: results

Outcome Greenlight TSP Upstate Total SignificanceOutcome Greenlight TSP Upstate Total Significance

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

Any newAny new

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

New Felony New Felony

Arrests 24% 19% 16% 21% NsArrests 24% 19% 16% 21% Ns

Revocations 29% 25% 17% 25% .05 Revocations 29% 25% 17% 25% .05

Vera Institute of Justice

Effect Size of MI Over TimeEffect Size of MI Over Time

0

0.2

0.4

0.6

0.8

1

1.2

1.4

0-1 >1-3 >3-6 >6-12 >12

All StudiesC1C2C3

MARMITEMARMITE

ControlledControlledAdditiveAdditiveComparativeComparative

1010

A 3-year MI-training project A 3-year MI-training project

Workshops in MI since 1998Workshops in MI since 1998 2500 probation officers and tutors and client 2500 probation officers and tutors and client

related staff in prison were trainedrelated staff in prison were trainedduring 3-day workshops 2001-2003.during 3-day workshops 2001-2003.

Government money to reduce Government money to reduce substance abuse in prions –substance abuse in prions – approx 80000 USDapprox 80000 USD Extremely positive feedbackExtremely positive feedback Bill and Steve contributedBill and Steve contributed Government funds helped Government funds helped

1111

MI in Swedish prison and probationMI in Swedish prison and probation

After about 100 of these 3-day workshops for After about 100 of these 3-day workshops for prison staff, the Swedish National Council for prison staff, the Swedish National Council for Crime Prevention reported ” Crime Prevention reported ” there is no evidence there is no evidence that there had been any motivational sessions that there had been any motivational sessions with clients” (2005).with clients” (2005).

Risk for negative perception of MI (type 3 error)Risk for negative perception of MI (type 3 error) Hypothesis: The work situation had not changed Hypothesis: The work situation had not changed

for prison officers and othersfor prison officers and others

1313

The Implegration Report –The Implegration Report –

• 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 Manual, originally

presented 2003presented 2003

A Driver´s Guide through MIA Driver´s Guide through MI

1515

Supervision and support in BSFSupervision and support in BSF

Geographic organizationGeographic organization Peer groups – peer review Peer groups – peer review

every 5th week; peer every 5th week; peer monitoring and feedback on monitoring and feedback on tapes (1 PASS)tapes (1 PASS)

Certification – 3 audio tapes Certification – 3 audio tapes with feedback between with feedback between supervisor and tutor (program supervisor and tutor (program leader)leader)

Supervisors meet in head Supervisors meet in head office 4 times a year office 4 times a year

Positive feedback or lie! Make Positive feedback or lie! Make participants enjoy!participants enjoy!

Local ownership! Important!Local ownership! Important!

PL

PL

PL

PL

PL

PL

PHL

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

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

1818

COMPLETIONS – a closer lookCOMPLETIONS – a closer look

Programme presented for the first time APRIL 2003Programme presented for the first time APRIL 2003 2003: 175 completions2003: 175 completions 2004: 568 = 79% completion rate2004: 568 = 79% completion rate BSF: 73% of increase of programs 2003-04BSF: 73% of increase of programs 2003-04 BSF: 36% av program volume 2004.BSF: 36% av program volume 2004. 2005: 777 completions, 84% completion rate – 64 % of 2005: 777 completions, 84% completion rate – 64 % of

total program volumetotal program volume 2006: 1011 completions2006: 1011 completions 2007: 1698 completions; 90 % completion rate2007: 1698 completions; 90 % completion rate 2008: 2020; 93% completion rate2008: 2020; 93% completion rate 2009 – 2011: more than 2000 completions/year2009 – 2011: more than 2000 completions/year

SOCRATES 8/DSOCRATES 8/D

N Probl recognition /Ambivalence/ StepsN Probl recognition /Ambivalence/ Steps

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

950 0,36 - 0,66 1,84 950 0,36 - 0,66 1,84

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

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

AverageAverage

differencedifference

from pre- to from pre- to

post testpost test

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

SOCRATES 8/ASOCRATES 8/A

N Probl recognition /Ambivalence/ StepsN Probl recognition /Ambivalence/ Steps

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

304 0,63 - 0,56 1,78 304 0,63 - 0,56 1,78

p<.03 p<.01 p<.0001 p<.03 p<.01 p<.0001

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

AverageAverage



post testpost test

URICAURICA

N Pre C/ Contempl/ Action/ MaintenanceN Pre C/ Contempl/ Action/ Maintenance

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

645 0,54 -0,83 1,69 -1,11 645 0,54 -0,83 1,69 -1,11

p<.004 p<0001 p<.0001 p<.0001 p<.004 p<0001 p<.0001 p<.0001

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

AverageAverage



post testpost test

The Change Questionnaire – a motivational The Change Questionnaire – a motivational index based on change talk (Miller, Moyers, index based on change talk (Miller, Moyers,

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

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

Motivational factors (scales)Motivational factors (scales)

Desire: 3,85; p<.0001Desire: 3,85; p<.0001 Self Efficacy: 0,43; p<.0001Self Efficacy: 0,43; p<.0001 Priority; 0,83; p<.0001Priority; 0,83; p<.0001 Inner motivation: 0,61; p<.0001Inner motivation: 0,61; p<.0001 Total;3,85; p<.0001Total;3,85; p<.0001

AverageAveragedifferencedifferencefrom pre- to from pre- to post testpost test

The Scale of Balance Exercise: Why I want to change personally (ME) orThe Scale of Balance Exercise: Why I want to change personally (ME) or

Other people or circumstances that influence me (OTHERS)Other people or circumstances that influence me (OTHERS)

MEME OTHERSOTHERS

Graphical position in TTMGraphical position in TTM

MAINTENANCE RELAPSE/DRUG USE= continuation of change…! ”Now I might just as well ”once --always…” keep on - or…”

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

treatment ...

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

beginning to see disadvantages...

PREPARATION beginning to think how… trying out...

I am asking others how they…

18

STAGES OF CHANGE; Where are you in the wheel? Put a mark in the figure!

The Transtheoretical Model according toProchaska- DiClemente

DATES AND DEGREES

/ - = °

/ - = °

/ - = °

C. Åke Farbring, 2003

ResultsResults

N Prep-5th 5th-laterN Prep-5th 5th-later

1368 43,82 24,511368 43,82 24,51

P<.0001 P<.0001P<.0001 P<.0001

AverageAverage differencedifference from pre- to from pre- to post testpost test

Program counselors assessment of client´s Program counselors assessment of client´s progress during interventionprogress during intervention

QuestionQuestion NN %%

yesyes

%%

nono

%%

no no answer answer

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

15531553 52.5452.54 37.03 37.03 10.4310.43

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

15371537 44.1244.12 38.7138.71 17.1717.17

Have you noticed improvement in Have you noticed improvement in collaborationcollaboration

15411541 55.0955.09 38.6138.61 6.296.29

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

15501550 80.7180.71 15.5515.55 3.743.74

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

StatementStatement NN % %

AbsoluAbsolutely tely

NOTNOT

%%

May-May-bebe

%%

Yes, to Yes, to some some degreedegree

%%

Yes, Yes, very very muchmuch

%%

No No answeranswer

I am thinking more about I am thinking more about change now than I did change now than I did before the programmebefore the programme

306306 0.650.65 9.89.8 33.0133.01 46.4146.41 10.1310.13

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

305305 1.311.31 4.594.59 32.7932.79 51.851.8 3.743.74

What accounts for the effect?What accounts for the effect?

2828

1. MI?1. MI?2. The person doing MI? His 2. The person doing MI? His or her education? Or his or or her education? Or his or her personal skill?her personal skill?3. Something else?3. Something else?

2929

Evaluation of 38 programs in OhioEvaluation of 38 programs in Ohio

Group N Effect sizeGroup N Effect size

All 38 - 0.43

Completers 38 0.15

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

3030

A closer lookA closer look

Correctional Program Assessment Inventory Correctional Program Assessment Inventory (CPAI)(CPAI)

Unsatisfactory level (24 programs): -1,7%Unsatisfactory level (24 programs): -1,7%

Satisfactory but in need of improvement (13): - 8,1% Satisfactory but in need of improvement (13): - 8,1%

Satisfactory (1): - 22%Satisfactory (1): - 22%

Very satisfactory (0)Very satisfactory (0)

(Andrews & Gendreau, 2001)

3131DAA – Don Andrews 3131

0.0%

10%

20%

30%

40%

50%

60%

70%

Control Treatment

40%r = .40

Rec

idiv

ism

Rat

e

Positive Effect Size Negative Effect Size

0.0%

10%

20%

30%

40%

50%

60%

70%

Control Treatment

40%r = -.40

Rec

idiv

ism

Rat

e

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

But not always….But not always….

3232

DAA (Don Andrews, 2007) 32

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

“Small Demonstration” Project“Small Demonstration” Project

Mark LipseyMark Lipsey: effects from treatment in : effects from treatment in demonstration projects are much higher demonstration projects are much higher than in the “real world” of regular than in the “real world” of regular programmingprogramming

Real world: Large samples; Evaluator not Real world: Large samples; Evaluator not involved in design and/or delivery of involved in design and/or delivery of serviceservice

3333DAA – Don Andrews 33

Two Separate Worlds of PracticeTwo Separate Worlds of Practice

““REAL WORLD” (k =209) REAL WORLD” (k =209) “DEMO PROJECT” (k = 47)“DEMO PROJECT” (k = 47) Any Human ServiceAny Human Service 65%65% 98%98% Mean RNR AdherenceMean RNR Adherence 0.82 0.82 2.302.30 Mean BreadthMean Breadth

0.060.06 2.112.11 Staff Selection, Training, Clinical SupervisionStaff Selection, Training, Clinical Supervision 01%01% 28%28% Sum Core Correctional PracticesSum Core Correctional Practices 0.230.23 2.192.19 Sum of Integrity ScoresSum of Integrity Scores 1.52 1.52 4.324.32 Mean ESMean ES 0.03 0.03 0.290.29

3535

Integrated implementation Integrated implementation (implegration) ≠ one size fits all(implegration) ≠ one size fits all

Implementation – an Implementation – an intentionalintentional process process Bottom-up perspectiveBottom-up perspective An exploring and listening attitudeAn exploring and listening attitude Local ownership (from the centrally decided goal Local ownership (from the centrally decided goal

orientation) orientation) Balance between guidelines and mindlinesBalance between guidelines and mindlines Adjusting to local conditions = integrationAdjusting to local conditions = integration Positive support more than monitoring and controlPositive support more than monitoring and control

3636

ImplegrationImplegration – –

a practitioner´s reporta practitioner´s report

ICTAB 12, Santa ICTAB 12, Santa Fe, February 8-10, Fe, February 8-10, 20102010Carl Åke FarbringCarl Åke Farbring

ImplegrationImplegration - - Integrated Integrated implementation of Motivational implementation of Motivational Interviewing, an evidence based Interviewing, an evidence based treatment in Swedish Correctionstreatment in Swedish Corrections

Implementation - a new scienceImplementation - a new science

3737

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

Dean L. Fixsen, NIRNDean L. Fixsen, NIRN

99% of budget goes to understanding etiologi and writing evidence 99% of budget goes to understanding etiologi and writing evidence based treatments; only 1% of the budget to make them workbased treatments; only 1% of the budget to make them work

People cannot benefit from treatment that they do not experience as People cannot benefit from treatment that they do not experience as useful for themuseful for them!!

Implementionteam! 80% in 3 years compared to 14% pin 17 years.Implementionteam! 80% in 3 years compared to 14% pin 17 years. Treatment intervention is not the same thing as implementation.Treatment intervention is not the same thing as implementation.

Effective NOT effective

Effective Positive outcome Shortlived /negative outcome

NOT effective Negative outcome Negative or even harmful outcome

ImplementationImplementation

TreatmentTreatment

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

3939

What is implementation?What is implementation?

””Implementation – the forgotten issue” Implementation – the forgotten issue” (Gendreau, 1999)(Gendreau, 1999)

E g. not just doing the ”right things” E g. not just doing the ”right things” (evidence based) but doing them ”right”.(evidence based) but doing them ”right”.

””The implementation gap” (knowledge is The implementation gap” (knowledge is not disseminated)not disseminated)

Not a clear discipline and too little Not a clear discipline and too little research…research…

4040

Implementation: new demands from Implementation: new demands from politicians demand new perspectivespoliticians demand new perspectives

Reduce relapse in crime, increase cost-Reduce relapse in crime, increase cost-effectiveness from investments.effectiveness from investments.

Well posed hypothesis: Well posed hypothesis: Variations in Variations in effects = variations in quality of effects = variations in quality of implementation…implementation…

Eliminate risk for (Eliminate risk for (typ III-errorstyp III-errors)) Use a deliberate implementation strategy Use a deliberate implementation strategy

to increase effects from evidence based to increase effects from evidence based knowledge and skills.knowledge and skills.

4141

What is in play?What is in play?

OrganizationOrganization – problem and deficits on – problem and deficits on organizational level cannot be corrected by organizational level cannot be corrected by eduction (Fridell, 1996). eduction (Fridell, 1996).

Teaching Teaching ≠ (≠ (learning)learning) > courses, rules, > courses, rules, regulations…regulations…

Climate Climate Rethoric = Rethoric = realityreality Requires “Requires “supervision”supervision” from the executive level, from the executive level,

but…more but…more supportivesupportive than controlling and… than controlling and… Not just contents (program integrity) but Not just contents (program integrity) but quality quality

in implementationin implementation

4242

Implementation by rulesImplementation by rules

Large byreaucratic organisations with large Large byreaucratic organisations with large distances between staff, high level of formal and distances between staff, high level of formal and strict (hierarchical) ways of decisions; strict (hierarchical) ways of decisions;

Rules, (sanctions)Rules, (sanctions) Top – down Top – down Production ideology, selling inProduction ideology, selling in Lack of collective view, lack of feeling of Lack of collective view, lack of feeling of

collaboration, different motivescollaboration, different motives Insufficent analysis of employer´s situation Insufficent analysis of employer´s situation Risk for high levels of frustrationRisk for high levels of frustration Risk for defensive attitudesRisk for defensive attitudes

4343

Implementation > decisions/ordersImplementation > decisions/orders

Rationality is overestimatedRationality is overestimated by heads and the need for by heads and the need for implementation is underestimatedimplementation is underestimated

””*That´s my decision (these are my orders)”*That´s my decision (these are my orders)” Of 356 attempts to introduce changes in organisations Of 356 attempts to introduce changes in organisations

more than half failed. (Nutt, 1999more than half failed. (Nutt, 1999)) I most cases this was caused by using the wrong I most cases this was caused by using the wrong

strategy ; orders, rules, top-downstrategy ; orders, rules, top-down

Nutt, 1999, citerad i Robert Holmbergs rapport: Implementering av nya behandlingsprogram i kriminalvården, 2006

4444

Adjusted implementation Adjusted implementation (implegration)(implegration)

Implementation – an Implementation – an intentionalintentional process process Bottom-up perspectiveBottom-up perspective An exploring and listening attitudeAn exploring and listening attitude Local ownership (from the centrally decided goal Local ownership (from the centrally decided goal

orientation) orientation) Balance between guidelines and mindlinesBalance between guidelines and mindlines Adjusting to local conditions = integrationAdjusting to local conditions = integration Positive monitoring and supportPositive monitoring and support

4545

Is the organisation motivated for Is the organisation motivated for working with programmesworking with programmes

A validated instrument for assessing suitability and readiness A validated instrument for assessing suitability and readiness for organisations. Organizational Readiness for change. for organisations. Organizational Readiness for change. (ORC) (ORC) Lehman, Greeener, Lehman, Greeener, Simpson (2002)Simpson (2002)

Research at the Institute of Behavioral Research, Texas Research at the Institute of Behavioral Research, Texas Christian University.Christian University.

JSATs special issue October 2007: 10 articles about JSATs special issue October 2007: 10 articles about implemation (only).implemation (only).

4646

Positive correlations between Positive correlations between outcome and implementation: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.

4747

An implegration model for Swedish An implegration model for Swedish Corrections (CIM)Corrections (CIM)

Dimensioner:Dimensioner:

A.A. OrganisationOrganisation

B.B. Program characteristicsProgram characteristics

C.C. StaffStaff

D.D. Clinical skillsClinical skills

E.E. Integration, contextual factorsIntegration, contextual factors

F.F. ClientsClients

G.G. EvaluationEvaluation(Farbring, 2007)

4848

An implegration model for Swedish An implegration model for Swedish Corrections (KIM)Corrections (KIM)

Goals:Goals:1.1. Increase effectiveness from programmes Increase effectiveness from programmes

- reduce relapse- reduce relapse2.2. Assess need for supportAssess need for support3.3. Produce information for self assessmentProduce information for self assessment4.4. Assess suitabilty for (further) programme Assess suitabilty for (further) programme

workwork

(Farbring, 2007)

4949

KIM- exempel på schema för bedömningar

5050

KIM - exempel på kodnyckel

5151

RESEARCH ON THE RESEARCH ON THE MI-IMPLEGATION IN MI-IMPLEGATION IN SWEDISH SWEDISH CORRECTIONSCORRECTIONS

Forsberg, L., Ernst, D., & Farbring, C. Å. (2010) Forsberg, L., Ernst, D., & Farbring, C. Å. (2010) Learning motivational interviewing in a real-life Learning motivational interviewing in a real-life setting: A randomised controlled trial in the setting: A randomised controlled trial in the Swedish Prison Service. Swedish Prison Service. Criminal Behaviour and Criminal Behaviour and Mental Health.Mental Health. (wileyonlinelibrary.com) DOI: (wileyonlinelibrary.com) DOI: 10.1002/cbm.792 10.1002/cbm.792

ABSTRACT:ABSTRACT:BackgroundBackground Motivational interviewing (MI) is a Motivational interviewing (MI) is a client-centred, directive counselling style for client-centred, directive counselling style for helping people to explore and resolve helping people to explore and resolve ambivalence about behaviour change and ambivalence about behaviour change and shown to decrease drugshown to decrease drug and alcohol use. A five-and alcohol use. A five-session semi-structured MI intervention session semi-structured MI intervention (Beteende Samtal Förändring (BSF; Behaviour, (Beteende Samtal Förändring (BSF; Behaviour, Counselling, Change)) was implemented in Counselling, Change)) was implemented in Swedish prisons.Swedish prisons.

Aims Aims To examine whether, in a real-life To examine whether, in a real-life implementation of semi-structured MI, staff implementation of semi-structured MI, staff receiving ongoing MI training, based on audio-receiving ongoing MI training, based on audio-recorded feedback in peer groups (BSF+) recorded feedback in peer groups (BSF+) possess greater MI skill compared with staff possess greater MI skill compared with staff receiving workshop-only MI training (BSF), and receiving workshop-only MI training (BSF), and staff conducting usual prison planning interviews staff conducting usual prison planning interviews (UPI).(UPI).Methods Methods Prisoners were randomised to one of Prisoners were randomised to one of the three interventions. The first sessions the three interventions. The first sessions between staff and prisoner with complete data between staff and prisoner with complete data were assessed with the Motivational were assessed with the Motivational Intreviewing Treatment Integrity Code 3.0.Intreviewing Treatment Integrity Code 3.0.ResultsResults Content analysis of 45 staff: prisoner Content analysis of 45 staff: prisoner sessions revealed that counsellors in the BSF+ sessions revealed that counsellors in the BSF+ group were significantly more competent in MI group were significantly more competent in MI than those in the UPI group, but there was no than those in the UPI group, but there was no difference in MI competency between the BSF difference in MI competency between the BSF and the UPI groups. Overall, staff were rated as and the UPI groups. Overall, staff were rated as not having achieved beginning proficiency.not having achieved beginning proficiency.ConclusionsConclusions Our findings suggest that staff Our findings suggest that staff delivering motivational interviewing programmes delivering motivational interviewing programmes for substance-misusing prisoners in Sweden are for substance-misusing prisoners in Sweden are not being given sufficient training for the task. not being given sufficient training for the task. Previous literature has suggested that staff need Previous literature has suggested that staff need more than a basic 3- to 5-day workshop training, more than a basic 3- to 5-day workshop training, but our findings suggest that they may need but our findings suggest that they may need longer-term continuing supervision and support longer-term continuing supervision and support than previously recognised.than previously recognised.

Aims Aims To examine whether, in a real-life implementation To examine whether, in a real-life implementation of semi-structured MI, staff receiving ongoing MI of semi-structured MI, staff receiving ongoing MI training, based on audio-recorded feedback in peer training, based on audio-recorded feedback in peer groups (BSF+) possess greater MI skill compared with groups (BSF+) possess greater MI skill compared with staff receiving workshop-only MI training (BSF), and staff staff receiving workshop-only MI training (BSF), and staff conducting usual prison planning interviews (UPI).conducting usual prison planning interviews (UPI).Methods Methods Prisoners were randomised to one of the Prisoners were randomised to one of the three interventions. The first sessions between staff and three interventions. The first sessions between staff and prisoner with complete data were assessed with the prisoner with complete data were assessed with the Motivational Intreviewing Treatment Integrity Code 3.0.Motivational Intreviewing Treatment Integrity Code 3.0.ResultsResults Content analysis of 45 staff: prisoner sessions Content analysis of 45 staff: prisoner sessions revealed that revealed that counsellors in the BSF+ group were counsellors in the BSF+ group were significantly more competent in MI than those in the UPI significantly more competent in MI than those in the UPI group, but there was no difference in MI competency group, but there was no difference in MI competency between the BSF and the UPI groups.between the BSF and the UPI groups. Overall, staff Overall, staff were rated as not having achieved beginning were rated as not having achieved beginning proficiency.proficiency.

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

Global variables

Reflec-tions/q

Complex r/r (%)

Open q/q (%)

MI adherent

MI non-adherent

Informa-tion giving

Ref valueUPI Mn=14 SDBSF Mn=27 SDBSF+ Mn=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

.951.24 *1.34

1.701.571.141.66.521.12

11.5010.5713.146.1614.625.43

5555

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

BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI scores BSF > UPI but not significant. Here BSF+ and even – if not significantly – BSF 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 seems to matter. (Note no difference between BSF and BSF+) However suggested level of proficiency is not reached.proficiency is not reached.

Global variables

Empathy Evocation Collabor Autonom MI Spirit Direction

UPI Mn=10 SDBSF MN=14 SDBSF+ MN=21 SD

2.30.822.50.853.10 (*).89

2.10.742.431.023.10 *.89

2.40.972.57.763.10.89

2.20.792.71.823.14 *.79

2.23.742.57.723.11 *.71

4.201.034.141.454.71.56

5656

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

Analysis of variance: BSF+ > (s) UPI/BSF in empathy, evocation, autonomy and MI spirit. Analysis of variance: BSF+ > (s) UPI/BSF in empathy, evocation, autonomy and MI spirit. BSF+ scores > 3 on average (ref.value 3.5 (Moyers et al., 2007) No difference between BSF+ scores > 3 on average (ref.value 3.5 (Moyers et al., 2007) No difference between UPI and BSFUPI and BSFAdjusted (Bonferroni, post hoc tests) indicate significant differences in evocation : (mean Adjusted (Bonferroni, post hoc tests) indicate significant differences in evocation : (mean difference -.995, p = .019), autonomy (-.943, p = .012), MI spirit: -878, p = .008)difference -.995, p = .019), autonomy (-.943, p = .012), MI spirit: -878, p = .008)

Global variables

Reflec-tions/q

Complex r/r (%)

Open q/q (%)

MI adherent

MI non-adherent

Informa-tion giving

Ref valueUPI Mn=14 SDBSF Mn=27 SDBSF+ Mn=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

.951.24 *1.34

1.701.571.141.66.521.12

11.5010.5713.146.1614.625.43

5757

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

BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI scores BSF > UPI but not significant. Here BSF+ and even – if not significantly – BSF 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 seems to matter. (Note no difference between BSF and BSF+) However suggested level of proficiency is not reached.proficiency is not reached.

Training or implementation?Training or implementation?

Basic training in MI Basic training in MI BUTBUT --- --- The The effecteffect is an effect from is an effect from

implementation/implegration – not training.implementation/implegration – not training.

5858

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

Abstract: A sample of 296 drug-using inmates in 1 Abstract: A sample of 296 drug-using inmates in 1 Swedish prisons was randomized during 2004-2006 into Swedish prisons was randomized during 2004-2006 into three intervention groups; Motivational interviewing three intervention groups; Motivational interviewing deleviered by counselors with workshop-only training, or deleviered by counselors with workshop-only training, or by counselors with workshop training followed by peer by counselors with workshop training followed by peer group supervision, and controls. Drug and alcohol use group supervision, and controls. Drug and alcohol use was measured by the Addiction Severity Index (ASI) at was measured by the Addiction Severity Index (ASI) at intage and at 10 months after release. Complete data intage and at 10 months after release. Complete data from 114 clients were analyzed by a stepwise regression from 114 clients were analyzed by a stepwise regression analysis. All three groups reduced alcohol and drug analysis. All three groups reduced alcohol and drug use. ..use. .. There were no significant differences between the There were no significant differences between the groups.groups.

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

Intervention

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 Number of days of illegal activity in 30 days prior to interviewto interview

Intervention


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 Number of days working 30 days prior to interviewinterview

Intervention


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 # 1Observation # 1

MI implegration has been highly successful in MI implegration has been highly successful in increasing client motivation to changeincreasing client motivation to change

MI implegration (MI+) outperforms significantly UPI MI implegration (MI+) outperforms significantly UPI in clinical excellence. Effect is probably in clinical excellence. Effect is probably underestimated, since the study was performed underestimated, since the study was performed very early …very early …

There is no evidence so far that MI changes There is no evidence so far that MI changes offender´s behavior in prison contexts (for many offender´s behavior in prison contexts (for many reasons).reasons).

Training means very little and may be overratedTraining means very little and may be overrated So here is more empirical evidence for…So here is more empirical evidence for…

6363

So can MI help?So can MI help?

McMurran (2009) * - 19 studies and McMurran McMurran (2009) * - 19 studies and McMurran (offending – N=9; substance misuse – N=10), at (offending – N=9; substance misuse – N=10), at the ICMI 2 conference, Stockholm 2010:the ICMI 2 conference, Stockholm 2010:

Three aims with MI:Three aims with MI: 1. To enhance 1. To enhance retentionretention in treatment in treatment 2. To improve 2. To improve motivationmotivation to change to change 3. To change 3. To change behaviour. behaviour.

6464* Motivational interviewing with offenders: A systematic review. * Motivational interviewing with offenders: A systematic review. Legal and Criminological Legal and Criminological PsychologyPsychology (2009) 14, 83-100) (2009) 14, 83-100)

Retention in treatmentRetention in treatment

Completers show a modest positive effect in Completers show a modest positive effect in reducing recidivism (reducing recidivism (d = 0.11)d = 0.11)

Important to reduce drop out rates because Important to reduce drop out rates because non-completers show a negative (non-completers show a negative (dd= - 0.16) = - 0.16) effect even compared to untreated controls. effect even compared to untreated controls. ”Non-completers are ”Non-completers are more likelymore likely to be to be reconvicted than untreated.” * reconvicted than untreated.” *

Conclusion: 3 good quality studies: MI appears Conclusion: 3 good quality studies: MI appears successful at enhancing retention in treatment successful at enhancing retention in treatment for substance misuse.for substance misuse.

6565McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with increased McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with increased reconviction over no treatment? reconviction over no treatment? Psychology Crime and Law. 13. 333-343)Psychology Crime and Law. 13. 333-343)

McMurran, M. (2009) – MI with offenders: A McMurran, M. (2009) – MI with offenders: A systematic review. systematic review. Legal and Criminological Psychology, 14, 83-100Legal and Criminological Psychology, 14, 83-100

MI appears to improve: MI appears to improve: - retention in treatment. (Important: - retention in treatment. (Important: Non-completers are more Non-completers are more

likely to be reconvicted than are untreated offenders.likely to be reconvicted than are untreated offenders. Q: What are people doing to reduce non-completion.Q: What are people doing to reduce non-completion. A: Not much. Room for MI here.)A: Not much. Room for MI here.)

- self reported motivation to change self reported motivation to change

- MI may be effective in reducing substance abuse MI may be effective in reducing substance abuse especially in conjunction with other treatment especially in conjunction with other treatment components.components.

- Mixed evidence in changing offending behavior.Mixed evidence in changing offending behavior. McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with

increased reconviction over no treatment? increased reconviction over no treatment? Psychology, Crime and Law, 13, 333-343 Psychology, Crime and Law, 13, 333-343 16 studies, 19.563 offenders.16 studies, 19.563 offenders.

6666(McMurran, ICMI 2, Stockholm, (McMurran, ICMI 2, Stockholm, 2010)2010)

General conclusions about effectsGeneral conclusions about effects

Effects from interventions vary from negative to positiveEffects from interventions vary from negative to positive Teaching means very little. Learning is what it is all about. Teaching means very little. Learning is what it is all about.

MONTY ROBERTSMONTY ROBERTS Style of communication means more than content – Style of communication means more than content –

empathy-collaboration-engagementempathy-collaboration-engagement Implementation means more than learning through (even Implementation means more than learning through (even

superior quality) workshops and classes: superior quality) workshops and classes: ► Learning by ► Learning by doing!doing!

Very few interventions meet these criteriaVery few interventions meet these criteria MI works better combined with other ”practical” MI works better combined with other ”practical”

interventions – preferably structured in ”MI-style” – for interventions – preferably structured in ”MI-style” – for instance: (see next slide)instance: (see next slide)

Vaccination against relapse – A scientifically accredited Vaccination against relapse – A scientifically accredited relapse prevention program in MI style (2006,2011)relapse prevention program in MI style (2006,2011)

Smedslund, G., Berg, R. C., Hammarstrom, K. T., Steiro, A., Leiknes, Smedslund, G., Berg, R. C., Hammarstrom, K. T., Steiro, A., Leiknes, K. A, Dahl, H. M., Karlsen, K. (2011) Motivational Interviewing for K. A, Dahl, H. M., Karlsen, K. (2011) Motivational Interviewing for

Substance Abuse Substance Abuse .. Cochrane Database of Systematic Reviews 2011, Issue Cochrane Database of Systematic Reviews 2011, Issue 5- Art. No.: CD008063. DOI: 10.1002/14651858pub2. (forts.)5- Art. No.: CD008063. DOI: 10.1002/14651858pub2. (forts.)

Conclusions:Conclusions:

Implications for practice: If the counselor feels Implications for practice: If the counselor feels comfortable with MI it works better than no treatment. comfortable with MI it works better than no treatment. Compared to CBT there is not enough material to Compared to CBT there is not enough material to make conclusions if one is better than the other.make conclusions if one is better than the other.

Implications for research: There is no lack of RCTs Implications for research: There is no lack of RCTs showing if MI works or not. Time has come to find out showing if MI works or not. Time has come to find out how MI works and under what condititions. Reference how MI works and under what condititions. Reference to Apodaca and Longabaugh (2009) – about to Apodaca and Longabaugh (2009) – about causality in MI.causality in MI.

More lessons learnedMore lessons learned

John C. NorcrossJohn C. NorcrossICTAB - IIICTAB - II

University of University of Scranton, Scranton,

PennsylvaniaPennsylvania

Striking and large variations in Striking and large variations in outcomes of treatment (MI). Why?outcomes of treatment (MI). Why?

MI is not a ”method” not a set of MI is not a ”method” not a set of skills. Different counselors will yield skills. Different counselors will yield different quality outcome… different quality outcome…

Outcome variance attributed to factors in Outcome variance attributed to factors in therapy (%)therapy (%)

Unexpl var

relation

method

counselor

interplay

client

Client contribution 25% Unexplained

variance 45%

Relation

10%

Method

8%

Interplay 5%

Counselor

contrib

ution 7

%

John Norcross, ICTAB 11, 2006.John Norcross, ICTAB 11, 2006.

MI as a communication style is unique in its focus on MI as a communication style is unique in its focus on general factors and trying to operationalize them !! general factors and trying to operationalize them !!

General Factors in treatment explain more General Factors in treatment explain more of variance of change than specific factorsof variance of change than specific factors

ExpectationsExpectations EmpathyEmpathy AllianceAlliance AffirmationsAffirmations

Can these factors be more accentuated in Can these factors be more accentuated in MI?MI?

7373

HQ Dutch Prison HQ Dutch Prison Service Service

Netherlands, 2012Netherlands, 2012Carl Åke FarbringCarl Åke Farbring

Expectations – An important part Expectations – An important part of MIof MI

Limitations in treatment Limitations in treatment (e.g.corrections) - expectations(e.g.corrections) - expectations

Negative expectations (account for 15% of Negative expectations (account for 15% of outcome variation (Lambert, 1992) and 15outcome variation (Lambert, 1992) and 15—40% of variance in TA ratings.—40% of variance in TA ratings.

Overly high expectations can also affect Overly high expectations can also affect outcomeoutcome

Risk: repeated relationship terminations… Risk: repeated relationship terminations… (”waste of time” – or worse…)(”waste of time” – or worse…)

The nature of expectationsThe nature of expectations Lambert & Bartley (2002) Expactations the third most Lambert & Bartley (2002) Expactations the third most

important factor after client variables and relation: important factor after client variables and relation: 15%.15%.

Probably mediated by allianceProbably mediated by alliance Expectations and motivation? Relationship?Expectations and motivation? Relationship? Clients who have high expectations will work more Clients who have high expectations will work more

actively…. (Joyce at al., 2003)actively…. (Joyce at al., 2003) There is some evidence that clients with modest There is some evidence that clients with modest

expectations fare better than clients with high expectations fare better than clients with high expectations – cf base line motivationexpectations – cf base line motivation

Expectations -- what does the research say?Expectations -- what does the research say?Constantino, M, J., Arnkoff, D. B., Glass, C. R., Ametrano, R. M., & Smith, J. Z (2011) Constantino, M, J., Arnkoff, D. B., Glass, C. R., Ametrano, R. M., & Smith, J. Z (2011)

Expectations. Expectations. Journal of Clinical Psychology: In Session, Journal of Clinical Psychology: In Session, 67 (2), 184-192 (2011) Adapted 67 (2), 184-192 (2011) Adapted from chapter in J. C. Norcross (ed) (2011) Psychotherapy relationships that work (2nd from chapter in J. C. Norcross (ed) (2011) Psychotherapy relationships that work (2nd

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

Expectations are a key ingredient of successful Expectations are a key ingredient of successful psychotherapy psychotherapy (Goldfried, 1980; Goldstein, 1960; Rosenzweig, 1936)(Goldfried, 1980; Goldstein, 1960; Rosenzweig, 1936)

” ” a mobilization of hope for improvement a mobilization of hope for improvement (Frank, (1961) (Frank, (1961)

Persuasion and Healing. Persuasion and Healing. ”Restoring hope and positive ”Restoring hope and positive expectation is a powerful change ingredient”…expectation is a powerful change ingredient”…

” ”Psychotherapies are inextricably linked with the Psychotherapies are inextricably linked with the manipulation and revision of patients´ expectations manipulation and revision of patients´ expectations (Greenberg, Constantino, & Bruce, 2006).(Greenberg, Constantino, & Bruce, 2006).

Continuum from benefits of treatment to Continuum from benefits of treatment to expectations of positive outcome expectations of positive outcome

Expectations are Expectations are influenced by earlier treatment influenced by earlier treatment and contacts with therapists.and contacts with therapists.

Some used measures in little researched Some used measures in little researched areaarea

Brief (4 items) and study-specific and sometimes Brief (4 items) and study-specific and sometimes confounded with other constructs – e.g. credibility.confounded with other constructs – e.g. credibility.

Common questions:Common questions:- At this point, how logical does the therapy offered seem to you?At this point, how logical does the therapy offered seem to you?- How successful do you think this treatment will be in reducing your How successful do you think this treatment will be in reducing your

symptoms?symptoms?- By the end of the therapy period, how much improvement do you think will By the end of the therapy period, how much improvement do you think will

occur?occur?

In some analyses credibility items hung together In some analyses credibility items hung together while the expectancy items hung together with while the expectancy items hung together with affectively-anchored items – e.g.affectively-anchored items – e.g.

- How much do you really - How much do you really feel feel that therapy will help you reduce your that therapy will help you reduce your symptoms? How much improvement in your symptoms do you symptoms? How much improvement in your symptoms do you feel will feel will occur?occur?

More about measures etc.More about measures etc.

Pessimistic item:Pessimistic item: - Actually I am rather skeptical about whether treatment can help - Actually I am rather skeptical about whether treatment can help

me… me…

Prognostic expectations are also affected by Prognostic expectations are also affected by context and one´s own learning experiences. context and one´s own learning experiences.

Outcome expectations and treatment Outcome expectations and treatment expectations probably interact. expectations probably interact. (Constantino et al., 2011)(Constantino et al., 2011)

Is knowledge about patients´and client´s Is knowledge about patients´and client´s expectations useful for us in MI? expectations useful for us in MI?

Meta-Analytic Review (Constantino et al., 2011) Meta-Analytic Review (Constantino et al., 2011) Effects of outcome expectations on outcome.Effects of outcome expectations on outcome.

RESULTS:RESULTS: N= 8.016 patients across 46 independent N= 8.016 patients across 46 independent

samplessamples >80% adult (18-65), > 60% White , > 60% >80% adult (18-65), > 60% White , > 60%

womenwomen Overall weighted effect size Overall weighted effect size d d = .24, p< .001 = .24, p< .001

(Cohen´s (1988) (Cohen´s (1988) d.), r d.), r = . 12, p< .001 (CI.= . 12, p< .001 (CI.9595 . 10 to .15) . 10 to .15)

Moderators and MediatorsModerators and Mediators

Thus: there is a small but Thus: there is a small but significant association significant association between outcome expectations and treatment between outcome expectations and treatment outcome.outcome.

However little is known about specific mechanisms However little is known about specific mechanisms through which they operate through which they operate (Arnkoff, Glass, & Shapiro, 2002)(Arnkoff, Glass, & Shapiro, 2002)

Three studies have Three studies have directly directly investigated the putative investigated the putative mediator pathway mediator pathway (Meyer et al., 2002; Joyce, Ogrodniczuk, Piper, & (Meyer et al., 2002; Joyce, Ogrodniczuk, Piper, & McCallum, 2003; Abouguendia, Joyce, Piper, & Ogrodniczuk, 2004) …McCallum, 2003; Abouguendia, Joyce, Piper, & Ogrodniczuk, 2004) …

iindicating that therapeutic ndicating that therapeutic alliancealliance is a robust is a robust mechanism.mechanism.

Patients with positive outcome expectations are more Patients with positive outcome expectations are more likely to engage in a collaborative relationship with the likely to engage in a collaborative relationship with the counselor.counselor.

What about high expectations?What about high expectations?

Prognostic expectations can sometimes be Prognostic expectations can sometimes be too too highhigh (like motivation) and can end in (like motivation) and can end in disappointment, frustration and even anger disappointment, frustration and even anger but…but…

Expectations are Expectations are malleablemalleable Single assessment or static understanding of Single assessment or static understanding of

expectations at the start is not productive.expectations at the start is not productive. Expectations – like motivation – is something Expectations – like motivation – is something

that the counselor needs to that the counselor needs to adress and work onadress and work on..

Implications for practice (Constantino et al., Implications for practice (Constantino et al., 2011)2011)

1.1. Explicitly assess (Explicitly assess (understandunderstand) prognostic ) prognostic expectations at the beginning of treatment.expectations at the beginning of treatment.

2.2. Behave in a way that matches the patient´s level Behave in a way that matches the patient´s level of optimism and use strategies to enhance a of optimism and use strategies to enhance a positive outcome – look out for unrealistic speed positive outcome – look out for unrealistic speed or degree of changeor degree of change

3.3. Make hope-inspiring statements: ”What you are Make hope-inspiring statements: ”What you are dealing with right now is very common and can be dealing with right now is very common and can be changed”; ”You are the kind of person who can changed”; ”You are the kind of person who can really accomplish things that you put your mind to”really accomplish things that you put your mind to”

4.4. Normalize possible fluctuations towards change.Normalize possible fluctuations towards change.

Carl Åke Farbring, 2009Carl Åke Farbring, 2009

Make conversation (don´t read) and adapt to your own Make conversation (don´t read) and adapt to your own context - context - Practitioner´s task: working with expectations = Practitioner´s task: working with expectations = antecipatory socialisation – Expectations must be met.antecipatory socialisation – Expectations must be met.

Implications for practiceImplications for practice

8484

MI In Dutch MI In Dutch Prison Service Prison Service Netherlands 2012Netherlands 2012Carl Åke FarbringCarl Åke Farbring

Alliance – Who is performing the Alliance – Who is performing the change? change? A suggestion for practice.A suggestion for practice.

General factors explain more of the variance of General factors explain more of the variance of change than special factors and methodschange than special factors and methods

Alliance (MI ≈ empathy, collaboration)Alliance (MI ≈ empathy, collaboration)

explains about7-8 % of the variance of changeexplains about7-8 % of the variance of change weakened alliance correlates with weakened alliance correlates with unilateral termination.unilateral termination. alliance ”at first sight ”alliance ”at first sight ” Note: clients i CJ and similar contextsNote: clients i CJ and similar contextsare often defensive at the start (affirmations).are often defensive at the start (affirmations).

carl åke farbring, 2009 - www.farbring.comcarl åke farbring, 2009 - www.farbring.com

SUPERSHRINKS. What´s the secret of SUPERSHRINKS. What´s the secret of their success?their success?

Enormous differences in success Enormous differences in success between therapists in the same between therapists in the same organization with same education and organization with same education and working with similar patients. working with similar patients.

What are supershrinks doing that the What are supershrinks doing that the others are not doing?others are not doing?

Cf. Terri Moyers´ metaphor about the Cf. Terri Moyers´ metaphor about the surgeon… and psychosocial surgeon… and psychosocial counselorscounselors

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

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

Working and therapeutic alliance is an Working and therapeutic alliance is an important predictor of behavior changeimportant predictor of behavior change

How it operates is little understoodHow it operates is little understood Prison and probation settings make clear Prison and probation settings make clear

obstacles for working alliance to emergeobstacles for working alliance to emerge In fact systemic factors may even In fact systemic factors may even

intervene intervene againstagainst alliance alliance

Findings (2)Findings (2) Words like: psychopath, punishment, aversiveness, Words like: psychopath, punishment, aversiveness,

obtrusive, rules, personality disorder, distasteful, obtrusive, rules, personality disorder, distasteful, crimes…are often used.crimes…are often used.

Counselors in corrections routinely experience Counselors in corrections routinely experience challenges that threaten TA. How do you develop challenges that threaten TA. How do you develop TA with a client that you value in negative termsTA with a client that you value in negative terms

Clients will not change within a negative counselor-Clients will not change within a negative counselor-client relationship - alliance is a prerequisiteclient relationship - alliance is a prerequisite

Client´s perception of the counselor as an empathic Client´s perception of the counselor as an empathic individual rather than actual counselor behaviorindividual rather than actual counselor behavior

Skeem: Dual role; care and control Skeem: Dual role; care and control and resource oriented instrumentsand resource oriented instruments

A validated TA-instrument made for correctionsA validated TA-instrument made for corrections Improvement over WAI in correctionsImprovement over WAI in corrections In stead of problem oriented instrumentes: Good In stead of problem oriented instrumentes: Good

Lives Model Lives Model (Ward & Stewart, 2003)(Ward & Stewart, 2003)

Goal Matrix, motivational structure model (Cox, Goal Matrix, motivational structure model (Cox, Klinger, 2002):Klinger, 2002):

Personal Concerns Inventory, OA, (Psychology, Personal Concerns Inventory, OA, (Psychology, Crime and Law.) Crime and Law.) (Sellen, McMurran, Theodosi, Cox, Klinger, in press)(Sellen, McMurran, Theodosi, Cox, Klinger, in press)

What is alliance?What is alliance?

Bordin´ s theory (1979):Bordin´ s theory (1979):

1.1. AgreementAgreement on the goals the offender must on the goals the offender must work onwork on

2.2. Clear Clear collaborationcollaboration on the tasks on the tasks3.3. BondBond between client and counselor between client and counselor

(relationship)(relationship) WAI predicts outcome (Horvath, 1994) WAI predicts outcome (Horvath, 1994) Bordin, E. S. (1979) Psychotherapy: Theory, Bordin, E. S. (1979) Psychotherapy: Theory,

Research and Practice, 16, Research and Practice, 16, 252-260252-260

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

for offender rehabilitation. for offender rehabilitation. Aggression and Violent Behavior, 13, 462-480Aggression and Violent Behavior, 13, 462-480

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

2.Two factor model – bond and goals/tasks2.Two factor model – bond and goals/tasks

3. Reciprocal intimacy was a high predictor 3. Reciprocal intimacy was a high predictor of session quality ratings and overall of session quality ratings and overall effectieness (Saunders, 1999)effectieness (Saunders, 1999)

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


Alliance and feedbackAlliance and feedback

Lambert (2003) reports an ES of 0.39 on Lambert (2003) reports an ES of 0.39 on feedbackfeedback compared to a group where compared to a group where feedback was not given.feedback was not given.

In a recent study in Norway (2009) Anker, In a recent study in Norway (2009) Anker, Duncan & Sparks report a 4 times bigger Duncan & Sparks report a 4 times bigger clinically significant difference to the clinically significant difference to the advantage of the feedback group.advantage of the feedback group.

(JCCP, 2009, Vol 77, No 4, 693-704.(JCCP, 2009, Vol 77, No 4, 693-704.

It is the It is the client´s understandingclient´s understanding of alliance that of alliance that predicts outcome – not the therapist´spredicts outcome – not the therapist´s

The Engagement Ruler - an alliance The Engagement Ruler - an alliance instrument (side B)instrument (side B)


Let the client invest in your Let the client invest in your collaboration, building alliancecollaboration, building alliance

Note: In conversation – not assessment!Note: In conversation – not assessment!

- If you were to give some advice on how I could be If you were to give some advice on how I could be more helpful to you – what would you suggest?more helpful to you – what would you suggest?

- 1….1….

- 2….2….

- 3….3….

The Engagement Ruler - an alliance The Engagement Ruler - an alliance instrument (side A)instrument (side A)

At the end of the session (make conversation – At the end of the session (make conversation – don´t read) Hand over the instrument to the don´t read) Hand over the instrument to the client/patient.client/patient.

Regardless of rating an important question will Regardless of rating an important question will follow!follow!

9898

MI as Walk and TalkMI as Walk and Talk

9999

MI on the organizational level, part II.MI on the organizational level, part II.Three styles – Three styles –

• Taking MI from the therapy room into Taking MI from the therapy room into the the realreal world world – corridors, kitchens – corridors, kitchens

• Authored by Steve Rollnick in Authored by Steve Rollnick in collaboration with Carl Åke Farbring, collaboration with Carl Åke Farbring,

• An interactive product with An interactive product with videorecorded ”situations” videorecorded ”situations”

• Three communication styles in Three communication styles in ”short” and ”difficult” conversations – ”short” and ”difficult” conversations – telling (instruct), listening, guidingtelling (instruct), listening, guiding

► ► Primary focus on reducing stress Primary focus on reducing stress (stress cortisole) and secondly(stress cortisole) and secondly

► ► Creating a climate more conducive Creating a climate more conducive for change (for clients)for change (for clients)

100100

The three styles intervention The three styles intervention relates to this recent bookrelates to this recent book

The three styles further developed inThe three styles further developed in::

Rollnick, S., Miller, W. R., Rollnick, S., Miller, W. R.,

& Butler, C. C. (2008) & Butler, C. C. (2008)

Motivational Interviewing in Motivational Interviewing in

Health Care.Health Care.

Helping PatientsHelping Patients

Change Behavior. Change Behavior.

Guilford Press.Guilford Press. Swedish editionSwedish edition

101101

RESULTS RESULTS (Forsberg, L., Lundberg, U., Theorell, T., Farbring, C. Å., Rollnick, S. (Forsberg, L., Lundberg, U., Theorell, T., Farbring, C. Å., Rollnick, S.

under preparation)under preparation)

• Staff involved in non-therapeutic Staff involved in non-therapeutic communication with (e.g. prison officers, communication with (e.g. prison officers, staff in mental hospitals) rate applicability staff in mental hospitals) rate applicability higher than full scale MI: 8.2 on average.higher than full scale MI: 8.2 on average.

• In a randomized trial, stress cortisol In a randomized trial, stress cortisol among staff has been reduced – this among staff has been reduced – this finding is not supported by psychological finding is not supported by psychological questionnaires, burn out etc.questionnaires, burn out etc.

• It has been estimated to change work It has been estimated to change work climate by heads of organizationsclimate by heads of organizations

Documents

Presentation for HQ Dutch Prison Service, the Netherlands 2012