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The Danish MITI Project
Lotte Kramer Schmidt, M.D. PhD.Unit of Clinical Alcohol Research,
Psychiatric department, Odense, DenmarkStockholm Conference
RFMA: Riksförbundet mot alkohol- och narkotikamissbruk18. February 2020
Alcohol in Denmark
Almost all Danes drink alcohol
16 Years – Legal to buy16.5% alcohol
18 Years
Estimate of alcohol problems in Denmark
High risk limit use of alcohol860.000 persons20% of 16+ years old
Harmful use of alcohol585.000 persons13% of 16+ years old
Addicted to alcohol140.000 persons3% of 16+ years old
AUD in DK
Young
Elderly
The Elderly project
+ 60 years with Alcohol Use Disorder (DSMV)Motivational Enhancement Therapy (MET)Community Reinforcement Approach-Senior (CRA-S)
Denmark, Germany and the USA
4 weeks
12 weeks
MET
MET CRA-S
Arguments for the extendedversion
1) Learning new skills to reduce drinking has strong research support
2) Learning new skills requires a therapist with expertise to teach and coach
3) Patients need both information and practice to be successful with new skills
Hypothesis: Participants who receive the extended version will have an effect that is 10%-points better than the standard version.
The Danish MITI Project
Assess the fidelity to Motivational
Interviewing (MI)in the Elderly project
+
Overview
Treatments of the Elderly study MET: Motivational Enhancement Therapy CRA-S: Community Reinforcement Approach Senior
Results of the MITI-project Fidelity to MI in the Elderly Study Associations with effect of treatment
Between sites differences in the fidelity to MI
MET
Manualized MI with feedback Questionnaires from the baseline interview 4 sessions basicly following the 4 processes in MI Engaging, focusing, evoking and planning But always prioritizing engaging and MI-Spirit no matter the
session number Provides specific tools for evoking change talk
MET: Session1
Engaging the patient ”Pure MI” Introduce an invitation of a supportive significant other in
session 4 Introduce home-work: ” Desired Effects of Drinking Form”
By the end af session 1, the therapists would write a hand-written note and send to the patient
Hand written note
There are several elements that can be included in this note, personalized to the patient, listed below:
A "joining message" [e.g., "I was glad to see you"] Affirmations of the patient A reflection of the seriousness of the problem A brief summary of highlights of the first session, especially
self-motivational statements that emerged A statement of optimism and hope A reminder of the next session.
Example
Dear Mr. Anderson: This is just a note to say that I'm glad you came in today. I agree with you that you have some serious concerns to work on, and I appreciate how openly you are exploring them. You are already seeing some ways in which you could make a healthy change. I think that together we will be able to find a way through these problems. I look forward to seeing you again on Tuesday the 24th at 2:00.
From the Manual for treatment in the Elderly Study
Link to the manual on SDU homepage:https://www.sdu.dk/da/om_sdu/institutter_centre/ucar/materialer/manuals
MET: Session 2
Personalized Feedback and Evoking Change Talk A personalized feedback form is prepared prior to this
session from answers the patient provided at the baseline interview including: Total standard drinks per week Max blood alcohol concentration Experienced consequences from drinking Medical risks Rulers Importance, Confidence and Readiness scores
A very important part of this process is monitoring of and responding to the patient during the feedback
MET: Session 3
Functional Analysis (Evoking and Planning) Through the use of different forms including The desired effects
from drinking form and Personal happiness card sort test Discussing possible areas for a later treatment plan
Example THERAPIST: Now that we've spent some time talking about the "why" of change, I'd like, if you're willing, for you to help me get a clearer picture of how drinking has fit into your life in the past. We can also start considering here the "how" of change-what you think you might want to do.
1. Cards that name an area of your life that you think is at least partly related to your drinking
2. Areas of your life in which you might like to make a change or in which you think it may be important for you to make a change.
3. Two “yes” areas and maybe asking carefully about areas which were affected but not important
MET: Session 4
MET alone: Planning how to continue on your own: A selfchange plan
MET + CRA-S: Planning how to continue treatment in CRA-S, including which modules to incorporate
Involving a supportive significant other
Role of SupportiveSignificant other
Does not include any policing or enforcing but that the main focus is to be supportive for sobriety during treatment, both inside and outside of sessions. Offering helpful ideas and input
Giving encouragement Supporting and reinforcing the patient's efforts to stay sober Helping-in ways the patient wishes to carry out plans for
staying sober. He/she can help to improve the effectiveness of treatment. However, remind the patient that no one else can make the
ultimate decision about change or take responsibility for it.
CRA-S
Modules with CBT-orientated content based on the community reinforcement approach (CRA)
The CRA utilizes familial, social, recreational and occupational reinforcers to aid patients in the recovery process.
The goal of CRA is to rearrange multiple aspects of the patient’s ‘community’, so that a sober life-style becomes more rewarding than one dominated by alcohol.
Andersen et al. Evaluation of adding the community reinforcement approach to motivational enhancement therapy for adults aged 60 years and older with DSM-5 alcohol use disorder: a randomized controlled trial. Addiction 2019.
CRA-S
5 different modules to pick from 8 session, but not predifined end You could have 8 sessions with the same module or 3 sessions
with 3 different modules Max 2 modules at a time in a session
Combined with MI: The underlying communicative approach is emphasized through out the manual as MI
CRA-S: 5 modules
1. Mood management training2. Coping with craving and urges3. Building a sober network4. Social and recreational counseling5. Coping with concerns related to aging
1. Mood management training
Focus on managing negative emotions with exercises like:
Analysis of situations with negative emotions.
Identifying negative automatic thoughts (NAT).
Practicing new ways to cope with focus both on avoiding situations that provoke NAT and constructive thoughts and behaviors after NAT have occurred.
2. Coping with craving and urges
Focus on coping with craving, urges, and social pressure to drink: Identifying triggers of urge and craving.
Training strategies like avoiding, escaping, distracting and enduring of situations with craving or urge.
3. Building a sober network
Focus on increasing positive support from others and engaging in recovery programs: Writing a letter to important people.
Practicing how to ask for support from significant others.
Inviting significant others into treatment
Identifying possible meaningful recovery programs in the local area.
4. Social and recreational counseling
Focus on finding pleasant recreational activities which do not involve drinking Exploring different recreational activities.
Trying out possible identified activities.
5. Coping with concerns related to aging
Focus on coping with loss and sadness associated with aging: Problem focused coping or acceptance focused coping.
Focus on different perspectives of aging.
Identifying things that are meaningful.
Identifying values.
Writing letters to grandchildren or lost ones.
Identifying toxic thoughts
Module name Focus Examples of exercisesMood management training
Managing negative emotions
Analysis of situations with negative emotions.Identifying negative automatic thoughts (NAT). Practicing new ways to cope with focus both on avoiding situations that provoke NAT and constructive thoughts and behaviors after NAT have occurred.
Coping with craving and urges
Coping with craving, urges, and social pressure to drink.
Identifying triggers of urge and craving.Training strategies like avoiding, escaping, distracting and enduring of situations with craving or urge.
Building a sober network.
Increasing positive support from others and engaging in recovery programs.
Writing a letter to important people.Practicing how to ask for support from significant others.Inviting significant others into treatment Identifying possible meaningful recovery programs in the local area.
Social and recreational counseling
Finding pleasant recreational activities which do not involve drinking
Exploring different recreational activities.Trying out possible identified activities.
Coping with concerns related to aging
Coping with loss and sadness associated with aging
Problem focused coping or acceptance focused coping.Focus on different perspectives of aging.Identifying things that are meaningful.Identifying values. Writing letters to grandchildren or lost ones.Identifying toxic thoughts
Therapists in the Elderly project
7 therapists in Denmark, 37 therapists in Germany and 3 in USA.
Rotating therapists at one of the sites in Denmark
Training
A 5-day workshop in English including a min of 2 therapists from all sites
‘Train the Trainer’ model by an experienced MI-trainer and member of the MINT (Motivational Interviewing Network of Trainers)
All therapists trained in both MET an CRA-S
Supervision
All session were recorded An effort was made to secure similar supervision across all
sites of the Elderly Study by regular videoconferencing meetings between supervisors throughout the study period, and particularly often in the beginning
Offered supervision both on random recordings of sessions once monthly and on request from the therapists
Results of The Elderly Study
Baseline demographics by country in the Elderly StudyDenmark (n=341)
Germany (n=203) USA (n=149) All (n=693)
Age: mean years (SD)** 65 (4) 67 (5) 65 (5) 66 (5)
Gender: % male* 64 52 60 60
Married or cohabiting, %** 45 57 39 47
Employment, % full or part time work** 15 24 28 20
Retired, % *** 63 71 50 63
Education, %high school or more*** 43 43 91 54
Previously received treatment, %*** 62 19 37 44
Alcohol Dependence Scale, mean (SD)***
12 (6) 6 (4) 12 (7) 10 (6)
Symptoms of mild to moderate depression, % ns
10 5 9 8
Rulers, Importance, mean (SD) on a scale 0-10***
8.8 (2.1) 8.2 (1.7) 8.6 (2.1) 8.5 (2.0)
Rulers, Confidence, mean (SD) on a scale from 0-10***
7.6 (2.2) 6.9 (2.0) 6.7 (2.5) 7.2 (2.2)
Rulers, Readiness, mean (SD) on a scale from 0-10***
8.9 (1.8) 8.4 (1.8) 7.9 (2.2) 8.5 (1.9)
Drinks per drinking day1, mean (SD)*** 10 (7) 7 (4) 9 (7) 9 (6)
Percent days abstinent, mean (SD)* 32 (37) 21 (28) 27 (33) 28 (34)
Percent heavy days of drinking, mean (SD)ns
58 (39) 60 (39) 56 (39) 58 (39)
*p<0.05 **p<0.01 ***p<0.001 NS: Not significant 1One drink=12 grams of alcohol.
Baseline demographics by country in the Elderly StudyDenmark (n=341)
Germany (n=203) USA (n=149) All (n=693)
Age: mean years (SD)** 65 (4) 67 (5) 65 (5) 66 (5)
Gender: % male* 64 52 60 60
Married or cohabiting, %** 45 57 39 47
Employment, % full or part time work** 15 24 28 20
Retired, % *** 63 71 50 63
Education, %high school or more*** 43 43 91 54
Previously received treatment, %*** 62 19 37 44
Alcohol Dependence Scale, mean (SD)***
12 (6) 6 (4) 12 (7) 10 (6)
Symptoms of mild to moderate depression, % ns
10 5 9 8
Rulers, Importance, mean (SD) on a scale 0-10***
8.8 (2.1) 8.2 (1.7) 8.6 (2.1) 8.5 (2.0)
Rulers, Confidence, mean (SD) on a scale from 0-10***
7.6 (2.2) 6.9 (2.0) 6.7 (2.5) 7.2 (2.2)
Rulers, Readiness, mean (SD) on a scale from 0-10***
8.9 (1.8) 8.4 (1.8) 7.9 (2.2) 8.5 (1.9)
Drinks per drinking day1, mean (SD)*** 10 (7) 7 (4) 9 (7) 9 (6)
Percent days abstinent, mean (SD)* 32 (37) 21 (28) 27 (33) 28 (34)
Percent heavy days of drinking, mean (SD)ns
58 (39) 60 (39) 56 (39) 58 (39)
*p<0.05 **p<0.01 ***p<0.001 NS: Not significant 1One drink=12 grams of alcohol.
Overall Results of the ElderlyStudy
Overall both treatment arms were effective Successrate MET: 49% (95%CI:43;55) and MET+CRA-S: 52%
(95%CI:46;58) No differences in effects of treatment between sites
4 weeks
12 weeks
Andersen et al. Evaluation of adding the community reinforcement approach to motivational enhancement therapy for adults aged 60 years and older with DSM-5 alcohol use disorder: a randomized controlled trial. Addiction 2019.
MET
MET CRA-S
Break?
Therapist competences in the Elderly Study
Measuring treatment integrity
Treatment integrity = Treatment fidelity
How well the treatment is implemented as intended. (Perepletchikova, 2011)
To secure integrity of the method: MI
Differences in effect of MI may be due to differences in the integrity in the performance of MI
How?
Motivational Interviewing TreatmentIntegrity manual version 4
= MITI 4
MITI 4
10 Therapist behaviors 4 global measures of therapist competence
4 summary measures with recommended benchmarks
20 minutes sections Only therapist behaviors are measured
MITI 4 Behavioural counts
Question Simple reflection Complex reflection Affirmation Seeking collaboration Emphasize autonomy Confront Persuade Persuade with permission Giving information
Essential but not specific to MI
Behavioral counts
Question Simple reflection Complex reflection Affirmation Seeking collaboration Emphasize autonomy Confront Persuade Persuade with permission Giving information
Essential and specific: MI adherent behaviour (MIA)
Behavioural Counts
Question Simple reflection Complex reflection Affirmation Seeking collaboration Emphasize autonomy Confront Persuade Persuade with permission Giving information
Should be avoided: MI non adherent behaviour (MINA)
Behavioural counts
Question Simple reflection Complex reflection Affirmation Seeking collaboration Emphasize autonomy Confront Persuade Persuade with permission Giving information
Compatible with the method but not essential, maybe neutral?
4 global measures of therapistcompetence
Cultivating Change Talk
How well is the therapist working on evoking and cultivating change talk
during the 20 minutes
1 2 3 4 5
Softening Sustain Talk
How well is the therapist working on softening and leading attention away
from sustain talk
1 2 3 4 5
Partnership
How well is the therapist sharing power with the client over the 20
minutes
1 2 3 4 5
Empathy
How well does the therapist seem to reach a deeper understanding of the
client
1 2 3 4 5
MITI 4 summary measures
MITI 4 expert recommendations: Fair MI Good MI
Relational: average empathy and partnership
3.5 4Technical: Average cultivatingchange talk and softening sustain talk
3 4
% Complex reflections of all reflections
.40 .50Reflections to questions ratio 1 2MIA: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)
- -
MINA: MI-non-adherent (persuasions + confronts) - -
Measuring treatmentintegrity in The Elderly Study
Alignment across international sites:
4 coding labs two in Germany (Münich and Dresden) one in Denmark one in the US
Rated and trained together in the use of the MITI 4 prior to the actual fidelity assessment
Measuring treatmentintegrity: Reliability
Each coding lab: Recommended to measure inter rater reliability levels prior to actual fidelity measurement.
To secure inter rater reliability: 10-20% of ratings at eachcoding lab were multiple rated.
Intraclass Correlations Coefficient: ICC
Benchmark value
0.00-0.39 Poor0.40-0.59 Fair0.60-0.74 Good0.75-1.00 Excellent
Cicchetti 1981
To secure inter rater reliability – Danish site
1) out of every five recordings there would be at least one which was multiply rated by all raters
2) the raters were blinded to which recordings were multiply rated 3) weekly meetings were held to discuss the ratings and compare already multiply
rated recordings 4) the raters were encouraged to rate at least three, but no more than ten,
recordings per week 5) if a rater stopped rating for more than two weeks, they had to compare
interrater reliability on a minimum eight recordings with the rest of the group before they could continue
6) disagreements among the raters were reduced by making specific decision rules 7) helping tools providing guidance on and anchors for different measures were
supplied to the raters
Additional rules for the MITI 4.2.1 fidelity measurement at the Danish sites of
the Elderly Study. When doubt about whether the conversation is small talk, it should be rated. When the counselor is saying out loud in full sentences what she is writing in the
treatment plan, this should be rated. Feedback on the questionnaires where the therapist is repeating what the client
answered in the questionnaire should be rated as giving information. Seeking collaboration should not be rated when the counselor is arranging with
the client how to perform an activity: example: “Do you want to write it down or should I?”
If a question is repeated with the same words because the client did not hear the question, it should not be rated again.
The overall change goal is decreasing use of alcohol. In the CRA-S sessions this may be interpreted indirectly as working with the content of the module. As an example, working with relationships which in turn could be related to use of alcohol.
Adfærd + Globale MITI 4.2
GI Information, undervisning , feedback eller profession mening udenat overtale eller advare. Neutral tonefald og ordvalg (ofte ”Man”)
Persuade Signal om at ændre holdning eller adfærd, evt. i tonefaldet, samtidig med, at der anvendes argumenter, egne erfaringer, fakta, anbefalinger, løsninger, farvet information, råd, forslag eller lignende. Bemærk tonefald og ordvalg (ofte ”Du”)
PWP Persuade kombineret med søgende ordvalg, EA, Seek eller klienten spørger til emnet. Hvis både P og PWP, kodes kun PWP. (Husk også at kode Seek)
Q Både åbne og lukkede. Trumfes af Seek. Bemærk tonefald og ordstilling.
SR Reflekterer det sagte, gentagelse, omformulering eller opsummering uden at tilføje nyt.
CR Tilføjer ny mening, værdi, omfortolkning, billedsprog, dobbeltsidet, reflekterer det uudsagte, en følelse eller fortsættelses refleksion. Kan virke ledende. Hvis både CR og SR kodes kun CR.
Affirm Udsagn, ofte CR, der kædes direkte sammen med klientens styrker, egenskaber, anstrengelser, intentioner eller værdi. Trumfer CR.
Seek Udsagn der deler magt med eller tydeligt anerkender klientens ekspertise. Spørger om tilladelse til at dele information eller overtale eller spørger til klientens tanker om dette. Søger enighed med klienten om samtalens forløb. Evt. også PWP-kode.
EA Udsagn, der klart har fokus på klientens eget ansvar og frihed for at træffe beslutninger og mulighed for at vælge attitude og adfærd. Fremhæver at ansvar for forandring ligger hos klienten.
Confront Direkte og utvetydig uenighed, argumentering, irettesættelse , bebrejder, advarer, fordømmende mv. Ved tvivl mellem confront og CR gives ingen kode.
Strukturerende (Kodes ikke): Instruktioner, indhold fra sidst, hilsener, aftaler om forløb, faciliterendetale som ”Okay””Godt””Dejligt”, uden for sammenhæng (small talk), ufuldstændige udsagn, hvor terapeutens tanke ikke når at komme til udtryk samt egen mening uden det er overtalende.
CCT 1 2 3 4 5
SST 1 2 3 4 5
Partnership 1 2 3 4 5
Empathy 1 2 3 4 5
Elderly ID:_______Session:___Minuttal:________Koder:_____Dato:_______
Results
693 participated in The Elderly Study
Danish site:341 Participants
2127 sessions423 rated with MITI52 rated by all raters
How was the fidelity to MI?
MITI 4 expert recommendations: Fair MI Good MI
Relational: average empathy and partnership
3.5 4Technical: Average cultivatingchange talk and softening sustain talk
3 4
% Complex reflections of all reflections
.40 .50Reflections to questions ratio 1 2MIA: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)
- -
MINA: MI-non-adherent (persuasions + confronts) - -
Mean values of fidelity to MIFair MI Good MI Mean Elderly CI95%
Relational: average of empathy and partnership
3.5 4 4.19 4.13;4.25
Technical: average ofcultivating change talk and softening sustain talk
3 4 3.94 3.88;4.00
% Complex reflections of all reflections
.40 .50 .58 .56;.59
Reflections to questions ratio
1 2 2.68 2.37;3.00
Relational Technical
Percent Complex Reflections Reflection to Question Ratio
Good MI
Fair MI
Good MI
Good MI
Good MIFair MI
Fair MI
Fair MI
MI fidelity in MET and CRA-S Danish site only!
CRA-S sessions: 158MET Sessions: 265
Inter rater reliability MET vs CRA-S
Interrater reliability MET vs CRABehavioral counts ICC MET
n= 3295% CI ICC CRA-S
n=2095% CI
Giving information .95 .91;.97 .93 .87;.97
Persuade .89 .81;94 .77 .56;.90
Persuade with permission
.79 .64;.88 .29 -.36;.68
Question .96 .94;.98 .97 .94;.99
Simple reflection .87 .78;.93 .93 .87;97
Complex reflection .92 .87;.95 .93 .87;.97
Affirmation .85 .75;.92 .86 .74;.94
Seeking collaboration .86 .76;.92 .83 .68;.93
Emphasize autonomy .60 .34;.79 .28 -.37;.68
Confront .24 -.28;59 .83 .68;.93
Global scoresCultivating change talk .79 .64;.88 .80 .62;.91
Softening sustain talk .56 .26;.76 .43 -.09;.75
Partnership .81 .69;.90 .87 .75;.94
Empathy .73 .55;.85 .74 .51;.88
Interrater reliabilityBehavioral counts ICC MET
n= 3295% CI ICC CRA-S
n=2095% CI
Giving information .95 .91;.97 .93 .87;.97
Persuade .89 .81;94 .77 .56;.90
Persuade with permission
.79 .64;.88 .29 -.36;.68
Question .96 .94;.98 .97 .94;.99
Simple reflection .87 .78;.93 .93 .87;97
Complex reflection .92 .87;.95 .93 .87;.97
Affirmation .85 .75;.92 .86 .74;.94
Seeking collaboration .86 .76;.92 .83 .68;.93
Emphasize autonomy .60 .34;.79 .28 -.37;.68
Confront .24 -.28;59 .83 .68;.93
Global scoresCultivating change talk .79 .64;.88 .80 .62;.91
Softening sustain talk .56 .26;.76 .43 -.09;.75
Partnership .81 .69;.90 .87 .75;.94
Empathy .73 .55;.85 .74 .51;.88
ICC Benchmark value
0.00-0.39 Poor
0.40-0.59 Fair
0.60-0.74 Good
0.75-1.00 Excellent
Differences in treatment fidelity between session of Motivational Enhancement Therapy (MET) and Community Reinforcement Approach Senior (CRA-S)Summary scores from the MITI 4 Sessions fulfilling this
criteria for good fidelity to MI
Only MET-session n=265
Sessions fulfilling this criteria for
good fidelity to MIOnly CRA-session
n=158
Significant difference
Relational: average of empathy and partnership
83% 74% P<0.05
Technical: average of cultivating change talk and softening sustain talk
74% 53% P<0.001
% Complex reflections of all reflections 74% 78% NS
Reflections to questions ratio 44% 48% NS
Mean MIA’s: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)
2.27 (1.99;2.54) 2.01 (1.71;2.31)
NS
Mean MINA’s: MI-non-adherent (persuasions + confronts)
0.61 (0.46;0.76) 0.96 (0.68;1.23)
NS
MI combined with CRA
The combination of MI with other therapeutictechniques in the CRA-S may comprimize the technical and relational elements of MI
Face validity of the MITI 4 – it does seem to measure MI
Fidelity to MI and effect of treatment
Treatment fidelity and effect of Motivational Interviewing
Effect
Higher fidelity to MI
Elements of MI associated with better outcomes
EmpathyMI spirit: evocation, collaboration, autonomy Affirmations Complex Reflections
Apodaca et Longabaugh 2008, Copeland et al. 2015, Romano et al. 2014, Houck et Moyers 2015, Apodaca et al. 2015, Pace et al 2017, Magill et al 2018, McCambridge et al 2011, Spohr et al .2015.
Not MI and associated with poorer outcomes
Persuasions Confrontations
Apodaca et Longabaugh , Pace et al 2017, 2008, Magill et al 2018
Outcome is use of alcohol and consequences of alcohol 26 weeks
Fidelity measures of the MITI 4
?
Mixed effects linear regression
Effect or Outcome is use of alcohol and consequences of alcohol
Fidelity measures of the MITI 4
NO ASSOCIATIONS FOUND
Participants in the CRA-S sessions Very good MI Worse outcomes!Not significant after BonferroniNot found at 12 weeks
Sub-analyses
Discussion
MI elementspatient change talk
Effect
Fidelity to MI and effect
MI elementspatient change talk
Effect
Fidelity to MI and effect
MI elementspatient change talk
Effect
Fidelity to MI and effect
X
The proportional increase in patient change talk
Discussion
Patient Change talkPatient Change talk + Sustain talk
Discussion
Population high in motivation
Low variation in the global fidelitymeasures
Sample size
The inverse finding of high fidelity MI and worse outcomes in CRA-S?
Type 1 errorBad timing of MI elements in the
combined setting - Stage of changemismatch?
Discussion
Fidelity between countries of the Elderly Study
707 rated sessions36 therapists
412 participants4 rating teams
What about the inter rater reliability?
ICCs from the fidelity measurement with MITI 4.2.1 at the four rating teams in the Elderly project
ICC (95% CI) Danish rating team (n=52)
ICC (95% CI) Dresden rating team
(n=12)
ICC (95% CI) Munich rating team
(n=13)
ICC (95% CI) US rating team (n=20)
Question 0.95 (0.90;0.97) 0.99 (0.97;1.00) 0.88 (0.71;0.96) 0.96 (0.89;0.98) Simple reflection 0.86 (0.76;0.92) 0.89 (0.47;0.97) 0.60 (0.08;0.86) 0.38 (-0.21;0.75)Complex reflection 0.87 (0.74;0.93) 0.67 (-0.13;0.90) 0.62 (0.12;0.87) 0.82 (0.34;0.94)
Affirmation 0.85 (0.78;0.91) 0.59 (-0.18;0.88) 0.86 (0.64;0.95) 0.66 (0.18;0.87)Seeking collaboration 0.83 (0.74;0.89) 0.04 (-0.95;0.65) 0.89 (0.71;0.96) 0.18 (-0.26;0.57)
Emphasize autonomy 0.52 (0.29;0.69) -0.22 (-4.85;0.67) 0.35 (-0.71;0.79) 0.27 (-0.33;0.66)
Summary scoresRelational: average of Empathy and Partnership
0.84 (0.75;0.90) 0.81 (0.34;0.94) 0.36 (-0.61;0.79) 0.26 (-0.93;0.71)
Technical: average of Cultivating change talk and Softening sustain talk
0.80 (0.70;0.88) 0.42 (-0.30;0.81) 0.48 (-0.32;0.83) 0.05 (-1.00;0.59)
% Complex reflections of all reflections
0.65 (0.47;0.78) 0.61 (-0.18;0.89) 0.27 (-0.60;0.74) 0.19 (-0.12;0.56)
Reflections to Questions ratio
0.95 (0.93;0.97) 0.77 (0.25;0.93) 0.47 (-0.16;0.81) 0.68
MIA: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)
0.85 (0.76;0.91) 0.27 (-0.32;0.72) 0.90 (0.74;0.97) 0.58 (-0.16;0.85)
MINA: MI-non-adherent (persuasions + confronts)
0.86 (0.79;0.91) 0.99 (0.98;1.00) 0.62 (0.06;0.87) 0.00 (-1.53;0.60)
ICCs from the fidelity measurement with MITI 4.2.1 at the four rating teams in the Elderly project
ICC (95% CI) Danish rating team (n=52)
ICC (95% CI) Dresden rating team
(n=12)
ICC (95% CI) Munich rating team
(n=13)
ICC (95% CI) US rating team (n=20)
Question 0.95 (0.90;0.97) 0.99 (0.97;1.00) 0.88 (0.71;0.96) 0.96 (0.89;0.98) Simple reflection 0.86 (0.76;0.92) 0.89 (0.47;0.97) 0.60 (0.08;0.86) 0.38 (-0.21;0.75)Complex reflection 0.87 (0.74;0.93) 0.67 (-0.13;0.90) 0.62 (0.12;0.87) 0.82 (0.34;0.94)
Affirmation 0.85 (0.78;0.91) 0.59 (-0.18;0.88) 0.86 (0.64;0.95) 0.66 (0.18;0.87)Seeking collaboration 0.83 (0.74;0.89) 0.04 (-0.95;0.65) 0.89 (0.71;0.96) 0.18 (-0.26;0.57)
Emphasize autonomy 0.52 (0.29;0.69) -0.22 (-4.85;0.67) 0.35 (-0.71;0.79) 0.27 (-0.33;0.66)
Summary scoresRelational: average of Empathy and Partnership
0.84 (0.75;0.90) 0.81 (0.34;0.94) 0.36 (-0.61;0.79) 0.26 (-0.93;0.71)
Technical: average of Cultivating change talk and Softening sustain talk
0.80 (0.70;0.88) 0.42 (-0.30;0.81) 0.48 (-0.32;0.83) 0.05 (-1.00;0.59)
% Complex reflections of all reflections
0.65 (0.47;0.78) 0.61 (-0.18;0.89) 0.27 (-0.60;0.74) 0.19 (-0.12;0.56)
Reflections to Questions ratio
0.95 (0.93;0.97) 0.77 (0.25;0.93) 0.47 (-0.16;0.81) 0.68
MIA: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)
0.85 (0.76;0.91) 0.27 (-0.32;0.72) 0.90 (0.74;0.97) 0.58 (-0.16;0.85)
MINA: MI-non-adherent (persuasions + confronts)
0.86 (0.79;0.91) 0.99 (0.98;1.00) 0.62 (0.06;0.87) 0.00 (-1.53;0.60)
ICC Benchmark value
0.00-0.39 Poor
0.40-0.59 Fair
0.60-0.74 Good
0.75-1.00 Excellent
Percentage of agreement on global measures - the percentage of ratings were the raters differed by more than one on the Likert scale
Danish site Dresden site Munich site
US site
Cultivating change talk
50% 92% 92% 70%
Softening sustain talk
85% 92% 92% 95%
Partnership 79% 92% 77% 100%
Empathy 94% 100% 77% 100%
How was the fidelity to MI?
MITI 4 expert recommendations: Fair MI Good MI
Relational: average empathy and partnership
3.5 4Technical: Average cultivatingchange talk and softening sustain talk
3 4
% Complex reflections of all reflections
.40 .50Reflections to questions ratio 1 2MIA: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)
- -
MINA: MI-non-adherent (persuasions + confronts) - -
Description of MITI 4 scores and median values for each country in the Elderly Study
Denmark (Sessions rated=423)
Germany (Sessions rated=107)
USA (Sessions rated=177)
Behavioural counts Median (p25;p75) Median (p25;p75) Median (p25;p75)
Summary scoresRelational 4 (4.0;4.5) 4.5 (4.0;4.5) 4.5 (4.5;5.0)
Technical 4 (3.5;4.5) 4.3 (4.0;5.0) 4 (3.0;4.5)
%Complex Reflections 59 (50;68) 30 (18;44) 42 (36;50)
R/Q-ratio 1.8 (1.3;3.0) 1.3 (0.8;2.1) 1.9 (1.3;3.0)MI Adherent : Affirmations, seeking collaboration, emphasize autonomy
2 (1;3) 3 (1;5) 6 (4;8)
MI Non-Adherent 0 (0;1) 1 (0;2) 0 (0;0)
Percentage of sessions fulfilling 4 benchmarks, Fair MI
72% 27% 53%
Percentage of sessions fulfilling 4 benchmarks, Good MI
27% 7% 11%
MITI 4 scores and median values for each country in the Elderly Study
Denmark (N=423)
Germany (N=107)
USA (N=177)
Behavioural counts Median (p25;p75)
Median (p25;p75)
Median (p25;p75)
Questions 11 (6;17) 11 (8;16) 9 (6;12)Simple Reflections 8 (5;13) 11 (6;17) 10 (7;14)
Complex Reflections 12 (8;17) 4.5 (3;7) 7 (5;10)
Affirmation 0 (0;1) 1 (0;2) 2 (1;3)
Seeking Collaboration 1 (0;2) 1 (0;3) 2 (1;4)
Emphasize Autonomy 0 (0;0) 0 (0;1) 1 (0;2)
Baseline demographics by country in the Elderly StudyDenmark (n=341)
Germany (n=203) USA (n=149) All (n=693)
Age: mean years (SD)** 65 (4) 67 (5) 65 (5) 66 (5)
Gender: % male* 64 52 60 60
Married or cohabiting, %** 45 57 39 47
Employment, % full or part time work** 15 24 28 20
Retired, % *** 63 71 50 63
Education, %high school or more*** 43 43 91 54
Previously received treatment, %*** 62 19 37 44
Alcohol Dependence Scale, mean (SD)***
12 (6) 6 (4) 12 (7) 10 (6)
Symptoms of mild to moderate depression, % ns
10 5 9 8
Rulers, Importance, mean (SD) on a scale 0-10***
8.8 (2.1) 8.2 (1.7) 8.6 (2.1) 8.5 (2.0)
Rulers, Confidence, mean (SD) on a scale from 0-10***
7.6 (2.2) 6.9 (2.0) 6.7 (2.5) 7.2 (2.2)
Rulers, Readiness, mean (SD) on a scale from 0-10***
8.9 (1.8) 8.4 (1.8) 7.9 (2.2) 8.5 (1.9)
Drinks per drinking day1, mean (SD)*** 10 (7) 7 (4) 9 (7) 9 (6)
Percent days abstinent, mean (SD)* 32 (37) 21 (28) 27 (33) 28 (34)
Percent heavy days of drinking, mean (SD)ns
58 (39) 60 (39) 56 (39) 58 (39)
*p<0.05 **p<0.01 ***p<0.001 NS: Not significant 1One drink=12 grams of alcohol.
Statistics by site in the Elderly study
Mixed effects linear regression
Adjusted for demographicdifferences.
Nested within country and patient-baseline.
USARelational score and MIA’s
DenmarkComplex reflections
GermanyTechnical score and Persuasions
Fidelity between countries
What about differences between sites?
The same analysis
Nested within site
Fidelity between countries
Affirmations by site in the Elderly study
Mixed effects linear regression
Seeking collaboration by site
Emphasize autonomy by site
% Complex Reflections
Technical score
Relational score
Being male participant was found associated with the delivery of less complex reflections, less affirmations, and less partnership and empathy. Gender differences were found in the Elderly Study: Female participant had worse outcomes!Depressed symptoms – associated with higher level of affirmationsWorking – associated with lower levels of affirmationsHigher education – more complex reflections
Demographic factors
Despite the effort for alignment there were large differences in the delivery in MI across countries and
sites
No differences in effects of treatment between site or country in The Elderly Study
Comparisons between studies with caution
Discussion
MI is highly adaptable – maybe this is why it workswell with ethnic minorities
MI follows the patient – the therapist is assumed to adapt to the cultural language, norms and values of the patient – thus depending on the patient, delivery of MI
may changeLanguage and linguistics are particularly emphasized in
MI – conceptual equivalence may be hard to document?
Comparing how MI is delivered across countries and cultures is hampered by the diversity of studies
Discussion
Only a few studies shed light on how patient characteristics alter MI-delivery:
Owen et al. 2017: Illegal activity MI fidelity lower
Imel et al. 2011 (ITRS): Use of substance during treatment, Psychiatric symptoms or social problems
MI fidelity lowerLegal problems MI fidelity higher
Discussion
Westra et al. 2016CBT combined with MI for Anxiety disordersResistance in sessions and increased MI-fidelity
The timing of MI-elements more important than the overall fidelity to MI
Is this captured by the MITI 4?
Discussion
What about the rater and how he affects the ratings?
Some level of subjectivity – minimized by training
Sensitivity to tone of voice may differ based on:Level of stress
Personality/Empathic abilityLanguage
Lack of reporting on rating teams in general– a gray area in research which may compromise our
conclusions from MITI ratings
Discussion
MITI 4 ratings assesses one perspective of the quality of MI
The MITI scores are a result of not only the therapist behavior, but also the client, the rater and the culture/setting in
combination
Predictive validity of the summary scores was not confirmed in this study
Maybe the change in summary scores within therapists are more important measures?
Discussion
Supervisors during the phd project: Anette Søgaard Nielsen
Kjeld AndersenTheresa B. Moyers
Thank you for unconditional financial support to:
Thank you for listening