Where does MI fit in the family of psychotherapies?

So far, most descriptions of MI practice and coding of MI sessions have used MI-specific instruments

Miller & Rose 2009 described relational and technical hypotheses for MI effects

Using both MI and general psychotherapy coding systems may better describe MI

Coding systems must be practical and useful

To explore the utility of a novel 2-pass coding system composed of existing, validated instruments that assess MI and psychotherapy concepts

To describe MI through the lens of traditional psychotherapy concepts

First pass: Psychotherapy Q Set (PQS): ranked top 13 of 100 Proportion Time Focus: past, present, near future,

far future Dimensional rating and CLOPT: Interpersonal

characteristics of therapist and client MITI- 3: MI Fidelity MISC-1/2 elements: selected therapist and client

behaviors MISTS: MI principle-based strategies

Second pass: Patient Change Talk tallies: importance,

confidence, commitment, taking steps, (plus/minus coding)

Working Alliance Inventory-O: Goal, task, bond

YACS and Strategies Checklist: Treatment-specific content and strategies

Client Centered Therapy and MI share: humanistic perspective, reflective listening

Cognitive Therapy and MI share: task orientation, planning and initiating behavior change

Can the coding system distinguish them? General Hypotheses

Relational elements: Client => MI > Cog

Technical/directive: Client <MI <= Cog

Demonstration Tapes used as exemplars of three methods

Client centered therapy: Carl Rogers “Gloria”

Motivational Interviewing: Bill Miller “Soccer Guy”

Cognitive therapy: Judith Beck “Depressed Mom”

5 raters experienced with MITI and other MI and psychotherapy coding, involved in larger projects

4 week training phase: raters coded other audio and videotapes until good agreement reached

Clarifications and reminders in weekly rater group meetings

Subsequent to reaching good agreement across raters, each rater independently coded all 3 full length videos

Raters each coded tapes twice (two passes) Final inter-rater agreement was calculated

for global, behavior count/ratio, and interactional variables using Shrout & Fleiss IntraClass Correlation Coefficients (ICCs)

Behavior count variables were divided by session length to create variables representing behaviors per minute

Therapist Global Variables

Intra-Class Correlation

Client Global Variables

Intra-Class Correlation

MITI Empathy .57 Client Self Exploration .49

MITI MI Spirit .80 Disclosure .57

MITI Direction .71 Engagement .80

Therapist affiliation (Friendly-Hostile) .05 Patient affiliation (F-H) .82

Therapist control (Dominance-Submission)

.92 Patient control (D-S) .90

MISTS Attends to change talk .88

MISTS Addresses ambivalence .87

MISTS Roll with resistance .80

MISTS Support self efficacy .76 N=3 samples, K=5 judges/raters

Therapist Count/Ratio Variables

Intra-Class Correlation

Client Count/Ratio Variables

Intra-Class Correlation

MI Adherent .90 Importance Plus & Minus .62

MI Non adherent .91 Confidence Plus & Minus .49

Provide information .92 Commitment Plus & Minus .29

Closed questions .98 Taking Steps Plus & Minus .67

Open questions .99

Simple reflections .98

Complex reflections .94

Interaction Global Variables Intra-Class Correlation

Interaction Proportional Variables

Intra-Class Correlation

Alliance goal .72 Time Focus Past .19

Alliance task .21 Time Focus Present .75

Alliance bond .89 Time Focus Near Future .49

Time Focus Far Future .66

Client-Centered

Therapist clarifies, restates, or rephrases

patient’s communication

Therapist adopts supportive stance

Patient seeks therapist’s approval, affection, or

sympathy

Self-image is a focus of discussion

Therapist conveys a sense of nonjudgmental

acceptance

MI

Therapist conveys a sense of nonjudgmental

acceptance

Therapist adopts supportive stance

Therapist asks for more information or

elaboration

Therapist clarifies, restates, or rephrases

patient’s communication

Dialogue has a specific focus

Cognitive Therapy

Patient’s interpersonal relationships are a major

theme

Discussion centers on ideas or belief systems

Therapist is sensitive to the patient’s feelings, attuned to

the patient; empathic

Therapist actively exerts control over the interaction

(e.g., structuring, and/or introducing new topics)

There is discussion of specific activities or tasks for the

patient to attempt outside of session

0

10

20

30

40

50

60

70

Past Present NearFuture

Far Future

Client Centered MI Cognitive

Interactant Circumplex

Friendly- Dominant

Dominant

Hostile- Dominant

Hostile

Hostile- Submissive

Submissive

Friendly- Submissive

Friendly

Interpersonal Ratings: Therapist

45

90

135

180

225

270

315

0

Client Centered

MI

Cognitive

0

10

20

30

40

50

60

70

Total Goal Task Bond

Client Centered MI Cognitive

0 1 2 3 4 5

PlanCommit

PlanBehaviors

Set Goals

SupportSystem

ExploreDenial

Feedback

Check In

SetAgenda

Cognitive MI Client CenteredX axis = n Raters who

endorsed the strategy

0 1 2 3 4 5

Task or HW

ChallengeAutothoughts

ID Thinking errors

ID Auto thoughts

Cognitive MI Client CenteredX axis = n Raters who endorsed

the strategy

Empathy

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

Empathy Direction MI Spirit

Client Centered MI Cognitive

1

2

3

4

5

6

7

Attends to CT Address Ambivalence

RollwResist Support Self Efficacy

Client Centered MI Cognitive

0

2

4

6

8

10

12

14

16

MI Adherent MI NonAdherent

Client Centered MI Cognitive

Adherent= Asking Permission to Provide, Emphasize Choice/Control, Reframe

Non-adherent=Advice without Permission, Confront, Direct

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Client MI Cognitive

Info

Questions

Reflections

1

2

3

4

5

6

7

Self-Exploration

Cooperation Disclosure Benefit

Client Centered MI Cognitive

Client Globals: Self-Exploration, Cooperation, Disclosure, Benefit

-0.2

-0.1

0

0.1

0.2

0.3

0.4

0.5

Client Centered MI Cognitive

(MI = Client Centered) > Cognitive on Empathy, MI Spirit

(MI =Cognitive) > Client Centered on Direction Client Centered < MI < Cognitive on

Interpersonal dominance All = on Working Alliance (MI = Cognitive) < Client-Centered in Client

Self-Exploration All = in Client Cooperation, Benefit,

Disclosure

Cognitive> MI > Client Centered in Questions and MI Adherent behaviors

MI > Client Centered > Cognitive on Reflections Cognitive > (Client Centered =MI) on MI-Non

Adherent behaviors MI > (Client Centered = Cognitive) on

Responding to change talk (MI > Client Centered) > Cognitive in

Addressing ambivalence, Rolling with resistance

(MI = Cognitive) > Client Centered in Supporting self efficacy

(MI = Cognitive) > Client Centered in Direction Client Centered < MI < Cognitive on number of

technical therapy strategies (Client Centered =MI) > Cognitive on net

Importance Change Talk (Client Centered = MI) > Cognitive on net

Confidence Sustain talk All = in and near zero in net Taking Steps and

Commitment talk (Cognitive =Client Centered) < MI on Focusing on

the Present and Future

Coding system distinguished MI from Cognitive and Client-Centered therapies

Coding system illuminated relational and technical qualities of MI through a psychotherapeutic lens

The specific combination of MI and other relational and technical processes in MI may be unique

Coding system is not reliable enough on time orientation, therapist interpersonal style, and net change talk in importance, confidence, and commitment areas

Objective coding of many important psychotherapy processes can be done in 2 passes

Using existing instruments in combination is a parsimonious method to gain information about MI’s characteristics from a psychotherapy perspective

The coding system should be refined to improve inter-rater agreement

Supported by NIH R01AA015930 Thanks to our Demonstration Video project

coding team: Amy Fansler, Leah Farrell, Kendall Plageman, Stefania Fabbri, and Jenny Hettema