Thoughts on the real active ingredients in Motivational Interviewing outcomes

Pace, et al. (2017) completed a meta-analysis in an attempt to clarify links between Motivational Interviewing (MI) processes and clinical outcomes; in other words trying to get to the active ingredients in MI therapy.  They looked for links between: therapist fidelity to MI, client change talk and clinical outcomes; client change talk and outcomes; therapist fidelity to MI and their global ratings of empathy and MI spirit; client change talk and therapist global ratings; and therapist global ratings and clinical outcomes.  Their findings reflect gradients of success that do suggest some things worth thinking about as they relate to our understandings of consciousness and as considered from a phenomenological perspective. 

In their literature review they cited studies by McCambridge et al. (2011) and Tollinson et al. (2008) that suggest that complex vs. simple reflections and MI spirit yield better outcomes; outcome was not defined in the former and the latter found no other correlate to cannabis use cessation.  A humanistic psychology perspective would suggest that MI is based in a heuristic process that facilitates self discovery and that therapist’s that generate more complex reflections, empathy and positive regard (MI spirit) are likely more engaged in the encounter, or more authentic in their interest (Handmaker, & Walters (2002).  This idea is also supported by the likelihood that the development of more complex reflections requires the close listening that would arise when a sincere empathy and an authentic intentionality to be helpful are in place; for example see Billow (2010), Heery (2009) and Orange (2001).  Are Roger’s Empathy and Authenticity (Raskin & Rogers, 2005) the real and perhaps only active ingredients in MI?  

Backing through the results of the Pace, et al. (2017) model, expectantly client sustain talk strongly and negatively correlated with positive client outcomes (r=-.23); unexpectedly client change talk also negatively correlated to positive outcomes but the correlation was not significant (r=-.05).  Fidelity to MI significantly correlated with both client change talk (r=.17) and sustain talk (r=.10) suggesting that extra-therapeutic factors, including client stage of change, likely influence whether fidelity to MI results in negative or positive outcomes.   MI therapist inconsistency correlations to both change (r=.02) and sustain (r=.06) talk were not significant also reinforcing the important role that extra-therapeutic factors likely play in therapy outcomes (Wampold, 2001).  Therapist global ratings of perceived empathy and MI spirit significantly correlated with both client change (r=.25 and .25 respectively) and sustain (r=-.18 and -.13 respectively) talk, and overall empathy and MI spirit present as having the greatest positive, but not significant influence on client outcomes (r=.03 and .04 respectively).  

These results appear to parallel Wampold’s (2001) findings that extra-therapeutic factors account for 87% of therapy outcomes with the remaining contributions coming from: the quality of the therapeutic alliance (8%); allegiance to, or belief in the technique or therapy being applied (4%); and, with only 1% resulting from the efficacy of the technique, or therapy applied, in this case MI. 

In their attempt to further clarify these disparate findings Pace, et al. (2017) indicated that their outcomes support the idea that empathic therapists are more MI consistent in their approach and that this may result in more clinically relevant talk in general; the results also appear to suggest no or a limited control over the direction of this talk and they emphasized the likely importance of reinforcing change talk.  They also suggested that their results may indicate that clients manifest a variable investment in change talk with less investment resulting in the reduced probability of a targeted change.  In line with the second point, only sustain talk significantly predicted outcomes, albeit negative ones, and this suggests that sustain talk may represent a stronger investment in sustaining the behaviors targeted for change; a selective bias and automatic attention toward the interpretation of any factors in a way that defends the status quo.    

Sathian (2002) considers a modern theory of consciousness that builds upon William James' belief that consciousness embodies a constant stream of thought that exercises a considerable selectivity with only the most attractive exposures attended to.  James also suggested that we are not as conscious as we think we are and recommends taking a phenomenological approach to get “beyond initial and surface experiences that are organically …shaped to fit  the preexisting, subjective, conceptual categories of the observer” (Lee, 2007).  James 19^th century thought also parallels modern thought that consciousness is dependent upon the physical actions of neural networks that are constantly reconfigured through their being drawn to selective attention from innumerable possibilities.  The mechanism for how this works is still not fully understood especially as it relates to the subsequent psychology that arises in the process (Block, 2015), but James’ thoughts on consciousness appear to be holding up in today’s research.  Ironically, there is also a great deal interest in conscious processes in marketing and advertising and thus much research related to brand loyalty and selection appears to apply similarly; for example see Janiszewski, Kuo, & Tavassoli (2013) and Ratneshwar, Mick, & Reitinger (1990).                      

And so the Pace, et al. (2017) meta-analysis appears to reinforce the powerful roles that Empathy and Authenticity (Raskin & Rogers, 2005) likely play as active ingredients in MI, as well as the overriding role that extra-therapeutic factors contribute to the outcome of any therapeutic work.  It also reinforces my simple formula that calls for developing and sustaining a productive therapeutic relationship with the sincere intent to be helpful as a client finds his or her way to a more productive way of being.  In William James’ words:

People have goals, and the closer they can get to these goals through practical insight, changes in behavior, and understanding, the less suffering they will have. Concepts and approaches are most valid when they have a meaningful and apparent positive impact in our daily world (James, 1907/1975).

References

Billow, R. M. (2010). Models of therapeutic engagement. Part 2: Sincerity and authenticity. International Journal of Group Psychotherapy, 60(1), 29-58.

http://dx.doi.org/10.1521/ijgp.2010.60.1.29

Block, N. (2015). Consciousness, big science, and conceptual clarity. In G. Marcus & J. Freeman (Eds.), The future of the brain: Essays by the world’s leading neuroscientists (pp. 161-176). Princeton, NJ: Princeton University Press.

Handmaker, N. S., & Walters, S. T. (2002). Motivational interviewing for initiating change in problem drinking and drug use. In S. G. Hofmann & M. C. Tompson (Eds.), Treating chronic and severe mental disorders: A handbook of empirically supported interventions (pp. 215-233). New York: Guilford Press.

Heery, M. (2009). Global authenticity. In L. Hoffman, M. Yang, F. J. Kaklauskas, & A. Chan (Eds.), Existential psychology East-West (pp. 205-219). Colorado Springs, CO: University of the Rockies Press.

James, W. (1975). Pragmatism: A new name for some old ways of thinking. Cambridge, MA: Harvard University Press. (Original work published 1907)

Janiszewski, C., Kuo, A., & Tavassoli, N. (2013). The influence of selective attention and inattention to products on subsequent choice.  Journal of Consumer Research, 39, 1258-1274. Accessed Retrieved August 30, 2017 from the World Wide Web: http://www.jstor.org/stable/10.1086/668234 .

Lee, D. E. (2007). “Instead of Erklarren and Verstehen: William James on Human Understanding.”  In: Historical perspectives on Erklaren and Verstehen, edited by Uljanan Feest, 121-140.  Berlin: Max Planck Institute for the History of Science.     

Orange, D. M. (2002). There is no outside: Empathy and authenticity in psychoanalytic process. Psychoanalytic Psychology, 19(4), 686-700.

http://dx.doi.org/10.1037/0736-9735.19.4.686

Raskin, N. J., & Rogers, C. R. (2005). Person-centered therapy. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies(pp. 130-165). Belmont, CA: Thomson Brooks/Cole.

Ratneshwar, S., Mick, D., & Reitinger, D. (1990). Selective attention in consumer information processing: The role of chronically accessible attributes," in NA - Advances in Consumer Research Volume 17, eds. Marvin E. Goldberg, Gerald Gorn, and Richard W. Pollay, Provo, UT : Association for Consumer Research, Pages: 547-553.

Sathian, K. (2002). The buzz of consciousness. Neurology, 59(6), 800-801.

http://dx.doi.org/10.1212/WNL.59.6.800

Wampold, B. (2001).  The Great Psychotherapy Debate.  New York: Lawrence Erlbaum.

Three articles I came across this month have implications for treatment.  Two relate to the care of adolescents and one to the possibility for positive change to take place with adults during incarceration that may be a relevant target for reinforcement post incarceration.    

 Mattos, Henderson, Schmidt, & Hogue (2017) Looked into the role that the therapeutic alliance plays in the engagement and treatment outcome of conduct disturbed adolescents that present with callous-unemotional (CU) traits; disregard of the feelings of others, blunted affect and little concern for the effect their actions have on others.  Literature cited indicates that these youth generally have a greater expectation of positive outcomes for aggressive behaviors and, in fact callousness in adolescents has been found to predict psychopathy evaluations later in life (Burke, Loeber & Lahey, 2007).   While this is the case, youth higher in CU traits have been found to have better problem solving, relationship and verbal intelligence skills than similarly acting out youth that do not present with CU traits.  Conduct disordered youth high in CU traits have also been found to be better at forming a therapeutic alliance than their low CU trait counterparts but the alliances formed under this condition did not necessarily translate into improved outcomes; it is suggested that high CU trait engagement may have a manipulative intent. 

As with these previous studies, the Mattos (2017) team found that high CU trait youth rated therapeutic alliances more positively supporting previous findings that those with high CU traits have an improved ability to form a positive working alliance.  Inconsistent with previous findings, the Mattos team found that high CU trait youth reporting a poor working alliance also had poorer outcomes (fewer reductions in delinquent acts), while those reporting a positive alliance showed significant improvements (reduced delinquent acts). 

These are clearly contradictory findings and the Mattos team did not suggest a reason for the contradiction.  The work of Matthews (2014) and others may have some insight into a possible reason for the different outcomes.  He cites previous research that suggests that there are differences in the rational decision making traits and skills of psychopaths where some may act impulsively and lack an ability to connect with their own self-interest whereas others may be acting fully rationally and on the basis of a “means by any ends” self interest without regard for others.  The difference in outcome between the studies above may relate to the facilitation of a functional engagement that allows for making a meaningful connection between improvements in behavior, social consciousness and personal self interest.  It would seem that we have an even better opportunity with adolescents to turn this corner by working closely with developmental impulsivity as well as with an improved understanding of individual self interest to facilitate better ways for adolescents to get what it is that they want out of life both short and long term.  Again it appears that a solid working alliance is key to making this happen.  

   

Burke, J. D., Loeber, R., & Lahey, B. B. (2007). Adolescent conduct disorder and interpersonal callousness as predictors of psychopathy in young adults. Journal of Clinical Child and Adolescent Psychology, 36(3), 334-346. http://dx.doi.org/10.1080/15374410701444223

Matthews, E. (2014). Psychopathy and moral rationality. In T. Schramme (Ed.), Philosophical psychopathology. Being amoral: Psychopathy and moral incapacity (pp. 71-89). Cambridge, MA: MIT Press.

Mattos, L. A., Schmidt, A. T., Henderson, C. E., & Hogue, A. (2017). Therapeutic alliance and treatment outcome in the outpatient treatment of urban adolescents: The role of callous–unemotional traits. Psychotherapy, 54(2), 136-147. http://dx.doi.org/10.1037/pst0000093

Lawrence, Nangle, Schwartz-Mette, & Erdley (2017) reviewed the literature on the use of medications for adolescent depression and provided practical suggestions for the clinical practice of non-prescribers.  They found that only SSRIs have been found to be effective in treating depression in youth, but that response rates are similar to the response experienced for adults; approximately 60% respond positively.  They also found that 50% of depressed youth also respond to placebo, and the fact that that response to an active drug is greater than placebo is significant.  Taking all of this into consideration, the exact mechanism that reduces depression is not clear.  For example, “…70 to 87% of symptom reduction seen in antidepressant groups is also seen in placebo groups.”  The Lawrence team cited outcome measures selected, inadequate study design, and publication bias against studies with null or negative findings left out of meta-analyses as well founded reasons to raise the question of whether SSRIs do in fact outperform placebo. 

Whether antidepressants or psychotherapy (Cognitive Behavioral, or Interpersonal for adolescents, CBY, IPT) individually or in combination are superior was also not clear in research reviewed and further research was called for.  One study suggested that adding CBT to antidepressant therapy may improve treatment response, but this did not result in greater improvement over time.  It was also suggested that the combination may result in reduced relapse rates and allow for lower dose medication.  In combination, the findings of studies comparing psychotherapy, antidepressants and their combination were found to be inconsistent in part because of different outcomes reported and inconsistent follow-up times. 

There is also little known about how antidepressants affect rates of depression relapse.  There was one trial that suggested that fluoxetine may lower relapse risk, but contra indications that antidepressants actually increase the risk of relapse over placebo and CBT interventions were cited.  A theory of why this proposed by Whitaker (2015) is cited suggesting that the increased relapse risk may be based in a “compensatory adaptation” where the brain adapts to the SSRI blocking of serotonin uptake that make more available, by reducing natural serotonin production.  In contrast to this, it is also interesting to note that “…no research has found a causal link between serotonin deficits and depression.” 

While this is the case, the FDA has approved two antidepressants for use with youth.  Fluoxetine (Prozac) is approved for 8-17 year olds and escitalopram (Lexapro) for 12-17 year olds.  These two approvals were based on FDA rules requiring at least two adequately completed clinical trials showing a significant difference between drug and placebo.  There appear to be some loop holes in this process however, as the review of other studies, length of study, amount of symptom change, statistical difference (significance defined) and the fact that most of these studies are completed by the drug manufacturers are not taken into consideration in this process. 

In 2005 the FDA convened a panel of experts to respond to concerns raised that antidepressants may increase the risk of suicidality in youth.  The panel concluded that there was an increased risk and a black box warning was added to all antidepressants relating this increased risk with youth.  While this is the case, the panel’s decision is not consistent with empirical evidence that there is not an increased risk; Wagner (2005) found the risk to be 4% in antidepressant treated youth and 2% in those treated with placebo.  The 2% difference does not rise to the level of significance.  It is also suggested that the black box warning may have had a chilling effect overall on the treatment of youth depression; depression diagnoses with youth decreased after the warning was implemented and suicides increased. 

So what does this mean for us non prescribing mental health clinicians?  It seems many of us are not comfortable discussing medications out of fear of crossing some ethical boundary relating to scope of practice.  While this is a healthy attitude it is also short cited from the standpoint of our responsibility to take a whole person perspective on the individuals in our care.  This includes our staying current with all aspects of mental health treatments including the potential benefits of medication when other therapies are not working.  We can and should be able to communicate effectively about the potential efficacy and downsides of medications in relation to the problems that our clients are dealing with.  After all, they are likely already looking things up on the internet and we should be able to serve as filters to help them better understand what it is they are finding.  This is also remembering that clients are ultimately responsible for making treatment decisions and that we can help them in that process by providing relevant information including knowing when a consult with a prescribing practitioner is called for.   

We also need to be able to collaborate effectively with prescribers and it is important that we be able to communicate with them in terms and ways that they will understand.  We most likely see our clients far more frequently than prescribers and thus are in a better position to monitor to see if medications prescribed are working as they should.  When we communicate our observations and concerns in language that a prescriber is used to, we strengthen that relationship, make it more likely that appropriate actions will be taken and our clients ultimately get better care.       

 Lawrence, H. R., Nangle, D. W., Schwartz-Mette, R. A., & Erdley, C. A. (2017). Medication for child and adolescent depression: Questions, answers, clarifications, and caveats. Practice Innovations, 2(1), 39-53. http://dx.doi.org/10.1037/pri0000042

Wagner, K. D. (2005). Pharmacotherapy for major depression in children and adolescents. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 29(5), 819-826. http://dx.doi.org/10.1016/j.pnpbp.2005.03.005

Vanhooren, Leijssen & Dezutter (2017) interviewed 10- prisoners to build on previous literature that indicated differences in offender post incarceration recidivism were related to the continuation of empty meanings vs. the development of “self-transcendent values and the desire to mean something for others. “  They wanted to find out if the development of new meaning is related to the losses experienced and the possible way that prisoners cope as a pathway to posttraumatic growth; experienced loss, search for and the finding of new meaning through an experience of existential guilt and despair that leads to an ability to choose otherwise and to take responsibility through a new or renewed self efficacy.  

They did in fact find that the experience of incarceration after the commission of a crime was initially experienced as dehumanizing; physical discomfort, concerns for safety, and harsh treatment by prison guards was found to lead to despair and a more general loss of meaning in life.  Being imprisoned also appears to reinforce guilt and shame.  Inevitably these prisoners struggled to cope primarily through seeking social and emotional support and the minds work to make sense of and give meaning to their experiences.  More pragmatic coping included the avoidance of contact with other prisoners, isolating/ sleeping more and the use of drugs and medications.  Given a great deal of unstructured time, these prisoners began to reflect on the meaning of their lives, found emotional support in religious pursuits and engagement in therapy; coping became a matter of exercising choice, the facilitation of  a sense of self efficacy and an improved sense of self worth.  Collectively the experiences appear to have shed light on histories that suggest an avoiding the task or I-it approach to engaging life vs. the practice of an I-thou true engagement with life; improved self worth, autonomy, connectedness, responsibility to,  acceptance of and openness and these processes appear to suggest that post traumatic growth actually positively affects what otherwise may be seen as relatively fixed personality traits. 

While the collective literature suggests that post traumatic growth could take place, it does not necessarily have to and the question is raised as to whether it can be facilitated in any way.   While this is a question for further research, it would seem to make sense for post incarceration treatment and rehabilitation settings to assess for and reinforce any post traumatic growth identified.  This might be accomplished by exploring the Vanhooren team findings in a series of groups or individual sessions, or therapy exploring:

• ·         Insight into one’s personal story and dynamics – shift in past experience of self and current
• 
  
• ·         Levels of self worth – ratings and descriptions of self respect, self care and felt autonomy
• 
  
• ·         Perceived strengths – perceptions of seeking and accepting help, conscientiousness, responsibility for and to
• 
  
• ·         Ways of thinking – narrow, impulsive vs. expanded and nuanced
• ·         Meaning in life, and
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• ·         Continued struggles and anxieties about the future

It is expected that these explorations may serve to highlight the processes of recovery from real losses experienced, reinforce some of the resilience skills that served that coping, and build upon new ways of being and thinking that will support a continued recovery trajectory.      

Vanhooren, S., Leijssen, M., & Dezutter, J. (2017). Ten prisoners on a search for meaning: A qualitative study of loss and growth during incarceration. The Humanistic Psychologist, 45(2), 162-178. http://dx.doi.org/10.1037/hum0000055