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 19th 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).
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