Jim McCambridge. London School of Hygiene & Tropical Medicine. January 2013

Transcription

1 Jim McCambridge London School of Hygiene & Tropical Medicine January 2013

2 Part 1: Introduction Part 2: Studying MI fidelity and effectiveness Part 3: Findings in practice with young cannabis users

3 >1300 research papers published and growing fast, >200 randomised trials, find out what s already been done and build on it

4 Elimination of general principles of MI Expanding the Spirit of MI: Partnership, Acceptance, Compassion, and Evocation Directional, not directive Counseling with neutrality informed by MI Change is broader than behavior Change Talk: Preparatory and Mobilizing Responding to Change Talk Replacing Resistance: Sustain Talk and Discord Deletion of two phases of MI Description of four central processes in MI

5 1. Engaging 2. Focusing 3. Evoking 4. Planning

6 Outcome OR 95% CI Overall effect Alcohol amount Cannabis amount Tobacco abstinence

7 P value Number of M.I. sessions.49 Time spent training.16 Patients age.81 Sex.66 Rigor.90 ** Total minutes delivering M.I. = time in session x # of sessions **.07

8 The dancers The context The dance

9 Clients/Participants Counselors/Interventionists

10 Help-seeking vs. Opportunistic Pristine vs. Non-responders Single problem vs. Multiple problem Age range Ethnic minority/disadvantaged Stage of change Exclusion criteria?

11 Client characteristics impact outcome Baseline moderators: Who responds? Initial motivation (e.g., stage) Severity Ethnicity in US (Hettema et al. 2005) Traits (e.g., anger) What factors would you bet on? In-session client mediators

12 Type of interventionist Professional background/education Professional vs. Peer Prescreened for skill (e.g., empathy) Training/experience in MI

13 Starting skill level Training to criterion vs. Training dose Skill threshold for efficacy? Basic competence vs. proficiency Set the bar high to get less therapist variability Not just initial training Ongoing monitoring, coaching

14 Usually large in MI research Baseline moderators? Typically not In-session process measures predict outcome

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16 No treatment Assessment only Waiting list Brief advice Treatment as usual Bona fide comparison treatment (horse race) Non-inferiority design Active treatment with/without MI (additive) Pre-implementation baseline (cohort) MI-untrained clinicians

17 Intensity/extensity Pure vs. hybrid Manual-guided? Fidelity/QA Qualitative

18 Exclusivity Pure MI only (Clinical style) MI Plus (e.g., MET) Hybrid (e.g., MI and CBT) Embedded in normal practice Manual guided?

19 Observation is essential (audio/video) Selection of sessions to record (or all) Coding How long a sample? Where in the session? Counselor only (MITI) or Client talk, too (MISC) Transcription vs. on the fly What dimensions are most important to outcome? Limitations of global ratings vs. behavior counts Sequential coding

20 Empathy Strong and consistent effects MICO Autonomy support may be central Whether to include OQ and CR MIIN The more MIIN, the less change Spirit Modest effect; measurement problem? R:Q Modest effect and Client Change Talk!

21 Brief interventions for multiple behaviours What matters most? Group interventions Recording challenges; identifying speakers Limited talk time of individuals Break-out discussions Is MI fidelity different in groups?

22 Effectiveness findings London studies - non-help seekers Other studies brief treatments Fidelity findings

23 CYT MET/CBT combos Bob Stephens/Denise Walker MCU (plus non-tx) Jan Copeland et al. 6/4 session F-F CB/MI combo, now phone and online as RYU Amanda Baker combos for mental health issues Kathy Carroll combo programme incl. data on young adults

24 2004 demonstration of impressive short-term effects (ES=0.75) in topic-based multiple-behaviour targeting vs no intervention 2005 demonstration of deterioration of these effects 2008 low fidelity indistinguishable in effects from structured information and advice 2011 universal prevention ineffective (for all subs)

25 Non-significant differences in outcome among all 4 practitioners Practitioner 1 higher crude cessation rates than 2-4; 50% cp 21-27%; χ2 [1] = 4.79, p=0.029 Practitioner effect (ICC) too small to be estimated in hierarchical model - behaviour very different in different sessions

26 Ceased use (n=23) Continued use (n=52) t= p= Empathy 5.17 (1.15) 4.63 (1.41) Spirit 5.04 (1.11) 4.33 (1.45) Reflections/questions ratio 0.71 (0.22) 0.70 (0.29) % Complex reflections 0.60 (0.21) 0.49 (0.16) % Open questions 0.35 (0.09) 0.36 (0.09) % MI adherent 0.73 (0.29) 0.72 (0.30)

27 Log Odds ratio (95% CI), p-value MI Spirit 0.5 ( ), <0.001 % Complex reflections 3.9 ( ), <0.001 Points towards Miller s original combination of Rogers and behaviour therapy (interaction ns)

28 >1300 research papers published and growing fast, >200 randomised trials, find out what s already been done and build on it