Presentation for HQ
Dutch Prison Service, the Netherlands 2012 www.farbring.com


Effective treatment in Criminal Justice to reduce recidivism in drugs and crime
 Berman, A., & Farbring, C.Å.
(2010) Criminal Justice in practice. Strategies to reduce relapse in crime and drug use.
Studentlitteratur. I boken medverkar bl.a. James
McGuire, Don Andrews, Philip
Priestley, Joel Ginsburg,
Belinda Seagram, Johan
Franck, Sten Levander, Marie
Levander, Sten Rönnberg,
Johan Kakko , Björn Fries,
Agneta Öjehagen, Hans
Bergman, Helene Lööw, Siv
800 pages

MI - an explosion of knowledge

> 1000 publikationer

> 200 randomised clinical studies

Dozens of books

10 Multisite clincal trials

Coding system to control quality

Research on how to learn MI

MIA-STEP – Structure as a help for trainers

And still we are only in the beginning!!! We know very little on how
MI works.
 Motivational Interviewing; carl åke farbring, 2001- workshopmaterial

Farbring, C. Å. &
Johnson, W.R. (2008). MI Corrections.
In Hal Arkowitz, Henny Westra, William
R. Miller & Steve Rollnick: Motivational
Interviewing in the Treatment of
Psychological Problems. New York:
Guilford c åke farbring, 2008

What Works; accredited programs

Reasoning and Rehabilitation

One-to-One

ART

Offender Substance Abuse Program (OSAP)

Brotts-Brytet

Enhanced Thinking Skills

ROS; sexual offenders

Domestic Violence (IDAP)

PRISM

BSF(MI:5;semistructured MI in five sessions)

Relapse Prevention/MI 5

 ”…results do not provide strong evidence of treatment effectiveness .”
 …”there is limited evidence to demonstrate what impact these interventions actually have in practice .”
 ”Thus, no outcome evaluation in this report provides unequivocal evidence of ”what works ” in corrections.”
Harper & Chitty (2005). The
Impact of corrections on reoffending. A review of What
Works. Home Office Research
Study 291


A multidimensional re-entry demonstration programme to reduce recidivism in New York

Randomised design

Supervised by researchers, organisational support

Evidensbased programmes (R & R, Relapse Prevention,
Job preparation training, social counseling, social skills training, drug treatment, prevention to avoid homelessness, family reunion groups; action plan etc.)

Two control groups
 Results: ……..
7

Outcome Greenlight TSP Upstate Total Significance n=344 n=278 n=113 n=735
Any new arrest 44% 35% 32% 39% .02
New Felony
Arrests 24% 19% 16% 21% Ns
Revocations 29% 25% 17% 25% .05
Vera Institute of Justice
8

0.6
0.4
0.2
0
1.4
1.2
1
0.8
0-1 >1-3 >3-6 >6-12 >12
All Studies
C1
C2
C3
Controlled
Additive
Comparative
MARMITE


Workshops in MI since 1998

2500 probation officers and tutors and client related staff in prison were trained during 3-day workshops 2001-2003.

Government money to reduce substance abuse in prions – approx 80000 USD

Extremely positive feedback

Bill and Steve contributed

Government funds helped
10


After about 100 of these 3-day workshops for prison staff, the Swedish National Council for
Crime Prevention reported ” there is no evidence that there had been any motivational sessions with clients ” (2005).

Risk for negative perception of MI (type 3 error)

Hypothesis: The work situation had not changed for prison officers and others
11

The Implegration Report –
• 5 guided semi structured conversations about change with a work book for clients
•
• Advantage 1 : Intentionally, deliberately performed motivational sessions – not just
”chat” sessions.
• Advantage 2 : Sessions are visible to all, recorded, counted and evaluated.

A Driver ´s Guide through MI
Manual, originally presented 2003
13


Geographic organization

Peer groups – peer review every 5th week; peer monitoring and feedback on tapes (1 PASS)

Certification – 3 audio tapes with feedback between supervisor and tutor (program leader)

Supervisors meet in head office 4 times a year

Positive feedback or lie! Make participants enjoy!

Local ownership! Important!
PL
PL
PL
PHL
PL
PL
PL
15

ONE PASS – monitoring, coaching and positive feedback in BSF/1

ONE PASS
– monitoring, coaching and positive feedback in BSF/2


Programme presented for the first time APRIL 2003

2003: 175 completions

2004: 568 = 79% completion rate

BSF: 73% of increase of programs 2003-04

BSF: 36% av program volume 2004.

2005: 777 completions, 84% completion rate – 64 % of total program volume

2006: 1011 completions

2007: 1698 completions; 90 % completion rate

2008: 2020; 93% completion rate

2009 – 2011: more than 2000 completions/year
18

Average difference from pre- to post test
N Probl recognition /Ambivalence/ Steps
----------------------------------------------------------------
950 0,36 - 0,66 1,84 p<.03 p<.0001 p<.0001
-----------------------------------------------------------------
Clinical observation: Just mentioning change ”inflates” ratings of intentions to change.

Average difference from pre- to post test
N Probl recognition /Ambivalence/ Steps
----------------------------------------------------------------
304 0,63 - 0,56 1,78 p<.03 p<.01 p<.0001
-----------------------------------------------------------------

Average difference from pre- to post test
N Pre C/ Contempl/ Action/ Maintenance
----------------------------------------------------------------
645 0,54 -0,83 1,69 -1,11 p<.004 p<0001 p<.0001 p<.0001
-----------------------------------------------------------------

The Change Questionnaire – a motivational index based on change talk (Miller, Moyers,
Amrhein, 2008)
DIMENSIONS:
Problem recognition: p <.02
Need: p <.3
Desire: p <.0006
Confidence: p <.002
Commitment/Do: p <.02
Taking Steps: p <.0009
Total (N=88) p <.0005
____________________________________

Pearson r = .072 (2-tailed) p<.0001 (N=78)

Average difference from pre- to post test

Desire: 3,85; p<.0001

Self Efficacy: 0,43; p<.0001

Priority; 0,83; p<.0001

Inner motivation: 0,61; p<.0001

Total;3,85; p<.0001
ME OTHERS
The Scale of Balance Exercise: Why I want to change personally (ME) or
Other people or circumstances that influence me (OTHERS)

STAGES OF CHANGE; Where are you in the wheel? Put a mark in the figure!
The Transtheoretical Model according to
Prochaska- DiClemente
DATES AND DEGREES
/ =
°
MAINTENANCE RELAPSE/DRUG USE
= continuation of change…! ”Now I might just as well
”once --always…” keep on - or…”
/ =
°
/ =
°
ACTION
What Works; accredited programs, treatment ...
PRECONTEMPLATION
It doesn´t concern me at all
DECISION
”Now I have had enough…
I really have do to something…”
CONTEMPLATION
= I am ambivalent beginning to see disadvantages...
PREPARATION trying out...
beginning to think how…
I am asking others how they…
18
C. Åke Farbring, 2003

N Prep-5th 5th-later

Average
 difference
 from pre- to
 post test
1368 43,82 24,51
P<.0001 P<.0001

Program counselors assessment of client ´s progress during intervention
Question N % yes
% no
% no answer
1553 52.54
37.03 10.43
Does the client intend to go into more treatment
Does the client want follow-up sessions in
BSF
1537 44.12
38.71
17.17
Have you noticed improvement in collaboration
1541 55.09
38.61
6.29
Have you noticed improvement in desire to change
1550 80.71
15.55
3.74

Client ´s own assessment of the effect of the program on their thinking about change
Statement N %
Absolu tely
NOT
%
Maybe
9.8
I am thinking more about change now than I did before the programme
306 0.65
%
Yes, to some degree
33.01
%
Yes, very much
46.41
%
No answer
10.13
I have already started to make changes
305 1.31
4.59
32.79
51.8
3.74




28

Group N Effect size
All 38 - 0.43
Completers 38 0.15
Lowenkamp, C. T., Latessa, E. J., & Smith, P.
(2006). Does Correctional Program Quality Really
Matter? Criminology & Public Policy, 5, 3, 201-220
29

Correctional Program Assessment Inventory
(CPAI)
(Andrews & Gendreau, 2001)
Unsatisfactory level (24 programs): -1,7%
Satisfactory but in need of improvement (13): - 8,1%
Satisfactory (1): - 22%
Very satisfactory (0)
30

 But not always….
Valence of the Effect Size: the difference between
Positive and Negative
Positive Effect Size Negative Effect Size
70% 70%
60% 60%
50%
40%
r = .40
50%
40%
r = -.40
40% 40%
30% 30%
20%
10%
20%
10%
31
0.0% 0.0%
Control Treatment
DAA – Don Andrews
Control Treatment

A MAJOR CHALLENGE: Programming in the “Real World of Corrections” versus the
“Small Demonstration” Project

Mark Lipsey : effects from treatment in demonstration projects are much higher than in the “real world” of regular programming

Real world: Large samples; Evaluator not involved in design and/or delivery of service
DAA (Don Andrews, 2007)

“REAL WORLD” (k =209)
Any Human Service
65%
Mean RNR Adherence
0.82
Mean Breadth
0.06
“DEMO PROJECT” (k = 47)
98%
2.30
0.23
Sum of Integrity Scores
2.11
Staff Selection, Training, Clinical Supervision
01% 28%
Sum Core Correctional Practices
2.19
1.52
Mean ES
0.03
4.32
0.29
DAA – Don Andrews


Implementation – an intentional process

Bottom-up perspective

An exploring and listening attitude

Local ownership (from the centrally decided goal orientation)

Balance between guidelines and mindlines

Adjusting to local conditions = integration

Positive support more than monitoring and control
35

 Implegration Integrated implementation of Motivational
Interviewing, an evidence based treatment in Swedish Corrections
– a practitioner´s report
February 8-10, 2010
Carl Åke Farbring
36

Dean Fixsen et al., 2005)
37



99% of budget goes to understanding etiologi and writing evidence based treatments; only 1% of the budget to make them work

People cannot benefit from treatment that they do not experience as useful for them !

Implementionteam! 80% in 3 years compared to 14% pin 17 years.

Treatment intervention is not the same thing as implementation.

Implementation
Treatment
Effective
NOT effective
Effective NOT effective
Positive outcome Shortlived
/negative outcome
Negative outcome Negative or even harmful outcome

ICTAB 12, Santa FE, 2010

 ”Implementation – the forgotten issue”
(Gendreau, 1999)
 E g. not just doing the ”right things”
(evidence based) but doing them ”right”.
 ”The implementation gap” (knowledge is not disseminated)

Not a clear discipline and too little research…
39

Implementation: new demands from politicians demand new perspectives

Reduce relapse in crime, increase costeffectiveness from investments.

Well posed hypothesis: Variations in effects = variations in quality of implementation…

Eliminate risk for ( typ III-errors )

Use a deliberate implementation strategy to increase effects from evidence based knowledge and skills.
40


Organization – problem and deficits on organizational level cannot be corrected by eduction (Fridell, 1996).

Teaching ≠ ( learning) > courses, rules, regulations…

Climate

Rethoric = reality
 Requires “ supervision” from the executive level, but…more supportive than controlling and…

Not just contents (program integrity) but quality in implementation
41


Large byreaucratic organisations with large distances between staff, high level of formal and strict (hierarchical) ways of decisions;

Rules, (sanctions)

Top – down

Production ideology, selling in

Lack of collective view, lack of feeling of collaboration, different motives

Insufficent analysis of employer ´s situation

Risk for high levels of frustration

Risk for defensive attitudes
42


Rationality is overestimated by heads and the need for implementation is underestimated
 ”*That´s my decision (these are my orders)”

Of 356 attempts to introduce changes in organisations more than half failed. (Nutt, 1999 )

I most cases this was caused by using the wrong strategy ; orders, rules, top-down
Nutt, 1999, citerad i Robert Holmbergs rapport: Implementering av nya behandlingsprogram i kriminalvården,
2006
43


Implementation – an intentional process

Bottom-up perspective

An exploring and listening attitude

Local ownership (from the centrally decided goal orientation)

Balance between guidelines and mindlines

Adjusting to local conditions = integration

Positive monitoring and support
44


A validated instrument for assessing suitability and readiness for organisations. Organizational
Readiness for change. (ORC)
Lehman, Greeener, Simpson (2002)

Research at the Institute of Behavioral
Research, Texas Christian University.

JSATs special issue October 2007: 10 articles about implemation (only).
45

• Experienced possibility for peer influence
• Organisation can with credibility impart ”a mission”
• Easy access to the Internet
• Feeling of need to get better in working with programmes
• Generous possibilties for personal growth and development
• A certain level of stress in the organisation (!?)
Fuller, Rieckmann, Nunes, Miller, Arfken, Edmundson, McCarty. (2007) Organizational readiness for change and opinios toward treatment innovations. Journal of Substance
Abuse Treatment.
46

Dimensioner:
A.
Organisation
B.
Program characteristics
C.
Staff
D.
Clinical skills
E.
Integration, contextual factors
F.
Clients
G.
Evaluation
(Farbring, 2007) 47

Goals:
1.
Increase effectiveness from programmes
- reduce relapse
2.
Assess need for support
3.
Produce information for self assessment
4.
Assess suitabilty for (further) programme work
(Farbring, 2007) 48

KIMexempel på schema för bedömningar
49

KIM exempel på kodnyckel
50

51

 Forsberg, L., Ernst, D., & Farbring, C. Å. (2010)
Learning motivational interviewing in a real-life setting: A randomised controlled trial in the
Swedish Prison Service. Criminal Behaviour and
Mental Health.
(wileyonlinelibrary.com) DOI:
10.1002/cbm.792

ABSTRACT:

Background Motivational interviewing (MI) is a client-centred, directive counselling style for helping people to explore and resolve ambivalence about behaviour change and shown to decrease drug and alcohol use. A fivesession semi-structured MI intervention
(Beteende Samtal Förändring (BSF; Behaviour,
Counselling, Change)) was implemented in
Swedish prisons.


Aims To examine whether, in a real-life implementation of semi-structured MI, staff receiving ongoing MI training, based on audio-recorded feedback in peer groups (BSF+) possess greater MI skill compared with staff receiving workshop-only MI training (BSF), and staff conducting usual prison planning interviews (UPI).

Methods Prisoners were randomised to one of the three interventions. The first sessions between staff and prisoner with complete data were assessed with the
Motivational Intreviewing Treatment Integrity Code 3.0.

Results Content analysis of 45 staff: prisoner sessions revealed that counsellors in the BSF+ group were significantly more competent in MI than those in the UPI group, but there was no difference in MI competency between the BSF and the UPI groups.
Overall, staff were rated as not having achieved beginning proficiency.


Conclusions Our findings suggest that staff delivering motivational interviewing programmes for substance-misusing prisoners in Sweden are not being given sufficient training for the task.
Previous literature has suggested that staff need more than a basic 3- to 5-day workshop training, but our findings suggest that they may need longer-term continuing supervision and support than previously recognised.

Mean value of indices calculated on estimates of behavioral measures and behavior counts for all intervention groups
Global ReflecComplex Open q/q MI MI nonvariables tions/q r/r (%) (%) adherent adherent
Information giving
Ref value
UPI M n=14 SD
BSF M n=27 SD
BSF+ M n=42 SD
M=1.0
.49
.24
.53
.32
.56
.31
M=0.40
.09
.12
.21
.16
.27 *
.21
M=0.50
.26
.15
.28
.11
.33
.15
.10
.32
.86
.95
1.24 *
1.34
1.70
1.57
1.14
1.66
.52
1.12
11.50
10.57
13.14
6.16
14.62
5.43
BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI scores BSF > UPI but not significant. Here BSF+ and even – if not significantly – BSF seems to matter. (Note no difference between BSF and BSF+) However suggested level of proficiency is not reached.
55

Mean value for estimate of global measures in all intervention groups
Global variables
UPI M n=10 SD
BSF M
N=14 SD
BSF+ M
N=21 SD
Empathy Evocation Collabor Autonom MI Spirit Direction
2.30
.82
2.50
.85
3.10 (*)
.89
2.10
.74
2.43
1.02
3.10 *
.89
2.40
.97
2.57
.76
3.10
.89
2.20
.79
2.71
.82
3.14 *
.79
2.23
.74
2.57
.72
3.11 *
.71
4.20
1.03
4.14
1.45
4.71
.56
Analysis of variance: BSF+ > (s) UPI/BSF in empathy, evocation, autonomy and MI spirit.
BSF+ scores > 3 on average (ref.value 3.5 (Moyers et al., 2007) No difference between
UPI and BSF
Adjusted (Bonferroni, post hoc tests) indicate significant differences in evocation : (mean difference -.995, p = .019), autonomy (-.943, p = .012), MI spirit: -878, p = .008)
56

Mean value of indices calculated on estimates of behavioral measures and behavior counts for all intervention groups
Global ReflecComplex Open q/q MI MI nonvariables tions/q r/r (%) (%) adherent adherent
Information giving
Ref value
UPI M n=14 SD
BSF M n=27 SD
BSF+ M n=42 SD
M=1.0
.49
.24
.53
.32
.56
.31
M=0.40
.09
.12
.21
.16
.27 *
.21
M=0.50
.26
.15
.28
.11
.33
.15
.10
.32
.86
.95
1.24 *
1.34
1.70
1.57
1.14
1.66
.52
1.12
11.50
10.57
13.14
6.16
14.62
5.43
BSF+ > (s) UPI in percentage complex reflections and MI adherent than UPI. Mean MITI scores BSF > UPI but not significant. Here BSF+ and even – if not significantly – BSF seems to matter. (Note no difference between BSF and BSF+) However suggested level of proficiency is not reached.
57


Basic training in MI BUT ---

The effect is an effect from implementation/implegration – not training.
58

 Forsberg, L. G., Ernst, D., Sundqvist, K., & Farbring, C. Å. (2011)
Motivational Interviewing Delivered by Existing Prison Staff: A
Randomized Controlled Study of Effectiveness on Substance Use After
Release.
Substance Use & Misuse . Informa Healthcare. DOI:
10.3109/10826084.2011.591880.

Abstract: A sample of 296 drug-using inmates in 1
Swedish prisons was randomized during 2004-2006 into three intervention groups; Motivational interviewing deleviered by counselors with workshop-only training, or by counselors with workshop training followed by peer group supervision, and controls. Drug and alcohol use was measured by the Addiction Severity Index (ASI) at intage and at 10 months after release. Complete data from 114 clients were analyzed by a stepwise regression analysis. All three groups reduced alcohol and drug use.
..
There were no significant differences between the groups.


Days with drug use in 30 days prior to arrest (pre-
ASI) and 30 days prior to post-ASI interview for subjects with complete data (n=114)
Interventi on
Pre M(SD) Post
M(SD)
UPI (N=24) 21.8 (11.8) 6.5 (11,8)
BSF (n=35) 23.1 (11.5) 6.5 (11.7)
BSF
+(n=55)
Total
(n=114)
Difference betw. groups
19.9 (12.1) 7.2 (11,6)
21.3 (11.8) 6.8 (11.6)
F= .839
F= .045
p= .435
p= .956
5.63
6.30
6.07
10.23
t df
23
34
54
113 p
<0.001
<0.001
<.001
<.001


Number of days of illegal activity in 30 days prior to interview
Interventi on
Pre M(SD) Post
M(SD)
UPI (N=23) 16.0 (13.8) 3.3 (9.0)
BSF (n=33) 18.6 (13.5) 3.1 (8.8)
BSF
+(n=47)
Total
(n=103)
Difference betw.
Groups
12.2 (13.2) 4.5 (9.5)
15.1 (13.6) 3.8 (9.1)
F= 2.176
F=.083
p=.119
p=.920
4.16
6.5
3.54
7.79
t df
22
32
46
102 p
<0.001
<0.001
<.001
<.001


Number of days working 30 days prior to interview
Interventi on
Pre M(SD) Post
UPI (N=24) 5.1 (9.1)
M(SD)
7.8 (11.0)
BSF (n=33) 2.0(5.9)
BSF
+(n=53)
Total
(n=110)
Difference betw.
Groups
2.1(6.1)
2.73 (6.8)
F= 2.049
p=.134
5.5 (9.9)
4.8 (8.8)
5.7 (9.6)
F=.818
p=.444
-1.07
-1.90
- 2.13
-2.99
t df
23
32
52
109 p
<.296
<.067
<.038
<.003


MI implegration has been highly successful in increasing client motivation to change

MI implegration (MI+) outperforms significantly
UPI in clinical excellence. Effect is probably underestimated, since the study was performed very early …

There is no evidence so far that MI changes offender ´s behavior in prison contexts (for many reasons).

Training means very little and may be overrated

So here is more empirical evidence for…
63


McMurran (2009) * - 19 studies and McMurran
(offending – N=9; substance misuse – N=10), at the ICMI 2 conference, Stockholm 2010:

Three aims with MI:

1. To enhance retention in treatment

2. To improve motivation to change

3. To change behaviour.
* Motivational interviewing with offenders: A systematic review. Legal and Criminological
Psychology (2009) 14, 83-100)
64


Completers show a modest positive effect in reducing recidivism ( d = 0.11)

Important to reduce drop out rates because non-completers show a negative ( d = - 0.16) effect even compared to untreated controls.
”Non-completers are more likely to be reconvicted than untreated .” *

Conclusion: 3 good quality studies: MI appears successful at enhancing retention in treatment for substance misuse.
McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with increased reconviction
65 over no treatment? Psychology Crime and Law. 13. 333-343)

McMurran, M. (2009) – MI with offenders: A systematic review.
Legal and Criminological Psychology, 14, 83-100

MI appears to improve:

- retention in treatment. (Important:
Non-completers are more likely to be reconvicted than are untreated offenders.

Q: What are people doing to reduce non-completion.

A: Not much. Room for MI here.)
self reported motivation to change
MI may be effective in reducing substance abuse especially in conjunction with other treatment components.
Mixed evidence in changing offending behavior.

McMurran, M., & Theodosi, E. (2007) Is treatment non-completion associated with increased reconviction over no treatment? Psychology, Crime and Law, 13, 333-343

16 studies, 19.563 offenders.
66
(McMurran, ICMI 2, Stockholm,
2010)

General conclusions about effects

Effects from interventions vary from negative to positive

Teaching means very little. Learning is what it is all about. MONTY ROBERTS

Style of communication means more than content – empathy-collaboration-engagement

Implementation means more than learning through
(even superior quality) workshops and classes: ►
Learning by doing!

Very few interventions meet these criteria

MI works better combined with other ”practical” interventions – preferably structured in ”MI-style” – for instance: (see next slide)

Vaccination against relapse – A scientifically accredited relapse prevention program in MI style (2006,2011)

Smedslund, G., Berg, R. C., Hammarstrom, K. T., Steiro, A., Leiknes,
K. A, Dahl, H. M., Karlsen, K. (2011) Motivational Interviewing for
Substance Abuse .
Cochrane Database of Systematic Reviews 2011, Issue
5- Art. No.: CD008063. DOI: 10.1002/14651858pub2. (forts.)
Conclusions:

Implications for practice: If the counselor feels comfortable with MI it works better than no treatment.
Compared to CBT there is not enough material to make conclusions if one is better than the other.

Implications for research: There is no lack of RCTs showing if MI works or not. Time has come to find out how MI works and under what condititions. Reference to Apodaca and Longabaugh (2009) – about causality in MI.

John C. Norcross
ICTAB - II
University of Scranton,
Pennsylvania
Striking and large variations in outcomes of treatment (MI). Why?
MI is not a ”method” not a set of skills. Different counselors will yield different quality outcome…

Outcome variance attributed to factors in therapy (%)

MI as a communication style is unique in its focus on general factors and trying to operationalize them !!
Client contribution
25%
Interplay 5%
Method
8%
Unexplained variance 45%
John Norcross, ICTAB 11, 2006.
Unexpl var relation method counselor interplay client

General Factors in treatment explain more of variance of change than specific factors

Expectations

Empathy

Alliance

Affirmations
Can these factors be more accentuated in
MI?

 Expectations – An important part of
MI
HQ Dutch Prison
Service
Netherlands, 2012
Carl Åke Farbring
73


Negative expectations (account for 15% of outcome variation (Lambert, 1992) and
15 —40% of variance in TA ratings.

Overly high expectations can also affect outcome

Risk: repeated relationship terminations …
(”waste of time” – or worse…)


Lambert & Bartley (2002) Expactations the third most important factor after client variables and relation: 15%.

Probably mediated by alliance

Expectations and motivation? Relationship?

Clients who have high expectations will work more actively …. (Joyce at al., 2003)

There is some evidence that clients with modest expectations fare better than clients with high expectations – cf base line motivation

Expectations -- what does the research say?
Constantino, M, J., Arnkoff, D. B., Glass, C. R., Ametrano, R. M., & Smith, J. Z (2011)
Expectations. Journal of Clinical Psychology: In Session, 67 (2), 184-192 (2011) Adapted from chapter in J. C. Norcross (ed) (2011) Psychotherapy relationships that work (2nd ed). New York: Oxford University Press.

Expectations are a key ingredient of successful psychotherapy
(Goldfried, 1980; Goldstein, 1960; Rosenzweig, 1936)
 ” a mobilization of hope for improvement
(Frank,
(1961) Persuasion and Healing.
”Restoring hope and positive expectation is a powerful change ingredient ”…
 ”Psychotherapies are inextricably linked with the manipulation and revision of patients ´ expectations
(Greenberg, Constantino, & Bruce, 2006).

Continuum from benefits of treatment to expectations of positive outcome

Expectations are influenced by earlier treatment and contacts with therapists.

Some used measures in little researched area

Brief (4 items) and study-specific and sometimes confounded with other constructs – e.g. credibility.

Common questions:
At this point, how logical does the therapy offered seem to you?
How successful do you think this treatment will be in reducing your symptoms?
By the end of the therapy period, how much improvement do you think will occur?

In some analyses credibility items hung together while the expectancy items hung together with affectively-anchored items – e.g.
How much do you really feel that therapy will help you reduce your symptoms? How much improvement in your symptoms do you feel will occur?

More about measures etc.

Pessimistic item:
Actually I am rather skeptical about whether treatment can help me …

Prognostic expectations are also affected by context and one ´s own learning experiences.

Outcome expectations and treatment expectations probably interact.
(Constantino et al., 2011)

Is knowledge about patients ´and client´s expectations useful for us in MI?

Meta-Analytic Review (Constantino et al., 2011)
Effects of outcome expectations on outcome.

RESULTS:

N= 8.016 patients across 46 independent samples

>80% adult (18-65), > 60% White , > 60% women

Overall weighted effect size d = .24, p< .001
(Cohen ´s (1988) d.), r = . 12, p< .001 (CI.
95
. 10 to .15)

Moderators and Mediators

Thus: there is a small but significant association between outcome expectations and treatment outcome.

However little is known about specific mechanisms through which they operate
(Arnkoff,
Glass, & Shapiro, 2002)

Three studies have directly investigated the putative mediator pathway
(Meyer et al., 2002; Joyce,
Ogrodniczuk, Piper, & McCallum, 2003; Abouguendia, Joyce, Piper,
& Ogrodniczuk , 2004) …i ndicating that therapeutic alliance is a robust mechanism.

Patients with positive outcome expectations are more likely to engage in a collaborative relationship with the counselor.

What about high expectations?

Prognostic expectations can sometimes be too high (like motivation) and can end in disappointment, frustration and even anger but …

Expectations are malleable

Single assessment or static understanding of expectations at the start is not productive.

Expectations – like motivation – is something that the counselor needs to adress and work on .

Implications for practice (Constantino et al.,
2011)
1.
Explicitly assess ( understand ) prognostic expectations at the beginning of treatment.
2.
Behave in a way that matches the patient ´s level of optimism and use strategies to enhance a positive outcome – look out for unrealistic speed or degree of change
3.
Make hope-inspiring statements : ”What you are dealing with right now is very common and can be changed ”; ”You are the kind of person who can really accomplish things that you put your mind to”
4.
Normalize possible fluctuations towards change.


Make conversation (don ´t read) and adapt to your own context - Practitioner ´s task: working with expectations = antecipatory socialisation – Expectations must be met.
Carl Åke Farbring, 2009

 Alliance – Who is performing the change? A suggestion for practice.
MI In Dutch
Prison Service
Netherlands 2012
Carl Åke Farbring
84

General factors explain more of the variance of change than special factors and methods
 Alliance (MI ≈ empathy, collaboration)
 explains about7-8 % of the variance of change
 weakened alliance correlates with unilateral termination.
 alliance ”at first sight ”

Note: clients i CJ and similar contexts are often defensive at the start (affirmations).


Miller, Hubble, & Duncan, 2008)

Enormous differences in success between therapists in the same organization with same education and working with similar patients.

What are supershrinks doing that the others are not doing?

Cf. Terri Moyers ´ metaphor about the surgeon … and psychosocial counselors carl åke farbring, 2009 - www.farbring.com


Working and therapeutic alliance is an important predictor of behavior change

How it operates is little understood

Prison and probation settings make clear obstacles for working alliance to emerge

In fact systemic factors may even intervene against alliance


Words like: psychopath, punishment, aversiveness, obtrusive, rules, personality disorder, distasteful, crimes…are often used.

Counselors in corrections routinely experience challenges that threaten TA. How do you develop TA with a client that you value in negative terms

Clients will not change within a negative counselor-client relationship - alliance is a prerequisite

Client ´s perception of the counselor as an empathic individual rather than actual counselor behavior


A validated TA-instrument made for corrections

Improvement over WAI in corrections

In stead of problem oriented instrumentes: Good
Lives Model
(Ward & Stewart, 2003)

Goal Matrix, motivational structure model (Cox,
Klinger, 2002):

Personal Concerns Inventory, OA, (Psychology,
Crime and Law.)
(Sellen, McMurran, Theodosi, Cox, Klinger, in press)


Bordin ´ s theory (1979):
1.
Agreement on the goals the offender must work on
2.
Clear collaboration on the tasks
3.
Bond between client and counselor
(relationship)
WAI predicts outcome (Horvath, 1994)
Bordin, E. S. (1979) Psychotherapy: Theory,
Research and Practice, 16, 252-260

Ross, E. C., Polaschek, D. L. L. & Ward, T. (2008) The therapeutic Alliance: A Theoretical revision for offender rehabilitation. Aggression and Violent Behavior, 13, 462-480
1.Bond can predict change irrespective of goals and tasks
2.Two factor model – bond and goals/tasks
3. Reciprocal intimacy was a high predictor of session quality ratings and overall effectieness (Saunders, 1999)
4. Bond may be even more important in brief therapies.

Lambert (2003) reports an ES of 0.39 on feedback compared to a group where feedback was not given.
In a recent study in Norway (2009) Anker,
Duncan & Sparks report a 4 times bigger clinically significant difference to the advantage of the feedback group.
(JCCP, 2009, Vol 77, No 4, 693-704.
It is the client ´s understanding of alliance that
Carl Åke Farbring, 2009 predicts outcome – not the therapist´s

The Engagement Ruler - an alliance instrument (side B)


Note: In conversation – not assessment!
If you were to give some advice on how I could be more helpful to you – what would you suggest?
1….
2….
3….
Carl Åke Farbring, 2009


The Engagement Ruler - an alliance instrument (side A)

At the end of the session (make conversation – don ´t read) Hand over the instrument to the client/patient.

Regardless of rating an important question will follow!


MI as Walk and Talk
98

• Taking MI from the therapy room into the real world – corridors, kitchens
• Authored by Steve Rollnick in collaboration with Carl Åke Farbring,
• An interactive product with videorecorded ”situations”
• Three communication styles in
”short” and ”difficult” conversations – telling (instruct), listening, guiding
► Primary focus on reducing stress
(stress cortisole) and secondly
► Creating a climate more conducive for change (for clients)
99

The three styles further developed in :
Rollnick, S., Miller, W. R.,
& Butler, C. C. (2008)
Motivational Interviewing in
Health Care.
Helping Patients
Change Behavior.
Guilford Press.

Swedish edition
100

(Forsberg, L., Lundberg, U., Theorell, T., Farbring, C. Å., Rollnick, S. under preparation)
• Staff involved in non-therapeutic communication with (e.g. prison officers, staff in mental hospitals) rate applicability higher than full scale MI: 8.2 on average.
• In a randomized trial, stress cortisol among staff has been reduced – this finding is not supported by psychological questionnaires, burn out etc.
• It has been estimated to change work climate by heads of organizations
101