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The widely-disseminated clinical method of motivational interviewing MI arose through a convergence of science and practice. Such specification of outcome-relevant aspects of practice is vital to theory development, and can inform both treatment delivery and clinical training.
An emergent theory of MI is proposed, How Am I Different - Various - Schöner Hören Vol #6 two specific active components: a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and This Is A Call - Foo Fighters - Greatest Hits of client change talk A resulting causal chain model links therapist training, therapist and client responses during treatment sessions, and post-treatment outcomes.
Failure to confirm expectations is a particularly fruitful point of meeting between the scientific contexts of justification and discovery. Unexpected findings, if taken seriously, lead one back to the drawing board of discovery to develop a better theory for subsequent testing. This article reviews three decades of research and development of motivational interviewing MI.
The method and research of MI arose from a series of unexplained outcomes, leading to an emergent theory of the underlying mechanisms of this brief psychotherapy. An unanticipated finding drew attention to the impact of interpersonal processes on behavior change. After initial certification of the counselors, three supervisors observed them delivering the behavioral intervention with self-referred outpatients and independently rank ordered the extent to which they had manifested empathic understanding while delivering behavior therapy.
This effect of therapist style was far larger than differences among the behavioral interventions being compared. With these surprising findings, Miller went on sabbatical leave to Bergen, Norway. His original clinical description of motivational interviewing Miller, was an unanticipated product of interacting with a group of colleagues there. He had been invited to lecture on behavioral treatment for alcohol problems, and also was asked to meet regularly with a group of young psychologists.
This group asked him to demonstrate how he might respond to clients they were treating, and in the role-play process frequently stopped him to ask why he had said what he did, where he was going, and what was guiding his thinking. Thus they caused him to verbalize what had previously been an implicit model guiding his clinical practice, of which he had not been consciously aware, and that differed from the behavior therapies on which he was lecturing.
It focused on responding differentially to client speech, within a generally empathic person-centered style. Pushing or arguing against resistance seemed particularly counterproductive, in that it evoked further defense of the status quo. A guiding principle of MI was to have Too Young - Nat King Cole - 20 Golden Greats client, rather than the counselor, voice the arguments for change.
In describing MI, Miller explored links between this conceptual approach and prior psychological theories. Miller mailed the manuscript to several colleagues, asking for comments. Among them was Ray Hodgson, then editor of the British journal Behavioural Psychotherapywho persuaded him to publish a reduced version of the conceptual paper Miller, Returning to New Mexico, Miller continued to develop what had emerged. The DCU combined MI with personal feedback of assessment findings in relation to population or clinical norms.
The DCU was expected to increase engagement in treatment for alcohol problems, similar to effects previously reported by Chafetz et al. Instead, the DCU group showed an abrupt decrease in their drinking, a change that was mirrored when the waiting list control group was subsequently given a DCU. It appeared that the DCU alone induced significant change in problem drinking.
The next three clinical trials evaluated MI as a prelude to treatment. In all three, clients entering substance abuse treatment programs were randomly assigned to receive or not receive a single MI session at the outset of treatment.
Unexpectedly, the specific effect size was larger Burke et Aquamarine (Voiceless Remix) - Blood Groove & Kikis - Aquamarine. This suggests a synergistic effect of MI with other treatment methods. The Clinical Trials Network of the U. MI-based interventions have been found to promote sustained reductions in alcohol use Ball et al.
Site-by-treatment interactions also appeared, such that MET exerted a significant beneficial effect at some sites but not others Ball et al. Not all trials have been positive. Null findings for MI Le Ciel - Guylaine Guy - Darling Of Paris been reported, for example, with eating disorders Treasure et al.
Even within well controlled multisite trials, MI has worked at some sites but not others Ball et al. It is apparent that some clinicians are significantly more effective than others in delivering the same MI-based treatment Project MATCH Research Group, band of course even in positive trials a certain proportion of clients do not respond to MI.
The efficacy of MI also can vary across populations. Similarly, Clinical Trials Network studies How Am I Different - Various - Schöner Hören Vol #6 some evidence for differential How Am I Different - Various - Schöner Hören Vol #6 from MET among pregnant drug users from minority backgrounds Winhusen et al.
Such variability in outcomes across and within studies suggests the need to understand when and how a treatment works How Am I Different - Various - Schöner Hören Vol #6 the conditions of delivery that may affect its efficacy. An implicit causal chain originally hypothesized for MI was relatively straightforward Miller, Conversely, evoking sustain talk would favor behavioral status quo.
Rogers hypothesized that accurate empathy, congruence, and positive regard are critical therapeutic conditions that create an atmosphere of safety and acceptance in which clients are freed to explore and change.
These relational factors were predicted How Am I Different - Various - Schöner Hören Vol #6 themselves to promote positive change Miller, As described above, studies preceding the introduction of MI supported a specific and strong relationship between therapist empathy and drinking outcomes Miller et al.
These technical and relational components are not rival or incompatible hypotheses. Psychotherapy research has long postulated a combination of specific technical and general or non-specific relational factors that influence outcome. Figure 1 illustrates a variety of pathways by which MI may facilitate behavior change.
The remainder of this article explores current empirical evidence for the various links in this putative chain. Before reviewing MI process research, a brief explanation is in order regarding how How Am I Different - Various - Schöner Hören Vol #6 fidelity of delivery has been assessed.
We know of no reliable and valid way to measure MI fidelity other than through the direct coding of practice samples. The original MISC required three coding passes: one for global skill ratings, one for therapist and client behavior counts, and one for relative talk time. Categories and definitions were refined with experience, eliminating unreliable or redundant codes and sharpening distinctions, to form the current MISC version 2.
In Figure 1this relationship between MI and client speech is reflected in pathways 1 and 2. In the first study to incorporate process measures of MI, clients receiving the DCU were randomly Talking Bear Mountain - Bob Dylan - Early Dylan to one of two styles of personal feedback Miller et al. In one style, counselors sought to persuade clients of the need for change, confronting resistance as it arose.
The same counselors delivered both interventions. Clients in the MI condition voiced about twice as much change talk and half as much resistance. This between-group effect mirrored findings from Patterson and Forgatchwhere client resistance increased and decreased in step-function as clinicians shifted within-session between directive and reflective counseling styles. These studies indicate that client change talk and resistance are highly responsive to counselor style.
Further evidence that MI influences client change talk emerged from psycholinguistic analysis of session tapes before versus after clinicians had been trained in MI. Examining relationships of MI-consistent and MI-inconsistent therapist utterances with client change talk and resistance, they found strong support for the mediational hypothesis.
Specifically, MI consistent therapist responses tended to be followed by client change talk, whereas MI-inconsistent utterances were likely to be followed by Sit Back Relax - Bizzy Bone - Alpha And Omega talk.
There also appeared to be a synergy between therapist and client utterances, in that MI elicits change talk which then increases the probability of further MI-consistent therapist responses. Taken together, these data provide strong support for pathways 1 and 2 in Figure 1. MI-consistent practice does significantly increase client change talk and decrease resistance. A How Am I Different - Various - Schöner Hören Vol #6 link in the chain is the relationship between client change talk and outcome paths 3—4 and 5 in Figure 1.
Early support for this linkage came from analysis of DCU session tapes Miller How Am I Different - Various - Schöner Hören Vol #6 al. No significant relationship was observed, however, between change talk frequency and outcome. Again, no relationship was found between change talk frequency and behavioral outcome — a problem for the causal chain. Psycholinguist Paul Amrhein, suggested an alternative classification scheme based on his analysis of natural language by which people negotiate change and make commitments Amrhein, Using the same clinical trial MI tapes, he differentiated change talk into linguistic subcategories reflecting various components of motivation for change: desire, ability, reasons, need, and commitment.
Rather than recording Morgana Lefay - The Secret Doctrine mere occurrence of these speech acts, he used an established taxonomy to rate the strength of utterances favoring change drug abstinence or status quo continued drug use. His three years of work yielded valuable insights into processes of MI. One of the six linguistic categories directly and robustly predicted behavior change: strength of commitment language.
The strength of expressed desire, ability, reasons, and need for change all reliably predicted the strength of commitment, but none of them directly predicted behavior change. In this sense, these seemed to be preparatory steps toward commitment. Why had we previously failed to detect this effect? In essence, we had been studying the wrong parameter intercept instead of slope for the wrong measure frequency instead of strength of the wrong variable change talk instead of commitment during the wrong part of the session beginning instead of end.
Mean commitment strength predicted drug-free urine samples, and a positive in-session slope of commitment strength predicted treatment retention. Commitment language specifically predicted month gambling outcomes, whereas preparatory change talk desire, ability, reasons and need did not. These studies offer support for the robustness of commitment as a construct predictive of client outcome, not only in Andrea Fiorito - Voodoo Grooves Vol.
1 but in behavioral treatment more generally. As commitment language emerges, behavior change is more likely to occur path 4. In the first phase, the interviewer focuses on eliciting change talk to elicit intrinsic motivation for change. When sufficient motivation appears to be present, the interviewer transitions to a second phase of strengthening commitment to change, focusing on converting motivation into commitment to specific change goals and plans.
Recent research replicates the connection between client change talk and subsequent behavior change. Moyers et al. In all three therapies, frequency of change talk and sustain talk independently predicted drinking outcomes even after accounting for baseline variance in readiness to change and alcohol use.
In this study, change talk and sustain talk did not function as opposite poles of a single dimension, but rather as independent constructs each contributing to drinking outcomes. Summarizing research on substance use disorders alone, Apodaca and Longabaugh found that client change talk exerted a small to medium effect on behavioral outcome.
Could psycholinguistic analyses also help us to understand what went wrong when MI does not work? Failure analysis seeks to spin gold from the straw of null results. As a first step, Amrhein utilized cluster analysis to differentiate treatment outcomes into four groups. Amrhein then proceeded to examine what clients in each of these groups had said during their MI session Amrhein et al.
The language patterns for Changers and Maintainers were quite similar: a steady increase over the course of the session in strength of commitment to drug abstinence. The principal difference was in their starting points.
Both ended the session expressing strong commitment to abstinence. The combined in-session speech patterns of these two good-outcome groups are shown in Figure 2. In contrast, the speech patterns of the Strugglers looked quite different, and resembled the language pattern of the fourth group who did not honestly report their drug use.
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