the danish miti project - rfma · rfma: riksförbundet mot alkohol- och narkotikamissbruk. 18....

The Danish MITI Project

Lotte Kramer Schmidt, M.D. PhD.Unit of Clinical Alcohol Research,

Psychiatric department, Odense, DenmarkStockholm Conference

RFMA: Riksförbundet mot alkohol- och narkotikamissbruk18. February 2020

Alcohol in Denmark

Almost all Danes drink alcohol

16 Years – Legal to buy16.5% alcohol

18 Years

Estimate of alcohol problems in Denmark

High risk limit use of alcohol860.000 persons20% of 16+ years old

Harmful use of alcohol585.000 persons13% of 16+ years old

Addicted to alcohol140.000 persons3% of 16+ years old

AUD in DK

Elderly

The Elderly project

+ 60 years with Alcohol Use Disorder (DSMV)Motivational Enhancement Therapy (MET)Community Reinforcement Approach-Senior (CRA-S)

Denmark, Germany and the USA

4 weeks

12 weeks

MET CRA-S

Arguments for the extendedversion

1) Learning new skills to reduce drinking has strong research support

2) Learning new skills requires a therapist with expertise to teach and coach

3) Patients need both information and practice to be successful with new skills

Hypothesis: Participants who receive the extended version will have an effect that is 10%-points better than the standard version.

The Danish MITI Project

Assess the fidelity to Motivational

Interviewing (MI)in the Elderly project

Overview

Treatments of the Elderly study MET: Motivational Enhancement Therapy CRA-S: Community Reinforcement Approach Senior

Results of the MITI-project Fidelity to MI in the Elderly Study Associations with effect of treatment

Between sites differences in the fidelity to MI

Manualized MI with feedback Questionnaires from the baseline interview 4 sessions basicly following the 4 processes in MI Engaging, focusing, evoking and planning But always prioritizing engaging and MI-Spirit no matter the

session number Provides specific tools for evoking change talk

MET: Session1

Engaging the patient ”Pure MI” Introduce an invitation of a supportive significant other in

session 4 Introduce home-work: ” Desired Effects of Drinking Form”

By the end af session 1, the therapists would write a hand-written note and send to the patient

Hand written note

There are several elements that can be included in this note, personalized to the patient, listed below:

A "joining message" [e.g., "I was glad to see you"] Affirmations of the patient A reflection of the seriousness of the problem A brief summary of highlights of the first session, especially

self-motivational statements that emerged A statement of optimism and hope A reminder of the next session.

Example

Dear Mr. Anderson: This is just a note to say that I'm glad you came in today. I agree with you that you have some serious concerns to work on, and I appreciate how openly you are exploring them. You are already seeing some ways in which you could make a healthy change. I think that together we will be able to find a way through these problems. I look forward to seeing you again on Tuesday the 24th at 2:00.

From the Manual for treatment in the Elderly Study

Link to the manual on SDU homepage:https://www.sdu.dk/da/om_sdu/institutter_centre/ucar/materialer/manuals

MET: Session 2

Personalized Feedback and Evoking Change Talk A personalized feedback form is prepared prior to this

session from answers the patient provided at the baseline interview including: Total standard drinks per week Max blood alcohol concentration Experienced consequences from drinking Medical risks Rulers Importance, Confidence and Readiness scores

A very important part of this process is monitoring of and responding to the patient during the feedback

MET: Session 3

Functional Analysis (Evoking and Planning) Through the use of different forms including The desired effects

from drinking form and Personal happiness card sort test Discussing possible areas for a later treatment plan

Example THERAPIST: Now that we've spent some time talking about the "why" of change, I'd like, if you're willing, for you to help me get a clearer picture of how drinking has fit into your life in the past. We can also start considering here the "how" of change-what you think you might want to do.

1. Cards that name an area of your life that you think is at least partly related to your drinking

2. Areas of your life in which you might like to make a change or in which you think it may be important for you to make a change.

3. Two “yes” areas and maybe asking carefully about areas which were affected but not important

MET: Session 4

MET alone: Planning how to continue on your own: A selfchange plan

MET + CRA-S: Planning how to continue treatment in CRA-S, including which modules to incorporate

Involving a supportive significant other

Role of SupportiveSignificant other

Does not include any policing or enforcing but that the main focus is to be supportive for sobriety during treatment, both inside and outside of sessions. Offering helpful ideas and input

Giving encouragement Supporting and reinforcing the patient's efforts to stay sober Helping-in ways the patient wishes to carry out plans for

staying sober. He/she can help to improve the effectiveness of treatment. However, remind the patient that no one else can make the

ultimate decision about change or take responsibility for it.

Modules with CBT-orientated content based on the community reinforcement approach (CRA)

The CRA utilizes familial, social, recreational and occupational reinforcers to aid patients in the recovery process.

The goal of CRA is to rearrange multiple aspects of the patient’s ‘community’, so that a sober life-style becomes more rewarding than one dominated by alcohol.

Andersen et al. Evaluation of adding the community reinforcement approach to motivational enhancement therapy for adults aged 60 years and older with DSM-5 alcohol use disorder: a randomized controlled trial. Addiction 2019.

5 different modules to pick from 8 session, but not predifined end You could have 8 sessions with the same module or 3 sessions

with 3 different modules Max 2 modules at a time in a session

Combined with MI: The underlying communicative approach is emphasized through out the manual as MI

CRA-S: 5 modules

1. Mood management training2. Coping with craving and urges3. Building a sober network4. Social and recreational counseling5. Coping with concerns related to aging

1. Mood management training

Focus on managing negative emotions with exercises like:

Analysis of situations with negative emotions.

Identifying negative automatic thoughts (NAT).

Practicing new ways to cope with focus both on avoiding situations that provoke NAT and constructive thoughts and behaviors after NAT have occurred.

2. Coping with craving and urges

Focus on coping with craving, urges, and social pressure to drink: Identifying triggers of urge and craving.

Training strategies like avoiding, escaping, distracting and enduring of situations with craving or urge.

3. Building a sober network

Focus on increasing positive support from others and engaging in recovery programs: Writing a letter to important people.

Practicing how to ask for support from significant others.

Inviting significant others into treatment

Identifying possible meaningful recovery programs in the local area.

4. Social and recreational counseling

Focus on finding pleasant recreational activities which do not involve drinking Exploring different recreational activities.

Trying out possible identified activities.

5. Coping with concerns related to aging

Focus on coping with loss and sadness associated with aging: Problem focused coping or acceptance focused coping.

Focus on different perspectives of aging.

Identifying things that are meaningful.

Identifying values.

Writing letters to grandchildren or lost ones.

Identifying toxic thoughts

Module name Focus Examples of exercisesMood management training

Managing negative emotions

Analysis of situations with negative emotions.Identifying negative automatic thoughts (NAT). Practicing new ways to cope with focus both on avoiding situations that provoke NAT and constructive thoughts and behaviors after NAT have occurred.

Coping with craving and urges

Coping with craving, urges, and social pressure to drink.

Identifying triggers of urge and craving.Training strategies like avoiding, escaping, distracting and enduring of situations with craving or urge.

Building a sober network.

Increasing positive support from others and engaging in recovery programs.

Writing a letter to important people.Practicing how to ask for support from significant others.Inviting significant others into treatment Identifying possible meaningful recovery programs in the local area.

Social and recreational counseling

Finding pleasant recreational activities which do not involve drinking

Exploring different recreational activities.Trying out possible identified activities.

Coping with concerns related to aging

Coping with loss and sadness associated with aging

Problem focused coping or acceptance focused coping.Focus on different perspectives of aging.Identifying things that are meaningful.Identifying values. Writing letters to grandchildren or lost ones.Identifying toxic thoughts

Therapists in the Elderly project

7 therapists in Denmark, 37 therapists in Germany and 3 in USA.

Rotating therapists at one of the sites in Denmark

Training

A 5-day workshop in English including a min of 2 therapists from all sites

‘Train the Trainer’ model by an experienced MI-trainer and member of the MINT (Motivational Interviewing Network of Trainers)

All therapists trained in both MET an CRA-S

Supervision

All session were recorded An effort was made to secure similar supervision across all

sites of the Elderly Study by regular videoconferencing meetings between supervisors throughout the study period, and particularly often in the beginning

Offered supervision both on random recordings of sessions once monthly and on request from the therapists

Results of The Elderly Study

Baseline demographics by country in the Elderly StudyDenmark (n=341)

Germany (n=203) USA (n=149) All (n=693)

Age: mean years (SD)** 65 (4) 67 (5) 65 (5) 66 (5)

Gender: % male* 64 52 60 60

Married or cohabiting, %** 45 57 39 47

Employment, % full or part time work** 15 24 28 20

Retired, % *** 63 71 50 63

Education, %high school or more*** 43 43 91 54

Previously received treatment, %*** 62 19 37 44

Alcohol Dependence Scale, mean (SD)***

12 (6) 6 (4) 12 (7) 10 (6)

Symptoms of mild to moderate depression, % ns

10 5 9 8

Rulers, Importance, mean (SD) on a scale 0-10***

8.8 (2.1) 8.2 (1.7) 8.6 (2.1) 8.5 (2.0)

Rulers, Confidence, mean (SD) on a scale from 0-10***

7.6 (2.2) 6.9 (2.0) 6.7 (2.5) 7.2 (2.2)

Rulers, Readiness, mean (SD) on a scale from 0-10***

8.9 (1.8) 8.4 (1.8) 7.9 (2.2) 8.5 (1.9)

Drinks per drinking day1, mean (SD)*** 10 (7) 7 (4) 9 (7) 9 (6)

Percent days abstinent, mean (SD)* 32 (37) 21 (28) 27 (33) 28 (34)

Percent heavy days of drinking, mean (SD)ns

58 (39) 60 (39) 56 (39) 58 (39)

*p<0.05 **p<0.01 ***p<0.001 NS: Not significant 1One drink=12 grams of alcohol.

Age: mean years (SD)** 65 (4) 67 (5) 65 (5) 66 (5)

Gender: % male* 64 52 60 60

Retired, % *** 63 71 50 63

12 (6) 6 (4) 12 (7) 10 (6)

10 5 9 8

8.8 (2.1) 8.2 (1.7) 8.6 (2.1) 8.5 (2.0)

7.6 (2.2) 6.9 (2.0) 6.7 (2.5) 7.2 (2.2)

8.9 (1.8) 8.4 (1.8) 7.9 (2.2) 8.5 (1.9)

58 (39) 60 (39) 56 (39) 58 (39)

Overall Results of the ElderlyStudy

Overall both treatment arms were effective Successrate MET: 49% (95%CI:43;55) and MET+CRA-S: 52%

(95%CI:46;58) No differences in effects of treatment between sites

4 weeks

12 weeks

Andersen et al. Evaluation of adding the community reinforcement approach to motivational enhancement therapy for adults aged 60 years and older with DSM-5 alcohol use disorder: a randomized controlled trial. Addiction 2019.

MET CRA-S

Break?

Therapist competences in the Elderly Study

Measuring treatment integrity

Treatment integrity = Treatment fidelity

How well the treatment is implemented as intended. (Perepletchikova, 2011)

To secure integrity of the method: MI

Differences in effect of MI may be due to differences in the integrity in the performance of MI

Motivational Interviewing TreatmentIntegrity manual version 4

= MITI 4

MITI 4

10 Therapist behaviors 4 global measures of therapist competence

4 summary measures with recommended benchmarks

20 minutes sections Only therapist behaviors are measured

MITI 4 Behavioural counts

Question Simple reflection Complex reflection Affirmation Seeking collaboration Emphasize autonomy Confront Persuade Persuade with permission Giving information

Essential but not specific to MI

Behavioral counts

Essential and specific: MI adherent behaviour (MIA)

Behavioural Counts

Should be avoided: MI non adherent behaviour (MINA)

Behavioural counts

Compatible with the method but not essential, maybe neutral?

4 global measures of therapistcompetence

Cultivating Change Talk

How well is the therapist working on evoking and cultivating change talk

during the 20 minutes

1 2 3 4 5

Softening Sustain Talk

How well is the therapist working on softening and leading attention away

from sustain talk

1 2 3 4 5

Partnership

How well is the therapist sharing power with the client over the 20

minutes

1 2 3 4 5

Empathy

How well does the therapist seem to reach a deeper understanding of the

client

1 2 3 4 5

MITI 4 summary measures

MITI 4 expert recommendations: Fair MI Good MI

Relational: average empathy and partnership

3.5 4Technical: Average cultivatingchange talk and softening sustain talk

% Complex reflections of all reflections

.40 .50Reflections to questions ratio 1 2MIA: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)

MINA: MI-non-adherent (persuasions + confronts) - -

Measuring treatmentintegrity in The Elderly Study

Alignment across international sites:

4 coding labs two in Germany (Münich and Dresden) one in Denmark one in the US

Rated and trained together in the use of the MITI 4 prior to the actual fidelity assessment

Measuring treatmentintegrity: Reliability

Each coding lab: Recommended to measure inter rater reliability levels prior to actual fidelity measurement.

To secure inter rater reliability: 10-20% of ratings at eachcoding lab were multiple rated.

Intraclass Correlations Coefficient: ICC

Benchmark value

0.00-0.39 Poor0.40-0.59 Fair0.60-0.74 Good0.75-1.00 Excellent

Cicchetti 1981

To secure inter rater reliability – Danish site

1) out of every five recordings there would be at least one which was multiply rated by all raters

2) the raters were blinded to which recordings were multiply rated 3) weekly meetings were held to discuss the ratings and compare already multiply

rated recordings 4) the raters were encouraged to rate at least three, but no more than ten,

recordings per week 5) if a rater stopped rating for more than two weeks, they had to compare

interrater reliability on a minimum eight recordings with the rest of the group before they could continue

6) disagreements among the raters were reduced by making specific decision rules 7) helping tools providing guidance on and anchors for different measures were

supplied to the raters

Additional rules for the MITI 4.2.1 fidelity measurement at the Danish sites of

the Elderly Study. When doubt about whether the conversation is small talk, it should be rated. When the counselor is saying out loud in full sentences what she is writing in the

treatment plan, this should be rated. Feedback on the questionnaires where the therapist is repeating what the client

answered in the questionnaire should be rated as giving information. Seeking collaboration should not be rated when the counselor is arranging with

the client how to perform an activity: example: “Do you want to write it down or should I?”

If a question is repeated with the same words because the client did not hear the question, it should not be rated again.

The overall change goal is decreasing use of alcohol. In the CRA-S sessions this may be interpreted indirectly as working with the content of the module. As an example, working with relationships which in turn could be related to use of alcohol.

Adfærd + Globale MITI 4.2

GI Information, undervisning , feedback eller profession mening udenat overtale eller advare. Neutral tonefald og ordvalg (ofte ”Man”)

Persuade Signal om at ændre holdning eller adfærd, evt. i tonefaldet, samtidig med, at der anvendes argumenter, egne erfaringer, fakta, anbefalinger, løsninger, farvet information, råd, forslag eller lignende. Bemærk tonefald og ordvalg (ofte ”Du”)

PWP Persuade kombineret med søgende ordvalg, EA, Seek eller klienten spørger til emnet. Hvis både P og PWP, kodes kun PWP. (Husk også at kode Seek)

Q Både åbne og lukkede. Trumfes af Seek. Bemærk tonefald og ordstilling.

SR Reflekterer det sagte, gentagelse, omformulering eller opsummering uden at tilføje nyt.

CR Tilføjer ny mening, værdi, omfortolkning, billedsprog, dobbeltsidet, reflekterer det uudsagte, en følelse eller fortsættelses refleksion. Kan virke ledende. Hvis både CR og SR kodes kun CR.

Affirm Udsagn, ofte CR, der kædes direkte sammen med klientens styrker, egenskaber, anstrengelser, intentioner eller værdi. Trumfer CR.

Seek Udsagn der deler magt med eller tydeligt anerkender klientens ekspertise. Spørger om tilladelse til at dele information eller overtale eller spørger til klientens tanker om dette. Søger enighed med klienten om samtalens forløb. Evt. også PWP-kode.

EA Udsagn, der klart har fokus på klientens eget ansvar og frihed for at træffe beslutninger og mulighed for at vælge attitude og adfærd. Fremhæver at ansvar for forandring ligger hos klienten.

Confront Direkte og utvetydig uenighed, argumentering, irettesættelse , bebrejder, advarer, fordømmende mv. Ved tvivl mellem confront og CR gives ingen kode.

Strukturerende (Kodes ikke): Instruktioner, indhold fra sidst, hilsener, aftaler om forløb, faciliterendetale som ”Okay””Godt””Dejligt”, uden for sammenhæng (small talk), ufuldstændige udsagn, hvor terapeutens tanke ikke når at komme til udtryk samt egen mening uden det er overtalende.

CCT 1 2 3 4 5

SST 1 2 3 4 5

Partnership 1 2 3 4 5

Empathy 1 2 3 4 5

Elderly ID:_______Session:___Minuttal:________Koder:_____Dato:_______

Results

693 participated in The Elderly Study

Danish site:341 Participants

2127 sessions423 rated with MITI52 rated by all raters

How was the fidelity to MI?

Mean values of fidelity to MIFair MI Good MI Mean Elderly CI95%

Relational: average of empathy and partnership

3.5 4 4.19 4.13;4.25

Technical: average ofcultivating change talk and softening sustain talk

3 4 3.94 3.88;4.00

.40 .50 .58 .56;.59

Reflections to questions ratio

1 2 2.68 2.37;3.00

Relational Technical

Percent Complex Reflections Reflection to Question Ratio

Good MI

Fair MI

Good MI

Good MIFair MI

Fair MI

MI fidelity in MET and CRA-S Danish site only!

CRA-S sessions: 158MET Sessions: 265

Inter rater reliability MET vs CRA-S

Interrater reliability MET vs CRABehavioral counts ICC MET

n= 3295% CI ICC CRA-S

n=2095% CI

Giving information .95 .91;.97 .93 .87;.97

Persuade .89 .81;94 .77 .56;.90

Persuade with permission

.79 .64;.88 .29 -.36;.68

Question .96 .94;.98 .97 .94;.99

Simple reflection .87 .78;.93 .93 .87;97

Complex reflection .92 .87;.95 .93 .87;.97

Affirmation .85 .75;.92 .86 .74;.94

Seeking collaboration .86 .76;.92 .83 .68;.93

Emphasize autonomy .60 .34;.79 .28 -.37;.68

Confront .24 -.28;59 .83 .68;.93

Global scoresCultivating change talk .79 .64;.88 .80 .62;.91

Softening sustain talk .56 .26;.76 .43 -.09;.75

Partnership .81 .69;.90 .87 .75;.94

Empathy .73 .55;.85 .74 .51;.88

Interrater reliabilityBehavioral counts ICC MET

n= 3295% CI ICC CRA-S

n=2095% CI

Giving information .95 .91;.97 .93 .87;.97

Persuade .89 .81;94 .77 .56;.90

Persuade with permission

.79 .64;.88 .29 -.36;.68

Question .96 .94;.98 .97 .94;.99

Simple reflection .87 .78;.93 .93 .87;97

Complex reflection .92 .87;.95 .93 .87;.97

Affirmation .85 .75;.92 .86 .74;.94

Seeking collaboration .86 .76;.92 .83 .68;.93

Emphasize autonomy .60 .34;.79 .28 -.37;.68

Confront .24 -.28;59 .83 .68;.93

Global scoresCultivating change talk .79 .64;.88 .80 .62;.91

Softening sustain talk .56 .26;.76 .43 -.09;.75

Partnership .81 .69;.90 .87 .75;.94

Empathy .73 .55;.85 .74 .51;.88

ICC Benchmark value

0.00-0.39 Poor

0.40-0.59 Fair

0.60-0.74 Good

0.75-1.00 Excellent

Differences in treatment fidelity between session of Motivational Enhancement Therapy (MET) and Community Reinforcement Approach Senior (CRA-S)Summary scores from the MITI 4 Sessions fulfilling this

criteria for good fidelity to MI

Only MET-session n=265

Sessions fulfilling this criteria for

good fidelity to MIOnly CRA-session

Significant difference

Relational: average of empathy and partnership

83% 74% P<0.05

Technical: average of cultivating change talk and softening sustain talk

74% 53% P<0.001

% Complex reflections of all reflections 74% 78% NS

Reflections to questions ratio 44% 48% NS

Mean MIA’s: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)

2.27 (1.99;2.54) 2.01 (1.71;2.31)

Mean MINA’s: MI-non-adherent (persuasions + confronts)

0.61 (0.46;0.76) 0.96 (0.68;1.23)

MI combined with CRA

The combination of MI with other therapeutictechniques in the CRA-S may comprimize the technical and relational elements of MI

Face validity of the MITI 4 – it does seem to measure MI

Fidelity to MI and effect of treatment

Treatment fidelity and effect of Motivational Interviewing

Effect

Higher fidelity to MI

Elements of MI associated with better outcomes

EmpathyMI spirit: evocation, collaboration, autonomy Affirmations Complex Reflections

Apodaca et Longabaugh 2008, Copeland et al. 2015, Romano et al. 2014, Houck et Moyers 2015, Apodaca et al. 2015, Pace et al 2017, Magill et al 2018, McCambridge et al 2011, Spohr et al .2015.

Not MI and associated with poorer outcomes

Persuasions Confrontations

Apodaca et Longabaugh , Pace et al 2017, 2008, Magill et al 2018

Outcome is use of alcohol and consequences of alcohol 26 weeks

Fidelity measures of the MITI 4

Mixed effects linear regression

Effect or Outcome is use of alcohol and consequences of alcohol

Fidelity measures of the MITI 4

NO ASSOCIATIONS FOUND

Participants in the CRA-S sessions Very good MI Worse outcomes!Not significant after BonferroniNot found at 12 weeks

Sub-analyses

Discussion

MI elementspatient change talk

Effect

Fidelity to MI and effect

Effect

The proportional increase in patient change talk

Discussion

Patient Change talkPatient Change talk + Sustain talk

Discussion

Population high in motivation

Low variation in the global fidelitymeasures

Sample size

The inverse finding of high fidelity MI and worse outcomes in CRA-S?

Type 1 errorBad timing of MI elements in the

combined setting - Stage of changemismatch?

Discussion

Fidelity between countries of the Elderly Study

707 rated sessions36 therapists

412 participants4 rating teams

What about the inter rater reliability?

ICCs from the fidelity measurement with MITI 4.2.1 at the four rating teams in the Elderly project

ICC (95% CI) Danish rating team (n=52)

ICC (95% CI) Dresden rating team

(n=12)

ICC (95% CI) Munich rating team

(n=13)

ICC (95% CI) US rating team (n=20)

Question 0.95 (0.90;0.97) 0.99 (0.97;1.00) 0.88 (0.71;0.96) 0.96 (0.89;0.98) Simple reflection 0.86 (0.76;0.92) 0.89 (0.47;0.97) 0.60 (0.08;0.86) 0.38 (-0.21;0.75)Complex reflection 0.87 (0.74;0.93) 0.67 (-0.13;0.90) 0.62 (0.12;0.87) 0.82 (0.34;0.94)

Affirmation 0.85 (0.78;0.91) 0.59 (-0.18;0.88) 0.86 (0.64;0.95) 0.66 (0.18;0.87)Seeking collaboration 0.83 (0.74;0.89) 0.04 (-0.95;0.65) 0.89 (0.71;0.96) 0.18 (-0.26;0.57)

Emphasize autonomy 0.52 (0.29;0.69) -0.22 (-4.85;0.67) 0.35 (-0.71;0.79) 0.27 (-0.33;0.66)

Summary scoresRelational: average of Empathy and Partnership

0.84 (0.75;0.90) 0.81 (0.34;0.94) 0.36 (-0.61;0.79) 0.26 (-0.93;0.71)

Technical: average of Cultivating change talk and Softening sustain talk

0.80 (0.70;0.88) 0.42 (-0.30;0.81) 0.48 (-0.32;0.83) 0.05 (-1.00;0.59)

0.65 (0.47;0.78) 0.61 (-0.18;0.89) 0.27 (-0.60;0.74) 0.19 (-0.12;0.56)

Reflections to Questions ratio

0.95 (0.93;0.97) 0.77 (0.25;0.93) 0.47 (-0.16;0.81) 0.68

MIA: MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)

0.85 (0.76;0.91) 0.27 (-0.32;0.72) 0.90 (0.74;0.97) 0.58 (-0.16;0.85)

MINA: MI-non-adherent (persuasions + confronts)

0.86 (0.79;0.91) 0.99 (0.98;1.00) 0.62 (0.06;0.87) 0.00 (-1.53;0.60)