August 2023 – Vol. #21, No.5

Welcome to the August edition of Tips and Topics and to all the new subscribers.

In SAVVY, I recommend you watch William Miller highlight the What and Why of some of the new changes in Motivational Interviewing (MI). I highlight how MI helps you be a more effective agent in helping people change and grow.

In SKILLS, listen to Scott Miller on Mike McGee’s podcast talk about how to use feedback to identify where you might need a coach rather than an overall supervisor. The coach is expert in a particular skill that feedback measurement has identified you as falling short.

In SOUL, Dr. James O. Prochaska, a pioneer in the field of psychology who revolutionized the science of behavior change died on July 9, 2023, at the age of 80. How do you say good-bye to such an icon?

David Mee-Lee, M.D.
DML Training and Consulting

SAVVY

Motivational Interviewing (MI) has had a huge impact not just initially on the addiction treatment field but increasingly on general healthcare and even in fields beyond healthcare. The first edition was published in 1991 and the 4th edition, “Motivational Interviewing - Helping People Change and Grow” is just out now this month. Who better to give an overview of the major changes in this new edition than William Miller, Ph.D., co-author with Stephen Rollnick.

You can watch (I highly recommend it) that free webinar if you go to The Change Companies website, click on Webinars and you will see the MI webinar and also one on the upcoming new 4th edition of The ASAM Criteria. (An interesting bit of trivia is the the first edition of The ASAM Criteria was published also in 1991 and both MI and The ASAM Criteria’s 4th editions are out this year too).

You can also go directly to the MI webinar. 

Dr. Miller started with the What and the Why of changes in the 4th edition. But I was especially interested in his information on what the research says about what it takes to be an effective therapist. Then he showed how MI overlaps with those characteristics and supports the development of those skills.

Tip 1

The therapist’s skills affects the outcomes of treatment far more significantly that what therapy model you believe in and practice

At minute 18:44 of the webinar, Dr. Miller summarized research on outcomes and comparisons between different schools of therapy. He said:

  • It is now well documented that when "different" bona fide therapies are compared with each other, there is usually no clinically meaningful difference in client outcomes.
  • Whereas therapists' outcomes do vary significantly.
  • Therapist factors account for far more variance in outcome than do treatment methods.

In other words, you may think your favorite model of therapy is far superior to someone else’s model of care. But actually there’s not a lot of difference. The real difference depends on what the therapist is good at, not what model they are using.

Reference: Wampold, B. E., & Imel, Z. E. (2015). “The great psychotherapy debate: The evidence for what makes psychotherapy work” (2nd ed.). Routledge.

Tip 2

These therapist factors and skills determine who does better in treatment.

At minute 19:44, Dr. Miller reviewed the therapist factors that are responsible for who does better in treatment. Here are the clinical skills that the research says really matter:

  1. Accurate Empathy
  2. Positive Regard
  3. Genuineness/Congruence
  4. Acceptance
  5. Focus
  6. Hope
  7. Evocation
  8. Offering Information and Advice

Reference: William R. Miller & Theresa B. Moyers (2021). “Effective Psychotherapists – Clinical Skills That Improve Client Outcomes” Routledge.

Tip 3

Motivational Interviewing overlaps and supports the therapist factors that make for more effective ouctomes in helping people change and grow.`

At minute 20:36, Dr. Miller explains what key elements and foundational concepts of MI overlap with the essential therapist factors effective in helping people change.

  1. Accurate Empathy - Foundational in MI
  2. Positive Regard - Affirmation
  3. Genuineness - Not emphasized before 4th ed.
  4. Acceptance - Key element of MI spirit in MI
  5. Focus - Focusing is a key process
  6. Hope - Evoke hope, support self-efficacy
  7. Evocation - Evoking is a key process in MI
  8. Information/ Advice - Included in MI

Tip 4

Motivational Interviewing helps you do better in whatever treatments and models of change you are using, both inside and outside of healthcare.

At minute 23:14 Dr. Miller explains that MI is not meant to be done instead of other treatments. It cuts across all kinds of treatments and helping models. In fact, while it started in the addiction treatment field, it is now commonly combined with other treatments as a way of doing whever else you do.

At minute 25:17, Dr. Miller reviewed all the ways MI is a way of doing:

  • Cognitive behavior therapy
  • Health care
  • Diabetes and nutrition education
  • Preventive dentistry
  • Social work
  • Case management
  • Probation supervision
  • Sports coaching
  • Education
  • Leadership

SKILLS

Last month I reviewed several issues to do with Feedback Informed Treatment (FIT). As it happened, my friend and colleague Michael McGee, M.D. also focused on FIT in his July 29, 2023 podcast with Scott Miller (no relation of William Miller, but one of a handful of mentors who have taught me so much).

So in addition to the William Miller webinar, I highly recommend listening to Dr. McGee’s interview with Scott Miller, Ph.D. There’s even a transcript of the interview so you can read and listen and not miss a thing. Mike McGee summarizes below some of what he discussed with Scott Miller, but better to hear it from “the horse’s mouth” on the podcast. (I have re-formatted what Dr. McGee wrote and put it in Tips & Topics format.)

FIT began about 30 years ago, like Motivational Interviewing. Most clinicians actually decline in efficacy over the years. More education doesn’t help. What helps to improve outcomes is getting feedback. But not just getting feedback, but actually doing something with the results. Discussing the results with clients.

Tip 1 

To improve your clinical skills, get a coach who can help you with repeated deficits in your practice that you may be blind to.

There is a psychological tendency towards complacency when we reach a certain level of proficiency, a tendency to “let it be.” To becomes clinical masters, we need to counter that tendency. By intentionally getting feedback, we can identify non-random errors in our practice that we may be blind to.

What deliberate practice requires is not supervision, which has not been shown to improve outcomes, but a coach; someone with skills that can help you address identified deficits. The way to find a coach is to be proactive and reach out and ask experts who you feel might be able to coach you.

Tip 2

You don’t need an overall supervisor. You need a coach who is expert in a particular skill that feedback measurement has identified you as falling short.

There is the need for deliberate practice, which can be difficult. This requires dedicated time. Therapy time is not necessarily practice time, it is a performance. Deliberate practice might be working with a coach to practice a particular skill, such as empathy, trying it in a practice session with your coach, and getting feedback on your work from your coach, and then trying it again. It is intentional, focused work to hone specific clinical skills that are identified from client feedback.

Here’s what Scott Miller says:

“What deliberate practice requires is a coach. A good model for this is to look to Olympic athletes because most of these elite athletes don't have one overall coach and they don’t pick them from a pool of potential coaches. Instead, championship figure skaters have an equipment coach, a dance coach, a choreography coach, an upper body strength, a lower body strength coach. They have people who specialize in areas that may be in need of improvement. And therapists also need that.

We don't need an overall supervisor. You don't need the best supervisor. You need someone who is an expert in the area in which you evince shortcomings. And that means measurement.”

SOUL

About 7 years ago, I was at a conference where a trainer was talking about Motivational Interviewing and the Transtheoretical Model of Change. We were instructed to do a “real-play”, not a role-play, with an attendee seat mate.....“real-play” as it needed to be a subject that was real for us in our lives. I happened to be sitting near Jim Prochaska so we were it. I did a real-play with “Dr. James O. Prochaska, a pioneer in the field of psychology who revolutionized the science of behavior change and who died on July 9, 2023, at the age of 80.”

That was one of the last times I saw him up close and personal. I don’t think he would mind my telling you that he was at Action Stage of Change for eating more vegetables and staying healthy so he could be with his grandchildren for as long as possible.

How do you say good-bye to an icon whose work transformed the way I and thousands of other people approach addiction treatment, smoking cessation, weight management, and many other areas of behavior change? I say you say good-bye by:

  •  Embodying in our own lives the compassion, respect, humility and leadership that Jim Prochaska represented.
  • Carrying on the spirit and specifics of the Stages of Change Model that he and Carlo DiClemente championed.
  • Striving to attract more people into behavior change not by coercion, disempowering and demanding compliance but by meeting people where they are at in their various stages of change.

Jim Prochaska, Bill Miller and Scott Miller are mentors and leaders who revolutionized my knowledge and skills for the better. Two of them I can still say “thank-you” to their face. One of them, I wished I had.

Until Next Time

Thanks for joining us this month. See you in late September.

David