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Relationships that Heal

Relationships that Heal. William R. Miller, Ph.D. The University of New Mexico The Eileen Pencer Memorial Lecture. What’s Missing in EBTs?. Have you noticed: that in multisite clinical trials (like CTN) of treatments that are already evidence-based

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Relationships that Heal

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  1. Relationships that Heal William R. Miller, Ph.D. The University of New Mexico The Eileen Pencer Memorial Lecture

  2. What’s Missing in EBTs? • Have you noticed: that in multisite clinical trials (like CTN) of treatments that are already evidence-based even under highly controlled, supervised, manual guided delivery conditions the expected main effects are often quite small? and that efficacy often varies by therapist and by site? • This even happens with pharmacotherapies • In practice, EBTs are not homogeneous entities

  3. Percent Days AbstinentNIAAA Multisite Trials Project MATCH COMBINE Study

  4. UK Alcohol Treatment Trial (UKATT) MI = 3 Sessions vs. SBNT = 8 Sessions

  5. Primary outcome CTN Psychosocial Trial OutcomesEBT vs. Treatment as Usual Treatment Tested 004 MET 005 MI 013 MET 021 MET 009 Smoking cess. 011 Tele calls 015 Seeking Safety 006 Incentives 007 Incentives Drug use & retention days - nsd Use: nsd 5 vs. 4 sessions p<.05 Retention nsd (pregnant users) Drug use & retention nsd Cessation nsdby 13 weeks Retention nsd; PTSD symptoms & drug use nsd 8.6 vs 5.2 sessions abstinent p<.001 5.5 vs 2.3 sessions abstinent p <.001

  6. How Large An Effect Matters? • The specific effect size for manual-guided EBT is typically small • Even small effects may be clinically meaningful • With large multisite samples, statistical significance can be found for small effects, but do clinicians care?

  7. What CTN Clinicians Think is MeaningfulHow much better would a new treatment have to be? Miller, W. R., & Manuel, J. K. (2008). How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug and Alcohol Review, 27, 524-528. Clinically significant improvement = large enough to be interested in learning a new treatment method. Approximately 10 point increase in % doing well or doubling or halving of continuous measures

  8. Beyond the Horse Race Learning More from Clinical Trials

  9. In theory, there is no differencebetween theory and practice In practice, there is. In practice, evidence-based treatments are not homogeneous entities

  10. So Where’s the Beef? Where are the bigger effects?

  11. 1. Therapist Belief Matters – A Lot % Days Abstinent

  12. Therapist Belief % Days Abstinent

  13. Leake & King (1977) • Psychologists tested patients in three different treatment programs • They identified patients with particularly high alcoholism recovery potential (HARP) • HARP vs. non-HARP patients did not differ from each other on prior treatment history or severity of alcoholism

  14. Counselor Ratings During Treatment Showed HARPS to be: • More motivated for counseling • More punctual in meeting appointments • Showing greater self-control • Neater and more attractive in appearance • More cooperative • Trying harder to stay sober • Showing better recovery

  15. Throughout 12 months of Follow-up HARP Patients Showed: • Higher rates of abstinence • Longer spans of abstinence • Fewer slips • More employment

  16. The Psychologist’s Secret: “HARPs” had been selected at random.

  17. How do we look at our patients? Counselor expectations matter a lot.

  18. 2. Treatment as Usual is Pretty Good Average 12-Month Drinking Outcomes for 8,389 Clients • Survival 98.5% • Percent Continuous Abstinence 24.1% • Percent Days Abstinent: 81.4% • Average Reduction in Consumption 87.0% • Overall outcomes were fairly similar for treatment as usual (RAND, VAST, RREP), pharmacotherapy trials (lithium, disulfiram), and controlled trials of psychosocial treatments (MATCH) Miller, W. R., Walters, S. T., & Bennett, M. E. (2001). How effective is alcoholism treatment? Journal of Studies on Alcohol, 62, 211-220.

  19. TAU Clients vs. MATCH Clients Percent Days Abstinent Westerberg, V. S., Miller, W. R., & Tonigan, J. S. (2000). Comparison of outcomes for clients in randomized versus open trials of treatment for alcohol use disorders. Journal of Studies on Alcohol, 61, 720-727

  20. TAU Clients vs. MATCH Clients Percent Days Abstinent Westerberg, V. S., Miller, W. R., & Tonigan, J. S. (2000). Comparison of outcomes for clients in randomized versus open trials of treatment for alcohol use disorders. Journal of Studies on Alcohol, 61, 720-727

  21. 3. All Therapists Are Not the Same Luborsky, McLellan, Woody, O’Brien & Auerbach, 1985 Archives of General Psychiatry 42:602-611

  22. Differences in Clients’ Drug Use Outcome by Counselor • Two drug treatment counselors resigned • Their 62 cases were assigned randomly to the four remaining counselors • There were dramatic differences in client outcomes. McLellan et al., 1988 Journal of Nervous and Mental Disease, 176, 423-430.

  23. Client OutcomesBeforevs. AfterRandom Transfer to 4 Counselors % Positive Urines Methadone Dose % Arrested % Employed McLellan et al. (1988). Journal of Nervous and Mental Disease, 176, 423-430.

  24. Therapists’ Outcomes in CBI All Clients got “the same” manual-guided treatment in the NIAAA COMBINE Study

  25. 4. It Matters What You Doand How You Do It • Much emphasis is given to “common factors” as an alternative to EBTs • So-called “common factors” may or may not be all that common in practice • If they do exert a large effect, they should not be hard to observe • “Nonspecific” just means that they have not yet been adequately specified and tested • So why not both . . and?

  26. How you do it matters:Same Counselors, Same EBTbut Different Styles Miller, Benefield & Tonigan (1993) JCCP 61: 455-461

  27. Variance in Client Drinking at 12 mo.Accounted for by Clinician Behavior Confront (r = .65) 42% Miller, Benefield & Tonigan (1993) JCCP 61: 455-461

  28. Therapist Empathy • Accurate empathy is a well-specified, learnable, reliably measurable therapist skill – the ability to understand and reflect clients’ meaning • Originally defined and studied by Carl Rogers • It is not identification with your client

  29. All Nine Counselors • Were delivering the same manual-guided behavior therapy (self-control training) • Were trained both in behavior therapy and accurate empathy • Had sessions independently observed and rated by three supervisors, including the Truax & Carkhuff scale for accurate empathy • Were then rank-ordered (1-9) for empathic skill while delivering behavior therapy • And when we examined 6-month client outcomes . . . .

  30. Therapist Empathy 60 Miller, Taylor & West (1980) JCCP 48:590-601

  31. Variance in Client Drinking Outcomes Accounted for by Therapist Empathy 6 months 12 months 24 months r = .82 r = .71 r = .51 67% 52% 26% Miller & Baca (1983) Behavior Therapy 14: 441-448

  32. Counselors’ Interpersonal Skill (Rogers) and Clients’ Drinking Relapse RatesValle (1981) J Studies on Alcohol 42: 783-790 Patients in treatment for alcoholism were randomly assigned to counselors with: LOW levels of empathy and related skills MEDIUM levels of empathy and related skills or HIGH levels of empathy and related skills What percentage of patients relapsed?

  33. Rogerian Skill and Client Outcomes Valle (1981) J Studies on Alcohol 42: 783-790

  34. Normal Human Responses to a Direct/Demand/Confront Style Invalidated Resist Withdraw Not respected Arguing Disengaged Not understood Discounting Disliking Not heard Defensive Inattentive Angry Oppositional Passive Ashamed Denying Avoid/leave Uncomfortable Delaying Not return Unable to change Justifying

  35. Normal Human Responses to a Listen/Evoke Style Affirmed Accept Approach Understood Open Talk more Accepted Undefensive Liking Respected Interested Engaged Heard Cooperative Activated Comfortable/safe Listening Come back Empowered Hopeful/Able to change

  36. Which People Would You Rather Work With? Open Cooperative Arguing Engaged Active Empowered Hopeful Liking Defensive Oppositional Listening Disengaged Passive Powerless Unable to change Disliking

  37. Add MI as a Prelude to TAURandomized Trial Outcomes at 3 months Bien et al 1993 Brown & Miller 1993 Aubrey 1998

  38. Therapist Compassion 20 minutes in ER One handwritten letter One telephone call Systematic Encouragement

  39. A Modest Proposal Hire Empathic Therapists! It is an evidence-based practice to hire staff based on and to train staff in the skill of accurate empathy

  40. Empathy and Outcome Percentage of variance in 12-month drinking outcome determined by therapist factors (random assignment designs) There’s some beef! Miller, Taylor & West 1980 Valle 1981 Miller et al., 1993 52% 42% 65% Empathy Empathy+ Confronting (-)

  41. OR the BOARDS Have we been studying the trees . . .

  42. But not the forest?

  43. So which is more important?

  44. Of course client factors also matter and some of them are influenced by the therapist Motivation for change Self-efficacy Hope/optimism Attendance/adherence

  45. And families matter • Involving a spouse in treatment significantly improves client substance use outcomes • And again it matters what you do

  46. Unilateral Family InterventionsRandomized Clinical Trials

  47. Treatment Method and . . • There are some specific treatment effects generally supported by clinical trials • They are often relatively small compared to • Therapist effects • Client effects and social context • Overall impact of treatment • And perhaps for these reasons they vary across sites • These larger “nonspecifics” (e.g., empathy) need to be specified, tested, and trained as EBTs

  48. Disseminating EBTs • Treatment-as-usual is a high standard to beat • Re-training staff in EBTs can be challenging and expensive • Specific treatment effect size often shrinks with dissemination into clinical practice • Therapist belief/enthusiasm / style matters • Testable question: Is it cost effective to re-train staff in an EBT? • In any event, it makes sense to train the next generation of addiction professionals in EBTs from the very beginning!

  49. Often Missed Questions • What is it about the therapists who are delivering the treatment that affects outcome? • What is it about the treatment that really matters? • Understanding the underlying mechanisms of efficacy of treatments and therapists will help us to know: • Whom to hire • What is essential in training • What to focus on in fidelity monitoring • What can be changed in adaptations

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