The language of motivational interviewing and feedback: counselor language, client language, and client drinking outcomes

Integration of an Electronic Screening, Brief Intervention, and Referral to Treatment Program Into an HIV Testing Program to Reduce Substance Use and HIV Risk Behavior Among Men Who Have Sex With Men: Protocol for Intervention Development and a Pilot Randomized Controlled Trial

BACKGROUND

Men who have sex with men (MSM) are disproportionally affected by HIV and drug and alcohol use; however, few effective HIV prevention interventions for MSM who use substances exist. Screening, Brief Intervention, and Referral to Treatment is an early intervention for non-treatment-seeking individuals with problematic substance use and for timely referral to treatment for those with substance use disorders. Electronic screening and brief interventions (e-SBIs) reduce implementation challenges. An e-SBI tailored for MSM at the time of HIV testing might be particularly opportune to strengthen their motivation to reduce substance use and HIV risk behavior.

OBJECTIVE

This study aims to develop a tailored e-SBI program to reduce substance use and HIV risk behavior among MSM seeking HIV testing at Nexo Asociación Civil, our community partners in Argentina (primary); assess the feasibility and acceptability of integrating the e-SBI into the Nexo HIV testing program (primary); assess the feasibility and acceptability of implementing an adapted Men's Health Project (MHP) at Nexo (secondary); and finally, explore preliminary findings on substance use and sexual risk reduction outcomes (exploratory).

METHODS

This mixed methods study has 2 stages. During stage 1 (development), we will use the User Centered Rapid App Design process consisting of focus groups (n=16), individual interviews (n=24), and a pilot deployment of the e-SBI (n=50) to iteratively develop the e-SBI. Quantitative and qualitative assessments at each step will inform the revision of the e-SBI. Furthermore, we will use the assessment, decision, administration, production, topic experts, integration, training, testing framework to adapt MHP. During stage 2 (pilot randomized controlled trial [RCT]), we will randomize 200 MSM coming to Nexo for HIV testing. They will complete a baseline assessment and then their assigned intervention (e-SBI vs screening only) and will be followed-up for 6 months. We will also conduct in-depth interviews with up to 45 participants: 15 participants from either study condition who entered or completed MHP or other substance abuse treatment and 15 from each arm who met the criteria for MHP but did not request it.

RESULTS

The study began recruitment in October 2022, and the stage-1 pilot study is near completion. Preliminary findings from stage 1 show high e-SBI acceptability. Data analysis of the stage-1 pilot is now beginning. The stage-2 pilot RCT will be launched in March 2024, with all data collection completed by May 2025.

CONCLUSIONS

This study will allow us to assess the acceptability and feasibility of e-SBI implementation during HIV testing encounters. We will also build the necessary research infrastructure for a subsequent RCT to assess the efficacy of e-SBIs in reducing substance use and HIV sexual risk behavior among MSM in this setting.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05542914; https://tinyurl.com/yyjj64dm.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56683.

The role of the relational context and therapists' technical behaviors in brief motivational interviewing sessions for heavy alcohol consumption: Findings from a sample of Latinx adults

INTRODUCTION

Motivational interviewing (MI) theory and process research highlights the role of therapist technical and relational behaviors in predicting client in-session statements for or against behavior change (i.e., change and sustain talk, respectively). These client statements, in turn, have been shown to predict intervention outcomes. The current study examines sequential associations between therapist behaviors and client change and sustain talk in a sample of Latinx individuals who engage in heavy alcohol consumption.

DATA

Data are from a completed randomized clinical trial of a culturally adapted (CAMI) versus unadapted MI targeting alcohol use and consequences among Latinx individuals.

METHOD

The study collected observational coding data with the Motivational Interviewing Skill Code (MISC 2.5, i.e., therapist behaviors and global ratings) and the Client Language Assessment - Proximal/Distal (CLA-PD, i.e., client language). Frequentist and Bayesian sequential analyses examined the relationship among nine different categories of therapist behaviors and three different categories of client language (i.e., change talk, sustain talk, neutral). We examined odds ratios and conditional probabilities for the direction, magnitude, and significance of the association between the use of MI technical behaviors and subsequent client statements about change. The study compared these same transitional associations between low/average (i.e., <4) and high (i.e., ≥4) MI Spirit sessions.

RESULTS

The pattern of results was replicated across both analytic frameworks. Questions and reflections about change talk versus sustain talk versus neutral statements showed greater odds of predicting the intended client response (i.e., change talk, sustain talk, neutral, respectively) compared to other possible client responses. Conditional probabilities for these transitions were high, ranging from 0.55 to.88. The magnitude of certain technical transitions significantly differed between low/average and high MI Spirit sessions.

CONCLUSIONS

Analyses supported the hypothesized associations between therapist use of technical MI behaviors and client change language within this Latinx sample. Analyses of MI Spirit as a moderator of these transitions showed partial support.

What's In It for Me? Motivating the Untreated Abuser to Consider Treatment

This paper presents findings of a second trial evaluating telephone-based motivational enhancement therapy (MET) to motivate untreated and unadjudicated men who abuse their intimate partners to explore treatment options. Participants' perceptions of how their abuse is negatively affecting them personally are a highlight of the paper. One hundred forty-one adult men were recruited through social marketing and randomly assigned to the intervention (MET) or comparison (Mail) group. The MET condition consisted of two feedback sessions guided by a personalized feedback report on participants' intimate partner violence (IPV) and substance use. The Mail condition included a mailed educational brochure on IPV and substance use. Results supported the likely effectiveness of MET in short-term reduction of IPV behavior, marijuana use, and increasing motivation for treatment seeking particularly for participants who reported more adverse consequences of IPV to themselves. Findings emphasize the importance of including a focus in interventions on IPV's impact on the abusers themselves. The study's virtual participation and success in reaching and retaining a diverse population of male abusers can contribute to transformative justice and communities looking for alternative early interventions for men of color prior to encountering the criminal justice system.

Engagement With Personalized Feedback for Emotional Distress Among College Students at Elevated Suicide Risk

Depression and suicidal ideation have substantially increased among college students, yet many students with clinically significant symptoms do not perceive their distress as warranting mental health services. Personalized feedback (PF) interventions deliver objective data, often electronically, comparing an individual's reported symptoms or behaviors to a group norm. Several studies have shown promise for PF interventions in the context of mood and depression, yet little is known regarding how, and for whom, mood-focused PF interventions might be best deployed. The primary aim of this study was to examine the sociodemographic, clinical, and treatment-seeking factors associated with reviewing PF reports on emotional distress among college students (N = 1,673) screening positive for elevated suicide risk and not receiving mental health treatment. Results indicated that PF engagement was greatest among those with higher depression scores, and those reporting privacy/stigma concerns as barriers to treatment. Sexual minority students were more likely to review their PF than heterosexual students. Taken together, PF interventions may be a useful tool for engaging those with greater clinical acuity, and those hesitant to seek in-person care. Further research is warranted to examine the circumstances in which PF interventions might be used in isolation, or as part of a multitiered intervention strategy.

Change talk and sustain talk in treatment of generalized anxiety disorder: A secondary analysis of cognitive behavioral therapy and metacognitive therapy in adult outpatients

BACKGROUND AND OBJECTIVES

Measures of patient motivation have proven elusive, showing inconsistent results in relation to psychotherapy outcome. How patients talk about change is an alternative measure of motivation, with potential value in predicting treatment outcome. This study had two aims: (1) to examine if change talk and sustain talk (including its subcategories) predicted reduction in worry levels at post-treatment and 2-year follow-up, and (2) if there were differences between the cognitive behavioral therapy (CBT) and metacognitive therapy (MCT) conditions with respect to change talk.

METHODS

This study investigated 24 patients receiving CBT and 27 patients receiving MCT for generalized anxiety disorder (GAD), and coded patients' utterances in sessions 1 and 4.

RESULTS

Change talk was significantly associated with lower worry levels at post-treatment and 2-year follow-up, beyond initial worry severity and treatment condition. Change talk in session 4, and reduction in sustain talk from session 1 to 4, was positively associated with improvement, whilst sustain talk in session 4 showed a negative relationship. More specifically, commitment statements in session 1 and expressing signs of taking steps at session 4 were associated with reduction in worry levels. Moreover, patients in the MCT condition argued more both for and against change during session 1, but not session 4.

LIMITATIONS

The sample size was relatively small.

CONCLUSIONS

These results indicate that change talk sustain talk could be important in the treatment of GAD.

A Change Talk Model for Abstinence Based on Web-Based Anonymous Gambler Chat Meeting Data by Using an Automatic Change Talk Classifier: Development Study

BACKGROUND

Change and sustain talks (negative and positive comments) on gambling have been relevant for determining gamblers' outcomes but they have not been used to clarify the abstinence process in anonymous gambler meetings.

OBJECTIVE

The aim of this study was to develop a change talk model for abstinence based on data extracted from web-based anonymous gambler chat meetings by using an automatic change talk classifier.

METHODS

This study used registry data from the internet. The author accessed web-based anonymous gambler chat meetings in Japan and sampled 1.63 million utterances (two-sentence texts) from 267 abstinent gamblers who have remained abstinent for at least three years and 1625 nonabstinent gamblers. The change talk classifier in this study automatically classified gamblers' utterances into change and sustain talks.

RESULTS

Abstinent gamblers showed higher proportions of change talks and lower probability of sustain talks compared with nonabstinent gamblers. The change talk model for abstinence, involving change and sustain talks, classified abstinent and nonabstinent gamblers through the use of a support vector machine with a radial basis kernel function. The model also indicated individual evaluation scores for abstinence and the ideal proportion of change talks for all participants according to their previous utterances.

CONCLUSIONS

Abstinence likelihood among gamblers can be increased by providing personalized evaluation values and indicating the optimal proportion of change talks. Moreover, this may help to prevent severe mental, social, and financial problems caused by the gambling disorder.

Motivational Interviewing Produces Change Talk in Smokers with Serious Mental Illness

Change talk, or client language that is consistent with making a behavioral change, has been found to improve the efficacy of motivational interviewing (MI). It is not known, however, if change talk helps to explain MI's effect on instigating a quit attempt in smokers with serious mental illness. Methods: We measured change talk in smokers with a serious mental illness (SMI) randomized to receive either a single session adaptation of motivational interviewing or an interactive education intervention. We evaluated relationships between treatment condition, proportion of change talk, and study outcomes of quit attempts and willingness to follow up on treatment provider referrals. Results: Participants receiving the adaptation of motivational interviewing had higher proportions of change talk than participants in the interactive education condition. However, total proportion of change talk did not mediate the relationship between treatment and outcome, nor did it predict making a quit attempt or following up on a referral to contact a treatment provider. Conclusions: Our study found that motivational interviewing has the same change talk augmenting effect in individuals with SMI as those without SMI. Given that anhedonia, negative affect, and depressive symptoms are a major part of serious mental illnesses, it is encouraging that MI can generate change talk in this population. Future smoking cessation intervention trials with larger samples should investigate whether greater amounts of change talk lead to increased quit attempts in this population.

Client-Centered Adherence Counseling with Adherence Measurement Feedback to Support Use of the Dapivirine Ring in MTN-025 (The HOPE Study)

Fostering adherence and open communication about adherence challenges is key to harnessing the potential of biomedical HIV prevention products. We describe the counseling intervention and objective adherence measure feedback process implemented to support adherence to the dapivirine vaginal ring among participants in four sub-Saharan countries and present findings on the counselors' likeability and acceptability of the intervention. Most counselors (N = 42; 86%) liked Options counseling "very much" and during in-depth interviews (N = 22), reported that the intervention reshaped their adherence counselling approach by emphasizing understanding participants' experiences using the ring, which facilitated open discussion of adherence challenges. Counselors found that reframing residual drug level (RDL) discussions from the "adherence" to "protection" perspective encouraged adherence among consistent users and facilitated decisions to switch to a different HIV prevention approach among infrequent users. Among counselors, 24% said participants "liked it very much" while 26% said that participants "liked it a little" possibly due to two main complaints: perceived repetitiousness of sessions and variability in the RDL assay, which at times resulted in unexpected low RDLs.

Mechanisms of Motivational Interviewing for Antiretroviral Medication Adherence in People with HIV

Antiretroviral therapy (ART) for HIV requires strict regimen adherence. Motivational interviewing (MI) can improve ART adherence. MI process studies have rarely focussed on ART adherence. Such studies may facilitate MI modifications to improve outcomes. This study employed a single group pre and post-test design with 62 adults with HIV (16 female; mean age 40 years). Therapist use of MI-consistent (MICO) methods, MI spirit, and client change and sustain talk were coded from an MI session. Relationships were assessed with ART schedule adherence. MICO methods positively correlated with change and sustain talk and were negatively associated with proportion of change talk. No variables were associated with ART adherence change. Mediation analysis did not support the MI model of change. This may be due to the fact that ART adherence is determined by both motivational and non-motivational factors. It may also be that bidirectional relationships exist between therapist and client speech.

Implementation of a fidelity monitoring process to assess delivery of an evidence-based adherence counseling intervention in a multi-site biomedical HIV prevention study

Pre-Exposure Prophylaxis (PrEP) trials often implement counseling to support product adherence. Counseling fidelity can vary significantly across providers and time. Fidelity monitoring can ensure that counseling is delivered as designed. We describe the process, feasibility, and outcomes of monitoring Options counseling fidelity in an open-label study of the dapivirine vaginal ring MTN-025/HOPE. After initial training, 63 counselors from 14 sites in Sub-Sahara Africa audio-recorded counseling sessions with study participants. Sessions were rated by a New York-based team that included bilingual emigres from the study countries. Completed session rating forms were sent to counselors to provide feedback and counseling difficulties were discussed during monthly calls. Of 1456 study participants, 85.7% consented to at least one session, and 20% to all sessions, being audio-recorded. Among 9926 study visits in which Options was expected to occur, 5366 (54.1%) Options sessions were audio-recorded, of which 1238 (23.1%) were reviewed; 1039 (83.9%) were rated as "good" or "fair." Eleven counselors who failed to consistently deliver the intervention were reassigned to back-up status. This study demonstrates the feasibility and benefits of monitoring counseling fidelity using audio-recordings in a multi-site, multi-language, multi-country PrEP trial. Given the investment necessary to conduct such trials, providing counseling oversight is highly warranted.

A Sequential Analysis of Clinician Skills and Client Change Statements in a Brief Motivational Intervention for Young Adult Heavy Drinking

This study examined sequential relationships between clinician skills and client statements about behavior change in a randomized clinical trial comparing a brief motivational intervention (BMI) to a relaxation training control condition (REL) in a sample of heavy drinking young adults. Clinician and client interactions (N = 167) were assessed according to two established observational rating systems. Sequential analyses examined the transitional associations between clinicians' use of MI-eliciting skills (i.e., questions and reflections), MI-supportive skills (e.g., affirmations, emphasize client autonomy, statements of support), MI-inconsistent skills (e.g., confrontations, unsolicited advice), and subsequent client statements about behavior change (i.e., change talk or sustain talk). In both conditions, clinicians' use of MI-elicitation skills operated in a manner that was largely consistent (100% in BMI; 84% in REL) with the directional relationships proposed by MI theory (i.e., The Technical Hypothesis). More detailed analyses of the BMI condition showed clinician skills were related to statements about behavior change somewhat differently in drinking compared to coping discussions. While elicitations of change talk were associated with increased odds of their intended response (i.e., distal drinking and proximal coping change talk), elicitations of proximal coping sustain talk were associated with higher odds of proximal change talk. MI-supportive skills were also associated with increased odds of proximal change talk, and instances of proximal sustain talk were rare in the sample. This fine-grained analysis presents sequential transitions to client change and sustain talk with greater classification specificity than has been previously reported. Such efforts have the potential to advance our understanding of the function of MI skills in promoting client discussions about drinking (i.e., evoking) and coping (i.e., planning) behavior change.

Improvement in therapist skills over sessions in brief motivational interventions predicts client language and alcohol use outcomes

Brief motivational interventions (BMIs) are widely used and efficacious interventions that address alcohol misuse in mandated college students. Consistent with motivational interviewing (MI; Miller & Rollnick, 2013) theory, within-therapist improvements in MI-consistent (MICO) skills over time-that is, as a therapist gains skill through repeated practice-may be associated with concurrent increases in client change language and subsequent changes in behavior. This study examined how therapist skill changed over time and whether within-therapist improvement in MICO skills impacted in-session client change language and subsequent alcohol-related outcomes. BMI sessions (N = 228) from 2 randomized clinical trials that had led to significant reductions in alcohol use and alcohol-related problems in mandated student drinkers were coded using the Motivational Interviewing Skills Code 2.0 (Miller, Moyers, Ernst, & Amrhein, 2003). In both studies, the BMI consisted of a single 45- to 60-min session. Analyses examined session-by-session changes in therapist MICO skills, client change language, and alcohol use outcomes. Therapist MICO skills improved over time, and there were significant increases in client change language and decreases in client discussion of topics other than personal alcohol use. Among relatively heavy-drinking clients, those treated by a more experienced therapist demonstrated greater reductions in alcohol use; however, this association was not mediated by client change language. Increased experience conducting BMIs improved therapist MICO skills over time, which in turn increased the focus on personal alcohol use during the session. However, it remains unclear how client language predicts behavior change following a BMI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The role of therapist MI skill and client change talk class membership predicting dual alcohol and sex risk outcomes

OBJECTIVE

We investigated the technical model of motivational interviewing (MI) in a dual-outcome intervention (i.e., alcohol, sexual risk; N = 164; 57% female).

METHOD

We identified latent classes of client change statements, based on the proportion of change talk (CT) over the session. We then examined whether outcomes were related to CT class, and whether the relations between MI skill and outcomes varied by CT class.

RESULTS

We found three classes of alcohol-CT and two classes of sexual risk-CT. While CT class membership did not predict outcomes directly, greater therapist MI-consistent skill was associated with fewer heavy drinking days in the increasing alcohol-CT class. For sexual risk outcomes, therapist MI-consistent skill was associated with reduced odds of condomless sex for the low sexual risk-CT class.

CONCLUSIONS

The relation of therapist MI consistency to outcomes appears to be a function of client CT during the session.

Motivational interviewing technical process and moderated relational process with underage young adult heavy drinkers

This study tested technical and relational processes hypothesized to explain the therapeutic benefit of an efficacious brief motivational interview (BMI). A randomized controlled trial compared the efficacy of a BMI to an attention-matched control (i.e., relaxation training [REL]) for reducing heavy alcohol consumption and associated negative consequences. Participants were underage, past-month heavy drinkers recruited from community settings (N = 167; ages 17-20; 62% female; 59% White). Data were collected on session recordings, using established motivational interviewing process measures. Statistical analyses followed 3 steps. First, a latent class model determined the optimal class solution for characterizing proportion change talk means within BMI and REL. Next, the probability of proportion change talk class membership was examined as a mediator and then as a moderated mediator of BMI efficacy. The latent class model yielded a 3-class solution, including a low-increasing proportion change talk class (n = 61), a moderate-increasing proportion change talk class (n = 97), and a nonlinear proportion change talk class (n = 7). Across the outcomes examined, membership in the moderate-increasing class rather than the low-increasing class mediated BMI effects on alcohol-related consequences at 6 weeks. Mediation tests for consequences at 3 months and heavy drinking were nonsignificant. Moderated mediation results for therapist empathy and MI Spirit were nonsignificant. Findings suggest that moderate increases in prochange statements, relative to anti- or neutral-change statements, help explain BMI effects on reducing alcohol-related negative consequences soon after intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mechanisms of behavior change in motivational interviewing: do we understand how MI works?

This work provides an overview of Motivational Interviewing (MI) theory, the nature of the evidence for its mechanisms of action, and considers future directions. There are three hypotheses purported to explain how MI works: The Technical Hypothesis, the Relational Hypothesis, and the Conflict Resolution Hypothesis. In contrast to the latter two hypotheses, the Technical Hypothesis has received the most empirical attention in the MI process literature. Research shows that clinician technical skills in MI are well-defined, they relate to the intended client mechanisms (i.e. change talk and sustain talk), but the evidence supporting client mechanisms as predictors of subsequent changes to behavior is less conclusive. Future research and clinical implications are briefly considered.

The predictive capacity of self-reported motivation vs. early observed motivational language in cognitive behavioural therapy for generalized anxiety disorder

Client motivation to change is often considered a key factor in psychotherapy. To date, research on this client construct has largely relied on self-report, which is prone to response bias and ceiling effects. Moreover, self-reported motivation has been inconsistently related to treatment outcome. Early observed client in-session language may be a more valid measure of initial motivation and thus a promising predictor of outcome. The predictive ability of motivational factors has been examined in addiction treatment but has been limited in other populations. Addressing this lack, the present study investigated 85 clients undergoing cognitive behavioural therapy (CBT) alone and CBT infused with motivational interviewing (MI-CBT) for severe generalized anxiety disorder. There were two aims: (1) to compare the predictive capacity of motivational language vs. two self-report measures of motivation on worry reduction and (2) to examine the influence of treatment condition on motivational language. Findings indicated that motivational language explained up to 35% of outcome variance, event 1-year post-treatment. Self-reported motivation did not predict treatment outcome. Moreover, MI-CBT was associated with a significant decrease in the most detrimental type of motivational language compared to CBT alone. These findings support the importance of attending to in-session motivational language in CBT and learning to respond to these markers using motivational interviewing.

The relationship between in-session commitment language and daily self-reported commitment to reduce or abstain from drinking

BACKGROUND

Motivational interviewing is hypothesized to operate by enhancing a client's internal motivation to change. Past research operationalizes this process by measuring in-session statements for change (i.e., change talk), yet relationships between change talk and other measures of motivation have yet to be substantiated. This study tested whether in-session change talk predicted subsequent reports of commitment to abstain or moderate drinking assessed via ecological momentary assessment (EMA), and explored each of their contributions to drinking outcomes.

METHOD

Secondary data analysis was performed on data from 48 study participants who received therapy within a randomized controlled trial testing mechanisms of actions of MI. Multilevel models were used to test whether in-session commitment statements (strength, frequency, and slope of strength) made in two therapy sessions predicted subsequent daily reports of commitment to abstain or not drink heavily and drinking (21 days of data) in the weeks following each respective session.

RESULTS

A weak, negative relationship between in-session commitment and average daily commitment to abstain emerged. No relationship between in-session statements and average daily commitment to not drink heavily emerged. Only EMA commitment predicted drinking outcome. Post hoc analyses demonstrate a moderating impact of EMA commitment to abstain on in-session commitment strength: low pre-treatment commitment to abstain and increasing commitment strength across a session yielded the greatest drink reduction.

CONCLUSION

In-session change talk and EMA commitment may represent distinct aspects of motivation, yet their interaction appears important to treatment prognoses. Commitment to abstain may be important for treatment selection and successful drink reduction.

Do what you say and say what you are going to do: A preliminary meta-analysis of client change and sustain talk subtypes in motivational interviewing

Objective: This meta-analysis examines the predictive validity of client change language subtypes in motivational interviewing (MI) sessions addressing addictive behavior change. Method: A systematic review identified k = 13 primary studies, contributing 16 MI conditions (N = 1556). The pooled correlation coefficient was used to assess the significance, direction, and strength of seven language subtypes (i.e., reason, desire, need, ability, commitment, taking steps, and other) by three valences (i.e., frequency positive or change talk, frequency negative or sustain talk, and proportion change talk) and their relationship to subsequent engagement in addictive behavior. Results: For frequency measures, more sustain talk related to reason, desire, ability, and other were associated with more addictive behavior at follow up. Other change talk was associated with MI outcomes but in an unexpected direction (i.e., more addictive behavior). Proportion measures showed more proportion change talk-reason and -other statements were associated with less addictive behavior at follow up. Sensitivity analyses indicated some heterogeneity and instability of effect sizes, but no evidence of publication bias. Conclusions: This preliminary meta-analysis suggests that aggregate measures of change and sustain talk are comprised of statement subtypes that are not equally meaningful in predicting outcome following MI for addictive behavior change.

Toward an Emerging Role for Motivational Interviewing in Primary Care

PURPOSE OF REVIEW

Implementing Motivational Interviewing (MI) in primary care settings has been problematic due in part to persistent gaps in knowledge. Examples include poor understanding of how to effectively train persons to conduct MI, or of which aspects of MI-related communication are associated with better outcomes for patients. This review describes how recent research findings addressing the knowledge gaps support a growing role for MI in primary care.

RECENT FINDINGS

Two trials of MI training combined classroom time with ongoing coaching and feedback, resulting in enhanced MI ability relative to a control arm where PCPs received minimal or no MI training. A third MI training trial excluded coaching and feedback, failing to increase use of MI. Adding to a growing list of behavioral health-related problems for which MI training has shown some effectiveness, a trial of training PCPs to use MI with depressed patients was associated with significantly improved depressive symptoms. Moreover, aspects of the PCPs' MI-related language and patients' arguments for positive behavior changes, "change talk," appeared to explain the positive effects of MI training on depression outcome. MI-training approaches have improved such that PCPs and possibly other clinic staff may want to consider MI training as a way to more effectively support their patients as they address behavioral health-related problems (e.g., tobacco use). MI training should focus on eliciting "change talk" from patients. Researchers and funding agencies might collaborate to continue closing knowledge gaps in the MI literature.

Short- and Long-Term Effects of Within-Session Client Speech on Drinking Outcomes in the COMBINE Study

OBJECTIVE

There is evidence of a causal chain in motivational interviewing (MI) involving counselor MI-consistent skills, client change language, and outcomes. MI was a key component of the combined behavioral intervention in the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) Study. Participants in COMBINE were treatment-seeking and medication-seeking, and were required to maintain a period of abstinence before enrollment. Counselors were closely monitored and were temporarily removed from the study for remediation and supervision if their performance fell below threshold. The purpose of this study was to evaluate the MI causal chain among initial-session combined behavioral intervention audio recordings in this unique sample of highly motivated clients and highly monitored counselors.

METHOD

Session 1 audio recordings (N = 254, 73.5% men) were evaluated using the Motivational Interviewing Skill Code Version 2.0 with good interrater reliability. Counselor speech was measured using a summary measure of MI-consistent behavior. Client change language was assessed, using change talk and sustain talk. The outcome measure of drinks per week was computed using the COMBINE data set.

RESULTS

Higher sustain talk was significantly associated with increased drinking during treatment, whereas higher change talk was significantly associated with decreased drinking at the 1-year follow-up. In addition, there were significant indirect effects linking counselor behavior, client speech, and drinking both during treatment and at 1 year.

CONCLUSIONS

Results supported the posited causal chain for MI. Despite somewhat lower variability of counselor behavior and use of a coding instrument that did not capture directional counselor behaviors, counselor behavior, client speech, and drinking outcomes were clearly linked in this unique sample.

Reasons for Testing Mediation in the Absence of an Intervention Effect: A Research Imperative in Prevention and Intervention Research

OBJECTIVE

Mediation models are used in prevention and intervention research to assess the mechanisms by which interventions influence outcomes. However, researchers may not investigate mediators in the absence of intervention effects on the primary outcome variable. There is emerging evidence that in some situations, tests of mediated effects can be statistically significant when the total intervention effect is not statistically significant. In addition, there are important conceptual and practical reasons for investigating mediation when the intervention effect is nonsignificant.

METHOD

This article discusses the conditions under which mediation may be present when an intervention effect does not have a statistically significant effect and why mediation should always be considered important.

RESULTS

Mediation may be present in the following conditions: when the total and mediated effects are equal in value, when the mediated and direct effects have opposing signs, when mediated effects are equal across single and multiple-mediator models, and when specific mediated effects have opposing signs. Mediation should be conducted in every study because it provides the opportunity to test known and replicable mediators, to use mediators as an intervention manipulation check, and to address action and conceptual theory in intervention models.

CONCLUSIONS

Mediators are central to intervention programs, and mediators should be investigated for the valuable information they provide about the success or failure of interventions.

Exploration of treatment matching of problem drinker characteristics to motivational interviewing and non-directive client-centered psychotherapy

Motivational Interviewing (MI) is a known effective intervention for alcohol use disorder (AUD). MI's mechanisms of action remain inconsistently substantiated, and research in this area has been reliant on identifying relationships through strength of association rather than experimental manipulation of active ingredients. In two previous studies, a pilot and a larger replication study, we disaggregated MI into its hypothesized active ingredients by creating three conditions: MI, Spirit Only MI (SOMI, in which evocation of change talk was proscribed), and a non-therapy condition (NTC). Results from both studies yielded equivalent findings across all three conditions. In the current analyses, data from both studies were combined to test five participant characteristics as moderators of MI's component parts: 1) severity of baseline drinking, 2) severe AUD (met 6 or more criteria), 3) baseline self-efficacy to moderate drinking, 4) mean daily confidence to resist heavy drinking in the week prior to treatment initiation, and 5) depression. There were no significant findings related to baseline drinking, severe AUD, or baseline self-efficacy. Confidence yielded a significant interaction effect. When participants had high baseline confidence, drinking for those in MI increased compared to those in SOMI. Depression also yielded a significant moderating effect such that in the context of higher depressive symptoms, receipt of either therapy reduced drinking relative to NTC. Results are discussed in light of existing literature on MOBC with MI and the potential role exploring ambivalence may play for participants with particular characteristics.

A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change

OBJECTIVE

In the present meta-analysis, we test the technical and relational hypotheses of Motivational Interviewing (MI) efficacy. We also propose an a priori conditional process model where heterogeneity of technical path effect sizes should be explained by interpersonal/relational (i.e., empathy, MI Spirit) and intrapersonal (i.e., client treatment seeking status) moderators.

METHOD

A systematic review identified k = 58 reports, describing 36 primary studies and 40 effect sizes (N = 3,025 participants). Statistical methods calculated the inverse variance-weighted pooled correlation coefficient for the therapist to client and the client to outcome paths across multiple target behaviors (i.e., alcohol use, other drug use, other behavior change).

RESULTS

Therapist MI-consistent skills were correlated with more client change talk (r = .55, p < .001) as well as more sustain talk (r = .40, p < .001). MI-inconsistent skills were correlated with more sustain talk (r = .16, p < .001), but not change talk. When these indicators were combined into proportions, as recommended in the Motivational Interviewing Skill Code, the overall technical hypothesis was supported. Specifically, proportion MI consistency was related to higher proportion change talk (r = .11, p = .004) and higher proportion change talk was related to reductions in risk behavior at follow up (r = -.16, p < .001). When tested as two independent effects, client change talk was not significant, but sustain talk was positively associated with worse outcome (r = .19, p < .001). Finally, the relational hypothesis was not supported, but heterogeneity in technical hypothesis path effect sizes was partially explained by inter- and intrapersonal moderators.

CONCLUSIONS

This meta-analysis provides additional support for the technical hypothesis of MI efficacy; future research on the relational hypothesis should occur in the field rather than in the context of clinical trials. (PsycINFO Database Record

Effects of motivational interviewing fidelity on substance use treatment engagement in primary care

OBJECTIVE

Primary care (PC) may be an opportune setting to engage patients with opioid and alcohol use disorders (OAUDs) in treatment. We examined whether motivational interviewing (MI) fidelity was associated with engagement in primary care-based OAUD treatment in an integrated behavioral health setting.

METHODS

We coded 42 first session therapy recordings and examined whether therapist MI global ratings and behavior counts were associated with patient engagement, defined as the patient receiving one shot of extended-release injectable naltrexone or any combination of at least two additional behavioral therapy, sublingual buprenorphine/naloxone prescriptions, or OAUD-related medical visits within 30days of their initial behavioral therapy visit.

RESULTS

Autonomy/support global ratings were higher in the non-engaged group (OR=0.28, 95%CI: 0.09-0.93; p=0.037). No other MI fidelity ratings were significantly associated with engagement.

CONCLUSION

We did not find positive associations between MI fidelity and engagement in primary care-based OAUD treatment. More research with larger samples is needed to examine how providing autonomy/support to patients who are not ready to change may affect engagement.

PRACTICE IMPLICATIONS

Training providers to strategically use MI to reinforce change as opposed to the status quo is needed. This may be especially important in primary care where patients may not be specifically seeking help for their OAUDs.

Trajectories of in-session change language in brief motivational interventions with mandated college students

OBJECTIVE

Brief motivational interventions (BMIs) are currently the most efficacious individual intervention for mandated college students. However, little is known about how BMIs facilitate client language in relation to subsequent changes in alcohol use and problems in mandated student samples.

METHOD

The current study used the Motivational Interviewing Skills Code (MISC 2.0; Miller, Moyers, Ernst, & Amrhein, 2003) to code BMI sessions (N = 252) from 2 randomized clinical trials that led to significant reductions in alcohol use and alcohol-related problems in mandated student drinkers. A proportion of change language was calculated for each decile (1st to 10th) of the BMI sessions.

RESULTS

Latent class analyses of in-session speech indicated that there were 3 distinct trajectories of change language over the course of the session: high (n = 59), increasing (n = 122), and low (n = 71). Members of the high trajectory group showed higher rates of alcohol-related problems prior to the BMI and members of the low trajectory group were more likely to be male. Six months following the BMI, members of the high and low trajectory groups demonstrated significant reductions in alcohol use and problems, and members of the increasing trajectory group only reduced alcohol-related problems.

CONCLUSIONS

Associations among the 3 trajectories of client change language and subsequent reductions in alcohol use and problems partially supported the technical hypothesis of MI efficacy. Client factors as well as the nature of the discussion of personalized feedback may determine the link between in-session client language and subsequent behavior change. (PsycINFO Database Record

Dismantling motivational interviewing: Effects on initiation of behavior change among problem drinkers seeking treatment

Motivational interviewing (MI) is an efficacious treatment for alcohol use disorders. MI is thought to enhance motivation via a combination of 2 therapeutic strategies or active ingredients: 1 relational and 1 directional. The primary aim of this study was to examine MI's hypothesized active ingredients using a dismantling design. Problem drinkers (N = 139) seeking treatment were randomized to 1 of 3 conditions: MI, relational MI without the directional elements labeled spirit-only MI (SOMI), or a nontherapy control condition and followed for 8 weeks. Those assigned to MI or SOMI received 4 sessions of treatment over 8 weeks. All participants significantly reduced their drinking by Week 8, but reductions were equivalent across conditions. The hypothesis that baseline motivation would significantly moderate condition effects on outcome was generally not supported. Failure to find support for MI's hypothesized active ingredients is discussed in the context of the strengths and limitations of the study design. (PsycINFO Database Record

The language of change among criminal justice clients: Counselor language, client language, and client substance use outcomes

OBJECTIVE

Counselor and client language have been identified as mechanisms of change in motivational interviewing (MI) counseling sessions. This study evaluated whether language patterns exhibited during MI sessions with substance users in the community would also be found during MI sessions with substance users in the criminal justice system.

METHOD

Forty audio recordings of MI sessions with substance-using probationers were coded and analyzed sequentially using the Motivational Interviewing Skills Code (MISC) 2.5. Analyses examined the relationship between counselor and client language, and the relationship between client language and client substance use after 2 months.

RESULTS

Counselor MI inconsistent language was associated with decreased change talk (lnOR = - 0.76, p < .05) though not with increased sustain talk. Both sustain talk (b = - 4.591, t = - 18.634 p < .001) and MI inconsistent language MIIN (b = - 4.419, t = - 19.886, p < .001) were positively associated with substance use at 2 months. Sustain talk early in the session (i.e., during deciles 1 and 2) was significantly greater among clients who reported using substances at 2 months, compared to clients who did not use substances.

CONCLUSION

These findings are broadly consistent with previous literature documenting the association between counselor language, client language, and client outcome.

A multivariate meta-analysis of motivational interviewing process and outcome

Motivational interviewing (MI) theory proposes a process whereby a set of therapist behaviors has direct effects on client outcomes and indirect effects through in-session processes (e.g., client change talk). Despite clear empirical support for the efficacy of MI across settings, the results of studies evaluating proposed links between MI process and outcome have been less clear. In the present study, we used a series of multivariate meta-analyses to test whether there are differential relationships between specific MI-consistent and MI-inconsistent therapist behaviors, MI therapist global ratings, client change language, and clinical outcomes. Based on 19 primary studies (N = 2,614), we found a significant relationship between MI-consistent therapist behaviors and greater client change talk, as well as greater client sustain talk. Higher therapist global ratings (empathy and MI spirit) were significantly related to increased MI-consistent behaviors, decreased MI-inconsistent behaviors, increased client change talk, yet also increased client sustain talk. Therapist global ratings were not significantly related to clinical outcomes. Client sustain talk was a significant predictor of worse clinical outcomes, while client change talk was unrelated to outcome. Variability within the correlations indicated that MI-consistent and MI-inconsistent therapist behaviors were differentially related to therapist global ratings of empathy and MI spirit. Similar to past research, present findings provide equivocal support for hypothesized MI process outcome relationships. Clinical implications and future areas of MI mechanism research are discussed. (PsycINFO Database Record

Motivational Interviewing to prevent dropout from an education and employment program for young adults: A randomized controlled trial

This study tested the efficacy of Motivational Interviewing for improving retention at a "second chance" program in the United States for unemployed young adults who had not graduated high school (ages 18-24; 60% male). We investigated how Motivational Interviewing effects might be mediated by change talk (i.e., arguments for change) and moderated by preference for consistency (PFC). Participants (N = 100) were randomly assigned to (1) Motivational Interviewing designed to elicit change talk, (2) placebo counseling designed not to elicit change talk, or (3) no additional treatment. Motivational Interviewing sessions increased change talk, but did not increase program retention or diploma earning. PFC was a significant moderator of Motivational Interviewing's impact on program retention; Motivational Interviewing was most effective at increasing 8 week retention for high PFC participants, and least effective for low PFC participants. These results suggest that Motivational Interviewing could be a useful tool for improving retention in education and employment programs, but clinicians should be attentive to how participant characteristics might enhance or diminish Motivational Interviewing effects.

A randomized controlled trial to influence client language in substance use disorder treatment

BACKGROUND

Client language is hypothesized to be a mechanism of action in motivational interviewing (MI). Despite the association of change and sustain talk with substance treatment outcomes, it not known whether providers can intentionally influence this language as hypothesized.

OBJECTIVE

This is a randomized controlled trial to investigate whether substance use providers can be trained to influence client language.

METHODS

Treatment providers specializing in substance use disorders (n=190) were randomly assigned to standard training in MI (MI-AU) or training emphasizing an influence of client language (MI-LEAF). Treatment sessions with actual clients were evaluated 3, 6 and 12 months after training by masked raters. Frequencies of client change and sustain talk were the outcome variables.

RESULTS

Sustain talk, but not change talk, was significantly lower in clients whose providers had received the specialized training (b=-0.175, SE=0.087, p=0.046, CI[-0.348 to 0.002], d=-0.325). Mediation analyses supported a causal chain between a) training, b) providers' attempts to minimize sustain talk in treatment sessions via directive reflective listening and c) client sustain talk in the treatment session (κ²=0.0833, bootstrap SE=0.0394, 95% CI [0.0148, 0.1691]).

CONCLUSIONS

With specialized training, providers can reduce the amount of opposition language their clients offer when considering a change in their substance use. Demonstrating that client language is under partial control of the provider supports the feasibility of clinical trials to investigate the impact of shaping client language on treatment outcomes.

The relationship between counselors' technical skills, clients' in-session verbal responses, and outcome in smoking cessation treatment

BACKGROUND

The technical component of Motivational Interviewing (MI) posits that client language mediates the relationship between counselor techniques and subsequent client behavioral outcomes. The purpose of this study was to examine this hypothesized technical component of MI in smoking cessation treatment in more depth.

METHOD

Secondary analysis of 106 first treatment sessions, derived from the Swedish National Tobacco Quitline, and previously rated using the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE) Coder's Manual and the Motivational Interviewing Treatment Integrity code (MITI) Manual, version 3.1. The outcome measure was self-reported 6-month continuous abstinence at 12-month follow-up.

RESULTS

Sequential analyses indicated that clients were significantly more likely than expected by chance to argue for change (change talk) following MI-consistent behaviors and questions and reflections favoring change. Conversely, clients were more likely to argue against change (sustain talk) following questions and reflections favoring status-quo. Parallel mediation analysis revealed that a counselor technique (reflections of client sustain talk) had an indirect effect on smoking outcome at follow-up through client language mediators.

CONCLUSIONS

The study makes a significant contribution to our understanding of how MI works in smoking cessation treatment and adds further empirical support for the hypothesized technical component in MI. The results emphasize the importance of counselors avoiding unintentional reinforcement of sustain talk and underline the need for a greater emphasis on the direction of questions and reflections in MI trainings and fidelity measures.

Motivational Interviewing With and Without Normative Feedback for Adolescents With Substance Use Problems: A Preliminary Study

BACKGROUND

Many adolescents in need of substance use disorder treatments never engage in treatment. Further, the most promising interventions that could be adapted to target treatment engagement often use normative feedback (NF) despite concerns about its appropriateness for adolescents. This preliminary study will inform a larger trial designed to isolate whether NF is an inert, helpful, or harmful active ingredient within pretreatment motivational interviewing (MI) interventions designed to increase treatment engagement.

METHODS

Adolescents (N = 48) presenting for treatment intake assessments were randomized to receive MI (n = 22) or MI+NF (n = 26) immediately following their assessments. Three-month outcomes included the percentage of youth engaged in treatment, the percentage of youth reporting past-month binge drinking, and the percentage of days of abstinence.

RESULTS

Treatments were delivered with high fidelity, and a high proportion of eligible participants were recruited and retained in this study. Participants significantly increased their percentage of days of abstinence by approximately 10% at follow-up (d = .32, P =.03), with no significant differences between groups. Fifty-five percent of youth in MI and 41.7% of youth in MI+NF engaged in treatment (odds ratio [OR] = .60, nonsignificant; 95% confidence interval, CI [0.136-2.68]).

CONCLUSIONS

Larger trials should test whether NF is an active ingredient in adolescent MI interventions, and should also determine the mechanisms through which MI+NF may produce effects.

Therapist and Client Interactions in Motivational Interviewing for Social Anxiety Disorder

OBJECTIVE

The aim of the present study is to assess the bidirectional associations between therapist and client speech during a treatment based on motivational interviewing (MI) for social anxiety disorder.

METHOD

Participants were 85 adults diagnosed with social anxiety who received MI prior to entering cognitive behavioral therapy. MI sessions were sequentially coded using the Motivational Interviewing Skill Code 2.5.

RESULTS

Therapist MI-consistent behaviors, including open questions as well as positive and negative reflections, were more likely to be followed by client change exploration (change talk and counter-change talk). Therapist MI-inconsistent behaviors were more likely to precede client neutral language. Client language was also found to influence therapist likelihood of responding in an MI-consistent manner.

CONCLUSION

The findings support the first step of the MI causal model in the context of social anxiety and direct future research into the effect of therapist and client behaviors on MI treatment outcome.

How group factors affect adolescent change talk and substance use outcomes: implications for motivational interviewing training

Clients who verbalize statements arguing for change (change talk [CT]) in psychotherapy are more likely to decrease alcohol and other drug use (AOD) compared with clients who voice statements in opposition of change (sustain talk [ST]). Little is known about how CT and ST are expressed in groups in which adolescents may vary in their AOD use severity and readiness to change. First, we examined how session content was associated with CT/ST, and then we looked at whether different subtypes of CT/ST were associated with subsequent AOD outcomes 3 months later. Audio recordings (N = 129 sessions) of a 6-session group motivational interviewing (MI) intervention, Free Talk, were coded. Session content was not associated with CT; however, some session content was associated with higher percentages of ST (e.g., normative feedback). Subtypes of CT (Commitment and Reason) were associated with improved AOD outcomes, whereas Ability subtype remarks were related to increased marijuana use, intentions, and consequences. Findings offer helpful guidance for clinical training and narrow in on the type of CT to try to elicit in Group MI sessions. Regardless of session content, adolescents can benefit from hearing CT during the group.

A randomized controlled trial of culturally adapted motivational interviewing for Hispanic heavy drinkers: Theory of adaptation and study protocol

BACKGROUND

The NIH Strategic Plan prioritizes health disparities research for socially disadvantaged Hispanics, to reduce the disproportionate burden of alcohol-related negative consequences compared to other racial/ethnic groups. Cultural adaptation of evidence-based treatments, such as motivational interviewing (MI), can improve access and response to alcohol treatment. However, the lack of rigorous clinical trials designed to test the efficacy and theoretical underpinnings of cultural adaptation has made proof of concept difficult.

OBJECTIVE

The CAMI2 (Culturally Adapted Motivational Interviewing) study design and its theoretical model, is described to illustrate how MI adapted to social and cultural factors (CAMI) can be discriminated against non-adapted MI.

METHODS AND DESIGN

CAMI2, a large, 12month randomized prospective trial, examines the efficacy of CAMI and MI among heavy drinking Hispanics recruited from the community (n=257). Outcomes are reductions in heavy drinking days (Time Line Follow-Back) and negative consequences of drinking among Hispanics (Drinkers Inventory of Consequences). A second aim examines perceived acculturation stress as a moderator of treatment outcomes in the CAMI condition.

SUMMARY

The CAMI2 study design protocol is presented and the theory of adaptation is presented. Findings from the trial described may yield important recommendations on the science of cultural adaptation and improve MI dissemination to Hispanics with alcohol risk.

Advances in Motivational Interviewing for Pediatric Obesity: Results of the Brief Motivational Interviewing to Reduce Body Mass Index Trial and Future Directions

Rates of childhood obesity in the United States remain at historic highs. The pediatric primary care office represents an important yet underused setting to intervene with families. One factor contributing to underuse of the primary care setting is lack of effective available interventions. One evidence-based method to help engage and motivate patients is motivational interviewing, a client-centered and goal-oriented style of counseling used extensively to increase autonomous motivation and modify health behaviors. This article summarizes the methods and results from a large trial implemented in primary care pediatric office and concludes with recommendations for improving the intervention and increasing its dissemination.

The Motivational Interviewing Treatment Integrity Code (MITI 4): Rationale, Preliminary Reliability and Validity

The Motivational Interviewing Treatment Integrity code has been revised to address new evidence-based elements of motivational interviewing (MI). This new version (MITI 4) includes new global ratings to assess clinician's attention to client language, increased rigor in assessing autonomy support and client choice, and items to evaluate the use of persuasion when giving information and advice.

METHOD

Four undergraduate, non-professional raters were trained in the MITI and used it to review 50 audiotapes of clinicians conducting MI in actual treatments sessions. Both kappa and intraclass correlation indices were calculated for all coders, for the best rater pair and for a 20% randomly selected sample from the best rater pair.

RESULTS

Reliability across raters, with the exception of Emphasize Autonomy and % Complex Reflections, were in the good to excellent range. Reliability estimates decrease when smaller samples are used and when fewer raters contribute.

CONCLUSION

The advantages and drawbacks of this revision are discussed including implications for research and clinical applications. The MITI 4.0 represents a reliable method for assessing the integrity of MI including both the technical and relational components of the method.

Sustain talk predicts poorer outcomes among mandated college student drinkers receiving a brief motivational intervention

Within-session client language that represents a movement toward behavior change (change talk) has been linked to better treatment outcomes in the literature on motivational interviewing (MI). There has been somewhat less study of the impact of client language against change (sustain talk) on outcomes following an MI session. This study examined the role of both client change talk and sustain talk, as well as therapist language, occurring during a brief motivational intervention (BMI) session with college students who had violated college alcohol policy (N = 92). Audiotapes of these sessions were coded using a therapy process coding system. A series of hierarchical regressions were used to examine the relationships among therapist MI-consistent and MI-inconsistent language, client change talk and sustain talk, as well as global measures of relational variables, and drinking outcomes. Contrary to prior research, sustain talk, but not change talk, predicted poorer alcohol use outcomes following the BMI at 3- and 12-month follow-up assessments. Higher levels of client self-exploration during the session also predicted improved drinking outcomes. Therapist measures of MI-consistent and MI-inconsistent language, and global measures of therapist acceptance and MI spirit were unrelated to client drinking outcomes. Results suggest that client sustain talk and self-exploration during the session play an important role in determining drinking outcomes among mandated college students receiving a BMI addressing alcohol use.

Derived relations moderate the association between changes in the strength of commitment language and cocaine treatment response

The psycholinguistic analysis of client-counselor interactions indicates that how individuals talk about their substance use is associated with treatment outcome. However, the processes by which client speech influences out-of-session behaviors have not been clearly delineated. This study investigated the relationships between deriving relations-a key behavioral process by which language and cognition may come to influence behavior, shifts in the strength of client talk in favor of change, and treatment outcome among 75 cocaine-dependent participants (23% Female). Participants were trained to relate cocaine words, nonsense syllables, and negative-consequence words and were then assessed for a derived relation of equivalence before starting treatment. The DARN-C coding system was used to quantify the strength of participant speech during an early cognitive behavior therapy counseling session. Cocaine use during treatment was the outcome of interest. The analyses (a) characterized the process of deriving relations among individuals seeking help for their misuse of cocaine, (b) tested the relationships between shifts in the strength of participants' speech in favor of change and treatment outcome, and (c) tested if deriving equivalence relations moderated the relationship between shifts in the strength of in-session speech and treatment response. Results indicated that a minority of participants derived equivalence relations, however increases in the strength of commitment language predicted less cocaine use during treatment only among those who did. The findings suggest deriving relations may be an important process by which changes in the strength of commitment language comes to influence substance use.

Within-Provider Variability in Motivational Interviewing Integrity for Three Years after MI Training: Does Time Heal?

This study examined variability in Motivational Interviewing (MI) integrity among 15 providers for three years following training. Data come from an effectiveness trial in which providers were trained to deliver brief single-session MI interventions. Each session was audio-recorded and coded for MI integrity using the Motivational Interviewing Treatment Integrity (MITI) 3.1.1 rating system. Within-provider variation in MI integrity was large, especially for behavior count scores (e.g., open questions, complex reflections) and only slightly smaller for global session scores of MI Spirit and Empathy. Within-provider variability was in most cases larger than between-provider variability and there was no evidence that providers improved appreciably over time. These findings raise concerns about the quality of MI being delivered in large-scale implementation efforts and have implications for the monitoring and training of higher quality MI.

Reliability and Validity of an Observational Measure of Client Decision-Making: The Client Language Assessment - Proximal/Distal (CLA-PD)

OVERVIEW

The Client Language Assessment - Proximal/Distal (CLA-PD) is a language rating system for measuring client decision-making in interventions that target a specified behavior change (e.g., alcohol or other drug use). In the CLA-PD, there are five dimensions of change language (Reason, Ability, Commitment, Taking Steps, Other) adapted from the client portion of the Motivational Interviewing Skill Code (MISC). For the CLA-PD, language codes are sub-divided to discriminate statements regarding the primary, or target behavior change (distal change) from the intermediate coping activities (proximal change) that are prescribed to facilitate that target behavior change. The goal of the CLA-PD is to allow for higher specificity than existing client language measures, when process studies consider interventions that are multi-session and skill-based (e.g., cognitive behavioral therapy).

METHOD

Three raters received 40 hours of training on the use of the CLA-PD. The data were a sample of therapy session audio-files from a completed clinical trial (N=126), which enabled examination of client language across four sessions (i.e., first three and final attended) of three evidence-based alcohol interventions (cognitive behavioral therapy, twelve-step facilitation therapy, motivational enhancement therapy).

RESULTS

Inter-rater reliability results for summary scores showed "excellent" reliability for the measure. Specifically, two-way mixed intraclass coefficients ranged from .83 to .95. Internal consistency reliability showed alphas across sessions that ranged from "fair" to "good" (α=.74-.84). In convergent and discriminant validity analyses using data independently measured with MISC-based ratings, the pattern of results was as would be expected. Specifically, convergent correlations, by valence (i.e., change and sustain talk), between CLA-PD Distal and MISC-based language scores were moderate (r=.46-.55, p<.001) while discriminant correlations by valence for CLA-PD Proximal and MISC-based language scores were small (r=.22-.24, p<.05). Finally, proportion Change Talk Proximal predicted subsequent session coping behaviors (i.e., processes of change) as well as 3-month Alcoholics Anonymous involvement and attendance (ps<.05-.005), but not 3-month alcohol abstinence self-efficacy. Further, analyses of criterion predictive validity showed that proportion Change Talk Distal predicted 3- and 12-month drinking frequency and quantity measures (ps<.05-.005).

CONCLUSIONS

When behavior change treatments are multi-session and/or skill-based, the present analyses suggest the CLA-PD is a promising, psychometrically sound observational rating measure of client verbalized decision-making.