Temporal variation in facilitator and client behavior during group motivational interviewing sessions

Understanding effects of the group process on drinking outcomes for emerging adults experiencing homelessness

BACKGROUND

There is little research on group process for motivational interviewing-based group interventions with young people. We examine how change talk, group climate and cohesion, and facilitator empathy among emerging adults experiencing homelessness affect their drinking outcomes.

METHODS

Data come from a clinical trial at three drop-in centers serving emerging adults experiencing homelessness in Los Angeles County and focus on those who received the intervention (n = 132). Participants completed baseline, 3-, 6-, and 12-month follow-up surveys. They were predominantly male and non-white. Group sessions were digitally recorded and coded for percentage change talk (PCT), group climate and cohesion, and facilitator empathy.

RESULTS

Because baseline alcohol use was significantly higher at site 1 than sites 2 and 3, we examined associations separately by site. At 6 months, higher PCT was associated with fewer drinks per drinking day for sites 2 and 3, whereas higher PCT was associated with more drinks per drinking day for site 1. There were no effects of PCT at 12 months. Higher group cohesion scores were associated with fewer drinking days at 6 months; higher facilitator empathy was associated with fewer maximum drinks in a day at both 6 and 12 months. Group climate was not associated with drinking outcomes.

CONCLUSIONS

These findings highlight the importance of measuring multiple factors in the group process to understand outcomes. What is "uttered" during group and what is observed provide different methods to evaluate the group process and allow us to better bridge the gap between research and practice.

A randomized controlled trial of a brief motivational interviewing-based group intervention for emerging adults experiencing homelessness: 12-Month effects on substance use and sexual risk behavior

INTRODUCTION

Few brief evidence-based risk reduction programs for emerging adults experiencing homelessness focus on the interrelated problems of substance use and sexual risk behavior. This study examines outcomes from a 12-month evaluation of AWARE, a brief Motivational Interviewing (MI)-based group risk reduction intervention for this population.

METHODS

In a cluster randomized crossover trial, N = 276 18-25-year-olds received AWARE or usual care at drop-in centers serving homeless youth in Los Angeles County. We evaluated intervention effects on substance use and condomless sex (primary outcomes), as well as drinking consequences and protective strategies, number of casual partners, self-efficacy, and motivation for change (secondary outcomes).

RESULTS

AWARE participants self-reported reductions in their alcohol use and negative consequences from drinking, and an increase in use of drinking protective strategies. AWARE participants also reported an initial decrease in drug use other than marijuana, followed by a slight uptake later on, as well as an initial increase in importance of cutting down on other drug use followed by a decrease. Control group participants did not show change in these outcomes. Among those who reported casual sex partners at both baseline and 12-month surveys, exploratory analyses indicated that AWARE participants had a 29 % decline in condomless sex with casual partners compared to a 6 % decline for control group participants.

CONCLUSIONS

Findings build on our pilot work by demonstrating that AWARE has long-term benefits on drinking among emerging adults experiencing homelessness. Further work should seek to strengthen its long-term effectiveness in reducing drug use in this population.

Veterinary communication can influence farmer Change Talk and can be modified following brief Motivational Interviewing training

Current veterinary communication skills training often focuses on the strategies necessary to successfully transfer information and promote shared decision making rather than inspiring client motivation to engage in behaviour change(s). One evidence-based communication methodology with a specific focus on enhancing conversations about change is Motivational Interviewing (MI), which is perceived by veterinarians to be highly relevant to their profession. We examined whether veterinarians who experienced brief (4–5 hours) MI training (BMIT) were able to change their communication behaviours to be more MI consistent. Fourteen veterinarians recorded 31 veterinary herd health consultations before (n = 15) and after (n = 16) BMIT to allow pre-post intervention analysis of veterinarian and farmer verbal behaviour. Additionally, using a sequential linguistic analysis of 3885 veterinarian-farmer communication events within these consultations, the influence of veterinarians’ verbal behaviours on farmers’ response language was explored. Analysis of veterinary consultations undertaken before and after BMIT revealed that veterinarians changed their communication style to be more consistent with the MI methodology, including more use of reflection statements, a more empathic and partnership-oriented consultation style and greater emphasis on clients’ own language in favour of change goals. In response, farmers contributed more to the conversation and discussed more herd health-related changes. Sequential linguistic analysis suggested that following a veterinarian emphasising something positive about the farmer (e.g. efforts, strengths), seeking collaboration or emphasising farmer choice, farmers were subsequently more likely to express arguments in favour of change (‘Change Talk’), especially phrases indicative of commitment. This study offers the first evidence of the potential value of a BMIT experience to enhance veterinary communication skills, although conscious and disciplined use of MI principles, strategies and Spirit–an ethos of compassion, acceptance, partnership and evocation—requires longer and more complex training. Further studies examining the longevity and consistency of these verbal behaviour changes following BMIT are required.

Inside Alcohol Behavioral Couple Therapy (ABCT): In-session speech trajectories and drinking outcomes

The alcohol treatment literature has established in-session client speech as a mechanism of change that therapist behavior can influence and that can predict drinking outcomes. This study aimed to explore temporal patterns of in-session speech in Alcohol Behavioral Couple Therapy (ABCT), including the unique interplay between client and partner speech and the role of speech trajectories in predicting client drinking outcomes. Participants were 165 heterosexual couples receiving ABCT in one of four clinical trials. We coded client speech on an utterance-by-utterance basis using the System for Coding Couples' Interactions in Therapy-Alcohol. We focused on individual-level speech codes of change talk and sustain talk and couple-level variables of positive and negative interactions. We segmented the initial and midtreatment sessions into quartiles to conduct path analyses and latent growth curve models. Path analyses suggested that clients and partners may not have been aligned in terms of treatment goals at the start of the therapy. This misalignment within couples was pronounced during the initial session and decreased by the midtreatment session, reflecting progression toward treatment goals. Of the latent growth curve models, only client sustain talk during the midtreatment session predicted greater client drinking at the end of treatment. Results provide insight into the inner workings of ABCT and suggest recommendations for ABCT therapists. This study also supports a growing consensus that sustain talk may be a stronger mechanism of change than change talk in various alcohol treatment interventions.

Study protocol for a group-based motivational interviewing brief intervention to reduce substance use and sexual risk behavior among young adults experiencing homelessness

BACKGROUND

Young people experiencing homelessness have alarmingly high rates of alcohol and other drug (AOD) use, which is associated with sexual risk behaviors such as unprotected sex, trading sex, and sex with multiple casual partners. Few risk reduction programs for this population have been developed and rigorously evaluated, particularly those that address both of these interrelated behaviors, use a collaborative and non-judgmental approach, and are feasible to deliver in settings where homeless young people seek services. This paper describes the protocol of a study evaluating a four-session Motivational Interviewing (MI)-based group risk reduction intervention for this population. The protocol has been shown to be efficacious in pilot work over 3 months with 200 homeless young adults [1]. The current study seeks to refine the intervention protocol and evaluate the program on a larger scale.

METHODS/DESIGN

In a cluster-cross-over randomized controlled trial, 18-25 year olds will receive the AWARE risk reduction program (n = 200) or standard care (n = 200) at one of three drop-in centers serving homeless youth in the Los Angeles area. We will evaluate intervention effects on primary outcomes of AOD use and sexual risk behavior, as well as secondary outcomes of health-related quality of life and social stability, over a 12-month period.

DISCUSSION

This project has the potential to fill a significant gap in prevention services by demonstrating that a brief intervention, feasible to deliver within settings where young people experiencing homelessness typically seeks services, can significantly reduce the interrelated problems of AOD use and sexual risk behavior. Trial registration ClinicalTrials.gov Identifier: NCT03735784. Registered November 18, 2018, https://clinicaltrials.gov/ct2/show/record/NCT03735784 (retrospectively registered).

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.

Group motivational interviewing for homeless young adults: Associations of change talk with substance use and sexual risk behavior

Homeless young adults exhibit high rates of alcohol and other drug (AOD) use and sexual risk behaviors. This study is a secondary analysis of data collected in a randomized clinical trial of AWARE, a new 4 session group motivational interviewing intervention. AWARE mainly focused on alcohol use and sexual risk behavior given focus group feedback. We used sequential coding to analyze how the group process affected both AOD use and sexual risk behavior at 3-month follow up among homeless young adults by examining facilitator behavior and participant change talk (CT) and sustain talk (ST). We analyzed 57 group session digital recordings of 100 youth (69% male, 74% heterosexual, 28% non-Hispanic white, 23% African American, 26% Hispanic, 23% multiracial/other; mean age 21.75). Outcomes included importance and readiness to change AOD use and risky sexual behavior, AOD use and consequences, number of partners and unprotected sex, and condom self-efficacy. Sequential analysis indicated that facilitator open-ended questions and reflections of CT increased Group CT. Group CT was associated with a lower likelihood of being a heavy drinker 3 months later; Group ST was associated with decreased readiness and confidence to change alcohol use. There were no associations with CT or ST for drug use or risky sexual behavior. Facilitator speech and peer responses were related to CT and ST during the group sessions with this high risk population, which were then associated with individual changes for alcohol use. Further research is needed to explore associations with drug use and sexual risk behavior. (PsycINFO Database Record

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.

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.

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.

Within-session communication patterns predict alcohol treatment outcomes

BACKGROUND

Within-session client speech is theorized to be a key mechanism of behavior change in motivational interviewing (MI), a directional, client-centered approach to behavior change. Client change talk (CT: speech indicating movement toward changing a problematic health behavior) and sustain talk (ST: speech supporting continuing a problematic health behavior) have each shown relationships with outcomes. However, it may be the case that patterns of within-session client speech, rather than counts of client speech, are important for producing change.

METHODS

Recorded initial MI/MET psychotherapy sessions from Project MATCH had been previously rated using the Motivational Interviewing Sequential Code for Observing Process Exchange (MI-SCOPE), a mutually exclusive and exhaustive sequential coding system. From these existing data, session conditional probabilities for transitions of interest (the transition from CT to more CT, and the transition from reflections of CT to CT) were analyzed as empirical Bayes estimates of log-normalized odds ratios.

RESULTS

CT frequencies and these log-normalized odds ratios were entered as independent variables into longitudinal generalized estimating equation (GEE) models predicting within-treatment and post-treatment drinking. While all variables were significant predictors of within-treatment drinking, only the CT-CT transition emerged as a significant predictor of decreased drinking after treatment.

CONCLUSIONS

The momentum of a client's speech about change during an MI session may be a better predictor of outcome than is a simple frequency count of it. Attending not only to the mere occurrence of CT, but also recognizing the importance of consecutive client statements of CT, may improve treatment outcomes.

Brief Motivational Interviewing and Normative Feedback for Adolescents: Change Language and Alcohol Use Outcomes

Few studies have investigated the impact of adolescent change language on substance use treatment outcomes and even fewer have examined how adolescents respond to normative feedback. The purpose of this study was to understand the influence normative feedback has on adolescent change language and subsequent alcohol and cannabis use 3months later. We examined how percent change talk (PCT) was associated with subsequent alcohol and drug use outcomes. Adolescents (N=48) were randomly assigned to receive brief motivational interviewing (MI) or MI plus normative feedback (NF). Audio recordings were coded with high interrater reliability. Adolescents with high PCT who received MI+NF had significantly fewer days of alcohol and binge drinking at follow up. There were no differences between groups on cannabis use or treatment engagement. Findings indicate that NF may be useful for adolescents with higher amount of change talk during sessions and may be detrimental for individuals with higher sustain talk.