Issues in designing and implementing a Spanish-language multi-site clinical trial

A call to address structural barriers to Hispanic/Latino representation in clinical trials on Alzheimer's disease and related dementias: A micro-meso-macro perspective

Introduction

This perspective paper addresses the US Hispanic/Latino (herein, Latino) experience with regards to a significant public health concern-the underrepresentation of Latino persons in Alzheimer's disease and related dementias (AD/ADRD) clinical trials. Latino individuals are at increased risk for AD/ADRD, experience higher disease burden, and low receipt of care and services. We present a novel theoretical framework-the Micro-Meso-Macro Framework for Diversifying AD/ADRD Trial Recruitment-which considers multi-level barriers and their impact on Latino trial recruitment.

Methods

Based on a review of the peer-reviewed literature and our lived experience with the Latino community, we drew from our interdisciplinary expertise in health equity and disparities research, Latino studies, social work, nursing, political economy, medicine, public health, and clinical AD/ADRD trials. We discuss factors likely to impede or accelerate Latino representation, and end with a call for action and recommendations for a bold path forward.

Results

In the 200+ clinical trials conducted with over 70,000 US Americans, Latino participants comprise a fraction of AD/ADRD trial samples. Efforts to recruit Latino participants typically address individual- and family-level factors (micro-level) such as language, cultural beliefs, knowledge of aging and memory loss, limited awareness of research, and logistical considerations. Scientific efforts to understand recruitment barriers largely remain at this level, resulting in diminished attention to upstream institutional- and policy-level barriers, where decisions around scientific policies and funding allocations are ultimately made. These structural barriers are comprised of inadequacies or misalignments in trial budgets, study protocols, workforce competencies, healthcare-related barriers, criteria for reviewing and approving clinical trial funding, criteria for disseminating findings, etiological focus and social determinants of health, among others.

Conclusion

Future scientific work should apply and test the Micro-Meso-Macro Framework for Diversifying AD/ADRD Trial Recruitment to examine structural recruitment barriers for historically underrepresented groups in AD/ADRD research and care.

Somatic symptoms in treatment-naïve Hispanic and non-Hispanic patients with major depression

BACKGROUND

Somatic complaints are a major driver of health care costs among patients with major depressive disorder (MDD). Some epidemiologic and clinical data suggest that Hispanic and non-Hispanic Black patients with MDD endorse higher levels of somatic symptoms than non-Hispanic White patients.

METHODS

Somatic symptoms in 102 Hispanic, 61 non-Hispanic Black, and 156 non-Hispanic White patients with treatment-naïve MDD were evaluated using the somatic symptom subscale of the Hamilton anxiety rating scale (HAM-A). The other seven items of the HAM-A comprise the psychic anxiety subscale, which was also evaluated across ethnicities.

RESULTS

Hispanic patients reported significantly greater levels of somatic symptoms than non-Hispanic patients, but levels of psychic anxiety symptoms did not differ by ethnicity. Levels of somatic symptoms did not significantly differ between Black and White non-Hispanic patients. Within the Hispanic sample, somatic symptom levels were higher only among those who were evaluated in Spanish; Hispanics who spoke English showed no significant differences versus non-Hispanics.

CONCLUSIONS

In this medically healthy sample of patients with MDD, monolingual Spanish-speaking Hispanic patients endorsed high levels of somatic symptoms. Clinicians should be mindful that the depressive experience may manifest somatically and be judicious in determining when additional medical work-up is warranted for somatic complaints.

A randomized controlled trial of motivational interviewing tailored for heavy drinking latinxs

OBJECTIVE

This randomized controlled trial (Clinicaltrials.gov NCT [01996280]) compared the efficacy of a brief motivational interview (MI) adapted to address social stressors and cultural influences (culturally adapted MI [CAMI]) to a standard MI for heavy-drinking Latinxs. CAMI was hypothesized to reduce heavy drinking days and frequency of alcohol-related consequences more than MI. Moderators of treatment effect were explored.

METHOD

Latinxs (N = 296; 63% male, M age = 41 years) who reported 2+ past month heavy drinking episodes received a single-session (MI/CAMI), with assessments at baseline and 3, 6, and 12 months.

RESULTS

Both conditions showed significant reductions in percent heavy drinking days and frequency of alcohol-related consequences through 12-month follow-up when compared with baseline; reductions were not significantly different by condition. Acculturation moderated treatment condition effect on alcohol-related problems at 3 months (d = .22, 95% CI [.02, .41]); less acculturated individuals experienced less frequent consequences of drinking after CAMI than MI (d = .34, 95% CI [-.60, -.08]). Discrimination moderated condition effect on frequency of alcohol-related consequences at 3 months (d = .17, 95% CI [-.33, -.01]); individuals with higher levels of baseline discrimination had less frequent consequences after CAMI than MI (d = .20, 95% CI [-.39, -.01]).

CONCLUSIONS

Participants in both groups improved with no significant differences between groups. Moderation effects suggest that cultural adaptation has particular benefit for more vulnerable individuals and support the theory of change in this adaptation model. MI is efficacious with Latinx heavy drinkers and should be used to mitigate health disparities related to alcohol misuse. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Positive adaptations for trauma and healing (PATH), a pilot study of group therapy with Latino youth

OBJECTIVE

This study examines the acceptability and preliminary efficacy of Positive Adaptations for Trauma and Healing (PATH), a manualized treatment for Latino youth and their caregivers. PATH is a culturally adapted program that incorporates a trauma model, positive psychology, and resilience.

METHOD

Latino youth (N = 16) recruited from an urban community clinic participated in PATH with their caregiver. Pre- and postintervention measures on trauma symptoms, resilience, depression, caregiver's view of their youth's well-being, and positive and negative emotions were gathered. Following the intake meetings (1 to 3), the families participated in 10 90-minute weekly group sessions (total of 3 groups). Caregiver groups were conducted in Spanish, and youth in English.

RESULTS

At pretest, 56% of the youth endorsed clinically significant symptoms on the UCLA PTSD Index (M = 34.2, SD = 11.2); the percentage dropped to 0% at posttest (M = 17.3, SD = 7.6). Youth reported pre- to posttest reductions on the Child Depression Inventory (mean difference [Mdiff] = 7.3; p = .004) and externalizing (Mdiff = 6.1; p < .001) and internalizing (Mdiff = 9.4; p < .001) behaviors on the caregiver-reported Child Behavior Checklist. Overall, there was high treatment engagement (93% attendance over 10 weeks).

CONCLUSION

This novel treatment engaged a community-based Latino sample. The results suggest high acceptability and significant reduction in trauma symptoms and associated symptoms. This study included a small number of participants and results should be interpreted with caution. Future iterations will target larger number of participants to further assess feasibility. (PsycINFO Database Record

Substance use and treatment outcomes among Spanish-speaking Latino/as from four acculturation types

The purpose of this study was to examine the association of acculturation with substance use treatment outcomes in a sample of treatment-seeking Latino/as (N = 405). The study used data from a multisite randomized controlled trial of a culturally adapted version of Motivational Enhancement Therapy delivered in Spanish. Berry, Kim, Minde, and Mok's (1987) acculturation model was used to divide the sample into 4 types (integrated, assimilated, separated, marginalized), based on Bicultural Involvement Questionnaire scores. One-way analyses of variance, chi-squared tests, and repeated-measures regression were used to examine baseline acculturation, posttreatment outcomes, and follow-up outcomes. All participants were of Latino/a background, and 88.4% of the sample was male. Participants with greater acculturation to American culture (i.e., integrated and assimilated acculturation types) reported more substance use and associated problems at baseline, χ²(3) = 20.5, p < .001, with the integrated type reporting the highest percentage of substance use disorder symptoms and problems (67.6%). No significant differences in substance use were detected among acculturation types posttreatment or at follow-up. Although the integrated and assimilated acculturation types were associated at baseline with more substance use and associated problems, all acculturation types seemed to benefit at posttreatment from an evidence-based culturally adapted treatment. (PsycINFO Database Record

Blending Qualitative and Computational Linguistics Methods for Fidelity Assessment: Experience with the Familias Unidas Preventive Intervention

Careful fidelity monitoring and feedback are critical to implementing effective interventions. A wide range of procedures exist to assess fidelity; most are derived from observational assessments (Schoenwald and Garland, Psycholog Assess 25:146-156, 2013). However, these fidelity measures are resource intensive for research teams in efficacy/effectiveness trials, and are often unattainable or unmanageable for the host organization to rate when the program is implemented on a large scale. We present a first step towards automated processing of linguistic patterns in fidelity monitoring of a behavioral intervention using an innovative mixed methods approach to fidelity assessment that uses rule-based, computational linguistics to overcome major resource burdens. Data come from an effectiveness trial of the Familias Unidas intervention, an evidence-based, family-centered preventive intervention found to be efficacious in reducing conduct problems, substance use and HIV sexual risk behaviors among Hispanic youth. This computational approach focuses on "joining," which measures the quality of the working alliance of the facilitator with the family. Quantitative assessments of reliability are provided. Kappa scores between a human rater and a machine rater for the new method for measuring joining reached 0.83. Early findings suggest that this approach can reduce the high cost of fidelity measurement and the time delay between fidelity assessment and feedback to facilitators; it also has the potential for improving the quality of intervention fidelity ratings.

Smoking Status and Substance Use Treatment Outcomes Among Spanish Speakers Enrolled in Substance Abuse Treatment

OBJECTIVE

Smoking is highly prevalent among individuals with drug and alcohol disorders. Concurrent tobacco dependence treatment during substance use disorder (SUD) treatment is supported, yet the association between SUD treatment outcomes and smoking status has been understudied in minorities, including Latinos.

METHOD

Participants were 322 Spanish-speaking Latinos enrolled in a SUD treatment study in 5 U.S. cities. Logistic regression examined associations between baseline smoking status and treatment outcomes for nontobacco substance use at follow-up. Covariates included age, gender, level of education, marital status, treatment group, and mandated treatment status.

RESULTS

Results indicated smokers had a reduced likelihood of abstinence for all nontobacco substances (p = .001) and their primary drug of use (p = .007).

CONCLUSIONS

Findings contribute to the growing literature indicating a possible beneficial effect of smoking cessation services on SUD treatment, specifically among Latinos. Further research is needed to identify ideal smoking cessation treatments for Latinos.

Outcome expectations and associated treatment outcomes in motivational enhancement therapy delivered in English and Spanish

BACKGROUND AND OBJECTIVES

The relationship between patients' baseline expectations regarding treatment outcome and actual outcomes has not been widely studied within the field of substance use disorders. We hypothesized that outcome expectations would be unrelated to outcomes in a study investigating motivational enhancement therapy delivered in English (MET-E) consistent with our earlier work, and conducted exploratory analyses in a separate study that investigated the same treatment delivered in Spanish (MET-S).

METHODS

These secondary analyses compared patient outcome expectations and substance use treatment outcomes in two large, multisite randomized controlled clinical trials that evaluated three sessions of MET-E or MET-S. The MET-E sample included 461 participants and the MET-S sample included 405 participants. Outcome expectations were measured by a single item regarding expectations about abstinence prior to initiating treatment.

RESULTS

Outcome expectations were strongly associated with most substance use outcomes in the MET-S trial (but not in MET-E), even after controlling for severity of substance use at baseline. In MET-S, those who indicated that they were "unsure" that they would achieve abstinence during treatment submitted a greater percentage of drug-positive urine toxicology screens during the treatment period than those who were 'sure' they would achieve abstinence (F = 18.83, p < .001).

DISCUSSION AND CONCLUSIONS

Patients' outcome expectations regarding the likelihood of abstinence may be an important predictor of drug use treatment outcomes among Spanish-speakers, but not necessarily for English-speakers.

SCIENTIFIC SIGNIFICANCE

Individual differences and cultural factors may play a role in the association between outcome expectations and treatment outcomes.

Cultural adaptation of a brief motivational intervention for heavy drinking among Hispanics in a medical setting

Background

Hispanics, particularly men of Mexican origin, are more likely to engage in heavy drinking and experience alcohol-related problems, but less likely to obtain treatment for alcohol problems than non-Hispanic men. Our previous research indicates that heavy-drinking Hispanics who received a brief motivational intervention (BMI) were significantly more likely than Hispanics receiving standard care to reduce subsequent alcohol use. Among Hispanics who drink heavily the BMI effectively reduced alcohol use but did not impact alcohol-related problems or treatment utilization. We hypothesized that an adapted BMI that integrates cultural values and addresses acculturative stress among Hispanics would be more effective.

Methods/Design

We describe here the protocol for the design and implementation of a randomized (approximately 300 patients per condition) controlled trial evaluating the comparative effectiveness of a culturally adapted (CA) BMI in contrast to a non-adapted BMI (NA-BMI) in a community hospital setting among men of Mexican origin. Study participants will include men who were hospitalized due to an alcohol related injury or screened positive for heavy drinking. By accounting for risk and protective factors of heavy drinking among Hispanics, we hypothesize that CA-BMI will significantly decrease alcohol use and alcohol problems, and increase help-seeking and treatment utilization.

Discussion

This is likely the first study to directly address alcohol related health disparities among non-treatment seeking men of Mexican origin by comparing the benefits of a CA-BMI to a NA-BMI. This study stands to not only inform interventions used in medical settings to reduce alcohol-related health disparities, but may also help reduce the public health burden of heavy alcohol use in the United States.

Trial registration

Trial registration clinicaltrials.gov identifier NCT02429401; Registration date: April 28, 2015.

Enhancing Hispanic participation in mental health clinical research: development of a Spanish-speaking depression research site

BACKGROUND

Hispanics, particularly those with limited English proficiency, are underrepresented in psychiatric clinical research studies. We developed a bilingual and bicultural research clinic dedicated to the recruitment and treatment of Spanish-speaking subjects in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study, a large clinical trial of treatment-naïve subjects with major depressive disorder (MDD).

METHODS

Demographic and clinical data derived from screening evaluations of the first 1,174 subjects presenting for participation were compared between the Spanish-speaking site (N = 275) and the primary English-speaking site (N = 899). Reasons for ineligibility (N = 888) for the PReDICT study were tallied for each site.

RESULTS

Compared to English speakers, Spanish speakers had a lower level of education and were more likely to be female, uninsured, and have uncontrolled medical conditions. Clinically, Spanish speakers demonstrated greater depression severity, with higher mean symptom severity scores, and a greater number of previous suicide attempts. Among the subjects who were not randomized into the PReDICT study, Spanish-speaking subjects were more likely to have an uncontrolled medical condition or refuse participation, whereas English-speaking subjects were more likely to have bipolar disorder or a non-MDD depressive disorder.

CONCLUSION

Recruitment of Hispanic subjects with MDD is feasible and may enhance efforts at signal detection, given the higher severity of depression among Spanish-speaking participants presenting for clinical trials. Specific approaches for the recruitment and retention of Spanish-speaking participants are required.

Spanish language proficiency among providers and Latino clients' engagement in substance abuse treatment

Quality of care, such as provision of services in Spanish, is a common factor believed to improve treatment engagement among Spanish-speaking Latinos in health care. However, there is little evidence that Spanish language proficiency among providers increases treatment access and retention in publicly funded substance abuse treatment. We analyzed client and program data collected in 2010-2011 from publicly funded treatment programs in Los Angeles County, California. An analytic sample of 1903 Latino clients nested within 40 treatment programs located in minority communities was analyzed using multilevel negative binomial regressions on days to initiate and spent in treatment. As hypothesized, Spanish language proficiency was negatively associated with client wait time and positively associated with retention in treatment, after controlling for individual and program characteristics. The path analysis models showed that Spanish language proficiency played a mediating role between professional accreditation and client wait time and retention. These preliminary findings provide an evidentiary base for the role of providers' Spanish language proficiency and Latino engagement in treatment for a population at high risk of treatment dropout. Implications related to health care reform legislation, which seeks to enhance linguistically competent care, are discussed.

Psychometric properties of a Spanish-language version of the Short Inventory of Problems

Hispanic Americans are substantially underrepresented in clinical and research samples for substance use treatment, with language cited as one of the major barriers to their participation, indicating a need for more validated assessments in Spanish. This study evaluated the psychometric properties of a Spanish version of the Short Inventory of Problems (SIP), used in a multisite, randomized trial conducted for Spanish-speaking substance users. The sample included 405 Spanish-speaking treatment seekers, mostly male (88%) and legally mandated to treatment (71%). The Spanish version of the revised SIP (SIP-RS), as well as other commonly used assessment measures translated into Spanish, were administered at baseline and at the end of treatment. Internal consistency was excellent (α = .96), and construct validity was supported through correlations with composite scores from the Addiction Severity Index (ASI) (e.g., r = .57, p < .01 for ASI drug composite), and through differential SIP-RS scores according to diagnostic criteria. The SIP-RS also demonstrated an association with substance use and treatment retention, with higher baseline scores associated with significantly less abstinence during treatment (β = -.22, p < .01) and fewer days retained in treatment (β = -.14, p < .05). However, the latter association was moderated by participants' legal status. Nevertheless, this Spanish-translated version of the SIP (SIP-RS) appears to be a reliable and valid assessment of adverse consequences associated with alcohol and drug use, with psychometric properties comparable with the English version.

Increasing ethnic minority participation in substance abuse clinical trials: lessons learned in the National Institute on Drug Abuse's Clinical Trials Network

Underrepresentation in clinical trials limits the extent to which ethnic minorities benefit from advances in substance abuse treatment. The objective of this article is to share the knowledge gained within the Clinical Trials Network (CTN) of the National Institute on Drug Abuse and other research on recruiting and retaining ethnic minorities into substance abuse clinical trials. The article includes a discussion of two broad areas for improving inclusion-community involvement and cultural adaptation. CTN case studies are included to illustrate three promising strategies for improving ethnic minority inclusion: respondent-driven sampling, community-based participatory research, and the cultural adaptation of the recruitment and retention procedures. The article concludes with two sections describing a number of methodological concerns in the current research base and our proposed research agenda for improving ethnic minority inclusion that builds on the CTN experience.

Informal discussions in substance abuse treatment sessions with Spanish-speaking clients

This study investigated the extent to which bilingual counselors initiated informal discussions about topics that were unrelated to the treatment of their monolingual Spanish-speaking Hispanic clients in a National Institute on Drug Abuse Clinical Trial Network protocol examining the effectiveness of motivational enhancement therapy (MET). Session audiotapes were independently rated to assess counselor treatment fidelity and the incidence of informal discussions. Eighty-three percent of the 23 counselors participating in the trial initiated informal discussions at least once in one or more of their sessions. Counselors delivering MET in the trial initiated informal discussion significantly less often than the counselors delivering standard treatment. Counselors delivering standard treatment were likely to talk informally the most when they were ethnically non-Latin. In addition, informal discussion was found to have significant inverse correlations with client motivation to reduce substance use and client retention in treatment. These results suggest that informal discussion may have adverse consequences on Hispanic clients' motivation for change and substance abuse treatment outcomes and that maintaining a more formal relationship in early treatment sessions may work best with Hispanic clients. Careful counselor training and supervision in MET may suppress the tendency of counselors to talk informally in sessions.

Recruiting Latina families in a study of infant iron deficiency: a description of barriers, study adjustments and review of the literature

BACKGROUND

Maternal minority status is a risk factor for iron deficiency in infancy and pregnancy. Because language and cultural differences may limit research participation, a prospective study examining iron deficiency included maternal minority status as an inclusionary criterion. Cognizant of potential barriers to recruitment, goals were to quantify eligible Latina enrollees and refusals, examine participation barriers, and devise possible solutions.

METHODS

Mothers and their full-term newborns were eligible if the women were anemic, diabetic during pregnancy, of minority and/or lower socioeconomic status, and/or delivered an infant outside the average weight range for gestational age. Self-reported ethnicity and reasons for participation refusal were documented.

RESULTS

During the first 18 months, 255 mothers and their infants were enrolled. Based on inclusionary criteria and the percentage of minority women admitted to the birthing center in a year, we anticipated 25% minority enrollees, with 16.3% Latina. Although 27% minority enrollment was obtained, only 8% were Latina (P < 0.01). System barriers, researcher perception barriers, and participant perception barriers were encountered. Over the next 8 months, addressing these recruitment barriers improved Latina enrollment.

CONCLUSION

Enrollment barriers are significant hurdles to overcome, but with increased understanding and effort, more successful inclusion of Latina families can be achieved.

Methodological challenges in treatment outcome research with ethnic minorities

Treatment outcome research focused on ethnic minorities is critically needed to eliminate mental health disparities. Because the conduct of treatment outcome research with ethnic minorities is difficult and complex, we discuss key challenges and present some methodological options suited to provide answers to specific types of questions. We focus first on the randomized clinical trial (RCT) paradigm, reviewing specific challenges facing investigators conducting ethnically inclusive trials. We then highlight the promise of other methods of inquiry to expand the science on mental health treatment with ethnic minorities.

Do therapist cultural characteristics influence the outcome of substance abuse treatment for Spanish-speaking adults?

This secondary data analysis of the Clinical Trials Network's Motivational Enhancement Therapy effectiveness trial with Spanish-speaking substance users examined whether the degree of birthplace and acculturation similarities between clients and therapists, as well as the therapists' own level of acculturation and birthplace were related to the clients' participation in treatment and level of substance use during outpatient substance use treatment. Sixteen therapists and their 235 clients from the larger effectiveness trial were included in the analyses for this study. Results of the multilevel regression models for client participation in substance use treatment and client days of substance use, taking into account within and between therapist cultural characteristics, revealed that birthplace match and acculturation similarity between each therapist and his or her clients did not predict client outcomes. Instead, therapists' birthplace and level of acculturation independently predicted days of substance use, but not treatment participation for monolingual Spanish-speaking clients. These findings are discussed in the context of the results of the main effectiveness trial and of psychotherapy research with ethnic minority populations, in particular Hispanic minorities.

A multisite randomized effectiveness trial of motivational enhancement therapy for Spanish-speaking substance users

Hispanic individuals are underrepresented in clinical and research populations and are often excluded from clinical trials in the United States. Hence, there are few data on the effectiveness of most empirically validated therapies for Hispanic substance users. The authors conducted a multisite randomized trial comparing the effectiveness of 3 individual sessions of motivational enhancement therapy with that of 3 individual sessions of counseling as usual on treatment retention and frequency of substance use; all assessment and treatment sessions were conducted in Spanish among 405 individuals seeking treatment for any type of current substance use. Treatment exposure was good, with 66% of participants completing all 3 protocol sessions. Although both interventions resulted in reductions in substance use during the 4-week therapy phase, there were no significant Treatment Condition x Time interactions nor Site x Treatment Condition interactions. Results suggest that the individual treatments delivered in Spanish were both attractive to and effective with this heterogeneous group of Hispanic adults, but the differential effectiveness of motivational enhancement therapy may be limited to those whose primary substance use problem is alcohol and may be fairly modest in magnitude.

Role of ethnicity in the expression of features of hot flashes

The overall goal of this study was to determine the role of ethnicity on features of hot flashes (HFs) in a population of menopausal women in North Central Texas. A total of 397 ethnically diverse menopausal women from North Central Texas were administered our Menopausal Vasomotor Symptoms (MVS) survey to ascertain accurate information about number, length, intensity and behaviorally disruptive effects of hot flash episodes for subsequent analysis for the role of ethnicity in the occurrence of hot flashes. The mean (SD) age for participants was 50.2 (5.3) years; 40% were Caucasian, 38% were African-American and 22% were Hispanic. To evaluate and identify potential associations of hot flash (HF) features, ethnicity, and other independent variables, ordinal/multinomial/binary logistic regression models were used to calculate crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs). The analysis demonstrates strong associations with ethnicity and the number of HF's/day, the length of each HF episode, the intensity of HFs, and the interruption of daily activities and sleep. Ethnicity was important in the crude and adjusted model describing the association between the number of HFs per day and ethnicity. African-American women were 2.22 (95% CI, 1.38-3.56) times and Hispanic women were 1.85 (95% CI, 1.08-3.18) times more likely to experience more frequent HFs per day than Caucasian women. In contrast, Hispanic women were less likely than Caucasian women to experience sweating and disruption of both daily activities and sleep. Collectively, our results show more frequent and more bothersome HFs in African-American women and more frequent, but less intense and bothersome HFs in Hispanic women in comparison to Caucasian women.

Evaluating motivational enhancement therapy adherence and competence among Spanish-speaking therapists

Despite the fact that the number of Hispanic individuals in need of treatment for substance use problems is increasing internationally, no studies have investigated the extent to which therapists can provide empirically supported treatments to Spanish-speaking clients with adequate fidelity. Twenty-three bilingual Hispanic therapists from five community outpatient treatment programs in the United States were randomly assigned to deliver either three sessions of motivational enhancement therapy (MET) or an equivalent number of drug counseling-as-usual (CAU) sessions in Spanish to 405 Spanish-speaking clients randomly assigned to these conditions. Independent ratings of 325 sessions indicated the adherence/competence rating system had good to excellent interrater reliability and indicated strong support for an a priori defined fundamental MET skill factor. Support for an advanced MET skill factor was relatively weaker. The rating scale indicated significant differences in therapists' MET adherence and competence across conditions. These findings indicate that the rating system has promise for assessing the performance of therapists who deliver MET in Spanish and suggest that bilingual Spanish-speaking therapists from the community can be trained to implement MET with adequate fidelity and skill using an intensive multisite training and supervision model.