Sustaining motivational interviewing: a meta-analysis of training studies

Can the spirit of motivational interviewing be taught online? A comparative study in general practitioners

OBJECTIVE

Motivational Interviewing (MI) is an evidence-based approach to enhance patients' motivation and is increasingly in demand in medical practice. Online teaching methods offer advantages to train health care professionals, but only very few studies examined whether MI-specific interviewing skills (""MI-skills""), and especially MIspecific attitudes (the "MI-spirit"), can be taught online and whether learning gains differ from those in face-to-face courses. This study compared the effects of 7 h of basic training for experienced general practitioners (GP) in either an online or a traditional face-to-face format with a non-trained control group.

METHODS

"MI-skills" and "MI-spirit" were measured in a prospective analysis in 49 experienced GPs before and one week after training RESULTS: An ANOVA on gain-scores demonstrated significant differences between groups in both MI-specific skills (VASE-R, p = 0.006) and "MIspirit" (MIKAT, p = 0.029; HRQ, p < 0.001) from pre- to posttest. Post-hoc comparisons revealed significant improvement only in the training groups (VASE-R, p < 0.001; MIKAT, p = 0.014 for online, p = 0.003 for face-to-face; HRQ, p < 0.001).

CONCLUSION

The results suggest similar effects of both online and face-to-face training of "MI-skills" and "MI-spirit" to GPs.

PRACTICE IMPLICATION

Online learning opportunities should be integrated in MIT programs for general practitioners where appropriate.

Monitoring Motivational Interviewing Strategies: Creating Provider and Client Reports to Encourage Implementation

BACKGROUND

Motivational interviewing (MI) is an evidence-based practice that has been successfully applied to at-risk youth. Well-validated measures that track MI integrity may not be used in practice settings due to the time to complete them, recording requirements and training involved. A simpler, less resource-intensive instrument may encourage programs and providers to attend more to the quality of MI use during implementation.

PURPOSE

To validate a method involving two measures, Youth and Provider Logs, to assist in monitoring MI use.

METHODS

Clients and providers reported on provider behaviors consistent and inconsistent with MI during the session. Factor analyses were conducted to examine whether measures showed clear scales assessing MI use and analyses were conducted to assess validity of these measures.

RESULTS

Both Youth and Provider Logs showed a clear and consistent 3-factor structure assessing MI-consistent behavior, MI-inconsistent behavior, and alcohol-related topics. Significant correlations were found between Youth Logs and youth reports of rapport with providers, and satisfaction with services. Provider MI-inconsistent scores were significantly inversely predictive of observer fidelity scores over time.

CONCLUSION

This study offers provider and client measures for tracking use of MI in sessions, which are a simpler, less resource-intensive method for monitoring MI, and may encourage fidelity during implementation.

Motivational Interviewing Implementation in Primary Care: A "Terrifying Challenge" Becoming a "Professional Revelation"

INTRODUCTION

Motivational interviewing (MI) is an evidence-based counseling approach within primary care. However, MI rarely translates to practice following introductory training programs, and a lack of evidence regarding its implementation persists today. This study describes primary care clinicians' professional transformation in implementing MI through interprofessional communities of practice (ICP-MI).

METHOD

Qualitative data collection involved the research journal, participant observation of four ICP-MIs (76 hours/16 clinicians), and focus groups. A general inductive approach was used for data analysis. Results were conceptualized based on the Consolidated Framework for Implementation Research.

RESULTS

Four processes of MI implementation in primary care are presented as a motivational endeavor: ambivalence, introspection, experimentation, and mobilization. The clinicians were initially ambivalent, taking into consideration the significant challenges involved. After introspecting actual practices, they realized the limits of their previous clinician-centered approaches. The experimentation of MI in the workplace followed and enabled clinicians to witness MI feasibility and its added value. Finally, they were mobilized to ensure MI sustainability in their practices/organization. Intrinsic factors of influence included the clinicians' personal traits and their perception about MI as a clinical priority. Organizational support was also a crucial extrinsic factor in encouraging the clinicians' efforts.

CONCLUSION

As described in a fragmented manner in previous studies, MI implementation processes and influencing factors are presented as integrated findings. Incorporating engaging educational activities to provide clinicians with motivational support and collaborating with health care organizations to plan appropriate resources should be considered in the development of MI implementation programs from the onset.

Exploring the Impact of External Facilitation Using Evidence-Based Implementation Strategies for Increasing Motivational Interviewing Capacity Among Outpatient Substance Use Disorder (SUD) Treatment Providers

The large majority of individuals who access substance use disorders (SUD) treatment do not receive evidence-based care. Little attention has been paid to the notion that the scale-up of evidence-based practices (EBPs) has been limited in large part due to a weakness in the "distribution system" for bringing new innovations to the attention of practitioners and into practice settings. This study explores the impact of the Training and Practice Implementation Institute (TPII; funded by the New York City Department of Health and Mental Hygiene), an intensive technical assistance initiative that offers external facilitation to outpatient SUD treatment providers via the incorporation of multiple evidence-based implementation strategies to enhance the practice of motivational interviewing (MI). Findings from this study show that staff completed a large majority (86%) of required training/technical assistance (TTA) activities across the 9-month implementation period, demonstrating a high level of engagement among staff and the feasibility of externally facilitated intensive TTA delivered to community-based organizations for the purpose of enhancing implementation of MI for SUDs. Results also show statistically significant improvements in the delivery of MI's technical components among staff, though did not reveal corresponding improvements in the delivery of MI's relational components. An understanding of the potential return on investment associated with externally facilitated TA, offers organizations an opportunity to inform the allocation of limited resources to areas where they will have the greatest impact and ultimately improve the quality and efficacy of services.

"From Health Experts to Health Guides": Motivational Interviewing Learning Processes and Influencing Factors

Motivational interviewing is an evidence-based counseling approach. However, its learning processes and their influencing factors are understudied, failing to address the suboptimal use of motivational interviewing in clinical practice. A participatory action research was conducted in collaboration with 16 primary care clinicians, who encountered similar challenges through their previous counseling approaches. The study aimed to facilitate and describe the clinicians' professional transformation through interprofessional communities of practice on motivational interviewing (ICP-MI). Data were collected using the principal investigator's research journal and participant observation of four independent ICP-MIs (76 h) followed by focus groups (8 h). The co-participants performed inductive qualitative data analysis. Results report that learning motivational interviewing requires a paradigm shift from health experts to health guides. The learning processes were initiated by the creation of an openness to the MI spirit and rapidly evolved into iterative processes of MI spirit embodiment and MI skill building. The intrinsic influencing factors involved the clinician's personal traits and professional background; the extrinsic influencing factor was the shared culture disseminating the expert care model. Previously described in a fragmented manner, motivational interviewing learning processes, and its influencing factors were presented as integrated findings. Considerations in elaborating effective MI training/implementation programs are discussed for clinicians, trainers, and decision-makers. Future areas of investigation are also highlighted calling forth the research community to contribute to knowledge advancement on health education in primary care.

Motivational interviewing skills practice enhanced with artificial intelligence: ReadMI

BACKGROUND

Finding time in the medical curriculum to focus on motivational interviewing (MI) training is a challenge in many medical schools. We developed a software-based training tool, "Real-time Assessment of Dialogue in Motivational Interviewing" (ReadMI), that aims to advance the skill acquisition of medical students as they learn the MI approach. This human-artificial intelligence teaming may help reduce the cognitive load on a training facilitator.

METHODS

During their Family Medicine clerkship, 125 third-year medical students were scheduled in pairs to participate in a 90-minute MI training session, with each student doing two role-plays as the physician. Intervention group students received both facilitator feedback and ReadMI metrics after their first role-play, while control group students received only facilitator feedback.

RESULTS

While students in both conditions improved their MI approach from the first to the second role-play, those in the intervention condition used significantly more open-ended questions, fewer closed-ended questions, and had a higher ratio of open to closed questions.

CONCLUSION

MI skills practice can be gained with a relatively small investment of student time, and artificial intelligence can be utilized both for the measurement of MI skill acquisition and as an instructional aid.

Developing a Training in Motivational Counselling to Promote Return to Work: An Intervention Mapping Approach

PURPOSE

Due to the Belgian health insurance system's controlling nature, work-disabled claimants can feel forced to return to work (RTW), increasing their risk of relapse. RTW out of interest or importance is considered more sustainable. Such autonomous motivation for RTW can be promoted through 'motivational counselling', an integration of self-determination theory and motivational interviewing. To adopt this, health insurance practitioners need training, which can be designed through intervention mapping as an evidence-based planning tool. This paper reports on the development of a motivational counselling training for health insurance practitioners.

METHODS

Intervention mapping's six steps guided the formulation of programme goals and learning outcomes, matching the context. We then identified change methods which were translated into practical components. Together with the health insurances' input, this resulted in a concrete training programme with an implementation and evaluation plan.

RESULTS

The training was designed to increase practitioners' knowledge, skills, and beliefs relevant for learning motivational counselling, which also requires solution-focused strategies. Methods like guided practice were translated into built-in exercises, feedback, and information, which were implemented through an online training format of five sessions including one follow-up.

CONCLUSION

Reporting about training development increases understanding of its effectiveness and implementation, which will be evaluated via pre- and post-training data collection amongst practitioners. Future trainings can benefit from this by accounting for health insurances' organizational barriers or building on the training's evidence-based backbone whilst only requiring specific adaptations for other stakeholders and contexts. Further research should evaluate motivational counselling's impact on claimants' RTW trajectories.

Improving the quality of counseling and clinical supervision in opioid treatment programs: how can technology help?

BACKGROUND

The opioid epidemic has resulted in expanded substance use treatment services and strained the clinical workforce serving people with opioid use disorder. Focusing on evidence-based counseling practices like motivational interviewing may be of interest to counselors and their supervisors, but time-intensive adherence tasks like recording and feedback are aspirational in busy community-based opioid treatment programs. The need to improve and systematize clinical training and supervision might be addressed by the growing field of machine learning and natural language-based technology, which can promote counseling skill via self- and supervisor-monitoring of counseling session recordings.

METHODS

Counselors in an opioid treatment program were provided with an opportunity to use an artificial intelligence based, HIPAA compliant recording and supervision platform (Lyssn.io) to record counseling sessions. We then conducted four focus groups-two with counselors and two with supervisors-to understand the integration of technology with practice and supervision. Questions centered on the acceptability of the clinical supervision software and its potential in an OTP setting; we conducted a thematic coding of the responses.

RESULTS

The clinical supervision software was experienced by counselors and clinical supervisors as beneficial to counselor training, professional development, and clinical supervision. Focus group participants reported that the clinical supervision software could help counselors learn and improve motivational interviewing skills. Counselors said that using the technology highlights the value of counseling encounters (versus paperwork). Clinical supervisors noted that the clinical supervision software could help meet national clinical supervision guidelines and local requirements. Counselors and clinical supervisors alike talked about some of the potential challenges of requiring session recording.

CONCLUSIONS

Implementing evidence-based counseling practices can help the population served in OTPs; another benefit of focusing on clinical skills is to emphasize and hold up counselors' roles as worthy. Machine learning technology can have a positive impact on clinical practices among counselors and clinical supervisors in opioid treatment programs, settings whose clinical workforce continues to be challenged by the opioid epidemic. Using technology to focus on clinical skill building may enhance counselors' and clinical supervisors' overall experiences in their places of work.

Measuring a motivational interviewing practice orientation in criminal justice practitioners: initial validation of the response style screening questionnaire

Introduction

The use of collaborative communication techniques by criminal justice practitioners has been identified as a component of core correctional practices (CCPs). Criminal justice agencies and programs are investing in motivational interviewing (MI) training for their staff with varying intensity, follow-up coaching, and expectations for integration into practice. The present article describes the development and initial validation of the Response Style Screening Questionnaire (RSSQ), a practitioner completed tool assessing an MI-consistent practice orientation. Over three studies, we examined the factor structure, reliability, and correlations between the scale and self-reported and behavioral validity indicators.

Method

Study 1 examined the factor structure of the RSSQ with a sample of 825 criminal justice practitioners. In Study 2, data from 350 probation officers completing the RSSQ alongside measures of work-orientation and attitudes was used to conduct a confirmatory factor analysis and an initial assessment of its construct validity. In Study 3, correlations between the RSSQ and audio recorded office visits of 33 probation officers coded for MI and relationship building skills examined the scale's criterion validity.

Results

In Study 1, an exploratory factor analysis with an oblique rotation yielded 18 items on four factors. In Study 2, four and five factor models were tested, with the 4-factor model of Study 1 yielding the best fit. Two of the 4 factor-derived subscales reflect styles inconsistent with MI: (1) Confrontational style, and (2) Sustain Talk style; while the remaining two reflect styles consistent with MI: (3) Eliciting style, and (4) Change Talk style. Confrontational style scores were correlated with a work-orientation reflecting probation as a law enforcement endeavor, while Eliciting and Change Talk scores were correlated with a behavior change and resource broker work-orientations. In Study 3, Confrontational and Sustain Talk style scores were negatively correlated with a variety of MI skills and CCPs displayed on audio recordings, while Change Talk style scores were positively correlated with use of such skills.

Discussion

Overall, the findings suggest the RSSQ is a potentially useful new practitioner self-report tool for assessing an MI practice orientation.

The effects of motivational self-care promotion on depressive symptoms among adults with type 2 diabetes: A systematic review and meta-analysis

In individuals with type 2 diabetes (T2D), comorbid depression leads to increased health care costs and unsatisfactory treatment outcomes. Supporting healthy behaviors and self-efficacy might provide means to prevent depressive symptoms. We assessed the effects of motivational interviewing (MI) - based self-care promotion that specifically targets health behaviors, on depressive symptoms in adults with T2D. We followed PRISMA guidelines and searched Pubmed, Scopus, PsycINFO, Cinahl, and Cochrane Library to find randomized controlled trials (RCTs) published up to February 2023. Eligible RCTs had to target the T2D adult population, examine MI-based interventions that focus on multiple health behaviors, and measure depressive symptoms on a validated scale. Standardized mean differences (SMD) with 95% confidence intervals were calculated using a random-effects model. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence. After the screening, eleven studies with 2,682 individuals were eligible for the narrative synthesis. A meta-analysis of nine studies favored interventions with a pooled SMD of -0.19 (95% Cl = -0.34 to -0.05, p = 0.008, I2 = 52%). Due to the indirectness and imprecision of the evidence, we assessed the certainty of evidence based on GRADE as low. MI-based self-care promotion with a focus on health behaviors and implemented by a well MI-trained person had a preventive effect on depressive symptoms among adults with T2D. However, the certainty of evidence remained low. In future trials, the effect of MI-based self-care promotion on depression should be studied in clinically depressed populations.

Introducing lifestyle medicine into family medicine: Theory and applications

"Lifestyle medicine (LM) is an evidence-based therapeutic intervention delivered by clinicians trained and certified in this specialty to prevent, treat, and often reverse chronic disease". Eighty percent of the conditions primary care physicians routinely encounter in their offices, e.g., diabetes mellitus, hypertension, COPD, cardiovascular disease, have root causes in poor lifestyle choices, e.g., smoking, insufficient sleep, being sedentary, eating highly processed foods. Lifestyle is the foundation of most chronic disease management guidelines aimed at reducing morbidity and mortality. Studies have shown that changes in lifestyle can be achieved and the changes link almost directly to reduction in risk for chronic illness. Primary care physicians are ideally positioned to incorporate LM into their practices. It is important to recognize and find solutions to the many barriers to implementing LM from the patient, physician, and system level. There is an urgent need to increase opportunities for practicing physicians to increase their knowledge and skills related to LM and include this in medical school and residency curricula. Many resources exist that can provide the necessary training to seasoned physicians and students/residents to become competent in practicing LM and address barriers to implementing LM. LM has the potential to revolutionize clinical practice by placing a greater emphasis on disease prevention and the role of healthy lifestyle behaviors in disease management and remission.

Acceptance and Commitment Therapy Processes and Mediation: Challenges and How to Address Them

Acceptance and commitment therapy (ACT) emphasizes a focus on theory-driven processes and mediating variables, a laudable approach. The implementation of this approach would be advanced by addressing five challenges, including (a) distinguishing ACT processes in measurement contexts, (b) developing and rigorously validating measures of ACT processes, (c) the wide use of psychometrically weaker ACT process measures and the more limited use of stronger measures in earlier work, (d) the inconsistency of past evidence that ACT processes are sensitive or specific to ACT or mediate ACT outcomes specifically, and (e) improving statistical power and transparency. Drawing on the existing literature, we characterize and provide evidence for each of these challenges. We then offer detailed recommendations for how to address each challenge in ongoing and future work. Given ACT's core focus on theorized processes, improving the measurement and evaluation of these processes would significantly advance the field's understanding of ACT.

Rehabilitation Coordinators' Experiences of Group Supervision and Training in Motivational Interviewing: A Qualitative Study in Primary Health Care

The goals of this study were to describe how rehabilitation coordinators experienced regular group supervision and training in motivational interviewing and to evaluate whether the supervision and training influenced their self-efficacy in using the communication style. Four sessions that included supervision and training in motivational interviewing were offered to primary health care rehabilitation coordinators in Sweden. Focus group interviews were performed with eight participants, and data were analyzed with thematic analysis. Group supervision and training seemed to increase self-efficacy in using motivational interviewing. Components that contributed to enhancing perceived self-efficacy included a safe group climate, collegial feedback, and time between sessions to reflect on and practice motivational interviewing skills. Submitting motivational interviewing dialogues to a coding lab for objective feedback can be challenging but also can increase self-efficacy. The dropout rate was high. Thus, in the future, the sessions should be modified to reach more professionals while retaining the components that participants said could enhance their self-efficacy. [J Contin Educ Nurs. 2023;54(11):533-540.].

Adapted motivational interviewing for brief healthcare consultations: A systematic review and meta-analysis of treatment fidelity in real-world evaluations of behaviour change counselling

BACKGROUND

Behaviour change counselling (BCC) is an adaptation of motivational interviewing (MI) designed to maximize the effectiveness of time-limited health behaviour change consultations. To improve intervention quality and understanding of treatment effects, it is recommended that evaluations of health behaviour change interventions incorporate existing fidelity frameworks (e.g. The National Institutes of Health [NIH] Behaviour Change Consortium) and ensure that treatment fidelity is assessed and reported.

PURPOSE

This systematic review was designed to examine (a) adherence to NIH fidelity recommendations, (b) provider fidelity to BCC and (c) impact of these variables on the real-world effectiveness of BCC for adult health behaviours and outcomes.

METHODS AND RESULTS

Searches of 10 electronic databases yielded 110 eligible publications describing 58 unique studies examining BCC delivered within real-world healthcare settings by existing providers. Mean study adherence to NIH fidelity recommendations was 63.31% (Range 26.83%-96.23%). Pooled effect size (Hedges g) for short-term and long-term outcomes was .19 (95% CI [.11, .27]) and .09 (95% CI [.04, .13]), respectively. In separate, random-effects meta-regressions, neither short-term nor long-term effect sizes were significantly modified by adherence to NIH fidelity recommendations. For the subgroup of short-term alcohol studies (n = 10), a significant inverse relationship was detected (Coefficient = -.0114, 95% CI [-.0187, -.0041], p = .0021). Inadequate and inconsistent reporting within the included studies precluded planned meta-regression between provider fidelity and BCC effect size.

CONCLUSIONS

Further evidence is needed to clarify whether adherence to fidelity recommendations modifies intervention effects. Efforts to promote transparent consideration, evaluation and reporting of fidelity are urgently needed. Research and clinical implications are discussed.

The evolution of motivational interviewing

This review traces the development of motivational interviewing (MI) from its happenstance beginnings and the first description published in this journal in 1983, to its continuing evolution as a method that is now in widespread practice in many professions, nations and languages. The efficacy of MI has been documented in hundreds of controlled clinical trials, and extensive process research sheds light on why and how it works. Developing proficiency in MI is facilitated by feedback and coaching based on observed practice after initial training. The author reflects on parallels between MI core processes and the characteristics found in 70 years of psychotherapy research to distinguish more effective therapists. This suggests that MI offers an evidence-based therapeutic style for delivering other treatments more effectively. The most common use of MI now is indeed in combination with other treatment methods such as cognitive behaviour therapies.

Management of Patients After Treatment of Severe Alcohol-associated Hepatitis

Alcohol-associated liver disease is the leading indication for hospitalization among patients with chronic liver disease. Rates of hospitalization for alcohol-associated hepatitis have been rising over the last 2 decades. Patients with alcohol-associated hepatitis carry significant morbidity and mortality, but there is a lack of standardized postdischarge management strategies to care for this challenging group of patients. Patients warrant management of not only their liver disease but also their alcohol use disorder. In this review, we will discuss outpatient management strategies for patients who were recently hospitalized and discharged for alcohol-associated hepatitis. We will discuss short management of their liver disease, long-term follow-up, and review-available treatment options for alcohol use disorder and challenges associated with pursuing treatment for alcohol use disorder.

Virtual Worlds Technology to Enhance Training for Primary Care Providers in Assessment and Management of Posttraumatic Stress Disorder Using Motivational Interviewing: Pilot Randomized Controlled Trial

BACKGROUND

Many individuals with posttraumatic stress disorder (PTSD) first present to primary care rather than specialty mental health care. Primary care providers often lack the training required to assess and treat patients with PTSD. Virtual trainings have emerged as a convenient and effective way of training primary care providers in PTSD assessment and communication methods (ie, motivational interviewing [MI]).

OBJECTIVE

The aim of this study was to conduct a pilot randomized controlled trial of a synchronous Virtual Worlds (VW; a virtual world where learners were immersed as avatars) training versus an asynchronous web-based training on PTSD and MI, comparing the feasibility, acceptability, usability, and preliminary efficacy of 2 different training platforms among primary care providers.

METHODS

Participating primary care providers were randomized to a VW and a web-based PTSD training. Outcomes were collected at baseline, posttraining, and 90-days follow-up. Standardized patient interviews measured participants' communication skills in assessing and managing patients with PTSD symptoms.

RESULTS

Compared to the web-based training, the VW training platform achieved larger learning gains in MI (ie, partnership and empathy) and in discussing pharmacotherapy and psychotherapy for PTSD. Both VW and web-based trainings led to increases in PTSD knowledge and primary care providers' self-confidence.

CONCLUSIONS

The asynchronous web-based PTSD training improved PTSD-related knowledge and self-confidence but was not as effective as the VW immersive experience in teaching MI or clinical management. Because VW training is synchronous and new for many learners, it required more time, facilitation, and technical support. As computer technology improves, VW educational interventions may become more feasible, particularly in teaching clinical skills.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03898271; https://tinyurl.com/mu479es5.

Training medical students in motivational interviewing using a blended learning approach: a proof-of-concept study

Background

Difficulties in implementing behavior change in patients with chronic diseases are common in clinical practice. Motivational interviewing (MI) helps clinicians to support patients in overcoming ambivalence while maintaining self-determination. The inclusion of MI in German medical training curricula is still rare. Furthermore, the effects of systematic teaching of MI, especially via blended learning, have hardly been investigated.

Methods

Medical students participated in three curricular events related to MI, consisting of instructional videos and theoretical and practical components in a blended learning format. The aim of the study was to investigate the effect of teaching MI in students' medical education. A controlled, non-randomized study was conducted with an intervention group and a control group. Both groups completed questionnaires on their experience and knowledge related to MI, completed a knowledge test and rated their satisfaction with the course. MI was taught in the 6th semester of medical coursework as part of a psychosomatic course, in the 8th semester during a psychiatry course and in the 9th semester during a weekly psychiatry clerkship.

Results

Data from the intervention group (n = 35) and control group (n = 14) were analyzed, with 65.7% of students participating in all three parts of the curriculum. Overall interest in learning MI was high, with M = 2.92 (SD = 1.00). The results indicate a greater increase in knowledge over time in the intervention group. The majority (62.86%) stated that the curriculum was relevant to their future career. Free-form text responses indicated a high level of satisfaction with practical relevance.

Conclusion

This study demonstrates the usefulness of an MI curriculum for medical students. The integration of MI into medical curricula is a promising curricular addition to improve doctor-patient communication. Future research should address patient perceptions of MI competencies and the persistence of acquired competencies.

Health Professionals can Sustain Proficiency in Motivational Interviewing With a Moderate Amount of Training: An Intervention Fidelity Study

INTRODUCTION

Motivational interviewing (MI) proficiency may erode quickly, limiting its effectiveness. We examined whether health professionals completing a 2-day workshop, with 3 to 5 hours of personalized coaching, and twice-yearly group reflections sustained proficiency for the duration of a hip fracture rehabilitation trial and whether intervention was implemented as intended.

METHODS

A fidelity study was completed as part of a process evaluation of the trial that tested whether physical activity increased among hip fracture patients randomly allocated to receive MI (experimental) compared with dietary advice (control) over ten 30-minute sessions. Twelve health professionals (none were proficient in MI before trial commencement) delivered the intervention for up to 952 days. Two hundred experimental sessions (24% of all sessions, 83 patients) were randomly selected to evaluate proficiency using the MI Treatment Integrity scale; along with 20 control sessions delivered by four dietitians. Linear mixed-effects regression analyses determined whether proficiency was sustained over time. Dose was assessed from all experimental sessions ( n = 840, 98 patients).

RESULTS

Intervention was implemented as intended; 82% of patients received at least eight 30-minute sessions. All motivational interviewers were proficient, whereas dietitians did not inadvertently deliver MI. Time had no effect on MI proficiency (est < 0.001/d, P = .913, 95% CI, -0.001 to 0.001).

DISCUSSION

MI proficiency was sustained in a large trial over 2.6 years by completing a 2-day workshop, 3 to 5 hours of personalized coaching, and twice-yearly group reflections, even for those without previous experience; further research needs to establish the maximum duration of training effectiveness.

Implementing a workflow-integrated motivational interviewing training program for psychiatry trainees on an inpatient consultation-liaison rotation: lessons learned

Background

Effective consultation-liaison psychiatry (CLP) is proactive, collaborative, and requires providers to have proficiency with therapeutic skills beyond nosology and medication management. Motivational interviewing (MI) is an evidenced-based intervention that should be considered essential for CLP trainees to learn. Given that the demands of training and patient care are already experienced as stressful for many psychiatry trainees, the authors endeavored to create a MI training program that was integrated into trainees' normal CLP workflow.

Method

Twenty-two trainees on an inpatient CLP rotation participated in a six-week MI training program that was incorporated into their regular workflow. The program included didactic sessions with role-playing, as well as on-demand between-session coaching via an expert in MI. Trainee participation and perceptions of MI were measured via a questionnaire that was administered prior to each training session.

Results

Trainee participation in the didactic sessions was inconsistent. Questionnaire data revealed positive baseline perceptions of motivational interviewing and its usefulness in inpatient medical settings. Additionally, as trainees participated in the program, perceived knowledge of motivational interviewing as well as awareness of motivational issues among their patients increased. Finally, participation in program was not perceived as disruptive to daily workflow for the participants.

Discussion

This the first documented attempt at implementing a MI training program for CLP trainees that was integrated into their regular workflow. Preliminary data identified some encouraging trends, but also unexpected challenges. These lessons could inform how these types of training programs are implemented moving forward.

Taking a Magnifying Glass to Measurement-Based Care Consultation Sessions: with What Issues Do Mental Health Clinicians Struggle?

PURPOSE

Ongoing consultation following initial training is one of the most commonly deployed implementation strategies to facilitate uptake of evidence-based practices, such as measurement-based care (MBC). Group consultation provides an interactive experience with an expert and colleagues to get feedback on actual issues faced, yet there is little research that unpacks the questions raised in consultation and what types of issues are important to address.

METHODS

The current study characterized the questions and concerns raised by community mental health clinicians (N = 38 across six clinics) during group consultation sessions completed as part of an MBC implementation trial. We conducted a qualitative content analysis of consultation forms completed by clinicians before each MBC consultation session.

RESULTS

Clinicians sought MBC consultation for clients across a range of ages and levels of depression severity. Qualitative results revealed five main questions and concerns in consultation sessions: (1) how to administer the PHQ-9, (2) how to review PHQ-9 scores, (3) how to respond to PHQ-9 score, (4) the types of clients for whom MBC would be appropriate, and (5) how MBC could impact a clinician's usual care.

CONCLUSION

Findings highlight the need for ongoing consultation and limitations of workshop training alone. Practical recommendations for addressing the common questions and concerns identified are presented to support MBC use.

Supporting people affected by problematic alcohol, substance use and other behaviours under pandemic conditions: A pragmatic evaluation of how SMART recovery Australia responded to COVID-19

BACKGROUND

The COVID-19 pandemic prompted rapid, reflexive transition from face-to-face to online healthcare. For group-based addiction services, evidence for the impact on service delivery and participant experience is limited.

METHODS

A 12-month (plus 2-month follow-up) pragmatic evaluation of the upscaling of online mutual-help groups by SMART Recovery Australia (SRAU) was conducted using The Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Data captured by SRAU between 1st July 2020 and 31st August 2021 included participant questionnaires, Zoom Data Analytics and administrative logs.

RESULTS

Reach: The number of online groups increased from just 6 pre-COVID-19 to 132. These groups were delivered on 2786 (M = 232.16, SD = 42.34 per month) occasions, to 41,752 (M = 3479.33, SD = 576.34) attendees.

EFFECTIVENESS

Participants (n = 1052) reported finding the online group meetings highly engaging and a positive, recovery supportive experience. 91 % of people with experience of face-to-face group meetings rated their online experience as equivalent or better. Adoption: Eleven services (including SRAU) and five volunteers delivered group meetings for the entire 12-months.

IMPLEMENTATION

SRAU surpassed their goal of establishing 100 groups. Maintenance: The average number of meetings delivered [t(11.14) = -1.45, p = 0.1737] and attendees [t(1.95) = -3.28, p = 0.1880] per month were maintained across a two-month follow-up period.

CONCLUSIONS

SRAU scaled-up the delivery of online mutual-help groups in response to the COVID-19 pandemic. Findings support the accessibility, acceptability and sustainability of delivering SMART Recovery mutual-help groups online. Not only are these findings important in light of the global pandemic and public safety, but they demonstrate the potential for reaching and supporting difficult and under-served populations.

Expanding School-Based Motivational Interviewing Through Delivery by Paraprofessional Providers: A Preliminary Scoping Review

The supply of school mental health (SMH) providers and services cannot meet the demand of students in-need, and this gap is expected to widen in coming years. One way to increase the reach of helpful services for youth is to grow the SMH workforce through task-shifting to paraprofessionals. Task-shifting could be especially promising in expanding Motivational Interviewing (MI) interventions, as MI can be molded to target a number of academic and behavioral outcomes important to schools. However, no review of training exclusively paraprofessional samples in MI has yet been conducted. The current paper provides a scoping review of 19 studies of training paraprofessional providers to use MI to evaluate trainee characteristics, training content and format, and outcomes. Of these 19 studies, 15 reported that paraprofessionals improved in using MI following training. Nine studies reported that task-shifting MI was positively received by clients and/or providers. Six studies examined task-shifting MI in youth-serving contexts, and four examined the practice in traditional school contexts, suggesting its potential for use in SMH. Other findings and implications, such as client behavior change and provider fidelity, are shared, along with ideas for advancing research, practice, and policy in this subfield.

Designing Practical Motivational Interviewing Training for Mental Health Practitioners Implementing Behavioral Lifestyle Interventions: Protocol for 3 Pilot Intervention Studies

BACKGROUND

Motivational interviewing (MI) is an evidence-based, patient-centered communication method shown to be effective in helping persons with serious mental illness (SMI) to improve health behaviors. In clinical trials where study staff conducted lifestyle interventions incorporating an MI approach, cardiovascular disease (CVD) risk profiles of participants with SMI showed improvement. Given the disproportionate burden of CVD in this population, practitioners who provide somatic and mental health care to persons with SMI are ideally positioned to deliver patient-centered CVD risk reduction interventions. However, the time for MI training (traditionally 16-24 hours), follow-up feedback, and the coaching required to develop and maintain patient-centered skills are significant barriers to incorporating MI when scaling up these evidence-based practices.

OBJECTIVE

We describe the design and development of the following 2 scalable MI training approaches for community mental health practitioners: real-time brief workshops and follow-up asynchronous avatar training. These approaches are being used in 3 different pilot implementation research projects that address weight loss, smoking cessation, and CVD risk reduction in people with SMI who are a part of ALACRITY Center, a research-to-practice translation center funded by the National Institute of Mental Health.

METHODS

Clinicians and staff in community mental health clinics across Maryland were trained to deliver 3 distinct evidence-based physical health lifestyle interventions using an MI approach to persons with SMI. The real-time brief MI workshop training for ACHIEVE-D weight loss coaches was 4 hours; IMPACT smoking cessation counselors received 2-hour workshops and prescribers received 1-hour workshops; and RHYTHM CVD risk reduction program staff received 4 hours of MI. All workshop trainings occurred over videoconference. The asynchronous avatar training includes 1 common didactic instructional module for the 3 projects and 1 conversation simulation unique to each study's target behavior. Avatar training is accessible on a commercial website. We plan to assess practitioners' attitudes and beliefs about MI and evaluate the impact of the 2 MI training approaches on their MI skills 3, 6, and 12 months after training using the MI Treatment Integrity 4.2.1 coding tool and the data generated by the avatar-automated scoring system.

RESULTS

The ALACRITY Center was funded in August 2018. We have implemented the MI training for 126 practitioners who are currently delivering the 3 implementation projects. We expect the studies to be complete in May 2023.

CONCLUSIONS

This study will contribute to knowledge about the effect of brief real-time training augmented with avatar skills practice on clinician MI skills. If MI Treatment Integrity scoring shows it to be effective, brief videoconference trainings supplemented with avatar skills practice could be used to train busy community mental health practitioners to use an MI approach when implementing physical health interventions.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/44830.

Relations between provider adherence to a tailored motivational intervention protocol and competence in motivational interviewing

OBJECTIVES

To evaluate the association between provider adherence to Tailored Motivational Interviewing implementation strategy and motivational interviewing (MI) competence.

METHODS

156 youth-focused HIV providers enrolled in a parent implementation science trial completed: a) quarterly standardized patient assessments (SPI) during Baseline; b) a workshop, individual coaching sessions, and quarterly SPI plus feedback during Implementation; and c) quarterly SPI during Sustainment. Competence was measured using the MI-CRS and tracking data was used to assess adherence. We examined overall adherence as well as adherence to each implementation strategy in relation to MI competence.

RESULTS

Overall adherence was not associated with overall MI competence. MI competence significantly increased from Baseline to Implementation and Baseline to Sustainment. Some individual implementation strategies were associated with change in competence and the probability of achieving Intermediate/Advanced competence.

CONCLUSIONS

The results suggest that 100% percent adherence to all TMI implementation strategies may not be necessary. Completing some of the TMI implementation strategies yielded improvements in MI competence. The use of routine tracking data to measure adherence maybe more pragmatic than using observational coders and more objective than self-reports.

PRACTICE IMPLICATIONS

In busy HIV clinics, MI training should focus on strategies most directly associated with increased provider competence.

Multidimensional Evaluation of Screening Brief Intervention and Referral to Treatment Training for Medical Students

OBJECTIVE

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to identifying and addressing alcohol use in non-specialty settings. Many medical schools teach SBIRT, but most published evaluations of these efforts exclude rigorous skill assessments and teaching methods.

METHODS

During the 2017-2018 academic year, 146 third-year medical students received classroom-based learning on SBIRT and motivational interviewing (MI) and at least two SBIRT practices with feedback as part of a 4-week psychiatry clerkship. The objective of this curriculum was to improve SBIRT knowledge, attitudes, and confidence and enable learners to skillfully deliver SBIRT. Outcomes evaluated included satisfaction, knowledge, attitudes and confidence, and clinical skill in delivering SBIRT to a standardized patient (rated by the actor, as well as an expert).

RESULTS

Results indicated acceptable satisfaction at post-curriculum and significant improvements in attitudes and knowledge from pre- to post-curriculum. On the clinical skills exam, all students were rated as having mastered at least 80% of SBIRT elements by standardized patients and 91.8% were rated at this level by a faculty expert. Student attitudes and knowledge were unrelated to expert ratings, and standardized patient ratings had limited associations with expert ratings.

CONCLUSIONS

These results suggest curriculum objectives were achieved and provide unique contributions to the SBIRT curricular outcome research for healthcare trainees. Other findings included that trainee knowledge and confidence may not relate to skill, and standardized patient feedback provides different information on SBIRT and MI skill than expert ratings.

A multi-center, randomized, 12-month, parallel-group, feasibility study to assess the acceptability and preliminary impact of family navigation plus usual care versus usual care on attrition in managing pediatric obesity: a study protocol

BACKGROUND

Pediatric obesity management can be successful, but some families discontinue care prematurely (i.e., attrition), limiting treatment impact. Attrition is often a consequence of barriers and constraints that limit families' access to obesity management. Family Navigation (FN) can improve access, satisfaction with care, and treatment outcomes in diverse areas of healthcare. To help our team prepare for a future effectiveness trial, the objectives of our randomized feasibility study are to (i) explore children's and caregivers' acceptability of FN and (ii) examine attrition, measures of study rigor and conduct, and responses to FN + Usual Care vs Usual Care by collecting clinical, health services, and health economic data.

METHODS

In our 2.5-year study, 108 6-17-year-olds with obesity and their caregivers will be randomized (1:1) to FN + Usual Care or Usual Care after they enroll in obesity management clinics in Calgary and Mississauga, Canada. Our Stakeholder Steering Committee and research team will use Experience-Based Co-Design to design and refine our FN intervention to reduce families' barriers to care, maximizing the intervention dose families receive. FN will be delivered by a navigator at each site who will use logistical and relational strategies to enhance access to care, supplementing obesity management. Usual Care will be offered similarly at both clinics, adhering to expert guidelines. At enrollment, families will complete a multidisciplinary assessment, then meet regularly with a multidisciplinary team of clinicians for obesity management. Over 12 months, both FN and Usual Care will be delivered virtually and/or in-person, pandemic permitting. Data will be collected at 0, 3, 6, and 12 months post-baseline. We will explore child and caregiver perceptions of FN acceptability as well as evaluate attrition, recruitment, enrolment, randomization, and protocol integrity against pre-set success thresholds. Data on clinical, health services, and health economic outcomes will be collected using established protocols. Qualitative data analysis will apply thematic analysis; quantitative data analysis will be descriptive.

DISCUSSION

Our trial will assess the feasibility of FN to address attrition in managing pediatric obesity. Study data will inform a future effectiveness trial, which will be designed to test whether FN reduces attrition.

TRIAL REGISTRATION

This trial was registered prospectively at ClinicalTrials.gov (# NCT05403658 ; first posted: June 3, 2022).

Experiences of nurses and coordinators in a childhood obesity prevention trial based on motivational interviewing within Swedish child health services

Purpose

To explore the experiences of nurses and coordinators in the PRIMROSE childhood obesity prevention trial, and to understand the factors that might help to improve the outcome of future primary prevention of obesity.

Methods

Using a qualitative approach, data were obtained by interviewing nine intervention nurses and three regional study coordinators. All participants were female. The interviews were transcribed and analysed using content analysis.

Results

Two themes emerged: The nurses experienced that it was rewarding to participate in the trial, but challenging to combine the intervention with regular work; and The study coordinators experienced that they were in a difficult position handling the conflicting needs of the research group and the nurses’ commitment to usual child health care services. The importance of support, encouragement, briefer and simpler intervention, and adaptation of the training in motivational interviewing to the setting was emphasized. Stress and lack of time were major barriers to deliver the intervention as intended.

Conclusions

Although the PRIMROSE intervention was developed in collaboration with representatives from the child health services, and additional research funding was provided to compensate for time spent working with the trial, nurses experienced stress and time constraints. .

Supporting Clinical Development Through Integrative Continuing Education for Field Instructors

Field education is the signature pedagogy of social work education, but there is no standardized mechanism to ensure field instructors are trained in the same clinical modalities as social work students or are well-trained in the provision of clinical supervision. Feasibility was assessed of providing field instructors (n = 9) with a continuing education (CE) program to train them in a specialized evidence-based practice, motivational interviewing (MI) in a recovery context, and strategies for supervision. Participants of the CE program gained confidence (p < .05) and knowledge in the spirit (p < .01) and skills (p < .001) of MI; while participants described initial reactions of disdain when role-plays were introduced in the training, they ultimately identified role-plays and facilitator modeling as key features in producing their own practice change and mimicked the use of parallel process - using MI as a way to teach MI - in their provision of supervision. Findings suggest that offering a CE program to train field instructors in a specialized evidence-based practice embedded in course work and strategies for supervision is feasible and may result in enhanced supervision in field education.

Enhancing the quality of cognitive behavioral therapy in community mental health through artificial intelligence generated fidelity feedback (Project AFFECT): a study protocol

Background

Each year, millions of Americans receive evidence-based psychotherapies (EBPs) like cognitive behavioral therapy (CBT) for the treatment of mental and behavioral health problems. Yet, at present, there is no scalable method for evaluating the quality of psychotherapy services, leaving EBP quality and effectiveness largely unmeasured and unknown. Project AFFECT will develop and evaluate an AI-based software system to automatically estimate CBT fidelity from a recording of a CBT session. Project AFFECT is an NIMH-funded research partnership between the Penn Collaborative for CBT and Implementation Science and Lyssn.io, Inc. (“Lyssn”) a start-up developing AI-based technologies that are objective, scalable, and cost efficient, to support training, supervision, and quality assurance of EBPs. Lyssn provides HIPAA-compliant, cloud-based software for secure recording, sharing, and reviewing of therapy sessions, which includes AI-generated metrics for CBT. The proposed tool will build from and be integrated into this core platform.

Methods

Phase I will work from an existing software prototype to develop a LyssnCBT user interface geared to the needs of community mental health (CMH) agencies. Core activities include a user-centered design focus group and interviews with community mental health therapists, supervisors, and administrators to inform the design and development of LyssnCBT. LyssnCBT will be evaluated for usability and implementation readiness in a final stage of Phase I. Phase II will conduct a stepped-wedge, hybrid implementation-effectiveness randomized trial (N = 1,875 clients) to evaluate the effectiveness of LyssnCBT to improve therapist CBT skills and client outcomes and reduce client drop-out. Analyses will also examine the hypothesized mechanism of action underlying LyssnCBT.

Discussion

Successful execution will provide automated, scalable CBT fidelity feedback for the first time ever, supporting high-quality training, supervision, and quality assurance, and providing a core technology foundation that could support the quality delivery of a range of EBPs in the future.

Trial registration

ClinicalTrials.gov; NCT05340738; approved 4/21/2022.

To Change or Not to Change? A Study regarding the Satisfaction of Care Workers and Adolescents with the Motivational Interviewing Based Residential Youth Care Training Program Up2U

Long-term behavioral change is often difficult to achieve with adolescents staying in residential youth care. To achieve long-term behavioral change, we developed the Up2U training program to enhance these adolescents' intrinsic motivation for change. Based on motivational interviewing and solution-focused therapy, Up2U is designed for conducting one-on-one conversations with adolescents in residential youth care. The aim of this study is to evaluate the experiences that adolescents and care workers have had with Up2U. The results of semi-structured interviews show that, in general, the care workers were satisfied with Up2U. They identified the clarity, conciseness, and sample questions as positive elements of Up2U. In contrast, the care workers regarded the extensiveness and the implementation of Up2U as less positive. The adolescents also seemed to be positive about the use of Up2U during one-on-one conversations. In conclusion, although both care workers and adolescents were generally satisfied, there is still room for improvement.

The Status of SBIRT Training in Health Professions Education: A Cross-Discipline Review and Evaluation of SBIRT Curricula and Educational Research

PURPOSE

To assess the quality of curricular research on the Screening Brief Intervention and Referral to Treatment (SBIRT) approach and determine the presence of useful training modalities, particularly motivational interviewing (MI) training, across health care training curricula.

METHOD

The authors conducted a systematic review of published, peer-reviewed studies in PubMed, ERIC, CINAHL, Ovid HealthSTAR, and PsycINFO databases through March 2021 for English-language studies describing SBIRT, a curriculum for health care trainees, and curricular intervention outcomes. After the records were independently assessed, data were extracted and 20% of the studies were double-coded for interrater reliability.

RESULTS

Of 1,856 studies, 95 were included in the review; 22 had overlapping samples and were consolidated into 10 nested studies, leaving 83 total. Interrater reliability ranged from moderate (κ = .74, P < .001) to strong (κ = .91, P < .001) agreement. SBIRT training was delivered to trainees across many professions, including nursing (n = 34, 41%), medical residency (n = 28, 34%), and social work (n = 24, 29%). Nearly every study described SBIRT training methods (n = 80, 96%), and most reported training in MI (n = 54, 65%). On average, studies reported 4.06 (SD = 1.64) different SBIRT training methods and 3.31 (SD = 1.59) MI training methods. Their mean design score was 1.92 (SD = 0.84) and mean measurement score was 1.89 (SD = 1.05). A minority of studies measured SBIRT/MI skill (n = 23, 28%), and 4 studies (5%) set a priori benchmarks for their curricula.

CONCLUSIONS

SBIRT training has been delivered to a wide range of health care trainees and often includes MI. Rigor scores for the studies were generally low due to limited research designs and infrequent use of objective skill measurement. Future work should include predefined training benchmarks and validated skills measurement.

Can Outcomes of a Chat-Based Suicide Prevention Helpline Be Improved by Training Counselors in Motivational Interviewing? A Non-randomized Controlled Trial

Objective

To examine whether the outcomes of a chat-based suicide-prevention helpline could be improved by training counselors in motivational interviewing (MI).

Methods

In a pre- and post-test design, visitors of a chat-based suicide prevention helpline received either the Five-Phase Model (treatment as usual [TAU]) or MI. They completed a pre- and post-chat questionnaire on several suicide-related risk factors. Linear mixed modeling was used to estimate the effect of the condition. Furthermore, the treatment proficiency of newly trained counselors was assessed using MI-Scope.

Results

A total of 756 visitors and 55 counselors were included in this study. The visitors showed an improvement in suicidal ideation and psychological risk factors after a chat conversation. However, there were no significant differences between the MI and TAU conditions (β = 0.03, 95% CI [−0.23–0.30], p = 0.80). The treatment integrity indices showed that the counselors mostly used MI-consistent techniques but were unable to strategically employ these techniques to evoke enough change talk.

Conclusions

MI and TAU led to comparable outcomes in a chat-based suicide prevention helpline. The effectiveness of MI might improve by intensifying or improving the training of counselors, keeping the process of engaging more concise or offering visitors multiple sessions of MI.

A Behavior-based Coding Tool for Assessing Supervisors' Adherence and Competence: Findings From a Motivational Interviewing Implementation Study

Supervision seems to be an essential part of therapist training, and thus also of implementing evidence-based practices. However, there is a shortage of valid and reliable instruments for objective assessment of supervision competence that include both global measures and frequency counts of behavior - two essential aspects of supervisory competence. This study tests the internal consistency and inter-rater reliability of an assessment tool that includes both these measures. Additionally, strategies and techniques used by ten supervisors in 35 Motivational interviewing supervision sessions are described. Codings were conducted after two separate coding training sessions. The internal consistency across the global measures was acceptable (α = 0.70; 0.71). After the second training, the inter-rater reliabilities for all frequency counts were in the moderate to good range, except for two that were in the poor range; inter-rater reliability for one of the four global measures was in the moderate range, and three were in the poor range. A prerequisite for identifying specific supervisor skills central to the development of therapist skills, teaching these skills to supervisors, and performing quality assurance of supervision, is to create instruments that can measure these behaviors. This study is a step in that direction.

Can motivational interviewing for dental settings be taught online? Results of an uncontrolled interventional trial

BACKGROUND

Motivational interviewing (MI) is an evidence-based method of promoting oral healthcare behaviour. Conventional training of MI is a time-consuming and costly aspect in the dental curriculum. Therefore, the aim of this study was to evaluate the effectiveness and acceptance of a MI-blended learning programme for dental students.

MATERIALS AND METHODS

Dental students had to perform an interdisciplinary created "ecourse Motivational Interviewing in medical settings" (eMI-med). After completion, patient-student interviews were recorded and evaluated using the Motivational Interviewing Treatment Integrity Code (MITI-d). Furthermore, the students' self-efficacy regarding smoking cessation and oral hygiene motivation was examined and the acceptance of the tool was enquired.

RESULTS

Forty interviews with 25 different students were analysed with the MITI-d. Students showed high levels of MI-adherent behaviour (15.45 ± 6.98), open-ended questions (9.95 ± 6.90) and reflections (10.43 ± 8.85), which were comparable to previous classroom trainings. In addition, 90% of the students preferred e-learning over classroom teaching. Furthermore, the students' therapeutical self-efficacies were significantly increased by the programme.

CONCLUSION

Within the limitations of this study, the created e-learning programme was able to equip dental students with basic knowledge and MI skills. Furthermore, learning MI through e-learning may heighten the self-efficacy of dental students regarding smoking cessation and oral hygiene promotion. Students showed a high acceptance of e-learning, preferring it over traditional learning.

Technology-Based Methods for Training Counseling Skills in Behavioral Health: a Scoping Review

In the present review, we consider technology-based methods for training and monitoring counseling skills in behavioral health (i.e., addictions, mental health, and behavioral medicine). We provide an overview of topical foci and design features, as well as review the available research. The Arksey and O’Malley framework for scoping review was used and there were two project phases. First, we reviewed and charted design features and training topics. Second, we reviewed and charted published research evaluating training outcomes. The search process yielded six commercial companies or academic research centers targeting online training of behavioral health counseling skills. These programs could be categorized by an avatar (i.e., computer-generated) or video (i.e., human actor) client interface, as well as by a completely interactive experience (i.e., virtual reality) or an experience with a pre-programmed, branch-logic interaction (i.e., computer simulation). One final company provided monitoring services only, without an explicit training component. The literature in this area is in its nascent stages, with primarily pilot scope and comparatively less progress if contrasted with fields such as general medicine. Online training and monitoring of behavioral health counseling skills is a promising emerging field with positive qualities such as scalability, resource efficiency, and standardization. Future research should emphasize (1) between-group randomized clinical trials, (2) comparisons to standard training practices, and (3) alignment with professional competency standards.

Telehealth delivery of motivational interviewing for diabetes management: A systematic review of randomized controlled trials

OBJECTIVES

The objective of this systematic review was to explore and report the evidence and gaps in the literature for randomized controlled trials (RCTs) studying the effects of motivational interviewing (MI)-based telehealth interventions on outcomes among persons with diabetes (PWD) or prediabetes.

METHODS

Following a modified Cochrane approach, we searched Pubmed, CENTRAL, CINAHL, PsycINFO, and Clinicaltrials.gov. Included studies were RCTs published in English before March 25, 2021 evaluating MI-based telehealth on outcomes for adults with diabetes or prediabetes.

RESULTS

A total of 21 retained articles captured results for 6436 PWD. Among the most commonly investigated outcomes, 60% of articles documented A1C reductions (ranging from<1% to>3%), 56% documented systolic blood pressure reductions, 57% documented diabetes self-efficacy/empowerment improvements, and 40% documented physical activity improvements. Conversely, diastolic blood pressure, lipid panels, body mass index, depressive symptoms, and quality of life were frequently measured outcomes, where MI-based telehealth yielded minor effects (<30% of articles demonstrating improvements).

CONCLUSIONS

MI-based telehealth seems most effective for improving A1C, systolic blood pressure, diabetes self-efficacy, and physical activity behaviors. Variability in outcome assessment and intervention heterogeneity were key challenges impeding comparisons across retained articles.

PRACTICE IMPLICATIONS

MI-based telehealth interventions demonstrate promising results for improving outcomes in PWD.

Automated evaluation of psychotherapy skills using speech and language technologies

With the growing prevalence of psychological interventions, it is vital to have measures which rate the effectiveness of psychological care to assist in training, supervision, and quality assurance of services. Traditionally, quality assessment is addressed by human raters who evaluate recorded sessions along specific dimensions, often codified through constructs relevant to the approach and domain. This is, however, a cost-prohibitive and time-consuming method that leads to poor feasibility and limited use in real-world settings. To facilitate this process, we have developed an automated competency rating tool able to process the raw recorded audio of a session, analyzing who spoke when, what they said, and how the health professional used language to provide therapy. Focusing on a use case of a specific type of psychotherapy called "motivational interviewing", our system gives comprehensive feedback to the therapist, including information about the dynamics of the session (e.g., therapist's vs. client's talking time), low-level psychological language descriptors (e.g., type of questions asked), as well as other high-level behavioral constructs (e.g., the extent to which the therapist understands the clients' perspective). We describe our platform and its performance using a dataset of more than 5000 recordings drawn from its deployment in a real-world clinical setting used to assist training of new therapists. Widespread use of automated psychotherapy rating tools may augment experts' capabilities by providing an avenue for more effective training and skill improvement, eventually leading to more positive clinical outcomes.

Self-Coding of Fidelity as a Potential Active Ingredient of Consultation to Improve Clinicians' Fidelity

A key goal for implementation science is the identification of evidence-based consultation protocols and the active ingredients within these protocols that drive clinician behavior change. The current study examined clinicians' self-coding of fidelity as a potential active ingredient of consultation for the Attachment and Biobehavioral Catch-up (ABC) intervention. It also examined two other potential predictors of clinician fidelity in response to consultation: dosage of consultation and working alliance. Twenty-nine clinicians (97% female, 62% White, M age = 34 years) participated in a year of weekly fidelity-focused ABC consultation sessions, for which clinicians self-coded fidelity and received consultant feedback on both their coding and their fidelity. Data from the ABC fidelity measure were available for 1067 sessions coded by consultants, and clinicians' self-coding accuracy was calculated from 1044 sessions coded by both clinicians and consultants. Alliance was measured with the Working Alliance Inventory-Trainee and Supervisor Versions. The study was observational, and fidelity and self-coding accuracy were modeled across time using hierarchical linear modeling. Clinicians' ABC fidelity, as well as their self-coding accuracy, increased over the course of consultation. Clinicians' self-coding accuracy predicted their initial fidelity and growth in fidelity. Working alliance was also linked to fidelity and self-coding accuracy. These results suggest that clinician self-coding should be further examined as an active ingredient of consultation. The study has important implications for the design of consultation procedures and fidelity assessments.

Inconsistent Counselor Fidelity in Delivering an Evidence-Based Adherence Intervention During a PrEP Trial

Evidence-based adherence counseling interventions must be delivered with fidelity to ensure that their effectiveness is retained, but little is known regarding how counselors in biomedical HIV trials deliver these interventions. Forty-two counselors from the MTN-025/HOPE Study, which was conducted in 14 sites in sub-Saharan Africa, participated. They completed a quantitative assessment and consented for their HOPE counseling session ratings to be analyzed. Twenty-two (52%) self-identified as research nurses and 20 (48%) as counselors. Of 928 session ratings, 609 (66%) were classified as Good, 188 (20%) as Fair, and 131 (14%) as Poor, based on pre-established criteria. Overall mean ratings for session tasks and global components (each rated from 1 to 5) were 4.12 (SD = 0.45; range 2.46-4.73) and 4.02 (SD = 0.64; range 1.75-4.79), respectively. Twenty-six (62%) counselors attained Good or Fair ratings on at least 85% of their sessions, but 33% of counselors had more than 25% of their sessions rated as Poor; three counselors (7%) never met criteria for a Good session. Even after extensive training, counselors' fidelity to the intervention varied. Our findings highlight the value of fidelity monitoring using session audio-recordings, the importance of ongoing coaching and support, and the need to plan for counselors with consistently poor fidelity.

Contingency management for treatment attendance: A meta-analysis

BACKGROUND

Treatment providers have applied contingency management (CM) treatment, an intervention that often rewards individuals for drug abstinence (i.e., ABS CM), to treatment engagement as well. However, we know little about the magnitude of treatment effects when providers target attendance behaviors (i.e., ATT CM).

METHODS

This study conducted a systematic search to identify studies that included ATT CM, either in isolation or in combination with ABS CM. The study used meta-analysis to estimate the effect size of ATT CM and ABS CM + ATT CM on treatment attendance and drug abstinence. We identified a total of 10 studies including 12 CM treatments (6 ATT CM and 6 ABS CM + ATT CM) with 1841 participants.

RESULTS

Results indicated a moderate effect (d = 0.47, 95% confidence interval (CI) [0.25, 0.69]) of ATT CM on attendance relative to non-reward active comparison conditions. Frequency of rewards was significantly associated with larger effect sizes. Results also indicated a small effect (d = 0.22, 95% CI [0.12, 0.33]) of ATT CM on abstinence outcomes relative to nonreward comparisons, p < 0.001. The study found no significant differences in attendance or abstinence between ATT CM and ABS CM + ATT CM (p's > 0.05).

CONCLUSION

Overall, the results supported ATT CM for increasing treatment engagement, with smaller effects on abstinence. Effects on abstinence were smaller than those observed in prior meta-analyses focused on ABS CM. No significant differences existed in attendance or abstinence outcomes between ATT CM and ABS + ATT CM. However, future studies are needed to experimentally compare ABS CM + ATT CM to ABS CM, and ATT CM to determine additive effects. Clinics implementing CM should consider the differential effects between ATT CM and ABS CM when selecting target behavior(s).

Training Physicians in Motivational Communication to Address Influenza Vaccine Hesitation: A Proof-of-Concept Study

Background: Strategies to support health care professionals on how to address vaccine hesitancy are needed. Methods: We developed a 4-h Motivational Communication (MC) training program tailored to help physicians address hesitancy related to influenza vaccination among patients living with rheumatoid arthritis. Five MC competencies were evaluated at baseline and post-training with a standardized patient using the Motivational Interviewing Treatment Integrity [MITI] scale. Adherence to MC during clinical consultations and changes in vaccine intentions was measured as secondary outcomes. Results: Seven rheumatology physicians participated in the training. MITI scores increased in all participants, and 71% (n = 5) achieved thresholds of clinical competency (i.e., ≥3.5/5 at MITI global score and ≥3/5 on at least 3 individual competency score) post-training. Autonomy/support and empathy competencies reached competency thresholds (+2.4 ± 1.3 to +4.1 ± 0.7 and +2.1 ± 0.7 to +4.1 ± 0.7, respectively). Evocation and collaboration competencies improved but without reaching competency thresholds (+1.4 ± 0.8 to +3.1 ± 1.1; +1.4 ± 0.8 to +2.9 ± 1.1, respectively). Direction did not improve. Among 21 patient consultations post-training, 15 (71%) were MC-consistent. Of the 15 patients, 67% (10/15) intended to receive the influenza vaccine and 33% (5/15) received it. Conclusion: A brief MC training program targeting vaccine hesitancy increased MC competency among rheumatology physicians and promoted behavioral change among patients.

Facilitators and barriers for promoting healthy eating among primary care patients: results of a qualitative study among practice nurses

BACKGROUND

Practice nurses have an important role in promoting healthy eating to prevent or delay long-term complications from chronic lifestyle-related diseases.

OBJECTIVE

To identify the facilitators and barriers encountered by practice nurses at a professional level when promoting healthy eating among patients.

METHODS

Face-to-face semi-structured interviews were conducted with 21 Dutch practice nurses. Data were recorded, transcribed and analysed using inductive thematic analysis.

RESULTS

Two main themes were determined: professional characteristics and professional-patient encounter. Professional characteristics included good communication skills and experience facilitated the successful promotion of healthy eating, while a lack of communication skills and lack of knowledge about diet were perceived as barriers. The most frequently identified facilitators for professional-patient encounter included ensuring a personal connection with patients, creating food awareness, focussing on small changes, adopting a tailored approach, motivating and arranging extra consultations. Barriers included lack of skills to raise the topic, lack of persistence, inability to find a common understanding, lack of competence in handling patients' own choices and underuse of existing educational materials.

CONCLUSIONS

Further research using the identified facilitators and barriers for promoting healthy eating in primary care patients with chronic diseases could assist in the development of future training programmes for practice nurses.

Knowledge and Attitudes Toward an Artificial Intelligence-Based Fidelity Measurement in Community Cognitive Behavioral Therapy Supervision

To capitalize on investments in evidence-based practices, technology is needed to scale up fidelity assessment and supervision. Stakeholder feedback may facilitate adoption of such tools. This evaluation gathered stakeholder feedback and preferences to explore whether it would be fundamentally feasible or possible to implement an automated fidelity-scoring supervision tool in community mental health settings. A partially mixed, sequential research method design was used including focus group discussions with community mental health therapists (n = 18) and clinical leadership (n = 12) to explore typical supervision practices, followed by discussion of an automated fidelity feedback tool embedded in a cloud-based supervision platform. Interpretation of qualitative findings was enhanced through quantitative measures of participants' use of technology and perceptions of acceptability, appropriateness, and feasibility of the tool. Initial perceptions of acceptability, appropriateness, and feasibility of automated fidelity tools were positive and increased after introduction of an automated tool. Standard supervision was described as collaboratively guided and focused on clinical content, self-care, and documentation. Participants highlighted the tool's utility for supervision, training, and professional growth, but questioned its ability to evaluate rapport, cultural responsiveness, and non-verbal communication. Concerns were raised about privacy and the impact of low scores on therapist confidence. Desired features included intervention labeling and transparency about how scores related to session content. Opportunities for asynchronous, remote, and targeted supervision were particularly valued. Stakeholder feedback suggests that automated fidelity measurement could augment supervision practices. Future research should examine the relations among use of such supervision tools, clinician skill, and client outcomes.

Ongoing supervision as a method to implement Motivational interviewing: Results of a randomized controlled trial

OBJECTIVE

To assess skills in Motivational interviewing (MI) at the Swedish National Board of Institutional Care (SiS), and to evaluate different ways to provide MI supervision.

METHODS

SiS practitioners (n = 134) were randomized to regular group supervision, or individual telephone supervision based on only the behavioral component of a feedback protocol, or the full protocol. Participant's mean age was 43.2 (SD =10.2), and the majority (62.7%) were females.

RESULTS

Many participants showed beginning proficiency already at baseline, indicating a successful implementation. Still, results varied widely. The regular supervision and the supervision based on objective feedback were equally effective, and the group receiving feedback based on fewer variables of the protocol performed better on only one of the seven skill measures. The objective feedback did not provoke supervisee discomfort/distress, or negatively affect the supervisory relationship.

CONCLUSIONS

Extensive MI implementation can increase practitioners' skills in MI, but the question of the best mode of ongoing supervision needs further attention.

PRACTICE IMPLICATIONS

Objective feedback does not seem to negatively affect the supervisee's skill acquisition or the supervisor-supervisee working alliance, but the question of how to most efficiently provide feedback from multifaceted feedback tools remains unanswered.

Advancing Motivational Interviewing Training with Artificial Intelligence: ReadMI

BACKGROUND

Motivational interviewing (MI) is an evidence-based, brief interventional approach that has been demonstrated to be highly effective in triggering change in high-risk lifestyle behaviors. MI tends to be underutilized in clinical settings, in part because of limited and ineffective training. To implement MI more widely, there is a critical need to improve the MI training process in a manner that can provide prompt and efficient feedback. Our team has developed and tested a training tool, Real-time Assessment of Dialogue in Motivational Interviewing (ReadMI), that uses natural language processing (NLP) to provide immediate MI metrics and thereby address the need for more effective MI training.

METHODS

Metrics produced by the ReadMI tool from transcripts of 48 interviews conducted by medical residents with a simulated patient were examined to identify relationships between physician-speaking time and other MI metrics, including the number of open- and closed-ended questions. In addition, interrater reliability statistics were conducted to determine the accuracy of the ReadMI's analysis of physician responses.

RESULTS

The more time the physician spent talking, the less likely the physician was engaging in MI-consistent interview behaviors (r = -0.403, p = 0.007), including open-ended questions, reflective statements, or use of a change ruler.

CONCLUSION

ReadMI produces specific metrics that a trainer can share with a student, resident, or clinician for immediate feedback. Given the time constraints on targeted skill development in health professions training, ReadMI decreases the need to rely on subjective feedback and/or more time-consuming video review to illustrate important teaching points.

Motivational Interviewing Training for HIV Care Physicians in Argentina: Uptake and Sustainability of an Effective Behavior Change Intervention

Motivational interviewing (MI) utilizes a patient-centered approach to address patient ambivalence about treatment and has been found to improve treatment ART adherence among patients living with HIV disengaged from care. This study examined MI training for clinicians, uptake, and sustainability over time. Clinics (n = 7) with N = 38 physicians were randomized to condition (MI, Enhanced Standard of Care). Physicians completed video- recorded patient consultations at baseline and 6, 12, and 18-month follow-up. MI condition physicians had greater relational and technical scores over time and were more likely to adhere to and sustain MI over time. Overall, physicians found the MI training highly acceptable and were able to sustain their skills. Results illustrate the feasibility of MI training, implementation, and sustainment over 18 months. Findings support previous research in Argentina in which trained physicians found MI useful with challenging patients. Broader implementation of MI among HIV care physicians in Argentina is merited.