A multivariate meta-analysis of motivational interviewing process and outcome

Successes and Challenges From a Motivational Interviewing-Informed Diabetes Prevention Program Situated in the Community

To manage the rising prevalence of type 2 diabetes mellitus, sustainable diabetes prevention programs are needed. In this study, a process evaluation was conducted to qualitatively understand perceived successes and challenges of a diabetes prevention program situated in the community. This study took place in the first year of a multiyear project. Semistructured interviews were conducted with a sample of women clients (n = 14) postprogram and trainers (n = 10) 9 months into program implementation. Interviews were audio-recoded, transcribed verbatim, and analyzed using a Template Approach. Data were first analyzed deductively into two categories that aligned with the study's purpose (successes and challenges). Second, an inductive analysis was used to understand program delivery processes within each category. Clients and trainers expressed (a) program successes related to recruitment strategy, outlook on making behavior changes, and communication style used within the program and (b) program challenges surrounding effort of learning and applying the communication strategy, usefulness of program applications and tools, and program fit. This evaluation provides practical implications and future directions for diabetes prevention programs, and has informed tailoring and expansion of the program of focus. Results demonstrate the success of motivational interviewing from both client and trainer perspectives and the impact of community partnerships to increase prediabetes awareness in the community. Overall, the program's diabetes prevention and behavior change strategies coupled with a client-centered approach facilitated women clients in making diet and exercise modifications.

Technical and relational process in MI sessions with a sample of Hispanic/Latinx adults who engage in heavy drinking: A latent growth mediation model

The current study tests the Motivational Interviewing (MI) technical and relational hypotheses in a sample of Hispanic/Latinx adults (N = 276) who engage in heavy alcohol consumption. MI causal theory hypothesizes that therapist use of MI consistent skills (i.e., technical hypothesis) and embodiment of the MI Spirit (i.e., relational hypothesis) will elicit client change talk, which is a putative mechanism of positive client outcome after the session. We tested these associations in a rigorous parallel process latent growth curve mediation modeling framework. The data are from a completed randomized clinical trial of a culturally-adapted (CAMI) versus un-adapted MI targeting hazardous alcohol use and consequences. Results. The unconditional growth models for the mediator (i.e., proportion of change talk relative to sustain talk) and two study outcomes (i.e., percent of heavy drinking days; alcohol-related consequences) showed a linear effect over a 12-month period with a slower rate of growth at later timepoints. Contrary to expectations, the latent growth mediation models did not show relationships between MI-consistent skills (i.e., technical predictor) or latent MI Spirit (i.e., relational indicator) and the slope factor for proportion change talk. The slope factor for proportion change talk was also not associated with the slope factors for percent heavy drinking and consequences over follow-up. Conclusions. In this novel population for MI process analysis, the technical and relational hypotheses were not supported. Studies that are exploratory may be needed to further investigate the causal model in populations that are not often represented in MI process research.

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.

Change talk subtypes as predictors of alcohol use following brief motivational intervention

OBJECTIVE

To examine the relative importance of client change language subtypes as predictors of alcohol use following motivational interviewing (MI).

METHOD

Participants were 164 heavy drinkers (57.3% female, Mage = 28.5 years, 13.4% Hispanic/Latinx, 82.9% White) recruited during an emergency department visit who received MI for alcohol and human immunodeficiency virus/sexual risk in a randomized-controlled trial. MI sessions were coded with the motivational interviewing skill code (MISC) and the generalized behavioral intervention analysis system (GBIAS). Variable importance analyses used targeted maximum likelihood estimation to rank order change language subtypes defined by these systems as predictors of alcohol use over 9 months of follow-up.

RESULTS

Among GBIAS change language subtypes, higher sustain talk (ST) around change planning was ranked the most important predictor of drinks per week (b = -5.57, 95% CI [-8.11, -3.02]) and heavy drinking days (b = -2.07, 95% CI [-3.17, -0.98]); this talk reflected (a) rejection of alcohol abstinence as a desired change goal, (b) rejection of specific change strategies, or (c) discussion of anticipated challenges in changing drinking. Among MISC change language subtypes, higher ST around taking steps-reflecting recent escalations in drinking described by a small minority of participants-was ranked the most important predictor of drinks per week (b = 22.71, 95% CI [20.29, 25.13]) and heavy drinking days (b = -2.45, 95% CI [1.68, 3.21]).

CONCLUSIONS

Results challenge the assumption that all ST during MI is a negative prognostic indicator and highlight the importance of the context in which change language emerges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effect of combining motivational interviewing with cognitive remediation on personal recovery in patients with schizophrenia

Background/objective

We have been practising the Neuropsychological and Educational Approach to Remediation (NEAR) as cognitive remediation (CR) in a psychiatric hospital and have implemented it in combination with regular interviews based on Motivational Interviewing (MI) approximately 2 years after launching NEAR. In this study, we investigated whether combining MI with CR affected completion of the programme, cognitive functions, global functioning, and personal recovery of patients with schizophrenia by analysing medical records.

Methods

In this retrospective observational study, 14 participants were assigned to the NEAR group and 12 participants were assigned to the NEAR + MI group. Fifteen participants in the NEAR group (n = 6) and NEAR + MI group (n = 9) completed the programme. First, the difference in the completion rate between the groups was examined using the chi-squared test. Second, measures of cognitive functions, global functioning, and personal recovery pre-and post-intervention were examined using the Wilcoxon signed-rank tests for those in each group who completed the programme. Third, therapeutic responses for each group were compared using the Mann-Whitney U tests.

Results

There were no statistically significant differences in completion rates between the groups. In the NEAR group, verbal memory and overall cognition improved after the intervention. On the other hand, not only cognitive functions but also global functioning and personal recovery improved in the NEAR + MI group. Moreover, changes in global functioning and personal recovery were significantly higher in the NEAR + MI group.

Conclusion

Study findings indicated that combining MI with CR improves cognitive functions, global functioning, and personal recovery in patients with schizophrenia.

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

INTRODUCTION

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

DATA

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Can chatbots help to motivate smoking cessation? A study on the effectiveness of motivational interviewing on engagement and therapeutic alliance

Background

Cigarette smoking poses a major threat to public health. While cessation support provided by healthcare professionals is effective, its use remains low. Chatbots have the potential to serve as a useful addition. The objective of this study is to explore the possibility of using a motivational interviewing style chatbot to enhance engagement, therapeutic alliance, and perceived empathy in the context of smoking cessation.

Methods

A preregistered web-based experiment was conducted in which smokers (n = 153) were randomly assigned to either the motivational interviewing (MI)-style chatbot condition (n = 78) or the neutral chatbot condition (n = 75) and interacted with the chatbot in two sessions. In the assessment session, typical intake questions in smoking cessation interventions were administered by the chatbot, such as smoking history, nicotine dependence level, and intention to quit. In the feedback session, the chatbot provided personalized normative feedback and discussed with participants potential reasons to quit. Engagement with the chatbot, therapeutic alliance, and perceived empathy were the primary outcomes and were assessed after both sessions. Secondary outcomes were motivation to quit and perceived communication competence and were assessed after the two sessions.

Results

No significant effects of the experimental manipulation (MI-style or neutral chatbot) were found on engagement, therapeutic alliance, or perceived empathy. A significant increase in therapeutic alliance over two sessions emerged in both conditions, with participants reporting significantly increased motivation to quit. The chatbot was perceived as highly competent, and communication competence was positively associated with engagement, therapeutic alliance, and perceived empathy.

Conclusion

The results of this preregistered study suggest that talking with a chatbot about smoking cessation can help to motivate smokers to quit and that the effect of conversation has the potential to build up over time. We did not find support for an extra motivating effect of the MI-style chatbot, for which we discuss possible reasons. These findings highlight the promise of using chatbots to motivate smoking cessation. Implications for future research are discussed.

Barriers and Facilitators for Implementing Motivational Interviewing as a Return to Work Intervention in a Norwegian Social Insurance Setting: A Mixed Methods Process Evaluation

Purpose The aim of this study was to evaluate potential barriers and facilitators for implementing motivational interviewing (MI) as a return to work (RTW) intervention in a Norwegian social insurance setting. Methods A mixed-methods process evaluation was conducted alongside a randomized controlled trial involving MI sessions delivered by social insurance caseworkers. The study was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework using focus groups with the caseworkers. MI fidelity was evaluated through audio-recordings of MI sessions and questionnaires to sick-listed participants. Results Lack of co-worker and managerial support, time and place for practicing to further develop MI skills, and a high workload made the MI intervention challenging for the caseworkers. The MI method was experienced as useful, but difficult to master. MI fidelity results showed technical global scores over the threshold for "beginning proficiency" whereas the relational global score was under the threshold. The sick-listed workers reported being satisfied with the MI sessions. Conclusions Despite caseworker motivation for learning and using MI in early follow-up sessions, MI was hard to master and use in practice. Several barriers and facilitators were identified; these should be addressed before implementing MI in a social insurance setting.Trial registration ClinicalTrials.gov: NCT03212118 (registered July 11, 2017).

Patient motivation in group metacognitive therapy for generalized anxiety disorder

OBJECTIVE

The aim of this study was to investigate the predictive value of motivational language (change talk [CT] and sustain talk [ST]) on treatment outcome of group metacognitive therapy (g-MCT) for generalized anxiety disorder (GAD).

METHOD

Video recordings of the first, fourth, and seventh therapy sessions (55 patients) were encoded using the Motivational Interviewing Skill Code (MISC) manual. The strength of the patients' motivational utterances was encoded as CT or ST with seven subcategories.

RESULTS

The strength of CT-utterances and ST-utterances differed significantly between treatment responders and non-responders as therapy progressed. The strength of ST-utterances increased significantly more among non-responders than responders, whereas CT and positive taking steps utterances increased more among treatment responders than non-responders. CT and ST in session 1 were not associated with treatment outcome. CT and ST in sessions 4 and 7 significantly predicted lower and higher worry-scores at post-treatment, respectively. This effect was particularly evident for taking steps utterances in session 7.

CONCLUSION

These findings confirm the predictive value of MISC in sessions 4 and 7 of g-MCT for GAD and highlight the importance of therapists addressing patient motivation.

Should Substance Use Counselors Choose a Direction For Their Clients? Motivational Interviewing Trainers May Be Ambivalent

Motivational Interviewing (MI) is comprised of a client-centered relationship and a clear intention on the part of the practitioner to influence behavior change. This study explores MI trainers' decisions about their use of directionality in MI as they instruct others in the method. 111 MI trainers were asked to select content they would include in a hypothetical MI training. Almost half of trainers chose to teach trainees to "always maintain an attitude of equipoise", a strategy that is contradicted by MI theory and empirical data. This finding suggests a theoretical rift within the MI community with implications for substance use counseling.

A pilot trial of collaborative care with motivational interviewing to reduce opioid risk and improve chronic pain management

BACKGROUND AND AIMS

Opioid use and chronic pain are prevalent in the veteran population. Collaborative care enhances coordination between patients and their care teams, and motivational interviewing (MI) is a communication style designed to facilitate behavior change. This study evaluated the use of collaborative care with MI (CCMI) with patients with chronic pain and high-risk prescription opioid use.

DESIGN

Small pilot study of a randomized controlled trial.

SETTING

An urban Veterans Affairs (VA) Medical Center in the United States.

PARTICIPANTS

One hundred adult veterans with chronic pain currently enrolled into primary care and receiving long-term opioid therapy.

INTERVENTION AND COMPARATOR

During an initial 1-hour visit with a study primary-care physician (PCP), all veterans (n = 100) developed a personalized pain care plan, after which they were randomized to receive four sessions (at 4, 6, 8 and 12 weeks) of either CCMI (n = 51) or attention control psychoeducation (ACP; n = 49). Subsequently, participants had 30-minute follow-up visits with study PCPs and post-treatment assessment at 12 weeks.

MEASUREMENTS

Co-primary outcomes measures assessed opioid risk and pain interference; secondary measures assessed pain severity, PCP rating of opioid risk and pain management goals.

FINDINGS

At 12 weeks, intent-to-treat (ITT) analyses using multivariate mixed-effects linear regression were inconclusive regarding the between-group differences in primary and secondary outcomes at post-intervention (12 weeks). Bayes factors for opioid risk, pain interference, pain severity and PCP ratings were 1.96, 1.36, 0.45 and 0.82, respectively. Veterans in the CCMI group reported implementing more complementary integrative health (CIH) goals (e.g. yoga) than did those in the ACP group (d = 0.54).

CONCLUSIONS

US veterans with chronic pain who received collaborative care with motivational interviewing reduced their high-risk opioid use and showed improved pain interference and severity after an intake with a primary-care provider involving shared decision-making and the creation of a personalized pain care plan.

Evaluation of a Safe Sleep Training for Home Visitors and Their Clients

Sleep-related deaths are a common preventable cause of death, and such deaths occur disproportionately in families of color. Home visitors provide families with education about infant safe sleep guidelines; however, families face many barriers to engaging in safe sleep practices. This study evaluated the efficacy of a program to train home visitors to talk to clients about infant safe sleep using Motivational Interviewing and cultural sensitivity. We examined the effects of the intervention on home visitors' (n = 23) knowledge, MI skill use, and cultural sensitivity using a single group pre-post design. We also examined home visiting clients' (n = 78) knowledge, attitudes, and behaviors using a quasi-experimental design. Home visitors were primarily female (97%), had a college degree (86%), and were primarily white (50%) or African American (43%). The home visiting clients were all female and were primarily African American (43%) and Caucasian (36%). Most clients (59%) earned less than 30,000 dollars per year. Home visitors showed significant improvement in MI skill use and cultural sensitivity from pre- to post-test. Regarding client outcomes, our results indicate a significant group by time interaction when predicting changes in client knowledge such that the treatment group showed larger gains than the control group. There were no significant differences between groups when predicting changes in client attitudes or behavior. MI may be an effective technique for home visitors to help increase families' safe sleep knowledge. Additional research is needed to examine whether such training can translate to changes in families' safe sleep behavior.

Comparison of Patient Versus Trained Observer Assessments of Healthcare Providers' Use of Motivational Interviewing Techniques for Patients Experiencing Depression and Anxiety in the Dominican Republic

In settings with limited mental health system capacity, integrated care and the improvement of patient-provider communication surrounding common mental disorders is critical to advancing treatment outcomes. We trained primary care providers in the Dominican Republic in motivational interviewing (MI) to improve communication with patients experiencing depression and anxiety. Providers were randomized to an intervention group, which received MI training, or a control group. To evaluate the training’s effectiveness, patients assessed their clinical encounters using the Motivational Interviewing Measure of Staff Interaction (MIMSI). Trained research assistants (RAs) rated a sub-set of those interactions using an adapted MIMSI instrument. Overall, patients (n = 36) perceived their interactions with providers (n = 10) very positively; however, the RAs’ ratings strongly indicated that providers’ application of MI behaviors was insufficient. Patients generally could not distinguish between intervention and control providers. Findings underscore the need to carefully consider optimal training delivery and cultural influences surrounding the implementation of MI mental health interventions in settings where directive communication is highly valued.

Is fidelity to a complex behaviour change intervention associated with patient outcomes? Exploring the relationship between dietitian adherence and competence and the nutritional status of intervention patients in a successful stepped-wedge randomised clinical trial of eating as treatment (EAT)

BACKGROUND

Behavioural medicine is characterised by findings for the effectiveness and efficacy of complex behaviour change interventions. Comparatively, scant attention has been paid to key intervention components or mechanisms of action. Evaluating relationships between process variables (fidelity) and intervention effects is central to addressing this imbalance. Accordingly, in the current study, we sought to explore the magnitude and direction of effect between fidelity predictors (dietitian adherence and competence) and intervention effects (patient nutritional status) during the intervention phase of a real-world, stepped-wedge evaluation of 'EAT: Eating As Treatment'.

METHODS

The EAT clinical trial was conducted within five major Australian hospitals located in Queensland, Western Australia, Victoria and South Australia between 2013 and 2016. EAT is a dietitian-delivered health behaviour change intervention designed to reduce malnutrition in head and neck cancer (HNC) patients undergoing radiotherapy. Dietitian adherence and competence ratings were derived from a 20% random sample of audio-recorded dietetic consultations (n=194) conducted after dietitians (n=18) were trained in EAT. Sessions were coded by trained, independent, coders using a study checklist, the Behaviour Change Counselling Index (BECCI) and items from the Cognitive Therapy Scale-Revised (CTS-R). Patient nutritional status was measured using the Patient-Generated Subjective Global Assessment (PGSGA).

RESULTS

Dietitian adherence to a written nutrition plan (β=7.62, 95% CI=0.65 to 14.58, p=0.032), dietitian adherence to behaviour change counselling (β=0.69, 95% CI =0.02 to 1.38, p=0.045) and competence in delivering behaviour change counselling (β=3.50, 95% CI =0.47 to 6.53, p=0.024) were significant predictors of patient nutritional status. Dietitian adherence and competence ratings were higher during consultations with intervention patients at greater risk of malnutrition.

CONCLUSIONS

This study contributes new insights into the relationship between fidelity and treatment outcome by demonstrating that dietitian adherence and competence is greater when working with more challenging patients. This is likely central to the demonstrated success of the EAT intervention in reducing malnutrition and highlights the importance of ensuring that providers are adequately equipped to flexibly integrate intervention elements according to patient need.

TRIAL REGISTRATION

This study is a process analysis of a stepped-wedge randomised controlled trial prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12613000320752 ; Date of registration 21/03/2013).

Motivational Interviewing Produces Change Talk in Smokers with Serious Mental Illness

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

Integration of motivational interviewing and behavioral economic theories to enhance brief alcohol interventions: Rationale and preliminary examination of client language

Motivational interviewing (MI) is a widely disseminated evidence-based therapeutic approach for engaging clients and motivating health behavior change, especially risky substance use. Refinement of MI theory over the past few decades has provided empirical evidence that the technical component of MI (in-session client language) is a promising mechanism of behavior change (MOBC). However, heterogeneous and small to moderate effect sizes suggest the need for refinement of MOBC measurement and consideration of other types of client language. The current article presents a complementary integration of current MI theory and behavioral economic (BE) mechanisms to further understanding of in-session factors associated with subsequent behavior change. In this paper, we define some of the key MOBCs from MI and BE theories, describe our integrated framework, and present preliminary findings from a pilot study of the effectiveness and MOBCs of a novel BE-informed application of MI in risky college student drinkers. Results from preliminary coding development suggest that BE-informed measures of client language better predict response to a brief intervention in risky college students than traditional change talk measures. We posit that BE theory can offer insight into meaningful session content beyond the current MI constructs of change talk and sustain talk, which in turn may serve to enhance development of clinical practice and inform scientific investigations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Differences in the delivery of motivational interviewing across three countries

We do not know if the delivery of Motivational Interviewing (MI) differs across countries. In an international study targeting Elderly people with Alcohol Use Disorder, The Elderly Study, MI was part of the treatment applied. Treatment delivery was measured by means of the Motivational Interviewing Treatment Integrity code version 4 (MITI 4). Mixed effects models explored potential differences in delivery of MI between the countries. Delivery of MI differed significantly between participating countries: Denmark, Germany and the US. These findings are important to consider when comparing measures of MI integrity across studies from different cultures.

Multimodal Automatic Coding of Client Behavior in Motivational Interviewing

Motivational Interviewing (MI) is defined as a collaborative conversation style that evokes the client's own intrinsic reasons for behavioral change. In MI research, the clients' attitude (willingness or resistance) toward change as expressed through language, has been identified as an important indicator of their subsequent behavior change. Automated coding of these indicators provides systematic and efficient means for the analysis and assessment of MI therapy sessions. In this paper, we study and analyze behavioral cues in client language and speech that bear indications of the client's behavior toward change during a therapy session, using a database of dyadic motivational interviews between therapists and clients with alcohol-related problems. Deep language and voice encoders, i.e., BERT and VGGish, trained on large amounts of data are used to extract features from each utterance. We develop a neural network to automatically detect the MI codes using both the clients' and therapists' language and clients' voice, and demonstrate the importance of semantic context in such detection. Additionally, we develop machine learning models for predicting alcohol-use behavioral outcomes of clients through language and voice analysis. Our analysis demonstrates that we are able to estimate MI codes using clients' textual utterances along with preceding textual context from both the therapist and client, reaching an F1-score of 0.72 for a speaker-independent three-class classification. We also report initial results for using the clients' data for predicting behavioral outcomes, which outlines the direction for future work.

Mechanisms of Motivational Interviewing: a Conceptual Framework to Guide Practice and Research

Reviews of the motivational interviewing (MI) training literature demonstrate MI is a nuanced skill set that takes carefully planned didactic training, application of skills in context-specific practice settings, and ongoing support to promote reflective practice and sustained proficiency. Despite the robust knowledge base related to training and how MI works to achieve favorable outcomes, these two literature bases are not well integrated. In an effort to inform and guide future research, we propose the mechanisms of motivational interviewing (MMI) conceptual framework, which expands upon previous work. Specifically, the framework adds training as an ongoing process consistent with Bennett-Levy's (Behav Cogn Psychother 34:57-78, 2006) model of skill development and acquisition to the existing two-path framework that helps us to understand how MI works to achieve its desired effects (Magill et al., J Consult Clin Psychol 82:973-983, 2014). Herein, we describe measures used to evaluate the mechanisms within the four MMI framework links: initial training to competency, competency to proficiency, proficiency to talk about change, and talk about change to behavior change. Next, we synthesize the literature associated with each of the mechanisms of the MMI. We conclude by discussing implications for practice and research. This framework offers a more complete path structure to understand the mechanisms of change associated with MI that could improve our understanding of inconsistent effect sizes observed across prior trials evaluating MI effectiveness.

Motivational interviewing for social anxiety disorder: An examination of the technical hypothesis

ABSTRACT Background and objective: Motivational interviewing (MI) was originally developed to treat problematic drinking but is increasingly integrated into treatment for anxiety disorders. A causal model has been proposed which suggests technical and relational factors may account for the efficacy of MI. The technical hypothesis suggests that therapist MI-consistent behaviours are related to client change talk, and change talk is linked to treatment outcome. Research examining the technical hypothesis has typically been conducted in MI for substance use; therefore, the current study aimed to explore the technical hypothesis in MI for social anxiety disorder (SAD). Method: Participants diagnosed with SAD (n = 85) each received MI prior to receiving group cognitive-behavioural therapy (CBT). MI sessions were coded for behaviours relevant to the MI technical hypothesis. Results: The proportion of MI-consistent therapist behaviours and reflections of change language significantly predicted the proportion of change talk by the client during MI sessions; however, therapist and client behaviours did not predict treatment outcome. Conclusion: The findings support one path of the MI causal model in the context of social anxiety, though indicate that the occurrence of these behaviours during an MI pre-treatment may not extend to predict treatment outcome following CBT.

Pilot study of the influence of self-coding on empathy within an introductory motivational interviewing training

BACKGROUND

Motivational interviewing (MI) is a framework for addressing behavior change that is often used by healthcare professionals. Expression of empathy during MI is associated with positive client outcomes, while absence of empathy may produce iatrogenic effects. Although training in MI is linked to increased therapeutic empathy in learners, no research has investigated individual training components' contribution to this increase. The objective of this study was to test whether a self-coding MI exercise using smartphones completed at hour 6 of an 8-h MI training was superior in engendering empathy to training as usual (watching an MI expert perform in a video clip for the same duration at the same point in the training).

METHODS

This was a pilot study at two sites using randomization and control groups with 1:1 allocation. Allocation was achieved via computerized assignment (site 1, United Kingdom) or facedown playing card distribution (site 2, United States). Participants were 58 students attending a university class at one of two universities, of which an 8-h segment was dedicated to a standardized MI training. Fifty-five students consented to participate and were randomized. The intervention was an MI self-coding exercise using smartphone recording and a standardized scoring sheet. Students were encouraged to reflect on areas of potential improvement based on their self-coding results. The main outcome measure was score on the Helpful Responses Questionnaire, a measure of therapeutic empathy, collected prior to and immediately following the 8-h training. Questionnaire coding was completed by 2 blinded external reviewers and assessed for interrater reliability, and students were assigned averaged empathy scores from 6 to 30. Analyses were conducted via repeated-measures ANOVA using the general linear model.

RESULTS

Fifty-five students were randomized, and 2 were subsequently excluded from analysis at site 2 due to incomplete questionnaires. The study itself was feasible, and overall therapeutic empathy increased significantly and substantially among students. However, the intervention was not superior to the control condition in this study.

CONCLUSIONS

Replacing a single passive learning exercise with an active learning exercise in an MI training did not result in a substantive boost to therapeutic empathy. However, consistently with prior research, this study identified significant overall increases in empathy following introductory MI training. A much larger study examining the impact of selected exercises and approaches would likely be useful and informative.

Temporal pathways of change in two randomized controlled trials for depression and harmful drinking in Goa, India

BACKGROUND

The current study explored the temporal pathways of change within two treatments, the Healthy Activity Program (HAP) for depression and the Counselling for Alcohol Problems (CAP) Program for harmful drinking.

METHODS

The study took place in the context of two parallel randomized controlled trials in Goa, India. N = 50 random participants who met a priori criteria were selected from each treatment trial and examined for potential direct and mediational pathways. In HAP, we examined the predictive roles of therapy quality and patient-reported activation, assessing whether activation mediated the effects of therapy quality on depression (Patient Health Questionnaire-9) outcomes. In CAP, we examined the predictive roles of therapy quality and patient change- and counter-change-talk, assessing whether change- or counter-change-talk mediated the effects of therapy quality on daily alcohol consumption.

RESULTS

In HAP, therapy quality (both general and treatment-specific skills) was associated with patient activation; patient activation but not therapy quality significantly predicted depression outcomes, and patient activation mediated the effects of higher general skills on subsequent clinical outcomes [a × b = -2.555, 95% confidence interval (CI) -5.811 to -0.142]. In CAP, higher treatment-specific skills, but not general skills, were directly associated with drinking outcomes, and reduced levels of counter-change talk both independently predicted, and mediated the effects of higher general skills on, reduced alcohol consumption (a × b = -24.515, 95% CI -41.190 to -11.060). Change talk did not predict alcohol consumption and was not correlated with counter-change talk.

CONCLUSION

These findings suggest that therapy quality in early sessions operated through increased patient activation and reduced counter-change talk to reduce depression and harmful drinking respectively.

Is fidelity to motivational interviewing associated with alcohol outcomes in treatment-seeking 60+ year-old citizens?

BACKGROUND

Part of the variability in treatment outcomes for Motivational Interviewing (MI) may be explained by differences in the fidelity to MI. The Motivational Interviewing Treatment Integrity manual version 4 (MITI 4) is an improved measure of fidelity to elements of MI. It is not known whether the fidelity to MI, as measured by the MITI 4, is related to treatment outcome.

OBJECTIVES

To examine whether fidelity to MI is associated with alcohol use outcomes - predictive validity of the MITI 4.

METHOD

Twenty percent of the recorded sessions at the Danish sites of the Elderly Study were randomly drawn and coded for fidelity to MI with the MITI 4. The Elderly Study was an international, randomized controlled trial, in which people 60 years or older with Alcohol Use Disorders received either four weeks of Motivational Enhancement Therapy (MET) or four weeks of MET combined with up to eight additional sessions of the Community Reinforcement Approach- Senior (MET+CRA-S). Elements of MI and summary scores of the MITI 4 were used as predictors in a mixed effects regression analysis. Treatment outcomes were use of alcohol and consequences of drinking at 26-weeks follow-up.

RESULTS

In total, 423 sessions representing 238 participants were randomly drawn and coded for fidelity to MI. Mean values of the treatment elements indicated high fidelity to MI, with higher fidelity to MI in the MET sessions, as compared to CRA-S sessions. None of the predictors in the multilevel model analyses were associated with outcome at follow-up. Exploratory analysis indicated reverse associations between one measure of MI-fidelity and drinking outcomes in the combined treatment (CRAS).

CONCLUSION

The fidelity of the MI intervention, received by participants in this study, did not predict better treatment outcomes. MI may be less effective in populations which are already committed to change behavior. As expected and validating for the MITI 4, fidelity to MI-elements was lower in the combination of MI with other treatment approaches. Additionally, the timing of MI in these combined settings might be important for effectiveness.

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

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

Behavioral Counseling Training for Primary Care Providers: Immersive Virtual Simulation as a Training Tool

Behavioral counseling represents an efficacious approach for improving health behaviors on a population level, and the primary care setting is an appropriate context in which to implement this approach. However, evidence suggests that the utilization of behavioral counseling techniques in primary care, including those informed by motivational interviewing, is sub-optimal. Insufficient training has been cited as a barrier to utilizing counseling in the primary care setting. Recent work has evaluated the effectiveness of virtual simulations that can provide access to "virtual" patients while retaining the scalability inherent to a digital medium. However, these educational interventions have been limited to simulations delivered through a two-dimensional screen. More immersive simulations delivered through a head-mounted display can create a realistic practice environment that encompasses a learner's entire field of view, which may confer additional benefits with respect to training outcomes. The purpose of this short article is to briefly review the relevant literature across disciplines to conceptualize the potential effectiveness of this technology as a training tool for behavioral counseling. Immersive virtual simulations are designed to induce a psychological phenomenon referred to as presence, whereby a learner perceives themselves as existing within the virtual environment. As such, immersive virtual simulations can provide opportunities for practice, coaching, and feedback in an environment that closely approximates the clinical setting in which counseling will be delivered. Through its effects on presence, this technology may be particularly useful for developing empathy, which is an important component of counseling. Recommendations for future research are also provided.

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

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

Examining the influence of active ingredients of motivational interviewing on client change talk

Motivational Interviewing (MI) is an evidenced-based intervention designed to help clients explore and resolve ambivalence around substance use. MI combines a humanistic tradition with behavioral components to facilitate client decisions concerning behavior change. As such, there is marked interest in the relationship between the two active ingredients of MI - the relational, or person-centered, components and the technical, or directional, behavioral components - on client in-session language. Yet, few studies have examined how these active ingredients operate in concert. Therefore, the current study evaluated the constellation of relational skills associated with client language, as well as the influence of technical skills on the relationship between provider relational skills and client change language. Specifically, we tested a latent construct of relational skill and its direct association with the proportion of client change talk. We then explored the mediating role of reflections of change and sustain talk (RefCT and RefST) on this relationship. The data for this secondary analysis are from Project ELICIT (N = 131), a randomized control trial evaluating the effects of MI training on client change language. We found support for a latent construct of relational skill (i.e., empathy, acceptance, collaboration, and autonomy/support). However, the relational skill construct did not predict client change language. There was support for an indirect effect, such that relational skills predicted RefCT and RefST, and RefCT and RefST predicted client change language. These results suggest that the synergistic implementation of the relational and technical components of MI is critical to facilitating a higher percentage of change talk.

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

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

A sequential analysis of motivational interviewing technical skills and client responses

BACKGROUND

The technical hypothesis of Motivational Interviewing (MI) proposes that: (a) client talk favoring behavior change, or Change Talk (CT) is associated with better behavior change outcomes, whereas client talk against change, or Sustain Talk (ST) is associated with less favorable outcomes, and (b) specific therapist verbal behaviors influence whether client CT or ST occurs. MI consistent (MICO) therapist behaviors are hypothesized to be positively associated with more client CT and MI inconsistent (MIIN) behaviors with more ST. Previous studies typically examine session-level frequency counts or immediate lag sequential associations between these variables. However, research has found that the strongest determinant of CT or ST is the client's previous CT or ST statement. Therefore, the objective of this paper was to examine the association between therapist MI skills and subsequent client talk, while accounting for prior client talk.

METHODS

We analyzed data from a manualized MI intervention targeting both alcohol misuse and sexual risk behavior in 132 adults seen in two hospital emergency departments. Transcripts of encounters were coded using the Motivational Interviewing Skills Code (MISC 2.5) and an additional measure, the Generalized Behavioral Intervention Analysis System (GBIAS). Using these measures, we analyzed the association between client talk following specific classifications of MICO skills, with the client's prior statement as a potential confounder or effect modifier.

RESULTS

With closed questions as the reference category, therapist simple reflections and paraphrasing reflections were associated with significantly greater odds of maintaining client talk as CT or ST. Open questions and complex reflections were associated with significantly greater odds of CT following ST, were not associated significantly with more ST following ST, and were associated with more ST following CT (i.e., through an association with less Follow Neutral).

CONCLUSIONS

Simple and paraphrasing reflections appear to maintain client CT but are not associated with transitioning client ST to CT. By contrast, complex reflections and open questions appeared to be more strongly associated with clients moving from ST to CT than other techniques. These results suggest that counselors may differentially employ certain MICO technical skills to elicit continued CT and move participants toward ST within the MI dialogue.

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

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

Rating motivational interviewing fidelity from thin slices

Monitoring fidelity to psychosocial treatments is critical to dissemination, process and outcome research, and internal validity in efficacy trials. However, the costs required to behavior code fidelity to treatments like motivational interviewing (MI) over many therapists and sessions quickly become intractable. Coding less of a session accelerates the process, but it is not clear how much of a session must be evaluated to capture the fidelity of the entire session. The present study used a "thin slice" (Ambady & Rosenthal, 1992) paradigm to explore the degree to which variously sized thin slices of MI fidelity related to fidelity ratings for a full session. We randomly selected contiguous and noncontiguous segments of MI sessions at each whole percent of sessions (i.e., a slice consisting of 1% of session utterances, another at 2%, etc.). We then computed MI fidelity scores from these segments and calculated agreement with fidelity ratings obtained from the full session. We compared thin slice agreement with full sessions against interrater agreement and found that approximately a third of a session (9 min, 26 seconds in our sample) had sufficient agreement to approach interrater levels. These results provide a reference for researchers and clinicians to make efficient and informed use of their behavior coding resources. In addition, our results add to the behavior slicing literature, indicating that small therapist behavior samples adequately describe overall session behavior. (PsycINFO Database Record

Advancing Analytic Approaches to Address Key Questions in Mechanisms of Behavior Change Research

OBJECTIVE

Interest in studying mechanisms of behavior change (MOBCs) in substance use disorder (SUD) treatments has grown considerably in the past two decades. Much of this work has focused on identifying which variables statistically mediate the effect of SUD treatments on clinical outcomes. However, a fuller conceptualization of MOBCs will require greater understanding of questions that extend beyond traditional mediation analysis, including better understanding of when MOBCs change during treatment, when they are most critical to aiding the initiation or maintenance of change, and how MOBCs themselves arise as a function of treatment processes.

METHOD

In the present study, we review why these MOBC-related questions are often minimally addressed in empirical research and provide examples of data analytic methods that may address these issues. We highlight several recent studies that have used such methods and discuss how these methods can provide unique theoretical insights and actionable clinical information.

RESULTS

Several statistical approaches can enhance the field's understanding of the timing and development of MOBCs, including growth-curve modeling, time-varying effect modeling, moderated mediation analysis, dynamic systems modeling, and simulation methods.

CONCLUSIONS

Adopting greater diversity in methods for modeling MOBCs will help researchers better understand the timing and development of key change variables and will expand the theoretical precision and clinical impact of MOBC research. Advances in research design, measurement, and technology are key to supporting these advances.

Development and differentiability of three brief interventions for risky alcohol use that include varying doses of motivational interviewing

BACKGROUND

While brief intervention (BI) for risky alcohol use generally yields positive effects among those identified by screening, effect sizes are small and there is unexplained heterogeneity in outcome. The heterogeneity may be related to differences in intervention style and content, including elements of motivational interviewing (MI). To date, it has been difficult to interpret the role of MI in BI and these gaps in knowledge interfere with efforts to train, disseminate and implement BI that retains and maximizes efficacy. This study sought to develop BI protocols with varying doses of MI and test their differentiability. Differentiable BI protocols could allow for future studies that prospectively evaluate the role MI plays in affecting BI outcome.

METHODS

We developed three intervention protocols: brief advice, standard BI (NIAAA Clinician's Guide), and MI-enhanced BI and administered them to 45 primary care patients who reported exceeding recommended drinking limits. We then rated the BI sessions for fidelity to the assigned protocol as well as MI consistency based on Motivational Interviewing Treatment Integrity (MITI) scale scores. The differentiability of BI protocols was determined by calculating fidelity to assigned protocols and comparing MITI scores using pairwise, Tukey-adjusted comparisons of least squares mean scores.

RESULTS

High rates of fidelity to each protocol were achieved. The three BI protocols were also highly differentiable based on MITI scores.

CONCLUSIONS

The three interventions can be used in future trials to prospectively examine the role MI has in determining BI outcome. Trial registration clinicaltrials.gov NCT02978027, retrospectively registered 11/28/16.

Variability in motivational interviewing adherence across sessions, providers, sites, and research contexts

Providers' adherence in the delivery of behavioral interventions for substance use disorders is not fixed, but instead can vary across sessions, providers, and intervention sites. This variability can substantially impact the quality of intervention that clients receive. However, there has been limited work to systematically evaluate the extent to which substance use intervention adherence varies from session-to-session, provider-to-provider, and site-to-site. The present study quantifies the extent to which adherence to Motivational Interviewing (MI) for alcohol and drug use varies across sessions, providers, and intervention sites and compares the extent of this variability across three common MI research contexts that evaluate MI efficacy, MI effectiveness, and MI training. Independent raters coded intervention adherence to MI from 1275 sessions delivered by 216 providers at 15 intervention sites. Multilevel models indicated that 57%-94% of the variance in MI adherence was attributable to variability between sessions (i.e., within providers), while smaller proportions of variance were attributable to variability between providers (3%-26%) and between intervention sites (0.1%-28%). MI adherence was typically lowest and most variable within contexts evaluating MI training (i.e., where MI was not protocol-guided and delivered by community treatment providers) and, conversely, adherence was typically highest and least variable in contexts evaluating MI efficacy and effectiveness (i.e., where MI was highly protocolized and delivered by trained therapists). These results suggest that MI adherence in efficacy and effectiveness trials may be substantially different from that obtained in community treatment settings, where adherence is likely to be far more heterogeneous.