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Influence of Counselor Characteristics and Behaviors on the Efficacy of a Brief Motivational Intervention for Heavy Drinking in Young Men-A Randomized Controlled Trial
Abstract
Background:
Brief motivational intervention (BMI) has shown promising results to reduce alcohol use in young adults. Knowledge on mechanisms that predict BMI efficacy could potentially improve treatment effect sizes through data that optimize clinical training and implementation. Particularly, little attention has been given to counselor influence on treatment mechanisms.
Methods:
We investigated the influence of counselors on BMI efficacy in reducing alcohol use among non-treatment-seeking young men (age 20) screened as hazardous drinkers. Participants were randomly allocated to (i) a group receiving a single BMI from 1 of 18 counselors selected to maximize differences in several of their characteristics (gender, professional status, clinical experience, and motivational interviewing [MI] experience) or (ii) a control group receiving assessment only. Drinking at 3-month follow-up was first compared between the BMI and control groups to assess efficacy. Then, the influence of counselors' characteristics (i.e., gender, professional status, clinical experience, MI experience, BMI attitudes, and expectancies) and within-session behaviors (i.e., measured by the Motivational Interviewing Skill Code) on outcome was tested in regression analyses.
Results:
There was a significant (p = 0.02) decrease in alcohol use among the BMI group compared to the control group. Counselors that were male, more experienced, that had more favorable BMI attitudes and expectancies, higher MI skills, but surprisingly less MI-consistent behaviors, had significantly better outcomes than the control group while their counterparts did not.
Conclusions:
The current study demonstrated BMI efficacy on alcohol use reduction within a sample of non-treatment-seeking young adult males. Moreover, BMI effect was related to interindividual differences among counselors, and results therefore provide recommendations for BMI training and implementation with similar populations.
... Among the 9 (10.5%) studies that limited enrolment to participants of only 1 sex or only 1 gender, sex-and gender-specific terminology was not defined and how these identities were assessed or measured was unclear [37,38,57,[64][65][66]88,92,112]. Three of these studies (3.5%) stated that their eligibility criteria were limited to women, and these studies accurately deployed gender-specific terminology to describe eligible study participants [57,88,112], but it was unclear how the gender of study participants was measured. ...
... However, none of these 27 studies (31.4%) described how they undertook the task of assessing, collecting, and measuring the sexes and/or genders of the participants. Among the 9 studies (10.5%) that included participants of only one sex or gender, no details are provided about how the sexes or genders of those participants were collected and measured [37,38,57,64,65,66,88,92,112]. Without describing their data collection methods and measures, it was unclear how these 36 studies collected and measured participants' gender identities and/or sexes, making it difficult to assess whether these were used precisely, accurately, and inclusively in their approaches to data collection and measurement. ...
... Seven studies (8.1%) both discussed sex and/or gender within the context of their findings and recommended that sex and gender ought to be more fulsomely integrated into future research in the area of youth alcohol interventions [40,42,57,61,62,65,106]. A further 3 studies (3.5%) recommended that sex and gender ought to be integrated into future research, though they did not discuss sex and/or gender within the context of their own findings [43, 107,115]. ...
Background
While there is widespread consensus that sex- and gender-related factors are important for how interventions are designed, implemented, and evaluated, it is not currently known how alcohol treatment research accounts for sex characteristics and/or gender identities and modalities. This methodological systematic review documents and assesses how sex characteristics, gender identities, and gender modalities are operationalized in alcohol treatment intervention research involving youth.
Methods and findings
We searched MEDLINE, Embase, Cochrane Central Registry of Controlled Trials, PsycINFO, CINAHL, LGBT Life, Google Scholar, Web of Science, and grey literature from 2008 to 2023. We included articles that reported genders and/or sexes of participants 30 years of age and under and screened participants using AUDIT, AUDIT-C, or a structured interview using DSM-IV criteria. We limited the inclusion to studies that enrolled participants in alcohol treatment interventions and used a quantitative study design. We provide a narrative overview of the findings.
Of 8,019 studies screened for inclusion, 86 articles were included in the review. None of the studies defined, measured, and reported both sex and gender variables accurately. Only 2 studies reported including trans participants. Most of the studies used gender or sex measures as a covariate to control for the effects of sex or gender on the intervention but did not discuss the rationale for or implications of this procedure.
Conclusions
Our findings identify that the majority of alcohol treatment intervention research with youth conflate sex and gender factors, including terminologically, conceptually, and methodologically. Based on these findings, we recommend future research in this area define and account for a spectrum of gender modalities, identities, and/or sex characteristics throughout the research life cycle, including during study design, data collection, data analysis, and reporting. It is also imperative that sex and gender variables are used expansively to ensure that intersex and trans youth are meaningfully integrated.
Trial registration
Registration: PROSPERO, registration number: CRD42019119408
... Clinician factors most frequently measured in such studies include demographics (e.g. gender, age, experience, education, [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]), knowledge [25,31,33] and attitudes [18,21,22,26,27,29]). Organisational change theories such as Rogers' [34] diffusion of innovations theory have also highlighted the importance of clinician perceptions of the capacity of their organisation to support and implement new innovations, and drug and alcohol clinician perceptions of factors related to their organisational context have been evaluated as a possible mediator of implementation fidelity [18]. ...
... Clinician factors most frequently measured in such studies include demographics (e.g. gender, age, experience, education, [18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33]), knowledge [25,31,33] and attitudes [18,21,22,26,27,29]). Organisational change theories such as Rogers' [34] diffusion of innovations theory have also highlighted the importance of clinician perceptions of the capacity of their organisation to support and implement new innovations, and drug and alcohol clinician perceptions of factors related to their organisational context have been evaluated as a possible mediator of implementation fidelity [18]. ...
... Likewise, findings from this study did not provide any additional insight into the potential role of clinician attitudes in the uptake of EBPs. Previous research related to salient attitudes has found that low endorsement of disease belief models [18], higher self-efficacy [22,52] and an increased belief in the efficacy of the intervention [22] have implications for implementation outcomes. Although the relationship between self-efficacy and comorbidity practice was not significant, there was a trend toward significance observed in this small population which would warrant further investigation in a larger sample. ...
Background
The process of determining the best strategy for increasing the uptake of evidence-based practice might be improved through an understanding of relevant clinician-level factors. The Pathways to Comorbidity Care (PCC) training program (Louie E, et al., J Dual Diagnosis 17:304–12, 2021) aimed to facilitate integrated management of comorbid drug and alcohol and mental disorders amongst drug and alcohol clinicians. We hypothesised that uptake of integrated management of comorbidity following the implementation of the PCC program would be associated with clinician-level: (i) demographics (gender, education, experience), (ii) attitudes (evidence-based practice, therapist manuals, counselling self-efficacy), and (iii) organisational readiness to change.
Methods
Twenty clinicians participated in the 9-month PCC training program. Attitudes towards evidence-based practices and psychotherapist manuals, self-efficacy, and organisational readiness to change, along with demographics, were measured at baseline. At follow-up, change in Comorbidity Practice (CoP) scores related to integrated comorbidity management were obtained using a file audit checklist and categorised into high (at least 60% increase in CoP), medium or low (a decrease of − 20% or less in CoP). Clinician-level characteristics were examined across the implementation categories.
Results
There were no significant differences found between implementation groups on sociodemographic variables (p’s > 0.30), attitudes to evidence-based practices, attitudes to therapist manuals, and self-efficacy (p’s > 0.52). The high implementation group demonstrated significantly higher scores on leadership practices aspect of organisational readiness to change relative to the low and medium implementation group ((F(2, 16) = 3.63, p = 0.05; Cohen’s d = .31) but not on the other subscales (p’s > 0.07).
Conclusions
Confidence that leadership will play a positive role in the implementation process may improve effectiveness of comorbidity training programs for drug and alcohol clinicians. On the other hand, contrary to our hypothesis, counselling self-efficacy, evidence-based practice attitudes, attitudes towards therapist manuals, gender, education and experience were not distinguishing factors.
... Clinician factors most frequently measured in such studies include demographics (e.g. gender, age, experience, education, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]), knowledge [22,28,30] and attitudes [15,18,19,23,24,26]). Organisational change theories such as Rogers' [31] diffusion of innovations theory have also highlighted the importance of clinician perceptions of the capacity of their organisation to support and implement new innovations, and drug and alcohol clinician perceptions of factors related to their organisational context have been evaluated as a possible mediator of implementation delity [15]. ...
... Clinician factors most frequently measured in such studies include demographics (e.g. gender, age, experience, education, [15][16][17][18][19][20][21][22][23][24][25][26][27][28][29][30]), knowledge [22,28,30] and attitudes [15,18,19,23,24,26]). Organisational change theories such as Rogers' [31] diffusion of innovations theory have also highlighted the importance of clinician perceptions of the capacity of their organisation to support and implement new innovations, and drug and alcohol clinician perceptions of factors related to their organisational context have been evaluated as a possible mediator of implementation delity [15]. ...
... Findings demonstrating a relationship between clinician knowledge and implementation outcomes have emphasised the importance of increased knowledge and optimism about treatment outcomes [33], and increased knowledge acquisition and retention skills [34]. Findings related to salient attitudes have found that low endorsement of disease belief models [15], higher self-e cacy [19,35] and an increased belief in the e cacy of the intervention [19] have implications for implementation outcomes. Furthermore, studies have shown that clinicians who are prepared for change and who have positive attitudes to EBP [15,[36][37][38], and treatment manuals [32] are more likely to implement such practices. ...
Background
A more nuanced understanding of the interrelationships between clinician-level factors and implementation outcomes may enhance the utility of evidence-based practice implementation strategies. The Pathways to Comorbidity Care (PCC) training program [1] aimed to facilitate integrated management of comorbid drug and alcohol and mental disorders amongst drug and alcohol clinicians. We hypothesised that implementation outcomes would be associated with clinician-level: (i) demographics (gender, education, experience), (ii) attitudes (evidence-based practice, therapist manuals, counselling self-efficacy), and (iii) organisational readiness to change.
Methods
Twenty clinicians participated in the 9-month PCC training program. Attitudes towards evidence-based practices and psychotherapist manuals, self-efficacy, and organisational readiness to change, along with demographics, were measured at baseline. At follow-up, change in Comorbidity Practice (CoP) scores related to integrated comorbidity management were obtained using a file audit checklist and categorised into high (at least 60% increase in CoP), medium or low (a decrease of -20% or less in CoP). Clinician-level characteristics were examined across the implementation categories.
Results
There were no significant differences found between implementation groups on sociodemographic variables (p’s > 0.30), attitudes to evidence-based practices, attitudes to therapist manuals, and self-efficacy (p’s > 0.52). The high implementation group demonstrated significantly higher scores on leadership practices aspect of organisational readiness to change relative to the low and medium implementation group ((F(2, 16) = 3.63, p = 0.05; Cohen’s d = .31) but not on the other subscales (p’s > 0.07).
Conclusions
Confidence that leadership will play a positive role in the implementation process may improve effectiveness of comorbidity training programs for drug and alcohol clinicians. On the other hand, contrary to our hypothesis, counselling self-efficacy, evidence-based practice attitudes, attitudes towards therapist manuals, gender, education and experience were not distinguishing factors.
... Study participants were from a randomized controlled trial of Brief motivational intervention (BMI) among hazardous drinkers included within the Army Recruitment Center of Lausanne, Switzerland (Gaume et al., 2014). Briefly, 1,023 conscripts were randomly selected and offered participation in the study, while attending the 2-day army conscription process (i.e., mandatory for all males at age 19). ...
... Intervention was a nonmanualized, 20-30-min BMI, exploring alcohol use, its related consequences, and upon participant agreement, a change plan discussion. Therapists were nine physicians and nine psychologists, selected to provide varied backgrounds, gender parity, and a range of clinical and MI experience for the parent trial (Gaume et al., 2014). Study procedures were approved by the Ethics Committee for Clinical Research of the Medical School of the University of Lausanne (Protocol 15/07) and registered on www.isrctn.com/ISRCTN92486583. ...
... Measures were the same for the 3-month follow-up as at baseline except that they were framed within a 3-month window instead of 12-month. The outcome measure was the primary outcome from the parent study (Gaume et al., 2014), which was a drinking composite score computed from the mean of the z scores for (a) usual drinking days per week, (b) usual drinks per drinking day, and (c) frequency of binge drinking (third question of the AUDIT used as continuous scale from 0 to 4). In order to illustrate the size of the measured effects (which are not straightforward using z scores), we used the measure of weekly drinking amount, which is the combination of (a) usual drinking days per week and (b) usual drinks per drinking day, which was highly correlated with our composite score, r(172) = .87, ...
Objective: Change talk has been proposed as a mechanism of change in motivational interviewing (MI) by mediating the link between MI technical skills and behavioral outcomes. We tested the influence of therapists' relational skills on this mediation model. Method: Secondary analysis of a randomized controlled trial of individual brief MI for heavy drinking among 20-year-old-Swiss young men, where the MI group (n = 179) significantly reduced drinking compared to an assessment-only control. We coded MI sessions and derived: therapists' MI technical skills, clients' change talk (CT) and sustain talk (ST), and global relational ratings (empathy and MI spirit). We tested moderated mediation models with technical skills as the independent variable, CT and ST as parallel mediators, predicting drinking at 3-month follow-up (controlling for baseline drinking), and relational skills as moderators of the path from technical skills to client mediators. Results: Conditional indirect effects were significant for overall MI technical skills, open questions, and simple reflections (i.e., more of these behaviors related to more ST, which was related to more drinking) when relational skills were low. In contrast, there was a significant conditional indirect effect for complex reflections when relational skills were high (i.e., more complex reflections related to less ST). Conclusions: This study provides partial support for the MI technical and relational process models. Interestingly, support was found regarding the negative side of client ambivalence (ST) in this highly precontemplative sample. Accordingly, MI therapists should work cautiously with ST when clients are at early stages of motivational readiness. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... The majority of studies (16, 80% [39, 42, 45, 47, 54, 59-62, 65, 66, 68-71]) were conducted in the United States of America (USA), outpatient, not-for-profit drug and alcohol services. Alternate settings included one USA adolescent day programme affiliated with the University of Miami Medical School and Jackson Memorial Hospital [55], one outpatient drug and alcohol service affiliated with a university hospital in Switzerland [46], one drug abuse treatment organisation in Peru funded by a US Department of State contract [50], and one involved outpatient addiction treatment centres in South Africa [67]. Study participants were most often female (50-82%) drug and alcohol clinicians, with a mean age ranging from 37 to 48 years. ...
... supervision, workshops and champions) approaches to training [47,59,62,65,66,68,71], while 20% (n = 4) focused on discrete strategies (e.g. supervision [61], financial incentives [45], booster sessions [50], and workshop only [46]). Another third (n = 6) used technological strategies such as teleconferencing and web-based training [42,54,[67][68][69][70]. ...
... Suggestions from Carroll and Rounsaville [72] were also incorporated in one study [59] specifically in regards to the lack of effective programbased supervision in empirically supported treatments being one of the largest barriers to the implementation of these approaches in clinical practice. While only two studies were guided by Rogers' [44,48] argument that individuals are more likely to adopt an intervention after they have an increased knowledge about it and then develop a more favourable attitude towards it, eight (40%) adopted the notion that clinician factors may mitigate the relationship between fidelity to an intervention and patient outcomes [39,42,43,46,47,54,60,62]. Clinician factors of interest included demographics (e.g. ...
Background
There is a paucity of translational research programmes to improve implementation of evidence-based care in drug and alcohol settings. This systematic review aimed to provide a synthesis and evaluation of the effectiveness of implementation programmes of treatment for patients with drug and alcohol problems using the Consolidated Framework for Implementation Research (CFIR).
Methods
A comprehensive systematic review was conducted using five online databases (from inception onwards). Eligible studies included clinical trials and observational studies evaluating strategies used to implement evidence-based psychosocial treatments for alcohol and substance use disorders. Extracted data were qualitatively synthesised for common themes according to the CFIR. Primary outcomes included the implementation, service system or clinical practice. Risk of bias of individual studies was appraised using appropriate tools. A protocol was registered with (PROSPERO) (CRD42019123812) and published previously (Louie et al. Systematic 9:2020).
Results
Of the 2965 references identified, twenty studies were included in this review. Implementation research has employed a wide range of strategies to train clinicians in a few key evidence-based approaches to treatment. Implementation strategies were informed by a range of theories, with only two studies using an implementation framework (Baer et al. J Substance Abuse Treatment 37:191-202, 2009) used Context-Tailored Training and Helseth et al. J Substance Abuse Treatment 95:26-34, 2018) used the CFIR). Thirty of the 36 subdomains of the CFIR were evaluated by included studies, but the majority were concerned with the Characteristics of Individuals domain (75%), with less than half measuring Intervention Characteristics (45%) and Inner Setting constructs (25%), and only one study measuring the Outer Setting and Process domains. The most common primary outcome was the effectiveness of implementation strategies on treatment fidelity. Although several studies found clinician characteristics influenced the implementation outcome (40%) and many obtained clinical outcomes (40%), only five studies measured service system outcomes and only four studies evaluated the implementation.
Conclusions
While research has begun to accumulate in domains such as Characteristics of Individuals and Intervention Characteristics (e.g. education, beliefs and attitudes and organisational openness to new techniques), this review has identified significant gaps in the remaining CFIR domains including organisational factors, external forces and factors related to the process of the implementation itself. Findings of the review highlight important areas for future research and the utility of applying comprehensive implementation frameworks.
... Several interpersonal skills (e.g. acceptance, empathy, collaboration and support of client autonomy) have been related to client involvement in MI [38][39][40] and to alcohol outcomes in BMI [41][42][43]. Reflective listening is an important technique to deepen understanding of the patient's perspective [14]. It has been related to more discussion on change (change talk) and enhanced outcomes [43][44][45]. ...
... Reflective listening is an important technique to deepen understanding of the patient's perspective [14]. It has been related to more discussion on change (change talk) and enhanced outcomes [43][44][45]. On the other hand, confrontation has been found to be particularly unhealthy, in that it decreases client change talk, reinforces resistance and sustain talk, and in some studies directly affects client outcomes negatively [43,44,46,47]. ...
... It has been related to more discussion on change (change talk) and enhanced outcomes [43][44][45]. On the other hand, confrontation has been found to be particularly unhealthy, in that it decreases client change talk, reinforces resistance and sustain talk, and in some studies directly affects client outcomes negatively [43,44,46,47]. ...
Background
Unhealthy alcohol use among young adults is a major public health concern. Brief motivational interventions for young adults in the Emergency Department (ED) have shown promising but inconsistent results.
Methods
Based on the literature on brief intervention and motivational interviewing efficacy and active ingredients, we developed a new motivational intervention model for young adults admitted in the ED with alcohol intoxication. Using an iterative qualitative design, we first pre-tested this model by conducting 4 experimental sessions and 8 related semi-structured interviews to evaluate clinicians’ and patients’ perceptions of the intervention’s acceptability and feasibility. We then conducted a consultation meeting with 9 international experts using a nominal group technique. The intervention model was adjusted and finally re-tested by conducting 6 new experimental sessions and 12 related semi-structured interviews. At each round, data collected were analyzed and discussed, and the intervention model updated accordingly.
Results
Based on the literature, we found 6 axes for developing a new model: High level of relational factors (e.g. empathy, alliance, avoidance of confrontation); Personalized feedback; Enhance discrepancy; Evoke change talk while softening sustain talk, strengthen ability and commitment to change; Completion of a change plan; Devote more time: longer sessions and follow-up options (face-to-face, telephone, or electronic boosters; referral to treatment). A qualitative analysis of the semi-structured interviews gave important insights regarding acceptability and feasibility of the model. Adjustments were made around which information to provide and how, as well as on how to deepen discussion about change with patients having low levels of self-exploration. The experts’ consultation addressed numerous points, such as information and advice giving, and booster interventions.
Discussion
This iterative, multi-component design resulted in the development of an intervention model embedded in recent research findings and theory advances, as well as feasible in a complex environment. The next step is a randomized controlled trial testing the efficacy of this model.
... Previous studies conducted in the field of substance abuse treatment have demonstrated relatively good inter-rater agreement for the MISC 2.1. Focusing on the counselor and interpreting the indices according to Cicchetti's (1994) classification, Gaume et al. (2014) found an excellent inter-rater reliability for the behavior classification with Cohen's k = .87 and for the three-categories level (MICO, MIIN, and Other) with intraclass correlation ranging from .83 to .99. ...
... In other words, as the client's speech tends more toward the change option and results in making a decision, the counselor displays a more complex use of MI-consistent behaviors. These observations are consistent with the results of studies on MI conducted in the field of substance abuse treatment (Moyers & Martin, 2006;Moyers et al., 2007) and with Miller and Rose (2009) Gaume et al., 2013;Gaume et al., 2014). ...
... Two external coders independently rated the counselor's behaviors and the client's talk during the BMI using the MISC 2.1. Both coders were Caucasian and were career counselors or clinical psychologists who had been extensively trained on the use of the MISC 2.1 in the context of clinical research on the impact of MI on young men's drinking behaviors (e.g.,Daeppen et al., 2011;Gaume et al., 2013;Gaume et al., 2014). Their training was completed at the University Hospital of the state of Vaud and comprised approximately 60 hours of sequencing interviews and classifying the statements of counselors and clients. ...
À l’heure où les trajectoires professionnelles se font de plus en plus changeantes et imprévisibles, la motivation des individus à s’engager dans des démarches d’orientation et d’insertion professionnelles est de plus en plus cruciale pour la réussite des nombreuses transitions qui jalonnent les carrières. Toutefois, jusqu’alors, la question de la motivation avait reçu peu d’intérêt de la part des chercheurs en orientation, ce qui laissait les psychologues conseiller·ère·s en orientation singulièrement démuni·e·s face à des consultant·e·s ne présentant pas ou peu de motivation. Depuis quelques années, la méthode de l’entretien motivationnel (Miller & Rollnick, 1991, 2006, 2013) a ainsi commencé à recevoir une attention croissante dans le domaine de l’orientation.
L’objectif de cette thèse est alors d’étudier dans quelle mesure et avec quelle efficacité il est possible d’avoir recours à cette méthode en appui aux prestations d’orientation scolaire et professionnelle. À cette fin, trois angles d’approche ont été favorisés. D’une part, au travers d’une réflexion théorique, la pertinence du recours à l’entretien motivationnel pour accroitre la motivation des consultant·e·s et les accompagner dans un processus de modération des aspirations est étudié. D’autre part, l’effet d’une formation à l’entretien motivationnel sur les comportements de psychologues conseiller·ère·s en orientation et sur le discours de leurs consultant·e·s est évalué de manière empirique, au moyen d’un dispositif quasi-expérimental.
Enfin, l’efficacité clinique de cette approche pour produire un changement réel dans la vie des individus est investiguée au moyen d’une étude de cas. Le produit de ces réflexions est présenté sous la forme de cinq articles. Une introduction générale inscrit ces articles dans le cadre théorique de la living system theory of vocational behavior and development (Vondracek, Ford & Porfeli, 2015) et une discussion finale souligne les apports et limites de l’adoption d’une approche intégrative en orientation.
... There was diversity in study designs and ways in which the clinician and organisational workforce characteristics were measured. Some studies directly assessed these characteristics (Garner, Rodney, & Hunter, 2013;Gaume et al., 2014;Project MATCH Research Group, 1998) whereas other studies represented a much more indirect measurement approach (De Leon, Hawke, Jainchill, & Melnick, 2000;Fiorentine & Anglin, 1997). Of the 12 studies, the majority had some risk of bias, ranging from no proper randomisation and small sample sizes to poor treatment outcome and/or clinician and organisational measures. ...
... Of the 12 studies, the majority had some risk of bias, ranging from no proper randomisation and small sample sizes to poor treatment outcome and/or clinician and organisational measures. Studies assessed as higher quality were Gaume et al. (2014), Woodward, Das, Raskin, and Morgan-Lopez (2006), Hser, Joshi, Maglione, Chou, and Anglin (2001) and Project MATCH Research Group (1998); all using a multi-variate analysis. See Tables 1 and 2 for details of the 12 studies. ...
... Six studies empirically assessed the relationship between years of clinical experience and treatment outcomes (De Leon et al., 2000;Gaume et al., 2014;Miller, Taylor, & West, 1980;Project MATCH Research Group, 1998;Sanchez-Craig, Spivak, & Davila, 1991;Schulte, Meier, Stirling, & Berry, 2010). Of these studies, only Gaume et al. (2014) and Project MATCH Research Group (1998) were of high quality. ...
While there is a long-standing and commonly held belief that the characteristics of the alcohol and other drug (AOD) workforce and workplace can impact client treatment outcomes, the available literature has not been systematically reviewed to date. Knowing which characteristics may impact treatment outcomes can help maximise workforce development in AOD services. A systematic review was undertaken, to identify studies of five clinician and organisational workforce characteristics: (1) years of clinical experience; (2) level of education/qualifications; (3) staff turnover; (4) staff-to-client ratio; and (5) professional development, and their relationship to client treatment outcome. Each study was assessed for quality using the Cochrane risk of bias tool. The search identified 1317 records; only 12 studies directly examined the relationship between clinician and organisational workforce characteristics and AOD treatment outcomes. Our analysis revealed a limited number of studies, a lack of high-quality research, and highly variable evidence regarding the relationship between clinician and organisational characteristics, and treatment outcomes. At present, there is an absence of evidence to support a strong association in any direction. Importantly, these findings illustrate the need for higher quality and larger scale research that focuses on clinician and organisational characteristics, taking into account multiple intervening and mediating factors.
... (4) Planning process: to begin the planning process, the counselor asked Lucas to identify the next steps to be taken to obtain the information he needs, which triggered a sense of urgency Daeppen et al., 2011;Gaume et al., 2013;Gaume et al., 2014). Their training was completed at the University Hospital of the state of XXX and comprised approximately 60 hours of sequencing interviews and classifying the statements of counselors and clients. ...
... For this reason, even if the case study appears to be an effective way to provide insights into the potential effects of MI, additional studies on MI efficacy in career counseling should be conducted. For example, the predictive power of counselors' behaviors on clients' talk may be better determined in a large-scale study, as other authors have done in previous studies on MI efficacy (e.g., Gaume et al., 2013;Gaume et al., 2014). ...
Motivational interviewing (MI) is receiving increasing attention in the field of career counseling. However, none of the previous studies have concretely presented how this method could and why it should be integrated in career counseling. Through the use of a single case study design, this paper illustrates how a brief MI (BMI) intervention can be integrated into career counseling interventions to help resolve career dilemmas. An analysis of the interactions between the client and his counselor using the Motivational Interviewing Skills Code 2.1 illustrates why this method can be useful for career counseling. Immediate and long-term effects of the global career counseling intervention on the client's career decision-making difficulties, as well as the specific impacts of the BMI intervention, are assessed. This case study shows that the BMI approach can be integrated in a career counseling intervention to help career counseling clients overcome career dilemmas and increase their readiness to make career choices.
... e., searching for information on substance on the internet, a good understanding of information on health) was higher for substance users (alcohol, tobacco, cannabis) than for abstainers, and higher for at-risk users than for users not at risk . A randomized clinical trial embedded in C-SURF using brief motivational interventions showed a small beneficial effect in favor of the intervention (Gaume et al., 2014). ...
... On the other hand, brief interventions providing mainly mere information are considered to be effective (Bertholet, Daeppen, Wietlisbach, Fleming, & Burnand, 2005). C-SURF revealed a significant but small effect in reducing alcohol use in the intervention group compared with the control group in an embedded brief-intervention controlled trial (Gaume et al., 2014). The peculiarity of the study was that 18 counselors delivered the intervention, and their motivational skills were measured. ...
Aim: To summarize published findings in peer-reviewed journals of the first two waves of the Swiss Cohort Study on Substance Use Risk Factors (C-SURF), a longitudinal study assessing risk and protective factors of 5,987 young men during the phase of emerging adulthood (20 years at baseline, followed-up 15 months later). Methods: Included were 33 studies published until November 2014 focusing on substance use. Results: Substance use in early adulthood is a prevalent and stable behavior. The 12-month prevalence of nonmedical use of prescription drugs (10.6%) lies between that of cannabis (36.4%) and other illicit drugs such as ecstasy (3.7%) and cocaine (3.2%). Although peer pressure in the form of misconduct is associated with increased substance use, other aspects such as peer involvement in social activities may have beneficial effects. Regular sport activities are associated with reduced substance use, with the exception of alcohol use. Young men are susceptible to structural conditions such as the price of alcohol beverages or the density of on-premise alcohol outlets. Particularly alcohol use in public settings such as bars, discos or in parks (compared with private settings such as the home) is associated with alcohol-related harm, including injuries or violence. Being a single parent versus nuclear family has no effect on alcohol use, but active parenting does. Besides parenting, religiousness is an important protective factor for both legal and illegal substance use. Merely informing young men about the risks of substance use may not be an effective preventive measure. At-risk users of licit and illicit substances are more health literate, e.g., for example, they seek out more information on the internet than non-at-risk-users or abstainers. Discussion: There are a number of risk and protective substance use factors, but their associations with substance use do not necessarily agree with those found outside Europe. In the United States, for example, heavy alcohol use in this age group commonly takes place in private settings, whereas in Switzerland it more often takes place in public settings. Other behaviors, such as the nonmedical use of prescription drugs, appear to be similar to those found overseas, which may show the need for targeted preventive actions. C-SURF findings point to the necessity of establishing European studies to identify factors for designing specific preventive actions.
... First, we predicted that in the MI condition, therapists would show more MI skills, and in the active comparison condition, therapists would show more didactic skills. Second, following the literature, which shows that MI consistent therapist skills are positively related to treatment outcomes for adolescents through adults (e.g., Barnett, Moyers, et al., 2014;Gaume, Magill, et al., 2014;Moyers, Martin, Houck, Christopher, & Tonigan, 2009), we predicted that therapists' greater use of MI skills would relate to better treatment response (less substance use frequency and related problems) for both Hispanic and non-Hispanic youth at the three-month follow-up. Third, consistent with prior theoretical work, which suggests that different factors may be salient to Hispanic youth's treatment response, thus necessitating examination of therapeutic processes and outcomes for Hispanic youth (Feldstein Ewing et al., 2012;Salvador, DeVargas, & Feldstein Ewing, in press), we hypothesized that therapists would show greater MI skills with non-Hispanic versus Hispanic youth. ...
... Finally, these findings indicate the importance of continuing to examine within-session therapist behaviors to see how and why Hispanic youth may respond to different applications of therapist skill. Building upon the mixed literature in youth MI (e.g., Gaume, Magill, et al., 2014;McCambridge et al., 2011), this study suggests that adolescent treatment response across binge-drinking days and marijuana-related behaviors did not seem to be negatively or positively connected to therapists' varying levels of MI skills. Future work must unpack when therapist MI skills matter, in which intervention contexts, and when they may be less clinically relevant. ...
Brief addiction treatments, including motivational interviewing (MI), have shown promise with youth. One underexamined factor in this equation is the role of therapist behaviors. We therefore sought to assess whether and how therapist behaviors differ for Hispanic versus non-Hispanic youth and how that may be related to treatment outcome. With 80 substance-using adolescents (M age = 16 years; 65% male; 59% Hispanic; 41% non-Hispanic), we examined the relationship between youth ethnicity and therapist behaviors across two brief treatments (MI and alcohol/marijuana education [AME]). We then explored relationships to youth 3-month treatment response across four target outcomes: binge drinking days, alcohol-related problems, marijuana use days, and marijuana-related problems. In this study, therapists showed significantly more MI skills within the MI condition and more didactic skills in the AME condition. With respect to youth ethnicity, across both conditions (MI and AME), therapists used less MI skills with Hispanic youth. Contrary to expectations, therapists' use of MI skills was not connected to poorer outcomes for Hispanic youth across the board (e.g., for binge drinking days, marijuana use days, or marijuana-related problems). Rather, for Hispanic youth, therapists' use of lower MI skills was related only to poorer treatment outcomes in the context of alcohol-related problems. The observed relationships highlight the importance of investigating salient treatment interactions between therapist factors and youth ethnicity to guide improvements in youth treatment response. (PsycINFO Database Record
(c) 2015 APA, all rights reserved).
... These data are not necessarily in conflict with the view that MI skillfulness is an important component of BI, as greater use of these specific microskills may be indicative of lower overall skill. Together with results from the study by Gaume and colleagues (36), these findings highlight the key importance of competent reflective listening skills (i.e., the use of more complex reflections). ...
... On the other hand, results from meta-analyses cited above [e.g., Ref. (8, 14)] compared BI including MI skills to BI not including this approach. A recent study tried to address these limitations by designing a study including heterogeneous counselors (18 counselors ranging from beginners to MI experts) and comparing participants receiving a BMI with high level of MI skills to those receiving a BMI with low MI skill level and to a control group receiving no BMI (36). This study included non-treatment seeking young men (age 20) screened as hazardous drinkers and found that BMI where MI global ratings (acceptance, empathy, and MI spirit) were high, with no MI-inconsistent behaviors, and with a higher percentage of complex reflections, had better outcomes than those having had no intervention, whereas those with lower scores on these dimensions did not significantly differ from those in the non-intervention control group. ...
A growing body of evidence has shown the efficacy of brief intervention (BI) for hazardous and harmful alcohol use in primary health care settings. Evidence for efficacy in other settings and effectiveness when implemented at larger scale are disappointing. Indeed, BI comprises varying content; exploring BI content and mechanisms of action may be a promising way to enhance efficacy and effectiveness. Medline and PsychInfo, as well as references of retrieved publications were searched for original research or review on active ingredients (components or mechanisms) of face-to-face BIs [and its subtypes, including brief advice and brief motivational interviewing (BMI)] for alcohol. Overall, BI active ingredients have been scarcely investigated, almost only within BMI, and mostly among patients in the emergency room, young adults, and US college students. This body of research has shown that personalized feedback may be an effective component; specific MI techniques showed mixed findings; decisional balance findings tended to suggest a potential detrimental effect; while change plan exercises, advice to reduce or stop drinking, presenting alternative change options, and moderation strategies are promising but need further study. Client change talk is a potential mediator of BMI effects; change in norm perceptions and enhanced discrepancy between current behavior and broader life goals and values have received preliminary support; readiness to change was only partially supported as a mediator; while enhanced awareness of drinking, perceived risks/benefits of alcohol use, alcohol treatment seeking, and self-efficacy were seldom studied and have as yet found no significant support as such. Research is obviously limited and has provided no clear and consistent evidence on the mechanisms of alcohol BI. How BI achieves the effects seen in randomized trials remains mostly unknown and should be investigated to inform the development of more effective interventions.
... These interventions are useful to reduce barriers such as stigma and perceived HIV risk and could be effective at improving initiation and adherence. Research in other prevention domains has examined the influence of MI counselors' personal characteristics, professional credentialing, and/or training on intervention efficacy (Gaume et al., 2009(Gaume et al., , 2014(Gaume et al., , 2016, highlighting the need for this inquiry among HIV prevention interventions. However, limited information is available regarding the specific components of MIbased interventions that aid in improving PrEP initiation and adherence. ...
Despite evidence that pre-exposure prophylaxis (PrEP) reduces HIV risk, initiation and adherence remain low among vulnerable communities. Motivational interviewing (MI) can improve HIV prevention behaviors. However, limited research identifies how MI impacts PrEP uptake and adherence. This scoping review examines essential components of MI-based interventions that aimed to improve PrEP use, including the number and duration of sessions, counselor characteristics, and interview content. We searched four databases, PubMed, CINAHL Plus, Embase, and Web of Science, and reviewed 379 articles. Studies were considered if they (a) were published between 2012 and 2023, (b) used MI independently or part of a multi-component intervention strategy, and (c) focused on improving PrEP initiation or adherence. Seven articles met inclusion criteria. Regarding intervention components, the number of MI sessions varied and duration ranged between 15 and 60 min. MI counselors varied in credentialing and demographic characteristics. MI content included PrEP education, identifying initiation and adherence barriers, and strategizing ways to overcome barriers. MI is an important component of interventions that aim to improve PrEP initiation and adherence. However, the variability and limited details across studies hinder our ability to assess MI efficacy on PrEP initiation and adherence or replicate these approaches in future interventions.
... Counselors with high efficiency are kind to clients (Grencavage & Norcross, 1990;Halinski, 2009;Pope & Kline, 1999;Sanberk, 2016), culturally knowledgeable (Cormier & Hackney, 2016), adept at using humor (Çekici, 2019), and conscious of their limitations (Grove, 2009). Counselors with these characteristics obtain better outcomes from the counseling process (Gaume et al., 2014;Lochman et al., 2009), may offer alternative solutions to clients' issues (Buyruk Genç & Yüksel Şahin, 2020), and create a more pleasant counseling atmosphere (Jackson & Thompson, 1971;Sakinah et al., 2020). ...
Research on counselors-in-training is necessary to improve the success of the counseling process. The counseling skills used by counselors are critical to managing this process. This paper aims to contribute to the existing body of knowledge in counseling pedagogy by examining the role of counselor characteristics as a mediator in the relationship between counselors-in-training values and counseling skills. In this study, we had 524 counselors-in-training from various universities in Turkey. The results showed that the values of counselors-in-training significantly predict their counselor characteristics. Specifically, the values of the counselors-in-training predict their counseling skills, with the mediating role of the counselor characteristics. Additionally, the counselor characteristics of the counselors-in-training significantly predicted their counseling skills. Various practices and methods can be applied to improve counseling skills. Given that the development of values allows counselors-in-training to acquire important counselor characteristics, value education is essential in the training of counselors. Individuals who acquire essential counselor characteristics can use their counseling skills effectively.
... However, ABI has also been delivered in college, hospital, accident, and emergency and community settings. [13][14][15][16] A systematic review and meta-regression analysis by Platt et al. showed a modest effect of BI in the primary care setting but limited efficacy in community settings and college settings. [17] ABI but does not require highly skilled training in the management of substance use disorders and can be provided by counselors, nurses, general practitioners, and other primary health-care workers with a brief period of training in delivering ABI. ...
Introduction:
At the population level, screening and brief intervention (BI) is the most cost-effective method to reduce the burden of disease due to hazardous alcohol use. In delivering BI at individual level, trained workforce as well as time is a limiting factor. Hence, a study was conducted to assess the outcome of a "modified brief intervention" program delivered at workplace in a group setting for the participants identified with hazardous alcohol use pattern, as a secondary prevention measure.
Materials and methods:
Study was a pre- and post-intervention study without a control group. Following an educational lecture, conducted by a mental health team including a psychiatrist, participants were screened using the WHO ASSIST questionnaire, V3.0 version. Those screened positive for hazardous alcohol use were given "modified brief intervention" in a group setting at their workplace which consisted of two semi-structured sessions of 1-h duration each. The sessions were spaced in a month. First session was based on motivation enhancement measures along with gathering of current alcohol use details and second session focused on relapse prevention. Three months later, the outcomes were assessed using a semistructured questionnaire and ASSIST was reapplied. The analysis was done using the R-commander from R-software.
Results:
No significant difficulty was experienced in conducting the interventions. Fifty (55.6%) participants stayed alcohol abstinent following second session and another 22 (24.44%) had reduced both the quantity and frequency of use. Paired t-tests revealed statistically significant reduction in all secondary outcome parameters (ASSIST scores, usual dose in one sitting, maximum dose, and number of days of use in month). Eighty (88.89%) participants reported the program to be effective. Only 3 months of observation is a limitation.
Conclusion:
The study provides an efficient secondary prevention model to reduce hazardous drinking at the population level needing less workforce, cost, and time.
... If MI works as hypothesized, by conveying a relational and technical component (Miller and Rose, 2009), there should be clear associations between the fidelity of these elements and client outcomes. Although MI therapist behaviors are commonly linked to outcomes in studies of MI (Borsari et al., 2015;Gaume et al., 2014;Gaume, Heather, Tober, and McCambridge, 2018;Grodensky et al., 2017), meta-analyses of this hypothesized association have not detected direct associations between MI elements and outcome (Magill et al., 2018;Pace et al., 2017). Indications were found, https://doi.org/10.1016/j.jsat.2019.03.004 ...
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.
... Taking these findings also into account implies that complementing a stricter alcohol policy environment with selective prevention measures, which target the abovementioned aspects of drinking, would be more potent than either approach used alone. Such measures could be, for example, brief interventions and interventions targeting self-regulation for those who already lean towards heavy drinking (Gaume et al., 2014;Jonas et al., 2012 interventions that are fine-tuned to personality characteristics, as developed by Conrod et al. (Conrod, 2016). ...
Background:
A basic, yet untested tenet underlying alcohol control policies is that they should affect both light and heavy drinking, thereby shifting the entire population in a favourable direction. The aim of this study was to test this assumption in young Swiss men.
Methods:
Cross-sectional self-reported data - from 5755 young Swiss men participating in the Cohort Study on Substance Use Risk Factors (C-SURF), a large cohort study on young men living within 21 jurisdictions across Switzerland - were analysed via nested logistic regression. With this approach, a set of increasingly-heavy drinking patterns was broken down into a set of nested regression models, each one estimating the probability of heavier drinking, conditional on the lighter drinking pattern. Drinking patterns relating to heavy episodic drinking (HED), heavy volume drinking (HVD) on weekends, and workweek drinking, as well as alcohol use disorder (AUD) were examined. The explanatory variable was a previously-used alcohol policy environment index (APEI) reflecting the number of alcohol control policies implemented in each jurisdiction. Conventional and multilevel logistic regression models were tested, adjusted for age, education, linguistic region, urban/rural status, attention-deficit/hyperactivity disorder, depression, sensation seeking, antisocial personality disorder, and unobserved heterogeneity between jurisdictions.
Results:
For HED, weekend HVD, and AUD, negative relationships with the APEI were found, such that with a higher APEI the probability of lighter drinking patterns was increased while the probability of heavier patterns was reduced, including a reduced probability of the heaviest patterns. These relationships were non-linear, however, and tapered off towards the heavy end of the drinking spectrum. No relationship was identified between the APEI and workweek drinking patterns.
Conclusion:
Among young Swiss men, stricter alcohol policy environments were associated with a global shift towards lighter drinking, consistent with the basic tenet behind the universal prevention approach.
... The present project was a secondary analysis of the audio files of clinical interviews collected for two unrelated projects (see Figure 1). Study 1 (Gaume et al., 2014) was a randomized controlled trial of brief motivational interventions (BMI) among hazardous drinkers included within the Army Recruitment Center of Lausanne, Switzerland. Switzerland has a mandatory 2-day army conscription process for all men at age 19 to determine eligibility for service in the Swiss military. ...
Empathy is a well-defined active ingredient in clinical encounters. To measure empathy, the current gold standard is behavioral coding (i.e., trained coders attribute overall ratings of empathy to clinician behaviors within an encounter), which is labor intensive and subject to important reliability challenges. Recently, an alternative measurement has been proposed: capturing empathy as synchrony in vocally encoded arousal, which can be measured as the mean fundamental frequency of the voice (mean F0). This method has received preliminary support by one study (Imel, Barco, et al., 2014). We aimed to replicate this study by using 2 large samples of clinical interactions (alcohol brief motivational interventions with young adults, N = 208; general practice consultations, N = 204). Audio files were segmented to identify respective speakers and mean F0 was measured using speech signal processing software. All sessions were independently rated by behavioral coders using 2 validated empathy scales. Synchrony between clinician and patient F0 was analyzed using multivariate multilevel models and compared with high and low levels of empathy derived from behavioral coding. Findings showed no support for our hypothesis that mean F0 synchrony between clinicians and patients would be higher in high-empathy sessions. This lack of replication was consistent for both clinical samples, both behavioral coding instruments, and using measures of F0 synchrony occurring at both the session-level and minute-level. We considered differences in culture and language, patients' characteristics, and setting as explanations for this failure to replicate. Further replication testing and new developments regarding measurement methods and modeling are needed.
... This suggests there might be a need for better MI technique when working with young, non- treatment seeking individuals. Similarly, in a study with community-based young men in Switzerland, the technical hypothesis was supported only when therapist experience and client problem severity were high ( Gaume et al., 2014). Research also suggests the negative side of client ambivalence, or sustain talk, might be a particularly important process to consider when college students are mandated to brief alcohol intervention ( Apodaca et al., 2014;Borsari et al., 2015). ...
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.
... Similarly, across the MI literature, growing evidence suggests that high levels of treatment-specific therapy quality (or 'MI-consistent' skills) are favorably linked to within-session patient behaviors (Magill et al., 2010). A recent RCT demonstrated that higher treatment-specific therapy quality showed better patient outcomes, irrespective of the level of experience of the counselor in treatment delivery (Gaume et al., 2014a). ...
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.
... Therapist empathy predicts reduced drinking across a wide range of clients and settings (Miller & Baca, 1983;Miller, Taylor, & West, 1980;Moyers & Miller, 2013). A recent process study of brief MI intervention has shown that counselors that were more experienced and had higher MI-relational skills, had significantly better outcomes (Gaume et al., 2014). Data from this same study also demonstrated that a key mechanism hypothesized by MI theory (i.e., strength of change talk) was operative only when counselors were experienced in MI, suggesting the importance of therapist selection, training, and supervision (Gaume et al., 2016). ...
Objective:
To determine whether treatment outcomes are mediated by therapist behaviors consistent with the theoretical postulates on which two contrasting treatments are based.
Method:
We used data from the U.K. Alcohol Treatment Trial (UKATT), a pragmatic, multicenter, randomized controlled trial comparing the effectiveness of Motivational Enhancement Therapy (MET) and Social Behavior and Network Therapy (SBNT) in the treatment of alcohol problems. N = 376 clients (mean age 42.5, 74.5% male) had 12-month follow-up data and one treatment session recorded and coded using the UKATT Process Rating Scale, a reliable manual-based assessment of treatment fidelity including frequency and quality ratings of treatment-specific therapist tasks and therapist styles. Analyses were conducted using a mediation framework.
Results:
Analysis of individual paths from treatment condition to treatment process indices (a path) and from treatment process indices to alcohol outcomes (b path) showed that (a) SBNT therapists more often used SBNT-specific behaviors, and did so with overall higher quality; (b) MET therapists more often used MET-specific behaviors, but there was no evidence that they performed these behaviors with higher quality than SBNT therapists; (c) only the quality of MET behaviors significantly predicted 12-month alcohol outcomes, irrespective of treatment condition. Consistently, there were no significant indirect effects. Multiple component analysis indicated that therapist quality of specific tasks influenced outcomes.
Conclusions:
The quality of delivery of the same treatment tasks in both treatments studied transcended the impact of delivering treatments according to different theoretical underpinnings in UKATT. (PsycINFO Database Record
... In most cases, the clinicians displayed significantly higher levels of MI proficiency based on at least one of the MI indicators (e.g., percentage of MIconsistent behaviors [% MICO], percentage of complex reflections [% REC], percentage of open questions [% QUO], or reflections-per-questions ratio). However, some studies suggest that these results may be influenced by counselors' personal and sociodemographic characteristics such as gender and clinical experience (e.g., Gaume et al., 2014;Miller & Mount, 2001;Rochat & Rossier, 2016). Unfortunately, little is known about the effect of MI training on counselors' behaviors and clients' talk in the context of career counseling. ...
Motivational interviewing (MI) is receiving increasing attention in the field of career counseling. Using a quasi-experimental design, this pilot study examines the impact of MI training on career counselors’ behaviors and clients’ talk within audio-recorded interviews. Eight school-based career counselors participated in the study. They audio-recorded their interviews with 30 students prior to MI training and with 32 students after it. Counselors’ behaviors and students’ talk were coded using the Moti- vational Interviewing Skills Code 2.1. The results demonstrate mixed outcomes in terms of career counselors’ MI proficiency after the training. Career counselors’ proficiency improved in some of the indicators (percentages of MI-consistent behaviors and reflections-to-questions ratio) and worsened in others (percentages of complex reflections [% REC] and open questions). Reaching proficiency in the % REC influenced students’ change talk, but reaching proficiency in the % MICO did not. Impli- cations for MI training and research in career counseling are discussed.
... Although MI was originally developed as a counselling style to be delivered in-person, other studies have also demonstrated the efficacy of MI as a telephone-delivered intervention Mello et al., 2008Mello et al., , 2012. Gaume et al. (2014) tested telephone MI on a sample of men from the emergency department who were not seeking treatment for heavy alcohol consumption. They found that MI delivered by telephone was an effective treatment for this sample in reducing alcohol consumption. ...
Introduction:
The stages of change model suggests that individuals seeking treatment are in the 'preparation' or the 'action' stage of change, which is the desired outcome of successful Motivational Interviewing (MI) interventions. MI is known to enhance treatment attendance among individuals with mental health problems.
Aim:
This study examined the published research on MI as a pre-treatment to enhance attendance among individuals treatment-seeking and non-treatment seeking for mental health issues.
Methods:
Fourteen randomised controlled trials were identified and MI efficacy was examined dichotomously: attendance or non-attendance for post-MI therapy. Sub group analysis investigated treatment seeking and non-treatment seeking groups.
Results:
Despite wide variations in sample sizes, blinding and monitoring, intervention fidelity was absent in the majority of published studies. Meta-analysis revealed that MI pre-treatment improved attendance relative to comparison groups.
Conclusions:
Individuals not seeking treatment for mental health issues benefitted the most from MI. Despite differences in MI treatment intensity, short interventions were as effective as longer interventions, whereas two MI sessions for as little as 15 minutes were effective in enhancing treatment attendance.
Implications for practice:
MI is a useful tool for clinicians in all therapeutic interactions to help motivate patients to seek assistance for mental health issues. This article is protected by copyright. All rights reserved.
... Traditional essential principles of successful implementation include that the core program components are delivered with fidelity; absence of barriers such as unavailable transportation, not enough time to deliver a minimum of intervention dosage, and scheduling problems; and service providers being sufficiently trained and supervised [10]. Regarding the latter point, a recent study showed that the effectiveness of BIs was associated with counsellors who were proficient in client-centered counselling and motivational interviewing [14]. ...
Public health concerns regarding adolescent alcohol and other drug involvement emphasize the need for continuing research to develop and evaluate preventive interventions for use in a variety of settings. This focus includes research on brief interventions. This short commentary piece provides an overview of the brief intervention literature and highlights future directions.
... This might well enable the retraining of such biases [15]. Finally, although we appreciate the precision of MI coding, evidence linking specific MI techniques directly to favorable outcomes is limited [16]. Therefore, we also welcome utilization of a more general process coding system that includes emphasis on relational factors and the ratio of counselor to client utterances, such as the Generalized Medical Interaction Analysis System (GMIAS) [17] or our more recently developed Generalized Behavioral Intervention Analysis System (GBIAS), which has been used in conjunction with the Motivational Interviewing Skills Code (MISC) towards developing more sensitive evaluations of provider-client interactions. ...
Commentary to: Ambivalence: Prerequisite for success in motivational interviewing with adolescents?
... An alcoholism treatment study found positive behaviour outcomes varying from 25 to 100%, depending on the counsellors' interpersonal functioning [7]. Recently Gaume and colleagues [8] found similar variability across 18 counsellors in a standardized brief MI efficacy study in young men, also supporting the influential role of relational factors in MI. These results may reflect the relative importance of relational factors compared to specific ingredients on the efficacy of MI. ...
Commentary to: Ambivalence: Prerequisite for success in motivational interviewing with adolescents?
... One explanation of these data is that the quality of the clinical relationship may be what was measured here. In line with the treatment arena [88][89][90], one cautious interpretation of this work is that these data suggest that strong and effective clinicians can change the adolescent brain and catalyze positive treatment outcomes, even when using approaches that can have been discouraged in the addictions treatment literature (e.g., closed questions) [69,91]. While larger sample sizes are needed to offer firm support, this exploratory work suggests that the nature of therapeutic statements (complex reflection vs. ...
Despite foundational work, we still do not know how therapist behaviors influence brain response and related treatment outcomes for alcohol-using adolescents. Therefore, we examined this question with 17 binge drinking youth (mean age = 16.62 years; 64.3% female; 42.9% Hispanic; 28.6% bi-/multi-racial). In this within-subjects design, all youth completed a baseline assessment, two therapy sessions, an fMRI scan, and were re-evaluated for behavior change at one-month post-treatment. During the fMRI session, youth were presented with two types of therapist responses from their treating therapist: higher-skill therapeutic statements prescribed in an empirically-supported addiction treatment (complex reflections) versus language standard within addiction treatment more broadly (closed questions). In terms of behavior change, at the one-month follow-up, youth showed significant reductions in their number of drinking days and binge drinking days post-treatment. Further, we found main effects for complex reflections and closed questions across the superior middle temporal gyrus and middle temporal gyrus (FWE-corrected, p<.05). Complex questions showed a relatively stronger response than closed questions within the bilateral anterior cingulate gyrus. Additionally, greater BOLD response in the parietal lobe during closed questions was significantly associated with less post-treatment drinking. Finally, lower BOLD responses during both complex reflections and closed questions in the precuneus were associated with greater post-treatment ratings of importance of changing drinking. This study represents a first step in understanding how certain therapist behaviors influence the developing adolescent brain and how that neural response may be associated with youth treatment outcomes in the context of addiction treatment.
... MI has been met with considerable enthusiasm as a brief AUD treatment. To date, MI has established empirical support for efficacy (Lundahl and Burke, 2009), as well as an emerging body of research on the treatment ingredients and client mechanisms, accounting for this efficacy (see Apodaca and Longabaugh, 2009;Gaume et al., 2014;Magill et al., 2014). At the time of the 2004 symposium, very little was known about MI causal process. ...
Background:
The current review revisits the article entitled: "Active Ingredients: How and Why Evidence-Based Alcohol Behavioral Treatment Interventions Work" published in Alcoholism: Clinical and Experimental Research. This work summarized proceedings from a 2004 Symposium of the same name that was held at the Annual Meeting of the Research Society on Alcoholism (RSA). A decade has passed, which provides occasion for an evaluation of progress. In 2014, an RSA symposium titled Active Treatment Ingredients and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later did just that.
Methods:
The current review revisits state-of-the-art research on the 3 treatments examined 10 years ago: cognitive behavioral therapy, alcohol behavior couples therapy, and 12-step facilitation. Because of its empirically validated effectiveness and robust research agenda on the study of process outcome, motivational interviewing has been selected as the fourth treatment modality to be discussed. For each of these 4 treatments, the reviewers provide a critical assessment of current theory and research with a special emphasis on key recommendations for the future.
Results:
Noteworthy progress has been made in identifying active ingredients of treatments and mechanisms of behavior change in these 4 behavioral interventions for alcohol and other drug use disorders. Not only have we established some of the mechanisms through which these evidence-based treatments work, but we have also uncovered some of the limitations in our existing frameworks and methods.
Conclusions:
Further progress in this area will require a broader view with respect to conceptual frameworks, analytic methods, and measurement instrumentation.
Background:
Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.
Objectives:
To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.
Search methods:
We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.
Selection criteria:
We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.
Data collection and analysis:
We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).
Main results:
We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.
Authors' conclusions:
Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.
Importance
Heavy drinking among young adults is a major public health concern. Brief motivational interventions in the emergency department have shown promising but inconsistent results.
Objective
To test whether young adults receiving a newly developed brief motivational intervention reduce their number of heavy drinking days and alcohol-related problems over 1 year compared with participants receiving brief advice.
Design, Setting, and Participants
This randomized clinical trial was conducted at an emergency department of a tertiary care university hospital in Lausanne, Switzerland. Recruitment ran from December 2016 to August 2019. Follow-up was conducted after 1, 3, 6, and 12 months. All adults aged 18 to 35 years presenting for any cause and presenting with alcohol intoxication were eligible (N = 2108); 1764 were excluded or refused participation. Follow-up rate was 79% at 12 months and 89% of participants provided follow-up data at least once and were included in the primary analyses. Statistical analysis was performed from September 2020 to January 2021.
Interventions
The novel intervention was based on motivational interviewing and comprised in-person discussion in the emergency department and up to 3 booster telephone calls. The control group received brief advice.
Main Outcomes and Measures
Primary outcomes were the number of heavy drinking days (at least 60 g of ethanol) over the previous month and the total score on the Short Inventory of Problems (0-45, higher scores indicating more problems) over the previous 3 months. Hypotheses tested were formulated before data collection.
Results
There were 344 young adults included (median [IQR] age: 23 [20-28] years; 84 women [24.4%]). Among the 306 participants providing at least 1 follow-up point, a statistically significant time × group interaction was observed (β = −0.03; 95% CI, −0.05 to 0.00; P = .02), and simple slopes indicated an increase of heavy drinking days over time in the control (β = 0.04; 95% CI, 0.02 to 0.05; P < .001) but not in the intervention group (β = 0.01; 95% CI, −0.01 to 0.03; P = .24). There was no effect on the Short Inventory of Problems score (β = −0.01; 95% CI, −0.03 to 0.02; P = .71).
Conclusions and Relevance
This randomized clinical trial found that a brief motivational intervention implemented in the emergency department provided beneficial effects on heavy drinking, which accounts for a substantial portion of mortality and disease burden among young adults.
Trial Registration
ISRCTN registry: 13832949
A qualitative, hermeneutic, phenomenological, holistic case study was completed to gain insight into the experiences of drug and alcohol (D&A) counselors in rural Alaska. The goal was to describe why counselors in rural Alaska work in their positions and continue to perform, despite existing research indicating challenges in the occupation and the location. Interviewing homogeneous, purposively selected D&A counselors working in rural Alaska provided rich experiential information answering the research question. The approach to information gathering and analyses of interview transcripts for common themes captured the lived experiences of the counselors. It illuminated their perceptions of incentives supporting and encouraging their service. Counselors’ stories highlighted common themes known to the field (challenges, stigma) and themes previously unnamed but taken-for-granted (community/giving-back, prevention, personal/professional growth). The nation’s addiction problems are not decreasing; intervention by skilled professionals is needed. The authors’ searches of existing literature revealed no qualitative research describing why counselors persist. Results indicated that despite challenging deadlines, politics, stigma, and more, counselors certainly enjoy their work, allowing them to give back to their communities and save lives. Counselors also appreciate the personal and professional growth opportunities provided to them. Conclusions suggested future research regarding recruitment and retention, such as personal experience with addiction, being an established community member, and the desire for opportunities to provide unique and professional growth. In addition, governmental and professional organizations should better support counselors in their essential work.
Background
We applied Motivational Interviewing (MI) techniques, early after stroke, to facilitate psychological adjustment to life post-stroke. In our trial, MI-plus-usual-care increased the likelihood of normal mood at 3-months post-stroke, compared to usual-care alone. Whilst appropriate training, manuals, and supervision may increase adherence to core principles of this complex intervention, unintended variability in implementation inevitably remains. We aimed to explore the impact of variability on participant outcome.
Methods
Using our trial data (411 participants), we explored variation in MI delivery, examining: therapist characteristics (stroke care expertise/knowledge, psychology training); MI content (fidelity to MI techniques assessed with Motivational Interviewing Treatment Integrity code, describing therapist behaviours as MI-consistent, MI-neutral or MI-inconsistent); and MI dose (number/duration of sessions).
Results
The four MI therapists (two nurses/two psychologists) had varying expertise and MI delivery. Across therapists, mean average session duration ranged 29.5–47.8 min. The percentage of participants completing the per-protocol four sessions ranged 47%–74%. These variations were not related to participant outcome. There were uniformly high frequencies (>99%) of MI-consistent and MI-neutral interactions, and low frequencies (<1%) of MI-inconsistent interactions.
Conclusions
Variation in therapist characteristics and MI dose did not affect participant outcome. These may have been tolerated due to high fidelity to MI principles.
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IMPLICATIONS FOR REHABILITATION
• Motivational Interviewing (MI) can help reduce depression in stroke survivors when delivered early after stroke.
• The effectiveness of our MI intervention depends on the delivery of high quality MI; in particular, interactions with low levels of MI-inconsistency, and high global MI ratings, ideally delivered over more than one session, each lasting at least 30 minutes.
• Provided high quality MI is being delivered, the intervention can still have a beneficial effect on participant outcome, even with flexibility and variation in therapist characteristics, and duration and number of sessions, which may be inevitable in a clinical context.
Background:
Relaxation, biofeedback, and cognitive behavioral therapy are evidence-based behavioral therapies for migraine. Despite such efficacy, research shows that only about half of patients initiate behavioral therapy recommended by their headache specialists.
Objective:
Motivational interviewing (MI) is a widely used method to help patients explore and overcome ambivalence to enact positive life changes. We tested the hypothesis that telephone-based MI would improve initiation, scheduling, and attending behavioral therapy for migraine.
Methods:
Single-blind randomized controlled trial comparing telephone-based MI to treatment as usual (TAU). Participants were recruited during their appointments with headache specialists at two sites of a New York City medical center.
Inclusion criteria:
ages from 16 to 80, migraine diagnosis by United Council of Neurologic Subspecialty fellowship trained and/or certified headache specialist, and referral for behavioral therapy for prevention in the appointment of recruitment.
Exclusion criteria:
having done behavioral therapy for migraine in the past year. Participants in the MI group received up to 5 MI calls. TAU participants were called after 3 months for general follow-up data. The prespecified primary outcome was scheduling a behavioral therapy appointment, and secondary outcomes were initiating and attending a behavioral therapy appointment.
Results:
76 patients were enrolled and randomized (MI = 36, TAU = 40). At baseline, the mean number of headache days was 12.0 ± 9.0. Self-reported anxiety was present for 36/52 (69.2%) and depression for 30/52 (57.7%). Follow-up assessments were completed for 77.6% (59/76, MI = 32, TAU = 27). The mean number of MI calls per participant was 2.69 ± 1.56 [0 to 5]. There was a greater likelihood of those in the MI group to initiating an appointment (22/32, 68.8% vs 11/27, 40.7%, P = .0309). There were no differences in appointment scheduling or attendance. Reasons stated for not initiating behavioral therapy were lack of time, lack of insurance/funding, prioritizing other treatments, and travel plans.
Conclusions:
Brief telephone-based MI may improve rates of initiation of behavioral therapy for migraine, but other barriers appear to lessen the impact on scheduling and attending behavioral therapy appointments.
Given the documented gender differences in characteristics of alcohol use disorder, men and women might also respond differently to some treatments for this disorder. If so, this would be important for physicians to consider when selecting treatment. The purpose of this systematic review was to synthesize the evidence for gender differences in effects of treatments for the disorder. RAND researchers culled 13,771 citations, contacted authors, and reviewed 1,434 publications as full text. Of the 1,434 publications reviewed, only 24 original studies published in 63 publications and four systematic reviews met inclusion criteria. Studies reported efficacy or safety results for men and women separately or presented analyses of gender differences. The review used innovative analytic methods to assess gender differences in treatment effects by analyzing the differences in outcome between active and control treatments in studies with US adults undergoing evidence-based treatments. Although individual studies demonstrated gender differences in treatment effects, researchers did not identify systematic differences across studies. Most notably, despite an extensive search and thorough screening procedure, very few studies were found to report on treatment effects according to gender, hindering all analyses. The review showed a profound lack of information on the presence and absence of gender differences. Those studies that met inclusion criteria tended to be smaller and/or did not enroll comparable numbers of men and women; tended to assess a wide variety of outcomes, making cross-study comparisons difficult; and tended to have relatively high risk of bias.
Given the workforce shortage of adequately trained behavioral health professionals, schools of social work are ideally positioned to teach empirically supported treatments for preventing and reducing substance use, specifically, screening and brief interventions. Traditionally, opportunities to practice screening and brief intervention skills occur in classes and field placements; however, these opportunities are limited by class time, placement setting, and multiple demands placed on field instructors. Online client simulation has potential to address these limitations as an asynchronous training and assessment tool. This article details the integration of online interactive client simulation technology in advanced-level master of social work curricula. Drawing on longitudinal pre- and postdata, we present a preliminary analysis of changes in students’ screening and brief intervention skills.
Effects of counselor and client verbal behaviors, in a single motivational interviewing (MI) session during inpatient detoxification, were evaluated in relation to 17 study participants’ self-reported drug use 3 months later. Also, counselor-to-client transitions in the single MI session were explored for 24 participants, using the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE) coding instrument. Surprisingly, counselor neutral/double-sided reflections predicted lower levels of drug use (r = − 0.42), higher treatment interest (r = 0.40), and self-efficacy for abstaining from drug use when experiencing positive feelings (r = 0.48) and negative feelings or craving (r = 0.40). Client change talk predicted motivation to change (r = 0.42) and perceptions of negative aspects of drug use (r = 0.44), while higher levels of client sustain talk predicted lower levels of drug use (r = − 0.45) and lower interest in treatment (r = − 0.68). The counselor-client transition analysis showed an odds ratio (OR) of 13.84 (95% CI 9.75; 19.66) for client change talk in response to counselor reflections on change talk (RCT), and an OR of 55.98 (95% CI 26.53; 118.12) for client sustain talk in response to counselor reflections on sustain talk (RST). Future research should increase sample size and extend follow-up.
Motivational interviewing (MI) theory proposes a process whereby a set of therapist behaviors has direct effects on client outcomes and indirect effects through in-session processes (e.g., client change talk). Despite clear empirical support for the efficacy of MI across settings, the results of studies evaluating proposed links between MI process and outcome have been less clear. In the present study, we used a series of multivariate meta-analyses to test whether there are differential relationships between specific MI-consistent and MI-inconsistent therapist behaviors, MI therapist global ratings, client change language, and clinical outcomes. Based on 19 primary studies (N = 2,614), we found a significant relationship between MI-consistent therapist behaviors and greater client change talk, as well as greater client sustain talk. Higher therapist global ratings (empathy and MI spirit) were significantly related to increased MI-consistent behaviors, decreased MI-inconsistent behaviors, increased client change talk, yet also increased client sustain talk. Therapist global ratings were not significantly related to clinical outcomes. Client sustain talk was a significant predictor of worse clinical outcomes, while client change talk was unrelated to outcome. Variability within the correlations indicated that MI-consistent and MI-inconsistent therapist behaviors were differentially related to therapist global ratings of empathy and MI spirit. Similar to past research, present findings provide equivocal support for hypothesized MI process outcome relationships. Clinical implications and future areas of MI mechanism research are discussed.
Background
While the efficacy and effectiveness of brief interventions for alcohol (ABI) have been demonstrated in primary care, there is weaker evidence in other settings and reviews do not consider differences in content. We conducted a systematic review to measure the effect of ABIs on alcohol consumption and how it differs by the setting, practitioner group and content of intervention.
Methods
We searched MEDLINE, EMBASE, PsycINFO; CINAHL, Social Science Citation Index, Cochrane Library and Global Health up to January 2015 for randomised controlled trials that measured effectiveness of ABIs on alcohol consumption. We grouped outcomes into measures of quantity and frequency indices. We used multilevel meta-analysis to estimate pooled effect sizes and tested for the effect of moderators through a multiparameter Wald test. Stratified analysis of a subset of quantity and frequency outcomes was conducted as a sensitivity check.
Results
52 trials were included contributing data on 29 891 individuals. ABIs reduced the quantity of alcohol consumed by 0.15 SDs. While neither the setting nor content appeared to significantly moderate intervention effectiveness, the provider did in some analyses. Interventions delivered by nurses had the most effect in reducing quantity (d=−0.23, 95% CI (−0.33 to −0.13)) but not frequency of alcohol consumption. All content groups had statistically significant mean effects, brief advice was the most effective in reducing quantity consumed (d=−0.20, 95% CI (−0.30 to −0.09)). Effects were maintained in the stratified sensitivity analysis at the first and last assessment time.
Conclusions
ABIs play a small but significant role in reducing alcohol consumption. Findings show the positive role of nurses in delivering interventions. The lack of evidence on the impact of content of intervention reinforces advice that services should select the ABI tool that best suits their needs.
Objective: Client change talk has been proposed as a mechanism of change in motivational interviewing (MI) by mediating the link between therapist MI-consistent behaviors (MICO) and client behavioral outcomes. We tested under what circumstances this mechanism was supported in the context of a clinical trial of brief MI for heavy drinking among nontreatment seeking young men. Method: We conducted psycholinguistic coding of 174 sessions using the MI Skill Code 2.1 and derived the frequency of MICO and the strength of change talk (CTS) averaged over the session. CTS was examined as a mediator of the relationship between MICO and a drinking composite score measured at 3-month follow-up, controlling for the composite measure at baseline. Finally, we tested therapist gender and MI experience as well as client readiness to change and alcohol problem severity as moderators of this mediation model. Results: CTS significantly predicted outcome (higher strength related to less drinking), but MICO did not predict CTS. However, CTS mediated the relationship between MICO and drinking outcomes when therapists had more experience in MI and when clients had more severe alcohol problems (i.e., significant conditional indirect effects). Conclusions: The mechanism hypothesized by MI theory was operative in our brief MI with heavy drinking young men, but only under particular conditions. Our results suggest that attention should be paid to therapist selection, training, and/or supervision until they reach a certain level of competence, and that MI might not be appropriate for nontreatment seeking clients drinking at a lower level of risk.
Background:
Alcohol use and misuse in young people is a major risk behaviour for mortality and morbidity. Motivational interviewing (MI) is a popular technique for addressing excessive drinking in young adults.
Objectives:
To assess the effects of motivational interviewing (MI) interventions for preventing alcohol misuse and alcohol-related problems in young adults.
Search methods:
We identified relevant evidence from the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 12), MEDLINE (January 1966 to July 2015), EMBASE (January 1988 to July 2015), and PsycINFO (1985 to July 2015). We also searched clinical trial registers and handsearched references of topic-related systematic reviews and the included studies.
Selection criteria:
We included randomised controlled trials in young adults up to the age of 25 years comparing MIs for prevention of alcohol misuse and alcohol-related problems with no intervention, assessment only or alternative interventions for preventing alcohol misuse and alcohol-related problems.
Data collection and analysis:
We used the standard methodological procedures expected by Cochrane.
Main results:
We included a total of 84 trials (22,872 participants), with 70/84 studies reporting interventions in higher risk individuals or settings. Studies with follow-up periods of at least four months were of more interest in assessing the sustainability of intervention effects and were also less susceptible to short-term reporting or publication bias. Overall, the risk of bias assessment showed that these studies provided moderate or low quality evidence.At four or more months follow-up, we found effects in favour of MI for the quantity of alcohol consumed (standardised mean difference (SMD) -0.11, 95% confidence interval (CI) -0.15 to -0.06 or a reduction from 13.7 drinks/week to 12.5 drinks/week; moderate quality evidence); frequency of alcohol consumption (SMD -0.14, 95% CI -0.21 to -0.07 or a reduction in the number of days/week alcohol was consumed from 2.74 days to 2.52 days; moderate quality evidence); and peak blood alcohol concentration, or BAC (SMD -0.12, 95% CI -0.20 to 0.05, or a reduction from 0.144% to 0.131%; moderate quality evidence).We found a marginal effect in favour of MI for alcohol problems (SMD -0.08, 95% CI -0.17 to 0.00 or a reduction in an alcohol problems scale score from 8.91 to 8.18; low quality evidence) and no effects for binge drinking (SMD -0.04, 95% CI -0.09 to 0.02, moderate quality evidence) or for average BAC (SMD -0.05, 95% CI -0.18 to 0.08; moderate quality evidence). We also considered other alcohol-related behavioural outcomes, and at four or more months follow-up, we found no effects on drink-driving (SMD -0.13, 95% CI -0.36 to 0.10; moderate quality of evidence) or other alcohol-related risky behaviour (SMD -0.15, 95% CI -0.31 to 0.01; moderate quality evidence).Further analyses showed that there was no clear relationship between the duration of the MI intervention (in minutes) and effect size. Subgroup analyses revealed no clear subgroup effects for longer-term outcomes (four or more months) for assessment only versus alternative intervention controls; for university/college vs other settings; or for higher risk vs all/low risk participants.None of the studies reported harms related to MI.
Authors' conclusions:
The results of this review indicate that there are no substantive, meaningful benefits of MI interventions for preventing alcohol use, misuse or alcohol-related problems. Although we found some statistically significant effects, the effect sizes were too small, given the measurement scales used in the included studies, to be of relevance to policy or practice. Moreover, the statistically significant effects are not consistent for all misuse measures, and the quality of evidence is not strong, implying that any effects could be inflated by risk of bias.
Commentary to: Ambivalence: Prerequisite for success in motivational interviewing with adolescents?
Motivational Interviewing (MI) is a communication style that aims to motivate a conversational partner for behavior change by enhancing change talk (e.g., “I want to change”) and reducing counter change talk (“I will not change”). The effectiveness of MI has not been evaluated within the domain of environmental behavior change. This experimental field study examines the effects of Motivational Interviewing on environmental behavior within an input-process-output framework. Recorded conversations of MI trained participants (n = 49) were compared to conversations with untrained participants (n = 28). We compared communication skills, client language, and environmental behavior immediately after the intervention and at a three-month follow-up between groups. Trained interviewers showed higher proficiency in MI than untrained interviewers did. Change talk was higher in the MI group, whereas counter change talk showed no difference between intervention groups. Environmental behavior did not differ between groups. Client language — particularly commitment talk — was related with short- and long-term environmental behavior. Our results suggest that MI can foster long-term environmental behavior changes if interviewers succeed to decrease counter change talk, specifically negative commitments.
Client change talk (CT) during motivational interviewing (MI) has been described as a predictor of change in alcohol use. We examined the predictive validity of different strength levels of CT within a brief MI session for 174 young men from the general population screened as hazardous drinkers. CT was measured using the MI Skill Code (MISC 2.1) and categorized with positive (toward change) and negative (against change) valence and 3 strength levels (1=low, 2=medium, 3=high). Analyses included linear regression models predicting drinking at 3-month follow-up, while controlling for baseline drinking. Frequency of overall negative CT (i.e., sum of − 1, − 2, − 3) significantly predicted poorer drinking outcomes. In a multivariate model entering frequency of CT utterances at each level of strength (i.e. + 1, + 2, + 3, − 1, − 2, − 3), the directionality of negative strength ratings was consistently in the expected direction, but only CT-2 was statistically significant. In contrast, overall CT positive (i.e., sum of + 1, + 2, + 3) was not a significant predictor of less alcohol use, but the multivariate model showed that the presence of CT+3 significantly predicted less drinking at 3-month follow-up. Averaged strength summary score (i.e. on the scale from − 3 to + 3) was a significant predictor of better outcome, while percent positive CT was not. Moderation analyses showed that young men with lower baseline readiness to change or lower alcohol problem severity had higher follow-up drinking when they expressed more CT+1 or CT+2, while the opposite pattern was observed with those reporting higher baseline readiness to change or higher alcohol problem severity. Mixed findings for varying levels of positive CT strength might explain previous studies showing poor predictive validity of positive client language in MI. Together with other studies in similar settings, these findings suggest the importance of advanced MI techniques to shape client language to soften negative change talk (also known as sustain talk) and elicit positive CT verbalized with high intensity.
Objective:
Client change talk has been proposed as a mechanism of change in motivational interviewing (MI) by mediating the link between therapist MI-consistent behaviors (MICO) and client behavioral outcomes. We tested under what circumstances this mechanism was supported in the context of a clinical trial of brief MI for heavy drinking among nontreatment seeking young men.
Method:
We conducted psycholinguistic coding of 174 sessions using the MI Skill Code 2.1 and derived the frequency of MICO and the strength of change talk (CTS) averaged over the session. CTS was examined as a mediator of the relationship between MICO and a drinking composite score measured at 3-month follow-up, controlling for the composite measure at baseline. Finally, we tested therapist gender and MI experience as well as client readiness to change and alcohol problem severity as moderators of this mediation model.
Results:
CTS significantly predicted outcome (higher strength related to less drinking), but MICO did not predict CTS. However, CTS mediated the relationship between MICO and drinking outcomes when therapists had more experience in MI and when clients had more severe alcohol problems (i.e., significant conditional indirect effects).
Conclusions:
The mechanism hypothesized by MI theory was operative in our brief MI with heavy drinking young men, but only under particular conditions. Our results suggest that attention should be paid to therapist selection, training, and/or supervision until they reach a certain level of competence, and that MI might not be appropriate for nontreatment seeking clients drinking at a lower level of risk. (PsycINFO Database Record
Prior research indicates that therapist effects can be sizeable in substance-abuse treatment. Therapist differences were examined within a multisite (N = 1726) randomized trial of three psychosocial treatments for alcohol problems: twelve-step facilitation (TSF), cognitive-behavioral skills training (CBT), and motivational enhancement therapy (MET). Therapists (N = 80) were nested within treatments, selected and trained for expertise in a specific approach. This report describes: (1) differences in therapist characteristics across the three treatments; (2) the magnitude of therapist effects within each treatment; and (3) exploratory analyses of therapist attributes associated with successful outcomes. Therapist characteristics differed between TSF and the other two conditions. Significant therapist effects were found in client satisfaction and outcomes, even after covarying for effects of treatment sites and client baseline characteristics. Specific therapist attributes were predictive of client outcomes. Outlier therapists whose caseloads showed unusually poor outcomes accounted for most of the observed effects.
The aim of the study was to explore the evidence base on alcohol screening and brief intervention for adolescents to determine age appropriate screening tools, effective brief interventions and appropriate locations to undertake these activities.
A review of existing reviews (2003-2013) and a systematic review of recent research not included in earlier reviews.
The CRAFFT and AUDIT tools are recommended for identification of 'at risk' adolescents. Motivational interventions delivered over one or more sessions and based in health care or educational settings are effective at reducing levels of consumption and alcohol-related harm.
Further research to develop age appropriate screening tools needs to be undertaken. Screening and brief intervention activity should be undertaken in settings where young people are likely to present; further assessment at such venues as paediatric emergency departments, sexual health clinics and youth offending teams should be evaluated. The use of electronic (web/smart-phone based) screening and intervention shows promise and should also be the focus of future research.
MI-based interventions are widely used with a number of different clinical populations and their efficacy has been well established. However, the clinicians' training has not traditionally been the focus of empirical investigations. We conducted a meta-analytic review of clinicians' MI-training and MI-skills findings. Fifteen studies were included, involving 715 clinicians. Pre-post training effect sizes were calculated (13 studies) as well as group contrast effect sizes (7 studies). Pre-post training comparisons showed medium to large ES of MI training, which are maintained over a short period of time. When compared to a control group, our results also suggested higher MI proficiency in the professionals trained in MI than in nontrained ones (medium ES). However, this estimate of ES may be affected by a publication bias and therefore, should be considered with caution. Methodological limitations and potential sources of heterogeneity of the studies included in this meta-analysis are discussed.
In the context of the development of prototypic assessment instruments in the areas of cognition, personality, and adaptive functioning, the issues of standardization, norming procedures, and the important psychometrics of test reliability and validity are evaluated critically. Criteria, guidelines, and simple rules of thumb are provided to assist the clinician faced with the challenge of choosing an appropriate test instrument for a given psychological assessment. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Parents, referral sources, and even therapists wonder whether the gender and racial match between therapists and patients contributes to poorer alliances and treatment dropout. Six hundred adolescent substance abusers and their therapists from a large randomized clinical trial were grouped according to matches and mismatches on both gender and race, and alliance ratings were collected from both patients and therapists. Results revealed that gender-matched dyads reported higher alliances and were more likely to complete treatment. Racial matching predicted greater retention but not patient-rated alliance. However, therapists in mismatched dyads rated significantly lower alliances. Results suggest that, although multicultural training remains critical, training emphasis should also be placed on understanding how gender and racial differences affect therapeutic processes. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Clinicians’ impact on substance use disorder treatment has been much less studied than therapy and patient variables. Yet,
in this selective review of literature, a growing body of empirical work on clinicians’ impact highlights several key issues
that have relevance to both clinical practice and future research. These issues include clinicians’ effect on treatment retention
and outcome, professional characteristics, recovery status, adherence to protocols, countertransference, alliance, personality,
beliefs about treatment, and professional practice issues. Specific recommendations are offered to help improve the quality
of care that clinicians provide. In particular, it is suggested that greater accountability for clinicians’ performance be
balanced with increased support for their very difficult role. Methodological issues in studying clinicians are also addressed.
Training through traditional workshops is relatively ineffective for changing counseling practices. Teleconferencing supervision (TCS) was developed to provide remote, live supervision for training motivational interviewing (MI).
Ninety-seven drug treatment counselors completed a 2-day MI workshop and were randomized to live supervision via teleconferencing (TCS; n = 32), standard tape-based supervision (tape; n = 32), or workshop alone (workshop; n = 33). Supervision conditions received 5 weekly supervision sessions at their sites using actors as standard patients. Sessions with clients were rated for MI skill with the Motivational Interviewing Treatment Integrity (MITI) Coding System pre-workshop and 1, 8, and 20 weeks post-workshop. Mixed-effects linear models were used to test training condition on MI skill at 8 and 20 weeks.
TCS scored better than workshop on the MITI for spirit (mean difference = 0.76; p < .0001; d = 1.01) and empathy (mean difference = 0.68; p < .001; d = 0.74). TCS was superior to workshop in reducing MI non-adherence and was superior to workshop and tape in increasing reflection to question ratio. Tape was superior to TCS in increasing complex reflections. Percentage of counselors meeting proficiency differed significantly between training conditions for the most stringent threshold (spirit and empathy scores ≥ 6).
TCS shows promise for promoting new counseling behaviors following participation in workshop training. However, further work is needed to improve supervision methods to bring more clinicians to high levels of proficiency and facilitate dissemination of evidence-based practices.
Teaching community program therapists to use motivational interviewing (MI) strategies for addictions treatment with sufficient frequency (i.e., adherence) and skill (i.e., competence) is a priority and challenge for the field. The development of psychometrically valid MI integrity measures that can be used for supervision and evaluation and be both sensitive and robust across clinical situations is needed.
This article examines the performance of the Independent Tape Rating Scale (ITRS) when used to evaluate the delivery of MI within a one-session assessment intake.
Audiotapes of 315 sessions of therapists in MI and counseling-as-usual conditions were rated according to the ITRS by raters blind to treatment condition.
Results indicate that community therapists were successfully trained and supervised to use MI within an assessment intake session, with MI adherence and competence that was discriminable from counseling-as-usual practices. Increased therapist MI adherence and competence was associated with increases in an index of client motivation for change, though unrelated to treatment outcome.
The ITRS appears to be a valid instrument for measuring therapist MI adherence and competence within an assessment intake.
Client speech in favor of change within motivational interviewing sessions has been linked to treatment outcomes, but a causal chain has not yet been demonstrated. Using a sequential behavioral coding system for client speech, the authors found that, at both the session and utterance levels, specific therapist behaviors predict client change talk. Further, a direct link from change talk to drinking outcomes was observed, and support was found for a mediational role for change talk between therapist behavior and client drinking outcomes. These data provide preliminary support for the proposed causal chain indicating that client speech within treatment sessions can be influenced by therapists, who can employ this influence to improve outcomes. Selective eliciting and reinforcement of change talk is proposed as a specific active ingredient of motivational interviewing.
Numerous studies have reported that brief interventions delivered in primary care are effective in reducing excessive drinking. However, much of this work has been criticised for being clinically unrepresentative. This review aimed to assess the effectiveness of brief interventions in primary care and determine if outcomes differ between efficacy and effectiveness trials.
A pre-specified search strategy was used to search all relevant electronic databases up to 2006. We also hand-searched the reference lists of key articles and reviews. We included randomised controlled trials (RCT) involving patients in primary care who were not seeking alcohol treatment and who received brief intervention. Two authors independently abstracted data and assessed trial quality. Random effects meta-analyses, subgroup and sensitivity analyses and meta-regression were conducted.
The primary meta-analysis included 22 RCT and evaluated outcomes in over 5800 patients. At 1 year follow up, patients receiving brief intervention had a significant reduction in alcohol consumption compared with controls [mean difference: -38 g week(-1), 95%CI (confidence interval): -54 to -23], although there was substantial heterogeneity between trials (I(2) = 57%). Subgroup analysis confirmed the benefit of brief intervention in men but not in women. Extended intervention was associated with a non-significantly increased reduction in alcohol consumption compared with brief intervention. There was no significant difference in effect sizes for efficacy and effectiveness trials.
Brief interventions can reduce alcohol consumption in men, with benefit at a year after intervention, but they are unproven in women for whom there is insufficient research data. Longer counselling has little additional effect over brief intervention. The lack of differences in outcomes between efficacy and effectiveness trials suggests that the current literature is relevant to routine primary care.
Of 45 Ss who began treatment for problem drinking, 21 males and 20 females completed enough sessions to be regarded as treated in 1 of 4 groups: (a) bibliotherapy, in which clients received self-help materials but no treatment sessions; (b) behavioral self-control training (BSCT), consisting of 6 weekly sessions; (c) BSCT plus 12 sessions of relaxation, communication, and assertion training; or (d) BSCT plus 12 wks of individually tailored broad-spectrum modules. Multimodal assessment was used to evaluate drinking behavior, life problems, and general functioning. All groups showed significant improvement on drinking measures and general improvement on other dimensions, a trend confirmed by collateral reports. Bibliotherapy clients spent more hours per week intoxicated than other groups, but no other significant group differences were observed. The degree to which therapists showed accurate empathy proved to be a good predictor of client outcome. (43 ref)
Clinicians' impact on substance use disorder treatment has been much less studied than therapy and patient variables. Yet, in this selective review of literature, a growing body of empirical work on clinicians' impact highlights several key issues that have relevance both to clinical practice and future research. These issues include clinicians' effect on treatment retention and outcome, professional characteristics, recovery status, adherence to protocols, counter-transference, alliance, personality, beliefs about treatment, and professional practice issues. Specific recommendations are offered to help improve the quality of care clinicians provide. In particular, it is suggested that greater accountability for clinicians' performance be balanced with increased support for their very difficult role. Methodological issues in studying clinicians are also addressed.
To determine the effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting.
Systematic review.
Medline, PsychInfo, Cochrane Library, reference lists from identified studies and review articles, and contact with experts.
Change in alcohol consumption.
Eight studies were retrieved. Most had methodological weaknesses. Only one study, with a relatively intensive intervention and a short follow up period, showed a significantly large reduction in alcohol consumption in the intervention group.
Evidence for the effectiveness of opportunistic brief interventions in a general hospital setting for problem drinkers is still inconclusive.
The Evaluating Methods for Motivational Enhancement Education trial evaluated methods for learning motivational interviewing (MI). Licensed substance abuse professionals (N = 140) were randomized to 5 training conditions: (a) clinical workshop only; (b) workshop plus practice feedback; (c) workshop plus individual coaching sessions; (d) workshop, feedback, and coaching; or (e) a waiting list control group of self-guided training. Audiotaped practice samples were analyzed at baseline, posttraining, and 4, 8, and 12 months later. Relative to controls, the 4 trained groups showed larger gains in proficiency. Coaching and/or feedback also increased posttraining proficiency. After delayed training, the waiting list group showed modest gains in proficiency. Posttraining proficiency was generally well maintained throughout follow-up. Clinician self-reports of MI skillfulness were unrelated to proficiency levels in observed practice.
The purpose of this study was to replicate and extend previous findings (Tollison et al., 2008) on the association between peer facilitator adherence to motivational interviewing (MI) microskills and college student drinking behavior. This study used a larger sample size, multiple follow-up time-points, and latent variable analyses allowing for more complex models to be tested in a sample with different characteristics than Tollison et al. Matriculating students who participated in high school sports (N=327) took part in a Brief Alcohol Screening and Intervention for College Students led by peer facilitators trained in motivational interviewing (MI). Participants were assessed pre- and immediately postintervention on contemplation to change, as well as pre-, 5months, and 10months postintervention on drinking quantity. Independent coders used the Motivational Interviewing Treatment Integrity scale (Moyers, Martin, Manuel, & Miller, 2003) to evaluate therapist MI adherence. Contrary to our previous study, results indicated that a higher number of open questions was positively related to increases in drinking, especially for heavier drinkers. Congruent with the previous study, more simple reflections was positively related to increases in drinking. Finally, this study revealed that heavier baseline drinking was associated with more simple reflections. There were no significant results found for changes in contemplation. Results corroborate previous findings that the excessive use of simple reflections may be indicative of countertherapeutic outcomes while raising questions about the relationship between the frequency of open questions and therapeutic outcomes.
Aims:
With the increased need for sanctioning behavioral addiction treatments to guide key stakeholders, focus has shifted to developing and applying criteria for establishing empirically supported treatments (EST). Among the many criteria offered, demonstration of incremental efficacy over a placebo or comparison in at least two independent randomized clinical trials (RCTs) has been the gold standard. While necessary, the present EST criteria are not sufficient. The present work: (i) argues for empirically supported specificity in behavioral addiction treatment, (ii) explores the limitations of empirical support for EST efficacy without evidence of specificity and (iii) discusses implications and recommendations for ultimately raising the bar for status as an EST.
Methods:
The authors review relevant literature on ESTs, evidence-based practice and clinical trial design in the addictions and related disciplines.
Results:
We clarify that the additional bar of specificity does not denote uniqueness in causal processes and we argue that specificity should not be inferred only via the nature of the experimental contrast. Rather, a treatment has specificity if its active ingredients are identified and validated empirically as predictors of subsequent treatment-related outcomes. Within this new definition, there are implications for clinical research and other key stakeholders.
Conclusions:
A heightened centrality of empirically supported addiction treatment ingredients moving forward will advance clinical knowledge and evaluation methodology at a far greater pace.
The purpose of this study was to examine whether counselor adherence to Motivational Interviewing (MI) principles was associated with more productive within-session client behavior in a smoking cessation trial for African American smokers. For these analyses 89 baseline counseling sessions of the trial were audiotaped and coded using the Motivational Interviewing Skill Code (MISC). Counselor adherence indicators included a global subjective rating of MI adherence and the frequency of MI-consistent and MI-inconsistent counselor behaviors described in the MISC. Indicators of productive client behaviors included global subjective ratings of within-session client functioning and counselor-client interaction, as well as the frequency of statements by the client favorable toward changing behavior (“change talk”) and resistant regarding changing behavior (“resist-change talk”). Results provided support for the principles of MI. Counselor adherence indexed by both the global subjective rating and MI-consistent behavior frequency was significantly positively associated with global ratings of within-session client functioning and counselor-client interaction, as well as more change talk.
Professional training in motivational interviewing, as on many other topics, is often delivered via a one-time
clinical workshop. To what extent do practitioners actually acquire skillfulness through such training? Twenty-two
counselors participated in training, of whom 15 completed a study of changes in practice behavior up to 4 months
after a motivational interviewing workshop. In addition to self-report questionnaires, they provided taped practice
samples before and after training, which were coded for counselor and client behavior. On paper-and-pencil measures,
participants reported large increases in motivational interviewing skills. Observational measures reflected more modest
changes in practice behavior that were often retained 4 months after training. Clients, however, did not show the
response changes that have been found to be predictive of better outcomes with motivational interviewing. While
practice behavior changed to a statistically significant extent, the effect of training was apparently not large enough to
make a difference in client response. Possible implications for training and quality control of psychotherapies are
considered.
Alcohol misuse occurs commonly on college campuses, necessitating prevention programs to help college drinkers reduce consumption and minimize harmful consequences. Computer-delivered interventions (CDIs) have been widely used due to their low cost and ease of dissemination but whether CDIs are efficacious and whether they produce benefits equivalent to face-to-face interventions (FTFIs) remain unclear. Therefore, we identified controlled trials of both CDIs and FTFIs and used meta-analysis (a) to determine the relative efficacy of these two approaches and (b) to test predictors of intervention efficacy. We included studies examining FTFIs (N=5237; 56% female; 87% White) and CDIs (N=32,243; 51% female; 81% White). Independent raters coded participant characteristics, design and methodological features, intervention content, and calculated weighted mean effect sizes using fixed and random-effects models. Analyses indicated that, compared to controls, FTFI participants drank less, drank less frequently, and reported fewer problems at short-term follow-up (d(+)s=0.15-0.19); they continued to consume lower quantities at intermediate (d(+)=0.23) and long-term (d(+)=0.14) follow-ups. Compared to controls, CDI participants reported lower quantities, frequency, and peak intoxication at short-term follow-up (d(+)s=0.13-0.29), but these effects were not maintained. Direct comparisons between FTFI and CDIs were infrequent, but these trials favored the FTFIs on both quantity and problem measures (d(+)s=0.12-0.20). Moderator analyses identified participant and intervention characteristics that influence intervention efficacy. Overall, we conclude that FTFIs provide the most effective and enduring effects.
A major proportion of the disease burden and deaths for young people in developed nations is attributable to misuse of alcohol and illicit drugs. Patterns of substance use established in adolescence are quite stable and predict chronic patterns of use, mortality, and morbidity later in life. We integrated findings of systematic reviews to summarise evidence for interventions aimed at prevention and reduction of harms related to adolescent substance use. Evidence of efficacy was available for developmental prevention interventions that aim to prevent onset of harmful patterns in settings such as vulnerable families, schools, and communities, and universal strategies to reduce attractiveness of substance use. Regulatory interventions aim to increase perceived costs and reduce availability and accessibility of substances. Increasing price, restricting settings of use, and raising legal purchase age are effective in reducing use of alcohol and tobacco and related harms. Screening and brief intervention are efficacious, but efficacy of a range of treatment approaches has not been reliably established. Harm-reduction interventions are effective in young people involved in risky and injecting substance use.
Two-year blind fllow-up interviews were completed with 69 of 82 problem drinkers treated by behavioral self-control training offered in various formats including bibliotherapy, individual counseling, and group therapy. Corroborative data were obtained via breath tests and collateral interviews. Significant improvement observed on drinking and other measures at prior follow-up points was found to be maintained at 2 years. Stability of outcome over the 2-year period was found to be good, with more than 80% of clients showing equal or greater improvement at 24 months relative to any prior follow-up point. Relapse rates from controlled drinking were found to be similar to those from abstinent outcomes. Severity of problem drinking at intake remained the best single predictor of controlled drinking vs. abstinent outcomes, with more severe cases tending toward abstinence.
Heavy drinking is one of the leading causes of morbidity and mortality in young men. Brief motivational intervention (BMI) has shown promising results for young people, but has never been tested in young men in the community who volunteered to receive an intervention.
We evaluated the effectiveness of BMI in reducing alcohol use among heavy episodic users and in maintaining low-risk drinking among nonheavy episodic users. Participants were French-speaking young men attending the mandatory Swiss army conscription process. They were offered the opportunity to receive a 20-minute BMI, and those interested were randomized into an intervention group (BMI immediately) or into a control group (BMI after the 6-month follow-up assessment, in a waiting list design). Analyses were conducted separately for heavy and nonheavy episodic users (separated using baseline heavy episodic use frequency) as the hypotheses tested were different between both groups (primary vs. secondary prevention intervention).
From a pool of 6,085 young men invited to receive BMI, 727 (11.9%) showed up and 572 were included in the study (after exclusions related to organizational aspects of the conscription process). Among nonheavy episodic users, there was a protective effect of BMI on weekly alcohol use (p < 0.05). Among heavy episodic users, there were no significant effects of BMI.
About 12% of young men were interested in addressing their drinking within the BMI framework, suggesting that there is some need for easily accessible alcohol intervention. The present intervention did have a preventive effect among low-risk young drinkers in helping them maintain their patterns of alcohol use. An explanation for the lack of effectiveness among heavy episodic users might be that those individuals interested in BMI had patterns of more severe alcohol use, thereby making change more difficult.
Brief motivational intervention (BMI) is one of the few effective strategies targeting alcohol consumption, but has not been tested in young men in the community. We evaluated the efficacy of BMI in reducing alcohol use and related problems among binge drinkers and in maintaining low-risk drinking among non-bingers.
A random sample of a census of men included during army conscription (which is mandatory for 20-year-old males in Switzerland) was randomized to receive a single face-to-face BMI session (N=199) or no intervention (N=219). A six-month follow-up rate was obtained for 88.7% of the subjects.
Among binge drinkers, there was 20% less drinking in the BMI group versus the control group (incidence rate ratio=0.80, confidence interval 0.66-0.98, p=0.03); the BMI group showed a weekly reduction of 1.5 drinks compared to an increase of 0.8 drinks weekly in the control group. Among subjects who experienced one or more alcohol-related consequences over the last 12 months, there was 19% less drinking in the BMI group compared to the control group (incidence rate ratio=0.81, confidence interval 0.67-0.97, p=0.04). Among non-bingers, BMI did not contribute to the maintenance of low-risk drinking.
BMI reduced the alcohol use of binge drinkers, particularly among those who experienced certain alcohol-related adverse consequences. No preventive effect of BMI was observed among non-bingers. BMI is a plausible secondary preventive option for young binge drinkers.
The process of eliciting client language toward change (change talk [CT]) is implicated as a causal mechanism in motivational interviewing (MI) and brief motivational interventions (BMI). We investigated the articulation of counselor behaviors and CT during BMI with young men. We coded 149 sessions using the Motivational Interviewing Skill Code and summarized these codes into three counselor categories (MI-consistent [MICO], MI-inconsistent [MIIN], other) and three client categories (CT, counter CT [CCT], follow/neutral [F/N]). We then computed immediate transition frequencies and odds ratios using sequential analysis software. CT was significantly more likely following MICO behaviors, whereas MIIN behaviors only led to CCT and F/N. This strongly supports the use of MI skills to elicit CT during BMI with young men, whose speech also predicted counselor behaviors (particularly CT to MICO and CCT to MIIN). Additional analyses showed that among MICO behaviors, reflective listening may be a particularly powerful technique to elicit CT.
This study is the first to examine within-session therapist and client language/process predictors of a client's decision to complete a written Change Plan in an alcohol-focused motivational interview (MI). Data were from an ongoing hospital-based clinical trial (N = 291). Trained raters coded audiorecorded MI sessions using the Motivational Interviewing Skill Code. Logistic regression analyses found that therapist MI-consistent behaviors (b = .023, p < .001) and client change talk (b = .063, p < .001) were positive predictors, and client counter change talk (b = -.093, p < .001) was a negative predictor of the decision to complete a Change Plan regarding alcohol use. Mean comparisons showed that compared to noncompletion, Change Plan completion did not result in significantly greater changes in client motivational readiness. Completion of a Change Plan is a proximal outcome in MI that is associated with client intention to change (change talk) and may predict follow-up alcohol outcomes. Analyses of such theory-driven proximal client mechanisms provide a more complete model of MI process and may inform MI providers of necessary treatment ingredients.