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Motivational interviewing versus feedback only in
emergency care for young adult problem drinking
Peter M. Monti1,2, Nancy P. Barnett2, Suzanne M. Colby2, Chad J. Gwaltney2, Anthony Spirito2,
Damaris J. Rohsenow1,2 & Robert Woolard3
Providence VA Medical Center, RI, USA,1Brown University Center for Alcohol and Addiction Studies, Providence, RI, USA2and Brown University Medical School,
Rhode Island Hospital, RI, USA3
ABSTRACT
Aim To establish the efficacy of a brief motivational intervention compared to feedback only when delivered in an
emergency department for reducing alcohol use and problems among young adults. Design Two-group randomized
controlled trial with follow-up assessments at 6 and 12 months. Setting Level I Trauma Center. Participants A total
of 198 18–24-year-old patients who were either alcohol positive upon hospital admission or met screening criteria for
alcohol problems. Intervention Participants were assigned randomly to receive a one-session motivational interven-
tion (MI) that included personalized feedback, or the personalized feedback report only (FO). All participants received
additional telephone contact 1 month and 3 months after baseline. Measurements Demographic information,
alcohol use, alcohol problems and treatment seeking. Findings Six months after the intervention MI participants
drank on fewer days, had fewer heavy drinking days and drank fewer drinks per week in the past month than did FO
patients. These effects were maintained at 12 months. Clinical significance evaluation indicated that twice as many MI
participants as FO participants reliably reduced their volume of alcohol consumption from baseline to 12 months.
Reductions in alcohol-related injuries and moving violations, and increases in alcohol treatment-seeking were
observed across both conditions at both follow-ups with no differences between conditions. Conclusions This study
provides new data supporting the potential of the motivational intervention tested to reduce alcohol consumption
among high-risk youth.
Keywords Alcohol, brief intervention, emergency room, motivational interviewing, young adults.
Correspondence to: Peter M. Monti, Center for Alcohol and Addiction Studies, Brown University, Box G-S121-5, Providence, RI 02912, USA.
E-mail: peter_monti@brown.edu
Submitted 5 September 2006; initial review completed 21 November 2006; final version accepted 7 March 2007
INTRODUCTION
The highest rates of alcohol consumption and problem
drinking in the United States are among 18–25-year-olds,
with approximately 41% of young adults engaging in
heavy episodic drinking (five or more drinks on one occa-
sion) in the past month [1]. Young adults have the highest
rate of alcohol-related traffic deaths, and in the past 3
years unintentional alcohol-related deaths have increased
significantly in 18–24-year-olds [2]. Despite their high
level of risk, adolescents and young adults are less likely
than older adults to perceive a need and less likely to
present for treatment for alcohol and substance abuse [3].
As many as 47% of injured trauma patients have posi-
tive blood alcohol levels and approximately 40% of
trauma patients with negative blood alcohol levels meet
criteria for current alcohol dependence [4,5]. Urgent care
settings provide an opportunity to reach young adults
who might benefit from intervention, and brief interven-
tions conducted in these settings have proved useful with
adults in reducing both alcohol consumption and
alcohol-related injuries when compared to controls [6,7].
Brief interventions for alcohol are recommended for
medical settings [8] including emergency departments
(ED; [9]), and are now mandated in trauma centers [10].
Brief intervention studies conducted in medical set-
tings have typically followed guidelines of motivational
interviewing (MI; [11]), which is a client-centered, direc-
tive method for enhancing intrinsic motivation to change
by exploring and resolving ambivalence. MI is guided by
RESEARCH REPORT doi:10.1111/j.1360-0443.2007.01878.x
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
four principles: expressing empathy, developing discrep-
ancy, rolling with resistance and supporting self-efficacy.
MI has proved effective in reducing problem drinking
among adult drinkers [12,13] and college students (see
[14] for review), and with adults, young adults and high-
risk adolescents in the ED [15–17]. MI is particularly well
suited for use in an ED in that it is used easily with
patients at all levels of readiness to change [11]. Relative
to no-treatment control groups the evidence in favor of
using MI in the ED is strong.
Personalized feedback about a patient or client’s
alcohol use and alcohol-related risks is almost always
included in brief interventions and MI sessions. Person-
alized feedback typically includes gender- and age-based
normative information about alcohol use rates and spe-
cific information about personal risk levels [18,19]. Per-
sonal feedback per se does not require the presence of a
counselor and its delivery takes considerably less time
than a full MI. As a very brief but personalized and edu-
cational approach it is an ecologically valid alternative to
in-person counseling, and in studies of college students
there is support for its efficacy as a stand-alone interven-
tion [20–22]. Given the personnel required to deliver MIs
as well as the additional time required, above and beyond
the time associated with personalized feedback, the ques-
tion arises as to whether personalized feedback only
would have the same impact as a full MI. This question is
especially pertinent for working in an ED where time and
clinical personnel are most valuable. Because this ques-
tion has not been addressed in an ED setting, the present
study was designed to do so.
The objective of this study was to examine the efficacy
of a brief MI that included personalized feedback com-
pared to a feedback only (FO) condition when delivered in
an ED setting with a sample of young adult patients with
drinking problems. We selected an active comparison
condition without controlling for contact time, as MI has
already been shown to be superior to a no-treatment
group, and we wished to test it in a real-world setting
against an intervention with proven efficacy in a similar-
age population. We provided booster sessions 1 and
3 months after the intervention for both conditions, as
additional contact following treatment is recommended
by clinical guidelines [23,24]. Given the additional coun-
seling that the MI provides, we hypothesized that patients
who received MI would show lower levels of consumption
and alcohol-related problems at 6- and 12-month
follow-up than those receiving FO.
METHODS
Patients between the ages of 18–24 years at a level 1
trauma center in Rhode Island were invited to participate
in the study between January 2000 and June 2003 if
they were treated in the ED and: (a) had a blood alcohol
concentration (BAC) greater than 0.01% according to a
biochemical test, (b) reported drinking alcohol in the
6 hours prior to the event that caused their visit or (c)
scored 8 or higher on the Alcohol Use Disorders Identifi-
cation Test (AUDIT; [25]). Excluded were patients who did
not speak English, had a self-inflicted injury or were in
police custody. After establishing eligibility, research
counselors conducted a mini-mental status examination
which included being able to remember and explain
important components of the study. Counselors used the
results of the mini-mental examination and clinical
judgement to establish readiness for consent and assess-
ment. All procedures were approved by the university and
hospital Institutional Review Boards and all participants
gave written informed consent. Counselors administered
baseline assessments using a laptop computer (30–
45 minutes), after which patients were assigned ran-
domly to a treatment condition (by the project
coordinator using a random numbers table).
Counselor training and supervision
Counselors were nine bachelor’s and master’s level clini-
cians with previous experience. Counselor expertise level
was intended to be similar to (non-research) clinicians
who might conduct these interventions in medical set-
tings. Counselors received approximately 30 hours of
training in MI, which included readings, exercises,
viewing demonstrations and extensive observed role-
playing of MI techniques and the specific project protocol.
Weekly supervision in MI was conducted by the second
author. Patient reports of therapist behavior (see below)
were also reviewed to ensure standardization.
Follow-up assessments
Follow-up assessments were conducted 6 and 12 months
after baseline by research assistants blind to intervention
condition. Participants received a $25 gift certificate for
participating at baseline, $15 cash for the 1-month
booster, $30 for the 3-month booster, $40 each for 6- and
12-month follow-ups, and a $30 bonus if all follow-ups
were completed within 1 month of their due dates.
Measures
The time-line follow-back (TLFB; [26]) method was used
to measure alcohol use for the 30 days prior to the ED
visit, and prior to the 6-month and 12-month follow-up
appointments. Number of days drinking, number of
heavy drinking days (ⱖfive drinks for men, ⱖfour for
women), and average drinks per week were calculated.
Alcohol-related consequences were measured using the
Rutgers Alcohol Problem Index (RAPI; 27), which had a
Brief interventions for young adults 1235
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
3-year time-frame at baseline and a 6-month window at
each follow-up (Cronbach’s alpha =0.90). Other mea-
sures included a count of alcohol-related injuries (Ado-
lescent Injury Checklist; [28]), frequency of driving
within an hour of drinking one or more drinks [29] and
five items measuring counseling or treatment for alcohol
problems. For the injury, driving and treatment mea-
sures, information collected at baseline reflected the past
year; 6- and 12-month follow-ups reflected the past
6 months and were combined to reflect the year of
follow-up. Driving records from participants’ State
Department of Motor Vehicles were reviewed, from which
driving violations, including alcohol-related violations,
for the 1 year before and after baseline were extracted.
Patient perception of the interventions was measured
by seven items reflecting session process and content
(Cronbach’s alpha =0.70; Table 1). Patients who com-
pleted follow-up interviews provided the name of an
informant who was contacted to provide a collateral
report of the patient’s alcohol use (number of heavy
drinking days) and alcohol consequences using a modi-
fied RAPI.
MI condition
The MI (30–45 minutes) was delivered in the ED and
incorporated open-ended exploration, personalized feed-
back, support for self-efficacy and discussion about
patients’ alcohol use and associated risky behaviors [30].
Session components included establishing rapport,
assessing motivation for change, enhancing motivation
and establishing goals for change. A worksheet was used
to outline the patient’s reasons for change and barriers to
change. A graphic personalized feedback report was
derived from the baseline assessments and included nor-
mative information about consumption, summaries of
the patient’s alcohol-related consequences and indicators
of risk, and was discussed in the MI session to enhance
motivation. If the patient was interested in discussing
change, a goal worksheet containing reduction and ces-
sation strategies was used to facilitate this process.
Patients received copies of the worksheets and feedback
report, and handouts about alcohol risks and local treat-
ment facilities.
Telephone booster sessions were conducted 1 and
3 months after baseline. The 1-month booster
(20 minutes) started with an assessment (30-day TLFB)
of the patient’s past-month drinking. The counselor then
reviewed the patient’s goals from the first session and
inquired about progress. Goals were adjusted or new
goals set. For the 3-month booster (25–30 minutes),
patients completed a short assessment battery of alcohol
consumption and problem measures described above. A
new feedback sheet about the patient’s recent behavior
relative to their baseline report was generated and
reviewed, and a copy mailed to the patient. Progress
toward goals since the first booster was reviewed and new
goals were generated and discussed.
FO condition
Patients in FO received the same baseline assessment and
computer-generated personalized feedback report as
those in MI. Counselors introduced the report as provid-
ing information about how much the patients drink and
what happens when they drink, and how they compare to
others their age. Conversation with the counselor was
minimal, but any questions or concerns were addressed
appropriately. Contact lasted 1–3 minutes. Patients
received the same handouts as in MI. One month after
baseline patients in the FO condition received a telephone
call from the counselor, which consisted only of the
assessment described in the MI section above
(5–10 minutes). At 3 months FO patients completed the
Table 1 Patient reports of motivational interview and feedback only sessions.
Measure
MI (n =87)
M (SD)
FO (n =91)
M (SD) df t
The counselor was concerned about me 3.69 (0.49) 3.42 (0.70) 176 3.01**
The counselor helped me believe that I can change my drinking if I want to 3.52 (0.71) 3.12 (0.95) 176 3.15**
The counselor made me feel that it is up to me to make decisions about my
drinking and what I do when I drink
3.80 (0.53) 3.14 (0.99) 175 5.55***
The counselor gave me some helpful suggestions about drinking or things
that happen when I drinka
3.66 (0.65) 2.64 (1.13) 141 6.64***
The counselor was easy to talk to 3.92 (0.27) 3.92 (0.27) 176 -0.09
The counselor gave me the chance to ask questionsa3.83 (0.45) 3.75 (0.50) 140 1.06
How satisfied were you with the session?a4.65 (0.69) 4.58 (0.60) 141 -0.18
The first item was answered on a five-pointscale from 1, ‘not at all satisfied’, to 5, ‘very satisfied’. The other items were answeredon a four-point scale from
1, ‘strongly disagree’, to 4, ‘strongly agree’. aThis item was added to the measure after the start of the trial, which resulted in a lower n.**P<0.01;
***P<0.001.
1236 Peter M. Monti et al.
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
same assessment as MI patients (10–15 minutes) and
were mailed a new feedback sheet identical to the one
used in the MI booster.
Data analysis
Patients who were randomized to condition were
followed-up and included in analyses, regardless of
whether boosters were completed. Frequency distribu-
tions were evaluated for normality and outliers adjusted
[31]. The driving after drinking variable was log-
transformed to correct for positive skew. The alcohol-
related injuries measure was also positively skewed but
remained skewed after transformation, so was dichoto-
mized. For continuous measures, repeated-measures
analysis of variance (ANOVA) or analysis of covariance
(ANCOVA) were conducted. Repeated-measures c2analy-
sis was used for dichotomous outcomes.
Clinical significance was evaluated using the Jacobsen
& Truax [32] reliable change index which determines the
reliability of change that occurred following an interven-
tion by comparing change in participants from baseline
to follow-up to the standard error of measurement of the
outcome. The reliable change index =x1–x
2/√2(s1√1-
rxx)2, where x1=baseline score, x2=12-month score,
s1=the standard deviation of the baseline score and
rxx =the test–retest reliability of the measure (0.96) [33].
Jacobsen & Truax also recommend defining a cut-off
point to establish when an individual’s behavior falls into
a normal distribution. In our sample, using a cut-off 2
standard deviations (SD) from the baseline mean of
average drinks per week (recommended by Jacobsen &
Truax when a normative population is not available)
resulted in a cut-off of 0. As this is not a reasonable cut-off
we did not use a cut-off score, which limited us only in
that we were not able to establish the proportion of indi-
viduals who were ‘recovered’ (i.e. reliably below the cut-
off), a distinction not particularly important in this
sample. Using a 95% confidence interval around the
baseline score, we determined the proportion of partici-
pants in each condition who were reliably improved or
reliably worse.
RESULTS
A total of 198 patients (111 BAC positive, 40 self-report
positive and 47 AUDIT-positive) were randomized. Infor-
mation about these three groups is presented in Table 2.
Patient eligibility and enrollment are shown in Fig. 1.
Baseline differences
Patients’ descriptive information is presented in Table 3.
Patients in FO had more years of school, but no other
significant differences in demographics, consumption or
alcohol problems between the conditions were detected.
There were no significant differences in the proportion of
patients assigned to the intervention conditions for each
counselor.
Treatment fidelity
Items reflecting non-specific counseling techniques and
session quality (i.e. ‘the counselor was easy to talk to’,
‘the counselor gave me the chance to ask questions’ and
‘how satisfied were you with the session?’) did not differ
between conditions but MI patients, compared to FO, gave
higher ratings for the counselors on MI-consistent topics
(Table 1).
Booster sessions
Booster 1 was completed by 81.6% of patients in MI and
92.0% in FO, c2(1, n=198) =4.66, P<0.05. Booster 2 was
completed by 73.5% of patients in MI and 90.0% in FO,
c2(1, n=198) =9.09, P<0.01.
Follow-up assessments
c2and t-test analyses showed that completion rates for 6-
and 12-month follow-up assessments (83.3% and
81.3%, respectively) did not differ by gender or condition.
Six- and 12-month completers had higher baseline
numbers of drinking days, t(196) =-2.48, P<0.05,
heavy drinking days, t(196) =-3.26, P<0.05 and drinks
per week, t(196) =-3.08, P<0.01 than non-completers.
Intervention outcomes
Separate repeated-measures ANOVAs were conducted on
number of days drinking, heavy drinking days and stan-
dardized drinks per week for the two follow-ups. For all
these measures time effects were significant, with both
groups significantly reducing their consumption from
baseline to 6- and 12-month follow-up (see Table 4). In
Table 2 Blood alcohol concentration (BAC) and AUDIT total score by trial entry status.
Measure
BAC +(n =111)
M (SD)
Self-report (n =40)
M (SD)
AUDIT (n =47)
M (SD)
BAC 0.132 (0.077) 0.033 (0.049) 0.000 (0.000)
AUDIT Total 11.2 (6.8) 8.5 (6.8) 11.9 (3.8)
AUDIT: Alcohol Use Disorders Identification Test.
Brief interventions for young adults 1237
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
addition, treatment ¥time interactions were found on all
three consumption measures. Follow-up tests showed
that the MI group had significantly greater reductions in
consumption than FO on all three consumption mea-
sures at both 6 and 12 months (Table 4). Analyses of
covariance were also conducted on the three consump-
tion outcomes at 6 and 12 months, with the baseline
value as the covariate, with similar results.
From baseline to 12 months MI patients reduced con-
sumption by 45–53%, depending on the measure,
whereas FO reduced consumption by 11–18%. The clini-
cal significance evaluation of these findings using the
Jacobsen & Truax [32] method indicated that 38.5% of
the patients in MI and 19.3% in FO had reliably reduced
their use (drinks per week) at the 12-month follow-up,
whereas 5.1% and 8.4% had reliably increased their use
in MI and FO, respectively. Follow-up one-way ANOVAs
on the three consumption outcomes at both follow-ups
indicated that there were no counselor differences in out-
comes.
An ANCOVA was conducted with 12-month RAPI
scores using the baseline score as a covariate; treatment
condition effects were not significant. Repeated-measures
ANOVA was used to analyze the drinking and driving
scores, with no significant results. Repeated-measures
ANOVA on the number of moving violations revealed a
significant time effect, F(1, 123) =5.38, P<0.05, indicating
a reduction in moving violations at the 12-month follow-
up but no time ¥condition interaction. Alcohol-related
driving violations were very low (3.7% of the sample at
baseline and 1.6% at follow-up), so were not analyzed
between groups. A repeated-measures c2analysiswith the
alcohol-related injury data revealed a significant time
effect, c2(1, n=138) =36.75, P<0.001, reflecting a reduc-
tion in alcohol-related injuries across conditions with no
condition ¥time interaction. A repeated-measures c2
analysis was also conducted on additional treatment
which revealed a significant time effect, c2(1, n=155) =6.55,
P<0.05, reflecting greater treatment-seeking following
intervention, but no time ¥condition interaction.
198 Patients
randomized
Follow-up assessment
79 Completed 6-month follow up
78 Completed 12-month follow up
10 Withdrew during follow up
2498 Patients ineligible
2482 Eligibility assessment not completed
2439 Eligibility status unknown
43 Refused eligibility assessment
5607 Patients identified
406 Patients not enrolled
208 Refused to participate
101 Agreed to be contacted; never reached
97 Discharged before enrollment attempt
23 Patients not randomized due to discharge
16 Left before assessment began
7 Began assessment but discharged before completed
627 Patients eligible
221 Patients consented
98 Assigned to MI
98 Received intervention
88 Completed at least 1 booster
100 Assigned to FO
100 Received intervention
96 Completed at least 1 booster
Follow-up assessment
86 Completed 6-month follow up
83 Completed 12-month follow up
6 Withdrew during follow up
3125 Patients completed
eligibility assessment
79 Analyzed 86 Analyzed
Figure 1 Flowchart of patient eligibility, enrollment and par ticipation
1238 Peter M. Monti et al.
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
Collateral reports
Collateral reports were completed for 126 (76.4%) and
125 (77.6%) of patients who completed 6- and
12-month follow-ups, respectively. Correlation between
patient and collateral report on number of heavy drink-
ing days in the past 6 months was 0.54 (P<0.001) at 6
months and 0.59 (P<0.001) at 12-month follow-up.
Correlation between patient and informant on alcohol
problems (RAPI score) was 0.48 (P<0.001) at 6 months
and 0.44 (P<0.001) at 12 months. Between-groups
analyses conducted on the collateral report on number of
heavy drinking days, covarying the participant’s report of
heavy drinking days at baseline, resulted in a significant
between-groups difference at 6 months, F(1, 102) =4.94,
P<0.05, but not quite a significant difference at
12 months, F(1, 109) =3.60, P<0.06, both favoring MI.
DISCUSSION
Reductions in alcohol use, alcohol-related injuries and
moving violations, and increases in treatment seeking,
were seen in alcohol-involved young adults following our
brief interventions in a busy ED. Administering a full MI
showed greater efficacy than FO on several measures of
consumption, an effect that persisted up to 12 months.
The magnitude of the effect of MI was striking: patients
who received the full MI reduced their consumption three
to four times as much as FO patients, and over one-third
of the MI group showed clinically significant and reliable
improvement in consumption 1 year following the inter-
vention. However, there were non-significant differences
between groups at baseline on some variables which may
have given participants in the MI group more ‘room’ to
reduce their drinking. Therefore, interpretation of the
within-groups effects on these variables should be made
with caution. Nevertheless, FO does not appear to
improve outcomes in our sample of young adults. Enroll-
ment of participants was inclusive of patients who either
had alcohol detected in the ED or a history of alcohol
problems. Thus, the heterogeneity of this sample sup-
ports the external validity as well as the generalizability of
our findings.
That we did not find group differences on alcohol prob-
lems is somewhat puzzling, especially as an earlier study
of MI with a similar age group showed an impact on
alcohol-related negative consequences, but not consump-
tion, after 6 months [16], although this inconsistency in
findings across studies is not unusual [34]. It is possible
that the personalized feedback had a direct harm reduc-
tion effect, whereas the in-person MI was necessary to
affect alcohol use. Alternatively, effects on use may have
emerged as a result of the boosters. There is evidence that
alcohol use is reduced among patients for several months
following discharge from an ED [35], suggesting that a
one-session MI may add relatively little to the motiva-
tional effects of ED treatment [15]. Boosters may have
strengthened the effect of the intervention and allowed
effects on use to emerge, providing support for clinical
guidelines that recommend telephone or in-person
follow-up after MI.
Table 3 Description of participants.
Measure
MI (n =98)
M (SD) or percentage
FO (n =100)
M (SD) or percentage df t c2
Male 68 (69.4%) 66 (66.0%) 1 0.26
Age 20.7 (1.8) 20.4 (1.9) 196 0.99
Race
White 60 (61.2%) 70 (70.0%) 5 6.31
Hispanic 13 (13.3%) 12 (12.0%)
Black 5 (5.1%) 8 (8.0%)
Asian 2 (2.0%) 1 (1.0%)
American Indian 3 (3.1%) 0 (0.0%)
Other or multiple race 15 (15.3%) 9 (9.0%)
Years of education 11.9 (1.9) 12.7 (1.7) 196 3.07**
BAC in ED 0.083 (0.085) 0.081 (0.086) 196 0.23
Reason for treatment
Assault/fight 23 (23.7%) 26 (26.0%) 5 0.94
Motor vehicle crash 21 (21.6%) 21 (21.0%)
Fall 11 (11.3%) 12 (12.0%)
Other injury 19 (19.6%) 23 (23.0%)
Illness 3 (3.1%) 2 (2.0%)
Substance use only 20 (20.6%) 16 (16.0%)
**P<0.01. MI: motivational interviewing; FO: feedback only; BAC: blood alcohol concentration; ED: emergency departments.
Brief interventions for young adults 1239
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
Table 4 Differences between intervention conditions at 6- and 12-month follow up.
Measure
MI (n =78)
M (SD)
FO (n =83)
M (SD) df
F
(baseline)
F
(time)
F
(Tx)
F
(Tx ¥time)
F (w/in-group
change)
Effect size
(w/in-group
change)
No. days drinking, past month
Baseline 8.27 (6.35) 7.31 (6.27) 1163 0.94
6-month follow-up 4.73 (5.64) 6.19 (6.58) 1163 23.90*** 0.09 6.36** (MI) 26.34***
(FO) 2.92
0.56
0.18
12-month follow-up 4.52 (5.70) 6.54 (6.24) 1159 27.31*** 0.37 11.02*** (MI) 35.41***
(FO) 1.88
0.59
0.14
No. heavy drinking days past month
Baseline 5.49 (5.94) 4.01 (4.48) 1163 3.31
6-month follow-up 2.87 (4.77) 3.64 (4.47) 1163 16.82*** 0.28 9.49** (MI) 24.75***
(FO) 0.54
0.44
0.08
12-month follow-up 2.72 (4.70) 3.53 (4.28) 1159 18.74*** 0.16 8.20** (MI) 25.18***
(FO) 1.11
0.45
0.12
Ave. no. drinks per week past month
Baseline 13.07 (11.95) 10.77 (10.73) 1163 1.69
6-month follow-up 6.63 (9.22) 9.20 (12.16) 1163 21.68*** 0.01 7.98** (MI) 26.84***
(FO) 1.75
0.54
0.15
12-month follow-up 6.10 (8.33) 8.83 (9.67) 1159 31.41*** 0.02 10.35** (MI) 37.73***
(FO) 2.94
0.58
0.18
Measure
MI (n =65)
M (SD)
FO (n =75)
M (SD) df
F
(baseline)
F
(time)
F
(Tx)
F
(Tx ¥time)
Effect size
(Tx ¥time)
RAPI total, past yeara
12-month follow-up 26.96 (25.84) 27.40 (20.06) 1,137 – – 0.02 – -0.03
Times drove w/in 1 hour of drinking, past yearb
Baseline 10.68 (18.71) 14.49 (28.43) 0.04
12-month follow-up 17.40 (30.86) 16.53 (34.06) 1,138 2.98 0.13 0.85 0.00
Driving violations, past yearc
Baseline 0.76 (1.28) 0.60 (0.98) 0.66
12-month follow-up 0.46 (1.00) 0.44 (0.90) 1,123 5.38* 0.31 0.57 0.00
1240 Peter M. Monti et al.
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
Alternatively, the time effects that we observed could
be a reaction to the trauma of the event, to the overall
treatment received in the ED, to the assessment proce-
dures, or to a combination of these factors. Reactivity to
assessment procedures is certainly a possible explana-
tion, as has been illustrated recently in MI findings with a
college student population [36].
Further elaboration on the study’s limitations is war-
ranted. It is important to note that we did not have a
no-treatment control group in this study and, as men-
tioned above, nor could we control for the effects of our
assessment battery or medical treatment in the ED itself.
Both these factors may lead to reductions in alcohol use
and related behavior. Further, the lack of a control group
prevents us from being able to conclude that the reduc-
tions in consumption that occurred in both groups were a
function of our interventions. The lack of equivalence in
counselor contact time between conditions also allows for
an alternative explanation of our favorable findings for
MI. Nevertheless, given the evidence in support of MI
with this population and the mandate to conduct brief
interventions with alcohol-involved patients treated in
trauma settings, we believe including a no-treatment
group or controlling for contact time were less important
than testing a briefer ecologically valid approach in this
applied setting.
It is also important to note that it would have been
ideal to have objective verification of fidelity, but audio-
taping treatment was not feasible in our ED. Indeed, we
started the study audiotaping sessions but found that the
tapes could not be rated confidently due to the quality of
the recordings, so we discontinued audiotaping. Never-
theless, patient assessments of treatment content and
process suggested that MI principles were being followed.
An additional limitation of the present study is that the
sample was limited to young adults, and the results may
not generalize to other age groups.
Another concern is that the FO group completed
boosters at higher rates than did the MI group. However,
if the boosters reduce risk for future alcohol consump-
tion, this difference in completion rates should serve to
make the groups more similar and therefore our results
may actually underestimate the effects of the MI. Finally,
this study did not address experimentally the effect of
adding the boosters to the MI, so we are unable to state
whether the additional contact had incremental effect
over the baseline session.
In sum, this study is the first to compare two active
interventions with ED patients and to demonstrate an
effect on alcohol use among young adults in an ED. While
both the interventions studied hold promise as low-
intensity methods for reducing alcohol-related injuries
and mortality in this high-risk population, only the full
MI impacted alcohol consumption through a 12-month
Measure
MI (n =65)
n(%)
FO (n =73)
n(%) df
c2
(baseline)
c2
(time)
c2
(Tx)
c2
(Tx ¥time)
Effect size
(Tx ¥time)
Alcohol-related injury, past year
Baseline 52 (80.0%) 56 (76.7%) 0.21
12-month follow-up 31 (47.7%) 32 (43.8%) 1 36.75*** 0.40 0.00 0.00
MI (n =75)
n(%)
FO (n =80)
n(%)
Alcohol treatment, past year
Baseline 13 (17.3%) 11 (13.8%) 0.38
12-month follow-up 22 (29.3%) 16 (20.0%) 1 6.55* 1.49 0.65 0.13
Numbers of subjects included in analyses vary for the different measures due to different rates of follow up at 6 and 12 months (e.g. nat 6-month follow-up were 79 for MI and 86 for FO), and to the combination of data from different
follow-up time-points to get a 1-year time-frame (RAPI, driving, driving violations, alcohol-related injury and alcohol treatment). aThe RAPI (Rutgers Alcohol Problem Index) was administered at baseline but the measure reflected
the previous 3 years. The baseline value was used as a covariate in analyses but as the time-frame of the measure was different at follow-up, the baseline values are not presented. Analysis of covariance was the analytical approach
and means presented are adjusted means. bBaseline and follow-up measures were log-transformed for analysis due to skewed distributions. Original scores are presented for interpretational clarity. cReports obtained for 78.8% of
participants who had licenses at baseline and 88.8% at follow-up. *P<0.05; **P<0.01; ***P<0.001. MI: motivational interviewing; FO: feedback only.
Brief interventions for young adults 1241
© 2007 The Authors. Journal compilation © 2007 Society for the Study of Addiction Addiction,102, 1234–1243
follow-up. Nevertheless, it is possible that FO is the more
cost-effective option. Unfortunately, limitations in our
methodology preclude our being able to test this hypoth-
esis. Future studies should replicate these results and
determine the cost-effectiveness of a full MI compared to
feedback only when delivered in an ED setting.
Acknowledgements
This investigation was supported by research grant
AA09892 from the National Institute on Alcohol Abuse
and Alcoholism and by a Department of Veterans Affairs
Senior Career Research Scientist Award to Peter M.
Monti. Portions of this study were presented at the 35th
Annual Meeting of the Western Trauma Association,
Jackson Hole, WY, March 2005.
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