The methods are presented in according to the stated goals. For Goal 1—training Israeli methadone maintenance staff in ME, the principal investigator (PI) adapted a previously developed (manuscript in preparation) 66-page ME manual into a six-session intervention, specifically targeting HCVT behaviors. The manual incorporated components from an MI substance abuse manual, as others have done (Carels et al., 2007
; Channon et al., 2007
; Miller & National Institute on Drug Abuse, 1995
). The six-session design and its content (see ) were based upon a validated SDT-based intervention for tobacco dependence (Williams et al., 2006a
). The investigators held a 3-day training workshop that included brief didactic presentations, demonstration video, and extensive skills practice. These methods were based upon ME facilitator trainings, and materials were adapted with permission (Miller & Deci, personal communication, November 12, 2007). All staff members of two methadone maintenance centers (in the cities of Jerusalem and Ashdod) attended the workshop. The supervision component of the training was continued only for the four counselors in the Jerusalem center chosen to perform the intervention, based upon English proficiency, clinical skill level, and degree of rapport with the PI. Those in supervised training received an ME training manual, which was revised iteratively according to the counselors’ input, and review of audio or videotaped sessions. In all of the seven supervision sessions over 8 weeks, the counselors were instructed to enhance autonomous self-regulation through building rapport and exploring advantages and disadvantages of health-promoting behaviors. The counselors were instructed to offer information about the consequences and treatment of HCV as follows: ask patients what they know already about HCV course and treatment, supplement knowledge as needed and desired, and then solicit patient responses (Williams, Gagné, Ryan, & Deci, 2002
). Materials regarding HCV and depression were written in patient-friendly language by relevant specialists. The counselors were instructed to explore patients’ perceived personal and systemic barriers to facilitate HCV health behaviors, while providing support for patients’ autonomy and perceived competence. Individualized HCV health plans were developed according to patients’ readiness using a template plan on which patients highlighted self-chosen behaviors. The counselors were also instructed in the use of empathy, reflection, and confrontation avoidance in resistant patients, which are counseling strategies common to SDT and MI and are expected to increase autonomous self-regulation.
Study goals and method of assessment
Instruction was in English and Hebrew, while the intervention was held in Hebrew and Russian. An interpreter facilitated mutual understanding between the Hebrew-speaking counselors and the English-speaking PI at all training sessions. Training materials were culturally adapted and translated or subtitled into Hebrew by the investigator (MS) and the translator (a social work graduate student)—both fluent in written and spoken Hebrew and English. The PI met with a Hebrew or Russian translator to preview all the taped intervention sessions for the four counselors prior to group supervision. The PI and one of the trainee counselors independently recorded process notes. Investigators administered an anonymous questionnaire in Hebrew to workshop participants to evaluate the training. The evaluation addressed general satisfaction (1 question); internalization of ME tactics (10 questions) including empathy, discrepancy, rolling with resistance, supporting self-efficacy, open-ended questions, reflective listening, affirmation, summarizing, response to change talk, and response to resistance talk (Cronbach’s alpha = 0.93); utility of learning methods (6 questions) including manual, lecture, exercises, video examples, skills practice in small groups, and discussion in the large group (Cronbach’s alpha = 0.88); and plans for the future incorporation of lessons learned (2 questions) regarding using ME spirit/components and working according to the ME manual (Cronbach’s alpha = 0.75). All questions were rated on a 10-point Likert-type scale ranging from 1 “not at all” to 10 “to a great extent.”
For Goal 2—applying ME to HCVT, the research team held a discussion about HCVT barriers and facilitators with five methadone program clients, who recently completed HCVT, and their spouses. Their input informed subsequent HCV-oriented ME strategies and was integrated into the ME training. The PI and coinvestigators adapted the treatment self-regulation questionnaire (TSRQ) and perceived competence scale (PCS; Williams et al., 2006b
) to measure autonomous regulation and competence regarding HCVT for the preliminary estimation of reliability and face validity.
For Goal 3—implementing the intervention among Israeli methadone patients, four pilot HCV patients, who were not then undergoing HCVT, received a six-session intervention in their native language (Hebrew or Russian), using ME to address pretreatment fears and ambivalence about HCVT and its physical and psychological side effects. The written TSRQ and PCS measures were also piloted among 30 patients.
This project was approved by the institutional review board of the School of Social Work and Social Welfare, Hebrew University, and conducted in 2007–2008.
Of 321 Jerusalem methadone center patients, 146 (45.5%) were HCV positive. Of 102 available patients, we randomly chose 30 to perform the written measures. From those 30, we purposefully chose 4 for the intervention based upon their not having taken any medical action regarding their HCV and having engaged in a therapeutic alliance with a social worker at the center.
We computed first-order descriptive analyses [means and standard deviations (SDs)] to assess participants’ satisfaction with the workshop. We reviewed field notes from the counselor supervision sessions for their reports of client engagement, counselor adherence to the ME approach, and needed cultural adaptation. We computed Cronbach’s alpha coefficients on the TSRQ and PCS measures to assess the internal reliability of the scale items.