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1.  Therapist Focus on Ambivalence and Commitment: A Longitudinal Analysis of Motivational Interviewing Treatment Ingredients 
The present study examines two core therapeutic principles of Motivational Interviewing (MI) with alcohol and other substance use disorders. Specifically, therapist focus on client ambivalence and commitment to change, as well as a more general indicator of goal assessment, were tested as process predictors of subsequent alcohol use across four sessions of Motivational Enhancement Therapy. Participants were adult alcohol users involved in a large multi-site clinical trial (Project MATCH; two arms Aftercare [AC] and Outpatient [OP]). A series of multi-level models examined the effect of proposed MI ingredients on alcohol use (percent abstinent days; drinks per drinking day) over a 12-week treatment period, and whether these effects interacted with time and client baseline motivation. Therapist effort to elicit client commitment to change alcohol use was associated with greater rates of abstinence among both AC and OP participants, and reduced drinking quantity among OP participants. However, therapist focus on ambivalence was associated with greater drinking quantity among OP participants, and when motivation was low, among AC participants. Goal assessment was a marginal to non-significant predictor across outcomes, and all interactions with time were non-significant. Therapist reported treatment foci are important to subsequent patterns of drinking within a multi-session MI, but the role of ambivalence and discrepancy is worthy of further clinical and empirical consideration.
doi:10.1037/a0029639
PMCID: PMC3650101  PMID: 22905897
Ambivalence; Brief Interventions; Commitment to Change; Process Research; Stages of Change; Treatment Ingredients; Motivational Interviewing
2.  Effect of a Significant Other on Client Change Talk in Motivational Interviewing 
Journal of consulting and clinical psychology  2012;81(1):10.1037/a0030881.
Objective
To examine significant-other (SO) and therapist behaviors as predictors of client change language within motivational interviewing (MI) sessions.
Method
Participants from an emergency department received a single session of MI that included SO participation (N = 157). Sessions were coded using therapy process coding systems. Sessions were subdivided into ten equal deciles to facilitate sequential analyses. Multilevel modeling was used to examine the relationships among the following variables: therapist MI-consistent and MI-inconsistent behavior; client change talk and sustain talk; SO Support Change and SO Against Change.
Results
Therapist MI-consistent and MI-inconsistent behaviors failed to predict either client change talk or sustain talk at the decile level. Global measures of therapist MI spirit and acceptance were associated with lower levels of client sustain talk (p = .002 and p < .001 respectively). Higher levels of SO Support Change were more likely to be followed by higher levels of client change talk (p < .001) and lower levels of client sustain talk (p <.001). SOs who engaged in behaviors that discouraged the patient’s drinking in the six months prior to the intervention had higher levels of SO Support Change language (p = .02). When analyzed at the aggregate level, therapist behavior was significantly associated with client change talk, but effect sizes were quite modest.
Conclusions
Within-session SO behavior impacts client verbalizations regarding changes in alcohol use. Results raise questions about the role of therapist behavior when an SO is present.
doi:10.1037/a0030881
PMCID: PMC3808251  PMID: 23231575
Motivational Interviewing; therapy process; alcohol use; brief intervention; change language
3.  Using Daily Drinking Data to Characterize the Effects of a Brief Alcohol Intervention in an Emergency Room 
Addictive behaviors  2010;36(3):248-250.
Clinical trials often aggregate daily alcohol consumption data across long-term follow-up intervals (e.g., 6 or 12 months). Although important in understanding general treatment outcomes, these analyses tell us little about when treatment effects emerge or decline. We previously demonstrated that motivational interviewing (MI) reduced heavy drinking (vs. personalized feedback only; FO) among young adult drinkers (N = 198; ages 18-24) recruited in a hospital Emergency Room (ER) using aggregated drinking data from 6-month follow up. In the current study, we used daily alcohol consumption data from a calendar-assisted interview (Timeline Followback) to examine the timing and course of these treatment effects. Participants in both conditions received brief telephone booster sessions at 1 and 3 months. There were no treatment effects in the time between the initial intervention session and the 3-month booster session. Significant effects emerged after the 3-month booster and were driven by an increase in heavy drinking within the FO group. This suggests that the effects of brief interventions may not emerge immediately following an initial session. Aggregated data would be unable to detect this time trend. This research underscores the potential value added by examining the day-to-day timing of effects following treatments for alcohol use.
doi:10.1016/j.addbeh.2010.10.010
PMCID: PMC3021247  PMID: 21126827
Daily Drinking; Timeline Followback; Motivational Interviewing; Screening and Brief Intervention; Young Adult
6.  Motivational Interviewing with Significant Other Participation: Assessing Therapeutic Alliance and Patient Satisfaction and Engagement 
Inclusion of concerned significant others (SO) in alcohol use treatment has demonstrated efficacy but has not been tested in the context of brief interventions. In this study, individual Motivational Interviewing (MI) sessions were compared to MI sessions including a significant other (SOMI) on within treatment outcomes (alliance, fidelity, client satisfaction and engagement). Participants (N = 382) were adult alcohol users recruited in a Level I Trauma Center. Perceived alliance did not differ across conditions, but patients and SOs reported higher alliance, satisfaction and engagement than was perceived by the therapist. The occurrence of MI components, or discussion areas, was consistent across conditions. Higher baseline SO drinking was associated with lower patient engagement, while higher baseline SO acceptance of patient drinking was associated with lower SO engagement. Results suggest individual MI sessions can be adapted to include an SO with minimal impact on patient acceptability and treatment fidelity. Research should, however, consider SOs’ influence on participant outcomes and the relevance of specific SO characteristics.
doi:10.1016/j.jsat.2010.07.006
PMCID: PMC2967605  PMID: 20817382
Alcohol Treatment; Emergency Department; Motivational Interviewing; Significant Others; Treatment Fidelity
7.  The Route to Change: Within-Session Predictors of Change Plan Completion in a Motivational Interview 
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 audio-recorded 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 non-completion, 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.
doi:10.1016/j.jsat.2009.12.001
PMCID: PMC2835844  PMID: 20149571
Alcohol Use; Change Language or Change Talk; Mechanisms of Behavior Change; Motivational Interviewing; Therapy Process
8.  Moderators and Mediators of Two Brief Interventions for Alcohol in the Emergency Department 
Addiction (Abingdon, England)  2010;105(3):452-465.
Objective
Evaluate moderators and mediators of brief alcohol interventions conducted in the Emergency Department.
Methods
Patients (18–24 years; N = 172) in an Emergency Department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow ups. Gender, alcohol status/severity group (ALC+ Only, AUDIT+ Only, ALC+/AUDIT+), attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event, and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy, and alcohol treatment seeking.
Results
Alcohol status, attribution, and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event, and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ Only group those who received MI showed lower rates of alcohol-related injury at follow up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found.
Conclusions
Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects.
doi:10.1111/j.1360-0443.2009.02814.x
PMCID: PMC2858352  PMID: 20402989
Alcohol; Brief Intervention; Emergency Room
9.  Mechanisms of change in Motivational Interviewing: A review and preliminary evaluation of the evidence 
Addiction (Abingdon, England)  2009;104(5):705-715.
Aims
Motivational interviewing (MI) is an efficacious treatment for substance use disorders. However, little is known about how MI exerts its therapeutic effects. This review is a first attempt to summarize and evaluate the evidence for purported within-session mechanisms of change. The primary question of interest was: Which MI constructs and variables appear to be the most promising candidates for mechanisms of change?
Methods
Literature searches were conducted to identify studies delivering MI in an individual format for the treatment of substance use disorders. Our search identified a total of 152 studies for review; 19 studies met inclusion criteria by providing data on at least one link in the causal chain model under examination. Effect size estimates were calculated for every possible step in the causal model where sufficient data were provided by study authors.
Results
Four constructs of therapist behavior were evaluated: MI Spirit, MI-Consistent behaviors, MI-Inconsistent behaviors, and therapist use of specific techniques. Five constructs of client behavior were evaluated: change talk/intention, readiness to change, involvement/engagement, resistance, and the client’s experience of discrepancy. The absence of experimental and full mediation studies of mechanisms of change was notable. Effect sizes were generally mixed.
Conclusions
The most consistent evidence was found for three constructs: client change talk/intention (related to better outcomes); client experience of discrepancy (related to better outcomes); and therapist MI-Inconsistent behavior (related to worse outcomes). Regarding therapist use of specific techniques, use of a decisional balance exercise showed the strongest association to better outcomes.
doi:10.1111/j.1360-0443.2009.02527.x
PMCID: PMC2756738  PMID: 19413785
Motivational interviewing; brief intervention; mechanisms of change; mediator; therapy process; active ingredients of treatment
10.  Readiness to Change Smoking Behavior in Adolescents with Psychiatric Disorders 
Addictive behaviors  2006;32(6):1119-1130.
There has been recent increased interest in utilizing motivational interviewing (MI) to increase adolescents readiness to quit smoking, but attempts to impact quit rates have thus far been discouraging. A better understanding of factors associated with adolescent readiness to quit smoking prior to receiving any intervention may provide guidance when tailoring future MI interventions in order to increase their effectiveness with this population. Adolescent smokers (N = 191) who had been admitted to a psychiatric hospital and enrolled in a clinical trial evaluating MI completed questionnaires that assessed smoking behavior and variables thought to be related to smoking. Confidence to quit smoking and negative beliefs about smoking were significant predictors of adolescents' baseline readiness to quit smoking. The failure to demonstrate relationships between health consequences and readiness suggest that caution may be warranted in the use of feedback, a common component of MI-based interventions. Such feedback tends to focus on health consequences, which was unrelated to adolescent baseline readiness to change smoking behavior in the current study. Parallels between current results and the Theory of Planned Behavior are discussed in consideration of developing more effective MI-based interventions for adolescent smokers.
doi:10.1016/j.addbeh.2006.07.016
PMCID: PMC1892166  PMID: 16950572
Smoking; Tobacco use; Adolescents; Motivation

Results 1-10 (10)