Substance use among adolescents with one or more psychiatric disorders is a significant public health concern. In this study, 151 psychiatrically hospitalized adolescents, ages 13-17 with comorbid psychiatric and substance use disorders, were randomized to a two-session Motivational Interviewing intervention to reduce substance use plus treatment as usual (MI) vs. treatment as usual only (TAU). Results indicated that the MI group had a longer latency to first use of any substance following hospital discharge relative to TAU (36 days versus 11 days). Adolescents who received MI also reported less total use of substances and less use of marijuana during the first 6 months post-discharge, although this effect was not significant across 12 months. Finally, MI was associated with a significant reduction in rule-breaking behaviors at 6-month follow-up. Future directions are discussed, including means of extending effects beyond 6 months and dissemination of the intervention to community-based settings.
Substance Abuse; Adolescents; Psychiatric Comorbidity; Motivational Interviewing; Externalizing Symptoms; Moderators
Each year, thousands of college students receive mandated intervention as a sanction for alcohol use or alcohol-related behavior. For these mandated students, Brief Motivational Interventions (BMIs) are currently the most efficacious individual intervention. However, little is known about how the technical (therapist behaviors) and relational (e.g., global ratings of therapist empathy) components of BMIs influence client language as well as subsequent change in alcohol use and consequences in mandated students.
This study used the Motivational Interviewing Skills Code (MISC 2.0; Miller, Moyers, Ernst, & Amrhein, 2003) to code BMI sessions from two randomized clinical trials that facilitated significant reductions in alcohol use (Study 1, n = 91) and alcohol-related consequences (Study 2, n = 158) in mandated students.
There were significant relationships among therapist behaviors, global scores, and client language both for and against change, yet there were no links between in-session client language and subsequent changes in alcohol use or problems. In contrast, relational aspects of MI (global ratings of therapist MI Spirit and client self-exploration) were most predictive of post-session alcohol use. Mediation models incorporating both technical and relational components revealed that higher levels of client self-exploration mediated the relationship between higher therapist ratings of MI Spirit and improved drinking at follow-up.
Findings highlight the importance of considering how both technical and relational components of MI may influence alcohol use in mandated college students, and also suggest more exact analyses to better understand this complex relationship.
Motivational Interviewing; therapy process; alcohol use; brief intervention; change language
Effects of brief motivational interventions (BMIs) for heavy drinkers identified by alcohol-related emergency department (ED) visits are mixed. The successes of including significant others (SOs) in behavioral treatment suggest that involving SOs in ED-delivered BMI might prove beneficial. This study investigated the relative efficacy of an SO-enhanced Motivational Intervention (SOMI) compared to an Individual Motivational Intervention (IMI) to address heavy drinking in emergency care settings.
ED (n = 317) or trauma unit (n = 89) patients were randomly assigned to receive either an IMI or an SOMI and were re-assessed at 6 and 12 months for alcohol consumption, alcohol-related consequences, and perceived alcohol-specific SO support.
GEE analyses showed consistent reductions over time for both alcohol consumption and consequences. At one-year follow up, the average reduction in total drinks consumed per week was greater for patients in the SOMI condition than the IMI condition. In SOMI, 9.4% more patients moved to within the national guidelines for weekly drinking than did IMI patients. Frequency of heavy drinking and negative alcohol consequences showed no differential effects of intervention.
Emergence of a modest treatment effect at 12 months suggests that SO involvement in the SOMI condition may have led to more sustained positive influence on patient drinking than in the IMI condition. Implications and limitations regarding SO involvement in brief treatment are discussed.
Emergency care; alcohol; motivational intervention; significant others
The technical hypothesis of motivational interviewing (MI) posits that therapist implemented MI skills will be related to client speech regarding behavior change and that client speech will predict client outcome. The current meta-analysis is the first aggregate test of this proposed causal model.
A systematic literature review, using stringent inclusion criteria, identified k = 16 reports describing 12 primary studies. Review methods calculated the inverse-variance-weighted pooled correlation coefficient for the therapist to client and the client to outcome paths across multiple targeted behaviors (i.e., alcohol or illicit drug use, other addictive behaviors).
Therapist MI-consistent skills were correlated with more client language in favor of behavior change (i.e., change talk; r = .26, p < .0001), but not less client language against behavior change (i.e., sustain talk; r = .10, p = .09). MI-inconsistent skills were associated with less change talk (r = −.17, p = .001) as well as more sustain talk (r = .07, p = .009). Among these studies, client change talk was not associated with follow-up outcome (r = .06, p = .41), but sustain talk was associated with worse outcome (r = −.24, p = .001). In addition, studies that examined composite client language (e.g., an average of negative and positive statements) showed an overall positive relationship with client behavior change (r = .12, p = .006; k = 6).
This meta-analysis provides an initial test and partial support for a key causal model of MI efficacy. Recommendations for MI practitioners, clinical supervisors, and process researchers are provided.
motivational interviewing; change talk; sustain talk; change language; therapy process
Within-session client language that represents a movement toward behavior change (change talk) has been linked to better treatment outcomes in the literature on motivational interviewing (MI). There has been somewhat less study of the impact of client language against change (sustain talk) on outcomes following an MI session. This study examined the role of both client change talk and sustain talk, as well as therapist language, occurring during a brief motivational intervention (BMI) session with college students who had violated college alcohol policy (N = 92). Audiotapes of these sessions were coded using a therapy process coding system. A series of hierarchical regressions were used to examine the relationships among therapist MI-consistent and MI-inconsistent language, client change talk and sustain talk, as well as global measures of relational variables, and drinking outcomes. Contrary to prior research, sustain talk, but not change talk, predicted poorer alcohol use outcomes following the BMI at 3- and 12-month follow-up assessments. Higher levels of client self-exploration during the session also predicted improved drinking outcomes. Therapist measures of MI-consistent and MI-inconsistent language, and global measures of therapist acceptance and MI spirit were unrelated to client drinking outcomes. Results suggest that client sustain talk and self-exploration during the session play an important role in determining drinking outcomes among mandated college students receiving a BMI addressing alcohol use.
Motivational Interviewing; therapy process; alcohol use; brief intervention; change language; mandated students
Motivational interviewing is a collaborative style of communication designed to strengthen a person’s own motivation and commitment to change. We report on our ongoing efforts to implement motivational interviewing to address health behavior change among several patient populations in our pediatric hospital, including sexual risk reduction among adolescents, increased self-care for patients with spina bifida, increased adherence for adolescents with Type 1 diabetes, and facilitation with transition from pediatric to adult care among gastroenterology patients.
pediatrics; motivational interviewing; provider-patient communication
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.
Ambivalence; Brief Interventions; Commitment to Change; Process Research; Stages of Change; Treatment Ingredients; Motivational Interviewing
To examine significant-other (SO) and therapist behaviors as predictors of client change language within motivational interviewing (MI) sessions.
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.
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.
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.
Motivational Interviewing; therapy process; alcohol use; brief intervention; change language
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.
Daily Drinking; Timeline Followback; Motivational Interviewing; Screening and Brief Intervention; Young Adult
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.
Alcohol Treatment; Emergency Department; Motivational Interviewing; Significant Others; Treatment Fidelity
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.
Alcohol Use; Change Language or Change Talk; Mechanisms of Behavior Change; Motivational Interviewing; Therapy Process
Evaluate moderators and mediators of brief alcohol interventions conducted in the Emergency Department.
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.
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.
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.
Alcohol; Brief Intervention; Emergency Room
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?
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.
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.
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.
Motivational interviewing; brief intervention; mechanisms of change; mediator; therapy process; active ingredients of treatment
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.
Smoking; Tobacco use; Adolescents; Motivation