Reliability and Validity of an Observational Measure of Client Decision-Making: The Client Language Assessment - Proximal/Distal (CLA-PD)

Technical and relational process in MI sessions with a sample of Hispanic/Latinx adults who engage in heavy drinking: A latent growth mediation model

The current study tests the Motivational Interviewing (MI) technical and relational hypotheses in a sample of Hispanic/Latinx adults (N = 276) who engage in heavy alcohol consumption. MI causal theory hypothesizes that therapist use of MI consistent skills (i.e., technical hypothesis) and embodiment of the MI Spirit (i.e., relational hypothesis) will elicit client change talk, which is a putative mechanism of positive client outcome after the session. We tested these associations in a rigorous parallel process latent growth curve mediation modeling framework. The data are from a completed randomized clinical trial of a culturally-adapted (CAMI) versus un-adapted MI targeting hazardous alcohol use and consequences. Results. The unconditional growth models for the mediator (i.e., proportion of change talk relative to sustain talk) and two study outcomes (i.e., percent of heavy drinking days; alcohol-related consequences) showed a linear effect over a 12-month period with a slower rate of growth at later timepoints. Contrary to expectations, the latent growth mediation models did not show relationships between MI-consistent skills (i.e., technical predictor) or latent MI Spirit (i.e., relational indicator) and the slope factor for proportion change talk. The slope factor for proportion change talk was also not associated with the slope factors for percent heavy drinking and consequences over follow-up. Conclusions. In this novel population for MI process analysis, the technical and relational hypotheses were not supported. Studies that are exploratory may be needed to further investigate the causal model in populations that are not often represented in MI process research.

The role of the relational context and therapists' technical behaviors in brief motivational interviewing sessions for heavy alcohol consumption: Findings from a sample of Latinx adults

INTRODUCTION

Motivational interviewing (MI) theory and process research highlights the role of therapist technical and relational behaviors in predicting client in-session statements for or against behavior change (i.e., change and sustain talk, respectively). These client statements, in turn, have been shown to predict intervention outcomes. The current study examines sequential associations between therapist behaviors and client change and sustain talk in a sample of Latinx individuals who engage in heavy alcohol consumption.

DATA

Data are from a completed randomized clinical trial of a culturally adapted (CAMI) versus unadapted MI targeting alcohol use and consequences among Latinx individuals.

METHOD

The study collected observational coding data with the Motivational Interviewing Skill Code (MISC 2.5, i.e., therapist behaviors and global ratings) and the Client Language Assessment - Proximal/Distal (CLA-PD, i.e., client language). Frequentist and Bayesian sequential analyses examined the relationship among nine different categories of therapist behaviors and three different categories of client language (i.e., change talk, sustain talk, neutral). We examined odds ratios and conditional probabilities for the direction, magnitude, and significance of the association between the use of MI technical behaviors and subsequent client statements about change. The study compared these same transitional associations between low/average (i.e., <4) and high (i.e., ≥4) MI Spirit sessions.

RESULTS

The pattern of results was replicated across both analytic frameworks. Questions and reflections about change talk versus sustain talk versus neutral statements showed greater odds of predicting the intended client response (i.e., change talk, sustain talk, neutral, respectively) compared to other possible client responses. Conditional probabilities for these transitions were high, ranging from 0.55 to.88. The magnitude of certain technical transitions significantly differed between low/average and high MI Spirit sessions.

CONCLUSIONS

Analyses supported the hypothesized associations between therapist use of technical MI behaviors and client change language within this Latinx sample. Analyses of MI Spirit as a moderator of these transitions showed partial support.

A Sequential Analysis of Clinician Skills and Client Change Statements in a Brief Motivational Intervention for Young Adult Heavy Drinking

This study examined sequential relationships between clinician skills and client statements about behavior change in a randomized clinical trial comparing a brief motivational intervention (BMI) to a relaxation training control condition (REL) in a sample of heavy drinking young adults. Clinician and client interactions (N = 167) were assessed according to two established observational rating systems. Sequential analyses examined the transitional associations between clinicians' use of MI-eliciting skills (i.e., questions and reflections), MI-supportive skills (e.g., affirmations, emphasize client autonomy, statements of support), MI-inconsistent skills (e.g., confrontations, unsolicited advice), and subsequent client statements about behavior change (i.e., change talk or sustain talk). In both conditions, clinicians' use of MI-elicitation skills operated in a manner that was largely consistent (100% in BMI; 84% in REL) with the directional relationships proposed by MI theory (i.e., The Technical Hypothesis). More detailed analyses of the BMI condition showed clinician skills were related to statements about behavior change somewhat differently in drinking compared to coping discussions. While elicitations of change talk were associated with increased odds of their intended response (i.e., distal drinking and proximal coping change talk), elicitations of proximal coping sustain talk were associated with higher odds of proximal change talk. MI-supportive skills were also associated with increased odds of proximal change talk, and instances of proximal sustain talk were rare in the sample. This fine-grained analysis presents sequential transitions to client change and sustain talk with greater classification specificity than has been previously reported. Such efforts have the potential to advance our understanding of the function of MI skills in promoting client discussions about drinking (i.e., evoking) and coping (i.e., planning) behavior change.

Motivational interviewing technical process and moderated relational process with underage young adult heavy drinkers

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. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Examining the influence of active ingredients of motivational interviewing on client change talk

Motivational Interviewing (MI) is an evidenced-based intervention designed to help clients explore and resolve ambivalence around substance use. MI combines a humanistic tradition with behavioral components to facilitate client decisions concerning behavior change. As such, there is marked interest in the relationship between the two active ingredients of MI - the relational, or person-centered, components and the technical, or directional, behavioral components - on client in-session language. Yet, few studies have examined how these active ingredients operate in concert. Therefore, the current study evaluated the constellation of relational skills associated with client language, as well as the influence of technical skills on the relationship between provider relational skills and client change language. Specifically, we tested a latent construct of relational skill and its direct association with the proportion of client change talk. We then explored the mediating role of reflections of change and sustain talk (RefCT and RefST) on this relationship. The data for this secondary analysis are from Project ELICIT (N = 131), a randomized control trial evaluating the effects of MI training on client change language. We found support for a latent construct of relational skill (i.e., empathy, acceptance, collaboration, and autonomy/support). However, the relational skill construct did not predict client change language. There was support for an indirect effect, such that relational skills predicted RefCT and RefST, and RefCT and RefST predicted client change language. These results suggest that the synergistic implementation of the relational and technical components of MI is critical to facilitating a higher percentage of change talk.

Advancing Analytic Approaches to Address Key Questions in Mechanisms of Behavior Change Research

OBJECTIVE

Interest in studying mechanisms of behavior change (MOBCs) in substance use disorder (SUD) treatments has grown considerably in the past two decades. Much of this work has focused on identifying which variables statistically mediate the effect of SUD treatments on clinical outcomes. However, a fuller conceptualization of MOBCs will require greater understanding of questions that extend beyond traditional mediation analysis, including better understanding of when MOBCs change during treatment, when they are most critical to aiding the initiation or maintenance of change, and how MOBCs themselves arise as a function of treatment processes.

METHOD

In the present study, we review why these MOBC-related questions are often minimally addressed in empirical research and provide examples of data analytic methods that may address these issues. We highlight several recent studies that have used such methods and discuss how these methods can provide unique theoretical insights and actionable clinical information.

RESULTS

Several statistical approaches can enhance the field's understanding of the timing and development of MOBCs, including growth-curve modeling, time-varying effect modeling, moderated mediation analysis, dynamic systems modeling, and simulation methods.

CONCLUSIONS

Adopting greater diversity in methods for modeling MOBCs will help researchers better understand the timing and development of key change variables and will expand the theoretical precision and clinical impact of MOBC research. Advances in research design, measurement, and technology are key to supporting these advances.

The Alcohol Intervention Mechanisms Scale (AIMS): Preliminary Reliability and Validity of a Common Factor Observational Rating Measure

The present work provides an overview, and pilot reliability and validity for the Alcohol Intervention Mechanisms Scale (AIMS). The AIMS measures therapist interventions that occur broadly across modalities of behavioral treatment for alcohol use disorder. It was developed based on identified commonalities in the function rather than content of therapist interventions in observed therapy sessions, as well as from existing observer rating systems. In the AIMS, the primary function areas are: explore (four behavior count codes), teach (five behavior count codes), and connect (three behavior count codes). Therapist behavior counts provide a frequency rating of occurrence (i.e., adherence). The three functions (explore, teach, connect) are then rated on global skillfulness, which provides a quality valence (i.e., competence) to the entire session. In the present study, three independent raters received roughly 30 hours of training on the use of the AIMS by the first author. Data were a sample of therapy session audio files from a Project MATCH clinical research site. Reliability results showed generally good performance for the measure. Specifically, 2-way mixed intraclass coefficients were 'excellent', ranging from .94 to .99 for function summary scores, while prevalence-adjusted, bias-adjusted kappa for global skillfulness measures were in the 'fair' to 'moderate' range (k=.36 to.40). Internal consistency reliability was acceptable, as were preliminary factor models by behavioral treatment function (i.e., explore, teach, connect). However, confirmatory fit for the subsequent three factor model was poor. In concurrent validity analyses, AIMS summary and skillfulness scores showed associations with relevant Project MATCH criterion measures (i.e., MATCH Tape Rating Scale) that were consistent with expectations. The AIMS is a promising and reliable observational measure of three proposed common functions of behavioral alcohol treatment.

Therapist and client discussions of drinking and coping: a sequential analysis of therapy dialogues in three evidence-based alcohol use disorder treatments

BACKGROUND AND AIMS

Research into the active ingredients of behavioral interventions for alcohol use disorders (AUD) has focused upon treatment-specific factors, often yielding disappointing results. The present study examines common factors of change in motivational enhancement therapy, cognitive-behavioral therapy and 12-Step facilitation therapy by (1) estimating transitional probabilities between therapist behaviors and subsequent client Change (CT) and Sustain (ST) Talk and (2) examining therapist skillfulness as a potential predictor of transition probability magnitude.

DESIGN

Secondary data analysis examined temporal associations in therapy dialogues.

SETTING

United States: data were from Project MATCH (Matching Alcoholism Treatments to Client Homogeneity) (1997).

PARTICIPANTS

One hundred and twenty-six participants who received motivational enhancement therapy, cognitive-behavioral therapy or 12-Step facilitation therapy.

MEASUREMENTS

Therapist behaviors were measured in three categories (exploring, teaching, connecting) and client statements included five categories (CT-distal, ST-distal, CT-proximal, ST-proximal, neutral). Therapist skillfulness was measured using a five-point ordinal scale.

FINDINGS

Relative to chance, therapist exploratory behaviors predicted subsequent client discussion of distal, drinking behavior [odds ratio (OR) = 1.37-1.78, P < 0.001] while suppressing discussion of proximal coping and neutral content (OR = 0.83-0.90, P < 0.01). Unexpectedly, therapist teaching suppressed distal drinking language (OR = 0.48-0.53, P < 0.001) and predicted neutral content (OR = 1.45, P < 0.001). Connecting behaviors increased both drinking and coping language, particularly language in favor of change (CT OR = 1.15-1.84, P < 0.001). Analyses of exploring and connecting skillfulness revealed that high skillfulness maximized these behaviors effect on client responses, but not teaching skillfulness.

CONCLUSIONS

In motivational enhancement therapy, cognitive-behavioral therapy, and 12-Step facilitation therapy for alcohol use disorders, the therapists who explore and connect with clients appear to be more successful at eliciting discussion about change than therapists who engage in teaching behavior. Therapists who are more skilled achieve better results than those who are less skilled.

The In-Session and Long-Term Role of a Significant Other in Motivational Enhancement Therapy for Alcohol Use Disorders

OBJECTIVE

To examine how significant other (SO) language in support of or against client abstinence from alcohol influences clients' in-session speech and drinking behavior over the 9 months post-Motivational Enhancement Therapy (MET).

METHOD

Sequential analyses were used to examine the language of Project MATCH clients who invited an SO to participate in an MET session. Hierarchical regressions investigated the predictive relationship between SO language and clients' post-treatment drinking behavior. A cohort analytic design compared the change language of these SO-involved participants against a matched group who chose client-only therapy.

RESULTS

'SO Support Change' language increased the odds of client Change Talk in the next utterance (p<.01). SO Support Change did not significantly predict reduced post-treatment drinking, whereas 'SO Against Change' significantly predicted an increase in average drinks per drinking day (DDD) across months 7-9 post-MET (p=.04). In the matched comparison, the proportion of change-related client language was comparable across the SO-involved and client-only groups.

CONCLUSIONS

Motivational interviewing theory was supported by the sequential association between SO and client language as well as the predictive link between SO Against Change and client drinking intensity. Given the centrality of pro-sobriety language in the literature, it was surprising that SO Support Change did not predict alcohol use outcomes. Findings are discussed in relation to contemporary treatment process research and clinical practice.