Temporal pathways of change in two randomized controlled trials for depression and harmful drinking in Goa, India

BACKGROUND

The current study explored the temporal pathways of change within two treatments, the Healthy Activity Program (HAP) for depression and the Counselling for Alcohol Problems (CAP) Program for harmful drinking.

METHODS

The study took place in the context of two parallel randomized controlled trials in Goa, India. N = 50 random participants who met a priori criteria were selected from each treatment trial and examined for potential direct and mediational pathways. In HAP, we examined the predictive roles of therapy quality and patient-reported activation, assessing whether activation mediated the effects of therapy quality on depression (Patient Health Questionnaire-9) outcomes. In CAP, we examined the predictive roles of therapy quality and patient change- and counter-change-talk, assessing whether change- or counter-change-talk mediated the effects of therapy quality on daily alcohol consumption.

RESULTS

In HAP, therapy quality (both general and treatment-specific skills) was associated with patient activation; patient activation but not therapy quality significantly predicted depression outcomes, and patient activation mediated the effects of higher general skills on subsequent clinical outcomes [a × b = -2.555, 95% confidence interval (CI) -5.811 to -0.142]. In CAP, higher treatment-specific skills, but not general skills, were directly associated with drinking outcomes, and reduced levels of counter-change talk both independently predicted, and mediated the effects of higher general skills on, reduced alcohol consumption (a × b = -24.515, 95% CI -41.190 to -11.060). Change talk did not predict alcohol consumption and was not correlated with counter-change talk.

CONCLUSION

These findings suggest that therapy quality in early sessions operated through increased patient activation and reduced counter-change talk to reduce depression and harmful drinking respectively.

The Global State of the Genetic Counseling Profession

The profession of genetic counseling (also called genetic counselling in many countries) began nearly 50 years ago in the United States, and has grown internationally in the past 30 years. While there have been many papers describing the profession of genetic counseling in individual countries or regions, data remains incomplete and has been published in diverse journals with limited access. As a result of the 2016 Transnational Alliance of Genetic Counseling (TAGC) conference in Barcelona, Spain, and the 2017 World Congress of Genetic Counselling in the UK, we endeavor to describe as fully as possible the global state of genetic counseling as a profession. We estimate that in 2018 there are nearly 7000 genetic counselors with the profession established or developing in no less than 28 countries.

A sequential analysis of motivational interviewing technical skills and client responses

BACKGROUND

The technical hypothesis of Motivational Interviewing (MI) proposes that: (a) client talk favoring behavior change, or Change Talk (CT) is associated with better behavior change outcomes, whereas client talk against change, or Sustain Talk (ST) is associated with less favorable outcomes, and (b) specific therapist verbal behaviors influence whether client CT or ST occurs. MI consistent (MICO) therapist behaviors are hypothesized to be positively associated with more client CT and MI inconsistent (MIIN) behaviors with more ST. Previous studies typically examine session-level frequency counts or immediate lag sequential associations between these variables. However, research has found that the strongest determinant of CT or ST is the client's previous CT or ST statement. Therefore, the objective of this paper was to examine the association between therapist MI skills and subsequent client talk, while accounting for prior client talk.

METHODS

We analyzed data from a manualized MI intervention targeting both alcohol misuse and sexual risk behavior in 132 adults seen in two hospital emergency departments. Transcripts of encounters were coded using the Motivational Interviewing Skills Code (MISC 2.5) and an additional measure, the Generalized Behavioral Intervention Analysis System (GBIAS). Using these measures, we analyzed the association between client talk following specific classifications of MICO skills, with the client's prior statement as a potential confounder or effect modifier.

RESULTS

With closed questions as the reference category, therapist simple reflections and paraphrasing reflections were associated with significantly greater odds of maintaining client talk as CT or ST. Open questions and complex reflections were associated with significantly greater odds of CT following ST, were not associated significantly with more ST following ST, and were associated with more ST following CT (i.e., through an association with less Follow Neutral).

CONCLUSIONS

Simple and paraphrasing reflections appear to maintain client CT but are not associated with transitioning client ST to CT. By contrast, complex reflections and open questions appeared to be more strongly associated with clients moving from ST to CT than other techniques. These results suggest that counselors may differentially employ certain MICO technical skills to elicit continued CT and move participants toward ST within the MI dialogue.

Counselor competence for telephone Motivation Interviewing addressing lifestyle change among Dutch older adults

Counselor competence in telephone Motivation Interviewing (MI) to change lifestyle behaviors in a primary care population was assessed using the Motivational Interviewing Treatment Integrity (MITI) rating system. Counselor behavior was evaluated by trained raters. Twenty minutes of a random sample of 336 MI sessions were coded representing 232 counselees. Ninety-four sessions (28%) were double coded to assess inter-rater agreement. The MI fidelity was examined by comparing the MI fidelity scores direction, empathy, spirit, % open questions, % complex reflections, reflections-to-questions ratio, % MI-adherent responses with the matching beginner proficiency MITI threshold. The inter-rater agreements for the MI fidelity summary scores were good (spirit, reflections-to-questions ratio), fair (empathy, % open questions, % MI-adherent responses) or poor (direction, % complex reflection). The MI fidelity scores for direction, empathy, spirit and the percentage of complex reflections exceeded the MITI threshold, but lower scores were found for the percentage of open questions, the reflections-to-questions ratio and the percentage of MI-adherent responses. In conclusion, evidence that MI was implemented was revealed. However, the inter-rater agreements scores and some fidelity scores leave room for improvement indicating that raters and counselors may need more ongoing training and feedback to achieve and maintain adequate competence. These findings apply to more complex skills (as rating complex reflections) in particular.

National Society of Genetic Counselors Code of Ethics

This document is the revised Code of Ethics of the National Society of Genetic Counselors (NSGC) that was adopted in April 2017 after majority vote of the full membership of the NSGC. The explication of the revisions is published in this volume of the Journal of Genetic Counseling. This is the fourth revision to the Code of Ethics since its original adoption in 1992.

Portrait of the Master Genetic Counselor Clinician: A Qualitative Investigation of Expertise in Genetic Counseling

This study comprises an initial empirical description of personal and professional characteristics of master genetic counselors-those considered to be experts in the profession. Fifteen peer-nominated genetic counselors, actively engaged in providing clinical services to patients, participated in semi-structured telephone interviews exploring their personal qualities, inspirations, and perspectives on professional development of expertise. Analysis using modified Consensual Qualitative Research methods yielded 7 domains and 33 categories. Findings indicate master genetic counselors have a strong passion for and dynamic commitment to the profession. They also have insatiable curiosity and are life-long learners who are reflective, self-aware, confident, and recognize their limitations. They are authentic and genuine, and consider their personality to be their counseling style. They form collaborative and interactive relationships with patients based on trust, and they have nuanced attunement to the complexity and multiple levels of the counseling process. Master genetic counselors have deep empathy and are inspired by patients and colleagues, and they derive personal meaning from their work. They are affected emotionally by their work, but effectively manage the emotional impact. They view their professional development as ongoing, influenced by colleagues, patients, mentoring, multicultural considerations, and their own family of origin. They also believe professional development of expertise occurs through critical reflection upon the experiences one accrues. Additional findings and their relationship to theory and research, study strengths and limitations, implication for training and practice, and research recommendation are discussed.