A Randomized Controlled Trial of a Telephone Intervention for Alcohol Misuse With Injured Emergency Department Patients.

STUDY OBJECTIVE: We conduct a randomized controlled trial to test efficacy of a telephone intervention for injured emergency department (ED) patients with alcohol misuse to decrease alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences. METHODS: ED patients screening positive for alcohol misuse were randomized to a 3-session telephone brief motivational intervention on alcohol, delivered by a counselor trained in motivational interviewing during 6 weeks, or a control intervention of a scripted home fire and burn safety education delivered in 3 calls. Patients were followed for 12 months and assessed for changes in alcohol use, impaired driving, alcohol-related injuries, and alcohol-related negative consequences. RESULTS: Seven hundred thirty ED patients were randomized; 78% received their assigned intervention by telephone, and of those, 72% completed 12-month assessments. There were no differential benefits of telephone brief motivational intervention versus assessment and a control intervention in all 3 variables of alcohol use (frequency of binge alcohol use during the previous 30 days, maximum number of drinks at one time in the past 30 days, and typical alcohol use in the past 30 days), alcohol-impaired driving, alcohol-related injuries, and alcohol-related negative consequences. CONCLUSION: Despite the potential advantage of delivering a telephone brief motivational intervention in not disrupting ED clinical care, our study found no efficacy for it over an assessment and control intervention. Potential causes for our finding include that injury itself, alcohol assessments, or the control intervention had active ingredients for alcohol change.

Test-Retest Reliability and descriptive analyses of the Modified Important People and Activities (MIPA) Interview.

BACKGROUND: The Important People and Activities (IPA) instrument assesses network characteristics and social support for drinking and abstinence. The IPA has garnered widespread use in the alcohol treatment field. We modified the IPA to assess HIV status, drug of choice, and IV drug use among social network members. Further, we queried frequency of unprotected sex, between the participant and network members. AIM: Since this measure was modified, and the test-retest reliability of the IPA has only rarely been examined, we conducted a small substudy (n=26) to examine 1-week test-retest reliability of this measure. METHODS: Participants were individuals in a day treatment program with an SUD and/or AUD diagnosis. RESULTS: Drug of choice for the participants represented roughly equal thirds of heroin, cocaine, and alcohol. The sample was 62% female and 39% Latino/a. At pretest 198 persons were named on the MIPA (M=7.6 network members per subject). It was determined that 152 of the people were overlapping between the test and retest. CONCLUSIONS: Percent agreement, ICCs, and kappas for the items ranged from acceptable to excellent across the two time periods. Classification of network members as positive, negative, or neutral influences on sobriety also demonstrated good to excellent kappas.

Active Ingredients of Treatment and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later.

BACKGROUND: The current review revisits the article entitled: "Active Ingredients: How and Why Evidence-Based Alcohol Behavioral Treatment Interventions Work" published in Alcoholism: Clinical and Experimental Research. This work summarized proceedings from a 2004 Symposium of the same name that was held at the Annual Meeting of the Research Society on Alcoholism (RSA). A decade has passed, which provides occasion for an evaluation of progress. In 2014, an RSA symposium titled Active Treatment Ingredients and Client Mechanisms of Change in Behavioral Treatments for Alcohol Use Disorders: Progress 10 Years Later did just that. METHODS: The current review revisits state-of-the-art research on the 3 treatments examined 10 years ago: cognitive behavioral therapy, alcohol behavior couples therapy, and 12-step facilitation. Because of its empirically validated effectiveness and robust research agenda on the study of process outcome, motivational interviewing has been selected as the fourth treatment modality to be discussed. For each of these 4 treatments, the reviewers provide a critical assessment of current theory and research with a special emphasis on key recommendations for the future. RESULTS: Noteworthy progress has been made in identifying active ingredients of treatments and mechanisms of behavior change in these 4 behavioral interventions for alcohol and other drug use disorders. Not only have we established some of the mechanisms through which these evidence-based treatments work, but we have also uncovered some of the limitations in our existing frameworks and methods. CONCLUSIONS: Further progress in this area will require a broader view with respect to conceptual frameworks, analytic methods, and measurement instrumentation.

Social network moderators of naltrexone and behavioral treatment effects on heavy drinking in the COMBINE study.

BACKGROUND: Oral naltrexone is an efficacious medication for treatment of alcohol dependence, but small effect sizes and variability in outcomes suggest the presence of person-level moderators of naltrexone response. Identification of contextual or psychosocial moderators may assist in guiding clinical recommendations. Given the established importance of social networks in drinking outcomes, as well as the potential effects of naltrexone in reducing cue reactivity which may be especially important among those with more heavy drinkers and more alcohol cues in their networks, we examined pretreatment social network variables as potential moderators of naltrexone treatment effects in the COMBINE study. METHODS: The sample included all COMBINE study participants in medication conditions with full data on the Important People Inventory (IPI) and covariates at intake (N = 1,197). The intake IPI assessed whether participants had any frequent drinkers in their network and the average frequency of contact with these drinkers. The effects of treatment condition, pretreatment network variables, and their interactions on percent heavy drinking days were tested in hierarchical linear models, controlling for demographics and baseline clinical covariates. RESULTS: In treatment conditions involving medical management and combined behavioral intervention (CBI), the effects of active naltrexone on heavy drinking were significantly greater for individuals with frequent drinkers in their network (z = -2.66, p < 0.01) and greater frequency of contact with those drinkers (z = -3.19, p < 0.01). These network variables did not moderate the effects of active naltrexone without CBI. CONCLUSIONS: When delivered in conjunction with behavioral interventions, naltrexone can be more potent for alcohol-dependent adults who have greater contact with frequent drinkers prior to treatment, which may indicate patterns of environmental exposure to alcohol. Contextual, social risk factors are a potential avenue to guide personalized treatment of alcohol dependence.

Participant report of therapist-delivered active ingredients in a telephone-delivered brief motivational intervention predicts taking steps towards change.

OBJECTIVE: Given the widespread potential for disseminating Motivational Interviewing (MI) through technology, the question of whether MI active ingredients are present when not delivered in person is critical to assure high treatment quality. The Participant Rating Form (PRF) was developed and used to evaluate therapist-delivered active ingredients in phone-delivered MI with hazardous drinking Emergency Department patients. METHOD: A factor analysis of all PRFs completed after receiving one call (n=256) was conducted. Multiple regression analysis was used to examine whether PRF factors predicted a measure of motivation to change -- taking steps-at the second call (n=214). RESULTS: The majority of participants were male (65%), with a mean age of 32 years and with an average alcohol ASSIST (Alcohol, Smoking, and Substance Involvement Screening Test) score of 20.5 (SD = 7.1). Results of the factor analysis for the PRF revealed Relational (working collaboration) and Technical (MI behaviors) factors. After controlling for demographics, alcohol severity, and baseline readiness, the technical factor predicted self-report of increased taking steps towards change while the relational factor did not explain any additional variance. CONCLUSIONS: Our study adds to the growing literature investigating patient perspectives of therapist skill as a source of information to better understand MI active ingredients. The PRF is a feasible instrument for measuring the patient's experience of phone-based MI. Results indicate that MI active ingredients of change (relational and technical components) were present in the telephone intervention as hypothesized. Clinical Trial Registration # 01326169.

Influence of counselor characteristics and behaviors on the efficacy of a brief motivational intervention for heavy drinking in young men--a randomized controlled trial.

BACKGROUND: Brief motivational intervention (BMI) has shown promising results to reduce alcohol use in young adults. Knowledge on mechanisms that predict BMI efficacy could potentially improve treatment effect sizes through data that optimize clinical training and implementation. Particularly, little attention has been given to counselor influence on treatment mechanisms. METHODS: We investigated the influence of counselors on BMI efficacy in reducing alcohol use among non-treatment-seeking young men (age 20) screened as hazardous drinkers. Participants were randomly allocated to (i) a group receiving a single BMI from 1 of 18 counselors selected to maximize differences in several of their characteristics (gender, professional status, clinical experience, and motivational interviewing [MI] experience) or (ii) a control group receiving assessment only. Drinking at 3-month follow-up was first compared between the BMI and control groups to assess efficacy. Then, the influence of counselors' characteristics (i.e., gender, professional status, clinical experience, MI experience, BMI attitudes, and expectancies) and within-session behaviors (i.e., measured by the Motivational Interviewing Skill Code) on outcome was tested in regression analyses. RESULTS: There was a significant (p = 0.02) decrease in alcohol use among the BMI group compared to the control group. Counselors that were male, more experienced, that had more favorable BMI attitudes and expectancies, higher MI skills, but surprisingly less MI-consistent behaviors, had significantly better outcomes than the control group while their counterparts did not. CONCLUSIONS: The current study demonstrated BMI efficacy on alcohol use reduction within a sample of non-treatment-seeking young adult males. Moreover, BMI effect was related to interindividual differences among counselors, and results therefore provide recommendations for BMI training and implementation with similar populations.

DIAL: a randomised trial of a telephone brief intervention for alcohol.

BACKGROUND: Decreasing Injuries from ALcohol (DIAL) is a randomised control trial of a telephone brief intervention (BI) with injured emergency department (ED) patients with high-risk alcohol use. Here the authors examine 12-month outcomes of the intervention's effect on alcohol use, alcohol-related injuries and alcohol-related negative consequences. METHODS: ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, all participants received by telephone an assessment of their alcohol use, alcohol-related injuries, and alcohol-related negative consequences and then were randomised to treatment or standard care. Treatment consisted of two telephone sessions of BI focusing on risky alcohol use. Both groups were reassessed after 12 months. RESULTS: At 12 months, 249 (89%) participants completed follow-up assessments. After using a log transformation, the difference in alcohol-related injuries between baseline and 12-month follow-up was greater in the BI group than the standard care group (p=0.04); this is an effect size of Cohen's d=0.21. No difference between groups was found when comparing change in alcohol consumption and other alcohol-related negative consequences at 12 months. CONCLUSIONS: These findings suggest that a telephone BI with injured ED patients may decrease alcohol-related injuries. Identifying patients with risky alcohol use in the ED and then subsequently delivering the intervention by telephone after discharge has promise as a model for BI and deserves further study.

Recent advances in behavioral addiction treatments: focusing on mechanisms of change.

In the latter half of the 20th century, research on behavioral treatments for addictions aimed to develop and test effective treatments. Among the treatments found to be at least moderately effective, direct comparisons failed to reveal consistent superiority of one approach over another. This ubiquitous finding held true despite underlying theories that differed markedly in their proposed causal processes related to patient change. In the 21st century, the focus of treatment research is increasingly on how treatment works for whom rather than whether it works. Studies of active treatment ingredients and mechanisms of behavioral change, while promising, have yielded inconsistent results. Simple mediation analysis may need to be expanded via inclusion of models testing for moderated mediation, mediated moderation, and conditional indirect effects. Examples are offered as to how these more complex models can lead to increased understanding of the conditions under which specific treatment interventions will be effective and mechanisms of change operative in improving behavioral treatments for addictions.

Readiness to change as a mediator of the effect of a brief motivational intervention on posttreatment alcohol-related consequences of injured emergency department hazardous drinkers.

Brief motivational interventions (BMIs) are usually effective for reducing alcohol use and consequences in primary care settings. We examined readiness to change drinking as a mediator of the effects of BMI on alcohol-related consequences. Participants were randomized into three conditions: (a) standard care plus assessment (SC), (b) SC plus BMI (BI), and (c) BI plus a booster session (BIB). At 12-month follow-up BIB patients had significantly reduced alcohol consequences more than had SC patients. Patients receiving BI or BIB maintained higher readiness scores 3 months after treatment than did patients receiving SC. However, readiness mediated treatment effects only for those highly motivated to change prior to the intervention but not for those with low pre-intervention motivation. BI and BIB for these patients decreased alcohol consequences in part because they enhanced and maintained readiness for those highly motivated prior to the intervention, but not for those with low motivation. Results are opposite of what would be expected from MI theory. An alternative explanation is offered as to why this finding occurred with this opportunistically recruited Emergency Department patient population.

An intervention for treating alcohol dependence: relating elements of Medical Management to patient outcomes with implications for primary care.

PURPOSE: Alcohol dependence, frequently seen in medical settings, is a major problem that affects the health and well-being of many individuals and their families. The purpose of this study was to examine the relationship between treatment outcomes and patient and clinician factors specifically associated with a medically oriented intervention given for the treatment of alcohol dependence. The intervention was developed for the National Institute on Alcohol Abuse and Alcoholism-sponsored COMBINE Study, a randomized controlled trial combining 2 medications, naltrexone and acamprosate, with Medical Management, with or without specialty alcohol treatment. METHODS: We examined the effect of patient adherence to treatment (number of Medical Management visits, total minutes in treatment, alliance or therapeutic relationship with the clinician, patient satisfaction with treatment, and clinician adherence to the Medical Management protocol) on abstinence from alcohol, amount of heavy drinking, and clinical improvement during treatment. RESULTS: More Medical Management visits attended and less total time spent in Medical Management treatment was associated with more days of abstinence from alcohol, reductions in heavy alcohol drinking, and a higher likelihood of clinical improvement. The patients' positive perceptions of their alliance with their clinician and their satisfaction with treatment was significantly associated with more days of abstinence from alcohol during treatment. Two clinician factors clinician confidence in the Medical Management treatment and flexibility in delivering Medical Management were also associated with better patient outcomes. CONCLUSIONS: Medically trained clinicians with minimal specialty training in alcohol dependence treatments were able to deliver a brief and effective medication management intervention that was designed to be consistent with primary care practice.

DIAL: a telephone brief intervention for high-risk alcohol use with injured emergency department patients.

STUDY OBJECTIVE: Brief interventions for high-risk alcohol use for injured emergency department (ED) patients have demonstrated effectiveness and may have a more pronounced effect with motor vehicle crash patients. We report on 3-month outcome data of a randomized controlled trial of injured patients, using a novel model of telephone-delivered brief interventions after ED discharge. METHODS: ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, participants received by telephone an assessment of alcohol use and impaired driving and then were randomized to treatment (n=140) or standard care (n=145). Treatment consisted of 2 sessions of brief interventions done by telephone, focusing on risky alcohol use. At 3 months, both groups had an assessment of alcohol use and impaired driving. RESULTS: Two hundred eighty-five patients were randomized and had a baseline mean Alcohol Use Disorders Inventory Test (AUDIT) score of 11.0 (SD=7.4). Three-month follow-up assessments were completed on 273 (95%). Mean AUDIT score decreased in both the treatment (mean change=-3.4; 95% confidence interval [CI] -4.5 to -2.3) and standard care group (mean change=-3.2; 95% CI -4.2 to -2.2). Measures of impaired driving decreased for the treatment group (mean change=-1.4 95%; CI -3.0 to 0.2) compared with standard care group (mean change=1.0; 95% CI -0.9 to 2.9; P=.04; d=0.31). Participants were stratified post hoc into 3 groups by baseline alcohol problem, with the treatment effect only being in the highest-scoring group (d=.30). CONCLUSION: Telephone brief interventions decreased impaired driving in our treatment group. Telephone brief intervention appears to offer an alternative mechanism to deliver brief intervention for alcohol in this at-risk ED population.

Naltrexone's suppressant effects on drinking are limited to the first 3 months of treatment.

RATIONALE: Twelve weeks of naltrexone significantly improves drinking outcomes in alcoholics; however, the clinical benefits of naltrexone decline shortly after treatment is discontinued. OBJECTIVE: The present study investigated whether extended treatment with naltrexone significantly improved drinking outcomes. METHODS: One hundred forty-six alcohol-dependent patients received broad spectrum treatment or motivational enhancement therapy and either 12 or 24 weeks of naltrexone. The primary dependent variables were percent days abstinent and percent heavy drinking days. RESULTS: Using an intention-to-treat analysis, there were no significant differences in percent days abstinence or percent heavy drinking days at the end of phase 2 between patients who received 24 weeks of treatment with naltrexone (chi = 63.23) or patients who received 12 weeks of treatment with naltrexone followed by 12 weeks of treatment with placebo (chi = 65.82). Similarly, the average percent heavy drinking days was not significantly different at the end of phase 2 between the group that received 24 weeks of naltrexone (chi = 21.9) and the group that received 12 weeks of naltrexone followed by 12 weeks of placebo (chi = 22.14). Medication compliance was low in the second phase of the study. Drinking outcomes declined with declining compliance whether patients were taking naltrexone or placebo. CONCLUSIONS: The results of this study suggest that administering naltrexone beyond an initial 12 weeks of treatment may not be beneficial to all patients and should be administered along with close medical monitoring to insure compliance.

Does matching matter? Examining matches and mismatches between patient attributes and therapy techniques in alcoholism treatment.

AIMS: This study assessed the predictive validity of the level of matching and mismatching between patients' personal attributes and aspects of outpatient psychotherapy they received. DESIGN AND PARTICIPANTS: On the basis of patient-by-treatment interactions observed for this sample in previous research, patients with alcohol abuse or dependence (n = 137) were designated retrospectively as being matched, unmatched or mismatched on each of four patient and treatment variable pairings. These pairings included (1) patient depressive symptoms and therapy emotion focus, (2) patient trait anger and therapy confrontation, (3) patient interpersonal reactance and therapy confrontation and (4) patient interpersonal reactance and therapy structure. MEASUREMENTS: Analyses of variance and logistic regression were used to assess the individual and additive effects of being matched and mismatched on the percentage of abstinent days (PDA) and recovery status in the year after treatment. FINDINGS: Being mismatched on any of the four patient-treatment pairings was a significant predictor of more frequent alcohol use post-treatment. Being matched on only two pairings predicted less frequent alcohol use, namely matches on therapy emotion focus with patient depressive symptoms and therapy structure with patient reactance. Matches appeared to optimize otherwise good outcomes, while mismatches had larger effect sizes and tended to predict relatively poor outcomes. The data supported the presence of an additive effect for mismatches on post-treatment PDA. The group with the most mismatches fared considerably worse than a group with fewer mismatches. Several matches and mismatches also predicted recovery status, with some support found for additive effects. CONCLUSIONS: Mismatches between patient attributes and treatment appear to have serious consequences, and this effect is magnified with multiple mismatches. Matches, on the other hand, while beneficial, may not be necessary to achieve good outcomes.

Do patient intervention ratings predict alcohol-related consequences?

Little is known about treatment process for behavior change for brief interventions. Patient ratings of treatment process during a patient-centered brief intervention for alcohol were used to predict post-treatment alcohol use and consequences. We use data from a randomized clinical trial that compared the effects of BI (1 session) to BI and booster (BIB, 2 sessions) to reduce harmful drinking and alcohol consequences. Subjects were n=167 (BI) and n=82 (BIB). Five of the 12 ratings were rated significantly higher by those in the BIB condition compared to BI. The only predictor of reduced alcohol consequences at 12-months was higher ratings of, "I have obtained some new understanding," for BIB participants (t=-2.50, p<.05). Patient perspectives on treatment may have a role in patient outcomes and should be explored as a dimension of treatment process.

Concurrent validity of the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT zones in defining levels of severity among out-patients with alcohol dependence in the COMBINE study.

AIMS: To examine among alcohol-dependent out-patient clients the concurrent validity of the Alcohol Use Disorders Identification Test (AUDIT) total score and 'zones' suggested by the World Health Organization for defining levels of severity of alcohol use problems. DESIGN: Participants were classified into AUDIT zones (AUDIT total score = 8-15, 16-19, 20-40) and compared on measures of demographics, treatment goals, alcohol consumption, alcohol-related consequences, severity of dependence, physiological dependence, tolerance, withdrawal and biomarkers of alcohol use. SETTING: Eleven out-patient academic clinical research centers across the United States. Participants Alcohol dependent individuals (n = 1335) entering out-patient treatment in the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) study. MEASUREMENTS: The AUDIT was administered as part of an initial screening. Baseline measures used for concurrent validation included the Structured Clinical Interview for Diagnostic and Statistical Manual, 4th edition (DSM-IV) Disorders, the Alcohol Dependence Scale, the Drinker Inventory of Consequences, the Obsessive-Compulsive Drinking Scale, the University of Rhode Island Change Assessment, the Thoughts about Abstinence Scale, the Form-90, %carbohydrate-deficient transferrin and gamma-glutamyl transferase. Findings Indicators of severity of dependence and alcohol-related problems increased linearly with total score and differed significantly across AUDIT zones. The highest zone, with scores of 20 and above, was markedly different with respect to severity from the other two zones and members of this group endorsed an abstinence goal more strongly. CONCLUSIONS: The AUDIT total score is a brief measure that appears to provide an index of severity of dependence in a sample of alcohol-dependent individuals seeking out-patient treatment, extending its potential utility beyond its more traditional role as a screening instrument in general populations.

Relapse-onset factors in Project MATCH: the Relapse Questionnaire.

Previously, items on the relapse-onset section of the Relapse Questionnaire have been grouped together based on face validity. In the present article, an empirical scoring method for this measure is derived through a factor analysis of Project MATCH data. Three factors replicate the factor solutions of other measures of alcohol relapse onset and relapse risk. The three factors found in this study include the following: Negative Affect/Family Influences, Craving/Cued, and Social Pressure. This study also replicates earlier findings that social pressure relapses are most likely to repeat, and that negative affect relapses are more severe. Earlier studies typing relapses have hypothesized that this may be one method to detect treatment effects that might otherwise be missed if relapses are not differentiated and only generic measures (such as time to first drink) are used. This hypothesis is tested in the present article, and Motivational Enhancement Therapy is revealed to offer protection against social pressure relapses that is less than those offered by Cognitive-Behavioral Coping Skills Therapy or Twelve-Step Facilitation Therapy.

Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial.

CONTEXT: Alcohol dependence treatment may include medications, behavioral therapies, or both. It is unknown how combining these treatments may impact their effectiveness, especially in the context of primary care and other nonspecialty settings. OBJECTIVES: To evaluate the efficacy of medication, behavioral therapies, and their combinations for treatment of alcohol dependence and to evaluate placebo effect on overall outcome. DESIGN, SETTING, AND PARTICIPANTS: Randomized controlled trial conducted January 2001-January 2004 among 1383 recently alcohol-abstinent volunteers (median age, 44 years) from 11 US academic sites with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnoses of primary alcohol dependence. INTERVENTIONS: Eight groups of patients received medical management with 16 weeks of naltrexone (100 mg/d) or acamprosate (3 g/d), both, and/or both placebos, with or without a combined behavioral intervention (CBI). A ninth group received CBI only (no pills). Patients were also evaluated for up to 1 year after treatment. MAIN OUTCOME MEASURES: Percent days abstinent from alcohol and time to first heavy drinking day. RESULTS: All groups showed substantial reduction in drinking. During treatment, patients receiving naltrexone plus medical management (n = 302), CBI plus medical management and placebos (n = 305), or both naltrexone and CBI plus medical management (n = 309) had higher percent days abstinent (80.6, 79.2, and 77.1, respectively) than the 75.1 in those receiving placebos and medical management only (n = 305), a significant naltrexone x behavioral intervention interaction (P = .009). Naltrexone also reduced risk of a heavy drinking day (hazard ratio, 0.72; 97.5% CI, 0.53-0.98; P = .02) over time, most evident in those receiving medical management but not CBI. Acamprosate showed no significant effect on drinking vs placebo, either by itself or with any combination of naltrexone, CBI, or both. During treatment, those receiving CBI without pills or medical management (n = 157) had lower percent days abstinent (66.6) than those receiving placebo plus medical management alone (n = 153) or placebo plus medical management and CBI (n = 156) (73.8 and 79.8, respectively; P<.001). One year after treatment, these between-group effects were similar but no longer significant. CONCLUSIONS: Patients receiving medical management with naltrexone, CBI, or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy, with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management. Placebo pills and meeting with a health care professional had a positive effect above that of CBI during treatment. Naltrexone with medical management could be delivered in health care settings, thus serving alcohol-dependent patients who might otherwise not receive treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00006206.

Under what conditions? Therapist and client characteristics moderate the role of change talk in brief motivational intervention.

OBJECTIVE: Client change talk has been proposed as a mechanism of change in motivational interviewing (MI) by mediating the link between therapist MI-consistent behaviors (MICO) and client behavioral outcomes. We tested under what circumstances this mechanism was supported in the context of a clinical trial of brief MI for heavy drinking among nontreatment seeking young men. METHOD: We conducted psycholinguistic coding of 174 sessions using the MI Skill Code 2.1 and derived the frequency of MICO and the strength of change talk (CTS) averaged over the session. CTS was examined as a mediator of the relationship between MICO and a drinking composite score measured at 3-month follow-up, controlling for the composite measure at baseline. Finally, we tested therapist gender and MI experience as well as client readiness to change and alcohol problem severity as moderators of this mediation model. RESULTS: CTS significantly predicted outcome (higher strength related to less drinking), but MICO did not predict CTS. However, CTS mediated the relationship between MICO and drinking outcomes when therapists had more experience in MI and when clients had more severe alcohol problems (i.e., significant conditional indirect effects). CONCLUSIONS: The mechanism hypothesized by MI theory was operative in our brief MI with heavy drinking young men, but only under particular conditions. Our results suggest that attention should be paid to therapist selection, training, and/or supervision until they reach a certain level of competence, and that MI might not be appropriate for nontreatment seeking clients drinking at a lower level of risk.

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.