A behaviour-based coding tool for assessing supervisors' adherence and competence: Findings from a motivational interviewing implementation study.

Supervision seems to be an essential part of therapist training and thus also of implementing evidence-based practices. However, there is a shortage of valid and reliable instruments for objective assessment of supervision competence that include both global measures and frequency counts of behaviour-two essential aspects of supervisory competence. This study tests the internal consistency and inter-rater reliability of an assessment tool that includes both these measures. Additionally, strategies and techniques used by 10 supervisors in 35 Motivational interviewing supervision sessions are described. Codings were conducted after two separate coding training sessions. The internal consistency across the global measures was acceptable (α = 0.70; 0.71). After the second training, the inter-rater reliabilities for all frequency counts were in the moderate to good range, except for two that were in the poor range; inter-rater reliability for one of the four global measures was in the moderate range, and three were in the poor range. A prerequisite for identifying specific supervisor skills central to the development of therapist skills, teaching these skills to supervisors and performing quality assurance of supervision, is to create instruments that can measure these behaviours. This study is a step in that direction.

Providing objective feedback in supervision in motivational interviewing: results from a randomized controlled trial.

BACKGROUND: The effects of the use of objective feedback in supervision on the supervisory relationship and skill acquisition is unknown. AIMS: The objective of this study was to evaluate the effects of two different types of objective feedback provided during supervision in motivational interviewing (MI) on: (a) the supervisory relationship, including potential feelings of discomfort/distress, provoked by the supervision sessions, and (b) the supervisees' skill acquisition. METHOD: Data were obtained from a MI dissemination study conducted in five county councils across five county councils across Sweden. All 98 practitioners recorded sessions with standardized clients and were randomized to either systematic feedback based on only the behavioral component of a feedback protocol, or systematic feedback based on the entire protocol. RESULTS: The two different ways to provide objective feedback did not negatively affect the supervisory relationship, or provoke discomfort/distress among the supervisees, and the group that received the behavioural component of the feedback protocol performed better on only two of the seven skill measures. CONCLUSIONS: Objective feedback does not seem to negatively affect either the supervisor-supervisee working alliance or the supervisees' supervision experience. The observed differences in MI skill acquisition were small, and constructive replications are needed to ascertain the mode and complexity of feedback that optimizes practitioners' learning, while minimizing the sense of discomfort and distress.

Relational Skills and Client Language Predict Outcome in Smoking Cessation Treatment.

BACKGROUND: We currently lack insight into the predictive processes of Motivational Interviewing (MI) in smoking cessation treatment. More knowledge is necessary to be able to further enhance the treatment effect in smoking cessation interventions. OBJECTIVES: To examine certain hypothesized active components of MI in smoking cessation treatment delivered in an ordinary clinical setting. METHODS: Audio-recordings of 106 smoking cessation treatment sessions were analyzed using the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE) Coder's Manual and the Motivational Interviewing Treatment Integrity code (MITI) Manual, version 3.1. The outcome measure was self-reported 6-month continuous abstinence at 12-month follow-up. RESULTS: Client Activation utterances in favor of change were positively associated with smoking cessation at follow-up. The combined category of client language expressing a Desire or a Need to continue to smoke was negatively predictive of smoking cessation. In addition, we found preliminary support for a negative interaction effect between counselors' demonstration of the spirit of MI and clients Activation utterances in favor of change. Conclusions/Importance: Our data suggest that if smoking cessation counselors cultivate client Activation utterances in favor of abstinence and softening client utterances expressing desire or perceived need to smoke, this could contribute to higher rates of treatment success. In addition, counselors' demonstration of the spirit of MI was a statistically significant predictor of outcome when the negative interaction effect between Activation utterances in favor of change and MI spirit was taken into account. These findings should be evaluated in larger studies in the future.

Primary care nurses' communication and its influence on patient talk during motivational interviewing.

AIM: The aim of this study was to describe what verbal behaviours/kinds of talk occur during recorded motivational interviewing sessions between nurses in primary care and their patients. The aim was also to examine what kinds of nurse talk predict patient change talk, neutral talk and/or sustain talk. BACKGROUND: Motivational interviewing is a collaborative conversational style. It has been shown to be effective, in addressing health behaviours such as diet, exercise, weight loss and chronic disease management. In Sweden, it is one of the approaches to disease prevention conversations with patients recommended in the National Guidelines for Disease Prevention. Research on the mechanisms underlying motivational interviewing is growing, but research on motivational interviewing and disease prevention has also been called for. DESIGN: A descriptive and predictive design was used. METHODS: Data were collected during 2011-2014. Fifty audio-recorded motivational interviewing sessions between 23 primary care nurses and 50 patients were analysed using Motivational Interviewing Sequential Code for Observing Process Exchanges. The frequency of specific kinds of talk and sequential analysis (to predict patient talk from nurse talk) were computed using the software Generalized Sequential Querier 5. FINDINGS: The primary care nurses and patients used neutral talk most frequently. Open and negative questions, complex and positive reflections were significantly more likely to be followed by change talk and motivational interviewing-inconsistent talk, positive questions and negative reflections by sustain talk. CONCLUSIONS: To increase patients' change talk, primary care nurses need to use more open questions, complex reflections and questions and reflections directed towards change.

"Sometimes It Felt Great, and Sometimes It Just Went Pear-Shaped": Experiences and Perceptions of School Nurses' Motivational Interviewing Competence: A Convergent Mixed-Methods Study.

In this convergent mixed-methods study, the aim was to explore how objective and subjective quality ratings of school nurses' motivational interviewing (MI) correlate whilst also considering the perceptions of delivering and participating in the same MI sessions. Quantitative and qualitative data were derived from seven intervention schools participating in the Healthy School Start Plus parenting support intervention. School nurses were trained in MI and conducted an MI session with parents of 6-7-year-old children to discuss children's physical health and development. Quantitative data comprised objective ratings of school nurses' MI competence using the Motivational Interviewing Treatment Integrity 4.2 [MITI-4] protocol, as well as parents' and school nurses' subjective ratings of the MI sessions. Qualitative data comprised semi-structured interviews with parents and school nurses about their perceptions of the MI sessions. First, quantitative data were analysed using Spearman's rank correlation, and qualitative data were analysed using content analysis. Next, quantitative and qualitative findings were merged. Our findings suggest that school nurses' MI performances were rated and perceived as valuable and family-centred by both school nurses and parents who had left the meeting feeling motivated and empowered to promote their children's healthy behaviours. Nonetheless, school nurses were critical to their own MI technical performance, and they found that reflections were easier to deliver and to self-rate. Overall, MITI ratings were the lowest and parents' ratings were the highest. Future studies should focus on relating clients' subjective ratings of MI with clients' behavioural outcomes.

Correspondence between practitioners' self-assessment and independent motivational interviewing treatment integrity ratings.

As evaluation of practitioners' competence is largely based on self-report, accuracy in practitioners' self-assessment is essential for ensuring high quality treatment-delivery. The aim of this study was to assess the relationship between independent observers' ratings and practitioners' self-reported treatment integrity ratings of Motivational interviewing (MI). Practitioners (N = 134) were randomized to two types of supervision [i.e., regular institutional group supervision, or individual telephone supervision based on the MI Treatment Integrity (MITI) code]. The mean age was 43.2 years (SD = 10.2), and 62.7 percent were females. All sessions were recorded and evaluated with the MITI, and the MI skills were self-assessed with a questionnaire over a period of 12 months. The associations between self-reported and objectively assessed MI skills were overall weak, but increased slightly from baseline to the 12-months assessment. However, the self-ratings from the group that received monthly objective feedback were not more accurate than those participating in regular group supervision. These results expand findings from previous studies and have important implications for assessment of practitioners' treatment fidelity: Practitioners may learn to improve the accuracy of self-assessment of competence, but to ensure that patients receive intended care, adherence and competence should be assessed objectively.

Ongoing supervision as a method to implement Motivational interviewing: Results of a randomized controlled trial.

OBJECTIVE: To assess skills in Motivational interviewing (MI) at the Swedish National Board of Institutional Care (SiS), and to evaluate different ways to provide MI supervision. METHODS: SiS practitioners (n = 134) were randomized to regular group supervision, or individual telephone supervision based on only the behavioral component of a feedback protocol, or the full protocol. Participant's mean age was 43.2 (SD =10.2), and the majority (62.7%) were females. RESULTS: Many participants showed beginning proficiency already at baseline, indicating a successful implementation. Still, results varied widely. The regular supervision and the supervision based on objective feedback were equally effective, and the group receiving feedback based on fewer variables of the protocol performed better on only one of the seven skill measures. The objective feedback did not provoke supervisee discomfort/distress, or negatively affect the supervisory relationship. CONCLUSIONS: Extensive MI implementation can increase practitioners' skills in MI, but the question of the best mode of ongoing supervision needs further attention. PRACTICE IMPLICATIONS: Objective feedback does not seem to negatively affect the supervisee's skill acquisition or the supervisor-supervisee working alliance, but the question of how to most efficiently provide feedback from multifaceted feedback tools remains unanswered.

Brief manual-based single-session Motivational Interviewing for reducing high-risk sexual behaviour in women - an evaluation.

The objective of this study was to develop and evaluate brief Motivational Interviewing (MI) to facilitate behaviour change in women at high risk of contracting sexually transmitted infections (STIs). One hundred and seventy-three women (mean age 24.7) at high risk of contracting STIs were randomized to a brief risk-reducing MI counselling intervention (n = 74) or assigned to the control group (n = 99). MI skill was assessed using the Motivational Interviewing Treatment Integrity (MITI) Coding System. Seventeen of 74 (23%) women tested for Chlamydia trachomatis (CT) in the MI intervention group and 22 of 99 (22%) in the control group had a genital CT infection 0-24 months before baseline. All additional CT testing was monitored up to 24 months for all 173 women in the study. None of the 49 CT-retested women in the MI group was CT infected, as compared to 3 of 72 (4%) women in the control group. A generalized estimating equations model with sexual high-risk behaviour measured at baseline and at six-month follow-up produced an adjusted estimated odds ratio of 0.38 (95% confidence interval = 0.158, 0.909), indicating efficacy. Brief manual-based single-session MI counselling seems to be effective in reducing high-risk sexual behaviour in women at high risk of acquiring STIs.

The relationship between counselors' technical skills, clients' in-session verbal responses, and outcome in smoking cessation treatment.

BACKGROUND: The technical component of Motivational Interviewing (MI) posits that client language mediates the relationship between counselor techniques and subsequent client behavioral outcomes. The purpose of this study was to examine this hypothesized technical component of MI in smoking cessation treatment in more depth. METHOD: Secondary analysis of 106 first treatment sessions, derived from the Swedish National Tobacco Quitline, and previously rated using the Motivational Interviewing Sequential Code for Observing Process Exchanges (MI-SCOPE) Coder's Manual and the Motivational Interviewing Treatment Integrity code (MITI) Manual, version 3.1. The outcome measure was self-reported 6-month continuous abstinence at 12-month follow-up. RESULTS: Sequential analyses indicated that clients were significantly more likely than expected by chance to argue for change (change talk) following MI-consistent behaviors and questions and reflections favoring change. Conversely, clients were more likely to argue against change (sustain talk) following questions and reflections favoring status-quo. Parallel mediation analysis revealed that a counselor technique (reflections of client sustain talk) had an indirect effect on smoking outcome at follow-up through client language mediators. CONCLUSIONS: The study makes a significant contribution to our understanding of how MI works in smoking cessation treatment and adds further empirical support for the hypothesized technical component in MI. The results emphasize the importance of counselors avoiding unintentional reinforcement of sustain talk and underline the need for a greater emphasis on the direction of questions and reflections in MI trainings and fidelity measures.

The dissemination of motivational interviewing in Swedish county councils: Results of a randomized controlled trial.

OBJECTIVE: A significant number of Swedish practitioners are offered workshop trainings in motivational interviewing through community-based implementation programs. The objective of this randomized controlled trial was to evaluate to what extent the practitioners acquire and retain skills from additional supervision consisting of feedback based on monitoring of practice. MATERIALS AND METHODS: A total of 174 practitioners in five county councils across Sweden were randomized to one of the study's two groups: 1) Regular county council workshop training, 2) Regular county council workshop training followed by six sessions of supervision. The participant's mean age was 43.3 years, and the majority were females (88.1%). RESULTS: Recruiting participants proved difficult, which may have led to a biased sample of practitioners highly motivated to learn the method. Although slightly different in form and content, all the workshop trainings increased the participants' skills to the same level. Also, consistent with previous research, the additional supervision group showed larger gains in proficiency compared to the group who received workshop training only at the six-month follow-up. However, analyses showed generally maintained levels of skills for all the participants at the follow-up assessment, and the majority of participants did not attain beginning proficiency levels at either post-workshop or follow-up. CONCLUSIONS: The results of this study address the real-life implications of dissemination of evidence-based practices. The maintained level of elevated skills for all participants is a promising finding. However, the low interest for obtaining additional supervision among the Swedish practitioners is problematic. In addition, neither the workshop trainings nor the additional supervision, although improving skills, were sufficient for most of the participants to reach beginning proficiency levels. This raises questions regarding the most efficient form of training to attain and sustain adequate practice standards, and how to create incentive and interest among practitioners to participate in such training.

Self-reported availability of kinship cues during childhood is associated with kin-directed behavior to parents in adulthood.

Reliable recognition of kin is an important factor in modulating kin-directed behaviors. For example, in selectively directing cooperative behavior to kin and diverting sexual interest away from them, kin first need to be recognized as such. Although an increasing number of studies have examined what information is employed in recognizing siblings and children, less is known about the information children employ in identifying their parents. In a web-based survey, we asked 702 Finnish undergraduate and graduate students to report the availability of a number of possible kinship cues during their childhood and youth. After factorization of the responses, we found that the reported amount of parental support, phenotypic similarity, and behavioral similarity generally predicted subjective certainty in relatedness and kin-directed behavior (i.e., cooperative behavior and inbreeding aversion) to parents in adulthood. Although the data suffer from their retrospective nature, the present study provides potentially useful information about kin-recognition of parents.

Motivational interviewing in an ordinary clinical setting: a controlled clinical trial at the Swedish National Tobacco Quitline.

INTRODUCTION: The present study aimed to assess the effect of adding motivational interviewing (MI) to the first session of an effective smoking cessation treatment protocol in an ordinary clinical setting: the Swedish National Tobacco Quitline (SNTQ). METHOD: The study was designed as a controlled clinical trial. Between September 2005 and October 2006, 772 clients accepted the invitation to participate in the study and were semi-randomised to either standard treatment (ST) or MI. The primary outcome measures were self-reported 7-day point prevalence abstinence and 6-month continuous abstinence. RESULTS: At 12-month follow-up, the 772 clients were included in an intention to treat analysis. Of the clients allocated to MI, 57/296 (19%) reported 6-month continuous abstinence compared to 66/476 (14%) of the clients allocated to ST (OR 1.48, 95% CI 1.00-2.19; P=.047). CONCLUSIONS: Integrating MI into a cognitive behavioural therapy-based smoking cessation counselling in an ordinary clinical setting at a tobacco quitline increased client 6-month continuous abstinence rates by 5%.

Clinician acquisition and retention of Motivational Interviewing skills: a two-and-a-half-year exploratory study.

BACKGROUND: Motivational interviewing (MI) is a collaborative, client-centred counselling style aimed at eliciting and strengthening clients' intrinsic motivation to change. There is strong research evidence supporting the efficacy of MI, notably in its application among alcohol and drug abuse populations. MI interventions in smoking cessation may yield modest but significant increases in quitting. The present study sought to assess the acquisition and retention of MI skills in counsellors at the Swedish National Tobacco Quitline. METHODS: Three audio-recorded sessions from each of three counsellors were assessed using the Motivational Interviewing Treatment Integrity (MITI) Code Version 3.0 over 11 assessment periods at fixed intervals in a two-and-a-half year period during which counsellors received ongoing supervision. RESULTS: The mean skill for all counsellors improved throughout the study period in most MITI variables. However, great variations in MI skill between counsellors were observed, as well as fluctuations in performance in counsellors over time. CONCLUSION: The present exploratory study covers a longer time period than most evaluations of MI training, and has several advantages with regard to study design. It may provide a basis for (larger sample) replication to test MI skill (as measured by the MITI) in relation to behaviour change in clients, to evaluate MI training, and to assess the acquisition and retention of MI skill over time. Difficulties in acquiring and retaining MI skill may raise the issue of a selection policy for MI training. Moreover, fluctuations in MI skill over time emphasise the greater importance of continuous feedback and supervision over initial MI training, and the need for the use of validated treatment integrity assessment instruments in ordinary clinical implementations of MI.