Process Study

Patterson, G. A., & Forgatch, M. S. (1985). Therapist behavior as a determinant for client non compliance: A paradox for the behavior modifier. Journal of Consulting and Clinical Psychology, 53, 846-851. 

It has been observed that some therapeutic conditions designed to help clients often have quite the opposite effect. The present two studies were conducted to investigate the impact of therapists' behaviors on the noncompliance of patients. Client noncompliance was suggested to be determined both by personal and social factors, and by therapists' attempts to intervene. Client noncompliance was analyzed via observable behaviors during psychotherapy, and by client compliance to the treatment, which together would be expected to predict treatment results. Videos of parent training sessions where analyzed and coded for therapists' behaviors in both studies. In the first study, it was found that therapists' attempts to teach and confront were associated with higher client noncompliance, whereas efforts to support or facilitate were associated with lower client noncompliance. The second study provided further support for these findings, such that client noncompliance increased when therapists showed directive behaviors (i.e. teach and confront), whereas client noncompliance decreased as these behaviors also decreased. It was further suggested that client noncompliance may also influence the behavior of the therapist, so that the client may even be evaluated in a negative way, creating a self-perpetuating spiral. 
Abstract by Patricia Juarez

Miller, W. R., Sovereign, R. G., & Krege, B. (1988). Motivational Interviewing with Problem Drinkers: II. The Drinker's Check up as a Preventive Intervention. Behavioral Psychotherapy, 16, 251-268. 

The importance of motivation for change in the prevention and treatment of alcohol abuse is widely recognized, but it is still often believed that treatment failure is due to the lack of clients' personal motivation. Miller (1983) introduced an approach called motivational interviewing (MI), which de-emphasizes labeling, encourages individual responsibility and increases the client's dissonance between ideal goal and present behavior. MI emphasizes a combination of discrepancy and self-efficacy in order to better motivate people for change. The Drinker's Check-up (DCU) is a set of measures designed to help the person see how alcohol consumption is negatively affecting his or her life, thus increasing the awareness of risk associated with alcohol consumption. The DCU can be administered in settings such as health screening, treatment selection and matching, self-assessment and research. In order to evaluate the usefulness of the DCU, it was administered to 42 people in this first evaluation of the efficacy of MI. Participants showed significant reduction in alcohol use at the 6 week and 18 month follow up. The DCU intervention did not significantly decrease symptoms and problems related to alcohol use. Therefore, it is recommended that the DCU should be used to motivate and prepare the client to seek treatment, and it should also be used as an initial assessment, part of the whole intervention process of motivation and treatment. 
Abstract by Patricia Juarez

Outcome Study

Kuchipudi, V., Hobein, K., Fleckinger, A., & Iber, F. L. (1990). Failure of a 2-hour motivational intervention to alter recurrent drinking behavior in alcoholics with gastrointestinal disease. Journal of Studies on Alcohol, 51, 356-360. 

Alcohol abuse is often the cause of gastrointestinal diseases, so one of the main goals in the treatment of these diseases is to control alcohol consumption. This study investigated the impact of a brief motivational intervention on the alcohol use of patients diagnosed with gastrointestinal disease who were currently drinking, and were not receiving alcoholism treatment. The intervention was delivered in 3 sessions to discuss the relationship of the patients' drinking to their disease, in a motivational approach that invoked the authority of the physician. Patients were also given information on different treatment alternatives available for them. There were no significant differences between those patients receiving the intervention and those who did. Patients who volunteered to talk about treatment and alcohol use did better at remaining sober than those who didn't. It was also found that those patients who remained in treatment for 2 to 3 appointments did significantly better than those who didn't, and those patients who completed the whole treatment, either inpatient or outpatient, reported higher sobriety than all the other participants. It was concluded that this intervention didn't work due to the patients' characteristics, which made them an especially difficult group to treat, due to their apparent unwillingness to seek and receive treatment. It was suggested that this was due to not having included an informed consent to participate in the study, suggesting that studies that use informed consents may find different results. 
Abstract by Patricia Juarez 

Other Empirical Study

Haynes, P., & Ayliffe, G. (1991). Locus of control of behavior: Is high externality associated with substance misuse? British Journal of Addiction, 86, 1111-1117. 

According to the motivational interviewing therapeutic technique, clients' personal characteristics such as internal attribution, self-efficacy and self-esteem are key elements that have to be considered in order to produce positive change in the treatment of alcohol abuse. Motivational interviewing encourages clients to acquire an internal attributional style such that they associate change with internal or personal factors through reflective listening and empathy. Also referred to as internal locus of control, internal attribution is closely related to self-efficacy and to learned helplessness. The purpose of the present study was to investigate the differences in locus of control among alcohol and drug users and three other non-user groups. It was found that users indeed differed from the other three groups such that users tended to believe they had less personal control. Furthermore, regression analyses showed that there was no significant correlation between locus of control and variables such as class, sex and age. Finally, it was found that self-diagnosed substance misuse was significantly related to locus of control. It was concluded that high external control tends to be associated with substance abuse. In order to produce behavior change these beliefs in personal control should be carefully considered and addresed. Abstract by Patricia Juarez

Outcome Study

Baer, J. S., Marlatt, G. A., Kivlahan, D. R., Fromme, K., Larimer, M., & Williams, E. (1992). An Experimental test of three methods of alcohol risk reduction with young adults. Journal of Consulting and Clinical Psychology, 60, 974-979. 

This is a replication of the results of a skills-based approach to reduce alcohol consumption among young people, incorporating motivational interviewing principles. Participants were randomly assigned to a cognitive-behavioral 6-week group treatment, a six-unit cognitive behavioral self-help manual, or a single session of individualized feedback and professional advice in the style of motivational. Participants in the 6-week group treatment and in the single session (but not the self-help condition) reported an overall 40% decrease in their alcohol use over the 2-year follow up. The lack of significant change in the self-help program was attributed to the high attrition rate in this group, since those who completed the program showed comparable decreases in drinking to the other groups. The participants' response to the different treatments was strongly related to age, such that as participants reached legal drinking age, their alcohol consumption increased, whereas those who were 21 or older during the program showed an overall decrease in their drinking. 
Abstract by Patricia Juarez 

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Instrument Development Study

Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short "readiness to change" questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 87, 734-754. 

There has been an increasing interest in the development of brief interventions for the treatment of alcohol abuse in people who show low levels of dependence, and the method of motivational interviewing is suggested to be the most appropriate way to motivate clients for change. The model for stages of change developed by Prochasta and Diclemente implies that the particular stage where a person is during the process of changing his/her behavior can be assessed with precision. The present investigation is an attempt to develop a measure of "readiness to change" to determine the stage of change in which the client is at, so that he/she can be matched to the appropriate stage of treatment. This scale was administered to 141 alcohol abusers in order to be psychometrically evaluated. Factor analysis showed a distinction for precontemplation," "contemplation," and "action" stages of change, leading to development of a 12-item "readiness for change" questionnaire. The scale showed high inter-item reliability, test-retest reliability and concurrent validity with participants' responses to cartoons representing the different stages of change and to screening questions about their drinking behavior. This scale is suggested to be used as an assessment measure of the stages of change model for the treatment of alcohol abuse. 
Abstract by Patricia Juarez

Outcome Study

Bien, T. H., Miller, W. R., & Boroughs, J. M. (1993). Motivational interviewing with alcohol outpatients. Behavioural and Cognitive Psychotherapy, 21, 347-356. 

Therapist behavior can directly affect clients' motivation for change. Motivation should be viewed as a result of interpersonal processes rather than of personal characteristics. Other studies have also showed that brief outpatient interventions can be successful at reducing alcohol use and abuse among problem drinkers. This kind of intervention involves aspects such as: objective feedback, acceptance of personal responsibility, advice, menu of alternatives for treatment, empathy and self-efficacy. The present investigation studied the effects of this kind of brief intervention with 32 clients seeking treatment for severe substance abuse. Participants were thoroughly assessed before being randomly assigned either to the MI brief intervention or control group as a prelude to outpatient alcoholism treatment. All participants in this study were considered to be relatively severe alcohol abusers according to the Michigan Alcoholism Screening test (MAST; Selzer, 1971). At the 3-moth follow up, participants receiving the brief MI intervention showed significant decreases in their total standard drinks, their peak alcohol levels and in their percent days abstinent, relative to those in the control group who received the outpatient treatment program. These results were further validated by the reports of significant others. By 6-month follow up, no significant between-group differences remained. 
Abstract by Patricia Juarez

Outcome Study, Process Study

Miller, W. R., Benefield, R. G., & Tonigan, S. (1993). Enhancing motivation in problem drinking: A controlled comparison of two therapist styles. Journal of Consulting and Clinical Psychology, 61, 455-461. 

It is widely acknowledged that one of the largest concerns in health psychology, especially in the area of addictions, is the lack of motivation to seek and remain in treatment. Often this lack of motivation is attributed to personal, enduring characteristics of the clients, while substantive research has shown that motivation can be increased through brief motivational interventions. The present investigation studied the effects of therapists' style on 42 alcohol abusers, using a 2-session motivational check-up. Participants were randomly assigned to one of three groups: 1) immediate check-up with directive confrontational feedback, 2) immediate check-up with client-centered feedback, or 3) delayed check-up. The intervention significantly reduced drinking in the 6-week follow up, and this change was maintained over a yearof follow-up. Participants assigned to the immediate check-up conditions showed a significant reduction in alcohol use compared to those participants in the control group. Similarly, therapists using a directive-confrontational style elicited more resistance from clients and therefore produced less positive results at the 1 year follow-up, such that those clients receiving this kind of counseling drank more than other participants. 
Abstract by Patricia Juarez

Outcome Study

Brown, J. M., & Miller, W. R. (1993). Impact of motivational interviewing on participation in residential alcoholism treatment. Psychology of Addictive Behaviors, 7, 211-218. 

Motivational interviewing (MI) is a therapeutic approach originally designed to increase people's motivation to seek and remain in treatment. This study investigated the effects of this approach as a preparation for inpatient alcoholism treatment in a private psychiatric hospital, and also tested a new measure of client treatment expectations. 28 clients entering an inpatient substance abuse treatment program were assessed and then alternately assigned to receive or not receive an MI intervention, in addition to receiving a standard treatment protocol and a 3-month follow up interview. Patients who received MI sessions were judged by therapists to be more engaged in treatment, and showed a substantially larger decrease in alcohol use 3-months after discharge. Client treatment expectations also influenced the final outcome of therapy. At the beginning of treatment, clients were asked to indicate (via questionnaire) what items they wanted from treatment. Then after treatment they were asked what items they had actually received during treatment. Better treatment outcomes were predicted by the extent to which clients received what they said they wanted. The extent to which clients were given other components, which they had said they did not want, was unrelated to outcomes. This study provides further support for the effectiveness of brief feedback and motivational interventions in increasing treatment involvement and improving treatment results. 
Abstract by Patricia Juarez

Outcome Study

Swanson, A.J., Pantalon, M.V., & Cohen, K.R. (1999). Motivational interviewing and treatment adherence among psychiatric and dually-diagnosed patients. Journal of Nervous & Mental Disease, 187, 630-635.

The effect of motivational interviewing on outpatient treatment adherence among psychiatric and dually-diagnosed inpatients was investigated. Subjects were 121 psychiatric inpatients, 93 (77%) of whom had concomitant substance abuse/dependence disorders, who were randomly assigned to: 1) Standard Treatment (ST), including pharmacotherapy, individual and group psychotherapy, activities therapy, milieu treatment, and discharge planning; or 2) ST plus Motivational Interviewing (ST+MI), which involved 15-minutes of feedback on the results of a motivational assessment early in the hospitalization, and a 1-hour motivational interview just prior to discharge. Interviewers utilized motivational techniques described in Miller and Rollnick (1991), such as reflective listening, discussion of treatment obstacles, and elicitation of motivational statements. Results indicated that the proportion of patients who attended their first outpatient appointment was significantly higher for the ST+MI group (47%) than for the ST group (21%; X2 = 8.87, df = 1, p<.01) overall, and for dually diagnosed patients (42% for ST+MI versus 16% for ST only; X2 = 7.68, df = 1, p<.01). Therefore, brief motivational interventions show promise in improving outpatient treatment adherence among psychiatric and dually diagnosed patients.
Abstract by Michael V. Pantalon

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Outcome Study

Motivational Interviewing Enhances the Adoption of Safe Water Handling Practices in Zambia, Africa

Angelica K. Thevos, Ph.D, MSW
Department of Psychiatry and Behavioral Sciences
Medical University of South Carolina
Charleston, SC

Robert E. Quick, M.D.,  MPH
Foodborne and Diarrheal Diseases Branch
Centers for Disease Control and Prevention
Atlanta, GA

Purpose:  In the developing world, lack of safe water results in diarrheal disease which is a leading cause of  morbidity and mortality, particularly among children.  A simple, inexpensive system that includes water treatment,
safe storage, and education, has been developed to disinfect household water.  We compared the effectiveness of the standard practice of health education to Motivational Interviewing (MI), in initiating and sustaining use of this safe water system in Zambia, Africa.

Methods:  Focus groups, individual interviews, and community surveys were conducted.  The study design for two trials included a health education (comparison) group and an MI (experimental) group.   Local health workers and nurses were trained in MI using didactic instruction, viewing of videotapes, role play, and practice exercises.  These health workers delivered one of the two experimental interventions and visited households
weekly.   Two field trials were conducted consecutively, 8 weeks for Field Trial 1 (FT1), and 8 months for Field Trial 2 (FT2).   Main outcome variables were detectable disinfectant levels in stored household water (for
FT1) and disinfectant sales (for FT2).

Results:  In FT1 (N = 185 households), a very high adherence rate was achieved (range 71.1% to 94.7%), with no statistical differences between the health education and MI groups.  There are several possible explanations for this finding including overtraining of health workers in the comparison group and provision of free disinfectant.  FT2  (N = 427 households) results indicated much higher usage rates of the disinfectant in the MI group, t (7) = 10.69, p< .001.  The strength of this effect was very strong, eta2 =.94.

Conclusions: These results support the use of culturally competent, theory-driven behavioral change interventions such as MI in the developing world.  Further work is needed in the adaptation and application of MI as
well as other efficacious behavior change techniques to the special challenges and community based problems of non-developed countries.

Outcome Study

Fisher, Douglass and Ryan, Rosemary.  The effect of a brief MI-related intervention upon the high-risk sexual practices of HIV+ men.

Overview: Project SHAPE works with HIV+ gay and bisexual men to reduce the occurrence of their  articipation in unprotected anal sex with partners whose  HIV serostatus is negative or unknown.  It is a  collaboration of the UW School of  Social Work and POCAAN, in which POCAAN provides targeted services to Latino and  African American MSM and the UW serves other populations. 

The intervention consists of an interview and a feedback session for which  participants are paid $50.  In the first session they complete a structured,  closed-ended questionnaire that collects detailed information about their  attitudes, beliefs, substance use, and up to four of their most recent anal and/or vaginal sex partners in the past four months (past 12 months for Latino and  African American men due to these being harder to each  opulations).  The second session is based on Motivational Interviewing  principles and consists of a discussion of information they provided in the questionnaire, selected to highlight areas of apparent conflict between values, 
beliefs and risky sexual behaviors.  Staff explore these conflicts or paradoxes with participants, and support and amplify self-motivating statements by respondents that indicate some interest in adopting safer sex practices. 

At 6 months, the interview and feedback sessions are repeated.  In this second round, participants are given feedback that compares their responses on the baseline and the 6-month interview.  This provides the interviewer and client with the opportunity to explore evidence of change, or the lack of same.  Participants are again paid $50. 

Results:  Data collection is still going on.  As of the end of March (this month) we will add new cases and reanalyze the data. 107 men have completed baseline  interviews and 38 have completed 6 month follow-up sessions.  Mean age is 39,  range is 20-62.  Men of color comprise 36% of the sample, roughly double their  representation among local AIDS cases.  On average, the men have known they were  seropositive for 8 years (range 1 month - 17 years).  Nearly 2/3 are disabled  (largely due to HIV/AIDS), 62% receive HAART (highly active anti-retroviral  therapies), and 74% report annual incomes of less than $15,000.  Respondents 
reported anal sex during the prior 4 months with a total of 466 partners.  Detailed partner reports were completed for 253 of them, and represent complete partner reporting for 83% of respondents. 

Methamphetamine use in the last 4 months was reported by 31% of participants,  half of whom used at least weekly. 

Out of 107 HIV+ men, 53 (50%) reported unprotected anal sex (UA) with 88  partners whose serostatus was negative or not known.  Among this group, 30  reported UA with 51 partners who may not have know the respondent was seropositive. 

Outcome: Six month follow-up data with 38 participants showed a 31% reduction in  the proportion of participants reporting unprotected anal sex with a partner of  negative or unknown serostatus. 

Outcome Study

Aubrey Lawendowski, L. (1998).  Motivational interviewing with adolescents presenting for outpatient substance abuse treatment (Doctoral dissertation, University of New Mexico, 1998). Dissertation Abstracts International, 59-03B, 1357.

Supported by a grant from NIAAA: Aubrey, L. L. (1995, March).  Motivational induction for adolescents seeking treatment.  NIAAA #1 R03 AA10648-01.Motivational Interviewing (MI) is a brief psychotherapeutic intervention to increase the likelihood of a client’s considering, initiating and maintaining specific change strategies to reduce harmful behavior.  MI is founded on principles of motivational psychology, client-centered therapy and stages of change in natural recovery from addiction.  MI treatment includes components common to most brief interventions for addictive behavior that have been empirically tested (Bien, Miller and Tonigan, 1993).  This paper presents research evidence for the efficacy of MI, a description of the methods and goals of MI, the rationale for MI as an appropriate brief intervention for adolescents, and a specific application of MI to an adolescent sample.

Seventy-seven youths (14 to 20 years old) presenting for outpatient substance abuse treatment at The University of New Mexico’s Center on Alcoholism, Substance Abuse and Addictions (CASAA) Adolescent Treatment Program consented to participate in this study.  After completing a lengthy assessment, participants were randomly assigned to receive or not receive personalized MI feedback of assessment results conducted in an empathic, nonjudgmental, objective and supportive manner.  All participants, regardless of study condition, were strongly encouraged to attend at least one  session with their assigned CASAA program counselor.  Three-month follow-up interviews were completed for half of the study sample and CASAA records were reviewed for the entire sample.  Participants receiving the MI feedback showed significantly better treatment engagement and outcome as well as significant decreases in substance use.  These findings are consistent with previous research of MI with adult samples, and support the utility of this brief intervention with adolescents with substance use problems.

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NOTE TO WEB SITE USERS: THE FOLLOWING ABSTRACTS ARE BEING FORMATTED AND ADDED TO THE ABOVE LIST, BUT IN THE INTERESTS OF HAVING THE INFORMATION AVAILABLE, THEY ARE POSTED HERE UNEDITED AND UNFORMATTED.

 

Other Empirical Study

Miller, W. R., & C'deBaca, J. (1994). Quantum change: Toward a psychology of transformation. In T. Heatherton & J. Weinberger (Eds.), Can personality change? (pp.252-280). Washington, DC: American Psychological Association.

One of psychology's oldest interest are sudden, profound and radical changes of behavior, which have been referred to as quantum changes. It is suggested that this phenomenon is hard to investigate due to its often private and unreported occurrences, therefore how, when and why does it occurs remains a puzzling question for psychology. This article presents a scientific study of quantum change. 52 participants were asked aspects about their transcendent experiences, further details about these experiences, their value structure, life experiences before and after the change, religious background and beliefs. Furthermore, they completed three personality measures. Participants were interviewed in a reflective listening style. The common characteristics of quantum change that were observed among the sample were: sudden onset, surprising, emanating from an external source or event, relatively brief, previous emotional distress, previous negative life experiences, previous spirituality and/or strong religious beliefs, related expectations to the experience, life improvement, confidence in the permanence of change, feelings of liberation after the experience, positive feelings and happiness, a new kind of meaning and perception, and a shift in value priorities. These characteristics suggest that quantum change may not be part of a normal continuum of behavior change, but may refer to a unique phenomenon. Four mechanisms are suggested to explain this unique process of change: awakening of self-regulatory processes, a shift in perception, value and attitude conflicts, and a transcendental experience. In conclusion, it is important to recognize that behavior change can occur in ways that don't fit our current gradual theories of personality change.  
Abstract by Patricia Juarez

Van Bilsen, H. P. J. G., & Whitehead. (1994). Learning Controlled Drugs Use: A Case Study. Behavioral and Cognitive Psychotherapy, 22, 87-95.

There is been a controversy in the area of addiction in which it is argued that controlled drinking may be an appropriate treatment goal for some clients. Nevertheless, this is not maintained in the context of heroin or other illegal drug use because these other drugs are often referred to as uncontrollable. The present investigation presents a method to help clients regain control over their heroin addiction. The method is based on current knowledge over controlled drug use, the relapse prevention model by Marlatt, and the motivational intervention concept by Miller. This method is illustrated with a case instance. In order to help the client regain control over his behavior, a "Guide book for responsible Drug Use" was provided for the participant. His motivation was assessed, goals were set, the client's efforts towards change were reinforced, personal rules and regulations were set, a carefully directed feedback session was provided, and there were discussions on relapse prevention and refusing drugs. There were 38 sessions (from 15-60 min) over a period of six months. In conclusion, it was found that the combination of a behavioral self-control guide book, behavior therapy and the use of motivational interviewing techniques was successful at helping the client regain control over his drug use for at least 18 months, suggesting that there might be no important differences in the use patterns of these kinds of illegal drugs and alcohol. Limitations and suggestions for future research are discussed.  
Abstract by Patricia Juarez

Outcome Study

Rollnick, S., Heather, N., Bell, N., & Richmond, R. (1994). Matching Excessive drinkers to brief interventions by readiness to change: Brief motivational intervention versus skills-based counseling. Submitted for publication.

The purpose of the present study was to investigate whether alcohol abusers could be matched to different kinds of treatment according to the stage of change they are in. There were two main hypothesis: First, people in the precontemplation or contemplation stage would consume less alcohol brief motivational interviewing (BMI), since it has been shown that this kind of intervention helps prepare people for change. On the other hand, people in the action stage of the model would respond more to a skills-based counseling (SBC). 174 male drinkers were given a new measure of readiness for change: The Readiness for Change Questionnaire (RCQ) and were randomly assigned to three conditions (BMI, SBC or no intervention). It was found that those participants classified as being in the early stages of change, that were assigned to the brief motivational intervention showed significantly lower levels of alcohol consumption at the six-month follow up than those in the other two conditions. For those participants in the action stage of change, there were no significant differences among the three groups. These results suggest that it is relatively possible to match clients to different kinds of treatment according to their degree of change, especially if they are at the early stages of readiness to change.  
Abstract by Patricia Juarez

Stephens, R. S., Roffman, R. A., Cleveland, B. L., Curtin, L., & Wertz, J. (1994, November). Extended versus minimal intervention with marijuana with dependent adults. Paper presented at the annual meeting of the Association for Advancement of Behavior Therapy, San Diego, California.

291 people wanting to stop smoking marijuana were randomly assigned to two types of interventions: Relapse Prevention Support group (RPSG) and to an Individual Assessment Intervention (IAI), or to a delayed treatment control group. The relapse prevention support group was based on Marlatt and Gordon's relapse prevention model and was further supplemented with partner and support interventions. The IAI intervention consisted of two monthly individual counseling sessions, and was based on motivational interviewing techniques. In the control condition, participants waited four months to receive whichever treatment they chose. Participants were reassessed 4 and 16 months after the intervention, and the highest rates of abstinence were found among those participants in the RPSG or IAI. These results were also consistent over reductions in the use of marijuana, rates of dependence and related problems. It was important that no significant differences were found between RPSG and IAI participants on any of the variables measured. Furthermore, there were no significant gender differences. It was therefore concluded that similar positive results can be obtained with long and short-term approaches for the treatment of the abuse of marijuana.  
Abstract by Patricia Juarez

Outcome Study

Agostinelli, G., Brown, J. M., & Miller W. R. (1995). Effects of normative feedback on consumption among heavy drinking college students. Journal of Drug Education, 25, 31-40.

It is widely recognized that alcohol consumption is related to serious and significant problems for college students and young adults. For this reason, college students are often the targets for preventive interventions on alcohol use. It has been hypothesized that this problem stems from the fact that students fail to recognize the risks and problems involved in alcohol consumption. They usually overestimate the incidence of drinking among people their age, and therefore, they don't perceive their behavior as abnormal, thus perpetuating risky behaviors. In the present study, 64 college students identified as heavy drinkers completed a survey on drinking behavior. Only 26 completed and returned the questionnaires. These participants were then randomly assigned to receive or not to receive mailed personal feedback on their drinking behavior, in comparison with actual population data and norms. Those participants who received the feedback reported drinking less and getting less intoxicated at a follow-up interview, than those who didn't receive the feedback. It was therefore concluded that this type of impersonal intervention may indeed be effective and inexpensive at reducing alcohol consumption and risky related behaviors.  
Abstract by Patricia Juarez

Outcome Study

Long, C. G. & Hollin, C. R. (1995). Assessment and management of eating disordered patients who over-exercise: A four year follow up of six single case studies. Journal of Mental Health, 4, 309-316.

There is still debate on whether excessive exercise is a risk factor for the development and maintenance of eating disorders, and this topic has been mostly ignored in the area of anorexia nervosa. Excessive exercise has been found to precede anorexia for some patients. It has also been found that it persists even in recovered patients and it is suggested that it should be viewed as a risk factor for relapse. The present study describes a four-year follow up of six (5 woman and 1 men) anorexic clients where excessive exercise was one of the focus of treatment. Therapists used a sympathetic style, referred to as motivational interviewing, to treat these clients and to help them move from the contemplation to the action and maintenance stages of change. The treatment consisted of a discussion of objective feedback, self-monitoring of exercise, exercise education, and a cognitive behavioral approach to treat the eating disorder. Four participants showed a reduction in the symptoms of anorexia nervosa and in psychological distress. Most relevant to the present investigation, these four participants reported using exercise for social reasons and for fitness, and not as a compulsion related to body image.  
Abstract by Patricia Juarez

Outcome Study

Richmond, R., Heather, A. W., Kehoe, L., & Webster, I. (1995). Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction, 90, 119-132.

The present investigation examines the effect of a general practitioner (GP) brief intervention on heavy alcohol users. 378 heavy drinkers were identified in general practice and were assigned to one of four conditions administered in random order: Alcohol Screen Program, which included a self-help manual and five brief sessions in a motivational interviewing style (AS group); 5-minute single session minimal intervention with advice, feedback and a self-help manual (MI group); only alcohol related assessment and self-help manual (NI group); and nor assessment or intervention (NA group). Participants were assessed during two follow ups, at six and 12 months. The AS program was not found to produce greater reductions in alcohol use than the other conditions, although participants in this condition reported less alcohol related problems at the 6 month follow up. Neither the MI or the NI group were found to be effective in reducing alcohol use or related problems. There were no significant differences among the groups at the 12 month follow up, although the same trend was observed. The implications and future research directions are discussed.  
Abstract by Patricia Juarez

Outcome Study

Saunders, B., Wilkinson,, C., & Philips, M. (1995). The impact of a brief motivational intervention with opiate users attending a methadone programme. Addiction, 90, 415-424.

Motivational interviewing (MI) has become a new paradigm in the treatment of addictions, although it has not received wide research support for its effectiveness and superiority over other approaches to treatment, and most of the few studies involve only clients with alcohol abuse problems. The present investigation is an attempt to provide further support for this approach using a sample of 122 opiate users. These participants were initially assessed on measures of opiate related problems, self-efficacy, stages of change, outcome expectancy, severity of opiate dependence, and intent. 51 participants were then assigned to a motivational interviewing intervention and 65 were assigned to the control (education package). Participants completed one week, 3-month and six month follow ups. It was found that in the 6-month follow up the MI group had a greater commitment to remain abstinent, they had more positive expectancies, had fewer opiate related problems, showed more compliance with the program, showed more contemplation of change, and relapsed less quickly than the control group. No significant differences were found in the severity of dependence, and the control group reported more self-efficacy. It was concluded that this type of motivational interventions could provide a beneficial component of treatments for methadone maintenance programs. 
Abstract by Patricia Juarez

Senft, R. A., Polen, M. R., Freeborn, D. K., & Hollis, J. F. (1995). Drinking patterns and health: A randomized trial of screening and brief intervention in a primary care setting: Final Report.

The purpose of this study was to reduce alcohol use and risks associated with its heavy use in 516 clients seeking primary care, and who reported engaging in "hazardous" drinking patterns as assessed by the AUDIT. Participants were randomly assigned to either regular care or to a brief 15-minute intervention in order to reduce drinking. Their frequency and intensity of drinking was assessed at 6 and 12 months after the intervention during phone interviews. It was found that those clients who received the brief intervention showed a decrease in their alcohol consumption and drinking days per week at the 6-month follow up, than those participants in the control condition. However, at the 12-month follow up, this difference was no longer significant. Furthermore, clients did not differ on their scores on the AUDIT, their drinking pattern, or the estimated blood alcohol levels. Collateral information was collected in order to increase confidence in the information provided by participants. It was observed that according to this information, groups didn't differ on total alcohol use, frequency or intensity of drinking at the 6-moth follow up. Finally, there were no differences in the clients' use of outpatient or inpatient health care services in the 12-month follow up. It was concluded that the AUDIT could be a useful screening tool for alcohol abuse in primary care settings. It is further suggested that a brief motivational intervention might prove useful at reducing frequency of alcohol use in clients seeking this type of medical care.  
Abstract by Patricia Juarez

Outcome Study

Woollard, J., Beilin, L., Lord, T., Puddey, I., MacAdam, D., & Rouse, I. (1995). A controlled trial of nurse counseling on lifestyle change for hypertensives treated in general practice: Preliminary results. Clinical and Experimental Pharmacology and Physiology, 22, 466-468.

The purpose of the present investigation was to study the effects of a lifestyle modification program on the blood pressure and cardiovascular risk of treated hypertensive patients, implemented by nurse counselors in a general practice setting. The main goal was to see if current behavior modification counseling was effective and dose dependent. 166 patients were randomly assigned either to high level of counseling (6 individual sessions), low level of counseling (one individual session and five telephone sessions), or general practitioner care. The two counseling conditions were based on principles of the stages of change model and of Motivational Interviewing (MI), and the main goals of the interventions were to reduce alcohol use, salt and fat intake, weight, smoking, and to increase exercise. It was found that at the 18 week follow up, those participants assigned to the low level of counseling reported drinking less alcohol, and taking less salt, than the control group. In addition, those participants receiving the high level of counseling also reported significant weight losses and improvements in blood pressure over the 18 weeks. It was concluded that nurse counseling can be effective at promoting behavior change in treated hypertensive patients.  
Abstract by Patricia Juarez

Berg-Smith, S. M., Stevens, V. J., Brown, K. M, Van Horn, L. Gernhofer, N., Peters, E., Greenberg, R., Snetselaar, L., Ahrens, L., & Smith K. (1996) A brief motivational intervention to improve dietary adherence in adolescents. In press (Health Education Research).

Motivational interviewing (MI) is a therapeutic technique that can be effective at increasing clients' motivation, or readiness, to change problem health behaviors. The components of this technique have been incorporated into a brief therapy format for its use in health care settings, and it has been shown to be effective for a wide range of behaviors. The present paper describes a brief motivational intervention designed to improve and renew dietary adherence with adolescents in the Dietary Intervention Study in Children (DISC). It further provides a description of DISC, reasons why this kind of intervention should be appropriate and effective for adolescents, and results from a preliminary feasibility test. In the first phase of the study, 334 children (ages 8-13) were given family-based group therapy to change their diets. During adolescence (ages 13-17), 127 of these participants were given individual, brief motivational therapy. The components of this intervention include: establishment of rapport, opening statement, assessment of current eating behavior and progress, feedback, assessment of readiness to change, tailored intervention, final encounter, follow up sessions, and training of practitioners. It was found that this intervention showed improvements in dietary adherence, it was also acceptable for the participants, the practitioners liked it, and it seemed to be an age-appropriate next step from a family intervention approach. The need to evaluate the effects of the program against a control group is encouraged, as well as further investigations with other health behaviors. 
Abstract by Patricia Juarez

Heather, N. , Rollnick, S., Bell, A., & Richmond, R. (1996). Effects of brief counseling among heavy drinkers identfied on general hospital wards. Drug and Alcohol Review, 15, 29-38.

The presen investigation was conducted in order to study the effects of brief counseling on the reduction of alcohol consumption in patients in general hospital wards. 174 male patients were screened as heavy drinkers, and were later assigned to one of three conditions, a skills-based brief counseling, a brief motivational interviewing, or a control condition with no intervention. Data from 123 patients, and from collateral sources to confirm the self-repor information was collected at a 6-month follow up after discharge from the hospital. Patients were assessed on self-report measures of alcohol consumption. Those clients who received counseling showed significant reductions in their alcohol consumption than those in the control group, and there were no significant differences among the two intervention groups. However, there were greater reductions in alcohol consumption among those patients who received the brief motivational intervention that were identified as being "not ready to change," than among those who received the skills-based brief counseling.  
Abstract by Patricia Juarez

Miller, W. R., & Tonigan, J. S. (1996). Assessing drinkers' motivation to change: The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). Psychology of addictivve behaviors, 10, 81-89.

Motivation for treatment has traditionally been regarded as a personal characteristic of the clients, and it is considered to be a prerequisite for treatment. On the contrary, motivation for change is also seen as dynamic states varying on a continuum, and that are influenced by several factors in the environment. Based on this idea, a transtheoretical model describing a sequence of stages people go through while changing a behavior, was developed by Prochasta and DiClemente (1982, 1986). The Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) is a questionnaire designed to measure motivation to change in problem drinkers, corresponding these stages of change. The purpose of the present investigation was to test the reliability of this measure using data from 1672 participants from a multisite clinical study and from a test-retest study (N = 82). Factor analysis yielded 3 relatively independent and stable factors: Recognition, Ambivalence, and taking steps. It was found that scores on the Recognition factor were moderately correlated to intensity of alcohol consumption and related problems. Similar scale scores were found for shorter versions of the questionnaire (a 19-item and a 39 item scales).  
Abstract by Patricia Juarez

Peterson, T. R., Waldron, H. B., & Miller, W. R. (1996) A sequential analysis of client and therapist behaviors during motivational enhancement therapy for problem drinking.

Recent advancements in the treatment can be suggested to be based on careful analysis of processes that occur during therapy. A recent therapeutic style designed to motivate people to change behaviors, called motivational enhancement therapy (MET), is a brief intervention specifically designed to treat addictive behaviors and problem drinking which might prove useful as a test for these therapeutic processes. In the present investigation, 22 therapeutic sessions were taped for 30 minutes in which clients were employing the MET techniques. These tapes were later coded with a behavioral coding system, and analyzed in order to observe the therapists' behaviors and see how these related to therapy outcome and clients' reactions and cooperation during therapy. The intervention consisted of 4 sessions where the goal was to help clients move towards higher stages of change and behavior change commitment. The basic components of this type of therapy are the development of clients' discrepancy between present behavior and future goals, reduction of ambivalence, reduction of client resistance, use of empathic listening, and the reinforcement of self-motivation statements from the clients. After conducting a sequential analysis of the therapist-client interactions, it was found that the more support the therapist demonstrated towards the client, the more cooperation and the less resistance was showed by the client. Furthermore, it was observed that the more confrontation the therapist employed, the more resistance and less cooperation was elicited from the client. 
Abstract by Patricia Juarez

Training Study

Rubel, E. C., Sobell, L. C., & Miller, W. R. (1996) Effectiveness of a Workshop on Motivational Interviewing with Alcohol abusers. Manuscript submitted for publication.

Professional development and continuing education requirements have increased significantly for health care professionals in the last years, and so have the demand and availability of workshops and seminars to increase therapists' skills. Consequently, it has become of greater importance to find ways to evaluate the effects of these workshops on actual clinical practice. The present article presents the results of a study designed to evaluate the effects of a clinical training workshop on motivational interviewing (MI) for alcohol and drug abusers, on 44 participants' knowledge and skills before and after the program. Furthermore, the article suggests methods in which the effectiveness of the training program can be evaluated. Participants showed a significant improvement on their knowledge about MI techniques after participating in the workshop. Even though the demonstration of these techniques in actual practice was not significant, as evaluated with audiotaped therapy sessions, participants showed an increase in their use of motivational statements after the MI workshop. This may reflect the difficulty that is often encountered when trying to put theory into practice. Therefore, it is suggested that therapists practice should be followed for a longer period of time, and if feasible, supervised practice should be employed to evaluate workshop outcomes.  
Abstract by Patricia Juarez

Other Empirical Study

Wylie, K., House, A., Storer, D., Raistrick, D., & Henderson, M. (1996). Deliberate self-harm and substance dependence: The management of patients seen in the general hospital. Journal of Mental Health Administration, 23, 246-252.

The purpose of the present study was to study the management of 1,364 patients after an instance of deliberate self-harm in the general hospital. Since people with substance abuse problems are more at risk of suicide, the effects of referrals to a specialized addiction unit, for 107 patients diagnosed with alcohol or drug dependence, were also studied in the present investigation. The study also describes the factors that may be involved when making clinical decisions to give the appropriate strategies for self-harm cases in which alcohol-related variables play a role. This investigation found that simply referring patients to a specialized addiction unit was not enough to comprehensively address the problems of substance abuse and self-harm. The authors suggest that follow up community services after discharge from the hospital should be developed. Furthermore, they also suggest that motivational interviewing techniques should be used in this kind of settings in order to increase the number of patients who would seek and accept further specialist training.  
Abstract by Patricia Juarez

Allsop, S., Saunders, B., Philips, M., & Carr, A. (1997). A trial of relapse prevention with severely dependent male problem drinkers. Addiction, 92, 61-74.

Regardless of therapeutic approach, relatively poor outcomes are the norm in the treatment of alcohol related problems. This report presents the results of a controlled trial of a relapse prevention program with 60 male problem drinkers (ages 21-60) in an alcohol treatment facility in Scotland. Participants were sequentially assigned to either a relapse prevention intervention, a discussion, or to a control condition, in addition to the regular treatment procedures of the facility. The relapse prevention intervention included motivational interviewing aspects (as described by Miller, 1983), and performance-based strategies to enhance self-efficacy and skills. At the 6 month follow up, it was found that participants in the relapse prevention program showed significant increases in self-efficacy from pre treatment to follow-up assessments, compared to the discussion group; and a higher probability of maintaining complete abstinence at than the control participants. Furthermore, it was found that participants in the relapse prevention program showed a longer period of time between the intervention and the first lapse and relapse, than participants in the control condition. The effects of the intervention disappeared by the 12 month follow up. It was suggested that relapse prevention programs of this kind may be effective short term interventions, and that more intensive maintenance focused programs should be implemented to have a more long lasting impact on alcohol consumption.  
Abstract by Patricia Juarez

Bernstein, E., Bernstein, J., & Levenson, S. (1997). Project ASSERT: An ED-based intervention to increase access to primary care, preventive services, and the substance abuse treatment system. Annuals of Emergency Medicine, 30, 181-189.

The purpose of the present study was to investigate the effects and feasibility of Project ASSERT (Alcohol and Substance abuse Services and Education providers to Refer patients to Treatment), which is a program designed to increase the use of substance abuse treatment, primary care and preventive services, for patients with drug and alcohol related problems entering the emergency department. Patients were first screened for alcohol or illicit drug problems and then referred for any service required. Patients were then given a brief negotiated interview (BNI) based on the stages of change model and the readiness to change construct. A total of 1096 participants were assessed on their number of referrals to the substance abuse treatment system, self-reported satisfaction with and use of the services, and self-reported frequency of drug and alcohol use between intake and follow up (60 to 90 days). Those clients who returned for follow-up (n = 245) showed significant reductions in the severity of their drug problems, and they used less alcohol. Furthermore, participants also expressed satisfaction with the services, especially regarding their referrals for further treatment. Due to the effectiveness of Project ASSERT, it was adopted by Boston Medical Center as an valuable service for the emergency department.  
Abstract by Patricia Juarez

Bombardier, C. H., Ehde, D., & Kilmer, J. (1997). Readiness to change alcohol drinking habits after traumatic brain injury. Archives of Physical Medicine and Rehabilitation, 78, 592-596.

The goal of this study was to describe the level of readiness to change alcohol use, and the factors that affect this motivation, in persons with recent traumatic brain injury (TBI). 50 patients in an acute rehabilitation program were surveyed on two main outcome measures: the Readiness to Change Questionnaire (RTC), the Michigan Alcoholism Screening Test (MAST), and other questions on frequency and quantity of alcohol consumption. Eighty percent of the participants were found to be in the contemplation or action stage of change. Compared to a general medical sample of heavy alcohol users, the TBI patients showed a higher contemplation of change, and a higher readiness to take action and change drinking behavior, which was hypothesized to be related to the TBI. It was also found that in the TBI sample, a positive history of alcoholism, involvement of alcohol in the accident, and a higher frequency of alcohol use were associated with higher contemplation and therefore higher readiness to change. It was concluded that after a TBI, drinkers usually contemplate changing their drinking, which suggests that this is a good opportunity to prevent further alcohol use, abuse and injury. The authors finally suggest that Motivational Enhancement therapy may be an appropriate intervention to encourage behavior change in this situations, due to its nonconfrontational nature.  
Abstract by Patricia Juarez

Outcome Study

Project MATCH Research Group (1997). Project MATCH secondary a priori hypotheses. Addiction, 92, 1671-1698.

The purpose of the present investigation was to see if clients would benefit more from three different kinds of treatment if they were matched to one of them on the basis of 11 client characteristics. This report also discussed the implications of the project's results and of they hypothesis that were previously reported. Participants were either receiving outpatient therapy or aftercare therapy after inpatient treatment or hospitalization. Participants from these two settings were randomly assigned to either Cognitive Behavioral Coping Skills Therapy (CBT), Motivational Enhancement Therapy (MET), or to Twelve-Step Facilitation Therapy (TSF). The three conditions were all 12-week, manual-guided, individual treatments. All participants were monitored for 15 months, which included a 1 year follow-up assessment after the treatment intervention. 17 previously specified contrasts were conducted in terms of client attributes. It was found that those outpatient participants who reported high levels of anger and received MET reported drinking less than those who received CBT. The aftercare clients who reported high levels of alcohol dependence showed more positive results in their drinking when they received TSF; while those who were low on alcohol dependence were more benefited by CBT. It is suggested that these two client characteristics be taken into account as useful matching attributes for these treatments.  
Abstract by Patricia Juarez

Outcome Study

Senft, R. A., Polen, M. R., Freeborn, D. K., & Hollis, J. F. (1997). Brief intervention in a primary care setting for hazardous drinkers. American Journal of Preventive Medicine, 13, 464-470.

The present study was designed to study the effects of a brief motivational intervention to reduce alcohol use and health care use in moderated to hazardous drinkers in a busy HMO primary health care setting. 516 hazardous drinkers were identified using the AUDIT screening questionnaire. They were then randomly assigned to either the intervention or to a control condition (no further information or advice). The intervention consisted of a 30 second advice to cut down alcohol use from the primary health care clinician, and a 15 minute motivational interviewing (MI) session with a health counselor. The MI session included further assessment of drinking habits, explanation of the effects of alcohol use, recommendations on daily alcohol use, suggestion of several options for change, building the patient's confidence, and a packet of printed materials. At the six month follow up, clients who received the MI intervention reported fewer standard drinks in the past three months and fewer drinking days per week, than those clients in the control condition, but both groups reported similar number of drinks per drinking day. Similarly, at the 12 month follow up, participants in the intervention reported fewer drinking days per week but similar number of drinks per drinking day than control participants. Furthermore, those participants in the intervention group reported drinking more within the daily amount recommended at the two follow ups, than those in the control condition. Participants did not differ on any other outcome measure. Therefore, it was concluded that brief motivational interventions can moderately reduce alcohol consumption in a busy primary care population, but more research is required on how to maintain changes in the long term.  
Abstract by Patricia Juarez

Smith, D. E., Heckemeyer, C. M., Kratt, P. P., & Mason, D. A. (1997). Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM.: A pilot study. Diabetes Care, 20, 52-54.

The purpose of this study was to investigate if adding motivational interviewing techniques to a behavioral treatment for obesity would increase adherence to treatment and glucose control in older obese women with NIDDM. 22 obese women, ages 50 or older, participated in the study. Participants were randomly assigned to two conditions: 1) a standard 16-week group behavioral weight-control program including education about diet, exercise, and behavior modification. 2) the same intervention with the same components, but adding three individual motivational interview sessions. It was found that the group receiving the motivational interviewing sessions attended to more group meetings, completed more food diaries, and recorded their glucose level more often, than the group receiving just the standard treatment. It was also found that the group in the motivational intervention had a better glucose control after the treatment, but although both groups had a significant weight reduction, they were no differences between the two groups. It was concluded that adding a motivational interviewing component to standard behavioral treatment for obese women with NIDDM would significantly increase client adherence to the program and its recommendations, and their glucose control.  
Abstract by Patricia Juarez

Project MATCH Research group (1997). Matching alcoholism treatments to client heterogeneity: Project MATCH Posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7-29.

The purpose of the present investigation was to study the benefits of matching alcohol dependent clients to three different treatments depending on several client characteristics. This investigation was conducted in two different settings. Participants were either receiving outpatient treatment (N=952), or aftercare therapy after inpatient treatment or day hospital treatment (N=774). Clients in both trials were randomly assigned to one of three therapies: Cognitive Behavioral Coping Skills Therapy, Motivational Enhancement Therapy, or Twelve-step Facilitation Therapy. The three interventions were 12 week, manually guided, individual therapies. 16 planned contrasts were conducted with 10 different client characteristics as matching variables. Overall, clients in the three conditions showed significant reductions is drinking (as measured by percent days abstinent and drinks per day) at the one year follow up. Some of the client characteristics that had an impact on outcome measures over time were motivational readiness, network support for drinking, alcohol involvement, gender, psychiatric severity and sociopathy. The only client characteristic that interacted with type of treatment was psychiatric severity such that clients low in psychiatric severity, in the outpatient trial, showed more improvement after receiving the 12-step facilitation treatment, than after cognitive behavioral therapy. This results suggests that psychiatric severity should be the only client characteristic considered when assigning clients to any of these three outpatient treatments.  
Abstract by Patricia Juarez

Trigwell, P., Grant, P. J., & House, A. (1997). Motivation and glycemic control in diabetes mellitus. Journal of Psychosomatic Research, 43, 307-315.

Fluctuations in glycemic control in diabetics can significantly affect the daily lives of diabetic patients, and increase their risk for other medical complications. One of the things that prevents this negative effect is by promoting adherence to treatment regimes. This article presents a study to investigate the effects of a brief motivational intervention to improve treatment compliance and therefore, glycemic control. 361 diabetic patients were assessed on their stages of change, and on their HbA1c level after receiving the intervention. It was found that stages of change also apply to the study of diabetes since 86.7% of the participants could be classified as being in a specific stage of change. Furthermore, it was found that HbA1c level and the stage of change were related but not as it was expected, so that those patients in an earlier motivational stage (precontemplation) had lower levels of HbA1c than those in higher stages of change (contemplation, determination and action). It was suggested that these results were due to the feedback given by the HbA1c level, which may impact the patients' motivation to change their behavior.  
Abstract by Patricia Juarez

Literature Review

Miller, W. R., Andrews, N. R., Wilbourne, P., & Bennett, M. E. (1998). A wealth of alternatives: Effective treatments for alcohol problems. In W. R. Miller & N. Heather (Eds.), Treating addictive behaviors: Processes of change (2nd ed., pp. 121-132). New York: Plenum Press.

The treatment for alcohol and substance abuse has been relatively reluctant to respond to new scientific developments and results, creating a gap between research and practice. The present chapter presents a summary of the research on alcohol abuse treatment. It specifically focuses on a project called "Mesa Grande", which is an attempt to review and summarize the methodologies and results of controlled trials of treatments for alcohol problems. Each study reviewed was rated in terms of its methodological quality and outcome, giving a rating of the study's overall efficacy. It was found, that treatments differ significantly on their effectiveness. The two treatment approaches found to have the greatest positive impact were brief interventions and MET. When combined, these two approaches attempt to elicit the client's motivation for change, and they generally include six basic components (feedback, emphasis on client's responsibility, advice, menu of alternatives for change, empathic listening, and building self-efficacy). Another strategy found to be very effective was the teaching of general coping, social and/or self-control skills. Community reinforcement approach was also found to be a very effective therapeutic technique. Its main purpose is to change the client's social environment by clients can learn to receive positive reinforcement without alcohol. On the other hand, treatments involving medications, and those referred to as "family therapy" have given generally modest or puzzling results due to the lack of controlled trials or definitional problems. The treatment approaches that were found to result in either no or detrimental impact on drinking were educational approaches, psychodynamic techniques, confrontational approaches, undifferentiated types of individual or group therapy, relaxation and stress management training, and residential treatments. Three other crucial findings of the "Mesa Grande" project were first that therapist styles have significant effects on clients, such that therapist empathy has significant positive and long term effects on drinking behavior. Another crucial finding was that when therapists demonstrate genuine and active interests on their clients, they show significantly better results. Finally, one of the best predictors of change was found to be just doing "something" toward change and adhering to treatment.  
Abstract by Patricia Juarez

Daley, D. C., Salloum, I. M., Zuckoff, A., Kirisci, L., & Thase, M. E. (1998). Increasing treatment adherence among outpatients with depression and cocaine dependence: Results of a pilot study. American Journal of Psychiatry, 155, 1611-1613.

The purpose of the present pilot study was to investigate the effects of a modified version of an individual and group motivational therapy intervention on treatment adherence and completion among 23 outpatients diagnosed with depression and cocaine dependence. After being stabilized with antidepressants and discharged from a psychiatric dual diagnosis unit, patients were assigned to either motivational therapy or regular treatment during the first month of outpatient treatment. The motivational intervention was based on the motivational interviewing strategies described by Miller and colleagues, which are primarily designed to increase patients' internal motivation for change. Patients assigned to the motivational therapy reported more days of sobriety, showed an improvement of mood, attended to more treatment sessions during the first month, completed more 30 and 90 days of outpatient treatment, and had fewer psychiatric rehospitalizations and days in the hospital during the first year of being in outpatient treatment. It was therefore concluded that combining individual and group motivational therapy sessions for the treatment of depressed and cocaine dependant patients is a promising alternative for improving treatment adherence and completion.  
Abstract by Patricia Juarez

Harper, R. (1998). An Evaluation of Motivational Interviewing. Middlesex Probation Service, London WIP 9LA.

The present report describes a an evaluation of motivational interviewing (MI) with a nonrandom sample of 36 probation practitioners in Middlesex Probation Service, as a technique to help in the assessment and supervision of offenders with alcohol or drug problems. The purpose was to investigate the impact of MI on the attitudes of 65 offenders, staff reactions towards the implementation of this intervention, and on integration of MI into actual practice. It was found that all offenders showed an improvement on their CRIME PICS II scores during the contact with the probation service regardless of type of treatment received. More specifically, those who received the intervention reported less anticipation for re-offending, less positive evaluations of crime as worthwhile, decreases in the general attitude to offending, and a decrease in the perception of current life problems. There were no significant differences on SOCRATES scores among the offenders. In terms of the qualitative evaluation of the MI intervention, the18 officers interviewed reported that it enhanced and complemented their training, that it was easily implemented into practice, and that it was less confrontational. Nevertheless, they said that it was time consuming. Most of the officers considered MI as "nothing new" and said it contradicted the demands of the probation service. Officers also showed fatalistic views about recovery such that offenders had to recognize their drug/alcohol problem in order for something to be done about it. Officers also complained about all the paper work involved in research, and they felt their role was changing towards risk assessment and administration rather than welfare orientation. 
Abstract by Patricia Juarez

Outcome Study

Marlatt, G. A., Baer, J. S., Kivlahan, D. R., Dimeff, L. A., Larimer, M. E., Quigley, L. A., Somers J. M., & Williams E. (1998). Screening and brief intervention for high-risk college student drinkers: Results from a 2-year follow-up assessment. Journal of Consulting and Clinical Psychology, 66, 604-615.

This study was conducted in order to investigate the effects of a brief motivational intervention to reduce the negative consequences of alcohol abuse among heavy drinking college students, using a randomized controlled design. 188 women and 160 men were identified as being at risk for alcohol problems during their senior year in high school. They were then randomly assigned to either receive a motivational brief intervention during their first year in college, or to a control condition. Furthermore, they also included another comparison group of students selected from the total screening pool (regardless of their level of risk), in order to have a natural history group. Two years after the intervention it was found that the students who received the motivational session reported less drinking and fewer negative consequences, than those in the control condition. It was also found that high-risk students still experienced more alcohol related problems than the natural history group, but they still had a reduction in their problems over time, which was suggested to be due to a maturational effect.  
Abstract by Patricia Juarez

Project MATCH Research Group. (1998). Therapist effects in three treatments for alcohol problems. Psychotherapy Research, 8, 455-474.

Previous investigations have found that therapists can have significant effects in the treatment of substance abuse regardless of the type of treatment they provide. The present study investigated the effects of different therapists that participated in a multisite randomized trial, testing three kinds of therapy for alcohol abuse and related problems: twelve step facilitation (TSF), cognitive behavioral skills training (CBT), and motivational enhancement therapy (MET). 80 therapists were selected and trained to provide therapy in one of these approaches, to which clients (N=1726) were later randomly assigned. The main focus of this report is on the differences in therapist characteristics across the three types of treatment, the differences on therapist effects in each group, and the correlations between therapist characteristics and successful client outcomes. It was found that therapist characteristics were different in those in TSF than those in CBT and MET. Furthermore, regardless of type of treatment, differences in sites, and client baseline characteristics, therapist effects were found to be significantly related to client satisfaction and drinking measures (drinks per drinking day and abstinence). It was also found that the specific attributes of the therapists were predictive of the client progress, however, most of the observed effects were due to cases in which therapists were not very successful and their results seemed unusually poor.  
Abstract by Patricia Juarez

Training Study

Handmaker, N. S., Hester, R. K., & Delaney, H. D. (1999). Videotaped training in alcohol counseling for obstetric care practitioners: A randomized controlled trial. 93, 213-217.

The purpose of the present study was to see how effective is videotape training for obstetric care practitioners on brief sessions of motivational interviewing (MI) to address problem drinking. 15 health care practitioners were randomly assigned to see a 20-minute MI training videotape. The other 15 practitioners were assigned to see a 20-minute docu drama of a pregnant problem drinker. All participants were required to role play and record two sessions with an hypothetical pregnant drinker, one before the videotapes and one after. Ratings of all these role plays, individually rated by two graduate students, and participant evaluations of the MI video constituted the main measures of interest. Overall, participants reported that the MI video was clear at showing and explaining MI skills and strategies. Ancova analysis of the role play ratings, to control for pre existing differences on clinical skills, also showed that global MI skills improved from pre to post test for those in the experimental group. The health care practitioners in the MI group were rated as showing more empathy, minimizing client resistance, and supporting self-efficacy, whereas those in the control group showed more confrontational behaviors. It was therefore concluded that obstetric care practitioners can improve their clinical interviewing skills with a 20 minute MI training video, which would in turn provide them the skills to better intervene with their drinking pregnant clients.  
Abstract by Patricia Juarez

Handmaker, N. S., Miller, W. R., & Manicke, M. (1999). Findings of a pilot study of motivational interviewing with pregnant drinkers. Journal of Studies on Alcohol, 60, 285-287.

The present investigation describes a pilot study designed to examine the effectiveness of a brief motivational intervention on pregnant drinkers, in order to reduce the incidence and risks of fetal alcohol exposure. 42 pregnant drinkers, who reported having at least one drink in the past month, were randomly assigned to either receive written information on the risks of alcohol consumption during pregnancy, or to a one-hour motivational interview (MI). During the MI session, participants received feedback on their assessment results, and information on the potential risks for their babies. The main goal was to increase the mothers' awareness of the risks related to their drinking, while at the same time emphasizing their ability to change, in order to encourage them to quit drinking during their pregnancy. At the 2 month follow up, the 32 participants who remained in the study reduced their drinking and peak intoxication levels. Those participants who had reported the highest blood alcohol concentration (BAC) at the early stages of pregnancy showed a significant reduction in BAC at later stages, if they had been assigned to the MI intervention. It was therefore concluded that MI can be a useful intervention to promote less drinking among pregnant women who are at the highest risk, while simple assessment and written advice might be enough for those at a lower risk for alcohol related problems.  
Abstract by Patricia Juarez

Nye, E. C., Agostinelli, G., & Smith, J. E. (1999). Enhancing alcohol problem recognition: A self-regulation model for the effects of self-focusing and normative information. Journal of Studies on Alcohol, 60, 658-693.

This study investigated the individual and joint effects of self-monitoring and self-evaluation processes in the problem recognition of heavy drinking college students. These two processes have been suggested to lead to a discrepancy between present behavior and some other goal or standard, which in turns leads to problem recognition. 72 heavy drinkers were randomly assigned to one of 4 conditions: self-focusing information plus normative information, self-focusing information alone, normative information alone, and control. It was found that when either of the two types of information was presented alone, they elicited the most negative evaluations of one's drinking, and the largest problem recognition or least denial, as measured by a decisional balance measure (DBM) the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) and by verbal self-reports on immediate reactions to the information. On the other hand, it was found that presenting both kinds of information together decreased problem recognition and failed to decrease the positive evaluations of one's drinking. This last finding was suggested to be due to a defensive/denial reaction to the information, which is commonly observed in confrontational approaches for alcohol abuse. These last effects appeared to be moderated by "self-deception", so that the most self-deceptive participants tended to react more defensively and to evaluate alcohol use more favorably. Of similar importance, participants who received self-focusing information alone reacted the least defensively, and showed the most problem recognition across all dependent measures.  
Abstract by Patricia Juarez

Training Study

Rubell, E. C., Sobell, L. C., & Miller, W. R. (submitted). Do continuing education workshop improve participants' skills? Effects of a motivational interviewing workshop on substance abuse counselors' skills and knowledge. (Manuscript submitted for publication).

The main goal of continuing education workshops is to help clinicians be up to date on recent advances and to learn new skills to use in their practices. Unfortunately, there are very few formal evaluations of these training opportunities. This report presents a quasi-experimental pre-post within subjects study designed to evaluate the effectiveness of a 2-day continuing education workshop on motivational interviewing (MI) at improving clinician's skills and knowledge. MI is an interviewing technique designed to increase people's motivation and commitment to change addictive and problem behaviors. It was found that there was a significant improvement of the participant's knowledge about alcoholism and MI skills/strategies, three weeks after the workshop as compared to a pre-workshop questionnaire. The authors also observed significant improvements in MI skills on the clinical vignettes (hypothetical clients presenting with alcohol or drug problems) used to evaluate their skills. Finally issues of the generalizability of the findings to actual clinical settings are discussed.  
Abstract by Patricia Juarez

Training Study

Miller, W. R., & Mount, K. A. (in press). A small study of training in motivational interviewing: Does one workshop change clinician and client behavior? Behavioural and Cognitive Psychotherapy.

In teaching motivational interviewing, as well as many other approaches, professional training often relies upon a one-time clinical workshop. Little is known, however, about whether such workshops actually change practice behavior. We trained 22 counselors in a 2-day workshop, of whom 15 provided us with taped practice samples before and immediately after training, and again 4 months later. We developed a structured Motivational Interviewing Skill Code (MISC) for recording counselor and client behavior in these sessions. On self-report questionnaires, practitioners reported large increases in their motivational interviewing skills. Coding of the practice sample tapes indicated modest but statistically significant changes in practice samples immediately after training, which were largely retained 4 months later. Certain client responses that are predictive if better outcomes, however, showed no change. We conclude that although practice behavior was modified to a modest extent, the effect of a one-time workshop was not sufficient to make any difference in client response. In essence, we added a few MI-consistent behaviors to an existing counseling style, without reducing other responses associated with less favorable outcomes. Training in MI may therefore need to focus not only on shaping up MI-consistent responses, but also on suppressing MI-inconsistent counseling habits.

Abstract by Bill Miller

Thevos, A.K., Kaona, F.A.D., Siajunza, M.T., & Quick, R.E. Adoption of safe water behaviors in Zambia: Comparing educational and motivational approaches. Education for Health (joint issue with the Annual of Behavioral Sciences and Medical Education) 2000: 13(3): 366-376.

Context: In the developing world, drinking water is an important route for transmission of diarrheal disease, a leading cause morbidity and mortality in children. Objectives: In Field Trial 1 (FT1) and Field Trial 2 (FT2), the effectiveness of the behavior change approach known as Motivational Interviewing (MI) was compared to the standard practice of health education alone in initiating and sustaining safe water treatment and storage behavior among community residents. In Field Trial 3 (FT3), MI was compared with social marketing only. Design: Community surveys were conducted prior to local health promoter training and at follow-up. Setting and Participants: Low socioeconomic status peri-urban communities in Zambia were project sites. Local volunteer health promoters from communities were trained in an adaptation of MI for safe water treatment and storage. Interventions: All health promoters received instruction in the causes and prevention of diarrhea. Health promoters in the experimental (MI) group received MI training. Main Outcome Measures: FT 1 and FT3 measured detectable disinfectant levels in stored household water. FT 2 measured disinfectant sales. Findings: No significant differences between the treatment groups were found in FT1. Subsequent MI training incorporated lessons learned from the previous trial and resulted in much higher purchase rates of the disinfectant (FT2) and levels of disinfectant in stored household water (FT3) in the MI group. Conclusion: MI appears promising for public health initiatives in the developing world. Further research to improve and refine the method is needed.

Abstract by Angelica Thevos

 

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