Toward a theory of motivational interviewing.

The widely disseminated clinical method of motivational interviewing (MI) arose through a convergence of science and practice. Beyond a large base of clinical trials, advances have been made toward “looking under the hood” of MI to understand the underlying mechanisms by which it affects behavior change. Such specification of outcome-relevant aspects of practice is vital to theory development and can inform both treatment delivery and clinical training. An emergent theory of MI is proposed that emphasizes two specific active components: a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and reinforcement of client change talk. A resulting causal chain model links therapist training, therapist and client responses during treatment sessions, and posttreatment outcomes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

How Does Motivational Interviewing Work? Therapist Interpersonal Skill Predicts Client Involvement Within Motivational Interviewing Sessions.

Although many studies have shown that motivational interviewing (MI) is effective in reducing problem behaviors, few have investigated purported causal mechanisms. Therapist interpersonal skills have been proposed as an influence on client involvement during MI sessions and as a necessary precursor to client commitment language. Using the Motivational Interviewing Skills Code (MISC; Version 1.0) rating system, the authors investigated 103 unique MI sessions for substance abuse and found that therapist interpersonal skills were positively associated with client involvement as defined by cooperation, disclosure and expression of affect. An unexpected finding indicated that behaviors inconsistent with MI enhanced the impact of therapist interpersonal skills upon client involvement. Drawbacks to the study include a potential sampling bias and uneven reliability of the variables measured. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The language of motivational interviewing and feedback: Counselor language, client language, and client drinking outcomes.

Previous research has suggested that motivational interviewing (MI) may affect client language, which in turn predicts client drinking outcome. In this study, we examined the relationship between counselor language and client language, personalized feedback and client language, and client language and client drinking outcome, in a sample of heavy-drinking college students. MI was delivered in a single session with or without a personalized feedback report (MI with feedback [MIF]; MI only). Sessions were coded using the Motivational Interviewing Skill Code 2.1. A composite drinking outcome score was used, consisting of drinks per week, peak blood alcohol concentration, and protective drinking strategies. We found three main results. First, in the MIF group, MI consistent counselor language was positively associated with client change talk. Second, after receiving feedback, MIF clients showed lower levels of sustain talk, relative to MI only clients. Finally, in the MIF group, clients with greater change talk showed improved drinking outcomes at 3 months, while clients with greater sustain talk showed poorer drinking outcomes. These results highlight the relationship between counselor MI skill and client change talk, and suggest an important role for feedback in the change process. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Motivational interviewing in relational context.

Responds to M. Stanton's comments (see record 2010-08987-013) on the current author's original article (see record 2009-13007-002). One of the puzzles of motivational interviewing is why it works at all. How can it be that an individual interview or two yields change in a long-standing problem behavior even without any effort to alter social context? The time involved is such a tiny part of the person’s ongoing daily life. How does it work? That is a question that has fascinated us and that prompted our article (Miller & Rose, September 2009). The model we proposed is intentionally focused on individual intervention, for that is how motivational interviewing (MI) has been delivered and tested in most studies. The current science base is drawn primarily from MI interventions that do not include concerned significant others (CSOs). Of course it is possible for CSOs to be included in MI sessions. CSO involvement was an option within MI components of treatment in at least three multisite trials: the COMBINE study (Anton et al., 2006), the UK Alcohol Treatment Trial (UKATT Research Team, 2005), and Project MATCH (Babor & Del Boca, 2003). The primary purpose of the MATCH trial was to evaluate, as Stanton (2010) suggested, a range of factors that might mediate or moderate the relationship between treatments and behavior change (Babor & Del Boca, 2003). One of these factors was social context, or more specifically, the person’s level of social support for drinking versus sobriety. A wide variety of external factors might mediate or moderate the efficacy of MI (or of any psychotherapy). Our article focused on the therapeutic interaction, not on a comprehensive model of all that influences behavior change. The domain of “social context” encompasses a broad range of factors (such as employment, family history, peer influence, and religious involvement), and any number of other components might also be considered in predicting substance use outcomes (e.g., age, conceptual level, severity of dependence, comorbidity). The model that we proposed (Miller & Rose, 2009) was focused on interpersonal and intrapersonal factors involved when a therapist interacts with an individual client. MI as an individual intervention has been found to be efficacious across a broad range of problem areas. As the processes and efficacy of MI become better understood, it will also be possible to explore how these operate within the person’s ongoing social context. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

What explains the relationship between the therapist structure × patient reactance interaction and drinking outcome? An examination of potential mediators.

Recent research found that among patients in aftercare treatment for alcoholism the level of therapist structure interacted with the level of patients' interpersonal reactance to predict alcohol use outcomes. The present study examined two sets of potential mediators of this interaction effect among a sample from two aftercare sites of Project MATCH (n = 127). The mediator constructs were types of pro-recovery change talk and resistance to therapeutic work. Dependent variables were percentage of days abstinent (PDA) and percentage of heavy drinking days (PHDD) across the year after treatment. Multiple-mediator models using bootstrapped estimates of indirect effects were used to test for mediation. Results indicated that the 'taking steps' aspect of change talk partially mediated the Structure × Reactance interaction effect on both PDA and PHDD post treatment. Resistance was not found to mediate the interaction effect though resistance did predict worse drinking outcomes. Depending on patients' openness to being influenced by others, therapist structure early in treatment may promote or inhibit pro-recovery steps taken by aftercare patients between treatment sessions. Those steps in turn play an important role in predicting future alcohol use. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reducing sexual risk behaviors and alcohol use among HIV-positive men who have sex with men: A randomized clinical trial.

This randomized clinical trial (N = 253) evaluated the efficacy of a theory-based intervention designed to reduce both alcohol use and incidence of unprotected sexual behaviors among HIV-positive men who have sex with men with alcohol use disorders. An integrated, manualized intervention, using both individual counseling and peer group education/support, was compared with a control condition in which participants received resource referrals. The intervention was based on the transtheoretical model’s stages and processes of change, and motivational interviewing was used to enhance client readiness for change. Major findings include treatment effects for reduction in number of drinks per 30-day period, number of heavy drinking days per 30-day period, and number of days on which both heavy drinking and unprotected sex occurred. Practitioners employing this intervention may achieve enhanced client outcomes in reduction of both alcohol use and risky sexual behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The structure of client language and drinking outcomes in project match.

Client language during Motivational Interviewing interventions is an important predictor of drinking outcomes, but there are inconsistencies in the literature regarding what aspects of client language are most predictive. We characterized the structure of client language by factor analyzing frequency counts of several categories of client speech. The results provide limited support for a model proposed by Miller et al. (2006) and Amrhein et al. (2003) but with some important differences. While Amrhein et al. (2003) found that only increasing strength in client commitment language predicted behavior change, the current study revealed that client language preparatory to commitment predicted drinking outcomes. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Efficacy of group motivational interviewing (GMI) for psychiatric inpatients with chemical dependence.

Dually diagnosed patients with chemical dependency and a comorbid psychiatric disorder typically show poor compliance with aftercare treatment, which may result in costly and pervasive individual and societal problems. In this study, the authors investigated the effect of adding motivational interviewing in a group format to standard treatment for dually diagnosed psychiatric inpatients. The patients (n = 101) all received standard care and in addition were assigned to either group motivational interviewing (GMI) or a therapist attention activity control group (TAAC). Of patients who attended aftercare and who used alcohol or drugs, those who participated in GMI attended significantly more aftercare treatment sessions, consumed less alcohol, and engaged in less binge drinking at follow-up compared with those in TAAC. Differences between conditions in the overall percentage of participants who achieved complete abstinence or who attended aftercare treatment were not significant, possibly because of a lack of power. These results provide preliminary evidence for the efficacy of GMI when added at the outset to an inpatient program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men.

This study tested the efficacy of behavioral treatments for alcohol use disorders (AUD) among men who have sex with men (MSM) and who are at risk for HIV transmission. HIV-negative MSM with current AUD (N = 198) were recruited, offered treatment focused on reducing drinking and HIV risk, and followed during treatment and 12 months posttreatment. Participants (n = 89) accepted treatment and were randomized to either 4 sessions of motivational interviewing (MI) or 12 sessions of combined MI and coping skills training (MI + CBT). Other participants (n = 109) declined treatment but were followed, forming a non-help-seeking group (NHS). MI yielded significantly better drinking outcomes during the 12-week treatment period than MI + CBT, but posttreatment outcomes were equivalent. NHS participants significantly reduced their drinking as well. Service delivery and treatment research implications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles.

To investigate the impact of counselor style, a 2-session motivational checkup was offered to 42 problem drinkers (18 women and 24 men) who were randomly assigned to 3 groups: (1) immediate checkup with directive-confrontational counseling, (2) immediate checkup with client-centered counseling, or (3) delayed checkup (waiting-list control). Overall, the intervention resulted in a 57% reduction in drinking within 6 wks, which was maintained at 1 yr. Clients receiving immediate checkup showed significant reduction in drinking relative to controls. The 2 counseling styles were discriminable on therapist behaviors coded from audiotapes. The directive-confrontational style yielded significantly more resistance from clients, which in turn predicted poorer outcomes at 1 yr. Therapist styles did not differ in overall impact on drinking, but a single therapist behavior was predictive (r?=?.65) of 1-yr outcome such that the more the therapist confronted, the more the client drank. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Impact of motivational interviewing on participation and outcome in residential alcoholism treatment.

Tested motivational interviewing (a strategy to increase motivation for change) as a preparation for residential alcoholism treatment. 28 consecutive alcoholism admissions to a psychiatric hospital were assigned alternately to receive or not to receive a 2-session motivational assessment and interview shortly after intake, in addition to standard evaluation and treatment procedures. Patients who received the motivational interview participated more fully in treatment (as evidenced by therapist ratings) and showed significantly lower alcohol consumption at a 3-mo follow-up interview. The beneficial effects of motivational interviewing on outcome were mediated by increased participation in treatment. The extent to which the received treatment outcome conformed to patients' pretreatment expectations was predictive of outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Therapist perspectives on countertransference: Qualitative data in search of a theory.

A consensual qualitative research strategy was used to examine data from 127 interviews conducted with 8 psychologists immediately following their sessions of brief therapy with 8 clients. Analyses revealed 3 domains relevant to countertransference: origins (including categories of family issues, needs and values, therapy specific issues, and cultural issues), triggers (including categories of content of client material, therapist comparing client with others, change in therapy structure or procedures, therapist assessing progress of therapy, therapist perception of client, and emotions), and manifestations (including categories of approach, avoidance, negative feelings, and treatment planning). The frequency of categories within and across cases was classified, and relationships among categories from the 3 domains were detected, generating hypotheses for future empirical research. Implications for practice, training, and continued research are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Motivational interviewing and the social context.

Comments on the article by Miller and Rose (see record 2009-13007-002). As Miller and Rose opened “the black box of treatment to examine linkages between processes of delivery and client outcomes” (p. 529) in motivational interviewing (MI), it is important that their model include factors from the social context that may explain conditions that enhance or diminish MI interventions. Aspects of the social context may serve as mediators or moderators of the relational (MI spirit) and technical (change talk) components in MI theory. In this comment, the author suggests the addition of social influence to their theoretical model. The author suggests that existing research on the role of significant others argues that the conceptual model should include a box for Social Influence as a hypothesized process variable that relates to “Client Preparatory Change Talk and Diminished Resistance” and “Commitment to Behavior Change” (see Figure 1, p. 530). In addition, a second new box, labeled Significant Other Training in MI, should be added in direct relationship to the new Social Influence variable. Further research is needed to explore these variables and their specific functions within the model. These additions to the theoretical model affirm the active components of MI and potentially extend the effects through positive social influence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison of dream interpretation, event, interpretation, and unstructured sessions in brief therapy.

Twenty-five distressed adult clients received 2 sessions each of dream and event interpretation using the Hill model during 12 sessions of successful therapy. No differences were found in depth, insight, and working alliance among dream interpretation, event interpretation, and unstructured sessions, suggesting that dream interpretation is as effective as other therapist strategies. Dream and event interpretation may be equally effective because both lead back to relevant waking concerns and past memories. Pretreatment measures of client psychological mindedness, openness, and insight were generally unrelated to each other, to evaluations of insight within sessions, to therapist evaluations of client insight, and to pre- and posttherapy changes in insight. Cognitive complexity of client dialogue was related to the process and outcome of dream interpretation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Expectations of psychotherapy duration: How long should psychotherapy last?

Surveyed 234 members (aged 36–55 yrs) of American Psychological Association (APA) Division 29 (Psychotherapy) regarding their expectations of the number of psychotherapy sessions needed to successfully treat persons with various psychological disorders. Psychologists expected 30–40 sessions of individual psychotherapy to achieve clinically significant change. Differences in treatment duration expectancies were associated with client diagnosis and with therapist age, gender, therapeutic orientation, and experience. Psychotherapists' judgments of appropriate treatment durations should be considered when establishing guidelines for the duration of psychotherapy for specific psychological problems and disorders. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials.

A meta-analysis was conducted on controlled clinical trials investigating adaptations of motivational interviewing (AMIs), a promising approach to treating problem behaviors. AMIs were equivalent to other active treatments and yielded moderate effects (from .25 to .57) compared with no treatment and/or placebo for problems involving alcohol, drugs, and diet and exercise. Results did not support the efficacy of AMIs for smoking or HIV-risk behaviors. AMIs showed clinical impact, with 51% improvement rates, a 56% reduction in client drinking, and moderate effect sizes on social impact measures (d=0.47). Potential moderators (comparative dose, AMI format, and problem area) were identified using both homogeneity analyses and exploratory multiple regression. Results are compared with other review results and suggestions for future research are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Combined use of root conditioning, fibrin-fibronectin system and a collagen membrane to treat a localized gingival recession: a 10-case report

The relationship between the therapeutic alliance and treatment participation and drinking outcomes during and after treatment was evaluated among alcoholic outpatient and aftercare clients. In the outpatient sample, ratings of the working alliance, whether provided by the client or therapist, were significant predictors of treatment participation and drinking behavior during the treatment and 12-month posttreatment periods, after a variety of other sources of variance were controlled. Ratings of the alliance by the aftercare clients did not predict treatment participation or drinking outcomes. Therapists ratings of the alliance in the aftercare sample predicted only percentage of days abstinent during treatment and follow-up. The results document the independent contribution of the therapeutic alliance to treatment participation and outcomes among alcoholic outpatients.     

Contributions from ethics and research that guide integrating religion into psychotherapy.

Historically ignored or “treated,” clients' religious beliefs are being incorporated into psychotherapy because they influence client and therapist thinking and have potential to heal and harm. This paper examines how professional codes of ethics and research on religion-friendly therapeutic interventions and on helpful and harmful religious beliefs and practices provide direction in dealing with religious matters in psychotherapy. Ethical codes emphasize self-determination, beneficence, and nonmaleficence, which lead to different treatment decisions depending on how they are prioritized. The informed consent process and motivational interviewing have potential to ethically reduce harm and maximize benefits from the client's religious beliefs. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Relationship and techniques in cognitive-behavioral therapy--A motivational approach.

Motivational attunement is presented here as a set of guiding principles that can be used to foster the therapeutic alliance in cognitive-behavioral therapy (CBT). The overarching goal of motivational attunement is to provide the client with need-satisfying experiences. In order to do so, the therapist must attune his or her interventions to the client's motivational goals. The authors attempt to demonstrate how therapists can assess motivational goals and use this information to foster the central components of the alliance. The authors also outline how motivational attunement can be used to prevent and resolve alliance ruptures. Finally, empirical support for the effects of motivational attunement is briefly described. (PsycINFO Database Record (c) 2010 APA, all rights reserved)