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Brief motivational interventions (BMIs) are widely used and efficacious interventions that address alcohol misuse in mandated college students. Consistent with motivational interviewing (MI; Miller & Rollnick, 2013) theory, within-therapist improvements in MI-consistent (MICO) skills over time-that is, as a therapist gains skill through repeated practice-may be associated with concurrent increases in client change language and subsequent changes in behavior. This study examined how therapist skill changed over time and whether within-therapist improvement in MICO skills impacted in-session client change language and subsequent alcohol-related outcomes. BMI sessions (N = 228) from 2 randomized clinical trials that had led to significant reductions in alcohol use and alcohol-related problems in mandated student drinkers were coded using the Motivational Interviewing Skills Code 2.0 (Miller, Moyers, Ernst, & Amrhein, 2003). In both studies, the BMI consisted of a single 45- to 60-min session. Analyses examined session-by-session changes in therapist MICO skills, client change language, and alcohol use outcomes. Therapist MICO skills improved over time, and there were significant increases in client change language and decreases in client discussion of topics other than personal alcohol use. Among relatively heavy-drinking clients, those treated by a more experienced therapist demonstrated greater reductions in alcohol use; however, this association was not mediated by client change language. Increased experience conducting BMIs improved therapist MICO skills over time, which in turn increased the focus on personal alcohol use during the session. However, it remains unclear how client language predicts behavior change following a BMI. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

OBJECTIVE. This meta-analysis examines the predictive validity of client change language subtypes in motivational interviewing (MI) sessions addressing addictive behavior change. METHOD. A systematic review identified k = 13 primary studies, contributing 16 MI conditions (N = 1,556). The pooled correlation coefficient was used to assess the significance, direction, and strength of seven language subtypes (i.e., reason, desire, need, ability, commitment, taking steps, and other) by three valences (i.e., frequency positive or change talk, frequency negative or sustain talk, and proportion change talk) and their relationship to subsequent engagement in addictive behavior. RESULTS. For frequency measures, more sustain talk related to reason, desire, ability, and other were associated with more addictive behavior at follow up. Other-change talk was associated with MI outcomes, but in an unexpected direction (i.e., more addictive behavior). Proportion measures showed more proportion change talk-reason and -other statements were associated with less addictive behavior at follow up. Sensitivity analyses indicated some heterogeneity and instability of effect sizes, but no evidence of publication bias. CONCLUSIONS. This preliminary meta-analysis suggests that aggregate measures of change and sustain talk are comprised of statement subtypes that are not equally meaningful in predicting outcome following MI for addictive behavior change.

BACKGROUND While there is a substantial literature on the efficacy of brief motivational intervention (BMI) for college student drinkers, research has focused less on young adults who do not attend a 4-year college, despite their elevated risk for excessive alcohol use and associated harmful consequences. METHODS This randomized controlled trial (NCT01546025) compared the efficacy of BMI to a time-matched attention control intervention (relaxation training [REL]) for reducing alcohol consumption and related negative consequences in an underage young adult sample. BMI was tailored to the developmental transition out of high school for young adults who were not immediately planning to enroll in a 4-year college. Non-treatment-seeking underage drinkers who reported past-month heavy drinking (N = 167; ages 17 to 20; 42% female; 59% non-Hispanic White) were randomly assigned to receive a single session of BMI or REL. Outcomes were evaluated 6 weeks and 3 months postintervention via in-person assessments. RESULTS Generalized estimating equation models provided strong support for the efficacy of BMI for reducing harmful drinking in these young adults. Compared to REL, and after controlling for baseline covariates including gender, those who received BMI subsequently reported significantly fewer average drinks per week, percent drinking days, percent heavy drinking days, lower peak and typical estimated blood alcohol concentration on drinking days, and fewer adverse consequences of drinking (all ps

The Client Language Assessment - Proximal/Distal (CLA-PD) is a language rating system for measuring client decision-making in interventions that target a specified behavior change (e.g., alcohol or other drug use). In the CLA-PD, there are five dimensions of change language (Reason, Ability, Commitment, Taking Steps, Other) adapted from the client portion of the Motivational Interviewing Skill Code (MISC). For the CLA-PD, language codes are sub-divided to discriminate statements regarding the primary, or target behavior change (distal change) from the intermediate coping activities (proximal change) that are prescribed to facilitate that target behavior change. The goal of the CLA-PD is to allow for higher specificity than existing client language measures, when process studies consider interventions that are multi-session and skill-based (e.g., cognitive behavioral therapy).Three raters received 40 hours of training on the use of the CLA-PD. The data were a sample of therapy session audio-files from a completed clinical trial (N=126), which enabled examination of client language across four sessions (i.e., first three and final attended) of three evidence-based alcohol interventions (cognitive behavioral therapy, twelve-step facilitation therapy, motivational enhancement therapy).Inter-rater reliability results for summary scores showed "excellent" reliability for the measure. Specifically, two-way mixed intraclass coefficients ranged from .83 to .95. Internal consistency reliability showed alphas across sessions that ranged from "fair" to "good" (α=.74-.84). In convergent and discriminant validity analyses using data independently measured with MISC-based ratings, the pattern of results was as would be expected. Specifically, convergent correlations, by valence (i.e., change and sustain talk), between CLA-PD Distal and MISC-based language scores were moderate (r=.46-.55, p.001) while discriminant correlations by valence for CLA-PD Proximal and MISC-based language scores were small (r=.22-.24, p.05). Finally, proportion Change Talk Proximal predicted subsequent session coping behaviors (i.e., processes of change) as well as 3-month Alcoholics Anonymous involvement and attendance (ps.05-.005), but not 3-month alcohol abstinence self-efficacy. Further, analyses of criterion predictive validity showed that proportion Change Talk Distal predicted 3- and 12-month drinking frequency and quantity measures (ps.05-.005).When behavior change treatments are multi-session and/or skill-based, the present analyses suggest the CLA-PD is a promising, psychometrically sound observational rating measure of client verbalized decision-making.

OBJECTIVE: Although emergency department (ED) visits offer an opportunity to deliver brief behavioral interventions to improve health, provision of ED-based interventions targeting adolescent sexual health is uncommon. The objectives for this study were to evaluate the feasibility and preliminary effects of a novel sexual health service intervention for adolescents. METHODS: In this cross-sectional feasibility study, sexually active patients aged 14 to 19 years presenting to a Midwestern pediatric ED were recruited to receive an intervention to improve sexual health. The intervention, based on motivational interviewing (MI), included agenda setting, exploration of behaviors, a decisional balance exercise, tailored feedback, and provision of personalized health services (including condoms, prescription for emergency contraception, urine testing for Chlamydia trachomatis and Neisseria gonorrheae, and referral to the hospital-affiliated adolescent clinic). Data were collected before and after intervention administration and at a 3-month follow-up telephone interview. Surveys assessed sexual risk behaviors, satisfaction with the intervention, health care use, and demographics. Feasibility criteria were (1) subject-rated interventionist fidelity to MI principles (Likert scale 1 [strongly agree] to 4 [strongly disagree]), (2) subject satisfaction (Likert scale 1 [not at all] to 5 [very]), and (3) session duration (minutes, recorded by the interventionist). A secondary outcome was the proportion of subjects who completed at least 1 health service. Services provided at the adolescent clinic were determined by an electronic medical record review. Comparisons of responses between sex subgroups were analyzed using Χ test. RESULTS: From August to November 2012, 69 adolescents were approached, 66 (96%) completed the screening survey, and 24 (37%) reported previous sexual activity. Of those, 20 (83%) agreed to participate. The mean (SD) age was 16.2 (1.4) years; 60% were female. Most (78%) reported that the interventionist maintained high fidelity to MI principles and most (80%) were very satisfied with the intervention. Mean (SD) intervention length was 15.7 (2.2) minutes. Most subjects (65%) accepted 1 or more health services, including 42% who completed clinic follow-up. In the ED or the referral clinic, the following services were provided to the subjects: condoms (n = 11), emergency contraception prescription (n = 5), C. trachomatis/N. gonorrheae testing (n = 4), hormonal birth control provision (n = 2), and human immunodeficiency virus testing (n = 3). Fifteen subjects (75%) were reached for the 3-month follow-up, and condom use was maintained by 67% of those reporting sexual activity. CONCLUSIONS: This study demonstrated the feasibility and potential utility of an MI-based service navigation intervention to connect youth with point-of-care services as well as resources for ongoing sexual health needs. Language: en

Although nearly 18 million adults have been diagnosed as having a current alcohol abuse or dependence disorder, only 1 in 7 reports ever having received any kind of alcohol treatment (Grant et al., 2004; Cohen et al., 2007). At the same time, people with alcohol use problems are likely to be treated in trauma care centers and emergency departments (EDs) (Cohen et al., 2007) for problems related or unrelated to their alcohol use. People with alcohol-related problems are overrepresented in ED and primary care settings compared with those in the general population (Cherpitel, 1994). Furthermore, alcohol-related ED visits have increased significantly over the past 15 years (Cherpitel & Ye, 2012). Therefore, EDs provide an opportunity for screening and brief intervention for problematic alcohol use. Although it has been over three decades since a WHO Expert Committee first called for the development of methods that could be efficiently applied in primary care settings (World Health Organization, 1980), national goals for a reduction in substance-related ED visits (Healthy People 2010, U.S. Department of Health and Human Services, 2005) have not been realized (Cherpitel & Ye, 2012). A recent review (Nilsen et al., 2008) of 14 studies of brief motivational intervention (BMI) in EDs for alcohol indicates that although some studies have found that BMI reduced alcohol consumption, hazardous use of alcohol, and alcohol-related injuries (compared to usual ED care), approximately 35% of the reviewed studies found no effect (e.g. Daeppen, et al., 2007; D’Onofrio, et al., 2008). Also somewhat mixed are the results of a recent meta-analysis (Kaner et al., 2009) of 22 randomized controlled trials in primary care settings that confirmed the benefit of BMI for men but not women. Furthermore, even when positive treatment effects are reported, not all outcome measures are impacted similarly (e.g., Field et al., 2009; Monti et al., 1999). For example, past studies have identified BMI effects (i.e., group differences) in alcohol use but not in alcohol-related problems (Monti et al., 2007); others have found intervention group differences in alcohol-related problems, but not in drinking behaviors (Longabaugh et al., 2001; Monti et al., 1999). These discrepancies in results suggest the need for a more impactful approach. One possible avenue for enhancing the effects of BMI in emergency care might be to incorporate significant others (SO) into the treatment. Concerned SOs tend to be present soon after hospital admissions, and may be open to supporting their family member/friend’s behavior change. SOs can provide positive and/or negative influences on alcohol treatment process and outcome in various ways (Magill et al., 2010). For example, Havassy et al. (1991) found the social network can inhibit drinking; friends or family members can (a) provide feedback that might help motivate the problem drinker to change the drinking behavior; (b) affirm skills of the problem drinker that enhance the probability of successful change; (c) help set treatment goals; and (d) provide support for changes in drinking behavior (Miller et al., 1995a). On the negative side, an alcohol abuser’s social network is likely to include other heavy drinkers, and many will drink with their partners (e.g., Fernandez-Pol et al., 1986), which can make reducing alcohol intake or abstinence especially difficult (e.g., Havassy et al., 1991; Hunter-Reel et al., 2010), and can make it challenging to select an appropriate SO for intervention. Nevertheless, there is a basis for including SOs in brief alcohol treatment. There is a substantial literature establishing the efficacy of SO-enhanced interventions for alcohol problems (e.g., Epstein & McCrady, 1998; McCrady et al., 2009) although including SO’s in treatment does not always increase benefits (Monti, et al., 1990). Having family and friend networks that are supportive of alcohol use reduction is predictive of successful change (Longabaugh et al., 1995; Stout et al., 2012), with SO-involved alcohol interventions reliably increasing the likelihood that an at-risk drinker will initiate positive changes (O’Farrell, 1993). In a recent meta-analysis, a clear advantage was found for Behavioral Couples Treatment (BCT) over individual-based treatments for frequency and consequences of alcohol use as well as relationship satisfaction (Powers et al., 2008). Although the benefit of BCT with low severity problem drinkers has been studied less, there is some evidence for lower efficacy with these individuals (Powers et al., 2008). Miller and Rollnick (2002) support the notion that SOs are a natural support that can reinforce the identified patient’s change process. The Motivational Enhancement Therapy Manual created for Project MATCH (MET: Miller et al., 1992) suggests the inclusion of a SO in early treatment sessions to help patients resolve ambivalence regarding change. The premise was that SOs could describe alcohol-related consequences, offer support, comment on the feedback provided by the therapist, and generally contribute opinions that may be more positively received by the patient than if delivered by the therapist. Unfortunately, in Project MATCH only 17% of outpatient and 13% of aftercare MET patients elected to include SOs (Carroll et al., 1998), and only 2% did so in a subsequent study of MET (Miller et al., 2003a). Despite the number of studies examining and supporting BCT and couples treatment for alcohol use disorders, few studies incorporating SOs into motivational interviewing (MI) sessions have been conducted, and to date, such interventions have been delivered almost exclusively in individual format (cf. Cordova, et al., 2001). The efficacy of an enhanced MI that includes both the patient and a SO as a design element is unknown. Given the low rates of optional SO participation in prior research, any study designed to test the addition of SOs to MI sessions would necessarily have to require that both the patient and SO participate. It is likely that this requirement has been a deterrent to conducting this type of treatment study. Inherent difficulties and the additional work involved in recruiting appropriate SOs who are motivated to participate are indeed challenges. Nevertheless, given that SOs are often present and concerned about the patient in the hospital, recruitment and inclusion of SOs in such a study might be more successful in this “opportunistic setting.” Another variable that may influence outcomes is recruitment site. The efficacy of BMI has been studied most often in the ED, less often in the trauma unit, and very few studies have recruited patients from both sites. These treatment sites are distinct; trauma units treat more severely injured patients and over longer periods of time. Most trauma patients are hospitalized following acute treatment for the trauma; ED patients are not typically admitted to a trauma service. Both settings are appropriate for an opportunistic BMI as both provide a window of opportunity occasioned by a medical event (Field et al., 2010). Since the optimal application and practice of BIs in medical settings has been questioned (Field et al., 2010; Nilsen et al., 2009) this study enrolled patients from both sites. The objective of this study was to investigate the relative efficacy of a SO-enhanced Motivational Intervention (SOMI) compared to an Individual Motivational Intervention (IMI). Our primary aim was to test the hypothesis that patients who received SOMI would drink less alcohol and suffer fewer alcohol-related consequences in the year following their hospital visit as compared to patients assigned to IMI. Our secondary aim was to test the extent to which SOMI (compared to IMI) led to significant changes in SO behaviors related to patient drinking. Both sets of aims (primary and secondary) incorporated an exploration of the effects of intervention setting (trauma unit vs. ED) without a theoretical basis for hypothesizing any interaction.

The present study examines two core therapeutic principles of Motivational Interviewing (MI) with alcohol and other substance use disorders. Specifically, therapist focus on client ambivalence and commitment to change, as well as a more general indicator of goal assessment, were tested as process predictors of subsequent alcohol use across four sessions of Motivational Enhancement Therapy. Participants were adult alcohol users involved in a large multi-site clinical trial (Project MATCH; two arms Aftercare [AC] and Outpatient [OP]). A series of multi-level models examined the effect of proposed MI ingredients on alcohol use (percent abstinent days; drinks per drinking day) over a 12-week treatment period, and whether these effects interacted with time and client baseline motivation. Therapist effort to elicit client commitment to change alcohol use was associated with greater rates of abstinence among both AC and OP participants, and reduced drinking quantity among OP participants. However, therapist focus on ambivalence was associated with greater drinking quantity among OP participants, and when motivation was low, among AC participants. Goal assessment was a marginal to non-significant predictor across outcomes, and all interactions with time were non-significant. Therapist reported treatment foci are important to subsequent patterns of drinking within a multi-session MI, but the role of ambivalence and discrepancy is worthy of further clinical and empirical consideration.

The present work provides an overview, and pilot reliability and validity for the Alcohol Intervention Mechanisms Scale (AIMS). The AIMS measures therapist interventions that occur broadly across modalities of behavioral treatment for alcohol use disorder. It was developed based on identified commonalities in the function rather than content of therapist interventions in observed therapy sessions, as well as from existing observer rating systems. In the AIMS, the primary function areas are: Explore (four behavior count codes), Teach (five behavior count codes), and Connect (three behavior count codes). Therapist behavior counts provide a frequency rating of occurrence (i.e., adherence). The three functions (Explore, Teach, Connect) are then rated on global skillfulness, which provides a quality valence (i.e., competence) to the entire session. In the present study, three independent raters received roughly 30 hours of training on the use of the AIMS by the first author. Data were a sample of therapy session audio files from a Project MATCH clinical research site. Reliability results showed generally good performance for the measure. Specifically, 2-way mixed Intraclass Coefficients were ‘excellent’, ranging from .94 to .99 for function summary scores, while Prevalence-Adjusted, Bias-Adjusted Kappa for global skillfulness measures were in the ‘fair’ to ‘moderate’ range (k = .36 to .40). Internal consistency reliability was acceptable, as were preliminary factor models by behavioral treatment function (i.e., Explore, Teach, Connect). However, confirmatory fit for the subsequent three factor model was poor. In concurrent validity analyses, AIMS summary and skillfulness scores showed associations with relevant Project MATCH criterion measures (i.e., MATCH Tape Rating Scale) that were consistent with expectations. The AIMS is a promising and reliable observational measure of three proposed common functions of behavioral alcohol treatment.

Motivational interviewing (MI) is often incorporated into screening, brief intervention, and referral to treatment (SBIRT) interventions in critical care settings to address alcohol and other drug use. However, cognitive status has been linked to differential response to MI sessions in emergency department (ED) settings. The current study examined one possible explanation for this differential response: whether higher versus lower mental status impacts patient response to clinician statements during MI sessions conducted in an ED. Participants were 126 patients receiving an MI-based single-session alcohol brief intervention, and 13 therapists who provided treatment. Participants completed a mental status exam (MSE) as part of the screening process, and intervention sessions were audio-taped, and transcribed and coded using the Motivational Interviewing Skills Code (MISC 2.0; Miller, Moyers, Ernst, & Amrhein, 2003). The MISC 2.0 coded therapist behaviors that are related to the use of motivational interviewing, and patient language reflecting movement toward (change talk) or away from (sustain talk) changing personal alcohol use. Overall, patients responded in a similar manner to therapist MI behaviors regardless of high versus low level of mental functioning at the time of the intervention. Group differences emerged on patient response to only three specific therapist skills: giving information, open questions, and complex reflection. Thus, the differential effects of SBIRT in critical care settings do not appear to be a result of differences in the therapist and patient communication process.

BACKGROUND AND AIMS: Research into the active ingredients of behavioral interventions for alcohol use disorders (AUD) has focused upon treatment-specific factors, often yielding disappointing results. The present study examines common factors of change in motivational enhancement therapy, cognitive-behavioral therapy and 12-Step facilitation therapy by (1) estimating transitional probabilities between therapist behaviors and subsequent client Change (CT) and Sustain (ST) Talk and (2) examining therapist skillfulness as a potential predictor of transition probability magnitude. DESIGN: Secondary data analysis examined temporal associations in therapy dialogues. SETTING: United States: data were from Project MATCH (Matching Alcoholism Treatments to Client Homogeneity) (1997). PARTICIPANTS: One hundred and twenty-six participants who received motivational enhancement therapy, cognitive-behavioral therapy or 12-Step facilitation therapy. MEASUREMENTS: Therapist behaviors were measured in three categories (exploring, teaching, connecting) and client statements included five categories (CT-distal, ST-distal, CT-proximal, ST-proximal, neutral). Therapist skillfulness was measured using a five-point ordinal scale. FINDINGS: Relative to chance, therapist exploratory behaviors predicted subsequent client discussion of distal, drinking behavior [odds ratio (OR) = 1.37-1.78, P

Inpatient smokers with major depressive disorder (MDD) have high rates of relapse to smoking after hospital discharge. The risk of health consequences that may contribute to increased morbidity and mortality among this population underscores the need to develop a program for psychiatric inpatient cigarette smokers with MDD. Using a motivational interviewing (MI) intervention, we sought to facilitate engagement of smokers with elevated depression symptoms in an outpatient treatment with demonstrated efficacy for nicotine dependence. In Phase 1 of this program, we recruited 15 smokers with MDD who were receiving inpatient psychiatric services. This preliminary report focuses on the development of the intervention, and explores perceived barriers to quitting, methods of quitting, and interest in smoking cessation treatment following discharge from an inpatient stay. Understanding inpatient cigarette smokers’ interests in making changes in smoking, and in willingness to attempt cessation and engage in cessation treatment can inform efforts to curb smoking in this high-risk population.

OBJECTIVE: To evaluate moderators and mediators of brief alcohol interventions conducted in the emergency department. METHODS: Patients (18-24 years; n = 172) in an emergency department received a motivational interview with personalized feedback (MI) or feedback only (FO), with 1- and 3-month booster sessions and 6- and 12-month follow-ups. Gender, alcohol status/severity group ALC+ only, Alcohol Use Disorders Identification Test (AUDIT+) only, ALC+/AUDIT+., attribution of alcohol in the medical event, aversiveness of the event, perceived seriousness of the event and baseline readiness to change alcohol use were evaluated as moderators of intervention efficacy. Readiness to change also was evaluated as a mediator of intervention efficacy, as were perceived risks/benefits of alcohol use, self-efficacy and alcohol treatment seeking. RESULTS: Alcohol status, attribution and readiness moderated intervention effects such that patients who had not been drinking prior to their medical event, those who had low or medium attribution for alcohol in the event and those who had low or medium readiness to change showed lower alcohol use 12 months after receiving MI compared to FO. In the AUDIT+ only group those who received MI showed lower rates of alcohol-related injury at follow-up than those who received FO. Patients who had been drinking prior to their precipitating event did not show different outcomes in the two interventions, regardless of AUDIT status. Gender did not moderate intervention efficacy and no significant mediation was found. CONCLUSIONS: Findings may help practitioners target patients for whom brief interventions will be most effective. More research is needed to understand how brief interventions transmit their effects. Language: en

The aim of this research was to study marijuana use, associated risks, and response to brief motivational intervention among young adult drinkers treated in an emergency department.Study participants (N = 215; ages 18-24) were in a randomized controlled trial for alcohol use that compared motivational interviewing with personalized feedback (MI) with personalized feedback only. Past-month marijuana users were compared with nonusers on demographics, readiness, self-efficacy, and behavioral risk variables. Marijuana use was examined as a potential moderator of alcohol outcomes. Whether marijuana use alone or combined marijuana and alcohol use would be reduced as a result of brief intervention for alcohol was examined at 6 and 12 months.Current marijuana users were younger, were more likely to be white, and reported more alcohol use, other illicit drug use, and more alcohol-related consequences than nonmarijuana users. Marijuana use at baseline did not moderate response to brief alcohol treatment. Marijuana use declined from baseline to 6 months for both treatment groups, but only MI participants continued to reduce their use of marijuana from 6- to 12-month follow-up. Reductions in number of days of use of marijuana with alcohol appeared to be primarily a function of decreased alcohol use.Young adult drinkers reporting current marijuana use are at generally higher risk but responded to brief alcohol treatment by reducing alcohol and marijuana use.

Because alcohol use plays a major role in many injuries that require hospital care, there is increasing interest in developing interventions to address alcohol problems among emergency department and trauma center patients. The aim of the current study was to extend past research on brief interventions by investigating the use of a self-help manual to treat problem drinkers in a hospital trauma center. Forty injured patients who were either intoxicated at the time of injury or screened positive for harmful drinking were randomly assigned to receive either a brief assessment and a self-help booklet with no more than 5 minutes clinician contact (bibliotherapy) or brief assessment only. Follow-up data obtained five months after hospital discharge indicated that patients in both conditions made significant reductions in drinking and associated negative consequences. There was a trend toward further treatment-seeking among those in the bibliotherapy condition (40% versus 13%). Results suggest that the provisio...

Substance use among adolescents with one or more psychiatric disorders is a significant public health concern. In this study, 151 psychiatrically hospitalized adolescents, ages 13-17 with comorbid psychiatric and substance use disorders, were randomized to a two-session Motivational Interviewing intervention to reduce substance use plus treatment as usual (MI) vs. treatment as usual only (TAU). Results indicated that the MI group had a longer latency to first use of any substance following hospital discharge relative to TAU (36 days versus 11 days). Adolescents who received MI also reported less total use of substances and less use of marijuana during the first 6 months post-discharge, although this effect was not significant across 12 months. Finally, MI was associated with a significant reduction in rule-breaking behaviors at 6-month follow-up. Future directions are discussed, including means of extending effects beyond 6 months and dissemination of the intervention to community-based settings.

There has been increased interest in the use of brief interventions and the delivery of alcohol treatment services through nonspecialist health care settings. One possible resource for reaching untreated individuals is "bibliotherapy," the provision of self-help materials to motivate and guide the process of changing drinking behavior. Research on the effectiveness of self-help materials for problem drinkers has been done for three decades. This report summarizes a meta-analytic review of 22 studies evaluating the effectiveness of such self-help materials. Each study was rated on 12 methodological criteria, and effect sizes of bibliotherapy were computed. The methodological quality of studies was generally high relative to other treatment-outcome studies. Modest support was found for the efficacy of self-help materials in decreasing at-risk and harmful drinking. The weighted mean pre/post-effect size for bibliotherapy was .80 with self-referred individuals seeking help for drinking problems, and .65 for individuals identified through health screening. Between-group comparisons of bibliotherapy with no-intervention controls appear to have a small to medium effect, with a weighted mean effect size of .31 with self-referred drinkers; effect size was more variable in opportunistic interventions based on health screening. Finally, between-group comparisons of effects on drinking of bibliotherapy versus more extensive interventions yielded effect size values near zero. These findings provide support for the cost-effective use of bibliotherapy with problem drinkers seeking such help to reduce their consumption, and to a lesser extent with drinkers who are identified through screening as at risk.

There is now a variety of replicable, empirically supported family-based treatments for substance use disorders. Unfortunately, the gap between evidence-based substance abuse treatment methods and treatment as usual remains wide. Disseminating evidence-based treatments into practice is of obvious importance as the overall effectiveness of health care depends on transferring best practices into routine standards of care. This article seeks to identify empirically supported interventions to substance use so that practitioners may then seek further information or training in one or more of these modalities. Three approaches to involving family members in substance abuse treatment are identified: community reinforcement and family training, marital/couples therapy, and family therapy.

Adolescents naturally experience an increased interest in sexual behavior, but they usually lack much experience. Thus, any prescription medication that holds the potential to ease or facilitate sexual matters holds a unique allure. Widespread cultural awareness of medications to treat erectile dysfunction (ED) has combined with a recent trend toward increased adolescent prescription drug abuse to create unique challenges for industry, clinicians, and researchers.

Heavy drinking peaks during late adolescence and early adulthood and is especially common among young adults who attend college (Hingson, Heeren, Winter, & Wechsler, 2005). Tens of thousands of college students violate campus alcohol policy per year for issues such as possession of alcohol, behavioral problems while intoxicated, and alcohol-related medical complications (Porter, 2006). Colleges often require these students to complete an alcohol intervention to reduce the likelihood of future heavy drinking episodes (Wechsler et al., 2002). One common intervention provided to mandated college students is Brief Motivational Intervention (BMI), which incorporates motivational interviewing (MI), and commonly includes personalized feedback along with other MI components designed to motivate behavior change. Individual BMIs (typically delivered in one or two sessions) have generally been found to be more effective at reducing alcohol use in college students than a variety of less intensive interventions such as alcohol education and normative education (see Carey, Scott-Sheldon, Carey, & DeMartini, 2007; Cronce & Larimer, 2011; Larimer & Cronce, 2007). For example, Borsari and Carey (2005) compared a BMI to individual alcohol education among mandated students. BMI participants showed a significantly greater reduction in alcohol problems at 3- and 6-month follow-up. However, other studies have found more equivocal results. For example, White and colleagues (2006) found no differences in consumption or alcohol problems comparing a BMI vs. a written feedback report (with no counselor contact) at 3-month follow-up. Similarly, a pilot study implementing BMI in a stepped care framework found no differences between BMI and assessment only control at a 6-week follow-up (Borsari, O'Leary-Tevyaw, Barnett, Kahler, & Monti, 2007). However, a recent large-scale study of the same intervention framework (stepped care) found BMI participants to report significantly fewer alcohol-related problems than assessment-only participants at a 9-month follow-up (Borsari et al., 2012). In sum, recent evidence indicates that counselor-delivered interventions may be effective with mandated students, but findings vary across studies and at different follow-up points. There is a need to understand how these interventions facilitate change in students who receive them, because such understanding can lead to refinements and improvements in future BMIs. Mechanisms of Behavior Change in BMIs Mechanisms of behavior change are defined as processes or events that lead to therapeutic improvement (Kazdin & Nock, 2003). To date, efforts to identify mechanisms of behavior change in BMIs among college students have been primarily focused on (self-reported) mediators of treatment effects (e.g., Borsari & Carey, 2000; McNally, Palfai, & Kahler, 2005). While this research has been useful, there is also a need for greater understanding of how within-session processes contribute to reductions in alcohol use and problems in order to further refine and improve BMI treatment. A theory of MI has been proposed that emphasizes two components: a relational component focused on therapist and client global factors (such as empathy, acceptance, self-exploration), and a technical component involving specific therapist behaviors to elicit client change language (Miller & Rose, 2009). There is a growing body of literature on the technical components, focusing on therapist and client behaviors within MI sessions and how these processes link to outcomes. A number of studies have examined client language defined as either change talk or sustain talk. Miller and Rollnick define change talk as “any self-expressed language that is an argument for change.” (2013, p. 159) and sustain talk as “the person's own arguments for not changing, for sustaining the status quo.” (2013, p. 7). An influential study by Amrhein and colleagues (2003) found that an increase in the strength of change talk over the course of an MI session predicted reduced client substance use at 12-month follow-up. However, because the strength of change talk was created by averaging change talk and sustain talk, the relative contribution of each construct was not ascertainable from this study. A study by Moyers and colleagues (2007) examined the relationship of both client change talk and sustain talk to drinking outcomes across three different treatment modalities (Motivational Enhancement Therapy, Cognitive Behavioral Therapy, and Twelve Step Facilitation). Both change talk and sustain talk uniquely predicted drinks per drinking day (one of the two outcomes measured), while only sustain talk predicted a lower percent of days abstinent. The sample was then split into positive outcomes and poor outcomes. Analyses revealed both change talk and sustain talk each significantly predicted outcomes, highlighting the importance of both types of within-session client language in predicting later alcohol use. A recent study examined the role of client language within BMIs with heavy drinking college students (Vader, Walters, Prabhu, Houck, & Field, 2010), using audiotapes from a previous study in which MI with personalized feedback was found to significantly reduce drinking outcomes more than MI without feedback (Walters et al. 2009). Findings indicated that in the MI-with-feedback group, therapist MI-consistent language was associated with greater levels of both student change talk and sustain talk, and each was predictive of 3 month drinking outcome in the expected directions. In contrast, in the MI without feedback condition, while MI-consistent language was again found to be associated with both greater change and sustain talk, change talk was unrelated to drinking outcome, while sustain talk was directionally but not significantly related (p = .058) to poorer drinking outcome. Tollison and colleagues (2013) have examined the role of specific therapist behavior directly on outcomes among college students receiving a BMI, and found that certain microskills (e.g., open questions, simple reflections) are associated with poorer outcomes such as increased drinking. Hence, the role of therapist and client speech behavior within the BMI are emerging as an important aspect of understanding mechanisms of behavior change in BMIs. In addition to these technical aspects (specific behaviors) of motivational interviewing, relational aspects (global approach) are important in the change process (Miller & Rose, 2009). These relational factors include global measures such as therapist empathy, MI spirit, and acceptance, as well as client measures such as therapeutic engagement. Moyers, Miller, and Hendrickson (2005) reported measures of clinician global approach (e.g., acceptance, empathy, MI spirit) correlated significantly with measures of client involvement (e.g., collaboration, disclosure, disclosure of affect) during the session. These relational aspects also have been found to predict substance use outcomes. Therapist MI spirit has been shown to predict less frequent marijuana use at a 3-month follow-up (McCambridge et al., 2011), and therapist empathy has been associated with lower levels of drinking at a 12-month follow-up (Gaume, Gmel, Faouzi, & Daeppen, 2008). Finally, Baer and colleagues (2008) reported global client “task orientation” (how much the client remained focused and engaged during therapeutic tasks) predicted more days abstinent at a 3-month follow-up. In sum, relational as well as technical components of motivational interviewing have shown to be important in understanding the change process. Current Study The current study is an analysis of therapist and client language from audiotapes of BMI sessions from a completed randomized controlled trial of mandated students who received either BMI or computer-delivered intervention (Barnett, Murphy, Colby, & Monti, 2007). Our primary objective was to investigate the relationship between therapist and client language within the BMI condition of the larger study and student alcohol use and consequences. We hypothesized that client change talk would be negatively associated with subsequent alcohol use and problems, and that client sustain talk would be positively associated with subsequent alcohol use and problems measured at several time-points after treatment. We also examined the relationship of therapist MI-consistent and MI-inconsistent language and global aspects of therapist approach and client engagement with outcomes, and hypothesized that higher levels of MI-consistent language, lower levels of MI-inconsistent language, and higher global scores would be positively associated with improved drinking outcomes.

Inclusion of concerned significant others (SOs) in alcohol use treatment has demonstrated efficacy but has not been tested in the context of brief interventions. In this study, individual motivational interviewing (MI) sessions were compared with MI sessions including a significant other on within-treatment outcomes (alliance, fidelity, client satisfaction, and engagement). Participants (N = 382) were adult alcohol users recruited in a Level I trauma center. Perceived alliance did not differ across conditions, but patients and SOs reported higher alliance, satisfaction, and engagement than was perceived by the therapist. The occurrence of MI components, or discussion areas, was consistent across conditions. Higher baseline SO drinking was associated with lower patient engagement, whereas higher baseline SO acceptance of patient drinking was associated with lower SO engagement. Results suggest that individual MI sessions can be adapted to include an SO with minimal impact on patient acceptability and treatment fidelity. Research should, however, consider SOs' influence on participant outcomes and the relevance of specific SO characteristics.

This study is the first to examine within-session therapist and client language/process predictors of a client’s decision to complete a written Change Plan in an alcohol-focused motivational interview (MI). Data were from an ongoing hospital-based clinical trial (N = 291). Trained raters coded audio-recorded MI sessions using the Motivational Interviewing Skill Code. Logistic regression analyses found that therapist MI-consistent behaviors (b = .023, p < .001) and client change talk (b = .063, p < .001) were positive predictors, and client counter change talk (b = −.093, p < .001) was a negative predictor of the decision to complete a Change Plan regarding alcohol use. Mean comparisons showed that compared to non-completion, Change Plan completion did not result in significantly greater changes in client motivational readiness. Completion of a Change Plan is a proximal outcome in MI that is associated with client intention to change (change talk), and may predict follow-up alcohol outcomes. Analyses of such theory-driven proximal client mechanisms provide a more complete model of MI process and may inform MI providers of necessary treatment ingredients.

Aims Motivational interviewing (MI) is an efficacious treatment for substance use disorders. However, little is known about how MI exerts its therapeutic effects. This review is a first attempt to summarize and evaluate the evidence for purported within-session mechanisms of change. The primary question of interest was: which MI constructs and variables appear to be the most promising candidates for mechanisms of change? Methods Literature searches were conducted to identify studies delivering MI in an individual format for the treatment of substance use disorders. Our searchidentifiedatotalof 152studiesforreview;19studiesmetinclusioncriteriabyprovidingdataonatleastonelink in the causal chain model under examination. Effect size estimates were calculated for every possible step in the causal model where sufficient data were provided by study authors. Results Four constructs of therapist behavior were evaluated: MI-Spirit, MI-Consistent behaviors, MI-Inconsistent behaviors and therapist use of specific techniques. Five constructs of client behavior were evaluated: change talk/intention, readiness to change, involvement/engagement, resistance and the client’s experience of discrepancy. The absence of experimental and full mediation studies of mechanismsof changewasnotable.Effectsizesweregenerallymixed.Conclusions Themostconsistentevidencewas found for three constructs: client change talk/intention (related to better outcomes); client experience of discrepancy (related to better outcomes); and therapist MI-Inconsistent behavior (related to worse outcomes). Regarding therapist use of specific techniques, use of a decisional balance exercise showed the strongest association to better outcomes.

There has been recent increased interest in utilizing motivational interviewing (MI) to increase adolescents readiness to quit smoking, but attempts to impact quit rates have thus far been discouraging. A better understanding of factors associated with adolescent readiness to quit smoking prior to receiving any intervention may provide guidance when tailoring future MI interventions in order to increase their effectiveness with this population. Adolescent smokers (N = 191) who had been admitted to a psychiatric hospital and enrolled in a clinical trial evaluating MI completed questionnaires that assessed smoking behavior and variables thought to be related to smoking. Confidence to quit smoking and negative beliefs about smoking were significant predictors of adolescents' baseline readiness to quit smoking. The failure to demonstrate relationships between health consequences and readiness suggest that caution may be warranted in the use of feedback, a common component of MI-based interventions. Such feedback tends to focus on health consequences, which was unrelated to adolescent baseline readiness to change smoking behavior in the current study. Parallels between current results and the Theory of Planned Behavior are discussed in consideration of developing more effective MI-based interventions for adolescent smokers.

Alcohol is the leading risk factor for severe injury. This study examined whether patients hospitalized after an alcohol-related injury are motivated to change alcohol use, thus making them potential candidates for brief motivational interventions.Fifty patients hospitalized in a Level I trauma center, admitted with a positive blood alcohol concentration, were assessed for motivation to change alcohol-related behavior using validated questionnaires. Information was gathered regarding level of alcohol use, consequences of use, and motivation to change drinking habits. Demographic variables, alcohol use measures, perception of alcohol's contribution to the current injury, and negative consequences of use were evaluated by linear regression to predict readiness to change drinking.Mean blood alcohol concentration was 197 mg/dL at admission. Patients reported a pattern of binge drinking, with 86% reporting at least one binge-drinking episode in the past month, and a mean of 3.4 days of binge drinking per month. Most patients (84%) reported considering making a change (cutting down or quitting) in their drinking. Finally, patients reported experiencing an average of 22.5 negative lifetime consequences to their drinking. Having more negative consequences was found to significantly predict readiness to change drinking (p0.001).In this study, most patients were motivated to change their drinking. An increased number of negative consequences of alcohol use before admission predicted readiness to change drinking habits. Brief motivational interventions would be a reasonable option in this group of patients.

This study looked at an emergency department based intervention to reduce sexual risk behaviors.

BACKGROUND: Alcohol interventions decrease alcohol consumption and recurrent injury. The study hypotheses are (1) intoxicated passengers are similar to intoxicated drivers in crashes and driving under the influence of alcohol (DUI), and (2) DUI conviction rates after injury are low. METHODS: Intoxicated motor vehicle occupants hospitalized for injury in 1996-1998 were matched to the state traffic database for crashes and DUI. Drivers and passengers were compared for crashes and DUI in the 2 years preceding and 1 year after admission. Driver DUI citation at the time of admission was also recorded. A logistic regression model for crash and DUI probability was constructed. RESULTS: Six hundred seventy-four patients met inclusion criteria. In the 2 years preceding admission, passengers and drivers were equally cited for crashes (14.7% vs 19.3%, p = 0.12). In 1 year after admission, they were also equally cited (7.1% vs 7.7%, p = 0.92). Driver/passenger status was not a predictor by logistic regression; 13.4% of intoxicated drivers were convicted of DUI for the admitting crash. CONCLUSION: Intoxicated passengers and drivers are equally likely to be cited for crashes and DUI before and after admission for injury. Few admitted intoxicated drivers are convicted of DUI. Screening and intervention for all intoxicated crash occupants is warranted.

Hypotheses Intoxicated motor vehicle passengers are similar to intoxicated drivers in recurrent health care encounters and risk of death for 5 years after injury. Intoxicated passengers have a greater risk of death than population controls. Design Historical cohort study. Setting University-based level I trauma center. Participants Motor vehicle crash victims admitted to a level I trauma center in 1993. Main Outcome Measures Recurrent hospitalization, emergency department visits, survival analysis, and standardized mortality ratios for 5 years following injury. Results More than one quarter of intoxicated passengers and drivers had recurrent hospitalizations and emergency department visits. Intoxicated occupants were more likely to return to the hospital and the emergency department than nonintoxicated controls (odds ratios, 2.0 and 2.7, respectively). Intoxicated passengers were at increased risk of dying compared with nonintoxicated occupants ( P = .008) and with the general population (standardized mortality ratio = 5.8). Intoxicated occupants were more likely to die an alcohol-related death ( P Conclusions Intoxicated passengers injured in a motor vehicle crash are similar to intoxicated drivers in recurrent hospitalizations and emergency department visits. Intoxicated passengers have an increased mortality rate in the 5 years following injury.