A Lifestyle Risk Reduction Model for Preventing High-Risk Substance Use Across the Lifespan.

While effective models of alcohol and drug prevention exist, they often focus solely on youth or young adults. This article describes the Lifestyle Risk Reduction Model (LRRM), an approach applicable across the lifespan. The intent behind the LRRM is to guide the development of prevention and treatment programs provided to individuals and small groups. The LRRM authors' goals are to help individuals reduce risk for impairment, addiction, and substance use's negative consequences. The LRRM identifies six key principles that conceptualize the development of substance-related problems by drawing parallels with health conditions, such as heart disease and diabetes, which often result from combined effects of biological risk and behavioral choices. The model also proposes five conditions that describe important steps for individuals as they progress toward greater perception of risk and lower risk behavior. One LRRM-based indicated prevention program (Prime For Life) shows positive results in cognitive outcomes and in impaired driving recidivism for people across the lifespan. The model emphasizes common elements across the lifespan, responds to contexts and challenges that change across the life course, complements other models, and is usable for universal, selective, and indicated prevention programs.

Methods for Quantifying the Clinical Significance of Change During Intervention Program Participation.

Assessing the practical or clinical significance (CS) of an intervention program's outcomes is useful in determining its effectiveness. The CS approach gives information beyond traditional analyses by quantifying the proportions of people who meaningfully improve and deteriorate. We link latent transition analyses (LTA) to the CS literature and use a case study to contrast it with the long-standing Jacobson and Truax (JT) approach. Data came from 2,717 individuals convicted of a substance-related offense who participated in an indicated prevention program Prime For Life® (PFL). We selected outcomes describing drinking beliefs and behavior. Both CS approaches categorized a majority of participants as improved (i.e., transitioning from baseline subgroups with risky behaviors and cognitions into posttest subgroups showing lower risk). Results demonstrate how the JT approach allows the assessment of improvements on individual outcomes, while the LTA provides more nuanced information about risk groupings. Selecting a CS approach depends on research goals, availability of normative data, and data considerations. JT is an appropriate method when evaluating single outcomes. In contrast, LTA is better when a multivariate description is desired, advanced missing data handling methods are needed, or outcomes are not normally distributed. Although infrequently done, evaluating CS provides useful information about program effectiveness.

Operating under the influence: Three year recidivism rates for motivation-enhancing versus standard care programs.

Operating a motor vehicle under the influence of alcohol (OUI) is an international problem. In the United States, one intervention strategy is to require offenders to attend group-delivered interventions. We compared three year rearrest rates among 12,267 individuals in Maine receiving either a motivation-enhancing (ME) program, Prime For Life(®), or historical standard care (SC) programs. We created two cohorts, one when Maine used SC (9/1/1999-8/31/2000) and one after the ME program was implemented (9/1/2002-8/31/2003). Adjusted for control variables, rearrest rates among people not completing an assigned program did not differ for the ME versus SC cohorts (12.1% and 11.6%, respectively; OR=1.05, ns). In contrast, ME compared to SC program completers had lower rearrest rates (7.4% versus 9.9%, OR=0.73, p<.05). The same pattern occurred for people required to take these programs plus substance use treatment (12.1% versus 14.7%, OR=0.82, p<.01). For those rearrested, time to rearrest did not differ between ME and SC cohorts. Among those required to have substance abuse treatment, ME and SC arrest rates did not differ for younger individuals; otherwise, the ME cohort's lower rearrest rates occurred across gender, age, having a previous OUI, and having completed a previous intervention program.

Evaluating therapist adherence in motivational interviewing by comparing performance with standardized and real patients.

OBJECTIVE: The goal of measuring therapist adherence is to determine whether a therapist can perform a given treatment. Yet, the evaluation of therapist behaviors in most clinical trials is limited. Typically, randomized trials have few therapists and minimize therapist variability through training and supervision. Furthermore, therapist adherence is confounded with uncontrolled differences in patients across therapists. Consequently, the extent to which adherence measures capture differences in actual therapist adherence versus other sources of variance is unclear. METHOD: We estimated intra-class correlations (ICCs) for therapist adherence in sessions with real and standardized patients (RPs and SPs), using ratings from a motivational interviewing (MI) dissemination trial (Baer et al., 2009) in which 189 therapists recorded 826 sessions with both patient types. We also examined the correlations of therapist adherence between SP and RP sessions, and the reliability of therapist level adherence scores with generalizability coefficients (GCs). RESULTS: ICCs for therapist adherence were generally large (average ICC for SPs = .44; average ICC for RPs = .40), meaning that a given therapist's adherence scores were quite similar across sessions. Both ICCs and GCs were larger for SP sessions compared to RPs on global measures of MI adherence, such as Empathy and MI Spirit. Correlations between therapist adherence with real and standardized patients were moderate to large on 3 of 5 adherence measures. CONCLUSION: Differences in therapist-level adherence ratings were substantial, and standardized patients have promise as tools to evaluate therapist behavior.

Reports of past alcohol and drug use following participation in a motivation enhancing intervention: implications for clinical assessment and program evaluation.

BACKGROUND: There is significant interest in the value of motivational approaches that enhance participant readiness to change, but less is known about clients' self-reports of problematic behavior when participating in such interventions. METHODS: We examined whether participants in a motivationally-based intervention for DUI offenders changed their reports of substance use at postintervention (when reporting on the same 30 days that they reported on at preintervention). Specifically, Study 1 (N = 8,387) tested whether participants in PRIME For Life (PFL) changed their reports about baseline substance levels when asked at postintervention versus at preintervention. Study 2 (N = 192) compared changes in self-reported baseline drinking between PFL and intervention as usual (IAU) participants. RESULTS: Many participants in Study 1 did not change their reports about how much they used substances during the 30-day period before baseline. Among those who did, the most common change was an increase in reported amounts of baseline drug use, and typical and peak alcohol use. This sample also showed changes in reports of their baseline pattern of high-risk-use (consistent versus occasional). At postintervention, participants who were younger, single, or endorsing more indicators of alcohol dependence were more likely to later report greater frequency of baseline drug use, and greater peak and typical number of baseline drinks. Gender, education, and race were also associated with reporting inconsistency on some behaviors. In Study 2, PFL participants showed greater increases in reports of peak alcohol use compared to IAU, but both conditions showed similar increases for drugs and typical alcohol use. CONCLUSIONS: In both research and clinical settings, a segment of participants may initially report less substance use than they do when asked later about the same baseline period. These preliminary findings suggest clinicians and researchers may find postintervention evaluations yield reports of greater baseline alcohol or drug use for some people. For some behaviors, this may occur more often in interventions that target client motivation. Future research should attempt to identify which reports - preintervention vs. postintervention - better reflect actual baseline substance use.

Short-term outcomes of a motivation-enhancing approach to DUI intervention.

OBJECTIVE: We compared a group-delivered, theory-based, motivation-enhancing program (PRIME For Life(®) - PFL, n=450) to an intervention as usual (IAU, n=72). METHOD: Individuals convicted of a substance related offense in North Carolina, typically first offense alcohol and drug-impaired driving, participated in a PFL or IAU group. We compare the interventions on program satisfaction and changes made from preintervention to postintervention, and examined the moderating effects of demographics and alcohol dependence level. RESULTS: When significant, findings varied in magnitude from small to medium effects. Participants in both interventions showed intentions to use statistically significantly less alcohol and drugs in the future compared to their previous use, and differences between the groups were not statistically significant. Otherwise, findings favored PFL. PFL exhibited greater benefit than IAU on understanding tolerance, perceived risk for addiction, problem recognition, and program satisfaction. Additionally, IAU perceived less risk for negative consequences postintervention than they had at preintervention. Moderation analyses showed that the between-condition findings occurred regardless of gender, age, education, and number of alcohol dependence indicators. Additionally, younger people and those with more dependence indicators - groups of particular concern - showed the greatest change. CONCLUSIONS: Findings suggest that a motivation-enhancing approach can be effective in producing short-term change in factors that can help facilitate and sustain behavioral change. This is consistent with previous research on the use of motivational approaches, and extends such findings to suggest promise in group-based settings and with people across demographic categories and dependence levels. Future research should focus on larger studies looking at long-term behavioral change, including recidivism.

Computer Assessment of Simulated Patient Interviews (CASPI): psychometric properties of a web-based system for the assessment of motivational interviewing skills.

OBJECTIVE: Benefits of empirically supported interventions hinge on clinician skill, particularly for motivational interviewing (MI). Existing MI skill assessments are limited with respect to validity (e.g., self-report) and practicality (e.g., coding session tapes). To address these limitations, we developed and evaluated two versions of a web-based assessment of MI skills, the Computer Assessment of Simulated Patient Interviews (CASPI). METHOD: Ninety-six counselors from the community and 24 members of the Motivational Interviewing Network of Trainers (MINT) completed the CASPI (N = 120), in which they verbally responded via microphones to video clips comprising three 9-item vignettes. Three coders used an emergent coding scheme, which was compared with alternative MI skills measures. RESULTS: CASPI demonstrated excellent internal consistency when averaging across two or three vignettes (α's = .86-.89). Intraclass correlations were above .40 for most items. Confirmatory factor analyses supported a correlated three-factor model: MI-consistent, resistance-engendering, and global change talk orientation rating. Means and factor loadings were invariant across forms (i.e., the two alternative versions of CASPI), and factor loadings were invariant across subgroup (i.e., community counselor or MINT member). Test-retest reliability was good for MI-consistent and resistance-engendering scores (r = .74 and .80, respectively) but low for change talk orientation (r = .29) unless coder was taken into account (r = .69). CASPI showed excellent construct and criterion-related validity. CONCLUSIONS: CASPI represents a promising method of assessing MI skills. Future studies are needed to establish its performance in real-world contexts.

Deconstructing proficiency in motivational interviewing: mechanics of skilful practitioner delivery during brief simulated encounters.

BACKGROUND: Proficient delivery of motivational interviewing (MI) is often determined by global rating of relational elements or cumulative tallies of technical elements. Yet limited empirical evidence exists to clarify how relational and technical elements are associated, or if rates of skill indices and their constituent technical elements vary within a clinical encounter. AIMS: This study sought to document temporal variance in rates of MI skill indices and their constituent technical elements during brief clinical encounters with a standardized patient wherein delivery was "MI-proficient", and to distinguish those temporal patterns from those observed in encounters with "MI-inconsistent" delivery. METHOD: Data were accessed from a large MI training trial wherein relational and technical elements of MI delivery were scored for 503 recordings of a simulated 20-minute clinical encounter. Notably, independent raters tallied technical elements in 5-minute segments, allowing evaluation of potential variance among the encounter's quartile intervals. Global ratings of MI spirit identified subsets of recordings with MI-proficient (n = 49) and MI-inconsistent (n = 43) delivery for stratified analyses. RESULTS: Analyses contrast temporal trajectories of technical aspects of MI-proficient and MI-inconsistent delivery, with the former characterized by: 1) elicitation and reflective listening as primary opening strategies; 2) increased depth of reflective listening as a predominant strategy in subsequent, focused therapeutic discussion; and 3) increased use of elicitation and information provision in change planning as the encounter approached conclusion. CONCLUSIONS: Findings are generally consistent with seminal descriptions of MI (Miller and Rollnick, 1991, 2002), and document temporal aspects of skilful MI delivery in brief encounters.

Agency context and tailored training in technology transfer: a pilot evaluation of motivational interviewing training for community counselors.

Few empirical studies are available to guide best practices for transferring evidenced-based treatments to community substance abuse providers. To maximize the learning and maintenance of new clinical skills, this study tested a context-tailored training (CTT) model, which used standardized patient actors in role-plays tailored to agency clinical context, repetitive cycles of practice and feedback, and enhanced organizational support. This study reports the results of a randomized pilot evaluation of CTT for motivational interviewing (MI). Investigators randomly assigned community substance abuse treatment agencies to receive either CTT or a standard 2-day MI workshop. The study also evaluated the effects of counselor-level and organizational-level variables on the learning of MI. No between-condition differences were observed on the acquisition and maintenance of MI skills despite reported higher satisfaction with the more costly context-tailored model. Analyses revealed that those counselors with more formal education and less endorsement of a disease model of addiction made the greatest gains in MI skills, irrespective of training condition. Similarly, agencies whose individual counselors viewed their organization as being more open to change and less supportive of autonomy showed greater average staff gains in MI skills, again, irrespective of training method. Posttraining activities within agencies that supported the ongoing learning and implementation of MI mediated the effects of organizational openness to change. This pilot study suggests that tailored training methods may not produce better outcomes than traditional workshops for the acquisition of evidence-based practice, and that efforts to enhance skill acquisition can be focused on characteristics of learners and ongoing organizational support of learning.

The video assessment of simulated encounters-revised (VASE-R): reliability and validity of a revised measure of motivational interviewing skills.

The video assessment of simulated encounters-revised (VASE-R) is a video-based method, administered in individual or group settings, for assessing motivational interviewing (MI) skills. The 18-item instrument includes three video-based vignettes, in which actors portray substance abusers, with each vignette followed by questions that prompt examinees to write responses that are then scored against MI standards. The VASE-R was administered to two independent samples: (1) substance abuse practitioners participating in a study of MI training methods, and (2) MI training facilitators with a high level of MI skill and expertise. This multi-study report describes basic VASE-R psychometric properties -- including scoring reliability, internal consistency, concurrent validity, and sensitivity to the effects of training -- and then presents proficiency standards based on administration to a sample of MI training facilitators (MI Experts). The findings indicate excellent inter-rater reliability using intra-class correlations for the full-scale score (.85) and acceptable levels for subscales (.44 to .73). The instrument displayed strong concurrent validity with the Helpful Responses Questionnaire (HRQ) and a behavioral sample of clinician behavior with a standardized patient scored using the MI Treatment Integrity (MITI) system, as well as good sensitivity to improvement in MI skill as a result of training. The findings provide an empirical basis for suggesting VASE-R benchmarks for beginning proficiency and expert MI practice.

The video assessment of simulated encounters (VASE): Development and validation of a group-administered method for evaluating clinician skills in motivational interviewing.

The authors developed and evaluated a group-administered method for measuring motivational interviewing (MI) skills. The video assessment of simulated encounters (VASE) consists of three videotaped vignettes of actors playing substance abusers. Each vignette is followed by eight questions asking examinees to generate written responses consistent with MI principles. Twenty-two clinicians completed the VASE questionnaire and two other measures of MI skill: a paper-and-pencil measure that elicited responses to written scenarios and an audiotaped interaction with a standardized patient (SP), subsequently scored for MI skill by independent tape raters. Psychometric analyses of this original VASE scale evaluated: (1) scoring reliability of the 24 VASE items; (2) internal reliability of the VASE full-scale score, seven subscale scores and the three vignettes; and (3) concurrent validity with aforementioned indices of MI skill. Analyses informed the removal of two subscales, redesign of a third and revisions to a fourth. The resulting 18-item VASE-R scale retains its three-vignette format, and assesses overall MI skill as well as the following five MI "microskills": reflective listening, responding to resistance, summarizing, eliciting change talk and developing discrepancy. The VASE-R requires further analysis to evaluate these revisions, but shows promise as a cost-effective alternative for use in MI skill assessment in a variety of training and research contexts.

An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians.

We evaluated a 2-day training workshop on motivational interviewing (MI) for addiction and mental health clinicians (n = 22). Clinicians completed the helpful responses questionnaire (HRQ) and taped interactions with a standardized patient (SP). Independent, blinded coders rated the tapes using the motivational interviewing skills code (MISC). Post-training assessment showed significant increase on the HRQ and two of four MISC summary scores for SP interviews. At 2-month follow-up, means of the HRQ and two MISC summary scores remained higher than baseline, but declined from post-training. Some MI skills improved to a greater degree than others, and a subset of clinicians (> 40%) showed continued improvement at follow-up. Results were consistent across interviews with different SPs, supporting the use of this assessment method. Findings highlight the need for additional research on the use of standardized patients, alternative assessment techniques, and effective methods of technology transfer for MI skill acquisition and retention.

Gender, waitlists, and outcomes for public-sector drug treatment.

This study evaluated gender differences in baseline characteristics and treatment outcomes among 654 treatment seekers referred to state-funded drug treatment. Women were significantly less likely than men to enter treatment following referral, but not significantly less likely to complete treatment, once they entered. After adjustment for treatment dose, gender differences in substance use at followup (3-6 months after leaving the treatment wait list) were nonsignificant. The genders did not differ significantly in rates of psychosocial improvement between referral and followup. Women waited significantly longer than men before leaving the treatment wait list (with or without treatment entry), but wait time was associated with entry rates only among men. The authors discuss system-level and personal characteristics that potentially affect wait times and call for additional study of whether abbreviating waits can increase women's treatment entry rates.

Primary heroin users + drug-free treatment: an equation for success?

This study of persons referred to publicly funded drug-free substance abuse treatment in Washington State compares 122 primary heroin users (those specifying heroin as a drug of choice) with 532 persons who preferred other substances. Information on treatment entry and completion was obtained through review of client charts at the referral agency. Follow-up interviews with 587 participants provided self-reports of substance use during a 90-day period 3-6 months following removal from the treatment waitlist. Primary heroin users were significantly less likely than others to enter the treatment programs to which they were referred. Among treatment entrants, primary heroin users were somewhat less likely than other users to complete inpatient programs but no less likely to complete outpatient programs. The heroin preference group reported less abstinence and greater frequency of use during the follow-up period than did other users, patterns that almost entirely coincided with the lower treatment compliance in the heroin group. The authors note the importance of investigating methods for increasing treatment entry rates for opiate users who desire drug-free treatment.