Motivational interviewing: Key ingredients associated with taking a step toward employment.

Objective: This study sought to identify key ingredients of motivational interviewing (MI) associated with taking a step in the direction of competitive employment (CE) for unemployed veterans with serious mental illness (SMI). Method: Data were analyzed from 195 audiotaped MI sessions targeted to employment conducted with 39 veterans with SMI. Sessions were coded and analyzed to identify components of MI practice predictive of taking any step in the direction of CE (e.g., asking for a referral to supported employment or conducting a job search). Predictor variables were (a) counselor MI talk behaviors and adherence to MI technical and relational principles and (b) client intensity and frequency of change talk and sustain talk. Covariates were age, gender, race, duration of unemployment, receipt of disability income, health status, work importance, work confidence, mental health diagnosis, and session number. Generalized estimating equations were used to create multivariate models. Results: After controlling for session number, work importance, work confidence and duration of unemployment, variables significant in the adjusted multivariate model were intensity of client change talk and sustain talk and counselor adherence to MI technical principles of cultivating change talk and softening sustain talk. Conclusions and Implications for Practice: Findings suggest that change talk and sustain talk during counseling sessions are associated with taking a step toward employment and that counseling focused on cultivating change talk and softening sustain talk increases the likelihood that unemployed veterans with SMI will take steps toward becoming competitively employed. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cytoplasmic Fibrillar Aggregates in Gallbladder Epithelium Are a Frequent Mimic of Cystoisospora in Pediatric Cholecystectomy Specimens.

CONTEXT.­: Cystoisospora belli is an intracellular parasite associated with gastrointestinal disease in immunocompromised hosts. Although infection has been classically associated with intestinal disease, studies have identified Cystoisospora in the gallbladder of immunocompetent patients based on hematoxylin-eosin morphology. Recently, the identity of this histologic finding as Cystoisospora has been questioned based on negative results of nucleic acid studies. OBJECTIVE.­: To determine the prevalence of this histologic feature in pediatric patients, we retrospectively reviewed all cholecystectomy specimens from a pediatric hospital during a 24-month period. DESIGN.­: In 180 cholecystectomy specimens, we identified 11 cases (6.1%) with classical histologic features previously described to represent Cystoisospora organisms. To further investigate these structures, we retrieved tissue from paraffin-embedded blocks and performed electron microscopy. RESULTS.­: Ultrastructural examination identified ovoid perinuclear cytoplasmic structures composed of dense fibrillar aggregates rather than organisms. Patients with positive cases were similar in age to controls (positive cases: mean patient age 13.4 years [range, 2-23 years]; negative cases: mean patient age 14.7 years [range, 12 weeks-31 years]; P = .35). There was no significant association of this finding with cholelithiasis (54.5% versus 65.1%, P = .52), cholesterolosis (0% versus 22.5%, P = .12), acute cholecystitis (9.1% versus 10.1%, P > .99), or chronic cholecystitis (45.5% versus 66.3%, P = .20). CONCLUSIONS.­: To our knowledge, this is the first positive identification of these structures as cytoplasmic fibrillar aggregates rather than parasitic inclusions by ultrastructural examination, and the first study of this histologic finding in pediatric cholecystectomies.

A sequential analysis of motivational interviewing technical skills and client responses.

BACKGROUND: The technical hypothesis of Motivational Interviewing (MI) proposes that: (a) client talk favoring behavior change, or Change Talk (CT) is associated with better behavior change outcomes, whereas client talk against change, or Sustain Talk (ST) is associated with less favorable outcomes, and (b) specific therapist verbal behaviors influence whether client CT or ST occurs. MI consistent (MICO) therapist behaviors are hypothesized to be positively associated with more client CT and MI inconsistent (MIIN) behaviors with more ST. Previous studies typically examine session-level frequency counts or immediate lag sequential associations between these variables. However, research has found that the strongest determinant of CT or ST is the client's previous CT or ST statement. Therefore, the objective of this paper was to examine the association between therapist MI skills and subsequent client talk, while accounting for prior client talk. METHODS: We analyzed data from a manualized MI intervention targeting both alcohol misuse and sexual risk behavior in 132 adults seen in two hospital emergency departments. Transcripts of encounters were coded using the Motivational Interviewing Skills Code (MISC 2.5) and an additional measure, the Generalized Behavioral Intervention Analysis System (GBIAS). Using these measures, we analyzed the association between client talk following specific classifications of MICO skills, with the client's prior statement as a potential confounder or effect modifier. RESULTS: With closed questions as the reference category, therapist simple reflections and paraphrasing reflections were associated with significantly greater odds of maintaining client talk as CT or ST. Open questions and complex reflections were associated with significantly greater odds of CT following ST, were not associated significantly with more ST following ST, and were associated with more ST following CT (i.e., through an association with less Follow Neutral). CONCLUSIONS: Simple and paraphrasing reflections appear to maintain client CT but are not associated with transitioning client ST to CT. By contrast, complex reflections and open questions appeared to be more strongly associated with clients moving from ST to CT than other techniques. These results suggest that counselors may differentially employ certain MICO technical skills to elicit continued CT and move participants toward ST within the MI dialogue.

Patient-provider concordance with behavioral change goals drives measures of motivational interviewing consistency.

OBJECTIVE: Motivational Interviewing (MI) consistent talk by a counselor is thought to produce "change talk" in clients. However, it is possible that client resistance to behavior change can produce MI inconsistent counselor behavior. METHODS: We applied a coding scheme which identifies all of the behavioral counseling about a given issue during a visit ("episodes"), assesses patient concordance with the behavioral goal, and labels providers' counseling style as facilitative or directive, to a corpus of routine outpatient visits by people with HIV. Using a different data set of comparable encounters, we applied the concepts of episode and concordance, and coded using the Motivational Interviewing Treatment Integrity system. RESULTS: Patient concordance/discordance was not observed to change during any episode. Provider directiveness was strongly associated with patient discordance in the first study, and MI inconsistency was strongly associated with discordance in the second. CONCLUSION: Observations that MI-consistent behavior by medical providers is associated with patient change talk or outcomes should be evaluated cautiously, as patient resistance may provoke MI-inconsistency. PRACTICE IMPLICATIONS: Counseling episodes in routine medical visits are typically too brief for client talk to evolve toward change. Providers with limited training may have particular difficulty maintaining MI consistency with resistant clients.

Motivational interviewing and decisional balance: contrasting responses to client ambivalence.

BACKGROUND: A recommendation in original descriptions of motivational interviewing (MI) was to "explore ambivalence". Contrasting procedures for doing so have been clarified through the evolution of MI. AIMS: This article describes two conceptually distinct methods for responding to ambivalence: decisional balance (DB) and MI's evocation of change talk, and reviews empirical evidence to recommend when each procedure is appropriate (and inappropriate) in clinical practice. METHOD: The authors summarize findings of clinical outcome research to examine how these two interventions impact the resolution of client ambivalence. RESULTS: With ambivalent people, a DB intervention tends to decrease commitment to change, whereas evocation (a key element of MI) promotes change. When a person has already made the decision to change, evocation is unnecessary and may deter change, whereas DB may further strengthen commitment. CONCLUSIONS: DB is an appropriate procedure when the clinician wishes to maintain neutrality and not favor the resolution of ambivalence in any particular direction. Evocation is appropriate when the clinician intends to help clients resolve ambivalence in the direction of change.

Treatment acceptance and adherence in HIV disease: patient identity and the perceived impact of physician-patient communication.

Studies have found that physician-patient relationships and communication quality are related to medication adherence and outcomes in HIV care. Few qualitative studies exist of how people living with HIV experience clinical communication about their self-care behavior. Eight focus groups with people living with HIV in two US cities were conducted. Participants responded to a detailed discussion guide and to reenactments of actual physician-patient dialogue about antiretroviral adherence. The 82 participants were diverse in age, sex, and ethnicity. Most had been living with HIV for many years and had stable relationships with providers. They appreciated providers who knew and cared about their personal lives, who were clear and direct about instructions, and who were accessible. Most had struggled to overcome addiction, emotional turmoil, and/or denial before gaining control over their lives and becoming adherent to medications. They made little or no causal attribution for their transformation to any outside agency, including their providers. They generally saw medication adherence as a function of autonomous motivation. Successful coping with HIV with its prevalent behavioral comorbidities, stigma, and other challenges requires a transformation of identity and internalization of motivation to maintain health. Effective methods for clinicians to support such development are needed.

Pathways to vocational services: factors affecting entry by veterans enrolled in Veterans Health Administration mental health services.

The current study provides naturalistic data documenting the pathways-to-care to vocational services for 155 veterans who were receiving some form of mental health care from the Veterans Health Administration and had a vocational need but were not currently enrolled in vocational services. Of the participants, 94.2% had recognized their vocational need, 80.6% reported that they or someone else had sought help to alleviate the need, and 77.4% had previously received some form of vocational services. The median length of the participants' vocational need was more than 4.2 years. Delays associated with recognition, help-seeking, and treatment entry all contributed to the overall delay in entering appropriate care. Filtering factors associated with quicker recognition, seeking help, and receiving services included diagnosis, level of disability, type of vocational need, and support from primary providers, family, and friends. The results provide information for designing interventions to improve service entry by adults with mental health problems and vocational needs.

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.