Jennifer K. Manuel

A Randomized Trial Investigating Training in Motivational Interviewing for Behavioral Health Providers

. Evidence indicates that workshop training, personalized feedback, and individual consultation can increase competence in motivational interviewing (MI) among highly motivated and skilled substance abuse counselors. Little is known, however, about the translational value of these training strategies for counselors with fewer counseling skills and less stated motivation to learn MI. This study presents evidence from a randomized, controlled trial of 129 behavioral health providers assigned to receive workshop training and enrichments to learn MI. A diverse group of Air Force behavioral health providers working in substance abuse treatment programs were trained in MI and subsequently observed in clinical sessions at 4, 8 and 12 months after training. Results indicate that training was effective in increasing the skill level of these clinicians; however, these gains had decreased by the 4-month follow-up point. Training enrichments in the form of personalized feedback and consultation phone calls did not have an expected, additive effect on clinician skill level. The results of this study lend support to the hypothesis that a greater investment of resources and incentives may be necessary to achieve gains in MI skills for counselors with relatively lower baseline skills than those commonly participating in research studies.

A Randomized Trial of a Hepatitis Care Coordination Model in Methadone Maintenance Treatment

OBJECTIVES We evaluated the efficacy of a hepatitis care coordination intervention to improve linkage to hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination and clinical evaluation of hepatitis C virus (HCV) infection among methadone maintenance patients. METHODS We conducted a randomized controlled trial of 489 participants from methadone maintenance treatment programs in San Francisco, California, and New York City from February 2008 through June 2011. We randomized participants to a control arm (n = 245) and an intervention arm (n = 244), which included on-site screening, motivational-enhanced education and counseling, on-site vaccination, and case management services. RESULTS Compared with the control group, intervention group participants were significantly more likely (odds ratio [OR] = 41.8; 95% confidence interval [CI] = 19.4, 90.0) to receive their first vaccine dose within 30 days and to receive an HCV evaluation within 6 months (OR = 4.10; 95% CI = 2.35, 7.17). A combined intervention adherence outcome that measured adherence to HAV-HBV vaccination, HCV evaluation, or both strongly favored the intervention group (OR = 8.70; 95% CI = 5.56, 13.61). CONCLUSIONS Hepatitis care coordination was efficacious in increasing adherence to HAV-HBV vaccination and HCV clinical evaluation among methadone patients.

The Motivational Interviewing Treatment Integrity Code (MITI 4): Rationale, Preliminary Reliability and Validity

UNLABELLED The Motivational Interviewing Treatment Integrity code has been revised to address new evidence-based elements of motivational interviewing (MI). This new version (MITI 4) includes new global ratings to assess clinicians attention to client language, increased rigor in assessing autonomy support and client choice, and items to evaluate the use of persuasion when giving information and advice. METHOD Four undergraduate, non-professional raters were trained in the MITI and used it to review 50 audiotapes of clinicians conducting MI in actual treatments sessions. Both kappa and intraclass correlation indices were calculated for all coders, for the best rater pair and for a 20% randomly selected sample from the best rater pair. RESULTS Reliability across raters, with the exception of Emphasize Autonomy and % Complex Reflections, were in the good to excellent range. Reliability estimates decrease when smaller samples are used and when fewer raters contribute. CONCLUSION The advantages and drawbacks of this revision are discussed including implications for research and clinical applications. The MITI 4.0 represents a reliable method for assessing the integrity of MI including both the technical and relational components of the method.

Smoking cessation interventions with female smokers living with HIV/AIDS: a randomized pilot study of motivational interviewing.

Smoking among people living with HIV, particularly women living with HIV, is associated with higher morbidity and mortality rates when compared to nonsmoking individuals with HIV. Despite patients’ higher risk of adverse health outcomes, in particular preventable smoking-related diseases for smokers living with HIV, few smoking cessation interventions have been examined with this population. The aim of the current study was to test the potential efficacy of a brief motivational intervention for smoking cessation with HIV-infected women smokers. Participants (N=30) were randomly assigned to receive a single session of motivational interviewing (MI) or prescribed advice (PA). The primary outcome was seven-day point prevalence abstinence at the one-month follow-up interview. Secondary outcome measures included mean cigarettes smoked per day, desire to quit smoking, perceived difficulty in quitting smoking, and expectation of success. We detected no significant differences between intervention and control groups in self-reported seven-day point prevalence abstinence at the one-month follow-up. However, participants in the MI condition reported a significant decrease in the mean cigarettes smoked per day when compared to the PA condition. There were no significant between-group differences in participants’ desire to quit, perceived difficulty, and expectation of success. The results of this pilot study indicate that MI may be an effective smoking cessation intervention for HIV-positive women smokers and should be studied further in a larger clinical trial.

A SBIRT curriculum for medical residents: development of a performance feedback tool to build learner confidence.

ABSTRACT A major barrier to actualizing the public health impact potential of screening, brief intervention, and referral to treatment (SBIRT) is the suboptimal development and implementation of evidence-based training curricula for healthcare providers. As part of a federal grant to develop and implement SBIRT training in medical residency programs, the authors assessed 95 internal medicine residents before they received SBIRT training to identify self-reported characteristics and behaviors that would inform curriculum development. Residents’ confidence in their SBIRT skills significantly predicted SBIRT practice. Lack of experience dealing with alcohol or drug problems and discomfort in dealing with these issues were significantly associated with low confidence. To target these barriers, the authors revised their SBIRT curriculum to increase residents’ confidence in their skills and developed an innovative SBIRT Proficiency Checklist and Feedback Protocol for skills practice observations. Qualitative feedback suggests that, despite the discomfort residents experience in being observed, a proficiency checklist and feedback protocol appear to boost learner confidence.

Does treatment fidelity predict client outcomes in 12-Step Facilitation for stimulant abuse?

OBJECTIVE This study examined the relationships between treatment fidelity and treatment outcomes in a community-based trial of a 12-Step Facilitation (TSF) intervention. METHOD In a prior multi-site randomized clinical trial, 234 participants in 10 outpatient drug treatment clinics were assigned to receive the Stimulant Abuser Groups to Engage in 12-Step (STAGE-12) intervention. A secondary analysis reviewed and coded all STAGE-12 sessions for fidelity to the protocol, using the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES). Linear mixed-effects models tested the relationship between three fidelity measures (adherence, competence, empathy) and six treatment outcomes (number of days of drug use and five Addiction Severity Index (ASI) composite scores) measured at 3 months post-baseline. RESULTS Adherence, competence and empathy were robustly associated with improved employment status at follow up. Empathy was inversely associated with drug use, as was competence in a non-significant trend (p=.06). Testing individual ASI drug composite score items suggested that greater competence was associated with fewer days of drug use and, at the same time, with an increased sense of being troubled or bothered by drug use. CONCLUSIONS Greater competence and empathy in the delivery of a TSF intervention were associated with better drug use and employment outcomes, while adherence was associated with employment outcomes only. Higher therapist competence was associated with lower self-report drug use, and also associated with greater self-report concern about drug use. The nature of TSF intervention may promote high levels of concern about drug use even when actual use is low.

Community Reinforcement and Family Training: a pilot comparison of group and self-directed delivery.

In a randomized clinical pilot study, 40 concerned significant others (CSOs) of treatment-refusing alcohol- and drug-using individuals were randomized to either Community Reinforcement and Family Training (CRAFT) conducted in a group format (Group CRAFT) or a Self-Directed CRAFT condition. Although results indicated no significant between-group difference in engaging treatment-refusing substance-using individuals (referred to as identified patients or IPs) into treatment, the engagement rate in Group CRAFT was similar to rates previously reported with individual CRAFT. For the intent-to-treat analysis, 60% of Group CRAFT CSOs engaged their loved one into treatment, as compared with 40% in Self-Directed CRAFT. Of CSOs in the Group condition who received at least one session of group therapy, 71% engaged their IP into treatment. CSOs in both conditions reported improvements in family cohesion and conflict at the 3- and 6-month follow-up, replicating prior CRAFT findings.

Assessing Fidelity of Treatment Delivery in Group and Individual 12-Step Facilitation

Twelve step facilitation (TSF) is an emerging, empirically supported treatment, the study of which will be strengthened by rigorous fidelity assessment. This report describes the development, reliability and concurrent validity of the Twelve Step Facilitation Adherence Competence Empathy Scale (TSF ACES), a comprehensive fidelity rating scale for group and individual TSF treatment developed for the National Drug Abuse Treatment Clinical Trials Network study, Stimulant Abuser Groups to Engage in 12-Step. Independent raters used TSF ACES to rate treatment delivery fidelity of 966 (97% of total) TSF group and individual sessions. TSF ACES summary measures assessed therapist treatment adherence, competence, proscribed behaviors, empathy and overall session performance. TSF ACES showed fair to good overall reliability; weighted kappa coefficients for 59 co-rated sessions ranged from .31 to 1.00, with a mean of .69. Reliability ratings for session summary measures were good to excellent (.69-.91). Internal consistency for the instrument was variable (.47-.71). Relationships of the TSF ACES summary measures with each other, as well as relationships of the summary measures with a measure of therapeutic alliance provided support for concurrent and convergent validity. Implications and future directions for the use of TSF ACES in clinical trials and community treatment implementation are discussed.

Adapting Screening, Brief Intervention, and Referral to Treatment for Alcohol and Drugs to Culturally Diverse Clinical Populations.

Objectives:To review the literature on the screening, brief intervention, and referral to treatment (SBIRT) approach to alcohol and drug use with racial and ethnic subgroups in the United States and to develop recommendations for culturally competent SBIRT practice. Methods:Articles reporting on the use of SBIRT components (screening, brief intervention, referral to treatment) for alcohol and drug use were identified through a comprehensive literature search of PubMed from 1995 to 2015. Results:A synthesis of the published literature on racial and ethnic considerations regarding SBIRT components (including motivational interviewing techniques) was created using evidence-based findings. Recommendations on culturally competent use of SBIRT with specific ethnic groups are also described. Conclusions:On the basis of the literature reviewed, SBIRT offers a useful set of tools to help reduce risky or problematic substance use. Special attention to validated screeners, appropriate use of language/literacy, trust building, and incorporation of patient and community health care preferences may enhance SBIRT acceptability and effectiveness. Practice Implications:Providers should consider the implications of previous research when adapting SBIRT for diverse populations, and use validated screening and brief intervention methods. The accompanying case illustration provides additional information relevant to clinical practice.

Confidentiality protections versus collaborative care in the treatment of substance use disorders

Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients’ primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems.