Richard Longabaugh

Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence.

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 search identified a total of 152 studies for review; 19 studies met inclusion criteria by providing data on at least one link 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 clients experience of discrepancy. The absence of experimental and full mediation studies of mechanisms of change was notable. Effect sizes were generally mixed. CONCLUSIONS The most consistent evidence was 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.

The Therapeutic Alliance and Its Relationship to Alcoholism Treatment Participation and Outcome

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

General and alcohol-specific social support following treatment

Both general and alcohol-specific support have been shown, albeit inconsistently, to affect drinking behavior. The discrepant findings may be clarified by examining how they work together. In exploratory analysis of clients following private outpatient alcoholism treatment, we found that the two variables add uniquely to the explanation of the variance in proportion of days abstinent (PDA). Both contribute significantly in the short term (3 months posttreatment), but only alcohol-specific support helps to explain variance over the longer term (15 months posttreatment), and alcohol-specific support explains more of the variance in PDA than general support at both time periods. More complex relationships are operating when short-term treatment effects have diminished. Alcohol-specific support mediates the relationship between general support and PDA, and both general social support and alcohol-specific support are moderators of one another in their relationships to PDA. Knowing how different types of social support affect drinking behavior at different intervals following treatment may help treatment providers to better prepare their clients for the posttreatment social environment.

Matching Treatment Focus to Patient Social Investment and Support: 18-Month Follow-up Results.

Patients were randomly assigned to 1 of 3 treatments: brief broad-spectrum (BBS), extended relationship enhancement (ERE), or extended cognitive-behavioral (ECB). A hierarchical latent growth model was used to analyze the data of 188 patients (82%) followed for 18 months. ERE treatment was significantly more effective in increasing abstinence of patients entering treatment with a network unsupportive of abstinence or with a low level of investment in their network, whereas BBS treatment was more effective for patients with either (a) both a social network unsupportive of abstinence and a low level of network investment or (b) high investment in a network supportive of abstinence. ECB outcomes were neither as good as those matched nor as bad as those mismatched to the different exposures of relationship enhancement. This suggests that dose of relationship enhancement should be determined after assessing patient relationships.

Active ingredients: how and why evidence-based alcohol behavioral treatment interventions work.

This article summarizes the proceedings of a symposium that was organized and chaired by Richard Longabaugh and presented at the 2004 Research Society on Alcoholism meeting in Vancouver, British Columbia, Canada. The aim of the presentation was to focus on evidence for the active ingredients of behavioral therapies for patients with alcohol use disorders. Dennis M. Donovan, PhD, reviewed evidence for the active ingredients of cognitive behavioral therapy. Barbara S. McCrady, PhD, presented a conceptual model for mechanisms of change in alcohol behavior couples therapy and reviewed evidence for this model. J. Scott Tonigan, PhD, presented data testing three hypothesized mechanisms of change in twelve-step facilitation treatment. Mitchell P. Karno, PhD, presented therapy process data that tested whether matching therapist behaviors to client attribute across three therapies affected drinking outcomes. Jon Morgenstern served as discussant.

The technical hypothesis of motivational interviewing: a meta-analysis of MI's key causal model.

OBJECTIVE The technical hypothesis of motivational interviewing (MI) posits that therapist-implemented MI skills are related to client speech regarding behavior change and that client speech predicts client outcome. The current meta-analysis is the first aggregate test of this proposed causal model. METHOD A systematic literature review, using stringent inclusion criteria, identified 16 reports describing 12 primary studies. We used review methods to calculate the inverse-variance-weighted pooled correlation coefficient for the therapist-to-client and the client-to-outcome paths across multiple targeted behaviors (i.e., alcohol or illicit drug use, other addictive behaviors). RESULTS Therapist MI-consistent skills were correlated with more client language in favor of behavior change (i.e., change talk; r = .26, p < .0001), but not less client language against behavior change (i.e., sustain talk; r = .10, p = .09). MI-inconsistent skills were associated with less change talk (r = -.17, p = .001) as well as more sustain talk (r = .07, p = .009). Among these studies, client change talk was not associated with follow-up outcome (r = .06, p = .41), but sustain talk was associated with worse outcome (r = -.24, p = .001). In addition, studies examining composite client language (e.g., an average of negative and positive statements) showed an overall positive relationship with client behavior change (r = .12, p = .006; k = 6). CONCLUSIONS This meta-analysis provides an initial test and partial support for a key causal model of MI efficacy. Recommendations for MI practitioners, clinical supervisors, and process researchers are provided.

DIAL: A Telephone Brief Intervention for High-Risk Alcohol Use With Injured Emergency Department Patients

STUDY OBJECTIVE Brief interventions for high-risk alcohol use for injured emergency department (ED) patients have demonstrated effectiveness and may have a more pronounced effect with motor vehicle crash patients. We report on 3-month outcome data of a randomized controlled trial of injured patients, using a novel model of telephone-delivered brief interventions after ED discharge. METHODS ED research assistants recruited adult injured patients who screened positive for high-risk alcohol use and were to be discharged home. After discharge, participants received by telephone an assessment of alcohol use and impaired driving and then were randomized to treatment (n=140) or standard care (n=145). Treatment consisted of 2 sessions of brief interventions done by telephone, focusing on risky alcohol use. At 3 months, both groups had an assessment of alcohol use and impaired driving. RESULTS Two hundred eighty-five patients were randomized and had a baseline mean Alcohol Use Disorders Inventory Test (AUDIT) score of 11.0 (SD=7.4). Three-month follow-up assessments were completed on 273 (95%). Mean AUDIT score decreased in both the treatment (mean change=-3.4; 95% confidence interval [CI] -4.5 to -2.3) and standard care group (mean change=-3.2; 95% CI -4.2 to -2.2). Measures of impaired driving decreased for the treatment group (mean change=-1.4 95%; CI -3.0 to 0.2) compared with standard care group (mean change=1.0; 95% CI -0.9 to 2.9; P=.04; d=0.31). Participants were stratified post hoc into 3 groups by baseline alcohol problem, with the treatment effect only being in the highest-scoring group (d=.30). CONCLUSION Telephone brief interventions decreased impaired driving in our treatment group. Telephone brief intervention appears to offer an alternative mechanism to deliver brief intervention for alcohol in this at-risk ED population.

Determinants of neuropsychological impairment in antisocial substance abusers.

Persons displaying Antisocial Personality Disorder (ASP) may be at risk for neuropsychological impairment due to a number of developmental and later life experiences to which they are prone. Thirty substance abusers meeting research criteria for ASP were compared to a demographically matched non-ASP cohort on neuropsychological test performance. The ASP subjects were found to have a higher prevalence of neuropsychological deficit. The groups were then compared on factors which might lead to brain impairment. Presence of ASP was associated with earlier and heavier past drinking patterns, more negative health and behavioral effects of alcohol abuse, and greater abuse of other drugs in addition to alcohol. The ASP alcoholics also reported a high prevalence of serious head injury (58%), although they did not differ from non-ASP alcoholics in this regard. Implications for the neuropsychology of alcoholism and for treatment are discussed.

Smoking and treatment outcome for alcoholics: Effects on coping skills, urge to drink, and drinking rates

The interrelationship between alcohol and tobacco addiction is beginning to receive more attention because it has conceptual and practical significance for understanding and treating addictive disorders. This investigation focuses on the effects of smoking on risk for relapse after alcoholism treatment. The relationships between smoking and: (1) alcohol consumption rate and dependence at pretreatment, (2) reactions to coping with alcohol high-risk-for-relapse role plays, and (3) alcohol treatment outcome were investigated. These relationships were studied first in a sample of male VA alcoholics (n=45) and then replicated and extended in a different sample from a private hospital (n=53 females, 110 males). Smoking and drinking rate, and smoking and alcohol dependence, were significantly correlated at pretreatment. Smokers with greater dependence on cigarettes (i.e., higher Fagerstrom Tolerance Questionnaire scores; shorter latency to smoking first cigarette of the day) experienced significantly greater urge to drink, urge to smoke, difficulty, and anxiety in role plays of alcohol high-risk situations, independent of their pretreatment drinking rate or alcohol dependence. Smoking dependence did not predict mean number of drinks per day or frequency of drinking days during 6-month follow-up. In the private hospital sample, among alcoholics who drank at all during follow-up, the more dependent smokers drank more alcohol on drinking days than did the less dependent smokers. Implications for theory and treatment of addictive disorders are discussed.

The Psychosocial Functioning Inventory

The derivation and psychometric analyses of a general purpose outcome/survey instrument—the Psychosocial Functioning Inventory (PFI—are described. The instrument contains scales designed to measure a wide array of constructs, including subjective well-being, social functioning, stressful events, treatment dependency/aftercare, and consumer satisfaction. Extensive reliability and validity analyses are reported, indicating reasonable reliability and validity for the PFI scales.