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Gaume J., Bertholet N., Faouzi M. et al.
Journal of Substance Abuse Treatment: 2010, 39, p. 272–281.
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In the study of Swiss army conscripts, reflective listening emerged as possibly the key active ingredient in a brief alcohol intervention based on motivational interviewing.
Summary This study capitalised on the fact that all Swiss men aged 19 are conscripted in to the army via an assessment of their fitness to serve. Two trials of a brief intervention conducted along motivational interviewing lines were conducted at an army intake centre serving the French-speaking part of Switzerland. Researchers and the psychologists who delivered the interventions stressed their independence from the army and the confidentiality of the sessions. The featured analysis did not assess the effectiveness of the interventions overall. Instead it focused on the 264 heavy drinkers At-risk alcohol use was defined as more than 210gm of alcohol – about 26 UK units – a week or the consumption at least twice a month of 60gm or more in a single drinking episode. in the trials who were allocated to the brief interventions, micro-analysing their interactions with counsellors to discover what sorts of interactions promote 'change talk' – explicit indications by the client that they are inclined to some degree to curb their drinking or control resultant risks and harms. Generating such statements is thought to be the main final common pathway via which motivational interviewing promotes actual change.
149 of the 264 conscripts yielded successfully taped sessions. Typically aged 19–20, on average they drank 158gm alcohol or about 20 UK units a week, and nearly 9 in 10 exceeded the score (8) on the AUDIT screening questionnaire considered indicative of hazardous and harmful drinking.
In a 20–30 minute session, counsellors explored drinking and related hazardous behaviours and the conscript's own drinking. The aim was to generate a perspective from which the young men would consider curbing their drinking and/or associated risks or harms, and to do so in the nonjudgmental, empathic, and collaborative manner characteristic of motivational interviewing. These interactions were categorised Communications on both sides were coded using the MI Skill Code (MISC), version 2.1. MISC codes are composed of 19 counsellor and eight interviewee codes. The counsellor behaviours are advise with permission, advise without permission, affirm, confront, direct, emphasize control, facilitate, filler (ie, salutations, pleasantries, and so on), giving information, closed question, open question, raise concern with permission, raise concern without permission, simple reflections, complex reflections, reframe, structure, support, and warn. Interviewee change talk behaviours are ability or inability to change, commitment to change or not to change, desire to change or not to change, need to change or lack of need for change (or a need not to change), reasons to change or reasons not to change, and taking steps toward or away from change. An 'other' category allowed coders to capture language that clearly reflects interviewee movement toward or away from change but does not necessarily fit easily into any change talk category (eg, problem recognition or minimisation, and hypothetical language). Finally, the so-called follow/neutral category allowed coders to characterise interviewee utterances with no inclination or link with the target behaviour change and interviewee questions. by raters who listened to session tapes. The counsellor's comments were classified as being consistent Advising but only after getting permission from the client to do so, affirming, emphasising the client's control over their goals and behaviour, asking open questions, reflecting back to the client their own comments, reframing the client's comments, or being supportive. with motivational interviewing, inconsistent, Advising without permission, confronting or directing the client, raising concern without permission, or delivering warnings. or other comments Being facilitative, filling a gap in the conversation, giving information, asking a closed question, raising concern with the client's permission, and structuring the session. neither clearly consistent nor inconsistent. The conscript's comments were classified as indicative of an inclination, readiness or intention either to curb ('change talk') or not to curb ('counter-change talk') their drinking or to control resultant risks and harms, or as comments not relevant to either tendency. Key issues were what type of counsellor comments promoted a response in the form of change talk (or its opposite), and how the young men's comments were responded to by the counsellor.
Counsellor comments consistent with the spirit of motivational interviewing were likely to be followed by positive change talk from the conscript; this kind of sequence occurred far more often than would have been expected by chance. But to a lesser degree, the same was true of counter-change talk. There was a clearer picture in respect of counsellor comments inconsistent with motivational interviewing. Compared to what would have been expected by chance, such comments were very unlikely to be responded to with positive change talk and very likely instead to be followed by the opposite – counter-change talk. More neutral counsellor comments tended not generate either change or counter-change talk. So the only types of counsellor comments associated with change talk were those consistent with the spirit of motivational interviewing.
A more fine-grained analysis found that the only subdivisions of motivationally consistent counsellor comments which were associated with a change talk response were 'reflections' – the times when the counsellor signified their listening and their understanding by selectively echoing back to the conscript (with or without elaboration) some of what they had said. To a lesser degree these counsellor responses were also likely to be followed by counter-change talk. Other types of motivationally consistent counsellor comments were not associated with an increased (in fact, often with a decreased) chance of either change talk or counter-change talk.
The conscript interviewees were also active in the exchanges and influenced the counsellors' responses. When they expressed an inclination to curb their drinking or its risks and harms (change talk), or the opposite inclination (counter-change talk), counsellors overwhelmingly responded with comments consistent with the spirit of motivational interviewing. There were patterns too within sequential remarks by the conscripts, which were extremely likely to fall in the same category (eg, change talk tended to follow change talk).
Findings in this study (and similar findings in other studies of motivational interventions) that counsellor comments consistent with motivational interviewing were especially often followed by change talk, and that inconsistent comments were often followed by counter-change talk, are both in line with the way motivational interviewing is thought to work. Since an initial change talk utterance is overwhelmingly followed by another, the counsellor's motivationally consistent comments may be prompting a self-reinforcing process of change. In finer detail, the most powerful active ingredient appears to be the counsellor's reflections back of what the client has said or seems to be feeling. Since change talk has itself been found associated with actual change, the implication is that these counsellor responses help promote the changes client and counsellor are seeking – in the featured study, to curb excessive drinking or control resultant risks and harms.
In this study, counter-change talk by clients signifying an inclination not to curb their drinking or resultant risks and harms seemed to provoke remarks inconsistent with motivational interviewing by the counsellors, which themselves could provoke further counter-change talk in a negative feedback loop. An important implication is that counsellors should be trained to avoid motivationally inconsistent reactions when confronted with non-desired client behaviour.
commentary This study of young men not actively seeking treatment and generally devoid of severe drink problems presents a coherent and plausible picture of statements by the counsellor intended to generate motivation and intention to change actually doing so, presumably leading to the desired change. Reflective listening seemed the key active ingredient. Motivational interviewing's originators say this core but challenging skill should form a substantial proportion of counsellor comments in the early stages of the intervention. Within the study, the findings were replicated in each of the two randomised trials combined in the main analysis, showing they were not a 'one-off' restricted to a single site, caseload or set of counsellors.
However, this finding is has only limited corroboration from other studies. These include one from the same lead author on brief interventions in an emergency department, and another on the treatment of alcohol dependence derived from the US Project MATCH study. Importantly, the MATCH study also found that change talk was related (if weakly) to actual changes in drinking, completing the chain from counsellor comments to the desired changes.
But even this does not establish a causal chain. While it is plausible that counsellor reflections actually stimulate change talk, which in turn leads the client to drink less, it could be that these links are simply signs of an underlying change process which would have happened anyway. We know for example that in the featured study change talk by the client was very likely to be followed by further change talk (change talk 1 > change talk 2). It could be that the counsellor's reflective comments stimulated by change talk 1 had no impact on whether change talk 2 would or would not follow, but simply neutrally intervened between a pair of comments which would have happened anyway. Just looking at the last pair (counsellor comment followed by change talk 2) of the trio would give the false impression that it was the counsellor who stimulated change talk rather than the client simply continuing in the same vein. Nor was there within this study (though there have been in others) any direct investigation of whether change talk really was associated with corresponding changes in drinking.
Nevertheless these and some other findings are consistent with the proposition that the principles and techniques of motivational interviewing stimulate change via the generation of self-motivational statements and the voicing by the client themselves of an intention (or the precursors of an intention) to change. The theoretical grounding and plausibility of this proposition, and the experiences of many counsellors and clients, mean that this possibility has to be taken seriously, even if the research is not as yet conclusive. In particular, there is backing for the proposition that both in brief interventions for risky drinking and in the treatment of alcohol dependence, skilful reflective listening is a key element stimulating change, though one which perhaps has to rely on less directly potent ingredients, such as the ability to forge a trusting relationship within which the client will be prepared to give the counsellor opportunities to reflect back change talk statements. Based on research in the very different setting of an alcohol treatment clinic and with much heavier drinkers than in the featured study, another report has argued that "therapists who wish to see more change talk should selectively reflect the change talk they hear and provide fewer reflections for counterchange talk. What therapists reflect, they will hear more of ... the relatively sophisticated MI skill of differential reinforcement of client speech may be more important in evoking high levels of change talk than previously supposed.".
Thanks for their comments on this entry in draft to Jacques Gaume of the Alcohol Treatment Centre at the Lausanne University Hospital in Switzerland. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 02 October 2010. First uploaded
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