Seminal and key studies on the impact of the practitioner in brief interventions.
S Seminal studies K Key studies R Reviews G Guidance more Search for more studies
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S Confrontation provokes resistance (1993). Validated motivational interviewing’s empathic, client-centred style rather than the more confrontational approach typical of the era. When therapists fed back the results of an alcohol-harm check-up in a motivational style, heavy drinkers who had responded to ads exhibited less resistance to change and later made greater reductions in their drinking.
K Is it best to stick to the script? (2012; free source at time of writing). US researchers developed a scale to measure fidelity to a commonly researched form of brief intervention and it worked well at assessing practitioners’ competence in an emergency department study … but scores on the scale were not found to be related to how much patients drank at follow-up, showing that ‘competence’ of this kind does not always make a brief intervention more effective.
K Emergency patients respond to motivational style (2009). Rather than topping the numerical league in emitting recommended comments, motivational interviewing’s impact on heavy drinkers at emergency departments in Switzerland depended on the practitioner’s ability to embody the client-centred spirit of the approach and to avoid remarks inconsistent with this ethos.
K Reflective listening key to provoking intention to change (2010). Micro-analysis of interactions between heavy-drinking Swiss army conscripts and counsellors found reflective listening – when the counsellor signified their listening and understanding by selectively echoing back the young men’s feelings and comments – the key way to provoke responses indicative of intention to reduce drinking. Counsellor comments inconsistent with motivational interviewing provoked the opposite kinds of responses. Similar findings below seem to confirm impacts on actual drinking.
K Reflective listening related to later drinking (2014). Study of Swiss army conscripts (also the subjects of study listed above) exposed the influence of the counsellor’s proficiency in motivational interviewing on subsequent drinking, especially the degree to which they reflected back the client’s remarks while offering an additional or deeper meaning. Just a few comments inconsistent with the approach were associated with worse outcomes, as was piling on lots of remarks of the kind recommended in motivational interviewing.
K Drinking unaffected by counsellor’s motivational skills and qualities (2014). When rated by an observer, across three trials (1 2 3) of brief interventions based on motivational interviewing, the “surprise” was how little the counsellor’s proficiency in this counselling style, qualities such as acceptance and empathy, or the strength of their relationship with the client, affected subsequent drinking. Evidence was strongest for doing in motivational terms the ‘wrong’ thing: confrontation was consistently related to more drinking. Two of the trials involved Swiss army conscripts also involved in studies above (1 2).
R Doctors or nurses? (2011). Brief interventions still work if conducted by nurses or other primary care staff instead of doctors, and perhaps more patients can be reached more cheaply.
R Barriers and facilitators to implementing screening and brief intervention (2011). UK-focused review for Britain’s National Institute for Health and Care Excellence concentrating on the views of professionals and patients and the implementation process; includes the influence of staff characteristics and attitudes on whether they implement screening and brief intervention.
R Implementation strategies in primary care (2011). International literature analysed, including the influence of staff characteristics.
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What is this cell about? Screening and brief interventions are usually seen as public health measures, aiming to reduce alcohol-related harm across a population of drinkers rather than focusing on dependent individuals or just those seeking help. Screening programmes aim to spot drinkers at risk of or already experiencing alcohol-related harm while for some other purpose they come in contact with services whose primary remit is not substance use. Many are not at the stage where treatment is appropriate, so the typical response to those who seem at risk is brief advice, counselling and/or information aiming to moderate their drinking and/or its consequences – the ‘brief intervention’.
This cell is however not about the content of the intervention (for which see cell A1), but about whether its impact depends on the interpersonal style and other features of the person doing the counselling – a much less commonly researched topic. In fully-fledged psychotherapy it is well established (see cell B4) that the approach of the person doing the therapy and their ability to forge therapeutic relationships are important influences on outcomes – but is the same true in what are often the fleeting, one-off encounters of brief interventions? A briefing based on a conference held in England in 2015 needed no convincing: “ultimately quality [alcohol identification and brief advice] comes down to the beliefs, motivations and skills of the practitioner”.
Where should I start? No better place than our analysis of a seminal study led by William Miller, originator of motivational interviewing, an approach first tested as a brief intervention and still the dominant inspiration behind these when they extend beyond simple advice. Importantly, this is an interactional style, not a programme, one some people are more adept at learning and implementing than others (for which see cell B4). Rather than confronting directly, it nudges the drinker to themselves find reasons to cut back – an approach likely to be more acceptable to people not seeking help.
The results of Miller’s study turned the spotlight on how therapists actually behave, not how they are meant to. Compared to a confrontational style typical of the day, patients allocated to what was meant to be a motivational style did better, but only marginally. But in practice the differences in the approaches taken (the same therapists delivered both) were slight. When subsequent drinking was related to how therapists actually behaved, the results were clear-cut: the more they had confronted, the more the client drank a year later.
Read our analysis and you will see that while the link between confrontation and drinking was clear, the study could not determine what caused what; perhaps patients who drank more forced exasperated therapists to be more confrontational. But within the context of other research, it seems probable that a real effect had emerged – a harbinger of later findings ( below) on the negative impacts of even infrequent confrontation or other counsellor behaviours which fail to concede to the client the right to decide whether, what and how they want to change.
Despite its limitations, this study highlighted the importance of how the counsellor related to the client. What would now be considered one of those limitations may have been critical to the emergence of this finding. Unlike many later studies, the counsellors had no detailed, manualised script to follow and (as they would in normal practice) their approaches varied considerably. Modern researchers want to know exactly what they are studying, so commonly tightly control the intervention, minimising what would normally be an important influence – the characteristics of the counsellor. Published over 20 years later and conducted in a different continent, setting and with a different caseload, a Swiss study (highlighted below) which shared this methodological ‘weakness’ seemed to confirm these early findings.
Highlighted study Capitalising on the fact that at age 20 Swiss men are assessed for their fitness to be conscripted in to the army, a series of studies has uniquely dissected how alcohol brief interventions work with a representative set of young European men whose screening results indicated risky drinking. One of the studies set out to reveal the impact of the counsellors rather than the intervention by deliberately recruiting 18 counsellors who differed widely in professional status, clinical experience, and experience of the motivational interviewing approach used in the brief intervention. Further duplicating normal practice, after initial training counsellors conducted the 20 to 30 minute session without manuals, further guidance or supervision. Left to their own widely differing devices, they also delivered interventions which while overall of good quality (and modestly effective in reducing drinking) varied widely around this level, as assessed by ratings of audio-recorded sessions.
On several quality indicators, three months later only conscripts who had seen counsellors or been in sessions in the top half of the range drank less relative to a control group offered screening and assessment only. Best results came from the more experienced counsellors, those who were more confident of their motivational interviewing abilities and in the efficacy of the approach, and/or who were rated as especially proficient. On average, it could not be shown that counsellors and sessions outside these upper ranges were any better at reducing drinking risky than no counselling at all.
That much is perhaps not unexpected, but it was the details in this study which were thought-provoking. Experience was important, but only because it was associated with better motivational interviewing skills, an amalgam of demonstrating acceptance of and empathy with the client and embodying the collaborative spirit of the approach. So-called ‘complex reflections’ – the times when the counsellor reflected back the client’s feelings or comments, but with a spin which extended or deepened their meaning – seemed particularly important. When these formed a relatively small portion of all the reflections whether simple or complex, the brief intervention made no difference to drinking; when a larger portion, drinking was reduced.
Complex reflections are an advanced competence, involving an ability to delve underneath a comment or behaviour to a deeper meaning, one which perhaps the client themselves might see as a persuasive reason to moderate drinking. In surprising contrast, simply accreting more of the other responses considered compatible with motivational interviewing actually seemed counterproductive. These sorts of comments were common, occurring on average once or twice per minute of the sessions. When sessions were evenly divided into those in which they were more or less common, only the bottom half were significantly associated with reduced drinking. Sessions in the top half were followed by reductions no greater than no intervention at all. It seemed that frequent interjections by the counsellor which conveyed support, affirmation, reflected back the client’s comments, and so on, were fine, but when these became very, very frequent, something was happening to make the session ineffective.
The other side of the equation was counsellor comments incompatible with motivational interviewing. These were very uncommon – usually one or none per session – but when they happened, that session was no more effective at moderating drinking than no counselling at all.
What was happening in these and similar studies and what are the practice implications? Below you are invited reflect on these, in some respects, unexpected findings.
Are you surprised that in such brief encounters the practitioner matters? Or would you expect sensitivity to be critical when someone unexpectedly starts talking about your drinking while you are seeking help for something else? Turn to our analysis of the Swiss emergency department study listed above. There we point out that the dynamics of interacting with someone intercepted through screening are likely to be very different from those with patients at substance use treatment clinics, who have usually already acknowledged their problems and resolved to do something about them. Brief interventions have to generate this resolve in people who were not even thinking about their drinking and do not see it as something they needed to change. Doing that well may be a trickier skill.
In particular, in brief interventions based on motivational interviewing it seems critical (see below) to avoid confrontation, direction and those other behaviours which treat the patient as less than equal. In contrast, in a treatment context, to be told by an expert what is wrong with them and how they can get better may be just what a patient is looking for when they initiate contact with a doctor or therapist. In this context, the kind of behaviours proscribed in motivational interviewing are not necessarily destructive, but may signal a concern implicitly invited by the patient. In brief intervention studies, in respect of drinking there is no implicit permission for the counsellor to play ‘doctor’ and the risky drinker has not implicitly adopted the patient role.
Check for yourself: is the evidence for the impact of the practitioner as strong for fully-fledged treatment (compare this cell with cell B4) as it is for brief interventions?
Are some practitioners naturally effective? Look at our analysis of the Swiss emergency department study listed above. Qualifications, experience and training were equalised, yet still counsellors varied widely in effectiveness. A counsellor who often emitted responses and comments of the type recommended in motivational interviewing ended with the worst drinking outcomes – an average 18 UK units more per drinking week – while another who emitted these less often averaged a nine unit reduction. Their advantage seemed to come from better embodying the accepting, non-judgemental spirit of the approach and more completely avoiding comments which belied this ethos. Check the background notes to that analysis and you will see that variability in the outcomes achieved by brief interventionists is not uncommon. What makes the difference is it seems not necessarily the approach itself, nor the therapist’s strengths and weaknesses, but the combination of approach and therapist; some who do well with a more directive approach do badly when they attempt the client-centred style of motivational interviewing.
The highlighted study teaches us that in itself experience may not be important – it is the skills and confidence which can (but not always) come with it. Experience was associated with better motivational interviewing skills, but just as effective were inexperienced counsellors who were either ‘naturally’ skilled or far enough along this road to have rapidly absorbed the approach. From this study and from another with a different set of professions, we can gather that the impacts of brief interventions do not depend on whether the interventionist is a doctor, nurse or psychologist, nor on the level they have reached in their profession; personal qualities matter more. Look too at cell C2’s bite. It cites studies which suggest that recruiting the ‘right’ clinicians who have not been trained in motivational interviewing would be better than choosing the ‘wrong’ ones who have been.
Is it what you don’t do that matters? Here we address a possibly dispiriting finding: that doing lots of the ‘right’ things in a brief motivational intervention matters little, while just one lapse to the ‘wrong’ sort of comment can be destructive.
Run your eye down the list of seminal and key studies above and you will see that each one testifies to the negative power of doing (in client-centred counselling terms) the ‘wrong‘ thing. We saw it right from the start in the seminal study’s findings on confrontation, times when the counsellor imposes their perspective or will on the client: “These are the expert-like responses that have a particular negative-parent quality, an uneven power relationship accompanied by disapproval, disagreement, or negativity. There is a sense of ‘expert override’ of what the client says.”
Confrontation is one of those counsellor behaviours considered incompatible with the client-centred core of motivational interviewing. What they share is the non-collaborative stance of someone who knows best and is therefore in a position to confront, warn, direct, or advise the drinker. In the studies listed above, these behaviours were consistently related to weaker intention to change drinking and lesser reductions in drinking itself.
Of most relevance to real-world practice is the latest of the studies of Swiss army conscripts, highlighted above. The authors warned that “even one behavior inconsistent with [motivational interviewing], such as unsolicited advising or confrontation, can be particularly damaging”, while “the quality and the exact combination of skills matters more than the quantity ... using a high number of open questions and simple reflections without eventually showing support or in-depth understanding might not be sufficient”.
Look at the other studies. Findings were very similar in the Swiss study of emergency patients. Move down the list to another of Swiss army conscripts, and we get a glimpse into the mechanism behind drinking outcomes. Complex reflections top the list of counsellor behaviours which generate ‘change talk’ indicative of intention to reduce drinking, while “surprisingly”, interjecting more of the other motivational-type comments such as open questions, simple reflections, and affirming and supporting, were like the proverbial water off a duck’s back, not moving the conversation in any particular direction. It will by now come as no surprise that non-motivational comments like confrontation and directing or advising the client counterproductively prompted comments indicative of intention not to change one’s drinking. Finally, an omnibus analysis of two Swiss army conscript trials and a US trial confirmed the negative impact of these kinds of comments.
What do you make of these findings? Can they be dismissed as not cause and effect or even a reverse causality, the more ‘difficult’ clients who were always going to carry on drinking eliciting non-motivational responses from exasperated counsellors? What was going on in sessions when counsellors made very, very frequent, but not very deeply probing, motivational-type responses? Why did these fail to generate change and sometimes seem to obstruct it? Were the counsellors energetically doing what their training had mandated, without really paying attention to and trying to understand the individual before them? Attempts at understanding are signified above all by complex reflections, which most consistently among motivational interviewing’s repertoire were associated with positive outcomes.
Here we seem to have a picture forming of any number of perhaps superficially positive or affirming remarks (the equivalent of ‘Have a nice day’ wishes) failing to connect with clients, while just a few which showed the counsellor really is trying to understand make a positive impact. On the other side of the balance, just a few which demonstrated the counsellor was not on and by the client’s side, but pursuing their own agenda from a superior position, scuppered the session. Why was sometimes just one remark confronting or directing the client, or issuing uncalled-for warning or advice, associated with nil or counterproductive impacts on drinking? Does that make sense to you from your work or personal life?
In a laboratory task, 90 participants carried out a series of math tasks designed to be stressful, while their physiologic responses were measured. During the tasks, participants were randomly assigned to receive validating, invalidating, or no feedback from the experimenter. For example, if the participant said that he/she found the task stressful, the experimenter might say, “I don’t understand why you found it stressful – it’s just adding and subtracting numbers” (an invalidating response), or “That’s understandable – lots of people have said they found this task stressful” (a validating response). Compared to no such feedback, invalidation had a detrimental effect on psychological and psychological functioning and made participants less willing to take part in the study again. In contrast, validating responses made little difference.
Bear in mind that this would be no peculiarity of brief interventions but probably (research is lacking) a feature of medical practice in general. In 2015 a duo of UK-based authors writing in the American Journal of Medicine advanced the argument that in interactions between patients and clinicians, “bad is more powerful than good”. Specifically, their thesis was that communications which ‘invalidate’ the patient by failing to accept or understand their perspective damage the patient–clinician relationship and lead to feelings of hopelessness, anger and being dismissed and disbelieved (these had actually been recorded in real consultations at a pain management clinic), which in turn can be detrimental to the patient’s treatment and to their health. One of the authors had conducted a more definitive study (but not in a medical context) which seemed to prove the impact of invalidation and the relative non-impact of validation panel.
Even an apparently empathic response can be invalidating if it fails to chime with the patient’s perspective, as might be expected from seminal therapist Carl Rogers’ stress on accurate empathy. However, accuracy can’t be guaranteed and authoritative advice is at least not to impose what may be a damaging understanding. Instead, “Empathy should always be offered with humility and held lightly, ready to be corrected.” As the UK duo pointed out, though particularly sharp for people in distress, concerned over their health, and with a right to expect validation, such responses are not limited to medical practice: “It is part of being human to want to feel understood by others, and our general life experience tells us that harsh words and criticism can hurt and have lasting negative effects.”
Non-motivational interventions – elephant in the room? Nearly everything known about how brief interventions work relates to those based on motivational interviewing. Briefer interventions of the kind typically studied in primary care usually comprise feedback on how the patient’s drinking compares to the norm, encouragement to set a date for cutting down, and perhaps a few simple hints on how cutting down might best be achieved, often informed by the FRAMES principles. In respect of these kinds of interventions, little or nothing is known of how they work, and whether the interventionist and how they behave makes a difference.
“Thank you for taking part in this project. Your screening test result shows that you’re drinking alcohol above safe levels, which may be harmful to you. This leaflet describes the recommended levels for sensible drinking and the consequences for excessive drinking. Take time to read the leaflet. There are contact details on the back should you need further help or advice.”
Yet in the English SIPS study detailed in cell A1’s bite, relatively unsophisticated and brief advice ( panel right) was no less effective than longer interventions which drew on motivational interviewing. Perhaps variation in outcomes due to the interventionist applies only to interventions which are harder to acquire and practice. Or perhaps the interventionist is just as important when the intervention is simple advice, but in different ways.
One thing we do know – that the staff concerned are a strong influence (see review listed above and these notes) on whether screening and brief interventions get done at all. Though partly determined by the organisational and policy context within which they work, their views on the legitimacy of this activity and its effectiveness and acceptability to patients, and the priority they give to it, all seem to matter. Perhaps these factors also influence their tone of voice, impressions given of the importance of the advice and the issue, their authenticity, and their persistence in the face of an unenthusiastic reception from the patient.
In what has been identified as the very first study of a brief intervention, emotion betrayed months later by emergency department doctors in response to the question, “What has been your experience with alcoholics?”, predicted how many of their patients had followed through on a referral to the hospital’s alcohol clinic. It seemed that the more a doctor showed personal (rather than ‘coldly professional’) concern for the patient, and evidenced this in tone as well as words, the more likely the patient was to treat this as the start of a therapeutic relationship they wished to continue. However, this was not a typical brief intervention in today’s terms, involving patients typified as ‘skid row’ alcoholics who needed no screening tests to identify them, and who were referred to a clinic for treatment rather than given immediate advice.