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Counselor skill influences outcomes of brief motivational interventions

Important implications

This study is one of the few in substance misuse to deeply address a key issue across 'talking therapies' – how therapists relate to clients in ways which promote positive change. It seems the first to depth-analyse interaction during a brief intervention which (from the patient's point of view) unexpectedly addresses their drinking while they are seeking help for something else entirely. The implication is that in this situation, the impact of motivational interviewing with heavy drinkers depends on the ability of the counsellor to embody the spirit of the approach, not in minute or tick-box detail, but in broad-brush and consistent application. Given this spirit, as intended, patients in general respond not by defensively deflecting this uncalled-for advance, but by re-evaluating their drinking in ways which lead to a lasting reduction.

In this non-treatment sample not heavily dependent, claims of 'inability' to change are probably a more socially acceptable proxy for unwillingness to change. If this is the case, then the findings show that true-to-type motivational interviewing (again, as intended by its creators) can counter low motivation and doubts, raising outcomes to near the level of the most promising patients. Another implication is that while training plays its part in developing this ability, still it leaves big differences between counsellors, who presumably vary in the degree to which they can implement what they have learned. The more 'trainable' dimensions of the frequency of recommended types of comments was relatively unimportant to outcomes, the more nebulous 'spirit' dimensions more important. Despite expert training and supervision, the result is some therapists whose patients drink more than they did before, others whose patients drink less, a finding which turns the spotlight on staff recruitment. Get this right, then with training and supervision brief interventions might fulfil their promise to tackle heavy drinking across the population; get it wrong, and much of this effort will be wasted.

To place the findings in context, though across the entire sample the intervention had been ineffective, had it been conducted solely by the therapist with the consistently best outcomes, it would probably have proved The 'best' therapist averaged a nine UK units per week reduction in drinking among their patients; without intervention (but with assessment) the average reduction across all patients was three units. a resounding success. Most of the other counsellors did well only with 'fertile-ground' motivated/confident patients. Since confidence was low across the caseload, so too was the average change these counsellors were able to produce, accounting for the overall lack of impact.

How easy it is to find such people must be a concern. All the counsellors were clinical psychologists educated to master degree level, trained by an experienced therapist and supervised throughout using actual client session recordings or observations. This exceptional combination of qualifications, training and ongoing support still resulted in just one of the therapists having a marked positive effect on drinking.

Limitations of the study

While these are important findings with echoes in other studies, inevitably they stand on a narrow and inadequate evidence base. Studies which probe deeply enough to make sense of what is going on in therapy require labour-intensive analyses, so tend to be limited to perhaps one site and a few therapists. The upside is that we can dig down to the level of each individual therapist, the downside that the results may be limited in their applicability to those few individuals seeing the patients seen in that setting. These analyses also tend to be by-products of studies designed to address the effectiveness not of therapists, but of therapies, so lack an appropriate methodology.

Particular caution is needed before assuming that the implications extend to substance misuse treatment. The dynamics in the emergency department are likely to be very different from those in substance misuse treatment clinics, whose patients have already acknowledged their problems and decided at least to give treatment a try. In this situation, the overwhelming influence is the strength of the patient's resolution. Therapists have still been found to make a sometimes substantial difference to outcome. In the major US Project MATCH alcohol treatment trial, their influence was greater than which type of therapy they practised, and the individual therapist particularly mattered in motivational interviewing rather than in the more formulaic 12-step and cognitive-behavioural therapies trialled in the study. But overall the impact of the therapist's relationships with their clients is more evident in terms of whether clients want to extend the relationship by staying in treatment, than in whether they change their substance use.

Even within the limited arena from which the featured study's findings emerged, non-random allocation of patients to therapists weakens confidence in their validity because varying caseloads might have influenced the therapists' performances. That this is not a complete explanation is indicated by the fact that the therapist with the most promising In terms of expressed patient ability to change. caseload did only moderately well, while the therapist with the best outcomes had an unexceptional caseload. As the authors comment, there is also the possibility that the patient's expressed ability to change was not a pre-existing quality, but was itself affected by the interaction between patient and therapist, muddying the implications of the findings. Again, this seems unlikely to be the full story, since the most effective therapists did not have caseloads most confident of their ability to change.

Related brief intervention studies

Confidence in the findings and in their generalisability is increased by findings from different contexts but with similar implications. A review combining studies of treatment-seeking patients, substance users identified through screening, and people volunteering for studies, found that motivational interviewing was associated with the expected behaviours among therapists, and that these improved substance use outcomes, partly by changing how clients reacted during therapy sessions in terms of talking about change, expressing motivation, not resisting change, and becoming aware of the incompatibility between their substance use and other aspects of their lives or self-identity. In terms of the full chain from treatment via therapist behaviours through client reactions to outcomes, the evidence was strongest for therapists' avoidance of behaviours inconsistent with a motivational approach, but this may simply have reflected the lack of adequate studies. Inconsistent behaviour was also a major influence in the featured study.

Echoes of the featured study's findings came from a similar US study of brief motivational interviewing targeted at risky drinkers in an emergency department. This found that returning for a second scheduled session was associated with reduced alcohol-related problems at follow-up, and that some interventionists were much better than others at encouraging return. Further analysis revealed that initially focusing on building an emotional bond rather than tackling drinking was the key factor which led patients to return. Unfortunately we don't know whether the therapists who did this also had better drinking outcomes among their clients. It could be that they encouraged return, but at the cost of ineffectively postponing the issue of drinking.

Possibly in this study rapid introduction of their drinking was perceived by the patient as confrontational or directive, some of the incompatible behaviours which had a damaging effect in the featured study. Confrontation is perhaps the most contraindicated behaviour in motivational interviewing, a stipulation which emerged from a study of heavy drinkers more like those identified in brief intervention studies than those seen in alcohol treatment centres. Having volunteered merely for a 'check-up' of their drinking, the more the counsellor confronted them, the more they drank a year later. Similarly with smokers identified through screening at a health fair, the participant's engagement with a five-session motivational interviewing intervention was strongest when the session typified the overall spirit of the approach, and even more robustly weakened by confrontational behaviour. As in the featured study, counts of the number of 'correct' behaviours were relatively weak predictors of engagement.

A study of brief interventions with heavy drinkers who volunteered for the study (but were not judged as dependent or in need of treatment) found that one of the three therapists was significantly less successful with the motivational version of the intervention (in fact, their patients did not cut their drinking at all) than with the coping skills version. This therapist was also the one who most often used the specific techniques recommended for motivational therapy, another indication the quantity of these behaviours is not the major factor in the effectiveness of the approach.

Another study also tested motivational interviewing as a brief intervention with people not seeking treatment, but this time with young British college students who smoked cannabis at least weekly. Judged by substance use outcomes assessed three and six months later, overall this approach was no better than drug information and advice based on discussing a series of harm reduction leaflets. However, some interventionists were markedly more successful with motivational interviewing than with simple advice, while others did slightly better with the more straightforward and familiar advice option. What made the difference it seemed was not the approach itself, but the combination of approach and individual. Some advisers were able to realise the potential of motivational interviewing, others were not.

The same message emerged from a study of motivational interviewing training which found that initial gains in skills had waned two months later. However, this was not the case for the addiction and mental health clinicians who, even before training, had been more proficient than the other trainees would be after training. Not only did these 'natural experts' start from a higher level, they went on to absorb and retain more of what they had learnt. In contrast, within months much of the training was wasted when it fell on less fertile human ground. Among this set of trainees, given a choice between choosing the 'right' people who had not been trained, and the 'wrong' people who had, the right people would have been the better choice.

Treatment seeking dynamics different?

That the dynamics of the therapist-patient encounter might differ in a treatment context is suggested by a US study of motivational interviewing training for counsellors specialising in treatment for substance use problems. Where it agreed with the featured study was in the importance of the overall spirit of the approach rather than micro measures of the frequency of certain therapist behaviours. Client engagement was strongly related to embodying this spirit, and also to more general social attributes including empathy, warmth, supporting the client's autonomy, and coming across as 'genuine'. It also agreed in finding that the sheer quantity of behaviours consistent with motivational interviewing was not influential. But unlike the featured study, engagement was also unrelated to the number of statements seen as incompatible For example, confronting clients, warning or directing them, and imposing advice or expressing concern without their permission. with motivational interviewing. In fact, within (and only within) the kind of empathic, caring context socially skilled therapists were able to create, occasionally and mildly 'breaking the rules' in these ways actually deepened the client's engagement, perhaps because the therapist came across as more genuine. In this context, with clients seeking help for a substance use disorder, there is more reason to show concern, be directive, and to warn about possible consequences. Patients who themselves are concerned and seeking direction might suspect that the total absence of such comments from their therapists meant they were withholding their true feelings, or even worse, that they lacked such feelings and were uncaring.

Among former problem users seeking to sustain their sobriety in a specialist accommodation, confrontation in the form of warnings about what would happen to them if they did not change their ways was seen as intended to be and actually helpful, and was associated with seeing the source as supportive.

Analysis of session tapes from one of the Project MATCH alcohol treatment trial clinics revealed that the generally low levels of confrontational behaviour by motivational therapists did not affect either retention in treatment or drinking outcomes, a further indication that some degrees and/or types of confrontation are not actually incompatible with good outcomes from the approach. For reasons not fully understood, confrontation, though no more frequent among cognitive-behavioural therapists, did within this therapy seem to have a damaging effect on both measures.

Another substudy from Project MATCH involving different sites reminds us that overall behaviour inconsistent with motivational interviewing is likely to elicit counterproductive anti-change statements from the patients, though in this study just 9% of the time. Consistent behaviours seemed more powerful, eliciting positive comments about change 17% of the time and also suppressing negative comments. But when it came to later drinking outcomes, a further substudy reported in the same paper found the negative comments to have a stronger relationship with poorer outcomes than positive comments did with good outcomes. Unfortunately the authors were unable to complete the links to establish whether via the patient's reactions, the therapist's behaviours actually did affect later drinking.

Differences in tolerance to directiveness in general are likely also to be a relevant distinction. Among treatment-seeking patients, those who like to see themselves as in control react badly to directive therapists, while the reverse is the case for people who feel in need of direction. Acknowledged lack of control over substance use and their lives in general is likely to be relatively high among people seeking help for substance use problems, but not for patients intercepted for a brief intervention while attending their GP or an emergency department. It would follow that directiveness would be more consistently damaging among brief intervention than treatment-seeking patients. This in turn may help explain why behaviours incompatible with motivational interviewing, like explicit directiveness, seem to be more closely associated with poorer outcomes in brief intervention studies.

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