Objective The technical hypothesis of motivational interviewing (MI) posits that therapist implemented MI skills will be related to client speech regarding behavior change and that client speech will predict 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 k = 16 reports describing 12 primary studies. Review methods calculated 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 that examined 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.

IMPORTANCE Substance use disorders (SUDs) represent a pressing public health concern. Combined behavioral and pharmacological interventions are considered best practices for addiction. Cognitive behavioral therapy (CBT) is a first-line intervention, yet the superiority of CBT compared with other behavioral treatments when combined with pharmacotherapy remains unclear. An understanding of the effects of combined CBT and pharmacotherapy will inform best-practice guidelines for treatment of SUD. OBJECTIVE To conduct a meta-analysis of the published literature on combined CBT and pharmacotherapy for adult alcohol use disorder (AUD) or other SUDs.

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Background: Cognitive-behavioral therapy (CBT) has long-standing evidence for efficacy in the treatment of alcohol use, yet implementation in clinical practice has been challenging. Delivery of CBT through technology-based platforms, such as web-based programs and mobile applications, has the potential to provide widespread access to this evidence-based intervention. While there have been reviews indicating the efficacy of technology-based delivery of CBT for various psychiatric conditions, none have focused on efficacy for alcohol use. The current meta-analysis was conducted to fill this research gap.Methods: Descriptive data were used to characterize the nature of the literature on technology-delivered, CBT-based interventions for alcohol use ("CBT Tech"). Inverse-variance-weighted effect sizes were calculated, and random effects, effect sizes were pooled in 4 subgroups.Results: Fifteen published trials conducted primarily with at-risk or heavy drinkers were identified. Of these studies, 60% explicitly targeted alcohol use moderation. The content of CBT Tech programs varied, ranging from 4 to 62 sessions/exercises, with many programs combining elements of motivational interviewing (47%). With respect to efficacy, CBT Tech as a stand-alone treatment in contrast to a minimal treatment control showed a positive and statistically significant, albeit small effect (g = 0.20: 95% CI = 0.22, 0.38, k es = 5). When CBT Tech was compared to treatment as usual (TAU), effects were nonsignificant. However, when CBT Tech was tested as an addition to TAU, in contrast to TAU only, the effect size was positive, significant (g = 0.30: 95% CI = 0.10, 0.50, k es = 7), and stable over 12-month follow-up. Only 2 studies compared CBT Tech to in-person CBT, and this pooled effect size did not suggest superior efficacy.Conclusions: These results show a benefit for technology-delivered, CBT-based interventions as a stand-alone therapy for heavy drinking or as an addition to usual care in specialty substance use settings.

Background: The technical hypothesis of Motivational Interviewing (MI) proposes that: (a) client talk favoring behavior change, or Change Talk (CT) is associated with better behavior change outcomes, whereas client talk against change, or Sustain Talk (ST) is associated with less favorable outcomes, and (b) specific therapist verbal behaviors influence whether client CT or ST occurs. MI consistent (MICO) therapist behaviors are hypothesized to be positively associated with more client CT and MI inconsistent (MIIN) behaviors with more ST. Previous studies typically examine session-level frequency counts or immediate lag sequential associations between these variables. However, research has found that the strongest determinant of CT or ST is the client's previous CT or ST statement. Therefore, the objective of this paper was to examine the association between therapist MI skills and subsequent client talk, while accounting for prior client talk. Methods: We analyzed data from a manualized MI intervention targeting both alcohol misuse and sexual risk behavior in 132 adults seen in two hospital emergency departments. Transcripts of encounters were coded using the Motivational Interviewing Skills Code (MISC 2.5) and an additional measure, the Generalized Behavioral Intervention Analysis System (GBIAS). Using these measures, we analyzed the association between client talk following specific classifications of MICO skills, with the client's prior statement as a potential confounder or effect modifier. Results: With closed questions as the reference category, therapist simple reflections and paraphrasing reflections were associated with significantly greater odds of maintaining client talk as CT or ST. Open questions and complex reflections were associated with significantly greater odds of CT following ST, were not associated significantly with more ST following ST, and were associated with more ST following CT (i.e., through an association with less Follow Neutral). Conclusions: Simple and paraphrasing reflections appear to maintain client CT but are not associated with transitioning client ST to CT. By contrast, complex reflections and open questions appeared to be more strongly associated with clients moving from ST to CT than other techniques. These results suggest that counselors may differentially employ certain MICO technical skills to elicit continued CT and move participants toward ST within the MI dialogue.

Objective To elucidate patient language that supports changing a health behavior (change talk) or sustaining the behavior (sustain talk). Methods We developed a novel coding system to characterize topics of patient speech in a motivational intervention targeting alcohol and HIV/sexual risk in 90 Emergency Department patients. We further coded patient language as change or sustain talk. Results For both alcohol and sex, discussions focusing on benefits of behavior change or change planning were most likely to involve change talk, and these topics comprised a large portion of all change talk. Greater discussion of barriers and facilitators of change also was associated with more change talk. For alcohol use, benefits of drinking behavior was the most common topic of sustain talk. For sex risk, benefits of sexual behavior were rarely discussed, and sustain talk centered more on patterns and contexts, negations of drawbacks, and drawbacks of sexual risk behavior change. Conclusions Topic coding provided unique insights into the content of patient change and sustain talk. Practice Implications Patients are most likely to voice change talk when conversation focuses on behavior change rather than ongoing behavior. Interventions addressing multiple health behaviors should address the unique motivations for maintaining specific risky behaviors.

Background and aims Research into the active ingredients of behavioral interventions for alcohol use disorders (AUD) has focused on treatment-specific factors often yielding disappointing results. The present study examines common factors of change in motivational enhancement therapy, cognitive-behavioral therapy, and twelve-step facilitation therapy by 1) estimating transitional probabilities between therapist behaviors and subsequent client Change (CT) and Sustain (ST) Talk and 2) examining therapist skillfulness as a potential predictor of transition probability magnitude. Design Secondary data analysis examined temporal associations in therapy dialogues. Setting USA: data were from Project MATCH (1997). Participants N = 126 participants who received Motivational Enhancement Therapy, Cognitive-Behavioral Therapy, or Twelve-Step Facilitation Therapy. Measurements Therapist behaviors were measured in three categories (Exploring, Teaching, Connecting) and client statements included five categories (CT-Distal, ST-Distal, CT-Proximal, ST-Proximal, Neutral). Therapist skillfulness was measured using a 5-point ordinal scale. Findings Relative to chance, therapist exploratory behaviors predicted subsequent client discussion of distal, drinking behavior (OR = 1.37 to 1.78, p < .001) while suppressing discussion of proximal coping and neutral content (OR = .83 to .90, p < .01). Unexpectedly, therapist teaching suppressed distal drinking language (OR = .48 to .53, p < .001) and predicted neutral content (OR = 1.45, p < .001). Connecting behaviors increased both drinking and coping language, particularly language in favor of change (CT OR = 1.15 to 1.84, p < .001). Analyses of exploring and connecting skillfulness revealed that high skillfulness maximized these behaviors effect on client responses, but not teaching skillfulness. Conclusions In motivational enhancement therapy, cognitive-behavioral therapy, and twelve-step facilitation therapy for alcohol use disorders, the therapists who explore and connect with clients appear to be more successful at eliciting discussion about change then therapists who engage in teaching behavior. Therapists who are more skilled achieve better results than those who are less skilled.

Overview The Client Language Assessment – Proximal/Distal (CLA-PD) is a language rating system for measuring client decision-making in interventions that target a specified behavior change (e.g., alcohol or other drug use). In the CLA-PD, there are five dimensions of change language (Reason, Ability, Commitment, Taking Steps, Other) adapted from the client portion of the Motivational Interviewing Skill Code (MISC). For the CLA-PD, language codes are sub-divided to discriminate statements regarding the primary, or target behavior change (distal change) from the intermediate coping activities (proximal change) that are prescribed to facilitate that target behavior change. The goal of the CLA-PD is to allow for higher specificity than existing client language measures, when process studies consider interventions that are multi-session and skill-based (e.g., Cognitive Behavioral Therapy). Method Three raters received 40 hours of training on the use of the CLA-PD. The data were a sample of therapy session audio-files from a completed clinical trial (N = 126), which enabled examination of client language across four sessions (i.e., first three and final attended) of three evidence-based alcohol interventions (Cognitive Behavioral Therapy, Twelve-Step Facilitation Therapy, Motivational Enhancement Therapy). Results Inter-rater reliability results for summary scores showed “excellent” reliability for the measure. Specifically, two-way mixed Intraclass Coefficients ranged from .83 to .95. Internal consistency reliability showed alphas across sessions that ranged from “fair” to “good” (α = .74 to.84). In convergent and discriminant validity analyses using data independently measured with MISC-based ratings, the pattern of results was as would be expected. Specifically, convergent correlations, by valence (i.e., change and sustain talk), between CLA-PD Distal and MISC-based language scores were moderate (r = .46 to .55, p < .001) while discriminant correlations by valence for CLA-PD Proximal and MISC-based language scores were small (r = .22 to .24, p < .05). Finally, proportion Change Talk Proximal predicted subsequent session coping behaviors (i.e., Processes of Change) as well as 3-month Alcoholics Anonymous involvement and attendance (ps < .05 – .005), but not 3-month alcohol abstinence self-efficacy. Further, analyses of criterion predictive validity showed that proportion Change Talk Distal predicted 3- and 12-month drinking frequency and quantity measures (ps < .05 – .005). Conclusions When behavior change treatments are multi-session and/or skill-based, the present analyses suggest the CLA-PD is a promising, psychometrically sound observational rating measure of client verbalized decision-making.