Journal of Counseling Psychology 2015. Vol. 62, No. 1, 79-86
© 2015 American Psychological Association 0022-0167/15/$ 12.00 http://dx.doi.org/10.1037/cou0000049
BRIEF REPORT
How Group Factors Affect Adolescent Change Talk and Substance Use Outcomes: Implications for Motivational Interviewing Training Karen Chan Osilla
J. Alexis Ortiz
RAND Corporation, Santa Monica, California
University of New Mexico
Jeremy N. V. Miles and Eric R. Pedersen
Jon M. Houck
RAND Corporation, Santa Monica, California
University of New Mexico
Elizabeth J. D ’Amico RAND Corporation, Santa Monica, California Clients who verbalize statements arguing for change (change talk [CT]) in psychotherapy are more likely to decrease alcohol and other drug use (AOD) compared with clients who voice statements in opposition of change (sustain talk [ST]). Little is known about how CT and ST are expressed in groups in which adolescents may vary in their AOD use severity and readiness to change. First, we examined how session content was associated with CT/ST, and then we looked at whether different subtypes of CT/ST were associated with subsequent AOD outcomes 3 months later. Audio recordings (N = 129 sessions) of a 6-session group motivational interviewing (MI) intervention, Free Talk, were coded. Session content was not associated with CT; however, some session content was associated with higher percentages of ST (e.g., normative feedback). Subtypes of CT (Commitment and Reason) were associated with improved AOD outcomes, whereas Ability subtype remarks were related to increased marijuana use, intentions, and consequences. Findings offer helpful guidance for clinical training and narrow in on the type of CT to try to elicit in Group MI sessions. Regardless of session content, adolescents can benefit from hearing CT during the group. Keywords: adolescents, substance use, Group Motivational Interviewing, change talk, alcohol and drug outcomes
Motivational interviewing (MI) is an empirically based counseling approach in which a clinician uses a collaborative, nonconfrontational, and nonjudgmental style to resolve a client’s ambivalence to
changing their behavior (Miller & Rollnick, 2012; Rollnick, Miller, & Butler, 2008). Client change talk (statements arguing for change; “Maybe I should stop using marijuana”) and sustain talk (statements in opposition to change; “I don’t think I need to stop using mari juana”) are often described as opposite sides of the client’s ambiva lence to change. Clinicians are encouraged to elicit and promote client change talk (CT) and reduce instances of sustain talk (ST) through the strategic use of open-ended questions, reflections, affirmations, and summaries (Miller & Rollnick, 2012). When clients express CT about the target behavior, it often indicates their readiness to change whereas clients who express ST are often more ambivalent about change. In fact, client CT has been posited as an active ingredient of successful MI interventions (Baer et al., 2008; Barnett et al., 2014; Moyers, Martin, Houck, Christopher, & Tonigan, 2009). Most research studies examining CT and ST are limited to evaluating individual sessions. Several research studies with adults show that clients who express CT report reduced substance use between 12 and 34 months later (Bertholet, Faouzi, Gmel, Gaume, & Daeppen, 2010; Walker, Stephens, Rowland, & Roffman, 2011). In the few studies that have evaluated adolescent CT in individual sessions, higher frequency of youth CT remarks has been associated with fewer substance use days (Amrhein, Miller,
Karen Chan Osilla, RAND Corporation, Santa Monica, California; J. Alexis Ortiz, Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico; Jeremy N. V. Miles and Eric R. Pedersen, RAND Corporation, Santa Monica, California; Jon M. Houck, Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico; Elizabeth J. D’Amico, RAND Corporation, Santa Monica, California. The authors thank the Council on Alcoholism and Drug Abuse for their support of this project. They also thank Emily Cansler and Megan ZanderCotugno for their oversight collecting the data. The current study was funded by grants from the National Institute on Drug Abuse (NIDA; R0IDA019938 and R21AA020546, Principal Investigator: E. J. D.) and supported in part by a grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA; K01AA021431, Principal Investigator: J. M. H.). NIDA and NIAAA had no role in the study design, collection, analysis, or interpre tation of the data; the writing the manuscript; or the decision to submit the paper for publication. Correspondence concerning this article should be addressed to Karen Chan Osilla, RAND Corporation, 1776 Main Street, Santa Monica CA 90407-2138. E-mail; [email protected]
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Yahne, Palmer, & Fulcher, 2003; Baer et al., 2008) and drinks per week (Bertholet et al, 2010). Conversely, youth who communicate more ST remarks are more likely to report poorer drinking out comes (Vader, Walters, Prabhu, Houck, & Field, 2010) and fewer days of abstinence at follow-up (Baer et al., 2008). Research examining individualized sessions (Amrhein et al., 2003; Baer et al., 2008; Gaume, Bertholet, Faouzi, Gmel, & Daeppen, 2013) has also shown that the subtype of CT may be important in predicting substance use outcomes. Subtypes of CT include statements indicating Desire (e.g., “I want to quit doing drugs”), Ability (e.g., “I can do i t . . . this is doable”), Reasons (e.g., “I hate the way cigarettes smell”), Need (e.g., “I need to stop”), Commitment (e.g., “I stopped seeing him so I wouldn’t smoke”), and Taking Steps (e.g., “This week, I won’t go to any parties”). Each of these subtypes can also be a subtype of ST if it is expressed in opposition of change. For example, Desire ST would indicate not wanting to change (e.g., “I do not want to quit”) and Reason ST would offer reasons why one continues to use (e.g., “I like smoking because it relaxes me”). Dismantling which subtype of CT is associated with behavior change may help clinicians narrow in on which statements to reflect on and emphasize during the busy group process. Research with adults who report alcohol and other drug (AOD) use has demonstrated that the Commitment CT subtype is partic ularly important in predicting AOD use outcomes (Amrhein et al., 2003). In one individual-based MI study with emerging adults, Desire, Ability, and Need subtypes of CT were associated with improved alcohol outcomes whereas Desire, Ability, and Need subtypes of ST were significantly associated with poorer alcohol use outcomes (Gaume et al., 2013). Another study evaluating individual MI among homeless adolescents showed that youth who expressed Reasons in favor of changing AOD use had higher reductions in AOD use days at the 1-month follow-up whereas youths’ expressions of Desire or Ability ST were predictive of fewer days abstinent at 1- and 3-month follow-ups (Baer et al., 2008). In group interventions, CT and ST both by the individual and by other group members may have a unique influence on the group process. Groups typically include youth who vary in their readi ness to change, severity of AOD use, problems, and willingness to speak up in a group of their peers (D’Amico, Osilla, & Hunter, 2010; Wagner & Ingersoll, 2012). This heterogeneity may either improve youth outcomes or lead to iatrogenic effects. Only two studies have evaluated CT and ST in Group MI sessions. They found that Group CT was associated with lower alcohol intentions, expectancies, past month drinking, and past month heavy drinking at 3-month follow-up (D’Amico et al., in press) and improved marijuana outcomes at 12-month follow-up (Engle, Macgowan, Wagner, & Amrhein, 2010). In contrast, Group ST was related to decreased motivation to change, greater alcohol expectancies, and marginal increases in marijuana use (D’Amico et al., in press). Only one study examined a subtype of CT or ST in adolescent group sessions. Engle and colleagues (2010) measured Commit ment CT and found that this type of talk was associated with less frequent marijuana use; however, they did not examine other subtypes of CT and ST. The current study moves the field forward by examining whether all subtypes of CT and ST in the adolescent group setting influence AOD outcomes.
Research on individual sessions has shown that specific session content such as decisional balance exercises can evoke CT when discussing the cons of using (LaBrie, Pedersen, Earleywine, & Olsen, 2006), and it may elicit ST when discussing the pros of using substances (Miller & Rose, 2013). To date, there is no research examining session content and group-level CT and ST. This is important to understand because group treatment is often used with youth (Kaminer, 2005) who typically receive multiple group sessions with various session content, often with rolling admission with youth attending different sessions. Ultimately, knowing the types of session content that may be positively associated with greater CT in the group setting could help clini cians better understand how to deliver more effective AOD groups and provide broader implications for how MI could be used when treating other target behaviors. We address these important questions in the current study by evaluating the CT and ST remarks of a six-session Group MI intervention trial, Free Talk, among at-risk youth who received a first-time AOD offense and were involved in the California Teen Court system (D’Amico, Hunter, Miles, Ewing, & Osilla, 2013; D’Amico et al., 2010). We first examined how session content was associated with CT and ST, and then we assessed whether different subtypes of CT/ST were associated with AOD outcomes 3 months later. On the basis of what we know from the available literature, we tested the hypotheses that session content explicitly focused on evoking CT (e.g., decisional balance; rulers) would be associated with more CT versus session content that utilized MI but was more focused on providing information (e.g., discussion of how AOD use affects the brain); we also expected that Reason and Commit ment subtypes of CT/ST would be more strongly associated with AOD outcomes than would other subtypes of CT/ST.
Method Data were obtained for secondary analyses from the Free Talk randomized clinical trial (D’Amico et al., 2013), which evaluated a group-based MI intervention developed for at-risk youth involved in the California Teen Court juvenile deferment program. Only data from the MI intervention group are included in this paper. Free Talk facilitators were four psychology doc toral graduate students at the University of Califomia-Santa Barbara who all had prior experience working with at-risk teens. Facilitators of the intervention were research staff that were trained in MI and supervised by clinical psychologists who were affiliated with the Motivational Interviewing Net work of Trainers (MINT) during 1-hr weekly supervision meet ings. The Motivational Interviewing Treatment Integrity scale (M1TI; Moyers, Martin, Manuel, Hendrickson, & Miller, 2005) was used to monitor intervention fidelity and to provide feed back during supervision. Sessions were audio recorded and coded using the procedures described below. Procedures were approved by the research institution’s internal review board. A National Institute of Health Certificate of Confidentiality was also obtained to protect participant privacy.
Participants One-hundred and ten youth participated in the Free Talk group intervention sessions and provided content for the analyses. Par-
CHANGE TALK IN GROUP MI
ticipants were involved in the Santa Barbara California Teen Court system, a diversion program for youth with a first-time AOD offense. Participants ranged in age from 14 to 18 years old (M = 16.8 years [SD = 1.02]). Most were male (65.5%) and ethnicity varied, with 52% White, 39% Hispanic, and 9% of mixed/other race/ethnicity. Most teens reported marijuana as their most used substance (56%) and 44% reporting alcohol as their most used substance. Groups contained approximately five adolescents (M = 4.54; SD = 1.96). All youth age 14-18 years who entered the California Teen Court system for a first-time alcohol or marijuana offense during the study period (January 2009 to October 2011) were recruited for this study. We excluded youth who did not speak and read English, youth who had multiple offenses, and youth who possessed a medical marijuana recommendation from a physician to use marijuana. Study refusals were limited (10%) and were primarily attributed to lack of time or transportation. Study participants did not differ in demographic information from non participants.
Free Talk Sessions Over the 22 months of the project, 110 participants participated in 135 Free Talk intervention sessions. Because youth needed to begin the groups right after they were sentenced through the California Teen Court, they could begin sessions at any point in the cycle and did not have to begin at session 1. If they were absent for a session, then they waited for that specific session to recur in the sequence to ensure that they could attend all six sessions. In our study, 90.3% attended all six Free Talk sessions. Each session was manualized and used an MI style. For example, facilitators began with a group discussion about confidentiality, group rules, and role of personal choice in decisions around AOD use. Facilitators utilized MI strategies such as open-ended questions, affirmations, reflections, and summarizing group discussions to build motiva tion to change and allow youth to explore their personal reasons for initiating change in their AOD use (D’Amico et al., 2013). Behavioral change tools were utilized throughout the sessions, such as decisional balance exercises to weigh the pros and cons of reducing use, willingness and confidence rulers to gauge motiva tion around change, and behavioral goal-setting. All exercises, handouts, and information were delivered in nonconfrontational and nonlecture MI style with elicitation of feedback from youth (e.g., “How does this fit for you?”) and group discussion (e.g., “What do others think?”) throughout. A detailed description of the session content has been published elsewhere (D’Amico et al., 2010).1 Through the use of MI tech niques (e.g., open-ended questions, reflections), facilitators gener ated group discussions in all sessions focused on the group mem bers’ thoughts about their use in relation to the material, reactions to the material and how it related to their personal use, and the role of personal choice in their own AOD use decisions. In brief, Session 1 (What are Teens Doing?) focused on providing teens with personalized normative feedback about how their AOD use compared to national data of similarly aged youth, a decisional balance exercise focused on the short- and long-term pros and cons of continuing versus stopping AOD use, and a Wheel of Change exercise focused on their goals for the future and how AOD use might affect those goals. Session 2 (What’s in Your Head vs. What’s in Your Bottle, or Myths About Substance Use) focused on
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willingness and confidence to change (or not change) AOD use and a discussion of alcohol expectancies (i.e., actual vs. expected effects) in relation to the balanced placebo design (Rohsenow & Marlatt, 1981). Session 3 (What Happened to You Last Night?) contained information regarding how to identify internal and ex ternal triggers to use AOD and a discussion around how individ uals may progress on a path from no use to experimental use to addiction and how individuals exit this path. Session 4 (Emotions and Communication) contained a discussion of emotional triggers for AOD use (e.g., sadness or excitement) as well as strategies related to managing negative emotions and affecting communica tion with others (e.g., drink refusal skills). Session 5 (The Brain and Addiction) included a discussion on how AOD use can affect the brain, including correcting AOD myths that youth may have believed and providing pictures and resources where youth could seek objective information about the short- and long-term effects of use. Finally, Session 6 (What Can Happen When People Use Alcohol and Drugs) included a focused discussion on the negative consequences resulting from AOD use (e.g., risky sex), setting of behavioral goals, and a discussion around how AOD use could impede goal attainment.
Coding Procedure Four coders were trained to use the Motivational Interviewing Skill Code (MISC 2.5; Houck, Moyers, Miller, Glynn, & Hallgren, 2010) and Center for Alcoholism, Substance Abuse, and Addiction (CASAA) Application for Coding Treatment Interactions (CACTI; Glynn, Hallgren, Houck, & Moyers, 2012) to assess facilitator and participant speech during the six group sessions. Only adolescent speech was used in analyses for the present study. Training for these coders included approximately 40 hr per coder over a 6-week period following training procedures established by Moyers and colleagues (2009). Six sessions from the 135 recordings in the clinical trial were used in coder training and subsequently ex cluded from all analyses, leaving 129 sessions for the present study. Each session was randomly assigned to one of four coders for assessment. Approximately 20% of sessions were randomly se lected for double-coding throughout the duration of the study. Coders were blind to whether the session they were coding was for double-coding. After initial training, coder meetings were held every 2 weeks to address progress, prevent coder drift, and to discuss sessions that were difficult to code. Coders also groupcoded gold-standard recordings in meetings or double-coded ses sions already coded by at least one group member to verify accuracy. These meetings were supervised by an expert in CT coding and the lead author of the MISC manual (J. M. H.).
Subtypes of CT and ST Subtypes of CT and ST included statements of Desire for change (D +) or for the status quo (D-), Ability to change (A +) or inability to change (A-), Reasons to change (R + ) or to maintain (R-), Weed for change (N+) or no need for change (N-), Commit ment to change (C + ) or not change (C-), recently Taken Steps
' A copy of the Free Talk manual can be found at http://www .groupmiforteens.org/programs/freetalk.
OSILLA, ORTIZ, MILES, PEDERSEN, HOUCK, AND D’AMICO
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toward changing (TS+) or maintaining (TS-) the target behavior, and Other statements that clearly indicated movement toward change ( 0 + ) or support for the status quo (0-) that did not fit into any other category, typically hypothetical language or statements of problem recognition (e.g., “I guess I’d feel comfortable saying ‘no’ if I’d had a bad experience the night before” or “It doesn’t really cause me any problems.” (Houck et ah, 2010; Miller, Moy ers, Ernst, & Amrhein, 2003).
Outcome Measures Alcohol use, consequences, and intentions. Items from the RAND Adolescent/Young Adult Panel Study (Ellickson, Tucker, & Klein, 2001; Tucker, Orlando, & Ellickson, 2003) assessed frequency of drinking (i.e., “at least one drink of alcohol”) and frequency of heavy drinking (i.e., “five or more drinks of alcohol in a row, that is, within a couple of hours”) in the past 30 days. Eight response options ranged from 0 days to 21-30 days. Alcohol-related consequences were assessed with six items from these studies (e.g., missed school or work, passed out; a = .81). Four response options ranged from 0 (never) to 3 (3 or more times). Intention to use alcohol was assessed with a single item regarding whether the participant thought they would drink any alcohol in the next 6 months. Responses for each item ranged from 1 (definitely yes) to 4 (definitely no) and were reverse coded so that a higher value indicated greater intentions to use. Marijuana use, consequences, and intentions. Items from the RAND Adolescent/Young Adult Panel Study (Ellickson et al., 2001; Tucker et al., 2003) assessed use, consequences, and intentions to use marijuana. Frequency of marijuana use was assessed with a single item (i.e., “In the past 30 days, how many days did you use marijuana [pot, weed, grass, hash, bud, sins]?) with eight response options (0 days to 21-30 days). Five items with response options of never to 3 or more times assessed marijuana-related consequences (e.g., blacked out, missed school or work, passed out, regretted activities, got in trouble, trouble concentrating; a = .77). Intentions to use marijuana in the next 6 months were assessed with a single item and response ranging from definitely yes to definitely no.
Statistical Analysis We first examined whether session content was associated with group-level CT and ST to determine which sessions were more or less likely to elicit this type of language. For each of the six sessions, we calculated the number and percentage of change remarks and number and percentage of sustain remarks. We then used regression analysis with effect coding to compare the session mean to the overall mean across all sessions to determine whether that specific session had more or less CT or ST than the average session. Next, we examined whether different subtypes of CT at the group level were associated with improved youth individual-level AOD outcomes and whether different types of ST were associated with worse individual-level AOD outcomes. Again using effect coding, we compared the session mean of CT and ST subtypes and compared it to the overall mean of the subtypes across the sessions, and we used these session totals to predict teen outcomes using the model described below. Several subtypes of CT and ST were rarely expressed; thus, we only analyzed the subtypes that occurred in at least 50% of sessions because the measures were otherwise highly skewed. Because of the rolling groups design, there was no specific “group” structure of teens at any given session (MorganLopez & Fals-Stewart, 2008; Paddock, Hunter, Watkins, & Mc Caffrey, 2010). To account for this nonindependence, we used a cross-classified multilevel model (Browne, Goldstein, & Rasbash, 2001; D’Amico et al., 2013). We used the baseline measure of the outcome, age, race, and gender as covariates in the models.
Results Session Content Table 1 provides the mean number of CT and ST remarks for each of the six sessions, and it shows a significance test to compare each session to the average CT and ST across all of the sessions. Overall, approximately one third of the total remarks teens spoke were CT (min = 28.23% in Session 6, max = 38.24% in Session
Table 1 Means and Standard Deviations o f CT and ST fo r Each Session Session
Content
1
Personalized normative feedback, pros/cons of substance use, wheel of change Motivation rulers, alcohol expectancies, balanced placebo design Internal and external triggers, path to addiction Managing emotions, ' communication styles Effects of alcohol and drugs on the developing brain Negative consequences, setting and attaining goals
2 3 4 5 6 All
" p < .05.
**p < .01.
Number of Sessions
Total Client Remarks
Change Remarks
Sustain Remarks
Change as % of Total
22
165.91*** (47.78)
50.05* (23.94)
34.27** (20.09)
29.35(11.5)
23
114.43 (40.96)
39.78 (18.39)
19.65 (11.39)
36.33 (14.43)
17.45 (9.83)
23
127.74 (43.48)
37.17 (17.54)
21.96(11.34)
30.40(11.2)
17.00 (7.18)
20
106.2** (42.82)
37.4 (12.89)
10.9** (7.28)
38.24(14.39)
10.63* (7.04)
24
97.29*** (31.93)
33.29 (24.27)
18.08(18.69)
36.47 (26.86)
25
162.8*** (39.26)
42.12(24.77)
17.96 (18.13)
28.23 (19.29)
137
129.55 (48.48)
39.93 (21.25)
20.53 (16.6)
33.04(17.51)
***p < .001 for difference between the session and overall mean.
Sustain as % of Total 20.45* (8.8)
18.60 (16.67) 10.15** (9.34) 15.73 (10.98)
CHANGE TALK IN GROUP MI
4), whereas approximately 15% of remarks were ST (min = 10.15 in Session 6, max = 20.45 in Session 1). Second, we examined each session by CT and ST remarks. Session 1 had a significantly greater number of change and sustain remarks than the average session, and Session 4 (Emotions and Communication) had signif icantly fewer sustain remarks. We then controlled for the total number of remarks given that some sessions generated more discussion than other sessions. We calculated the percentage of change and sustain remarks for each session and compared it with the percentage of these remarks across sessions. We found no significant differences in the mean percentage of CT remarks by session compared with the average session. With regard to sustain remarks, we found that Session 1 had a significantly higher per centage of sustain remarks, and Sessions 4 and 6 were significantly lower in the percentage of sustain remarks compared with the average session.
CT and ST Subtypes Table 2 shows descriptive statistics for the subtypes of change and sustain remarks in an average session. Youth more frequently expressed the following subtypes of CT: Other (M = 8.33, SD = 12.62), Reason (M = 8.44, SD = 7.7), Ability (M = 5.19, SD = 5.79), and Commitment (M = 2.87, SD = 3.48). Youth more frequently expressed Reason (M = 4.11, SD = 4.84) and Other ST (M = 2.23, SD = 3.08). CT subtypes included in the analyses were Ability, Reason, Commitment, and Other (see Table 3). For ST, only the Reason subtype occurred with sufficient frequency to be included in the analyses. Commitment CT was associated with the most positive effects, with this type of CT being associated with fewer days of alcohol use in the past month, less heavy drinking in the past month, fewer alcohol consequences, lower alcohol intentions, and lower marijuana intentions at the 3-month follow-up. Reason CT was associated with fewer days of alcohol use, less heavy drinking, and fewer alcohol intentions at 3-month follow-up. Finally, Ability CT was associated with increases in marijuana use in the past
Table 2 Descriptive Statistics fo r the Amount o f CT and ST Subtypes Across All Six Sessions Subtype CT Subtype Desire Ability Reason Need Commitment Taking Steps Other ST Subtype Desire Ability Reason Need Commitment Taking Steps Other
Mean“
SD
min
max
0.79 5.19 8.44 0.25 2.87 1.07 8.44
1.47 5.79 7.7 0.69 3.48 2.2 12.62
0 0 0 0 0 0 0
12 29 38 4 18 13 61
0.57 0.91 4.11 0.19 1.14 0.06 2.23
1.04 1.58 4.84 0.56 2.23 0.29 3.08
0 0 0 0 0 0 0
5 8 24 4 12 2 18
Mean refers to how often a subtype occurred in an average session.
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month, greater marijuana-related consequences, and higher mari juana intentions at 3-month follow-up. Reason ST was not signif icantly associated with outcomes.
Discussion This study contributes to our growing understanding of the adolescent group process by examining whether session content was associated with CT/ST and whether subtypes of CT/ST were related to AOD outcomes. We found that the frequency of CT remarks were approximately twice as prevalent as ST remarks, which suggests that Free Talk, a manualized MI intervention (D’Amico et al., 2013, 2010), was successful in eliciting CT among nontreatment-seeking at-risk youth. Overall, teens had more CT and ST remarks in sessions that provided a discussion of personalized normative feedback and pros/cons and content fo cused on the consequences and goals for AOD use. Teens had the least amount of CT and ST remarks with content related to how AOD use affects the brain. This is not surprising because the former two sessions tended to elicit more discussion given the content (e.g., open-ended questions regarding reactions to norma tive feedback, discussion of personal goals) whereas Session 5 provided more education in the initial part of the session with open-ended questions facilitating the discussion about the long term consequences of AOD use after the information was pre sented. The percentage of CT did not differ significantly between ses sions. However, the percentage of ST was higher in Session 1 and lower in Sessions 4 and 6. Sessions 4 and 6, which focused on emotions, effective communication styles, negative AOD conse quences, and future goals, may have generated fewer ST remarks because content focused on enhancing coping skills and identify ing effects of AOD use on present and future circumstances. Session 1 contained personalized normative feedback and may have generated more ST remarks because feedback commonly elicits surprise and ambivalence among adolescents, who may view their use as “normal” (Borsari & Carey, 2001; Prentice & Miller, 1993). Group ST has been associated with decreased mo tivation to change and increased alcohol expectancies (D’Amico et al., in press); however, several studies show that normative feed back is an effective way to decrease drinking and marijuana use (Neighbors, Lee, Lewis, Fossos, & Larimer, 2007; Spirito et al., 2011). Future research could explore whether ST in the context of normative feedback may help youth consider change. For many youth, a discussion of normative feedback is likely the first time that they have questioned their perceptions surrounding AOD use; therefore, ST is likely, but whether ST in this context is a catalyst for changing their misperceptions and future AOD use remains a question. Findings further emphasize that it is important to strengthen the facilitator’s ability to elicit CT and minimize ST (e.g., “It’s hard to believe this information and you’re wondering if you should cut down”), especially for manualized interventions that may have a lot of new content for the facilitator to learn. When therapists are trained to evoke CT, clients produce more CT in individual ses sions (Glynn & Moyers, 2010; Moyers, Houck, Glynn, & Manuel, 2011). Beyond intervention content, clinical training efforts should also consider the role of the interpersonal process in Group MI because MI strategies such as open-ended questions and reflec-
OSILLA, ORTIZ, MILES, PEDERSEN, HOUCK, AND D’AMICO
84 Table 3
Association Between CT and ST Subtypes and Individual-Level Outcome Measures Subtype
Measure
Alcohol Past 30 Days
Heavy Drinking Past 30 Days
Alcohol Consequences
Alcohol Intentions
Marijuana Past 30 Days
Marijuana Consequences
Marijuana Intention
Est SE P Est SE P Est SE P Est SE P
-0.01 (0.06) .911 -0.09 (0.04) .040 -0.20 (0.08) .017 -0.04 (0.03) .116
0.00 (0.05) .981 -0.08 (0.04) .036 -0.15 (0.08) .048 -0.04 (0.02) .093
0.00 (0.01) .770 -0.02 (0.01) .153 -0.05 (0.02) .044 0.00 (0.01) .584
0.045 (0.030) .134 -0.06 (0.02) .019 -0.10 (0.04) .023 0.02 (0.01) .153
0.16 (0.07) .027 -0.07 (0.06) .254 -0.21 (0.11) .075 -0.07 (0.04) .060
0.03 (0.01)
© 2015 American Psychological Association 0022-0167/15/$ 12.00 http://dx.doi.org/10.1037/cou0000049
BRIEF REPORT
How Group Factors Affect Adolescent Change Talk and Substance Use Outcomes: Implications for Motivational Interviewing Training Karen Chan Osilla
J. Alexis Ortiz
RAND Corporation, Santa Monica, California
University of New Mexico
Jeremy N. V. Miles and Eric R. Pedersen
Jon M. Houck
RAND Corporation, Santa Monica, California
University of New Mexico
Elizabeth J. D ’Amico RAND Corporation, Santa Monica, California Clients who verbalize statements arguing for change (change talk [CT]) in psychotherapy are more likely to decrease alcohol and other drug use (AOD) compared with clients who voice statements in opposition of change (sustain talk [ST]). Little is known about how CT and ST are expressed in groups in which adolescents may vary in their AOD use severity and readiness to change. First, we examined how session content was associated with CT/ST, and then we looked at whether different subtypes of CT/ST were associated with subsequent AOD outcomes 3 months later. Audio recordings (N = 129 sessions) of a 6-session group motivational interviewing (MI) intervention, Free Talk, were coded. Session content was not associated with CT; however, some session content was associated with higher percentages of ST (e.g., normative feedback). Subtypes of CT (Commitment and Reason) were associated with improved AOD outcomes, whereas Ability subtype remarks were related to increased marijuana use, intentions, and consequences. Findings offer helpful guidance for clinical training and narrow in on the type of CT to try to elicit in Group MI sessions. Regardless of session content, adolescents can benefit from hearing CT during the group. Keywords: adolescents, substance use, Group Motivational Interviewing, change talk, alcohol and drug outcomes
Motivational interviewing (MI) is an empirically based counseling approach in which a clinician uses a collaborative, nonconfrontational, and nonjudgmental style to resolve a client’s ambivalence to
changing their behavior (Miller & Rollnick, 2012; Rollnick, Miller, & Butler, 2008). Client change talk (statements arguing for change; “Maybe I should stop using marijuana”) and sustain talk (statements in opposition to change; “I don’t think I need to stop using mari juana”) are often described as opposite sides of the client’s ambiva lence to change. Clinicians are encouraged to elicit and promote client change talk (CT) and reduce instances of sustain talk (ST) through the strategic use of open-ended questions, reflections, affirmations, and summaries (Miller & Rollnick, 2012). When clients express CT about the target behavior, it often indicates their readiness to change whereas clients who express ST are often more ambivalent about change. In fact, client CT has been posited as an active ingredient of successful MI interventions (Baer et al., 2008; Barnett et al., 2014; Moyers, Martin, Houck, Christopher, & Tonigan, 2009). Most research studies examining CT and ST are limited to evaluating individual sessions. Several research studies with adults show that clients who express CT report reduced substance use between 12 and 34 months later (Bertholet, Faouzi, Gmel, Gaume, & Daeppen, 2010; Walker, Stephens, Rowland, & Roffman, 2011). In the few studies that have evaluated adolescent CT in individual sessions, higher frequency of youth CT remarks has been associated with fewer substance use days (Amrhein, Miller,
Karen Chan Osilla, RAND Corporation, Santa Monica, California; J. Alexis Ortiz, Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico; Jeremy N. V. Miles and Eric R. Pedersen, RAND Corporation, Santa Monica, California; Jon M. Houck, Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico; Elizabeth J. D’Amico, RAND Corporation, Santa Monica, California. The authors thank the Council on Alcoholism and Drug Abuse for their support of this project. They also thank Emily Cansler and Megan ZanderCotugno for their oversight collecting the data. The current study was funded by grants from the National Institute on Drug Abuse (NIDA; R0IDA019938 and R21AA020546, Principal Investigator: E. J. D.) and supported in part by a grant from the National Institute on Alcohol Abuse and Alcoholism (NIAAA; K01AA021431, Principal Investigator: J. M. H.). NIDA and NIAAA had no role in the study design, collection, analysis, or interpre tation of the data; the writing the manuscript; or the decision to submit the paper for publication. Correspondence concerning this article should be addressed to Karen Chan Osilla, RAND Corporation, 1776 Main Street, Santa Monica CA 90407-2138. E-mail; [email protected]
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Yahne, Palmer, & Fulcher, 2003; Baer et al., 2008) and drinks per week (Bertholet et al, 2010). Conversely, youth who communicate more ST remarks are more likely to report poorer drinking out comes (Vader, Walters, Prabhu, Houck, & Field, 2010) and fewer days of abstinence at follow-up (Baer et al., 2008). Research examining individualized sessions (Amrhein et al., 2003; Baer et al., 2008; Gaume, Bertholet, Faouzi, Gmel, & Daeppen, 2013) has also shown that the subtype of CT may be important in predicting substance use outcomes. Subtypes of CT include statements indicating Desire (e.g., “I want to quit doing drugs”), Ability (e.g., “I can do i t . . . this is doable”), Reasons (e.g., “I hate the way cigarettes smell”), Need (e.g., “I need to stop”), Commitment (e.g., “I stopped seeing him so I wouldn’t smoke”), and Taking Steps (e.g., “This week, I won’t go to any parties”). Each of these subtypes can also be a subtype of ST if it is expressed in opposition of change. For example, Desire ST would indicate not wanting to change (e.g., “I do not want to quit”) and Reason ST would offer reasons why one continues to use (e.g., “I like smoking because it relaxes me”). Dismantling which subtype of CT is associated with behavior change may help clinicians narrow in on which statements to reflect on and emphasize during the busy group process. Research with adults who report alcohol and other drug (AOD) use has demonstrated that the Commitment CT subtype is partic ularly important in predicting AOD use outcomes (Amrhein et al., 2003). In one individual-based MI study with emerging adults, Desire, Ability, and Need subtypes of CT were associated with improved alcohol outcomes whereas Desire, Ability, and Need subtypes of ST were significantly associated with poorer alcohol use outcomes (Gaume et al., 2013). Another study evaluating individual MI among homeless adolescents showed that youth who expressed Reasons in favor of changing AOD use had higher reductions in AOD use days at the 1-month follow-up whereas youths’ expressions of Desire or Ability ST were predictive of fewer days abstinent at 1- and 3-month follow-ups (Baer et al., 2008). In group interventions, CT and ST both by the individual and by other group members may have a unique influence on the group process. Groups typically include youth who vary in their readi ness to change, severity of AOD use, problems, and willingness to speak up in a group of their peers (D’Amico, Osilla, & Hunter, 2010; Wagner & Ingersoll, 2012). This heterogeneity may either improve youth outcomes or lead to iatrogenic effects. Only two studies have evaluated CT and ST in Group MI sessions. They found that Group CT was associated with lower alcohol intentions, expectancies, past month drinking, and past month heavy drinking at 3-month follow-up (D’Amico et al., in press) and improved marijuana outcomes at 12-month follow-up (Engle, Macgowan, Wagner, & Amrhein, 2010). In contrast, Group ST was related to decreased motivation to change, greater alcohol expectancies, and marginal increases in marijuana use (D’Amico et al., in press). Only one study examined a subtype of CT or ST in adolescent group sessions. Engle and colleagues (2010) measured Commit ment CT and found that this type of talk was associated with less frequent marijuana use; however, they did not examine other subtypes of CT and ST. The current study moves the field forward by examining whether all subtypes of CT and ST in the adolescent group setting influence AOD outcomes.
Research on individual sessions has shown that specific session content such as decisional balance exercises can evoke CT when discussing the cons of using (LaBrie, Pedersen, Earleywine, & Olsen, 2006), and it may elicit ST when discussing the pros of using substances (Miller & Rose, 2013). To date, there is no research examining session content and group-level CT and ST. This is important to understand because group treatment is often used with youth (Kaminer, 2005) who typically receive multiple group sessions with various session content, often with rolling admission with youth attending different sessions. Ultimately, knowing the types of session content that may be positively associated with greater CT in the group setting could help clini cians better understand how to deliver more effective AOD groups and provide broader implications for how MI could be used when treating other target behaviors. We address these important questions in the current study by evaluating the CT and ST remarks of a six-session Group MI intervention trial, Free Talk, among at-risk youth who received a first-time AOD offense and were involved in the California Teen Court system (D’Amico, Hunter, Miles, Ewing, & Osilla, 2013; D’Amico et al., 2010). We first examined how session content was associated with CT and ST, and then we assessed whether different subtypes of CT/ST were associated with AOD outcomes 3 months later. On the basis of what we know from the available literature, we tested the hypotheses that session content explicitly focused on evoking CT (e.g., decisional balance; rulers) would be associated with more CT versus session content that utilized MI but was more focused on providing information (e.g., discussion of how AOD use affects the brain); we also expected that Reason and Commit ment subtypes of CT/ST would be more strongly associated with AOD outcomes than would other subtypes of CT/ST.
Method Data were obtained for secondary analyses from the Free Talk randomized clinical trial (D’Amico et al., 2013), which evaluated a group-based MI intervention developed for at-risk youth involved in the California Teen Court juvenile deferment program. Only data from the MI intervention group are included in this paper. Free Talk facilitators were four psychology doc toral graduate students at the University of Califomia-Santa Barbara who all had prior experience working with at-risk teens. Facilitators of the intervention were research staff that were trained in MI and supervised by clinical psychologists who were affiliated with the Motivational Interviewing Net work of Trainers (MINT) during 1-hr weekly supervision meet ings. The Motivational Interviewing Treatment Integrity scale (M1TI; Moyers, Martin, Manuel, Hendrickson, & Miller, 2005) was used to monitor intervention fidelity and to provide feed back during supervision. Sessions were audio recorded and coded using the procedures described below. Procedures were approved by the research institution’s internal review board. A National Institute of Health Certificate of Confidentiality was also obtained to protect participant privacy.
Participants One-hundred and ten youth participated in the Free Talk group intervention sessions and provided content for the analyses. Par-
CHANGE TALK IN GROUP MI
ticipants were involved in the Santa Barbara California Teen Court system, a diversion program for youth with a first-time AOD offense. Participants ranged in age from 14 to 18 years old (M = 16.8 years [SD = 1.02]). Most were male (65.5%) and ethnicity varied, with 52% White, 39% Hispanic, and 9% of mixed/other race/ethnicity. Most teens reported marijuana as their most used substance (56%) and 44% reporting alcohol as their most used substance. Groups contained approximately five adolescents (M = 4.54; SD = 1.96). All youth age 14-18 years who entered the California Teen Court system for a first-time alcohol or marijuana offense during the study period (January 2009 to October 2011) were recruited for this study. We excluded youth who did not speak and read English, youth who had multiple offenses, and youth who possessed a medical marijuana recommendation from a physician to use marijuana. Study refusals were limited (10%) and were primarily attributed to lack of time or transportation. Study participants did not differ in demographic information from non participants.
Free Talk Sessions Over the 22 months of the project, 110 participants participated in 135 Free Talk intervention sessions. Because youth needed to begin the groups right after they were sentenced through the California Teen Court, they could begin sessions at any point in the cycle and did not have to begin at session 1. If they were absent for a session, then they waited for that specific session to recur in the sequence to ensure that they could attend all six sessions. In our study, 90.3% attended all six Free Talk sessions. Each session was manualized and used an MI style. For example, facilitators began with a group discussion about confidentiality, group rules, and role of personal choice in decisions around AOD use. Facilitators utilized MI strategies such as open-ended questions, affirmations, reflections, and summarizing group discussions to build motiva tion to change and allow youth to explore their personal reasons for initiating change in their AOD use (D’Amico et al., 2013). Behavioral change tools were utilized throughout the sessions, such as decisional balance exercises to weigh the pros and cons of reducing use, willingness and confidence rulers to gauge motiva tion around change, and behavioral goal-setting. All exercises, handouts, and information were delivered in nonconfrontational and nonlecture MI style with elicitation of feedback from youth (e.g., “How does this fit for you?”) and group discussion (e.g., “What do others think?”) throughout. A detailed description of the session content has been published elsewhere (D’Amico et al., 2010).1 Through the use of MI tech niques (e.g., open-ended questions, reflections), facilitators gener ated group discussions in all sessions focused on the group mem bers’ thoughts about their use in relation to the material, reactions to the material and how it related to their personal use, and the role of personal choice in their own AOD use decisions. In brief, Session 1 (What are Teens Doing?) focused on providing teens with personalized normative feedback about how their AOD use compared to national data of similarly aged youth, a decisional balance exercise focused on the short- and long-term pros and cons of continuing versus stopping AOD use, and a Wheel of Change exercise focused on their goals for the future and how AOD use might affect those goals. Session 2 (What’s in Your Head vs. What’s in Your Bottle, or Myths About Substance Use) focused on
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willingness and confidence to change (or not change) AOD use and a discussion of alcohol expectancies (i.e., actual vs. expected effects) in relation to the balanced placebo design (Rohsenow & Marlatt, 1981). Session 3 (What Happened to You Last Night?) contained information regarding how to identify internal and ex ternal triggers to use AOD and a discussion around how individ uals may progress on a path from no use to experimental use to addiction and how individuals exit this path. Session 4 (Emotions and Communication) contained a discussion of emotional triggers for AOD use (e.g., sadness or excitement) as well as strategies related to managing negative emotions and affecting communica tion with others (e.g., drink refusal skills). Session 5 (The Brain and Addiction) included a discussion on how AOD use can affect the brain, including correcting AOD myths that youth may have believed and providing pictures and resources where youth could seek objective information about the short- and long-term effects of use. Finally, Session 6 (What Can Happen When People Use Alcohol and Drugs) included a focused discussion on the negative consequences resulting from AOD use (e.g., risky sex), setting of behavioral goals, and a discussion around how AOD use could impede goal attainment.
Coding Procedure Four coders were trained to use the Motivational Interviewing Skill Code (MISC 2.5; Houck, Moyers, Miller, Glynn, & Hallgren, 2010) and Center for Alcoholism, Substance Abuse, and Addiction (CASAA) Application for Coding Treatment Interactions (CACTI; Glynn, Hallgren, Houck, & Moyers, 2012) to assess facilitator and participant speech during the six group sessions. Only adolescent speech was used in analyses for the present study. Training for these coders included approximately 40 hr per coder over a 6-week period following training procedures established by Moyers and colleagues (2009). Six sessions from the 135 recordings in the clinical trial were used in coder training and subsequently ex cluded from all analyses, leaving 129 sessions for the present study. Each session was randomly assigned to one of four coders for assessment. Approximately 20% of sessions were randomly se lected for double-coding throughout the duration of the study. Coders were blind to whether the session they were coding was for double-coding. After initial training, coder meetings were held every 2 weeks to address progress, prevent coder drift, and to discuss sessions that were difficult to code. Coders also groupcoded gold-standard recordings in meetings or double-coded ses sions already coded by at least one group member to verify accuracy. These meetings were supervised by an expert in CT coding and the lead author of the MISC manual (J. M. H.).
Subtypes of CT and ST Subtypes of CT and ST included statements of Desire for change (D +) or for the status quo (D-), Ability to change (A +) or inability to change (A-), Reasons to change (R + ) or to maintain (R-), Weed for change (N+) or no need for change (N-), Commit ment to change (C + ) or not change (C-), recently Taken Steps
' A copy of the Free Talk manual can be found at http://www .groupmiforteens.org/programs/freetalk.
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toward changing (TS+) or maintaining (TS-) the target behavior, and Other statements that clearly indicated movement toward change ( 0 + ) or support for the status quo (0-) that did not fit into any other category, typically hypothetical language or statements of problem recognition (e.g., “I guess I’d feel comfortable saying ‘no’ if I’d had a bad experience the night before” or “It doesn’t really cause me any problems.” (Houck et ah, 2010; Miller, Moy ers, Ernst, & Amrhein, 2003).
Outcome Measures Alcohol use, consequences, and intentions. Items from the RAND Adolescent/Young Adult Panel Study (Ellickson, Tucker, & Klein, 2001; Tucker, Orlando, & Ellickson, 2003) assessed frequency of drinking (i.e., “at least one drink of alcohol”) and frequency of heavy drinking (i.e., “five or more drinks of alcohol in a row, that is, within a couple of hours”) in the past 30 days. Eight response options ranged from 0 days to 21-30 days. Alcohol-related consequences were assessed with six items from these studies (e.g., missed school or work, passed out; a = .81). Four response options ranged from 0 (never) to 3 (3 or more times). Intention to use alcohol was assessed with a single item regarding whether the participant thought they would drink any alcohol in the next 6 months. Responses for each item ranged from 1 (definitely yes) to 4 (definitely no) and were reverse coded so that a higher value indicated greater intentions to use. Marijuana use, consequences, and intentions. Items from the RAND Adolescent/Young Adult Panel Study (Ellickson et al., 2001; Tucker et al., 2003) assessed use, consequences, and intentions to use marijuana. Frequency of marijuana use was assessed with a single item (i.e., “In the past 30 days, how many days did you use marijuana [pot, weed, grass, hash, bud, sins]?) with eight response options (0 days to 21-30 days). Five items with response options of never to 3 or more times assessed marijuana-related consequences (e.g., blacked out, missed school or work, passed out, regretted activities, got in trouble, trouble concentrating; a = .77). Intentions to use marijuana in the next 6 months were assessed with a single item and response ranging from definitely yes to definitely no.
Statistical Analysis We first examined whether session content was associated with group-level CT and ST to determine which sessions were more or less likely to elicit this type of language. For each of the six sessions, we calculated the number and percentage of change remarks and number and percentage of sustain remarks. We then used regression analysis with effect coding to compare the session mean to the overall mean across all sessions to determine whether that specific session had more or less CT or ST than the average session. Next, we examined whether different subtypes of CT at the group level were associated with improved youth individual-level AOD outcomes and whether different types of ST were associated with worse individual-level AOD outcomes. Again using effect coding, we compared the session mean of CT and ST subtypes and compared it to the overall mean of the subtypes across the sessions, and we used these session totals to predict teen outcomes using the model described below. Several subtypes of CT and ST were rarely expressed; thus, we only analyzed the subtypes that occurred in at least 50% of sessions because the measures were otherwise highly skewed. Because of the rolling groups design, there was no specific “group” structure of teens at any given session (MorganLopez & Fals-Stewart, 2008; Paddock, Hunter, Watkins, & Mc Caffrey, 2010). To account for this nonindependence, we used a cross-classified multilevel model (Browne, Goldstein, & Rasbash, 2001; D’Amico et al., 2013). We used the baseline measure of the outcome, age, race, and gender as covariates in the models.
Results Session Content Table 1 provides the mean number of CT and ST remarks for each of the six sessions, and it shows a significance test to compare each session to the average CT and ST across all of the sessions. Overall, approximately one third of the total remarks teens spoke were CT (min = 28.23% in Session 6, max = 38.24% in Session
Table 1 Means and Standard Deviations o f CT and ST fo r Each Session Session
Content
1
Personalized normative feedback, pros/cons of substance use, wheel of change Motivation rulers, alcohol expectancies, balanced placebo design Internal and external triggers, path to addiction Managing emotions, ' communication styles Effects of alcohol and drugs on the developing brain Negative consequences, setting and attaining goals
2 3 4 5 6 All
" p < .05.
**p < .01.
Number of Sessions
Total Client Remarks
Change Remarks
Sustain Remarks
Change as % of Total
22
165.91*** (47.78)
50.05* (23.94)
34.27** (20.09)
29.35(11.5)
23
114.43 (40.96)
39.78 (18.39)
19.65 (11.39)
36.33 (14.43)
17.45 (9.83)
23
127.74 (43.48)
37.17 (17.54)
21.96(11.34)
30.40(11.2)
17.00 (7.18)
20
106.2** (42.82)
37.4 (12.89)
10.9** (7.28)
38.24(14.39)
10.63* (7.04)
24
97.29*** (31.93)
33.29 (24.27)
18.08(18.69)
36.47 (26.86)
25
162.8*** (39.26)
42.12(24.77)
17.96 (18.13)
28.23 (19.29)
137
129.55 (48.48)
39.93 (21.25)
20.53 (16.6)
33.04(17.51)
***p < .001 for difference between the session and overall mean.
Sustain as % of Total 20.45* (8.8)
18.60 (16.67) 10.15** (9.34) 15.73 (10.98)
CHANGE TALK IN GROUP MI
4), whereas approximately 15% of remarks were ST (min = 10.15 in Session 6, max = 20.45 in Session 1). Second, we examined each session by CT and ST remarks. Session 1 had a significantly greater number of change and sustain remarks than the average session, and Session 4 (Emotions and Communication) had signif icantly fewer sustain remarks. We then controlled for the total number of remarks given that some sessions generated more discussion than other sessions. We calculated the percentage of change and sustain remarks for each session and compared it with the percentage of these remarks across sessions. We found no significant differences in the mean percentage of CT remarks by session compared with the average session. With regard to sustain remarks, we found that Session 1 had a significantly higher per centage of sustain remarks, and Sessions 4 and 6 were significantly lower in the percentage of sustain remarks compared with the average session.
CT and ST Subtypes Table 2 shows descriptive statistics for the subtypes of change and sustain remarks in an average session. Youth more frequently expressed the following subtypes of CT: Other (M = 8.33, SD = 12.62), Reason (M = 8.44, SD = 7.7), Ability (M = 5.19, SD = 5.79), and Commitment (M = 2.87, SD = 3.48). Youth more frequently expressed Reason (M = 4.11, SD = 4.84) and Other ST (M = 2.23, SD = 3.08). CT subtypes included in the analyses were Ability, Reason, Commitment, and Other (see Table 3). For ST, only the Reason subtype occurred with sufficient frequency to be included in the analyses. Commitment CT was associated with the most positive effects, with this type of CT being associated with fewer days of alcohol use in the past month, less heavy drinking in the past month, fewer alcohol consequences, lower alcohol intentions, and lower marijuana intentions at the 3-month follow-up. Reason CT was associated with fewer days of alcohol use, less heavy drinking, and fewer alcohol intentions at 3-month follow-up. Finally, Ability CT was associated with increases in marijuana use in the past
Table 2 Descriptive Statistics fo r the Amount o f CT and ST Subtypes Across All Six Sessions Subtype CT Subtype Desire Ability Reason Need Commitment Taking Steps Other ST Subtype Desire Ability Reason Need Commitment Taking Steps Other
Mean“
SD
min
max
0.79 5.19 8.44 0.25 2.87 1.07 8.44
1.47 5.79 7.7 0.69 3.48 2.2 12.62
0 0 0 0 0 0 0
12 29 38 4 18 13 61
0.57 0.91 4.11 0.19 1.14 0.06 2.23
1.04 1.58 4.84 0.56 2.23 0.29 3.08
0 0 0 0 0 0 0
5 8 24 4 12 2 18
Mean refers to how often a subtype occurred in an average session.
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month, greater marijuana-related consequences, and higher mari juana intentions at 3-month follow-up. Reason ST was not signif icantly associated with outcomes.
Discussion This study contributes to our growing understanding of the adolescent group process by examining whether session content was associated with CT/ST and whether subtypes of CT/ST were related to AOD outcomes. We found that the frequency of CT remarks were approximately twice as prevalent as ST remarks, which suggests that Free Talk, a manualized MI intervention (D’Amico et al., 2013, 2010), was successful in eliciting CT among nontreatment-seeking at-risk youth. Overall, teens had more CT and ST remarks in sessions that provided a discussion of personalized normative feedback and pros/cons and content fo cused on the consequences and goals for AOD use. Teens had the least amount of CT and ST remarks with content related to how AOD use affects the brain. This is not surprising because the former two sessions tended to elicit more discussion given the content (e.g., open-ended questions regarding reactions to norma tive feedback, discussion of personal goals) whereas Session 5 provided more education in the initial part of the session with open-ended questions facilitating the discussion about the long term consequences of AOD use after the information was pre sented. The percentage of CT did not differ significantly between ses sions. However, the percentage of ST was higher in Session 1 and lower in Sessions 4 and 6. Sessions 4 and 6, which focused on emotions, effective communication styles, negative AOD conse quences, and future goals, may have generated fewer ST remarks because content focused on enhancing coping skills and identify ing effects of AOD use on present and future circumstances. Session 1 contained personalized normative feedback and may have generated more ST remarks because feedback commonly elicits surprise and ambivalence among adolescents, who may view their use as “normal” (Borsari & Carey, 2001; Prentice & Miller, 1993). Group ST has been associated with decreased mo tivation to change and increased alcohol expectancies (D’Amico et al., in press); however, several studies show that normative feed back is an effective way to decrease drinking and marijuana use (Neighbors, Lee, Lewis, Fossos, & Larimer, 2007; Spirito et al., 2011). Future research could explore whether ST in the context of normative feedback may help youth consider change. For many youth, a discussion of normative feedback is likely the first time that they have questioned their perceptions surrounding AOD use; therefore, ST is likely, but whether ST in this context is a catalyst for changing their misperceptions and future AOD use remains a question. Findings further emphasize that it is important to strengthen the facilitator’s ability to elicit CT and minimize ST (e.g., “It’s hard to believe this information and you’re wondering if you should cut down”), especially for manualized interventions that may have a lot of new content for the facilitator to learn. When therapists are trained to evoke CT, clients produce more CT in individual ses sions (Glynn & Moyers, 2010; Moyers, Houck, Glynn, & Manuel, 2011). Beyond intervention content, clinical training efforts should also consider the role of the interpersonal process in Group MI because MI strategies such as open-ended questions and reflec-
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84 Table 3
Association Between CT and ST Subtypes and Individual-Level Outcome Measures Subtype
Measure
Alcohol Past 30 Days
Heavy Drinking Past 30 Days
Alcohol Consequences
Alcohol Intentions
Marijuana Past 30 Days
Marijuana Consequences
Marijuana Intention
Est SE P Est SE P Est SE P Est SE P
-0.01 (0.06) .911 -0.09 (0.04) .040 -0.20 (0.08) .017 -0.04 (0.03) .116
0.00 (0.05) .981 -0.08 (0.04) .036 -0.15 (0.08) .048 -0.04 (0.02) .093
0.00 (0.01) .770 -0.02 (0.01) .153 -0.05 (0.02) .044 0.00 (0.01) .584
0.045 (0.030) .134 -0.06 (0.02) .019 -0.10 (0.04) .023 0.02 (0.01) .153
0.16 (0.07) .027 -0.07 (0.06) .254 -0.21 (0.11) .075 -0.07 (0.04) .060
0.03 (0.01)
