Sustain Talk Predicts Poorer Outcomes among Mandated College Student Drinkers Receiving a Brief Motivational Intervention

Heavy drinking peaks during late adolescence and early adulthood and is especially common among young adults who attend college (Hingson, Heeren, Winter, & Wechsler, 2005). Tens of thousands of college students violate campus alcohol policy per year for issues such as possession of alcohol, behavioral problems while intoxicated, and alcohol-related medical complications (Porter, 2006). Colleges often require these students to complete an alcohol intervention to reduce the likelihood of future heavy drinking episodes (Wechsler et al., 2002). One common intervention provided to mandated college students is Brief Motivational Intervention (BMI), which incorporates motivational interviewing (MI), and commonly includes personalized feedback along with other MI components designed to motivate behavior change. Individual BMIs (typically delivered in one or two sessions) have generally been found to be more effective at reducing alcohol use in college students than a variety of less intensive interventions such as alcohol education and normative education (see Carey, Scott-Sheldon, Carey, & DeMartini, 2007; Cronce & Larimer, 2011; Larimer & Cronce, 2007). For example, Borsari and Carey (2005) compared a BMI to individual alcohol education among mandated students. BMI participants showed a significantly greater reduction in alcohol problems at 3- and 6-month follow-up. However, other studies have found more equivocal results. For example, White and colleagues (2006) found no differences in consumption or alcohol problems comparing a BMI vs. a written feedback report (with no counselor contact) at 3-month follow-up. Similarly, a pilot study implementing BMI in a stepped care framework found no differences between BMI and assessment only control at a 6-week follow-up (Borsari, O'Leary-Tevyaw, Barnett, Kahler, & Monti, 2007). However, a recent large-scale study of the same intervention framework (stepped care) found BMI participants to report significantly fewer alcohol-related problems than assessment-only participants at a 9-month follow-up (Borsari et al., 2012). In sum, recent evidence indicates that counselor-delivered interventions may be effective with mandated students, but findings vary across studies and at different follow-up points. There is a need to understand how these interventions facilitate change in students who receive them, because such understanding can lead to refinements and improvements in future BMIs. Mechanisms of Behavior Change in BMIs Mechanisms of behavior change are defined as processes or events that lead to therapeutic improvement (Kazdin & Nock, 2003). To date, efforts to identify mechanisms of behavior change in BMIs among college students have been primarily focused on (self-reported) mediators of treatment effects (e.g., Borsari & Carey, 2000; McNally, Palfai, & Kahler, 2005). While this research has been useful, there is also a need for greater understanding of how within-session processes contribute to reductions in alcohol use and problems in order to further refine and improve BMI treatment. A theory of MI has been proposed that emphasizes two components: a relational component focused on therapist and client global factors (such as empathy, acceptance, self-exploration), and a technical component involving specific therapist behaviors to elicit client change language (Miller & Rose, 2009). There is a growing body of literature on the technical components, focusing on therapist and client behaviors within MI sessions and how these processes link to outcomes. A number of studies have examined client language defined as either change talk or sustain talk. Miller and Rollnick define change talk as “any self-expressed language that is an argument for change.” (2013, p. 159) and sustain talk as “the person's own arguments for not changing, for sustaining the status quo.” (2013, p. 7). An influential study by Amrhein and colleagues (2003) found that an increase in the strength of change talk over the course of an MI session predicted reduced client substance use at 12-month follow-up. However, because the strength of change talk was created by averaging change talk and sustain talk, the relative contribution of each construct was not ascertainable from this study. A study by Moyers and colleagues (2007) examined the relationship of both client change talk and sustain talk to drinking outcomes across three different treatment modalities (Motivational Enhancement Therapy, Cognitive Behavioral Therapy, and Twelve Step Facilitation). Both change talk and sustain talk uniquely predicted drinks per drinking day (one of the two outcomes measured), while only sustain talk predicted a lower percent of days abstinent. The sample was then split into positive outcomes and poor outcomes. Analyses revealed both change talk and sustain talk each significantly predicted outcomes, highlighting the importance of both types of within-session client language in predicting later alcohol use. A recent study examined the role of client language within BMIs with heavy drinking college students (Vader, Walters, Prabhu, Houck, & Field, 2010), using audiotapes from a previous study in which MI with personalized feedback was found to significantly reduce drinking outcomes more than MI without feedback (Walters et al. 2009). Findings indicated that in the MI-with-feedback group, therapist MI-consistent language was associated with greater levels of both student change talk and sustain talk, and each was predictive of 3 month drinking outcome in the expected directions. In contrast, in the MI without feedback condition, while MI-consistent language was again found to be associated with both greater change and sustain talk, change talk was unrelated to drinking outcome, while sustain talk was directionally but not significantly related (p = .058) to poorer drinking outcome. Tollison and colleagues (2013) have examined the role of specific therapist behavior directly on outcomes among college students receiving a BMI, and found that certain microskills (e.g., open questions, simple reflections) are associated with poorer outcomes such as increased drinking. Hence, the role of therapist and client speech behavior within the BMI are emerging as an important aspect of understanding mechanisms of behavior change in BMIs. In addition to these technical aspects (specific behaviors) of motivational interviewing, relational aspects (global approach) are important in the change process (Miller & Rose, 2009). These relational factors include global measures such as therapist empathy, MI spirit, and acceptance, as well as client measures such as therapeutic engagement. Moyers, Miller, and Hendrickson (2005) reported measures of clinician global approach (e.g., acceptance, empathy, MI spirit) correlated significantly with measures of client involvement (e.g., collaboration, disclosure, disclosure of affect) during the session. These relational aspects also have been found to predict substance use outcomes. Therapist MI spirit has been shown to predict less frequent marijuana use at a 3-month follow-up (McCambridge et al., 2011), and therapist empathy has been associated with lower levels of drinking at a 12-month follow-up (Gaume, Gmel, Faouzi, & Daeppen, 2008). Finally, Baer and colleagues (2008) reported global client “task orientation” (how much the client remained focused and engaged during therapeutic tasks) predicted more days abstinent at a 3-month follow-up. In sum, relational as well as technical components of motivational interviewing have shown to be important in understanding the change process. Current Study The current study is an analysis of therapist and client language from audiotapes of BMI sessions from a completed randomized controlled trial of mandated students who received either BMI or computer-delivered intervention (Barnett, Murphy, Colby, & Monti, 2007). Our primary objective was to investigate the relationship between therapist and client language within the BMI condition of the larger study and student alcohol use and consequences. We hypothesized that client change talk would be negatively associated with subsequent alcohol use and problems, and that client sustain talk would be positively associated with subsequent alcohol use and problems measured at several time-points after treatment. We also examined the relationship of therapist MI-consistent and MI-inconsistent language and global aspects of therapist approach and client engagement with outcomes, and hypothesized that higher levels of MI-consistent language, lower levels of MI-inconsistent language, and higher global scores would be positively associated with improved drinking outcomes.