Differences in the delivery of motivational interviewing across three countries

Figures & data

Table 1. Description of MITI 4 scores and median values for each country in the Elderly Study.

	Denmark (No. of sessions rated = 423)	Germany (No. of sessions rated = 107)	USA (No. of sessions rated = 177)	All (No. of sessions rated = 707)
Behavioral counts	Median per session (p25;p75)	Median per session (p25;p75)	Median per session (p25;p75)	Median per session (p25;p75)
Give Information: The therapist is sharing information, giving professional advice, or feedback.	5 (3;7)	4 (2;8)	3 (1;5)	4 (2;7)
Persuade: The therapist is trying to persuade the patient to change attitude or behavior.	0 (0;1)	0 (0;2)	0 (0;0)	0 (0;1)
Persuade with Permission: The therapist is persuading but asking for permission to do so or is clearly signaling that the choice of what to do is up to the patient.	0 (0;1)	0 (0;1)	0 (0;0)	0 (0;1)
Questions: The therapist is asking a question	11 (6;17)	11 (8;16)	9 (6;12)	11 (6;15)
Simple Reflections: The therapist reflects solely on what the patient has said	8 (5;13)	11 (6;17)	10 (7;14)	9 (6;14)
Complex Reflections: The therapist reflects beyond what the patient has said, adding new meaning and direction.	12 (8;17)	4.5 (3;7)	7 (5;10)	9 (6;14)
Affirmation: The therapist is affirming the patient behavior, intentions or strengths.	0 (0;1)	1 (0;2)	2 (1;3)	1 (0;2)
Seeking Collaboration: The therapist is asking for permission to share information or advice, curious about what the patient thinks about information or advice given, or in another way clearly sharing power with the patient.	1 (0;2)	1 (0;3)	2 (1;4)	1 (0;3)
Emphasize Autonomy: The therapist is stating that the responsibility of the choices and the freedom to do decisions made are solely up to the patient.	0 (0;0)	0 (0;1)	1 (0;2)	0 (0;1)
Confront: The therapist is arguing, being judgmental, moralizing, blaming, or disagreeing with the patient.	0 (0;0)	0 (0;0)	0 (0;0)	0 (0;0)
Global scores
Cultivating Change Talk: How well is the therapist working on evoking and cultivating change talk during the 20 minutes. Change talk is statements in favor of changing.	4 (3;5)	4 (4;5)	4 (3;4)	4 (3;5)
Softening Sustain Talk: How well is the therapist working on softening and leading attention away from sustain talk. Sustain talk being statements from the patient arguing not to change.	4 (4;4)	4 (4;5)	4 (3;4)	4 (4;4)
Partnership: How well is the therapist sharing power with the patient in the 20 minutes listened.	4 (4;5)	4 (4;5)	5 (4;5)	4 (4;5)
Empathy: How well does the therapist seem to reach a deeper understanding of the patient.	4 (4;5)	4 (4;5)	4 (4;5)	4 (4;5)
Summary scores from the MITI 4
Relational: average of Empathy and Partnership	4 (4.0;4.5)	4.5 (4.0;4.5)	4.5 (4.5;5.0)	4.5 (4;5)
Technical: average of Cultivating change talk and Softening sustain talk	4 (3.5;4.5)	4.3 (4.0;5.0)	4 (3.0;4.5)	4 (3.5;4.5)
% Complex reflections of all reflections	59 (50;68)	30 (18;44)	42 (36;50)	50 (39;63)
Reflections to Questions ratio	1.8 (1.3;3.0)	1.3 (0.8;2.1)	1.9 (1.3;3.0)	1.8 (1.2;2.9)
MI-Adherent (affirmations + seeking collaboration + emphasize autonomy)	2 (1;3)	3 (1;5)	6 (4;8)	3 (1;5)
MI-non-adherent (persuasions + confronts)	0 (0;1)	1 (0;2)	0 (0;0)	0 (0;1)
Other measures
Median number of benchmarks of summary scores for Fair MI fulfilled	4 (3;4)	3 (2;4)	4 (3:4)	4 (3;4)
Median number of benchmarks of summary scores for Good MI fulfilled	3 (2;4)	2 (1;3)	2 (2;3)	3 (2;3)
Percentage of sessions fulfilling 4 benchmarks, Fair MI	72%	27%	53%	61%
Percentage of sessions fulfilling 4 benchmarks, Good MI	27%	7%	11%	20%

Table 2. Baseline demographics by country in the Elderly Study.

	Denmark (n = 341)	Germany (n = 203)	USA (n = 149)	All (n = 693)
Age: mean years (SD)**	65 (4)	67 (5)	65 (5)	66 (5)
Gender: % male*	64	52	60	60
Married or cohabiting, %**	45	57	39	47
Employment, % full or part time work**	15	24	28	20
Retired, % ***	63	71	50	63
Education, %high school or more***	43	43	91	54
Previously received treatment, %***	62	19	37	44
Alcohol Dependence Scale, mean (SD)***	12 (6)	6 (4)	12 (7)	10 (6)
Symptoms of mild to moderate depression, % ^ns	10	5	9	8
Importance to change, mean (SD) on a scale 0-10***	8.8 (2.1)	8.2 (1.7)	8.6 (2.1)	8.5 (2.0)
Confidence to change, mean (SD) on a scale from 0-10***	7.6 (2.2)	6.9 (2.0)	6.7 (2.5)	7.2 (2.2)
Readiness to change, mean (SD) on a scale from 0-10***	8.9 (1.8)	8.4 (1.8)	7.9 (2.2)	8.5 (1.9)
Drinks per drinking day, mean (SD)***	10 (7)	7 (4)	9 (7)	9 (6)
Percent days abstinent, mean (SD)*	32 (37)	21 (28)	27 (33)	28 (34)
Percent heavy days of drinking, mean (SD)^ns	58 (39)	60 (39)	56 (39)	58 (39)

*p < 0.05; **p < 0.01; ***p < 0.001 NS: Not significant.

Figure 1. Flow diagram of the fidelity measurement in the Elderly study.

Table 3. ICCs from the fidelity measurement with MITI 4.2.1 at the four rating teams in the Elderly study.

	ICC (95% CI) Danish rating team (n = 52)	ICC (95% CI) Dresden rating team (n = 12)	ICC (95% CI) Munich rating team (n = 13)	ICC (95% CI) US rating team (n = 20)
Behavioral counts
Giving information	0.94 (0.90;0.96)	0.94 (0.79;0.98)	0.88 (0.69;0.96)	0.85 (0.64;0.94)
Persuade	0.85 (0.78;0.91)	0.99 (0.97;1.00)	0.61 (0.02;0.87)	0.00 (-1.53;0.60)
Persuade with permission	0.69 (0.52;0.80)	0.78 (0.28;0.94)	0.39 (-0.20;0.77)	0.00 (-1.53;0.60)
Question	0.95 (0.90;0.97)	0.99 (0.97;1.00)	0.88 (0.71;0.96)	0.96 (0.89;0.98)
Simple reflection	0.86 (0.76;0.92)	0.89 (0.47;0.97)	0.60 (0.08;0.86)	0.38 (-0.21;0.75)
Complex reflection	0.87 (0.74;0.93)	0.67 (-0.13;0.90)	0.62 (0.12;0.87)	0.82 (0.34;0.94)
Affirmation	0.85 (0.78;0.91)	0.59 (-0.18;0.88)	0.86 (0.64;0.95)	0.66 (0.18;0.87)
Seeking collaboration	0.83 (0.74;0.89)	0.04 (-0.95;0.65)	0.89 (0.71;0.96)	0.18 (-0.26;0.57)
Emphasize autonomy	0.52 (0.29;0.69)	−0.22 (-4.85;0.67)	0.35 (-0.71;0.79)	0.27 (-0.33;0.66)
Confront	0.53 (0.30;0.71)	0.94 (0.80;0.98)	0.79 (0.48;0.93)	*
Global scores
Cultivating change talk	0.79 (0.69;0.87)	0.46 (-0.29;0.83)	0.44 (-0.39;0.81)	0.12 (-0.70;0.60)
Softening sustain talk	0.49 (0.25;0.68)	0.47 (-0.30;0.83)	0.34 (-0.72;0.78)	0.00 (-1.59;0.61)
Partnership	0.84 (0.76;0.90)	0.73 (0.15;0.92)	0.11 (-1.48;0.72)	0.25 (-0.54;0.68)
Empathy	0.73 (0.60;0.83)	0.61 (-0.23;0.88)	0.45 (-0.33;0.82)	0.21 (-0.96;0.69)
Summary scores
Relational: average of Empathy and Partnership	0.84 (0.75;0.90)	0.81 (0.34;0.94)	0.36 (-0.61;0.79)	0.26 (-0.93;0.71)
Technical: average of Cultivating change talk and Softening sustain talk	0.80 (0.70;0.88)	0.42 (-0.30;0.81)	0.48 (-0.32;0.83)	0.05 (-1.00;0.59)
% Complex reflections of all reflections	0.65 (0.47;0.78)	0.61 (-0.18;0.89)	0.27 (-0.60;0.74)	0.19 (-0.12;0.56)
Reflections to Questions ratio	0.95 (0.93;0.97)	0.77 (0.25;0.93)	0.47 (-0.16;0.81)	0.68
MI adherent behavior^1	0.85 (0.76;0.91)	0.27 (-0.32;0.72)	0.90 (0.74;0.97)	0.58 (-0.16;0.85)
MI non adherent behavior^2	0.86 (0.79;0.91)	0.99 (0.98;1.00)	0.62 (0.06;0.87)	0.00 (-1.53;0.60)

* Confront was not rated at all; therefore, the ICC could not be calculated.

¹ MI adherent: affirmations + seeking collaboration + emphasize autonomy.

² MI non adherent: persuasions + confronts.

Table 4. Percentage of agreement on global measures from the fidelity measurement with MITI 4.2.1 from the four rating teams in the Elderly study.

	Danish site	Dresden site	Munich site	US site
Cultivating change talk	50%	92%	92%	70%
Softening sustain talk	85%	92%	92%	95%
Partnership	79%	92%	77%	100%
Empathy	94%	100%	77%	100%

Table 5. Results of the mixed effects linear model in the study of differences in delivery of Motivational Interviewing, as measured by the MITI 4 across three countries in the Elderly study.

	Relational summary score	Technical summary score	Percent complex reflections	Reflection to question- ratio	Affirmations	Seeking collaboration	Emphasize Autonomy	Persuasions	Persuade with permission
Predictor	Coefficient (95% CI)	Coefficient (95% CI)	Coefficient (95% CI)	Coefficient (95% CI)	Coefficient (95% CI)	Coefficient (95% CI)	Coefficient (95% CI)	Coefficient (95% CI)	Coefficient (95% CI)
Denmark	0	0	0	0	0	0	0	0	0
Germany	−0.07 (-0.22;0.07)	0.21 (0.04;0.37)*	-0.26 (-0.3;-0.23)*	-0.96 (-1.68;-0.24)*	0.28 (-0.02;0.56)	0.24 (-0.15;0.62)	0.16 (-0.03;0.36)	0.87 (0.54;1.24)*	0.35 (0.09;0.6)*
USA	0.37 (0.23;0.5)*	-0.22 (-0.37;-0.08)*	-0.17 (-0.2;-0.14)*	0.08 (-0.58;0.74)	1.51 (1.25;1.78)*	1.53 (1.17;1.89)*	1.19 (1.01;1.36)*	-0.57 (-0.88;-0.26)*	-0.36 (-0.6;-0.13)*

¶ The model is controlling for differences in the following patient characteristics: age, cohabiting, gender, previous treatment attempts, symptoms of depression, education, severity of alcohol dependence, level of motivation, and drinks per drinking day.

* Significant difference defined by 95% CI does not include zero. Due to bootstrapped 95% CI’s p-values are not provided.

Denmark is the reference group in the comparisons of countries.

Andersen, K., Behrendt, S., Bilberg, R., Bogenschutz, M. P., Braun, B., Buehringer, G., Ekstrøm, C. T., Mejldal, A., Petersen, A. H., & Nielsen, A. S. (2020). Evaluation of adding the community reinforcement approach to motivational enhancement therapy for adults aged 60 years and older with DSM-5 alcohol use disorder: A randomised controlled trial. Addiction, 115(1), 69–81. https://doi.org/10.1111/add.14795

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Andersen, K., Bogenschutz, M. P., Bühringer, G., Behrendt, S., Bilberg, R., Braun, B., Ekstrøm, C. T., Forcehimes, A., Lizarraga, C., Moyers, T. B., & Nielsen, A. S. (2015). Outpatient treatment of alcohol use disorders among subjects 60+ years: Design of a randomized clinical trial conducted in three countries (Elderly Study). BMC Psychiatry, 15(1), 280. https://doi.org/10.1186/s12888-015-0672-x

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