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BACKGROUND: To assess the effects of a motivational interviewing (MI)-based patient empowerment program (PEP) on type 2 diabetes mellitus (DM) patient self-management compared to traditional diabetes health education. METHODS: Two hundred and twenty-five patients, recruited from community health centers (CHCs) and the family medicine clinic in the University of Hong Kong-Shenzhen Hospital in Shenzhen, were randomly assigned to the intervention or control groups. Patients in the intervention group (n = 117) received a four-session PEP in small groups over 1 month by trained nurses and doctors. The control group (n = 108) received the traditional lecture-style health education on DM. All the patients were followed up for 3 months. Outcomes included problem areas in diabetes (PAID) that measures diabetes-related emotional distress, patient enablement index (PEI), mental health, patient satisfaction respectively as well as lifestyle behaviors were assessed at baseline, post-activity and 3 months. RESULTS: At post-intervention and the 3-month follow-up, the PAID score improved significantly in the intervention group (12.7 ± 13.6, 5.8 ± 7.6) compared to the control group (22.7 ± 22.8, 11.7 ± 14.6). No difference was found between groups for changes to exercise, diet, and medication adherence. The PEI score improved significantly at the 3-month follow-up in the MI group (7.27 ± 2.45 vs 5.81 ± 2.97). CONCLUSION: The PEP has a significant effect on improving diabetes-related distress, but MI was not significantly different from the traditional health education programs when it comes to the readiness to change. TRIAL REGISTRATION: NCT04120844, ClinicalTrials.Gov. Date of registration: October 9th 2019 (Retrospectively registered).

Importance: Emergency department (ED) visits present opportunities to identify and refer suicidal youth for outpatient mental health care, although this practice is not routine. Objective: To examine whether a motivational interviewing-based intervention increases linkage of adolescents to outpatient mental health services and reduces depression symptoms and suicidal ideation in adolescents seeking emergency care for non-mental health-related concerns who screen positive for suicide risk. Design, Setting, and Participants: In this randomized clinical trial, adolescents aged 12 to 17 years who screened positive on the Ask Suicide Screening Questions (ASQ) during a nonpsychiatric ED visit at 2 academic pediatric EDs in Ohio were recruited from April 2013 to July 2015. Intention-to-treat analyses were performed from September 2018 to October 2019. Interventions: The Suicidal Teens Accessing Treatment After an Emergency Department Visit (STAT-ED) intervention included motivational interviewing to target family engagement, problem solving, referral assistance, and limited case management. The enhanced usual care (EUC) intervention consisted of brief mental health care consultation and referral. Main Outcomes and Measures: Primary outcomes were mental health treatment initiation and attendance within 2 months of ED discharge and suicidal ideation (assessed by the Suicidal Ideation Questionnaire JR) and depression symptoms (assessed by the Center for Epidemiologic Studies-Depression scale) at 2 and 6 months. Exploratory outcomes included treatment initiation and attendance and suicide attempts at 6 months. Results: A total of 168 participants were randomized and 159 included in the intention-to-treat analyses (mean [SD] age, 15.0 [1.5] years; 126 [79.2%] female; and 80 [50.3%] white). Seventy-nine participants were randomized to receive the STAT-ED intervention and 80 to receive EUC. At 2 months, youth in the STAT-ED group had similar rates of mental health treatment initiation compared with youth in the EUC group as assessed by parent report (29 [50.9%] vs 22 [34.9%]; adjusted odds ratio [OR], 2.08; 95% CI, 0.97-4.45) and administrative data from mental health care agencies (19 [29.7%] vs 11 [19.3%]; adjusted OR, 1.77; 95% CI, 0.76-4.15). At 2 months, youth in the STAT-ED group and the EUC group had similar rates of treatment attendance (1 appointment: 6 [9.7%] vs 2 [3.6%]; adjusted OR, 2.97; 95% CI, 0.56-15.73; ≥2 appointments: 10 [16.1%] vs 7 [12.7%]; adjusted OR, 1.43; 95% CI, 0.50-4.11). There were no significant group × time differences in suicidal ideation (F = 0.28; P = .72) and depression symptoms (F = 0.49; P = .60) during the 6-month follow-up period. In exploratory analyses, at 6 months, STAT-ED participants had significantly higher rates of agency-reported mental health treatment initiation (adjusted OR, 2.48; 95% CI, 1.16-5.28) and more completed appointments (t99.7 = 2.58; P = .01). Conclusions and Relevance: This study's findings indicate that no differences were found on any primary outcome by study condition. However, STAT-ED was more efficacious than EUC at increasing mental health treatment initiation and attendance at 6 months. Trial Registration: ClinicalTrials.gov identifier: NCT01779414.

BACKGROUND: Each year, millions of Americans receive evidence-based psychotherapies (EBPs) like cognitive behavioral therapy (CBT) for the treatment of mental and behavioral health problems. Yet, at present, there is no scalable method for evaluating the quality of psychotherapy services, leaving EBP quality and effectiveness largely unmeasured and unknown. Project AFFECT will develop and evaluate an AI-based software system to automatically estimate CBT fidelity from a recording of a CBT session. Project AFFECT is an NIMH-funded research partnership between the Penn Collaborative for CBT and Implementation Science and Lyssn.io, Inc. ("Lyssn") a start-up developing AI-based technologies that are objective, scalable, and cost efficient, to support training, supervision, and quality assurance of EBPs. Lyssn provides HIPAA-compliant, cloud-based software for secure recording, sharing, and reviewing of therapy sessions, which includes AI-generated metrics for CBT. The proposed tool will build from and be integrated into this core platform. METHODS: Phase I will work from an existing software prototype to develop a LyssnCBT user interface geared to the needs of community mental health (CMH) agencies. Core activities include a user-centered design focus group and interviews with community mental health therapists, supervisors, and administrators to inform the design and development of LyssnCBT. LyssnCBT will be evaluated for usability and implementation readiness in a final stage of Phase I. Phase II will conduct a stepped-wedge, hybrid implementation-effectiveness randomized trial (N = 1,875 clients) to evaluate the effectiveness of LyssnCBT to improve therapist CBT skills and client outcomes and reduce client drop-out. Analyses will also examine the hypothesized mechanism of action underlying LyssnCBT. DISCUSSION: Successful execution will provide automated, scalable CBT fidelity feedback for the first time ever, supporting high-quality training, supervision, and quality assurance, and providing a core technology foundation that could support the quality delivery of a range of EBPs in the future. TRIAL REGISTRATION: ClinicalTrials.gov; NCT05340738 ; approved 4/21/2022.

Treatment fidelity in health behavior research is vital for obtaining results that are interpretable. Dr. Borrelli provides a comprehensive review and “state of the science” guidelines for implementing trials with rigorous fidelity. Certain fidelity challenges occur in behavioral trials, particularly those conducted in community treatment settings which are often effectiveness studies involving diverse samples of providers and participants. Health behavior interventions typically occur within the context of relationships between providers and participants. Individual characteristics may act as moderators that influence outcomes. In community settings, provider characteristics, including demographics, education, training, and experience, often vary widely. Strict criteria for provider selection may neither be feasible, nor preferable for assessing external validity. Similarly, participant samples may be quite diverse. With careful fidelity monitoring, contributions of treatment effects and those of provider and participant moderators can be identified with greater confidence, informing both research and practice in patient–provider-treatment matching when it is possible. Relationships create processes that impact outcomes. One of the most studied is the therapeutic alliance (TA), found to operate in many behavioral treatments including pharmacotherapy and placebo pharmacotherapy 1. Relationship variables should be addressed when considering study design, training, and treatment delivery monitoring. In study design, both content and relational components of behavioral treatments should be considered as potential active ingredients when operationalizing treatments. For example, Motivational Interviewing (MI) specifies provider behaviors including empathy, acceptance, and MI spirit as crucial to its efficacy 2. Training providers explicitly in treatment relationship skills is important regardless of whether they are postulated as active treatment mechanisms. This is particularly relevant in community-based research, using providers whose skills may vary widely at inception. Resources for training are often stretched thin, leaving skill training to the last minute. The result can mean that wide variations in provider relationship skills remain after training content, a challenge that can be minimized by planning sufficient training time to include this focus. Fidelity monitoring of treatment delivery is a third important element; ratings typically measure intervention adherence and skill (i.e., competence), although measures of skill are rarely operationalized and should be. Clearly, fidelity ratings should measure all relationship skill elements that are considered active treatment ingredients; they should also measure relationship elements that are non-specific factors, such as therapeutic alliance or empathy. Ratings of these variables inform supervision and, if validated, can be used to examine contributions to outcomes. In a meta-analytic study, Webb et al. 3 found that studies that controlled for TA reported significantly smaller effect sizes for competence–outcomes relationships. Finally, community-based research often uses “treatment-as-usual” control conditions. Borrelli raises the important issue of fidelity monitoring of control groups. Ideally, both treatment content and relationship skill should be measured. Providers in the experimental condition may have had the benefit of both content and relationship skill training; differences in both the treatment content and provider relationship skills between experimental and control conditions may contribute to outcomes; fidelity monitoring of control conditions allows this to be examined. Health behavior trials offer the opportunity to identify active treatment ingredients within the complexities of provider–participant relationships. Community-based trials offer the rich experience of working with diverse, “front line” providers, and a wide range of patients to identify treatments that apply in “real world” settings. Fidelity monitoring that takes these factors into account enhances both internal and external validity. The author declares no conflict of interest.

BACKGROUND: The aim of this study was to determine whether a twelve-week, health coaching intervention could result in changes in physical activity, anthropometrics and health-related outcomes in adults presenting to an ambulatory hospital clinic. METHODS: Seventy-two participants who reported being insufficiently active were recruited from an ambulatory hospital clinic and randomised to an intervention group that received an education session and eight 30-min telephone sessions of integrated motivational interviewing and cognitive behaviour therapy (MI-CBT), or to a control group that received the education session only. ActiGraph GT3X accelerometers were used to measure moderate-to-vigorous physical activity at baseline, post-intervention (3-months) and follow-up (6-months). Secondary outcome measures (anthropometrics, physical activity self-efficacy, health-related quality of life, type 2 diabetes risk) were also assessed at the three time points. RESULTS: , respectively. Treatment group influenced the pattern of physical activity over time (p < 0.001). The intervention group increased moderate-to-vigorous physical activity from baseline to post-intervention and remained elevated at follow-up by 12.9 min/day (95%CI: 6.5 to 19.5 min/day). In contrast, at follow-up the control group decreased moderate-to-vigorous physical activity by 9.9 min/day (95%CI: -3.7 to -16.0 min/day). Relative to control, at follow-up the intervention group exhibited beneficial changes in body mass (p < 0.001), waist circumference (p < 0.001), body mass index (p < 0.001), physical activity self-efficacy (p < 0.001), type 2 diabetes risk (p < 0.001), and health-related quality of life (p < 0.001). CONCLUSIONS: This study demonstrates that a low contact coaching intervention results in beneficial changes in physical activity, anthropometrics and health-related outcomes that were maintained at follow-up in adults who report being insufficiently active to an ambulatory care clinic. TRIAL REGISTRATION: ANZCTR: ACTRN12616001331426 . Registered 23 September 2016.

In this study, we examined the efficacy of a version of the Family Check-Up (FCU) adapted for kindergarten school entry with regard to parenting skills during the transition to school. We also examined whether improvements in parenting skills would mediate improvements in parent- and teacher-rated child behavior problems from kindergarten to second grade. The FCU is a motivational interviewing (MI) intervention designed to engage parents in treatment to improve parenting skills. Participants were parents of 365 children enrolled in one of five elementary schools in the Pacific Northwestern United States. Main and indirect effects were tested with structural equation path modeling using an intent-to-treat approach. The FCU was associated with improved change in parenting skills, and changes in parenting skills, in turn, predicted reductions in child behavior problems. Implications for embedding MI in family-centered interventions at kindergarten school entry are discussed. Trial registration: NCT02289092.

Millions of people participate in online peer-to-peer support sessions, yet there has been little prior research on systematic psychology-based evaluations of fine-grained peer-counselor behavior in relation to client satisfaction. This paper seeks to bridge this gap by mapping peer-counselor chat-messages to motivational interviewing (MI) techniques. We annotate 14,797 utterances from 734 chat conversations using 17 MI techniques and introduce four new interviewing codes such as ''chit-chat'' and ''inappropriate'' to account for the unique conversational patterns observed on online platforms. We automate the process of labeling peer-counselor responses to MI techniques by fine-tuning large domain-specific language models and then use these automated measures to investigate the behavior of the peer counselors via correlational studies. Specifically, we study the impact of MI techniques on the conversation ratings to investigate the techniques that predict clients' satisfaction with their counseling sessions. When counselors use techniques such as reflection and affirmation, clients are more satisfied. Examining volunteer counselors' change in usage of techniques suggest that counselors learn to use more introduction and open questions as they gain experience. This work provides a deeper understanding of the use of motivational interviewing techniques on peer-to-peer counselor platforms and sheds light on how to build better training programs for volunteer counselors on online platforms.