Substance Use & Misuse, 47:418–428, 2012Copyright C© 2012 Informa Healthcare USA, Inc.ISSN: 1082-6084 print / 1532-2491 onlineDOI: 10.3109/10826084.2011.641057

ORIGINAL ARTICLE

Boosting a Teen Substance Use Prevention Program with MotivationalInterviewing

Elizabeth Barnett, Donna Spruijt-Metz, Jennifer B. Unger, Ping Sun, Louise Ann Rohrbachand Steve Sussman

Department of Preventive Medicine, University of Southern California, Los Angeles, California, USA

A brief motivational interviewing (MI) interventionmay be a viable adjunct to school-based substanceabuse prevention programs. This article describes thedevelopment and implementation of a brief MI inter-vention with 573 adolescents (mean age 16.8; 40.3%female, 68% Latino) enrolled in eight continuationhigh schools in Southern California. Study partici-pants were assigned to the MI condition in a random-ized controlled trial of Project Toward No Drug Abuse.Data are provided on dosage, topics discussed, andquality of MI determined with the Motivational Inter-viewing Skill Code (MISC). Results suggest that theprotocol was feasible and implemented with adequatefidelity. The study’s limitations are noted.

Keywords adolescent, motivational interviewing, substance use,prevention, intervention, telephone, school-based, booster

INTRODUCTION

Substance misuse is among the most prevalent causes ofadolescent morbidity and mortality in the United States(Brannigan, Schackman, Falco, & Millman, 2004; Suss-man & Ames, 2008), particularly among older teens andemerging adults. There are few effective drug use preven-tion programs that target older teens (Skara & Sussman,2003). One of these few programs is Project Towards NoDrug Abuse (TND), which has been evaluated in six pre-vious randomized controlled trials. Although these trialshave shown reductions in the use of cigarettes, alcohol,marijuana, and hard drugs, consistent effects have beenobtained on hard drug use only and some program effects(e.g., on alcohol and marijuana use) have faded after 1year (Sun, Skara, Sun, Dent, & Sussman, 2006). Hencewe hypothesized that a booster program might be able tobolster these effects.

This article was supported by a grant from the National Institute on Drug Abuse (no. DA020138). The authors wish to thank Dr. Theresa Moyers;Lisa Hagen Glynn, M.S.; and Kevin Hallgren from the University of New Mexico and Mary Beth Abella, M.S.W.Address correspondence to Elizabeth Barnett, Department of Preventive Medicine, University of Southern California, 2001 North Soto St, LosAngeles, CA 90032, USA. Email: embarnet@usc.edu.

For our purposes, booster programming refers to anyactivity that is designed to enhance the effects of a pro-gram (Cuijpers, 2002), including reviewing or reinforc-ing previously learned material or enhancing motivationto follow through with behavioral intentions developedduring the intervention. Skara and Sussman (2003) con-cluded, based on a review of 25 adolescent substance useprevention programs, that school-based programs have agreater chance of maintaining long-term effects if suchprograms are “boosted.” However, most of the supportfor booster programming has been obtained from meta-analyses (Rooney & Murray, 1996; White & Pitts, 1998)because very few studies have provided direct tests of therelative effects of adding booster programs within an ex-perimental or quasi-experimental trial (Cuijpers, 2002).The most recent randomized controlled trial of TND wasdesigned to determine the efficacy of a booster (Sussman,Sun, Rohrbach, & Spruijt-Metz, 2011) and thus addressthe gap in the literature identified by Cuijpers.

For the booster, we selected a motivational interview-ing (MI) approach. MI is a client-centered counselingapproach designed to enhance intrinsic motivation forbehavior change by exploring and resolving ambivalencetoward changing behavior and habits (Miller & Rollnick,2002). MI has often been used as an adjunct to othertreatments, (Hettema, Miller, & Steele, 2004), suggest-ing it would be compatible with our 12-session classroombased intervention and has been delivered in brief doses of10–20 minutes, with the ability to affect behavior in 1–3sessions (Hettema et al., 2004). Of the 68 studies includedin the Hettema et al. meta-analysis, the MI interventionlength ranged from 15 minutes to 12 hours (average in-tervention length was 2.24 hours [SD 2.15]). Effect sizeson alcohol, drug, or tobacco related studies were an aver-age of d= .3 for 6–12 months postintervention (lower forcigarette smoking, d = .14) and dipped down to around

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MOTIVATIONAL INTERVIEWING BOOSTER 419

.2 at greater than 12 months, except when MI was usedto supplement other programming (e.g., when MI wasbeing used as an initial screening tool or as a means offollow-up). In the latter case, the effect size showed sta-bility at d = .6. Thus, the use of MI as booster program-ming for TND materials appears well indicated from thisreview.

According to a 2006 literature review by Grenard,Ames, Pentz, and Sussman (2006) on substance use in-terventions with adolescents and young adults, 30% ofthe included studies (n = 17) demonstrated that the MIcondition had a significant advantage over the compari-son group among youth. They also concluded that lengthof the sessions did not appear to be an important influenceon reducing outcomes.

Furthermore, it appears to be feasible to deliver MI toteens over the telephone (Kaminer, Burleson, & Burke,2008; Kealey et al., 2009; Peterson et al., 2009). The tar-get population for this intervention was high-risk continu-ation high school students who appear to bemore transientthan their regular high school counterparts (McCuller,Sussman, Holiday, Craig, & Dent, 2002), and many re-search teams have suggested that telephone interventionsmay be the only way to reach these youth (McCuller etal., 2002; Mermelstein, Hedeker, &Wong, 2003; Mıguez,2002). Hence, a telephone-based intervention appeared tobe the most promising modality to deliver booster pro-gramming.

Numerous MI studies with adolescents have been de-livered via telephone. Kealey et al.’s (2009) process eval-uation demonstrated that an MI-based proactive smok-ing cessation intervention among regular high school stu-dents in Seattle was successful in reaching 956 (67.2%)participants for at least one contact. Outcomes fromthat same study showed that the intervention increasedthe percentage of prolonged smoking abstinence (Peter-son et al., 2009). In a direct comparison of MI pro-vided in person versus over the telephone, Kaminer et al.(2008) found no difference between the aftercare treat-ment groups, suggesting that advantages of a telephoneintervention did not compromise the effect of MI amongadolescents.

The present article describes the development and im-plementation of the MI booster component, specifically,interventionist hiring, retention, training and coaching,participant retention, topics discussed during the MI ses-sions, and intervention fidelity.

MATERIALS AND METHODS

Design, Study Sample, Measurement, and ProceduresDesign and Study SampleTwenty-four continuation high schools participated in themain trial. School selection criteria are described in Lishaet al. (in press). Schools were randomly assigned to oneof three possible conditions: standard care control, TNDclassroom program only, or TND + MI, resulting in asample with eight schools per condition. Within eachschool, at least two classrooms were selected to partici-

pate in the study. Participation in the study was voluntary.At each school, one teacher was assigned as a contact forProject TND. We attempted to enroll and consent all thestudents in the classes taught by this teacher, regardless ofdrug use status. In order to participate, signed parental in-formed consent and subject assent were required for youthunder age 18. For those 18 and over, signed informed con-sent was obtained from the participant. Students were pro-vided with elective class credits for their participation inthe research study.

Of the enrolled students in the teachers’ classes,1,694 (70.7%) were consented to participate in the study.Of these, 1,676 students completed the pretest survey.Reasons for subject level decline were parental non-response (23.4%), student decline (5.1%), and parentdecline (0.8%). Overall, a total of 80% of the participantsattended the first classroom session. Across the otherclassroom sessions, the average attendance was 77%.

The consent form explained their possible assignmentinto the TND+MI condition. Once the schools had beenrandomized, students in the MI condition were furtherinformed about the follow-up contacts during the class-room portion of the program. An interventionist made a5-minute announcement to the students during the laterportion of the program (between Sessions 8 and 11, ofthe 12 sessions). Students were told that they would bemeeting individually with someone from the project, notthe classroom program instructor, to discuss their thoughtsabout the program as well as any goals or changes theywould like to pursue in the near future. After the an-nouncement was made, students participated in a 5- to 10-minute brainstorming process about the pros and cons ofparticipating in these sessions.

Intervention DevelopmentThe booster to the TND classroom programwas originallyconceptualized as a six-session, telephone-based boostercomponent. The objective of the first session was to re-view the key points of the classroom program. MI wouldbegin in the second session, followed by four additionalMI contacts. We initially intended to implement a boosterprogram session every 4 months after implementation ofthe classroom program for a period of 2 years (i.e., a totalof six calls to each subject), with each call lasting 15–20minutes.

In order to refine the protocol, we pilot tested the six-session booster intervention with 16 youths who had pre-viously participated in a TND evaluation trial, but whowere not from the current study schools. Based on dif-ficulties establishing rapport over the telephone, imple-menters’ anecdotes regarding negative reactions from stu-dents, and input from a focus group of continuation highschool students, we decided to modify our original plan.First, we would conduct the first interview in person im-mediately after the classroom-based program in order toestablish rapport with the students. Second, we would re-move the program material review because it was redun-dant with what the youth had just learned in the classroom.Third, we would reduce the number of contacts from six

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420 E. BARNETT ET AL.

to three. Our decision to reduce the number of sessionswas influenced by the reception and challenges we en-countered while contacting students. Over the telephone,this resistance was displayed as varying degrees of ap-athy during the discussion and avoidance in taking thecalls. Furthermore, the decision to redesign the boosterto be delivered in three sessions allowed us to completethe entire MI intervention between the end of the school-based program and administration of the 1-year follow-upsurvey.

Transitioning From TND to the BoosterAlthough TND ends with a personal commitment fromstudents, the booster was designed to begin with elicitingreasons to change. The overall purpose of the MI boosterwas to enhance motivation or intention to quit, thereby in-creasing the likelihood that students would actually quit.It was our belief that starting the booster with the stu-dent’s commitment would have circumvented the build-ing motivation phase of MI (Miller & Rollnick, 2002)Research has shown that one of the mechanisms throughwhich MI builds motivation is dependent upon elicitingand reinforcing reasons to change as well as commitmentlanguage (Apodaca & Longabaugh, 2009)

Final MI Booster InterventionUltimately, the booster intervention consisted of three 20-minute contacts between the youth and an MI interven-tionist. The first contact was conducted in person 1–3 daysafter the completion of the classroom-based instructionand the immediate posttest administration. The secondand third contacts were conducted via the telephone in 3-to 4-month intervals. In cases where we were unable tomeet the youth in person for the first contact, participantswere contacted by telephone and the second contact wasattempted in person if they were still attending the sameschool.

The MI booster intervention structure included sevencomponents: an opening, finding a target behavior, ex-ploring ambivalence, summarizing, asking a key or tran-sitional question, action planning, and closing. The struc-tured opening informed the youth of the purpose of thesession (to gather their impressions about the TND pro-gram and discuss behavior of interest to them), theirrights, and the limits of confidentiality and provided anopportunity for youth to decline audio recording if he/shedesired. For the second and third contacts, the openingconsisted of reestablishing an understanding of the pur-pose of the call and checking-in regarding the topic or be-havior discussed in the previous session.

Once interventionists perceived adequate rapport, theyshifted their attention to establishing a behavioral targetfor change. Since the first session occurred immediatelyfollowing the TNDprogram,we believe that students wereprimed and opened to speaking about substance use. In-terventionists prioritized finding a substance use target be-havior when possible. If students reported use of multi-ple substances, the interventionist either asked the studentwhich of the substances they wished to focus on or in-

terventionists proceeded with the topic they deemed mostproblematic or amenable to change based on details pro-vided by the student. In cases where students disclosednot using any substances, they were either directly askedif there was a health behavior they would like to workon or interventionists used an agenda-setting tool (Spruijt-Metz, Barnett, Davis, & Resnicow, 2011) that allowed theyouth to choose among a variety of target behaviors. Ac-cording to Rollnick,Mason, and Butler (1999), an agenda-setting tool facilitates client engagement as they select thetopic and can increase overall effectiveness. We designedan agenda-setting tool to cover a wider range of ado-lescent health and life concerns, including getting a job,graduating from high school, practicing safe sex, smok-ing cigarettes, drinking alcohol, smoking marijuana, us-ing club drugs, becoming independent/moving out, exer-cise, healthy eating, going to college, choosing friends,and having a baby. The flexible protocol and the spirit ofclient autonomy underpinning this MI intervention makeit unlikely that the emphasis on substance use harmed re-tention rates. For the second and third contacts, interven-tionists began by following up on the previously estab-lished target. Depending on reported progress or change,the interventionist either decided to continue to pursue thetopic or went through the agenda-setting process again tofind a new target behavior.

Once the target behavior had been established duringthe first contact, interventionists explored ambivalence byinquiring about the pros and cons of the behavior. If ap-propriate, they also explored the pros and cons of chang-ing the behavior. The second contact employed the use ofa personal values exercise (Miller, C’de Baca, Matthews,& Wilbourne, 2001), where students were asked over thephone to select 3 of 15 values, such as good student, goodson/daughter, good brother/sister, etc., belief in god, thatwere read to them. Once students had selected the values,interventionists inquired about why they chose the values.Ultimately, they asked how the target behavior fits in withthese values. For the third contact, interventionists askedstudents to choose three words from a list of positive at-tributes, such as reliable, strong, honest, trustworthy, etc.,that the student felt described them (Miller, editor, 2004;Miller, Hedrick, & Orlofsky, 1991). These words werethen used by the interventionist to affirm client strengthsand support client self-efficacy to change. The interven-tionist also explained that these words described peoplewho were successful in making changes in their behavior.Interventionists then asked students to describe how theyfelt these attributes might be helpful to change the behav-ior they had been discussing.

After completing the exploration exercise, the proto-col indicated the use of a transitional summary and keyquestion to reinforce the youth’s stated importance or con-fidence to change and a question that invited the youthto consider what his/her next steps would be. If the stu-dent responded to the transitional question by indicat-ing that some type of action or change was needed, theinterventionist proceeded to elicit action steps. If a stu-dent indicated feeling stuck or ambivalent about making

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MOTIVATIONAL INTERVIEWING BOOSTER 421

change, the interventionist acknowledged this and pro-posed that the action be limited to checking in about thetopic again in a few months to see if his/her thoughts orfeelings had changed. Finally, once all of the other stepshad been conducted, the contact ended by thanking thestudent for his/her engagement, openness, and thoughtful-ness; expressing optimism about his/her proposed changeor enthusiasm about talking to him/her again; confirmingthe best phone number to reach him/her; and establishingan approximate time at which the student would be calledagain.

Hiring, Training, and Managing InterventionistsWe hired interventionists using a two-stage process. First,applicants completed an adapted Helpful Response Ques-tionnaire (HRQ; Miller et al., 1991), a tool used to assistin assessing counselor empathy. We used a five-item mea-sure asking them to write a response to a client statementthat would indicate they were listening (e.g., client state-ments included “Just because I use drugs doesn’t make ita problem. Everybody uses drugs.”) Applicants respond-ing with open-ended questions or reflective listening re-ceived invitations to interview. In addition to a structuredin-person interview, applicants participated in a recordedmock-telephone interview. Two Motivational Interview-ing Network of Trainers (MINT) trained project staff re-viewed the recordings for both global skills and behaviorcounts as set forth in the Motivational Interviewing Treat-ment Integrity (MITI) 3.0 (Moyers et al., 2007) codingscheme.We selected interventionists based on their abilityto meet the global skill proficiency standard in the MITI(see Appendix for more details).

We hired and trained a total of 15 interventionists, hop-ing to keep caseloads manageable at 20–30 students perinterventionist and to have the same interventionist forall contacts with each student. All interventionists had atleast a 4-year college degree. We provided a minimumof 40 hours of MI training to interventionists and usedthe Video Assessment of Simulated Encounters (VASE-R) as a posttest measure of skill (Rosengren, Baer, Hart-zler, Dunn, & Wells, 2005). The VASE-R presents threevideo scenarios that trainees watch and then provide writ-ten responses to client statements. These statements arethen rated based on established criteria set forth in themanual. All interventionists met these criteria by the endof training (mean score 32 of 36 possible points).

A total of 10 attempts were made to reach each stu-dent during each 8-week call period. If a student couldnot be reached during a contact period, we made an-other 10 attempts during the next call period, which began3 months later. Supervision and coaching were providedby two MINT-trained staff members on a biweekly basisto all interventionists. Because all in-person and telephonecontacts were recorded, supervisors used theMITI to codea randomly selected recording for coaching, or interven-tionists could request that a certain contact be reviewed.During supervision, interventionists received feedback onglobal skills, behavior counts, and adherence to the proto-col.

Data Collection ProceduresStudent SurveyA closed-ended, self-report questionnaire was adminis-tered to students at a pretest, with items that assessed de-mographic characteristics, substance use behaviors, andpsychosocial correlates of substance use. The survey wasadministered on-site during regular classroom periods andtook approximately 20–30 minutes to complete. All studyprocedures, including informed consent, were approvedby the University of Southern California’s InstitutionalReview Board.

Demographic measures included age, gender, and eth-nicity (coded as Latino/Hispanic, Caucasian, AfricanAmerican, Mixed, Asian American, Native American,or Other). To assess substance use, subjects were asked“How many times in the last month have you used. . .” each of 12 different drug categories. Frequency ofcigarette and alcohol use, getting drunk on alcohol, mar-ijuana, and hard drug use (cocaine, hallucinogens, stim-ulants, inhalants, ecstasy, pain killers, tranquilizers, orother hard drugs) were assessed. The responses to the lasteight drug categories (cocaine through other drugs) weresummed to form a hard drug use index (alpha = .82). Re-sponses were reported on 12-point scales, starting at “0times,” increasing in intervals of 10 (e.g., “1–10 times,”“11–20 times,”) with the last (12th) category being “over100 times.”

Recorded MI ContactsWe attempted to record all contacts between the stu-dents and MI interventionists. In-person interviews wererecorded with handheld digital recorders, while telephonecontacts were recorded via a web-based client resourcemanagement (CRM) system. The CRM provided an in-terface for interventionists to access their caseload, keepnotes about their conversations, and complete a processmeasure after each contact. The CRM tracked the date andtime of each attempt, providing information to supervisorsfor staff management purposes.

Client Engagement MeasureFollowing each MI contact, interventionists completed aclient engagement measure that included identifying thetarget behavior and completing six items assessing howcomfortable the interventionist felt during the call, howmuch rapport they felt, how engaged they believed the stu-dent to be, how helpful they found the protocol, their be-liefs about the helpfulness of the call, and the likelihoodthat the participant would follow through with the behav-ior change discussed. For each item, responses were mea-sured using a 5-point Likert scale ranging from not all toextremely. Factor analysis revealed that all items loadedon a single factor with an alpha of .87.

Coding of MI ContactsWe listened to 231 (22%) of the recorded contacts in or-der to assess whether the MI met proficiency standards,whether interventionists adhered to the protocol, and whatbehavior change was targeted during the contact. In order

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422 E. BARNETT ET AL.

to answer future research questions, recordings were cho-sen to include 100% of the conversations with a substanceuse target. They were not stratified. Targets were deter-mined by interventionist report on the client engagementmeasure. We coded recordings using an unpublished ver-sion of the Motivational Interviewing Skill Code (MISC)2.5 provided to us by its developer Dr. Theresa Moy-ers at the University of New Mexico in November 2010.The MISC coding scheme allows one to draw conclu-sions about both counselor skills and client language. Forthis article, we analyzed measures of counselor empa-thy, collaboration, autonomy/support, evocation, and di-rection; as well as behavior counts including open andclosed questions, simple, and complex reflections; andMI consistent and MI nonconsistent behaviors (see Ap-pendix). Instead of using a 20-minute segment of eachtape as suggested in the MITI, we coded the entire lengthof the recording, as our mean recording length was only18.9 minutes. MI proficiency was established using stan-dards set forth in the MITI 3.0 (Moyers et al., 2007). Forfurther details about either coding scheme, please consultthe manuals (http://casaa.unm.edu/codinginst.html).

Coding was conducted using the Center on AlcoholismSubstance Abuse and Addictions (CASAA) Applicationfor Coding Treatment Interactions (CACTI; Glynn, Hall-gren, Houck, McLouth, & Fischer, 2011). This softwarewas designed to automate the parsing of recordings priorto their coding and to store sequential coding of each ut-terance with no manual data entry. Using this process fordouble coding ensures that all coders code the same ut-terances thereby increasing reliability. Although CACTIsoftware does not require or utilize transcripts, we had ourentire sample of recordings transcribed for ease of parsingand coding.

Five graduate level students were provided 40 hours ofinitial training in the MISC 2.5 and the CACTI software.Coders were trained to parse recordings when a new ideawas spoken and/or the speaker shifted. Once a recordinghad been parsed, it was assigned to a different coder, whothen, using CACTI, assigned a code to each utterance.Coders practiced on a series of recordings until their inter-rater reliability was at criterion of 0.60 using establishedintraclass correlation (ICC) guidelines (Cicchetti, 1994).Weekly coding meetings were held throughout codingto improve or maintain reliability. We randomly selected20% of our coded sample using a random number gener-ator. These 47 recordings were double coded in order tocalculate final ICCs. Cicchetti’s criterion identifies ICCsbelow .40 as poor, .40–.59 as fair, .60–.74 as good, andabove .75 as excellent. For our data, final ICCs were .94for open questions, .80 for closed questions, .94 for re-flections overall, .48 for simple reflections, .45 for com-plex reflections, .68 for MI consistent behaviors, and .29for MI inconsistent behaviors. These results indicate thatcoders had some difficulty in differentiating simple reflec-tions from complex reflections and in reliably identifyingMI inconsistent behaviors (see Appendix).

In order to assess fidelity to the protocol, we developeda dichotomous scale to assess whether interventionists ad-

hered to each of its seven components. We coded calls forthe presence of the opening, establishing a target, explor-ing ambivalence, transitional summary, key question, ac-tion plan, and closing as described earlier. Each contactcould earn from 0 to 7 points. Coders also performed areliability check on the target behavior recorded by theinterventionists.

Based on the independent assessment of the coders, 11recordings were removed from the coding sample, as thetarget did not meet criteria as a substance use target. Inorder to be considered a substance use target, substanceuse had to be addressed with the exploration exercise. Forexample, if an interventionist asked about substance useand the student reported that they had cut back, and theinterventionist moved on to another topic, this would notbe considered as a substance use target even though thetopic was addressed.

Data AnalysisDescriptive statistics were calculated on the sample char-acteristics and quality of MI. Multilevel regressions wereconducted to determine predictors of the number of con-tacts received by students (PROC MIXED) and whetherthey discussed a substance use target (PROCGLIMMIX).All analyses were conducted with SAS 9.2 (SAS Institute,2008).

RESULTS

Sample CharacteristicsTable 1 presents the demographic characteristics of thestudent sample with complete data. Approximately 60%of the sample wasmale, with a mean age of 16.8 years (SD

TABLE 1. Sample demographics (N = 573)

Characteristic Percent

GenderFemale 40.3Male 59.7

Age15 years and under 8.216 years old 27.617 years old 44.918 years and over 19.3

EthnicityLatino/Hispanic 67.7Caucasian 6.8Mixed 12.6African American 5.8Other 4.4Asian 2.0Native American 0.7

Drug use prevalence in past 30 daysCigarettes 40.2Alcohol 57.2Drunk 41.8Marijuana 46.2Hard drugs 23.5

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MOTIVATIONAL INTERVIEWING BOOSTER 423

= .96). Student ethnicity was 67.7% Latino, 6.9% Cau-casian, 12.6% Mixed, 5.8% African American, and 7.2%“Other.” The 30-day prevalence of drug use ranged from57.2% using alcohol to 23.5% using hard drugs. Approx-imately 30% of the students reported not using any drug(alcohol, tobacco, marijuana, or hard drugs) in the past 30days.

Description of MI ContactsAmong the 573 students included in the TND+MI condi-tion, 462 (80.6%) were reached for the first contact, 352(61.4%) were reached for the second contact, and 226(39.4%) were reached for the third contact, for a grandtotal of 1,040 contacts (mean contacts per student = 1.8).Overall, we reached 92% of students for at least one con-tact. Of those reached, 31% (n = 178) of students werereached once, 36% (n = 207) were reached twice, and24% (n= 139) were reached three times. Of those reachedtwo and three times, 53% and 38%, respectively, werecontacted by the same interventionist on all contacts. Allothers were contacted by at least two different interven-tionists.

In the final adjusted multilevel linear regression modelwith school as the random effect, the number of contactswas found to be significantly associatedwith both youngerage and living with both parents (p < .05). No significantassociations were found for gender, Latino ethnicity, orbaseline alcohol, tobacco, marijuana, or hard drug use.

Based on our protocol, we intended each MI session totake approximately 20 minutes. After review of our codedsample (n = 231), we determined that the average calllasted 18.9 minutes. Contact length ranged from 5 to 86minutes with 5% of the contacts taking less than 10 min-utes and 10% lasting more than 30 minutes.

Target BehaviorsOver 50% of the contacts focused on graduating or findingeither current or future employment, while substance usetopics accounted for approximately 30% of the conver-sations (see Table 2). The “interpersonal” category (9%)

TABLE 2. Target behaviors in MI contactsa (n = 1,040)

Behavior Number Percent

Graduation 432 41.08Employment 130 12.33Marijuana 116 11.01Interpersonal 91 8.63Drug-related lifestyle 87 8.25Alcohol 57 5.41Tobacco 54 5.12Other 31 2.94Nutrition 24 2.28Physical activity 20 1.90Hard drugs 8 0.76Sex 3 0.28

aTotal does not equal 1,040 as some contacts were coded for multi-ple targets.

TABLE 3. Drug use self-report on survey by drug use targetduring MI intervention (n = 562)

No target drug usebehavior in MIintervention

Target drug usebehavior in MIintervention

No drug useself-reported onsurvey

138 (80.7%) 33 (19.3%)

Drug use self-reportedon survey

227 (56.5%) 175 (43.5%)

contained topics related to self-improvement (e.g., “workon my temper or stop gossiping”). The “other” category(3%) was used for targets that provided specific othertypes of goals (e.g., obtain driver’s license). The drug-related lifestyle category (8%) was used when no specificsubstance was mentioned; rather, the student describedpartying, getting into trouble, hanging in the streets, andusing drugs.

Of those who reported using drugs on the survey,43.5% talked about substance use with the MI interven-tionist at least once. Among students who did not reportdrug use on the survey, 19.3% talked about substance usetargets with the MI interventionist (see Table 3). Amongthe students who received more than one MI session, ifthey did not speak to us about substance use at their firstcontact (n = 330), only 6.3% did so on a subsequent con-tact. For those who did speak to us about substances at thefirst contact (n= 187), 35.3% spoke about it again duringa subsequent contact.

In the final adjusted multilevel logistic regressionmodel with school as the random effect, speaking to usabout a substance-related target behavior was between1.5 and 2 times as likely for those reporting the fol-lowing: male gender (adjusted odds ratio [AdjOR] 1.55;95% confidence interval [C.I.] 1.04, 2.29), baseline mari-juana use (AdjOR 2.07; 95%C.I. 1.37, 3.12), and baselinecigarette use (AdjOR 1.81, 95% C.I. 1.20, 2.11). No sig-nificant associations were found between speaking about asubstance-related target behavior and age, livingwith bothparents (vs. not), Latino ethnicity, or baseline alcohol orhard drug use.

Quality of Motivational InterviewingOn average, the intervention met the proficiency standardput forth in the MITI guidelines, exceeding the standardfor all global measures and behavior counts (see Table 4).Eighty eight percent of the contacts exceeded proficiencyin percent MI Consistent behaviors, 68% exceeded profi-ciency in percent complex reflection, 62% exceeded pro-ficiency in percent open question, and 64% exceeded pro-ficiency in reflection to question ratio.

Fidelity to ProtocolThe majority of calls (69%) had five or more componentsof the structure. The component most likely to be ex-cluded was creating a change plan; only 40% of the calls

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TABLE 4. MI Proficiency (n = 231)

MITI proficiencystandard Average Std. dev.

Global SkillsEvocation 3.5 3.63 0.77Collaboration 3.5 4.00 0.82Autonomy 3.5 3.78 0.70Direction 3.5 4.18 0.90Empathy 3.5 3.95 0.69

Behavior count summary scoresPercent MIconsistent

90% 98.9%

Percent openquestion

50% 56.8%

Percent complex 40% 56.2%Reflection toquestion ratio

1:1 1.33

contained this element. The change plan was excludedwhen, in response to the transitional question, students in-dicated that they were not interested in making an actionplan Client Engagement Measure Data. Overall, the en-gagement of clients was perceived by the interventioniststo be moderately high. On the five-point scales, mean (sd)responses ranged from a low of 3.1 (.85) for the helpful-ness of the call to a high of 3.5 (.94) for student engage-ment.

DISCUSSION

The data presented in this evaluation suggest that MI canbe feasibly used as an adjunct to classroom-based preven-tion programs and that reasonable fidelity can be obtained.The protocol developed for this project provided adequatestructure and flexibility for the interventionists. Target be-haviors were established in 92% of theMI contacts. Basedon the findings from our coded sample, almost three quar-ters of the contacts included at least five of the seven proto-col components. Feedback from interventionists indicatedthat the addition of a face-to-face contact at the outset in-creased their comfort and confidence when trying to reachstudents by telephone, and the CRM telephone recordingsystem allowed for easymonitoring of interventionist’s ef-fort as well as data management.

To our knowledge, this booster is the first to offer MIin conjunction with a classroom-based targeted substanceabuse prevention program, designed for youth at psy-chosocial or behavioral risk for substance misuse, makingit unique in that MI sessions not only addressed substanceuse, but also myriad other life issues relevant to adoles-cents (e.g., graduating, employment). Furthermore, it dif-fered from other MI applications as it was conceived ofas a motivational “booster” to be administered every fewmonths, rather than an opportunistic intervention for peo-ple exhibiting substance use problems or a pretreatmentactivity to enhance readiness to change.

The majority of students in our study chose to discussgraduating and seeking employment as a target or goalthat they were pursuing. In general, students did not ex-press ambivalence about accomplishing these goals, sointerventionists chose to focus more on action planning.This finding causes us to consider whether interventionistsneeded to be better prepared to deal with change planningrather than exploring ambivalence about change, which isoften emphasized in anMI approach. In addition, it is pos-sible that providing booster programming primarily aimedat helping youth graduate and find employment, with sec-ondary messages that drug use is inconsistent with thosegoals, is more appropriate than a primary focus of sub-stance use prevention for youth in continuation or alterna-tive high school settings.

At baseline, more than one fourth of the students whoparticipated in the MI booster reported that they had notused any substances in the past 30 days. Data show that thebooster encouraged 33 of 167 students to disclose druguse that they did not report on their pretest survey. Thestudy is also notable among the adolescent MI literaturefor its sample size, over 1,000 contacts with more than550 students. Although the data are nested within schools,the sample size will allow investigators sufficient power todetect effects regarding mechanisms of change.

The implementation and evaluation also conformed tobest practices with respect to training, monitoring, super-vision, and evaluation. Training, supervision, booster de-velopment, and project management were provided bytwo MINT trained trainers, under the advisement of athird. Contacts were reliably recorded using a web-basedCRM system, giving supervisors remote and immediateaccess to recordings, allowing the opportunity to monitor,code, and coach interventionists throughout the interven-tion. Thus, it was possible to address concerns identifiedwithin the MI literature that interventionist competence isfrequently not reported, not monitored consistently, or notperformed using standardized instruments (Dunn, Deroo,& Rivara, 2001; Kealey et al., 2009). Without rigorousmonitoring that employs tools designed specifically to as-sess MI, it is impossible to determine whether or not “mo-tivational interviewing” interventions actually conform toMI standards. In this study, on averageMI quality reachedMITI proficiency standards for all behavior count andglobal measure indicators. Furthermore, the coding wasdone with the most recent version of the MISC, and usedthe CASAA CACTI for the first time outside of the Uni-versity of New Mexico.

Limitations of the booster implementation include sev-eral staffing issues. First, we encountered difficulty inretaining interventionists due to the schedule for theirwork, which involved making calls after school and in theevening and weekend hours during 3-month intervals forthe 2-year duration of the project. It was also difficult forinterventionists to maintain the perseverance necessary toreach participants via telephone with an average of sixattempts per successful telephone contact. As a result ofstaffing issues, nearly one third (32%) of students spoketo multiple interventionists. Staff turnover might have

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MOTIVATIONAL INTERVIEWING BOOSTER 425

jeopardized the development of successful helping rela-tionships, which might have decreased our ability to reachparticipants. Ultimately, only 25%of the students receivedthe full 3-session intervention. Kealey et al. (2009) re-ported the ability to reach 53.2% (756) participants for allplanned counseling calls; however, their intervention de-sign was significantly different from ours. In the presentstudy, theMI contacts were conceived of as a “booster” formotivation and occurred approximately every 3 months.Whereas, in the Peterson and Kealey’s design, contactsoccurred within close succession to each other. Ninety-eight (17.1%) students had an MI contact at school only,meaning we never reached them by telephone despite re-peated attempts during both contact periods, suggestingsome limitations with the telephone modality. Our experi-ence suggests that the students’ ability to screen telephonecalls facilitated avoiding the contacts. It was not uncom-mon for students to ask to be contacted at a later time andthen proceed to ignore the attempt to reach them. Theseavoidance behaviors were likely the most important fac-tor contributing to our retention rates.

One limitation relates to the measurement of the qual-ity of the MI sessions. Despite an “excellent” ICC of.94 for the ability to differentiate reflections from otherbehaviors, we found “fair” ICCs for differentiating re-flections into subcategories of simple (.48) and complex(.45) reflections, even with ongoing weekly supervisionand training of coders. This suggests perhaps larger is-sues with the assessment of these behaviors in the MISC.Differentiating between simple and complex reflectionsrequires determining whether or not the interventionistadded meaning, emphasis, additional points, or directionto a client statement. Also, as noted by the authors of theMISC, behaviors that occur infrequently are often diffi-cult to be coded reliably, hencewe believe this explains the“poor” ICC for codingMI inconsistent behaviors found inthis study (Moyers, Martin, Catley, Harris, & Ahluwalia,2003). Our coding revealed that only 7 of 231 (.03%)recordings contained any MI inconsistent behaviors.

In addition, while the averageMITI scores for the inter-ventionists were above established proficiency, the stan-dard deviations indicate that there was variation across in-terventionists. This finding is not atypical of MITI scorevariations due to the subjective nature of their coding.

An additional limitation should be noted that althoughover 40% of students reported drinking in the past 30 days,only approximately 5% of students chose alcohol use asthe target behavior. Possible explanations for this discrep-ancy include that students do not perceive their alcoholuse as problematic and therefore do not see the need tochange it, and perhaps the high rates of reported alcoholuse co-occur with other drugs, which students are morelikely to discuss due to their perception of these drugs ascausing problems for them.

In future analyses of these data, we will examinewhether the quality of theMI differentially affects the con-tent of the contacts, student retention, and successful be-havior change.We will examine possible effects of havingcontact with multiple interventionists on client engage-

ment. We will also be able to examine sequential effectsof participant and interventionist utterances on subsequentsessions and drug use outcomes. In future investigations, itwill be important to determine how, in a similar context,interventionists could achieve greater disclosure of sub-stance use issues. For instance, participants might be moreforthcoming about drug and alcohol use with intervention-ists with whom they have established a regular, trustingrelationship.

Ultimately, this study brings us one step closer to an-swering important implementation and program develop-ment questions in our efforts to prevent and reduce sub-stance use among at-risk adolescents. Furthermore, weconclude that this implementation was conducted withsufficient fidelity to infer that any incremental effects ob-served at subsequent follow-ups may be attributed to theinclusion of the MI booster.

GLOSSARY

Motivational Interviewing (MI): A client-centered coun-seling style designed to explore and resolve ambiva-lence about behavior change.

Motivational Interviewing Treatment Integrity (MITI): Acoding scheme meant to assess counselor adherence tothe practice of MI.

Motivational Interviewing Skill Code (MISC): A codingscheme that assesses both counselor adherence to MIand client language regarding desire, ability, reason,need, and commitment to change behavior.

Declaration of Interest

The authors report no conflicts of interest. The authorsalone are responsible for the content and writing of thearticle.

RESUME

Mots-cles: adolescent, entrevue motivationnelle, abusde substances psychoactives, toxicomanie, alcoolisme,prevention, intervention, telephone, scolaire, stimulant

Une breve intervention faisant appel a la techniqued’entrevue motivationnelle pourra constituer une aide vi-able dans les programmes de prevention de l’abus desubstances psychoactives dans le cadre scolaire. Cet ar-ticle decrit la mise au point et la mise en œuvre d’unebreve intervention de ce type aupres de 573 adolescents(age moyen, 16,8 ans, 40,3 % de jeunes filles, 68%d’Hispaniques) inscrits dans 8 ecoles secondaires post-scolaires de Californie du Sud. Les participants a l’etudeont ete affectes a cette intervention lors d’un essai controlerandomise dans le cadre du Project Toward No DrugAbuse (Projet vers le zero usage abusif de substances psy-choactives). Des donnees sont fournies sur le dosage, lessujets discutes et la qualite de l’entrevue motivationnelledeterminee a l’aide du code Motivational InterviewingSkill Code (soit MISC, code de competence en interview

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426 E. BARNETT ET AL.

motivationnelle). Les resultats suggerent que le protocoles’est revele realisable et qu’il a ete mis en œuvre avec unefidelite adequate.

RESUMEN

Palabras clave: adolescente, entrevista motivadora,abuso de sustancias, prevencion, intervencion,telefono, basado en la escuela, refuerzo

Una breve intervencion con una entrevista motivadora(MI, siglas en ingles) podrıa ser un complemento viablede los programas de prevencion de abuso de sustanciasbasados en la escuela. Este documento describe el desar-rollo e implementacion de una breve intervencion con unaentrevista motivadora con 573 adolescentes (de una edadpromedio de 16.8; 40.3% mujeres, 68% latinos) inscritosen 8 preparatorias de continuacion en el sur de Califor-nia. Los participantes en el estudio fueron asignados a lacondicion de EntrevistaMotivadora en una prueba contro-lada al azar del Proyecto Tendiente a Evitar el Abuso deDrogas. Los datos incluyen las dosis, los temas tratadosy la calidad de las entrevistas motivadoras determinadosmediante el uso del Codigo de Aptitudes para las Entrevis-tas Motivadoras (MISC, siglas en ingles). Los resultadossugieren que el protocolo fue viable y que fue implemen-tado con la fidelidad apropiada.

THE AUTHORSMs. Elizabeth Barnett receivedher M.S.W. from BostonUniversity in 2000 and is apredoctoral student at the KeckSchool of Medicine, Universityof Southern California. Hercurrent research interestsinclude the use of motivationalinterviewing with adolescentsubstance users.

Dr. Donna Spruijt-Metz’research focuses on pediatricobesity and is particularlyconcerned with understandinghow psychosocial, metabolicbuilt environmental, and socialenvironmental forces interactto influence behavior andhealth. She has studied childfeeding practices and the impactthat these have on childhoodobesity. She received her Ph.D.in Adolescent Medicine and

Medical Ethics from the Vrije Universitiet Amsterdam. She isan Associate Professor at the University of Southern California’sDepartment of Preventive Medicine and Director, ResponsibleConduct in Research for the Keck School of Medicine.

Dr. Jennifer B. Unger isa Professor of PreventiveMedicine at the Keck Schoolof Medicine, Universityof Southern California.Her research focuses onpsychological, social, andcultural risk and protectivefactors for substance use amongadolescents.

Dr. Ping Sun received hisPh.D. in Preventive Medicinein 1999 from the University ofSouth Carolina (USC) School ofMedicine. His current researchinterests include etiologyof addiction and outcomeevaluation for group randomizedhealth studies.

Dr. Louise A. Rohrbach iscurrently an Associate Professorof Preventive Medicine atInstitute for Health Promotionand Disease PreventionResearch, in the Keck Schoolof Medicine, University ofSouthern California. Herresearch focuses on interventionsto prevent tobacco, alcohol, andother drug abuse among youth.Currently, her primary emphasisis translational research,

including investigation of factors that explain and strategies thatenhance the dissemination and implementation of evidence-basedprograms and practices in real-world settings. She has been theprincipal investigator on a number of National Institutes of Healthfunded studies and program evaluations and has published widelyin the areas of substance use prevention, school-based health, andetiology of adolescent substance use.

Dr. Steve Sussman, Ph.D.,FAAHB, FAPA, received hisdoctorate in social-clinicalpsychology from the Universityof Illinois at Chicago in 1984.He is a professor of preventivemedicine and psychology atthe University of SouthernCalifornia, and he has beenat the USC for 27 years. Hestudies etiology, prevention, andcessation within the addictionsarena, broadly defined. He has

over 385 publications. His programs include Project Towards NoTobacco Use, Project Towards No Drug Abuse, and Project EX,which are considered model programs at numerous agencies (i.e.,Centers for Disease Control and Prevention, National Institute

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MOTIVATIONAL INTERVIEWING BOOSTER 427

on Drug Abuse, National Cancer Institute, Office of JuvenileJustice and Delinquency Prevention, Substance Abuse and MentalHealth Services Administration, Center for Substance AbusePrevention, Colorado and Maryland Blueprints, Health Canada,U.S. Department of Energy, and various State Departments ofEducation). He received the honor of Research Laureate for theAmerican Academy of Health Behavior in 2005, and he wasPresident there (2007–2008). Also, as of 2007, he received thehonor of Fellow of the American Psychological Association(Division 50, Addictions). He is the current Editor of Evaluation& the Health Professions (SAGE Publications).

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Appendix: Explanation of Motivational Interviewing Proficiency Data

Measure Description Example

Behavior CountsOpen Questions (OQ) Questions intended to elicit more than a yes/no or

specific answerTell me about . . . What are your thoughts?

Closed Questions (CQ) Questions that elicit yes/no or specificinformation.

When did you start? Did you try . . ..?

Simple Reflections (SR) Statements made to demonstrate that thecounselor hears what the subject has said.

“So one reason to quit is your health”

Complex Reflections (CR) Statements that attempt to convey the underlyingmeaning of what the subject said

“So you’re health is something that’s reallyimportant to you”

MI Consistent Behaviors (MICO) Counselor statements that affirm clients’ strengthsor efforts, show support, ask permission beforeproceeding, or emphasize personal choice orcontrol

“It’s great that you are trying so hard.”

MI Inconsistent Behaviors (MIIN) Counselor statements that are inconsistent withthe philosophy of MI such as advising,confronting, warning without permission.

“You know you should really stop smoking.”

Behavior Count Summary ScoresPercent Complex Reflection CR/ SR + CRPercent Open Question OQ/OQ + CQPercent MICO MICO/ MICO + MIINQuestion to Reflection Ratio SR+CR/OQ + CQ

Global MeasuresAutonomy Counselor support of client autonomyCollaboration Counselor ability to treat client as a partnerEvocation Counselor ability to draw out client’s reasons and

ideas about changeEmpathy Counselor ability to demonstrate understanding of

the client’s perspectiveDirection Counselor ability to remain focused on a

behavioral change target

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