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Videotaped Training in Alcohol Counseling for Obstetric Care Practitioners: A Randomized Controlled Trial

From the Alcohol Self-Control Program, Research Division, Behavior Therapy Associates, Albuquerque, New Mexico, and the Psychology Department, University of New Mexico, Albuquerque, New Mexico.

Address reprint requests to: Reid K. Hester, PhD Behavior Therapy Associates 3810 Osuna Road NE, Suite 1 Albuquerque, NM 87109 E-mail: rhester{at}unm.edu

	Abstract

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Objective: To determine the feasibility of videotaped training for obstetric care practitioners in motivational interviewing skills that could be used in brief patient consultations on problem drinking.

Methods: Thirty health care practitioners participated in a clinical trial using a 20-minute videotape to instruct them in motivational interviewing. Participants engaged in a pretest roleplay with an actress playing a drinking pregnant woman. Those randomly assigned to the experimental condition watched the motivational interviewing videotape. Control condition participants watched a 20-minute docu-drama of a pregnant problem drinker. Both groups then engaged in a post-test roleplay similar to the pretest. Behavioral ratings of the roleplays and participant evaluations of the motivational interviewing video constituted the outcome measures.

Results: Participant evaluations indicated that the training video was clear in explaining and demonstrating the principles and skills of motivational interviewing. Change in behavioral ratings from pretest to post-test showed significant differences in motivational interviewing skills between the experimental and control groups. Obstetric care practitioners who viewed the training video were rated as showing greater empathy, minimizing patient defensiveness, and supporting women’s beliefs in their ability to change.

Conclusion: Obstetric care practitioners can improve their alcohol intervention skills through the use of a 20-minute videotaped instruction in motivational interviewing. Clinicians who improve their skills in motivational interviewing can intervene more effectively with their drinking pregnant patients. Using motivational interviewing with this population holds promise for helping prevent alcohol-related health problems.

Fetal alcohol exposure is the leading known cause of mental retardation in this country. However, mental retardation represents only a portion of the permanently disabling effects linked to brain damage caused by prenatal alcohol consumption.¹ Excessive drinking during pregnancy is associated with maternal health problems, stillbirths, and delivery complications, and with other behaviors that compromise maternal and fetal health, such as smoking and illicit drug use. Although obstetric care practitioners advise pregnant women to abstain, about one in five continues to drink.¹

Prevention efforts held in prenatal clinics showed favorable outcomes^2–7; however, health care practitioners lack intervention skills. Most medical schools and continuing medical education courses offer minimal, if any, training in alcohol counseling, and little time is available for education after beginning a practice.⁸ Training opportunities are needed for strategies that foster patient compliance with advice to abstain and with referrals to alcohol treatment suitable for brief patient consultations.

In the past 2 decades, randomized clinical trials in primary health care settings have shown that brief interventions (one or two contacts) conducted by health care practitioners can significantly reduce drinking, improve health, and increase the rate of successful referrals to alcohol treatment.⁹ In the absence of addiction treatment, the primary effect of brief interventions is increased patient motivation. Miller and Rollnick¹⁰ combined the essential elements of brief interventions into a therapeutic technique known as motivational interviewing. The crux of motivational interviewing is to help patients explore and resolve their ambivalence about change. Critical to resolving ambivalence is increasing the discrepancy between the patient’s risky drinking behavior and desired goals or values. A fundamental principle is to avoid eliciting defensive reactions from the patient. Essential to minimizing confrontation and patient defensiveness is empathic listening skills. In an analysis of feedback from a two-session motivational intervention, the Drinker’s Check-up,¹¹ empathic therapist style predicted decreased client defensiveness. The opposite also was true, that is, when the therapist was more overtly confrontational, the client reacted defensively. Client defensiveness elicited during these single, 1-hour sessions was predictive of greater drinking up to 1 year later.

Randomized clinical studies of motivational interviewing^12,13 demonstrated reduced drinking when offered as the sole intervention for problem drinkers, and increased compliance when used as a prelude to treatment for alcoholics and drug abusers. In a study of these methods with a pregnant population,¹⁴ a significant reduction in drinks consumed per drinking occasion (ie, lower peak blood alcohol concentration) was found for the heaviest drinkers who received the motivational interview versus the patients in the control group at 2-month follow-up. The purpose of this study was to develop and test the feasibility of a brief videotape for training obstetric care practitioners in motivational interviewing skills.

	Materials and Methods

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There are four levels of outcome in evaluating effectiveness of training in a clinical skill. The first level is feedback from the participants about clarity, length, and satisfaction with the training. The second level is whether there is any demonstrable change in the skill levels of those participating in the training. The third is whether the participants use these skills in their clinical practices. Fourth is whether the changes in their practices affect the behaviors of their patients. Because this project was a 6-month video development and feasibility study, only the first two levels of outcome were evaluated.

Women’s health care practitioners on staff at Presbyterian Healthcare System in Albuquerque were invited to participate in a study of the effect of videotaped training on their skills counseling pregnant drinkers, with study approval by Presbyterian’s Institutional Review Board. To help recruit busy practitioners, participants were paid $100 each for participation. Those willing to participate were phoned and scheduled for 1-hour appointments. The first 30 practitioners who met their scheduled appointments were included in the study: ten physicians, eight certified medical assistants, eight nurses, three nurse practitioners, and two midwives. Ninety percent were female. The ethnic distribution was 20% Hispanic, 76% white, and 4% native American. Nine participants had previous training or experience in counseling. Only four had any alcohol counseling experience.

After they consented, participants were asked to read brief vignettes of patients for pretest roleplays. There were two vignettes, which were based on composites of actual patients and were intended to represent obstetric patients for whom motivational intervention would be helpful toward their readiness for alcohol treatment. One vignette was of a 23-year-old, unmarried woman in her 20th week of pregnancy, whose binge drinking caused minimal obvious impairment to her functioning. The second case was of a 30-year-old, married woman in her 15th gestational week, with a history of alcohol dependence, who recognized drinking as a problem, but who felt incapable of changing. To avoid an interaction between the character played in the vignette with the order of the roleplay, a coin was flipped to determine which vignette was used first for every participant.

The participants were told they would be videotaped for up to 10 minutes while they counseled the role-played pregnant patient about her drinking. To avoid experimenter bias, the participants were assigned, using a restricted randomization procedure, to either the experimental or the control group after the pretest roleplay. To have equal numbers in the groups, group assignment was determined in pairs. The first participant of each pair was assigned to a group by a flip of the coin. The other participant was assigned to the other condition. The categories of practitioners were distributed evenly between the control and treatment groups. The two most prevalent categories of practitioners, physicians and medical assistants, ended up being assigned randomly in exactly equal numbers to the two conditions, ie, five were physicians in the control and five in the experimental condition, and similarly, four medical assistants in the control and four in the experimental condition. Six of the other 12 participants filled out the required number of subjects in the control and experimental conditions.

The experimental subjects viewed the 20-minute motivational interview training videotape. The video presented the essential components of motivational interviewing: expressing empathy, warmth, and acceptance; contrasting the patient’s values with her drinking; avoiding confrontation; minimizing defensiveness; and supporting the patient’s belief in her ability to change. Specific strategies of asking open-ended questions (eg, "What are your concerns about your drinking?"), empathic reflection of her responses (eg, "You have been very clear that it’s important to stop drinking for your family and your baby’s health"), asking for a drinking reduction goal, and making a referral.

The control group watched a 20-minute docudrama developed as an intervention for pregnant alcohol and substance abusers. The film portrayed a young pregnant alcohol and substance user who was being counseled by a health care practitioner and a mother of a child with fetal alcohol syndrome. After viewing their respective films, the participants followed the same procedures as in the pretest, reading the vignette and role-playing a consultation. After viewing the training videotape, both groups were asked to complete a questionnaire to address the first-level outcome analysis of the summary statistics on their feedback.

The actresses were referred by local talent agencies and selected by videotaped audition. The two chosen were judged unanimously as the best by several observers, including the researchers and the film production staff. The actresses were assigned to the vignette in which they were most convincing in the role. Actresses were instructed to act according to how their characters might respond to the practitioners. Each actress rehearsed her part with the researchers in six 10-minute videotaped segments. These tapes were used later for training the raters. During the roleplays, the actresses were not informed of the participants’ group assignments. The researchers and role-players waited in separate rooms while the participants watched the videotapes.

Two graduate students in clinical psychology rated each roleplay independently. The counseling segments for all the participants were copied on to two separate videotapes, one for each of the vignettes. The raters were not informed of participant group assignment or whether they were viewing the pretest or post-test roleplays. One rater had a background in obstetric-gynecologic nursing. The other had specialized training and experience in alcohol counseling. Both had completed the introductory classes and practica in interviewing for clinical psychology. The raters were trained by the senior author in the observational rating methods, using the role-played segments mentioned above.

The second-level outcome analyses involved an examination of the participants’ interviewing skills in their pretest and post-test roleplays, as evaluated on our interviewer behavior rating scale. These were evaluated first through more global, qualitative ratings of the interviewer’s manner using a five-point Likert scale, and then through more analytical, quantitative measures of the interviewer’s behavior. In terms of global ratings, in keeping with the goals of the motivational interviewing training, the primary dimensions rated were the clinician’s empathy, the clinician’s contrasting of the patient’s values with her drinking, the clinician’s effectiveness in dealing with defensiveness, and the clinician’s support of the patient’s belief in her ability to change. The mean of the two raters’ responses on each of these Likert scales was used as the value of the dependent variable for the primary analyses of treatment effects. To adjust for preexisting differences, multivariate analyses of covariance were used to test for group differences using the mean pretest rating on the corresponding variable. This allowed for adjustment for any differences among subjects that might have resulted from variation in the previous training or experience of the health care practitioners. Finally, the raters noted whether the health care practitioners asked the client to make a decision about her drinking, made a referral, or talked about the risks of drinking and fetal alcohol syndrome during the roleplay. In quantitative terms of interviewer behavior, the breakdown of time spent on various behaviors and counts of different kinds of statements made by the health care practitioners in the role play also were analyzed. The counts of behaviors included empathic, supportive statements and open-ended questions eliciting reasons for change versus confrontational statements (eg, "Hey, wise up. You’ve got to stop drinking.")

	Results

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Responses of the health care practitioners to the video were uniformly positive for the first level of outcomes. On five-point Likert scales (1 = strongly disagree to 5 = strongly agree), they reported that the essential skills of motivational interviewing demonstrated were clear and easy to understand (range of means = 4.0–4.4, range of standard deviations [SDs] = .8–1.0). They also reported that the length of the training video was appropriate for its goals (mean = 4.2, SD = .8), that the amount of information presented was about right (mean = 4.1, SD = .9), that the companion guide was helpful (mean = 4.2, SD = 1.0), their overall satisfaction with the training (mean = 4.4, SD = .8), and whether they would recommend the training program to others (mean = 4.5, SD = .9).

The mean values averaging across the 15 individuals in each group on the primary dimensions of interviewer behavior, evaluated by the two raters, are shown in Table 1. Before treatment, there were no significant differences on t tests comparing the experimental and control groups on any of the four dimensions in the pretest role play, P > .10. In contrast, t tests of the group effect on the post-test roleplay indicated a significant advantage for the experimental group on each of the four dimensions, P < .05. Of greatest interest was the result of a multivariate test comparing the interviewing skills of the experimental and control participants on the post-test role play, which was significant: F(4,21) = 2.848, P .05. Follow-up univariate analyses of covariance of each dimension separately covarying the corresponding pretest rating indicated that the mean ratings of these interviewing skills were consistently higher in the experimental group than the control group. Specifically, health care practitioners who watched the training video showed greater empathy than control group participants (F[1,27] = 11.783, P = .002). Although there was a substantial change from pretest to post-test in the extent to which patient’s values were contrasted with her drinking, the experimental group mean post-test was not quite significantly greater than that of the control group (F[1,27] = 6.845, P = .060). Experimental group participants minimized defensiveness more than control group participants (F[1,27] = 6.457, P = .017). Experimental group participants supported the patient’s belief in her ability to change more than control group participants (F[1,27] = 11.822, P = .002).

Also of interest were the effect sizes for the between-group differences based on post-test means. These were computed by dividing the difference between the experimental and control group means by the pooled within-group SD. Using Cohen’s criteria,¹⁵ large effects of motivational interviewing training were observed for expressing empathy (d = 1.32), contrasting values (d = .89), minimizing defensiveness (d = 1.11), and supporting self-efficacy (d = 1.09) relative to controls.

The amount of time health care practitioners spent talking in the 10-minute post-test roleplay did not differ across conditions (P > .2). The control health care practitioners actually spent a greater amount of time (5.31 minutes) than the experimental health care practitioners (3.92 minutes) talking about drinking in this post-test roleplay (F[1,27] = 4.858, P = .036). The experimental group tended to make a greater number of statements showing motivational interviewing skills than the control group. The summary measure on the number of empathic statements or open-ended questions as opposed to confrontational statements did not differ across groups in the pretest role play (P > .1). In the post-test roleplay, the experimental group mean on this summary measure was more than twice that in the control group (6.13 versus 2.93). Although a t test comparing these post-test means was significant (t = 2.283, P = .030), when the pretest values were covaried, the test of the group effect missed significance (F[1,27] = 3.739, P = .064).

The raters noted whether the health care practitioners asked the woman to make a decision about her drinking, made a referral, or talked about the risks of drinking and fetal alcohol syndrome during the role-play. Using Fisher’s exact test, there were no differences across conditions in any of these categoric variables at pretest. At post-test, although the control clinicians had a slightly higher tendency to talk about risks of drinking and fetal alcohol syndrome (P = .109), the only difference to reach significance was the percentage of clinicians asking for a decision, which was clearly greater in the experimental group (80%) than in the control group (27%) (P = .009).

	Discussion

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The results of this study suggest that it is feasible to use brief videotaped instruction for training obstetric care practitioners in skills to reduce alcohol use. The randomly assigned group of practitioners who viewed the 20-minute training videotape showed significantly more improvement on global ratings of motivational interviewing attributes during their post-test roleplays than the group who watched the film portraying counseling for a pregnant problem drinker. The training group showed more empathy, warmth, and acceptance; more optimism, overt support of the role-played patients’ beliefs about changing; and more skill in minimizing defensiveness, whereas the control group showed a decline in these dimensions. Both groups improved significantly in their efforts to contrast core values with drinking. Apparently, the docudrama seen by the control group raised concern about alcohol-related birth defects but offered minimal practical strategies for intervening. In contrast, the practitioners who watched motivational interview training learned a narrow set of skills quickly. For example, more in the experimental group (80%) asked their role-played patients for a decision about drinking (eg, "What do you think you should do about your drinking?") than the control group (20%). This also is an example of how the training group was directing the consultation more effectively toward a commitment to change, even though they spent significantly less time talking about drinking. A major difference seen in the effect of the docudrama versus skill training was that the latter led to change in the practitioner’s behavior in a predictable direction. Increased awareness about the problem in the absence of skill training with the docudrama led to more overtly confrontational practices, associated with negative patient outcomes. This is an important distinction, because many prevention training efforts are aimed at increasing knowledge and not at skill training in empirically based counseling approaches.

The small sample size of predominantly female practitioners presents limitations to the generalizability of these findings. The practitioners also were paid for their participation. Although most of the control group viewed the film and returned favorable ratings even after receiving their compensation, it is arguable that busy practitioners would not view the training film on their own and that the ratings were biased.

The principal challenges to this study are whether the practitioners would incorporate the alcohol counseling skills learned from videotaped training into their patient consultations, and if so, whether they would affect their patients’ drinking behavior. Although it was shown that abridged training from a videotape improved practitioner communication skills significantly, the average behavioral ratings were in the low-to-mid range. This suggests that those who saw the training film were off to a good start, but they were not proficient in motivational skills. It should be noted that this is the first study to include pretest and post-test role-plays immediately after videotaped training in motivational interviewing skills. Consequently, the cutoff for determining proficiency is not yet established. Even more extensive training in analogous patient-centered approaches has not yielded such consistent, large, positive changes⁸ in practitioner interviewing skills. Practice with periodic feedback from a trainer would probably lead to greater proficiency without imposing too much of a burden of cost or time on the practitioner. The optimal length and essential components of motivational interview training are empirical questions that this study begins to address. Future research with behavioral ratings of actual physician-patient interviews and patient drinking outcomes is needed.

	Footnotes

 
This study was supported by grant R44AA10175-01A2 from the National Institute on Alcohol Abuse and Alcoholism, "Secondary prevention of fetal alcohol syndrome."

PII S0029-7844(98)00377-9

Received February 11, 1998. Received in revised form July 6, 1998. Accepted July 30, 1998.

	References

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