Counselor Ratings Research Articles

Analysis of the Counseling Competency Scale-Revised Using Trainees’ Self-Assessment Data

Objective The Counseling Competencies Scale – Revised (CCS-R) measures counselor trainees’ therapeutic skills and dispositions and is a tool for counseling outcome research and evaluation. Prior research on the CCS-R has focused on supervisors’ ratings of counselors’ competencies. Our study evaluated the factor structure of CCS-R scores based on the counselors’ self-reports. Method The present study utilized confirmatory factor analysis to test if the factor structure of the CCS-R fits using self-reported scores on the measure. Results The data (N = 998) produced a good fit with the factor structure of the CCS-R. Conclusions The results demonstrated that the CCS-R model from prior research is consistent when the scale is used as a self-report measure. The results demonstrated evidence of construct validity when applying CCS-R as a supervisee self-report tool. Future research can look for additional ways to demonstrate the construct validity of the CCS-R across different supervisee groups.

The association between counselor ratings of working alliance and in‐session empathy among sex offender counselors

AbstractFactors such as the therapeutic relationship and working alliance have been shown to be important predictors for client outcomes in broad counseling settings with diverse client populations. The present study used linear multiple regression analysis to explore how relational factors such as in‐session empathy and mindfulness impact working alliance when providing sex offender counseling. Results from sex offender counselor participants (N = 109) showed that the perspective taking aspect of empathy was most impactful on working alliance and that in‐session mindfulness was less impactful on working alliance.

Examining bidirectional associations between sleep and behavior among children with attention-deficit/hyperactivity disorder.

Children with attention-deficit/hyperactivity disorder (ADHD) have more sleep problems than their peers which contribute to behavioral and functional impairments. This study examines the bidirectional relationship between nightly sleep (i.e., total sleep time and sleep efficiency) and daily behavior of children with ADHD. Forty-three children (ages 6-13 [mean=9.05, 54% male, 77% medicated]) participated in a 2-week study during an ADHD Summer Treatment Program (STP). Sleep was measured with actigraphy. Behavior was assessed using STP clinical data and daily parent and counselor ratings of ADHD symptoms, oppositional defiant disorder behaviors, and emotion regulation (e.g., difficulty regulating emotional disposition and controlling emotions). We hypothesized that healthier night's sleep measured by actigraphy (i.e., sleep efficiency and total sleep time [TST]) would relate to less ADHD symptoms, less emotional dysregulation, and better academic performance the next day. Additionally, we hypothesized that less ADHD symptoms, less emotional dysregulation, and greater academic performance would relate to healthier sleep that night. Higher nightly sleep efficiency was related to improved parent-ratings of ADHD the next day (R 2=0.04, p=0.04) and improved parent-ratings of ADHD during the day lead to higher sleep efficiency that night (R 2=0.002, p=0.02). Higher rates of daily assignment completion were related to higher sleep efficiency at night (R 2=0.035, p=0.03). TST was not related to any behavioral outcomes. Sleep efficiency may be more relevant than TST to behavioral performance the next day. Additionally, a bidirectional relationship exists between sleep efficiency and parent ratings of ADHD. Findings highlight the importance of assessing for manifestations of poor sleep efficiency, waking minutes, and wakings after sleep onset when diagnosing and treating ADHD.

Can we Modulate Therapeutic Interpersonal Style Experimentally to Address Alliance? A Proof-of-Concept Study

BackgroundWith a lack of experimental designs that explore which therapeutic style is helpful for which patient, the aim of this study was to test the feasibility of experimentally varying the therapeutic style under realistic conditions and to investigate how this affects alliance ratings by clients and counselors.MethodsWe defined two manualized therapeutic styles (neutral/distant relational style vs. high affiliation relational style) based on the interpersonal circumplex. In a randomized two-group design, 64 healthy university students (70% female, Mage = 23.78, SDage = 2.81) received a single psychological counseling session on interpersonal conflicts by one of four counselors and in one of the two styles. We checked the manipulation success using observer-rated degree of affiliation and ratings of counselors’ interpersonal behavior with the Interpersonal Message Inventory (IMI-R). A series of linear regression models analyzed whether the style predicted working alliance, assessed via the Working Alliance Inventory (WAI).ResultsIn accordance with the hypotheses, significant differences in the rated degree of affiliation (p ≤ .001) and IMI-R ratings (p ≤ .001 in friendly, p = .003 in hostile dimension) were found between the two groups. Overall, alliance ratings were high across groups and raters (WAI overall scores ranging from 3.76 to 4.07). The style did not predict clients’ alliance ratings.ConclusionThe experimental variation of the therapeutic style proved feasible under realistic conditions with high overall alliance ratings. The novel experimental design may provide a basis for further research.

Client-Rated Working Alliance Quality Relates to Perceptions of Therapists as Trustworthy Experts, Rather Than to Therapists' Positive Nonverbal Behavior

Introduction: The present study sought a better understanding of the sources of client-perceived quality of the working alliance. Methods: At the end of psychotherapy sessions 3 and 5, 60 outpatient clients completed the Working Alliance Inventory-client form (WAI-c) and the Counselor Rating Form (CRF) measuring perceived therapists’ social power. At the same time, therapists estimated their clients’ WAI-c ratings (WAI-c-t). Also, frequency/duration of seven video-recorded positive nonverbal therapist behaviors in session 3 were coded. Results: WAI-c correlations with CRF were high (rs = .62 and .81) and WAI-c-moderate was (rs = .33 and .49). Nonverbal therapist codes, jointly (p = .64) and separately (ρs ≤ .14), were unrelated to WAI-c ratings, with the exception of Forward lean frequency (ρ = .29). Discussion: Client-perceived quality of the working alliance relates to therapists coming across as attractive, skilled, and trustworthy rather than to their actual positive nonverbal behavior.

Individuals who text crisis text line: Key characteristics and opportunities for suicide prevention.

ObjectiveText‐based crisis services are increasingly prominent, with inclusion in the national 988 crisis number launching in 2022. Yet little is known about who uses them. This study seeks to understand the population served by Crisis Text Line (CTL), the largest crisis text service in the United States.MethodsSecondary data analysis was conducted on de‐identified Crisis Counselor reports, texter post‐conversation survey responses, and anonymized text conversation data from 85,877 texters who contacted CTL during a 12‐month period. We examined Crisis Counselor's ratings of suicide ideation severity, texters' reports of race, gender, sexual orientation, recent mental health symptoms, and additional sources of help, and logs of frequency of contact.Results76% of texters were under 25. 79% were female. 48% identified as other than heterosexual/straight. 64% had only one conversation. 79% were above the clinical cutoff for depression and 80% for anxiety, while 23% had thoughts of suicide. 23% received help from a doctor or therapist, and 28% received help only from CTL.ConclusionsCTL reaches a highly distressed, young, mostly female population, including typically underserved minorities and a substantial percentage of individuals who do not receive help elsewhere. These findings support the decision to include texting in the forthcoming national 988 implementation.

What makes summer camp therapeutic for siblings separated by out-of-home care? Associations from counselor ratings of program implementation to youth-reported outcomes

Recognition of the developmental importance of sibling relationships has resulted in the proliferation of programs and services for siblings in out-of-home care. Empirical support is limited to a small number of these programs, however; and the mechanisms through which sibling-focused programs work to promote youth outcomes remains largely unexplored. To address this gap in research, the current study examined associations from counselor ratings of program implementation to youth-reported outcomes at Camp To Belong, a manualized camp-based reunification program for siblings separated by out-of-home care. Paper and pencil surveys were administered to 655 youth and 236 counselors at 11 camps operating in the U.S.A. during one camp season. Youth completed pre-test post-test measures of individual resilience, sibling support, sibling conflict, and post-test measures of belonging. Counselors completed post-test measures rating the enabling environment of the camp setting, the activities and events offered at camp, counselor satisfaction with program implementation, and critical events counselors observed at camp. A series of generalized linear models examined associations from the four dimensions of program implementation to each of the four youth-reported outcomes. Significant associations were observed from the program implementation domains to youth belonging and resilience, but not to sibling conflict or sibling support. Associations were observed in both expected and unexpected directions, illuminating the complexity of ways in which sibling-focused programs may affect the well-being of youth in out-of-home care. Insights and recommendations to inform future research and practice with siblings in out-of-home care are provided.

The Impact of an Agent’s Voice in Psychological Counseling: Session Evaluation and Counselor Rating

As an agent delivers content during the communication between an artificial intelligence (AI) machine and a person, the voice of the agent is a crucial factor to be considered. Particularly in the fields of eHealth, the perception of users toward an agent is crucial as it significantly affects the communication between the agent and its patients, as well as the treatment results. Thus, this study examined the effects of the voice of an agent on the perception of users toward the agent and its counseling effects. This study developed a psychological counseling agent with four voices according to gender and age, communicated with the subjects through such agent, and measured the perception of users toward the agent and its counseling effects through a questionnaire. Results demonstrated that the female-voiced agent had a higher level of attractiveness than the male-voiced agent, regardless of the age of such voice, and the agent using an older voice had a higher level of expertness and depth than the agent using a younger voice, regardless of the gender of such voice. The findings of this study are expected to be effectively used to design a voice-based AI agent that considers the optimal voice according to the purpose of use.

Description of the Mental Health and Psychosocial Support (MHPSS) Program Run by Médecins Sans Frontières – Spain (MSF) in Borno State, Nigeria

Introduction: Mental Health and psychosocial support (MHPSS) programs are essential during humanitarian crises. For the last 20 years and over 200 projects worldwide, Medecins Sans Frontieres (MSF) integrates MHPSS when responding to humanitarian crises. Here we describe an MSF-Spain MHPSS program, including patients’ clinical features, sociodemographic characteristics, and intervention outcomes. Methods: Retrospective study of 11,709 patients who attended MHPSS program in Pulka and Gwoza (Nigeria) during 2018 and 2019. Patients' information, symptoms, stressors, severity (CGI-S scale), and clinical improvement (CGI-I and MHGS scales) were assessed by patient and counselor during the intervention. Patients' characteristics and associations between symptoms, stressors, severity of illness and clinical improvement are presented.. Findings: Among patients, 78% were classified as of mild or moderate severity at enrollment. Anxiety and depression were the most common disorders. Sexual violence, torture, and other conflict/violence related stressors were strongly associated with posttraumatic stress disorder (PTSD). Being an unaccompanied minor was associated with higher severity. Most patients presented an improvement in outcome at discharge, either by counselor rating (92%, CGI-I) or self-rated (73%, MHGS). Patients who benefited from three to six sessions, according to severity, were more likely to present improvement. Interpretation: The number of sessions together with the most powerful potentially traumatic stressors identified were decisive factors associated with patient’s improvement. Therefore, the identification of patients’ stressors and severity to provide the most appropriate number of sessions, and the reduction of the drop-out rate, should be prioritized. Funding Information: Medicins sans Frontieres is the only funding source for this research by the corresponding salaries paid to their employees. Declaration of Interests: All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest other than Medecins Sans Frontieres, or non-financial interest in the subject discussed in this manuscript. Ethics Approval Statement: As this study utilized routine programmatic data and took the necessary steps to protect patient confidentiality, it was exempted from full review by the MSF Ethical Review Board and the National Health Research Ethics Committee of Nigeria (NHREC).

The Effect of Clients’ Perceived Trustworthiness of Counselors on the Counseling Outcome: Longitudinal Mediating Effect of Self-Disclosure and Self-Concealment

본 연구는 상담자에 대한 내담자의 신뢰가 상담성과에 미치는 영향에서 자기개방과 자기은폐가 종단적 매개효과를 나타내는지 검증하고자 하였다. 이를 위해 전국의 대학상담센터, 사설 상담센터, 기업체 상담센터에서 최소 4회 이상의 상담을 받은 내담자 100명을 대상으로 상담자에 대한 신뢰, 상담성과, 자기개방, 자기은페에 관한 질문지를 매 회기 상담을 마친 후에 실시하였다. 수집된 자료는 잠재성장모형을 활용해 분석되었으며, 연구의 결과는 다음과 같다. 첫째, 상담자에 대한 내담자의 신뢰, 자기개방, 상담성과는 상담이 진행됨에 따라 유의하게 선형으로 증가하며, 자기은폐는 유의하게 선형으로 감소하였다. 둘째, 상담자에 대한 내담자의 신뢰가 상담성과를 예측하는 과정에서 상담자에 대한 내담자의 신뢰의 초기치와 변화율은 자기개방이 매개하는 모형과 자기은폐가 매개하는 모형에서 각각 다르게 상담성과를 예측하였다. 셋째, 상담자에 대한 내담자의 신뢰가 상담성과의 변화에 미치는 영향에서 자기개방과 자기은폐의 매개효과는 유의하지 않았다. 마지막으로 이 연구의 결과를 바탕으로 제한점과 후속연구를 위한 제언을 논의하였다.The purpose of this study was to verify the longitudinal mediating effects of self-disclosure and self-concealment on the effect of clients’ perceived trustworthiness of counselors on the counseling outcome. This study included one hundred clients who received at least four counseling sessions at various counseling service facilities, such as university counseling centers, private counseling centers, or counseling service centers for the employees. Participants completed inventories including the Counselor Rating Form, the Session Evaluation Scale, the Self-Disclosure Scale, and the Self-Concealment Scale after each session. Data were analyzed using LGM and the results indicated the followings. First, the clients’ perceived trustworthiness, self-disclosure, and counseling outcome linearly increased as the counseling progressed, while self-concealment significantly decreased linearly. Second, the initial value and rate of change of clients’ perceived trustworthiness predicted counseling outcome differently in the model mediated by self-disclosure and the model mediated by self-concealment. Third, the mediating effect of self-disclosure and self-concealment was not significant in the effect of the clients’ perceived trustworthiness on the change of counseling outcome. Finally, limitations and suggestions for future study were discussed.

Perceptions of a therapist using animal assisted therapy in an analogue brochure study: Is there a halo effect?

Abstract Animal assisted therapy (AAT) involves the integration of an animal (usually a dog or horse) in a clinical setting as part of treatment for a broad range of presenting problems involving emotional distress, trauma, and stress related issues. The use of ATT by therapists is on the rise. Our analogue study was designed to explore the impact a counselor’s purported use of ATT had on how they were perceived as measured by the Counselor Rating Form–Short Version (CRF-S). That is, would subjects who examined a brochure about counseling services provided by a factitious therapist rate the therapist more positively when it was stated, “Dr. Smith” provided animal assisted therapy and was accompanied by a picture of the therapy dog present in his/her office. To explore these hypotheses, two therapy brochures were developed one with and without the mention of the therapist’s integration of ATT and accompanying therapy dog. The results from our analogue brochure study found that a therapist described as utilizing AAT (which was punctuated by having a picture of the therapy dog in the office) was perceived as significantly more attractive and trustworthy, but not different in terms of being more expert-like. Therapists need to pay special attention to how clients may experience the therapist-therapy dog dyad over the course of treatment. There may be a potential halo effect that is bestowed on either the therapy dog or therapist, and/or on the team consisting of the therapeutic dyad. Implications for research and clinical practice are discussed.

Developing an Online Early Detection System for School Attendance Problems: Results From a Research-Community Partnership

School refusal and other school attendance problems are vexing problems for school-aged youth, families, school personnel, and clinicians. However, few resources exist to detect problematic attendance. The current report describes three steps of a research-community partnership to develop an early identification program to detect youth at risk for problematic attendance. First, a survey was conducted to estimate the scope and cost of school refusal across grades K–12. School administrators estimated relatively few youth exhibiting significant school refusal (missing 5 or more days per year) but estimated the costs associated with services for these youth to be very high (mean cost of in-district programs: $94,052; mean cost of out-of-district placements: $496,657). Second, elementary school counselors were tasked with tracking absenteeism among at-risk youth using an online attendance tracking prototype. Counselors identified a high number of youth who showed elevated absences, lates, or early departures (17.2% of enrolled students), and counselor ratings were significantly related to whether the student (a) had received an individualized education plan or 504 plan, (b) had a sibling with similar attendance problems, (c) was older, or (d) had divorced or separated parents. In a final step, counselor feedback was sought and revisions were incorporated in the attendance tracker. Findings reinforce the prevalence and cost of school attendance problems, provide guidance for using technology to monitor attendance and related indices (tardies, early departures), and direct attention to youth factors that may be useful in identifying youth at risk for poor attendance.

Therapist Directiveness and Client Reactance in the Administration of Homework in Therapy with College Students

ABSTRACTThe present study used an analog design with three vignettes portraying homework administrations at three levels of therapist directiveness (low, medium, and high) and the Therapeutic Reactance Scale to measure participant reactance. Participants (N = 436) read the vignettes and completed the Homework Completion Scale (HCS), Counseling Continuation Scale (CCS), Counselor Rating Form-Short (CRF-S) Attractiveness and Expertness subscales. A repeated measures analysis of variance revealed significant differences between low and high reactant groups on the HCS and CCS for the High and Medium directiveness homework administrations. These results suggest that therapist directiveness does interact with client reactance in the administration of homework.

Counselor Knows Best? Clinician Assessments of In-Prison Substance Abuse Treatment Participants

Research has examined responses to substance abuse treatment among criminal justice populations primarily through client self-assessments, and comparatively fewer studies have focused on clinician ratings of client progress. Recently, Blasko and Hiller examined counselor ratings and their association with reincarceration but found no relationship between the two. The current study partially replicated their analyses and explored its own factor structure to compare the findings from a different sample using the same instrument, the Criminal Justice Counselor Rating of Client (CJ CRC). Analyses revealed that although none of the replicated counselor measures predicted reincarceration, higher levels of one measure produced from the factor analysis, Psychological Barriers to Recovery, indicated a significantly higher probability for reincarceration. In light of these conflicting findings, practical implications of this research suggested that clinical assessments of clients may be useful for criminal justice decision making.

Investigating Supervisory Relationships and Therapeutic Alliances Using Structural Equation Modeling

The authors used structural equation modeling to examine the contribution of supervisees' supervisory relationship levels to therapeutic alliance (TA) scores with their clients in practicum. Results showed that supervisory relationship scores positively contributed to the TA. Client and counselor ratings of the TA also differed.

Patient and genetic counselor perceptions of in-person versus telephone genetic counseling for hereditary breast/ovarian cancer.

Telephone genetic counseling (TC) for high-risk women interested in BRCA1/2 testing has been shown to yield positive outcomes comparable to usual care (UC; in-person) genetic counseling. However, little is known about how genetic counselors perceive the delivery of these alternate forms of genetic counseling. As part of a randomized trial of TC versus UC, genetic counselors completed a 5-item genetic counselor process questionnaire (GCQ) assessing key elements of pre-test sessions (information delivery, emotional support, addressing questions and concerns, tailoring of session, and facilitation of decision-making) with the 479 female participants (TC, N=236; UC, N=243). The GCQ scores did not differ for TC vs. UC sessions (t (477)=0.11, p=0.910). However, multivariate analysis showed that participant race/ethnicity significantly predicted genetic counselor perceptions (β=0.172, p<0.001) in that the GCQ scores were lower for minorities in TC and UC. Exploratory analyses suggested that GCQ scores may be associated with patient preference for UC versus TC (t (79)=2.21, p=0.030). Additionally, we found that genetic counselor ratings of session effectiveness were generally concordant with patient perceptions of the session. These data indicate that genetic counselors perceive that key components of TC can be delivered as effectively as UC, and that these elements may contribute to specific aspects of patient satisfaction. However, undefined process differences may be present which account for lower counselor perceptions about the effectiveness of their sessions with minority women (i.e., those other than non-Hispanic Whites). We discuss other potential clinical and research implications of our findings.

Adolescent Substance Treatment Engagement Questionnaire for Incarcerated Teens

BackgroundTreatment engagement is often measured in terms of treatment retention and drop out, resource utilization, and missed appointments. Since persons may regularly attend treatment sessions but not pay close attention, actively participate, or comply with the program, attendance may not reflect the level of effort put into treatment. Teens in correctional settings may feel coerced to attend treatment, making it necessary to develop measures of treatment involvement beyond attendance. This study describes the development and validation of the Adolescent Substance Treatment Engagement Questionnaire (ASTEQ), Teen and Counselor versions. MethodsThe psychometric properties of the ASTEQ were examined in a sample of incarcerated teens (N=205) and their counselors. Principal component analysis was conducted on teen and counselor versions of the questionnaire. ResultsScales of positive and negative treatment engagement were found, reflecting both overt behaviors (joking around, talking to others) and attitudes (interest in change). Significant correlations with constructs related to treatment attitudes and behaviors, and misbehaviors (including substance use) demonstrate good concurrent and predictive validity. Teen and counselor ratings of engagement produced validity correlations in the medium effect size range. ConclusionsThese measures comprise a valid and reliable method for measuring treatment engagement for incarcerated teens.

Genetic counselors' implicit racial attitudes and their relationship to communication.

Implicit racial attitudes are thought to shape interpersonal interactions and may contribute to health-care disparities. This study explored the relationship between genetic counselors' implicit racial attitudes and their communication during simulated genetic counseling sessions. A nationally representative sample of genetic counselors completed a web-based survey that included the Race Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998; Cooper et al., 2012). A subset of these counselors (n = 67) had participated in an earlier study in which they were video recorded counseling Black, Hispanic, and non-Hispanic White SCs about their prenatal or cancer risks. The counselors' IAT scores were related to their session communications through robust regression modeling. Genetic counselors showed a moderate to strong pro-White bias on the Race IAT (M = 0.41, SD = 0.35). Counselors with stronger pro-White bias were rated as displaying lower levels of positive affect (p < .05) and tended to use less emotionally responsive communication (p < .10) when counseling minority SCs. When counseling White SCs, pro-White bias was associated with lower levels of verbal dominance during sessions (p < .10). Stronger pro-White bias was also associated with more positive ratings of counselors' nonverbal effectiveness by White SCs. Implicit racial bias is associated with negative markers of communication in minority client sessions and may contribute to racial disparities in processes of care related to genetic services.

Treatment adherence in patients with headache: a systematic review.

To review and critically evaluate the extant research literature pertaining to adherence in youth and adults with headache and to provide recommendations for future research. This article provides the first systematic review of pediatric headache adherence and updates a previous review of treatment adherence in adults with headache. Systematic review of empirical literature. A literature search with no date restriction was conducted using PubMed and PsycINFO electronic databases and bibliographies of relevant articles. Adherence rates in adults with headache range considerably from 25% to 94% across treatment, assessment method, and definition of adherence utilized. Methods to assess adherence included retrospective prescription claims data, paper or electronic diaries, follow-up appointment attendance, written and verbal self-report of general adherence, verbal self-report of adherence over a specific amount of time via in person interview or telephone, validated adherence measures, adherence questionnaires without validation, and counselor ratings of homework. Each methodology and assessment tool demonstrated strengths and weaknesses. No studies have systematically examined medication adherence in children with headache, and the few available studies examining adherence to behavioral treatment have documented adherence rates ranging from 52% to 86%. Adherence research in adults with headache is growing, but studies demonstrate a number of methodological shortcomings. Adherence research in children with headache, and adherence intervention research in both adults and children, is scant. Future research should use objective measures of adherence, consider over-the-counter medications and medication overuse, examine demographic, psychological, and behavioral correlates of adherence, assess adherence to botulinum toxin type A, and examine the efficacy of adherence interventions in individuals with headache.

Do Brief Alcohol Motivational Interventions Work Like We Think They Do?

Questions remain about how brief motivational interventions (BMIs) for unhealthy alcohol use work, and addressing these questions may be important for improving their efficacy. Therefore, we assessed the effects of various characteristics of BMIs on drinking outcomes across 3 randomized controlled trials (RCTs). Audio recordings of 314 BMIs were coded. We used the global rating scales of the Motivational Interviewing Skills Code (MISC) 2.1: counselor's acceptance, empathy, and motivational interviewing (MI) spirit, and patient's self-exploration were rated. MI proficiency was defined as counselor's rating scale scores ≥5. We also used the structure, confrontation, and advice subscale scores of the Therapy Process Rating Scale and the Working Alliance Inventory. We examined these process characteristics in interventions across 1 U.S. RCT of middle-aged medical inpatients with unhealthy alcohol use (n=124) and 2 Swiss RCTs of young men with binge drinking in a nonclinical setting: Swiss-one (n=62) and Swiss-two (n=128). We assessed the associations between these characteristics and drinks/d reported by participants 3 to 6months after study entry. In all 3 RCTs, mean MISC counselor's rating scales scores were consistent with MI proficiency. In overdispersed Poisson regression models, most BMI characteristics were not significantly associated with drinks/d in follow-up. In the U.S. RCT, confrontation and self-exploration were associated with more drinking. Giving advice was significantly associated with less drinking in the Swiss-one RCT. Contrary to expectations, MI spirit was not consistently associated with drinking across studies. Across different populations and settings, intervention characteristics viewed as central to efficacious BMIs were neither robust nor consistent predictors of drinking outcome. Although there may be alternative reasons why the level of MI processes was not predictive of outcomes in these studies (limited variability in scores), efforts to understand what makes BMIs efficacious may require attention to factors beyond intervention process characteristics typically examined.