Counterchange Talk Research Articles

The impact of a deliberate practice workshop on therapist demand and support behavior with community volunteers and simulators.

The present study used a newly developed simplified coding system, the Therapist Demand and Support Code, to examine specific therapist behaviors in the context of a previously conducted training trial on Deliberate Practice (DP). The parent trial randomized trainees to a DP workshop or its Traditional, more didactic counterpart (Westra et al., 2020). In both groups, trainees were taught to use Support, rather than Demand, for managing ambivalence and resistance, with the DP group having more feedback and practice. In this study, 68 trainees interviewed both an ambivalent community volunteer and an ambivalent simulator 4 month post workshop. The DP group was found to exhibit significantly fewer Demand behaviors than the Traditional group, with the latter also being significantly quicker to use Demand in the interviews. Moreover, the simulator evoked significantly greater Demand from therapists, regardless of the Training group, suggesting the simulators were more resistant. Although therapist use of Support was equal for community volunteers across training groups, Traditional workshop trainees decreased Support when interviewing the more resistant simulators, whereas DP trainees increased their Support with this same group. This is consistent with findings that DP trainees were more appropriately responsive, making fewer Demands following interviewee counterchange talk and using more Support at these times. These results provide some initial validation of the simplified therapist behavior coding system and offer further evidence for the benefits of DP workshop training for managing resistance. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Rolling with resistance: A client language analysis of deliberate practice in continuing education for psychotherapists

AbstractContinuing education workshops have been criticised for focusing on knowledge rather than skill acquisition by a focus on didactic teaching methods. A recent randomised controlled trial conducted by Westra et al. (2020) demonstrated that a deliberate practice (DP) training workshop for responding to ambivalence and resistance resulted in longer‐lasting skill acquisition than the same workshop in a traditional, more didactic format. The present study examined whether this same DP workshop was also efficacious at the level of client motivational language in 4‐month post‐testing interviews used to assess trainee skill in the Westra et al. parent study. Sixty therapists from the community (30 = DP and 30 = traditional) conducted an interview with either an ambivalent simulator or an ambivalent community volunteer. Interviews were coded for interviewee motivational language using the Motivational Interviewing Skills Code (MISC 1.1; Glynn & Moyers, 2009). Counterchange talk (CCT) was further classified into either Ambivalent‐CCT (uttered to disclose conflict about change) or Resistant‐CCT (statements against change uttered to oppose the therapist). Results revealed a significant difference between training groups, with the DP group eliciting less Resistant‐CCT than the traditional training group. This study provides further support for the use of DP training for potentially creating more productive conversations by minimising Resistant‐CCT; a form of speech that has been found to be negatively associated with client outcomes.

Patient motivational language in the prediction of symptom change, clinically significant response, and time to response in psychotherapy for generalized anxiety disorder.

Existing research demonstrates that patient change-talk (CT), or self-arguments for change, associates variably with favorable outcomes, whereas counter change-talk (CCT), or self-arguments against change, associates consistently with poorer outcomes. However, most studies on change language have focused on posttreatment versus more proximal outcomes. Addressing this gap, we examined Session 1 CT and CCT as predictors of during-treatment worry change, likelihood of clinically significant response during treatment, and time to response across cognitive-behavioral therapy (CBT; n = 43) and CBT integrated with motivational interviewing (MI; n = 42) for generalized anxiety disorder. We also explored whether treatment moderated these associations. Multilevel modeling revealed that, across both treatments, more CT associated with lower midtreatment worry level (p = .04), whereas more CCT associated with lower worry level (p = .048) and a slower rate of worry reduction at midtreatment (p = .04). Treatment moderated only the associations between CT and both midtreatment worry level (p = .03) and rate of change (p = .03). CBT patients with higher versus lower CT had lower worry and a faster rate of worry reduction; in MI-CBT, CT was unrelated to these outcomes. Survival analyses revealed that, across both treatments, more CT associated with a greater likelihood of response (p = .004) and approached a faster time to response (p = .05), and more CCT associated with a lower likelihood of response (p = .001) and approached a slower time to response (p = .06). Motivational language predicts proximal outcomes and may be useful in treatment selection. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The Impact of Therapists’ Responses to Resistance to Change: A Sequential Analysis of Therapist Client Interactions in Motivational Interviewing

The study aims to examine how therapists trained in motivational interviewing (MI) respond to resistance and whether this has an impact on subsequent client speech. Fifty recorded Motivational Enhancement Therapy sessions were examined using a sequential behavioural coding method for speech. Client counter-change talk formed the baseline for coding and categorizing subsequent therapist speech and the following client speech. Transitional analysis identified the probable occurrence of specific therapist and client utterances at each stage. Following client expressed resistance or counter-change talk, MI consistent therapist utterances were most commonly observed. A moderate to strong predictive relationship was found between MI-consistent therapist speech and subsequent client change talk. A moderate predictive relationship was found between therapist MI-consistent behaviours and client ambivalence. A moderate to strong predictive relationship was found between MI-inconsistent therapist speech and subsequent client counter-change talk and a weak negative predictive relationship was found between MI-inconsistent therapist speech and client expressed ambivalence. In the face of initial expressed resistance to change, MI-consistent therapist speech appears to increase subsequent client utterances regarding intentions to change drinking behaviour.

Client Motivation and Engagement in Transdiagnostic Group Cognitive Behavioral Therapy for Anxiety Disorders: Predictors and Outcomes

Client motivation is regarded as a key factor in cognitive behavioral therapy (CBT) for anxiety disorders. To date, client motivation has only been measured during individual-CBT, with little known about the predictive capacity of motivation in group settings. The current study aimed to explore the role of client motivation in group-CBT. Measuring motivation during individual-CBT has proven somewhat difficult with many self-report measures providing weak and inconsistent results. For this reason observational measures of motivation, such as rating client change (CT) language during CBT, have been trialled with some success. The current study aimed to measure motivation using an observational coding system of CT and counter change talk (CCT) during two components of group CBT: cognitive restructuring and exposure sessions. The study explored the predictive capacity of CT and CCT in determining treatment outcomes, and baseline characteristics that predicted in session CT and CCT. Results indicated that CT and CCT predicted different treatment outcomes depending on the stage of therapy. CT and CCT predicted symptom severity at post-treatment and slope of improvement in cognitive restructuring sessions. During exposure sessions only CCT was predictive of poorer treatment outcomes but CT determined client attendance and treatment drop out. Furthermore, baseline characteristics including symptom severity, education, and age were predictive of CT and CCT throughout treatment. These findings are discussed and comparisons are drawn to the role of motivation in individual-CBT. Limitations and implications of this research are explored, specifically the utility of coding motivational language using observational methods in group settings.

Temporal pathways of change in two randomized controlled trials for depression and harmful drinking in Goa, India.

The current study explored the temporal pathways of change within two treatments, the Healthy Activity Program (HAP) for depression and the Counselling for Alcohol Problems (CAP) Program for harmful drinking. The study took place in the context of two parallel randomized controlled trials in Goa, India. N = 50 random participants who met a priori criteria were selected from each treatment trial and examined for potential direct and mediational pathways. In HAP, we examined the predictive roles of therapy quality and patient-reported activation, assessing whether activation mediated the effects of therapy quality on depression (Patient Health Questionnaire-9) outcomes. In CAP, we examined the predictive roles of therapy quality and patient change- and counter-change-talk, assessing whether change- or counter-change-talk mediated the effects of therapy quality on daily alcohol consumption. In HAP, therapy quality (both general and treatment-specific skills) was associated with patient activation; patient activation but not therapy quality significantly predicted depression outcomes, and patient activation mediated the effects of higher general skills on subsequent clinical outcomes [a × b = -2.555, 95% confidence interval (CI) -5.811 to -0.142]. In CAP, higher treatment-specific skills, but not general skills, were directly associated with drinking outcomes, and reduced levels of counter-change talk both independently predicted, and mediated the effects of higher general skills on, reduced alcohol consumption (a × b = -24.515, 95% CI -41.190 to -11.060). Change talk did not predict alcohol consumption and was not correlated with counter-change talk. These findings suggest that therapy quality in early sessions operated through increased patient activation and reduced counter-change talk to reduce depression and harmful drinking respectively.

Therapist and Client Interactions in Motivational Interviewing for Social Anxiety Disorder.

The aim of the present study is to assess the bidirectional associations between therapist and client speech during a treatment based on motivational interviewing (MI) for social anxiety disorder. Participants were 85 adults diagnosed with social anxiety who received MI prior to entering cognitive behavioral therapy. MI sessions were sequentially coded using the Motivational Interviewing Skill Code 2.5. Therapist MI-consistent behaviors, including open questions as well as positive and negative reflections, were more likely to be followed by client change exploration (change talk and counter-change talk). Therapist MI-inconsistent behaviors were more likely to precede client neutral language. Client language was also found to influence therapist likelihood of responding in an MI-consistent manner. The findings support the first step of the MI causal model in the context of social anxiety and direct future research into the effect of therapist and client behaviors on MI treatment outcome.

The interpersonal context of client motivational language in cognitive-behavioral therapy.

Previous research has found that client motivational language (especially arguments against change or counterchange talk; CCT) in early therapy sessions is a reliable predictor of therapy process and outcomes across a broad range of treatments including cognitive-behavioral therapy (CBT). Existing studies have considered the general occurrence of CCT, but the present study differentiated 2 types of CCT in early CBT sessions for 37 clients with generalized anxiety disorder: (a) statements that are uttered to express ambivalence regarding change versus (b) statements that are intended to oppose the therapist or therapy. Two process coding systems were used to accomplish this differentiation. Findings indicated that a higher number of CCT statements that occurred in the presence of resistance (opposition to the therapist or therapy) were a substantive and consistent predictor of lower homework compliance and poorer outcomes, up to 1 year posttreatment. Moreover, when both types of CCT were considered together, only opposition CCT was related to outcomes, and ambivalent CCT was not significantly predictive of proximal and distal outcomes. These findings suggest that the interpersonal context in which CCT statements occur may be critically important to their predictive capacity. More broadly, the findings of this study have implications for the future study of client motivational language and underscore the clinical importance of detecting opposition CCT.

Bidirectional relationships between client and counselor speech: the importance of reframing.

In the study of motivational interviewing (MI), counselor skill has been posited to influence client language about change or "change talk." This study investigates the relationship between a specific counselor behavior, valenced reflective listening, and client change talk in a MI intervention with substance-using adolescents. A combination of recorded in-person and telephone (n = 223) sessions were sequentially coded using the Motivational Interviewing Skill Code 2.5. Reflections were categorized by valence, meaning they included content that was either moving toward (i.e., positive reflection) or away from change (i.e., negative reflection). Client language was coded as either moving toward change, away from change, or neutral about change. Probability analyses showed positive reflections were 11 times more likely to be followed by change talk and 71% less likely to be followed by counter change talk. Negative reflections were 19 times more likely to be followed by counter change talk and 65% less likely to be followed by change talk. Client language was also predictive of counselor reflections, such that positive reflections were 10 times more likely to occur after client change talk and negative reflections were 19 times more likely to follow counter change talk. Because the percentage of change talk expressed in a session has been shown to be positively related to improved behavioral outcomes, counselors should avoid unintentional reflections of counter change talk and use reframing techniques to change the valence of client change language. Implications for MI practice and training are discussed.

Disentangling the Impact of Resistance and Ambivalence on Therapy Outcomes in Cognitive Behavioural Therapy for Generalized Anxiety Disorder

Resistance and ambivalence about change are increasingly recognized as important determinants of treatment outcomes. Moreover, resistance and ambivalence are thought to be theoretically related in that clients who are more ambivalent about change are more likely to demonstrate resistance to the process and tasks of treatment. In the context of cognitive behavioural therapy (CBT) for generalized anxiety disorder, the present study simultaneously examined early resistance and ambivalence using two observer-based coding systems in order to determine their inter-relationship and, importantly, to investigate their relative contributions to outcome. Resistance was also coded during mid-treatment in order to investigate possible mediation pathways. Early ambivalence (clients’ arguments against change or counter-change talk) was found to be no longer related to outcomes when early resistance was taken into account, suggesting that disharmony in the therapeutic relationship is more important to outcomes than ambivalence per se. Moreover, mid-treatment resistance partially mediated the relationship between early resistance and post-treatment worry severity. That is, higher early opposition to therapist direction is related to poorer outcomes, in part because it is associated with greater resistance during the working phase of CBT. The findings underscore the critical need for therapists to be sensitive to identifying resistance early and throughout treatment.

Ambivalence and Alliance Ruptures in Cognitive Behavioral Therapy for Generalized Anxiety

Client ambivalence about change (or motivation) is regarded as central to outcomes in cognitive behavioral therapy (CBT). However, little research has been conducted to examine the impact of client ambivalence about change on therapy process variables such as the therapeutic alliance. Given the demonstrated limitations of self-report measures of key constructs such as ambivalence and motivation, the present study instead employed a newly adapted observational measure of client ambivalence. Client statements regarding change (change talk (CT) and counter-change talk (CCT)) were coded in early (session 1 or 2) therapy sessions of CBT for generalized anxiety disorder. The frequency of CT and CCT was then compared between clients who later experienced an alliance rupture with their therapist, and clients who did not. The results showed that clients in dyads who later experienced an alliance rupture expressed significantly more CCT at the outset of therapy than clients who did not later experience an alliance rupture. However, CT utterances did not significantly differ between alliance rupture and no-rupture groups. CCT may strain the alliance because clients expressing higher levels of CCT early in therapy may be less receptive to therapist direction in CBT. Consequently, it is recommended that clients and therapists work together to carefully address these key moments in therapy so as to prevent alliance rupture and preserve client engagement in therapy.

Measuring Motivation: Change Talk and Counter-Change Talk in Cognitive Behavioral Therapy for Generalized Anxiety

How clients talk about change early in treatment has been found to be a potent predictor of their subsequent treatment success. Studies examining such client motivational language (arguments for and against change) have typically been conducted in the context of motivational interviewing for addictions. This study examined the capacity of client motivational language to predict treatment outcomes in the context of cognitive behavioral therapy (CBT) for generalized anxiety. Client early in-session statements against change (counter-change talk) were found to be robust predictors of post-treatment worry scores and differentiated treatment responders from nonresponders. Moreover, client motivational language predicted outcomes beyond initial symptom severity and self-report measures of motivation. These results strongly support the relevance of client motivational language outcomes in CBT and provide a foundation for advancing research on motivation for change in a CBT context.

Provider Communication Behaviors that Predict Motivation to Change in Black Adolescents with Obesity

The goal of this research was to identify communication behaviors used by weight loss counselors that mostly strongly predicted black adolescents' motivational statements. Three types of motivational statements were of interest: change talk (CT; statements describing their own desires, abilities, reasons, and need for adhering to weight loss recommendations), commitment language (CML; statements about their intentions or plans for adhering), and counterchange talk (CCT; amotivational statements against change and commitment). Thirty-seven black adolescents with obesity received a single motivational interviewing session targeting weight-related behaviors. The video-recorded transcribed sessions were coded using the Minority Youth Sequential Coding for Observing Process Exchanges generating a sequential chain of communication. Data were then subjected to sequential analysis to determine causal relationships between counselor and adolescent communication. Asking open-ended questions to elicit adolescent CT and emphasizing adolescents' autonomy most often led to CT. Open-ended questions to elicit CML, reflecting adolescent CML, and emphasizing autonomy most often led to CML. In contrast, open-ended questions to elicit CCT, reflecting CCT, reflecting ambivalence, and neutral open-ended questions about the target behavior led to CCT. This study provides clinicians with insight into the most effective way to communicate with black adolescents with obesity about weight loss. Specifically, reflective statements and open questions focusing on their own desires, abilities, reasons, need, and commitment to weight loss recommendations are more likely to increase motivational statements, whereas other types of reflections and questions may be counterproductive. Finally, because adolescents have a strong need for autonomous decision making, emphasizing their autonomy may be particularly effective in evoking motivational statements.

Integrating brain and behavior: Evaluating adolescents’ response to a cannabis intervention.

Client language (change talk [CT] and counterchange talk [CCT]) is gaining increasing support as an active ingredient of psychosocial interventions. Preliminary work with adults suggests that there may be a neural basis for this. With a diverse sample of adolescent cannabis users, we evaluated the influence of CT and CCT on blood oxygen level dependent (BOLD) response during an fMRI cannabis cue-exposure paradigm. We also investigated how BOLD activation related to treatment outcomes. Adolescent cannabis users (N = 43; 83.7% male; 53.5% Hispanic; M age = 16 years) were presented with CT and CCT derived from their prescan intervention session during the fMRI paradigm. Additionally, BOLD activation during CT (vs. CCT) was tested as a predictor of 1-month follow-up cannabis use behavior (frequency of cannabis use, cannabis problems, cannabis dependence). We observed a significant interaction, with greater activation during CT (vs. CCT) during the cannabis (but not control) cues in several areas key to self-referential processes (uncorrected p < 0.001; medial frontal gyrus, insula). Furthermore, BOLD activation during CT (vs. CCT) during cannabis (but not control) cues in areas that underlie introspection (posterior cingulate, precuneus) was significantly related to youths' 1-month follow-up cannabis use behavior (frequency of cannabis use, cannabis problems, cannabis dependence; uncorrected p < 0.001). These data indicate a unique interaction pattern, whereby CT (vs. CCT) during the cannabis (but not control) cues was associated with significantly greater activation in brain areas involved in introspection. Further, this activation was related to significantly better treatment outcomes for youth.

How psychosocial alcohol interventions work: a preliminary look at what FMRI can tell us.

Current work in motivational interviewing (MI) has supported the role of in-session client and therapist language in predicting postintervention substance use outcomes. In particular, a relationship has been found between specific therapist language (e.g., MI-consistent behaviors), specific types of client speech (e.g., change talk; CT and counterchange talk; CCT), and subsequent drinking outcomes. One hypothesis to explain this phenomenon is that CT is an indication of a neurocognitive shift that happens during the course of a psychosocial intervention. And, it is possible that this shift is responsible for catalyzing and maintaining changes in drinking behaviors following MI interventions. To investigate this question, the effect of CT on blood oxygen level-dependent (BOLD) response during the presentation of alcohol cues was evaluated using functional magnetic resonance imaging. To examine changes in neural response to alcohol cues following client language, 10 adults with alcohol dependence (50% men; 40% Caucasian; 40% Hispanic; M age = 42.6; M years of education = 13.3) were presented with CT and CCT derived from their prescan MI session during the presentation of alcohol cues. Following CCT, there was significant neural response to alcohol cues in several key reward areas (cluster-corrected p < 0.05, z > 2.3; orbitofrontal cortex, nucleus accumbens, anterior insula, posterior insula, caudate, and putamen). On the contrary, there were no areas of significant reward activation following CT. These results indicate that CT may be effectively inhibiting activation in brain regions that respond to the salience of alcohol cues. These findings provide preliminary biological support of the psychosocial literature findings, highlighting the critical importance of change talk during psychosocial interventions.

The route to change: Within-session predictors of change plan completion in a motivational interview

This study is the first to examine within-session therapist and client language/process predictors of a client's decision to complete a written Change Plan in an alcohol-focused motivational interview (MI). Data were from an ongoing hospital-based clinical trial ( N = 291). Trained raters coded audiorecorded MI sessions using the Motivational Interviewing Skill Code. Logistic regression analyses found that therapist MI-consistent behaviors ( b = .023, p < .001) and client change talk ( b = .063, p < .001) were positive predictors, and client counter change talk ( b = −.093, p < .001) was a negative predictor of the decision to complete a Change Plan regarding alcohol use. Mean comparisons showed that compared to noncompletion, Change Plan completion did not result in significantly greater changes in client motivational readiness. Completion of a Change Plan is a proximal outcome in MI that is associated with client intention to change (change talk) and may predict follow-up alcohol outcomes. Analyses of such theory-driven proximal client mechanisms provide a more complete model of MI process and may inform MI providers of necessary treatment ingredients.

The neural substrate of self-perceptual speech in psychotherapy: A first look

Event Abstract Back to Event The neural substrate of self-perceptual speech in psychotherapy: A first look Jon Houck1*, Theresa Moyers2 and Claudia Tesche2 1 University of New Mexico, Mind Research Network, United States 2 University of New Mexico, United States Little study has been made of the neural processes underlying successful psychotherapeutic methods. Those studies that have evaluated talk therapies have not evaluated processes that occur within the therapy session itself. Motivational interviewing (MI) is an empirically supported treatment for substance abuse and a strong candidate for such a study. A mechanism of action, change talk (CT; i.e., client statements indicating a desire to change behavior), has been posited for MI. The present study is a preliminary exploration of the brain activity underlying participants’ perception of their own change talk from an MI session using magnetoencephalography (MEG). Participants were six individuals who expressed ambivalence about their substance use. This dataset represents 1/5 of the planned sample for this study, which is ongoing. Each participant had a recorded MI session with a licensed psychologist. Following each participant’s session, the precise time of each CT and counter-change talk utterance was noted, and these utterances were extracted from the session recording. During the MEG scan approximately 200 repetitions of each utterance type were presented binaurally in a random order with a random inter-trial interval. Brain activity was measured using a 306-channel whole-cortex MEG array (Neuromag, Elekta Neuromag Oy) at the Mind Research Network (Albuquerque, NM). MEG data were sampled at 1000 Hz (pass-band 0.1-330 Hz) and co-localized to the anatomical MRI of each subject using a Polhemus head position device. Head position was monitored continuously throughout the MEG session. The data were downsampled to 500 Hz and waveforms were averaged off-line over trials and band-pass filtered. Preliminary analyses are focused on the m400 response. Results will be presented. Progress at this point indicates that, despite the privacy and logistical hurdles of obtaining stimuli from treatment sessions, such data can be reliably acquired and analyzed. NIDA 1R21DA025135 Conference: Biomag 2010 - 17th International Conference on Biomagnetism , Dubrovnik, Croatia, 28 Mar - 1 Apr, 2010. Presentation Type: Poster Presentation Topic: Language Citation: Houck J, Moyers T and Tesche C (2010). The neural substrate of self-perceptual speech in psychotherapy: A first look. Front. Neurosci. Conference Abstract: Biomag 2010 - 17th International Conference on Biomagnetism . doi: 10.3389/conf.fnins.2010.06.00282 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 01 Apr 2010; Published Online: 01 Apr 2010. * Correspondence: Jon Houck, University of New Mexico, Mind Research Network, Albuquerque, United States, jhouck@mrn.org Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers Jon Houck Theresa Moyers Claudia Tesche Google Jon Houck Theresa Moyers Claudia Tesche Google Scholar Jon Houck Theresa Moyers Claudia Tesche PubMed Jon Houck Theresa Moyers Claudia Tesche Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Client Language as a Mediator of Motivational Interviewing Efficacy: Where Is the Evidence?

Identifying in-session indicators of client outcomes is important in determining the mechanisms of psychotherapeutic treatments, including Motivational Interviewing (MI). The current studies sought to determine if clinician behavior influences client speech, and the extent to which client speech predicted treatment outcome in clients receiving treatment for substance abuse. Study 1 examined 38 sessions from 5 sites in Project MATCH. Sessions were coded using the Sequential Code for Process Exchanges (SCOPE) behavioral coding system. Transition probabilities and inter-rater reliability were calculated. Study 2 examined 45 sessions from the New Mexico site in Project MATCH. Sessions were coded using the MISC 1.0 behavioral coding system. Distal outcome measures were calculated for proportion of days abstinent (PDA) and drinks per drinking day (DDD). Hierarchical multiple regression and hierarchical logistic regression were used to characterize the relationship between client speech and outcome. In Study 1, inter-rater reliability estimates indicate that coders reliably distinguished between the categories within the SCOPE. Behaviors consistent with MI (MICO) were significantly likely to be followed by client Change Talk (CT) and behaviors inconsistent with MI (MIIN) were significantly likely to be followed by Counterchange Talk (CCT). There was also a significant negative transition probability between MICO and CCT. In Study 2, CT was found to account for significant portions of outcome variability beyond that attributable to baseline measures of problem severity. Client speech during early therapy sessions appears to be a powerful predictor of substance abuse outcome. The pattern of therapist behaviors and subsequent client language found in this data supports the intervention test in the causal chain we have described for motivational interviewing. These studies provide preliminary support for a causal chain between therapist behaviors, subsequent client speech, and drinking outcomes within motivational interviewing sessions. The results of both studies provide further support to the proposition that client speech impacts the likelihood of behavioral change, and that the occurrence of such speech is influenced by the therapist.