Measuring adaptations of motivational interviewing: the development and validation of the behavior change counseling index (BECCI)

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Abstract

One of the most common challenges faced by health professionals is encouraging patients to change their behavior to improve their health. This paper reports the development of a checklist, the behavior change counseling index (BECCI). This aims to measure practitioner competence in behavior change counseling (BCC), an adaptation of motivational interviewing suitable for brief consultations in healthcare settings. The checklist has demonstrated acceptable levels of validity, reliability and responsiveness, and aims to assist trainers and researchers in assessing change in practitioner behavior before, during and after training in BCC. BECCI will also provide valuable information about the standard of BCC that practitioners were trained to deliver in studies of BCC as an intervention.

Introduction

Consultations about behavior change are fairly widespread in healthcare settings, and usually involve talking to patients about changes in lifestyle (e.g. diet, exercise, smoking, alcohol) and medication use. They occur in most settings (primary, secondary and tertiary care), and embrace both the management and prevention of a wide range of conditions, for example, diabetes, asthma and heart disease.

It has been suggested that these consultations present particular challenges to practitioners and patients alike [1]. Among their main characteristics is the potential for disagreement about why, how and when change might occur. Value judgements about resistant or unmotivated patients are often close to the surface, and quasi-psychoanalytical terms like “being in denial” are often used to describe patients who apparently do not see the need for change. Efforts to find constructive ways through these consultations have emerged in the form of the stages of change model [2] and motivational interviewing [3]. At their heart is an attempt to encourage patients to be more active in the consultation, to think aloud about the importance of change and their confidence to achieve it.

Systematic reviews of motivational interviewing and its adaptations point to a lack of precision about what skills were actually used by practitioners in a wide range of controlled trials [4], [5]. Guidelines for evaluating complex interventions [6], which stress the need to focus on the training of practitioners in skills that are reliably measured, have often been bypassed by enthusiasm to conduct controlled trials that look primarily at patient outcomes [7]. It is only recently that efforts to list essential skills have emerged, thus opening up the possibility to develop reliable measures.

One recent development has been the description of behavior change counseling (BCC)—an adaptation of motivational interviewing which might be suitable for brief consultations about behavior change in healthcare settings [8]. Many of the skills overlap with motivational interviewing, while some of the more psychotherapeutic elements of the “parent method” have been omitted. This paper describes the development of The behavior change counseling index (BECCI)—a scale for use by trainers and researchers when helping practitioners to learn the essential skills of BCC.

Although motivational interviewing and behavior change counseling are related methods, they are somewhat different in nature [8]. Motivational interviewing is a style of counseling amenable for use by psychotherapists (though not restricted to them), and incorporates a number of skills found in generic counseling, such as using open questions and reflective listening [3]. However, these skills are used not only to understand the client’s perspective, but to selectively and strategically elicit ‘change talk’ (e.g. commitment language) from a client, and to ‘develop discrepancy’—a way of pointing out conflicts between the client’s current behavior and their personal values [3].

BCC was developed for brief healthcare consultations with a more modest goal in mind: simply to help the person to talk through the why and how of change, with the practitioner’s main task being to understand how the person is feeling and what plans they might have for change. The practitioner uses listening skills to understand the patient’s perspective, but not with a view to strategically eliciting change talk and developing discrepancy as in motivational interviewing [8]. BCC is linked to the patient centered method of consulting [9], and incorporates many of the skills and principles from motivational interviewing [3]. It can be used in both help-seeking and opportunistic settings. Many skills used in BCC overlap with motivational interviewing—for example, demonstrating respect for patient choice, asking open questions, using empathic listening, summarizing and so on [8].

There is a range of instruments available to measure patient centredness in its pure form, and general physician–patient interaction [10], [11]. However, none are specific to the topic of health behavior change, and the microskills of motivational interviewing and behavior change counseling are largely absent from these measures.

There is one instrument currently available for measuring motivational interviewing—the Motivational Interviewing Skill Code (MISC) [12], [13], [14]. This is a research tool, which requires three passes or phases of analysis. The first pass consists of global ratings for the therapist, client and the relationship between them. It focusses on the spirit of the consultation rather than specific microskills. The second pass provides tally charts to count the number of specific client and therapist behaviors. Thirdly, total talk time for the therapist and the client is calculated.

Although the MISC has proved to be a useful research tool [13], [14], [15], there are a number of factors that make it unsuitable for use as a training tool. It is a lengthy instrument that requires three passes. Although it has been suggested that one pass could be used for BCC consultations, this would be difficult, as there are three sections to code (the globals, behavior counts and timing) and this threatens to reduce rater reliability. There are also a number of subsections that would not be essential for trainers in BCC to assess—for example, items on the specific type of reflective listening strategy used. Shortening the MISC to simply include the global ratings would not be suitable for trainers, as information regarding the acquisition of microskills would be lost. Work done by Boycott concluded that MISC was not suitable for training purposes—rating was time consuming and expensive, and the point was made that although the MISC provided counts of actual behaviors, it did not provide an assessment of the overall strength of those behaviors [16]. Therefore, it was felt that a new measure needed to be designed, specifically with BCC trainers in mind, that was brief, could be coded in one pass, and focussed on the spirit and principles of BCC.

Our strategy was to design an instrument that could be used either in training itself as an aid to learning, or as a tool for assessing improvement in competence associated with training. The aim was therefore to focus on practitioner consulting behavior and attitude, rather than the response of the patient. We wanted BECCI to be scored as easily as possible (as trainers are often subject to time constraints when assessing competence), and therefore conducted the initial psychometric work using audio-recordings rather than transcripts. Finally, we decided to examine reliability and validity using mainly simulated patients, since these are more commonly used in training than real patients.

Section snippets

Method

A summary of the development process can be viewed in Fig. 1. A number of different data sets were used in the development of BECCI. The details of each data set can be found in Table 1.

Internal consistency

Initial internal consistency (phase 1) testing showed that the item on information exchange did not correlate with the rest of the items, as information exchange was not occurring in every consultation (but when it did, it needed to be assessed). The item was therefore given non-core status. The item dealing with practitioner talk time was found to have a negative weighting effect. As it was an important element of BCC, and therefore important to record, it was removed from the scale, but

Discussion and conclusion

Although the MISC has shown to be of potential use for researchers and trainers in motivational interviewing [15], its length and nature have been highlighted as unsuitable for trainers in BCC [14], [16]. This new tool, BECCI, shows potential as a measure of practitioner competence in BCC, an adaptation of motivational interviewing. The focus of this paper has been on its use in simulated consultations in training, the primary context in which BECCI will be used.

Although the checklist was

Acknowledgements

Many thanks to Jeff Allison, Denise Ernst, Steve Berg Smith, Jacqui Hecht, Gary Rose, Chris Butler, Brian Burke, Stephanie Balliasotes and Tom Barth for their input in the item development stage. Thanks also to David Tappin for the data used in the item development stage. Thanks to Tom Fowler for his assistance with coding, and finally thank you to Ian Russell and Nigel Stott for their guidance during the development of BECCI.

References (25)

  • A framework for the development and evaluation of RCTs for complex interventions to improve health. Medical Research...
  • S. Rollnick

    Enthusiasm, quick fixes and premature controlled trials—commentary

    Addiction

    (2001)
  • Cited by (0)

    View full text