Becoming skilled in MI: rewards and challenges.

Motivational Interviewing (MI) is a counseling style that's generating a great deal of "buzz" lately. For good reason.

Randomized clinical trials using MI with real-world clients have provided substantial evidence that MI reduces client resistance, enhances motivation for change, improves compliance in treatment, and improves outcomes following treatment. See www.motivationalinterview.org for a bibliography of papers and studies. In these studies, though, MI has been evaluated only as part of a brief motivational intervention (BMI). BMIs typically include an assessment, personalized feedback, and motivational enhancement using MI.

MI integrates well with various "action-oriented" treatment protocols and is only incompatible with aggressively confrontational approaches. We have trained counselors in MI who are using it in 12-Step programs, in cognitive-behavioral programs, and in traditional Native American protocols. Most counselors using MI use it as a prelude to and integrated with action-oriented treatment.

We have some good news and some not-so-good news about MI. First, the good news. There is now a network of MI trainers, a list of which is available at www.motivationalinterview.org. Chances are good that there's a trainer close to you. Now, the not-so-good news. Current research in how best to train counselors indicates that one cannot become proficient in MI by just attending a one- or two-day workshop. There's a lot more involved.

To address how to become proficient in MI, I asked longtime colleague Joseph "Bo" Miller, M.S.W., to be interviewed. Miller, a social worker and licensed alcohol and drug abuse counselor, is a senior research scientist at the University of New Mexico's Center on Alcoholism, Substance Abuse & Addictions (CASAA). Since 1990, he has pursued an interest in the application of brief motivational interventions in substance abuse treatment, in community prevention efforts, and in other health care settings. Bo got involved in MI clinical trials serving as a research therapist on various projects directed by William Miller, Ph.D., the originator of MI. He has been a therapist where the rubber meets the road: applying the strategies and spirit of MI with real clients in randomized clinical trials.

Q: Bo, what attracted you to MI as a clinical approach?

A: I first got introduced to MI as part of a substance abuse prevention program at the University of New Mexico. We offered free "Drinker's Check-ups" to anyone on campus with concerns about their alcohol use. The non-judgmental and non-confrontational approach was in marked contrast to some of what I'd seen in my work in outpatient and inpatient treatment programs at that time. I liked the idea of letting people make their own arguments for change and getting myself out of the thankless position of trying to convince them that they had to quit drinking or using other drugs "for their own good." It's much easier on the therapist to recognize that clients are the experts on what's going to work for them, that we don't have to have all of the answers, or meet resistance head-on. A few well-chosen questions and a lot of reflective listening can help people see the gap between where they are now and where they would like to be. It also became clear to me that this low-keyed approach actually worked with surprisingly brief contacts.

Where have you and others used MI and other BMIs?

MI was originally seen as a strategy for boosting engagement in alcohol treatment. I've also encouraged its use in workplace and school settings (employee assistance programs, student health centers, DOT drug testing, etc.). Emergency rooms and primary health care settings offer another venue for BMIs, whether performed by the health care providers themselves or by substance abuse professionals at the facility. I've found MI to be particularly useful in rural or other underserved areas where counselors are scarce and have to get the most out of infrequent sessions. We've got good evidence that adding a well-designed MI session to the beginning of inpatient or outpatient treatment improves compliance with and outcomes for clients. In the last five to seven years. I've seen a huge increase in demand for using MI with other health behaviors (e.g., diet, exercise, medication adherence).

What are the different ways in which people can learn about MI?

A good first step is to get a hold of the basic text by Miller and Rollnick (1991, 2002). If you are a substance abuse professional, the 1991 edition has some material on addiction treatment that is not duplicated in the second edition and is worth looking at. Other resources include CSAT TIP, Project Match Manual, and a few training videotapes (see http://motivationalinterview.org/training/videos.html). Training workshops (one to three days) are the most helpful resource to give someone a hands-on experience of the approach. Training workshops get you started, but--as with most therapeutic skills--actual work with clients coupled with good supervision is essential to becoming proficient.

As a trainer, what works best in helping counselors become effective in MI?

The "gold standard" for teaching MI has been the two-day intensive training. The training typically introduces people to both the strategies and the "spirit" of the approach, i.e., the values, attitudes and mindset you use when talking to people about change. In my experience, most people see things that are compatible with their own approach, regardless of theoretical orientation. The sessions include plenty of hands-on skill-building and practice. A recent study on training MI by Bill Miller and his colleagues here at the University of New Mexico revealed that, compared to waiting-list controls, practitioners who got that basic training significantly improved their MI skills. Most importantly, they stopped doing some "non-MI" kinds of behaviors that might sabotage the potential for change in their clients. Participants who just got the two-day training, however, tended to lose their edge on MI skills by the four-month follow-up. Those in other conditions got the basic training plus personalized feedback on taped practice; individualized coaching; or both the feedback and coaching. Each of these groups maintained their MI skills over time.

What are the stumbling blocks people encounter in learning MI?

The first challenge for many of us is to avoid the natural tendency to advocate for change. We want to jump in and offer advice and solutions when we should be letting the client generate the reasons for making a change. It's also challenging for trainees, regardless of their therapeutic experience, to consistently use client-centered communication skills (e.g., reflective listening, open-ended questions, etc.) in a manner that respectfully directs the discussion toward change without being pushy. As clinicians, we are likely to rely too heavily on questions to draw people out rather than listening attentively and reflecting what we hear. The art of the approach emerges in being able to sort through what people are saying and to highlight the key things--the "change talk"--that will tip the scale for that person toward action. Once people get this aspect of the MI style going well, they sometimes have trouble "closing the deal" for change. When we think people are ready to consider change, it's important to ask for commitment: "What do you want to do about your drinking or drug use?" Hearing a clear commitment statement is not the signal to shift into the expert role and start offering advice. Maintaining MI's collaborative approach during this planning phase helps clients find solutions that will work for them and highlights the sense that they are responsible for any changes that take place--which they are!

What do clinical supervisors need to keep in mind when supervising therapists in MI?

It's important to model the approach in your supervision. This means you've got to put some time into learning and practicing MI with clients before you try to supervise someone else. The spirit and strategies of MI lend themselves to a collaborative, reflective supervisory style that invites people to examine their own interactions with clients. I encourage people to audiotape sessions to provide concrete material for supervision. Focusing on things that went well in a session in addition to things that got off track can help the supervisor keep the discussion from getting too critical. Supervisees can use coding sheets and behavior counts of taped sessions to help them zero in on both non-MI and MI-consistent behaviors. Role-playing--including some modeling of MI skills by the supervisor--rounds out the supervisory experience.

What's the next step for individuals or agencies that would like to learn more about MI and integrating it into their work?

I would certainly encourage them to check out the resources already mentioned: articles, books, and the website. Following that, I urge people to get the best training and supervision they can. Many state programs and other entities are offering MI training sessions as part of a commitment to evidence-based interventions. Programs wanting to add MI to their treatment regimen may want to have their clinical supervisors get trained first or at least along with their treatment staff. In settings where a trained supervisor is not available. I've encouraged practitioners who've gone through training on their own to work out some form of peer supervision. Finally, as with any new approach, find a way to evaluate your skill development and your impact on client outcomes. Taping your sessions will give you a clearer view of what happened.

Reid K. Hester is director of the Research Division at Behavior Therapy Associates LLP, an organization of psychologists providing clinical services, research, training and consultation to health and behavioral health providers. The Research Division is involved primarily in research in alcohol and drug problems. Hester can be reached via e-mail at [e-mail].

By Reid K. Hester, Ph.D.

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