Motivational Enhancement Interventions and Health Behaviors

Thad R Leffingwell. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.

Most behavioral health specialists are interested in how to encourage change in health behaviors among their patients. These behavior changes might include reductions or cessations of behaviors harmful to health, such as tobacco use and excessive alcohol use, or adoption/enhancement of new or infrequent behaviors that may improve or protect health, such as adhering to a special diet and increasing physical activity. Certainly, an individual’s motivation to make a behavior change may determine whether or not change is attempted or implemented successfully. If motivation for change in important, the question for the behavior health specialist becomes “How can I motivate my patients to make important behavior changes?” This chapter describes approaches to enhancing motivation and encouraging behavior change based on principles of motivational interviewing, a patient-centered counseling approach (Miller & Rollnick, 2002). Rather than focusing on “pure” motivational interviewing alone, this chapter focuses on a variety of similar approaches and strategies that are consistent with the principles and spirit of motivational interviewing. A variety of interventions that alter the structure and setting of the intervention, while retaining the fundamental principles and spirit of motivational interviewing, have been developed and tested (Dunn, Deroo, & Rivara, 2001; Rollnick et al., 2002).

Before considering interventions for enhancing motivation, it would be helpful to discuss what motivation is. Motivation is a complex concept that has intrigued psychologists for years. Motivation has most often been described as a property of an individual. From this perspective, motivation may either be state-like (e.g., driven by transitory states of deprivation or need) or trait-like (e.g., something a client either had or lacked). Both of these perspectives place the responsibility for modifying motivation in the hands of the patient (if motivation can be modified at all) and offer little guidance on how to enhance this critical ingredient for change. The guiding conceptualization of motivation in this chapter is more complex and is based on an assumption that motivation is dynamic and can be modified by social interactions (Miller, 1985, 1999). From this perspective, motivation is conceptualized as a product of an interpersonal process between patient and provider, and certainly the job of the provider is to create conditions that maximize motivation (Miller & Rollnick, 2002).

Two other fundamental issues deserve mention at the outset. First, the motivational enhancement interventions described in this chapter focus on reducing ambivalence about behavior change as a means to enhance motivation. With most health behaviors, the patient typically feels more than one way about changing the status quo; part of the patient wants to change, and another part does not. It is this ambivalence that has the patient stuck in his or her current patterns of behavior. The practitioner can intervene in certain ways with the ambivalent patient to “tip the scales” in favor of change. Second, contemporary models of behavior change have moved beyond simple doing/not doing conceptualizations of change and now acknowledge several stages in the change process (Prochaska, DiClemente, & Norcross, 1992). These stages not only include various active stages of attempting change, such as preparation, action, and maintenance, but also include differentiations among individuals not actively involved in change, such as precontemplation and contemplation. This transtheoretical model is well known to most behavioral health specialists and now guides most research and clinical practice regarding health behavior change. The interventions described in this chapter are consistent with this model in that they provide means for intervening appropriately with patients in nonactive stages and maximize the probability of moving patients along the stages of change—ultimately toward successful change.

Historical Background

Clinical Development of Approach

Although the principles of motivational interviewing are seen today as generalizable to many health behavior problems, they were initially developed in the substance abuse field. At the time, the prevailing conceptualization of motivation to change addictive behaviors was based on a belief in trait-like motivation, and resistance and denial were seen as common symptoms of substance dependence. The principles and techniques of motivational interviewing with alcoholics were first described during the early 1980s. Building on social-cognitive processes and a Rogerian counseling style, Miller (1983) described a new approach to patient motivation and a counseling style that offered a compelling alternative to the prevailing model. Miller described client motivation as a product of the interpersonal process or as “a product of the way in which counselors have chosen to interact with problem drinkers” (p. 150). This recasting of client motivation and related behaviors of resistance and denial required a different kind of approach to counseling from the existing approach of direct persuasion, confrontation, and the “breaking through” of denial (e.g., DiCicco, Unterberger, & Mack, 1978). Furthermore, this new approach essentially implicated the confrontational interpersonal approaches typically used by counselors for the frequent observation of resistance and denial with ambivalent individuals. Clearly, motivational interviewing was a radical innovation for encouraging change in patient health behavior. The motivational interviewing approach quickly gained popularity, perhaps due to frustration with then current approaches or the attractiveness of the less confrontational style of the approach.

Since its inception, motivational interviewing has undergone significant refinement and adaptation. The first text describing the approach in great detail appeared in 1991 (Miller & Rollnick, 1991). Subtitled Preparing People to Change Addictive Behaviors, this manual focused specifically on how to effectively prepare individuals with substance abuse and dependence problems to make self-directed or assisted changes. This innovative new approach was also described in a Treatment Improvement Protocol (TIP) series manual distributed by the U.S. Department of Health and Human Services (Miller, 1999), and a treatment manual was prepared for the motivational enhancement condition of Project MATCH (National Institute on Alcohol Abuse and Alcoholism, 1995). Building on work to develop a brief method of motivational interviewing for physicians counseling patients (Butler et al., 1999; Rollnick, Heather, & Bell, 1992), Rollnick, Mason, and Butler (1999) published a text describing a model of brief motivational enhancement intervention for physicians that retains the spirit of motivational interviewing while simplifying the technique for applications in more brief encounters. Finally, Miller and Rollnick (2002) produced an extensive revision of the original motivational interviewing text, this time reflecting the broad popularity of the negotiating style by describing the approach as a more general strategy applicable to patients who might be ambivalent about any behavior change, not just changing addictive behavior.

Empirical Support

Since the release of the original detailed manual (Miller & Rollnick, 1991), numerous clinical trials investigating motivational interviewing interventions or related adaptations have appeared in the literature. A regularly updated comprehensive bibliography of motivational interviewing literature lists more than 60 reports of clinical outcome studies, and most of these are randomized trials (http://www.motivationalinterview.org). Although the majority of these reports focus on applications with substance use, applications of brief motivational enhancement interventions to other behavioral problems include problem gambling (Hodgins, Currie, & el-Guebaly, 2001), nutrition (Resnicow, Jackson, Wang, Dudley, & Baranowski, 2001; Resnicow et al., 2000), medication compliance (Schmaling, Blume, & Afari, 2001), HIV infection protective behaviors (Carey et al., 2000), tobacco use (Butler et al., 1999), mammography screening (Ludman, Curry, Meyer, & Taplin, 1999), engagement in treatment for bulimia nervosa (Treasure et al., 1999), weight control (Smith, Heckemeyer, Kratt, & Mason, 1997), diabetes self-care (Trigwell, Grant, & House, 1997), and even water disinfecting practices for individuals living near unsafe water sources (Thevos, Quick, & Yanduli, 2000).

Reviews of the available motivational interviewing literature are challenging because motivational interviewing is more of a counseling style than a set of techniques or a collection of tasks. This means that interventions may vary significantly in form, including the setting for the intervention (e.g., emergency room, therapy office, physician’s exam room) and structure (e.g., duration of interaction), while still retaining the style or spirit of motivational interviewing. Although this flexibility almost certainly accounts for some of the popularity of the motivational interviewing approach as a clinical tool, it creates difficulties for making inferences about exactly which interventions have which effects. Nonetheless, three reviews of this literature have been attempted.

Noonan and Moyers (1997) performed a qualitative review of the available clinical trials that applied motivational interviewing to substance use problems. They reviewed 11 randomized trials and concluded that 9 studies supported the efficacy of motivational interviewing for substance abuse and dependence problems.

A more comprehensive review was conducted by Dunn and colleagues (2001). They attempted to capture the diverse nature of motivational interviewing approaches while retaining internal validity of the interventions by defining Adaptations of Motivational Interviewing (AMIs). To qualify as an AMI, an intervention had to claim to adhere to basic principles of motivational interviewing. Consistent with a definition of motivational interviewing offered by Rollnick and Miller (1995), this meant that the intervention had to use a client-centered empathic style to reduce resistance, develop motivational discrepancies, and support the patient’s self-efficacy. A structure most often used in AMIs incorporates some sort of review of assessment feedback as the focus of the interview, while the counselor uses an interpersonal style and strategies consistent with motivational interviewing to facilitate the processing of the feedback and to elicit self-motivational statements (e.g., Miller, Sovereign, & Krege, 1988). Using this definition of AMIs and other exclusion criteria regarding study design and outcome measurement, Dunn and colleagues (2001) found 29 studies for inclusion in their review.

The Dunn and colleagues (2001) review included applications of AMIs in four different behavioral change contexts: substance use, tobacco use, HIV risk behaviors, and diet/exercise. These investigators found that 60% of the studies reviewed had significant effect sizes favoring the AMI. The most consistent evidence for AMI effectiveness was observed where the AMI was used as an enhancement to standard treatment for substance use when delivered at the onset of a treatment episode. The findings for applications for tobacco use, HIV risk, and diet/exercise were more mixed but still encouraging, and more research was recommended.

The third review of the motivational interviewing literature was conducted by Burke, Arkowitz, and Dunn (2002). Using a similar approach to that used by Dunn and colleagues (2001), but with slightly more restrictive inclusion criteria, these investigators identified 26 randomized trials of an AMI for review. This review reached similar conclusions, with the most impressive findings emerging for AMIs as both a treatment adjunct to standard treatment and a stand-alone treatment for patients with alcohol problems. Studies of AMIs applied to problems of tobacco use, illicit drug use, diet/exercise, and eating disorders were reported to be encouraging but too sparse to make strong findings or recommendations. No support was found for the use of AMIs to reduce HIV risk behaviors. The authors concluded that reasonable evidence supports the use of AMIs as both a standalone intervention and a treatment adjunct at the onset of other treatment. Although the data are fairly consistent that AMIs are efficacious, the data are very unclear as to how, why, and for whom the interventions work.

Variations of Motivational Enhancement Interventions

As noted previously, motivational interviewing rarely exists in “pure” form in the empirical literature, and it seems likely that this is also reflected in clinical practice. For example, the 29 studies reviewed by Dunn and colleagues (2001) used eight different labels other than “motivational interviewing” to describe their interventions. Furthermore, the durations of the interventions ranged from 5 to 360 minutes. Clinicians in practice, receiving little direct guidance from the heterogeneous empirical literature, are likely to create motivational enhancement motivations customized to their patient populations, behavioral problems encountered, and settings. The purpose of this section is to introduce a few prevailing models of motivational enhancement interventions and to introduce key principles from motivational interviewing that would be required to capture the spirit of the motivational interviewing style.

Rollnick and colleagues (2002) attempted to add clarity to the varieties of AMIs that exist in the literature and in practice. According to their framework, brief motivational enhancement interventions could be categorized as one of three general types of intervention: (a) brief advice, (b) behavior change counseling, and (c) motivational interviewing. What these share in common could be considered the core of effective motivational enhancement interventions—a nonconfrontational style and a goal of eliciting change from within the patient rather than imposing from the outside via blaming, coercion, or direct persuasion. The approaches may differ on several domains, including the duration of the consultation, the role of the practitioner, the use of confrontation, and the use of direct information. Rollnick and colleagues also attempted to describe the skill sets necessary for each of these types of intervention, with more complex and varied skills necessary for the longer and more complex interaction of motivational interviewing.

Brief Advice

Rollnick and colleagues (2002) described brief advice as a typically brief (less than 15 minutes) opportunistic intervention delivered by nonspecialists in behavior change counseling. The goals are typically to raise awareness of a behavioral problem and to initiate at least contemplation of change. Information exchange is largely one-way, from practitioner to patient. Goals for behavior change are often suggested rather than elicited. Although the inequality of roles is not consistent with motivational interviewing, the practitioner can maximize the motivational impact of the information and advice by carefully choosing a good opportunity for the intervention, presenting information in a respectful and compassionate manner, and using at least some open-ended questions and reflections.

Behavior Change Counseling

Behavior change counseling, as described by Rollnick and colleagues (2002) is an approach somewhere between brief advice and “pure” motivational interviewing. The consultation is typically longer in duration and may involve more than one problem area. The practitioner and the patient typically share a more equal role in the decision-making and goal-setting process. Using a person-centered approach, the practitioner often uses open-ended questions and reflection to understand the patient’s perspective and to check for understanding. Information typically flows in both directions between the practitioner and the patient, in contrast to the one-way flow seen with brief advice. Most often, the goal is to elicit a decision and plan for change in a more pragmatic sense than in motivational interviewing, where one tries to enhance the quality and commitment of the plans for change as well.

Rollnick and colleagues (1999) described a model of behavior change counseling based on earlier work trying to develop “brief motivational interviewing” (Rollnick et al., 1992). Designed for nonspecialists working in time-pressured settings such as primary care clinics, this model simplifies the goals and strategies of the behavior change consultation. After establishing basic rapport and setting an agenda for the consultation, the practitioner’s task is to explore the patient’s feelings about a behavior change using two dimensions: importance and confidence. In this model, these two dimensions adequately capture the nature of ambivalence, and enhancing both increases the likelihood of both a change attempt and a successful outcome. Throughout the consultation, the practitioner may exchange information (as in brief advice) or use interpersonal strategies to reduce resistance (as in motivational interviewing).

One very creative technique recommended as part of this intervention model is the use of scaled questions (e.g., 1 to 100) for assessing the importance of a behavior change and confidence in making a change. For example, the practitioner might ask “If 0 is ‘not important at all’ and 100 is ‘very important,’ what number would you say represents how important it is to you now to change||||?” Whatever answers a patient might provide to these types of questions, the answers provide great fodder for reflection, amplification, and investigation. The patient typically will give a number somewhere between the extremes. For the question of importance, this would allow the practitioner to follow up this answer to identify concerns the patient may have about his or her behavior (e.g., “You said ‘40’. Why not lower? What makes it ‘40’ in importance?”) or to identify gaps in knowledge/awareness or other priorities the patient may have (e.g., “Why is the number not higher? What would it take for you to increase the importance of this change?”). For the response to a scaled question about confidence, the practitioner may follow up with questions or reflections to explore barriers perceived by the patient (e.g., “You rated your confidence as ‘60’. Why not ‘70’ or ‘80’?”) or to identify skills or resources the patient may have available to support a change effort (e.g., “You rated your confidence as ‘40’. You must feel that there is some chance you could do it if you tried. Why?”).

The Rollnick and colleagues (1999) brief intervention model includes several other strategies for exploring importance, building confidence, assessing readiness for change, and making strategies for change. As with all brief behavior change counseling AMIs, practitioners are encouraged to capture the spirit of motivational interviewing in their interactions with clients by using a supportive and nonconfrontational style to minimize and respond to resistance. Practitioners are encouraged to choose from the menus of strategies to create an adaptation that fits their needs and settings rather than adopting a formulaic treatment approach.

Motivational Interviewing

Rollnick and colleagues (2002) described “pure” motivational interviewing as the most complex and involved approach to brief motivational enhancement. Applications of motivational interviewing are typically less opportunistic planned encounters that normally last longer than 30 minutes and often span more than one session. Motivational interviewing requires the full complement of skills and strategies as well as adherence to the core principles of motivational interviewing (Miller & Rollnick, 2002). Confrontational style is always avoided, and direct advice is usually provided only when directly requested by the patient. Communication is used more strategically, with the goal of creating motivational discrepancies, resolving ambivalence, and eliciting self-motivational statements (or “change talk”) from the patient.

Miller and Rollnick (2002) defined motivational interviewing as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 25). Motivational interviewing has also been described as “a counseling style rather than a set of techniques applied to or on people” (Rollnick, 2001, p. 1769, emphasis added). Although a number of techniques and strategies are recommended as consistent with motivational interviewing, other strategies could be used so long as they are consistent with the principles and style of motivational interviewing. In fact, adaptation and creative application of the principles are encouraged. Motivational interviewing in practice, unlike other manualized treatments, might not necessarily have a structured beginning, middle, and end but instead may occur at various times during a treatment relationship between practitioner and patient. It may be left and revisited or may be integrated with an ongoing treatment plan. Motivational interviewing is not something to be done to patients but rather is a way of being with patients (Miller, 2002).

Fundamentals of Motivational Interviewing

Essential Spirit. Miller and Rollnick (2002) described the spirit of motivational interviewing as “understanding and experiencing the human nature that gives rise to that way of being” and as absolutely fundamental to any intervention that might claim to be motivational interviewing or a reasonable adaptation. How the practitioner thinks about the patient and the process is as important as any technique in determining the nature of the intervention. Miller and Rollnick further described the spirit of motivational interviewing as captured by three fundamental considerations: (a) a collaborative relationship, rather than an authoritarian or prescriptive relationship, between the practitioner and the patient; (b) an eliciting evocative approach rather than a persuasive or educative stance; and (c) a commitment to the ultimate autonomy of the patient to make decisions about change and to marshal personal resources for change. These considerations are mutually consistent in their respect for the patient’s freedom of choice as well as competence and expertise in his or her own life.

Phases of the Interview. A comprehensive and complete motivational interview would include two overlapping phases: increasing motivation for change (Phase 1) and strengthening commitment to a decision for change (Phase 2) (Miller & Rollnick, 2002). Phase 1 typically involves strategies for building rapport; increasing problem recognition; and identifying, exploring, and resolving the various aspects of patient ambivalence. Phase 2 typically involves tasks such as goal setting, making behavioral plans, and negotiating time lines while being careful to avoid roadblocks to a successful change attempt (e.g., unrealistic goals, underestimated effort, shallow commitment).

Four Principles. Refinements to Miller’s (1983) original description of motivational interviewing have resulted in the distillation of four fundamental principles (Miller & Rollnick, 2002). These principles help to translate the spirit of motivational interviewing into behavioral strategies to guide the practitioner. The principles are not necessarily meant to be initiated in order or in equal amounts but rather are intended to be skillfully and elegantly woven together during and throughout the process of the interview.

The first principle is expressing empathy. Probably nowhere is it more important than here that one believes in the spirit of motivational interviewing. This principle builds on classic work by Rogers (1951, 1961) and assumes that acceptance of patients as they are paradoxically makes it easier for them to change. As with Rogers’s approach, careful reflective listening is the key to communicating empathy to the client. The practitioner may use a number of familiar listening skills, including open-ended questions, a variety of reflective statements, and nonverbal behaviors. Reflective listening simultaneously accomplishes several goals, including encouraging elaboration by the patient (which aids in understanding by the practitioner by eliciting data) and communicating to the patient both an effort to understand and ultimately greater understanding for the practitioner of the patient. This behavior often prevents resistance from the outset of the interview because typical behaviors that would be likely to elicit resistance (e.g., direct persuasion, confrontation, appeals to authority) are avoided altogether.

How one thinks about the nature of ambivalence is a key to demonstrating empathy in motivational interviewing. Ambivalence about behavior change is normal and natural, and it occurs for most behavior changes involving habitual behavior patterns, including changing addictive behaviors. Change is difficult. The status quo is comfortable. Patients have frequently had either direct or modeled failure experiences involving behavior change. If one sees ambivalence about change as normal and natural rather than as a sign of pathology, immorality, or other undesirable personality characteristics, it immediately becomes much easier to be comfortable with understanding and exploring that experience.

The second principle, developing discrepancies, involves understanding and amplifying differences between the patient’s current behavior and his or her goals, values, and/or self-image (Miller & Rollnick, 2002). This discrepancy serves as a motivating force that can be used to elicit self-motivational statements. If an individual perceives a behavior as inconsistent with other important goals, the probability of change increases. Enhancing motivational discrepancies may involve decreasing the importance of current unhealthy behaviors; increasing the importance of behaviors, values, or goals inconsistent with this current behavior; or both. The patient’s current behavioral patterns are seen as the result of a balancing attempt among various behaviors, goals, and values that are often conflicting. The practitioner’s goal is to tip that balance in the direction of change.

The third principle, responding to resistance, is a hallmark principle that truly separates motivational interviewing from most other approaches and is probably the most innovative aspect of the approach. As mentioned previously, resistance is viewed as the result of the interpersonal process, or the way in which the practitioner is interacting with the patient at that moment, rather than as a characteristic of the patient himself or herself. Interactions create resistance; people are not resistant. From this perspective, it follows that the practitioner holds responsibility for creating conditions in the interpersonal interaction to reduce resistance. When resistance is encountered in the interview, the practitioner sees that as a signal to change strategies rather than as a signal to press onward as in confrontational or persuasive approaches. Because of the paramount importance and complexity of the task of responding to resistance, Miller and Rollnick (2002) offered several strategies for accomplishing this task. These are summarized in Table 4.1.

The final principle, supporting self-efficacy, refers to communicating a belief in the patient’s ability to be an agent of change on his or her own behalf. This principle is sometimes manifest subtly by the practitioner’s implicit belief in the patient’s role in the change process. When the patient is treated as the ultimate decision maker and as a collaborative partner in exploring change, a belief in the patient’s ability to change is assumed. Also, when the practitioner inquires in a sincere way as to how a patient might go about making a change, this implies a belief in the patient’s own resources and ideas. A number of more explicit strategies can also be employed, including reviewing past successes or models, amplifying personal strengths, brainstorming new ideas, and even occasionally giving direct advice (Miller & Rollnick, 2002).

Use of Feedback. Although not inherent to motivational interviewing itself, most investigations of motivational enhancement approaches have used assessment feedback as part of the process (Dunn et al., 2001). Feedback may include information about health status, presence or absence of disease states, and comparisons with normative data. These data provide a useful start to conversations about change. Reviewing personalized feedback with a patient provides many opportunities to explore concerns a patient may have about his or her current behavior or health status. This type of feedback happens frequently in behavior medicine settings, providing practitioners with numerous rich opportunities to use motivational enhancement strategies. Objective feedback alone, especially if it contains bad or anxiety-provoking news, is likely to be experienced by the patient as confrontive and to elicit resistance. Use of a motivational interviewing style and strategies when reviewing the feedback can aid in the patient’s ability to process the information and use it effectively to motivate change.

Table 4.1 Examples of Various Useful Methods for Responding to Resistance
Method Description Example
Reflective methods
Simple reflection Statement that reflects observed resistance “You would rather not talk about your weight.”
Amplified reflection Restatement of what was heard in exaggerated form “You would rather never talk about your weight. It doesn’t concern you at all.”
Double-sided reflection Restatement of both sides of ambivalence “On the one hand, it’s embarrassing to talk about your weight, and on the other, you are worried about it and would like to ask for help.”
Strategic methods
Shift focus Change in focus of interaction “Let’s not worry about what I think right now; let’s just talk about any concerns you might have.”
Reframe Giving new interpretation to patient’s perspective “You say you’ve tried and failed many times. It sounds like you have tremendous persistence and courage to keep trying.”
Agree with a twist Agreeing with part of patient’s message while reframing another part “Food is your favorite form of recreation, and it’s important to enjoy life, even if it is causing you health problems.”
Emphasize personal control Reaffirming patient’s ultimate freedom of choice “Of course it’s up to you what to do next. No one can make the decision for you.”
Coming alongside Taking patient’s side of the ambivalence to encourage him or her to voice the other side “You’re right that it would be difficult to change—maybe impossible.”

Source: Miller and Rollnick (2002). Reprinted with permission.

Training in Motivational Enhancement Interventions

The varieties of motivational enhancement interventions require a diverse set of skills that vary in complexity depending on the type of intervention employed (Rollnick et al., 2002). For very brief advice encounters, basic knowledge about risks of the current behavior, behavior change strategies, and rudimentary appreciation for the spirit of motivational interviewing likely are all that are required. The more complex interventions, including behavior change counseling and motivational interviewing, require more complex skills and strategies that can probably be learned only through training and supervision. Reflective listening alone is a deceptively complex set of skills to master and is made even more complex by the strategic use of listening in motivational interviewing. In motivational interviewing, the practitioner is not simply expected to mindlessly parrot open-ended questions and reflections for the sake of ongoing dialogue but rather is expected to ask particular questions and make selectivereflective statements to promote motivation for change (Rollnick et al., 2002).

Limited information is available in the empirical literature on appropriate training or on the effects of training. Of 29 studies reviewed by Dunn and colleagues (2001), only 10 reported the durations of training provided to practitioners in the studies, and the durations of that training ranged from 2 to 31 hours. In addition, 11 of the studies reported providing training but offered few details, and 8 of the studies did not include any information about training. Two other studies have examined the effects of training on the knowledge and skills of trainees directly. The first study found that professional participants did demonstrate increases in knowledge about motivational interviewing and basic listening skills in a simple pre-post design (Rubel, Sobell, & Miller, 2000). A second study found that a 2-day workshop on motivational interviewing had significant effects on self-reports of motivational interviewing by trainees and had modest gains in skill use demonstrated on observed practice samples, but expected changes in client behavior were not observed (Miller & Mount, 2001). Unfortunately, although participants in this study did modestly increase their frequency of motivational interviewing consistent strategies, they did not necessarily decrease their use of inconsistent strategies. This is of great concern because it may take only very few confrontational interactions to resurrect resistance and spoil the potential gains of motivational strategies. These preliminary results are encouraging but insufficient to make recommendations on empirical grounds for a necessary amount of training for competent practice. Further research is warranted and would be aided by the development of reliable and valid methods for assessing skill acquisition (Barsky & Coleman, 2001).

Unlike the originators of many other empirical treatments, the originators of motivational interviewing have devoted a good deal of thought and energy to training. Both versions of the motivational interviewing text (Miller & Rollnick, 1991, 2002) included sections on teaching and learning the approach. Over the past several years, Miller and Rollnick have annually provided intensive training for professionals already proficient in the method to become trainers in the technique. Members of this group also stay in regular contact with each other via an e-mail listserv, a regular newsletter, and an annual meeting. A list of these “trained trainers” is available on the motivational interviewing Web site (http://www.motivationalinterview.org).

Miller (2002) proposed a tiered system of training as shown in Table 4.2. This system would allow individuals to tailor the necessary training for their setting and patient needs. Individuals interested in applying the approach to a specific behavioral domain and narrowly defined patient population could do with less training than those interested in a more broad application of the approach and certainly could do with less training than those interested in having the expertise to provide training.

At a minimum, any practitioner interested in applying an approach based on the principles of motivational interviewing should read one or more of the available manuals described earlier. Further training could be obtained via introductory workshops available at many national and regional professional conferences. More intensive training could be arranged from one of the network of trainers. The best possible training will occur with opportunities for practice with feedback, both with role-play exercises and with actual cases (Miller & Rollnick, 2002). Finally, even after formal training in motivational interviewing, a great deal of learning can occur by carefully observing the effect of one’s counseling approach on clients. Miller (1996) described motivational interviewing as an approach he “had learned from [his] clients” (p. 835).

Table 4.2 Miller’s Proposed Tiered System for Levels of Training in Motivational Interviewing
Type of Training Goals Approximate Length
Introduction to motivational interviewing Learn about the basics of motivational interviewing and decide level of interest in learning more. 2 hours to 1 day
Application of motivational interviewing Learn about more specific applications of motivational interviewing, including direct practice with a particular application. 1 hour to 1 day
Clinical training Learn basic style of motivational interviewing, including extended practice. Strengthen empathic listening skills. Learn to recognize client cues for resistance and change talk. 2 to 3 days or several 4- to 8-hour seminars
Advanced training Learn advanced clinical usefulness of motivational interviewing. Receive individual feedback on intensive practice. Learn methods of evaluating motivational interviewing. Update knowledge of research developments. 2 to 3 days (plus prior minimum proficiency)
Training for trainers Learn a flexible range of skills for helping others learn motivational interviewing. Learn to assess needs of trainees and adapt accordingly. Update knowledge of research developments. 3 days

Source: Miller (2002). Reprinted with permission.

Summary

Motivational enhancement interventions based on the style and principles of motivational interviewing have enjoyed increasing popularity over the past decade. Some have even expressed concern that the clinical popularity of the approach may be inappropriate given the young nature of the empirical literature (Dunn et al., 2001). Although the extant empirical literature is encouraging and largely supportive of the effectiveness of motivational enhancement interventions, much more research is needed to better understand how, why, when, and for whom the approach can be effective.

The clinical popularity of this approach is expected to continue. Practitioners interested in applying the principles of motivational interviewing with their patients are cautioned that the approach is deceptively complex and intricate, and training and supervision are recommended for individuals interested in developing proficiency in the methods. Creative adaptations are encouraged, but caution is also warranted before implementing radical departures (e.g., group motivational interviewing, computer-guided motivational interviewing) until further research can evaluate whether these innovative adaptations can demonstrate similar efficacy. Practitioners are further cautioned that if aspects of current intervention attempts with patients are inconsistent with motivational interviewing style, it is unlikely that simply adding new strategies to the repertoire will be effective. For some, it may be necessary to abandon old strategies of confrontation, coercion, and persuasion to achieve better outcomes with motivating patient health behavior change.