How Effective are Motivational Interview (MI) Trainings for Addiction?
Motivational interviewing and a related treatment package, motivational enhancement therapy, are approaches for the treatment of alcohol and other drug use problems that are typically brief (between 1 and 4 sessions) and aim to resolve individuals’ ambivalence about behavior change.
There is a substantial body of evidence showing that motivational approaches are typically more effective than no treatment and often as effective as other active treatments in helping individuals reduce alcohol use in the short-term.
WHAT PROBLEM DOES THIS STUDY ADDRESS?
Understanding the potential public health impact of a treatment, however, involves not only its efficacy but also its reach and adoptability. That is, will treatment providers in a multitude of settings successfully use strategies that have been tested in clinical research? This is a particularly important question in motivational approaches for addiction and its related problems because many clinicians believe “they are already doing it.”
This approach requires specific training and supervision to reach and maintain clinical competence. There has been a strong emphasis among clinical researchers who study motivational interviewing to develop and test training interventions for practicing clinicians. In the current study, authors conducted a systematic review of the scientific literature (meaning they had specific criteria they used to determine whether a study was included or not) on the effectiveness of these training interventions.
HOW WAS THIS STUDY CONDUCTED?
This systematic review examined the effectiveness of clinical training interventions for motivational interviewing, particularly in substance use disorder (SUD) treatment settings (e.g., not in general medical units or college campuses, as some studies have examined).
The effectiveness of the training in each of these studies was measured with “Motivational Interviewing Spirit” (i.e., each was rated as to whether the practitioners conveyed the essence of the motivational approach in their work) using one of three coding systems:
- Motivational Interviewing Treatment Integrity (MITI)
- Motivational Interviewing Skills Code (MISC)
- Independent Tape Rating Scale (ITRS)
Specifically, study staff needed to have reviewed clinician tapes or other recordings to determine whether providers were using collaborative (including both the provider and patients’ views), evocative (eliciting patients’ reasons for change rather than that of the provider), and autonomy-supportive (respectful of patients’ rights to change or remain the same, and avoidance by the provider of imposing their understandable desire for the patient to engage in healthy behaviors) strategies.
The primary goal was to determine whether training interventions could promote “beginning MI proficiency” in 75% of participating providers. Beginning proficiency corresponded with 5 on a scale from 1 to 7 for the MISC and MITI, and 4 on a scale from 1 to 7 on at least half of the ten MI items on the ITRS.
WHAT DID THIS STUDY FIND?
Of the 20 studies that initially met inclusion criteria, 15 used a measurement of treatment fidelity and integrity (i.e., how closely providers delivered the treatment as intended by the treatment developers). As mentioned above, fidelity/integrity was captured by MI global spirit. Of these 15, eight used the MITI to measure global MI spirit, but only six provided enough information to calculate the proportion of participants that had basic motivational interviewing (MI) proficiency at follow-up. Four studies used the MISC, though one was excluded due to insufficient information. Three studies used the ITRS.
Among 12 studies reviewed that had enough information to calculate whether participants met “beginning proficiency”, only 2 met or exceeded this threshold
Both of these studies included ongoing supervision and monitoring of providers’ clinical work well past the initial training intervention.
Among three studies that examined patient outcomes, one study showed that the extent to which providers adhered to the motivational interviewing (MI) model and the skillfulness with which they did this was modestly associated (r ~ .2) with patients’ negative toxicology screens.
The remaining two did not find an association between motivational interviewing (MI) adherence/skill and patient outcomes.
These clinical approaches have been shown to promote initiation of recovery from addiction. This study showed that although prior research has found motivational interviewing approaches can be an important tool in helping patients reduce alcohol and other drug use, training providers in the competent delivery of the model as it is intended to be delivered may pose challenges.
Also, it is uncertain whether enhancing providers’ ability to deliver the motivational interviewing (MI) approach as originally intended actually promotes better patient outcomes.
WHY IS THIS STUDY IMPORTANT
The study is important because it highlights research on the implementation of an evidence-based approach. That is, the study moves beyond questions about the effectiveness of such treatments & toward whether practitioners actually can learn, adopt, & become competent in delivering such treatments in their regular clinical practice.
Even the best treatments that have been rigorously developed and tested have limited utility in actual practice if they cannot be readily adopted and integrated.
Treatment providers that have been trained in motivational interviewing may not be delivering the treatment as developers intended. Therefore, it is possible that studies supporting the efficacy of motivational interviewing do not apply to individuals seeking treatment from providers and community programs where these approaches are not delivered skillfully.
- The study used a specific definition of “beginning proficiency” (e.g., 75% of providers demonstrating good global MI spirit). Other markers of motivational interviewing (MI) skill may have yielded different results. However, studies that examine training outcomes with these more fine grained measurements were rare. Also, of the 20 studies that met inclusion criteria, only 12 were included in authors’ evaluation because they had requisite information to calculate the proportion who met ‘beginning proficiency”. It is unclear whether these remaining 8 studies would have yielded different results.
Further investigation is needed into how to enhance community providers’ fidelity to the motivational interviewing approach, and whether increased fidelity to the model’s delivery predicts improved patient outcomes.
- For individuals & families seeking recovery: There is not sufficient evidence to conclude whether a therapists’ faithfulness to or skill in delivering motivational interviewing approaches will have any bearing on your loved ones’ treatment outcomes.
- For scientists: This review highlights the value of research evaluating clinical training interventions, the need for greater understanding of the effectiveness of training interventions for “evidence-based treatments”, and whether or not more effective training interventions result in better patient outcomes. Findings suggests the mechanisms through which clinical effects are transmitted are complex.
- For policy makers: Consider greater funding to enhance the evaluation of the implementation of evidence-based treatments in community programs to ensure these treatments will result in improved patients’ outcomes.
- For treatment professionals and treatment systems: If you wish to maximize the skill with which you deliver motivational interviewing, ongoing supervision specific to this approach will likely be needed after an initial training course or seminar.
Hall, K., Staiger, P. K., Simpson, A., Best, D., & Lubman, D. I. (2015). After 30 years of dissemination, have we achieved sustained practice change in motivational interviewing? Addiction. doi:10.1111/add.13014