D-1 Motivational Interviewing Is Better “Tried” Than “Described”

Read: Miller & Rollnick: Chapter 16

Miller, W. R., & Rollnick, S. (2023). Mo va onal interviewing : Helping people change and grow. Guilford Publica ons.

Learning Mo va onal Interviewing

Learning Mo va onal Interviewing You need knowledge and you need skill. Knowledge you can even get just from reading a book. Skill you cannot get from a book— you need to prac ce again and again. —Paul Ekman We have two ears and one mouth, and we should use them propor onally. —Susan Cain

S o how can you develop skillfulness in the prac ce of MI? What does it take to teach and learn this approach? There is already a large body of research on this topic. 1 Our early assump on was that it could be accomplished through clinical training workshops, which is a fairly standard method for con nuing professional educa on. In our first evalua on of MI training, providers gave us recorded samples of their prac ce with clients prior to a ending a 2-day clinical workshop. 2 To demonstrate what they had learned a er the workshop, par cipants interviewed an actor who was portraying a standardized client role. Then 4 months later, they provided another recorded sample of their actual clinical work applying MI. This study required us to develop the first Mo va onal Interviewing Skills Code (MISC) to measure the quality of MI, a complex observa on system of global ra ngs and behavior counts for both counselors and clients. 3 On sa sfac on ques onnaires, par cipants in the workshop gave us high marks on the quality of training and subsequently indicated that they were using MI and finding it very helpful in their own prac ce. However, expert observers’ coding of their sessions with clients told a different story. Some skill improvements took place immediately a er training (when interviewing an actor) but quickly faded. Some ny (albeit sta s cally significant) changes remained at 4 months— for example, there was one more reflec ve listening response per 10 minutes of counseling— but it wasn’t enough to make any difference to clients, whose in- session responses changed not at all. In essence, there was li le evidence that the par cipants had been trained in MI despite their self- reported substan al gains in skills. You can’t tell how good someone is at listening just by asking them; they don’t know what they don’t know. 4 Because MI is rRELATIVEly brief and it can look easy when done well, people expect it will be straigh orward to learn. It turns out that developing skill in the prac ce of MI is not as easy as we imagined. Even when it doesn’t give the answer that you hoped for, well-done research can teach you to ask be er ques ons. We moved from the naïve ques on, “Does MI training work?,” to asking, “What does it actually take to help people develop competence in MI?” In a controlled trial comparing different training methods, we tested the impact of two follow-up

enhancements on quality of prac ce up to 12 months a er a clinical MI workshop. 5 One extra aid that we provided a er workshop training was individual feedback given to trainees based on objec ve coding of their recorded prac ce sessions. The other was some personal coaching with up to six half-hour telephone calls in the months following the workshop. Either (or both) of these enhancements substan ally improved learning and maintenance of MI skills. However, there was only one condi on in which we observed a significant change in how their clients were responding (in change talk and sustain talk); this happened only when providers had received both individual feedback and personal coaching in addi on to their workshop training. This is now a fairly consistent finding in training research: that merely a ending a workshop o en has li le or no impact on prac ce behavior. 6 Why did we ever think it would? Imagine just receiving classroom instruc on in tennis, French cuisine, playing guitar, or flying an airplane. The normal way to learn such complex skills involves observed prac ce with some expert coaching. The research literature on teaching and learning of MI is already large enough to warrant mul ple meta- analyses. 7 Here is a summary of lessons learned thus far: • MI is learnable. Averaging across a variety of training approaches, providers usually do show medium to large increases in MI prac ce skills. • Learning MI on your own is not easy. Just reading about MI or watching demonstra ons is unlikely to improve your skillfulness. • Similarly, a ending a class or workshop on MI may produce some short-term improvement in prac ce skills but is usually not enough in itself to sustain competence. • People normally overes mate their own proficiency in the prac ce of MI. • Receiving objec ve feedback and expert coaching based on observed prac ce strengthens learning and maintenance of competence in MI. 8 When we are invited to offer a training workshop on MI, we are now likely to ask, “Do you want your staff to know about MI, or do you want them to be able to do it?” • The ability to learn MI seems unrelated to one’s years of educa on. Even people with advanced degrees can learn it! • Demonstrated skill in empathic listening (as described in our chapters on engaging skills) is a very good head start in learning MI. When we had to train therapists for a mul site clinical trial within a rRELATIVEly short period of me, we screened and preselected for reflec ve listening skills, which substan ally facilitated learning of MI. 9

There is no standard “dose” of training that is sufficient or required for people to develop reasonable skillfulness in the prac ce of MI. What makes more sense is to train up to a skill criterion. It’s also prudent to assume that you are not finished with learning a er ini al training. As in music or sports, we do see some prodigies in MI who seem to develop talent quickly, some mes with li le formal training. We have also worked with people who struggle to learn and prac ce the fundamentals of MI even with extended training. In between these extremes there is wide variability in how much me and training people require to become comfortable and capable with MI. This in turn raises the ques on, “Capable enough for what?” How will the learner be using MI? Some applica ons of MI require a higher level of proficiency and flexibility.

For those applying to a Training of New Trainers ( TNT ), the Mo va onal Interviewing Network of Trainers (MINT) 10 has required a prac ce sample demonstra ng reasonable skillfulness in the prac ce of MI. The ra onale is straigh orward: in order to teach pianists, you ought to be able to play piano well yourself. A competent trainer should be able to demonstrate MI when teaching and provide prac cal examples when ques ons arise. The good news is that a er ini al training, a rRELATIVEly modest amount of follow-up coaching can o en yield a reasonable skill level. In the randomized trial of training methods men oned earlier, 11 we found that an average of five 30-minute telephone coaching sessions brought clinicians up to a reasonable level of competence in observed prac ce, enough to be sa sfied that they could deliver MI in a clinical trial. This belies the some mes- expressed worry that developing proficiency in MI requires an extraordinary amount of me and training. Such skill enhancement can also be achieved in group format. A er ini al training, primary care clinicians mee ng as an interprofessional learning community experienced a “paradigm shi ” in their understanding and prac ce of MI, transi oning “from educa on to evoca on, confronta on to acceptance, imposi on to collabora on, and protec on to compassion,” and thinking of themselves as health guides rather than health experts. 12 We honestly don’t know what accounts for differences in how readily people learn MI. We tested a variety of personality characteris cs that we thought might predispose people for learning MI. None of them did, 13 nor, as noted above, did years of advanced educa on or professional background. Already being skillful in accurate empathy makes it easier to learn the rest of MI (such as evoking change talk and responding to sustain talk and discord), 14 but that’s somewhat tautological because MI is inseparable from high- quality listening. It’s like predic ng skill in calculus from mastery of algebra. Thus armed with much research and experience as well as a bit of mystery, we set out in this chapter to help you develop your skills in the prac ce of MI. Here’s what we know so far. Engaging Skills A vital first step in learning MI is to strengthen your comfort and competence with the person- centered engaging skills described in Chapters 4 and 8. These are valuable helping skills in themselves and provide a strong founda on for the overall method of MI. Indeed, learning the rest of MI is not viable without some proficiency in empathic listening skills. There is some good news in this regard. Daily life offers regular conversa onal opportuni es to prac ce your skills in asking open ques ons, affirming, reflec ve listening, and summarizing (OARS). 15 When you do prac ce in this informal way, you can receive natural feedback by paying a en on to how people respond. When you reflect, for example, there is usually immediate feedback (both verbal and nonverbal) about the accuracy of your guess. When you reflect well, the person normally keeps talking and clarifying even if your ini al reflec on wasn’t quite right. People also tend to appreciate good listening. It’s a rewarding experience to be given someone’s full a en on with no purpose other than understanding. Thus, you don’t need special occasions to prac ce engaging OARS skills. The opportuni es are there in everyday conversa on. The point is to be inten onal about prac cing the skills that you

want to strengthen. Of course, you can also arrange opportuni es specifically to prac ce MI with others who want to learn it, no cing what happens as you try out various component skills. 16 Here is an example of engaging skills prac ced outside the context of a helping rela onship. The se ng is a family dinner with rRELATIVEs who do not visit o en. They have been welcomed as guests and have se led in, and now they sit down with their hosts for an evening meal. The conversa on turns to poli cs, and one of the visi ng rRELATIVEs voices a strong opinion that differs from the hosts’ own views.

H R H R : You feel strongly about this. [Reflec on] HOST R RELATIVE : And I know that your faith is important to you. You try to live your life in a way that is true to what you believe. [Affirma on] OST H R RELATIVE : Even when it’s difficult. [Reflec on, con nuing the paragraph] HOST : Yes, I do! It’s a ma er of faith for me. : What I value is that we are family, and I care about you. [Affirma on] HOST : I do. It’s hard some mes, but it’s how I want to live. RELATIVE : I get into some real arguments with people who don’t agree with me. I don’t know; maybe you don’t agree with me. [Poten al discord] RELATIVE : How about this. I would like to hear more about what you think on this hot topic. I want to just listen so I can understand you be er, without interrup ng, agreeing, or disagreeing. Actually, I need more prac ce in listening to people on hot topics like this because I think we should be listening to each other more even when it’s hard. Are you willing to do that? [Asking permission] HOST : That means a lot. We’re family. R H R H RELATIVE R : Yes, and why it ma ers to you. What you really care about. OST H RELATIVE : Nope. I may ask you a few ques ons, but mostly I just want to listen and understand what you think and feel on issues like this. Is that OK HOST : Just talk about what I believe? RELATIVE : Good! So tell me a li le more about what you were saying before. HOST : And you’re not going to argue with me?

HOST: Sure. Talking about myself is easy. The RELATIVE is right; it’s easy for most people to talk about what they believe. It’s the host who has the more challenging job here: s cking with pure empathic listening. I (Bill) inten onally did this recently with several friends whose poli cal views were, I suspected, different from my own (which actually could be almost anyone). I spent an hour prac cing reflec ve listening with each of them, and I unexpectedly found that once I put on my listening hat, it was surprisingly easy. That’s all I had to do— just listen well! No other agenda. When we finished an hour, one of my friends said, “Now I want to listen to your views” and he did. 17

Beyond Engaging Skills

MI is much more than good listening. The vital person- centered skills are then applied in purposeful ways to help people move toward change. 18 Empathic listening can be done without any par cular goal in mind. 19 In MI, the focusing task (Chapters 5 and 9) iden fies specific change goals toward which you then move using some technical skills for evoking

mo va on for change. 20 First among these skills, you need to be able to recognize change talk, sustain talk, and discord as especially important natural occurrences that signal whether you are headed toward or away from change. You therefore train your ear to no ce these par cular forms of speech when you hear them. If you fail to no ce them, you can’t inten onally adjust your own responses accordingly. You should also promptly no ce conversa onal pa erns that are likely to be detrimental. For example, if you find yourself arguing for change while the other person is arguing against it, you should recognize that it’s me to adjust what you’re doing. MI involves ongoing in-the- moment awareness of what is happening in the language of change, with par cular alertness for change talk, sustain talk, and discord. Second, as discussed in our chapters on the evoking process, you don’t just wait for change talk to happen, but you invite it. You arrange the interview to evoke change talk through strategic use of OARS, for example by consciously asking par cular ques ons rather than others. MI therefore also involves ongoing in-the- moment awareness of your own speech and the person’s reac ons to them. You think one step ahead. “If I ask this ques on, how is this person likely to respond?”“Where is there change talk in what I just heard, and how can I invite more of it?” Third, within the evoking task, you consciously respond in ways intended to strengthen change talk. Thus, an important part of MI is what you say next a er you hear change talk. You differen ally reflect, affirm, and summarize change talk when you hear it and pay close a en on to how the person responds. The technical skills of evoking thus involve recognizing, invi ng, and then strengthening change talk. Here is an example of prac cing MI skills beyond engaging. The se ng is an a er- school program in which students can enroll, staffed by volunteer tutors. The student is a 10-year-old boy, Liam, who is reading below the expected level for grade 5 and worried about going on to middle school next year. The tutor is a re red high school geography teacher. They were introduced and visited the Book Café together where Liam picked out two books that looked interes ng to him. A er you hear change talk, what will you say next. LIAM : This one has a couple of boys looking down a deep hole and I wonder what’s in it. TUTOR : I know both of the books you chose. What did you like about them? LIAM: You want to find out. [Reflec on, con nuing the paragraph]

LIAM : Yeah. And this one has all kinds of things on the cover— some kind of castle, a horse, kids; this looks like a dog or a lion, and a big face up here, I can’t tell what kind of face it is. TUTOR : Just the cover makes you curious, like you want to know the story. [Reflec on] LIAM : I like books with more pictures, though. TUTOR : Books let us imagine things we’ve never seen. [Reflec on] LIAM: Do you do that, imagine things? TUTOR: I do! I like to imagine places where I’ve never been. It sounds like you do that, too. What do you enjoy most about stories? [Evoca ve ques on: Desire] TUTOR : They’re easier for you. [Reflec on, a guess] LIAM : And it gives me a picture of what’s happening; it helps me imagine it. TUTOR : But books like this are hard; I get red and don’t remember what I read. [Sustain talk] LIAM : I don’t know what’s going

to happen next. TUTOR: It’s kind of exci ng like an adventure, wondering where the story will go next. [Reflec ng change talk]

LIAM: Yeah. And this one has all kinds of things on the cover— some kind of castle, a horse, kids; this looks like a dog or a lion, and a big face up here, I can’t tell what kind of face it is. TUTOR: Just the cover makes you curious, like you want to know the story. [Reflec on) LIAM: I like books with more pictures, though. TUTOR: Books let us imagine things we’ve never seen. [Reflec on] TUTOR: Do you do that, imagine things? LIAM: I do! I like to imagine places where I’ve never been. It sounds like you do that, too. What do you enjoy most about stories? [Evoca ve ques on: Desire] TUTOR: They’re easier for you. [Reflec on, a guess] : And it gives me a picture of what’s happening; it helps me imagine it. LIAM: But books like this are hard; I get red and don’t remember what I read. [Sustain talk] LIAM: I don’t know what’s going to happen next. TUTOR: It’s kind of exci ng like an adventure, wondering where the story will go next. [Reflec ng change talk] TUTOR : And yet here you are, staying a er school to get be er at reading. Why did you sign up? [Evoca ve ques on: Reasons] UTOR : My teacher said I should. I do want to be able to read be er. I need to. [Change talk] Next year I’ll be in sixth grade and it will be harder. IAM L T : You’re looking ahead and want to be ready. [Reflec ng change talk] And, also I do see that interest and curiosity in you, ready to discover and hear more stories. [Affirma on] There are stories on TV and movies, too, but you know what I love about reading books? UTOR L L IAM L IAM T : What? : It lets me use my imagina on. Instead of making up the pictures for me, I can see them in my mind. So let’s try it, OK? [Asking permission] UTOR IAM T L IAM : All right. UTOR UTOR T : ( Reads a page and then has Liam read the second page to get a sense of his reading ability. ) That’s Chapter 1. What are you already wondering about? [Open ques on] UTOR : Which book should we start on? [Offering choice] : This one— Holes . Will you read to me? IAM : I’ll start off and we can take turns, a page at a me.