Addiction (2001) 96, 1725–1742

REVIEW

The use of brief interventions adapted from

motivational interviewing across behavioral
domains: a systematic review

CHRIS DUNN1,4, LISA DEROO2,4 & FREDERICK P. RIVARA2,3,4

Departments of 1Psychiatry, 2Epidemiology and 3Pediatrics and 4the Harborview Injury

Prevention and Research Center, University of Washington, USA

Abstract
Aims. To examine the effectiveness of brief behavioral interventions adapting the principles and techniques
of Motivational Interviewing (MI) to four behavioral domains: substance abuse, smoking, HIV risk and
diet/exercise. Design. We conducted a systematic review of 29 randomized trials of MI interventions. Data
on methodological quality were extracted and tabulated. Between-group behavior change effect sizes and
conŽ dence intervals were calculated for each study. Findings. Due to varying intervention time lengths,
targeted problem behaviors, settings and interventionists’ backgrounds and skill levels, outcomes were not
combined meta-analytically. Sixty per cent of the 29 studies yielded at least one signiŽ cant behavior change
effect size. No signiŽ cant association between length of follow-up time and magnitude of effect sizes was found
across studies. There was substantial evidence that MI is an effective substance abuse intervention method
when used by clinicians who are non-specialists in substance abuse treatment, particularly when enhancing
entry to and engagement in more intensive substance abuse treatment treatment-as-usual. Data were
inadequate to judge the effect of MI in the other domains. Client attribute–treatment interactions were
understudied and the sparse and inconsistent Ž ndings revealed little about the mechanism by which MI works
or for whom it works best. Conclusion. To determine more effectively how well MI works in domains other
than substance abuse and for whom it works best in all domains, researchers should study MI with risk
behaviors other than substance abuse, while examining both interactions and the theoretical components of
MI.

Introduction behaviors Ž nd themselves under increasing

Successfully reducing risk behaviors such as sub-
stance abuse, smoking and unprotected sexual
activity can potentially result in large public
health gains (US Preventive Services Task Force,
1996; WHO, 1980). Consequently, health prac-
titioners who do not specialize in treating risk
pressure to provide opportunistic interventions
with patients not presenting for treatment for
risk behaviors (IOM, 1990; U.S. Preventive Ser-
vices Task Force, 1996). An example is a mental
health practitioner providing anxiety treatment
to a client who also abuses substances or prac-

Correspondence to: Chris Dunn PhD, 325 9th Ave., Box 359911, Seattle WA 98104–2499, USA. Tel: 206 731
6093; fax: 206 731 3236; e-mail: cdunn@u.washington.edu
Submitted 22nd May 2000; initial review completed 10th October 2000; Ž nal version accepted 9th March 2001.

ISSN 0965–2140 print/ISSN 1360–0443 online/01/121725–18 Ó Society for the Study of Addiction to Alcohol and Other Drugs
Carfax Publishing, Taylor & Francis Limited
DOI: 10.1080/09652140120089481
1726 Chris Dunn et al.
tices unsafe sex. Other examples are general
medical practitioners who could intervene with
diabetic patients who should quit smoking or
with hypertensive patients who should exercise
more. The US Preventive Services Task Force
has made strong recommendations for interven-
ing on a public health level in substance abuse,
smoking, HIV risk reduction and diet/exercise
(US Preventive Services Task Force, 1996). The
purpose of this review is to examine the effects of
motivational interviewing (MI) as an interven-
tion method in these four behavioral domains.
Motivational Interviewing (MI) is a style of
behavior change counseling developed originally
to prepare people to change substance abuse
behaviors (Miller, 1983). In 17 years, MI has
grown rapidly in popularity. Current practices on
Ž ve continents have shown that it is feasible to
adapt MI to numerous risk behaviors and popu-
lations. These behaviors include condom use
(Carey et al., 1997), smoking (Colby et al.,
1998), exercise (Harland et al., 1999) and weight
reduction (Rollnick, 1996). Out of concern that
the popularity of MI has outstripped the evi-
dence for its effectiveness, we undertook a sys-
tematic review of randomized trials of MI. If MI
were found to be effective in these four behav-
ioral domains, this evidence would better justify
its widespread use and warrant further dissemi-
nation to practitioners as a generic method for
health interventions for these risk behaviors.
DeŽ nition of MI
MI is a method deŽ ned by Rollnick & Miller
(1995) as a directive, client-centered style of
counseling that helps clients to explore and re-
solve their ambivalence about changing. The MI
style is a collaborative method using distinct
principles and techniques. While using client-
centered techniques to build trust and reduce
resistance, the provider focuses directively on
increasing readiness for change (Prochaska &
DiClemente, 1986). Principles of MI include
understanding the client’s view accurately,
avoiding or de-escalating resistance and increas-
ing clients’ self-efŽ cacy and their perceived dis-
crepancy between their actual and ideal behavior
(Miller & Rollnick, 1991). The techniques of MI
are described in detail and contrasted with non-
MI techniques in Miller (1983) and Miller &
Rollnick (1991). Brie y, they include listening
re ectively and eliciting motivational statements
from clients, examining both sides of clients’
ambivalence and reducing resistance by monitor-
ing clients’ readiness and not pushing for change
prematurely.
Perhaps due to the complexity of MI, con-
fusion about its deŽ nition has arisen, manifested
by some researchers and clinicians claiming to
use MI but failing to adhere to its principles and
techniques (Rollnick & Miller, 1995). In clarify-
ing the deŽ nition of MI, Rollnick & Miller
(1995) introduced a deŽ nitive concept that they
called the “spirit” or style of MI. This is a way of
being with clients that incorporates the MI prin-
ciples listed above. A counselor performing MI
techniques while contradicting or judging a cli-
ent would not actually be employing MI. In this
paper, the term “Motivational Interviewing”
refers to any intervention method used by the
reviewed studies that claimed to adhere to the
MI principles and techniques, even if labeled
other than “Motivational Interviewing” (more
inclusion criteria below).
Questions asked in this review
Past reviews of various brief intervention meth-
ods for reducing substance abuse (Bien, Miller &
Tonigan, 1993b; Kahan, Wilson & Becker,
1995; Wilk, Jensen & Havighurst, 1997) suggest
that brief interventions work better than no in-
tervention at all and sometimes as well as more
intensive treatment. However, the studies re-
viewed tested mainly brief intervention methods
other than MI, such as client education or
coping skills training. The only review of MI
studies to date (Noonan & Moyers, 1997)
reviewed 11 MI studies in the substance abuse
domain, concluding that MI is generally effective
with substance abusers. However, the authors
stated that, given the variance in effect sizes
noted across these 11 studies, further research
should identify interaction variables that might
in uence MI effect sizes, as well as examine how
long MI effects last. No other reviews of MI
effectiveness have been performed in behavioral
domains other than substance abuse.
The time it takes to learn and deliver MI are
issues related to MI effectiveness that would help
to estimate its cost-effectiveness. Two barriers to
practitioners’ intervening with multiple behaviors
are the training time required to learn inter-
vention methods for each of these behaviors and

the time required to perform the interventions.
Having to learn only one “generic” method
could theoretically reduce training time and re-
sult in higher skill levels by practicing repeatedly
a single method with multiple behaviors. MI
possibly takes less time to deliver than other
methods. In Project MATCH (Project MATCH
Research Group, 1997a), 4 hours of Motiva-
tional Enhancement Therapy (an adaptation of
MI) produced similar drinking outcomes to 12
hours of each of two other treatments. In an-
other study, 3 hours of an MI marijuana inter-
vention produced results that were comparable
to 28 hours of skills training (Stephens, Roffman
& Curtin, 2000). These Ž ndings are promising
but preliminary. The question of how long it
takes to learn and deliver MI has not yet been
addressed systematically.
A Ž nal question related to effectiveness con-
cerns interaction variables that might explain the
mechanisms by which MI works. Theoretically
active components of MI are increasing readi-
ness to change, using empathic listening tech-
niques, increasing self-efŽ cacy and increasing the
perceived discrepancy between actual and ideal
behavior (Miller & Rollnick, 1991). Heather et
al. (1996) found that for people with low base-
line readiness, MI reduced drinking more than
skills-based counseling at 6 months. At the 6-
month follow-up point in Project MATCH
(Project MATCH Research Group, 1997a), sub-
jects low in baseline readiness drank less if they
had received Cognitive Behavioral Therapy than
MI (Motivational Enhancement Therapy); by 15
months this effect had reversed in favor of MI.
Other psychosocial variables are also import-
ant as variables that might interact with MI
treatment to in uence its effects. The largest
interaction study to date examined many psycho-
social variables including alcohol involvement,
cognitive impairment, gender and psychopathol-
ogy, but concluded that MI worked as well but
no better than two comparison treatments for
most types of alcoholics (Project MATCH Re-
search Group, 1997a). Secondary analyses of a
priori hypotheses from this study reported that
MI produced better drinking outcomes 1 year
post-treatment than cognitive behavioral treat-
ment for angry outpatient clients (Project Match
Research Group, 1997b). As part of the current
review, we examined all studies for Ž ndings on
all possible interaction variables.
Before MI can be disseminated as an effective
Motivational interviewing review 1727
method for intervening with multiple behaviors,
we must ask the following questions:
(1) How many of the reviewed MI studies had
signiŽ cant behavioral effect sizes, and did
the effects fade over time?
(2) How long did it take to learn and deliver
MI?
(3) What did these studies report about client
attribute interactions?
Methods
Study selection
The authors searched Medline, PsychInfo and
Dissertation Abstracts International from 1983
to 1999, using the terms “motivational inter-
viewing”, “motivational intervention”, “brief in-
tervention” and “motivational counseling” in all
Ž elds. The reference lists from review papers on
brief substance abuse interventions were also
searched (Bien et al., 1993a; Kahan et al., 1995;
Wilk et al., 1997). This yielded 107 studies that
were screened according to the inclusion criteria
listed below, yielding the 29 studies reviewed in
this paper. The interventions tested in these 29
studies used eight labels other than “MI” (e.g.
brief motivational intervention, Motivational
Enhancement Therapy, Drinker’s Checkup).
The a priori inclusion criteria for articles in
this review were: (a) claiming to utilize the prin-
ciples and techniques of MI and also reporting
some form of monitoring of MI sessions, (b)
randomizing subjects into at least one group
receiving MI and at least one group receiving no
treatment or a comparison treatment, (c) deliver-
ing the MI intervention face to face (individually
or in group format), not by computer or tele-
phone and (d) measuring behavioral and/or
health outcomes rather than only knowledge or
attitudes. Because Rollnick & Miller (1995) state
that it is unknown how brief an adaptation of MI
can be and still capture MI principles and tech-
niques, we included studies of even the briefest
interventions as long as they met our inclusion
criteria.
Analysis
The 29 studies were heterogeneous in the follow-
ing ways: group design, intervention “dose”
(from 5 to 360 minutes), interventionist training
and skill level and outcome variables. Therefore,
1728 Chris Dunn et al.
we chose not to combine effect sizes meta-
analytically to report a common effect across
studies (Hedges & Olkin, 1985).
Data describing sample, setting, group design,
duration of MI interventions, type and training
of interventionist, intervention quality control
and length of follow-up time interval were ex-
tracted from all studies and tabulated. Studies
were categorized according to three design types:
(1) MI vs. no-treatment control group, (2) MI
vs. a comparison treatment group and (3) MI
enhancing treatment-as-usual vs. treatment-as-
usual (e.g. intensive, specialized substance abuse
treatment).
For each study reporting complete infor-
mation, effect sizes and conŽ dence intervals for
all behavioral and health outcomes at all re-
ported follow-up times were calculated. Unit-
free effect sizes were calculated according to the
following formula (Hedges & Olkin, 1985):
Effect size 5 g5 (YE 2 YC)/s and
(nE 2 1)(sE)2 1 (nC 2 1)(sC)2
s5
nE 1 nC 2 2
where s is the pooled standard deviation and nE
and nC are the experimental and control group
sample sizes. For studies reporting means, the
effect size was obtained by subtracting the con-
trol group mean from the treatment group mean
and dividing the result by the pooled standard
deviation. For studies reporting percentage data,
a probit transformation was used. Hedges &
Olkins’ correction for small sample bias was
applied to all effect sizes (1985). In the few
studies comparing MI to both a no-treatment
and a comparison condition, we calculated effect
sizes for the MI vs. no-treatment comparison.
Most of the reviewed studies measured more
than one dependent variable for a given follow-
up time period. To regress effect size onto length
of follow-up interval, we Ž rst calculated for each
study a single average effect size for any given
follow-up interval. This was undertaken so that
each study would contribute only one effect size
per time period to the regression equation. A
linear regression was then performed, using
length of follow-up interval as the independent
variable and magnitude of effect size as the de-
pendent variable. To examine effect size as a
function of study design these conŽ dence inter-
vals were plotted separately for each of the three
study designs and inspected visually.
Results
As seen in Table 1, the 29 studies included 17 in
substance abuse, two in smoking cessation, four
in HIV risk reduction and six in diet/exercise.
Youth were well-represented in the substance
abuse and smoking samples, and all four do-
mains included samples in which women were
adequately represented. In the substance abuse
studies, clients with substance dependence as
well as abuse were well represented.
How many of the reviewed MI studies had
signiŽ cant behavioral effect sizes, and did the effects
fade over time?
A visual inspection of Figs 1, 2 and 3, which plot
effect sizes for each of three study designs, re-
vealed no obvious differences in magnitude of
effects.
Twenty-six of the 29 studies reported ad-
equate information to calculate effect sizes. As
seen in Table 2, only the effect sizes in bold type
were signiŽ cant (95% conŽ dence interval did not
contain zero). Also in Table 2, means and vari-
ances of outcome variables are provided for clin-
icians to judge clinical signiŽ cance. Of those 26
studies, 18 (69%) had at least one outcome with
a signiŽ cant effect size. In all but one of these
(Project MATCH Research Group, 1997a), the
effect was in favor of MI. The effect sizes in 10
of 15 substance abuse studies were signiŽ cant
and in favor of MI, ranging from 0.30 (Marlatt et
al., 1998) to 0.95 (Aubrey, 1998). One of two
smoking studies had a signiŽ cant effect size, 0.23
(Butler, 1999). Two of four HIV risk reduction
studies had signiŽ cant effect sizes ranging from
0.46 to 0.64 (Carey et al., 1997; Belcher et al.,
1998). Three of Ž ve diet/exercise studies had
signiŽ cant effect sizes ranging from 0.36 (Har-
land et al., 1999) to 2.17 (Smith et al., 1997).
The largest effect sizes in these 26 studies were
found in a weight reduction study (Smith et al.,
1997) in which effect sizes for treatment sessions
attended and food diaries submitted were 1.68
and 2.17, respectively. The smallest effect sizes
reported were found in a smoking cessation
study (Butler et al., 1999) in which the effect size
for percent of smokers abstinent in the past 24
hours was 0.23.
The results of the regression analysis found no
signiŽ cant decline in effect sizes across studies as a
function of length of follow-up time (p 5 0.84).
Within studies, we looked for evidence of dimin-
 Motivational interviewing review 1729

Table 1. Characteristics of studies reviewed

Study N Age Gen Sev Set Des Dur Int Tng MI

Substance abuse studies

Aubrey 98 80 Y M,F A,D 1 3 45 1 Yes 1
Baer 92 134 A M,F A 2 2 60 1 12 3
Bien, 93 31 A M D 1 3 60 1 X 1
Booth 98 192 A M,F D 1 2 120 2 31 1
Gentilello, 99 762 A M,F D 3 1 30 1 24 2
Handmaker 99 42 A F A,D 4 2 60 1 X 3
Heather 96 174 A M A,D 3 1,2 35 1,4 Yes 1
Marlatt 98 348 A M,F A 2 1 60 1 Yes 2
Miller, 88 42 A M,F A 6 1 60 5 X 3
Miller, 93 42 A M,F A 6 1,2 60 3 30 1
Monti 99 94 Y M,F A 5 2 35 3 Yes 1
Proj Match 97 1726 A M,F D 1 2 240 1,2 Yes 1
Saunders, 95 123 A M,F D 1 3 60 3 X 3
Schneider 99 89 A M,F A,D 6 2 120 1,2 20 2
Stephens 00 291 A M,F D 6 1,2 180 5 X 2
Swanson 99 123 A M,F A,D 3 3 60 3 6 2
Wertz 94 42 A M D 1 3 60 1 Yes 2
Smoking studies
Butler, 99 536 A M,F 24 2 10 6 2 2
Colby 98 40 Y M,F 3,4,5 2 30 1,2 Yes 3
HIV risk reduction studies
Baker 93 200 A M,F 6 2 90 1,4 18 1
Baker 94 200 A M,F 6 1 30 1,4 Yes 2
Belcher, 98 74 A M,F 6 2 120 1,3 X 3
Carey 97 102 A F 6 1 360 1 Yes 2
Diet/exercise studies
Harland 99 523 A M,F 4 2 40 4 Yes 3
Mhurchu 98 123 A M,F 4 2 150 4 X 1
Scales 98 61 A M,F 4 3 60 4 Yes 1
Smith 97 23 A F 4 3 150 1 X 3
Thevos 00 611** A M,F 6 2 X 4 10 3
Treasure 99 125 A F 4 2 200 1,3 Yes 2

N 5 sample size, all groups combined; Age 5 age of subjects: A 5 adult . 18 years; Y 5 youth # 18 years.
Gen 5 gender: M 5 male; F 5 female. Sev 5 severity of substance use (for substance abuse studies only):
A 5 abuse (less severe); D 5 dependence (more severe). Set 5 setting in which MI occurred: 1 5 specialist
substance abuse treatment agency; 2 5 university campus; 3 5 hospital (inpatient); 4 5 outpatient medical
clinic; 5 5 emergency room; 6 5 outpatient community agency. Des 5 design of groups: 1 5 MI alone vs.
No-treatment (wait-list or assessment-only condition); 2 5 MI alone vs. a comparison treatment;
3 5 MI 1 treatment-as-usual vs. treatment-as-usual. Dur 5 minutes of MI; X 5 minutes not reported.
Int 5 type of MI interventionist: 1 5 PhD psychologist or doctoral student; 2 5 specialist substance abuse
clinician; 3 5 college degree or undergraduate student; 4 5 health counselor, nurse or dietician; 5–o
information given. Tng 5 hours of MI training given to interventionists; Yes 5 study stated that
interventionists were trained but not for how long; X 5 no information given. MI 5 Measures taken to
monitor the intervention integrity: 1 5 audio or videotapes reviewed with supervisor; 2 5 regular supervision
but no mention of tapes being monitored; 3 5 report explicitly claims to have adhered to MI principles and
these principles are described in text.

ishing effects over time for the Ž ve studies that
reported both signiŽ cant effect sizes and multiple
follow-up time periods. The results were mixed.
Bien et al. (1993a) reported a signiŽ cant effect at
3 months for a composite behavioral drinking
index (0.83), which became non-signiŽ cant by 6
months. Marlatt et al.’s data (1998) included
Ž ndings in all three directions. First, an effect for
drinking frequency (0.30) was signiŽ cant at 12
but not 24 months. Secondly, a behavioral prob-
lem inventory effect (0.35) was signiŽ cant at 12
months and remained so at 24 months (0.35).
Thirdly, a non-signiŽ cant effect for a behav-
iorally anchored alcohol dependence score at 12
months became signiŽ cant by 24 months (0.31).
At 1.5 months, Miller (1993) reported two non-
 Table 2. Means, standard deviations and effect sizes of study outcomes for four behavioral domains
1730

Mean (SD) of
control or
Mean (SD) of comparison Effect size
Study and design type Outcomes MI group group (95% CI)

Substance abuse studies

Aubrey (1998) 3-month
(3) Percentage of days abstinent 70% (0.30) 43% (0.44) 0.57 ( 2 0.1, 1.24)
Total use days 94 (65) 165 (91) 0.95 (0.26, 1.63)
Chris Dunn et al.

Number of drugs used 2.96 (2.05) 4.36 (2.31) 0.65 ( 2 0.02, 1.32)
Treatment sessions attended 17.36 (17.57) 6.43 (6.23) 0.75 (0.07, 1.42)
Termination rating 1.16 (0.37) 1.50 (0.52) 0.79 (0.12, 1.47)
Bien (1993) 3-month
(3) Drinks per week 12.9 (26.4) 272.2 (528.9) 0.72 ( 2 0.07, 1.52)
Blood alcohol concentration 41.9 (100.0) 190.9 (265.2) 0.77 ( 2 0.03, 1.56)
Percentage of days abstinent 95.7% (9.3) 80.1% (26.6) 0.30 ( 2 0.47, 1.08)
Composite index 2 1.01 (0.73) 1.18 (3.80) 0.83 (0.03, 1.63)
6-month
Drinks per week 113.6 (181.3) 394.1 (1176.0) 0.35 ( 2 0.43, 1.12)
Blood alcohol concentration 50.1 (87.1) 91.1 (167.1) 0.32 ( 2 0.46, 1.09)
Percentage of days abstinent 71.1% (38.1) 81.3% (34.0) 2 0.20 ( 2 0.97, 0.58)
Composite index 2 0.18 (1.67) 0.20 (3.51) 0.14 ( 2 0.63, 0.91)
Booth (1998) Entry into treatment 40% 43% 2 0.06 ( 2 0.46, 0.34)
(2) Entry into free treatment 52% 31% 0.40 (0.00, 0.80)
Gentilello (1999) 6-month
(1) Drinks per week 21.6 (42.6) 18.2 (44.8) 2 0.08 ( 2 0.26, 0.11)
12-month 18.3 (38.3) 22.7 (54.6) 0.09 ( 2 0.12, 0.31)
Handmaker (1999) (2) 2-month
Total alcohol consumption F-test statistic 0.03 ( 2 0.64, 0.71)
Abstinent days F-test statistic 0.38 ( 2 0.30, 1.05)
Blood alcohol concentration F-test statistic 0.73 (0.03, 1.42)
Heather (1996) 6-month
(1,2) Drinks per week 27.6 (20.6) 30.7 (18.4) CG 0.16 ( 2 0.29, 0.60)
Drinks per week 27.6 (20.6) 35.5 (24.7) SG 0.35 ( 2 0.07, 0.76)
Marlatt (1998) 12-month
(1) Drinking frequency (per month) 2.3 (1.0) 2.6 (1.0) 0.30 (0.07, 0.53)
 Quantity (no. drinks) 2.4 (1.5) 2.6 (1.4) 0.14 ( 2 0.09, 0.37)
Peak 3.4 (1.5) 3.7 (1.4) 0.23 ( 2 0.02, 0.44)
Rutgers Alc Problem Inventory 4.0 (4.0) 5.5 (4.6) 0.35 (0.12, 0.58)
Alcohol Dependence Scale 7.1 (4.1) 8.0 (4.5) 0.23 ( 2 0.2, 0.44)
24-month
Drinking frequency per month 2.2 (0.9) 2.4 (1.0) 0.23 ( 2 0.02, 0.44)
Quantity (no. drinks) 1.9 (1.4) 2.1 (1.5) 0.14 ( 2 0.09, 0.36)
Peak 3.3 (1.6) 3.6 (1.4) 0.20 ( 2 0.03, 0.43)
Rutgers Alc Problem Inventory 3.3 (3.5) 4.7 (4.4) 0.35 (0.12, 0.58)
Alcohol Dependence Scale 6.5 (3.5) 7.8 (4.5) 0.31 (0.09, 0.55)
Miller (1993)
(1,2) Drinks per week 15.14 (23.10) 15.07 (13.98) 0.00 ( 2 0.74, 0.74)
CG
Drinks per week 15.14 (23.10) 22.21 (30.07) 0.26 ( 2 0.49, 1.00)
DCC
Weekly peak BAC (mg%) 71.4 (103.5) 68.9 (69.4) CG 2 0.03 ( 2 0.77, 0.71)
Weekly peak BAC (mg%) 71.4 (103.5) 81.5 (89.2) 0.10 ( 2 0.64, 0.76)
DCC
Drinking days per week 3.36 (2.59) 4.71 (2.95) 0.49 ( 2 0.26, 1.24)
Drinking days per week 3.36 (2.59) 4.07 (2.84) 0.25 ( 2 0.49, 1.0)
DCC
12-month
Drinks per week 12.00 (8.90) 23.18 (18.48) 0.78 (0.0, 1.54)
Drinks per week 12.00 (8.90) 17.0 (12.42) 0.45 ( 2 0.30, 1.20)
DCC
Weekly peak BAC (mg%) 56.2 (46.2) 74.9 (42.1) 0.42 ( 2 0.33, 1.17)
Weekly peak BAC (mg%) 56.2 (46.2) 59.1 (50.1) 0.06 ( 2 0.68, 0.80)
DCC
Drinking days per week 4.10 (2.38) 6.18 (2.14) 0.92 (0.14, 1.70)
Drinking days per week 4.10 (2.38) 5.33 (2.65) 0.47 ( 2 0.28, 1.23)
DCC
Monti (1999) 6-month
(2) Alcohol-related problems 0.87 (1.18) 1.46 (1.43) 0.45 (0.00, 0.90)
Drinking & driving (%) 62% 85% 0.58 (0.11, 1.05)
Alcohol-related injuries (%) 23% 50% 0.64 (0.19, 1.08)
Motivational interviewing review

Moving violations 3.2% 22.6% 0.59 (0.08, 1.10)

Project MATCH 9-month (outpatient arm)
Research Group
1731

(1997a)
 Table 2.—continued
1732

Mean (SD) of
control or
Mean (SD) of comparison Effect size
Study and design type Outcomes MI group group (95% CI)

Drinking consequences 23.5 (23.2) 21.4 (24.3) 2 0.09 ( 2 0.28, 0.11)

CBT
(2) Drinking consequences 23.5 (23.2) 16.7 (21.8) 2 0.30 ( 2 0.49, 2 0.12)
Chris Dunn et al.

TSF
15-month (outpatient arm)
Drinking consequences 19.9 (23.4) 19.7 (23.1) 2 0.01 ( 2 0.20, 0.19)
CBT
Drinking consequences 19.9 (23.4) 15.9 (20.7) 2 0.18 ( 2 0.37, 0.01)
TSF
9-month (aftercare arm)
Drinking consequences 20.0 (26.8) 19.6 (27.9) 2 0.02 ( 2 0.23, 0.20)
CBT
Drinking consequences 20.0 (26.8) 19.4 (28.3) 2 0.02 ( 2 0.24, 0.19)
TSF
15-month (aftercare arm)
Drinking consequences 16.9 (23.1) 19.3 (29.3) 0.09 ( 2 0.13, 0.31)
CBT
Drinking consequences 16.9 (23.1) 21.2 (29.0) 0.16 ( 2 0.05, 0.38)
TSF
Saunders (1995) 6-month
(3) Days in treatment F-test statistic 0.51 (0.15, 0.87)
Time to heroin relapse v 2 test statistic 0.35 ( 2 0.01, 0.71)
Severity of opiate dependence F-test statistic 0.04 F( 2 0.31, 0.40)
Opiate-related problems F-test statistic 0.38 (0.02, 0.74)
Schneider (1999)
(2) 3-month
Alcohol Addiction Severity Index 0.13 (0.18) 0.18 (0.23) 0.24 ( 2 0.17, 0.66)
Drug Addiction Severity Index 0.03 (0.08) 0.05 (0.08) 0.25 ( 2 0.17, 0.67)
Standard drinks past 30 days 39.1 (72.1) 31.9 (88.9) 2 0.09 ( 2 0.51, 0.31)
9-month
Alcohol Addiction Severity Index 0.08 (0.11) 0.14 (0.17) 0.42 (0.00, 0.84)
Drug Addiction Severity Index 0.03 (0.09) 0.03 (0.06) 0.00 ( 2 0.42, 0.42)
Standard drinks past 30 days 23.8 (51.8) 23.4 (45.4) 2 0.01 ( 2 0.43, 0.41)
Stephens (2000) 4-month
(1,2) Abstinent for past 90 days 37% 9% CG 0.58 (0.27,0.88)
Abstinent for past 90 days 37% 37% RPCG 0 ( 2 0.28, 0.28)
Mean days of use per month 7.88 (10.98) 24.61 (6.29) 0.12 ( 2 0.18,0.42)
for past 90 days CG
Mean days of use per month 7.88 (10.98) 6.68 (9.87) 2 0.12 ( 2 0.39, 0.16)
for past 90 days RPCG
Mean marijuana-related problem 4.06 (5.39) 13.67 (6.06) 0.01 ( 2 0.29,0.30)
score CG
Mean marijuana-related problem 4.06 (5.39) 4.40 (6.00) 0.06 ( 2 0.22, 0.34)
score RPCG
Mean number of dependence 2.00 (2.78) 6.71 (1.77) 0.03 ( 2 0.27,0.33)
symptoms
Mean number of dependence 2.00 (2.78) 1.92 (2.67) 2 0.03 ( 2 0.31, 0.25)
symptoms
Swanson (1999) % Patients attended 1st 47% 23% 0.56 (0.19, 0.74)
outpatient appointment
(3) Abstinent for past 90 days 37% 9% 0.58 (0.27, 0.88)
Mean days of use per month for 23.84 (6.46) 24.61 (6.29) 0.12 ( 2 0.18, 0.42)
past 90 days
Mean marijuana-related problem 13.64 (5.30) 13.67 (6.06) 0.01 ( 2 0.29, 0.30)
score
Mean number of dependence 6.65 (1.95) 6.71 (1.77) 0.03 ( 2 0.27, 0.31)
symptoms
Wertz (1994) 1-month
Alcohol
(3) Days in treatment 24.10 (8.48) 24.71 (7.28) 2 0.08 ( 2 0.68, 0.53)
Participation rating 5.23 (0.83) 5.25 (1.23) 2 0.04 ( 2 0.64, 0.57)
Number standard drinks 1.17 (4.04) 8.00 (24.00) 0.43 ( 2 0.44, 1.30)
Smoking cessation studies
Butler (1999) 6-month
(2) % Abstinent in previous month 3.0% 1.5% 0.10 ( 2 0.07, 0.27)
% Abstinent in past 24 hrs 8.1% 3.0% 0.23 (0.06, 0.39)
Colby (1998) 3-month
Motivational interviewing review

(2) Percentage abstinent 20% 10% 0.28 ( 2 0.35, 0.90)

Mean cigarettes per day 9.2 (12.5) 8.8 (10.8) 2 0.03 ( 2 0.67, 0.60)
Mean smoking days per week 5.2 (2.8) 5.4 (2.7) 0.07 ( 2 0.56, 0.71)
Mean days of longest attempt 18.8 (27.7) 14.4 (27.3) 0.16 ( 2 0.48, 0.80)
1733

24-hour quit attempts (%) 72 60 0.25 ( 2 0.39, 0.89)

 Table 2.—continued
1734

Mean (SD) of
control or
Mean (SD) of comparison Effect size
Study and design type Outcomes MI group group (95% CI)

HIV risk reduction studies

Belcher (1998) 3-month
(2)
Frequency of condom use 13.1 (24.2) 3.6 (4.2) 0.56 (0.07, 1.04)
Chris Dunn et al.

Freq. of unprotected vag. sex 8.2 (18.5) 17.2 (29.6) 0.36 ( 2 0.12, 0.84)
% Vaginal sex using condoms 66 (39) 43 (42) 0.46 ( 2 0.02, 0.95)
Carey (1997) 0.75-month
(1) Had sexual discussion w/prtnr 0.95 (1.01) 0.57 (0.88) 0.40 ( 2 0.04, 0.84)
Protected vaginal intercourse 1.26 (3.27) 0.84 (1.35) 0.16 ( 2 0.27, 0.60)
Unprotected vaginal intercourse 0.67 (1.73) 2.30 (4.78) 0.46 (0.02, 0.90)
Number of sex partners 0.63 (0.98) 0.97 (1.24) 0.30 ( 2 0.14, 0.74)
Used alcohol/drugs before sex 7% 38% 0.64 (0.19, 1.09)
Unprotected vaginal intercourse 1.16 (2.26) 2.39 (8.42) 0.20 ( 2 0.23, 0.64)
3-month
Had sexual discussion w/prtnr 0.35 (0.52) 0.34 (0.53) 0.02 ( 2 0.42, 0.45)
Protected vaginal intercourse 0.44 (1.08) 1.68 (8.10) 0.23 ( 2 0.23, 0.66)
Number of sex partners 0.62 (0.58) 0.61 (0.52) 2 0.02 ( 2 0.45, 0.42)
Unprotected vaginal intercourse 1.16 (2.26) 2.39 (8.42) 0.20 ( 2 0.23, 0.64)
Number of partners 0.62 (0.58) 0.61 (0.52) 2 0.02 ( 2 0.45, 0.42)
Used alcohol/drugs before sex 17% 26% 0.18 ( 2 0.26, 0.61)
Baker (1994) 3-month
(1) Injecting Risk Taking Score 3.19 (3.56) 3.46 (3.27) 0.08 ( 2 0.28, 0.44)
Sexual Risk Taking Score 3.60 (3.60) 3.46 (3.78) 2 0.04 ( 2 0.39, 0.31)
6-month
Injecting Risk Taking Score 3.14 (3.29) 3.83 (4.01) 0.19 ( 2 0.23, 0.60)
Sexual Risk Taking Score 3.24 (3.11) 3.00 (3.50) 2 0.07 ( 2 0.49, 0.35)
Baker (1993) 6-month
(2) HIV risk-taking behaviors (total) 6.92 (4.77) 5.96 (7.19) 2 0.16 ( 2 0.70, 0.39)
Needle risk 2.64 (3.52) 3.00 (4.79) 0.09 ( 2 0.46, 0.63)
Sexual risk 4.28 (3.36) 2.96 (3.98) 2 0.36 ( 2 0.91, 0.19)
Diet and exercise studies
Harland (1999) 3-month
Physical activity
(2) Increased physical activity Score 36% 16% 0.40 (0.11, 0.70)
 Increased total sessions of 26% 11% 0.30 (0.00, 0.60)
vigorous exercise
Increased total sessions of 31% 13% 0.36 (0.07, 0.66)
moderate exercises
12-month
Increased physical activity score 23% 23% 0.00 ( 2 0.29, 0.29)
Increased total sessions of 18% 12% 0.12 ( 2 0.17, 0.41)
vigorous exercise
Increased total sessions of 23% 19% 0.04 ( 2 0.25, 0.31)
moderate exercise
Scales (1998) 3-month
Cardiovascular
disease
(3) Physical activity 275.7 (38.1) 260.7 (31.6) 0.42 ( 2 0.09, 0.93)
Dietary fat (%) 17.5% 23.3% 0.09 ( 2 0.41, 0.60)
Smith (1997) 4-month
Weight reduction
(3) Treatment sessions attended 13.3 (2.0) 8.9 (2.9) 1.68 (0.53, 2.84)
Food diaries submitted 15.2 (1.8) 10.1 (2.6) 2.17 (0.93, 3.41)
Self-monitoring blood glucose 46.0 (16.1) 31.2 (10.2) 1.09 (0.02, 2.17)
Reported exercises (days) 35.2 (13.2) 23.7 (11.6) 0.94 ( 2 0.12, 2.00)
Recorded calories (days) 76.8 (15.2) 55.7 (24.7) 0.97 (0.0, 2.03)
Glycemic control (%GHb) 9.8 (1.3) 10.8 (3.1) 0.38 ( 2 0.64, 1.40)
Weight loss (kg) 5.5 (3.9) 4.5 (2.2) 0.34 ( 2 0.68, 1.37)
Thevos (2000) Sales of disinfectant t-test statistic 1.03 (0.83, 1.24)
Water disinfection
(2)
Treasure (1999) 1-month
Bulimia nervosa
(2) % achieving clinically signiŽ cant 53% 68% 2 0.23 ( 2 0.72, 0.27)
change in binge eating
% achieving clinically signiŽ cant 58% 46% 0.17 ( 2 0.31, 0.65)
change in vomiting
% achieving clinically signiŽ cant 27 13 0.25 ( 2 0.26, 0.76)
change in laxative abuse

Non-zero effect sizes shown in bold type.

Motivational interviewing review

Design type: 1 5 MI vs. no-treatment control

2 5 MI vs. comparison treatment
3 5 MI 1 treatment-as-usual vs. treatment-as-usual
CG 5 control group; CBT 5 cognitive behavioral treatment; TSF 5 12-Step facilitation treatment; DCC 5 directive, confronta-
1735

tional counseling; RPCG 5 relapse prevention control group.

1736 Chris Dunn et al.

Figure 1. Effect sizes with 95% conŽ dence intervals for Design 1 studies comparing MI vs. no-treatment control groups. For
studies with more than one follow-up interval, effect sizes were averaged and then plotted. 1, Gentilello et al. (1999); 2, Heather
et al. (1998); 3, Marlatt et al. (1998); 4, Miller et al. (1993); 5, Stephens et al. (1994); 6, Carey et al. (1997); 7, Baker
et al. (1994).

Figure 2. Effect sizes with 95% conŽ dence intervals for Design 2 studies comparing MI vs. brief comparison treatment. For
studies with more than one follow-up interval, effect sizes were averaged and then plotted. 1, Booth et al. (1998); 2, Handmaker
et al. (1999); 3, Heather et al. (1996); 4, Project MATCH (1997); 5, Miller et al. (1993); 6, Monti et al. (1999); 7,
Schneider et al. (1999); 8, Stephens et al. (1994); 9, Butler et al. (1999); 10, Colby et al. (1998); 11, Belcher et al. (1998);
12, Baker et al. (1993); 13, Harland et al. (1999); 14, Thevos et al. (2000); 15, Treasure et al. (1999).

signiŽ cant effects for weekly drinks and drinking
days per week, both of which increased to
signiŽ cance by 12 months (0.78 and 0.92, re-
spectively). Carey’s data (1997) included two
effects for unprotected vaginal intercourse (0.46)
and alcohol use before sex (0.64), both of which
were signiŽ cant at 3 weeks but non-signiŽ cant at
3 months. Harland et al. (1999) found signiŽ cant
3-month effects for increasing physical activity
(0.40) and number of exercise sessions (0.36),
both of which were non-signiŽ cant by 12
months.
How long did it take to learn and deliver MI?
Of 29 studies, 10 reported the number of hours
of training provided to MI interventionists,
which ranged from 2 hours (Butler et al., 1999)
 Motivational interviewing review 1737

Figure 3. Effect sizes with 95% conŽ dence intervals for Design 3 studies comparing MI added onto treatment-as-usual vs.
treatment-as-usual. For studies with more than one follow-up interval, effect sizes were averaged and then plotted. 1, Aubrey
(1998); 2, Bien et al. (1993a); 3, Saunders et al. (1995); Swanson et al. (1999); 5, Wertz (1994); 6, Scales (1998);
7, Smith et al. (1997).

to 31 hours (Booth et al., 1998) and averaging
15 hours. Eleven studies reported providing
training but did not specify the number of hours,
and eight failed to mention anything about train-
ing.
In the nine studies comparing MI to a no-
treatment control group, the average duration of
MI was 104 minutes. In the 14 studies compar-
ing MI to a comparison treatment, the average
duration of MI studies was 98 minutes, whereas
the average duration of the comparison treat-
ments was 190 minutes. In seven studies testing
MI as an enhancement to usual treatment, the
average duration of MI was 70 minutes, and the
duration of usual treatment ranged from 20
hours to 28 days.
What did these studies report about client attribute
interactions?
Except for readiness to change, few studies re-
ported data on the major theoretical components
of MI. Only two studies reported empathy re-
sults. In Saunders, Wilkinson & Phillips’ (1995)
study, MI counselors were perceived as equal in
empathy to counselors in an education-only
group, although the same interventionist pro-
vided both treatments. Clients in the Stephens et
al. (2000) study perceived MI counselors as
more empathic than relapse prevention compari-
son group counselors, who were different inter-
ventionists in both conditions. In terms of
forming a therapeutic alliance with bulimic pa-
tients, Treasure et al. (1999) reported that MI
was no more effective than cognitive behavioral
treatment. Belcher et al. (1998) reported that MI
was no more effective than patient education in
improving self-efŽ cacy, and Saunders et al.
(1995) found equal self-efŽ cacy among MI and
comparison groups at 6 months.
Regarding other psychosocial variables poss-
ibly interacting with MI, three studies found that
MI works equally well for men and women
(Saunders et al., 1995; Marlatt et al., 1998;
Monti et al., 1999). Gentilello et al. (1999)
found that MI was more effective among patients
with mild to moderate alcohol dependence than
among mild problem drinkers or those with
severe dependence. This study also found that
MI worked better with patients who were un-
married, unemployed and had no prior alcohol
treatment. Miller, BeneŽ eld & Tonigan (1993)
reported that MI worked better than confronta-
tional counseling, with clients viewing alco-
holism as a bad habit rather than a disease.
Seventeen of 29 studies measured readiness to
change, and their Ž ndings are organized by three
questions: (a) did MI work better with low or
high readiness clients? (b) did MI increase readi-
ness? and (c) did readiness predict outcomes
independently of treatment type? Four studies
reported on the Ž rst question. Heather et al.
(1996) and Butler et al. (1999) found that pa-
tients low in readiness at baseline changed more
1738 Chris Dunn et al.
if they received MI than skills training for heavy
drinking or brief advice for smoking, respect-
ively. Monti et al. found no interaction between
readiness and treatment response for heavy-
drinking adolescents in an emergency room set-
ting. Project MATCH Research Group (1997a)
reported readiness interactions differing in direc-
tion at four and 15 months such that by 15
months, MI patients with low baseline readiness
drank less than cognitive behavioral patients with
low baseline readiness.
Eight studies reported mixed results on the
question of whether MI increases readiness. In
two alcohol studies (Handmaker, Miller & Man-
icke, 1999; Schneider, Casey & Kohn, 1999),
MI increased readiness more than an infor-
mation pamphlet or confrontational counseling,
respectively. In one HIV study (Carey et al.,
1997), MI increased readiness more than a no-
treatment control condition. Three studies re-
ported equal increases in readiness between
groups (Belcher et al., 1998; Colby et al., 1998;
Mhurchu, Margetts & Speller, 1998). It is inter-
esting that Saunders et al. (1995) found that
neither group increased in readiness to change
heroin use, although MI as an enhancement to
usual treatment produced better outcomes than
education in treatment adherence and heroin
use. In one study (Treasure et al., 1999), cogni-
tive behavioral treatment increased readiness
more than MI.
Four studies reported on readiness as an
independent predictor of outcomes. For out-of-
treatment injection drug users, readiness pre-
dicted treatment entry better than receiving MI
or skills interventions (Booth et al., 1998).
Among alcohol-dependent men, readiness pre-
dicted retention in intensive treatment better
than receiving MI as treatment enhancement or
treatment-as-usual (Wertz, 1994). For smokers
and bulimic patients, readiness predicted out-
comes better than treatment type (Butler et al.,
1999; Treasure et al., 1999). In all four studies,
readiness was measured in stages rather than as
a single dimension, and change occurred in the
direction predicted by the stages of change
model (Prochaska & DiClemente, 1986).
Discussion
Effectiveness and duration of effects
Due to the large number of studies, the most
cumulative evidence for MI effectiveness was
found in the substance abuse domain, where 11
of 15 studies (73%) found signiŽ cant effect sizes
comparable in magnitude to those found across
all brief intervention methods reviewed by Bien
et al. (1993b). Only one study found a signiŽ cant
negative effect for MI, Project MATCH (Project
MATCH Research Group, 1997a), in which 9-
month drinking consequences were worse for 4
hours of MI versus 12 hours of Twelve-Step
facilitation treatment. A wide range of popula-
tions, problem severity and settings were repre-
sented by these MI substance abuse studies.
There is good evidence that MI works with
substance-dependent as well as substance-
abusing people. Both substance abuse studies of
MI with youth had signiŽ cant, positive results.
Two evidence-based criteria for recommend-
ing health interventions that have been put forth
are that study results must be consistent in size
and direction (Task Force on Community Pre-
ventive Services, 2000). By these standards, the
best evidence for MI effectiveness found by this
review was when it was used as an enhancement
to more intensive substance abuse treatment. In
four of Ž ve studies of drug- and alcohol-
dependent adults (Bien et al., 1993; Saunders et
al., 1995; Aubrey, 1998; Swanson, Pantalon &
Cohen, 1999), MI’s effects on treatment partici-
pation and substance abuse outcomes were con-
sistent in direction and size. For dissemination
purposes it is important to note in these cases
that MI was not simply blended into the reper-
toires of real-world, specialist substance abuse
clinicians after an inservice training. Rather, one
or two separate MI sessions were added before
the start of treatment-as-usual, usually per-
formed at the treatment-as-usual site by inten-
sively trained MI research interventionists not on
the clinical staff at that site.
For smoking cessation, the Butler et al. (1999)
study produced a small but signiŽ cant effect.
This is encouraging because its brief training (2
hours) and intervention times (2–5 minutes)
made it feasible for general medical practitioners.
The Colby et al. (1998) study, a small-sample
study of youth in the emergency room, was also
encouraging in that most of its effect sizes were
in a positive direction, although non-signiŽ cant.
More studies of different clinicians and popula-
tions are needed before disseminating MI as a
smoking cessation method.
In two studies of HIV risk reduction, MI was
found to increase condom use (Belcher et al.,

1998) and reduce unprotected sex among high-
risk women (Carey et al., 1997). The effects of
both studies were consistent in size and direc-
tion. However, among injecting drug users,
Baker et al. (1993) found that MI did not reduce
HIV risk by reducing injecting or sex practices,
results which were replicated (Baker et al.,
1994). More HIV studies are needed to examine
if MI can reduce HIV risk among men and
injecting drug users.
Of the four behavioral domains examined,
diet/exercise was the most heterogeneous in out-
comes studied and in magnitude of effects. In-
creasing exercise was one Ž nding consistent in
size and direction that emerged. Among general
medical practice patients, MI increased exercise
for up to 3 months, but worked best if delivered
in six sessions rather than one (Harland et al.,
1999). Two other studies with small samples
produced positive but non-signiŽ cant effect sizes
for exercise among obese women (Smith et al.,
1997) and coronary artery disease patients
(Scales, 1998). The largest magnitude of effect
of MI was in enhancing weight-loss treatment
adherence but not weight loss among obese
women (Smith et al., 1997) and treatment ad-
herence in the Scales (1998) study. The Thevos,
Quick & Yanduli (1999) study produced large
effects in sanitizing drinking water among rural
African families. The evidence in this domain
may warrant dissemination of MI for increasing
exercise, but not for bingeing and purging behav-
iors among clients with eating disorders, where
data are inadequate.
Unexpectedly, we found no evidence across
studies that the effects of MI were smaller if
measured over longer periods of time. Re-
gression analyses found no signiŽ cant decline in
effect sizes across studies as a function of length
of follow-up. In terms of “additive dose effects”
of MI, the results were also counterintuitive. We
expected to Ž nd the largest effects for study
designs comparing MI to no treatment, and
smaller effects for MI versus comparison treat-
ments. Because in the enhancement study de-
signs the MI components added only slightly to
overall treatment duration, we expected to see
the smallest effects in these studies. Figures 1, 2
and 3 do not illustrate such a trend clearly.
Duration of MI training and delivery
There was some evidence that MI saves time
over comparison methods, because when com-
Motivational interviewing review 1739
pared to other treatments it took on average only
half as long to deliver (98 vs. 198 minutes).
When tested against no-treatment conditions,
MI took an average of 104 minutes. While this
duration seems feasible for mental health clini-
cians who might add one or two MI sessions to
longer treatment, 104 minutes is too long for
opportunistic interventions in most medical set-
tings. More studies of extremely brief interven-
tions adapting the principles and only a few MI
techniques should be further tested in medical
settings. Because MI took less time than com-
parison treatments, and because MI enhance-
ments add only slightly to the total time of usual
care, MI seems potentially cost-effective. Cost-
effectiveness studies of MI are needed.
Only 10 of these studies reported the training
time provided to MI interventionists, which av-
eraged 15 hours. This duration of training is
feasible in some settings but not feasible in oth-
ers. Unfortunately, we cannot tell from the re-
viewed studies what skill levels of MI were
achieved by this amount of training. Studies are
needed of MI training to better determine opti-
mal training duration and skill levels.
Interactions
Because of the limited and mixed Ž ndings on the
major theoretical components of MI, these stud-
ies allow us to conclude very little about how MI
might work. For example, the evidence was not
convincing that MI interventionists are perceived
as more empathic by clients, or that MI effec-
tively increases self-efŽ cacy. None of the studies
examined the discrepancy between clients’ real
and ideal behaviors. This concept is labeled cog-
nitive dissonance and emphasized as central to
MI by Draycott & Dabbs (1998) although Roll-
nick & Miller (1995) place less emphasis on
dissonance theory. We conclude that the major
theoretical components of MI are understudied,
Furthermore, no conclusions can be reached
about other psychosocial interaction variables
that might in uence responsiveness to MI.
There was modest evidence that MI works at
least as well as other treatments for clients with
low baseline readiness, but we cannot say it does
so better than other methods. The evidence is
inconclusive about whether MI increases readi-
ness better than comparison treatments. The
only consistent readiness Ž nding was that base-
line readiness sometimes predicted behavior
1740 Chris Dunn et al.
change more strongly than treatment type. This
suggests that readiness is a salient change vari-
able that should be studied more carefully to
determine how it mediates behavior change and
how it is best increased.
Limitations of this review and the studies reviewed
This review did not include all available evidence
for MI effectiveness, because we selected only
published studies, which may have created a
selection bias. It was thought that peer-reviewed
studies would be of higher quality than non-
reviewed studies, permitting greater conŽ dence
in inferences from their data. We did not contact
investigators personally to learn more about MI
session monitoring and skill levels obtained by
interventionists.
By deŽ nition, the randomized trials reviewed
here tended to maximize internal validity at the
expense of external validity, making some real-
world generalizations difŽ cult. For example,
truly opportunistic interventions (including an
unexpected intervention in an illness visit) were
not well tested by these studies. This is because
randomized subjects must consent in advance to
an assessment and possible intervention, some-
times making the intervention topic more salient
than it might be in the real world, and biasing
selection toward those most open to discussing
the target behaviors and perhaps more ready to
change. These studies tended to use research
staff as MI interventionists rather than “real-
world” clinicians actually working in the settings
in which the interventions took place.
Suggestions for future research
In addition to reporting the results of power
analyses, MI researchers should report effect
sizes and conŽ dence intervals so that relative risk
reduction, cost-effectiveness and clinical
signiŽ cance can be judged. It is important to
apply a standardized coding system for monitor-
ing MI style and technique, so that skill level vs.
outcome can be analyzed. To operationalize the
style and technique of MI, Miller is currently
developing a standardized coding system (per-
sonal communication) which was not used by
the studies under review. In this review, we are
less certain that the style of MI was captured by
these studies than we are of the techniques.
In the substance abuse domain, where the
evidence recommending its dissemination is
strongest, best practices for training in MI are
still unknown. Although mere training in the
absence of service delivery system changes is not
enough to change clinician behavior (Babor &
Higgins-Biddle, 2000), it is still important to
quantify the training process. For example, what
does it take to learn MI and who can learn it?
What levels of MI skill are needed? What dura-
tions of MI are optimal? In all behavioral do-
mains, questions of MI mechanism remain
unanswered. Can the unique style of MI be
reliably measured and trained, and is this style
essential? Are advanced counseling skills such as
re ective listening, which are difŽ cult to train,
essential for MI to work? Is increasing dis-
sonance without increasing self-efŽ cacy harmful?
In sum, there is good empirical evidence sup-
porting dissemination of MI as a brief interven-
tion method for substance abuse, particularly as
an enhancement to more intensive treatment.
However, it is unknown what levels of MI train-
ing, MI skill, or MI duration are optimal. The
evidence for MI effectiveness in smoking cess-
ation, HIV risk reduction, and diet/exercise is
promising but not strong enough to recommend
its dissemination.
Acknowledgements
This study was funded in part by the National
Highway TrafŽ c Safety Administration, Co-
operative Agreement no. DTNH23–97-H-30572
and Center for Disease Control Grant no.
RRC49.
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