EDITORIAL
What is this thing called motivational interviewing?
INTRODUCTION—A PROMISING
APPROACH
Those interested in the history of clinical endeavour will
be engaged by Miller’s description of the nativity of
motivational interviewing (MI):
Motivational interviewing began in a barber shop in
Norway [1, p. 835].
From these humble beginnings two decades ago, MI
has been widely adopted and adapted for use with a
diverse range of clients. There are several reviews of the
accumulating evidence attesting to the impact and
limitations of MI, and the intrepid reader can explore the
evidence thoroughly through the library devoted to this
issue at http://www.motivationalinterview.org/library/
biblio.html. To date there is a limited number of rigorous
studies assessing the impact of MI (e.g. see [2]) and it will
be important for systematic reviews to help interpret the
accumulating body of evidence. However, interpretation of
the accumulated evidence is not helped by diverse
descriptions of what MI is and is not. In order to build and
reliably interpret the evidence for MI, there is a need to
have agreed definitions, to assess fidelity in application
and to understand the processes by which MI is alleged to
affect clinical outcomes.
The history of MI provides an interesting case study for
students of knowledge diffusion and utilization. This
‘client-centered, directive method for enhancing intrinsic
motivation to change by exploring and resolving
ambivalence’ [3, p. 25] was rapidly embraced. ‘Clinical
researchers noticed these developments and got going’ [4,
p. 1769] initially ahead of efficacy data [5]. The
intervention emerged at a time of increasing frustration
with the unsubstantiated, and clinically unsustainable
belief that one should confront and coerce clients to
change. These latter practices were inconsistent with the
increasingly influential humanist psychotherapies and also
with emerging evidence about treatment and treatment
outcome. One suspects that the appealing rationale and the
emerging evidence were bolstered by the fact that many
clinicians were more comfortable with an approach that
fostered collaboration as opposed to some of the more
confrontational methods commonly sanctioned. Some
early reports of improved treatment retention signified that
clients also found MI more engaging (e.g. see [6]).
WHAT IS MI AND WHAT DOES IT DO?
Miller & Rollnick have emphasized consistently that the
spirit of MI is as important as the various techniques.
© 2007 The Author. Journal compilation © 2007 Society for the Study of Addiction
doi:10.1111/j.1360-0443.2006.01712.
Indeed, they have counselled that if MI is simply
reduced toabagof
techniquesortricks,thenitcannotbeproperly considered
as MI. Those who have claimed a particular
intervention to be MI appear to vary in the degree to
which they have embraced this counsel. Determining
fidelity has been difficult due to three main (related)
factors: first, adoption of MI has advanced with a
limited theoretical base. This has made it difficult to
determine,
andthusunderstand,thecriticalandeffectiveingredients
and processes of MI; secondly, there has been a lag in
the development of reliable and practical instruments
and methods that allow assessment of training and
supervision outcomes, and similarly make it difficult
to assess treatment fidelity and quality; thirdly, many
research reports either fail to give sufficient detail to
determine treatment fidelity and/or claim to use MI but
fail to adhere to important, indeed critical, principles
and techniques.
A theoretical understanding of MI is lacking, partly
because most research has focused on assessing
efficacy, neglecting questions about the processes that
are involved in and affected by the intervention [2]. A
few studies have attempted to examine the impact of
the constituents of MI (e.g. see [7]). Even when MI
has been associated with improved treatment outcome,
there has been little assessment regarding its impact on
motivational variables. Miller & Rollnick have both
acknowledged this weakness, which precludes bold
conclusions about how and why MI has an influence,
and limits inference regarding which of the various
components might be important and why. Markland
and colleagues concluded that:
while various aspects of the principles and practice
of motivational interviewing have been linked to a
variety of social psychological and social cognitive
models, this has been largely on a piecemeal and
descriptive basis [8, p. 812].
Theory contributes to the development of testable
hypotheses that can help us understand, refine and
improve clinical discovery. We should therefore
welcome the Markland and colleagues’ recent
examination of MI in relation to self-determination
theory. Their sortie into the theoretical realms can help
us understand the potential impact of MI on
motivational processes. They have facilitated the
generation of testable hypotheses, for example around
Addiction, 102, 343–345
the issues of external regulation, selfregulation and fidelity and taping and analysis of treatment delivery.
internal and external autonomy, that can help us better However, in general and specifically in relation to MI,
comprehend the impact of MI on treatment adherence. Miller and others have noted that currently there is
344 Editorial limited evidence about which training, supervision and
accreditation processes are associated with improved
clinical outcomes. Consequently, we do not know
THE IMPORTANCE OF TREATMENT
which clinicians are best suited to deliver MI and what
FIDELITY
training and supervision they may require to make a
MI is a complex intervention, demanding judicious difference to clinical outcomes.
application. Unfortunately, with limited evidence to Assessingtheeffectivenessof
guide us on who is best placed to deliver MI, MIclinicalskillstraining
considered clinician selection and comprehensive andtreatmentfidelityhavebeenrestrainedbyapaucityof
training programmes appear to be overshadowed by a reliable,validandpracticalassessmenttools.Recentwork
plethora of short courses. Despite their popularity, has attempted to fill this void, but the quintessential
they may be insufficient to train clinicians adequately, style of MI has presented a substantial challenge. The
or worse, they could create an unfounded sense of MotivationalInterviewingSkillCode(MISC)
capability. Miller has commented that embracing the [9,11]wascriticized as having limited application,
spirit of MI might not only involve learning new particularly because it is complex and labour intensive
behaviours—existing behaviours may need to be (for example, it can take 4 hours to rate one therapy
suppressed. For example, Miller & Mount [9] reported session) (e.g. see [12,13]).
that while training in MI enhanced adoption of the Madsonandcolleagues[12]respondedtocriticismsof the
spirit and skills of MI, pre-existing behaviours that MISCbydevelopingtheMotivationalInterviewingSuper
may be inconsistent with MI were retained. They also vision andTraining Scale (MIST), which measures
noted that increased confidence gained from a adherence to and quality of implementation of MI.
workshop might not always be matched by While the instrument has, to some extent, combined
competence, a worrying combination. Insufficient good psychometric qualities with practicality, the lack
clinical training may: of understanding of the relative importance of the
. . . even serve as a kind of inoculation against various constituents of MI may have contributed to
further learning, inflating clinician self-efficacy some psychometric limitations and more work on the
without altering practice behaviour enough to reliability and validity of this and other instruments is
improve client outcomes [9, p. 468]. required.The approach will also need to result in tools
that are easy to use, a critical consideration if we
Miller has observed that even highly skilled
expect their widespread adoption.
practitioners demonstrate varied adherence to
Poordescriptionof complextreatmentsusedinclinical
interventions such as MI. He has also advised that
research is not restricted to MI. Guidelines on quality
self-report of clinical practice can be an unreliable
reporting of clinical interventions exist, but are not always
guide. For example, many clinicians may be unaware
observed. The absence of reliable and valid
of their shortcomings or errors they make. Such
treatmentfidelitymeasures,sometimescombinedwithcompli
concerns have led him to conclude that the only
ance with editorial demands for more succinct research
reliable method to assess adherence to a clinical style
reports, may contribute to this omission. Crudely put, the
is to directly monitor practice. He has actively
consequenceisthatsomereportsinformusthattheintervention
encouraged the adoption of standards for training and
wasorwasnotefficacious,withlittlereliableinformationdescri
measurement of treatment fidelity and quality across
bingwhatwasdelivered,bywhomandhow.
treatment domains. For example, in one treatment
Asalreadynoted,inrelationtoMI,thetaskmaybefurther
report (not specifically related to MI), Miller and
complicated because, while defining and measuring MI
colleagues [10] described what could be considered a
techniquesarecomparativelystraightforward,thespiritof MI
highly desirable
is a more challenging prospect. Nevertheless, the
approachtoselect,trainandsupportclinicalstaff.Aspart of
scientificveracityof MIresearchandclinicalapplicationwill
a clinical research programme, they described a
bemuchadvancedbyadoptingandensuringadherenceto
process of screening and selecting clinicians and
guidelines for reporting evidence-based interventions.
detailed training that involved skill rehearsal and
Innovative methods to respond to the pressure of journal
performance assessment. Clinicians were certified
space could also be explored—for example, using
when a given level of performance was met, a process
electronic links to provide more detail on interventions,
involving on-site supervision, strategies to maintain
clinicianselectionandeducationandtrainingandthecontext of
intervention.This is not just a challenge for MI, but for all
quality journals that publish reports of clinical trials.
As noted by Miller and colleagues:
. . . treatment process and adherence data should be
given the same status as outcome data in behavioural
intervention research [10, p. 194].
Miller & Rollnick have enriched clinical training and
practice and there is some evidence attesting to the
efficacy of MI in a range of treatment settings.They have
set clinical researchers some critical challenges. We are
yet to explore substantively the theoretical basis of MI or
its impact on motivational processes and we have little
that can help us understand the relative importance of its
constituents.Attemptstoaddressandmeasuretreatment
© 2007 The Author. Journal compilation © 2007 Society for the Study of Addiction
fidelity, especially in relation to the alleged critically
important spirit of MI, are in their infancy and the current
instruments are somewhat cumbersome.
WHERE NEXT?
Building on the seminal work of Miller, Rollnick and their
colleagues, we are left with some critical questions:
• What theoretical models best help us understand
andadvance MI?
• How do we effectively assess the impact of MI and
whatdoes the current body of evidence tell us?
• Why, or by what processes, does MI work?
• How do we define, operationalize and measure
theessence, or spirit, as well as the techniques of MI?
• How do we measure reliably and practically the effec-
tive application of MI?
Until we answer these questions, it will be difficult to
advance our understanding of what MI is and importantly
what it is not. Nor will we be able to interpret effectively
the evidence about its impact. If we do not endeavour to
explore these complex issues, there is the risk that this
valuable clinical approach will be diluted to a folk science,
or craft, adopted and adapted by the whims or persuasions
of individual advocates. We should ensure that this does
not occur.
Acknowledgements
I am indebted to Celia Wilkinson andTanya Chikritzhs for
helpful comments on an initial draft and to Maggie Halls
and Patricia Niklasson for technical support. Steve Allsop
is funded through the Australian Government Department
of Health and Ageing.
© 2007 The Author. Journal compilation © 2007 Society for the Study of Addiction
STEVE ALLSOP
National Drug Research Institute, Curtin University of
Technology, GPO Box U1987, Perth WA 6845, Australia.
E-mail: s.allsop@curtin.edu.au
Editorial 345
References
1. Miller W. R. Motivational Interviewing: research,
practiceand puzzles. Addict Behav 1996; 21: 835–42.
2. Burke B. L., Arkwowitz H., Dunn C. The efficacy of
motivational interviewing and its adaptations. In: Miller
W. R., Rollnick S., editors. Motivational Interviewing:
Preparing People for Change, 2nd edn. NewYork:
Addiction, 102, 343–345
Guilford Press; 2002, p. 217–50.
3. Miller W. R., Rollnick S. Motivational Interviewing:
Preparing People for Change, 2nd edn. NewYork:
Guilford Press; 2002.
4. Rollnick S. Enthusiasm, quick fixes and premature
controlled trials. Addiction 2001; 96: 1769–75.
5. Miller W. R. When is it motivational interviewing?
Addiction 2001; 96: 1770–1.
6. Stockwell T., Gregson A. Motivational Interviewing
withproblem drinkers—impact on attendance, drinking
and outcome. Br J Addict 1986; 81: 713.
7. LaBrie J., Pedersen E., Earleywine M., Olsen H.
Reducingheavy drinking in college males with the
decisional balance: analyzing an element of
Motivational Interviewing. Addict Behav 2006; 31:
254–63.
8. Markland D., Ryan R., Tobin V., Rollnick S.
MotivationalInterviewing and self-determination
theory. J Soc Clin Psychol 2005; 24: 811–31.
9. Miller W., Mount. K. A small study of training in
motivational interviewing: does one workshop change
clinician and client behavior? Behav Cogn Psychother
2001; 29: 547– 471.
10. Miller W., Moyers T., Arciniega L., Ernst D.,
Forcehimes A.Training, supervision and quality
monitoring of the COMBINE study behavioral
interventions. J Stud Alcohol Suppl 2005; 15: 188–95.
11. Miller W. R. Motivational interviewing skill code
(MISC): coder’s manual. Unpublished manual. Las
Cruces, NM: University of New Mexico; 2000.
Available at: http:// www.motivationalinterview.org
[Accessed August 2006].
12. Madson M., Campbell T., Barrett D., Brondino J.,
MelchertT. Development of the Motivational
Interviewing Supervision and Training Scale. Psychol
Addictive Behav 2005; 19: 303–10.
13. Jonge J., Schippers G., Schaap C. The Motivational
Interviewing skill code: reliability and a critical
appraisal. Behav Cogn Psychother 2005; 33: 285–98.
Addiction, 102, 343–345