Original Article
Using Motivational Interviewing to Meet Core
Competencies in Psychiatric Resident Training
Sebastian Kaplan, Ph.D.
Harold Elliott, M.D.
Objective: The authors propose that motivational interviewing
(MI), a brief intervention designed to manage ambivalence re-
garding complex behavior change, is well suited for integration
into psychiatric residency training programs.
Methods: The authors provide a brief description of MI. In
addition, based on a review of the literature the authors explore
which core competencies the empirically validated, client-
centered, and directive method of MI would address.
Results: The authors argue that psychiatric residency programs
can effectively address several core competencies through the
addition of MI training in their curricula, including Brief Psy-
chotherapy, Patient Care, and Interpersonal and Communica-
tion Skills.
Conclusion: The implementation of MI training offers psychi-
atric residency programs potential benefits in several key areas.
However, the authors provide guidance for important research
questions to more confidently ascertain whether MI training for
psychiatric residents is worthwhile.
Academic Psychiatry 2011; 35:46 –50
Received March 25, 2009; revised August 11, 2009; accepted September
8, 2009. The authors are affiliated with the Department of Psychiatry and
Behavioral Medicine at Wake Forest University School of Medicine in
Winston-Salem, North Carolina. Address correspondence to Sebastian
Gabriel Kaplan, Wake Forest University School of Medicine, Psychiatry
and Behavioral Medicine, Medical Center Blvd., Winston-Salem, NC
27157; sgkaplan@wfubmc.edu (e-mail).
Copyright © 2011 Academic Psychiatry
46 http://ap.psychiatryonline.org
M otivational interviewing (MI) is a technique with
the potential to be quite useful for training psychi-
atric residents. MI originated as a treatment approach for
alcohol addiction (1), but has since evolved into a brief,
evidence-based intervention for a range of psychiatric and
medical conditions (2, 3). Due to the applicability of MI
across medical disciplines, there has been growing interest
in the literature regarding training in MI at both the med-
ical student and resident levels. Recent articles describe
the development and evaluation of MI curricula for first-
and third-year medical students, with positive results
shown in self-reported comfort and familiarity for medical
students using MI techniques, and targeted areas for im-
provement in use of MI methods in patient-care (4, 5).
Residency programs have also begun to report on the
implementation of MI programs. Examples include a psy-
chiatric residency curriculum focused on patients with
dual diagnoses (6) and a pediatrics program designed to
prepare residents to address patient smoking (7). Further-
more, Greenberg and colleagues (8) noted that by provid-
ing MI instruction in addiction training, they have found
residents “becoming more hopeful and skillful in respon-
sibly engaging challenging patients.” The goal of our pa-
per is twofold: express our opinion that MI meets several
of the psychiatric residency core competencies and iden-
tify research goals needed to determine if training in MI
for psychiatric residents is worthwhile.
Overview of Motivational Interviewing
“MI is a client-centered, directive method for enhancing
intrinsic motivation to change by exploring and resolving
ambivalence” (9). Miller and Rollnick (10) describe four
general principles of MI: express empathy, develop dis-
crepancy, roll with resistance, and support self-efficacy.
The first principle of expressing empathy relies on reflec-
tive listening techniques, consistent with the client-cen-
Academic Psychiatry, 35:1, January-February 2011

tered approach associated with the work of Carl Rogers.
Second, the goal of developing discrepancy is to help the
patient elucidate a distinction between their current behav-
ior or general condition and the patient’s goals and values.
The third principle of rolling with resistance is both a
mindset and set of skills designed to manage resistance in
a supportive and noncritical manner. Finally, the principle
of supporting self-efficacy emphasizes that the patient is
ultimately responsible for change. Fostering a belief that
the patient is capable can in effect lead to the very change
that the patient is hoping for, while also relieving the
burden of change from the clinician.
Application of MI to Core Competencies
In Core Competencies for Psychiatric Education: De-
fining, Teaching, and Assessing Resident Competencies,
Andrews and Burruss (11) describe the requirements and
expectations for psychiatric residency programs based on
Beresin et al.’s (11) psychiatric-specific competencies ap-
plied to the ACGME’s six general competencies. In addi-
tion, Andrews and Burruss describe the five models of
psychotherapy required of psychiatric residency programs.
We highlight how MI fits directly with several important
areas described by Andrews and Burruss.
Therapeutic Relationship Three of the psychiatry-
specific competencies emphasize a therapeutic relation-
ship with the patient. The Patient Care competency men-
tions the “therapeutic interview,” while under Medical
Knowledge residents must “demonstrate knowledge of
psychosocial therapies including doctor-patient relation-
ship.” The competency most related to the therapeutic
relationship is Interpersonal and Communication Skills,
which contains the following expectations of psychiatric
residents:
• “Develop and maintain therapeutic relationships with
culturally diverse patients”
• “Gain an understanding of another’s position and rea-
soning”
• “The wish to build collaboration”
• “The desire to share information in a consultative
rather than dogmatic fashion” (11).
Training in MI not only advocates for the development
of a strong doctor-patient relationship, it provides specific
instruction on techniques a physician can employ to build
such a relationship. Skills such as simple, complex, and
summary reflections, as well as affirmations and empha-
Academic Psychiatry, 35:1, January-February 2011
KAPLAN AND ELLIOTT
sizing a patient’s personal choice, provide residents with
structured methods for fostering a therapeutic alliance. In
addition, a review of MI found that one of its strengths is
its utility with patients from diverse backgrounds (3). Fur-
thermore, MI advocates for a collaborative physician-pa-
tient relationship that recognizes the patient’s own exper-
tise with their strengths and limitations.
Empirically Based The Patient Care competency men-
tions the goal of conducting a “range of therapies using
standard accepted models that are evidence-based” (11)
(emphasis added). MI provides an evidence-based clinical
tool that has become widely used across medical disci-
plines. Within psychiatry, research regarding MI’s effi-
cacy in the management of addictions (12), co-occurring
disorders (13), depression (14), and anxiety (15) is con-
sistent with the goal established in the Patient Care com-
petency of “standard accepted models.” Of particular
value to psychiatric residents is the added effect of MI
when combined with other interventions (3). Since many
of today’s graduating psychiatric residents will likely uti-
lize psychopharmacological interventions as their primary
treatment approach, training in MI could afford residents a
tool that complements medication management.
Additionally, conditions such as HIV and diabetes have
shown positive patient outcomes when treatments incor-
porate elements of MI into the intervention strategy (16,
17). Given the challenges associated with treatment for
individuals with co-occurring mental illnesses and condi-
tions such as HIV and diabetes (18, 19), training in MI
would provide residents with an approach that could help
with the overall management of the patient and not just
their psychiatric condition.
Assessment of Competency Andrews and Burruss
(11) frequently mention the importance of empirical eval-
uation of resident learning, rather than using general im-
pressions of resident competence. The Motivational Inter-
viewing Treatment Integrity Code (MITI) (20) is a scale
that measures a practitioner’s application of MI in clinical
settings. It is a relatively simple measure to administer,
typically requiring the review of a 20-minute session seg-
ment, which can consist of an audio- or videotape, as well
as live observation. The MITI generates five “global
scores” that measure a clinician’s ability to conduct a
session consistent with the “spirit of MI.” The MITI also
utilizes “behavior counts” that assesses the frequency a
practitioner displays the following in-session behaviors:
giving information, questions, reflections, MI-adherent be-
http://ap.psychiatryonline.org 47
USING MOTIVATIONAL INTERVIEWING IN TRAINING
havior, and MI-nonadherent behavior. The MITI provides
a potentially useful method for residency programs to
meet the need for empirical evaluation of resident compe-
tence in skills inherent to MI, as well as in the overall
development of an effective psychiatrist.
Brief Psychotherapy Much of the empirical support
for MI is as a brief intervention for challenging behavior
changes (3). One of the five psychotherapies that psychi-
atric residents must demonstrate competence in is brief
psychotherapy. Andrews and Burrus (11) included several
MI-consistent elements within the knowledge, skills, and
attitudes components of brief psychotherapy, such as:
• “Demonstrate understanding of the use of brief therapy
in the overall treatment needs of the patient”
• “Establish and maintain a therapeutic alliance”
• “Establish and adhere to a focus”
• “Utilize at least one well-defined model of brief ther-
apy”
• “The resident will be empathic, respectful, curious,
open, nonjudgmental, collaborative, and able to tolerate
ambiguity and display confidence in the efficacy of brief
therapy” (11).
Being a well-defined model that uses a focus of inter-
vention and emphasizes elements of the doctor-patient
relationship, such as empathy, respect, and collaboration,
MI seems well-suited to meeting the requirements of the
brief psychotherapy core competencies.
Several examples of MI-based interventions that are
relevant to today’s psychiatric resident exist in the litera-
ture. Kemp and colleagues (21) conducted a randomized
controlled trial of compliance therapy, a method of in-
creasing medication adherence for patients with psychotic
disorders, based largely on MI. The authors report signif-
icant gains, following 4 – 6 sessions of compliance ther-
apy, in attitudes toward treatment, insight, and compliance
with medication over an 18-month follow-up period after
discharge from an inpatient unit relative to nonspecific
counseling. The authors also explain that booster sessions
were offered to both experimental and control groups at 3,
6, and 12 months as part of routine follow-up services.
With the average length of each compliance therapy ses-
sion ranging from 20 – 60 minutes, it seems plausible that
MI-based interventions seeking to increase medication ad-
herence may fit the time constraints experienced by many
practicing psychiatrists.
As mentioned previously, MI has shown particular util-
ity when combined with other treatments. Given that psy-
48 http://ap.psychiatryonline.org
chiatrists often work as partners with non-M.D. therapists,
research that shows increased adherence with psychother-
apy and other nonpharmacological interventions following
exposure to MI is relevant to our discussion. A random-
ized pilot study comparing an MI-based engagement ses-
sion plus interpersonal therapy for depression with a re-
ferral to a community mental health provider found
significantly higher percentages of attendance to first ses-
sion (96% compared with 36%) and treatment completion
(68% compared with 7%) for depressed economically dis-
advantaged women in the experimental condition (22).
One of many pathways for an individual to enter psycho-
therapy with a non-physician therapist is by referral from
their psychiatrist. Using an MI-adherent approach geared
toward increasing likelihood of adherence to psychother-
apy, as in the aforementioned engagement session study,
an MI-trained psychiatrist can be uniquely helpful in fa-
cilitating a coordinated multidisciplinary treatment plan.
Zerler (23) authored a compelling rationale for the ap-
plication of MI with suicidality. Although there has been
no research examining the impact of MI on suicidality,
Zerler provides an excellent description of the ethical chal-
lenges when working with this population and how the
collaborative nature of MI will naturally require more
directiveness from a clinician when questions of patient
safety arise. However, Zerler also emphasizes the need for
balancing patient safety with continued support of auton-
omy, within the confines of professional and ethical guide-
lines for managing a suicidal patient. Furthermore, Zerler
explains that MI can be “functionally integrated with crisis
evaluation, which, in effect, allows crisis evaluation to
also comprise brief therapy” (p. 179).
Discussion
The declining use of psychotherapy by psychiatrists is
well documented (24). If psychiatry continues the transi-
tion from a profession grounded in the use of long-term
psychotherapy to one characterized by more brief patient
encounters consisting largely of medication-based inter-
ventions, teaching residents MI could meet training needs
(see Table 1). MI training would provide residents with an
empirically based method consistent with the brief psy-
chotherapy core competency. Assessment of resident com-
petence in the use of MI with the Motivational Interview-
ing Treatment Integrity Code also fulfills the requirement
that training programs utilize empirical methods of resi-
dent assessment. Furthermore, the core principles of MI,
namely expressing empathy, developing discrepancy, roll-
Academic Psychiatry, 35:1, January-February 2011
 KAPLAN AND ELLIOTT

TABLE 1. Application of Motivational Interviewing to Psychiatry Core Competencies

Core Competency Motivational Interviewing Application

Patient Care ● Motivational interviewing is a standard accepted model in treating addictions,
co-occurring disorders, depression, and anxiety
● Has evidence-based efficacy in combining psychopharmacology and
psychotherapy
● Has demonstrated evidence of improved patient compliance
● Is an evidence-based clinical tool for managing psychiatric and non-
psychiatric illness
Medical Knowledge ● Can assess resident clinical competency using MITI
● Meets requirements of brief psychotherapy specific competency
Interpersonal and Communication Skills ● Provides instruction in utilizing simple, complex and summary reflections, as
well as affirmations
● Emphasizes personal choice and participation in care
● Has particular application to culturally diverse populations
● Promotes a collaborative relationship with patient
Systems-Based Practice ● Has demonstrated utility when combined with other treatments
● Has application in facilitating improved compliance with referral to non-MD
therapists and in coordinating multidisciplinary treatment teams

ing with resistance, and supporting self-efficacy, are con-
sistent with the core values of psychiatry as a profession.
Even if psychiatrists do not directly provide psychother-
apy, they must learn concepts that facilitate effective re-
lationships with patients for whom they manage medica-
tions and in collaborating with non-M.D. therapists.
The use of MI in psychiatry training programs may also
enhance the contribution of psychiatric residents as teach-
ers throughout their respective medical institutions. In
2001–2002, the Committee on Graduate Education issued
a revised version of Psychiatric Residents as Teachers: A
Practical Guide (25). In that guide, the committee notes
that residents are responsible for an increasing part of
medical student education. The guide also notes that past
studies have indicated that up to 20%–25% of resident’s
time is spent teaching medical students. The ACGME
requirements regarding psychiatry training note that “res-
ident teaching abilities must be documented by evalua-
tions by faculty and/or learners.” Given the interest MI has
generated across medical specialties, use of MI by resi-
dents in interviewing patients and in teaching medical
students to interview should continue to benefit these stu-
dents in all areas of medical practice.
However, before psychiatry training programs widely
adopt MI as an approach in their curricula, more research
is needed to determine whether training in MI will meet
the needs of psychiatric residents and their patients. Ques-
tions that first must be answered include, but are not
limited to: Will training psychiatric residents MI princi-
ples and techniques lead to improved comfort, knowledge,
and competence in the use of brief interventions? Is the
MITI a useful measure of resident competence? With the
ACGME’s emphasis on improved training for residents to
teach medical students, does training in MI afford psychi-
atric residents the ability to teach medical students MI?
Finally, does MI training lead to better patient care by
psychiatric residents? It is our belief that with increased
research on the application of MI in psychiatric residency
training programs, residents will benefit greatly from train-
ing that prepares them for the realities of today’s profes-
sional climate.
At the time of submission, the authors reported no competing
interests.
References
1. Miller WR: Motivational interviewing with problem drink-
ers. Behav Psychother 1983; 11:147–172
2. Knight KM, McGowan L, Dickens C, et al: Systematic re-
view of motivational interviewing in physical health care
settings. Br J Health Psychol 2006; 11:319 –332
3. Hettema J, Steele J, Miller WR: Motivational interviewing.
Annu Rev Clin Psychol 2005; 1:91–111
4. Poirier MK, Clark MM, Cerhan JH, et al: Teaching motiva-
tional interviewing to first-year medical students to improve
counseling skills in health behavior change. Mayo Clin Proc
2004; 79:327–331
5. White LL, Gazewood JD, Mounsey AL: Teaching students
behavior change skills: description and assessment of a new
motivational interviewing curriculum. Med Teach 2007; 29:
67–71
6. Renner JA: How to train residents to identify and treat dual
diagnosis patients. Biol Psychiatry 2004; 56:810 – 816
7. Scal P, Hennrikus D, Ehrlich L, et al: Preparing residents to

Academic Psychiatry, 35:1, January-February 2011 http://ap.psychiatryonline.org 49

USING MOTIVATIONAL INTERVIEWING IN TRAINING
counsel about smoking. Clin Pediatr (Phila) 2004; 43:703–
708
8. Greenberg WM, Ritvo JI, Fazzio L, et al: A survey of ad-
diction training programming in psychiatry residencies. Acad
Psychiatry 2002; 26:105–109
9. The Mid-Atlantic Addiction Technology Transfer Center: Mo-
tivational Interviewing: Resources for Clinicians, Researchers,
and Trainers. Available at http://motivationalinterview.org/
index.shtml
10. Miller WR, Rollnick S: Motivational Interviewing: Preparing
People for Change, 2nd ed. New York, NY, Guilford, 2002
11. Andrews LB, Burrus JW: Core Competencies for Psychiatric
Education: Defining, Teaching, and Assessing Resident
Competence. Washington, DC, American Psychiatric Pub-
lishing, 2004
12. Dunn C, Deroo L, Rivara FP: The use of brief interventions
adapted from motivational interviewing across behavioral
domains: a systematic review. Addiction 2001; 96:1725–
1742
13. Handmaker N, Packard M, Conforti K: Motivational inter-
viewing in the treatment of dual disorders, in Motivational
Interviewing: Preparing People For Change, 2nd ed. Edited
by Miller WR, Rollnick S. New York, NY, Guilford, 2002,
pp 362–376
14. Swartz HA, Zuckoff A, Grote NK, et al: Engaging depressed
patients in psychotherapy: integrating techniques from moti-
vational interviewing and ethnographic interviewing to im-
prove treatment participation. Prof Psychol: Res Pract 2007;
38:430 – 439
15. Westra HA, Dozois DJA: Preparing clients for cognitive
behavioral therapy: a randomized pilot study of motivational
interviewing for anxiety. Cogn Ther Res 2006; 30:481– 498
16. Naar-King S, Lam P, Wang B, et al: Brief report: mainte-
nance of effects of motivational enhancement therapy to
improve risk behaviors and HIV-related health in a random-
50 http://ap.psychiatryonline.org
ized controlled trial of youth living with HIV. J Pediatr
Psychol 2008; 33:441– 445
17. Channon SJ, Huws-Thomas MV, Rollnick S, et al: A multi-
center randomized controlled trial of motivational interview-
ing in teenagers with diabetes. Diabetes Care 2007; 30:1390 –
1395
18. Angelino AF, Treisman GJ: Issues in co-morbid severe men-
tal illnesses in HIV-infected individuals. Int Rev Psychiatry
2008; 20:95–101
19. Banerjea R, Sambamoorthi U, Smelson D, et al: Chronic
illness with complexities: mental illness and substance use
among veteran clinic users with diabetes. Am J Drug Alcohol
Abuse 2007; 33:807– 821
20. Moyers TB, Martin T, Manuel JK, et al: Motivational Inter-
viewing Treatment Integrity 3.0 (MITI 3.0) (Coding Man-
ual). Albuquerque, NM, University of New Mexico, Center
on Alcoholism, Substance Abuse and Addictions (CASAA),
2007
21. Kemp R, Kirov G, Everitt B, et al: Randomized controlled
trial of compliance therapy: 18-month follow-up. Br J Psy-
chiatry 1998; 172:413– 419
22. Grote NK, Swartz HA, Geibel SL, et al: A randomized
controlled trial of culturally relevant, brief interpersonal psy-
chotherapy for perinatal depression. Psychiatr Serv 2009;
60:313–321
23. Zerler H: Motivational interviewing and suicidality, in Mo-
tivational Interviewing in the Treatment of Psychological
Problems. Edited by Arkowitz H, Westra HA, Miller WR,
et al. New York, NY, Guilford, 2008, pp 173–193
24. Mojtabai R, Olfson M: National trends in psychotherapy by
office-based psychiatrists. Arch Gen Psychiatry 2008; 65:
962–970
25. Committee on Graduate Medical Education: Psychiatric Res-
idents as Teachers: A Practical Guide. Arlington, Va, Amer-
ican Psychiatric Association, 2002
Academic Psychiatry, 35:1, January-February 2011