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Section VII - Continued Learning


A great deal of research has been conducted to see how Motivational Interviewing is best learned by clinicians.  This research is very useful for the clinician who wants to become a highly-effective practitioner of Motivational Interviewing.  Reading a home-study like this one, or attending a several day conference on Motivational Interviewing will likely not be enough for a clinician to become proficient in Motivational Interviewing.  Instead a learner needs not only a foundational understanding of Motivational Interviewing concepts, skills, and interventions, but ongoing individualized feedback (preferably in real-time), as well as consultation.  (Moyers,, 2004)

Individualized feedback might be provided by a consultant who codes audio or video-recorded sessions with one of the several Motivational Interviewing fidelity tools such as the Motivational Interviewing Treatment Integrity Coding Manual used as an objective means to determine the integrity and fidelity of the clinician’s Motivational Interviewing practice. (Moyers, et. al, 2014)   Coders will look at specific behavioral counts in the session, such as the number of reflections to the number of question as well as rating the clinician on global skills such as empathy, softening sustain talk, and evoking change talk.  As a consultant, it is extraordinary to see the growth of a clinician when an expert is able to take a look at the session in its totality and point out strengths as well as areas that require improvement.

Ongoing consultation, in addition to individualized feedback via audio/video-taped sessions is also very important. Having an experienced Motivational Interviewing clinician who a learner can refer to and discuss nuanced interactions in difficult clinician scenarios is extremely helpful. For example, there are a lot of things that are kind of taken for granted that are implied throughout the course of this home study. In addition to ongoing consultation and individualized feedback, an aspiring Motivational Interviewing will continue build and maintain skills. There is a lot of great guidance on how to strengthen skills with clinician handbooks such as “Building Motivational Interviewing Skills, Second Edition: A Practitioner Workbook” by David Rosengren (Rosengren, 2018).

As a clinician becomes more sophisticated in their use of Motivational Interviewing, they may begin considering how to combine MI with other treatments.  For example, a clinician practicing Cognitive Behavioral Therapy with a client who is presenting with depressive symptoms might find it helpful to assign activities to behaviorally activate the client’s mood prior to other forms of intervention.  The clinician may very well encounter some ambivalence with the client during this process.  

The client might say “Yes, I want to come in and do things about my depression but the very nature of my symptoms make it very difficult for me to go and do some of the things that I used to do that I do find pleasure in.”  The clinician may incorporate Motivational Interviewing to assist the client in resolving their ambivalence about participating in behavioral activation exercises. 

Similarly, many evidence-based approaches to trauma treatment rely on a client’s exposure to uncomfortable memories or uncomfortable feelings attached to those memories. Understandably, clients may feel two ways about going into that level of treatment or going into that style of intervention. “Yes I want to feel better and I don’t want to feel this discomfort that is expected of me.”  Perhaps Motivational Interviewing is to be considered in this instance.

The final concept that I would like to discuss prior to the completion of this Home-Study course is equipoise.  Equipoise, is a term borrowed from the practice of medicine, that suggests that a clinician does not express their opinion about which decision to make and believes it should be up to the client. (Miller, et al, 2012) 

Within Motivational Interviewing, selectively reinforcing or softening particular language can ultimately influence decision-making and help to influence whether or not somebody makes a change in a behavior. We have to understand some of the ethical implications of that. Motivational interviewing should be used only when we believe that we are guiding somebody towards a target behavior that is 100% in their best interest.

 S,o for example, if somebody is considering stopping smoking, I can confidently say that guiding them towards smoking cessation is 100% in their best interest. If somebody is injecting intravenous drugs, I can confidently say that helping them to stop that behavior is in their best. 

If a client is considering whether or not to move across country and take a new job, it is not entirely clear in that case what is in the client’s best interest. As a clinician, it would not be appropriate to guide a client, through the use of motivational interviewing techniques, towards any particular decision. What I may instead is a neutral approach such as a cost-benefit analysis, where I can allow for the client to explore their ambivalence without any type of judgement or influence of the direction. 

With equipoise being such an important concept in Motivational Interviewing, it again reinforces the importance of working with a consultant or consultation group.  When it is unclear whether you should be guiding a client or helping them move towards a target behavior, and you are not entirely sure whether or not it’s in their best interest, being able to rely on consultation is important and necessary.   

A lot of ground has been covered in this home-study. The four processes have been introduced and explored.  The conceptual as well as the practical aspects of Motivational Interviewing have been examined.   Despite much ground being covered, this is certainly not the end of education in Motivational Interviewing.  Research studies are being conducted every day on the efficacy of Motivational Interviewing in different settings.  The community of Motivational Interviewing clinicians remain curious and humble, hoping to learn more about what makes this practice effective with certain populations, certain settings, and under particular conditions.