Learning Motivational Interviewing

Summary

Motivational Interviewing (MI) is a set of principles and skills that take time, practice and discipline to learn. Elements of MI can make a difference in practice quite quickly, while gaining competence in the approach requires the clinician to be highly self-reflective on their intention, use of skills and attention to the client. Beginner level learning starts with the use of individual skills or concepts, while more advanced learning requires integration of different elements in an increasingly subtle and considered way.

Methods of learning MI

There are many ways to approach learning MI. For example:

• Self-study: There are many resources available for learning MI, such as textbooks on a range of MI applications, skill workbooks with practical exercises, training DVDs and online resources. As MI is a complex skill, self-study is best used as a complement to other forms of learning.
• Practice check: Practitioners can audio record samples of MI practice (15-20 minutes, with written client consent) and either self-assess using any of the publicly available fidelity assessment instruments or seek professional coding services for feedback on competence and areas for improvement. Again, this approach is best when it complements other methods.
• Workshop: Attending a workshop is a good way to obtain an overview of the method, begin practicing skills, or continue skill practice. Introduction workshops are usually the equivalent of around sixteen hours. Advanced practice workshops can help support ongoing skill development or focus on specific applications of MI. As MI takes practice, workshops are considered a beginning of the learning process, and by themselves are not enough to gain competence in MI.
• Peer group learning: Following a workshop, practitioners within an agency or across agencies may form a peer learning group that meets regularly to deepen understanding of MI build skills through practice. The most successful groups have some structure to provide direction and guidelines for provision of feedback to maintain a safe and productive learning environment.  
• Group coaching: Similar to peer learning, group coaching is facilitated by a leader, such as a clinical supervisor or external consultant with some level of skill or expertise in MI. Ideally, practitioners take turns to present MI practice samples for review and feedback. Discussions may also include case studies, documentation review and application of MI in practice.
• Individual coaching: Coaching builds upon practitioners’ specific strengths and areas of need with a supervisor or external consultant. Coaching includes direct observation of practice, review of competence and feedback, skill building and practice, case discussion and developing a plan for ongoing learning.

Research indicates that a combination of coaching and coding following a workshop is one of the more effective ways to help transfer learning into more sustained practice.

Process of learning MI

Gaining competence in MI starts with practitioner willingness to try new ways of working, thinking, and behaving. This may in itself require a shift in thinking as many practitioners come to MI hoping to see change in their clients rather than themselves.

Like learning any other complex skill, such as a sport or musical instrument, it is not enough to learn about MI. It helps to have a plan for how to include regular practice the of skills and seek feedback. Effective learning ideally involves multiple cycles of practice-observation-feedback-planning. Although there is no one right way to go about a learning process, there are several well-established elements:

• Get ready to learn:
  • Check that the version of MI being learned is the most up to date.
  • Clarify why learning MI is important – including hopes, expectations and goals
  • Identify supports and resources – including learning tools and people who could provide feedback
  • Normalise the discomfort of learning – mistakes, setbacks, and performance anxiety are part of the process
• Practice core skills: Learning any complex skill involves dedicated and purposeful practice:
  • Practice individual skills – the core elements of MI can be practiced on their own, such as forming evoking questions, deepening reflections and responding to discord statements
  • Practice skills in combination – the skills may be combined into more complex practice, such as the exchange of information or working with building confidence
  • Practice skills in conversation – when practicing with a partner, it is suggested that practitioners use “real plays” (a small but real change topic) rather than “role plays” (pretending to be a client) for more authentic practice and meaningful feedback.
• Seek observation and assessment of practice: It is not enough to do the practice, it is also important to reflect on how it went using strategies such as:
  • Pay attention to a client or practice partner’s response – e.g. what engages them, what doesn’t
  • Record practice with permission
  • Identify a specific aspect of MI practice to review – e.g. ratio of questions to reflections
  • Use a standardized coding or feedback tool to provide guidance on counting or rating aspects of practice
• Seek performance-based feedback: Observation of practice is ideally paired with informed feedback from a practice partner or coach to support self-reflection and learning. It is important that feedback:
  • Emphasizes the practitioner’s strengths and what aspects of practice were consistent with MI
  • Is selective in identifying what could be improved – choose only one or two things that are relevant to where the learner is at
  • Views areas for improvement as opportunities for continued learning and professional growth rather than mistakes.
• Develop a learning plan: It is useful to have a personalized plan for learning MI that is regularly reviewed and updated, and identifies:
  • Specific and measurable goals
  • Learning methods, resources, and supports
  • How progress can be assessed.

It also helps to start by focusing on just one aspect of MI at a time until it feels more comfortable, then work on combining and moving between different skills in a more flexible and responsive way. Learning MI may also involve intentional “unlearning” – stopping or doing less of a behavior, such as being overly directive or problem solving for the client. Possible learning goals may be to:

• Develop the spirit of MI: Actively promote partnership, acceptance, compassion and evocation.
• Use a person-centered style: Develop and deepen the core skills for person-centered engagement, including open questions, affirming strengths, reflections and summaries (OARS).
• Focus: Collaborate with clients on identifying specific change and move toward change goals.
• Provide information and advice: Exchange information and give advice in an MI consistent manner.
• Recognize client language: Recognize client language toward change (change talk) and identify the difference between the language of no change (sustain talk) and dissonance in the relationship (discord).
• Elicit client change talk: Elicit client change talk through skillful and strategic use of core skills.
• Respond to change talk: Use core skills to strengthen and deepen client change talk.
• Respond to sustain talk and discord: Use core skills and other strategies to soften or sidestep sustain talk and discord – including recognizing when the client a change in approach.
• Be strengths based: Develop client awareness of their strengths and increase hope and confidence for change.
• Negotiate change plans: Develop skills to know when and how to discuss taking action towards change.
• Consolidate client commitment: Listen for and reinforce commitment language.
• Be flexible: Integrate MI with other evidence-based practices and routine service delivery and learn when to move between MI and other approaches.
• Unlearn behaviors: Reduce or stop using practices that are not consistent with MI.

Further questions

• Why would learning MI be helpful for you?
• What learning formats are available to you and suit your learning style?
• What will help support your ongoing learning and practice?
• Where would you like to start?

References and Resources

• Miller, W. R., Moyers, T. B., & Rollnick, S. (2013). Motivational interviewing: Helping people change [DVD]. Carson City, NV: The Change Companies.
• Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd edition). New York, NY: The Guilford Press.
• Miller, W. R., & Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64(6), 527-537.

• MINT (Motivational Interviewing Network of Trainers). (2017). Books. Access from http://www.motivationalinterviewing.org/books
• Rosengren, D. B. (2017). Building motivational interviewing skills: A practitioner workbook (2nd edition). New York, NY: The Guilford Press.