Moyers T.B., Miller W.R., Hendrickson S.M.L.
Journal of Consulting and Clinical Psychology: 2005, 73(4), p. 590–598.
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Analysis of counselling session recordings from therapists trained in motivational interviewing suggests that the important quality of seeming 'genuine' can suffer if training mandates unnaturally withholding normal responses; however, departing from these tenets is risky unless done by a socially skilled therapist.
Summary The featured report derives from a US study which randomly allocated an unusually diverse (in terms of initial proficiency) set of addiction counsellors and clinicians who applied for training in motivational interviewing to different training regimens. An earlier report from the study had established that client responses to trainees changed in the desired direction only when workshops had been reinforced by continued expert coaching and feedback on performance.
In more detail, the most basic training option was merely being given a training video and manual and being told to train yourself; these trainees altered their practice little. In comparison, those allocated to a workshop but no follow-up evidenced immediate improvements in counselling proficiency with a client-actor. During the workshop it had been stressed that this was not a complete training regimen, but a platform from which trainees could learn by paying attention to and responding to their clients in their everyday work: signs of commitment to change would indicate the counsellor was on the right track; resistance would call for a change of direction.
Nevertheless, as in previous studies, even after this workshop practice improvements were found to have dissipated four months later when the trainees submitted tapes of their work with real clients. The three forms of continuing support trialled in the study largely prevented this deterioration. One took the form of mailed feedback on the trainee's counselling samples, comparing their detailed proficiency profile with that of expert practitioners. The second instead took the form of six 'coaching' phone calls initiated by the trainer to ask about any problems and help solve them, each incorporating role play exercises. The third consisted of both forms of continuing input, meaning that counsellors could not only gain expert guidance on their problems with clients, but also on the feedback from their sample sessions.
Only the third, enriched form of continuing support made enough or the right kind of difference to what the trainees did for this to be reflected in increased 'change talk' (thought the main way the therapy promotes real change) and diminished resistance on the part of their clients. It seemed that the workshop's attempt at self-generated learning was insufficient without an external guide to help trainees recognise when clients were or were not responding well and to offer guidance on how best to respond.
For the featured report, the same post-training, real-client audiotapes from the study were used to relate therapist behaviour to the degree to which their clients cooperated with therapy and opened up emotionally and by disclosing personal information – responses which overlap with therapeutic alliance and signify active engagement in therapy.
Overall, client engagement was unrelated to the frequency with which the therapist made statements compatible (such as open questions) or incompatible (such as warning) with the specific techniques recommended in motivational interviewing, a surprise result. But engagement was strongly related to embodying the overall spirit of motivational interviewing and to more general social skills not confined to motivational therapists, including empathy, warmth, supporting the client's autonomy, and coming across as 'genuine', an amalgam of seeming open, honest and trustworthy.
This last quality, being genuine, was difficult for raters to agree on from the audiotapes (videos might have helped), but still about as strongly related to engagement as the other qualities. It also seemed to account for a twist in the findings with potentially far-reaching implications.
As mentioned above, doing the things a diligent motivational interviewer should avoid surprisingly made no overall impact on client engagement with therapy. In theory, confronting clients, warning or directing them, and imposing advice or expressing concern without their permission, should have provoked clients to resist therapy.
But when socially skilled counsellors 'broke the rules' in these ways, they actually enhanced the effect their skills had on client engagement. Moreover, it seemed that within (and only within) the kind of empathic, caring context these counsellors were able to create, doing things such as warning and expressing uncalled for advice and concern deepened the client's engagement with therapy. Socially skilled counsellors tended to avoid these risky manoeuvres, but also had the wherewithal to carry them off without alienating their clients – in fact, the reverse.
Genuineness seemed one explanation for this conundrum. Therapists who honestly and openly expressed the concerns they were feeling and gave advice they felt the client needed without holding their tongues, or trying to manipulate the client into doing the expressing for them, would have rated higher on being genuine, and perhaps also come across this way to the clients. This quality has long been recognised as one of the keys to effective therapy.
commentary The findings of this study can better be understood in the light of an evaluation of a two-day motivational interviewing workshop for probation staff in Oregon, who gave glowing accounts of the improvements in their understanding of and proficiency in motivational interviewing, a view they sustained over the subsequent four months. Their views were corroborated at the end of the workshop by a paper-and-pen evaluation of how they would respond to sample client statements.
The disappointment came when these in-theory assessments were checked against ratings of audiotapes of how the therapists actually behaved at three stages: before the workshop with a client; at the end with someone acting as a client; and with a real client four months later. Especially when the raters were assessing overall adherence to motivational principles rather than specific techniques, the improvements were quite small and left the trainees falling far short of expert practice, largely because they were unable to suppress their previous interactional styles. On one dimension which attempted to reflect how 'genuine' the therapists were, things had even got worse, seemingly because for them this new approach felt unnatural, making them feel uncomfortable.
By four months later even the post-workshop boost in use of specific techniques had eroded. Clinching this negative picture was the fact that, compared to pre-workshop tapes, their clients too did not 'improve' in the balance of commitment versus resistance to change. It seems likely that the natural way a parole officer relates to real 'clients' is quite far removed from motivational interviewing, and reversion to type was the dominant trend. Being trained to go against the grain simply meant that raters felt the parole officers were less genuine in their interactions with clients after than before the workshops. Told about this finding, the trainees explained that this new approach felt unnatural. It does not take much imagination to realise that within the undeniably unequal and coercive context of the criminal justice system, adopting an 'It's up to you' stance might feel like a false position, and also feel false to outsiders and clients.
In a way, this should not be a surprise. Everyone knows the difference between warning, advice and concern which conveys and comes from loving care and respect for one as an equal, and that which comes from and conveys accusation, denigration, and an attempt to exert control. We also know that the former is likely to be listened to and deepen our relationship with the carer, while the latter signifies an alternative agenda rather than common purpose in the pursuit of the recipient's welfare.
Despite intuitively 'making sense', the featured report's results came from a single study and should not be taken to give the green light to extreme negative responses contraindicated in motivational interviewing like shaming and sarcasm, indicative less of good social skills and a caring attitude than of the lack of them. And though we might expect it, we do not know if deepened client engagement in this study translated in to stronger commitment to curbing substance use and then in actual change. For example, one component of engagement was expressing emotion, yet this is not always related to better post-therapy outcomes.
If we take it at face value, overall this work confirms that learning technical skills and abstract principles is not enough to securely transfer the wisdom experts have gained over many years of practice, reflection, and discussion with colleagues, though some willing trainees with a head start in their existing social skills and attitudes to their clients can benefit from training and do even better.
As the analysts (including Bill Miller, co-originator of motivational interviewing) who found following manuals diminishes the effectiveness of motivational interviewing put it, "counselors sometimes attend such training in the hope of learning a few tricks to make clients do what they want them to do. MI is nothing of the sort. Rather, it is a complex clinical style for eliciting the client's own values and motivations for change. It is far more about listening than telling, about evoking rather than instilling."
Had they had the featured report's findings to hand, they might have added that the quality of being genuine can suffer from drilling in 'tricks' and in unnaturally withholding normal caring responses, but also that contravening motivational interviewing's tenets is risky unless done by a socially skilled therapist who by doing so conveys rather than contravenes the empathic concern at the heart of good therapy.
For more on these and similar studies see these background notes to an earlier Findings review.
Last revised 21 February 2013. First uploaded 21 February 2013
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