Journal of Consulting and Clinical Psychology © 2017 American Psychological Association

2017, Vol. 85, No. 8, 757–766 0022-006X/17/$12.00 http://dx.doi.org/10.1037/ccp0000179

Motivational Interviewing and the Clinical Science of Carl Rogers

William R. Miller and Theresa B. Moyers
University of New Mexico

The clinical method of motivational interviewing (MI) evolved from the person-centered approach of
Carl Rogers, maintaining his pioneering commitment to the scientific study of therapeutic processes and
outcomes. The development of MI pertains to all 3 of the 125th anniversary themes explored in this
special issue. Applications of MI have spread far beyond clinical psychology into fields including health
care, rehabilitation, public health, social work, dentistry, corrections, coaching, and education, directly
impacting the lives of many people. The public relevance and impact of clinical psychology are
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

illustrated in the similarity of MI processes and outcomes across such diverse fields and the inseparability
This document is copyrighted by the American Psychological Association or one of its allied publishers.

of human services from the person who provides them, in that both relational and technical elements of
MI predict client outcomes. Within the history of clinical psychology MI is a clear product of clinical
science, arising from the seminal work of Carl Rogers whose own research grounded clinical
practice in empirical science. As with Rogers’ work 70 years ago, MI began as an inductive
empirical approach, observing clinical practice to develop and test hypotheses about what actually
promotes change. Research on MI bridges the current divide between evidence-based practice and
the well-established importance of therapeutic relationship. Research on training and learning of MI
further questions the current model of continuing professional education through self-study and
workshops as a way of improving practice behavior and client outcomes.

What is the public health significance of this article?

The person-centered approach of motivational interviewing (MI) can effectively change health
behaviors that influence the prevention, course, treatment, and outcomes of a broad range of health
problems. Research on MI bridges the current divide between evidence-based practice and the
well-established importance of therapeutic relationship. Treatments of this kind are inseparable from
the person who provides them.

Keywords: motivational interviewing, client-centered counseling, empathy, therapist effects, nonspecific

factors

The election of Carl Rogers as President of the American measurable, can improve with training and practice, and pre-
Psychological Association in 1947 marked an historic melding dicts treatment outcome (Elliott, Bohart, Watson, & Greenberg,
of psychological science with clinical practice (Kirschenbaum, 2011; Malin & Pos, 2015). To call this a “common” factor is
2009). His commitment to the scientific testing of therapeutic somewhat misleading in that therapists vary widely in this skill
assertions was remarkable in clinical psychology at the time: to and it is unclear how common accurate empathy is in actual
operationally define and measure treatment process variables practice. Nor is “non-specific” an apt description of such fac-
and test their relationship to client outcomes by recording, tors, in that they can be specified, measured, and studied in
coding, and analyzing therapy sessions (including his own). In relation to treatment outcome. This is, in fact, what Carl Rogers
this way he anticipated by half a century the current clinical and his students began: to clarify through scientific study what
science emphasis on evidence-based treatment and research on aspects of clinical practice actually promote positive change.
therapeutic mechanisms. Rogers’ research on the necessary and This article describes the development and scientific study of
sufficient conditions for change provided a foundation for the motivational interviewing (MI), a clinical method that evolved
scientific study of what have come to be called nonspecific, from client-centered therapy and has continued Rogers’ commit-
common, or general factors in psychotherapy. The therapeutic ment to the empirical study of treatment processes and outcomes.
skill of accurate empathy is a prime example; it is reliably We first relate how MI evolved and discuss the surprisingly broad
dissemination of this approach. Next we turn to four areas of
research, summarizing (1) treatment outcome studies of MI, (2) the
linkage of specific therapeutic processes to client outcomes, (3) the
William R. Miller and Theresa B. Moyers, Department of Psychology,
University of New Mexico.
integration of MI with other treatment methods, and (4) how
William R. Miller received royalties from Guilford Press for books on practitioners learn and develop competence in MI. Finally, we
motivational interviewing. reflect on the “dustbowl empiricism” roots of MI and of the
Correspondence concerning this article should be addressed to William person-centered approach itself in contrast to the hypothetico-
R. Miller. E-mail: [email protected] deductive tradition that has dominated modern psychology.
757
 758 MILLER AND MOYERS

The development of MI parallels broader changes within the vations for change. In the early history of behavior therapy, Mer-
history of clinical psychology. As noted earlier it was Carl Rogers baum (1963; Merbaum & Southwell, 1965) verified that empathic
who pioneered the idea that psychotherapy can be studied system- reflections are a particularly strong form of verbal reinforcement
atically and its processes and outcomes should be subject to for specific kinds of client statements. Truax (1966) demonstrated
empirical verification and replication by others, now core assump- that Carl Rogers himself responded selectively to different types of
tions of clinical science. Hundreds of controlled trials of MI have client statements. Particular attention is given in MI to client
evaluated outcomes across a wide array of clinical problems. Other “change talk”— originally termed self-motivational statements
active lines of research have been documenting its therapeutic (Miller, 1983)—and a variety of specific methods (including em-
processes (now termed mechanisms) as well as methods and out- pathic reflection) are used to evoke and strengthen such speech.
comes of training for providers. Like Rogers’ own work, MI spans Addictive behaviors characteristically involve ambivalence be-
the current debate between “evidence-based” treatment methods tween immediate positive reinforcement and delayed adverse con-
and general factors in the practice of clinical psychology because sequences, a phenomenon that Eysenck (1976) termed the neurotic
its documented “active ingredients” include relational elements paradox. In MI the interviewer selectively explores ambivalence,
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

such as accurate empathy (Miller & Moyers, 2015; Norcross, eliciting the client’s own motivations for change while avoiding
This document is copyrighted by the American Psychological Association or one of its allied publishers.

2011). In this way research on MI is clarifying how such “non- directive/confrontational communications that evoke resistance
specific” factors can be specified and impact outcome across and psychological reactance (Brehm & Brehm, 1981; Patterson &
psychotherapies. Rogers’ work on therapeutic relationship has Forgatch, 1985).
similarly influenced practice and training in other contemporary Back at the University of New Mexico Miller and colleagues
evidence-based treatments such as dialectical behavior therapy began small randomized trials of MI, which they conceptualized as
(Linehan, 1993, 2015) and emotion-focused therapy (Greenberg & a motivational preparation for treatment. To their surprise, prob-
Watson, 1998, 2005). lem drinkers receiving a brief MI-based intervention (the “drink-
er’s check-up”) seldom sought further treatment but on average
Parallel Development of Motivational Interviewing and showed large reductions in alcohol use (Miller, Benefield, &
Tonigan, 1993; Miller, Sovereign, & Krege, 1988). In process
the Person-Centered Approach
analyses they found, as Rogers had predicted, that client “resis-
What was originally termed a nondirective approach in coun- tance” (as operationally defined by Chamberlain, Patterson, Reid,
seling and psychotherapy was derived not from theory but from Kavanagh, & Forgatch, 1984 and Patterson & Forgatch, 1985) was
clinical experience, Carl Rogers’ attempt to describe what he and associated with poorer outcomes and that a single therapist behav-
his colleagues had been learning and doing in practice (Braver, ior predicted both in-session resistance and subsequent client
Sandler, Hita, & Wheeler, 2016; Rogers, 1939, 1942). He regarded drinking: The more a therapist confronted, the more the client
his assertions as working hypotheses to be tested: If indeed spe- would be drinking 1 year later (Miller et al., 1993).
cific conditions during counseling predict change, then this rela- Subsequent collaboration with British psychologist Stephen
tionship should be observable and replicable by others. Rollnick resulted in the first textbook describing MI as a thera-
Like client-centered therapy, MI was derived not from any peutic method in its own right, contrasting strongly with the
preexisting theory but from experience in clinical practice (Moy- confrontational approaches popular in American addiction treat-
ers, 2004). The first description of MI emerged during Miller’s ment at the time (Miller & Rollnick, 1991). Rollnick contributed a
1982 sabbatical at the Hjellestad Clinic, an alcohol treatment focus on ambivalence as a key psychological dynamic whereby
facility near Bergen, Norway. He arrived with new findings from people considering change simultaneously want and do not want it.
a clinical trial showing large therapist effects in behavior therapy If a counselor argues for change, clients naturally respond with the
for alcohol problems and a strong predictive relationship between other side of their ambivalence by defending the status quo. This
counselor empathy and client outcomes across 2 years (Miller & might seem a harmless process, to act out the client’s ambivalence
Baca, 1983; Miller, Taylor, & West, 1980). He was discussing an (Engle & Arkowitz, 2005), except that people tend to be more
integration of behavior therapy with a person-centered approach in persuaded by their own than by others’ arguments (Bem, 1972).
regular meetings with the clinic’s psychologists, who asked him to Thus if one counsels in a way that causes a client to defend the
demonstrate his counseling style. The psychologists posed partic- status quo, the predictable outcome would be no change.
ular clinical problems they were experiencing, role-playing clients The influential transtheoretical model of change that was also
whom they had been treating. As Miller demonstrated his approach emerging in the 1980s emphasized a need for different clinical
the listeners stopped him often to ask good questions: “What are strategies depending on where clients are in the stages of change
you thinking now?” “Why did you ask that particular question?” (Prochaska & DiClemente, 1984). MI provided a clear example of
“From all the things that the client was saying, how did you decide an intervention particularly appropriate for clients who are initially
what to reflect?” In the process, they evoked a provisional set of less motivated for change—those in the precontemplation, con-
decision rules that he seemed to be using intuitively in practice, in templation, and preparation stages (DiClemente & Velasquez,
essence guiding the conversation so that it would be the client 2002). The “decisional balance” of pros and cons of change is a
rather than the counselor voicing the reasons for change. His reliable marker of transtheoretical stages, and MI has been shown
responses to these questions formed the basis for the original to alter that balance in clients’ speech (Amrhein, Miller, Yahne,
clinical description of MI (Miller, 1983). Palmer, & Fulcher, 2003; Gaume, Bertholet, Faouzi, Gmel, &
A defining difference of MI from nondirective counseling is the Daeppen, 2010; Glynn & Moyers, 2010).
interviewer’s intentional and strategic use of questions, reflections, It soon became apparent that ambivalence about change is a
affirmations, and summaries to strengthen the client’s own moti- common clinical issue across professions well beyond psychology.
 MOTIVATIONAL INTERVIEWING 759

In health care, for example, lifestyle behavior is a major determi- may be delivered (e.g., Mason et al., 2016; Naar-King & Safren,
nant of illness, recovery, longevity, and quality of life. Yet most 2017).
patients diagnosed with a chronic illness such as diabetes do not Simplicity. Perceived complexity is an obstacle to the adop-
make the changes needed to remain healthy (e.g., Kurth et al., tion of innovations. There is a deceptive simplicity to MI and to
2016). Thus MI found many applications in health care (Knight, client-centered counseling more generally. It looks easier than it is.
McGowan, Dickens, & Bundy, 2006; Rollnick, Miller, & Butler, Miller and Rollnick (2014) have described MI as “simple but not
2008), and its use has since spread into social work (Hohman, easy.”
2012), corrections (McMurran, 2009), dentistry (Carlisle, 2014), Observability. Readily observable results encourage adop-
coaching (Antiss & Passmore, 2016; Wu, Dai, Xiong, & Liu, tion. Practitioners can often see encouraging immediate changes in
2016), and education (Naar-King, Ernshaw, & Breckon, 2013; clients’ interpersonal response when shifting from a directive-
Snape & Atkinson, 2016). Subsequent editions of the MI text have persuasion stance to more MI-consistent practices (cf. Glynn &
therefore addressed change more generally, well beyond addic- Moyers, 2010; Patterson & Forgatch, 1985).
tions and no longer limited to behavior change (Miller & Rollnick, Trialability. Finally, adoption is also facilitated when an in-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

2013). This parallels the earlier progression of Carl Rogers’ novation can be tried out on a limited basis without making a
This document is copyrighted by the American Psychological Association or one of its allied publishers.

person-centered approach from individual counseling to many major commitment. Early in their collaboration Miller and Roll-
applications in other fields (Rogers, 1980). nick decided not to trademark, copyright, or otherwise attempt to
restrict the practice and training of MI. Detailed presentations of
the spirit and method of MI have been readily available in texts,
The Surprising Reach of Motivational Interviewing
counselor manuals, and video demonstrations. Practitioners can
As described in preceding text, the practice of MI has extended and do try it out without having to undergo training or certification.
far beyond its roots in clinical psychology. Many adoptions and A necessary consequence of the decision not to restrict practice
adaptations of MI have preceded empirical evidence of efficacy is a lack of any central quality control in delivery and training, a
within these applications, as is often the case in the diffusion of situation by no means limited to MI. Practitioners can “re-invent”
innovations (Rogers, 2003). MI texts have been published in 27 MI by changing and adapting it to their own context and style.
languages, and more than 3,000 professionals speaking at least 50 Reinvention is another condition that favors the diffusion of an
languages have received preparation as trainers through an inter- innovation (E. M. Rogers, 2003) but can create variability in
national motivational interviewing network of trainers (www delivery that complicates evaluation of its efficacy (Miller &
.motivationalinterviewing.org). From this subset of training alone, Rollnick, 2014).
a conservative estimate is that at least 15 million people worldwide
have already been recipients of MI (Miller & Rollnick, 2009). In Outcome Research
a recent national survey (Rieckmann, Abraham, & Bride, 2016)
two thirds of U.S. addiction treatment programs reported using MI. At present more than 500 controlled trials have been published
Training in MI has been implemented and even mandated for testing various applications of MI across a wide array of clinical
providers throughout entire state and national care systems. Carroll problems.1 Proliferating systematic reviews and meta-analyses
(2016) observed that “[t]here is no other empirically validated have supported (albeit not uniformly) the modest efficacy of MI in
therapy that has achieved this level of world-wide dissemination, addressing clinical problems including substance use (Jensen et al.,
including cognitive behavioral therapies or structured family ap- 2011; Kohler & Hofmann, 2015; Lundahl & Burke, 2009; Smed-
proaches” (p. 1153). All of this has occurred in response to slund et al., 2011; Vasilaki, Hosier, & Cox, 2006), smoking
demand, with virtually no centralized effort to advertise, market, or cessation (Heckman, Egleston, & Hofmann, 2010; Lindson-
promote MI. Hawley, Thompson, & Begh, 2015), weight loss (Armstrong et al.,
What may account for such broad dissemination of MI in 25 2011; Barnes & Ivezaj, 2015), eating disorders (Macdonald,
years since publication of the first text? In his masterful synthesis Hibbs, Corfield, & Treasure, 2012), diabetes (Chapman et al.,
of research in Diffusion of Innovations, Everett Rogers (2003) 2015; Ekong & Kavookjian, 2016), pediatric (Borrelli, Tooley, &
described five attributes that promote the adoption of new methods Scott-Sheldon, 2015; Cushing, Jensen, Miller, & Leffingwell,
or technologies. 2014; Gayes & Steele, 2014) and adult health behavior (Lundahl et
Relative advantage. MI directly addresses what is a very al., 2013; Martins & McNeil, 2009; McKenzie, Pierce, & Gunn,
common and often frustrating issue in practice: people’s reluctance 2015; O’Halloran et al., 2014; Rubak, Sandbaek, Lauritzen, &
to change despite advice to do so. Whereas many interventions Christensen, 2005), problem gambling (Yakovenko, Quigley,
presume readiness for action as a prerequisite, MI was designed Hemmelgarn, Hodgins, & Ronksley, 2015), and medication adher-
specifically to evoke and strengthen clients’ motivation for change. ence (Hamrin & Iennaco, 2016; Hill & Kavookjian, 2012).
Compatibility. Innovations tend to be adopted when they are Average effect sizes of MI, whether alone or in combination
compatible with other current practices. As discussed subse- with other treatments are in the small to medium range with wide
quently, MI is a complementary method that can be used in variability across studies. In multisite trials the efficacy of MI can
combination with various treatment procedures. It is not meant to vary by site (e.g., Ball et al., 2007). Large outcome differences
displace other practices except for those that may be incompatible across MI providers are typical even when counselors are trained
with a person-centered approach (such as the confrontational together, closely supervised, and following a therapist manual
methods that had been used in addiction treatment; White &
Miller, 2007). MI and a client-centered approach more generally 1
www.motivationalinterviewing.org/sites/default/files/controlled_trials_
can be a foundational clinical style within which other treatments with_mi.pdf
 760 MILLER AND MOYERS

(Project MATCH Research Group, 1998a). One meta-analysis effectiveness of MI focus on specific behaviors of interviewers
found that the use of a therapist manual predicted client outcomes, that are especially consistent with this approach (e.g., emphasizing
such that studies of MI using no manual reported double the effect autonomy, seeking collaboration, reflecting change talk) and that
size compared with studies in which MI was manual-guided quickly increase the probability of change talk (and decrease the
(Hettema et al., 2005). probability of sustain talk), which in turn predicts the likelihood of
Such variability of effect begs for explanation. Why would the subsequent change. Process research in this area has addressed
same treatment be effective for some studies, sites, and providers each of the links in this causal chain. Relatively good support is
and not others? One obvious answer is that it is not actually “the evident for the link between therapist behaviors and client lan-
same” treatment. Unlike medications, psychosocial treatments are guage during MI sessions. Specifically, better MI skills predictably
inseparable from the person who provides them. Therapist empa- increase the frequency and strength of client change talk in ses-
thy, for example, can exert a large effect on client outcomes with sions, whereas proscribed practices (such as confrontation, giving
behavioral treatments for which it is not an hypothesized mecha- advice without permission, and low empathy) increase sustain talk
nism of change (e.g., Miller et al., 1980). Therapist fidelity in (Borsari et al., 2015; Gaume et al., 2010; Hodgins, Ching, &
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

providing a treatment can be highly variable even in controlled McEwen, 2009; Magill et al., 2016). Further, the link between
This document is copyrighted by the American Psychological Association or one of its allied publishers.

trials, and this may be particularly true for a complex relationally client language and outcomes is promising, indicating that clients
based therapy like MI (Miller & Rollnick, 2014). Outcome vari- who offer relatively more change talk than sustain talk during
ability among providers within a treatment method can be much sessions are more likely to improve, whereas those who offer more
larger than differences between specific bona fide treatments. One sustain talk are not (Campbell, Adamson, & Carter, 2010; Gaume,
contributing factor found to predict outcome differences among Bertholet, Faouzi, Gmel, & Daeppen, 2013; Hodgins et al., 2009;
therapists is their level of humanistic “Rogerian” skills (Miller et Morgenstern et al., 2012; Walker, Stephens, Rowland, & Roffman,
al., 1980; Valle, 1981; Zuroff, Kelly, Leybman, Blatt, & 2011). Finally, the full causal chain between therapist behaviors,
Wampold, 2010). The limitations of providing and evaluating client language, and behavioral outcomes has been replicated in
manual-guided brand-name therapies is a core issue in the heated four different laboratories (Barnett et al., 2014; Moyers, Martin,
debate between specific “evidence-based” treatments versus “non- Houck, Christopher, & Tonigan, 2009; Pirlott, Kisbu-Sakarya,
specific” relational factors (Miller & Moyers, 2015). MI occupies
Defrancesco, Elliot, & Mackinnon, 2012; Vader, Walters, Prabhu,
an interesting middle ground in this discussion because its putative
Houck, & Field, 2010) indicating a level of support for the putative
mechanisms overlap with what are often regarded to be nonspe-
mechanisms of this treatment that is at least as strong as for other
cific factors.
psychotherapies. The evidence indicates that interviewers will hear
more change talk and less sustain talk if they avoid giving advice
Process Research: The Search for Active Ingredients and information to ambivalent clients and instead focus on reflect-
ing empathically the client’s own reasons for change. This shift in
Beyond the question of whether a treatment method works are
client language is, in turn, associated with greater subsequent
the deeper issues of its mechanisms of action—the specific pro-
behavior change.
cesses by which it evokes positive change. Miller and Rose (2009)
Although the empirical foundation for causal mechanisms in MI
proposed that at least two aspects of MI may account for its
effectiveness: a relational component and a technical component. is robust, all but two of the studies investigating this question to
These elements mirror the larger debate in the psychotherapy date have been correlational in nature. Observed correlations be-
literature about relative contributions of the helping relationship tween change talk and improved outcomes could be explained by
versus more specific technical procedures (Wampold & Imel, positing that an unmeasured mechanism of action such as client
2015). In MI, both spirit and technique are privileged and both are motivation, awareness of discrepancies between actions and val-
hypothesized to be important to the full impact of the intervention. ues, diminished resistance, or enhanced perception of autonomy
Treatment procedures have been well specified for both relational may be influencing both of these events. Experimental study of
and technical components of MI (Hardcastle, Fortier, Blake, & proposed active mechanisms in MI is an important next step,
Hagger, 2016). beyond simply showing a correlation between the presence of a
The relational or “spirit” component, as noted above, rests on variable and a subsequent change in behavior. With regard to client
the client-centered approach developed by Carl Rogers with par- language, current experimental evidence is encouraging. Using an
ticular emphasis on accurate empathy, respect for client autonomy, ABAB design Glynn and Moyers (2010) demonstrated that the
and egalitarian collaboration in the relationship. The technical frequency of client change talk can be substantially increased by
component of MI pays particular attention to certain elements of the interviewer’s intentional use of MI strategies and then reversed
client language during the interview. Specifically, client change to baseline within a single session. A randomized controlled study
talk is thought to increase the probability of a favorable outcome further demonstrated that frontline addiction counselors who were
when it occurs spontaneously in the context of an empathic con- trained in enriched strategies to intentionally influence language
versation. Conversely, language in favor of keeping things as they had less sustain talk from their clients than those trained in generic
are (called “sustain talk”) helps clients talk themselves into not MI skills (Moyers, Houck, Glynn, Hallgren, & Manual, in press)
changing if they hear themselves saying it during an interview indicating that clinicians can learn to intentionally influence cli-
(Miller & Rollnick, 2004). ents’ in-session speech.
“Evidence-based” therapies often do not seem to work for the In sum, research identifying specific processes that account for
hypothesized reasons (Longabaugh, Magill, Morgenstern, & the effectiveness of MI largely supports its theoretical model,
Huebner, 2013; Longabaugh & Wirtz, 2001). Explanations for the although contradictory findings have also been reported. Process
 MOTIVATIONAL INTERVIEWING 761

research in this area provides potentially important information Sorensen, Selzer, & Brigham, 2006; Schwalbe, Oh, & Zweben,
about how MI should be most effectively practiced and trained. 2014). Again paralleling other types of psychotherapy (Webb,
Derubeis, & Barber, 2010), some studies find that the skill level of
an MI practitioner after training predicts client outcomes (Cope-
Integrating MI With Other Treatment Methods
land, McNamara, Kelson, & Simpson, 2015; Gaume, Gmel,
In addition to being used as a “stand-alone” treatment, MI has Faouzi, & Daeppen, 2009; Martino, Ball, Nich, Frankforter, &
had a second life as an intervention that is combined with other Carroll, 2008; Thrasher et al., 2006), whereas others find no such
approaches, most commonly cognitive and behavioral interven- relationship (Martino et al., 2016). These linkage findings offer
tions (Naar-King & Safren, 2017). The rationale for this typically optimism that practitioners can learn this complex clinical method
involves using MI to focus on increasing motivation to make and that when done well it can be expected to improve client
changes (the “whether” and “why” of change), which are then outcomes. Demonstrating a clear causal chain between clinician
addressed by more structured and skill-oriented procedures (the training, improved fidelity, and better client outcomes awaits train-
“how” of change). Such combined treatments have typically fo- ing trials powered to evaluate training, process, and outcome
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

cused on specific problems such as generalized anxiety and de- measures within the same study.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

pression (Westra, Constantino, & Antony, 2016), addictions It remains to be determined what providers in an organization
(Longabaugh, Zweben, LoCastro, & Miller, 2005), obsessive– are the best candidates to learn and deliver MI, although it is clear
compulsive disorders (Meyer et al., 2010), medication adherence that not everyone can do so. Even when training is uniform,
in the treatment of HIV (Parsons, Golub, Rosof, & Holder, 2007), variability in trainees’ MI skills is the norm rather than the excep-
intimate partner violence (Woodin, 2015), and eating disorders tion (Imel et al., 2014). In both research and practice it makes
(Cassin & Geller, 2015). Hybrid treatments of this kind often yield sense to train and supervise providers up to competence criteria
encouraging outcomes relative to treatment as usual or to the other rather than relying on a fixed dose of instruction (Martino,
active treatment alone (Hettema, Steele, & Miller, 2005), although Canning-Ball, Carroll, & Rounsaville, 2011; Miller & Rollnick,
concrete procedures are seldom specified for choosing between the 2014).
two approaches when clinical choice points are reached (Moyers & It is a reasonable question whether it is cost-effective to retrain
Houck, 2011). With some exceptions (e.g., Westra, Constantino, & staff in a complex empirically supported treatment (Carroll, 2016;
Antony, 2016), these treatments front-load or add MI but do not Hall et al., 2016), particularly when treatment-as-usual controls
truly integrate it into the partner intervention, albeit sometimes may fare as well (Miller & Moyers, 2015). Substantial resources
using the relational and humanistic elements of the MI treatment as are needed to establish and maintain therapist skills in a complex
a foundation for the entire course of treatment. In essence MI intervention such as MI. Resources might be better spent in train-
serves as a framework for incorporating attention to “common” ing the next generation of providers in evidence-based practices
factors into longer and more structured treatments (Longabaugh et from the beginning and in hiring providers who can already
al., 2005). Rather than just adding MI to another treatment, Van- demonstrate the requisite clinical skills.
steenkiste and colleagues (2012) focused on truly integrating MI Alternatively, training can be focused on providers who are
with self-determination theory. Because of the emphasis on client better candidates for learning a particular approach. Neither expe-
autonomy support, certain elements of MI were more prominent rience nor professional background predict who will acquire better
than they might otherwise be, but the larger framework of each MI skills, and some studies even indicate that greater clinician
method was preserved. experience bodes poorly for learning MI (Dunn et al., 2015),
Hybrid treatments are rarely compared to an MI-only condition. perhaps because there is more to unlearn. It has been our experi-
This may reflect an assumption that a brief, motivation-focused ence that clinicians prescreened for empathic skill learn MI more
intervention would be insufficient to initiate change, although readily (Miller, Moyers, Arciniega, Ernst, & Forcehimes, 2005), a
exactly such outcomes are not unusual in the treatment of sub- far better predictor than personality styles, theoretical orientation,
stance use disorders, where MI informed interventions have usu- or educational achievement (Miller et al., 2004). Furthermore,
ally performed as well as more extensive treatments (e.g., Project providers’ baseline skill in empathic listening predicts their level
MATCH Research Group, 1998b; UKATT Research Team, 2005). of empathy in actual treatment sessions as long as a year later
(Moyers & Miller, 2013) as well as their clients’ outcomes (Moy-
ers et al., in press).
Training Research
Although behavioral demonstration of requisite skill level is
When there is evidence for the efficacy of a treatment method sensibly used in screening and hiring for various occupations, it
and for the mechanisms by which it works, a remaining question has seldom been implemented when selecting candidates to be
is how best to help clinicians develop and maintain fidelity in behavioral health providers. Therapist skill in accurate empathy is
delivering it. MI is a method that most (albeit not all) clinicians can observable, reliably measurable, and predicts client outcomes
learn with the help of structured training and enrichments such as (Moyers & Miller, 2013). It is therefore possible to assess em-
coaching and feedback on the basis of work samples (Madson, pathic skills as a hiring criterion for clinical providers, such as
Loignon, & Lane, 2009; Miller, Yahne, Moyers, Martinez, & those who will be expected to deliver MI. We used a behavioral
Pirritano, 2004). As with most psychosocial interventions, practi- practice sample of empathic skill in choosing therapists for the
tioner MI skills gained from a one-time workshop are modest at COMBINE Study (Miller et al., 2005). Despite a reduced range
best and tend to decay to baseline within a year, but gains are (we hired only candidates above a threshold for good empathic
stronger and are sustained longer if ongoing enrichments are skills), therapist empathy measured from treatment sessions still
available (Hall, Staiger, Simpson, Best, & Lubman, 2016; Miller, predicted client drinking at the end of treatment (Moyers et al., in
 762 MILLER AND MOYERS

press). Given the high cost of training and retraining providers, Neufeldt, 1994). Psychological practice still proceeds largely un-
prescreening for humanistic counseling skills including empathy observed behind closed doors without meaningful feedback to
may prove be a cost-effective criterion when hiring providers in promote learning (Lambert, Harmon, Slade, Whipple, & Hawkins,
agencies where MI is offered. 2005). Carl Rogers brought psychotherapy out from behind closed
doors with an open-minded and undefensive curiosity to discover
what it is about practice that actually helps clients change. Re-
Discussion
search on MI has taken a few more steps on that journey.
Motivational interviewing has continued the clinical science
tradition pioneered over 70 years go by Carl Rogers, that psycho-
therapy processes are reliably observable and therapeutic asser- References
tions should be tested and replicable (Rogers, 1939). Research on Amrhein, P. C., Miller, W. R., Yahne, C. E., Palmer, M., & Fulcher, L.
MI has also provided further support for hypotheses posed by (2003). Client commitment language during motivational interviewing
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

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