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Training in Motivational Interviewing as a Best Training Practice in
Pediatric Psychology: Relationship to Core Competencies
Stephen R. Gillaspy
and Catrina C. Litzenburg
University of Oklahoma
Thad R. Leffingwell
Oklahoma State University
Mary Beth Miller
Oklahoma State University and Brown University
This article describes an innovative Motivational Interviewing (MI) training that is
included in the current training program for psychology interns and fellows (trainees)
at 1 institution and outlines how this training experience aligns with multiple core
training competencies for pediatric psychologists. MI is an evidence-based approach to
behavior change counseling that is efficacious in motivating change in many health-risk
behaviors. The training module adds systematic practice with simulated patients and
objective feedback regarding adherence and fidelity to MI principles and strategies to
traditional didactics. This state-of-the-art training is particularly beneficial to our
pediatric psychology trainees, as it impacts treatment interventions with their patients
and families and maps onto several of the new pediatric psychology competencies.
Specific examples of training components are provided and demonstrate how the MI
training module aligns with the pediatric psychology competencies in several clusters:
crosscutting knowledge competencies in pediatric psychology, interpersonal, profes-
sionalism, and application. MI training is well-suited to be included in competency-
based training in pediatric psychology.
Keywords:
competencies, motivational interviewing, pediatric psychology, training
The Society of Pediatric Psychology recently
proposed and defined six competencies that are
integral to training in pediatric psychology: sci-
ence, professionalism, interpersonal skills, ap-
plication of science, education, and systemic
approach, in addition to cross-cutting knowl-
edge (Palermo et al., 2014). Training in Moti-
vational Interviewing (MI) is particularly suited
to meeting these competencies and has been
successfully integrated into our pediatric train-
ing program for psychology interns and fellows
(trainees). Over the past seven years, this MI
training module has progressed from one to two
hours of didactic lectures; to a daylong work-
shop with live demonstrations of MI; to the
current module, which adds systematic practice
with simulated patients and objective feedback
regarding adherence and fidelity to MI princi-
ples and strategies to traditional didactics. The
current article describes this innovative MI
training and outlines how this experience aligns
with multiple core competencies for pediatric
psychologists.
Why Motivational Interviewing?
Obesity, tobacco use, and alcohol use have
been identified as significant problems contrib-
uting to poor health outcomes among pediatric
populations. Pediatric psychologists need to be
prepared to address these health behaviors in
primary care and specialty medical settings. The
Stephen R. Gillaspy and Catrina C. Litzenburg, Depart-
ment of Pediatrics, University of Oklahoma Health Sciences
Center, College of Medicine; Thad R. Leffingwell, Depart-
ment of Psychology, Oklahoma State University; Mary
Beth Miller, Department of Psychology, Oklahoma State
University and Department of Psychiatry and Human Be-
havior, Alpert Medical School of Brown University.
Correspondence concerning this article should be ad-
dressed to Stephen R. Gillaspy, Section of General & Com-
munity Pediatrics, University of Oklahoma Health Sciences
Center, College of Medicine, Department of Pediatrics,
1200 Children’s Avenue, Suite 12400, Oklahoma City, OK
73104. E-mail: Stephen-Gillaspy@ouhsc.edu
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Clinical Practice in Pediatric Psychology © 2015 American Psychological Association
2015, Vol. 3, No. 3, 225–232 2169-4826/15/$12.00 http://dx.doi.org/10.1037/cpp0000106
225
American Academy of Pediatrics (AAP) has
issued position statements recommending that
pediatricians address obesity, tobacco, and al-
cohol use with patients (Barlow, 2007; Com-
mittee on Environmental Health, Committee on
Substance Abuse, Committee on Adolescence,
& Committee on Native American Child, 2009;
Committee on Substance Abuse, 2010). Brief
interventions utilizing the style of MI have been
featured in each of these policy recommenda-
tions as an evidence-based approach to address-
ing these health behaviors. The MI style is a
patient-centered approach that utilizes specific
interpersonal communication strategies to guide
patients toward an intrinsically motived and
committed decision to change health behaviors
while avoiding unsolicited advice, direct per-
suasion, or confrontation (Miller & Rollnick,
2013; Leffingwell, 2004). Although the core of
the MI style is a patient-centered approach uti-
lizing reflective listening and empathy within a
collaborative relationship, the style also in-
cludes a number of specific strategies and prin-
ciples.
MI has been found in adults to reduce sub-
stance misuse disorders (e.g., smoking, alcohol,
drug dependence) and enhance health behaviors
(e.g., exercise, diet; Burke, Arkowitz, & Men-
chola, 2003; Hettema, Steele, & Miller, 2005)
and in adolescents is effective addressing sub-
stance misuse (Jensen et al., 2011) and other
health behaviors (Cushing et al., 2014). The
opportunities for the pediatric psychologist to
utilize MI are numerous, including issues of
engagement and adherence to medical regimens
(e.g., diabetes, vaccinations, and transplant medi-
cations), and health-related lifestyle changes (diet
and physical activity).
Both theory and research indicate structured
practice with ongoing supervision and training
are integral to MI proficiency (Barwick et al.,
2012; Fu et al., 2015; Madson, Loignon, &
Lane, 2009; Miller & Rollnick, 2013), although
the importance of continued training may vary
based on baseline performance (Martino et al.,
2011). The majority of MI training programs
focus primarily on didactics and introductory
MI skills practice (Barwick et al., 2012; Madson
et al., 2009). The long-term impact of such
trainings is difficult to determine, as studies
vary considerably in methodology (Barwick et
al., 2012). However, in a randomized controlled
trial, Miller and colleagues (2004) demonstrated
that including feedback and individual coaching
to a more traditional workshop enhanced clini-
cians’ maintenance of clinical proficiency at 4,
8, and 12 months posttraining. Therefore, the
current training module incorporated MI coding
of structured practice sessions in order to pro-
vide trainees with feedback on their use of MI
skills and suggested areas for continued im-
provement.
MI Training Module
Training began with a 4-hr module aimed to
enhance psychology trainees’ understanding
and use of brief motivational interventions.
Content includes the evidence-base for MI in
medical settings, fundamental concepts of MI
theory and practice (including both global skills
and specific behaviors), and video examples of
MI-consistent and MI-inconsistent patient en-
counters. Trainees were provided with a copy of
workshop slides, transcripts of video examples,
a list of skills and behaviors that would be
coded during the simulated encounters, relevant
policy statements from the AAP, and several
peer-reviewed articles regarding the efficacy
and implementation of MI in health care set-
tings.
Training also included live practice using MI
and personalized feedback on MI adherence
during the simulated practice encounters. Be-
fore and immediately after the workshop, train-
ees participated in a brief (ⱕ10 minutes) en-
counter with a professionally trained simulated
patient presenting with one of three medical
concerns, which are randomly assigned: child-
hood ear infections secondary to parental to-
bacco use, childhood obesity, or adolescent al-
cohol abuse. Simulated patients were given
limited information regarding the purpose of the
encounter in order to prevent expectations from
influencing their behavior. They were, however,
instructed to be ambivalent regarding the target
behavior (i.e., neither completely resistant nor
highly motivated to change).
After the encounter, trainees were provided
with detailed personalized feedback on MI per-
formance. Feedback included adherence based
on the MI Treatment Integrity (MITI) coding
scheme (Moyers et al., 2010) and self-report
measures completed by the trainee, the simu-
lated patient, and the trained observer. Within
the MITI code, cut-points for both beginning
226 GILLASPY, LITZENBURG, LEFFINGWELL, AND MILLER
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
proficiency and expert competence were pro-
vided. Beginning proficiency is indicated by
global MI ratings above 3.5, 90% MI adher-
ence, at least 50% open (vs. closed) questions,
at least 40% complex (vs. simple) reflections, a
1:1 reflection to question ratio, and allowing the
patient’s responses to constitute at least 40% of
the conversation. Competency is indicated by
global ratings above 4.0, 100% MI adherence,
at least 70% open questions, at least 50% com-
plex reflections, a 2:1 reflection to question ra-
tio, and patients’ talking at least 50% of the
time.
Advanced doctoral students with training in
the MITI system reviewed and coded the pre-
and posttraining encounters. They then pro-
vided trainees with detailed written feedback
1
regarding their adherence to MI in each encoun-
ter via electronic mail. Written feedback in-
cluded adherence to the five global MI skills
and use of specific MI behaviors (e.g., open
questions, complex reflections) in comparison
with proficiency and competency standards.
The global skills are intended to capture the
proscribed “spirit” or attitude of the MI conver-
sation: Evocation (vs. imparting or inserting
knowledge); Collaboration (vs. one-up, author-
itarian relationship); Autonomy-supportive (vs.
controlling); Direction (vs. avoidant, dis-
tracted); and Empathy (vs. dismissive, disre-
spectful).
Feedback also included self-ratings of behav-
ior change counseling skill (Lane et al., 2005)in
comparison with simulated patients’ and obser-
vational coders’ ratings of their performance.
Trainees received written positive reinforce-
ment for MI-consistent behaviors and were pro-
vided with suggestions for strategies to use in
future practice. Trainees also had the opportu-
nity to view additional coder comments as
pop-up notes within the video recording itself.
MI Training Module in Relation to
Pediatric Psychology Competencies
MI is well-suited to be included in compe-
tency-based training in pediatric psychology,
relating to cross-cutting knowledge competen-
cies in pediatric psychology, interpersonal
skills, professionalism, and application of sci-
ence (see Table 1). To further illustrate how this
training aligns with specific competencies, one
trainee’s practice encounters with simulated pa-
tients targeting childhood obesity are described
below. The trainee completed the encounter be-
fore (pretraining) and immediately after (post-
training) the didactic portion of the MI training.
The trainee was given the following instruc-
tions:
You are seeing Mary Jones, the single parent of Brandy
Jones, an 8 year-old female. They are visiting the
Pediatric clinic today for Brandy’s yearly well-child
visit. The encounter will begin at a transition point
during the clinical visit. The physician has completed
the evaluation, including charting of Brandy’s BMI
(96.3 percentile), and asked you to speak with Ms.
Jones about Brandy’s weight.
Cross-Cutting Knowledge
The MI training module allows psychology
trainees to apply knowledge of concepts in clin-
ical child psychology (e.g., family systems) and
pediatric psychology (e.g., common barriers to
maintaining healthy weight). Within the MI
training module, trainees learn about the evi-
dence-base of MI interventions. They are pre-
sented with meta-analyses reporting effect sizes
and various practice guidelines that recommend
use of MI (Barlow, 2007; Committee on Envi-
ronmental Health, Committee on Substance
Abuse, Committee on Adolescence, & Commit-
tee on Native American Child, 2009; Commit-
tee on Substance Abuse, 2010). Completing
training in MI provides trainees the option of
choosing an empirically supported intervention
in instances when they may otherwise rely on
skills that are less effective (e.g., nondirective
empathic listening). This is particularly trouble-
some within a fast-paced, outcome-oriented
health care environment in which pediatric psy-
chologists work.
Psychology trainees are informed that at this
institution pediatric medical residents have
completed a similar training as part of a Resi-
dency Training Grant awarded to the first author
by the Health Resources and Services Admin-
istration (HRSA) but are reminded that, as ex-
perts in human behavior, psychologists are par-
ticularly well-suited to implement health
behavior change interventions. In the encounter,
a physician has already determined that Bran-
dy’s weight is a concern and identified a need
for behavioral health intervention. This scenario
1
Sample feedback forms are available from the first
author or at http://tinyurl.com/MIlearnerfeedback.
227MOTIVATIONAL INTERVIEWING BEST TRAINING PRACTICE
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
is common in pediatric psychology settings and
requires trainees to understand the roles of other
disciplines and interprofessional teams, which
prepares them for clinical practice because pe-
diatric psychologists do not work in isolation.
Interpersonal
Although the encounter described above is
common in pediatric psychology, these encoun-
ters may quickly become difficult, uncomfort-
able, and even damaging to the relationship
between not only the patient/family and psy-
chologist, but also the interprofessional team as
a whole. The MI training module provides psy-
chology trainees with specific instruction on
how to facilitate effective communication that
is tailored to the needs and understanding of all
parties involved. This goal is accomplished via
not only instruction on the microskills (or spe-
cific behaviors) of MI, but also the global rat-
ings or dimensions that are consistent with an
MI approach (i.e., being collaborative, evoca-
tive, autonomy supportive, directive, and em-
pathic). Trainees learn and demonstrate how to
“roll with resistance” rather than using a con-
frontational approach. This approach allows for
maximum preservation of the relationship while
also being evidence-based. Unlike with more
confrontational approaches, brief interventions
utilizing the MI approach are likely to
strengthen working relationships between pa-
tients and clinical staff.
Before the encounter the simulated patient
(Ms. Jones) was given the following instruc-
tions: “You are generally cooperative and open,
but may become defensive if you feel like you
are being told what to do or being caused to feel
guilt or shame about Brandy’s weight and lack
of regular exercise.” During the pretraining en-
counter (i.e., before the didactic portion of MI
training), the trainee began the encounter by
saying, “I understand Dr. Smith is concerned
Table 1
Pediatric Psychology Competencies Associated With Motivational Interviewing Training Module
Crosscutting
knowledge
1.1 Values and understands the scientific foundation underlying the practice of pediatric psychology
1.8 Understands the roles of other disciplines in health service delivery systems
Professionalism
3.1.A Exhibits professionalism in interactions with patients, research participants, and their families
3.2.A Provides clinical care to children and families, implementing appropriate personal boundaries
3.3.A Works effectively with colleagues from other disciplines to maintain a climate of mutual
respect and shared values
3.1.B Works effectively with diverse patients and families, as well as diverse professionals in
providing coordinated care
Interpersonal
4.1.A Uses and facilitates accurate, clear, and effective communication with and between patients,
their families, other health-care professionals, community institutions, and systems involving
the patient
4.1.B Supports a team approach to the maintenance and promotion of health and treatment of disease
4.2.B Develops and maintains relationships with patients, their families, other professionals,
communities, and other systems involving patients
4.3.B Effectively manages challenging relationships and interactions
Application
5.1.A Applies the concept and value of evidence-based practice and its role in scientific and applied
psychology
5.3.C Implements evidence-based wellness, health promotion, and prevention interventions appropriate
to the health concern
5.1.D Provides consultative/liaison services to health-care professionals across disciplines and systems
related to health and behavior
5.2.D Translated and communicates relevant clinical findings as they bear on health-care consultation/
liaison questions
Note. From “Recommendations for Training in Pediatric Psychology: Defining Core Competencies Across Training
Levels,” by T. M. Palermo et al., 2014, Journal of Pediatric Psychology, 39, pp. 969, 972, 974, 976. Copyright 2014 by
Oxford University Press. Reprinted with permission.
228 GILLASPY, LITZENBURG, LEFFINGWELL, AND MILLER
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
about Brandy’s weight. Let me share some
ideas of things you can do to help with that.”
This response was counter to the MI approach
and was met with defensiveness and frustration
on the part of the simulated patient. Similarly,
the psychology trainee spent 72% of the en-
counter time talking and focused on the physi-
cian’s reasons for addressing Brandy’s weight,
rather than evoking the parent’s concerns or
reasons for change.
During the posttraining encounter, when the
trainee has learned to demonstrate respect or
autonomy and desire for collaboration immedi-
ately, the trainee began the encounter with, “I
understand you and Dr. Smith briefly discussed
Brandy’s BMI. Would it be OK if we spent a
little time today visiting about Brandy’s
weight?” The psychology trainee spent 58% of
the encounter time talking and asked open-
ended questions to elicit how Ms. Jones thinks
and feels about Brandy’s weight while also ac-
knowledging challenges to behavior changes
she faces. This psychology trainee’s demonstra-
tion of increased competence in MI skills illus-
trates improved ability to navigate conversa-
tions about behavior change, which is a primary
component of work as a pediatric psychologist.
Professionalism
As a patient-centered approach, the spirit of
MI is explicitly one of respect and cultural
sensitivity. By participating in the MI training
module, trainees learn a way of being with
people that allows psychologists to serve as
models of professionalism for other disciplines
within interprofessional teams. Psychology
trainees learn that evoking the patient’s own
values and reasons for change prevents the im-
posing of the trainee’s values on the patient,
which is an important component of profession-
alism.
During the previously described pretraining
encounter, the trainee stated, “I know it must be
important to you as a mother that Brandy is at a
healthy weight.” This statement, while likely
true, is not consistent with an MI approach. It is
presumptive and lacks respect for Ms. Jones’
perspective. Conversely, during the posttraining
encounter, the trainee asked Ms. Jones a scaled
question: “Ona1to10scale, how important is
it to you today to get Brandy’s weight under
control?” In response to the trainee’s follow-up
question—“Why did you say a 6 and not a
3?”—Ms. Jones offered her sense of responsi-
bility as a mother as a consideration. The trainee
then demonstrated further curiosity by asking,
“Why else are you a 6 and not a 3?” Ms. Jones
then discussed her concerns regarding Brandy’s
increased risk of negative weight-related health
effects as an African American female. This
exchange allowed the trainee to gather a lot of
useful information that likely would not have
otherwise been available. The trainee would
then have the opportunity to share this informa-
tion, using Ms. Jones’ own words, with the
other members of the interprofessional team.
These are skills that psychology trainees will
apply across settings and populations.
Application
The MI training module closely relates to the
application cluster, as it requires psychology
trainees to demonstrate fidelity to MI via en-
counters that are videotaped and coded. The
feedback provided to trainees illustrates how
they are taught to use skills that are consistent
with MI, but also to be flexible in implementing
those skills. For example, the trainee discussed
earlier received feedback that s/he asked nine
questions during the encounter, 60% of which
were open questions and the “best example”
being, “How did you make the decision to
maintain a healthy weight for Brandy in the
past?” A second trainee also demonstrated be-
ginning proficiency in using open-ended ques-
tions (50% to 70%), but discussed completely
different values with Ms. Jones than the first
trainee. Both trainees demonstrated fidelity to
an evidence-based intervention (MI), but did so
in a flexible manner.
Innovation
The MI training module utilizes the Clinical
Skills Education and Testing Center (CSETC).
The CSETC is a state-of-the art facility that
features a suite of training exam rooms
equipped with audio and video observing and
recording equipment, as well as simulated pa-
tients demonstrating the most common health
behavior targets (obesity, tobacco use, binge
drinking, or other behavioral health issues).
This facility allows trainees to practice the MI
style in a setting very similar to the real-life
229MOTIVATIONAL INTERVIEWING BEST TRAINING PRACTICE
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
clinical setting. The technology of the CSETC
also allows for high-quality feedback to be pro-
vided via coding of recorded interactions. This
program makes innovative use of the availabil-
ity of the Motivational Interviewing Treatment
Integrity (MITI) coding system, a psychometri-
cally sound observational coding system for
evaluating fidelity to the MI style. The MITI has
been found to be a reliable and valid measure of
MI competency, and is sensitive to changes
resulting from training (Moyers et al., 2005).
The MITI is highly useful as a training tool
because the outputs of the coding provide very
specific feedback about well-specified behav-
iors including aspects of the “spirit” of MI (evo-
cation, collaboration, autonomy/support, direc-
tion, and empathy) as well as the use of specific
strategies by the interviewer (including open-
ended questions and reflections). This feedback
is useful to a trainee in making attempts to
modify their behavior over the course of multi-
ple trials to demonstrate greater competence
with the MI style.
Recommendations
The MI training described above is the result
of several years of training and modifications
aimed to better meet the needs of our trainees.
We recognize that use of the CSETC and its
resources (e.g., simulated patients, videotaping)
is unique and may not be available to other
training sites. Nevertheless, we propose that
implementing an MI training module that sim-
ilarly adheres to the core competencies for pe-
diatric psychologists is feasible at any training
site. We consider the following components es-
sential to any MI training module.
First, to achieve the cross-cutting knowledge
competency, trainings must include presenta-
tion of the evidence-base for MI along with
presentation of relevant practice guidelines.
Second, emphasize the role of pediatric psy-
chologists within interprofessional teams. For
example, although MI training is also recom-
mended for our physician colleagues, pediatric
psychologists are particularly well-suited to
successfully implement MI techniques because
we are behavioral health specialists. Third,
stress MI as not only an efficacious behavior-
change technique, but also as an interpersonal
strategy that fosters professionalism. This may
be accomplished by focusing on the global
skills of MI. Fourth, provide opportunity for
trainees to practice MI skills. This may be done
in varying degrees of real-world application.
For example, trainees may engage in practice
with other trainees or presenters who may take
on the role of patient/caregiver. We are in the
process of evaluating the efficacy of our MI
training module in its current iteration; how-
ever, we consider opportunity to practice skills
learned during traditional didactics to be vital to
achieving the application competency. Fifth,
provide trainees with feedback on their applica-
tion of MI skills. Again, this does not require
resources akin to those of the CSETC, but may
be accomplished by providing live MITI coding
either by a trained coder or the trainees them-
selves. The purpose of providing feedback is
not necessarily for coders to demonstrate fidel-
ity to the coding system, which requires exten-
sive training, but for trainees to obtain concrete
examples of how they were/were not faithful to
the spirit of MI.
In addition to defining competencies integral
to training in pediatric psychology, the Society
of Pediatric Psychology Task Force (Palermo et
al., 2014) defined behavioral anchors based on
three developmental/training periods: (a) early
graduate training or readiness for practicum; (b)
end of graduate training or readiness for intern-
ship; and (c) end of internship/ postdoctoral
fellowship or readiness for entry to practice.
Although we believe that trainees should re-
ceive MI training in graduate school, we think
the training module described is best suited at
the internship/fellowship level. To continue to
improve one’s MI skills and develop compe-
tency, there must be the opportunity to fre-
quently use the skills and receive feedback. As
clinical training is the primary focus of intern-
ship and fellowship, the current training module
appears most appropriate at this time.
In the current MI training module we did not
adjust or modify the training based on baseline
performance as suggested by Martino and col-
leagues (2011). Rather, we believe the person-
alized feedback trainees receive based on com-
pletion of the pre- and post-practice encounters
with standardized patients serves to represent a
measure of their baseline performance. Such
personalized feedback should provide the level
of proficiency of MI skills and highlight areas
need for improvement. Ideally, this feedback
should be reviewed with the trainee’s supervisor
230 GILLASPY, LITZENBURG, LEFFINGWELL, AND MILLER
This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
so that training plans can be adjusted to ensure
further development of MI skills. In the future
as MI training becomes more standard in grad-
uate school and trainees present to internship
and fellowship with more extensive MI experi-
ence, our current training model may need to be
modified to account for a higher baseline per-
formance.
Conclusions
MI is an evidence-based approach to behav-
ior change counseling that is effective in moti-
vating change in many health-risk behaviors.
Given the numerous opportunities for applica-
tion and strong evidence base with common
clinical problems, competency in MI is one skill
every pediatric psychologist should have in
their “clinical tool box.” Not only is MI an
evidence-based approach that can be used to
benefit treatment interventions with patients and
families, the training module also maps onto
several of the new pediatric psychology compe-
tencies. Specifically, the module relates to
cross-cutting knowledge competencies in pedi-
atric psychology, interpersonal, professional-
ism, and application. Finally, the training mod-
ule takes advantage of innovative technology
through the use of a state-of-the-art clinical
skills training center, a resource that should be
more frequently utilized in pediatric psychology
training.
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Received November 30, 2014
Revision received May 20, 2015
Accepted May 24, 2015 䡲
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