Training in motivational interviewing: A systematic review

Abstract

Motivational interviewing (MI), an evidence-based counseling approach, has received much recognition from a wide variety of health care professionals. Because of the rising interest in MI, there is increasing demand for training in this counseling approach. The MI training community has answered this call and as a result placed much emphasis on studying the MI training process. The purpose of this article is to provide a systematic review of the published research on MI training. Our goal is to provide a consolidated account of MI trainings outlining the populations receiving training, methods used, and training outcomes. We also identify which aspects of the (W. R. Miller & T. B. Moyers, 2006) eight stages of learning MI each study addressed. Recommendations for advancing the MI training research are highlighted.

Full text

Regular article
Training in motivational interviewing: A systematic review
Michael B. Madson, (Ph.D.)
a,
⁎, Andrew C. Loignon, (B.A.)
a
, Claire Lane, (Ph.D.)
b
a
University of Southern Mississippi, Hattiesburg, MS, USA
b
Cardiff University, Cardiff, UK
Received 28 January 2008; received in revised form 10 April 2008; accepted 5 May 2008
Abstract
Motivational interviewing (MI), an evidence-based counseling approach, has received much recognition from a wide variety of health care
professionals. Because of the rising interest in MI, there is increasing demand for training in this counseling approach. The MI training
community has answered this call and as a result placed much emphasis on studying the MI training process. The purpose of this article is to
provide a systematic review of the published research on MI training. Our goal is to provide a consolidated account of MI trainings outlining
the populations receiving training, methods used, and training outcomes. We also identify which aspects of the (W. R. Miller & T. B. Moyers,
2006) eight stages of learning MI each study addressed. Recommendations for advancing the MI training research are highlighted. © 2009
Elsevier Inc. All rights reserved.
Keywords: Motivational interviewing; Training; Education
1. Introduction
Motivational interviewing (MI) is a directive, client-
centered approach for eliciting behavior change by assisting
clients in exploring and resolving ambivalence (Miller &
Rollnick, 2002). MI achieves its therapeutic goals through
both factors that are common across psychotherapies and
those that are specific to MI. Common factors include
Rogerian skills like acceptance, expressing empathy, and
being nonjudgmental. Factors specific to MI, often referred
to as the “spirit of MI,”include collaboration, evocation, and
autonomy (Miller & Rollnick, 2002). First, behavior change
is best brought about in a collaborative manner. The
counselor interacts with the client in a partner-like fashion.
Both the client and the counselor perceive each other as
equals. There is a level of highly valued egalitarianism
between the two (Moyers, Miller, & Hendrickson, 2005).
Second, MI values an evocative relationship between the
client and the counselor. Therefore, educating or advice
giving are not seen as the most conducive forms of
interaction due to their tendency to increase resistance
(Rollnick & Miller, 1995; Miller & Rollnick, 2002). Instead,
positive reasons or beliefs for change are elicited or drawn
from within the client. Finally, the philosophy of MI holds
that a counselor must respect the autonomy of his or her
client. Thus, the ability and the decision to bring about
change are entirely under the client's control.
Beyond the spirit of MI, this counseling approach is
unique in that an emphasis is placed on both principles such
as rolling with resistance, developing discrepancy between
client values and behaviors, and supporting client self-
efficacy about changing and strategies such as exploring
client ambivalence and eliciting and reinforcing client
change talk (Miller & Rollnick, 2002). These principles
and strategies can be thought to occur within two phases.
Phase 1 of MI emphasizes using common counseling factors
and specific MI ingredients to build client motivation for
change (Miller & Rollnick, 2002). The Phase 2 of MI,
strengthening commitment and action for change, includes
Phase 1 strategies (e.g., common counseling factors) but also
includes a focus on developing a client-specific change plan
and building a client's commitment to acting on that plan
(Arkowitz & Miller, 2008).
Journal of Substance Abuse Treatment 36 (2009) 101–109
⁎Corresponding author. Department of Psychology, The University of
Southern Mississippi, 118 College Drive #5025, Hattiesburg, MS 39406-
5025, USA.
E-mail address: michael.madson@usm.edu (M.B. Madson).
0740-5472/09/$ –see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.jsat.2008.05.005

MI has been studied extensively and shows promise as an
efficacious intervention in a variety of settings and with a
variety substance use disorders such as alcohol, cocaine, and
marijuana (Burke, Arkowitz, & Menchola, 2003; Hettema,
Steele, & Miller, 2005). Beyond substance abuse treatment,
MI has demonstrated its ability for enhancing involvement in
HIV testing (Foley, Duran, & Morris, 2005), decreasing
risky sexual behaviors (Belcher et al., 1998), fostering
medication compliance (Hayward, Chan, & Kemp, 1995),
enhancing readiness to change with eating disorders (Dunn,
Neighbors, & Larimer, 2006), and facilitating healthy eating
behaviors (Resnicow, Jackson, & Wang, 2001). Further, MI
has been shown to be an efficacious approach to enhancing
client engagement and adherence in treatment (Carroll, Ball,
& Nich, 2006; Zweben & Zuckoff, 2002). One valuable
aspect of MI is the emphasis that has been placed on training
clinicians from various backgrounds to use this approach.
Because of this applicability to a broad spectrum of
professionals, training in MI has undergone several devel-
opments (Adams & Madson, 2006). First, in 1995, the
Motivational Interviewing Network of Trainers (MINT) held
its first meeting (Moyers, 2004). MINT is a group of
individuals with specialized training in how to educate others
in MI. More recently, Miller and Moyers (2006) have
outlined a process (discussed below) through which trainees'
may progress in their development of MI ability. Most
notable of the developments related to the emphasis on MI
training is the empirical examination of the training process
and transfer of MI into practice. For example, several
observational measures have been developed to facilitate
monitoring, feedback, and research on MI skills (e.g., Lane
et al., 2005; Madson & Campbell, 2006; Madson, Campbell,
Barrett, Brondino, & Melchert, 2005; Moyers, Martin,
Manuel, Hendrickson, & Miller, 2005). In addition, since
the late 1990s, there has been a variety of research that has
focused on MI training. Given these developments and the
increasing call for MI training, it would be valuable to
examine the current research to provide a complete synthesis
of current MI training practices and outcomes.
Given these developments, the purpose of this article is to
expand on previous work on MI training by providing a
current review of MI training research that has been
developed and described independently elsewhere. Pre-
viously, there has been no consolidated evaluation of this
research. Therefore, our review will specifically outline the
populations to which the MI trainings have been targeted, the
foci of trainings (aspects of MI being trained based on
authors' descriptions), training methods, length, and out-
comes. In addition, we will discuss the extent to which
studies integrated experiential/practice opportunities, if
feedback was provided to participants, and whether objective
feedback measures were used. Finally, we examine the
extent to which trainings outlined fit with Miller and
Moyers' stages of learning MI. This review summarizes
what has been accomplished thus far in the study of MI
training while providing information that can assist re-
searchers, educators, and clinical supervisors in developing
and evaluating MI training.
1.1. Learning MI
Learning MI is not a simple process. In fact, Miller and
Moyers (2006) identified eight particular stages for becom-
ing competent in MI, beginning with understanding its
philosophy and culminating in the integration of MI with
other theoretical approaches. One begins their progression in
learning MI by first becoming familiar with its underlying
philosophy (Miller & Moyers, 2006). This philosophy is
composed of three major tenets: collaboration, evocation,
and autonomy (Miller & Rollnick, 2002). Miller and Moyers
(2006) indicate that one should be, at the very least, open to
learning about the philosophy of MI through their ongoing
interactions with clients. The second stage in learning MI
involves acquiring basic client-centered counseling skills
(Miller & Moyers, 2006). Thus, counselors are encouraged
to be proficient in their ability to use open questions, affirm
the client's responses, apply accurate reflections, and
provide summaries when necessary (Miller & Rollnick,
2002). The third stage of learning MI, and where it deviates
from pure client-centered counseling, involves recognizing
and reinforcing change talk (Miller & Moyers, 2006). MI is
based upon a conscious directive toward change (Hettema
et al., 2005). Thus, counselors must be able to identify when
a client verbalizes the reasons, needs, desires, and benefits of
change (Miller & Rollnick, 2002). Miller and Moyers (2006)
indicate that it is not enough to be able to recognize change
talk, but that a counselor must be able to elicit such
statements from their clients. Therefore, in the fourth stage of
the model, counselors are encouraged to ask about, reflect,
and emphasize statements concerning change to prevent the
client from feeling stuck (Miller & Rollnick, 2002).
Counselors are encouraged to be mindful of how and when
they elicit change talk from their clients (Miller and Moyers,
2006). By being aware of how they are interacting with
clients, counselors are able to roll with resistance. Counse-
lors that avoid confrontations and arguments with a client are
successfully navigating Miller and Moyers' (2006) fifth
stage of learning MI. In this stage, individuals are
encouraged to view resistive behavior not as pathological
or defensive but as a natural component of the change
process (Miller & Rollnick, 2002). If addressed effectively
(e.g., through using reflections) a client's resistance can
become an asset in developing behavior change (Arkowitz &
Miller, 2008).
Although earlier stages in Miller and Moyers (2006)
model appear to reflect a trainees need to develop
proficiency in Phase 1 of MI, latter stages appear to address
the Phase 2. Thus, once a client has expressed an adequate
amount of change talk and resistance has been properly
addressed, both the counselor and the client may be asking
“What's next?”(Miller & Moyers, 2006). At this point in
training, the sixth stage in learning MI, it is important for one
102 M.B. Madson et al. / Journal of Substance Abuse Treatment 36 (2009) 101–109

to be able to transition into the next phase of behavior change
by beginning to develop a plan (Miller & Rollnick, 2002). In
the seventh stage of learning, MI counselors are able to help
a client develop their commitment to their change plan
(Miller & Moyers, 2006). Thus, rather than simply
expressing “Ican”or “I would like”to change, clients are
encouraged to verbalize more affirmative statements regard-
ing change, such as “I will”(Miller & Moyers, 2006). MI has
demonstrated synergistic effects when used with other forms
of treatment (Miller & Rollnick, 2002). Thus, in the final
stage of learning MI, counselors are able to integrate it
effectively with other interventions (Miller & Moyers,
2006). At this point, it is critical for counselors to be able
to identify whether their client would benefit from an MI
approach or from another form of therapy (Miller & Moyers,
2006). For instance, if a client is fully prepared to take action,
then using MI may stifle their desire to change (Miller &
Rollnick, 2002).
Although this model provides a logical process for
learning MI, it still requires empirical validation (Miller &
Moyers, 2006). As MI's popularity continues to grow, there
will be a need to further assess this model and its relevance
for assisting in the training and implementation of MI (Miller
& Moyers, 2006). Nonetheless, the eight stages of learning
MI model provide a reasonable structure to use when
reviewing MI training. Thus, this article will also provide an
Table 1
MI training studies reviewed with regard to fit with eight stages of learning MI model, sample size, population trained, length of training, type of training, and
outcomes measured
Reference
Stage(s) of model
addressed nPopulation trained
Length of
training
Type of
training Outcomes measured
Arthur (1999) 2 212 Nurses 5 weeks Course KN, SCIRS, SP
Baer et al. (2004) 1, 2, 3, 5 22 MH 14 hours WS HRQ, SP, RP
Bennett, Roberts, Vaughan,
Gibbins, and Rouse (2007)
1, 2, 3, 5 40 MH, SA MITI, SP
Brown and Oriel (1998) 2 21 Medical students 14 hours Course SP
Brug et al. (2007) 1, 2, 3 37 Dietitians 2 days WS MITI, MISC
Burke, Da Silva, Vaughan,
and Knight (2005)
1, 2, 3, 5 6 School personnel 12 hours WS
Byrne, Watson, Butler,
and Accoroni (2006)
1, 2, 3, 5 10 Nurses Half-day WS KN, CON
Carroll et al. (2006) 1, 2, 3, 5 38 MH, SA N16 hours WS, SU RP
Chossis et al. (2007) 2 MD 2 half-day WS
Doherty, Hall, James, Roberts,
and Simpson (2000)
2 13 Dietitian, nurses, MD 1 hour/month WS, SU KN, RP
Handymaker, Hester,
and Delaney (1999)
1, 2 31 MD, nurses 20 minutes Video SP
Hartzler, Baer, Dunn, Rosengren,
and Wells (2007)
1, 2, 3, 5 23 MH 15 hours WS SP, MITI, MISC
Lane, Hood, and Rollnick (2008) 1, 2, 3, 5 70 Health care professionals 4 days WS SP, BECCI
Lane et al. (2003) 2, 5 6 Nurses 2 hours WS, video SP, BECCI
Martino (2007) 2 45 Medical students 2 hours Course HRQ, KN, CON, IU
Miller et al. (2004) 1, 2, 3, 5 140 SA, MD, nurses, MH,
social workers
2 days WS, FB, CO,
self-taught
HRQ, MISC
Miller and Mount (2001) 1, 2, 3, 5 22 Probation officers 15 hours WS HRQ, SK, SP, MISC
Mounsey et al. (2006) 1, 2, 3, 5 93 Medical students Course MITI, SP
Poirier et al. (2004) 1, 2, 3, 4, 5 42 Medical students 10 hours Course CON, KN
Rubak, Sandbake, Lauritzen,
Borch-Johnsen,
and Christensen (2006)
1, 2, 3, 5 76 MD 2 days WS IU
Rubel, Sobell, and Miller (2000) 2 44 SA 12 hours WS KN, UAS, HRQ
Saitz et al. (2000) 2 87 MD, nurses, MH,
social workers
Half-day WS SP, IU, CON
Schoener, Madeja, Henderson,
Ondersma, and Janisse (2006)
1, 2, 3, 5 10 MH 2 days WS MISC
Shafer, Rhode, and Chong (2004) 1, 2, 3, 5 30 SA 15 hours WS KN, SUSAS, HRQ,
MISC, RC
Smith et al. (2007) 1, 2, 3, 5 12 SA 2 days WS, SU MITI
Thijs (2007) 2 MD, MH
Velasquez et al. (2000) 1, 2, 3, 5 73 Nurses, case workers 6 hours–2 days WS KN
Note. CO = coaching; CON = confidence; FB = feedback; HRQ = Helpful Response Questionnaire; IU = intention to use; KN = knowledge; MD = doctors;
MH = mental health; MISC = Motivational Interviewing Skill Code; MITI = Motivational Interviewing Treatment Integrity Scale; RP = real patient; RC =
readiness to change; SCIRS = Simulated Client Interview Rating Scale; SA = substance abuse; SK = skills; SP = simulated patient; SU = supervision; SUSAS=
Short Understanding of Substance Abuse Scale; UAS = Understanding Alcoholism Scale; WS = workshop.
103M.B. Madson et al. / Journal of Substance Abuse Treatment 36 (2009) 101–109

estimation of which stage(s) of learning MI the training
addressed. These estimations will be based on the authors'
training descriptions.
1.2. Procedure
To identify articles for inclusion in this review, we
conducted a literature search using the psycINFO, psycAR-
TICLES, Academic Search Premier, and Medline databases.
Database search terms used included MI, motivational
enhancement therapy, training, education, and workshop. A
thorough review of the bibliography page on the MI Web site
(http://motivationalinterview.org/library/biblio.html)was
also conducted to identify additional articles. This process
resulted in 32 articles identified. Studies for this review were
included if they directly stated that the training included MI
or upon review trained participants, indirectly, in skills
important to MI. One study, Hecht et al. (2005), provided a
description of several MI training efforts but did not provide
information on results; thus, it was not included for review.
This decision process resulted in 27 studies for inclusion in
this review from medicine, general health care (e.g.,
nutrition, exercise), substance abuse, and general mental
health. Each author reviewed the included articles indepen-
dently to determine which of Miller and Moyers' (2006)
eight stages were addressed based on training descriptions in
each article. In our review, we included some decisional rules
for determining if a training addressed a particular stage. If
the authors mention that the training addressed principles of
MI, we decided that this would include Stages 1, 2, 3, and 5.
These four stages (spirit of MI; open questions, affirmations,
reflection, and summaries [OARS]; recognizing and reinfor-
cing change talk; and rolling with resistance) based on Miller
and Moyers' description seem to incorporate the four
principles of MI more directly than the other four stages.
We determined that a training addressed Stages 4, 6, 7, and 8
only if direct reference to activities relating to these stages
were mentioned (e.g., eliciting change talk or developing a
change plan). Finally, if the authors only referred to MI
techniques, we determined the training only addressed Stage
2. The first author also reviewed the content of each article to
determine the (a) profession of participants, (b) length of
trainings in terms of hours, (c) training methods used, (c)
aspects of MI covered (e.g., spirit, principles, OARS,
specific skills—decisional balance, scaling), and (d) out-
comes. This analysis was then reviewed by the other authors
for accuracy and completeness. Table 1 presents some of
these results.
2. MI training review results
2.1. Participant's profession
The wide popularity of MI training is highlighted by the
variety of professions from which trainees have participated
in MI training based on published articles. Most of the
studies included in this review centered on training medical
professionals exclusively or as part of a more diverse group.
Of the 27 studies reviewed, eight included physicians, and 4
additional studies were exclusively targeting medical
students. Similarly, 10 studies trained nurses including
nurse practitioners and midwives. Of the 27 studies, 3
trained dietitians and other medical professionals such as
medical assistants and case workers. Interestingly, of the 27
studies reviewed, only 2 focused on general mental heath
professionals who provide psychotherapy (social workers,
counselors, psychologists) exclusively, with 4 focusing
exclusively on substance use professionals (counselors,
social workers, addictionologists, psychologists) and 3
combining mental health and substance use professionals.
One study focused on training probation officers. Most of the
studies (n= 22) described training of individuals with
advanced degrees, whereas 5 studies explicitly described
training individuals with bachelor degrees. Finally, unlike
the medical profession, no published studies were found on
training mental health graduate students (psychology,
counseling, social work) in MI. Arkowitz and Miller
(2008) refer to a practicum training sequence for clinical
psychology graduate students, but we found no empirical
study concerning this training effort.
2.2. Length of training
There was wide variability in the length of training
programs among the 28 studies. Seven of the studies were
less intensive and involved less than 8 hours of training.
Most of the trainings (16) varied from 9 to 16 hours of
training. One study was more involved and included more
than 24 hours of training. This study, as well as some of the
other more involved trainings, included follow-up/booster
sessions that included ongoing contact with the trainer as a
coach/supervisor.
2.3. Training methods
The most often used methods for training were through
didactic instruction of the material and experiential exercises
(22 studies each). Identified experiential exercises included
role plays (n= 13) using a standard patient (n= 5) and other
unspecified experiential activities. Related training activities
included group exercises (n= 6) and group discussion (n=
5). Some form of observation was directly described in 3 of
these studies, with 2 discussing the inclusion of an
observational measure as part of the training. Similarly, 6
studies discussed some form of ongoing coaching/super-
vision. Some form of trainee feedback was discussed in 6 of
the studies. Feedback included instructor or peer feedback.
Modeling activities were described in 16 studies as either
watching videos (n= 10) or live demonstrations (n= 6).
Finally, several studies described use of related readings (n=
6), handouts (n= 4), or outside content homework (n = 1).
With some small variability, it appears as though a common
104 M.B. Madson et al. / Journal of Substance Abuse Treatment 36 (2009) 101–109

approach among most MI trainings is to combine didactic
instruction and experiential activities to provide a more
inclusive training program.
2.4. Training outcomes
Overall, the training results reported were favorable.
Several studies reported increases in participant confidence
in using MI (n= 4), MI knowledge (n= 6), interest in
learning more about MI (n= 3), intention to use MI (n= 6),
and actual integration into one's practice (n= 2) based on
trainee self-report. Only one study reported no change
related to self-confidence in MI. Several studies examined
outcomes more objectively with favorable results. Using
either the Motivational Interviewing Treatment Integrity
Scale (Moyers, Martin, et al., 2005) or the Motivational
Interviewing Skill Code (Miller, 2000), nine studies reported
improvements in MI-related skills (e.g., reflections, open
questions). Two studies (Lane, Hood, & Rollnick, 2008;
Lane, Johnson, Rollnick, Edwards, & Lyons, 2003) demon-
strated improvements in MI skills following a 2-day
workshop as measured by the Behavior Change Counseling
Index (BECCI; Lane et al., 2005). Only one study reported
no significant difference relating to MI skill using an
objective measure (Mounsey, Bovbjerg, White, & Gaze-
wood, 2006). Four studies reported increases in the Helpful
Responses Questionnaire (Miller, Hedrick, & Orlofsky,
1991). In addition to the outcome criteria mentioned
above, seven studies reported that the participants found
value in the training, and two studies reported that
participants found the role-plays especially helpful. Unfortu-
nately, only a few of these studies examined the effect of
training on client outcomes. Miller and Mount (2001) found
no significant differences between MI-trained and non-
trained clinicians on client questions/requests for informa-
tion, change statements, resistance statements, and neutral
statements. However, Miller, Yahne, Moyers, Martinez, and
Pirritano (2004), in evaluating a more in-depth training
process, found significantly more change talk and less
resistance in clients of MI-trained counselors and that this
change was sustained at 4 months for counselors who
received follow-up and coaching. More recently, Chossis et
al. (2007) found no difference between MI- and non-MI-
trained residents relating to a clients' reported number of
drinks consumed and mean number of drinks per week. Yet,
Brug et al. (2007) found patients of MI-trained dietitians had
significantly lower saturated fat intake at posttreatment.
Clearly, to advance training further, future studies need to
examine the outcome of MI trainings with clients.
2.5. Relation to eight stages
One purpose of this article is to provide an estimation of
the extent to which each training study reviewed addressed
the eight stages of learning MI. Although we recognize that
there is some uncertainty whether these tasks must be
accomplished sequentially, the stages provide a reasonable
guide for developing training goals and tasks. Thus, we
outlined which aspects of the eight stages were addressed by
each study based on the training description in each article.
We are not suggesting that these trainings developed these
competencies, but that they simply addressed a particular
stage of learning MI. As seen in Table 1, every study
included in this review addressed Stage 2, whereas most of
the studies addressed Stages 1, 3, and 5. However, few
studies appeared to address stages related to Phase 2 aspects
of MI (strengthening commitment, developing a change
plan) and integrating MI with other approaches. This finding
suggests that most of the MI trainings studies to date focus
primarily on Phase 1 of MI and have yet to focus on aspects
of Phase 2. However, these findings need to be interpreted
with caution because space limitations may have limited the
authors' descriptions of MI trainings.
3. Evaluation of MI training studies
Our review of the 28 articles published from 1999 to 2007
highlighted several strengths and limitations as well as areas
for improvement in future studies. Based on our review, it
appears as though the trainings readily exposed trainees from
a variety of backgrounds to both the general principles and
other aspects of the first phase of MI (e.g., relationship
building, rolling with resistance, and recognizing change
talk). Similarly, an array of training techniques was used to
help trainees gain experience applying MI. Finally, most
trainings demonstrated positive outcomes relating to the
development of MI knowledge, attitudes, basic skills, self-
efficacy, interest in MI, and willingness to use MI. The shear
number of published studies in such a short length of time is
also a strength because it indicates an attention to the empirical
evaluation of training methods within the MI community.
A variety of limitations of these studies, however, call for
caution in evaluating their findings. One major concern that
must be considered is the use of a workshop format used in
most of these studies. As seen in Table 1, only four studies
described some form of workshop and supervision, and only
one (Miller et al., 2004) described ongoing coaching.
Walters, Matson, Baer, and Ziedonis (2005) highlight that
the workshop format helps trainees improve in knowledge,
attitudes, and confidence yet rarely facilitate maintenance of
skill acquisition over time. In this context, future MI training
studies must implement and evaluate additional training
strategies such as coaching and coaching using objective
feedback measures (Miller, Sorensen, Selzer, & Brigham,
2006). Another concern in evaluating these studies is the
variability with which the trainings were described in these
studies. From a scientific perspective, minimal description
makes replication difficult, whereas from a practical
perspective, such description limits the implementation of
potentially effective training methods. Although we recog-
nize that restricted publication space hinders the presentation
105M.B. Madson et al. / Journal of Substance Abuse Treatment 36 (2009) 101–109

of training details, we encourage future studies to attempt to
be more descriptive.
Furthermore, although the results of many of these studies
are positive, one must be careful in interpreting the findings
concerning trainee change over time due to the measures that
were used in assessing these variables. Based on our review,
there appears to be a lack of standard MI knowledge,
attitude, and self-confidence measures that have been
evaluated psychometrically. Without such validated mea-
sures, we cannot be confident in the results found in these
studies (Heppner, Wampold, & Kivlighan, 2008). Similarly,
these studies, which were primarily focused on a pre–post
training design, demonstrate a need to assess skill acquisition
over time (e.g., 3-month, 6-month follow-up) using
psychometrically validated measures (Madson & Campbell,
2006). Finally, a few of these studies examined the impact of
MI training on client outcomes. A major factor in success of
any technology transfer effort is to enhance client services
and outcomes (Stirman, Crits-Christoph, & DeRubeis,
2004). Thus, it will behoove researchers to study such
outcomes within the context of MI training. Despite their
limitations, the studies reviewed here provide the foundation
needed to move the investigation of MI training forward.
4. Discussion
Our goal for this article was to provide a systematic
review of the published articles relating to MI training to
facilitate further research in this area. The review provided a
wealth of quality information about MI training. In addition
to providing important information about the current state of
MI training, this review also raised several question and
recommendations that may be important to address in future
MI training studies beyond the methodological issues
mentioned above. These questions and recommendations
fall into three categories: (a) general versus specific MI
training, (b) training formats, and (c) transfer of MI from
training into practice. This review also raised questions and
recommendations relating to the eight-stage model outlined
by Miller and Moyers (2006).
4.1. General and specific MI training
It appears based on our review that most of the articles
covered in this article tended to focus on more general or
introductory MI training. We found that all trainings
reviewed described providing information relating to Phase
1 of MI (building motivation for change), whereas none of
them described training activities related to Phase 2
(strengthening commitment). We recognize that although
Phase 2 activities were not discussed, this does not mean that
they did not occur. Authors may have chosen to omit this
information from their articles for the sake of brevity.
However, the omission of Phase 2 training was a consistent
theme across our review. Thus, this finding raises questions
to be considered, such as (a) Does Phase 2 training require
more training time? (b) Are different formats such as
coaching—as described by Miller et al. (2004)—needed to
provide Phase 2 training? and (c) What are MI trainers'
beliefs about providing the full spectrum of MI training (e.g.,
Phase 1 and 2) or emphasizing specific focused trainings
(e.g., spirit and principles, OARS, etc.). Finally, do MI
trainers believe that trainees must develop a solid foundation
in Phase 1 knowledge and skill prior to learning Phase 2
information and skills? By addressing these questions, the
literature on MI training would certainly be advanced.
Further, to understand the full spectrum of learning MI,
future studies should examine the processes involved in
developing competency within both phases of MI.
Similarly, with the exception of the identification of MI
skills—OARS—the articles reviewed provided little infor-
mation about training in specific MI strategies. Given this
finding, questions arise about what specific strategies
beyond OARS trainees are being exposed to. For example,
are trainees being exposed to strategies such as agenda
setting, elicit–provide–elicit, examining the pros and cons,
and assessing readiness and confidence (Rollnick, Miller, &
Butler, 2008)? Trainers may have different opinions about
introducing or focusing on particular strategies. Some
trainers may believe that one must understand the spirit
and principles of MI prior to learning strategies, whereas
other trainers may believe that if one learns the strategies, the
principles and spirit of MI will follow. Similarly, a specific
focus on theory or strategies may vary depending on the
training audience. For instance, health care trainings may
place more emphasis on strategies, whereas mental health
trainings may focus more on theory. Thus, future research
should attempt to examine the prevalence of and differences
between trainings in specific strategies versus trainings
focused upon theory.
One potential lens through which to explore questions
about specific versus general MI training is to examine it
within the context of counselor development models.
Counselor developmental models, such as the integrated
developmental model (IDM; Stoltenberg & McNeill, 1997)
provide a theoretical foundation in relation to how one
develops counseling skill. Specifically, the IDM provides a
context to examine training issues such as focusing on skills
versus theory, trainee anxiety, self-efficacy, as well as how to
match supervisor interventions to trainee needs.
4.2. Training formats
Our review of published MI studies has also highlighted
valuable information about how trainings are structured.
Most of the trainings, with a few exceptions (e.g., Miller et
al., 2004), described a seminar/workshop format. Consis-
tently, these descriptions included presentation of didactic
information and experiential exercises. It seems apparent that
the use of multiple training methods is valued within the MI
training community. Although there seemed to be consis-
106 M.B. Madson et al. / Journal of Substance Abuse Treatment 36 (2009) 101–109

tency with regards to training methods, more variability was
found among the length of training. More specifically,
Martino, Haeseler, Belitsky, Pantalon, and Fortin (2007)
suggested that MI training can be effective in short durations,
whereas Miller et al. (2004) found the most efficacious
training for integration of MI into practice is one that is
longer in duration and integrates training, observation,
feedback, and coaching. Thus, it will be important for future
MI training research to examine what aspects of MI can be
appropriately taught and learned in what time periods (e.g.,
what can be accomplished in an hour talk). In fact, this is one
area in which Miller and Moyers' (2006) eight stages of
learning MI may be beneficial in guiding research. For
instance, researchers and trainers could use the eight stages
framework to examine what aspects might be best delivered
in a certain timeframe (e.g., overview of spirit and basic
OARS in an hour). Finding answers to these types of
questions will not only help inform the design of trainings
but also further empirical investigation of the eight
stages model.
Beyond what topics can best be covered in a specific
amount of time, it will behoove MI training researchers to
examine different training formats and populations. This
review demonstrated that MI trainings have been provided
to a variety of professionals from the mental and other
allied health care fields. In addition, our review found
studies that focused on the training of medical students.
Clearly, an interest in learning MI has expanded to many
professions. Although this growth is exciting, it also
requires one to understand the different methods for
providing the trainings. More specifically, most trainings
reviewed here described a seminar format as the main focus
of training. Miller et al. (2004) and Hecht et al. (2005)
emphasized more comprehensive programs for training
professionals. These developments have greatly expanded
our knowledge of training in traditional and intensive
formats. They also lay the foundation for additional study
of training formats. For example, no study we reviewed
examined training of graduate students in mental health or
MI training as a regular component of a classroom
environment. Graduate training in mental health fields
such as psychology and social work is where future
professionals are exposed to various counseling approaches
and learn the necessary counseling skills. It is also through
graduate education where trainees develop their theoretical
approach to counseling (Halbur & Vess Halbur, 2006) and
develop an identity as a mental health professional. These
tasks are accomplished through a variety of training
activities including instruction, activities, and the provision
of clinical services (Lee, 2007). Given these facts, graduate
mental health training programs appear to be fertile ground
on which to explore various approaches to training future
professionals in MI. Research in this area could (a) shed
light on the similarities and differences of training students
versus professionals, (b) outline how to best integrate MI
training into specific classes (e.g., counseling skills or
alcohol and drug treatment), (c) help identify an optimal
sequence for developing MI competence (e.g., 8 stages), (d)
examine the efficacy of MI training in a practicum format,
and (e) study optimal methods to train participants how to
integrate MI with other interventions.
4.3. Transfer of MI training
Our review also highlighted the need for further investiga-
tion of the optimal methods of transferring MI training into
practice. The MI training community appears to be very
invested in learning how to best provide effective training as
evidenced by the number of published training studies, the
development of potential frameworks for increasing compe-
tent practice (Miller & Moyers, 2006), and the organization of
training focused groups such as the MINT. Further, the
development of multiple MI-related observational measures
(Lane et al., 2005; Madson et al., 2005; Madson & Campbell,
2006; Moyers, Martin, et al., 2005) suggest that those
involved in MI training are focused on facilitating effective
transfer of MI from training to practice. This review highlights
some additional areas for investigation in relation to the
transfer of MI from training to practice. Trainee self-
confidence is an important factor relating to one probability
of engaging in a behavior (Bandura, 1997) and is an important
concept in MI (Miller & Rollnick, 2002). In other words, an
individual is more likely to engage in a behavior if they are
confident in their abilities to perform the behavior. Some of the
studies reviewed in this article examined the impact of the
training on trainee self-confidence. However, it would be
important for future studies to examine self-efficacy as a factor
relating to trainee integration of MI into practice and what
factors or training methods enhance or reduce self-efficacy.
This factor may be especially important for professionals for
whom using MI would require changes to their current clinical
behavior (e.g., physicians, dietitians). However, to assess
constructs like self-efficacy, the development of reliable and
valid measures is also warranted. Although some of the
studies reviewed addressed such constructs, the measures
used appeared for the most part to be designed specifically for
that study. Thus, another area of future research includes the
construction and psychometric evaluation of measures aimed
at assessing important training constructs such as self-
efficacy, intention to use MI, and MI attitude and knowledge.
In addition, because client perspective is important in MI, it
will be important to develop measures to ascertain client
observation of a clinician's MI skills. Such feedback can be
valuable in providing additional information about MI skill
development. Development of such measures will help
provide consistent and accurate evaluation of these constructs.
As well as “training factors”and “trainee factors,”another
influence in the transfer of skills from training to clinical
practice is the working environment (Baldwin & Ford, 1988;
Simpson, 2002). The risk with any kind of skills related
training is that trainees need to “use it or lose it,”and if there
is little support for MI within the workplace, there may be
107M.B. Madson et al. / Journal of Substance Abuse Treatment 36 (2009) 101–109

little incentive to “use it.”For example, the findings from one
notable study by Heaven, Clegg, and Maguire (2006)
demonstrated that although it appeared that communication
skills were enhanced immediately after training, without
supervision, there was little effect on actual clinical practice.
This suggests that without some degree of support and
coaching in the workplace following training, the transfer
of MI skills could potentially be more limited (Miller
et al., 2006).
Beyond the areas for future research mentioned above,
our review of the MI training literature reiterated Miller and
Moyers' (2006) emphasis on the importance for researchers
to empirically investigate the eight stages of learning MI.
One major issue relating to this model that became apparent
from the results of this review is whether this framework is
best conceptualized as a linear stage model (where stages
must be satisfied before moving on) or a set of guidelines for
developing trainings centered on improving MI competency.
The results of this review indicate that there are certainly
discrepancies in which stages of the model are being
addressed. Future studies will want to explore how the
omission of particular stages impacts the outcome of a
trainee's learning of MI. Researchers may also want to
explore what factors influence the exclusion of particular
stages. For example, is it essential to have learned the spirit
of MI before learning the skills or can an individual develop
a better understanding of the spirit through actually
implementing some of the skills in practice? Similarly, it
appears important to examine how trainers are using this
framework to design training activities and how these
activities are adjusted based on constraints (e.g., length of
time, environment, population, format). Better reporting of
MI training studies and explicit references to the stages
addressed by a particular training program could provide
further evidence for the eight stages model while assisting in
its development. At this time, the eight stages model
provides a logical framework for both researchers and
trainers alike. However, as indicated by both the results of
this review and Miller and Moyers (2006), further empirical
assessment remains to be done before a clear understanding
of this model can be achieved.
In sum, our goal for this project was to synthesize and
systematically review the current literature relating to MI
training. We were delighted to find a wealth of published
training articles within the last 10 years in addition to the
increase in studies during the past 5 years. To us, this
suggests that the MI training community is seriously
focused on providing effective training. Our review
highlighted who is being trained, in what formats, and
the related outcomes. In addition, the review raised many
questions we deem important to answer to move the MI
training literature forward. Our hope in providing these
suggestions was to encourage MI trainers and researchers
to engage in answering these questions, which we believe
will enhance the quality and effectiveness of MI training
programs.
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