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Not quite MI?

Monday, December 14, 2020
By:  Dan Mullin


Is practicing the spirit of Motivational Interviewing enough?  Implications for MI teachers and students

As patients struggle to change their behavior—to stop smoking, to take their medications as prescribed, to eat less and exercise more—motivational interviewing is recognized as an effective approach. Many clinicians intend to employ MI but acknowledge that they are more likely to use something that is not quite MI but seems similar. This may be due to a lack of knowledge or experience plus time constraints.  The resulting question is whether “MI style” or “MI informed” or “MI lite” interventions are superior to other approaches to behavior change.   

We know that high fidelity Motivational Interviewing interventions result in behavior change.  But what about low fidelity MI interventions?  Unfortunately, the medical literature is full of adaptations of MI interventions that have never been demonstrated to be effective.  Strategies like using importance-confidence rulers, or decisional balance, have been confused with actual MI interventions.  So we are left with the question, “Is an intervention that is sort of like MI a good intervention?”  We don’t know, but while we wait for an answer, there are many clinicians providing care that is sort of like MI, or an MI “style." 

As others have noted, developing and sustaining MI skills takes 16-24 hours of classroom work, plus individual observation, and feedback using a validated tool, plus ongoing skill-building, which can be completed in small groups.  We built our online MI course at UMass with this in mind  

Complicating issues further, we also know that there is a very low correlation between clinicians' self-reported confidence in their MI skills and observable MI skills in practice. We are faced with a question, should we spend our time training our PCP colleagues in MI?  My answer is a very clear, maybe. 

To frame my answer, let us consider a group other than physicians--substance abuse counselors.  From my personal experience, I would estimate that less than a quarter of substance abuse counselors use an MI-consistent approach in their work.  This is shocking to me given that SUD is a domain in which MI interventions consistently outperform other approaches.  That said, most of these clinicians could probably pass a written test on MI.  They could regurgitate what OARS stands for and describe the spirit of MI.  But this is similar to the difference between passing a test on the rules of golf and actually being able to play golf.  Most of these clinicians were required to pass a written test that discussed MI, but very few have ever had their MI skills assessed with real-world patients or an objective measure of their MI skills. 

So what do we take from this?  Nearly all SUD clinicians have been exposed to MI, but few of them use it in practice.  Should we give up on training SUD clinicians in MI? Probably not.  So why would we give up on training physicians in MI?  

We should, however, be thoughtful about when and how we train any clinician in Motivational Interviewing.  We do not want to give the impression that this is a skill that can be built by watching a 1-hour webinar.  We don’t want clinicians to confuse using an importance and confidence ruler with being able to practice MI. 

Based on 10+ years of training physicians in MI, I would suggest that after 20+ hours of training about half of them are able to regularly put their MI skills into practice.  Some of them integrate the approach they have learned into their work and seem to sustain the practice, though I’d like to see more evidence of sustainment.  Less intensive training will generally produce fewer competent MI practitioners.  I have not given up on training physicians in MI, but brief trainings simply tend to raise interest; getting them to engage with longer, more intensive trainings can actually produce results. 

One more thought - it could be that there is an unmeasured benefit of “MI style” or “MI lite” interventions.  I suspect that clinicians who try to put the spirit of MI into practice - and emphasize autonomy, limit confrontation, avoid judgment, practice unconditional positive regard, and so on, may experience lower levels of burnout.  So even if their technical MI skills are of low fidelity, they may experience a personal benefit from practicing in an “MI style.”.  While I am not aware of any research on this, if it is a possible outcome, it is one we should not ignore. 

Don’t abandon MI teaching, just be sure you are thinking big enough.