ResearchClinician acquisition and retention of ...

Forsberg et al. Substance Abuse Treatment, Prevention, and Policy 2010, 5:8http://www.substanceabusepolicy.com/content/5/1/8

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ResearchClinician acquisition and retention of Motivational Interviewing skills: a two-and-a-half-year exploratory studyLisa Forsberg*1, Lars G Forsberg1, Helena Lindqvist1 and Asgeir R Helgason2,3

AbstractBackground: Motivational interviewing (MI) is a collaborative, client-centred counselling style aimed at eliciting and strengthening clients' intrinsic motivation to change. There is strong research evidence supporting the efficacy of MI, notably in its application among alcohol and drug abuse populations. MI interventions in smoking cessation may yield modest but significant increases in quitting. The present study sought to assess the acquisition and retention of MI skills in counsellors at the Swedish National Tobacco Quitline.

Methods: Three audio-recorded sessions from each of three counsellors were assessed using the Motivational Interviewing Treatment Integrity (MITI) Code Version 3.0 over 11 assessment periods at fixed intervals in a two-and-a-half year period during which counsellors received ongoing supervision.

Results: The mean skill for all counsellors improved throughout the study period in most MITI variables. However, great variations in MI skill between counsellors were observed, as well as fluctuations in performance in counsellors over time.

Conclusion: The present exploratory study covers a longer time period than most evaluations of MI training, and has several advantages with regard to study design. It may provide a basis for (larger sample) replication to test MI skill (as measured by the MITI) in relation to behaviour change in clients, to evaluate MI training, and to assess the acquisition and retention of MI skill over time. Difficulties in acquiring and retaining MI skill may raise the issue of a selection policy for MI training. Moreover, fluctuations in MI skill over time emphasise the greater importance of continuous feedback and supervision over initial MI training, and the need for the use of validated treatment integrity assessment instruments in ordinary clinical implementations of MI.

BackgroundMotivational InterviewingMotivational interviewing (MI) is a collaborative, client-centred counselling style aimed at eliciting and strength-ening clients' intrinsic motivation to change [1]. Theprinciples of MI include cultivating discrepanciesbetween the client's behaviour and goals, expressingempathy, eliciting self-motivational statements (forexample, statements expressing reasons for change), non-confrontation of resistance and supporting self-efficacy[2]. There is strong research evidence supporting the effi-cacy of MI, notably in its application among alcohol and

drug abuse populations [3], but also in a number of otherbehaviour changes [4], When MI is used as a prelude toother treatments, outcomes appear to have greater lon-gevity and be more steadfast compared to when used as astand-alone treatment [3]. Research into the efficacy ofMI in smoking cessation has produced mixed results,although a recent systematic review (of randomised con-trol trials comparing MI to brief advice, usual care, andself-help materials) found that MI interventions may yieldmodest but significant increases in quitting [5].

Training of counsellors in MI: what we knowMI training ordinarily comprises a two to four-day work-shop. Short lectures are interspersed with video demon-strations and exercises where participants can practicespecific MI skills. In some settings, such as primary care,

* Correspondence: [email protected] Department of Clinical Neuroscience, Karolinska Institute, 171 76 Stockholm, SwedenFull list of author information is available at the end of the article

© 2010 Forsberg et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.

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MI training time is often shorter, with training compris-ing as little as two hours [6].

Teaching of MI techniques in these workshops hasbeen shown to influence counsellor behaviour [7]. A pilotstudy on the effects of a two-day MI training workshopon staff working within the probation services showed anincrease in newly acquired MI skills after completion.However, MI skills were not maintained at three-monthfollow-up [8].

In one study, 140 well-educated and motivated partici-pants were initially given Motivational Interviewing: Pre-paring People for Change [2], as well as sevendemonstration videotapes [9]. The participants were ran-domly allocated to five groups, each undergoing differentMI training. Measuring the degree of in-session changetalk and counter-change talk in clients, only the partici-pant group given a workshop, coded feedback, and tele-phone coaching on six submitted client sessions wereable to procure significant increase in change talk anddecrease in resistance after four months compared tobaseline.

Demand for MI training is ever-increasing, and MI iscontinually applied to new settings and tested on differ-ent problems [4]. However, evidence of successful imple-mentation of MI in ordinary clinical treatment settings issparse [10,11]. MI, although ostensibly simple, appears tobe rather a difficult method to implement to a high fidel-ity [10]. Therefore, how people acquire and retain MIskills and how the development of MI skills is best facili-tated remain important areas of study [7,10].

Evaluation of MI trainingIn order to have sufficient grounds for evaluation of theefficacy of MI, it is critical to assess to what extent coun-sellors responsible for delivering "MI treatment" are infact using the method. However, treatment integrity hasbeen an aspect overlooked in research into the efficacy ofMI (in a recent systematic review, only 1 of 14 selectedstudies used a validated instrument to measure fidelity toMI principles) [5].

Several instruments aimed at facilitating monitoring,feedback, and research on MI skills have been developed[12-15]. One early instrument was the MotivationalInterviewing Skills Code (MISC) [16]. The MISC mea-sures both therapist and client behaviours, and the inter-action between therapist and client and thus makes itpossible to study the in-session MI process. However,consisting of more than 30 different variables, the MISCis labour-intensive and expensive to use. Further effortslead to the development of a simpler instrument, theMotivational Interviewing Treatment Integrity (MITI)Code Version 2.0 [17]. In 2007, a revised and updated ver-sion of the MITI, Version 3.0, was introduced [18]. MITI's

scope is more limited than the MISC, measuring thera-pist behaviour only.

MITI has proved a reliable tool for evaluating the use ofMI [15,17,19], and has shown good discriminant validitywith regard to in-session behaviour and MI skill develop-ment over time (entry-level competence and post-MItraining) [10,20]. It has therefore been recommended as away of evaluating MI training [7,14,15].

Study aimKnowledge on how to assist clinicians to learn MI is scareand evaluation periods are short [15]. The present studyforms part of a larger project evaluating the effects of MIin smoking cessation among clients of the SwedishNational Tobacco Quitline (SNTQ) and was approved bythe Karolinska Institute Northern Research Ethics Com-mittee (00-367). It sought to follow a group of counsellorsduring a longer period of training to see what outcomethese efforts would have on their counselling behaviour.

The aims of the present exploratory study were toassess:

1. Development of MI skills in counsellors over time;2. Which MI skills were most and least easily acquired

by counsellors;3. Time taken for counsellors to reach the recom-

mended threshold for "Beginning Proficiency" suggestedin the MITI 3.0 manual;

4. Efficacy of training/supervision efforts used for thepurpose of the study in maintaining the level of MI profi-ciency over time.

MethodsStudy settingTelephone help lines (quitlines) are increasingly recogn-ised as an effective [21,22], and cost-effective [23], formof intervention to treat tobacco smoking [23], which isone of the largest preventable public health problems[24,25]. SNTQ is a nationwide free of charge serviceoperated by Stockholm County Council Health Serviceand funded by the Swedish Government. SNTQ has beenin operation since May 1998. Throughout the studyperiod three to four lines were in operation for approxi-mately 51 hours per week. The present study forms partof a wider project evaluating the effects of adding MI tothe standard tobacco counselling treatment protocol.Nine counsellors were allocated to the MI interventiongroup and nine counsellors were allocated to the standardtreatment group. At the time of the study, there were 18counsellors working at the SNTQ. Sessions with clientslasted on average 16 minutes.

MI training and supervision of counsellorsThe training of the nine SNTQ counsellors in the MIgroup was developed and conducted by a Motivational


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Interviewing Network of Trainers practitioner and clini-cal psychologist with considerable experience of MItraining in various settings. Initial MI training, conductedin February 2003, comprised a two-day workshop focus-ing on practical exercise and also involving a combinationof demonstrations, didactic and experiential activities. Intotal, 12 hours training was provided. Counsellors hadaccess to the Swedish translation of Motivational inter-viewing: Preparing people for change and had been intro-duced to the MITI [26].

Initial training was followed by supervision in groups offour to five counsellors, supported by feedback based onMITI coding of audio-recorded sessions with actualSNTQ clients (counsellors chose which of their sessionswere to be listened to in group supervision). Client con-sent was obtained before audio recording of sessions.During the first three months (Feb 2005-May 2005),counsellors were supervised every two weeks, with thefocus on increasing the proportion of reflections (reflec-tive listening skills), and decreasing the proportion of(unsolicited) advice and information giving. Over timetraining centred on increasing the proportion of complexreflections. Training goals were formulated and followedup on throughout the supervision period. During the firsthalf of 2006 the emphasis was on increasing skill in theEmpathy and MI Spirit variables, and in the latter half of2006 particular attention was given to ability to recogniseand reinforce change talk in clients. Throughout thewhole study period, supervision aimed to prevent exces-sive and unsolicited advice and information giving bycounsellors. Supervision was performed in 3-hour seg-ments and totalled 84 hours.

Criterion for study inclusion and counsellor backgroundOnly counsellors who had three or more audio-recordedsessions for each of the 11 assessment periods were eligi-ble for inclusion in the present study. Three of the ninecounsellors allocated to the MI intervention met the cri-terion. Of the excluded six counsellors, two wereexcluded because they had other work assignments thatdid not allow for monitoring throughout the studyperiod. The four remaining counsellors only had up totwo recorded treatment sessions from two or moreassessment periods. Work experience at the SNTQranged from 8-10 years. All counsellors included in thestudy had a background in traditional counselling (twowere health pedagogues and one was a dental hygienist byprofession) and were between 33 and 57 years of age.

Treatment integrityThe MITI rating scheme rates practitioner behaviours.Coding involves the scoring of global variables, andcounting the frequency of specific verbal behaviours[17,18]. In version 3.0 of the MITI, global ratings include

MI Spirit (comprising three sub-variables: Evocation,Collaboration and Autonomy Support), Empathy, andDirection, which are rated on a five-point Likert-typescale ranging from 1 (low) to 5 (high). Detailed instruc-tions on how to rate the global variables are provided inthe MITI manual [18].

MITI behaviour frequency counts are Giving Informa-tion, MI Adherent and MI Non-Adherent statements,Questions (Closed and Open), and Reflections (Simpleand Complex). Four calculated indices (Summary Scores)have been developed to measure MI skill: (1) Ratio of MIAdherent to MI Adherent and MI Non-Adherent state-ments; (2) Ratio of Reflections to Questions; (3) Ratio ofOpen Questions to Open and Closed Questions; and (4)Ratio of Complex Reflections to Simple and ComplexReflections [18].

MI Adherent statements are assigned for counsellorbehaviours such as asking permission before givingadvice or information; affirming clients or emphasisingclients' control or autonomy; or supporting clients', forexamples through expressing compassion. MI Adherentstatements are assigned for counsellor behaviours such asadvising without permission; confronting clients; ordirecting clients, for example through the use of orders,commands or imperatives [18]. Open questions have awide range of possible answers, whereas closed questionsare questions for which there is a particular answer, or towhich only "yes" or "no" may be replied [18]. The client'sresponse to the question does not affect its nature asOpen or Closed. Simple Reflections convey understand-ing, yet add little or no meaning to the client's statements,whereas Complex Reflections add substantial meaning oremphasis to what the client has said [18].

For every global variable and index (Summary Score)there are recommended thresholds for "Beginning Profi-ciency" and "Competency" levels of MI skill respectively,based on the MITI coding instrument. These thresholds,suggested by the New Mexico University Research Groupexpert opinion, are however in need of further empiricaltesting [18].

In the present study, the coding was undertaken by twosenior coders, from the Motivational Interviewing Cod-ing Laboratory (MIC Lab) at the Karolinska Institute inStockholm. MIC Lab coders participate in more than 40hours initial training, in accordance with the recommen-dations of the University of New Mexico Research Group,followed by three-hour training sessions every fortnight.The two coders responsible for the coding of the materialfor the present study had worked at the MIC Lab since2005 and 2006 respectively. The Swedish translation ofMITI 3.0 was used for the study [19]. Recent researchtesting the validity of the MITI found that intra-class cor-relation (ICC) coefficients for MIC Lab coders trained inthe Swedish translation of the MITI 3.0 demonstrated a


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significant improvement compared to ICC coefficientsyielded in coding using MITI 2.0 [20], in statistical analy-sis where all variables were transformed to z data [20].The authors concluded that MITI 3.0 appeared to be eas-ier for coders to use reliably, especially with regard to theglobal variables, which are more specifically defined inMITI 3.0, while measuring the same constructs as MITI2.0 [21].

Coder inter-rater reliability was high, with ICC coeffi-cients ranging from 0.68 to 1.0 for both global variablesand behaviour counts [20], thus ranging from "good" to"excellent" [27]. To reduce intra-rater and inter-rater vari-ations, all material was coded during a four-week periodin August-September 2007. Moreover, the same codercoded one counsellor for all his or her sessions. Coderswere blind as to the dates of recorded material.

Assessment periodsSNTQ counsellors were encouraged to audio-recordtreatment sessions at certain fixed intervals (assessmentperiods). Assessment periods ranged from two to sixweeks, according to counsellor working hours. At eachassessment period the three counsellors audio-recordedtheir first three sessions. Thus, for each assessmentperiod, three audio-recorded sessions from each of thethree SNTQ counsellors included in the study were treat-ment integrity assessed using the MITI 3.0. A mean scorewas calculated from the three different sessions for eachof the counsellors, and for each of the MITI 3.0 variablesat each assessment period. Therefore a particular MITI3.0 score at a given point in time represents the mean ofthree different sessions.

Baseline assessment of counsellor MI skill was con-ducted between September and December 2004 (initialMI training was conducted in February 2003). Their MIskill as measured by the MITI was then assessed at 10consecutive assessment periods at around six weeksinterval until the study's end in early February 2007.

ResultsMI skill as measured by MITI 3.0All three counsellors in the present study are below therecommended threshold for Beginning Proficiency in allof the MITI variables at baseline assessment. Figures 1, 2,3, 4, 5, 6, 7, 8, 9, 10 and 11 show each counsellor's MIskills and the mean score for all three counsellors, asmeasured by each of the MITI variables, throughout thetwo-and-a-half years of training and supervision. Thethreshold for Beginning Proficiency suggested in theMITI manual is indicated where applicable.

The Empathy variable (Figure 1) indicates to whatextent the counsellor understands or makes an effort tograsp the client's perspective. Approximately 12 monthspost baseline, the mean for all three counsellors coincides

with the MITI Manual's recommended threshold forBeginning Proficiency. There are great fluctuations in allcounsellor Empathy scores and in counsellor 1 (C1) inparticular. C1 remains below the recommended thresh-old for Beginning Proficiency until October 2006, almosttwo years post baseline. The most notable improvementis seen in counsellor 3 (C3). In counsellor 2 (C2) there is arapid increase in skill post baseline, and retention of skillabove the recommended threshold for Beginning Profi-ciency throughout the study period.

The Evocation scale (Figure 2) measures the extent towhich the counsellor conveys an understanding thatmotivation to change, and the ability to move towardchange, reside within the client, for example, by makingefforts to elicit change talk. There are great variationsbetween counsellors and fluctuations in counsellor per-formance over time. The mean for all three counsellors iscontinuously improving throughout the study period.

The Collaboration scale (Figure 3) measures the extentto which the clinician behaves as if the interview is occur-ring between two equal parties, both of whom possessknowledge that might be useful with regard to the prob-lem under consideration. The development illustrated inthe Collaboration variable is similar to that in Evocation.The mean shows an increase in Collaboration, but thereare variations across counsellors and in counsellors overtime.

The Autonomy Support variable (Figure 4) measuresthe extent to which the clinician supports and activelyfosters client perception of choice, as opposed toattempting to control the client's behaviour or choices.There is an increase in MI skill in the Autonomy Supportvariable in all counsellors. There is a continuous improve-ment in skill throughout the study period in C3. Thegreatest fluctuations in demonstrated skill in the Auton-omy Support variable are seen in C1. C2, rapidlyincreases in skill post baseline, remaining above the meanthroughout the study period.

The mean of the Evocation, Collaboration and Auton-omy Support variables gives the MI Spirit (Figure 5). TheMI Spirit variable demonstrates a gradual increase in MIskill, but fluctuations are great. The mean for all threecounsellors remains below the recommended thresholdfor Beginning Proficiency until October 2006, almost twoyears post baseline. The acquisition of MI Spirit skillsappears to take considerably longer than, for instance,Empathy skills.

The Direction variable (Figure 6) measures the extentto which clinicians maintain appropriate focus on issuesdirectly relevant to the specific target behaviour(s) thatconstitute the focal point for the session. The scores forthis variable remained roughly constant for all counsel-lors throughout the study.


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The Giving Information category (Figure 7) is usedwhen the interviewer gives information, educates, pro-vides feedback or discloses personal information, as wellas when the interviewer gives an opinion, without advis-ing. In this variable there is little change of note, neitherover time nor across counsellors.

One behaviour count index that shows considerablevariation across counsellors is the Ratio of Reflections toQuestions (Figure 8). C2 remains constantly (and at timesconsiderably) higher than the other counsellors. None-theless, after approximately six months, all counsellorsdemonstrate use of as many Reflections as Questions intheir sessions.

In the percentage of Complex Reflections as a propor-tion all Reflections index (Figure 9), the mean remainsbelow the recommended threshold for Beginning Profi-ciency until 15 months after the initial MI training ofcounsellors. There are great fluctuations in the use ofComplex Reflections.

In the percentage of Open Questions as a proportion ofOpen and Closed Questions index (Figure 10), the meanremains below the recommended threshold for Begin-ning Proficiency until 20 months after initial MI training,and the ability to use Open Questions rather than ClosedQuestions is not retained after October 2006.

The percentage of MI Adherent utterances as a propor-tion of MI Adherent and MI Non-Adherent utterancesindex (Figure 11) is used to capture particular counsellorbehaviours that are consistent with the MI approach,such as asking permission before giving advice or infor-mation or affirming the client. There are again consider-able differences across counsellors. In C2, there is a rapidincrease in skill demonstrated post baseline, performancethereafter remaining stable and above the recommendedthreshold for Beginning Proficiency up until the lastassessment period. C1 and C3 improve steadily, butremain below the recommended threshold for BeginningProficiency for the duration of the two-and-a-half yearstudy period.

DiscussionOnly three counsellors had 3 or more audio-recorded ses-sions for each of the 11 assessment periods and were thuseligible for inclusion in the study. This factor severelylimits the ability to draw conclusions based on the results.However, including counsellors with fewer recorded ses-sions from each assessment period would have made theMITI rating of counsellors' performance too vulnerableto difficulties experienced in individual sessions, such asparticularly "difficult" clients, and compromised thestudy's usefulness as a model for large scale replication.

Figure 1 MITI Empathy variable scores for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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The findings of the present study suggest that in spite ofits theoretical simplicity not all practitioners necessarilylearn MI easily. Any successful implementation in a natu-ralistic clinical setting requires ongoing supervision ofcounsellors, including feedback and monitoring clinicalpractice. These findings are in line with previous researchthat sought to evaluate MI training and supervision inter-ventions [9-11].

Like several other studies on MI training using objec-tive outcome measures, the present study finds improve-ments in MI skill, for example, an increased use ofreflections, after the initial workshop [7-9,28,29]. In arecent review only 1 out of 11 studies reported no signifi-cant difference post training relating to MI skill [7].Moreover, our findings show that counsellors improvedtheir MI skill compared to baseline level of skill in most ofthe MITI variables, though some variables took longer toimprove. Most interestingly, the MITI variables continu-ously and steadily improved over the two-and-a-half yearstudy period. From a client point of view, this means thatthe counsellor sessions were on average conducted moreskilfully each assessment period.

Although the mean for the three counsellors includedsteadily improved throughout the study period, therewere great variations in skill among counsellors and inlearning time. There were no differences in background

of counsellors included in the study that might explainthe variance in acquisition of MI skill and performanceover time. Literature in the field has found little or no cor-relation between the level of education or degree of workexperience and positive outcomes, although variations inoutcome have been found across counsellors [30-32].However, none of this helps to explain the causes of par-ticular counsellors' skill in certain variables.

According to counsellor comments, reduced in-sessionMI performance might depend on having "a bad day",tiredness and personal issues that negatively affect theability to maintain appropriate focus, external distur-bances of counsellor sessions in the workplace, and varia-tions in difficulty of client problems. Such factors mayaccount for some of the variations, both across counsel-lors and in counsellors over time. Moreover, differencesin acquisition of MI skills could relate to the degree ofmotivation or readiness to change in counsellors. Thestudy design might be improved by including an indepen-dent measure of counsellor readiness to change, or moti-vation to learn MI. More research is needed into possiblecauses for differences in skill and outcome in clientsacross clinicians.

The variability in acquisition and performance of MIskills, and the fact that performance within counsellorsfor specific skills varies over time, highlight the chal-

Figure 2 MITI Evocation variable scores for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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lenges facing those who wish to implement MI in real-world settings. The differences in ease of learning andlearning time are of sufficient significance to raise theissue of a selection procedure for MI training (as has beensuggested in the literature) [31,33], as well as renderingdeeper consideration of training and supervision meth-ods necessary. It may be that organisations wishing toimplement MI would better apply their resources toongoing supervision and treatment integrity assessmentof MI practice, as opposed to only investing in costly MIworkshop training - or at least develop a programme forcontinuous development of MI skill.

With regard to which MI skills were most and least eas-ily acquired by counsellors, the Ratio of Reflections toQuestions demonstrates a rapid improvement, suggestingthat reflective listening may not be difficult for counsel-lors to learn. After approximately six months, the meanfor the nine sessions coincided with the MITI Manual'srecommended threshold for Beginning Proficiency. Thisis encouraging, as use of Reflections contributes to Empa-thy, which is thought to set a necessary stage for MI ses-sions and has been shown to be predictive of outcome[34,35]. From a pedagogic viewpoint, this finding favoursMI training beginning with reflection or "OARS" (openquestions, affirmations, reflections, summaries) type

skills, which were the focus of all training schemesreviewed by Madson et al [7].

In the present study, it took two-and-a-half years for allthree counsellors to reach the recommended thresholdfor Beginning Proficiency in the MI Spirit variables,which have also been found to have bearing on outcome[3]. MI training might benefit from greater concentrationon skills associated with MI Spirit, such as elicitingchange talk, by adding training designed to meet theseneeds after the initial workshop. Another finding, how-ever, was that there were great variations in MI Spirit skillacquisition across counsellors, with C2 reaching Begin-ning Proficiency after a few months, and C1 only reach-ing Beginning Proficiency after two-and-a-half years ofpractice and supervision. This suggests that the ability tolearn to use some MI techniques will vary considerablyacross potential MI practitioners.

The MITI Direction variable was the only of the globalvariables that remained roughly constant for all counsel-lors throughout the study. This is consistent with thebackgrounds of the counsellors included in the study. Allcounsellors included were highly experienced in ordinarysmoking cessation counselling. Unlike the other of theglobal MITI variables, a high score for Direction does notnecessarily reflect a better use of MI, although the reverse

Figure 3 MITI Collaboration variable scores for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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is true, that is, in order for a session to reflect good use ofMI, it must have a high Direction rating [2].

SNTQ counsellors have a manual comprising a numberof Closed Questions, concerning, for example, clienttobacco consumption and smoking patterns, which mighthave affected the proportion of Open Questions to Openand Closed Questions index negatively. Moreover, codersdid not code counsellor questions on practical issues suchas whether clients wanted material sent to them, or theircontact details, since some counsellors included this aspart of the session whereas others did not.

The data represents counsellor performance asacquired and retained over an extended period of time, inan ordinary clinical setting of the type where MI might beordinarily implemented, thus providing a view of MI thatis substantially different from typical RCTs demonstrat-ing its efficacy. The great variation of MI skill in counsel-lors who have undertaken the same amount of trainingand supervision suggests that treatment integrity is cru-cial, in research as well as in ordinary clinical practice. Inresearch aiming to accurately assess the efficacy of MI,the first step must be to ensure that practitioners respon-sible for delivering the treatment are indeed using MI (ora treatment which bears sufficient similarity to MI). Thepresent findings suggest that attendance of initial MItraining is not a good measure of MI skill. In a recent

review of efficacy of MI in smoking cessation counselling,only 1 of 14 selected studies used a validated treatmentintegrity instrument [5]. Failure to account for the extentto which the proposed treatment intervention has beensuccessfully implemented, through treatment integrityassessment, risks discrediting the treatment methoditself, whereas the absence of positive outcome mayinstead be attributable to failed implementation. It is sub-mitted that the use of MI in ordinary clinical practiceought to be subject to (at least) periodic assessment oftreatment integrity using a validated instrument. Resultsof such assessment would not only serve as a trigger for"refresher" sessions where MI was not successfully imple-mented, but also provide a valuable learning tool for con-tinued development of MI skills. Treatment integrityassessment would also help to ensure that clients receiv-ing purported MI treatment actually receive that to whichthey consent.

One possible limitation is the nature of the SNTQ set-ting (self-initiated contact) that suggests considerablereadiness for change among clients. However, it has beensuggested that if a client is ready for change, the use of MImay stifle their desire to change [2]. It is possible that thisis common in SNTQ clients, and identified by (some)SNTQ counsellors. Consequently, for clients who no lon-ger display resistance or ambivalence towards smoking

Figure 4 MITI Autonomy Support variable scores for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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Figure 5 MITI MI Spirit (mean Evocation, Collaboration, Autonomy Support) variable scores for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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Figure 6 MITI Direction variable scores for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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Figure 7 MITI Giving Information behaviour count scores for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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Figure 8 MITI ratio Reflections to Questions index for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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Figure 9 MITI percentage Complex Reflections (Complex Reflections/Total Reflections) index for counsellors C1, C2, C3. Three coded ses-sions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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Figure 10 MITI percentage Open Questions (Open Questions/Open + Closed Questions) index for counsellors C1, C2, C3. Three coded ses-sions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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cessation, some counsellors may switch their approach tocognitive behavioural therapy inspired counselling. Suchin-session behaviour would result in lower MITI scores,but not necessarily negatively influence outcome. To thisextent, the validity of MITI is limited insofar as it is notconstructed to capture complex therapist competencemanifested in intentional and strategic use of MI [13],therefore potentially underestimating practitioner skill.

In spite of the limitations resulting from the small num-ber of included counsellors, the present study has severalimportant advantages with regard to design. The authorsare not aware of any other studies where MI training hasbeen followed by continual supervision and monitoringof counsellor MI skill in an ordinary clinical setting overas long a time period as the present study. Most otherstudies into the acquisition and retention of MI skills arelimited to workshop format training efforts and pre- orpost-training evaluations. Only 3 studies of 27 includedin a recent systematic review by Madson et al. coveredworkshop and supervision [7], and only 1 describedcoaching after initial MI training [9]. This is despite thesuggestion that a workshop-only format, although yield-ing improvements in knowledge and confidence, tendsnot to achieve competency or longevity in all MI variables[36,37]. Given these findings, and the considerableresources spent on attempts at en masse implementation

of MI using workshop-only formats, studies covering lon-ger time periods that examine training and supervisioninterventions in relation to acquisition and retention ofMI skills in participants are essential, and the presentstudy may provide a blueprint for future large scaleresearch.

The study is one of the first to provide empirical datarelating to Miller and Moyers' "Eight Stages in LearningMotivational Interviewing" [38]. However, contrary towhat is suggested by Miller and Moyers, the results sug-gest that the OARS skills that form part of the secondstage in learning MI are the skills that counsellors exhibitfirst in their clinical practice. The present study's designwould be suitable for large sample replication to test theauthors' hypotheses. Such a replication study has thepotential to influence the MI training literature in animportant manner. Similarly, the present study's designmight serve as a basis for (large sample) replication toempirically test the recommended thresholds for Begin-ning Proficiency suggested in the MITI 3.0 manual, ifoutcome measures are related to MI skill.

AbbreviationsC1: Counsellor 1; C2: Counsellor 2; C3: Counsellor 3; ICC: Intra-class correlation;MI: Motivational interviewing; MIC Lab: Motivational Interviewing Coding Lab-oratory; MITI: Motivational interviewing treatment integrity; MISC: Motiva-tional Interviewing Skills Code; OARS: Open questions, affirmations, reflections,

Figure 11 MITI percentage MI Adherent (MI Adherent/MI Adherent + Non Adherent) index for counsellors C1, C2, C3. Three coded sessions per assessment period for Sept/Nov 2004 (baseline) - Dec/Jan 2007, as well as mean for all counsellors.

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summaries; RCT: Randomised Controlled Trial; SNTQ: Swedish NationalTobacco Quitline.

Competing interestsThe authors declare that they have no competing interests.

Authors' contributionsLF drafted the manuscript, and made substantial contributions to the interpre-tation and analysis of results. LGF contributed to the conception and design ofthe study, in addition to the interpretation of the data and the initial drafting ofthe manuscript. HL contributed to the statistical analysis of data with regardsto tobacco abstinence in clients, and made helpful comments on previousdrafts of the manuscript. AH contributed with the material from the SNTQ, inaddition to helpful comments on previous drafts of the manuscript. All authorsapproved the version to be published.

AcknowledgementsThe research was funded by Cancerfonden (the Swedish Cancer Society), Hjärt-Lungfonden (the Swedish Heart and Lung Society) and Vetenskapsrådet (the Swedish Research Council). All authors worked independently of the funding bodies. The authors would also like to thank all the counsellors at Sluta Röka-Linjen (SNTQ), the Stockholm County Council Tobacco Prevention Programme, and the National Institute of Public Health. The considerable assistance of Catrine Björnström, Isra Black and Håkan Källmén, is gratefully acknowledged.Draft versions of some of the figures were presented at the International Con-ference on Motivational Interviewing in Interlaken, Switzerland, 9th June 2008.

Author Details1Department of Clinical Neuroscience, Karolinska Institute, 171 76 Stockholm, Sweden, 2Department of Public Health Sciences, Social Medicine, Karolinska Institute, Box 17070, 104 62 Stockholm, Sweden and 3School of Health and Education, Reykjavik University, 103 Reykjavik, Iceland

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Received: 15 November 2009 Accepted: 13 May 2010 Published: 13 May 2010This article is available from: http://www.substanceabusepolicy.com/content/5/1/8© 2010 Forsberg et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Substance Abuse Treatment, Prevention, and Policy 2010, 5:8

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38. Miller WR, Moyers TB: Eight Stages in Learning Motivational Interviewing. Journal of Teaching in the Addictions 2007, 5:3-17.

doi: 10.1186/1747-597X-5-8Cite this article as: Forsberg et al., Clinician acquisition and retention of Motivational Interviewing skills: a two-and-a-half-year exploratory study Sub-stance Abuse Treatment, Prevention, and Policy 2010, 5:8



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