Training health and mental health professionals in ...

Children and Youth Services Review 34 (2012) 1786–1795

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Children and Youth Services Review journal homepage: www.elsevier.com/locate/childyouth

Training health and mental health professionals in motivational interviewing: A systematic review Melanie A. Barwick a, b, c, d,⁎, Lindsay M. Bennett a, 1, Sabine N. Johnson a, 2, Jessie McGowan e, f, 3, Julia E. Moore g, 4 a

Research Institute, The Hospital for Sick Children, Toronto, ON, Canada Learning Institute, The Hospital for Sick Children, Toronto, ON, Canada Department of Psychiatry, University of Toronto, ON, Canada d Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada e Department of Medicine, University of Ottawa, 1 Stewart Street Ottawa, ON, Canada K1N 6N5 f Department of Family Medicine, University of Ottawa, 1 Stewart Street Ottawa, ON, Canada K1N 6N5 g Prevention Research Center, Human Development and Family Studies, Pennsylvania State University, USA b c

a r t i c l e

i n f o

Article history: Received 15 December 2011 Received in revised form 7 May 2012 Accepted 9 May 2012 Available online 17 May 2012 Keywords: Motivational interviewing Practitioner training Systematic review

a b s t r a c t Objective: This systematic review sought to determine the current state of the literature on the effectiveness of training health and mental health professionals in motivational interviewing (MI). Method: Data sources: The following databases were searched: MEDLINE/PreMEDLINE, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and CENTRAL Cochrane Central Trials Register. Inclusion criteria were empirical studies of any year that employed any research design to evaluate the effectiveness of training health or mental health professionals in MI. Studies with main outcomes other than behavioral or organizational were excluded. To minimize bias, dual review was employed. Full data abstraction was conducted independently by two reviewers. A qualitative synthesis of the findings and risk of bias data are reported. Results: A total of 22 studies were included in this review. Seventeen of the 22 studies reported significant practitioner behavior change relative to motivational interviewing skills, notwithstanding variation in training approach, population, outcome measures, and study quality. Conclusion: This review demonstrates practitioner behavior change on MI skills utilizing a variety of training and outcome methods. Future work of high methodological rigor, clear reporting, and that attends to training as one part of the implementation process will help to elucidate the factors that lead to the uptake of new practices. © 2012 Elsevier Ltd. All rights reserved.

1. Introduction Following widespread recognition that many interventions found to be effective in health services research are not implemented into real world service contexts, attention has turned to models and studies of implementation and behavior change that can inform the process (e.g., Barwick, Kimber, & Fearing, 2011; Damschroder et al., 2009; Fixsen, Naoom, Blase, Friedman, & Wallace, 2005). This research has identified barriers (Ferlie & Shortell, 2001) and facilitators (Domitrovich et al., 2008) to implementation, and factors that likely play a role in implementation success or lack thereof (Damschroder et al., 2009). ⁎ Corresponding author at: The Hospital for Sick Children, 555 University Avenue, Toronto, ON, Canada M5G 1X8. Tel.: + 1 416 813 1085; fax: + 1 416 813 7258. E-mail addresses: [email protected] (M.A. Barwick), [email protected] (L.M. Bennett), [email protected] (S.N. Johnson), [email protected] (J. McGowan), [email protected] (J.E. Moore). 1 Tel.: + 1 416 813 7654x228111; fax: + 1 416 813 7258. 2 Tel.: + 1 416 813 1962; fax: + 1 416 813 7258. 3 Tel.: + 1 613 562 5800x1945; fax: + 1 613 562 5659. 4 Tel.: + 1 289 997 1651. 0190-7409/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. doi:10.1016/j.childyouth.2012.05.012

Studies also point to the need for researchers to study both the outcomes of behavioral interventions and the implementation process. In attending to both, insight will be gained into how implementation is best achieved in different contexts in a way that is both effective in the short and long term. Implementation of research evidence is not only a matter of adoption and sustainability but is also related to patient outcomes. A review of research on the influence of implementation on program outcomes concluded that for promotion and prevention programs, quality of implementation affects the outcomes obtained (Durlak & DuPre, 2008). Use of evidence-based practices (EBPs) necessitates implementation models that consider the strength of the evidence for both the behavioral intervention and the implementation methods. Each stage in the implementation process must be considered. Strategies in support of behavior change have identified several approaches with good and mixed evidence in their support (Grol & Grimshaw, 2003). While it is evident that ineffective treatments yield null outcomes, it must also be acknowledged that effective treatments that are poorly implemented lead to ineffective or even harmful patient outcomes. Ultimately, the goal is to facilitate widespread adoption of EBPs to improve public health outcomes and quality of care.

M.A. Barwick et al. / Children and Youth Services Review 34 (2012) 1786–1795

According to a review of the commonalities of successfully implemented practices and programs (Fixsen et al., 2005), practitioner training is considered to be one of seven core components of implementation. Along with staff selection, consultation and coaching, performance evaluation, program evaluation, facilitative administrative supports, and system interventions, practitioner training works with these other elements as interactive implementation drivers. In behavioral healthcare, practitioner training methods are widely used and their effectiveness has been linked to activities (e.g., coaching) that exist alongside the discrete training endeavor to support practice change. Joyce and Showers (2002) demonstrated the importance of integrated implementation drivers in a meta-analysis of research on training and coaching. They learned that training that consisted of theory and discussion produced only a modest gain in knowledge and the ability of teachers to demonstrate the new skills in a protected training environment, but there was no skill transfer to the classroom. More substantial gains were made when demonstration, practice, and feedback were added to theory and discussion in a training workshop, yet even this training method yielded little transfer to the classroom. It was only when on-the-job coaching was added that large gains were seen in knowledge, ability to demonstrate the skills, and use of the new skills in the classroom. Motivational interviewing (MI) is a counseling approach that focuses on helping clients explore and resolve ambivalence and centers on motivational processes within the individual that facilitate change. Most recently, MI has been defined as a collaborative, person-centered form of guiding to elicit and strengthen motivation for change (Miller & Rollnick, 2009). A large body of work studying the effectiveness of MI has led to several systematic reviews published in support of MI effectiveness for a range of client outcomes (Heckman, Egleston, & Hofmann, 2010; Rubak, Sandboek, Lauritzen, & Christensen, 2005). Given the extensive literature on the effectiveness of MI for a range of client populations, and our interest in training as an implementation driver, the focus for this review was on the effectiveness of MI training approaches. Little research exists on how best to train practitioners in EBP and what types of supports are necessary for achieving and maintaining quality implementation (Ringwalt et al., 2009). We are aware of two additional reviews of training in MI (Lindhe Söderlund, Madson, Rubak, & Nilsen, 2010; Madson, Loignon, & Lane, 2009). Madson et al. (2009) reviewed studies that trained any participants (including students/trainees) in MI or skills important to MI but offered no quality appraisal of included studies. Lindhe Söderlund et al. (2010) reviewed the evidence for training general health care practitioners in primary care settings in MI but excluded studies in specialty settings such as mental health and substance abuse. The current review differs from the 2009 and 2010 reviews in several ways and delivers a clear picture of the state of the literature on training health and mental health professionals in MI. Most importantly, we offer a critical quality appraisal of included studies which yield important information about the weight of reported results and areas for future direction. Further, our adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and inclusion of an information flow diagram provides transparency of our methodology and replicability of our results. Our publication search period extends to June 2009 (presumably beyond that of Madson et al., although their search period is not specified) and our search strategy, including key terms, is more explicitly described. We included only studies that reported behavioral outcomes, excluding studies that looked only at changes in attitudes or knowledge. Changes in attitudes and knowledge do not necessarily lead to behavior change, which is the desired outcome when training people to learn a new skill or adopt a new practice. Thus, our study contributes uniquely to the literature by including all professionals from all disciplines, including mental health, excluding students and trainees, and only including studies that report at least one behavioral outcome related to MI skill acquisition.

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2. Methods 2.1. Search strategy A systematic search of the literature was conducted to include all studies of any empirical research design that evaluated the effectiveness of training health or mental health professionals in MI. A search strategy was developed for motivational interviewing for OVID MEDLINE (2006 to June Week 1 2009). The search was then adapted for other databases including OVID Embase (1980–2009 Week 23), OVID PsycINFO (1950–June Week 1 2009), the Cochrane Database of Systematic Reviews (1st Quarter 2009) and the Cochrane CENTRAL Registry (1st Quarter 2009). The MEDLINE search strategy searched for the concept “motivational interviewing” using both MeSH (motivation/) and (Interview, Psychological/ or *Counseling/ or interviews as topic/) and textwords (motivational interview$.tw. or motivational interview$.tw.). The concept of training was searched using both MeSH (exp Inservice Training/ or exp Education/ or ed.fs.) and textwords (train$ or education or inservice or in-service or workshop$ or work-shops). The two concepts were then combined. The search results were filtered using a filter based on EPOC (Effective Practice and Organization of Care) search filter to retrieve the study designs: RCT, CCT, ITS and CBA. 2.2. Eligibility criteria We sought to include studies that evaluated the effectiveness of training health or mental health clinicians in MI. Inclusion criteria for the search included English-language studies of any research design and any year up to June 2009 that assessed practice change (behavioral outcomes) related to MI skill acquired through training. Studies with main outcomes other than behavioral (i.e., changes in knowledge, attitudes) were excluded, as were studies that trained students. It was decided that studies that employed simulated assessments to measure outcomes would be included, given their potential to contribute important information to the review. 2.3. Data management References from the search were imported into an EndNote™ database and tagged to indicate the source database. A de-duplication was performed after each set of results was imported. We reviewed bibliographic records for a final set of 671 citations. 2.4. Selection process Each application of eligibility criteria involved a calibration exercise and a form was developed and tested especially for this review. Two reviewers independently assessed the eligibility of bibliographic records. Studies passing this first screening were retrieved and independently evaluated by two reviewers. All conflicts were resolved via a discussion between the two reviewers, or if necessary, third party intervention. 2.5. Data abstraction Data were abstracted independently by two reviewers and input into qualitative tables developed for the review. Data included results, evaluation strategy (e.g., research design), key characteristics of the intervention (e.g., components, media, timing), participant characteristics, implementation strategy, and risk of bias. The Cochrane Effective Practice and Organisation of Care Review Data Collection Checklist (Cochrane Effective Practice and Organisation of Care Group, 2002) was used to assess the risk of bias in RCT/CBA/ITS study designs. It should be noted that EPOC does not review studies that have subjective primary outcome measures and only accepts objective measures. Nonetheless,

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we included such studies as per our inclusion criteria and scored relevant items as Not Applicable (N/A) when the outcome measure was subjective. Three quality ratings were developed based upon relevant risk of bias criteria in the The Cochrane Effective Practice and Organisation of Care (EPOC) Review Data Collection Checklist (2002): positive, negative, and neutral. A positive rating indicates that the RCT met more than 50% of the risk of bias criteria; a neutral rating indicates that the RCT met 50% of the quality criteria; and a negative rating indicates that the RCT met less than 50% of the criteria. Items that scored ‘done’ contributed positively to a rating, whereas items that scored ‘unclear’ or ‘not done’ contributed negatively. Risk of bias was assessed for all other quasi-experimental study designs using the relevant items from the Downs and Black (1998) checklist. Using the ten-item criteria, studies were given a positive (greater than 50% criteria met), neutral (50% criteria met), or negative (less than 50% criteria met) rating. When a study was described by more than one report, data were abstracted from all documents.

Original search Yields (n) MEDLINE PreMEDLINE Embase PsycINFO CDSR CDSR TOTAL

Database De-Duplication (removed) (n= 262)

Title and Abstract Screening (n= 409)

Bibliographic records or citations excluded via first relevance assessment (n=302)

2.6. Classification of training Given the importance of active learning and follow-up supports in training endeavors (Joyce & Showers, 2002), we chose to classify studies based on their training components. The terms “workshop” and “training” are used interchangeably to describe learning endeavors intended to impart knowledge and the development of skills. Such endeavors were classified under Intervention in Table 2 as involving theory and discussion alone (1) or in conjunction with demonstration (2) and/or practice of skills (3). If training components were not clearly described, a classification of “not clear” (NC) was assigned. In addition to the training event(s), post-training supports such as feedback, supervision, or coaching were classified as follow-up supports and denoted by “f/u.”

205 3 73 229 34 127 671

Full-text Screening (n=107)

Records added (n= 2) (Reference lists, Web of Science, Pubmed related items, Identified by author contact)

Reports excluded via second relevance assessment (n= 87)

Data abstraction (n= 22)

3. Results A PRISMA flow diagram illustrates the number of records at each phase of the review (see Fig. 1). Of the 409 studies that entered initial relevance screening, 302 were excluded. The remaining 107 records were retrieved for full-text screening, 87 of which were excluded for one or more of the following reasons: 1) they did not investigate the effectiveness of MI training; 2) they included students or trainees; and 3) they assessed main outcomes other than behavioral skill acquisition. Two studies identified through reference lists were added. Data was abstracted for 22 included studies. Of the 22 included studies, 14 were from the addictions and mental health fields, 7 were from healthcare, and one was from corrections (see Table 2). 3.1. Classification of training Most studies incorporated active learning into their training endeavors and provided support post-training in the form of feedback, supervision, and/or coaching (see Table 1).

Included Studies (n= 22)

Fig. 1. PRISMA flow diagram. The data provided represent the flow of information through the phases of the systematic review.

studies. One study (Lane, Hood, & Rollnick, 2008) examined the impact of using role play with colleagues versus simulated patients to practice skills gained through workshop training and found no difference in role play method. In the remaining two studies, one RCT focused on a 12-hour enrichment intervention involving weekly worksheets and reflective tasks (Bennett et al., 2007) and the second RCT evaluated the effectiveness of a 20-minute video training (Handmaker, Hester, & Delaney, 1999). Face-to-face workshop training was generally characterized by one and one-half to three-day interventions, although some studies spread the equivalent number of hours over a longer period of time. For instance, one study described a total of 40 h of training, although the number of sessions and time span was unclear (Spiller & Guelfi, 2007).

3.2. Study characteristics The 22 included studies included 12 randomized controlled trials (RCT; 8 stemming from the addictions field), one interrupted time series (ITS), and nine quasi-experimental designs. Thirteen of the studies were conducted in North America (n = 12 in the United States), while nine were conducted in Europe (n= 6 in the United Kingdom). All studies were published between the years 1999 and 2009. 3.3. Randomized controlled trials 3.3.1. Training approach Face-to-face workshop training was the evaluated intervention in nine of twelve RCTs. Training intensity varied across these nine

Table 1 Training components of included studies. Training components

Number of studies

Theory and discussion (1)a • With follow-up support + Demonstration (2)a • With follow-up support + Practice (3)a • With follow-up support Not clear (NC)a • With follow-up support

0 0 1 (quasi) 0 5 (3 quasi, 2 RCTs) 11 (6 RCTs, 4 quasi, 1 ITS) 1 (RCT) 4 (3 RCTs, 1 quasi)

(+ f/u) (+ f/u)a (+ f/u)a (+ f/u)a

a Item in brackets identifies the category of training component that is referenced under “Intervention” in Table 2.


Workshop training was typically didactic in nature, but also involved experiential activities such as discussions, practice, and role play. Training was conducted by MINT (Motivational Interviewing Network of Trainers) trainers, MI qualified researchers/authors, or trained experts for whom, in some cases, the nature of their expertise and identity was unclear. Training approaches provided a variety of supports. Supervision was provided by six of ten studies that did workshop training, most of which was individual supervision. There was no mention of supervision being offered in the remaining four studies. Coaching was provided by four of the twelve RCT studies, while five of 12 RCTs offered feedback on simulation or real life clients. The nature and extent of the feedback provided was often not explicitly reported. Five of 12 RCTs explicitly stated that they allowed some practice, either during or post-training with real or simulated clients. Six of 12 RCTs distributed some form of educational materials, including manual, handout, background reading, or case briefing. 3.3.2. Population Studies targeted a variety of health practitioners within the substance abuse and general healthcare fields. Within the substance abuse field, studies included mental health and addiction workers (1 study), clinicians (1 study), substance abuse counselors (2 studies), adolescent drug treatment practitioners (1 study), behavioral healthcare providers (1 study), social workers (1 study), and nurses, counselors, psychiatrists, social workers, and physicians (1 study). Within the health care field, studies included dieticians (1 study), health care practitioners (2 studies), and physicians (1 study). Of the 12 studies, 10 had a sample size between 10 and 76 participants; the two remaining studies included 129 and 140 participants. 3.3.3. Outcome measures The main outcome of interest for this review was practitioner behavior change. Studies evaluated practitioners' motivational interviewing skills through objective and subjective assessments. To be considered an objective assessment, measures needed to be completed by observers; subjective assessments included participant self-reports. All but one RCT included an objective measure of practitioner behavior change (Rubak, Sandboek, Lauritzen, Borch-Johnsen, & Christensen, 2006). Among objective measures, four RCTs used the Motivational Interviewing Treatment Integrity code (MITI; Moyers, Martin, Manuel, Hendrickson, & Miller, 2005), one used the Motivational Interviewing Skill Code (MISC; Miller, Moyers, Ernst, & Amrhein, 2003), one used the Behavioral Change Counseling Index (BECCI; Lane et al., 2005), and one used the Independent Tape Rater Scale (ITRS; Ball, Martino, Corvino, Morgenstern, & Carroll, 2002). Four RCTs used checklists or researcher-developed objective measures. One RCT relied upon a self-report questionnaire designed for the study (Rubak et al., 2006). Only four of the 12 RCTs assessed behavior at follow up, which ranged from three to 12 months post training (Brug et al., 2007; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Mitcheson, Bhavsar, & McCambridge, 2009; Moyers et al., 2008). 3.3.4. Results Ten RCTs noted post-training practitioner behavior change in at least some aspects of MI skills (Bennett et al., 2007; Brug et al., 2007; Carroll et al., 2006; Handmaker et al., 1999; Martino, Ball, Charla, Frankforter, & Carroll, 2008; Miller et al., 2004; Moyers et al., 2008; Rubak et al., 2006; Spiller & Guelfi, 2007; Tober et al., 2005). No differences in post-training practitioner behavior for either intervention or comparison groups was noted by Lane et al. (2008) or Mitcheson et al. (2009). Table 2 provides further detail on results. 3.3.5. Quality Among the 12 RCTs, only four met or exceeded 50% of the EPOC criteria; eight RCTs met fewer than 50%. Gaps in quality were present

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for the following criteria: lack of clarity on concealment of allocation (7 studies), blinded assessment of primary outcomes (7 studies), reliability of the primary outcome measure (7 studies), and protection against contamination (6 studies). One study was unclear on all six criteria (Spiller & Guelfi, 2007), and two studies were unclear on five criteria (Lane et al., 2008; Martino et al., 2008) (see Table 3). 3.4. Interrupted time series Our review included only one interrupted time series study design (Schoener, Madeja, Henderson, Ondersma, & Janisse, 2006). 3.4.1. Training approach The training approach was a two-day didactic and experiential workshop followed by eight bi-weekly small group supervision sessions and coaching. 3.4.2. Population The authors, who were MINT trainers, trained ten community mental health therapists in MI. 3.4.3. Outcome measures Using the MISC (Miller et al., 2003), the investigators coded 156 randomly selected pre and post audio-taped work sessions involving 28 clients. 3.4.4. Results The study reports improvement in five of six MI skill categories (see Table 2). 3.4.5. Quality For this study, it was not possible to ascertain the number of pre and post data points for each practitioner. Schoener et al. (2006) met fewer than fifty percent of the EPOC quality criteria and rated unclear on four criteria: independence of other changes over time; blinded assessment of the primary outcome; completeness of the data set; and reliability of primary outcome measure (see Table 4). 3.5. Quasi-experimental 3.5.1. Training approach All but one of the nine quasi-experimental studies evaluated the efficacy of workshop training; one study evaluated the efficacy of distance education training. Four studies employed a two-day workshop, ranging from 12 to 16 h of training. Three studies broke up the training over a longer period of time, ranging from 130 min delivered over 6 weeks to five three-hour sessions bi-weekly. One study trained participants for 16 h but did not describe how this time was distributed. Practitioners were generally trained by MINT trainers, although in one study practitioners were trained by a psychologist; the trainer qualifications were unclear in two studies. There were a variety of training supports across studies. Four of the nine studies provided feedback as a method of supporting the intervention. Three studies included clinician supervision; methods of supervision included individual supervision based on videorecording and having a supervisor who was able to listen to the session as it was being delivered and provide real-time feedback to the clinician. Most studies distributed educational materials as part of the training. 3.5.2. Population The study participants (i.e. those who were trained in motivational interviewing) included clinicians (social workers, counselors and researchers who had a range of educational backgrounds), health care and substance abuse practitioners, and probation officers and community counselors. The number of participants in the studies varied; seven studies included between six and 23 participants, the other two studies had 44 and 351 participants.

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Table 2 Key characteristics of included studies. Study [sector]

Design

Participants

Intervention

Comparison

Outcome(s)

Baer et al. (2004) [addictions]

Quasi exp pre-post repeated measures no control

Clinicians (n = 22)

Training (3)

None

MI skill assessed at baseline, + post-, and 2-month f/u using HRQ and SP interviews coded using MISC.

Quality Results

Bennett et al. (2007) [addictions]

RCT

Mental health and addiction workers (n = 44)

Brug et al. (2007) [health care]

RCT

Diabetes-care dieticians (n = 37)

THEME intervention MI update day including worksheets, reflective tasks, feedback, coaching, interactive MI update day (3+f/u) No training or Training, on-demand feedback feedback (3 + f/u)

Carroll et al. (2006) [addictions]

RCT

Clinicians (n = 37)

Training, supervision (3 + f/u)

Practice as usual

Doherty et al. (2000) [health care]

Quasi experimental (feasibility study)

Healthcare practitioners (n = 13)

Training, supervision (individual and peer) (3 + f/u)

None

Handmaker et al. (1999) [health care]

RCT


Video training (NC)

Docudrama of pregnant problem drinker

Hartzler et al. (2007) [addictions]

Quasiexperimental: pre-post repeated measures design, no control

Substance abuse practitioners (n = 23)

Training, practice, role play, written feedback (3 + f/u)

None

Lane et al. (2008) [health care]

RCT


Workshop + practice with simulated patient; case scenario briefs (3)

Workshop + practice with fellow trainee

Lane, Johnson, Rollnick, Edwards, and Lyons (2003) [health care]

Quasi experimental: pre-post repeated measures design, no control

Nurses (n = 6)

Training, simulated consultations (3)

None

Martino et al. (2008) [addictions]

RCT

Substance abuse counselors (n = 35)

Training, supervision (NC + f/u)

Practice as usual

Miller and Mount (2001) [corrections]

Quasi experimental

Probation officers and community correction counselors (n = 22)

Training, optional discussion sessions, distribution of educational materials (3 + f/u)

None

Miller et al. (2004) [addictions]

RCT

Substance abuse profs. and

a) Workshop only b) Workshop + feedback

Wait list or selfguided training

Interv. Grp: ↑ in MI skill post-training and f/u (psb 0.01); ↓ between post-training and f/u in HRQ and some MISC scores (pb 0.01). Interv. Grp: signif. ↑ in MI spirit and overall competence in MI (ps b 0.05).

MI skill assessed at baseline and 15 weeks post-training via SP interviews coded using MITI.

+

Counseling style assessed 1 month post- and 5– 6 months post-training via RP interviews coded using MITI and MISC. MI, non-MI, and general counseling skill assessed via a minimum of 3 post-training RP interviews coded using validated adherence/ competence measure. Practitioner skill, attitudes, knowledge assessed via role play, supervision practice sessions, and RP interviews coded with competency checklist. Practitioner skill assessed via SP and 5-point Likert scale for empathy, contrasting of patient's values with binge drinking, effectiveness dealing with defensiveness, and support of patient belief in ability to change. Empathy, MI spirit, MI behavior counts (adapted from MITI) assessed via self-report and independent rating of SP interviews pre- and post-training.

–

Interv. Grp: signif.↑ empathetic, reflective; more likely to let patients talk (ps≤0.01).

–

Interv. Grp: signif. ↑ MI skill and adherence ratings (p b 0.01).

+

Descriptive report of difficulty in acquisition of competencies, most evident after one year of training. Interv. Grp: signif. ↑ empathy; Patient: ↓ defensiveness and ↑ belief in ability to change (ps ≤ 0.01).

Proportion of behavior consistent with behavior change counseling assessed via standardized SP interview pre- and post-training and coded using BECCI. Behavior change counseling skill assessed via SP interview pre- and post training and coded using BECCI. Adherence and competence in MI-consistent and inconsistent behavior, and general subst. abuse counsel. strategies assessed via audio taped client interviews independently rated using ITRS. MI skill assessed at baseline via self-report, HRQ, and work sample coded using MISC; post-training via self-report, HRQ, and SP consultation coded using MISC; 4-month follow-up via self-report, HRQ, and work sample coded using MISC.

+

+

–

+

–

+

Counselor proficiency in MI N assessed at baseline, posttraining, and 4, 8, and

Post-training: moderate corr. between most practitioner and indep. ratings (pb 0.05); MI skill ↑ (pb 0.01); practitioners underestimated training gains. No significant difference in skill levels between intervention and controls (p = 0.029). Descriptive report of ↑ BECCI scores posttraining; nurses reported new skill acquisition. Interv. Grp: ↑ adherence and competence for MIconsistent behavior and ↓ adherence to MIinconsistent behaviors (psb 0.001). Self-reported proficiency in MI skills in practice (pb 0.0001); ↑ in MI skills on HRQ (pb 0.001); observ. measures show modest changes in behavior (pb 0.04); some retained 4 months post training. Interv. Grp: ↑ MI proficiency for all trained groups


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Table 2 (continued) Study [sector]

Design

Participants

Intervention

counselors (n = 140)

c) Workshop + individual coaching d) Workshop + feedback + individual coaching (3 + f/u) Training, supervision, distribution of educational materials (NC + f/u)

Comparison

Delayed training

Mitcheson et al. (2009) [addictions]

RCT

Adolescent drug treatment practitioners (n = 30)

Moyers et al. (2008) [addictions]

RCT

Behavioral health providers (n = 129)

a) Workshop training b) Workshop training+ enrichments (NC+f/u)

Self-directed training

Rubak et al. (2006) [addictions]

RCT

Physicians (n = 65)

Training (3)

No training

Rubel, Sobell, and Miller (2000) [addictions]

Quasi experimental pre-post repeated measures design no control

Clinicians and researchers (n = 44)

Training (3)

None

Schoener et al. (2006) [community mental health]

ITS

Therapists (n = 10)

Training, supervision, coaching (3 + f/u)

None

Shafer et al. (2004) [addictions]

Quasi experimental pre-post repeated measures no control

Counselors, case managers, program managers (n = 351)

Distance education training, distribution of educational materials (2)

None

Smith et al. (2007) [addictions]

Quasi-experimental pre-post repeated measures design no control

Clinicians (n = 12)

Workshop, live telephone supervision (NC + f/u)

Spiller and Guelfi (2007) [addictions]

RCT

Social workers (n = 11)

MI training + intensive supervision (3 + f/u)

Tober et al. (2005) [addictions]

RCT

Training in motivational enhancement therapy + supervision (3 + f/u)

Wahab et al. (2008) [health care]

Quasi experimental: process evaluation

Nurses, counselors, psychiatrists therapists, social workers, physicians (n = 76) Social workers and psychologist (n = 3)

Training, telephone supervision (3 + f/u)

Outcome(s)

(ps b 0.05). Clinically, (not statistically) significant impact of feedback and/or coaching.

N MI skill assessed at baseline, 3 and 6 months post‐training via audio taped SP sessions and coded using MITI. Competence in MI assessed – at baseline, 4, 8, and 12 months post-training via audio taped work sample coded using MITI. – MI use and adherence assessed at follow-up with self-report quest.

No significant impact of intervention with the exception of MI spirit at 3 months (p = 0.009). Interv. Grp: ↑ in MI skill post-training (p b 0.001). Enrichments did not impact clinician skill level. Interv. Grp: ↑ adherence to MI (ps ≤ 0.005). ≥95% of GPs reported using MI methods in practice. Participants used ↑ motivational statements in response to vignettes post-workshop than baseline (p b 0.001).

Proportion of motivational statements in written responses to vignettes at baseline and post-training; knowledge questionnaire, Understanding Alcoholism Scale. MI skill assessed pre- and post-training via audio taped work samples coded using MISC.

Readiness to change; change in substance abuse and MI knowledge (pre and post); HRQ at baseline, during second and third telecasts and post-training; MI skill assessed for a subset of 30 participants at baseline, post-training and 4-month f/u via audio taped work samples coded using MISC. None MI skill assessed via SP interview post-training and RP interviews at 8 and 20 weeks post-training coded using MITI. Practice as usual MI skill assessed at baseline and post-training via Eight Situations Questionnaire; MI-consistent and inconsistent behavior assessed during training via role play. Training in social Therapist competence in MI assessed via video of behavior and network therapy practice and coded using checklists; duration of + supervision training to achieve competence; financial outcomes. None

Quality Results

12 months post-training via SP and work samples and coded using MISC; HRQ.

+

–

N

+

–

Improvement in 5 of 6 therapist MI skill categories (ps b 0.01); ↑ in client change talk (p ≤ 0.01) ↑ in HRQ measure of reflective listening (p b 0.001); only 9 participants submitted tapes at all 3 time points; no signif. change over time.

All MITI scores ↑ over time; only two summary scores (R/Q and % OQ) ↑ signif. (p b 0.05). Interv. Grp: ↑ improvement of MI skill post-training (p b 0.002).

–

Interv. Grp: 72% of therapists achieved competence; mean of 208 days required to achieve competence.

MI skill assessed via audio – recording 10% of therapists' calls coded using MITI.

All therapists demonstrated some MI proficiency during calls.

+: Study meets >50% of quality criteria. –: Study meets b 50% of quality criteria. N: Study meets 50% of quality criteria.

3.5.3. Outcome measures All but one of the studies used an objective outcome measure, while four studies also used subjective measures. In the objective category,

two studies used the Helpful Response Questionnaire (HRQ; Miller, Hedrick, & Orlofsky, 1991), two employed the Motivational Interviewing Skills Coding (MISC; Miller et al., 2003), three used the Motivational

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Table 3 Quality assessment of RCTs. RCT

Bennett et al. (2007)

Brug et al. (2007)

Carroll et al. (2006)

Handmaker et al. (1999)

Lane et al. (2008)

Martino et al. (2008)

Miller et al. (2004)

Mitcheson et al. (2009)

Moyers et al. (2008)

Rubak et al. (2006)

Spiller and Guelfi (2007)

Tober et al. (2005)

Concealment of allocation? Follow up of professionals? Blinded assessment of primary outcomes? Baseline measurement? Reliable primary outcome measures? Protection against contamination

✓ ✓ NC ✓ NC ✓

NC ✓ ✓ ☹ ☹ NC

✓ NC NC ☹ ☹ ✓

✓ ✓ ✓ ✓ NC ✓

NC NC NC NC NC ✓

NC ☹ NC NC NC NC

✓ ☹ ☹ ✓ ☹ ✓

☹ ✓ ✓ ✓ ☹ NC

NC × ✓ ☹ NC NC

NC ✓ NC ☹ ☹ ✓

NC NC NC NC NC NC

NC ☹ NC ☹ NC NC

✓: Done; ☹: Not done; NC: Not clear.

Interviewing Treatment Integrity code (MITI; Moyers et al., 2005), one used the Behavior Change Counseling Index (BECCI; Lane et al., 2005), and one used researcher-adapted vignettes. Six of the studies employed simulated patients and three used real patients. Post-training follow up assessments were collected in four of the nine studies. Self-report was used as a subjective outcome measure in one study (Hartzler, Baer, Rosengren, & Wells, 2007). 3.5.4. Results Immediately following the training, six of the nine studies reported a significant positive increase on at least one of the outcome measures. For one study the direction of the effects was unclear (Wahab, Menon, & Szalacha, 2008); another cited difficulty in skill acquisition, although no significance tests were run on the primary outcome (Doherty, Hall, James, Roberts, & Simpson, 2000); one study reported no change in MI skills likely due to a very small sample of participants who submitted audio taped work samples (Shafer, Rhode, & Chong, 2004). Findings were mixed for the studies that included follow-up assessments a minimum of 2 months after the completion of the training. One study found that effects were maintained at follow-up, while another found that the positive effects of the training had dissipated. One of the quasiexperimental studies included both objective and subjective outcome measures and found a significant correlation between the measures (Hartzler et al., 2007). This study found that compared to objective assessments, participants underestimated their abilities in self-report. 3.5.5. Quality Eight studies received a positive rating and one study received a neutral rating in the risk of bias assessment. In some cases, lack of reporting clarity made it impossible to determine if criteria were met. Specifically, four of the studies failed to identify whether an attempt was made to blind the coders to the assessment time point, five studies were unclear in the reporting of their time period of recruitment, and in three it was unclear whether there was adequate statistical adjustment for confounding. Only one study provided information on how confounds were considered in analyses; three studies provided limited information, and four studies failed to account for potential confounders. In contrast, all nine studies reported that the

Table 4 Quality assessment of ITS. ITS

Schoener et al. (2006)

Protection against secular changes? Data were analyzed appropriately? Reason for number of points pre and post intervention given? Shape of the intervention effect was pre-specified? Protection again detection bias? Blinded assessment of primary outcome? Completeness of data set? Reliable primary outcome measures?

NC ✓ ☹ ✓ ✓ NC NC NC


participants were recruited from the same population and completed the training (see Table 5). 4. Discussion This study reviewed the effectiveness of training behavioral health care practitioners in motivational interviewing. It improves upon a 2009 review (Madson et al., 2009) on the same topic by the inclusion of a critical quality appraisal, adherence to the PRISMA guidelines, an extended search period, and the requirement that included studies have at least one behavioral outcome. Additionally, this review included mental health and substance abuse practitioners, in contrast to a 2010 review (Lindhe Söderlund et al., 2010). Both randomized and quasi-experimental designs were included, requiring two methods of quality appraisal. This was done in recognition of the limitations of RCT for capturing the complexity and richness of implementation research (Stead, Hastings, & Eadie, 2002). For example, randomized controlled trials often exclude the very factors that influence implementation in the real world, producing little or no data on the complex processes or contextual variables. The end results have reduced validity and are extremely limited in the extent to which they can inform the successful use of an EBP in practice (Greenhalgh, Robert, Bate, Macfarlane, & Kyriakidou, 2005). Seventeen of the 22 studies reported significant practitioner behavior change relative to MI skills notwithstanding variation in training approach, population, outcome measures, and study quality. In considering why similar changes were not demonstrated in some of the studies with null findings, authors cited several factors: a very low return rate for audio taped work samples (Shafer et al., 2004), limited baseline counseling skills of trainees and low motivation to learn MI (Mitcheson et al., 2009), and time constraints faced by practitioners as well as the need for ongoing support and training (Doherty et al., 2000). All of these factors can be categorized either as ‘characteristics of the individual practitioner’ or ‘characteristics of the inner setting,’ two of the five major domains identified as important for implementation by the Consolidated Framework for Implementation Research (Damschroder et al., 2009). The limited baseline counseling skills of trainees suggest the need to ensure compatibility between the requirements of the EBP and practitioner competencies. Suboptimal practitioner engagement, as reflected in low motivation and tape return rate, reflects the need to assess individual practitioner readiness for change prior to training. We are currently employing a strategy in our current implementation research whereby practitioners are assessed for individual readiness for change and are invited to sign a memorandum of understanding which outlines training expectations and responsibilities for both the researchers and participants. It remains to be seen, but we feel this will facilitate tape return and adherence to the measurement of implementation fidelity. Recognition of these factors as potential barriers to training success provides organizations with an opportunity to plan adequately in preparation for successful EBP implementation. The quality of the 22 included studies based on risk of bias assessment criteria varied, often as a function of study design. Very few


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Table 5 Quality assessment of quasi-experimental studies. Quasi-experimental

Shafer Smith Wahab Miller and Rubel Doherty Hartzler Lane Baer et al. et al. et al. et al. Mount et al. et al. et al. et al. (2000) (2004) (2007) (2008) (2003) (2001) (2007) (2004) (2000)

Was an attempt made to blind those measuring the intervention? Have the characteristics of participants (likely clinicians) lost to follow-up been described? Do the analyses adjust for different lengths of follow-up of participants? Were the statistical tests used to assess the main outcomes appropriate? Was compliance with the intervention(s) reliable? Were the main outcome measures used accurate (valid and reliable)? Were the participants in different intervention groups recruited from the same population? Were study participants in different intervention groups recruited over the same period of time? Was there adequate adjustment for confounding in the analyses from which the main findings were drawn? Were losses of participants to follow-up taken into account?

NC ✓ ✓ ✓ ✓ ✓ ✓ NC

☹ ☹ ✓ N/A ✓ ☹ ✓ ✓

✓ ✓ NC ✓ ✓ ✓ ✓ NC

✓ ✓ ✓ NC ✓ ✓ ✓ ✓

NC ✓ ✓ ✓ ✓ ✓ ✓ ✓

NC ✓ ✓ ✓ ✓ ☹ ✓ ✓

NC ☹ ✓ ✓ ✓ ✓ ✓ NC

✓ ✓ ✓ ✓ ✓ ✓ ✓ NC

☹ ☹ ☹ NC ✓ ✓ ✓ NC

NC

N/A

✓

NC

NC

☹

☹

☹

☹

✓

✓

☹

✓

✓

✓

☹

✓

☹


randomized studies met the EPOC criteria (note that the EPOC criteria are more stringent than what may be clinically acceptable) for high quality and this was mainly due to a lack of reporting clarity on several factors. A greater proportion of quasi-experimental studies met criteria for high quality as per the Downs and Black (1998) risk of bias criteria. It is important to recognize that the Downs and Black quality criteria are less stringent than the EPOC criteria, contributing to this observation. It should also be noted that none of the quasi-experimental research designs included a comparison group. Pre- and post-test studies without a comparison group have several limitations including issues related to internal and external validity; for example, selection bias, history, maturation, and testing may influence internal validity (Mercer, DeVinney, Fine, Green, & Dougherty, 2007; Sanson-Fisher, Bonevski, Green, & D'Este, 2007). Although all studies employed objective assessments, the quality of the measures and their psychometric properties varied. Given these findings, caution must be used when interpreting the results of the quasi-experimental studies. Across studies, some attention was paid to sustainability to the extent that investigators measured skills at follow up and some provided follow up training. However, given the variability of outcomes observed at follow up, it is difficult to draw conclusions about the long-term impact of the motivational interview training on participant outcomes over the long term. For the most part, RCT and ITS studies were conducted with recognition that training is not a “one shot deal” and requires supervision and coaching beyond the initial training time. In particular, one included RCT (Miller et al., 2004) evaluated the relative and combined impact of individual feedback and coaching on MI skill acquisition and found that these supports, both individually and combined, significantly enhanced clinical proficiency. In contrast, the quasiexperimental studies utilized additional supports to a lesser extent. RCTs attended to adult learning principles such as opportunity for practice, modeling, and provision of feedback and coaching over time to a greater extent than did the quasi-experimental studies. Emphasis needs to be paid to such principles of adult education in recognition that short, quick doses of training do not typically translate to behavior change in practice (Joyce & Showers, 2002). All studies reflect the fact that the practice of MI is relevant for a variety of professionals and settings. As our understanding of EBP implementation grows and makes its way into practice settings, it is important to recognize that training is only one element of successful implementation. Research that explores training approaches and subsequent behavior change is necessary but insufficient for developing a comprehensive understanding of what is needed to promote EBP adoption in the field. For the most part, studies relied on established objective measures of behavior change. The MITI and MISC measures, in particular, have practice based limitations, as that they are mainly suitable for use in

research contexts and require intensive training and time to score, and consequently, are costly to use and not amenable to practice use by supervisors. We note that measures of behavior change are not necessarily equivalent in the depth with this they capture MI behavior. For instance, a researcher checklist does not capture the amount of detail of MI behavior as the MITI. In future, consideration should be given to how one might weight such differences when comparing MI measures. The behavioral healthcare field is in need of fidelity and outcome measures that are usable in real world practice contexts and that can improve external validity. Modifications to reduce length and complexity would be needed to enhance the utility of these measures in education, training, and clinical supervision settings (Madson & Campbell, 2006). While self-report measures of MI skills lend themselves to greater ease of use in practice, several studies in this review found clinicians' self-reported proficiency in delivering MI to be unrelated to proficiency ratings in practice as assessed by skilled coders (Miller & Mount, 2001; Miller et al., 2004); other studies found that participants underestimate (Hartzler et al., 2007) or overestimate (Miller & Mount, 2001) their MI ability. One strategy might be for researchers to more clearly identify the stages of learning MI on which they are focusing (e.g., OARS — open-ended questions, affirmation, reflective listening, and summarizing; and rolling with resistance, etc.). This clarity and framing would be useful for those seeking to develop methods to teach MI. Miller and Moyers' (2006) Eight Stages of Learning MI provides one way of standardizing this focus. The stages are clearly outlined and easy for any health provider to understand. Based on their research and experience in providing training on MI, Miller and Moyers have found that practitioners acquire MI expertise through a sequence of eight stages: (1) openness to collaboration with clients' own expertise, (2) proficiency in clientcentered counseling, including accurate empathy, (3) recognition of key aspects of client speech that guides the practice of MI, (4) eliciting and strengthening client change talk, (5) rolling with resistance, (6) negotiating change plans, (7) consolidating client commitment, and (8) switching flexibly between MI and other intervention styles. They note that these key skills are acquired roughly in order, with earlier steps representing logical prerequisites for later stages of skill acquisition. Research on MI training has yet to evolve to develop a product, process, or checklist for practitioners to utilize in the real world. A standard, feasible, and preferred method for establishing MI adherence in practice has not yet been developed. In our current research implementing MI in four community-based behavioral healthcare organizations, we are exploring the utility of the Behavior Change Counseling Index (BECCI; Lane, 2002) as fitting this need. The experience of these organizations, and namely, the supervisors and managers, has highlighted that they welcome a user-friendly method of

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tracking MI fidelity in the field but that it needs to be highly usable, simple, and resource neutral. As the use of evidence-based practices comes to the forefront of behavioral health, there is a need to examine each of the stages involved in the process of implementation (Barrera & Sandler, 2006; Titler, 2008). Training and coaching are understudied areas in implementation research, and more work is needed to understand how training and coaching delivery methods impact implementation quality (Domitrovich et al., 2008; Elliott & Mihalic, 2004; Rohrbach, Grana, Sussman, & Valente, 2006; Sorenson et al., 1988) and how these methods work for specific EBPs, such as MI. Future research also needs to improve upon substandard reporting of training methods, study procedures, and data analysis. In the absence of sufficient detail regarding methods, poor quality ratings may be due to lack of reporting rather than methodological weaknesses. Detailed descriptions of both training approach and subsequent implementation support are needed in order to develop an appreciation for the nuances of behavior change methods and subsequent use of MI in the field. Therefore to advance the field, better instrumentation, measurement and analytical methods relevant to translational research are required (Dawson, 2004; Titler, 2008; Tripp-Reimer & Doebbeling, 2004). 4.1. Limitations Several limitations bear mention. Our inclusion criteria were broader than those defined by EPOC in order to capture the diversity of studies and complexity of the implementation process. While the Downs and Black quality criteria for quasi-experimental studies represent the gold-standard, these criteria are more liberal than the EPOC criteria, potentially inflating the quality rating given to our non-randomized studies. Only English language studies were included. 5. Conclusion As the field moves toward bringing research to practice, it is encouraging to see recent literature on the state of training and implementation efforts in behavioral healthcare. This review demonstrates practitioner behavior change on MI skills utilizing a variety of training and outcome methods. Greater recognition is needed with respect to training as one aspect of the implementation process, and improved methodological reporting and rigor will contribute to greater clarity on what works in changing practitioner behavior. Role of the funding source Funding for this research was received from the Canadian Institutes of Health Research (Grant number TMF-88575. CIHR Emerging Team in Knowledge Translation for Child and Youth Mental Health). The funder provided peer review and monetary support only and did not have any role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication. References Baer, J. S., Rosengren, D. B., Dunn, C. W., Wells, A. E., Ogle, R. L., & Hartzler, B. (2004). An evaluation of workshop training in motivational interviewing for addiction and mental health clinicians. Drug and Alcohol Dependence, 73, 99–106. http: //dx.doi.org/10.1016/j.drugalcdep. 2003.10.001. Ball, S.A., Martino, S., Corvino, J., Morgenstern, J., & Carroll, K.M. (2002). Independent tape rater guide. Unpublished psychotherapy tape rating manual. Barrera, M., & Sandler, I. (2006). Prevention: A report of progress and momentum into the future. Clinical Psychology: Science and Practice, 13(3), 221–226. Barwick, M., Kimber, M., & Fearing, G. (2011). Shifting sands: A case study of process change in scaling up for evidence-based practice. International Journal of Knowledge, Culture and Change Management, 10(8), 97–114. Bennett, G. A., Moore, J., Vaughan, T., Rouse, L., Gibbins, J. A., Thomas, P., James, K., & Gower, P. (2007). Strengthening motivational interviewing skills following initial

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