Motivational interviewing (MI) is a technique with the potential to be quite useful for training psychiatric residents. MI originated as a treatment approach for alcohol addiction (1), but has since evolved into a brief, evidence-based intervention for a range of psychiatric and medical conditions (2, 3). Due to the applicability of MI across medical disciplines, there has been growing interest in the literature regarding training in MI at both the medical student and resident levels. Recent articles describe the development and evaluation of MI curricula for first- and third-year medical students, with positive results shown in self-reported comfort and familiarity for medical students using MI techniques, and targeted areas for improvement in use of MI methods in patient-care (4, 5).
Residency programs have also begun to report on the implementation of MI programs. Examples include a psychiatric residency curriculum focused on patients with dual diagnoses (6) and a pediatrics program designed to prepare residents to address patient smoking (7). Furthermore, Greenberg and colleagues (8) noted that by providing MI instruction in addiction training, they have found residents "becoming more hopeful and skillful in responsibly engaging challenging patients." The goal of our paper is twofold: express our opinion that MI meets several of the psychiatric residency core competencies and identify research goals needed to determine if training in MI for psychiatric residents is worthwhile.
"MI is a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence" (9). Miller and Rollnick (10) describe four general principles of MI: express empathy, develop discrepancy, roll with resistance, and support self-efficacy. The first principle of expressing empathy relies on reflective listening techniques, consistent with the client-centered approach associated with the work of Carl Rogers. Second, the goal of developing discrepancy is to help the patient elucidate a distinction between their current behavior or general condition and the patient's goals and values. The third principle of rolling with resistance is both a mindset and set of skills designed to manage resistance in a supportive and noncritical manner. Finally, the principle of supporting self-efficacy emphasizes that the patient is ultimately responsible for change. Fostering a belief that the patient is capable can in effect lead to the very change that the patient is hoping for, while also relieving the burden of change from the clinician.
In Core Competencies for Psychiatric Education: Defining, Teaching, and Assessing Resident Competencies, Andrews and Burruss (11) describe the requirements and expectations for psychiatric residency programs based on Beresin et al.'s (11) psychiatric-specific competencies applied to the ACGME's six general competencies. In addition, Andrews and Burruss describe the five models of psychotherapy required of psychiatric residency programs. We highlight how MI fits directly with several important areas described by Andrews and Burruss.
Three of the psychiatry-specific competencies emphasize a therapeutic relationship with the patient. The Patient Care competency mentions the "therapeutic interview," while under Medical Knowledge residents must "demonstrate knowledge of psychosocial therapies including doctor-patient relationship." The competency most related to the therapeutic relationship is Interpersonal and Communication Skills, which contains the following expectations of psychiatric residents:
Training in MI not only advocates for the development of a strong doctor-patient relationship, it provides specific instruction on techniques a physician can employ to build such a relationship. Skills such as simple, complex, and summary reflections, as well as affirmations and emphasizing a patient's personal choice, provide residents with structured methods for fostering a therapeutic alliance. In addition, a review of MI found that one of its strengths is its utility with patients from diverse backgrounds (3). Furthermore, MI advocates for a collaborative physician-patient relationship that recognizes the patient's own expertise with their strengths and limitations.
The Patient Care competency mentions the goal of conducting a "range of therapies using standard accepted models that are evidence-based" (11) (emphasis added). MI provides an evidence-based clinical tool that has become widely used across medical disciplines. Within psychiatry, research regarding MI's efficacy in the management of addictions (12), co-occurring disorders (13), depression (14), and anxiety (15) is consistent with the goal established in the Patient Care competency of "standard accepted models." Of particular value to psychiatric residents is the added effect of MI when combined with other interventions (3). Since many of today's graduating psychiatric residents will likely utilize psychopharmacological interventions as their primary treatment approach, training in MI could afford residents a tool that complements medication management.
Additionally, conditions such as HIV and diabetes have shown positive patient outcomes when treatments incorporate elements of MI into the intervention strategy (16, 17). Given the challenges associated with treatment for individuals with co-occurring mental illnesses and conditions such as HIV and diabetes (18, 19), training in MI would provide residents with an approach that could help with the overall management of the patient and not just their psychiatric condition.
Andrews and Burruss (11) frequently mention the importance of empirical evaluation of resident learning, rather than using general impressions of resident competence. The Motivational Interviewing Treatment Integrity Code (MITI) (20) is a scale that measures a practitioner's application of MI in clinical settings. It is a relatively simple measure to administer, typically requiring the review of a 20-minute session segment, which can consist of an audio- or videotape, as well as live observation. The MITI generates five "global scores" that measure a clinician's ability to conduct a session consistent with the "spirit of MI." The MITI also utilizes "behavior counts" that assesses the frequency a practitioner displays the following in-session behaviors: giving information, questions, reflections, MI-adherent behavior, and MI-nonadherent behavior. The MITI provides a potentially useful method for residency programs to meet the need for empirical evaluation of resident competence in skills inherent to MI, as well as in the overall development of an effective psychiatrist.
Much of the empirical support for MI is as a brief intervention for challenging behavior changes (3). One of the five psychotherapies that psychiatric residents must demonstrate competence in is brief psychotherapy. Andrews and Burrus (11) included several MI-consistent elements within the knowledge, skills, and attitudes components of brief psychotherapy, such as:
Being a well-defined model that uses a focus of intervention and emphasizes elements of the doctor-patient relationship, such as empathy, respect, and collaboration, MI seems well-suited to meeting the requirements of the brief psychotherapy core competencies.
Several examples of MI-based interventions that are relevant to today's psychiatric resident exist in the literature. Kemp and colleagues (21) conducted a randomized controlled trial of compliance therapy, a method of increasing medication adherence for patients with psychotic disorders, based largely on MI. The authors report significant gains, following 4—6 sessions of compliance therapy, in attitudes toward treatment, insight, and compliance with medication over an 18-month follow-up period after discharge from an inpatient unit relative to nonspecific counseling. The authors also explain that booster sessions were offered to both experimental and control groups at 3, 6, and 12 months as part of routine follow-up services. With the average length of each compliance therapy session ranging from 20—60 minutes, it seems plausible that MI-based interventions seeking to increase medication adherence may fit the time constraints experienced by many practicing psychiatrists.
As mentioned previously, MI has shown particular utility when combined with other treatments. Given that psychiatrists often work as partners with non-M.D. therapists, research that shows increased adherence with psychotherapy and other nonpharmacological interventions following exposure to MI is relevant to our discussion. A randomized pilot study comparing an MI-based engagement session plus interpersonal therapy for depression with a referral to a community mental health provider found significantly higher percentages of attendance to first session (96% compared with 36%) and treatment completion (68% compared with 7%) for depressed economically disadvantaged women in the experimental condition (22). One of many pathways for an individual to enter psychotherapy with a non-physician therapist is by referral from their psychiatrist. Using an MI-adherent approach geared toward increasing likelihood of adherence to psychotherapy, as in the aforementioned engagement session study, an MI-trained psychiatrist can be uniquely helpful in facilitating a coordinated multidisciplinary treatment plan.
Zerler (23) authored a compelling rationale for the application of MI with suicidality. Although there has been no research examining the impact of MI on suicidality, Zerler provides an excellent description of the ethical challenges when working with this population and how the collaborative nature of MI will naturally require more directiveness from a clinician when questions of patient safety arise. However, Zerler also emphasizes the need for balancing patient safety with continued support of autonomy, within the confines of professional and ethical guidelines for managing a suicidal patient. Furthermore, Zerler explains that MI can be "functionally integrated with crisis evaluation, which, in effect, allows crisis evaluation to also comprise brief therapy" (p. 179).
The declining use of psychotherapy by psychiatrists is well documented (24). If psychiatry continues the transition from a profession grounded in the use of long-term psychotherapy to one characterized by more brief patient encounters consisting largely of medication-based interventions, teaching residents MI could meet training needs (see Table 1). MI training would provide residents with an empirically based method consistent with the brief psychotherapy core competency. Assessment of resident competence in the use of MI with the Motivational Interviewing Treatment Integrity Code also fulfills the requirement that training programs utilize empirical methods of resident assessment. Furthermore, the core principles of MI, namely expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy, are consistent with the core values of psychiatry as a profession. Even if psychiatrists do not directly provide psychotherapy, they must learn concepts that facilitate effective relationships with patients for whom they manage medications and in collaborating with non-M.D. therapists.
TABLE 1.Application of Motivational Interviewing to Psychiatry Core Competencies
The use of MI in psychiatry training programs may also enhance the contribution of psychiatric residents as teachers throughout their respective medical institutions. In 2001—2002, the Committee on Graduate Education issued a revised version of Psychiatric Residents as Teachers: A Practical Guide (25). In that guide, the committee notes that residents are responsible for an increasing part of medical student education. The guide also notes that past studies have indicated that up to 20%—25% of resident's time is spent teaching medical students. The ACGME requirements regarding psychiatry training note that "resident teaching abilities must be documented by evaluations by faculty and/or learners." Given the interest MI has generated across medical specialties, use of MI by residents in interviewing patients and in teaching medical students to interview should continue to benefit these students in all areas of medical practice.
However, before psychiatry training programs widely adopt MI as an approach in their curricula, more research is needed to determine whether training in MI will meet the needs of psychiatric residents and their patients. Questions that first must be answered include, but are not limited to: Will training psychiatric residents MI principles and techniques lead to improved comfort, knowledge, and competence in the use of brief interventions? Is the MITI a useful measure of resident competence? With the ACGME's emphasis on improved training for residents to teach medical students, does training in MI afford psychiatric residents the ability to teach medical students MI? Finally, does MI training lead to better patient care by psychiatric residents? It is our belief that with increased research on the application of MI in psychiatric residency training programs, residents will benefit greatly from training that prepares them for the realities of today's professional climate.