Abstract
Many undergraduate psychology students assume positions as mental health paraprofessionals during or after college. The present study was a quasi-experimental evaluation of the effectiveness of teaching motivational interviewing (MI), a counseling approach that applies to many paraprofessional occupations. Results from 83 undergraduates indicated that both intensive and extended MI courses resulted in greater increases in MI knowledge, confidence, and skill than a brief MI lecture but did not differ from one another. Post-course reflective listening, summarizing sills, and ability to develop discrepancy for these two groups neared or exceeded beginning proficiency thresholds. Findings of this study suggest that even without outside practicum experience, students can achieve meaningful improvements in MI skill through undergraduate courses, which may enhance their performance as paraprofessionals.
Motivational interviewing (MI) is a counseling approach with demonstrated efficacy in improving outcomes related to substance use, health promotion, and probation and parole (Lundahl, Tollefson, Kunz, Brownell, & Burke, 2010). Use of MI has expanded to a wide array of disciplines, including mental health, medicine, and allied health (Miller & Rose, 2009). Thus, MI has broad applicability across helping fields of interest to psychology students, including those for which graduate/professional training may not be required (e.g., case manager, substance abuse counselor, parole officer). Undergraduates may choose psychology with an “I want to help people” mind-set (Kuther & Morgan, 2010); yet, few psychology graduates attend graduate school (Rajecki, 2012). In fact, Rajecki and Borden (2011) found that 6 of the top 10 job titles for psychology graduates were human service in nature and the other 4 required interpersonal communication skills. Thus, offering undergraduate coursework in MI may help psychology undergraduates better prepare for postgraduation employment opportunities (Brewer, 2006), whether it is in human services or other areas requiring active listening skills.
Tollison and colleagues (2008) demonstrated the value of teaching MI to undergraduate peer facilitators as part of an alcohol prevention program, but no studies have evaluated teaching MI through formal undergraduate coursework. The purpose of this study was to evaluate an MI curriculum offered in various course formats. We hypothesized that students in formal MI courses would achieve meaningful improvements in MI skill, knowledge, and self-confidence and that these improvements would exceed those demonstrated by students receiving only a brief lecture on MI as part of another course.
Method
Participants
Participants were 83 undergraduates from a mid-sized university in the southeastern United States, enrolled in either a 1-week intensive MI course (n = 15), 16-week extended MI course (n = 25), or counseling theories course with a 1-hr MI lecture (n = 43). The majority of participants were female (79.5%) and White non-Hispanic (59%) or African American (39.8%). The mean age was 23.7 (SD = 5.9) years. No group differences were found for age, sex, and race. Few participants (16.9%) had a counseling theories class prior to participating in the courses and 15.7% of participants held a counseling-related job prior to the courses.
Measures
Motivational Interviewing Knowledge Assessment Test (MIKAT)
The MIKAT is a 29-item measure that assesses participants’ knowledge of various fundamental aspects of MI (Leffingwell, 2006). For example, items ask participants to identify the various principles (e.g., rolling with resistance, developing discrepancy) of MI. Internal consistency in this sample was adequate (α = .72).
Motivational Interviewing Self-Skill Assessment (MISSA)
The MISSA is an 18-item measure that assesses participants’ confidence in their MI skills using a 5-point Likert-type scale ranging from 0 (lowest confidence) to 4 (highest confidence). Total scores range from 0 to 72 (Dyehouse, n.d.). Internal consistency for the MISSA with this sample was high (α = .94).
Video Assessment of Simulated Encounters–Revised (VASE-R)
Participants respond to 18 timed (60–90 s per item) questions that assess specific MI skills following three clinical vignettes of actors portraying clients resistant to change (Rosengren et al., 2005). Responses are scored on a 3-point scale (0 = MI-inconsistent responses to 2 = MI-consistent responses). VASE-R total scores range from 0 to 36, and subscale scores have varying ranges: reflective listening (0–8), responding to resistance (0–10), summarizing (0–6), change talk (0–6), and developing discrepancy (0–6). Higher scores indicate greater MI skill. Rosengren, Hartzler, Baer, Wells, and Dunn (2008) identified VASE-R score benchmarks for classifying trainees as (a) untrained, (b) beginning proficiency, and (c) expert proficiency. Two independent raters who were unaware of participant condition conducted ratings. Intraclass correlation coefficients (ICC) for the VASE-R in this sample were high for the total score (ICC = .82) and ranged from .33 (eliciting change talk) to .85 (responding to resistance). Eliciting change talk was the only subscale with an ICC below .70.
Procedure
Participants were enrolled in a counseling theories course that included a 1-hr lecture on MI, a 16-week MI course (two meetings for a total of 2.5 hr per week), or an intensive MI course (8 hr per day for five days). The two MI courses differed only in the duration of time over which the material was presented. Participants completed an Institutional Review Board-approved informed consent procedure before completing the pre-course assessment battery. We collected data through a 1-hr group administration of measures, given the first week and last week of the course or first day and last day of the intensive class. Participants completed the MIKAT first, MISSA second, and VASE-R third.
All courses/lectures were taught by the first author, a counseling psychology faculty member and followed the MI best practice recommendations (Madson, Lane & Noble, 2012; Madson, Loignon & Lane, 2009; Schumacher et al., 2012). The 1-hr MI lecture provided an overview of the major components of MI (e.g., spirit, principles, and skills). The MI courses presented the psychological theory related to MI (e.g., reactance theory, self-perception theory, self-efficacy theory) and skills through reading and lecture, video demonstrations, experiential exercises with feedback, homework assignments focused on building skill, and practice sessions. Content information was disseminated through required readings (i.e., Rosengren, 2009) and lecture. Experiential activities were derived from the Motivational Interviewing Network of Trainers (2006) training resource manual. Homework assignments were assigned from Rosengren (2009).
The course consisted of five segments organized to reflect the sequence of learning MI outlined by Miller and Moyers (2006), and each incorporated theoretical underpinnings, relevant empirical data, and practical skills. The first segment, MI Concepts, focused on the foundation and principles of MI and various theories of behavior change (e.g., the transtheoretical model of change). The second segment, Counseling Skills, focused on open questions, affirmations, reflections, and summaries. Identifying and reinforcing client utterances that support change was the focus of the third segment, Change Talk. The next segment of the coursework, Resistance, introduced participants to MI-consistent ways to view and manage resistance. Finally, participants were exposed to MI-Consistent Strategies for building motivation, providing information and feedback, securing commitment to change, and developing a change plan. Readers can contact the first author for more information or a course syllabus.
Results
Means and standard deviations for MI knowledge, confidence, and basic skill can be found in Table 1. A series of one-way, between-groups analyses of covariance (ANCOVAs) were conducted to compare groups on the dependent variables after the MI coursework, controlling for pre-course performance on these measures. The group variable had three levels: intensive course, extended course, and brief lecture. As seen in Table 1, the ANCOVAs were significant for MI knowledge, the MI skills, and self-confidence. The effect of MI group on increases in knowledge and skill were large, accounting for 42% and 60% of the variance, respectively, and small for self-confidence accounting for 10% of the variance, controlling for the contribution of pretest scores. The effect of MI courses on specific skills ranged from small (14% developing discrepancy) to large (51% for rolling with resistance). Post hoc, Bonferroni corrected (p < .002) pairwise comparisons revealed that for knowledge and skills, the courses outperformed the MI lecture but did not differ from one another. Using an uncorrected α (p < .05), the courses also outperformed the lecture for self-confidence. Although none of the students in the brief lecture condition achieved the beginning proficiency threshold for VASE-R total score established by Rosengren et al. (2008), 60% of those in the intensive course and 44% of those in the extended course met or exceeded this threshold (Figure 1).
Percentage of participants in each class who met or exceeded the beginning proficiency benchmark for total score and each subscale score on the Video Assessment of Simulated Encounters–Revised.
Pretest Means, Adjusted Posttest Means, Standard Deviations, and Analysis of Covariance Results for the Effects of Short Intensive, Extended, and Lecture Trainings on Nine Dependent Variables.
Note. CT = eliciting change talk; DD = developing discrepancy; MIKAT = Motivational Interviewing Knowledge Assessment Test; MISSA = Motivational Interviewing Self-Skill Assessment; RL = reflective listening; RR = responding to resistance; Sum = summaries; VASE-R = Video Assessment of Simulated Encounters–Revised.
VASE proficiency levels. aBelow untrained benchmark. bBetween untrained and beginning proficiency benchmark. cScore is approaching beginning proficiency. dBetween beginning proficiency and expert proficiency.
*p < .05. **p < .001.
Discussion
Consistent with our hypotheses, undergraduates enrolled in the MI courses achieved better outcomes in skill and knowledge than those who received a 1-hr lecture. Examination of the mean level of MI skill achieved by each group revealed that whereas students in the lecture had mean postscores below the “untrained” benchmark, all mean scores for students in the courses exceeded this benchmark. Moreover, mean scores for summarizing, reflective listening, and developing discrepancy approached or exceeded the “beginning proficiency” benchmark for MI in the courses. These results suggest that even without outside clinical practicum experience, undergraduates who generally have no prior experience providing counseling can achieve meaningful skill improvements in MI through undergraduate coursework. These skills may help them better transition to paraprofessional positions that do not require graduate/professional training (e.g., case manager, substance abuse counselor). Additionally, the active listening skills, such as using questions and reflections, that are taught as part of the course are valuable for a variety of nonclinical professions such as human resources and customer service.
Another important finding for general MI training was that there were no post-course differences between participants in the intensive course and the extended course. Research on MI training has demonstrated that extending training, typically for several months beyond the typical workshop, is important for building MI proficiency (Miller, Yahne, Moyers, Martinez, & Pirritano, 2004). Our results provide preliminary evidence that MI proficiency can also be developed in a short-term intensive period, which may reduce training attrition (Schumacher, Madson, & Norquist, 2011). Thus, this type of course is particularly appropriate for condensed learning formats such as between semester classes.
Our results need to be interpreted within the study limitations. The greatest limitation is the quasi-experimental design. The lack of random assignment necessitates caution in drawing conclusions about the impact of the courses on outcomes. Participants who chose to register for the counseling theories course may have had little desire to learn counseling skills or have less ability compared to participants who chose to take the MI courses. Another limitation is that the MI curriculum studied did not include provision of feedback on work samples. Other studies have suggested that coding participant work samples and providing feedback to trainees may enhance skill development (Miller et al., 2004).
In sum, we found that many undergraduate psychology students can achieve MI proficiency through undergraduate coursework without practicum placements. Thus, undergraduates can at least develop some proficiency through these courses to help them transition to helping positions available to individuals who do not possess graduate/professional training. Future studies may want to examine the additive value of individual feedback using coded work samples on MI skill development in undergraduates. In our study, all feedback was group based and focused on experiential exercises. It might be valuable to assess differences between didactic and activity-based training versus less didactic and more practice with feedback-based methods of training on skill development. Long-term follow-up to assess maintenance of skill gains and impact on occupational outcomes would also be valuable.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.