Journal of Substance Abuse T

Regular article

Assessing competence in the use of motivational interviewing

Theresa B. Moyers, (Ph.D.)*, Tim Martin, (M.A.), Jennifer K. Manuel, (B.A.),

Stacey M. L. Hendrickson, (M.S., M.B.A.), William R. Miller, (Ph.D.)

Center on Alcoholism, Substance Abuse, and Addictions, University of New Mexico, Albuquerque, NM, USA

Received 19 July 2004; received in revised form 13 October 2004; accepted 28 October 2004

Abstract

This report presents reliability, validity and sensitivity indices for the Motivational Interviewing Treatment Integrity (MITI) scale. Factor

analysis of MI treatment sessions coded with the Motivational Interviewing Skills Code (MISC) was used to derive 10 elements of MI

practice, forming the MITI. Canonical correlation revealed that the MITI captured 59% of the variability in the MISC. Reliability estimates

for the MITI were derived using three masked, independent coders. Intra-class coefficients ranged from .5 to .9 and were generally in the

good to excellent range. Comparison of MITI scores before and after MI workshops indicate good sensitivity for detecting improvement

in clinical practice as result of training. Implications for the use of this instrument in research and supervision are discussed. D 2005 Elsevier

Inc. All rights reserved.

1. Introduction

Despite strong clinical evidence of efficacy and wide-

spread use of motivational interviewing (MI) in a variety

of clinical and research settings, little attention has been

paid to documenting the integrity of MI delivery. Most

randomized clinical trials of MI lack any mention of the

adherence and competence of clinicians employing this

treatment (Burke, Arkowitz & Dunn, 2002) and this lack of

attention to the integrity of MI is associated with some

troubling trends. For example, interventions that seem to

contradict the spirit or procedures of this method are occa-

sionally described as MI in the empirical literature, calling

into question the nature of the intervention offered (Noonan

& Moyers, 1997). Furthermore, interventions that are simi-

lar to MI but contain additional elements, such as FRAMES

(Bien, Miller, & Tonigan, 1993) or Motivational Enhance-

ment Therapy (Miller, Zweben, DiClemente, & Rychtarik,

1992) can be confused with MI. When the integrity of such

0740-5472/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.jsat.2004.11.001

* Corresponding author. Department of Psychology Center on Alco-

holism, Substance Abuse and Addictions, University of New Mexico,

Albuquerque, NM 87131 1161, USA. Tel.: +1 505 925 2375; fax: +1 505

925 2393.

E-mail address: tmoyers@unm.edu (T.B. Moyers).

treatments is examined, it is often these additional elements,

such as giving advice or providing personalized feedback,

that are assessed, rather than the core elements of MI. Con-

cepts of central importance to the use of MI, such as (1)

therapist empathy, (2) elicitation of client change talk, (3)

a focus on the discrepancy between client behaviors and

values, (4) encouraging confidence, and (5) nonconfronta-

tional responses to resistance, are much more difficult to

capture. As with most therapeutic methods, what is easiest

to measure is usually least instructive.

The difficulty involved in identifying competence in the

practice of MI is not surprising given the explicit emphasis

on the spirit of the method rather than the techniques that

comprise it (Moyers, in press; Rollnick & Miller, 1995).

Clinician attributes such as empathy and egalitarianism are

presumed active ingredients in MI but can be difficult to

measure reliably, while elements such as providing person-

alized feedback are somewhat easier to quantify. In addi-

tion, MI goals such as developing a clientTs discrepancy

between deeply felt values and maladaptive behaviors can

be accomplished through a variety of processes that might

not be anticipated in a simple procedural checklist. In the

following sections, we review previous attempts to quantify

adherence and competence in the delivery of MI, discuss the

development of the Motivational Interviewing Skills Code

reatment 28 (2005) 19–26

T.B. Moyers et al. / Journal of Substance Abuse Treatment 28 (2005) 19–2620

(MISC) and present data describing a new instrument for

evaluating clinician competence in MI.

1.1. Treatment adherence

Ideally, treatment integrity measures for MI should serve

as manipulation checks to insure that MI can reliably be

distinguished from other interventions or control groups.

Bien, Miller, and Boroughs (1993) used an MI intervention

with veteran problem drinkers and reviewed audiotapes of

therapy sessions to assess whether MI had been delivered

as intended. They sorted therapist speech from both the

experimental and control groups into three categories: state-

ments consistent with MI (MIC), statements inconsistent

with MI (MII) and other. The percentage of the therapistsTtotal speech in both the MIC and MII categories was

calculated for each session. Patterns of MIC and MII speech

were significantly different across the two experimental

conditions, such that therapists in MI sessions exhibited

more than 95% MIC speech and less than 1% MII speech,

while therapists in the control condition showed only 62%

MIC and 25% MII speech. These indicators allowed the

investigators to conclude that MI was being offered in the

intended treatment sessions, but did not provide informa-

tion regarding the quality of the clinicianTs use of MI.

Similarly, Carroll, Connors, and Cooney (1998) found

that a checklist of specific events occurring within the

three alcohol treatment conditions in Project MATCH, one

of which was an adaptation of MI, was sufficient to

reliably distinguish treatments from each other although a

different scale was required to assess therapeutic skill.

These studies suggest that MI can be reliably differentiated

from other treatments by measuring either discrete events

or a percentage of the therapistTs behavior that is consistentwith MI.

1.2. Clinician competence

In addition to providing the ability to discriminate be-

tween one treatment and another, treatment integrity ap-

praisals will ideally offer some measure of the clinician’s

level of competence in delivering an intervention (Waltz,

Addis, Koerner, & Jacobson, 1993). Documenting the

quality of cliniciansT work bolsters confidence that an

intervention was delivered properly in outcome trials, and

further serves as a tool for giving feedback to therapists

in training. Miller and his colleagues developed a coding

system designed to assess specific domains of counselor and

client functioning within MI sessions called the Motivational

Interviewing Skills Code (MISC 1.0; Miller &Mount, 2001).

The MISC 1.0 used three separate methods for reviewing

therapist competence in the use of MI, each gathered in a

separate review or bpassQ of the session tape.

First, global assessments were made of MI relevant ther-

apist and client characteristics using a seven-point Likert

scale. For the therapist, six global characteristics were

measured: acceptance, egalitarianism, empathy, genuineness,

warmth and overall MI spirit. For the client, four global

characteristics were measured: affect, cooperation, disclo-

sure and engagement. Two characteristics of the interaction

between the therapist and client were also assessed with

global scores: benefit and collaboration.

In a second coding pass, specific behaviors were counted

during MI sessions. For therapists, 27 behaviors were coded,

including both those specific to MI (asking permission be-

fore giving advice) and those common to many different

types of therapy (asking questions, reflections). Four types

of client speech were counted, reflecting the importance of

client language in MI sessions. Frequency counts of client

speech about the possibility of changing (change talk) as

well as resistance to change (resist) were made, as well as

occasions where the client simply followed the therapistTsrequests for information (follow/neutral) or asked questions

of their own (ask). The third pass in the MISC 1.0 measured

the relative amount of time spent talking during the session

by both the client and the therapist.

The most common use of the MISC 1.0 has been to

document changes in therapist competence before and after

training in MI. For example, Miller and Mount (2001) used

the MISC to code both pre- and post-training sessions for

probation and parole officers enrolled in an MI workshop.

After training, probation and parole officers showed signifi-

cant increases in MI Consistent behaviors (such as reflective

listening) but not decreases in MI Inconsistent behaviors

(such as confrontation), leading the authors to conclude that

MI training must focus on both eliciting and diminishing

particular behaviors in trainees. Similarly, Miller, Yahne,

Moyers, Martinez, and Pirritano (in press) found that the

MISC 1.0 reliably detected changes in the in-session

behavior of clinicians after training in MI as evidenced by

increased ratings of adherence to the spirit of the method,

increased use of reflections and open questions, as well as a

higher percentage of MI-Consistent responses. Baer and

colleagues (2004) found that at least three measures from

the MISC were sensitive enough to detect differences

between students from baseline to post training samples.

In addition, these measures detected the predictable erosion

of clinician skills at post-training follow up, suggesting that

the MISC has sufficient sensitivity to document expected

changes in MI performance across the learning curve.

1.3. Disadvantages of the MISC for documenting

treatment integrity

Although the overall reliability estimates for the MISC

have been acceptable and sufficient to observe relationships

between independent and dependent variables (Moyers,

Martin, Catley, Harris & Ahluwalia, 2003), some items have

yielded only fair reliability in some studies. In particular, the

measurement of MI-Consistent items has been uneven. For

instance, Moyers, Miller, and Hendrickson (in press) found

that a structural equation model of MI therapy sessions

T.B. Moyers et al. / Journal of Substance Abuse Treatment 28 (2005) 19–26 21

using the MISC produced unacceptably low reliability for

the MI-Consistent construct, resulting in its elimination from

the model. Similarly, the MI-Consistent variable in the Baer

et al. (2004) study required transformation to include both

neutral and MI-specific items before reliability was suffi-

cient to allow analysis of outcome variables. Other studies

evaluating the reliability of the MISC have indicated dif-

ferential reliability between the overall domains (global

vs. behavior counts) as well as among specific behaviors

(Moyers, Martin, Catley, et al., 2003) perhaps explained by

the very low frequency of some items among highly trained

MI counselors (Baer, et al., 2004; Hendrickson et al., 2004).

A second disadvantage of the MISC concerns its complexity

and related cost. Training coders to use the MISC 1.0 in our

lab has required an average of three months of intensive,

ongoing supervision, and training. Once coders are profi-

cient and reliable, a three-pass review of a 20-minute seg-

ment of a therapy session tape using the MISC 1.0 requires

90–120 min of coder time.

1.4. A new therapist competence measure

Ongoing efforts to train therapists in MI, as well as

requirements to document integrity in clinical trials, have

suggested the need for a more condensed, reliable, and

economical version of the MISC 1.0 appropriate for evaluat-

ing clinician competence in MI without the effort of

examining other process variables. This paper describes the

development of a new instrument, called the Motivational

Interviewing Treatment Integrity (MITI) Scale, which fo-

cuses exclusively on therapist functioning and reduces

the number and complexity of the ratings from the MISC.

2. Methods

2.1. Participants

Participants for this study were 185 clinicians enrolled

in Project EMMEE, a randomized controlled trial to test

various strategies for learning MI (Miller et al., in press).

Participants in the EMMEE trial were licensed clinicians

including physicians, psychologists, social workers, coun-

selors and other health-related professionals who treated

at least five substance abusing clients per week. Because

the initial recruitment for the EMMEE project under-

represented clinicians treating minority populations, we used

targeted recruiting strategies (listserve announcements,

journal ads) to recruit an additional 31 (17%) Spanish-

speaking clinicians as well as 11 (6%) clinicians treating

predominantly Native American clients, resulting in a

slightly larger overall sample than that reported in the

previously published reports (Miller et al., in press). Partici-

pants were 54% female, with a mean age of 46.7 years.

Clinicians in this study had an average of 8 years of post-

secondary education and 13.7 years of experience in

counseling. These counselors endorsed cognitive-behavioral

(32%), humanistic (18%), and 12-step (18%) perspectives

as their most common theoretical orientations. After enroll-

ment, participants were assigned to groups receiving various

strategies for learning MI incorporating self-training with

books and videos, workshops and feedback.

2.2. Audiotaped session samples from the EMMEE study

Participants in the EMMEE study were asked to submit

audiotaped samples of a therapy session with a substance

abusing client prior to training, immediately after training

(using a simulated patient) and at 4, 8, and 12 months after

training. A total of 189 clinicians submitted tapes of sub-

stance abuse treatment sessions with unique clients, result-

ing in 624 clinician-client interactions. For each of these

624 tapes, the first 20 min were coded using the MISC 1.0

(Miller et al., in press).

2.3. Training of MITI coders

Coders were two undergraduates and one graduate

student at the University of New Mexico. Readings (Miller

& Rollnick, 1991) and videotapes (Miller, Rollnick, &

Moyers, 1998) were used to familiarize coders with the

clinical method of MI. Coders then proceeded through a

series of graded learning tasks such as the parsing of

therapist utterance, coding specific behaviors exemplifying

MI competence, and assessing global dimensions of MI

spirit. Competence in one level was required before pro-

ceeding to the next learning task (Moyers, Martin, Manuel,

et al., 2003).

Each level of competence was assessed using quizzes

graded against a gold standard provided by the first author,

and coders were expected to achieve competence to a cri-

terion of 80% before proceeding to the next level of com-

plexity. Weekly group meetings for all coders were held for

the duration of the coding project to prevent drift from the

manual. None of the audiotaped samples that comprised the

data set were used for initial training of coders. Coders were

not aware of whether the tapes they coded had been

recorded prior to or after training.

2.4. Overview of statistical analysis plan

An exploratory factor analysis (EFA) was performed

to derive orthogonal dimensions measured by MISC 1.0.

These factors were inspected and used to develop the initial

version of the MITI and a scoring manual for it. The new

MITI scoring system was then used to code a random sample

of tapes drawn from the EMMEE sample. Interrater

reliability for theMITI was assessed, using three independent

coders. We then assessed the ability of the MITI to detect

changes in clinician behavior after training by comparing

coded samples of pre- and post-training tapes. Finally, we

measured the efficiency of the MITI in comparison to the

T.B. Moyers et al. / Journal of Substance Abuse Treatment 28 (2005) 19–2622

MISC by estimating the amount of information from MISC

retained with this more limited coding system.

3. Results

3.1. Deriving the MITI

An EFA using Principal Component Analysis was used

to derive initial estimates of underlying factors within the

MISC. Factors with eigenvalues over 1 were retained. This

initial factor solution was then rotated using the varimax

criterion to obtain a final factor solution. The EFA revealed

11 factors with eigenvalues over 1. Factor loadings are pre-

sented in Table 1.

All global assessments of therapist characteristics loaded

on the first factor, indicating a general ability to assess the

Table 1

Factor loadings of an EFA (Varimax rotated) of the MISC

1 2 3 4

Warmth 0.831

MI Spirit 0.788

Acceptance 0.76

Empathy 0.753

Genuineness 0.73

Egalitarianism 0.698

Collaboration 0.674 0.504

Benefit 0.662 0.416

Confront –0.41

Cooperation 0.784

Engagement 0.753

Disclosure 0.687

Affect 0.55

Follow/Neutral 0.795

Closed Question 0.788

Reflect (Repeat) 0.672

Open Question 0.594

Advise 0.734

Raise Concern 0.703

Warn 0.587

Direct 0.42

Ask

Self Disclosure

Personal Feedback

Reflect (Paraphrase)

Reflect (Rephrase)

Reflect (Summarize)

Resistance

Change Talk

Emphasize Control

Affirm

Support

Facilitate

Structure

Clinician Talk Time

General Information

Filler

Reframe

Raise Concern w/Permission

Advise w/Permission

spirit of this method. The second factor represented an

estimate of the clientTs response to the therapist during the

session as well as an evaluation of the interaction between

client and therapist. The third factor encompassed questions

and simple reflections. The fourth factor was comprised of

clinician behaviors that are inconsistent with the practice of

motivational interviewing, such as advising, warning, and

directing. The fifth factor was formed by three variables in-

dicating the clinician had provided information to the client.

The sixth factor consisted entirely of various types of

reflective listening statements. The seventh and eighth fac-

tors included client change talk of both kinds, as well as a

variety of MI consistent responses such as emphasizing

control, affirming and supporting. The ninth factor was

comprised of three items, which seemed to indicate an

active and instructional clinician (percent of session time

clinician spent talking, giving information, and structuring

5 6 7 8 9 10 11

0.696

0.678

0.566 0.462

0.648

0.613

0.503

0.45

0.704

0.648

0.453

0.589

0.522

0.73

0.512

0.461 0.508

0.76

0.43

0.74

0.64

Table 2

Motivational Interviewing Treatment Integrity measures derived from EFA

of MISC

Global ratings Brief description

Represented

factors

Empathy/

Understanding

extent to which the therapist

understands and/or makes an effort

to grasp the clientTs perspective

1

Spirit collaboration, evocation and

support of autonomy

1

Behavior Counts

General

Information

interviewer gives information,

educates, provides feedback or

discloses personal information.

5,9

MI-Adherent interviewer behaviors that are

consistent with a motivational

interviewing approach.

7,8,11

MI-Nonadherent interviewer behaviors that are

inconsistent with a motivational

interviewing approach.

4

Closed Question interviewer asks the client a question

that can be answered with a byesQor bnoQ response.

3

Open Question the interviewer asks a question that

allows a wide range of possible

answers.

3

Simple Reflection conveys understanding or facilitates

client/therapist exchanges. These

reflections add little or no

meaning (or emphasis)

3,6

Complex

Reflection

adds substantial meaning or

emphasis to what the client has said.

6,10

Total Reflection sum of simple and complex

reflections

3,6

Table 3

Reliability estimates for the MITI

Measure ICC Lower Upper a r1–2 r1–3 r2–3

Global Ratings

Empathy/

Understanding

.5184 .3541 .6682 .7635 .7175 .4754 .4220

Spirit .5846 .4303 .7195 .8085 .6543 .4861 .6117

Behavior Counts

General Information .7580 .6471 .8446 .9038 .7544 .7306 .7927

MI-Adherent .8092 .7165 .8793 .9271 .8451 .7816 .8202

MI-Nonadherent .7505 .6371 .8394 .9002 .8408 .7315 .7418

Closed Question .9681 .9496 .9807 .9891 .9791 .9772 .9588

Open Question .9389 .9046 .9627 .9788 .9619 .9311 .9440

Simple Reflection .8126 .7212 .8815 .9286 .8396 .8094 .8133

Complex Reflection .5764 .4207 .7132 .8032 .7187 .6325 .5154

Total Reflection .8592 .7868 .9121 .9482 .8970 .8646 .8784

Note. Inter-rater reliability estimates for the MITI. ICC refers to the intra-

class correlation coefficient of three independent raters. Lower refers to the

lower 95 percent confidence interval of the ICC. Upper refers to the upper

95 percent confidence interval, a refers to Cronbach’s alpha for three

independent coders. r refers to the Pearson Product moment and subscripts

refer to specific coder pairs.

T.B. Moyers et al. / Journal of Substance Abuse Treatment 28 (2005) 19–26 23

of the session). The tenth factor was comprised of items

not coded in any other category of the MISC (Filler) as well

as one MI consistent item (Reframe). Because we could

not interpret this factor, we did not retain either item in the

MITI. Factor 11 was a permission-seeking factor, which

indicated the therapist requesting the clientTs agreement

before giving advice or information.

After examining this underlying factor structure, we

formed the MITI by defining categories for each factor

that reflected predominately clinician functioning, with the

exception of factor ten. This process yielded two global

measures and five behavior counts. The final MITI system

is found in Table 2.

The first global measure is intended to capture the over-

all spirit of the MI method, reflected in the first factor.

Although it is partially redundant and not strictly needed,

the global assessment of empathy was retained because

of its prominence in explanations for the effectiveness of

this method and prior evidence of its specific impact on

client outcomes (Miller, Taylor, & West, 1980; Valle, 1981).

The category of giving information is intended to reflect

factor 9, while factors 3 and 6 are captured in the categories

of questions and reflections, respectively. Behaviors indicative

of MI practice, found in factors 7,8, and 11, were captured

in a category we termed MI Adherent (to avoid confusion

with MI Consistent summary scores from the MISC).

Behaviors contraindicated in MI practice, found in factor

4, were captured in the MI Non-Adherent category.

3.2. Reliability estimates for the MITI

A subset of 50 tapes was randomly selected and the same

three coders independently coded them all. Inter-rater

reliability was estimated using the intra-class correlation

coefficient (ICC) for all three pairs of coders (Fleiss & Shrout,

1978), since this statistic adjusts for chance agreement

between raters, as well as systematic differences between

raters, and is therefore more conservative estimate than

either CronbachTs alpha or the Pearson product moment

correlation. Inter-rater reliability estimates are presented in

Table 3. Cicchetti (1994) has proposed a categorization

system for evaluating the usefulness of ICCs in clinical

instruments: below .40 = poor, .40 to .59 = fair, .60 to

.74 = good and .75 to 1.00 = excellent. Intra-class correla-

tions ranged from .5184 (empathy/understanding) to .9681

(closed questions), with 70% of ratings in the excellent

range. Note that correlations for the most experienced pair

of coders (1,2) were noticeably higher than those of the least

experienced pair (2,3), especially for the global ratings.

3.3. Estimates of sensitivity

To assess the sensitivity of MITI in detecting changes

in clinician behavior, 20 pairs of pre-post (baseline–post

training) tapes were coded. To obtain this subsample, we

coded all available partner tapes (pre or post) for any tape

already coded in the reliability sample, producing 18 pre-post

T.B. Moyers et al. / Journal of Substance Abuse Treatment 28 (2005) 19–2624

pairs. An additional two pairs (four tapes) were randomly

selected from the parent sample. Differences between base-

line and post-training sessions on all items were assessed

with paired sample t-tests. Compared to the baseline tapes,

therapists after training were rated significantly higher in

both empathy, t(18) = 5.99, p b .0005, and spirit, t(19) =

4.94, p b .0005. In addition, there were significantly more

complex reflections after training, t(19) = 3.73, p = .001.

Finally, summary measures were also significantly different

between baseline and post-training. There were more total

reflections, t(19) = 2.60, p = .018, a higher reflection to ques-

tion ratio, t(19) = 3.01, p = .007, and a higher percentage of

complex reflections, t(19) = 2.35, p = .03, after training than

at baseline. These are all key indicators of MI fidelity and

were used in previous studies to estimate MI fidelity (Miller

et al., in press).

3.4. Convergence of the MISC and MITI

Because all of these tapes had been previously coded

with MISC 1.0 (Miller et al., in press) direct comparisons of

the two instruments were conducted. A canonical correla-

tion between the MISC EFA factor scores and the MITI

variables was calculated, excluding the category of Total

Reflections, which is redundant with simple and complex

reflections. The first six canonical correlates were statisti-

cally significant, accounting for 59% of the variance in the

MISC factor scores.

4. Discussion

For clinicians, trainers and supervisors, the MITI

represents a cost-effective and focused tool for evaluating

competence in the use of MI. Potential training applica-

tions for the MITI include self-evaluations by clinicians

learning MI, assessment of the effectiveness of teaching

strategies for MI, and individualized feedback to improve

MI competence for clinicians in training. The MITI is

also appropriate as a self-learning tool, since clinicians

can use behavior counts to evaluate their own taped ses-

sions and compare them to recommended thresholds in

the MITI coding manual (available at no charge at casaa.

unm.edu). For researchers, the MITI offers a tool for the

evaluation of treatment integrity in clinical trials using

motivational interviewing.

Our data indicate that the MITI can be reliably applied to

the observation of therapy discourse by coders who have a

reasonable amount of training and experience. Indeed, with

more experienced coders, we observed overall higher reli-

ability estimates for the MITI than the MISC (Moyers et al.,

2003), which is unsurprising since the MITI collapses many

of the specific categories that require differentiation in the

MISC. The MITI also provides sensitive dependent mea-

sures, as evidenced by the significant differences between

pre- and post-training samples. This supports the use of

the MITI for the evaluation of changes in basic MI skills

and for use in the provision of feedback to students of

this method.

Because the MITI is considerably shorter than the MISC,

there was some concern on our part that too much crucial

information would be lost by using fewer and broader global

ratings and behavioral categories. However, our canonical

correlation analysis indicates that the MITI, while less than

half the length of MISC, still managed to capture over half

of the systematic variation in MISC scores as estimated

by factor analysis. In training and research settings, this in-

crease in efficiency may well be worth some loss of infor-

mation, particularly when the intent is to document fidelity

and provide feedback to clinicians quickly and economically.

When application of the MISC is prohibitive in terms of time,

money, personnel or some combination of these, the MITI

is a reliable, sensitive and informative alternative that

requires fewer resources to apply.

Nevertheless, it is important to note that the MITI cannot

replace the MISC as a process measure for examining causal

mechanisms about why MI might be effective. This is

especially evident in the case of client language, which is

captured with four codes in MISC 1.0 and nine codes on

the revised MISC 2.0 (Miller, Moyers, Ernst, & Amrhein,

2003), and is not coded at all in the MITI. Similarly the

MITI, with its exclusive focus on therapist competence,

runs the risk of perpetuating the myth of the therapist as

hero (Tallman & Bohart, 1999) since client variables are

not examined to indicate how they might influence the

process of the MI session or enhance clinician functioning.

When the primary research question concerns how MI

works as it does, the MISC will remain a better choice than

the MITI.

It is also the case that the restricted range of information

gathered by the MITI tells only so much about how well

a clinician is using a very complex therapeutic strategy.

Like most coding systems, the MITI ignores the context in

which the therapy occurs, meaning it can offer only limited

information about how well the clinician managed within

a particular coded segment (Waltz et al., 1993). This is

important when considering the use of the MITI as a tool for

clinical supervision. When clients are complex, the MITI

may underestimate the ability of the therapist to use MI and

several samples of clinician behavior across clients will be

needed to draw conclusions about competence.

Another limitation of the MITI (and the MISC as well)

is the ability to measure advanced skills in the use of

MI. These skills are usually seen in MI sessions when

therapists utilize foundational principles, such as creating

discrepancy between deeply held client values and behaviors,

opportunistically. Such proactive and diligent application

of MI principles (Miller & Rollnick, 2002), including the

elicitation of client change talk, is a hallmark of the expert

practice of this method. While the MITI does a good job of

measuring MI-relevant clinician attributes (such as empathy)

and the use of microskills (such as using open rather than

T.B. Moyers et al. / Journal of Substance Abuse Treatment 28 (2005) 19–26 25

closed questions), the intentional and strategic use of MI

principles is not as well captured. It is likely that additional

coding modules, with commensurate time and expense,

would be needed to capture more expert functioning in

MI. The MITI avoids the problem of complexity and

ambiguity in MI concepts (such as skill at eliciting change

talk) by limiting measurement of clinician behaviors to

relatively less complex exemplars of MI practice. These

limitations of the MITI lead us to conclude that it is likely

to be a good tool for measuring foundational or entry-level

competence in MI, rather than advanced or expert skills.

We note, however, that recent investigations in our labora-

tory have shown that exactly these foundational skills can

account for as much as 70% of in-session client cooperation

and engagement (Moyers, Miller, & Hendrickson, in press)

in MI sessions, indicating that careful attention to entry-level

skills is warranted.

One limitation of this study concerns the selection of

the portion of the therapy audiotapes that were analyzed. The

first 20 min were chosen in order to facilitate comparison

with previously published studies using the MISC (MIDAS,

EMMEE); however, a recent report by Amrhein, Miller,

Yahne, Palmer, and Fulcher (2003) suggests that critical

characteristics of MI sessions may occur toward the end of

the session, rather than the beginning. Although this does not

directly impact the main psychometric questions addressed

by this study, the use of the MITI to document treatment

integrity or provide supervision should ideally incorporate a

random sampling strategy, which we have now implemented

in our coding protocol.

Another limitation of this study concerns the sensitivity

analysis performed on the pre- and post-training samples of

the EMMEE participants. These participants were by defi-

nition highly motivated to learn and practice MI, thereby

offering an optimal opportunity for observing training effects.

It is possible the MITI would be less sensitive to the more

subtle changes in practice behavior that would be expected

from a more representative sample of clinicians. Further-

more, we are not aware of normative data regarding clini-

cian improvement in MI practice after training, using

the MITI or any other objective coding system. In the

absence of such norms, information derived from the MITI

about individual clinician progress after training or super-

vision should be used only as part of a larger constellation

of information.

Acknowledgments

This research was supported in part by DAMD 17-01-1-

0681 and NIAAA RO1 AA 13696 01 and NIDA R01 DA

13801. All study and consent procedures were reviewed and

approved by the human research Institutional Review Board

of the University of New Mexico. Correspondence should

be addressed to Theresa B. Moyers, Ph.D., Department

of Psychology, University of New Mexico, Albuquerque,

NM 87131-1161, USA. The authors wish to thank J. Scott

Tonigan, Ph.D., for statistical consultation for this project.

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