Editor’s note: William R. Miller, PhD, is a professor of psychology and psychiatry at the University of New Mexico and has authored 40 books. His continuing education presentation for GoodTherapy.org is scheduled for 9 a.m. PST on February 21. This event, free to GoodTherapy.org members, is good for two CE credits. For details, or to register, please click here.
In the world of U.S. behavioral health, there is a raging debate regarding “evidence-based treatment” versus “general” or “nonspecific” factors. Voices on one side argue that we should be using the treatment methods with the strongest evidence of specific effectiveness as demonstrated in controlled clinical trials—hardly a controversial position if one were seeking treatment for a life-threatening illness; it is what we expect of our health-care providers. In the realm of behavioral health, however, this is a surprisingly new and controversial idea. The opposing position is that outcome differences between specific treatments and standard care are so small as to be swamped by the effects of nonspecific factors such as therapeutic relationship.
Motivational interviewing (MI) occupies an interesting middle-earth position in this controversy. On one hand, there is abundant research literature supporting the efficacy of MI across a wide variety of behavior-change issues (e.g., Lundahl and Burke, 2009; Lundahl, Kunz, Brownell, Tollefson, and Burke, 2010), with more than 200 randomized clinical trials of interventions identified as MI. Admittedly, the average effect size is in the small to medium range, and there is great variability in outcomes across studies, sites, and providers. It is also the case that when compared head-to-head with other bona fide treatments, there is usually no significant difference, though MI tends to be briefer, yielding similar outcomes with less intervention. So, ho hum—another name-brand treatment that holds its own against the competition.
Yet MI was not originally intended as a stand-alone treatment, and certainly not as a comprehensive psychotherapy. It is a method that can be combined with a wide range of other active treatments, and doing so can enhance retention and adherence. It is in additive combination with other therapies that MI had shown the most sustained impact on outcomes (Hettema, Steele, and Miller, 2005). It also targets what is a widely recognized client factor that influences outcome: motivation for change.
MI also contains large components of what are often regarded as general therapeutic factors. It is fundamentally a person-centered approach, relying on foundational skills such as accurate empathy and positive regard that were originally described by Carl Rogers and his students (Rogers, 1980; Truax and Carkhuff, 1967). Empathy in particular is a skill that varies widely across therapists and is associated with client outcomes (Moyers and Miller, in press). But to call such factors “nonspecific” is merely to say that we haven’t done our homework. If indeed such relational factors exert such a large influence on our clients’ welfare, we ought to be specifying, measuring, and teaching these skills, at which point they become specific factors. They are certainly not equally present in all therapies and therapists, and it is unclear just how “common” they are.
What I find particularly exciting about MI research is that we are, I believe, explicating some of these previously nonspecific factors and making them learnable. At our current level of understanding, there are both relational and technical components of MI that contribute to its efficacy (Miller and Rose, 2009). That MI seems to cross cultures and problem areas fairly well suggests that we are honing in on some general psychological processes that facilitate change. It makes little sense to me to be debating whether it is “specific” or “general” factors that matter. The problem, I think, is in the binary thinking implicit in the word “or.” What is it about our interventions that really do help people change? That’s what interests me.
- Hettema, J., Steele, J., and Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91-111.
- Lundahl, B., and Burke, B. L. (2009). The effectiveness and applicability of motivational interviewing: A practice-friendly review of four meta-analyses. Journal of Clinical Psychology, 65(11), 1232-1245.
- Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., and Burke, B. L. (2010). A meta-analysis of motivational interviewing: Twenty-five years of empirical studies. Research on Social Work Practice, 20(2), 137-160.
- Miller, W. R., and Rose, G. S. (2009). Toward a theory of motivational interviewing. American Psychologist, 64, 527-537.
- Moyers, T. B., and Miller, W. R. (in press). Is low empathy toxic? Psychology of Addictive Behaviors, Online first publication. doi: 10.1037/a0030274
- Rogers, C. R. (1980). A way of being. Boston: Houghton Mifflin.
- Truax, C. B., and Carkhuff, R. R. (1967). Toward effective counseling and psychotherapy. Chicago: Aldine.
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