Motivational interviewing (MI) is a well-known, evidence-based, brief counseling approach for substance use disorders (SUDs) that combines person-centered principles with strategies for enhancing motivation for change (Miller & Rollnick, 2012). Counselors using MI help their clients talk themselves into change by exploring and developing their motivations for change and lessening and resolving their arguments against it. When counselors use MI proficiently, clients typically will express more statements that favor (called “change talk”) rather than disfavor (called “sustain talk”) change within a session. This resolution of ambivalence appears to be one of the main ways in which MI improves treatment outcomes (Magill et al., 2014).
A competency-based clinical supervision approach has been recommended to promote proficient MI practice (de Roten, Zimmermann, Ortega, & Despland, 2013; Schwalbe, Oh, & Zweben, 2014). This type of supervision explicitly identifies the knowledge and skills that counselors need to use specific treatments with clients in their clinical settings (Falender & Shafranske, 2007). Core elements of high quality competency-based supervision include (APA, 2014; Watkins & Scaturo, 2013):
- Directly observing counselors’ practice in sessions or reviewing audio or video recorded ones
- Using performance feedback to monitor practice
- Providing individualized coaching to further develop counselors’ knowledge and skills
Training professionals in competency-based clinical supervision is now recognized as a critical area of workforce development (Hoge, Migdole, Farkas, Ponce, & Hunnicutt, 2011).
In 2001, the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) Addiction Technology Transfer Centers (ATTC) collaborated to develop training products that would support the dissemination and implementation of research findings from NIDA-funded treatment studies into community-based practice (Condon, Miner, Balmer, & Pintello, 2008). One product, called Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP; Martino et al., 2006), was developed to support local, program-based supervision of MI. MIA: STEP adapted the supervision methods used to train clinical supervisors in several MI effectiveness trials (Ball et al., 2007; Carroll et al., 2006; Carroll et al., 2009), consistent with the competency-based clinical supervision approach. It aims to improve counselors’ adherence and competence using MI following initial workshop training, thereby contributing to better client treatment retention and outcome.
Multiple reviews of supervision research have been conducted (Freitas, 2002; Watkins, 2011; Wheeler & Richards, 2007) and have indicated that clinical supervision enhances counselors’ treatment knowledge, adherence, competence, self-confidence, and counselor-client relationship. Further, clinical supervision has been associated with a reduction in counselors’ emotional exhaustion and intention to quit their jobs (Knudsen, Ducharme, & Roman, 2008). Techniques consistent with a competency-based supervision approach (e.g., performance feedback, coaching via behavioral rehearsal or role-play) when used over several supervision sessions have been shown to maintain and sometimes additionally improve counselors’ therapeutic skills following initial didactic or workshop training (Milne, Sheikh, Pattison, & Wilkinson, 2011).
In contrast, research examining the impact of clinical supervision on client outcomes is scant. This hole in the literature is surprising in that one of the main functions of clinical supervision is to develop counselors’ therapeutic competencies such that they can improve their clients’ outcomes (Watkins, 2011). In addition, another area absent in supervision research is the cost of clinical supervision. Competency-based clinical supervision approaches require a significant expenditure of time and effort to train supervisors, observe counselor practice, gather performance feedback data, and conduct the supervision sessions. The cost of providing supervision needs to be justified by the capacity of competency-based supervision to achieve significantly better counselor treatment integrity and client outcomes than standard supervisory practices used in community treatment programs.
We previously reported on a multisite randomized controlled trial testing the effectiveness of MIA: STEP supervision, compared to supervision-as-usual (SAU), in improving community treatment program counselors’ MI adherence and competence within client intake sessions, as well as the program retention (i.e., percent scheduled sessions attended, percent retained in treatment) and days of primary substance abstinence of clients receiving MI in the study (Martino et al., 2016). We also calculated the cost of providing supervision. This article summarizes the study and its findings.
MIA: STEP Study Description
Sixty-six counselors, 450 clients, and twenty-two supervisors from eleven outpatient community addiction treatment programs located in Connecticut participated in the randomized controlled trial. The programs offered a variety of treatment options (individual, group, couples/family, rehabilitative services), but clients typically received group treatment weekly or more intensively several times per week. All programs required clients to be clinically evaluated within a single intake session as a prelude to the start of treatment.
Counselors in the study were mostly female (79 percent), Caucasian (65 percent; 20 percent Hispanic, 14 percent African American, 1 percent multiracial), and were on average forty-one years old. Most (68 percent) had master’s degrees and about half had received state certification as a substance abuse counselor and were licensed in their fields. Counselors averaged about nine years of general and eight years of substance abuse counseling experience. Few had past year MI training. Counselors were randomized to receive MIA: STEP or SAU supervision.
Client participants were non-opiate-agonist outpatient treatment seekers who had used their primary substance (i.e., the one self-identified as causing the most problems) in the past four weeks. They were on average thirty-five years old, mostly single (61 percent), unemployed (67 percent), and ethnically diverse—46 percent African American, 28 percent Caucasian, 21 percent Hispanic, 4 percent multiracial, and 1 percent other). All participants were current substance users, with many meeting current criteria for DSM-IV substance use disorders: alcohol (39 percent), cannabis (35 percent), cocaine (28 percent), opioids (7 percent), hallucinogens (3 percent), and stimulants (1 percent). Most clients reported having used alcohol (80 percent) and cannabis (57 percent) four weeks prior to randomization, including a large minority who had used cocaine (38 percent). On average, clients had been abstinent from their primary substance for about fourteen to fifteen days in the month prior to enrolling in the study. About half the clients were court-mandated to treatment. In general, clients presented to treatment with self-reported recognition of their alcohol or drug problems, openness to reflect about the pros and cons of their substance use, and already having taken some steps to change their drinking or drug use. Clients were randomized to be seen by either a counselor supervised with MIA: STEP or SAU.
Two supervisors from each of the eleven programs participated in the study, one for MIA: STEP and one for SAU. A combination of MI training experience and preference typically dictated a supervisor’s assignment to MIA: STEP. The supervisors were demographically like the counselors, except that they had higher percentages of earning a master’s degree (82 percent), alcohol and drug counseling certification (64 percent), professional licensure (96 percent), and average years of general counseling experience (about seventeen years).
Training MI and MIA: STEP
MIA: STEP supervisors and all counselors within each program received an eight-hour, on-site MI workshop conducted by the second author per Motivational Interviewing Network of Trainers recommendations (Miller & Rollnick, 2012). Training focused on how to apply MI in an intake. All participants received an individual copy of a MI textbook (Miller & Rollnick, 2002) and a detailed MI intake manual used in our previous trial (Carroll et al., 2006). Following MI training, MIA: STEP supervisors received additional workshop training from the first or second author and ongoing expert consultation support for using MIA: STEP throughout the trial. Counselors in SAU were free to receive supervision from the SAU supervisor after the workshop as it naturally occurred within the program.
Description of MIA: STEP and Supervision-As-Usual
MIA: STEP (Martino et al., 2006) includes a system for rating ten MI-consistent items (e.g., use of reflections, use of strategies to elicit change talk, change planning) for adherence and competence and five MI-inconsistent items (e.g., direct confrontation, unsolicited advice) for adherence, and tools for providing rating-based feedback and coaching (e.g., teaching tools; descriptions of MI-consistent strategies; guidelines and a format for MI consistent supervision; audio-recorded, transcribed, and rated MI intake sessions). After counselors completed a MI intake, the MIA: STEP supervisor listened to and rated it, completed the feedback form, and met with counselors to discuss the session and coach skill development before other clients were seen. All MIA: STEP supervision sessions were audio recorded to ensure supervisors were delivering it well. MIA: STEP supervision was conducted up to seven times per counselor. Counselors did not see their next study clients until they had received MIA: STEP supervision for their prior cases.
SAU consisted of the practices typically used at each program to supervise counselors’ intakes. Supervisors and counselors were instructed to meet as they typically would to supervise intake sessions, and new intake assignments were not contingent on SAU supervision having occurred on the prior cases. These sessions were not recorded to minimize alteration of SAU practices. However, counselors were asked to complete a checklist when supervision of study-related client intakes occurred to characterize what happened in SAU. Moreover, to independently identify SAU practices and the extent to which SAU was different from MIA: STEP, before workshop training, the two program supervisors supervised the counselors’ intake sessions in their usual manner; these supervision sessions were audio recorded. At the end of the trial, the SAU supervisors conducted this task again with the counselors who were assigned to SAU.
Description of MI Intake
MI was used in an intake to improve client retention, consistent with our previous MI intake protocol (Carroll et al., 2006). The MI intake was construed as a “MI sandwich” (see Figure 1; Martino et al., 2006) in that
- The first twenty to thirty minutes of the intake focused on engaging clients, understanding their primary substance use, and enhancing their motivation for treatment as a means for cutting back or quitting substance use
- The last ten to fifteen minutes focused on making plans for change, if ready, or alternative actions if not ready to enter treatment or change substance use
A standard psychosocial intake assessment (thirty to sixty minutes) was sandwiched in-between the MI parts, and counselors were trained on how to transition from one part to the next. All MI intakes were audio recorded for MI adherence and competence assessment. On average MI intakes were one hour and twenty minutes.
Counselors completed assessments at baseline, after completing seven MI intakes (posttrial), and sixteen weeks posttrial. Clients completed assessments at baseline, four-week, and twelve-week follow-up. In addition, supervision integrity (i.e., supervisor adherence and competence) and cost were independently assessed at the end of the study. We assessed counselor MI adherence and competence using the Independent Tape Rater Scale (ITRS). The ITRS (Ball, Martino, Corvino, Morgenstern, & Carroll, 2002) is a reliable and valid measure (Martino, Ball, Nich, Frankforter, & Carroll, 2008) that assesses adherence and competence in MI and strategies inconsistent with MI. Average adherence and competence scores for five fundamental MI strategies that tap the client-centered aspects and basic skills of MI (e.g., reflection, fostering collaboration) and five advanced MI strategies related to evoking and mobilizing motivations for change (e.g., developing discrepancy between substance use and goals, change planning) are calculated, as well as for the average adherence score for five MI-inconsistent items (e.g., unsolicited advice, direct confrontation).
For client outcomes, we calculated the cumulative total number of sessions clients attended after their MI intakes and divided this sum by the total number of sessions they were each scheduled to attend to obtain the percentage of sessions attended as a common metric of treatment retention across sites. We also calculated the percentage of clients who remained enrolled in treatment at each follow-up point. In addition, we used the Time Line Follow-Back interview (Sobell & Sobell, 1992), a reliable and valid instrument for monitoring substance use (Fals-Stewart, O’Farrell, Freitas, McFarlin, & Rutigliano, 2000) in clinical trials. We obtained breath and urine screens from clients at each assessment point, which indicated high correspondence with clients’ self-reported substance use.
We also developed a Supervisor Adherence and Competence Scale (SACS; Martino, Paris, Añez, & Carroll, 2012) to see how supervisors delivered MIA: STEP and the degree to which it differed from SAU. Independent raters determined the adherence and competence in which supervisors used MIA: STEP and general supervision practices in the recorded supervision sessions. In addition, SAU counselors completed a three-item supervision checklist when they received supervision for any study MI intake.
Finally, we collected data about the cost of providing MIA: STEP and SAU supervision. A research assistant administered a survey to the chief financial officer, chief executive officer or accountants at each site to obtain necessary cost information. In addition, expert trainers, supervisors, and counselors reported their annual salary/hourly wage, and research staff collected data on resources used (e.g., space utilized for activities, number of supervision sessions held and time spent in them by supervisors and counselors, time spent by expert trainers/consultants in activities, time spent by MIA: STEP supervisors rating MI intakes and preparing feedback). Major cost categories used to derive the total cost of MIA: STEP and SAU supervision included:
- MI and MIA: STEP workshops
- Postworkshop practice cases
- MIA: STEP expert consultations
- Self-study activities
All counselors conducted at least one MI intake, 76 percent completed the posttrial assessment, and 59 percent completed the sixteen-week posttrial assessment. Rates of follow-up did not differ by condition. Of the 450 study clients, 91 percent received a MI intake, 91 percent completed the four-week follow-up, and 86 percent completed the twelve-week follow-up. Rates of follow-up did not differ by condition.
Each counselor within MIA: STEP received on average six to seven supervision sessions, with the average time per supervision about thirty-five minutes. In comparison, only five individual SAU supervisions occurred during the trial, all occurring at one site with two SAU counselors and each twenty minutes or less in duration. Analysis of the supervision adherence and competence data showed that MIA: STEP was delivered with good skill, and it differed from the supervisors’ usual supervision practices.
MIA: STEP and Counselors’ MI Practice
Counselors significantly improved their fundamental and advanced MI adherence and competence in both supervision conditions. However, counselors supervised with MIA: STEP, compared to those supervised with SAU, showed significantly greater improvement in fundamental MI competence from baseline to sixteen-week follow-up. In addition, MIA: STEP counselors showed significantly greater improvement in advanced MI strategy competence from baseline to the end of the trial and through the sixteen-week follow-up. Throughout the trial, counselors in both conditions rarely used MI-inconsistent strategies.
MIA: STEP and Client Outcomes
There were no significant differences between the supervision conditions in the percentage of scheduled sessions clients attended, or in the overall percentage of clients who were retained in treatment at the four-week and twelve-week follow-ups. At four weeks, clients attended about 60 percent of their scheduled sessions with slightly more than 70 percent remaining in treatment. At twelve weeks, clients similarly attended about 60 percent of their scheduled sessions, with about 50 percent still in treatment.
Likewise, there were no significant differences between supervision conditions for the total number of days on which clients reported remaining abstinent from their identified primary substance. At both the four-week and twelve-week follow-ups, clients reported not using their primary substances for an average of twenty-two of the past twenty-eight days, compared with their baseline fourteen to fifteen days of abstinence (about a 50 percent increase).
Cost of MIA: STEP
The total cost to implement MIA: STEP across the project was substantially more than SAU ($174,599 vs. $28,825 in 2014 US dollars). Per agency, this amounts to about $15,872.64 vs. $2,620.45. For MIA: STEP, the two costliest categories were consultations between experts and supervisors ($56,077) and supervisions between supervisors and counselors ($40,676), whereas for SAU the two costliest categories were the MI workshops ($18,236) and time spent by counselors self-studying MI materials ($9,680). Across both supervision conditions, the largest component of total cost was labor (85.7 percent).
This study showed that counselors supervised with MIA: STEP, more than those in SAU, significantly increased the competency in which they used advanced MI strategies at the end of the trial and fundamental and advanced MI strategies at the sixteen-week follow-up point. Counselors in both supervision conditions demonstrated similar increases in the frequency in which they used fundamental and advanced MI strategies (i.e., adherence) at both assessment points. Across conditions, MI inconsistent strategies were virtually absent. Thus, the main effect of MIA: STEP appears to be enhancing the counselors’ MI competence, not adherence, following a basic MI skill-building workshop. Postworkshop, counselors who received individualized feedback and coaching via MIA: STEP moved from somewhat less than adequate performance to adequate to good skill levels, whereas those in SAU continued to deliver MI at or below adequate levels of competency. This effect is strongest for advanced MI strategies. One explanation for these findings may be that the MI workshop, self-training materials (i.e., MI book and treatment manual), and repeated application of a manualized version of MI (the MI sandwich) were sufficient to support the counselors’ use of prescribed MI strategies during intakes. However, the individualized feedback and coaching based on a careful review of audio recorded sessions, as occurred in MIA: STEP, may have specifically helped these counselors develop more skills in how they delivered MI, particularly advanced ones.
A notable finding was the absence of clinical supervision being provided for intakes at the programs. Only five instances of SAU occurred in this study and only at one site. While counselors may not have reported some instances of supervision that had occurred, this finding suggests that clinical supervision-as-usual may be virtually no supervision at all, at least for the intake process. Intakes represent a critical juncture of care for clients in that counselors must engage clients in a discussion about their substance use, assess related biopsychosocial factors, formulate diagnoses, motivate clients for change, and plan treatment accordingly. Reliance solely on individual counselors’ judgments without supervisory checks and balances for intakes is suboptimal and, moreover, is a missed opportunity for improving counselor practice.
We were unable to show that MIA: STEP, compared to SAU, significantly improved the percentage of scheduled sessions attended by clients, retention rates or days of primary substance abstinence. Overall, clients in both conditions stayed in treatment (70 percent and 50 percent at four- and twelve-week follow-ups, respectively) and attended scheduled sessions (60 percent at both time points) at similar rates. Likewise, they increased the number of days in which they remained abstinent from their primary substance (from baseline to follow-up points) by about 50 percent. Several explanations may account for the congruent findings. First, clients in both conditions received some MI during their intakes, and the gradual differential gain in the quality of MI produced by MIA: STEP over the course of the trial may have been insufficient in magnitude to enhance client retention or outcome. Second, up to forty-five minutes of MI (twenty to thirty minutes up front and ten to fifteen minutes at the end) were used within intakes that were on average an hour and twenty minutes in length. Thus, the psychosocial assessment of the “MI sandwich” was a substantial component, and it may have diluted differential effects produced by supervision conditions. This very brief MI component of a single intake session, followed by varied treatment content and intensity across programs, likely reduced ability to detect the effect of supervision on retention or outcomes. Supervision of MI sessions, unadulterated by an extended psychosocial assessment or other treatment approaches, or of a multi-session MI intervention might have provided a better venue for studying the effectiveness of MIA: STEP. Third, across conditions baseline levels of client motivation to change their alcohol and drug use were quite high, and about half the clients were court-mandated to treatment. This combination of internal and external motivation to change may have limited the clinical relevance of MI for our study’s client sample. Fourth, MIA: STEP supervision may not have uniquely improved the counselors’ capacity to increase their clients’ change talk and help resolve their arguments against change, a key causal mechanism in MI (Magill et al., 2014). Studying the degree to which competency-based supervision can improve counselors’ ability to activate mechanisms directly related to client outcomes within different psychotherapeutic approaches should be the focus of future research.
A final consideration is the cost of delivering MIA: STEP relative to SAU. MIA: STEP was six times more expensive than SAU, as implemented across the eleven sites. This excess was mostly driven by the cost of time spent by the MIA: STEP experts in training and consulting with the program supervisors, supervisors reviewing the intakes and preparing feedback, and supervisors and counselors meeting for supervision, almost none of which happened in SAU. Given that MIA: STEP did not result in better client treatment retention or outcomes than SAU, the feasibility and acceptability of using this intensive and relatively expensive form of supervision as a strategy to implement MI in community treatment programs is questionable. Competency-based supervision approaches such as MIA: STEP might be better suited in clinical training environments (e.g., graduate schools, internships, postdoctoral fellowships) where intensive supervision resources typically are provided.
Limitations and Strengths
This study had several limitations and strengths. Some limitations included only fair counselor retention, use of MI within an intake instead of as a stand-alone treatment delivered several times, the near absence of SAU during the trial, and reliance on self-report substance use data rather than urine and breath specimen sample results. We also could not control how clients were assigned to counselors after their intakes and did not track if they had received any form of treatment from counselors in the alternative condition or had received MI at the program from other sources.
On the other hand, this study had many strengths, including randomization of both counselors and clients to conditions, clear definition of supervision and documentation that MIA: STEP was performed well, use of successively supervised cases to allow for examination of the growth in MI skills over time, and large and diverse samples of counselors and clients. In addition, unlike most prior MI training studies, this study had counselors conduct MI with clients as they entered treatment, reducing self-selection bias. Given these strengths, the mixed study findings in the context of the cost of MIA: STEP-guided supervision are not easily dismissed. Developing acceptable, feasible, and cost-effective ways to train counselors in MI remains a challenge to the field.
Acknowledgments: This study was funded by the US National Institute on Drug Abuse (R01 DA1049398 awarded to Steve Martino, with additional support provided by R01-DA034243, P50-DA09241, and U10-DA130038). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of NIDA.
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Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Martino, S., Paris, M., Jr., Añez, L., Nich, C., Canning-Ball, M., Hunkele, K., . . . Carroll, K. M. (2016). The effectiveness and cost of clinical supervision for motivational interviewing: A randomized controlled trial. Journal of Substance Abuse Treatment, 68, 11–23.