SECTION G:

Motivational Interview
Rating Guide & Forms
Topic Page

1. Interview Rating Guide ............................... 89

2. Forms - Masters........................................... 125
a. MI Interview Rating Worksheet ............... 127
b. MI Adherence and Competence Feedback.... 129
c. MI Skills Development Plan .................... 130
d. MI Clinician Self-Assessment Report ....... 131
3. References ................................................... 137

87
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MOTIVATIONAL INTERVIEW
RATING GUIDE:
A MANUAL FOR RATING CLINICIAN ADHERENCE AND COMPETENCE

Adapted from the NIDA National Drug Abuse Treatment

Clinical Trials Network Protocol 0005:
Motivational Interviewing to Improve Treatment Engagement and Outcome in
Individuals Seeking Treatment for Substance Abuse

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TABLE OF CONTENTS

Acknowledgments .......................................................................................... 92
Introduction .................................................................................................... 93
MI Supervision Guidelines ........................................................................... 95
General Interview Rating Guidelines .......................................................... 99
Rating Adherence and Competence ............................................................ 101
Description of Rating Items .......................................................................... 105
MI Consistent Items
1. MOTIVATIONAL INTERVIEWING STYLE OR SPIRIT ..................................... 105
2. OPEN-ENDED QUESTIONS ....................................................................... 106
3. AFFIRMATION OF STRENGTHS AND SELF-EFFICACY .................................. 107
4. REFLECTIVE STATEMENTS .................................................................................. 108
5. FOSTERING A COLLABORATIVE ATMOSPHERE .......................................... 109
6. DISCUSSING MOTIVATION TO CHANGE ................................................... 110
7. DEVELOPING DISCREPANCIES .................................................................. 111
8. EXPLORING PROS, CONS, AND AMBIVALENCE ........................................... 112
9. CHANGE PLANNING ................................................................................ 113
10. CLIENT-CENTERED PROBLEM DISCUSSION & FEEDBACK .......................... 114
MI Inconsistent Items
11. UNSOLICITED ADVICE, DIRECTION GIVING, OR FEEDBACK ...................... 115
12. EMPHASIS ON ABSTINENCE ...................................................................... 116
13. DIRECT CONFRONTATION ....................................................................... 117
14. POWERLESSNESS AND LOSS OF CONTROL ................................................. 119
15. ASSERTING AUTHORITY ........................................................................... 120
16. CLOSED-ENDED QUESTIONS (Optional) .............................................................. 121
General Ratings of Client
17. MOTIVATION – BEGINNING .................................................................... 122
18. MOTIVATION – END ................................................................................ 122
Forms - Masters
1. MI Interview Rating Worksheet ........................................................................... 127
2. MI Adherence and Competence Feedback Form ..................................................... 129
3. MI Skills Development Plan ............................................................................... 130
4. MI Clinician Self-Assessment Report .................................................................... 131
References ........................................................................................................ 137

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ACKNOWLEDGMENTS

T
he NIDA/SAMHSA Motivational Interviewing Blending Team members, representing
participants from the NIDA National Drug Abuse Treatment Clinical Trials Network
(CTN) and the CSAT Addiction Technology Transfer Centers network have adapted the
MI Supervisor Interview Rating Guide from the supervisory tape rating system used in CTN
Protocol 005 (Motivational interviewing to improve treatment engagement and outcome in
individuals seeking treatment for substance abuse). We gratefully acknowledge the authors of the
protocol’s tape rating system (Samuel Ball, Ph.D., Steve Martino, Ph.D., Joanne Corvino, M.P.H.,
Jon Morgenstern, Ph.D., and Kathleen Carroll, Ph.D.) and all the individuals who participated in
the protocol and contributed to the system’s development.

We specifically would like to acknowledge Kathleen Carroll, Ph.D. who was the protocol’s Lead
Investigator, the CTN Node trainers who helped refine the system: Deborah Van Horn, Ph.D. -
Delaware Valley Node; Chris Farentinos, MD and Kathyleen Tomlin, LPC - Oregon Node; Doug
Polcin, Ed.D., Jean Obert, MFT, MSM, and Robert Wirth, MA, MFT - Pacific Node;
Charlotte Chapman, MS, MAC, LPC - Mid-Atlantic Node; and William R. Miller, Ph.D. and
Theresa Moyers, Ph.D. who trained trainers in the CTN protocol.

Finally, we especially thank the community treatment programs and their supervisors, clinicians
and clients who participated in the protocol and the fifteen independent tape raters who rated
approximately 400 protocol sessions and provided the data for fine-tuning the system. The
culmination of this Guide truly has been a blended team effort to provide supervisors and
mentors with a tool that promotes the best practice of MI among community treatment
program clinicians.

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INTRODUCTION
This manual details a system for rating a clinician’s the system relies upon direct observation of the
adherence and competence in using Motivational clinicians’ MI practice via the use of audio recordings,
Interviewing (MI), a client-centered treatment it has the capacity for highly individualized
approach that targets the development and supervision based on what clinicians actually say and
enhancement of intrinsic motivation to change do in sessions rather than basing supervisory feedback
problem behaviors (Miller & Rollnick, 2002). solely on the clinicians’ self-report. This “ears-on”
Clinician MI adherence refers to the extent to which approach to supervision is very important given that
clinicians specifically implement MI strategies and clinician self-report is unrelated to proficiency levels
techniques, i.e., how “much” they did it. Clinician of observed practice (Miller, Yahne, Moyers,
MI competence refers to the skill with which Martinez,& Pirritano, 2004).
clinicians use these MI interventions, i.e., how “well”
they did it. The aim of this Guide is to provide THE GUIDE IS DIVIDED INTO FIVE SECTIONS:
supervisors and mentors with a systematic way for
monitoring clinician MI adherence and competence The first section, MI Supervision Guidelines,
and to provide clinicians with individualized describes recommendations for supervisor
supervisory feedback and coaching as a means to qualifications and makes suggestions for how to
further develop and refine their MI skills. supervise clinicians in a MI consistent fashion.

The Guide is a modification of the supervisor tape The second section, General Interview Rating
rating system used in the NIDA National Drug Abuse Guidelines, provides supervisors with six
Clinical Trials Network (CTN) MI Protocol 0005 recommendations for how to review session
(Motivational interviewing to improve treatment recordings and obtain accurate and consistent
engagement and outcome in individuals seeking adherence and competence ratings.
treatment for substance abuse) and is based on an
adaptation of the Yale Adherence Competence Scale The third section, Rating Adherence and
(YACS; Carroll, Nich, Sifry, Frankforter, Nuro, Ball, Competence, describes the system for rating how
Fenton, & Rounsaville, 2000). In brief, YACS is a often specific counseling strategies occurred
general system for evaluating therapist adherence and during a session (i.e., Adherence: Frequency and
competence across several types of manualized Extensiveness) and the clinician’s skill or quality
substance abuse treatments. Versions of it have been in using those strategies (i.e., Competence: Skill
used in several prior clinical trial studies, including Level).
Project MATCH in which Motivational
Enhancement Treatment (MET) was evaluated The fourth section, Description of Rating Items, is
(Carroll, Connors, Cooney, DiClemente, Donovan, divided into three subsections. The first
Longabaugh, Kadden, Rounsaville, Wirtz, & Zweben, subsection, MI Consistent Items, contains 10
1998). The YACS has shown high reliability and an items that describe MI strategies or techniques
ability to discriminate MET from other treatments clinicians may use to address a client’s substance
(Carroll et al., 1998, Carroll et al., 2000). use problems. The second subsection, MI
Inconsistent Items, contains 6 items that are
The Guide details a system for identifying the ways in inconsistent with a MI approach. For each item
which clinicians implement counseling strategies that in these two subsections, the manual provides
are consistent or inconsistent with MI. It also lays out definitions (Frequency and Extensiveness Rating
parameters that supervisors may use for establishing Guidelines), examples to help supervisors
the clinicians’ quality or skill of intervention. Because identify when each strategy occurs, and

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guidelines for determining the level of skill or develop a Motivational Interviewing Skills
quality in which the clinician implemented the Development Plan for addressing the needs
strategy. The MI consistent items also reference identified during the tape review. This section
teaching tools the supervisor might use with the also contains a Motivational Interviewing
clinician to develop targeted skill areas. The Clinician Session Report that the clinician has the
third subsection, General Ratings of Client option to complete at the end of each session.
Motivation, contains 2 items that address the
client’s motivation at the beginning and end of Other supervisory tools for helping clinicians
the session. develop and maintain proficiency in MI are
included elsewhere in the MIA:STEP package.
The fifth section, Forms - Masters, contains a Tools that summarize important MI concepts and
Motivational Interview Rating Worksheet to tally strategies can be found in section E. Self
instances when specific strategies occur and to assessment guidelines for ten specific MI skills are
write examples or notations about the quality of included in section F. All these tools can be
interventions. Based on the information on the reproduced and used in mentoring clinicians as
worksheet, the supervisor makes his or her final they work to improve their proficiency in MI
adherence and competence ratings and clearly skills.
records them on the Motivational Interviewing
Adherence and Competence Feedback Form. The
supervisor and clinician should compare and
discuss their ratings during supervision and then

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MI SUPERVISION GUIDELINES

S
upervisors and mentors have a very important Bachrach, DeCarlo, Farentinos, Keen, McSherry, Polcin,
role to play in the development of the Snead, Sockriter, Wrigley, Zammarelli, & Carroll, 2002).
clinician’s MI skills. Ongoing feedback and They may believe that the use of core MI skills is
coaching helps develop and maintain the skills of straightforward or elementary and that they can perform
clinicians trying to learn MI and other evidence-based these strategies fairly well with little practice.
substance abuse treatments (Miller et al, 2004;
Sholomskas, Syracuse, Rounsaville, Ball, Nuro, & While some clinicians find learning MI quite manageable
Carroll, 2005). This Guide provides a method for and progress in skill development readily, many clinicians
supervisors to implement these standards in a manner struggle to grasp the client-centered spirit of MI, to reflect
that mirrors the supervisory process used in the CTN with increasing depth and accuracy, to appreciate the
MI protocol. impact of questioning (open- and closed-ended) on client
elaboration and counseling style, to understand the
To use this MI rating system, supervisors will need to relationship between change talk and resistance, and to
have sufficient knowledge, experience, and support. know how to proceed strategically with directive methods
Minimum qualifications for conducting MI supervision for eliciting change talk and handling resistance skillfully.
include: (1) completion of a 15 hour MI skill-building Even recognizing overuse of close-ended questions and
workshop by a MINT (Motivational Interviewing incorporating more open-ended ones into the interview
Network of Trainers) trainer, (2) interest in becoming a may be challenging for some clinicians.
MI supervisor, and (3) be in a position with authority
to supervise other staff members. In addition, MI’s deceptive simplicity poses a dilemma for
supervisors should have the support of their clinical supervision. If the supervisor conveys to the clinician that
administrative leadership group for implementing this the clinician probably is less skilled than the clinician
method of supervision at their agencies. imagines him- or herself to be, the supervisor and
clinician may get into a confrontational trap in which
Before outlining a suggested format for conducting MI the supervisor becomes excessively corrective or
supervision, supervisors and mentors might benefit authoritative in pointing out what a clinician has done
from reviewing the following general guidelines. These wrong. The supervisor also might fail to address the
guidelines include: (1) being sensitive to the deceptive clinician’s understandable ambivalence about learning a
simplicity of learning and implementing MI, (2) being new counseling approach if he or she is used to
mindful of the complications posed by a clinician’s use conducting sessions in another manner. At the same
of MI inconsistent strategies when learning MI, (3) time, the supervisor’s responsibility is to promote the
handling clinician performance anxiety generated by clinician’s best MI practice (i.e., increase MI consistent
supervision, (4) practicing what you preach as a behaviors and decrease MI inconsistent behaviors) and to
supervisor by supervising in a MI consistent fashion, help the clinician appreciate that MI is more difficult to
and (5) considering clinician MI proficiency standards. learn than meets the eye. The supervisor navigates this
dilemma by acknowledging any familiarity the clinician
DECEPTIVE SIMPLICITY has with MI techniques and inquires about the clinician’s
experience using these skills. The supervisor attempts to
MI often is harder to conduct well than clinicians may meet the clinician where he or she is both in terms of
expect. When asked, many clinicians report that they interest in learning MI and initial skills the clinician
commonly use many MI consistent strategies such as brings to the supervision. The supervisor then asks the
open-ended questions and reflections as a mainstay of clinician in what ways he or she might hope to develop
how they work with clients and typically describe their further. In this way, the supervisor manages resistance to
work as empathic or attuned to the client’s needs (Ball, training and supervision, fosters a collaborative learning

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environment, and sets the stage for the clinician to CLINICIAN PERFORMANCE ANXIETY
discover and develop his or her essential MI skills. As the
supervisor provides the clinician with objective feedback Just as supervisors may not be familiar with the method
from the tape ratings, the clinician may become more of supervision outlined in this Guide, clinicians also may
mindful of his or her strengths and weaknesses and find the approach novel and may be surprised by the
appreciative of the subtleties and challenges posed by supervisors’ attention to their actual performance of MI
using MI. Thus, effective MI supervision incorporates instead of relying solely on self-report. While many
many elements of being a skilled MI clinician. clinicians find the degree of specificity and targeted
coaching very helpful and clearly benefit from it (Miller
MI INCONSISTENT COUNSELING BEHAVIORS et al., in press), occasionally some clinicians may become
anxious about the scrutiny of their work and become
Sometimes a clinician may experience resistance to uncomfortable with the process. If clinicians react in this
learning MI when the clinician realizes some of his or her manner, the supervisor might reinforce the expectation
counseling behaviors may be inconsistent with a MI that learning MI takes practice over time and that
approach. This type of resistance may arise when the clinicians commonly experience some difficulties initially
supervisor gives tape rating feedback about the clinician’s implementing the approach with fidelity. Supervisor
performance. As in MI, the supervisor avoids conveying efforts to recognize and affirm the clinicians’ MI
that MI is the “best” or “preferred” counseling approach. performance strengths often help to alleviate
Other methods might be appropriate alternatives. In performance anxiety and to support the clinicians’ self-
fact, clinical research does not support the superiority of efficacy in conducting MI.
any one major addiction counseling approach over all
others, provided that they are conducted with a high PRACTICE WHAT YOU PREACH
level of competence and have been empirically validated
(Project Match Research Group, 1997, 1998). Instead,
The three prior supervisory dilemmas underscore the
the supervisor presents MI on its own merits and
importance of conducting MI supervision in a manner
encourages the clinician to see what he or she thinks
consistent with MI. This means that the supervisor
about it by trying to learn and practice it in its purest
avoids presenting him- or herself as the expert fully
form. The clinician’s freedom to choose how to counsel
armed with interview ratings and helpful feedback, even
clients in the end may seem obvious, but might be worth
if well intentioned. Instead, MI supervisors ask about
underscoring at this point. The key is that the supervisor
the clinician’s view of his or her MI performance before
avoids the trap of “knowing better” than the clinician
commenting on the session. Focusing on what MI areas
and affirms his or her respect for the multitude of ways
went well, what progress happened, what challenges
in which the clinician may counsel others. At the same
occurred, what other ideas or options the clinicians
time, the supervisor highlights that the aim of MI
might entertain retrospectively, what the client
supervision is to develop the clinician’s MI adherence
communicated, and how to proceed with the client are
and competence and this process entails limiting or
all fruitful areas for discussion. Woven into these areas,
eliminating counseling approaches or styles that do not
the supervisor presents the interview rating results to the
work well with MI or that might be used after MI has
clinician and asks for the clinician’s reactions. Based on
been conducted. Once established, examination of how these discussions, the supervisor helps the clinician
to sequence and integrate other approaches with MI
identify focal areas for performance improvement,
(e.g., incorporating relapse prevention skills training after
mirroring the change planning process.
enhancing a client’s motivation for changing substance
use patterns) may become the focus of supervision. The supervisor also tries to understand resistance to
learning MI as an opportunity to see how MI may best
fit into a clinician’s practice. Resistance to learning MI
does not necessarily mean a clinician does not want to

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learn and practice MI. The clinician may confront real approaches the development of a clinician’s MI
implementation dilemmas involving agency practices proficiency as a collaborative work in progress. By
that hinder proficient use of MI (e.g., heavy information practicing what is preached, the supervisor models for
gathering demands with narrow time constraints at the clinician a style of interaction essential to performing
intake, clients presenting with complicated problems and MI and that may dually enhance the clinician’s intrinsic
symptoms that make using MI more challenging). motivation to learn the approach.
Listening carefully to and understanding this “resistance”
is an important part of supervision. How the supervisor A SUGGESTED SUPERVISION FORMAT USING
handles it will affect the clinician’s motivation to INTERVIEW RATING FEEDBACK
incorporate MI into his or her counseling approach. As
in MI where the clinician shares in the responsibility of The Supervisor Tape Rating Guide is a method for assessing
enhancing the clients motivation for change, the clinician MI performance and for constructing feedback that
supervisor shares in the responsibility for how well the provides the basis of individualized clinician coaching. While
clinician conducts MI. listening to a clinician’s taped session, the supervisor rates the
session using the MI Rating Worksheet and then completes the
MI Adherence and Competence Feedback Form. These ratings
Finally, the supervisor and clinician have the discretion to only are completed for the first and last 20 minutes of the
use additional methods to promote the clinician’s best session when the clinician is using MI as part of the MI
MI practice. Some options include: assessment sandwich. Because the middle portion of the MI
assessment involves collection of information necessary for
1. Having the clinician complete the MI Clinician intake form completion, sometimes including a formal
Session Report after sessions and discussing it with administration of the Addiction Severity Index (McLellan,
the supervisor; Kushner, Metzger, Peters, Smith, Grissom, Pettinati, &
Argeriou, 1992) or other intake assessment tool, rating this
2. Reviewing MI manuals, textbook chapters, or MI portion of the session is not useful for evaluating and
training tapes; supervising a clinician’s MI proficiency. In addition, the
supervisor has the option of asking the clinician to complete
3. Listening to recorded sessions together to highlight the MI Clinician Session Report after conducting the
well performed skills and to discuss what else the counseling session to help sensitize the clinician to his or her
clinician might have said when the interview veered MI efforts, increase greater MI self-evaluation skills, and
from proficiency; foster supervisor-clinician collaboration by comparing item
ratings. The supervisor may meet individually with the
4. Using structured role-plays targeting skills areas clinician, use a group supervision model in which clinicians
necessitating development or clinical circumstances rotate presentation of their work, or incorporate both means
in which clinicians have difficulty using MI; of reviewing MI performance. Individual MI supervision
sessions typically require a minimum of 30 minutes to
5. Forming a group or peer supervision to promote provide feedback and coaching. Group MI supervision
wider interest and dissemination of MI within the typically requires one hour.
agency.
While the supervisor and clinician will adjust the
Throughout this process, the supervisor tries to make supervision session to their needs, a suggested format is
him- or herself and other MI resources available to the as follows:
clinician. The clinician maintains the freedom to choose
in what additional ways he or she may enhance the 1. Openly discuss the clinician’s perception of his or her
supervision experience. session. Affirm the clinician’s use of the MI
Clinician Session Report and, if necessary, remind
In summary, the style of supervising clinicians in MI the clinician that it is an optional tool available to
mirrors the overall MI style central to the approach. MI him or her for honing MI skills.
supervision fundamentally is clinician-centered and

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2. Reflect the clinician’s main points. Look for evaluate performance. The MI Assessment protocol
opportunities to support the clinician’s efforts to use had proficiency standards for certifying clinicians as
MI in the session and to appreciate the challenges sufficiently competent to implement the motivational
the clinician may have had in trying to adhere to MI. interviewing assessment. The standards were set by the
protocol development team and represented a
3. Provide the clinician with feedback from the MI consensus decision among the team members. Miller
Adherence and Competence Feedback Form. Begin by also has proposed preliminary proficiency standards for
focusing on areas in which the clinician performed MI (Miller & Mount, 2001) based on an alternative
well. Next, note areas in which the clinician rating system called the motivational interviewing skills
struggled and provide some ideas in collaboration coding system or the MISC. In addition, a briefer
with the clinician about what might have adaptation of the MISC called the motivational
contributed to these difficulties (e.g., highly resistant interviewing treatment integrity code or the MITI is
client or relatively silent one, basis of ambivalence available. Supervisors interested in learning more about
not clarified during session, moved too far ahead of these systems should access the following website:
the client, ratio of questions to reflections was too http://casaa.unm.edu. Nonetheless, the proficiency
high, etc.). Discuss ways to promote the clinician’s standards for this protocol were established to provide a
abilities in these areas. competency threshold that would be feasible for clinical
4. Ask the clinician to identify an area in which he or practice among community treatment program
she wishes to focus. Spend time discussing this clinicians and sufficient to ensure an adequate level of
matter and, as indicated, supplement the discussion MI performance in the study in the absence of existing
with review of MI strategies and techniques. Use of benchmarks (Carroll, Farentinos, Ball, Crits-Christoph,
role-plays constructed to target the development of Libby, Morgenstern, Obert, Polcin, & Woody, 2002).
specific skills or to handle challenging client
scenarios often are very useful for this purpose. Use To be deemed sufficiently proficient in conducting the
of the MI Skill Development Plan may help clarify MI assessment, clinicians had to demonstrate in several
learning objectives and methods for both the sessions the use of at least half of the MI consistent items
supervisor and clinician. three to four times, namely, receive a “Somewhat” (4)
frequency and extensiveness rating and at least an
5. Either with the permission or at the clinician’s “Adequate” (4) skill level rating. In other words, the
request, listen to a segment of the recording together clinician had to show the capacity to use a moderate
and consider retrospectively what else the clinician amount of MI strategies and skills and show an adequate
might have said or done. This exercise may be level of performance when implementing them. After
particularly useful for providing feedback and skill reaching these standards, supervision of the clinicians
development opportunities for the clinician. continued on a biweekly basis throughout the protocol
using the method of supervision detailed in this manual
6. Summarize the supervision session with a succinct to maintain or make further gains in the clinicians’ MI
review of the clinician’s strengths and ongoing performance. If three successive sessions occurred in
learning objectives. which a clinician fell below proficiency standards, the
7. Schedule the next supervision session and review with clinician received additional training, feedback, and
the clinician the timeframe for obtaining another coaching until he or she demonstrated again the
recorded client session and having it rated by you. minimal MI proficiency standards. Supervisors
may elect to use the protocol’s MI proficiency
CLINICIAN MI PROFICIENCY STANDARDS standards as a supervisory benchmark for
their clinicians.
Supervision also entails training clinicians to some
standards of proficiency and using these standards to

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GENERAL INTERVIEW RATING GUIDELINES

R
ating tapes of counseling sessions and using ratings given to other items;
these ratings as the basis for clinical how skilled the supervisor believes the clinician is;
supervision may be unfamiliar to many how much the supervisor likes the clinician.
supervisors and clinicians. Supervisory interview
rating requires a supervisor to carefully follow the 3. RATE EACH CLINICIAN BEHAVIOR ON ALL
system outlined in this Guide and to learn how to use APPLICABLE ITEMS:
it with accuracy and consistency as a primary tool of
supervision. This systematic approach to supervision A clinician’s statement or question may be relevant
ensures a uniform approach for understanding what to several items. Because items may overlap in
occurs within and across counseling sessions, allows terms of breath of coverage, the same clinician
comparison of MI performance across clinicians, and behavior that is appropriately rated on one item
provides a means for the supervisor and clinician to may also apply to another item. Supervisors
track the clinician’s performance over time. To should carefully consider what they have observed
maximize these capacities, we recommend that and code their observation on all items that apply.
supervisors follow several guidelines when rating For example, a clinician may ask a client at the
clinician MI adherence and competence: beginning of a session, “What are some of the
good and bad things you get from drinking?”
1. RATE OBSERVABLE CLINICIAN BEHAVIORS AND This question is open-ended (Item 2 – Open-
FACILITATION EFFORTS: ended Questions) and related to the advantages
and disadvantages of substance use (Item 8 – Pros,
Each item describes explicit clinician behaviors that a Cons, and Ambivalence). Supervisors should rate
supervisor might observe when listening to a taped this one occurrence on both items.
session. The supervisor rates only clear, observable
instances in which a clinician implements a strategy 4. USE THE SUPERVISOR’S GUIDE DURING EACH
consistent with MI or that is contraindicated by the RATING SESSION:
approach. The client’s behavior and responses to
clinician interventions do not impact the ratings. To prevent supervisor rating drift, we strongly
The supervisor simply considers what the clinician recommend that all supervisors regularly review
actually attempted or facilitated and rates these the MI Supervisor Interview Rating Guide when
efforts according to the items’ specific definitions. rating a session. The Guide provides definitions,
The supervisor should have specific examples in guidelines, and specific examples to promote
mind to substantiate the ratings. accurate rating. Because of the complexity of the
scale items, it is essential that the supervisors are
2. AVOID BIASED RATING: completely familiar with the item definitions
before rating them. If supervisors are uncertain
This MI adherence and competence rating scale is about how to rate what the clinician has said, the
designed for the purpose of accurately describing supervisors should stop the tape and reference the
the clinician’s behavior in the session. To obtain Guide to isolate the best-matched item
the highest level of accuracy, the supervisor should descriptors.
be mindful of potentially biased ratings and strive
not to be unduly swayed by:

other behaviors the clinician engaged in during

the session;

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5. REVIEW THE MI PORTIONS OF THE MI ASSESSMENT the items. In particular, narrative note taking
SESSION, TALLY CLINICIAN BEHAVIORS, AND TAKE greatly helps supervisors make Skill Level ratings
NOTES BEFORE MAKING A RATING: and individualize feedback and coaching to the
unique training needs of the clinician.
Supervisors should listen to first and last 20
minutes of the session before making final ratings. 6. PROTECT CONFIDENTIALITY:
These portions of the session capture the parts of
the MI assessment sandwich where MI is used in All recordings and rating sheets and scores are
the absence of more structured intake assessment confidential materials. To maintain
tools. As they listen to the session, supervisors confidentiality, supervisors should instruct
should make hash marks to indicate when an item clinicians not to write any personal information
has occurred. In addition, we recommend on any tape or form. In addition, clinicians will
supervisors take notes while listening to the need to obtain a record consent that reviews how
session. Supervisors should record all of this the recordings are handled and the purpose of
information on the Interview Rating Worksheet recording the session. Once obtained, supervisors
(provided in the Rating Form section of this must listen to recordings and rate sessions in
Guide). Tallying and note taking enhance the places that ensure confidentiality. In other words,
accuracy of the ratings because they keep the supervisors should handle recordings like medical
supervisors focused on what actually occurred in records and not leave recordings or rating material
the session and provide supervisors with unattended.
information critical for making final ratings on all

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RATING ADHERENCE AND COMPETENCE

clinician engages in the intervention) and

F
or all items, supervisors must distinguish
between the clinician’s (1) Adherence: Extensiveness (i.e., the depth or detail with which
Frequency and Extensiveness of using strategies, the clinician covers any given intervention). These
and (2) Competence: Skill Level of implementing separate but related dimensions inform each
those strategies. The specific system for coding the rating interactively. In other words, the highest
interview for adherence and competence is described ratings involve clinician behaviors that are both
below. high on frequency and extensiveness, whereas
middle range scores may reflect behaviors that
1. Adherence: Frequency and were done less often or with less depth. All
Extensiveness supervisors use the following definitions to make
their final Frequency and Extensiveness ratings for
The adherence rating blends together both the each item.
Frequency (i.e., the number of discrete times the

RATING OF:

1 = Not at all ............. The variable never explicitly occurred.

2 = A little ................. The variable occurred once and was not addressed in any
depth.

3 = Infrequent........... The variable occurred twice, but was not addressed in

depth or detail.

4 = Somewhat .......... The variable occurred one time and in some detail OR the
variable occurred 3-4 times, but all interventions were very
brief.

5 = Quite a bit........... The variable occurred more than once in the session, and
at least once in some detail or depth OR the variable
occurred 5-6 times, but all interventions were very brief.

6 = Considerably ..... The variable occurred several times during the session and
almost always with relative depth and detail OR the
variable occurred more than 6 times, but all interventions
were very brief.

7 = Extensively ........ The variable occurred many times almost to the point of
dominating the session and was addressed in elaborate
depth and detail OR the variable occurred briefly at such a
high frequency that it became difficult to count.

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For the Frequency and Extensiveness ratings, the determination (i.e., at the end of listening to the
starting point for rating each item in the scale is “1”. entire session) that includes consideration of the
The supervisor should assign a rating of greater than depth/extensiveness of counseling interventions.
“1” only if he or she hears examples of the behavior
specified in the items. The supervisor must be able to Of note, the supervisors should rate all instances of an
substantiate with examples the rating assigned to every item’s occurrence. In some cases, an item will have a
item. This guide provides many examples of clinician very large number of un-circled hash marks that
behaviors that would “count” or endorse each item. indicate a high frequency of brief interventions.
Sometimes, no or very few instances may have
To acquire accurate counts, all supervisors should use occurred. In other cases, interventions may have been
a hash or tally mark system while reviewing the delivered in detail or an extensive fashion. In the end,
recording. Using the Interview Rating Worksheet, the supervisor must convert his/her tallies from the
supervisors should make a hash mark next to the Interview Rating Worksheet into final ratings on the
item when it occurs. If the item occurs more than Supervisor Interview Rating Form. The hash mark
once there should be corresponding hash marks (i.e., system should capture the supervisor’s overall best
item mentioned 3 times would look like this: / / /). judgment of the clinician’s style and technique used
If an item occurs in detail, the hash mark(s) can be during the session. For example, corresponding rating
circled to help supervisors make a final rating notations might look like this:

1 (Not at all) = ................................................................................................... (no hash marks)

The variable never explicitly occurred
2 (A little) = one hash mark, uncircled ............................................................................. ( / )
The variable occurred once and was not addressed in any depth.

3 (Infrequent) = two hash marks, uncircled .................................................................. ( / / )

The variable occurred more than once, but was not addressed
in depth or detail

4 (Somewhat) = one circled hash mark ......................................................................... ( Ø )

The variable occurred one time and in some detail OR the variable ............................... ( / / / )
occurred 3-4 times, but all interventions were very brief
5 (Quite a bit) = two or three hash marks, at least one circled .......................................( Ø / / )
The variable occurred more than once in the session, and at least ............................... ( / / / / / )
once in some detail or depth OR the variable occurred 5-6 times,
but all interventions were very brief.
6 (Considerably) = more than three hash marks, several circled ................................ ( Ø / Ø / )
The variable occurred several times during the session and almost ............................. ( / / / / / / / )
always with relative depth and detail OR the variable occurred
more than 6 times, but all interventions were very brief.
7 (Extensively) = more than five hash marks, almost all circled .......................... ( Ø Ø Ø Ø / Ø Ø )
The variable dominated the session, occurred many times, and was ................. ( / / / / / / / / / / / / / / / / /)
addressed in elaborate depth and detail OR the variable occurred
briefly at such a high frequency that it became difficult to count.

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2. Competence: Skill Level When rating Skill Level, the starting point for rating
each item should be “4.” That is, supervisors should
The clinician’s competence or Skill Level refers to begin by assuming that a clinician will behave
the clinician’s demonstration of: adequately or at an average level. Supervisors assigning
scale scores above or below a “4,” should have examples
expertise and competence or notations in mind to support their scores. To help
appropriate timing of intervention supervisors with this task, the Guide provides Skill
clarity of language Level Rating Guidelines that describe how a specific
responding to where the client appears to be strategy is of higher or lower quality than an “adequate”
rating of 4.
All supervisors use the following definitions to
make their final Skill Level ratings for each item: A useful method for recording Skill Level ratings while
listening to a session is to combine them with the hash
mark system.
When a strategy
RATING OF: occurs with
adequate skill, the
9 = Not at all .............. The variable was not observed (i.e., rated “1” for Frequency supervisor records
and Extensiveness). a simple hash mark
without a notation
1 = Very poor ............ The clinician handled this in an unacceptable, even
about quality (/).
unprofessional manner.
The absence of a
notation always
2 = Poor .................... The clinician handled this poorly (e.g., showing clear lack
connotes adequate
of expertise, understanding, competence, or commitment,
skill level. If a
inappropriate timing, unclear language).
strategy occurs
3 = Acceptable ......... The clinician handled this in an acceptable, but less than with more or less
‘average’ manner. than adequate skill,
the supervisor
4 = Adequate ............ The clinician handled this in a manner characteristic of an records a hash
‘average’, ‘good enough’ clinician. mark with a
superscripted
5 = Good ................... The clinician handled this in a manner slightly better than number that
‘average.’ corresponds to the
specific Skill Level
6 = Very good ........... The clinician demonstrated skill and expertise in handling rating. For
this issue. example, a strategy
implemented with
7 = Excellent ............ The clinician demonstrated a high level of excellence and poor skill would
mastery in this area. look like /2. A
strategy
implemented with
6
very good skill would look like / . The supervisors also
may include a few narrative examples of higher or lower
quality strategies on the worksheet. In this manner, the
supervisors can organize the data efficiently and more
easily cull and average the varying Skill Level ratings to

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determine and justify the final competency ratings for

each item. These narratives also are very useful in
supervision to provide specific examples.

Although there may be significant overlap

between the Skill Level and its effectiveness (implied
by the client’s verbal response), Skill Level is not the
same as effectiveness in that it does not require the
client’s positive response. A clinician may score highly
on Skill Level for a particular item regardless of the
client’s response. Of equal importance, Skill Level
must be distinguished from Frequency and
Extensiveness. For example, a clinician’s score of “6”
on Frequency and Extensiveness for a particular item
does not necessarily mean the Skill Level was high.
Supervisors should rate Skill Level independent of
Frequency and Extensiveness. Thus, it is perfectly
appropriate for a supervisor to give a rating of “3” on
Skill Level even if the Frequency and Extensiveness
rating is a “6.”

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DESCRIPTION OF RATING ITEMS

T
his section describes in detail different consistently aiming to elicit the client’s motivation
counseling strategies a clinician may use for change. This therapeutic style is one of calm and
during a session. Items 1 through 10 define caring concern and an appreciation for the
strategies that are consistent with MI and critical to the experiences and opinions of the client. The clinician
approach (e.g., open-ended questions, affirmations of conveys empathic sensitivity through words and tone
strengths and self-efficacy, reflective statements). Items 11 of voice, and demonstrates genuine concern and an
through 15 define strategies that are inconsistent with MI awareness of the client’s experiences. The clinician
(unsolicited advice giving, directly confronting, avoids advising or directing the client in an
emphasizing abstinence, emphasizing powerlessness and unsolicited fashion. Decision-making is shared. As
loss of control, asserting authority) and undercut the the clinician listens very carefully to the client, the
overall MI style or spirit. Item 16 (closed-ended clinician uses the client’s reactions to what the
questions) is an optional additional MI inconsistent item clinician has said as a guide for proceeding with the
supervisors may find helpful to track in their efforts to session. The clinician avoids arguments and
maximize a clinician’s MI proficiency. Each item includes sidesteps conflicted discussions or shifts focus to
a specific definition, frequency and extensiveness rating another topic where eliciting the client’s discussion
guidelines to help the supervisor capture all occurrences of and motivation for change may be more productive.
it, specific examples, and guidelines for rating the overall In brief, this item captures the client-centered way of
skill demonstrated by the clinician in using the particular being with a client a clinician maintains when
strategy. We strongly encourage supervisors to become conducting MI.
very familiar with the rating items and to continuously
refer to the definitions in order to provide clinicians with A higher Frequency/Extensiveness rating would be
the most accurate, consistent, and individualized rating achieved if the clinician consistently maintains the
feedback and coaching. MI spirit and pursuit of an accurate understanding
of the client throughout the session and clearly
MI CONSISTENT ITEMS demonstrates an ability to respond without
defensiveness to the client’s resistance behaviors such
1. MOTIVATIONAL INTERVIEWING STYLE as arguing, interrupting, negating (denial), or
OR SPIRIT: To what extent did the clinician provide ignoring. The clinician appears facile in using core
low-key feedback, roll with resistance (e.g., avoiding MI skills such as open-ended questions, reflections,
arguments, shifting focus), and use a supportive, warm, affirmations, and summaries and integrates these
non-judgmental, collaborative approach? To what skills with a variety of other techniques used to more
extent did the clinician convey empathic sensitivity directly elicit self-motivational client statements and
through words and tone of voice, demonstrate genuine to reduce resistance such as: Amplified reflection
concern and an awareness of the client’s experiences? To (reflecting the client’s statements in an exaggerated
what extent did the clinician follow the client’s lead in manner); Double-sided reflection (restating what the
the discussion instead of structuring the discussion client has said, but reminding them of the contrary
according to the clinician’s agenda? things they have said previously); Shifting focus
(changing the topic or focus to things the client is
FREQUENCY AND EXTENSIVENESS RATING less resistant to exploring and changing); Reframing
GUIDELINES: (acknowledging what the client has said, but offering
a different perspective); or Coming along side
This item refers to how much the clinician (taking the side of no change as a way to foster the
maintained an empathic, collaborative approach and client’s ambivalence and elicit change talk). Each of
handled resistance skillfully instead of head-on while these techniques is used to reduce resistance and

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facilitate the client’s consideration and discussion of strategies to the client’s shifting
change-related topics. Lower ratings occur when motivational state or who sounds
clinician behaviors supporting a MI stance are absent redundant in the interventions selected also
or seldom occur or if the clinician peppers the may receive lower Skill Level ratings.
session with several MI inconsistent interventions
that disrupt or negate the MI spirit. 2. ASKING OPEN-ENDED QUESTIONS: To
what extent did the clinician use open-ended questions
EXAMPLE: (i.e., questions or requests that elicit more than yes/no
responses) to elicit the client’s perception of his/her
Client: “Why do you keep asking me to talk about my problems, motivation, change efforts, and plans?
cocaine use? My kids are driving me crazy. You’d use
cocaine too if you had my problems!” FREQUENCY AND EXTENSIVENESS RATING
GUIDELINES:
Clinician: “You have a valid point. Maybe we should
think about having your family come to a session. This Open-ended questions are questions that result in
problem may be bigger than you alone.” more than yes/no responses and that don’t pull for
terse answers or very specific pieces of information.
SKILL LEVEL RATING GUIDELINES: Often these questions begin with the following
interrogatives: “What,” “How,” “In what,” and
HIGHER: A clinician demonstrates a high quality “Why” (somewhat less preferable) or lead off with
motivational interviewing style/spirit when the request, “Tell me…” or “Describe…” The
he/she establishes an overall tone of clinician uses open-ended questions to elicit an open
collaboration and respect. The clinician conversation about the client’s view of his/her
shows he/she cares about what the client is problems and commitment to change. In brief, by
saying and strives to accurately understand using open-ended questions, the clinician gives the
and reflect the client’s statements. The client a wide range for discussing his or her life
clinician uses any specific therapeutic circumstances and substance use patterns.
strategy in the service of promoting an
overall motivational interviewing style or A higher Frequency/Extensiveness rating would be
spirit. A clinician also demonstrates higher achieved if the clinician asks numerous questions
skill when, throughout the session, the that invite client conversation (see Correct
clinician deftly uses the client’s reactions as Examples) as opposed to asking only yes/no response
a guide for formulating subsequent MI questions (see Incorrect Examples). Lower ratings
strategies and techniques. The clinician’s occur when the clinician asks very few questions or
attunement to the client is obvious. almost all closed-ended ones.

LOWER: A low quality motivational interviewing EXAMPLES:

style occurs when the clinician controls the
interview process, insufficiently facilitates Correct
the client’s open exploration of his/her So, what brings you here today?
problem areas and motivation for change, What are some of the ways that substance use
and acts inflexibly and defensively in affects your life?”
response to client resistance. The clinician What kinds of differences have you noticed
may deliver therapeutic interventions in a in…?
technically correct manner but with little
facility, warmth, or engagement of the
client. A clinician who does not adjust

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Incorrect: questions, or does not pause sufficiently

Do you use marijuana? When was the last time after each question to give the client time
you used? to contemplate and respond.
Can you tell me how heroin affects you?
Your wife thinks you are addicted to cocaine. 3. AFFIRMATION OF STRENGTHS AND
Are you addicted to cocaine? CHANGE EFFORTS: To what extent did the
clinician verbally reinforce the client’s strengths, abilities,
SKILL LEVEL RATING GUIDELINES: or efforts to change his/her behavior? To what extent did
the clinician develop the client’s confidence by praising
HIGHER: High quality open-ended questions are small steps taken in the direction of change or expressing
relevant to the clinician-client conversation appreciation of personal qualities in the client that
and pull for greater client exploration and might facilitate successful efforts to change?
recognition of problem areas and
motivation for change, without appearing FREQUENCY AND EXTENSIVENESS RATING
to be judgmental or leading to the client. GUIDELINES:
They are simple and direct, thereby
increasing the chance that the client clearly This item refers to what extent the clinician expresses
understands what the clinician is asking. confidence in the client to achieve his/her goals. The
Usually, several open-ended questions do clinician may affirm the client using many different
not occur in close succession. Rather, high approaches: a) using compliments or praise, b)
quality open-ended questions typically are acknowledging the client’s personal qualities,
interspersed with reflections and ample competencies or abilities that might promote change,
client conversation to avoid the creation of c) recognizing effort or small steps taken by the client
a question-answer trap between the to change. Sometimes, the clinician might use a
clinician and client. The clinician pauses positive reframe to affirm the client (e.g., noting how
after each question to give the client time multiple treatment episodes and numerous relapses
to respond to each query. are evidence of the client’s persistence in trying to
deal with his or her drug use problems and not
LOWER: Low quality open-ended questions are giving up). By complimenting, positively
poorly worded or timed or target an area reinforcing, and validating the client, the clinician
not immediately relevant to the fosters the belief in the client that there is hope for
conversation and client concerns. They successful recovery and that the client can change
often will occur in close succession, giving his/her own substance use behaviors.
the conversation a halting or mechanical
tone rather than one that flows naturally Note: Raters should not rate a clinician’s simple
between the clinician and client. Lower statements of “Good” or “Great” as affirmations.
quality open-ended questions also may Affirmations must include direct references to
compound several questions into one query something about the client.
(e.g., “Tell me about how you felt before
and after you got high and how that all EXAMPLES:
affects your future risk for using cocaine.”),
making them harder to understand and Clinician: “It sounds as if you have really thought a lot
respond to by the client. Further about this and have some good ideas about how you
reductions in Skill Level ratings may occur might want to change your drug use.”
if the clinician seems to be leading or
steering the client, uses a judgmental or “That must have been really hard for you. You are really
sarcastic tone when asking open-ended trying hard to work on yourself.”

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SKILL LEVEL RATING GUIDELINES: techniques include repeating exactly what the client
just stated, rephrasing (slight rewording), paraphrasing
HIGHER: Higher quality affirmations occur when the (e.g., amplifying thoughts or feelings, use of analogy,
clinician affirms qualities or efforts made by making inferences) or making reflective summary
the client that promote productive change statements of what the client said. Reflective summary
or that the client might harness in future statements are a special form of reflection in which the
change efforts rather than being general clinician selects several pieces of client information
compliments. The clinician derives these and combines them in a summary with the goal of
affirmations directly from the conversation. inviting more exploration of material, to highlight
As a consequence, high quality affirmations ambivalence, or to make a transition to another topic.
are meaningful to the client rather than Often, summary reflections receive an extensive or in
being too global or trite. A key ingredient in depth tally mark on the worksheet.
a high quality affirmation is the appearance
of genuineness rather than the clinician EXAMPLES:
merely saying something generally affirming
in a knee-jerk or mechanical fashion. Client: “Right now, using drugs doesn’t take care of
how bad I feel like it used to. If anything, I feel
LOWER: Low quality affirmations are not worse now.”
sufficiently rooted in the conversation
between the client and clinician. The Simple Reflection
affirmations are not unique to the client’s
description of him/herself and life Using drugs makes you feel worse now.
circumstances or history. The clinician
may appear to affirm simply to buoy a Rephrasing
client in despair or encourage a client to try
to change when he/she has expressed doubt So, you have found that using drugs to deal
about his/her capacity to do so. In short, with how badly you feel is not working well
poor quality affirmations sound trite, for you anymore.
hollow, insincere, or even condescending.
Paraphrasing Using a Double-Sided Reflection
4. MAKING REFLECTIVE STATEMENTS: To
what extent did the clinician repeat (exact words), In the past using drugs helped you feel better
rephrase (slight rewording), paraphrase (e.g., when you were having a hard time or feeling
amplifying the thought or feeling, use of analogy, badly. Now, it is only making matters worse
making inferences) or make reflective summary for you.
statements of what the client said?
Introductions to a Reflective Summary
FREQUENCY AND EXTENSIVENESS RATING
GUIDELINES: Let me see if I understand what you’ve told
me so far…”
Reflective statements made by the clinician restate the Here is what I’ve heard you say so far…”
client’s comments using language that accurately
clarifies and captures the meaning of the client’s Skill Level Rating Guidelines:
communications and conveys to the client the
clinician’s effort to understand the client’s point of HIGHER: Higher quality reflections occur when the
view. The clinician uses this technique to encourage clinician accurately identifies the essential
the client to explore or elaborate on a topic. These meaning of what the client has said and

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reflects it back to the client in terms easily 5. FOSTERING A COLLABORATIVE

understood by the client. The clinician’s ATMOSPHERE: To what extent did the clinician
inflection at the end of the reflection is convey in words or actions that the therapy is a
downward. The clinician pauses sufficiently collaborative relationship in contrast to one where the
to give the client an opportunity to respond clinician is in charge? How much did the clinician
to the reflection and to develop the emphasize the (greater) importance of the client’s own
conversation. Well-delivered reflections decisions, confidence, and perception of the importance
typically are concise and clear. Over the of changing? To what extent did the clinician verbalize
course of the session, higher quality respect for the client’s autonomy and personal choice?
reflections usually have more depth (i.e.,
paraphrasing thoughts or feelings in manner FREQUENCY AND EXTENSIVENESS RATING
that effectively brings together discrepant GUIDELINES:
elements or that clarify what the client
meant). If the clinician reflects several client This item captures any explicit effort the clinician
statements, the clinician neatly arranges makes to seek guidance from the client or to act as
them in a manner that promotes further though therapy were a joint effort as opposed to
client introspection, conversation, and one in which the clinician consistently is in control.
motivation for change. Often high quality The clinician emphasizes the (greater) importance
reflections increase the time spent talking by of the client’s perspective and decisions about if and
the client, foster a collaborative tone, and how to change. Any explicit clinician statements
reduce client resistance. that verbalize respect for the client’s autonomy and
personal choice are examples of fostering
LOWER: Low quality reflections often are very collaboration during the session.
inaccurate (i.e., “miss the boat”) and may
contribute to the client feeling EXAMPLES:
misunderstood. They can be too vague,
complicated, or wordy. They also may Clinician: “What do you think would be a good
have an upward inflection at the end and way to handle this situation in the future?”
consequently function as disguised closed-
ended questions. Typically low quality “I would have thought you would…, but it sounds
reflections decrease the time spent talking like you made a better choice by…”
by the client and may increase the client’s
resistance. Skill Level ratings also may “Let’s look at that issue together.”
decrease, even with high frequency
reflections, if the reflections are too spread “We can spend some time talking about your
out rather than consecutively linked over situation at home.”
the session such that they do not increase
introspection, conversation, or motivation SKILL LEVEL RATING GUIDELINES:
to change. Likewise, reflections that are
redundant or remain repetitively simple HIGHER: Higher quality strategies occur in several
such that the conversation seems to go ways. The clinician may directly and
around in circles are lower in quality. clearly note the greater importance of the
client’s perception about his/her drug use
and related life events in contrast to what
the clinician or significant others might
think. The clinician may underscore the
collaborative nature of the interview by

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highlighting his or her interest in commitment, or explore how motivation might be

understanding the client’s perspective strengthened?
without bias. Likewise, direct and clear
references to the client’s capacity to draw FREQUENCY AND EXTENSIVENESS RATING
his or her own conclusions or to make GUIDELINES:
personal choices about how to proceed
with a plan for change receive higher Skill This item refers to the extent to which the clinician
Level ratings. Use of these strategies when made attempts to elicit client self-motivational
the clinician perceives that the client is statements or “change talk,” or any type of discussion
feeling coerced by significant others can be about change. This is often accomplished through
especially effective and lead to higher Skill questions or comments designed to promote greater
Level ratings. Emphasizing viable personal awareness/concern for a problem, recognition of the
choices rather than choices that are advantages of change, increased intent/optimism to
unrealistic to the client also improve Skill change, or elaboration on a topic related to change.
Level ratings. For example, a clinician may The clinician might ask the client about how other
provide a choice among treatment options people view the client’s behavior as concerning or
within a program rather than highlight the problematic and how these concerns by others
option of program non-enrollment to a impact the client’s motivation for change. The
client who presents to treatment in a job clinician also might initiate a more formal discussion
jeopardy situation; this type of client most of the stages of change or level of motivation by
likely will see treatment nonparticipation as helping the client develop a rating of current
too risky for losing his job. importance, confidence, readiness or commitment to
change and explore how any of these dimensions
LOWER: Lower quality strategies occur when the might be strengthened. In brief, this item captures
clinician emphasizes personal choices that somewhat more directive means for eliciting a client’s
do not seem realistic to the client. Also, change talk and addressing a client’s commitment to
vague, wordy, or poorly timed efforts to change. While these strategies very often lead to
articulate the client’s personal control, “change talk” or self-motivational statements and
autonomy, and collaborative role in the movement toward the negotiation of specific change
interview reduce quality ratings. Clinician plans, the client does not need to respond in this
advice giving in the context of seemingly fashion for this item to be rated highly.
collaborative statements also receives lower
ratings (e.g., “You are obviously in the A higher Frequency/Extensiveness rating would be
driver’s seat, but I wouldn’t do that if I were achieved if the clinician attempts to elicit remarks
you.). from the client indicating either recognition of a
problem, statements of concern, intention to change
6. DISCUSSING MOTIVATION TO CHANGE: To or optimism about change. The clinician will often
what extent did the clinician try to elicit client use techniques that are rated on other items (e.g.,
discussion of change (self-motivational statements) open-ended questions, reflections about substance
through evocative questions or comments designed to use and/or about general problem areas related to
promote greater awareness/concern for the problem, substance use) that, in this case, are meant to
recognition of the advantages of change, increased encourage “change talk” on the part of the client.
intent/optimism to change, or elaboration on a topic The clinician may also explicitly assess the client’s
related to change? To what extent did the clinician current motivation to become abstinent or decrease
discuss the stages of change, help the client develop a their substance use, especially if the client continues
rating of current importance, confidence, readiness or to use. A lower rating would be given when the

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clinician seldom strategically queries or reflects the inconsistent with the client’s stage of
motivational issues outlined above. change. Additionally, if a clinician’s efforts
to elicit self-motivational statements or to
EXAMPLES: assess the client’s readiness to change
become redundant, they receive lower Skill
Clinician: “What concerns you about your current use Level ratings. Clinician efforts to assess
of substances?” readiness to change that pull for resistance
or arguments against change also receive
“What are some reasons you might see for making a lower ratings. For example, a lower quality
change?” intervention would occur if after a client
selects a readiness to change rating of 6 on
“What do you think would work for you if you decide a scale of 1 (lowest readiness, to 10 (highest
to change?” readiness)), the clinician asks, “How come
you said a 6 rather than a 10?”
Client: “My wife really believes it is a problem, so she’s
always on my back about it.” 7. DEVELOPING DISCREPANCIES: To what
extent did the clinician create or heighten the internal
Clinician: “How do you feel about your drug use? conflicts of the client relative to his/her substance use? To
What are your concerns and what do you think might what extent did the clinician try to increase the client’s
need to happen?” awareness of a discrepancy between where his or her life
is currently versus where he or she wants it to be in the
SKILL LEVEL RATING GUIDELINES: future? How much did the clinician explore how
substance use may be inconsistent with the client’s goals,
HIGHER: Higher ratings occur on this item when the values, or self-perceptions?
clinician uses evocative questions to elicit a
client’s change talk that are targeted to the FREQUENCY AND EXTENSIVENESS RATING
client’s current level of motivation. For GUIDELINES:
example, if a client has not recognized drug
use as a problem, the clinician asks the This item involves efforts by the clinician to
client to explore any concerns or prompt the client’s increased awareness of a
problematic aspects of his or her drug use. discrepancy between where they are and where
If a client has recognized drug use as a they want to be relative to their substance use.
problem but is uncertain about his or her The clinician may do this by highlighting
capacity to change, the clinician directly contradictions and inconsistencies in the client’s
queries the client about factors that might behavior or stated goals, values, and self-perceptions.
impact intent or optimism for change. The clinician may attempt to raise the client’s
Higher ratings also occur when the awareness of the personal consequences of substance
clinician collaboratively explores the client’s use, and how these consequences seem contrary to
current readiness to change in depth by other aims stated by the client. The clinician may
combining rating scales and open-ended engage the client in a frank discussion of perceived
follow-up questions and reflections that discrepancies and help the client consider options to
prompt the client’s arguments for change, regain equilibrium. Other common techniques used
optimism, and self-efficacy. to create or develop discrepancies include 1) asking
the client to look into the future and imagine a
LOWER: Lower ratings on motivation to change changed life under certain conditions (e.g., absence
strategies occur when the clinician tries to of drug abuse, if married with children), 2) asking
elicit self-motivational statements that are the client to look back and recall periods of better

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functioning in contrast to the present circumstances, angers his wife and may lead to an
and 3) asking the client to consider the worst unwanted separation. A rater would give a
possible scenario resulting from their use or the best lower Skill Level rating if the clinician
possible consequences resulting from trying to responds by saying, “Yeah, but you said you
change. Sometime double-sided reflections that don’t want to be separated,” instead of
bring together previously unrecognized discrepant saying, “So even though you‘ve told me you
client statements are examples of a clinician’s attempt are concerned your wife might leave you,
to heighten discrepancies (which may also be rated you continue to want to smoke marijuana.”
on Item 8: Pros, Cons, and Ambivalence). Often this approach appears somewhat
argumentative and may heighten resistance
EXAMPLES: rather than develop dissonance in the client’s
position. Abruptness in posing
Clinician: “You say you want to save your marriage, discrepancies (“gotcha!”) or stating
and I also hear you say you want to keep using drugs.” discrepancies with a hint of accusation also
undermines clinician-client collaboration
“On the one hand, you want to go out to the bar every and reduces the overall quality of the
night. On the other hand, you have told me how going intervention. Finally, wordy, cumbersome,
out to the bar every night gets in the way of spending time or overly complex reflections of discrepant
with your son.” client statements receive lower Skill Level
ratings.
SKILL LEVEL RATING GUIDELINES:
8. EXPLORING PROS, CONS, AND
HIGHER: Higher quality efforts to develop discrepan- AMBIVALENCE: To what extent did the clinician
cies typically occur when the clinician address or explore the positive and negative effects or
attempts to make the client aware of a results of the client’s substance use and what might be
discrepancy in the client’s thoughts, feelings, gained and lost by abstinence or reduction in substance
actions, goals or values based upon the use? To what extent did the clinician use decisional
client’s previous statements. The clinician balancing, complete a cost-benefits analysis, or develop a
presents the discrepancies as legitimate list of pros and cons of substance use? How much did the
conflicts or mixed experiences rather than as clinician express appreciation for ambivalence as a
contradictions or judgments that prove the normal part of the change process?
client has a drug problem. In addition,
higher quality interventions are clear and FREQUENCY AND EXTENSIVENESS RATING
articulate reflections that encapsulate GUIDELINES:
divergent elements of what a client has said.
In short, integration of the client’s specific This item focuses on the extent to which the clinician
discrepant statements in well-stated terms facilitated the discussion of specific consequences of
using a supportive, nonjudgmental tone the client’s substance use. This may include the
improves the Skill Level rating. positive and/or negative results of the client’s past,
present, or future behaviors as related to active
LOWER: Low quality efforts to develop discrepancies substance use. Specific techniques used include
typically occur when the clinician highlights decisional balancing, a cost-benefits analysis, or listing
the opposite side of the client’s ambivalence and discussing the pros and cons of substance use. An
without sufficiently counterbalancing it. For important stylistic component accompanying these
example, a client might say he wants to techniques should be the clinician’s verbalizing an
continue to smoke marijuana after appreciation for ambivalence as a normal part of the
previously acknowledging how smoking change process?

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A higher Frequency/Extensiveness rating would be ratings, particularly when the clinician uses
achieved if the clinician discusses ambivalence in these discussions to tip the client’s
detail or explicitly facilitates a costs/benefits analysis motivational balance to the side of change.
with client input concerning change versus The specific technique of completing or
remaining the same. A high score on this item reviewing a decisional balance sheet or
typically involves the written completion of a Pros simply discussing the pros or cons does not
and Cons form either during the session or detailed directly affect the Skill Level rating.
review of a form completed prior to the session. A
lower rating occurs when the clinician devotes little LOWER: Lower Skill Level ratings occur when the
time or effort on any of these tasks. clinician seldom provides the client with
opportunities to respond freely to the
EXAMPLES: pros/cons dimensions or to more
thoroughly reflect upon meaningful pros
Clinician: “What do you see as the positive and and cons to the client. Instead, the
negative consequences of your drinking?” clinician provides the client with likely
pros and cons and asserts this view to the
“You have had a lot of chest pain after using cocaine client in a more closed-ended fashion.
and seem very concerned about your health, your family, Consequently, the client becomes more of
and where your life is going. And you have identified a passive recipient rather than an active
many possible benefits of stopping use, such as….” participant in the construction of the
decisional balance or discussion of factors
“So by getting high, you feel good and can avoid painful underlying the client’s ambivalence.
feelings. What are some of the downsides to using.” Lower ratings also occur when the
clinician asks the client to list pros and
SKILL LEVEL RATING GUIDELINES: cons one after the other without exploring
details or the personal impact of substance
HIGHER: Higher quality efforts to discuss the pros use on the client’s life. When
and cons of substance use occur when the summarizing the client’s pros, cons, or
clinician approaches the task in a ambivalence, the clinician does not
nonjudgmental, exploratory manner. involve the client in the review and simply
Throughout the examination of pros and restates the items in a mechanical or
cons, the clinician prompts the client to impersonal manner. The clinician makes
continue detailing dimensions of no effort to strategically tip the client’s
ambivalence using open-ended questions motivational balance in favor of change.
or reflections about consequences
previously noted by the client. Full 9. CHANGE PLANNING DISCUSSION: To
exploration of the pros and cons of what extent did the clinician discuss with the client
stopping substance use versus continuing his or her readiness to prepare a change plan. To
use improve quality ratings. During this what extent did the clinician develop a change plan
process, the clinician elicits responses from with the client in a collaborative fashion? How much
the client rather than suggesting positive did the clinician cover critical aspects of change
and negative consequences as possibilities planning such as facilitating a discussion of the
not previously mentioned by the client. client’s self-identified goals, steps for achieving those
Additionally, use of summary reflections goals, supportive people available to help the client,
within each dimension or to compare and what obstacles to the change plan might exist, and
contrast them may enhance the Skill Level how to address impediments to change?

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FREQUENCY AND EXTENSIVENESS RATING The clinician takes sufficient time to

GUIDELINES: explore each area and to encourage the
client to elaborate by using open-ended
This item measures the extent to which the clinician questions and reflections. Overall, the
helps the client develop a change plan. This process development of the change plan is highly
may include an initial discussion of the client’s collaborative and serves to strengthen the
readiness to prepare a change plan. It may include a client’s commitment to change. If the
more formal process of completing a Change client expresses ambivalence during the
Planning Worksheet or a less formal clinician- completion of the plan, the clinician
facilitated discussion of a plan without completing a attempts to resolve it in the direction of
worksheet. In either case, the intervention typically change instead of pushing forward when
involves a discussion that includes many of the the client may not be ready to proceed.
following areas: (1) the desired changes, (2) reasons
for wanting to make these changes, (3) steps to make LOWER: Lower Skill Level ratings occur when the
the changes, (4) people available to support the clinician approaches the change planning
change plan, (5) impediments or obstacles to change process in a cursory fashion. The
and how to address them, and (6) methods of clinician does not actively engage the
determining whether the plan has worked. client in change planning or
individualize the plan to the unique
A higher Frequency/Extensiveness rating would be circumstances of the client. The lowest
achieved if the clinician guides the client through a Skill Level ratings are given when the
thorough discussion of change planning. This process clinician takes on an authoritative and
does not have to include review of a completed prescriptive tone while completing the
Change Planning Worksheet, but a high score requires change plan with the client.
the development of a detailed change plan during the
session. A lower rating occurs when the clinician 10. CLIENT-CENTERED PROBLEM
addresses only a few elements of a change plan and DISCUSSION AND FEEDBACK: To what
spends little time examining them in detail. extent did the clinician facilitate a discussion of the
problems for which the client entered treatment? To
EXAMPLE: what extent did the clinician review or provide
personalized, solicited feedback about the client’s
Clinician: “So, it sounds like you have made a decision substance abuse and the evidence or indications of
to stop using drugs and reduce your drinking. Let’s spend problems in other life areas?
some time figuring out a plan that will help you get
started working toward that goal. What is the first thing FREQUENCY AND EXTENSIVENESS RATING
that comes to mind?” GUIDELINES:

“What do you think might get in the way of this plan or This item involves explicit attempts by the clinician
make it hard for you to continue to make these changes?” to inquire or guide a discussion about the problems
for which the client entered treatment. This
SKILL LEVEL RATING GUIDELINES: discussion can include both the substance use as
well as the many related problems in living that are
HIGHER: As a prerequisite, a higher Skill Level associated with substance use. The clinician
rating for change planning requires that facilitates the development of a full understanding
the clinician develop a detailed change of the nature of the client’s difficulties. This process
plan that addresses most of the key may involve the review of assessment results
change planning areas outlined above. obtained during prior clinical assessments,

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worksheets completed by the client, or more nonjudgmental about the feedback and
formally through use of specific feedback forms. uses open-ended questioning, affirmations,
The method is less important than is the task of and reflections as part of the feedback
learning about the client’s problems and providing process and only offers feedback when
feedback to the client about his/her problems in an solicited by the client or when obtaining
objective, client-centered manner. The clinician the client’s permission to do so first.
guides this discussion and provides feedback using a
non-judgmental, curious, collaborative client- LOWER: Lower quality ratings on this item typically
centered style. If the clinician provides formal occur when a clinician presents feedback to
feedback, the clinician implements this strategy a client in a generic way. The feedback may
only when solicited by the client or when seeking be unclear or presented in a judgmental
the client’s permission first. fashion. Lower quality feedback also
occurs when the clinician seems to be
EXAMPLES: lecturing the client or drawing conclusions
for the client without providing the client
Clinician: “I wonder if we might start by your with opportunities to respond to the
sharing with me some of the concerns that brought you feedback provided. This latter approach to
into treatment. What brought you into treatment?” providing client feedback creates the image
of the clinician as expert and often
“You have given me an excellent description of some decreases the amount of talking done by
of your concerns. I would like to put this information the client. Unsolicited feedback also
together with some of the other information you reduces the Skill Level rating.
provided when you began this study so we will both
have a complete view of what might be helpful for MI INCONSISTENT ITEMS
you. Would that be alright with you?”
11. UNSOLICTED ADVICE, DIRECTION
SKILL LEVEL RATING GUIDELINES: GIVING, OR FEEDBACK: To what degree did
the clinician provide unsolicited advice, direction, or
HIGHER: Higher quality problem discussion and feedback to the client (e.g., offering specific, concrete
feedback occurs in several ways. Initial suggestions for what the client should do)? To what
clinician efforts to facilitate a discussion of extent was the clinician’s style one of telling the client
the client’s problems may be fairly how to be successful in his/her recovery?
straightforward and of “adequate” quality
(e.g., What’s been happening that has led FREQUENCY AND EXTENSIVENESS RATING
you to come see me today?). Subsequent GUIDELINES:
clinician efforts may receive higher ratings
if they promote the client’s further This item assesses the degree to which the clinician
elaboration and fuller understanding of the provides unsolicited advice, direction-giving, or
presenting problems, particularly when feedback about a specific situation rather than drawing
efforts to promote problem discussion out the client’s intentions or plans (“I think the best
successively build upon each other. thing for your sobriety is to move out of your parent’s
Regarding feedback, higher ratings may house.”). In other words, this item should capture
occur when the feedback is very situations in which the clinician unilaterally offers
individualized to the client’s experiences specific suggestions, advice, direction, or feedback to
and self-report. The clinician presents the the client when the client has not asked for it. This
feedback in clear, straightforward, and item is distinguished from other directive clinician’s
supportive terms. Overall, the clinician is

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behaviors such as the provision of objective feedback SKILL LEVEL RATING GUIDELINES:
in a style consistent with MI (Item 10). In general, the
clinician typically adopts a prescriptive style of telling HIGHER: To be rated highly, the clinician must
the client how to be successful in his/her recovery present unsolicited advice, direction, or
instead of maintaining a more collaborative, client- feedback in a confident and clearly
centered tone. The message is one of “I’m telling you articulated manner. The advice and
what to do.” directions are very instructive or
prescriptive to the client. While the client
Importantly, this item should not be scored when the may “take it or leave it,” the advice leaves
client specifically asks for advice, direction, or no doubt about the clinician’s
feedback. Likewise, if the clinician has explored the recommendations to the client. Providing
client’s ideas for a solution first and seeks the client’s a rationale to the client about the value of
permission to provide feedback before offering following the advice and direction,
information or suggestions, this item is not scored. particularly when this rationale integrates
The key element is that whatever was provided by the details of the client’s life into it, improves
clinician was unsolicited. When the clinician’s the quality of the intervention.
unsolicited advice or feedback is provided in a very
directive, perhaps blunt manner to help the client LOWER: Lower ratings occur when the clinician
assess his or her circumstances in more realistic provides unclear advice, direction, or
terms, it also would be scored on Item 13 (Direct feedback or makes recommendations to the
Confrontation of Client). Depending on the content client in a tentative manner. The advice or
of the unsolicited feedback, occurrences of this item suggestions also may not be relevant to the
might also involve other MI inconsistent strategies. client and, thus, sound like a “party-line”
instead of individualized to the client’s
To be rated highly, the clinician would give unsolicited unique circumstance.
advice, direction, education, feedback, or skills
training many times throughout the session. A central 12. EMPHASIS ON ABSTINENCE: To what extent
feature of the session would be the clinician telling the did the clinician present the goal of abstinence as the
client what he needs to know or do. Lower ratings only legitimate goal and indicate that a controlled use
occur when the clinician gives unsolicited advice or goal was not acceptable or completely unrealistic? How
direction only once or twice. much did the clinician seek to impose his/her judgment
about the goals of abstinence and emphasize that
EXAMPLES: abstinence was considered to be the necessary standard
for judging any improvement during treatment?
Clinician: “I really think you need to tell your family
that you used again. You won’t be able to stay clean and FREQUENCY AND EXTENSIVENESS RATING
sober if you are not honest with the people closest to you GUIDELINES:
in your life.”
This item refers to the extent to which the clinician
“I don’t think you should be hanging out with him. You explicitly discussed the rationale for absolute
used to get high with him, and it only will be a matter abstinence and was unequivocal in his/her
of time before you start to use again.” recommendation of abstinence as the only acceptable
goal for treatment. In this process of emphasizing
“When I listen to you, it seems like you don’t have abstinence, the clinician also typically articulates the
enough support from people who can help you when you disadvantages or dangers of having a treatment goal
feel like using. Getting a sponsor might be a good idea. of reducing substance use. Typically, this item is
How come you haven’t gotten a sponsor yet?” meant to capture instances when the clinician seeks

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to impose his/her judgment about the goals of only realistic and acceptable treatment goal;
abstinence and emphasizes that abstinence is controlled or reduced use is dangerous. The
considered the necessary standard for judging any clinician corrects notions that controlled
improvement during treatment. use, drug or product substitution (e.g.,
near-beer), or other harm reduction
Although the clinician may praise smaller approaches are feasible treatment goals for
improvements in other areas of a client’s functioning, the client. When done well, the clinician
the clinician remains much more focused on makes the point through the client’s own
whether the client has stopped using substances substance use history, clinical examples or
completely. Likewise, the clinician may acknowledge anecdotes, or references to treatment
a reduction in use or that some substances have been approaches and clinical consensus that
stopped (e.g., cocaine cessation with episodic emphasizes total abstinence.
marijuana or alcohol use), but not accept this
outcome as a clear sign of progress until the client LOWER: Lower ratings occur when the clinician
initiates complete abstinence. As a concrete example, appears to be giving “lip service” to total
the clinician might praise one week of complete abstinence without conviction or a
abstinence with no change in other life areas more convincing rationale. The emphasis, while
than a longer period of significantly reduced use mentioned, is downplayed or casually
accompanied by some life improvements. The suggested rather than at the forefront of the
clinician sees a harm reduction goal as unacceptable clinician’s approach to substance abuse
and dangerous because it communicates a false sense treatment. A lower rating also occurs when
of control over addictive substances and keeps the the rationale is more rooted in an
individual in a state of being active in his/her administrative policy (“Our clinic requires
addiction and prone to full relapse and deterioration. sustained abstinence to complete the
program and any positive urines get
EXAMPLES: reported to your probation officer.”) rather
than based on the clinician’s philosophical
Clinician: “You cannot control your drinking by trying conviction or the client’s reported pattern
to drink less. If you pick up one drink, you will lose of uncontrolled use.
control and be right back where you started.”
13. DIRECT CONFRONTATION OF CLIENT:
“It’s great that you didn’t smoke weed last week, but you To what extent did the clinician directly confront the
drank beer and that concerns me because you used to client about his or her failure to acknowledge problems
smoke and drink together a lot. They’re connected, and or concerns related to substance use and other
soon you will be smoking weed again unless you commit behavioral difficulties (e.g., psychiatric symptoms,
to total abstinence.” lying, treatment noncompliance)? To what extent did
the clinician directly confront the client about not
Skill Level Rating Guidelines: taking steps to try to change identified problem areas?

HIGHER: Higher quality emphasis on abstinence FREQUENCY AND EXTENSIVENESS RATING

occurs when the clinician provides a clear, GUIDELINES:
persuasive, and confident rationale for
abstinence to the client and attempts to For this item, confrontation is defined as any
compel the client to adopt total abstinence clinician statement or series of statements that
as the central treatment goal. The involve telling the client what he or she has not
clinician’s message is loud and clear: acknowledged or needs to know and accept. The
complete abstinence from substances is the message of the clinician’s communication is clear: “I

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know better than you, and I am telling you what you “I think the reason you are giving me is just an excuse.
haven’t realized.” The clinician’s statement is a call to Think about what you were willing to do for your
the client to see his or her situation in more realistic addiction. Think about all the time, effort, and money
terms. Often, the clinician’s confrontations will be you put into getting high. You’d do anything to get your
blunt or, at times, dramatic, although it does not drugs. How come you are not willing to do anything for
need to occur in a flamboyant manner. It may also your recovery?”
occur in a lecturing style designed to impart
information to the client. However delivered, the “I don’t think that’s quite right what you are saying.”
confrontation in essence indicates to the client how
they are in ignorance or in denial about a problem or “Let me give you some information that might help you
need to acknowledge and accept the problem if the understand what you are having a hard time seeing
client is to improve. Although an affectively charged right now.”
interaction may ensue between clinician and client,
in most cases, it should be clear that the clinician’s SKILL LEVEL RATING GUIDELINES:
assertive involvement is motivated by his/her
concern over the destructiveness of the client’s HIGHER: Higher Skill Level use of confrontational
current behavioral pattern. Although shouting would strategies occurs when the clinician is clear,
be considered counter-therapeutic, a confrontational concise, and firm with the client about the
interaction may sound more like a controlled client’s defensiveness in talking about his/
argument or disagreement. The disagreement often her substance use and related areas as
revolves around the clinician’s use of a label problems. The clinician persists in
(alcoholic, addict, dry drunk, in denial) to which the pointing out the client’s denial and tries to
client objects. It will also often involve discussion of use the confrontation to get the client to
the client’s resistance to recognizing a problem, lying, acknowledge the problem and deal with it
or non-compliance as indicators of denial. in more realistic terms, even if the client
initially becomes more defensive. In
A higher score should usually be given when the addition, higher quality confrontational
confrontation of denial or defensiveness is raised strategies involve when a clinician tries to
several times or for a sustained period of the compel the client to change his behavior in
session. This intervention does not need to be addition to his/her mind (“walk the talk”
successful (reducing denial) to be rated high on instead of “talk the talk”).
the Frequency and Extensiveness scale. What
matters more is how much the clinician uses LOWER: Low Skill Level confrontational strategies
direct confrontation as the main therapeutic tool. insufficiently challenge the client’s
Lower ratings occur when the clinician seldom distortions about his/her substance use and
makes use of confrontational strategies. related life circumstances. Rather than
persisting in confronting a resistant client,
EXAMPLES: the clinician retreats from the
confrontation and may adopt less
Clinician: “Look. Your urine screen is positive for confrontational approaches to resolve the
cocaine. You say you haven’t used cocaine in over a week. resistance. Also, a clinician’s reference to
I think you are in denial. Denial will only continue to the client’s denial or defensiveness without
feed your addiction and ruin your life. If you really want effort to “break through” it (e.g., “A lot of
to change your life, then you should start by being honest addicts get dirty urines and say the lab
with me and, more importantly, with yourself.” must have made a mistake. It’s a sign that
you are still in denial of your addiction.”) is
lower quality. In short, a lower

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confrontation quality rating may be given EXAMPLES:

when the clinician’s statements have
content that is “confrontational,” but lacks Clinician: “Remember that if you use again, you most
the persistent or perhaps tenacious likely will pick up where you left off. Most addicts have
confrontational style at times necessary to found that they rapidly return to using as much or more
change client behavior. than they had in the past. Before they know it, their
lives fall apart very quickly and the hole they have dug
14. POWERLESSNESS AND LOSS OF only becomes deeper.”
CONTROL: To what extent did the clinician
emphasize the concept of powerlessness over addiction as “You seem to understand very clearly that you are
a disease and the importance of the client’s belief in this powerless over your addiction…that one drink is too
for successful sobriety? To what extent did the clinician much and a thousand are never enough. Clearly, that
express the view that all substance use represents a loss of has been your experience time and time again and you
control or that the client’s life is unmanageable when s/ are getting tired of it.”
he uses substances?
“Your addiction will progress. Every bottom has a
FREQUENCY AND EXTENSIVENESS RATING trap door, except death. Are you willing to take this
GUIDELINES: chance?

This item refers to the extent to which the clinician SKILL LEVEL RATING GUIDELINES:
discussed the disease concept of addiction, in that
the client has a chronic, progressive illness which, if HIGHER: Higher quality ratings occur when the
not arrested, will lead to further loss of control and clinician provides a clear and convincing
physical, mental, social and spiritual damage and discussion of the disease concept of
eventually insanity or death, much like many other addiction. This discussion would involve a
medical diseases. The clinician should refer to the thorough detailing of how drug and
characteristics of the disease as a progressive and alcohol addiction is a primary, progressive,
predictable loss of control and the importance of and chronic process that ultimately severely
accepting this loss of control as an early part of the damages a person’s life in all areas and, if
treatment process and necessary for successful long- left unchecked, will lead to “jails,
term sobriety. Any and all episodes of substance use institutions, and death.” Higher ratings
are regarded as symptoms of a loss of control process also may occur when the clinician directly
in which the client’s life will become progressively applies the principles to the client’s history
unmanageable when s/he uses substances. and presenting problems. In short, a
clinician who persuasively “makes the case”
This discussion will often involve an emphasis on that the client is powerless over addiction
abstinence (and so overlap with Item #11) as the and inevitably will lose control of his/her
only method of “controlling” or arresting the life receives a higher Skill Level rating on
progression of the disease. This overlap is most this item.
apparent when the clinician provides a justification
for why abstinence is the only appropriate treatment LOWER: Lower Skill Level ratings occur when the
goal. It may also contain direct confrontation (Item clinician merely mentions (even repeatedly)
#13) as a means of getting the concept of the disease concept of addiction,
powerlessness across to the client. Often, the powerlessness, or loss of control without
clinician will state that if a client takes even one really explaining what these principles
drink or drug, he/she inevitably will lose control and mean or the implications of them for the
have a full-blown relapse. client. The presentation of the concepts of

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powerlessness or loss of control sounds use of direct confrontation (Item 13). However, a
formulaic and untied to the nature and clinician might not invoke therapeutic authority
circumstances of the client’s substance use when providing direct advice or direction or when
problem. confronting a client. The key element for this item
is the promotion of the clinician’s authority via his or
15. ASSERTING AUTHORITY: To what extent did her position, expertise, or personal experience. For
the clinician verbalize clear conclusions or decisions example, a clinician might say, “I start the group at 5
about what course of counseling would be best for the pm sharp. I won’t allow anyone to attend the group
client? How much did the clinician warn that recovery once we begin, unless you let me know in advance.”
would be impeded unless the client followed certain steps
or guidelines in treatment? To what extent did the To be rated highly, the clinician must frequently
clinician try to lecture the client about “what works” control the flow of the session by introducing topics
about treatment or the likelihood of poor outcome if the to be discussed or redirecting the client to the tasks at
client tried to do his/her own treatment? To what extent hand. A moderate rating might be given when a
did the clinician refer to his or her own experiences, clinician is obviously following a treatment manual
knowledge, and expertise to highlight the points made to and makes references to what needs to be done next
the client? or which handouts, practice exercises, and
homework need to be completed. A very low rating
FREQUENCY AND EXTENSIVENESS RATING would be given if the clinician remains more client-
GUIDELINES: centered and rarely asserts authority during the
session.
This item refers to the degree to which the clinician
dominates the direction of the counseling session by EXAMPLES:
promoting his or her treatment agenda rather than
trying to elicit the client’s goals for treatment. A key Clinician: “I know what you are going through. I’ve
component to rating this item is that the clinician been there myself, and I had to struggle with the same
must somehow communicate that following the pre- feelings. But I quickly learned that I could not do it
established goals of the clinician or treatment myself. I had to involve other people in recovery into my
program is necessary for progress to occur. life for me to get better. That’s what you need to do too.”
Furthermore, the clinician may actually discourage
the client from “writing his or her own treatment “Take my advice. Don’t go see your parents right now.
plan” and to instead stick with what is known to be You told me you most likely will have a big argument
effective for promoting sobriety or recovery. The with them and feel like getting high afterwards. Is that
clinician may lecture the client about what does and what you want after all the time and effort you have
does not work in addiction treatment and warn that put into being clean and sober?”
recovery will be impeded and outcome will be poor
if the client follows their own rather than the usual “You really need to show up on time. A lot of other
guidelines in treatment. For this item to be rated, an people would like to get treatment for their addictions
explicit or implicit message must be communicated here. If you are not able to make your treatment a
that the clinician is more knowledgeable about priority, I will discharge you, and you can call me back
addiction and recovery and in a position of greater in 30 days if at that time you feel you are ready to
power or expertise relative to the client. address your drug abuse in a more serious way.

This item very often will be associated with high

ratings on Item 11 (Unsolicited advice/direction-
giving…). It might also accompany the clinician’s

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SKILL LEVEL RATING GUIDELINES: of the clinician’s speech is dominated by reflective

statements rather than questions, keeping track of the
HIGHER: To receive higher ratings, the clinician clinician’s use of closed-ended questions is important.
provides directives and recommendations This item, however, was not included in the CTN
with confidence and clarity. The clinician protocol’s tape rating system, although protocol
also may reference his or her scientific supervisors commonly monitored it. The extent to
knowledge base, clinical experience, or which it contributes to the MI Inconsistent dimension
personal recovery to fortify therapeutic is unknown. Nonetheless, given the clinical
authority during the session and to importance of monitoring closed-ended questions as a
underscore the need for the client to follow means to hone a clinician’s MI skill, we provide it here
the clinician’s directions. The clinician’s as an optional rating item. We encourage supervisors
more prescriptive tone aims to promote the to use this item initially with clinicians to determine if
client’s compliance with the clinician’s the overuse of closed-ended questions is a supervisory
recommendations and improve the client’s issue. If a clinician consistently limits his or her use of
treatment outcomes rather than merely to closed-ended questions and predominantly relies on
assert power and control over the client. open-ended ones when querying a client, the supervisor
may choose not to continue to rate this item.
LOWER: Lower Skill Level ratings occur when the
clinician softens an assertion of authority 16. CLOSED-ENDED QUESTIONS: To what
by seeking the client’s input, guidance, or extent did the clinician ask questions that could be
approval for what the clinician has said. answered with a yes or no response or that sought after
The initially prescriptive tone yields to a specific details or information from the client?
collaborative one. As a result, rather than
the clinician driving the treatment FREQUENCY AND EXTENSIVENESS RATING
recommendations, the client has excessive GUIDELINES:
input into their development, despite the
client’s potentially poor judgment about This item measures the extent to which the
what might be best for him or her. clinician uses closed-ended questions during the
interview. These questions typically seek very
OPTIONAL MI INCONSISTENT ITEM specific answers or information. Often the client
can answer them with a “yes” or “no” response.
Supervisors may have an interest in tallying the number The questions leave little room for client
of times clinicians use closed-ended questions. Overuse elaboration. Often clinicians use them to “get to
of questions, and closed-ended questions in particular, the point” or to acquire information the clinician
tend to diminish the amount of time a client talks deems as necessary for the purposes of evaluation
spontaneously by creating a question-answer trap and treatment. They typically begin with the
between the clinician and client. It also limits how interrogative stems: “Could/can you? Do/did you?
much a client may elaborate on his or her motivation Are you? Have you? Where? When?”
for change in that closed-ended questions pull for terse
answers. In short, by relying too heavily on closed- A higher Frequency/Extensiveness rating would be
ended questions, the clinician teaches the client to only achieved if the clinician asks numerous questions that
respond when prompted by the clinician and to only seek specific information or brief yes/no responses (see
answer the specific question (Miller & Rollnick, 2002). Correct Examples) as opposed to asking questions that
Also, because the overall spirit of MI depends upon a are open-ended (see Incorrect Examples). Lower
highly empathic counseling style in which the majority ratings occur when the clinician asks very few
questions or almost all open-ended ones.

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EXAMPLES: GENERAL RATINGS OF CLIENT MOTIVATION

Correct: The aim of a MI session is for the clinician to
Do you use marijuana? When was the last collaboratively work with the client to build and
time you used? strengthen the client’s motivation for change.
Can you tell me how heroin affects you? Helping the clinician attend to shifts in
Your wife thinks you are addicted to cocaine. motivation over the course of the session by
Are you addicted to cocaine? recognizing the relative balance of change talk and
resistance is an important skill in MI. Likewise,
Incorrect strategically using core MI consistent skills (open-
So, what brings you here today? ended questions, affirmations, reflections, and
What are some of the ways that substance use summaries or the OARS) and directive methods
affects your life?” for eliciting change talk or for handling resistance
What kinds of differences have you noticed skillfully to facilitate motivation for change are
in…? additional critical MI skills. While using these MI
strategies, the clinician follows the client’s lead in
SKILL LEVEL RATING GUIDELINES: the discussion and listens carefully for shifts in
motivation as a means to guide his or her next
HIGHER: Higher quality closed-ended questions intervention. Items 17 and 18 allow the
pull the client to answer the question supervisor to track how the client’s motivation
specifically asked rather than giving the changes from the beginning to end of the session
client leeway to elaborate on a topic or and provides a mechanism for giving the clinician
area. They occur in close succession as feedback about how the clinician’s use of MI
they follow-up on one another. When strategies may have affected this process.
performed well, closed-ended questions
establish that the clinician as in control of 17. MOTIVATION – BEGINNING: How would you
the session and in the role of the expert rate the client’s stage of change or motivation at the
trying to discern information important beginning of this session?
for clinical assessment/evaluation and
treatment. High quality closed-ended 18. MOTIVATION – END: How would you rate the
questions are very clear and direct, thereby client’s stage of change or motivation at the end of
minimizing any confusion a client may this session?
have about what the clinician has asked
and wants to know. Motivation is the readiness and commitment the
client demonstrates to change his or her substance
LOWER: Lower quality ratings occur if the use behaviors.
clinician’s questions are overly complex
due to the clinician asking the client RATING DEFINITION
several matters in one question or
stringing together many closed-ended 1 ........ NOT AT ALL. The client does not believe he/
questions before permitting the client to she has a substance use problem. The
answer them. Consequently, the client resists the clinician’s efforts to identify
specificity of the client’s answer may be substance use as problematic or
lost in the client’s inability to recall the concerning. The client believes no changes
question or in considering what part of are necessary and shows no initiative to
the question to answer first. change his/her behavior

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RATING DEFINITION RATING DEFINITION

2 ........ VERY WEAK. The client acknowledges a anticipates significantly greater benefits
few problematic aspects of his/her than costs through cessation or reduction.
substance use and considers the clinician’s The client makes a commit to a change
questions and comments. However, the plan, expresses some optimism about his/
client concludes substance use is relatively her capacity to change, and may have
non-problematic and no changes are begun to self-initiate specific change efforts.
necessary. If the client has initiated any
changes in substance use or related 6 ........ VERY STRONG. The client firmly believes
behaviors, the client made these changes he/she has a substance use problem. The
under coercion or as a temporary measure client shows little resistance to change and
to reduce the pressure from others to very openly and collaboratively talks with
change. the clinician. The client sees the relative
benefits of changing his/her substance use
3 ........ WEAK. The client is highly ambivalent as much greater than any benefits that
about the problematic aspects of his/her might accrue from continued status quo
substance use. The client engages with the patterns of use. The client makes the
clinician during the session, but vacillates argument for change with little assistance
in his/her position that substance use is a from the clinician. The client most likely
problem. If a client states a desire to has begun to change substance use
change, this desire is counterbalanced with behaviors and speaks positively about these
skepticism about his/her capacity to change initial experiences. The client is clearly
and the options available to produce it. hopeful and optimistic about his/her
The client approaches any initial change capacity to sustain a change plan.
efforts with only slight commitment and
fluctuating willingness to follow-through. 7 ........ EXTREMELY STRONG. The client
emphatically believes he/she has a
4 ........ ADEQUATE. The client believes he/she has a substance use problem. The client shows
substance use problem but continues to no resistance to change and works very
acknowledge some significant benefits to openly and collaboratively with the
use and anticipated difficulties in cessation. clinician. The client is very thoughtful and
The client wants to make changes in his/ earnest in his/her assessment of prior
her substance use patterns (abstinence or substance use and very clear and
reduced consumption) and commits to an convincing about how these experiences
initial plan for change. While not underpin his/her current reasons for
skeptical, the client is uncertain about his/ change. The client expresses determination
her capacity to sustain change and the to change his/her behavior and has begun
outcomes of these efforts. to initiate his/her change plans.

5 ........ STRONG. The client believes he/she has a

substance use problem. The client
responds well to the clinician’s efforts to
manage any client resistance that arises
during the session. The client
cooperatively discusses both positive and
negative aspects of substance use and firmly

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FORMS – MASTERS

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MOTIVATIONAL INTERVIEWING
CLINICIAN SELF-ASSESSMENT REPORT

INSTRUCTIONS: Listed below are a variety of Motivational Interviewing consistent and inconsistent skill
areas. Please rate the degree to which you incorporated any of these strategies or techniques into your session
with your client. Feel free to write comments below each item about any areas you want to discuss with your
supervisor. For each item please rate your best estimate about how frequently you used the strategy using the
definitions for each scale point.

1 (NOT AT ALL) ....... Never used the strategy

2 (A LITTLE) ........... Used the strategy 1 time briefly
3 (INFREQUENTLY) .... Used the strategy 2 times briefly
4 (SOMEWHAT) ........ Used the strategy 3-4 times briefly or once or twice extensively
5 (QUITE A BIT) ..... Used the strategy 5-6 times briefly or thrice extensively
6 (CONSIDERABLY) ... Used the strategy during more than half of the session
7 (EXTENSIVELY) ...... Use of the strategy almost the entire session

MOTIVATIONAL INTERVIEWING CONSISTENT ITEMS

1. MOTIVATIONAL INTERVIEWING STYLE OR SPIRIT: To what extent did you provide low-key
feedback, roll with resistance (e.g., avoiding arguments, shifting focus), and use a supportive, warm, non-
judgmental, collaborative approach? To what extent did you convey empathic sensitivity through words and tone
of voice, demonstrate genuine concern and an awareness of the client’s experiences? To what extent did you
follow the client’s lead in discussions instead of structuring the discussion according to your agenda?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

NOT AT ALL A LITTLE INFREQUENTLY SOMEWHAT QUITE A BIT CONSIDERABLY EXTENSIVELY

Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

2. OPEN-ENDED QUESTIONS: To what extent did you use open-ended questions (i.e., questions or
requests that elicit more than yes/no responses) to elicit the client’s perception of his/her problems,
motivation, change efforts, and plans? These questions often begin with the interrogatives: “What,” “How,”
and “In what” or lead off with the request, “Tell me…” or “Describe…”

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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3. AFFIRMATION OF STRENGTHS AND CHANGE EFFORTS: To what extent did you verbally
reinforce the client’s strengths, abilities, or efforts to change his/her behavior? To what extent did you try to
develop the client’s confidence by praising small steps taken by the client in the direction of change or by
expressing appreciation for the client’s personal qualities that might facilitate successful change efforts?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

NOT AT ALL A LITTLE INFREQUENTLY SOMEWHAT QUITE A BIT CONSIDERABLY EXTENSIVELY

Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

4. REFLECTIVE STATEMENTS: To what extent did you use reflective listening skills such as repeating
(exact words), rephrasing (slight rewording), paraphrasing (e.g., amplifying the thought or feeling, use of
analogy, making inferences) or making reflective summary statements of what the client says?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

NOT AT ALL A LITTLE INFREQUENTLY SOMEWHAT QUITE A BIT CONSIDERABLY EXTENSIVELY

Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

5. FOSTERING A COLLABORATIVE ATMOSPHERE: To what extent did you convey in words or actions
that counseling is a collaborative relationship in contrast to one where you are in charge? How much did you
emphasize the (greater) importance of the client’s own decisions, confidence, and perception of the importance of
changing? To what extent did you verbalize respect for the client’s autonomy and personal choice?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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6. MOTIVATION TO CHANGE: To what extent did you try to elicit client discussion of change (self-motivational
statements) through evocative questions or comments designed to promote greater awareness/concern for the
problem, recognition of the advantages of change, increased intent/optimism to change, or elaboration on a topic
related to change? To what extent did you discuss the stages of change, help the client develop a rating of current
importance, confidence, readiness or commitment, or explore how motivation might be strengthened?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

7. DEVELOPING DISCREPANCIES: To what extent did you create or heighten the internal conflicts of
the client relative to his/her substance use? To what extent did you try to increase the client’s awareness of a
discrepancy between where his or her life is currently versus where he or she wants it to be in the future? How
much did you explore how substance use may be inconsistent with a client’s goals, values, or self-perceptions?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

8. PROS, CONS, AND AMBIVALENCE: To what extent did you address or explore with the client the positive
and negative effects or results of his or her substance use and what might be gained and lost by abstinence or
reduction in substance use? To what extent did you conduct a decisional balance activity consisting of a cost-benefits
analysis or list of pros and cons of substance use? How much did you develop and highlight the client’s ambivalence,
support it as a normal part of the change process, and reflect back to the client the mixed thoughts and feelings that
underpin the client’s ambivalence?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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9 CHANGE PLANNING DISCUSSION: To what extent did you develop a change plan with the client in a
collaborative fashion. How much did you cover critical aspects of change planning such as facilitating
discussion of the client’s self-identified goals, steps for achieving those goals, supportive people available to
help the client, what obstacles to the change plan might exist, and how to address impediments to change?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

NOT AT ALL A LITTLE INFREQUENTLY SOMEWHAT QUITE A BIT CONSIDERABLY EXTENSIVELY

Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

10. CLIENT-CENTERED PROBLEM DISCUSSION AND FEEDBACK: To what extent did you facilitate a
discussion of the problems for which the client entered treatment instead of directing the conversation to
problems identified by you but not by the client? To what extent did you provide feedback to the client about his
or her substance use or problems in other life areas only when solicited by the client or when you explicitly
sought the client’s permission first?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

NOT AT ALL A LITTLE INFREQUENTLY SOMEWHAT QUITE A BIT CONSIDERABLY EXTENSIVELY

Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

MOTIVATIONAL INTERVIEWING INCONSISTENT ITEMS

11. UNSOLICITED ADVICE, DIRECTION-GIVING, OR FEEDBACK: To what degree did you provide
unsolicited advice, direction, or feedback (e.g., offering specific, concrete suggestions for what the client
should do)? To what extent was your style one of instructing the client how to be successful in his/her
recovery?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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12. EMPHASIS ON ABSTINENCE: To what extent did you present the goal of abstinence as the only legitimate
goal and indicate that a controlled use goal was not acceptable or realistic? How much did you try to definitively
emphasize a goal of abstinence or reinforce abstinence as a necessary standard for judging any improvement during
treatment?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

NOT AT ALL A LITTLE INFREQUENTLY SOMEWHAT QUITE A BIT CONSIDERABLY EXTENSIVELY

Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

13. DIRECT CONFRONTATION OF CLIENT: To what extent did you directly confront the client about his or
her failure to acknowledge problems or concerns related to substance use or other behavioral difficulties (e.g.,
psychiatric symptoms, lying, non-compliance with treatment)? To what extent did you directly confront the client
about not taking steps to try to change identified problem areas?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

14. POWERLESSNESS AND LOSS OF CONTROL: To what extent did you emphasize the concept of
powerlessness over addiction as a disease and the importance of the client’s belief in this for successful
sobriety? To what extent did you express the view that all substance use represents a loss of control or that the
client’s life is unmanageable when he or she uses substances?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

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15. ASSERTING AUTHORITY: To what extent did you verbalize clear conclusions or decisions about what
course of counseling would be best for the client? How much did you warn the client that recovery would be
impeded unless the client followed certain steps or guidelines in treatment? To what extent did you tell the
client about “what works” best in treatment or the likelihood of poor outcome if the client tried to do his/her
own treatment? To what extent did you refer to your own experiences, knowledge, and expertise to highlight
the points you made to the client?

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

NOT AT ALL A LITTLE INFREQUENTLY SOMEWHAT QUITE A BIT CONSIDERABLY EXTENSIVELY

Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

16. CLOSED-ENDED QUESTIONS: To what extent did you ask questions that could be answered with a
‘yes’ or ‘no’ response or that sought very specific answers, details, or information about the client’s past or
current behavior and circumstances? These questions typically begin with the interrogative stems: “Could/can
you,” “Do/did you,” “Are you,” or “Have you.”

... 1 ................... 2 .................. 3 .................. 4 .................. 5 .................. 6 .................. 7 ..................

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Comments: _____________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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REFERENCES
Ball, S. A., Bachrach, K., DeCarlo, J., Farentinos, C., Keen, M., McSherry, T., Polcin, D., Snead, N., Sockriter, R.,
Wrigley, P., Zammarelli, L., & Carroll, K. M. (2002). Characteristics, beliefs, and practices of community
clinicians trained to provide manual-guided therapy for substance abusers. Journal of Substance Abuse
Treatment. 23(4):309-18

Burke, B. L., Arkowitz, H., & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis
of controlled trials. Journal of Consulting and Clinical Psychology, 71, 843-861.

Carroll, K. M., Connors, G. J., Cooney, N. L., DiClemente, C. C., Donovan, D. M., Longabaugh, R. L., Kadden,
R. M., Rounsaville, B. J., Wirtz, P. W., & Zweben, A. (1998). Internal validity of Project MATCH
treatments: Discriminability and integrity. Journal of Consulting and Clinical Psychology, 66, 290-303.

Carroll, K.M., Farentinos, C., Ball, S.A., Crits-Christoph, P., Libby, B., Morgenstern, J., Obert, J.L., Polcin, D. &
Woody, G.E., for the Clinical Trials Network (2002). MET meets the real world: Design issues and
clinical strategies in the Clinical Trials Network. Journal of Substance Abuse Treatment, 23, 73-80.

Carroll, K. M., Nich, C., Sifry, R., Frankforter, T., Nuro, K. F., Ball, S. A., Fenton, L. R., & Rounsaville, B. J.
(2000). A general system for evaluating therapist adherence and competence in psychotherapy research in
the addictions. Drug and Alcohol Dependence, 57, 225-238.

McLellan, T. A., Kushner, H., Metzger, D., Peters, R., Smith, I., Grissom, G., Pettinati, H., & Argeriou, M.
(1992). The 5th edition of the Addiction Severity Index. Journal of Substance Abuse Treatment, 9, 199-213.

Miller, W. R. & Mount, K. A. (2001). A small study of training in motivational interviewing: does one workshop
change clinician and client behavior? Behavioural and Cognitive Psychotherapy, 29, 457-471.

Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed). New York:
Guilford Press.

Miller, W. R., Yahne, C. E., Moyers, T. B., Martinez, J., & Pirritano, M. (2004). A randomized trial of methods to
help clinicians learn motivational interviewing. Journal of Consulting and Clinical Psychology, 72, 6, 1050-
1062.

Project MATCH Research Group. (1997). Matching alcoholism treatment to client heterogeneity: Project
MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol, 58, 7-29.

Project MATCH Research Group. (1998). Therapist effects in three treatments for alcohol problems. Psychotherapy
Research, 8, 455-474.

Sholomskas, D., Syracuse, G., Rounsaville, B. J., Ball, S. A., Nuro, K. F., & Carroll, K. M. (2005). We don’t train
in vain: A randomized trial of three strategies for training clinicians in CBT. Journal of Consulting and
Clinical Psychology, 73, 1, 106-115.

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