Open Access Open Access  Restricted Access Subscription Access

“Focusing” in Motivational Interviewing: development of a training tool for practitioners

Nina Gobat, Lauren Copeland, Rebecca Cannings-John, Michael Robling, Judith Carpenter, Laura Cowley, Denitza Williams, Julia Sanders, Shantini Paranjothy, Theresa Moyers


Rationale, aims and objectives: Motivational Interviewing (MI) is an individual-level approach to behaviour change that has been evaluated in over 600 randomised clinical trials across multiple settings. Increasingly, research efforts focus on how MI works and how it can best be integrated into public health and clinical programmes. As the application of MI expands, a key integration challenge involves specifying the focus of a conversation such that a practitioner might ignite and intensify a patient’s internal motivation for change related to that focus. At present, this challenge is poorly conceptualised. We aimed to clarify the construct of “focusing” and to develop a practical tool that can be used to develop and assess practitioner competence.

Method: First we reviewed validated MI measures to elucidate current conceptualisations of focusing. Second, we identified practitioner speech acts that led to topic transitions. We then drafted the first version of MIFI. A gold standard rater, together with one expert MI and 3 non-expert MI raters, each used MIFI to coded 20 audio recordings from a feasibility study of MI and breastfeeding maintenance (n=170 observations). Internal consistency and inter-rater reliability analyses were conducted.

Results: Published MI measures include ‘focusing’ as a strategy to agree a target change or to hold attention on that change target. We observed practitioners create or shift focus using 4 skills: questions, listening statements, giving information or meta-statements. Moderate to strong correlations were demonstrated between 4 of 5 global measures on the MIFI. Reliability estimates were good to excellent overall (5 coder ICCs>0.65), fair to excellent for the non-expert coding group (ICCs>0.55) and for the best coding pair (MI expert and non-expert ICCs >0.52).

Conclusion: We offer conceptual clarity about focusing in MI and have developed a tool to train practitioners in “focusing” when integrating MI into healthcare and public health interventions.


Behavioural change, clinical practice, communication skills, complex intervention, fidelity assessment, focusing, measure, Motivational Interviewing (MI), person-centered healthcare, public health, staff training

Full Text:



Miller, W.R. & Rollnick, S. (2012). Motivational Interviewing - helping people change. New York: Guilford Press.

Lindon-Hawley, N., Thompson, T.P. & Begh, R. (2015). Motivational interviewing for smoking cessation. Cochrane Database of Systematic Reviews CD006936.

Kohler, S. & Hofmann, A. (2015). Can motivational interviewing in emergency care reduce alcohol consumption in young people? A systematic review and meta-analysis. Alcohol and Alcoholism 50 (2)107-117.

Tanner-Smith, E.E. & Lipsey, M.W. (2015). Brief alcohol interventions for adolescents and young adults: a systematic review and meta-analysis. Journal of Substance Abuse Treatment 51, 1-18.

Lundahl, B., Moleni, T., Burke, B.L., Butters, R., Tollefson, D., Butler, C. & Rollnick, S. (2013). Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling 93 (2)157-168.

Rubak, S., Sandbæk, A., Lauritzen, T. & Christensen, B. (2005). Motivational interviewing: a systematic review and meta-analysis. British Journal of General Practice 55 (513) 305-312.

O'Halloran, P.D., Blackstock, F., Shields, N., Holland, A., Iles, R., Kingsley, M., Bernhardt, J., Lannin, N., Morris, M.E. & Taylor, N.F. (2014). Motivational interviewing to increase physical activity in people with chronic health conditions: a systematic review and meta-analysis. Clinical Rehabilitation 28 (12) 1159-1171.

Wilson, A., Nirantharakumar, K., Truchanowicz, E.G., Surenthirakumaran, R., MacArthur, C. & Coomarasamy, A. (2015). Motivational interviews to improve contraceptive use in populations at high risk of unintended pregnancy: a systematic review and meta-analysis. European Journal of Obstetrics, Gynecology & Reproductive Biology 191, 72-79.

Lundahl, B.W., Kunz, C., Brownell, C., Tollefson, D. & Burke, B.L. (2010). A Meta-Analysis of Motivational Interviewing: Twenty-Five Years of Empirical Studies. Research on Social Work Practice 20 (2) 137-160.

Amrhein, P.C., Miller, W.R., Yahne, C.E., Palmer, M. & Fulcher, L. (2003). Patient commitment language during motivational interviewing predicts drug use outcomes. Journal of Consulting and Clinical Psychology 71 (5) 862-878.

Moyers, T.B., Martin, T., Christopher, P.J., Houck, J.M., Tonigan, J.S. & Amrhein, P.C. (2007). Patient Language as a Mediator of Motivational Interviewing Efficacy: Where Is the Evidence? Alcoholism: Clinical and Experimental Research 31, 40s-47s.

Bear, J.S., Beadnell, B., Garrett, S.B., Hartzler, B., Wells, E.A. & Peterson, P.L. (2008). Adolescent change Language within a Brief Motivational Intervention and Substance Use Outcomes. Psychology of Addictive Behaviors 22 (4) 570-575.

Gaume, J., Gmel, G. & Daeppen, J-B. (2008). Brief alcohol interventions: Do counsellors’ and patients’ communication characteristics predict change? Alcohol and Alcoholism 43 (1) 62-69.

Apodaca, T.R. & Longabaugh, R. (2009). Mechanisms of change in motivational interviewing: a review and preliminary evaluation of the evidence. Addiction 104 (5) 705-715.

Gaume, J., Gmel, G., Faouzi, M. & Daeppen, J-B. (2008). Counsellor behaviours and patient language during brief motivational interventions: a sequential analysis of speech. Addiction 103 (11) 1793-1800.

Moyers, T.B., Martin, T., Houck, J.M., Christopher, P.J. & Tonigan, J.S. (2009). From in-session behaviors to drinking outcomes: a causal chain for motivational interviewing. Journal of Consulting & Clinical Psychology 77 (6) 1113-1124.

Glynn, L.H. & Moyers, T.B. (2010). Chasing change talk: the clinician's role in evoking patient language about change. Journal of Substance Abuse Treatment 39 (1) 65-70.

Robling, M., Bekkers, M-J., Bell, K., et al. (2016). Effectiveness of a nurse-led intensive home-visitation programme for first-time teenage mothers (Building Blocks): a pragmatic randomised controlled trial. Lancet 387 (10014) 146-155.

Botting, B., Rosato, M. & Wood, R. (1998). Teenage mothers and the health of their children. Population Trends 93, 19-28.

Moffitt, T.E. (2002). Teen-aged mothers in contemporary Britain. Journal of Child Psychology and Psychiatry and Allied Disciplines 43 (6) 727-742.

Channon, S., Bekkers, M-J., Sanders, J., Cannings-John, R., Robertson, L., Bennert, K., Butler, C., Hood, K. & Robling, M. (2016). Motivational interviewing competencies among UK family nurse partnership nurses: a process evaluation component of the building blocks trial. BMC Nursing 15 (1) 55.

Paranjothy, S., Copeland, L., Merrett, L., Grant, A., Phillips, R., Gobat, N., Sanders, J., Fitzsimmons, D., Hunter, B., Regan, S., Playle, R., Brown, A., Tedstone, S., Trickey, H. & Robling, M. (2017). A novel peer-support intervention using Motivational Interviewing for breastfeeding maintenance: a UK feasibility study. Health Technology Assessments 21 (77) 1-138.

Streiner, D.L. & Norman, G.R. (2003). Health Measurement Scales: A Practical Guide to their Development and Use. Oxford: Oxford Medical Publications.

Madson, M.B. & Campbell, T.C. (2006). Measures of fidelity in motivational enhancement: a systematic review. Journal of Substance Abuse Treatment 31 (1) 67-73.

Dobber, J., van Meijel, B., Barkhof, E., Scholte op Reimer, W., Latour, C., Peters, R. & Linszen, D. (2015). Selecting an optimal instrument to identify active ingredients of the motivational interviewing-process. Journal of Psychosomatic Research 78 (3) 268-276.

MINT Inc. (2016). Motivational Interviewing Network of Trainers. Ontario, Canada: MINT Inc.

Moyers, T.B., Martin, T., Manuel, J.K., Hendrickson, S.M.L. & Miller, W.R. (2005). Assessing competence in the use of motivational interviewing. Journal of Substance Abuse Treatment 28 (1) 19-26.

Moyers, T.B., Rowell, L.N., Manuel, J.K., Ernst, D. & Houck, J.M. (2016). The Motivational Interviewing Treatment Integrity Code (MITI 4): Rationale, Preliminary Reliability and Validity. Journal of Substance Abuse Treatment 65, 36-42.

Gobat, N., Kinnersley, P., Gregory, J.W. & Robling, M. (2015). What is agenda setting in the clinical encounter? Consensus from literature review and expert consultation. Patient Education and Counseling 98 (7) 822-829.

Pett, M.A., Lackey, N.R. & Sullivan, J.J. (2003). Making sense of factor analysis: the use of factor analysis for instrument development in health care research. London, UK: Sage Publishers.

Shrout, P.E. & Fleiss, J.L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychological Bulletin 86 (2) 420-428.

Hallgren, K.A. (2012). Computing inter-rater reliability for observational data: An overview and tutorial. Tutorials in Quantitative Methods for Psychology 8, 23-34.

Cicchetti, D.V. (1994). Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychological Assessment 6 (4) 284-290.

Corps, I. (2011). IBM SPSS Statistics for Windows, Version 20.0. NY, USA: Armonk.

Gobat, N., Kinnersley, P., Gregory, J.W., Pickles, T., Hood, K. & Robling, M. (2015). Measuring clinical skills in agenda-mapping (EAGL-I). Patient Education and Counseling 98 (10) 1214-1221.

Lane, C., Huws-Thomas, M., Hood, K., Rollnick, S., Edwards, K. & Robling, M. (2005). Measuring adaptations of motivational interviewing: the development and validation of the behavior change counseling index (BECCI). Patient Education and Counseling 56 (2) 166-173.

McMaster, F. & Resnicow, K. (2015). Validation of the one pass measure for motivational interviewing competence. Patient Education and Counseling 98 (4) 499-505.

Campiñez Navarro, M., Pérula de Torres, L.Á., Bosch Fontcuberta, J.M., et al. (2016). Measuring the quality of motivational interviewing in primary health care encounters: The development and validation of the motivational interviewing assessment scale (MIAS). European Journal of General Practice 22 (3) 182-188.

Di Clemente, C.C., Crouch, T.B., Norwood, A.E., Delahanty, J. & Welsh, C. (2015). Evaluating training of screening, brief intervention, and referral to treatment (SBIRT) for substance use: Reliability of the MD3 SBIRT Coding Scale. Psychology of Addictive Behaviors 29 (1) 218-224.

Jackson, C., Butterworth, S., Hall, A. & Gilbert, J. (2015). Motivational Interviewing Competency Assessment (MICA1.2).

Moyers, T.B., Martin, T., Manuel, J.K., Miller, W.R. & Ernst, D. (2010). Motivational Interviewing Treatment Integrity 3.1.1 (MITI 3.1.1).

Ledoux, T., Hilmers, A., Watson, K., Baranowski, T. & O'Connor, T.M. (2013). Development and feasibility of an objective measure of patient-centered communication fidelity in a pediatric obesity intervention. Journal of Nutrition Education and Behavior 45 (4) 349-354.

Ingersoll, K. & Wagner, C.C. (2014). Rating the fidelity of MI groups sessions: the AMIGOS coding system. 4th International Conference on Motivational Interviewing, Amsterdam, 16-18 June.

Miller, W.R., Moyers, T.B., Ernst, D. & Amrhein, P. (2003). Manual for the Motivational Skill Code (MISC). Version 2.0.

Miller, W.R., Moyers, T.B., Ernst, D. & Amrhein, P. (2008). Manual for the Motivational Skill Code (MISC). Version 2.1.

Martin, T., Moyers, T.B., Houck, J., Christopher, P. & Miller, W.R. (2005). Motivational Interviewing Sequential Code for Observing Process Exchanges (SCOPE). Coder’s Manual.

Kahler, C.W., Caswell, A.J., Laws, M.B., Walthers, J., Magill, M., Mastroleo, N.R., Howe, C.J., Souza, T., Wilson, I., Bryant, K. & Monti, P.M. (2016). Using topic coding to understand the nature of change language in a motivational intervention to reduce alcohol and sex risk behaviors in emergency department patients. Patient Education and Counseling 99 (10) 1595-1602.

Moyers, T.B., Manuel, J.K. & Ernst, D. (2014). Motivational Interviewing Treatment Integrity Coding Manual 4.2.

Riou, M. (2015). A methodology for the identification of topic transitions in interaction. discours 16.

Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I. & Petticrew, M. (2008). Developing and evaluating complex interventions: the new Medical Research Council guidance. British Medical Journal 337, a1655.

Moore, G.F., Audrey, S., Barker, M., Bond, L., Bonell, C., Hardeman, W., Moore, L., O’Cathain, A., Tinati, T., Wight, D. & Baird, J. (2015). Process evaluation of complex interventions: Medical Research Council guidance. British Medical Journal 350, h1258.

Button, G. & Casey, N. (1985). Topic Nomination and Topic Pursuit. Human Studies 8 (1) 3-55.

Beckman, H.B. & Frankel, R.M. (1984). The effect of physician behavior on the collection of data. Annals of Internal Medicine 101 (5) 692-696.

Marvel, M.K., Epstein, R.M., Flowers, K. & Beckman, H.B. (1999). Soliciting the patient's agenda: Have we improved? Journal of the American Medical Association 281 (3) 283-287.

Heritage, J. & Robinson, J.D. (2006). The structure of patients’ presenting concerns: physicians’ opening questions. Health Communication 19 (2) 89-102.

Heritage, J., Robinson, J.D., Elliott, M.N., Beckett, M. & Wilkes, M. (2007). Reducing patients unmet concerns in primary care: the difference one word can make. Journal of General Internal Medicine 22 (10) 1429-1433.

Robinson, J.D., Heritage, J., Robinson, J.D. & Heritage, J. (2006). Physicians’ opening questions and patients’ satisfaction. Patient Education and Counseling 60 (3) 279-285.

Robinson, J.D. (2001). Closing medical encounters: two physician practices and their implications for the expression of patients' unstated concerns. Social Science & Medicine 53 (5) 639-656.

Byrne, P.S. & Long, B.E.L. (1976). Doctors Talking to Patients. London: RCGP Publications.

Ainsworth-Vaughn, N. (1992). Topic transitions in physician-patient interviews: Power, gender, and discourse change. Language in Society 21 (3) 409-426.

Mishler, E.G. (1984). The discourse of medicine. Westport, CT: Greenwood Publishing Group.

Makoul, G.P. (2001). Essential Elements of Communication in Medical Encounters: The Kalamazoo Consensus Statement. Academic Medicine 76 (4) 390-393.

Simpson, M., Buckman, R., Stewart, M., Maguire, P., Lipkin, M., Novack, D. & Till, J. (1991). Doctor-patient communication: the Toronto consensus statement. British Medical Journal 303 (6814) 1385-1387.

von Fragstein, M., Silverman, J.D., Cushing, A., Quilligan, S., Slisbury, H. & Wiskin, C. (2008). UK consensus statement on the content of communication curricula in undergraduate medical education. Medical Education 42, 1100-1107.

Wagner, C.C. & Ingersoll, K.S. (2012). Motivational Interviewing in Groups. NY: Guildford Press.

Mauksch, L.B., Dugdale, D.C., Dodson, S. & Epstein, R. (2008). Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Archives of Internal Medicine 168 (13) 1387-1395.

Peltenburg, M., Fischer, J.E., Bahrs, O., van Dulmen, S. & van den Brink-Muinen, A. (2004). The unexpected in primary care: a multicenter study on the emergence of unvoiced patient agenda. Annals of Family Medicine 2 (6) 534-540.



  • There are currently no refbacks.