In recent years, a number of state vocational rehabilitation agencies have adopted motivational interviewing (MI) as part of a process to revitalize the provision of vocational counseling and guidance in the state/federal vocational rehabilitation system. The approach is goal-oriented, consumer-centered, and designed to elicit behavior change by helping consumers to explore and resolve ambivalence (Miller & Rollnick, 1991). MI has proven to be an effective counseling technique to support behavior change across a number of domains including substance use, health-related issues, and gambling (Lundahl et al., 2010). MI has been recognized as a means to facilitate the development of a strong working alliance between the client and the therapist (Boardman et al., 2006). Iwanaga and colleagues (2019) demonstrated the importance of establishing a working alliance within vocational rehabilitation (VR) related to increased outcome expectancy and engagement in the VR process.
The fundamental components of MI include elements related to other therapeutic interventions and theoretical models. MI is rooted in the principles of the humanistic school of psychology and Rogerian client-centered therapy (Miller, 2015), as reflected in the MI goal of expressing empathy. Cognitive behavioral therapy (CBT) and MI both involve empathy and collaboration as elements of the therapeutic relationship (Carter et al., 2015). Although not as directive in nature as CBT, the MI approach does involve eliciting, guiding, and supporting the consumer in engaging in change talk, as reflected in the MI goals of developing discrepancy and rolling with resistance. The influence of self-determination theory (Deci & Ryan, 1985) is reflected in the MI goal of supporting self-efficacy, which incorporates autonomy and competence, and the focus on the development of a strong working alliance between the client and the therapist, incorporating relatedness. Isenhart (2005) noted that the working alliance is fundamental to MI, as it supports a therapeutic environment where the consumer can engage in change talk. Change talk invokes elements of the transtheoretical model, or stages of change model (Prochaska & DiClemente, 1983), focusing on engaging the consumer in discussions that address issues related to the precontemplation and contemplation stages, to facilitate transition to preparation and action. The "spirit of MI’’ is not a set of additional technical elements but represents a “way of being.” It is the foundation of every MI interaction and involves acting in collaboration with the client, evoking change talk, emphasizing autonomy, and demonstrating compassion for the concerns of the client (Miller & Rollnick, 2013).
Wagner & McMahon (2004) noted that both MI and vocational rehabilitation counseling focus on resolving ambivalence to change and promoting consumer self-determination through decision-making, goal setting, and achievement. The Oregon Department of Human Services – Vocational Rehabilitation has developed a video library that illustrates the use of MI in vocational rehabilitation. The videos are available for use by vocational rehabilitation counselors and community resource providers as an internet-based training program. The Washington State Division of Rehabilitation identified MI was as an evidence-based practice (EBP) focused on improving consumer support and successful employment outcomes (Chan et al., 2009, 2011). Missouri Vocational Rehabilitation adopted MI as a means to facilitate consumer engagement and found a significant impact on the engagement of both consumers and staff (Kelly & Schulte, 2014). An outgrowth of staff engagement and a novel application of MI was observed in Delaware Division of Vocational Rehabilitation as part of their implementation of MI. Staff members from two regional offices worked together to develop a consumer orientation module based on MI principles (Tos & Crenshaw, 2014). Although MI has been shown to be a promising technique for use in vocational rehabilitation, the ability to commit time and resources to training can be an obstacle to the implementation of MI for state vocational rehabilitation agencies.
According to the Motivational Interviewing Network of Trainers, the introductory workshop involves two to three days of training, with an additional two to three days required for the intermediate and advanced levels. The potential for introductory MI training to have an effect on the use of MI in vocational rehabilitation was previously addressed by two studies. A study conducted by Manthey (2013) involved case managers who worked with individuals who received supported employment services. Administration of the Motivational Interviewing Knowledge and Attitudes Scales – Vocational Rehabilitation (MIKAT-VR), administered pre- and post-training, indicated that introductory MI skills training contributed to increased knowledge of MI and an attitude shift toward the use of MI in an employment-focused setting. The second study assessed the effect of a four-hour standardized MI training and four weekly follow-up coaching sessions on consumer engagement and the working alliance with counselors (Torres, 2017). Assessment of the pre- and post-training MIKAT-VR showed significant gains in MI competence among the counselor participants and a significant improvement in consumer engagement and working alliance with the counselor among the clients whose counselors were in the experimental group.
Purpose of the Study
While Motivational Interviewing Network of Trainers introductory workshops involve two to three days of training, the purpose of this study was to assess whether a one-day introductory MI training could affect the perception of the participant’s ability to use MI as part of the vocational rehabilitation process.
Methods
Participants
Sixteen vocational rehabilitation staff members from the SCVRD participated in a one-day introductory MI workshop. Fourteen of the participants had a master’s degree in rehabilitation counseling, one in rehabilitation counseling and public administration, and one in public administration. Eight of the participants were certified rehabilitation counselors (CRC). Twelve of the 16 reported they had not participated in MI training prior to the seminar. All the participants were employed by the state vocational rehabilitation services agency with an average of 6.16 years of experience. Four participants had 16 years or more experience and the remaining 12 had three years or less. Fourteen of the participants were female; nine were Black and seven were White.
Procedure
A pre- and post-training survey design was used to assess whether a one-day MI training program could affect how the participants perceived their ability to use MI as part of the vocational rehabilitation process. The survey was administered online through Survey Monkey. The form consisted of 46 items assessing the use of MI in the vocational rehabilitation process across five topic areas including: Working Relationship with Consumers (6), Engagement with Consumers (8), Confidence in Using MI and the Underlying Principles (8), Barriers to Using MI (14), and the Effect of the Use of MI in Vocational Rehabilitation (10). The survey was composed of items developed by the Virginia Commonwealth University, Rehabilitation Research and Training Center on Employment of People with Physical Disabilities. Each item was scored based on a five-tier Likert scale: (1) strongly disagree, (2) disagree, (3) neutral, (4) agree, and (5) strongly agree.
Motivational Interviewing Training
The training consisted of a one-day seminar conducted by a university faculty member, using the Motivational Interviewing for Vocational Counselors training program developed by the Vocational Rehabilitation Technical Assistance Center for Targeted Communities (TC-TAC): Project E3: Educate, Empower, and Employ (https://projecte3.com). The manual outlines a framework for conducting MI in a group setting. The process includes: (a) the “spirit” of MI – respect for consumer autonomy and choice and the development of strong consumer-counselor working alliance; (b) the four core features of MI – express empathy, roll with resistance, develop discrepancy, and support self-efficacy; and (c) the MI four techniques – open-ended questions, affirming responses, reflective listening, and summarizing. The curriculum consists of five modules: (1) Motivation to Work; (2) Perceived Work Barriers; (3) Career Development; (4) Job Interview and Impression Management; and (5) Job Retention. Each module consists of specifically defined content, structured to last about 90 minutes, and includes a “homework” assignment. The program was designed for use with consumers across a range of disabling conditions, during any phase of the vocational rehabilitation process, and at varying levels of commitment to employment.
Results
A series of paired sample t-tests was used to assess whether there were statistically significant differences between the pre- and post-training ratings across the five areas of interest covered by the survey. At first, results (t = 3.5668, p < .01; Cohen’s d = 0.6581) indicated a statistically significant increase and moderate effect size related to the participant’s confidence in using MI and the underlying principles as part of the vocational rehabilitation process between pre- (M = 3.84, SD = .4715) and post-training (M = 4.11, SD = .3881). The primary factors that contributed to the result were the counselor’s confidence in using MI to help consumers explore and resolve ambivalence about change in favor of change, the ability to build rapport and manage resistance, and listening to the client instead of giving advice. A statistically significant difference and moderate effect size (t = 2.1882, p < .05; Cohen’s d = 0.6571) in perceived personal and organizational barriers to using MI was observed between pre- (M = 3.26, SD = .2459) and post-training (M = 3.42, SD = .2411). The primary factors that contributed to the result were collective support for using MI among coworkers, existence of evidence that supports the use of MI in vocational rehabilitation, the current use of MI to help clients deal with motivation to work issues, and proficiency in the use of MI to help consumers deal with psychosocial and vocational rehabilitation issues. See Table 1.
Three of the five areas of interest did not show an effect related to the MI training. Working alliance included factors such as agreement on what needed to be done to achieve the employment goal, consumers’ understanding what they are trying to accomplish, and the development of mutual trust. The pre- and post-training ratings were in the agree range, with a mean of 4.15 and 4.01, respectively. Staff engagement addressed issues such as consumers were actively involved in planning their vocational rehabilitation services, regularly communicated with the counselor, and were determined to complete all services on the individualized plan for employment. The pre- and post-training ratings remained just below the agree level, with means of 3.93 and 3.90. The pre- and post-training ratings for how the use of MI in vocational rehabilitation may affect factors such as employment outcomes, psychosocial outcomes, engagement, and working alliance were slightly below the agree level, with means of 3.89 and 3.89 respectively.
Recommendations and Implications for Practice
The results suggested that a one-day MI training seminar can increase a participant’s confidence to use MI and the underlying principles, and can reduce the perception of personal and organizational barriers to the use of MI in the vocational rehabilitation process. The results must be interpreted with the understanding that the study was conducted with a relatively small sample size, used a non-random selection of participants, and lacked a control group for comparison. As noted by Manthey (2013), introductory MI training without follow up has not been shown to be effective in establishing and maintaining MI skills. The results of this study, in conjunction with Manthey (2013) and Torres (2017), however, indicated the potential for introductory MI training to have a positive impact on the vocational rehabilitation experience for both the counselor and the consumer.
This study represents another step in the development of a body of evidence that introductory, time-limited MI training can be an effective means for integrating MI into the vocational rehabilitation process. The research conducted by Manthey (2013) and this study demonstrated introductory MI training can affect the participants knowledge of MI and the belief that MI can be used effectively in the vocational rehabilitation setting. The study by Torres (2017) showed that counselors who participated in MI training reported significant gains in competence, and consumers demonstrated significant improvement in engagement and working alliance with the counselor. Based on these studies, additional research on the effect of introductory, time-limited MI training on counselor’s use of MI in the vocational rehabilitation process and the subsequent impact on consumer engagement and working alliance is warranted. Research to evaluate the effect of the use of MI on employment outcomes (i.e., MI versus non-MI groups) and the quality of the employment (e.g., job match, salary, and benefits) is needed as part of the development of a comprehensive database related to the use of MI in vocational rehabilitation. Based on findings from this study, the following recommendations are offered:
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MI improves a VR counselor’s ability to help consumers resolve ambivalence about change and increase motivation toward change, as well as helps VR counselors support consumers in exercising informed choice and taking ownership of and accountability for their IPE and vocational goal.
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A single MI training session can increase VR Counselor confidence in implementing and using MI. This capstone project demonstrated that establishing MI into VR organizations can be less complicated than initially thought.
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The implementation of MI can be facilitated by an introductory, time-limited training; however, introductory training without follow-up has not been shown to be effective in establishing and maintaining MI skills.
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Further research to evaluate the effect of the use of MI on employment outcomes (i.e. MI versus non-MI groups) and the quality of the employment (e.g. job match, salary, and benefits) is recommended as part of the development of a comprehensive database related to the use of MI in vocational rehabilitation.
Author Note
The contents of this paper were developed under a cooperative agreement with the U.S. Department of Education, Technical Assistance Center for Vocational Rehabilitation Agency Program Evaluation and Quality Assurance (PEQA-TAC) (Grant Award Number: H263B150004). However, the contents and views expressed in this publication do not necessarily represent the positions or policies of the U.S. Department of Education, and you should not assume endorsement by the Federal government.