Dissemination and Training of Evidence-Based Treatments

One strong interest throughout my career has been promoting the transfer of science into practice, one important component of which is how best to train professionals in the use of evidence-based treatments.  It is clear that scientific evidence of efficacy does not automatically or even readily promote adoption of new treatment methods (Miller, 1987; Miller et al., 2006; Pritchard et al., 1987).

            We quickly found that evaluation of training needs to move beyond the usual post-workshop questionnaire, which tend to paint a rosy picture (Rubel et al., 2000). Professional training is presumably intended to change practice behavior in a way that will benefit client outcomes.  The first training outcome study that I did pertained to the effectiveness of a 2-day workshop that I offered on motivational interviewing (Miller & Mount, 2001).  We obtained taped samples of trainees’ actual practice with clients before and after training.  The results were humbling: although there were statistically significant changes in practice behavior, they were quite modest in size and clearly not enough to make a difference to clients, who were responding in the same way to their counselors after as before training.  On reflection, this caused me to wonder why we ever did expect changes in practice behavior as a result of coming to a workshop.

            So what else does it take to learn a complex skill?  Two time-tested components are personal feedback of performance (it’s hard to improve if you don’t know how you’re doing), and coaching.  We thus designed a randomized trial of methods for teaching motivational interviewing to people who wanted to learn it (Miller et al., 2004).  We offered the two-day workshop and tested the addition of feedback, coaching, or both.  The control conditions were workshop alone, or a waiting list group sent the book and training videotapes and encouraged to develop their skills on their own.  Again we used pre/post tapes of actual practice to obtain our outcome measures.  Neither of the control groups showed much change, but the addition of either feedback or coaching (or both) produced significantly more improvement in MI proficiency.  But did it make a difference to clients?  Within motivational interviewing, client “change talk” is a good in-session indicator of behavioral outcomes, so we examined whether trainees were more successful in eliciting change talk from their clients during actual practice.  Only one group showed substantial gains on this measure: those who received both feedback and coaching in addition to the workshop.  Actual observed competence in this study was basically unrelated to self-report measures of learning and skill.

            A larger review of research on dissemination indicated that this finding is by no means limited to motivational interviewing (Miller, Sorensen, Selzer & Brigham, 2006).  Behavioral psychotherapies are complex skills, much like playing a musical instrument or a sport, that would be learned over time with feedback and coaching, and not from a time-limited workshop.

Publications on Dissemination and Training  (in chronological order)

Christensen, A., Miller, W. R., & Muñoz, R. F. (1978).  Paraprofessionals, partners, peers, paraphernalia, and print: Expanding mental health service delivery.  Professional Psychology, 9, 249-270.

Miller, W. R. (1987).  Behavioral treatment research advances:  Barriers to utilization.  Advances in Behaviour Research and Therapy, 9, 145-164.

Pritchard, H. E., Wolfe, B. L., Waldron, D. J., & Miller, W. R. (1997).  What services are being offered by whom?  A survey of substance abuse programs in New Mexico. Alcoholism Treatment Quarterly, 15, 47-61.

Miller, W. R. (2000).  Professional ethics and marketing of treatment.  Addictions, 95, 1764-1765.

Rubel, E. C., Sobell, L. C., & Miller, W. R. (2000). Do continuing education workshops improve participants= skills? Effects of a motivational interviewing workshop on substance abuse counselors== skills and knowledge. The Behavior Therapist, 23, 73-77, 90.

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., & Anderson, R. E. (2003).  Impact of a faculty development program in addiction psychology.  Journal of Teaching in the Addictions, 2(2), 1-15.

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, 1050-1062.

Miller, W. R., Moyers, T. B., Arciniega, L., Ernst, D., & Forcehimes, A. (2005).  Training, supervision and quality monitoring of the COMBINE study behavioral interventions.  Journal of Studies on Alcohol, Supplement No. 15, 188-195.

Miller, W. R., Zweben, J. & Johnson, W. R. (2005).  Evidence-based treatment: Why, what, where, when and how?  Journal of Substance Abuse Treatment, 29, 267-276.

Adams, J. B., & Madson, M. B. (2006).  Reflection and outlook for the future of addictions treatment and training: An interview with William R. Miller.  Journal of Teaching in the Addictions, 5, 95-109.

Miller, W. R., & Moyers, T. B. (2006).  Eight stages in learning motivational interviewing.  Journal of Teaching in the Addictions, 5, 3-17.

Miller, W. R., Sorensen, J. L., Selzer, J., & Brigham, G. (2006).  Disseminating evidence-based practices in substance abuse treatment: A review with suggestions.  Journal of Substance Abuse Treatment, 31, 25-39.