Abstract
Background
Training in professional psychology is moving beyond knowledge-based education and toward competency-based education. Similarly, experiential learning, focused more on skills than facts, is emphasized in undergraduate education. Few studies, however, have investigated the use of skill-based learning for clinically relevant skills in undergraduate psychology courses.
Objective
This study investigated deliberate practice as a skill-based method for training undergraduates to use basic Motivational Interviewing and reflective listening skills.
Method
In an upper-level undergraduate clinical psychology course, students were randomly assigned to an MI workshop that included deliberate practice to learn basic reflective listening skills or a waitlist control group.
Results
In both between (workshop versus waitlist) and within (pre versus post) group comparisons, students’ ability to use reflective listening improved as evaluated by raters, blind to condition, and in self-report measures of MI knowledge and skill.
Conclusion
Deliberate practice may be effectively incorporated into undergraduate courses to prepare novice helpers with basic listening skills.
Teaching Implications
Competency-based training in listening skills may help undergraduate students prepare for graduate school in the helping professions or any of multiple post-graduation professions not requiring professional training and licensure.
Deliberate Practice with Motivational Interviewing: Basic Listening Skills for Undergraduates
This study focuses on two strategies for preparing future therapists: deliberate practice and training novice helpers. We examined deliberate practice (DP) within the motivational interviewing (MI) framework in an upper-level undergraduate clinical psychology course. We sought to establish a foundation for listening skills among undergraduates, which should be beneficial in various careers, but certainly for those planning for graduate training in the helping professions.
Helping Skills Training with Novice Helpers
Helping skills training can improve the skills of novice helpers (Hill et al., 2016; Knox & Hill, 2021). For example, Hill's helping skills model (2008) involves an organized approach, including readings, lectures, observations, practice, and feedback. Post-training, students demonstrated improved session performance, which included greater empathy, reduced talk time, and higher self-efficacy (Hill et al., 2008). Furthermore, a 5-year follow-up indicated that 33 students continued applying Hill's model in various work settings (Hill et al., 2020). These and other studies (e.g., Madson et al., 2013) suggest that undergraduate training can provide students with an early start to their clinical work.
The utility of listening skills is not limited to students who intend to pursue careers delivering psychotherapy. Listening skills can be applied in many professions and situations and are important to civility. For example, MI has been adapted for use in various service professions, and basic reflective listening skills are useful in any interpersonal relationship (e.g., Miller & Rollnick, 2023). In addition, undergraduate psychology students frequently work as paraprofessionals in social service settings where improved listening skills may be useful (Madson et al., 2013).
Motivational Interviewing
“MI is a particular way of talking with people about change and growth to strengthen their own motivation and commitment” (Miller & Rollnick, 2023, p. 3). MI was not intended to be a comprehensive treatment, but rather an approach to conversations about change that can be used in tandem with other therapeutic orientations (Miller & Arkowitz, 2015). Importantly, MI reflective listening skills have broad application across many helping fields including social service and health care providers, such as probation officers, nurses, teachers, and others (e.g., Clifford & Curtis, 2016; Ogles et al., 2021). Consequently, our study focused on basic reflective listening both to prepare students for subsequent training in graduate school or for any of several potential human service-oriented fields that might be pursued following the completion of an undergraduate degree in psychology.
Initial MI training focuses on attitudes about interpersonal interactions (partnership, acceptance, compassion, and empowerment) and four communication skills (open-ended questions, affirmations, reflections, and summaries in mnemonic form: OARS). Therapists who develop “the spirit of MI” use the skills to help clients discover their motivation to work through the tasks toward change (Miller & Rollnick, 2023, p. 7).
Extensive training in the MI approach is neither possible nor appropriate for an undergraduate class, especially since they are not engaged in professional clinical training. However, getting students started with basic reflective listening skills that could both prepare them for potential graduate training in the helping professions (Maslowski et al., 2022) and improve their ability to listen in many interpersonal conversations was a reasonable starting point. Miller and Arkowitz (2015) suggested five steps for beginning to learn MI. We focused on the first three steps for our training in an undergraduate course: 1) understanding the spirit of MI, 2) knowing reflective listening responses (OARS), and 3) providing at least 50% reflective listening responses in a conversation.
Deliberate Practice
Learning listening skills in MI often involves both didactic and experiential elements. With increasing emphasis on skill-based learning, the potential for DP as a training technique becomes a possibility. Ericsson (2021) defined the essential elements of DP: a task with well-defined performance goals, participants who can perform the task, immediate and constructive feedback on the task, consistent and regular repetition of the task, and individualized instruction from an expert teacher or coach. By merging these principles into the learning process, participants can maximize their skill growth as they seek expertise. Upper-level undergraduate students are well-suited to engage in DP for the acquisition of listening skills before entering graduate study in the helping professions.
Research supports the effectiveness of DP in enhancing knowledge and skill acquisition across diverse domains (Ericsson, 2009). DP has also gained attention as a potential method for promoting clinical expertise (Vaz & Rousmaniere, 2022). At the same time, DP for therapist training is in its early stages (Mahon, 2022), and its role as a skill development method for helping skills requires further exploration, especially when considering listening skills training with undergraduate students.
DP for Learning MI
Participants in MI workshops often learn about the basic principles along with observing example conversations and engaging in role plays, or what MI trainers call “real plays” because they encourage participants to use innocuous, real issues in the conversations. As a result, MI training is naturally amenable to an enhanced form of training that includes deliberate practice (Manuel et al., 2022). This would include the usual practice, but with more repetitions and expert feedback at the edge of the participant's current skill level. Research on the use of deliberate practice for learning MI listening skills is limited. Miller et al. (2004) conducted a study involving 140 licensed professionals in the helping professions randomized into five different training conditions. Their study preceded the recent focus on DP, yet it included two facets of DP: feedback utilization and expert coaching. They found that sustained proficiency in MI skills relied on coaching and/or individual performance feedback after training. In contrast, techniques such as self-study, observing videotapes, and merely participating in a workshop proved less effective.
In recent studies, researchers have successfully demonstrated that MI workshops that incorporate DP can be effective for training licensed professionals (e.g., Westra et al., 2021). Only one prior study, however, has investigated the possibility of training undergraduates in MI. Madson et al. (2013) investigated the benefit of one of three MI training methods: a 1-h lecture, an intensive week of training, or a 16-week MI course. They found that both intensive and extended MI courses resulted in greater increases in self-report knowledge and confidence in the use of MI skills than the MI lecture. Similarly, students in the extended training methods performed better in an MI skill demonstration protocol. Our study built on Madson's by incorporating principles of DP in the workshop and rating student performance using live, rather than analog, listening conversations.
Current Study
To date, no studies have explored the use of deliberate practice for training novices to use basic MI reflective listening skills. As with Madson et al. (2013), we believe a classroom environment provides an excellent opportunity to prepare undergraduates with basic listening skills. As a result, this research addressed the existing gap in the literature by exploring the integration of DP with an MI basic listening skills workshop in an undergraduate course.
We used a crossover waitlist design to investigate the benefit of a DP-infused MI training with undergraduates in an upper-level introduction to clinical psychology course. Outcomes of interest included ratings of pre- and post-workshop role-play recordings with practice partners and self-ratings of knowledge and skills. We hypothesized that participants in the MI workshop would exhibit higher reflective listening skill levels and increased self-reports of knowledge and ability from pre- to post-course.
Method
Participants
Participants were 45 undergraduate students enrolled in a face-to-face upper-level introduction to clinical psychology course. Students identified themselves as predominantly female (71%, n = 31 women; 29%, n = 14 men) and White (91% White, n = 41; 7%, n = 3 Asian; and 2%, n = 1 Other), with a mean age of 23 years (SD = 4.13). All students had completed some college (62% seniors, n = 28, 31%, n = 14 juniors, 7%, n = 3 sophomores) and most were interested in attending graduate school in the helping professions (89%, n = 40). Of the 64 students enrolled in the course, 49 were recruited through announcements at the start of the semester. Upon providing informed consent, participants permitted the researchers to use archival course data. As compensation for completing tasks that were not part of the course (pre- and post-course surveys), participants received a $20 gift card.
Measures
The course's Learning Management System (LMS) provided a platform for managing assignments, exams, and skill demonstrations. The primary self-report outcomes included participants’ MI knowledge and skill/ability. Observer outcomes included ratings of students’ use of OARS skills in four brief (max 7-min) listening skill demonstration videos.
MI Listening Skills Survey
A Qualtrics questionnaire gathered participant demographics and their pre- and post-course knowledge of and ability to use MI listening skills. Participants rated eight items (Vega et al., 2024) on a 1 “Very Limited” to 5 “Excellent” scale (e.g., “Rate your ability or skills needed to competently use reflections in practice”). Items were averaged to create two four-item scales (minimum 1 and maximum 5) for knowledge of MI (Cronbach's α = .87) and ability to use MI skills (Cronbach's α = .89), respectively.
Observer Ratings
Each student recorded five, 7 min role plays with volunteer practice partners using GoReact, a software extension to the LMS. Students identified their practice partners who could differ for each assignment. Four role plays were included in the study. Four raters were trained to use an abbreviated version of the Motivational Interviewing Skill Code version 2.1 (MISC-2; Miller et al., 2008) to rate student statements within the recordings. Raters coded each student statement using one of the following eight categories: open-ended questions, closed questions, affirmations, simple reflections, complex reflections, summaries, other MI-consistent responses (i.e., emphasize control, reframe, support), and MI-inconsistent responses (i.e., conversation blockers such as unsolicited advice, giving direction). Frequencies of each category of statement were then averaged for each video. At least two raters rated each video, and differences were resolved by the instructor. The four raters demonstrated moderate agreement in their ratings, with an average Kappa = .78.
Post Simulation Self-Report
Following three of the simulations (time 1, 2, and 4), students answered four questions to assess their perception of their attentiveness, anxiety, difficulty, and helpfulness during their listening practice session on a five-point scale (e.g., “Rate how anxious you felt while helping the person in this situation”) (Vega et al., 2024).
Procedure
Following IRB approval, participants in an undergraduate class were introduced to the study through in-class announcements and email notifications. Students who opened the pre-course survey first consented to and then completed the survey. Students then engaged in course activities: an MI workshop, skill demonstrations, and brief practice sessions along with regular course materials. At the conclusion of the course, students completed a second survey that included the identical eight knowledge and skill items. Only the surveys were separate from regular course assignments.
To examine the effect of the MI workshop, we used a crossover waitlist design (see Table 1). Students were randomly assigned to MI workshop or waitlist-control groups. Both groups completed pre-training listening skills role plays (Vega et al., 2024). The workshop group then received an MI workshop in the third week and submitted their post-workshop video recording within one week. Simultaneously, the waitlist-control group recorded their second pre-training video recording. In the next week, roles were reversed, with the waitlist-control group receiving the MI workshop while the workshop group submitted their post-training video. Data collection concluded with final skill demonstrations and post-course assessments in the last week of the semester.
Experimental Crossover Waitlist Design.
MI Workshop
The course was scheduled to meet one day per week for 150 min 14 times during the semester. The MI workshop was conducted by the course instructor (BMO), who received training via the Motivational Interviewing Network of Trainers (MINT). During the MI workshop (one class period), graduate students and teaching assistants supported practice. The workshop included instruction, demonstration, and practice. Practice included exercises with feedback to improve and increase reflections and reduce MI-inconsistent responses (e.g., unsolicited advice). In a typical 5-min-long practice role-play, participants were encouraged to use more open-ended questions than closed questions, twice as many reflections as questions, at least one affirmation, and one summary. An observer sheet that highlighted these goals was used in class as participants practiced in groups of three—helper, helpee, or observer. Participants were encouraged to continue practicing after the workshop. “MI breaks” were included in each class meeting, which consisted of MI practice periods that were approximately 10 min each. Finally, students received feedback on each of their video simulations submitted through the software. Teaching materials, PowerPoint slides, and handouts are available on the OSF website (Vega et al., 2024).
Results
Because the RMANOVAs required data at every time point, 45 participants were included in the final analysis (26 in the workshop and 19 in the waitlist condition).
Change in Performance
The primary analysis involved planned comparisons of the workshop and waitlist groups at time 2 (cell B versus Cell F in Table 2). Using Least Significant Difference (LSD), these were significant for reflections-to-questions ratio, MI-consistent responses, and conversation blockers. The planned comparison was not significant for total reflections (means, standard errors, and p values for the significant planned comparisons are displayed in Table 2 and in greater detail on OSF; Vega et al., 2024).
Observer-Rated Means and Standard Errors for Frequency of MI Skills per Person per Role Play over Time (A-L).
Note. N = 45 (workshop n = 26; waitlist n = 19). R/Q = reflections-to-questions ratio. Superscripts represent the planned comparisons:
Cell B compared to cell F significant, p < .05
Cell A compared to cell B significant, p < .001
Cell F compared to cell G significant, p < .05
Cell I compared to cell K significantly different, p < .001
Cell I compared to cell L significant, p < .001
Cell E compared to cell F significant, p < .05
Cell K compared to cell L significant, p < .05
Cell B compared to cell C significant, p < .05.
Exact p values and effect sizes for all planned comparisons provided on OSF (Vega et al., 2024).
The impact of the MI workshop on skill performance was also assessed over time for the separate workshop and waitlist participants. We analyzed performance changes from time 1 to time 2 (A versus B) for the workshop group and from time 2 to time 3 (F versus G) for the waitlist group. For the workshop group, within-subjects pairwise comparisons revealed significant improvements in all four dependent variables. For the waitlist group, significant within-subjects pairwise comparisons were found for total reflections, reflections-to-questions ratio, and conversation blockers, with no significant change in MI-consistent responses (see Table 2).
We also examined differences in MI skills for both groups combined over the semester. All four variables significantly differed between T1 to T3 and T1 to T4, but only conversation blockers (MI-inconsistent responses) improved from T3 to T4 (see Table 2).
Self-Report Data
We also examined students’ self-report data from the survey over the semester. Students reported improvement in MI knowledge from pre-course (M = 2.73, SD = .87) to post course (M = 4.26, SD = .59), F(1) = 104.34, p < .001, η² = .70. They also reported improvement in MI skills from pre-course (M = 2.45, SD = .85) to post course (M = 4.15, SD = .61), F(1) = 109.23, p < .001, η² = .70 (see Table S1 in OSF; Vega et al., 2024).
Lastly, we examined the change in students’ immediate post-simulation ratings of attentiveness, anxiety, difficulty, and helpfulness over three simulations during the semester. No statistically significant differences were observed in these variables when comparing time 1, time 2, and time 4. Students across groups and time consistently reported similar feelings throughout the semester immediately following their skill demonstrations (see OSF materials for supplemental findings including Table S2; Vega et al., 2024).
Discussion
We examined the use of DP to train undergraduates in basic MI listening skills. Existing evidence suggests that therapist training can be improved by beginning earlier in graduate school or prior to graduate training (Knox & Hill, 2021). This aligns with Ericsson et al.'s (1993) suggestion that commencing DP earlier may increase the likelihood of acquiring expertise. The results of our study support the idea that novices can benefit from basic training in MI listening skills (Madson et al., 2013) and that a focus on skills as a critical component of personal and professional development may be appropriate.
Student Improvement in MI Skills
Several findings from our study demonstrate the value of integrating DP principles into undergraduate courses for learning listening skills. First, students demonstrated increased MI-listening skills after the MI workshop. Key DP features incorporated into the workshop consisted of teaching a specific skill (e.g., reflections), involvement of an expert, and repetitive practice with feedback. Raters observed post-workshop improvements in reflections-to-questions ratio, MI-consistent statements, and reduced MI-inconsistent statements. The emphasis on reflections enhanced the potential for accurately interpreting the partner's perspective and provided a crucial element consistent with the DP model—a clearly defined task (Ericsson, 2021) that likely influenced skill acquisition. For instance, as students increased their frequency of reflections, they simultaneously decreased the number of questions. Encouraging students to use two reflections per question may have also reduced speaking by the student helper (Hill et al., 2008). In addition, following the workshop students maintained and improved MI skills. Importantly, the workshop occurred early in the semester and served as a crucial first step to learning MI skills.
Second, our study revealed a significant reduction in MI-inconsistent responses (i.e., giving advice without permission). This supports Miller et al.'s (2004) finding that understanding MI-inconsistent responses is an important aspect of MI training. Notably, the waitlist group increased in MI inconsistent responses from time 1 to time 2 prior to their participation in the workshop. They then experienced a significant decrease after participating in the workshop. This may have been connected to a workshop exercise exposing students to good and poor models of helping conversations.
Third, like other studies of undergraduates (Hill et al., 2008) participants reported increased knowledge and ability in using MI skills pre- to post-course. However, the transferability of these skills into more advanced therapy skills when entering graduate training remains unclear. We speculated that a higher frequency of MI basic skills (i.e., increased reflections) corresponds to increased proficiency in accurate empathy (Miller & Rollnick, 2023). Consistent with Hill's model, MI serves as a credible framework for understanding the helping process with clear skills that apply to novice helpers. Perhaps this “framework” is necessary for novices to walk through and understand how to help.
Recording sessions with volunteer listening partners added a unique element, allowing students to practice listening naturally. The MI workshop served as an introduction and offered foundational information that was followed by subsequent practice with immediate (in-class exercises) and delayed feedback (graded assignments). In addition, the minimal improvement in targeted outcomes for the waitlist group suggests that simple repetition of the role play exercise was insufficient without the workshop.
Overall, students improved in both skill performance and self-perceptions of improved knowledge and skills. This suggests that teaching through a DP method, introduced via a MI workshop, can yield significant changes. When providing relationship training to novices, a deep understanding of MI may not be necessary to effectively use the skills.
Implication for Research and Training
The blind observer ratings in this study contribute valuable insights into the efficacy of DP on skill performance since much criticism of DP research is rooted in self-reported measures (Baldwin & Imel, 2013). This also extends the findings of Madson et al. (2013) who used a video assessment of analog encounters to assess student skill improvement.
With free-flowing dialog in a role play, we also show that participants can flexibly apply the skills in a situation that more closely resembles helping conversations. GoReact's adaptability to record with a partner outside the classroom provides a natural setting that challenges helpers to adapt to their partner's context. GoReact also allows coding for helper and partner statements by the student and professor. The versatility of GoReact, or other similar software, offers a distinct advantage for future DP studies, enabling a multi-method approach to measure perspectives from helpers, partners, and trainers (Knox & Hill, 2021). We recommend consistently including observed skill ratings to provide a continuous and dynamic assessment of skill development. In addition, AI-generated coding of videos may soon improve the efficiency and reliability of coding.
Limitations and Future Directions
Several limitations are inherent in this study. First, the small and homogenous sample of students restricted diversity. The generalizability of results is also confined to novices enrolled in an introduction to clinical psychology course, most of who were specifically interested in pursuing graduate study in the helping professions. Second, the nature of the intervention did not allow for examining separate components of the MI workshop. As a result, it is unclear whether the inclusion of DP components added any benefit beyond a typical MI workshop (as in Madson et al., 2013). Third, the study occurred in a naturalistic classroom setting (Hill et al., 2008). For example, students could easily read the syllabus or other course material before skill demonstrations including a chapter summarizing the basics of MI. This may have led to inadvertent contamination of the waitlist control such that participants increased from time 1 to time 2 before receiving the workshop. After both groups participated in the workshop, however, contamination was not relevant. All students participated in the MI workshop as part of the course, and the instructor prioritized the classroom needs ahead of the study. Similarly, as in other studies, the instructor's influence on students is uncertain (Ahn et al., 2023).
Despite its limitations, our study provides initial support for training novice undergraduates in basic MI reflective listening skills using DP methods. We also believe it matches well with the aspirations of both the APA Guidelines for the Undergraduate Psychology Major (APA, 2023; e.g., Goal 4 and Appendix A, Quality Principle 2.5) and the value of experiential learning (Gallivet, 2018). We look forward to seeing additional research on effective strategies for training students earlier that incorporate MI/DP and other experiential approaches.
Implications for Educators
Our study also provides helpful directions for educators to consider as they implement competency-based education in the classroom. Specifically, given the a) benefits for preparing students earlier for graduate work in the helping professions, b) tangible effects of soft skills for students entering careers following an undergraduate degree, and c) frequent employment of undergraduate students in paraprofessional positions in social service settings, the immediate potential for teaching reflective listening skills seems obvious. Since both Madson et al. (2013) and this current study provide evidence that relatively brief, focused training with practice can result in performance-based and self-report changes for students, educators may consider incorporating skill-based listening modules into their courses. Future studies can extend these findings to identify essential components of training that will help students to develop this important set of skills.
Footnotes
Data Availability
Correspondence and requests for data sharing should be addressed to Ben Ogles, 268 TLRB, Comprehensive Clinic, Department of Psychology, Brigham Young University, Provo, UT 84602. Email: ben_ogles@byu.edu Phone: (801) 422-8193.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article. article has an Open badge, insert the open badge section and the statement as backmatter and the related logo on the article-opener page below the article title and above author names.
