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Evoke change talk to enhance motivation for change

 

Previously, we looked at Motivational Interviewing (MI) as having four key processes and reviewed practice exercises targeting the first two processes:  engaging and focusing. This week’s intentional practice centers on evoking, specifically on evoking change talk.

Once we have engaged with our client and have collaboratively identified a goal (focusing), ambivalence about change is still common. Increased client change talk is associated with increased likelihood for change. Evoking change talk is key. When ambivalence is present, it is normal for change talk to occur within the context of sustain talk. This activity will help you practice selectively reflecting the change talk content contained within ambivalence.

 

Instructions: Review the client statements below, containing both change talk and sustain talk, and develop reflective statements that are focused on the change talk.  

Here’s a pre-test to get you started:

Client statement:

“I am 78 years old, and this medication is ruining what life and pleasure I have left. I know the doctor said there is a good chance it will help things, but I just don’t think these side effects are worth it.”

Sample therapist responses: Which reflective response focuses on the change talk in the above statement?

a. You really don’t want to continue with this medication.

b. It’s pretty clear that the doctor wants you to continue.

c. You’re not sure whether it’s worthwhile to continue the medication.

(check out the end of this article for the correct answer)

 

Note: The point of this exercise is not to do a double-sided reflection, but rather to listen for and select the change talk, and make that your focus in your reflective statement.

Client Statement: Start out by underlining the change talk in the statements below

 

Reflection: Now write down a reflection that selectively responds only to the client change talk contained in the statement
1.      The material the clinic gave me for my high blood pressure said I should avoid processed food, or else read the labels. I’m so busy I barely have time to eat, let alone shop, analyze my groceries, and spend half the night in the kitchen. These people do not live in the real world.

 

 
2.      Is it such a crime that I want to enjoy life while I’m still young? Once I’m tied into work, paying the bills, kids and all that I can scale things back.

 

 
3.      It is so frustrating that the minute you get pregnant everyone expects you to be perfect! I am so stressed out, it can’t be good for the baby. I am only having a few cigarettes a day, and my partner is totally on my case about it.

 

 

Reflective practice questions:

  1. How easy or difficult was it for you to identify the change talk in each of the client statements?
  2. How easy or difficult was it for you to frame a complex reflection that would further evoke change talk?
  3. What are the implications of this for your own continued growth and practice as a Motivational Interviewing practitioner?

(Correct answer: b. It’s pretty clear that the doctor wants you to continue.)

Adapted from: MINT TNT Manual (2014), various authors. 

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Focusing means strategic centering with a collaborative goal

 

In a previous article, we looked at Motivational Interviewing (MI) as having four key processes: Engaging, Focusing, Evoking and Planning.

Motivational Interviewing is directional – not directive. There is a horizon, something that we and the client are committed to working toward. However, finding and collaboratively agreeing on goals can be a challenge! This week’s intentional practice looks at the process of working with your client to jointly identify an agreed-upon goal. Below are two brief case scenarios. With a partner, you will each take a turn with one of the scenarios as a departure point for a follow-up session with a client with the intention of setting an agenda for change. The skills for intentional practice in this activity are to:

Practice a focusing conversation using the skills of MI – with special attention to those noted above. How can you practice these skills to guide the client toward focusing on a meaningful and collaborative goal? Take five minutes and then switch roles. After you have both had an opportunity to practice, take five minutes to debrief and share feedback with your learning buddy.

 

Case Example 1:

You are meeting with your client, Akilesh, for a follow-up appointment. In your initial session, you learned that he has been under a great deal of stress due to impending lay-offs at his work place. To make matters worse, his wife is in her first month of maternity leave with a reduced income. His mother’s health is failing, and his older son has been acting out at school: hitting and spitting at other children in his class, and on one occasion, his teacher. Finally, at the end of your first session, Akilesh “came clean” with you and acknowledged that he smokes 10-15 cigarettes per day.

 

Case Example 2:

You are meeting with your client, Elina, for a follow-up appointment. At the end of your initial session, Elina reluctantly agreed to come back and see you again. You suspect that in addition to appeasing her cardiologist by attending the referral appointment with you last time, she is now coming back for this second appointment because she wants to appease you. In the previous session, Elina acknowledged that she would probably be healthier if she quit smoking, but stated that smoking is a profound pleasure for her. She shared that she has already made so many changes, she just can’t see herself giving up her cigarettes.

 

Reflective practice questions:

Was your “righting reflex” triggered by anything in the case example, or by any of the client responses in your role play? To what extent were you able to maintain MI Spirit throughout the conversation?

 

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Engaging is the Relational Foundation

 

In their 2012 edition of the Motivational Interviewing “textbook”, Miller and Rollnick outline four recursive processes of MI. My colleague Wayne Skinner and I summarized these in a recent book chapter on MI:

Engaging: Client engagement is essential to the helping relationship. Without engagement, it is not possible to proceed, as the client makes a decision about whether to join with the practitioner and actively participate in treatment. The skills of engagement must also continue throughout all stages in the helping relationship.

Focusing: This “strategic centering” process hones in, with the client as equal partner, on the possible target(s) or direction(s) for change. At all times, client autonomy is respected – it is for the client to determine what he or she would like to address or work towards in treatment. Periodic “re-focusing” may be needed as goals evolve or change over time.

Evoking: Once the client is engaged in treatment, and client and practitioner have agreed on areas of focus, it is the practitioner’s task to evoke from the client his or her ambivalence about changing, reasons for change and strategies for change. In this stage the skills of MI become strategic in guiding the person in the direction of change by paying special attention to evoking change talk.

Planning: The process of planning can occur when (and only when) the client is ready to make a commitment to change. The skills of evoking commitment language, as well as the client’s strategies and ideas for change are key in this process.

Note that these processes follow a logical sequence, as each builds on the one before. However, practitioners may circle back to previous processes throughout the helping relationship.

 

Advancing Practice

Advancing our clinical practice takes practice. People often ask how they can access further training in Motivational Interviewing (MI), and there are lots of options available, but the most effective way is to just practice the skills! Peer practice is a good approach especially for those new to MI. I like case-based simulation as a teaching tool in MI to support integrated practice.

 

Case-based Learning

This exercise challenges you to intentionally practice the spirit and skills of Motivational Interviewing as they relate to engaging with our clients. The first few minutes of the very first session are powerful: this time communicates a wealth of information to your client about who you are as a person and a practitioner, as well as how you regard them. As you practice, consider how you can optimize the spirit and skills of MI as a powerful and impactful entry into engagement.

Below are two brief case scenarios. With a partner, you will each take a turn with one of the scenarios as a departure point for the first five minutes of your consultation. Remember that your purpose in this activity is to:

  • Intentionally embody the spirit of MI: partnership, acceptance, compassion and evocation
  • Beware the “righting reflex” – your task is to engage, not to fix it!
  • Practice reflective listening – incorporate at least three reflective responses in your practice.

Take five minutes and then switch roles. After you have both had an opportunity to practice, take five minutes to debrief and share feedback with your learning buddy.

Case Example 1:

Akilesh has been referred to your clinic because he has just been diagnosed with Type 2 diabetes. He is not overly concerned, as he was told that his condition at this time is not severe and can be controlled with diet. He is hoping for some clear guidelines and advice about foods to stay away from, and how to adapt his eating patterns. His chart states that he does not drink alcohol and that he is an “occasional smoker”. When he comes into your office, you notice that he smells strongly of tobacco smoke.

Case Example 2:

Elina is attending her appointment to appease her cardiologist, who is very concerned because of her continuing heavy tobacco use following her heart attack nine months ago. Elena is polite but clear that she does not intend to quit smoking. She has started an exercise program and is now eating a healthier diet, and feels that there is a limit to what changes she is willing to make in order to maintain her “quality of life”.

Reflective practice questions:

Was your “righting reflex” triggered by anything in the case example, or by any of the client responses in your role play? To what extent were you able to maintain MI Spirit throughout the conversation?

Motivational Interviewing Change or No Change

 

 

 

 

 

 

Motivational interviewing is a form of collaborative conversation for strengthening a person’s own motivation and commitment to change.

 

In a recent workshop I presented on Motivational Interviewing (originated by Dr. William Miller and Dr. Stephen Rollnick), the audience of interprofessional clinical practitioners came with varying degrees of familiarity with this well-established and evidence-based practice model. Below is a short summary of the essentials, with links for further reading, exploration and video examples. Start with this short interview with Dr. Miller, offering an overview of the background and basics of Motivational Interviewing.

 

The Righting Reflex

 

The “righting reflex” happens when we are triggered to want to “fix it” for the person…and tends to evoke a “Yes, but…” response from the person we are trying to motivate. As soon as we hear a person respond “Yes, but…”, that is feedback that we have likely slipped into the righting reflex.

 

Motivational Interviewing Spirit

 

Motivational Interviewing Spirit

 

 

 

 

 

 

 

The spirit of Motivational Interviewing (compassion, acceptance, partnership, evocation) is even more important than the specific skills (Open questions, Affirmations, Reflective listening, Summary statements – OARS). The ‘spirit’ is the essential foundation from which we practice.

 

Four Motivational Interviewing Processes

 

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There are Four Processes in Motivational Interviewing. They are not all necessarily sequential or linear, and we may need to jump backwards and forwards depending on where the person is at.

 

1. The process starts with engaging: without engagement there can be nothing

2. Motivational Interviewing is directional (as opposed to directive), with a trajectory toward a common goal (with engagement comes the process of focusing)

3. Once we identify and agree on a goal with the person, we move to the process of evoking change talk to enhance motivation for change

4. Commitment language signals a person’s readiness for the process of planning key strategies and supports to mobilize change

Note that these processes are not linear – we are continuously moving between processes as we stay alongside the person we are working with.

 

Foundation Skills of Motivational Interviewing: OARS

There are four foundation skills in Motivational Interviewing. The OARS skills are used in different ways throughout the processes of Motivational Interviewing. Caution: these skills are simple but not easy!

1. Open questions help us to get to know the whole person – closed questions gather focused information

2. Affirmations offer a neutral observation of a person’s strengths, resources, efforts, values – and statements of affirmation are more motivational than praise

3. Reflective listening communicates understanding and attention. Complex reflections aren’t complicated – shorter can be better!

4. Summary statements offer an opportunity to gather together diverse aspects of a problem, issue or conversational journey, and can also link back to previous material or ideas, and/or further exploration and dialogue.

 

Here are some of my favourite “Motivational Interviewing Axioms”:

 

“People are most able to change when they feel free not to” (affirm autonomy)

 

“You have two ears and one mouth. Use them in that ratio” (listen to understand)

 

“People only change when the pain of change is less than the pain of staying the same” (working with ambivalence)

 

“I learn what I believe as I hear myself speak” (evoke change talk)

 

 

Guilford Press offers the definitive series of Motivational Interviewing ‘textbooks’ across a range of clinical practice populations, disciplines and target areas.

 

 

Motivational Interviewing Tip Sheet

 

 

 

 

 

 

Click here for a one-page Motivational Interviewing Tip Sheet

 

Click here for video examples of Motivational Interviewing

 

 

reflection

Why is Reflective Listening so difficult? And so important to clinical practice?

We all want to be understood – that’s the major impetus for any form of communication. And the trouble is that there are so many ways that communication can go wrong. In Thomas Gordon’s model of Parent Effectiveness Training, it’s evident how easy it is to misunderstand the intent and/or the content of another’s communication as our messages are coded and decoded through a series of filters:

thomas gordon listening

Reflective listening, considered to be THE foundation skill of Motivational Interviewing, is like offering a hypothesis about how we perceive someone else’s meaning. Reflections are offered in the spirit of “I’m listening to understand (not to judge, persuade or correct)”. True, unadulterated listening is rare, refreshing and affirming. It communicates respect and builds relationships. It goes “below the surface” and articulates the underlying meaning – thoughts, feelings, ideas, hopes, values – that a person may be expressing.

Bonus tip:  Reflections can sound contrived when they are prefaced by “stock” phrases such as:

“What I hear you saying is…”

“So you are saying that…”

“I am hearing that…”

I think practitioners use these phrases to (a) buy time while we’re busy figuring out what exactly we’d like to reflect; and (b) because we’re concerned that we might be ‘putting words into the other person’s mouth’. However, when we offer reflective listening statements with a spirit of partnership, acceptance, compassion and collaboration, it’s OK if we’re a little off-target with respect to the other person’s meaning, affect or intent. Our reflections can still evoke further elaboration.

Also: it might seem counter-intuitive, but reflections are more genuine and engaging when we just come right out with a statement (not an question, and no ‘stock phrase’ preface):

“You wish that…”

“It’s frustrating because…”

“It would be nice if…”

“You’re not too happy that…”

Understanding is at the heart of effective communication. It’s also key to building trust, rapport and safety. The saying: “I learn what I believe as I hear myself speak” articulates the power of dialogue in fostering insight and enhancing motivation for change. Reflective listening holds up the mirror.

Related articles:

Reflective Listening: The Most Powerful Tool in the Tool-box?

Reflective Listening Reflections

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“What I don’t know I don’t know” – That’s the most essential learning

 

In nearly every course or workshop I teach on Motivational Interviewing (MI), there are nearly always practitioners who express some variation of “I already do MI naturally”. In other words, why spend time “learning” about something that I already know how to do? A reasonable response, if accurate.

I say ‘if accurate’ because research on MI practice suggests a disconnect between what practitioners say they do versus the MI skills they can actually demonstrate. We’re talking video recordings of actual client sessions, coded by skilled clinicians trained in the use of a standardized instrument. So while there may be a small proportion of therapists who really are “MI naturals”, it’s likely that most practitioners, whether they know it or not, can not or do not demonstrate the skills of MI without training, coaching, practice, coaching, and practice.

 

Motivational interviewing is essentially a way of being with a client (Dr. William Miller, the originator of MI, calls this “MI Spirit”), comprised of partnership, acceptance, compassion and evocation. It seems intuitive, but the “Righting Reflex” is hard to resist. Additionally the processes of MI – engaging, focusing, evoking and planning – are accompanied by a range of skills and strategies. Integrating both spirit and skills demands artful practice, and integrating MI with other approaches (for example Cognitive Behavioural Therapy, CBT) involves even greater therapeutic sophistication.

No practitioner ever reaches the apex of clinical perfection – it doesn’t exist! Just like the clients we serve, practitioners are engaged in an ongoing process of development. And it’s the basics (reflective listening is a good example) that can be the most challenging.

 

People come to a learning environment with four general categories capturing both pre-exisiting knowledge and knowledge deficits:

  1. What I know that I know: Everyone comes in with something of value
  2. What I know that I don’t know: Everyone has areas they can identify as avenues for further learning
  3. What I don’t know that I know: Everyone has knowledge and skills of which they aren’t aware
  4. What I don’t know that I don’t know: We all have a blind spot when it comes to what we still need to learn. When we can shine a light on it, that’s the “aha” moment! 

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