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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. 

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

latte drakehotel

 

 

 

 

 

 

 

 

The latte factor in Motivational Interviewing

 

Reflective listening, as it’s used in Motivational Interviewing, can include both simple (content-focused) and complex (beneath-the-surface) reflections. I like to use the analogy of an iceberg to illustrate the difference between simple and complex reflections (link to article); but the iceberg image doesn’t quite to do justice to the richness of what’s “below the waterline”.

 

At a recent professional development workshop I attended, the facilitator used the image of a café latte to illustrate listening for varying verbal and non-verbal content. This got me thinking: a better (and better-tasting) analogy for reflective listening might well be a macchiato versus an iceberg:

The top layer of foam represents the spoken content that the person offers.

The middle (espresso) layer represents the person’s thoughts and feelings.

The bottom layer – the foundation, as it were – represents the person’s values and beliefs.

 

 

Accurate empathy (that is, listening with ears, eyes, undivided attention, and compassion/heart) is needed to hear and reflect a person’s unspoken emotions as well as underlying values.

 

Here’s a quick example:

 

Client: “It is way too stressful right now for me to make this change.”

 

Now you have three choices:

Reflect the spoken content (simple reflection)

Reflect your sense of what the person might be thinking or feeling (complex reflection)

Go for the underlying values/beliiefs as you understand them (complex relfection)

 

It goes without saying that this is offered in the spirit of Motivational Interviewing: Partnership, acceptance, compassion and evocation. You might be on target or not quite accurate, but in the end your reflective response – especially complex reflections – will forward the conversation (and exploration) in an affirming and supportive way.

 

 

squirrel left

 

Do one thing this year that scares the hell out of you

 

When I think about learning and all it implies, my mind automatically goes to unicorns and rainbows. Phrases like “transformative learning”, “learning community”, “lifelong learning”, “learner-centred”, etc. conjure up an idyll of intrinsically motivated and enriching experiences and endeavors. Don’t get me wrong – this is legitimate and genuine and real. But it doesn’t tell the whole story.

Yesterday I attended a talk focused on institutional commitments in a learning-centred organization. The speaker ended with a powerful call to action: her own. She committed to identifying and doing “one thing this year that scares the hell out of me”. And then she invited everyone in the audience to do the same. This got me thinking: deep learning happens when the going gets tough. Doing something that scares you is a 100% guarantee that you will learn something new.

In his book The Talent Code, Daniel Coyle talks about the phenomenon of deep learning. In this mode, peoples’ acquisition of a new skill resembles a herd of deer on an icy, slippery slope: tenuous, tentative, struggling, messy. In other words, deep learning is hard and it’s scary, but it may be the most effective route towards mastery.

A few years ago I gave my undergraduate university class a critical analysis assignment, consisting of three parts: (a) Read a challenging scientific research article (selected by me); (b) Submit a critique of the article, no more than three pages in length; (c) Locate two related research articles from an academic database. I loved this assignment because it so effectively assessed essential professional skills of understanding and critiquing research literature in the field, as well as navigating academic databases and locating relevant research. Practicing professionals need to be able to do this.

My students, on the other hand, hated the assignment. They were up in arms! Some said they had to read the article six or more times before they even understood it. Others struggled with how to even begin to critically analyze a scientific article published in a peer-reviewed journal. And still others had successfully avoided exposing themselves to Scholars Portal, and wanted to keep it that way.

Faced with an onslaught of indignation and outrage from approximately 60 people, I went into reflective listening mode: “So, what you’re saying is, this assignment was incredibly challenging. You hated reading a boring article ten times before it even began to make sense. Scientists aren’t too good at making the products of research accessible. Life would have been so much better if the assignment I gave you involved no more than a couple of hours work the night before.” Nods of agreement and reluctant smiles.

But here was my pivotal question to the group:

“If I had given you that easy assignment (welcome as that may have been), tell me this, would you have learned anything?”

Umm…no.

“And what about this terrible assignment…did you learn anything useful?”

An unequivocal Yes! … even though it was pretty aversive.

And then the conversation shifted – big time.

We talked as a group about why they had come to university in the first place. We talked about the experience of learning. About how, when things are hard, that is exactly when learning happens. Instead of a mutiny on my hands, the experience was an epiphany for all of us.

 

I have to keep reminding myself of that lesson. The challenge to commit to one really tough thing this year and follow through is the challenge to commit to the slippery slope of deep learning.

And maybe among the herd of deer on that icy slope, there will be a couple of unicorns.

 

 

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