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The Four Processes of Motivational Interviewing: Spotlight on Evoking

April 24, 2016
Clinical Education, Motivational Interviewing
1 Comment

Garden tools and watering can with grass

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. 

Reflective Listening Reflections

November 30, 2013
Clinical Education, Motivational Interviewing
5 Comments

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.

 

 

Perceived versus Actual Practice in Motivational Interviewing (MI)

August 3, 2013
Clinical Education, Education Research, Motivational Interviewing
1 Comment

ideas lightbulbs

 

 

 

 

 

 

 

 

 

 

 

“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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