MIE8299 - SECTION II- ENGAGING CLIENTS
Section II - Engaging the Client
The Four Processes of Motivational Interviewing
There are four key processes for successful Motivational Interviewing:
1) Engaging, 2) Focusing, 3) Evoking and 4) Planning.
The first of the four processes in Motivational Interviewing is Engaging. Engaging places a large emphasis on the therapeutic rapport and working relationship between the clinician and the client, or the interviewer and the interviewee. MI is no different than many other clinical approaches that emphasize the importance of therapeutic rapport, with consistent support from empirical evidence demonstrating the high degree of correlation between the working alliance and positive treatment outcomes.
Focusing, the second process of Motivational Interviewing, takes place when the client and the clinician collaboratively develop a target behavior. The target behavior should be actionable, specific and measurable. For clinicians familiar with SMART goals (Specific, Measurable, Achievable, Realistic and Time Limited), that model fits well within the framework of Motivational Interviewing.
Evoking, the third process, emphasizes elicitation and acknowledgement of change talk. Motivational Interviewing really establishes its uniqueness with its emphasis on linguistics, the specific type of language that clients demonstrate when they are ultimately moving through the change process. So, MI encourages us to emphasize change talk, and not only tune our ears to it, but respond in a way that elicits more of it.
Planning is the final of the four processes. Planning within a Motivational Interviewing approach does not look much different than other approaches to client interaction. Once a change plan has been established, the clinician will utilize his/her planning tools, reinforce the commitment to change, and help the development of a specific plan to get there. As previously noted, the change plan should be specific, measurable, attainable, realistic and time-sensitive.
Bordin named three aspects of positive engagement that are apparent in the Engaging process (Bordin, 1979). The first, and perhaps most important of the three aspects is establishing trust and mutual respect. Mutual respect is intrinsic to Motivational Interviewing, since the conceptualization of MI falls into the humanistic school of thought.
The humanistic viewpoint in Motivational Interviewing can be summarized in the belief that all human beings experience some difficulty in making difficult life changes, and that those experiencing ambivalence are not the exception, but the norm. It is natural for us to feel two ways about change: we want the positive outcomes that may result from it, and we also worry, or fear losing, some of the perceived or felt advantages that the particular problematic behavior offers us. For example, while I might want to stop eating desserts that cause my cholesterol to be dangerously high, I surely will miss the delicious flavor that cannot be replicated in the ‘healthy alternative’ section of the cookbook.
Accordingly, clinicians working within the Motivational Interviewing model should be prepared to provide calm acceptance of the ambivalence that may be present in the client. This suggests the importance of patience in the application of this approach, allowing the client to resolve the ambivalence at a rate of speed that is tolerable for them.
Another way in which the clinician helps to create a sense of mutual respect and trust is by communicating that the client is the expert on themselves. Emphasis on the importance of autonomy is not just some clever trick to develop rapport; the belief truly underlies the philosophy and perspective that exemplifies the Spirit of Motivational Interviewing.
Clinical Traps that Impede Engagement
Before exploring ways in which the clinician can positively engage with clients, let’s start by looking at some of the ways that we may inadvertently promote disengagement. These ‘traps’ are often well-intentioned and potentially influenced by other helping approaches. However, they run contrary to the spirit of MI and can interfere with the goals and purposes of MI.
The first of these traps is known as the Assessment Trap. The Assessment Trap can be thought of as an over-reliance on the information-gathering efforts of the clinician. Often when caught in the Assessment Trap, the clinician will ask a number of rapid-fire questions, often close-ended.
In my experience within the Substance Use Disorder treatment field, the first few interactions with clients are consumed by intake, screening, and psychosocial sessions where the clinician spends a great deal of time and energy trying to gather a large amount of information. Certainly, this emphasis on assessment is understandable from a safety perspective and in helping to determine the necessary level of care the client might require. However, it may also simultaneously impede the formation of trust and positive engagement.
One of the concerns in effectively engaging with a client while entrenched in the Assessment Trap is a tendency to assume that once the clinician obtains enough information/data, the expert clinician will be able to determine what the solution might be to the client’s ‘problem’. Motivational Interviewing clinicians, by contrast, tend to see the client as a partner in considering solutions.
The second way in which clinicians might promote disengagement with a client is through the Expert Trap. The Expert Trap can communicate that there is a ‘right’ and a ‘wrong’ way to approach the presenting problem(s), and those designations are determined exclusively from the clinician’s expertise. Despite, what might be a very limited experience with the client, the clinician is convinced that s/he knows what is in the client’s best interest. The clinician’s expertise is valued in MI, but it is only one part of the expertise that will help the client make a change, the other form of expertise, again, is the client’s expertise on themselves.
The Premature Focus Trap is the next of our potential engagement barriers. In my experience with the treatment of Substance Use Disorder problems, this is a trap that I have witnessed countless times. A client presents for an initial session and the clinician starts to make guesses about what the client is ready to work on and what they’re hoping to work on in treatment.
Perhaps this can be explained by the field’s historical roots in abstinence-only treatment approaches, where a client would present for treatment under the assumption that they want to change everything about their substance use and all at the same time. In effectively engaging with a client and collaboratively developing a plan, we may find, and often do, that the client is only willing and ready to make a limited number of changes.
The importance of avoiding the Labeling Trap is consistent with the person-first language evident throughout the Social Work field. Electing not to use labels is an effective way to fight stigma and communicate to our client the core of their identity is composed in ways unrelated to the reason they are meeting with the clinician. Terms like ‘Alcoholic’ or ‘Diabetic’ are eliminated, and instead replaced with person-first language: someone diagnosed with a Substance Use Disorder, or someone under the care of their physician for the treatment of Diabetes.
The Blaming Trap may arise as the result of attempts by the clinician to discover an explanation of the client’s presenting problem. Clinicians might inquire and look to explain “What is responsible for this problem?” While this information might be helpful, it can interfere with the process of engaging with clients.
Similarly, the Chat Trap might arise, particularly for the inexperienced clinician, from attempts to build rapport through casual, non-clinical interactions. On the surface, it seems perfectly reasonable to assume that we may engage in casual talk such as the news or weather in order to initiate a relationship with a new client. However, the Chat Trap can create an environment where the requirement for change work is not emphasized. A client can become comfortable in this conversational dynamic, instead of creating an environment that clarifies the need to focus on a behavior change.
Many of us entered the field to help others, so it is no surprise that at times we want to provide what seems like an obvious solution to a client’s struggle. We do this in a variety of ways including providing resources, coping skills, suggestions, and, education about the ill effects of potentially harmful behaviors. Resisting the Righting Reflex is a term used in Motivational Interviewing to remind the clinician to refrain from the sometimes-intuitive process of offering unsolicited solutions or suggestions to a client’s presenting concerns.
Daryl Bem’s Self-Perception Theory suggests that hearing one’s self argue for making a change results in a higher likelihood of change than does hearing someone else argue for the change. Also, this theory offers another important understanding about why “righting” a client’s obstacles may not be effective. When presented with options, resources, or suggestions from another person, Self-Perception Theory assumes that an individual will be inclined to make the counter-argument for why those things will not work for them. (Bem, 1967)
As a young clinician, there were countless times when I provided a suggestion or resource and was surprised to see that, at the next visit, this ‘valuable gem’ I thought I had provided was ignored. Not only are the resources, education, or suggestions we provide to clients unhelpful at times, but the wisdom we are providing is often unsolicited – and thus set aside by the client. Later in this course, there will be introduced a concept called, Elicit-Provide-Elicit, which provides a Motivational-Interviewing inspired framework for the clinician to provide clients with advice, opinions of the provider, and education on a topic.
***Brief Exercise- 10-15 minutes***
Write down and reflect upon the following:
What provider, teacher, or mentor have I had the strongest connection with?
What was unique about the relationship with that person?
What differentiated that relationship from the many others you may have had?
What factors in that relationship were most important in shaping my willingness to engage with that person and be receptive to their guidance to me?
Many people in this country are fortunate to have access to different doctors, therapists, or specialty providers. As a provider whom clients can freely choose to work with, this freedom of choice possessed by each client has led me to reflect on questions such as “What am I doing to make this client want to return and continue to work with me?” Is it my capacity to construct a really well-formed assessment? Probably not. Is it the decorations in my waiting room? I doubt it.
When I think about my own experiences as a client or a patient, I think about things like trust, I think about working with someone who is understanding, somebody who doesn’t rush me out the door, somebody who feels genuinely concerned. While those characteristics, and many others, are certainly important in engagement, the most common response I hear when talking with others about this question is the following key factor: feeling heard and listened to. Clinicians refer to the skill at generating this response as Active Listening.
Active Listening
Active listening, for those in the helping professions, might seem like a familiar and fairly straight-forward concept, and most clinicians may even believe that they apply good active listening skills in their clinical work. However, good active listening is actually quite difficult to apply and sustain, and there are routine roadblocks to good active listening to which many clinicians fall prey. Because the capacity to engage in successful active listening is such an important aspect of Motivational Interviewing, let’s examine how clinicians sometimes get in their own way when listening to clients, thereby interfering with the process of generating engagement.
Roadblocks to Effective Listening
Thomas Gordon identified Twelve Roadblocks to Effective Listening, helping to highlight some of those potential impediments to good active listening. (Gordon, 1970) The first of the 12 roadblocks is composed of ordering, directing, or commanding. The clinician might find him/herself saying things like “These are things you’re going to have to do in this treatment program” or “These are the things you’re required to do”. While on the surface, this approach might appear to get more directly and quickly to solutions to the client’s problems, it does not constitute good active listening, and is not in keeping with the spirit of MI.
Second is warning, cautioning, or threatening. “You know that if you don’t make this change the consequences are going to be quite significant.” In my experience, clients are oftentimes very aware of what those consequences are - or could be. Accordingly, warning, cautioning, or threatening have the potential to create harm to the trust and mutual respect that the clinician has worked so hard to develop within the relationship.
The third roadblock identified by Gordon is giving advice, making suggestions, or providing solutions. Like many of the other road blocks, this often arises from a good intention. Frequently when somebody comes to us with a struggle or problem, those of us in the helping field want to be able to offer the prospect of a welcome sense of relief – preferably sooner rather than later. What we’re hoping to do, in giving advice, making suggestions, or providing solutions, is say “Hey, here’s this way I think you could try that would ultimately relieve that stress, that tension, that suffering that you are experiencing.” Faster, in this case, is not necessarily the same as more effective. In utilizing Motivational Interviewing, and more specifically, actively listening, we are challenged as helpers to resist this righting reflex.
The next roadblock is persuading with logic, arguing, or lecturing. Once again, the temptation to apply these approaches often comes from a good place and is well-intentioned. The clinician is essentially asking “Why can’t you see this? If you could just simply listen to my point, then you would certainly understand why the way you are thinking about it is wrong, and how that recognition will help contribute to you making some changes.” Helpful in some cases, yes. Active listening, no.
Some other examples of Roadblocks to Effective Listening are….
Telling people what they should do.
“You know, I think you should try this. I think you should do this.”
Disagreeing, judging, criticizing, blaming.
Agreeing, approving, or praising.
Being a great cheerleader might be helpful in certain circumstances, as it may help affect a client’s sense of self-worth, self-efficacy, confidence. It may even help the relationship in some ways, but it is not active listening, and may interfere with active listening.
Shaming, ridiculing, labeling
“What you are describing is typical addict behavior.”
Interpreting or analyzing.
“So, what I’m thinking you might be saying, or what I’m hearing, and I’m interpreting you to say is that this is really from your childhood” When we are actively listening, we are not taking the data that we’re getting, analyzing it, computing it, and giving back our perception.
Reassurance, sympathy, consoling. Things that might make the person feel supported or a sense of warmth, but you guessed it, not active listening!
Questioning or probing.
Asking clarifying questions feels like, a normal, an important part of conversation; however, when we really sit back and think about what we’re trying to accomplish with questions, many times the answer is something like “You know, the reason I’m asking questions is to better understand the person’s problem, which will ultimately help me better problem solve.”
Withdrawing, distracting, humoring, or changing the subject.
You might be wondering “what’s actually left?” How do we actively listen - if all of those things are barriers to it? Let’s consider the process in which information is an exchange between two people, the way it is delivered, the way it is interpreted or misinterpreted. This is conceptualized as a communication loop: from one person to the other, then back to the originator in the form of feedback. There are many points of impact in this loop, many places where the process of Active Listening can go wrong.
Active Listening and the Communication Feedback Loop
The loop is entered into with the words that the speaker (client) says. This signifies the beginning of this loop. The client has said something within a specific context, and the clinician attempts to receive the information in the way the client intended it to be heard within that context.
The first potential place for misinterpretation is what is heard and seen, how accurately all the pieces of the information have been received: verbal, vocal, physical (body language). Perhaps there is excessive noise in the background, maybe the listener has a difficult time hearing. Or the listener may have lost focus during the communication and failed to gather all of the relevant information. Success in active listening may be impeded before it has a chance to begin from any of these simple factors.
After the words have been heard, the listener starts the process of decoding the information that has been transferred. They reflect on what they thought they heard and apply their previously stored knowledge to decode the information. This is a place where the intended message can become significantly misinterpreted. The clinician will decode the message based on a variety of things that may be sources of perceptual bias, such as past experiences, past things that clients have said, past understandings of particular behavioral patterns, or a fundamental misunderstanding about the nature of the context in which information is exchanged. The meaning of the message may become altered from any of these elements during the decoding process. There can be substantial differences between what the client intended and what the clinician decoded based upon these biases.
If these potential receptiveness problems have been successfully avoided during the decoding process, the clinician is likely to have a strong inclination that they understand what the client was intending to say. However, there is a further step in active listening that aims for a higher level of clarification about the meaning of the message received. In the application of active listening, the clinician first reflects back what they thought they heard, rather than asking clarifying questions or offering suggestions.
Client- “You know I’m really thinking about doing something different, I’m thinking it might be time to make a change.”
Clinician- “You think this might be the right time to do something different.”
When the clinician has taken what they have decoded and simply reflected it back, it both minimizes the risk of misinterpretation and demonstrates that the client has been truly heard. This enhances trust through successful efforts at engagement. At this point, the client is also presented with a unique opportunity provided by active listening: the opportunity to correct the clinician if the intended meaning was inaccurately received. The clinician’s willingness and openness to allow such corrections provides another opportunity to mitigate the risk of misinterpretation and enhance trust and engagement.
Client- “Well actually, part of that might be the case, but also what I was trying to say was…”
Reflective Listening
Active listening may also be described as a kind of Reflective Listening, reflecting back to the client the intentions of their communications. Motivational Interviewing clinicians use two distinctly different types of reflections. The first is simple reflections. Simple reflections add very little to what the client has already said, no deeper or additional meaning.
Client- “I really think I should make a change.”
Clinician- “You’re thinking about doing some things differently.”
In this example, the clinician has not added much to what has already been said. The benefit to simply reflecting back to a client what they have said is that it conveys that you’re actively listening while reducing the risk for miscommunication and/or misinterpretation. Simple reflections are easy and effective and serve and important function. Our second type of reflection, complex reflections add some additional insight, or test a hypothesis relating to what the client has said. There are several different kinds of complex reflections that will be reviewed later.
Foundational Micro-Skills
Micro-skills are the tools that equip clinicians with the means to invite and acknowledge change talk. Motivational Interviewing uses a technique with an easily remembered acronym to help the clinician remember the four elements of this technique: OARS. The four elements are: Open-Ended Questions, Affirmations, Reflections and Summaries. Used intentionally they will serve not only as the tools we rely on in reflectively listening and engaging a client, but also in guiding the client-clinician interaction towards the target behavior.
Open-ended questions are questions that require the client to provide expansive information around a topic area, instead simply answering with a single word answer, such as ‘yes’ or ‘no’. They create an opportunity for further elaboration, clarification, and exploration. Closed ended questions, while appropriate in some instances, limit the client’s options to a finite number of responses and limit the client’s participation in formulating more complex responses.
Affirmations can be used intentionally by a clinician to highlight strengths, current efforts, characteristics, traits, and past successes that clients will ultimately rely on to take on specific change attempts at various points in time, whatever the change may be. Affirmations help to increase a client’s sense of self-efficacy and help emphasize not only the importance of a change, but the client’s confidence in their ability to do so.
Reflections are the backbone of what we do in Motivational Interviewing. Reflections are the micro-skill that the clinician uses most frequently. In fact, when practicing MI, it is expected that the clinician will reflect at a ratio of two times for every one question that is asked.
When training clinicians in Motivational Interviewing, I have found that the opposite is often true. The baseline ratio used by a clinician new to MI typically tends to be a minimum of two questions for every one reflection used. Reversing this ratio can be difficult for less experienced clinicians, similar to what it might be like to learn to write with one’s non-dominant hand. Getting this ratio right requires focus and commitment on the part of the clinician.
Finally, the last of our micro-skills is concerned with Summaries. Summaries serve several functions while helping to guide the interaction towards the mutually-agreed upon target behavior. Summaries can be described as a process similar to picking a bouquet of flowers. The clinician views the ‘change talk’ as the flowers in a bouquet. The clinician selectively pulls out the statements that most support the work of therapy, the ones that favor change, while not focusing on statements that do not support change. The “good flowers” are then summarized, presented to the client as nicely organized, succinct, concentrated statements that direct the focus to the most important areas in the change work.
Open-Ended Questions: Further exploration and examples
Open-ended questions are used is to explore the needs, values, expectations, experiences, feelings, beliefs, priorities, importance and confidence of the individual we are interviewing. Some of the ways we might use an open-ended question in Motivational Interviewing is to ask questions such as…
“What would you like to see different about your situation?”
“What makes you think you need to change?”
“What would be different if you were to complete your probation, or referral to this program?”
“What would be some of the good things about changing your current use of alcohol?”
“Why do you think others are concerned about your current use of alcohol?”
These open-ended questions provide an opportunity for the client to elaborate upon some of their motivations to change. These questions can evoke client’s extrinsic motivations for change, fears related to making a change, and projections of their future if changes were to happen or stay the same.
Affirmations: Further exploration and examples
When I think about what makes an affirmation impactful, I often think of affirmations that start with “you” rather than “I”. In other words, affirmations should not be statements such as…
“I am proud of you”
“I think you are doing a great job.”
Starting an affirmation with “I” rather than “you” can convey a sense of judgement, positive yes, but still a judgement. We want to remove the perception that the affirmation is based on our opinion of a client’s successes, characteristics, and traits. Instead, it is helpful to use affirmations such as:
“You’re the type of person who doesn’t give up very easily.”
“You’re really committed to this change, despite some of the big barriers that are in your way,”
“You are resilient and won’t give up without a fight.”
Reflections: Further exploration and examples
As discussed earlier, MI clinicians use two distinctly different types of reflections. The first is simple reflections. Simple reflections add very little to what the client has already said, no deeper or additional meaning.
Client- “I really think I should make a change.”
Clinician- “You’re thinking about doing some things differently.”
In this example, the clinician has not added much to what has already been said. The benefit to simply reflecting back to a client what they have said is that it conveys that you’re actively listening while reducing the risk for miscommunication and/or misinterpretation. Simple reflections are easy and effective and serve and important function. Our second type of reflection, complex reflections add some additional insight, or test a hypothesis relating to what the client has said. There are several different kinds of complex reflections.
Amplified reflections are used when a clinician hopes to oversell or undersell what the client has said.
Client- “Listen, drinking has never caused any problems for me.”
Clinician- “You’ve never had any consequences in your life, resulting from drinking.
Client- “Well, actually that’s not true, I guess there have been some consequences.”
Double-sided reflections provide clients with a nicely organized statement expressing their ambivalence. The clinician aims to give back to the client the ambivalence that they are hearing in their statement.
Client- “I don’t know, I guess I have to do something about my smoking because of my health but I have been doing it for so long. I am not even sure that I would be able to stop and what will I do when I am feeling stressed…I have tried so many times”
Clinician- “On one hand, you’ve been smoking cigarettes for such a long time, you’ve made a number of efforts to quit and you are lacking confidence in your ability to make this change, and on the other hand you’re realizing this time feels different, the stakes are higher, there are some real consequences that might come about as a result of your smoking.”
Reflecting affect is a type of complex reflection that aims to identify the feeling a client might be expressing but not explicitly stating.
Client “You know, I’m really concerned about making this change. I’ve been so disappointed in the past when I haven’t followed through with it the way I hoped.”
Clinician- “You’re terrified that you might fail and this fear is making it difficult for you to move forward.”
Metaphors can be used to demonstrate a deeper understanding of what the client is saying, and again, what perhaps has not been explicitly stated, but expressed.
Client- “You know, I feel like if I don’t change, there’s going to be real big problems, and I also am so scared of making this change, that I just feel stuck.”
Clinician- “You’re stuck between a rock and a hard place.”
Finishing the paragraph allows us to take little bit of liberty as the clinician, to test our hypothesis.
Client- “You know, I originally didn’t want to come in here and meet with you today, and now that I’m here, I guess I’m realizing that there’s some problems with my drinking…”
Clinician “And you’re thinking you might need to do something different.”
Reflecting Values is a complex reflection helps us to emphasize the things in a client’s life that are most meaningful and may likely serve as an extrinsic motivating factor in their decision to make a change.
Client: “I just really want to get my kids back. I don’t want to be here in these classes. I just need to get it over with.”
Clinician- “Being actively engaged in your children’s life is extremely important to you.”
Summaries: Further exploration and examples
When a clinician ‘picks the bouquet’ of change talk and plans to present it back to the client, there are a few things to consider. The clinician should start with a statement indicating that you are about to make a summary, “I would like to take a second and summarize what we’ve just talked about.”
At this point the clinician pulls together all of the most relevant themes the client has referenced in making the case for change. The clinician is careful to give special attention to those change statements. When presenting the summarized change statements, the clinician aims to be concise.
Finally, the client is offered an invitation to correct, amend, or add additional insight on to the summarized statement. When compiling the information for a summary, the clinician should not feel limited to include only information that has been explicitly stated by the client. The clinician can and should incorporate all information that’s available to him/her, including clinical knowledge and research. The clinician can also incorporate information that was stated by client during a previous session, or information that was presented by family members or the referral source.