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MIE8299 - SECTION IV - EVOKING CHANGE TALK

 

Section IV- Evoking Change Talk

 

Introduction to the Evoking Process

We now shift the discussing to the third process of Motivational Interviewing, Evoking.  Evoking is the part of Motivational Interviewing that ultimately makes it unique or different from many other approaches. We will also discuss some of the basic skills and foundations that were also part of the Engaging process. Even though Engaging, Focusing, Evoking, and Planning are separate steps or separate processes, the four of them work in a coordinated way throughout our interactions with clients, therefore we are not using them in a vacuum.

This section will highlight some of the most important processes for working successfully with Motivational Interviewing. These are elements that clinicians can incorporate fairly quickly into the clinical interventions that they use with clients. However, it is important to remember that these interventions work within the overall philosophy and principles that underlie MI, not as stand alone techniques to be applied in a random manner.

As mentioned, the first two of the four processes are Engaging and Focusing.  Engaging really emphasized the therapeutic rapport in the client-therapist working relationship.  Even in our Evoking phase, as we elicit and acknowledge change talk, engaging with the client remains paramount to what we do in Motivational Interviewing.  So, even though we move to this more technical process in motivational interviewing, the other parts of MI remain central to our interaction with clients.

 

Change Talk

One of the things that was discovered through some of the newer research, particularly attributed to Paul Amrhein in the early 2000s, was this idea that there is a specific type of language we hear from clients that correlates with positive behavioral outcomes in treatment. This is called change talk, or commitment language. (Arnhein, et al, 2003)

We have come to recognize that there is a specific way in which the client speaks with us that starts to bring to the surface some of their ambivalence, which will be discussed later in more detail. Not only are they talking about some of the reasons of why making change may be difficult, or some of the reasons to sustain their problematic behaviors, we are also hearing language that favors change. Daryl Bem’s Self-Perception Theory underlies this idea “By hearing one’s self argue for some action, one tends to become more committed to that action.”  (Bem, 1972)

Let’s consider this theory with something relatable, such as a goal of going back to the gym. I may decide that I want to improve my fitness because there have been some recent reminders in my life that I am not as fit as I would like to be: pants not fitting as well as they used to, or getting winded going up a flight of stairs, for example.  But ambivalence begins to enter my mind when I start to consider changing my behaviors, as time and effort must be allocated to getting back to the gym.

Many of us have faced this challenge when we consider the effort involved in change, and the conflict between the desire for change and the ambivalence because of the effort required. We compare two possible scenarios. The first of the two scenarios is that I reflect on how unhappy I am with my level of fitness. I am worried about what the future holds if I don’t make a change.  These thoughts rattle around in my head, but they don’t go any further than that. They just stay in my consciousness as something that’s bouncing around. 

In scenario two, I put a voice to this. Perhaps it is with a counselor, a family member, or a friend. I talk to them about how I really want to start to make a change, I really want to get back in the gym, and I am really wanting to make this lifestyle change.  Based on what Daryl Bern has stated, and really what Motivational Interviewing relies on, is that the second of those two scenarios is going to result in the higher likelihood of a positive behavioral outcome because I have given voice to this argument that I should make a change.  So, Daryl Bem would say that I become more committed to the action simply by hearing myself argue. (Bem, 1972)

 

Ambivalence

Ambivalence in Motivational Interviewing is considered to be a normal human response and something to be accepted. It is expected that a client may feel more than one way about changing. From a humanistic perspective, we all through go this process of ambivalence when we are faced with a difficult change. As clinicians, we expect that our clients are going to present some degree of ambivalence.

Prochaska & DiClemente have outlined that there are different stages that clients go through as they address and resolve their ambivalence on the road to change. They refer to these as Transtheoretical Stages of Change. (Procheska, DiClemente, 1984). Clinicians who wish to learn more about these stages of change may consider taking yourceus.com’s course, Motivating Substance Abusers through the Stages of Change: A Comprehensive Overview for Mental Health Professionals

 

Sustain Talk and Change Talk

In the presence of ambivalence, we are likely to hear what is called sustain talk: oriented towards maintaining the status quo and avoiding the effort of change.  For example, a client who is thinking about entering a trauma treatment program that requires some type of prolonged exposure intervention may make the case for sustaining the status quo. The client might argue “It only gets bad sometimes, and when it does get bad, I tend to get through the crisis and then move on.”

Someone else might say “I’m really good at kind of keeping it locked up most of the time; If I just prepare for the anniversaries of my trauma or better understand some of the triggers, then I can go on without really getting into any formal treatment." Sustain talk is to be expected, especially when we think of a treatment intervention or some type of change that is going to require a lot of discomfort.

We can think of many examples of this kind of ambivalence attached to the problems that bring people into treatment. However, the other side of the ambivalence may also be present: the person may begin to contemplate the benefits of change. For instance, while a client may not want to make a change, that person may also think “It would be nice not to be waiting for my symptoms to emerge again.”

Or, “Maybe I have learned to live with these symptoms, but it really is affecting my family members and the people around me.” This person in such a case may be making the case for both sides: for why things are fine the way they are, while also recognizing that there would be some benefit to change.

In Motivational Interviewing, our role as the clinician is to begin to tilt the discussion in a way that favors change talk. We recall from Bem’s Self-Perception Theory that people are more likely to make a change when they hear themselves make the argument to do so (Bem, 1972). This leaves us with the question:

“How can I influence the way a client thinks or talks about change? Is there a way in which I can favor or tip the balance toward change?”

The technical part of Motivational Interviewing relies on the idea that we can influence, selectively reinforce, elicit, acknowledge, and invite change talk in order to help the client make a better case for change.

Here is a brief example of how this works.

A client comes into treatment and says,

“I’m really thinking about stopping smoking and I've tried so many times before.” Clinician A uses a solution-focused approach and may respond with “What do you think has gotten in the way?”  The client responds by saying something like “Well, you know I get really stressed from work. I have been trying to quit for so long that I’ve almost lost faith in my ability to do it. Sometimes I wonder if it’s even worth it at this point.” A well-intentioned solution-focused question resulted in a great deal of sustain talk.

Now consider Clinician B’s response: “Making a change to your smoking habits is important to you.” The client says “Yeah, it is really important to me. It’s creating a lot of problems in my life. I’m spending a lot of money. I’m having arguments with my family about it. It’s making it more difficult for me to do the things I enjoy.” The clinician’s reflection resulted in different responses from the client. If we believe this concept that the more the client makes the argument for change, the more likely it is that they will make the change, the second scenario certainly resulted in the client making more of an argument for change.

Sustain talk works at the opposite end of the spectrum. Sustain talk is really just talking about why to continue on with the current behavior – why it is not that bad, why other people seem to think it is worse than it actually is, why it is the only thing that helps me relax, and so on. Sustain talk is the client’s argument to maintain status quo or to make no change to this problematic behavior. It is counterproductive to utilize interventions that end up eliciting sustain talk when we are working with a high degree of ambivalence.

 

Dancing with Discord

Dancing with discord occurs when we do not push back directly against the sustain talk. Instead, we engage in a gentle and patient dance with the ambivalence, waiting for opportunities to support the change side of the ambivalence, while not being pulled into conflict in ways that strengthen the sustain side. It is central to maintaining the relationship with the client as we navigate through different views of treatment outcomes, treatment success, or even the focus of treatment. If we push back directly and forcefully against the sustain talk, we are likely to succeed in just pushing the client in the direction of holding more firmly onto the sustain side of the ambivalence.

This requires patience, trust, and skill on the part of the clinician. It requires that the clinician gently invite the client back towards change talk, while “rolling with the resistance” and avoiding entering into direct conflict with the sustain talk as presented by the client. Trying to push through the resistance in order to speed up the process of change paradoxically may end up slowing the process down, as we increase the sustain efforts of the client.

It is likely that we will still have clients who initially come in with (seemingly) no interest in making a change. Perhaps they are court mandated, or they need to fulfill some type of external obligation: to work, spouse, family members. The motivation for change has not yet reached a position of importance in relation to the sustain talk.

When such clients come through the door, they are not yet at the stage of change where they have begun to contemplate the reasons for change, and discord about change will be likely to occur. They will view the clinician as a representation of changing behaviors that, in many ways, they are perfectly content with sustaining. The goal under such conditions will be to facilitate movement towards the next stage of change, to enhance some of the reasons why change would improve their state of being.

 

Responding to Sustain Talk

There are many different ways we can respond to sustain talk. One method is a straight reflective response. For example, the client states “I don’t think smoking is really a problem for me.”  A straight reflection would be something like “Smoking has really not been much of an issue thus far.” This method is simply giving back to the client what they have said.

Some clinicians might worry that this is simply reinforcing or cosigning what the client said, however that is not the case. This technique is just simply reflecting what we heard.  We’re trying to show the client that we have some understanding of the client’s ambivalence, that we recognize they may feel two ways about it, and that we can understand why somebody may want to sustain a behavior despite all of this evidence that the behavior is problematic. This enhances trust.

Next, we have amplified reflections. Say, for example, a client states “I don’t think smoking is really a problem for me.” The clinician may use extremes as the response. In this case, an amplified reflection would sound like “Smoking has never caused any issues in your life.” The client may either respond with “Yeah, no issues” or say “Well, yeah, but my bank account would disagree.” This gives the clinician the opportunity to focus on change talk with a response of “It’s financially difficult and has created financial hardship for you.” An amplified reflection also allows the clinician to be respectful and understanding of the sustain talk and discord.

Another type of reflective response is a double-sided reflection. If we continue with the smoking example and a client expressing that they do not think smoking is a problem, a double-sided reflection would be “On one hand you don’t think smoking is an issue and on the other hand you’ve heard some other people in your life express concerns about it.” We selectively end the statement with change talk, hoping this will illicit additional change talk, while also recognizing the ambivalence that the client may experience.

Another way we might respond to sustain talk is by emphasizing autonomy. While this might feel like a statement of the obvious, when we emphasize autonomy, it can often times minimize defensiveness. For example, the clinician’s response to the smoking sustain talk would be “The choice to smoke or not smoke is ultimately yours to makes.” The clinician emphasizes the client’s autonomy by reflecting that it is the client’s choice to make. This often creates an opportunity for the client to feel empowered and to feel that the clinician is not someone who is going to force his or her own agenda on the client or tell the client he/she needs to act differently.

A clinician can respond to sustain talk by reframing. When a client says, “I don’t think smoking is really a problem for me,” a clinician might reframe the statement by saying, “You are curious why the people who you care about see this as a problem.” The client may say something like, “Yeah, I don’t understand why they may see this as a problem.  Tell me some of the things that they’ve mentioned.” 

Agreeing with a twist is another strategic response to sustain talk. The client states “I don’t think smoking is really a problem for me.”  The clinician’s response might be “You don’t think this is a problem for you today, but you recognize it could become a problem.” Much of what we do in our reflective listening and motivational interviewing with a more complex reflections are to test hypotheses.

At the end of the day, this is a guided intervention.  It’s not entirely a following intervention where we just simply reflect back the client’s comments. In motivational interviewing, we are moving towards target behavior, towards change talk.  At times that may require us to take some liberties as a clinician and test a hypothesis with more complex reflections. 

The next response type is called running head start. Client: “I don’t think smoking is really a problem for me.” Clinician: “For you at this time you feel the risks outweigh the rewards.” Client: “Well, I don’t know about that.”  In this case, we are not coming in and saying, “You know what, how can you not see smoking as a problem?  Haven’t you heard what the surgeon general’s been saying for the past four decades?”  We are giving the client a head start towards change talk and looking at both sides of the ambivalence, but we are avoiding a directly confrontational style, which might ultimately push the client to continue to make the case for why this behavior is not a problem.

A final type of response is coming alongside. Client: “I don’t think smoking is really a problem for me.” Clinician: “This doesn’t seem like the right time because you don’t think it’s really causing any issues.”  This intervention, on the surface, appears to side with the client, but it also anticipates a future where the relationship between the change talk and the sustain talk may change. This lays the groundwork for better focus on the change side of the ambivalence when the client is at a later stage of change.

Using a reflection in all of these instances facilitates the client processing what you’ve said, looking at their statements from a slightly altered perspective, while not directly entering into conflict with the sustain talk.  Hopefully some of these will create some opportunities for more change talk. At the very least, what you are doing is helping to establish the relationship.  The client will hopefully begin to see you as an advocate or somebody who is going to support them, not simply make them aware of the error in their ways.

 

Recognizing and Responding to Discord

What are some of the ways in which we can recognize discord? How do you know it’s happening? From the client, we may see defensiveness, squaring off, interrupting, or disengagement. They don’t let you finish what you were saying or they just don’t seem like they are all that interested, and really don’t want to be there. They’d rather be anywhere else.  Odds are that this is a pretty good sign that we are faced with some discord.

There are several ways in which we can respond to discord. First is apologizing. While some people may feel uncomfortable apologizing, it is absolutely a useful tool within the framework of Motivational Interviewing. When a client says, “No, that is not what I said.”  Clinician says “Oh, I’m sorry. I must have misunderstood. Help me better understand.”

Another method to respond to discord is shifting focus. A client may say something like “Do you agree with my wife?  Do you think that I am wrong here?” A clinician’s response that shifts focus is, “I’m not interested in blame or who is responsible in conflicts; I am only focused on developing a strong working relationship with you.”

You avoid taking sides or going into a combative or conflictual interaction, an approach that has historically been utilized in the world of substance abuse. For instance, the TV show Intervention uses the traditional technique. The people on the show essentially show someone the “error of their ways” by telling them all of the things they do that are problems. This is successful in some cases. However, in many cases, for reasons we have discussed, it creates further discord and conflict with a client.  It encourages more sustain talk. 

Affirmation is another type of response to discord. Client, in disbelief: “I cannot believe I’m even sitting here. I’ve always taken care of my family and gone to work.” The clinician’s response would be “You’re the type of person who values hard work and takes good care of your family.” This statement affirms the client’s value system and touches on the discrepancy between their values and behaviors.

In this client’s situation, going to work and providing for their family is a very important consideration.  If they are going to make a change in this behavior, they will have to recognize that the behavior is discrepant with what they care about most.  In order to make these big changes, oftentimes clients need to identify some type of incongruity between the way they are living and what their values.

 

Practice Example: Dancing with Discord

The following exchange is between a young clinician and six group members of the “Parenting Skills Group” at a local community agency.  Group attendance is mandated for parents who have an active case with the county Child Protective Services office.  Today is the first session of a 15-week program with all new group members.

Consider the different approaches utilized by the clinician in the following scenarios.

 

Scenario 1

Clinician- “Welcome, everyone! I will be facilitating the Parenting Skills Group over the next fifteen weeks and I am really looking forward to working with each and every one of you.  I thought we might start today’s first session by going around giving everyone a chance to introduce themselves.”

Group Member #1- “Wait a second, you look younger than all of us.  Do you even have children of your own?”

Clinician- “Well, this group is ultimately about each individual member’s parenting needs, and I don’t think whether I have children is really all that important.”

Group Member #2- “Not important? How are you going to tell me how to parent my child when you don’t even have any children of your own!”

Clinician- “I want to make sure we don’t get too far off topic here, so let’s continue on with the introductions.”

Group Member #1- “No, this is not off topic.  We are all wondering the same thing here, how are you going to help us when you don’t even have children of your own?”

(group members nodding heads in agreement)

Clinician- “I want to ensure you that I have received extensive education on healthy parenting skills and child development.  I have also facilitated this group many times before, so I am more that prepared to lead this group.”

Group Member #2- “You think real parenting is anything like what they taught you in those books.”

(group laughter)

Clinician- “Not necessarily, but again we are off topic.  I want to make sure the focus of this group is on all of your needs.”

 

Reflection: What did you like about the clinician’s response in this scenario to the collective discord?  What didn’t you like about the clinician’s response? How do you think that the clinician could have handled it differently?

Scenario #2

 

Clinician- “Welcome, everyone! I will be facilitating the Parenting Skills Group over the next fifteen weeks and I am really looking forward to working with each and every one of you.  I thought we might start today’s first session by going around giving everyone a chance to introduce themselves.”

Group Member #1- Wait a second, you look younger than all of us. Do you even have children?”

Clinician- “I am wondering why that is important to you.”

Group Member #2- “Well, because if you are going to be the one to teach us how to be a ‘good’ parent, it seems like you should have some experience with that.

(group members nod their heads in agreement) 

Clinician- “It is important to utilize this opportunity in group to learn new ways of parenting in this group and I am not sure whether focusing on whether or not I have any children will help us accomplish that.”

Group Member #1- “Whatever, I am Christine and I am FORCED to be at this group.” 

Clinician- “Thank you, Christine.  Let’s continue on with the introductions.”

Group Member #3- “I’m Fiona.”

Group Member #4- “I am Joseline”

Group Member # 5- “Morgan”

Group Member # 6- “Kisha”

Clinician- “Okay, now that we know who everyone is can you all tell me something about yourself?”

(guarded body language, crossed arms, group silence)

 

Reflection: What did you like about the clinician’s response in this scenario to the collective discord?  What didn’t you like about the clinician’s response? How do you think that the clinician could have handled it differently? 

Scenario # 3

Clinician- “Welcome, everyone! I will be facilitating the Parenting Skills Group over the next fifteen weeks and I am really looking forward to working with each and every one of you.  I thought we might start today’s first session by going around giving everyone a chance to introduce themselves.”

Group Member #1- Wait a second, you look younger than all of us. Do you even have children?”

Clinician- “You are worried that I am not going to understand.  Being a parent is very difficult and if someone is not a parent themselves, they could not possibly understand how challenging it truly is.” 

Group Member # 2- “You got that right!”

(group members nodding heads in agreement)

Clinician- “It seems like others’ have a thought about this as well.”

Group Member #3- “Well, I don’t know if I believe that everyone who is not a parent can’t understand…but I definitely think that if you have children of your own, you can understand.”

Group Member #2- “Yeah, but even if you have children of your own there are certain things that you might not understand about someone else’s situation.”

Clinician- “Say more about that.”

Group Member #2- “Well some people have another parent in the house to help them.  Some children require a lot more attention than others, like my son, Marcus. If you have help in the house and your child behaves really well than you might not know what it’s like for me.”

 Clinician- “On one hand it’s important to have others around you can relate to being a parent and on the other hand everyone kind of has a unique experience with parenting.” 

Group Member #1- “Yeah, some of my biggest issues are with other parents.  They are always judging how I do things with my children, it’s part of the reason I have to be here.  You would think they know how hard it is, and not be so judgmental.”

(group members nodding heads

Clinician- “I see a lot of heads nodding.  What are some other thoughts on this?

 

Reflection- What did the clinician do differently in this example? Was it effective? Why, or why not?

 

Types of Change Talk

Before a clinician can respond to change talk, one must know how to identify the different types of change talk language: mobilizing and activating. In order to easily remember them, we use the acronym DARN CATS. All mobilizing language falls under the DARN acronym, while activating language falls under the CATS acronym. 

(D)esire; “I want to do something different about my smoking.”

(A)bility: “I can try.”

(R)eason; “It’s important for me to be active in my kids’ lives.”

(N)eed; “I need to stop or I might die.”

 

(C)ommitment; “Now is the time.”

(A)ctivating; “It’s going to be different now.”

(T)aking (S)teps; “I joined the gym yesterday.”

 

These all speak to the importance of making a change and are signs that the client has made change talk statements. However, another key element of working with change talk is confidence. For change to take place, the change not only must be important for a client, but it also has to be something they believe they can do. A lack of confidence alters the balance between change and resistance to change, strengthening the side on which the sustain talk sits. 

It is not uncommon for me to meet someone in the substance abuse setting that says, “You know, you don’t have to convince me that this is important. You don’t have to tell me all of the things that would be better in my life and how much closer I would be living with my values. The problem for me is that I’ve tried 15 times and I haven’t been able to do it.” 

In another approach, through a solution-focused lens, for instance, a clinician would respond with, “Well, tell me what you think is different this time?” To which the client very likely could respond with “Well, I don’t know if anything is different, the consequences are getting worse.”  Another clinician response might be “What have you tried in the past?” The client’s response: “I’ve tried everything. I’ve tried literally every type of program that’s out there. Inpatient, outpatient, I’ve done it all. Nothing has worked.” This leads to a dead end and makes it even more difficult to engaging in change talk. It gets the client stuck in sustain talk.

An alternative response from the clinician is “You’ve been through treatment 16 times, and you are back here today. You are resilient. You do not give up very easily. You are not taking no for an answer.” The client may not have even ever heard their efforts in treatment referred to in this way.  In fact, they’ve probably helped to develop that poor self-perception, in part based on “failed” attempts in treatment.

If we reconsider the way those treatment attempts are referenced and framed, we can help the client to build a stronger sense of self-efficacy.  This two-pronged emphasis in responding to change talk addresses both the client’s perception related to the importance of change as well as their belief in their ability to do so, or confidence.

The way I think about the difference between mobilizing and activating language is influenced by the Transtheoretical Stages of Change Model. (Procheska, DiClemente, 1984).  When I hear a lot of mobilizing language from a client, I often find that their readiness to change might be considered from the Stages of Change Model in the Pre-contemplative or Contemplative stages of change.  They may still think that the presenting issue for treatment is still not really a problem, and ambivalence is tilted more in favor of sustain talk.  

Part of my responsibility in this pre-contemplative stage of treatment might be to respond to a client in a way that might create some discrepancy.  There might be attempts to help the client focus on aspects of their situation that highlights some reasons why change might alter their circumstances for the better.

The presence of activating language might tell me something different about a client’s readiness to change.  Often when I hear a lot of activating language from a client, they fit nicely into the Contemplative, Preparatory, or Action Stages of Change.  Common statements we might here from a client are… 

“You know this is the time.  I got to do it different this time.”

“I went to the store last week.  I bought some nicotine patches in preparation for this. I’m really taking it serious.” 

“I stayed up all night and watching an infomercial on exercise equipment.” 

Our focus with someone who is providing more activating language than mobilizing language might be very different as a clinician practicing Motivational Interviewing.  We would likely spend more time reaffirming a client’s commitment to this change and beginning to talk about how to get there.

 

PRACTICE EXERCISE # 1

 

            Recognizing Change Talk

 

Below is a list of client statements.  Please read each statement and identify a) whether or not there is change talk and b) what type of change talk do you see, mobilizing or activating? The key to answers can be found just below.

 

 

  1. I think I’m doing about as well as I can.
  2. I certainly don’t want to get cancer.
  3. I’ve just always disliked the taste of healthy food.
  4. I really hate how sore I feel after exercising.
  5. Well, I wouldn’t mind cutting down on stress in my life.
  6. I probably could eat less fried food.
  7. Yes, I’m going to take my medication every day.
  8. It’s really hard to stay on these medications.
  9. But I love beer!
  10. I used to take my medications regularly.
  11. I’ve got to get my cholesterol under control.
  12. I’m going to get my cholesterol under control.
  13. I’m willing to take oral medication, but I don’t want to take shots.
  14. There’s no way I want to take those medications.
  15. I would like to feel less angry all the time.
  16. I don’t think I really have COPD.
  17. I wouldn’t mind taking a once-a-day medication.
  18. I don’t like watching what I eat. I mean I guess I have to, but I don’t like being limited.
  19. I wish I could have less stress in my life.
  20. I might be able to cut down on liquor.
  21. I’m not much on exercising. I guess I’ll do it if I have to but I don’t enjoy it.
  22. It’s pretty scary thinking about not being able to smoke.
  23. I’ll think about eating more fruit.
  24. I heard that taking fish-oil pills will help with my cholesterol.
  25. I hope to eat at least twice as much fruits and vegetables.

 

 

PRACTICE EXERCISE # 2 (KEY)

 

            Recognizing Change Talk

 

 

  1. I think I’m doing about as well as I can. (no)
  2. I certainly don’t want to get cancer. (yes, mobilizing)
  3. I’ve just always disliked the taste of healthy food. (no)
  4. I really hate how sore I feel after exercising. (no)
  5. Well, I wouldn’t mind cutting down on stress in my life. (yes, mobilizing)
  6. I probably could eat less fried food. (yes, mobilizing)
  7. Yes, I’m going to take my medication every day. (yes, activating)
  8. It’s really hard to stay on these medications. (no)
  9. But I love beer! (no)
  10. I used to take my medications regularly. (yes, mobilizing)
  11. I’ve got to get my cholesterol under control. (yes, mobilizing)
  12. I’m going to get my cholesterol under control. (yes, activating)
  13. I’m willing to take oral medication, but I don’t want to take shots.
  14. There’s no way I want to take those medications. (no)
  15. I would like to feel less angry all the time. (yes, mobilizing)
  16. I don’t think I really have COPD. (no)
  17. I wouldn’t mind taking a once-a-day medication. (yes, mobilizing)
  18. I don’t like watching what I eat. I mean I guess I have to, but I don’t like being limited. (yes, mobilizing)
  19. I wish I could have less stress in my life. (yes, mobilizing)
  20. I might be able to cut down on liquor. (yes, activating)
  21. I’m not much on exercising. I guess I’ll do it if I have to but I don’t enjoy it. (yes, activating)
  22. It’s pretty scary thinking about not being able to smoke. (no)
  23. I’ll think about eating more fruit. (yes, activating)
  24. I heard that taking fish-oil pills will help with my cholesterol. (yes, activating)
  25. I hope to eat at least twice as much fruits and vegetables. (yes, mobilizing)

 

 

Responding to Change Talk: Open-Ended Questions

 

In response to change talk, when it does emerge, what we often want to do is to respond with the foundational micro skills that we use during the engaging process. These are the same things that we talked about as a mechanism for creating an environment where there is an active sense of listening.  This really acts as a kind of accurate empathy.  We are not only are going to use it in the same way that we talked about with engaging, but we’re also going to selectively respond to and invite opportunities for change talk.  

First, we will look at open-ended questions. The way we frame an open-ended question can shift the balance of discussion to increase the likelihood that somebody is going to make an argument for changing behavior. One of the ways a clinician can promote change talk is a projective question. For example, a clinician, in response to a case example, is noted below.

Clinician- “I know you have not decided whether or not to make a change at this point, but I would like for you to consider something for me.  If you were to make no changes, imagine you are sitting with me a year from today, how do you envision things might look.”

Sierra- “I guess things would probably just be getting worse.”

Clinician- “Tell me what you mean by that.”

Sierra- “Well, I would probably just be smoking more marijuana.”

Clinician- “What about that would make things worse?”

Sierra- “My mom will keep getting on my case.  My anxiety probably won’t be any better than it is now.”

Clinician- “On one hand you feel that marijuana helps with your anxiety and on the other hand you think things will get even worse if you continue to smoke.” 

Sierra- “Yeah, I mean it helps for a little bit but I always end up feeling anxious the next morning when I wake up.”

Clinician- “You feel like the marijuana is just masking those terrible anxious feelings.”

Sierra- “Yeah, I hate to say that. But, it’s true.”

 

The same thing happens when we ask the reverse of this question.

Clinician- “Let’s imagine in this scenario that you did make this change. You were able to stop smoking entirely. How do you imagine things would look 12 months from now?”

Sierra- “Well, I would have more money, that’s one thing.  My mom probably wouldn’t be on my case as much.  I mean, if I am not smoking at this time next year, I guess something must have happened to my anxiety, because I can’t imagine not smoking if my anxiety stays this bad.”

Clinician- “You believe if you were to stop smoking your relationship with mom would improve, you would have a little extra money in your pocket, and you would be rid of the anxiety.” 

Sierra- “Yeah, but stopping smoking is not going to get rid of the anxiety. It might make it worse, but it’s not like if I stop it will get any better.”

Clinician- “Improving your anxiety is going to take more than stopping marijuana use.”

Sierra- “Yeah, it definitely will.”

If one thinks back to the reasons for why and how Motivational Interviewing works, you think back to the argument, and making the case, for change.  What we have done by asking these questions is we have helped to make the case for those changes.

Another type of open-ended question is a clarifying question.  We use clarifying questions to help us stay on track, or bring a client back on track, when otherwise he/she has deviated for examining change.  For example, a client has been talking about all of the reasons why stopping smoking would be helpful and useful for the past two or three sessions. Today they come in and say “I am not actually thinking that I might make this change. I’m thinking that I may just kind of continue on with smoking.” 

What I might want to do as the clinician is use a clarifying question to take us back to the time when the client was considering that change and reminding them of some of the things that they identified as their reasons for wanting to change.  I might say something like, “I was just wondering, last week you mentioned that if you did not make these changes to smoking that you could really imagine yourself having some significant health issues. Tell me more about that.”  Client: “Well, yeah I guess so.” 

This use of a clarifying question simply returns the client to change talk that was previously stated. Other ways in which we can do it is by saying something like “Well, what other ways of making a change have you thought of?” As a clinician we want to be flexible. We want to be open to the idea that the client may have some other thoughts about how to make this change that might not necessarily be what we are thinking.  It may also not be exactly what was offered to other clients. It may be something entirely unique for this person - based on their own research. We want to keep an open mind in thinking about the client’s desire to make their own changes in ways that resonate for them. They are the experts of their own lives and their own motivations.    

Other open-ended questions that we may ask are, “What would you like to see different about your situation?” “What makes you think that you need to change?” “What would be different if you were to complete your probation or referral to this program?” “What would be the good things about changing this behavior?” “Why do you think others are concerned about this? I know you are not seeing smoking as much of a problem and I also know that you think highly of your doctor, that is part of the reason you came in here today to talk to me about this. I am wondering why you think your doctor might be concerned about your smoking.” These help to create opportunities for change talk.

 

Responding to Change Talk: Reflections

Earlier in this section, we discussed the use of reflections as a method of responding to sustain talk. Reflections may also be used to respond to change talk. This next section will address this issue, while also reinforcing understandings about the different kinds of reflections.

Simple reflections add little or no additional meaning to what the client has already said. The client says, “I am thinking about doing things different.” The clinician says, “You are really thinking about making a change.”  A simple reflection stays very close to what the client has already stated.  You are just simply reflecting back that you are actively listening and hear what they are saying.

Complex reflections, on the other hand, require a bit more thought, as they work to bring in hypothesis testing. It is the clinician’s attempt to take some further meaning out of what the client might have said. For example, the client says, “I do not even think my smoking is a problem. My grandfather lived until he was 95 and never had any problems as a result of smoking.” Clinician: “You are saying that your grandfather did not seem to have health problems related to smoking and you are hoping that this will be the case for you.”

Amplified reflections are a type of complex reflection. An example of a clinician’s amplified reflection could be:

 

Case Example # 1

Mr. A- “I don’t even really know why I am here.  This was all a big misunderstanding and my drinking is not even a problem.”

Client- “You are not even sure why you and I are talking today as drinking alcohol has never caused any problems in your life.

Mr. A- “Well, I didn’t say it hasn’t cause me any problems.”

With this amplified reflection, we are trying to overshoot or state an absolute version of the client’s statement, hoping the client explores further. And amplified reflection can be an oversell or an undersell. For instance:

Mr. A- “I don’t really see the big deal.”

Client- “You have a beer or two every once in a while, you don’t see the issue.”

Mr. A- “Well no, I drink more than a beer or two.”

A double-sided reflection involves working with the ambivalence, with the clinician stating both sides of the ambivalence, so the client can see and balance them in the process. 

 

Case Example #2       

Mr. B- “I have just been smoking for so long.  It’s hard to even think about not smoking because it has just been there for decades.”

Clinician- “On one hand, you are resigned to what your life might look like if you continue smoking. You have lived your life this way for a long time and you have started to imagine what it might look like if you just continue on this way.  On the other hand, you are recognizing that that does not fit with some of the other important things in your life like your health and your family. And now you are questioning whether or not it is time to do something different.” 

Next we have reflecting affect.

Clinician- “Smoking cigarettes is scary. It is hard to imagine what it is going to be like and how scary it might be to manage your emotions without smoking cigarettes. And you are also scared, even terrified that if you do not do something different that the consequences are pretty severe.”

Mr. B- “Yeah, isn’t that the truth.” 

We overshoot affect in a way that is more likely we are going to support the change, to really show a deeper understanding in some cases.  We do this even if it is sustain talk.  We’re just showing somebody that we understand what is being stated and its connection to the deeper emotions present. 

Another type of reflection is metaphor.

 

Case Example # 3

Sierra- Yeah, I just mean it feels like I am doomed either way.  If I continue to smoke weed, things will get worse and if I don’t smoke weed than I will have to deal with this terrible anxiety.

Clinician- “You feel stuck between a rock and hard place.”

We use a metaphor to help illustrate deeper meaning behind what the client is saying. 

Finishing the paragraph is another type of complex reflection. It allows us to take quite a bit of liberties as the clinician. 

 

Case Example # 4

Mr. Diamond- “You know I really did not want to come in here today because I knew you were just going to keep talking with me about an aftercare plan, but I see that you are just trying to help me out.”

Clinician- “And now you are thinking it is necessary to have some type of plan in place, even if it is not what you originally envisioned.”

Maybe the clinician is taking too big of a leap there or maybe not.  The clinician may be helping to guide them towards the change.  The good thing about taking these leaps and hypothesis testing is that if it is wrong, the client will correct us and we will get a clearer understanding of where the client is in regards to change. This is not a bad thing to have as a clinician.

Lastly, we have reflecting values.  

Mr. Diamond- “Yeah, I just have to be able to take care of my kids. I have been away for a month.”

Clinician- “you are the type of father who puts his children first.  You want to provide for them not only emotionally, but financially.”

 

Inviting Change Talk: Asking Questions

There are different strategies to invite change talk. One of them is asking questions. These questions tap into the DARN of our DARN CATS acronym that was reviewed earlier in the text. As clinicians, we may want to invite a desire to do things in a different way. You might ask “What don’t you like about how things are now with your smoking?”  “How do you hope to use our time together?” 

We might also try to tap into their ability to make the change.  “What ideas have you considered for making changes to your smoking?” “How do you think you would likely go about it if you did?”  Trying to gauge their reasons for making a change is another way to invite change talk. “Why would you want to stop smoking?” “What are the problems you are faced with now as a result of smoking?” Lastly, we look to invite change talk by opening discussion around the need to do things different. “How important would you say that it is that you stop smoking?”  “How urgent does…”

Another way to invite change talk is by querying extremes. Some examples of querying extreme questions include: “In the long run, what concerns you most about your smoking?” “If you were to make no changes to your current use of cigarettes, what do you imagine is the worst-case scenario?”  “If you did decide to make a change to your smoking, what are the best outcomes that may result from that decision?” “How might things be different in your life if you decided to make a change to your use of cigarettes?”

Looking back is another way we can do this. “You mentioned that your smoking started 15 years ago. Tell me how you remember things being different with your health at that time.” “You talked about being more active in the past, tell me about that.” “You have experienced some disappointment in yourself for continued use of cigarettes, how did you view yourself before you started smoking?”

Another question type that invites change talk is looking forward. “Take a look into the future five years. I know you have not made a commitment one way or the other at this point, but imagine you decided to stop smoking. What would things look like?” “Let’s take a look at how things would look if you decided not to make a change. Tell me about how things would look.”

Importance and Confidence Rulers (Figure 2).  The use of a confidence ruler is an alternative way in which we can invite change talk. For those familiar with Cognitive Behavioral Therapy, this is similar to the use of scaling questions.

 

Case Example # 3

Clinician- “On a scale of 1-10, how important is it for you to make this change?”

Sierra- “It’s a 7.” 

Clinician- “Why a 7 and not a 5?”

Sierra- “Well I guess because I know that it is not really going to work in the long run.  It will probably continue to make things worse between my mom and me.  I think she is losing respect for me.”

The idea in scaling down, as in the above example, is that the client will often respond with why the change is important.  Admitted, the numbers are not all that important. The whole idea behind this particular intervention is to create an opportunity for change and for change talk.  You can also feel free to follow up with the following question, which invites scaling up

Clinician- “What will it take for you to get to an 8?”

Sierra- “I guess some of the consequences would need to get worse. I might get into some trouble in school or something.”

Clinician- “In order for this problem to be increase in importance, you would have to see things really starting to decline.”

Sierra- “Yeah, I guess so….but hearing that out loud makes me wonder I would have to see more consequences for this to become more important.”

Clinician- “You think those consequences might be avoidable.”

In addition to importance, we may also want to ask a client about their confidence in making the change if they decide to move in that direction. In doing this, you may choose either to scale up or scale down.

Clinician- “On a scale of 1-10, how confident are you that if you decided to make this change you could?”

Sierra- “I am not really that confident. I have tried so many times. So maybe a three.”

Clinician- “Why a 3 and not a 1?”

Sierra- “I am the type of person that when I put my mind to something, I get it done. I accomplish it.  When things kind of get down to it, I tend to rise to the occasion.” 

Clinician- “you have accomplished difficult things in the past and know that you have the ability to do so again.”

As the clinician, my goal is to help identify strengths, characteristics, traits, and past successes that the client will ultimately rely on if they are going to take on his particular change.  A lower score on the confidence scale (than importance) might indicate to the clinician that additional focus might be necessary on affirmations and self-efficacy.

As demonstrated in the importance ruler above, the clinician can again follow up with

Clinician- “What would it take for you to get to a four?” 

Sierra “Time….I have to see that I can actually do it.  I would have to see that I can actually deal with my anxiety without smoking weed.  I think the only way that can happen is with time.”

Clinician- “The longer you can sustain this change, the more likely it is that your confidence will improve.”

Sierra-  “Yeah, I think so.  I definitely got more confident over time when I made changes in the past.” 

One of the major sources of change talk becomes evident when helping clients to explore the discrepancy between their values and current behaviors.  For example, a client explains that their health is of most importance to them and sees their use of cigarettes in inconsistent with this value.  As a clinician, I want to explore this discrepancy but in a delicate manner – with patience, skill and compassion. 

It is important that the clinician fight the temptation to ‘spike home’ the obvious discrepancy between their values and current behaviors.  Instead, the clinician should allow the client to dictate the pace with which they explore this discrepancy.  Understand that this information might be very difficult to face. 

In simply discussing what a client values, often a client will begin to make judgments on their current behavior within the context of that particular value.   My experience with this has also been that the more delicate I can be in exploring these discrepancies the better.  Not only for the therapeutic relationship, but I think it also allows the client to dictate the pace in which they want to be exposed to difficult realizations. This is important information.  Be patient with clients, but don’t miss opportunities to help them explore the discrepancy in a safe, accepting, and non-judgmental environment. 

Discussion about values can be accomplished through a formal activity, such as the Values Card Sort, a tool which can be located and accessed through a basic search of your preferred internet search engine.  The function of the Values Card Sort, or similar activity in Motivational Interviewing, will be to explore discrepancy between behavior and self-identified values. The presentation of the discrepancy between the client’s stated values and current behavior will, in itself, help amplify the discrepancy in ways that facilitate change talk. 

This brings us to the end of the evocation process of Motivational Interviewing.  The process of intentional evocation is really what makes MI unique as an intervention.  This emphasis on linguistics, on a clinician’s ability to recognize change talk and respond to it in a highly intentional way, is a central component in the success of MI.  Evoking change talk and amplifying discrepancy increase the likelihood that the client will continue making their own argument for change. This provides the clinician with a high impact set of skills and interventions. 

 

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