{Matulich, 2010. How To Do Motivational Interviewing: A Guidebook for Beginners}
We apply MI skills to evoke change talk.
Attitude. The MI Spirit is an attitude of extreme respect for your client and your client’s wisdom, knowledge, and ability to make decisions for her own life. The MI Spirit is to strive to work in partnership and see things from your client’s perspective. Your role is not to motivate your client or to fix a problem but to explore your client’s motivation and draw out her solutions. The client, and the client alone, is responsible for making decisions about her life. The Spirit of MI is summed up with the words “collaboration,” “evocation,” “autonomy,” and “respect.”
The client already has wisdom, knowledge, and motivation without you having to “instill” any. It is ultimately the client’s decision to change or not to change her behavior. You will work together to find solutions to whatever problems are presented.
The first step in preparing for an MI session is to keep the Spirit in mind: Collaboration, Evocation, and Autonomy. This client is a very important person deserving of your respect and appreciation.
Mind. Resist the tendency to tell your clients what to do or try to “fix” their problems. Uncover and understand your client’s motivations and solutions. Be empathic and listen carefully, striving to understand your clients’ perspectives. Empower your clients and encourage their hope and optimism. These four “principles” of MI form RULE: Resist, Understand, Listen, Empower; also EDRS: Expressing Empathy, Developing Discrepancy, Rolling with Resistance, and Supporting Self-Efficacy.
Listening has no immediate agenda other than understanding the other person’s perspective and experience.
The second step in preparing for an MI session is to put distractions out of your mind so that your energy is freed up to concentrate well. Devote all of your attention to your client.
Space. De-clutter your mind of distractions as well as your office or meeting space. Be respectful of your client and her time spent with you. Plan for and deal with distractions beforehand, before the session begins. Create an atmosphere of respect where you can devote all your attention to your client. Free the environment of clutter and distractions. Anticipate and plan for interruptions.
Act I: Openings and Beginnings
Goals
The beginning of a session is important for setting the tone for working with your client and establishing rapport. Express appreciation for the client coming in or keeping the appointment. Structure the session and let the client know what to expect. Allow enough flexibility so that the client can address, and you can respond to, her issues or concerns.
Setting the Agenda
Setting the tone depends on your role and what must be accomplished. Open the session by introducing yourself, expressing appreciation, and explaining your role and what you hope to accomplish. State the amount of time you have to meet and any details or tasks required to be taken care of during the session, like paperwork, information gathering, or information that must be shared. This beginning should end with an open question that invites your client to begin to discuss whatever is on her mind and/or freely respond to your opening statement.
“Hello, Karl. Thank you for coming in today. My name is the Mustafa. I’m an executive coach who works with engineering and manufacturing company executives who are establishing a positive culture and workplace. Your (organizational sponsor) has referred you because he thinks I might be of some help. We’ve got about 50 minutes together and I’d like to use the time to get to know a bit about you. I’m also interested to learn what your expectations might be. There is some paperwork that we need to complete at the end of the session, but for now, I’m wondering, what would you like to talk about?”
Your Client’s Agenda
Some settings require discussion of specific predetermined topics and completion of routine tasks, while others might be a vague, diffuse, non-directive exploration of issues.
The client’s agenda is the one to follow, at least at the beginning of the session.
What brings you in today? What’s on your mind? What would you like to talk about today? How can I be of service to you? How would you like to begin?
Mandated Agendas
In correctional or healthcare settings, a limited set of topics may be mandated to address. Find out what the client wants to discuss or address within the framework of your field of expertise and the scope of your position and practice while giving the client as much autonomy as possible.
“Your doctor asked me to discuss your lifestyle with you as a means of controlling your diabetes. There are many topics we can discuss including diet, exercise, stress management, and others. Which of these would you like to talk about today?”
Specific Tools Used at the Beginning of a Session
Micro-skills of MI: Open questions, Affirmations, Reflections, Summaries (OARS).
Open Questions
Useful in inviting the client to begin to talk about what is on her mind, gather information, identify a target behavior, and begin to elicit change talk.
Tell me a bit about your tasks. How does your new role fit into your career path? What do you already know about the new competencies required for your new role? What things do you do now (to engage your capacities)? Tell me how your (professional development) is coming along. How has the change project affected your life? What is your experience of conflict (in your team)?
Open-ended questions put the responsibility for moving the conversation along on your client.
Querying Commands and Useful Closed Questions
“Tell me about your life growing up” is technically not a question. However, the effect is the same as if you were asking an open question.
The Problem with Questions
Asking one (mostly closed) question after another may lead to a question-answer trap, and the client becomes more passive. At the same time, the practitioner feels more pressure to come up with the “expert” question. Ask more open questions and follow up answers to open questions with reflective listening.
Reflections
Reflections are statements made to the client that mirror, give back, repeat, rephrase, paraphrase, or otherwise manifest what you hear the client saying or see the client doing, such as smiling or looking sad. Reflections are guesses or hypotheses about what is going on in the client’s mind and heart. Good reflections are delivered confidently as statements with your voice inflection going down rather than up at the end. They stand alone and don’t need to be followed by a question such as “Is that right?”
Early in a session, rely more on simple reflections, such as repeating and rephrasing what you are hearing. Later as the session progresses, you may use more complex reflections, such as paraphrasing, double-sided reflections, using metaphors, and reflecting feelings.
Reflections convey that you are hearing and understanding what your client is telling you.
Stems to use: It sounds like … That makes me think … If I understand you correctly … What I am hearing …
If you reflect adequately, the client will generally keep talking. The session will progress smoothly, even if your reflection is inaccurate. Your client will just correct you gently and continue with the conversation. As you reflect, the client feels your interest and wants to be understood. Hence, an inaccurate reflection is just another chance for your client to correct a misinterpretation and be better understood. Inaccurate reflections do not slow the conversation down. If, on the other hand, you are asking a lot of questions in a row or responding in some other non-MI manner, such as arguing or trying to persuade with logic, you will know because the conversation will feel disjointed and jerky without a smooth flow and your client may start to withdraw and become resistant.
Summaries
Summaries are just long reflections. When you reach a point where you have exhausted a particular topic, you can summarize it to transition to a new one. You can highlight or reinforce some significant client motivational statements with a summary.
You might connect different things you’ve heard during a session with a summary. When you feel “stuck” and are unsure which direction to take, rather than relying on a question, try a summary and wait to see if your client adds anything or clarifies anything for you. You may follow a summary with an open question that moves the conversation to a new level or a different topic.
“So, how can I help you?”
Pause after summarizing. Your client will likely tell you if you got it right or missed something. Just like with reflections, it doesn’t matter how accurate you are because your client will generally correct you gently if your summary needs to be corrected. With a summary, you can ask your client for feedback directly, whereas you wouldn’t want to do so with a reflection.
“Have I got it right so far? What did I miss? Does that pretty much describe where you are right now? How am I doing?”
Affirmations
Affirmations recognize your client’s strengths, accomplishments, and positive behavior and help build self-efficacy by pointing out what your client is accomplishing or has accomplished.
“You’ve demonstrated commitment to your health by coming in today.”
“You feel confident you could do it if it were important to you.”
“Your commitment to your fellow veterans is commendable.”
Target Behavior
“What kinds of changes do you want to make in your life?”
“How would you like things to be different for you?”
“What things in your life would you like to be different?”
“What goals do you have for changing your behavior?”
Assessing Motivation
Once you’ve established rapport, expressed empathy, and established target behavior, you want to assess your client’s motivation using scaling questions.
Scaling Questions
“On a scale of 0 to 10, where “0” is not important at all and “10” is crucially important, how important is it for you to make this change?”
“On a scale of 0 to 10, where “0” is no confidence at all and “10” is completely confident, how confident are you that you can make a change?”
“Why did you pick (number) and not a lower number?”
“What would it take to move it to a higher number?”
Concerning the importance question, Your client may move into change talk about why behavior change is important; when you hear it, reinforce it and strengthen it with reflections.
Concerning the confidence number, “Why isn’t your confidence a lower number?” you will likely hear change talk about the client’s ability.
“I’ve done it before.”
“When I put my mind to something, I don’t give up until it’s done.”
Do not ask why the number isn’t higher. This will likely give you “sustain talk,” the opposite of change talk, and entrench your client more in resistance.
Avoid the “righting reflex,” the urge to fix the problem by offering solutions or advice that hasn’t been asked for.
Avoid “counselor advocacy responses,” which include arguing for change, assuming the expert role, criticizing, shaming, blaming, labeling, being in a hurry, or claiming preeminence.
Avoid “roadblocks,” which include, in addition to the above, ordering or commanding, threatening, persuading with logic, moralizing, judging, agreeing, interpreting or analyzing, and humoring.
If you do not reduce advocacy responses, the righting reflex, and roadblocks, there will be no change in your client’s behavior.
Checklist: Beginning of the Session
Greet your client warmly, express appreciation, and introduce yourself and your role.
Begin to negotiate an agenda by explaining your goals and details that must be attended to.
Explicitly state client autonomy. Explore client concerns and what your client wants to talk about first.
Ask an inviting open question.
Follow-up with reflections and summaries, using mostly simple reflections at first.
Continue to ask more open questions than closed questions.
Affirm when appropriate to establish rapport and acknowledge client strengths.
Avoid the righting reflex, counselor advocacy responses, and roadblocks.
Be patient.
When a target behavior becomes evident, assess your client’s motivation by asking scaling questions.
Follow up the scaling questions with open questions designed to strategically elicit change talk.
Act 2: The Middle of the Session
Checklist: The Middle of the Session
Continue to listen to your client and start to use more complex reflections.
Take more guesses about what is on the client’s mind and heart based on what you hear, and reflect these back.
Deepen the conversation by reflecting feelings.
Listen for ambivalence and reflect both sides to the client using double-sided reflections.
Listen for change talk and reinforce it by reflecting it when you hear it.
Use open questions and specific strategies to elicit change talk.
Follow up on your client’s answers to your questions with reflective listening.
Listen for resistance and if you hear it, use it as a signal to check in with yourself to see if you are resorting to resistance-producing responses.
Ask permission and acknowledge your client’s autonomy when giving required advice or information.
As the session progresses, focus on listening for change talk and ambivalence, and elicit and reinforce your client’s arguments for change. Amplify these arguments with OARS skills and guide the conversation toward a commitment to action. Explore ambivalence through reflections and summaries. Get more directive by selectively responding only to specific types of speech from the client. Ask few, specific questions to elicit change talk or explore ambivalence. Rely more on reflective, empathic listening than on questioning.
Ambivalence
Ambivalence means feeling two ways about a decision or a potential behavior change; wanting and not wanting something or wanting two incompatible things simultaneously.
Thinking about making a change implies that there are forces both for making the change and for not making the change, with equal forces operating to both encourage and discourage change.
Ambivalence produces anxiety, which is a state of discomfort, leading to avoidance which perpetuates ambivalence and keeps people stuck.
Hold your client in the anxiety-producing ambivalent state long enough to explore both sides thoroughly until your client begins to tip the balance toward healthy behavior change.
Do not argue for change with an ambivalent client. People resist persuasion. If you argue for change, your client may resist your arguments and argue for the status quo. People believe what they hear themselves saying, and hearing her own arguments, your client may then become less motivated to change and more entrenched in continuing old, unhealthy behaviors.
Change Talk
Change talk is client speech that favors movement in the direction of behavior change. Five important types of change talk are desire, ability, reason, need, and commitment to change (plus two more types of activation and taking steps).
Desire change talk expresses wanting, wishing, and hoping for.
“I want to be healthy for my grandchildren.”
“I wish my life were different.”
“I don’t want to end up (this way) like my father.”
“I hope to be helpful to my fellow veterans.”
Ability change talk expresses “I can,” “I’m going to,” or “I’m able.”
“I know I can quit smoking with the right system.”
“I’m going to learn how to deal with these symptoms of PTSD.”
“I could do these back exercises every day.”
“I’m able to check my blood glucose levels when I remember to do it.”
Reason change talk includes the benefits of change.
“I’d have more energy if I exercised regularly.”
“There would be more room in my house if I could get rid of all this stuff.”
“I’d save money if I quit smoking.”
Need change talk includes “need to,” “got to,” “have to,” and problems with the current situation.
“I need to be better organized.”
“I can’t continue to be hungover every morning.”
“I’ve got to make more money.”
“I have to learn to be more sensitive to my wife’s needs.”
Commitment change talk implies action.
“I am going to start counting my calories tonight.”
“I intend to go to the next AA meeting I can find.”
“I plan on making it to my next appointment on time.”
“I will complete all the homework this week.”
Specific Tools Used in the Middle of a Session
Strategic Open Questions
Use strategic open questions to elicit change talk. The follow-up questions to the scaling questions are one way to elicit change talk. Here are six other ways.
- Asking for it. Ask evocative questions directly for the kind of change talk you want.
“Why would you want to exercise?” (evoking desire talk)
“How do you know that you could do it if you tried?” (evoking ability talk)
“What are the three best reasons to take your pills?” (evoking reason talk)
“In what ways does your smoking concern you?” (evoking need talk)
“How will you do it?” (evoking commitment talk)
- Asking for elaboration.
“Tell me more about how you overcame difficulties in the past.”
“What other successes have you had with changing habits?”
“You said you’ve been able to lose 20 pounds and keep it off for a year. How did you do it?”
- Querying Extremes. Ask about the best and worst things that could happen if the client could change the behavior or didn’t change the behavior.
“What’s the best thing that could happen if you started to exercise regularly?”
“Tell me about the worst situation you can imagine happening if you continue to smoke.”
- Looking Back. Ask about a time in the past when things were different.
“What were things like in your life before you started using drugs?”
“What goals did you have for yourself when you were younger?”
“What did you want to be when you grew up?”
“What were you like before you went to war?”
- Looking Forward. Ask about an imagined time in the future if a change occurs or if there is no change.
“If you can achieve your goals, where will you be in five years?”
“Describe what your life would be like in five years if you didn’t make a change?”
- Exploring Values and Goals. Ask about how the target behavior fits with the client’s values and goals.
“What are some of your goals for the future? How does smoking fit with these goals?”
“What do you value most in life? What are you doing now that is inconsistent with your values? How can you change your behavior to be more consistent with your values?”
Pay attention to the types of responses; if you are getting change talk, great; if you are not getting change talk, reexamine your approach.
Are you trying to push your agenda, moving too quickly, or using roadblock responses or other non-MI types of interventions?
Let your client be your guide.
Explore and help resolve ambivalence by using a decisional balance worksheet, asking four open questions:
What are the advantages of changing? What are the disadvantages of changing?
What are the advantages of the status quo? What are the disadvantages of the status quo?
Use elaboration questions to get complete answers. “What else? Tell me more.”
Make ambivalence to change conscious, observable, and concrete.
Strategic open questions may elicit change talk or ambivalence. For example, exploring values and goals may reveal discrepancies between your client’s current behavior and her values and goals, which produces anxiety that is resolved by changing behavior to be more consistent with goals. Amplifying the discrepancy can create motivation.
Complex Reflections
Use double-sided reflections, paraphrasing, metaphor, continuing the paragraph, reflecting feelings, and generally taking more risky guesses as to what the client is meaning to reinforce change talk and highlight ambivalence strategically.
If your client isn’t giving clear change talk but seems tentative, reflect back change talk that you assume the client is meaning to say.
Assume desire: “You want to feel better than you’ve been feeling recently.”
Assume ability: “You think you could feel better if you knew what was wrong.”
Assume reason: “You might feel more normal if you got some help.”
Assume need: “Things can’t keep going on like they are.”
Use double-sided reflection to resolve ambivalence, repeating back the forces for change and the forces for the status quo in one statement, holding out and presenting both sides of an ambivalent situation to a client. Deliver non-judgmentally. Use the client’s words to call her attention to her struggle with herself and her conflicting emotions.
“On the one hand, you want to watch TV, and on the other, you want to write your book.”
“You want to quit (this or that) and you are worried what your friends will think of you if you do.”
“It sounds like getting things done at the last minute is kind of exciting to you and, at the same time, you want to quit procrastinating.”
“You want to be healthy and taking your medication is difficult and confusing to you.”
Reflect feelings. Tapping into emotions is tapping into energy to help motivate change.
“You are angry at your parents for making you come here today.”
“That makes me think that you are frustrated with your attempts to quit.”
“You’re worried that you couldn’t change even if you wanted to.”
Use reflection to reinforce change talk. Mirroring back change talk, your client hears herself saying change talk and then hears you saying it again. This produces more change talk.
“I’m hearing some real emotion in your voice. You really want to make things better for yourself and your family.”
Mirror back desire, ability, reason, need, and commitment types of change talk.
Affirm to Strengthen Confidence
Engage your client’s hope and optimism, thus building confidence.
Affirming accomplishments, strengths, and other positive behavior can increase overall confidence. Ask to connect success in one area to the present situation by applying some success strategies. Point to past attempts to change the target behavior, reframing those attempts as persistence or successes rather than failures.
“You are going to keep trying until you find a method that works for you.”
“You’ve been able to lose weight in the past and keep it off for a long time.”
“You already know a lot about what works for you.”
If you hear more confident statements, you are likely affirming appropriately.
At some point, ask the confidence scaling question again to assess the change in confidence level.
Your affirmation statements should be honest, and you should be genuine. Fake statements and artificial attitudes will erode momentum.
Summarize Strategically
A summary is a collection of reflections. You can summarize selectively and become directive. You can decide to summarize only change talk while ignoring sustain talk. This focuses your client’s attention in the direction of change, resolves ambivalence, and accelerates motivation.
If ambivalence hasn’t been examined sufficiently, you might get arguments for the status quo with summaries rather than change talk. Summarizing arguments for change without acknowledging voiced difficulties will result in “yes, but …”s.
Becoming directive too early will give you sustain talk, and you need to go back and explore the ambivalence some more.
Handling Resistance
Resistance is the flip side of motivation. As one increases, the other decreases.
Roadblocks and advocacy responses will increase a person’s resistance to change. Maintaining the spirit of MI and using OARS skillfully can reduce a person’s resistance.
Recognize increasing motivation in your clients as well as increasing resistance to inform your actions in the session.
The righting reflex may compel you to offer a solution in the form of advice prematurely and in a non-MI coherent manner, producing resistance in your client. This can result in feelings of insecurity, incompetence, frustration, hopelessness, stress, and burnout for you.
Resistance signals that we are moving too fast or the timing is off.
Take a breath and go back to the basics of MI.
Convey the Spirit of MI by remaining warm, caring, concerned, and curious about your client. Do not argue or meet resistance with any of the roadblocks or advocacy responses. Do not try to persuade with logic or argue for your point of view.
Reengage your reflective listening. Reflecting back the resistance you hear tends to lower the resistance.
Acknowledge your client’s autonomy.
“Many people in your life would like to see you change your behavior, but you are the only one who can make a change. It is up to you and nobody else to decide what is right for you.”
Shift focus.
“Since it sounds like you are here just because your parents sent you here, and you aren’t interested in talking about your drug use, what would you like to talk about? What would be useful for you?”
Giving Advice and Information
Often, clients know what to do to reach the desired goal. Once their ambivalence is resolved, they can move on and be successful. Some clients may not have the solution to their problems and may need some information or advice.
Advice-giving can be a roadblock, sometimes increasing resistance to change.
To provide necessary advice or information in the MI way, ensure that the client is asking for advice or has come to some impasse and lack of knowledge, without which she cannot continue to pursue her goal.
Resist the urge to engage in the righting reflex. Timing is crucial. If you are getting resistance, back off.
Keep in mind the Spirit of MI, of collaboration, evocation, and autonomy, and the respect you hold for your client. Ask permission first.
“Can I tell you what other clients have done in similar situations?”
“Would you be willing to hear my take on what you might do next?”
“Would it be OK for me to give you some advice at this point?”
Act 3: Commitment
Maintain the Spirit of MI and have a great deal of respect for your client.
Make your client comfortable coming in to see you.
Use reflections and open questions, affirmations, and summaries to get some information, establish rapport, and express empathy.
Together, settle on a target behavior.
Assess your client’s readiness to change by asking scaling questions about importance and confidence.
In your follow-up questions to the scaling questions, you start to get some change talk.
You recognize your client hasn’t changed her behavior because she is ambivalent.
Explore both sides of ambivalence by using a decisional balance worksheet and skillful double-sided reflections.
You have some ideas about what the client could do to solve her problem and prematurely present them to her. You notice her resistant response, so you back off and go back to exploring the client’s concerns using your OARS skills and employing several specific techniques to elicit change talk.
Pay close attention to your client’s speech, focus mostly on change talk and less on sustain talk, notice your client arguing for change herself.
Your client seems ready to commit to a change plan. So, what’s your next step?
Summary and Key Questions
Summarize all the change talk you’ve heard up to this point and then ask a key question to move the client into the commitment phase.
“What is your next step?”
“Where does this all leave you?”
“What are you willing to do about (this)?”
“What are your options at this point?”
“Where do you see yourself going from here?”
“How are you going to do it?”
Change Plan
Follow up with reflective listening to the answer to work out a change plan.
The commitment to a change plan completes the formal cycle of motivational interviewing.
A change plan consists of setting and clarifying goals, arriving at a plan, and eliciting commitment.
Make the goal as clear as possible. If there are multiple goals, work with the client to prioritize them. Be SMART with the goal:
Specific. What exactly does your client want to do?
Measurable. What are the specific methods for knowing whether or not the goal has been achieved or progress is being made? Build in measures of intermediate success to gauge progress.
Attainable. The goal should be something your client can accomplish. If a goal is too far out of reach, it is unlikely that your client will commit to it long enough to see some progress. Goals need to be challenging but achievable. Negotiate a short-term attainable goal rather than something too large and overwhelming.
Realistic. Make the goal doable based on where your client is currently. It may be better to achieve a smaller goal first, build on the success, and set another goal later.
Timely. Set a timeframe for accomplishing the goal and provide a clear target to aim for.
Ask for a clear commitment statement from your client of agreement to the change plan.
“Is this what you want to do?”
If the answer is an enthusiastic “Yes!” you’ve done your job. If, instead, you hear a less enthusiastic response, “Let me think about it,” or “I’ll try,” explore the client’s reluctance.
End the session by expressing appreciation to your client. Acknowledge your client’s hard work, express optimism and hope, and encourage your client to pursue her goals.
“Thank you for coming in today and working so hard on achieving your goals. This has been a really good session and we got a lot accomplished. You’ve put together a good plan to change your behavior and I think you can be successful and live a healthier life based on the decisions you’ve made today. You want to change and have many good reasons to do so. Keeping these in mind will help you stay motivated when things get tough. I’ll be available should you need anything else. Meanwhile, good luck to you. Is there anything you’d like to ask before we end?”
Checklist: Ending the Session
Summarize the change talk and ask a key question.
Negotiate a change plan.
Use SMART goal setting or a similar approach to clarify goals.
Ask for a commitment to the change plan.
End the session by expressing confidence and appreciation.