Discussion - Application Using Motivational Interviewing Concepts

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CHAPTER 15

Practicing Well

Out of clutter, find simplicity. From discord, find harmony. In the middle of difficulty lies opportunity.

—Albert Einstein

In this closing chapter of Part III we step back from the complexity of details to reflect on and integrate what has gone before. In particular, we

will reflect on the practice of MI from three perspectives: you as the helper, the person whom you are seeking to help, and your working relationship. This is a big picture view of MI, similar to where we began with the spirit of MI in Chapter 1, but now with the benefit of having much more how- to detail on the tasks of MI, all of which happen within the context of a person-to- person relationship. After discussing good practice of MI from these three perspectives, we will conclude with a real-life case story of tem- porarily stepping into the role of a helper for a friend.

The Helper

When you embody the role of a helper, you do not become a different per- son. It is not like putting on a mask or a disguise. You are still your imper- fect self, complete with your own foibles, biases, and vulnerabilities, who is accepting the temporary role and responsibility of a guide on a journey with another real and imperfect human being.

Lay Down the Burden

Guiding is effortful and demanding. A therapist, coach, teacher, or social worker practicing MI may appear to be quite relaxed, but underneath work

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is going on, much like a duck or swan whose course appears smooth while beneath the surface is doing a lot of paddling to stay on course or to push against the currents. You are continually conscious of your client’s experi- ence, your own internal state, and the well-being of your relationship. In itself that is a lot to monitor.

Now add to that the element of responsibility. The person you are helping could benefit from a change. You are conscious that what you do may help the person make the change or could get in the way. The research on that point is clear: what you say and do in these moments together does matter.

There is, however, one burden that you need not carry. It is not your role to make people change or grow. Indeed, you cannot make others’ choices for them. Some professional roles may seem to carry this charge. A judge or probation officer must make supervisees obey the law. A teacher must make students learn and grow. A nurse or physician must make patients do what they need to do to be well. Textbook writers must make their readers practice well. Yet short of extreme coercive tactics, it is impos- sible to make someone else do something. If you go to work thinking that your job is to make people change, you are likely to return home at the end of the day feeling frustrated and defeated. “I am doing my best, and still

they don’t change.” Carrying that assumption and onus is a recipe for burnout.

Helping professionals who have learned MI often tell us that it lifted a heavy burden from their shoulders. They find their work

more enjoyable and at the same time more effective. Several early studies indicate that the practice of MI can help prevent professional burnout.1 Much of this preventive effect seems to stem from a change in mindset and, consequently, in practice. When your intent is to cause (force, confront, manipulate, outsmart) people to change, they sense it and are likely to resist.2 You can invite and make it more possible for someone to change by providing optimal conditions that favor it, but you cannot make it hap- pen.3

Focus on the Present

MI involves conscious, close attention to what is happening in the present moment without imposing judgment, not unlike the practice of mindful- ness.4 In practicing MI well, it helps to have an uncluttered mind. A beginner’s mind of curi- osity displaces the distractions of inner states such as frustration and impatience, and at least for the time being sets aside fact- gathering and diagnosis. Undivided attention is devoted to

It is not your role to make people change.

A beginner’s mind helps you temporarily set

aside fact gathering.

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Practicing well 255

the person you mean to help. As in mindfulness meditation, paying atten- tion in this way is an ongoing discipline. Distractions may intrude, but you bring your full attention back to the person before you. This task requires some self- regulation of your internal states and competing agenda.

Eyes on the Horizon

At the same time, when practicing MI well, you also keep in focus the horizon of change and growth toward which you are moving. The horizon emerges and sometimes changes through the focusing task of clarifying shared goals. Where are we going? As you approach one horizon, a more distant vista may emerge. Your client may well be distracted by more imme- diate issues and concerns, and you do attend to those as well, but part of your job as a guide is to remember and keep moving toward the agreed- upon horizon. MI adds to a person- centered approach this consciousness of focus and direction, where the present moment is heading.

The Person

When you lay down the burden of having to fix or change someone, you enter into a collaborative relationship with another resourceful human being who, like yourself, has hopes, strengths, and wisdom. To you they are not a diagnosis, a label, a disorder, or a problem to be solved. Knowing so much about themselves, they are partners in the quest for change and growth.

People’s hopes find expression in both change talk and sustain talk— what they do (and don’t) want and need, and what they are (or aren’t) able, willing, and ready to do. You need to know what motivates the people whom you seek to help. Sometimes your best work is mostly a matter of getting out of their way as they discover where they want to go and how to get there. You evoke, mirror, and clarify their change talk.

Something else that you need to know about people you intend to help is their strengths, what they can do, have done, and are able to do. Change and growth require a person’s active participation. You may recommend or inspire, but the doing of change is the person’s own responsibility. The more you understand someone’s strengths, the better able you are to see how change can fit into those capabilities.

To tap people’s own wisdom about themselves, you ask their opinion. There is a temptation for helpers to become wisdom dispensers, and sharing your acumen can be part of your role, but understanding can- not be pushed in. That door opens from the

Sometimes your best work is a matter of getting out of a person’s way.

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inside. Act out of curiosity for how this person thinks about the problem and the need to change. Interacting out of this curiosity, you are showing interest in the individual as a person, giving paramount attention to their well-being.

The Relationship

When practicing MI, you enter into a helping relationship with one or more people at a time. Above and beyond the individuals’ contributions, the quality of this working alliance foreshadows outcomes in health care, education, and psychotherapy.5 There is good reason, then, to attend to the quality of your relationship with those you intend to help.

In MI there are some defining qualities of this working alliance. One is compassion—giving top priority to the other person’s well-being and best interests. We include compassion as part of the spirit of MI because we recognize that some of the same influence techniques can be used in either benign or self- serving ways.6 As a quality of relationship in MI, compassion is not a feeling so much as a benevolent intention and commitment to foster the other’s well-being.

The helping relationship of MI also honors the person’s autonomy and self- determination.7 Even if you have some decisional power, as is the case for a teacher, probation officer, or employer, you still recognize and honor the person’s volitional choice. Like shared decision making in health care, MI accepts people’s decisions about their own welfare.8 It begins by recog- nizing and overtly acknowledging the person’s independence.9 MI includes specific ways of seeking collaboration that explicitly share power, ask permission, seek consensus, acknowledge the person’s own expertise, and emphasize choice.

An MI relationship is also not about doing something to or on people, but rather for and with them. It is not about fixing people. You can offer professional expertise as appropriate, but when it comes to people’s change and growth, they are in the driver’s seat. You cannot make people change or grow, although you can invite and facilitate it.

Relatedly, the helping relationship in MI is neither defensive nor adver- sarial. Your workdays are likely to be unhappy if you think of your job as trying to overcome or outsmart those you serve. As we said in Chapter 1, MI is like dancing together, not wrestling. If the going seems rough, listen harder. If you’re unsure how your relationship is going, ask! An evidence- based trend in counseling and psychotherapy is to ask for clients’ feedback after every session. Obtaining such regular feedback and making course corrections in response to it have been shown to substantially improve treatment outcomes.10

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Practicing well 257

Can We Chat? An In-Depth Example with Commentary

A good friend asked one of us (Steve) to chat with her partner, who had been struggling with some personal emotional issues. Could I aid him in considering what kind of professional help he might seek? I offered to do so as friend to friend, and we found a private space to talk in the back corner of a coffee shop. As with other examples, his name and personal details have been changed to protect anonymity.

The coffee arrives and Jim comes straight out with it. He had been severely physically abused as a child, was removed from the home, and was taken into foster care. Many troubles followed. He did poorly at school, and though his foster parents had been supportive, he felt anxious, alone, and friendless most of the time. Now as an adult he still feels “very vulner- able.” Anxiety and despair come in waves that can last for weeks, to the extent that at times he feels suicidal.

Bill Commenting on the Helping Relationship

“Jim jumps right in the deep end, sharing painful facts of his history and his continued suffering. He lays his life open, willing to be vulner- able and trust Steve. He is perhaps anxiously wondering how Steve will respond to all this. Is there some help for him? There is the uncertainty of newness. What will this person think of me? Who is in charge here? Is this person trustworthy? Where is this conversation going?”

Steve Commenting on Himself

“Within 2 or 3 minutes I notice feeling the emotional weight. So many problems, one after another, and my mind is racing through possible diagnoses and remembering procedures for assessing suicide risk. I realize I am just going through the motions of listening, wondering where this conversation would end. I have heard plenty of this kind of stuff before. Now here is another story of terrible abuse and more. I have the impression that Jim is also going through the motions, follow- ing some kind of prepared script, listing his problems perhaps because ‘that’s what you do when you talk to a psychologist.’ It was as if both of us were on automatic pilot. Time to change tack, but how?”

STEVE: (after a few minutes of conversation) Jim, can we just pause for a moment here?

JIM: Oh, OK.

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STEVE: You are telling me about all these difficulties, and yet I know from your partner that you are a very capable and respected person at work, and are also loved and highly valued at home. You must be doing something right!

JIM: (laughing warmly) Thanks for that. Yes, it’s true. I’ve learned a thing or two about life, if you know what I mean.

STEVE: Tell me.

JIM: For a start, I learned not to blame myself for the abuse.

STEVE: That’s a victory of sorts, I guess.

JIM: More like a marathon to be honest. It took me ages to accept my lot and not blame myself, and that has helped a lot. At least I stopped bringing myself down like that. It was sort of like a habit I had gotten into, and it was hard to break.

STEVE: It’s taken courage and more.

JIM: Effort. I learned to let go of that blame game, and so it makes it easier to forget and get on with life, but I still get this feeling of being very vulnerable, exposed. Sometimes I can’t stop it from spiraling down and—this is frightening—I even want to take my own life. I never will, but the thoughts are hard to get rid of.

Steve on Himself

“After that initial shower of problem talk and noticing how heavy I was feeling, it was like a switch flipped in my head and I put on my ‘strengths lenses.’ Problems occur in the context of an ongoing life full of experience and strengths. I happened to know from his part- ner some of his positive experiences, and I pointed these out to him. Immediately, the engagement seemed to feel a whole lot deeper and our relationship more balanced. And now I know a bit more about his hopes—not to spiral down and feel so helpless. A focus is emerging.”

Bill on the Helping Relationship

“Even as a friend, there could be a temptation here to become what Steve calls a ‘deficit detective,’ discovering and exploring the very real catacombs of misery. Continuing to listen empathically is compassion- ate in one sense, but likely to leave Jim feeling more dismal and out of balance. Steve noticed this in Jim’s demeanor and in how he was feeling himself. How to restore some balance? Steve is also keeping his eyes on the horizon here, on the purpose of their conversation. His task is not to become Jim’s therapist, but rather to help him find a way forward, including any professional help from which he could benefit.”

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Practicing well 259

“How did Steve know what to say? He was paying close attention not only to Jim’s expression in the moment but to his own internal reactions. With experience, Steve has also learned the values of those ‘strengths glasses,’ to look for what is resilient and capable in a per- son to counterbalance the challenges. This is of value not only to the person being helped, but to helpers as well. Seeing only problems and deficiencies can predispose you to burnout. Looking for and finding positive qualities and accomplishments also offers you a means of get- ting a fuller understanding of people.”

STEVE: So here we are chatting away and you must be wondering how to not spiral down and feel so vulnerable.

JIM: That’s right. That’s what I’m looking for.

STEVE: And you’re wondering if a counselor or therapist might help you with that.

JIM: Yes, if I can learn to break that downward spiral, I wouldn’t need to feel so bad for weeks and weeks at a time. I notice that when I stop smoking it gets worse, and then I feel desperate for any drug that will give me release. Well, not just any drug (he laughs) but you know what I mean. It’s like a medicine that would let me get on with my life.

STEVE: So you did stop blaming yourself, and now you would like to find a way to keep from spiraling down.

JIM: Yeah, I want to work on that. Do you know a good therapist?

STEVE: I might be able to help yes, but can I first ask you, do you have any other questions or concerns?

JIM: Well yes, do you think I need to go back and examine the trauma with my Dad? I don’t mind, but I don’t want to just suffer going through this again if it’s not going to help, if you know what I mean.

STEVE: I am honestly not sure. I’m not experienced enough with trauma to feel confident to answer this, but I understand that you don’t want to suffer unnecessarily.

JIM: That’s right. I looked on the web and just got confused. It was so hard to work out what has good evidence behind it, and there’s all these fancy terms for different therapies. I had this appointment with a therapist two days ago in a trauma clinic place and she was fine, and suggested mindfulness but this just seemed like fluffy stuff to me.

STEVE: It somehow didn’t feel right for you.

JIM: She was OK, but she sort of flipped over this and that topic. She gave me a depression scale, and I came out at the low end as moderately depressed. That was helpful and a bit of a relief. I was not as bad as I thought I might be. But the fluffy stuff is what I don’t want.

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Steve on Himself

“At this point I am wondering, ‘What does he want from a therapist?’ I am putting the answers on little pegs in the back of my mind. To stop the downward spirals, yes. Perhaps to reexamine his history of trauma, but only if that would be helpful. What else, I wonder. It would be easy to close this down now, but my instinct is to slow down and listen some more.”

Bill on the Helping Relationship

“The primary feeling of their relationship at this point is collaborative. Jim began describing problems; now they are sorting out together how best to move forward. They are partners discussing the how possibili- ties of change. It happened relatively quickly. Steve first evoked some counterbalancing strengths and then invited some planning discussion without prescribing a plan himself.”

STEVE: I’m wondering how you feel about this trauma clinic experience.

JIM: Well, I’ll go back for another session, but somehow this did not feel like the answer.

STEVE: Something was missing.

JIM: Well, we danced around this and that topic, and maybe good things will come out of it eventually. I’ll go to one more appointment, and then I might stop. I never really took to the fluffy mindfulness sugges- tion, like it was the answer to all my prayers.

STEVE: It seems to you that she didn’t really understand what you need.

JIM: Something like that. I felt like I was just another patient going through the motions with her.

STEVE: And what you want help with is the spiraling down. You are willing to consider re- examining the trauma you experienced, and also you want to see someone who really cares about you.

JIM: That’s it.

STEVE: OK, so would it help if I made some calls, and then we can meet again to chat about the options?

JIM: Definitely, I would like that, thanks.

MI is not specific to a particular kind of helping relationship or context. In this example, it is being practiced friend-to- friend, but it could equally have occurred in a pastor’s office or an employee assistance program. The two people in this exchange did have different roles, as is characteristic of MI. One was in a helper role, the other had requested assistance. Steve was

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Practicing well 261

working hard to gain a beginning understanding of Jim’s perspective and hopes, and to consider how to help. There are also some hallmarks here of well- practiced MI. Jim talked more than Steve did, and it flowed as a con- versation rather than a question-and- answer session. In addition to affirma- tions, Steve voiced twice as many reflections as questions, and he offered (with permission) some expertise.

Again, we emphasize that MI is not something you do instead of or in addition to what else you do. Rather, it is a way of doing what else you do—in this particular case, having a helpful conversation with a friend. MI doesn’t have to take a long time. Busy health care workers sometimes worry that “I don’t have time for this,” but actually MI can save time. Empathic listening moves the conversation along and may yield more information than you would gain with a series of specific questions. MI is purposeful, and a lot can hap- pen within a relatively short time while strength- ening rather than sacrificing relationship.

From your perspective as a helper, perhaps the most persuasive reason to learn and practice MI well (beyond the evidence-based benefits to clients) is its impact on your own happiness in life and work. Not everyone finds this to be so; MI is not for everyone. If you have read this far, however, chances are that you find some positive resonance of MI for yourself. There is inherent satisfaction in bringing a calm, curious mind and a compassionate heart to your work and to those whom you serve, in being a healing presence amid a traumatizing world. Instead of trying to make change happen and fix people, there is a joy of witnessing them choose and pursue change and growth for their own rea- sons. In this way, developing skillfulness in MI is not only a boon to the people you help, but to yourself as well.

So how do people learn MI? That is the topic to which we now turn in Part IV. There is already extensive research on how to help your- self or others practice MI well, and there is no single prescribed formula. People learn MI in different ways and at various paces. The task really is to find what is the best way for you to learn it.

PERSON A L PERSPEC T IV E : A Soccer Story

Fluid conversations about change occur naturally and can be boosted by knowing and practicing MI. One sports coach I mentored had the

Empathic listening may yield more information

than a series of questions would.

Developing skillfulness in MI is not only a boon to the people you help, but to yourself as well.

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idea of transforming half-time team talks such that the players them- selves would say how they might improve in the second half. This idea was nicely compatible with the spirit and practice of MI. Instead of players being told what to do, could they improve their game through constructive conversation? She explained this challenge to her team, and they started trying this on practice days. She would pose a ques- tion, and the players took turns answering it, listening without inter- ruption to each other’s replies. Then she would summarize key mes- sages in what the players offered and might pose a further question. The team became so good at this that on game days they had a new routine. Instead of being ordered or scolded during huddles or at half time, the players were offering their own ideas about what to do. The coach also noticed a difference: after the huddle or half time, the play- ers actually did what they had decided. In time, the senior players were able to generate the questions and to summarize the key messages themselves. There is no way to know whether this change in half-time communication was responsible, but they also started winning more of their games.

—Steve

K E Y C O N C E P T S

• Beginner’s mind • Seeking collaboration

K E Y P O I N T S

• In the role of a helper-guide you do not become a different person. You are still yourself.

• In MI, you invite change and make it more possible. • Part of a guide’s task is to keep an eye on the horizon. • MI is a way of doing what else you do.

Notes and References

1. Endrejat, P. C., & Kauffeld, S. (2021). Learning motivational interviewing: pros- pects to preserve practitioners’ well-being. International Journal of Workplace Health Management, 14(1), 1–11.

Norman, Å., Lundberg, U., Farbring, C. Å., Källmén, H., & Forsberg, L. (2020). The feasibility and potential of training correctional officers in flexible styles of com- munication to reduce burnout: A multiple baseline trial in real-life settings. Scandi- navian Journal of Work and Organizational Psychology, 5(1), Article 12.

Ogunmilugba, B. J. (2021). Effects of motivational interviewing and mindfulness

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based cognitive therapies on academic burnout among extra-mural students in Ekiti state, Nigeria. Dissertation, University of Ibadan, Nigeria.

Pollak, K. I., Nagy, P., Bigger, J., Bilheimer, A., Lyna, P., Gao, X., et al. (2016). Effect of teaching motivational interviewing via communication coaching on clini- cian and patient satisfaction in primary care and pediatric obesity- focused offices. Patient Education and Counseling, 99(2), 300–303.

2. Brehm, S. S., & Brehm, J. W. (1981). Psychological reactance: A theory of freedom and control. Academic Press.

de Almeida Neto, A. C. (2017). Understanding motivational interviewing: An evolutionary perspective. Evolutionary Psychological Science, 3(4), 379–389.

3. Rogers, C. R. (1980). A way of being. Houghton Mifflin. 4. Davis, D.  M., & Hayes, J.  A. (2011). What are the benefits of mindfulness? A

practice review of psychotherapy- related research. Psychotherapy, 48(2), 198–208. Thich Nhat Hanh. (2015). The miracle of mindfulness: An introduction to the

practice of meditation (Mobi Ho, Trans.). Beacon Press. 5. Fuertes, J. N., Mislowack, A., Bennett, J., Paul, L., Gilbert, T. C., Fontan, G., &

Boylan, L. S. (2007). The physician- patient working alliance. Patient Education and Counseling, 66(1), 29–36.

Haug, T., Nordgreen, T., Öst, L.-G., Tangen, T., Kvale, G., Hovland, O. J., et al. (2016). Working alliance and competence as predictors of outcome in cogni- tive behavioral therapy for social anxiety and panic disorder in adults. Behaviour Research and Therapy, 77, 40–51.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta- analysis. Journal of Counseling Psychol- ogy, 38(2), 139–149.

Lacrose, S., Chaloux, N., Monaghan, D., & Tarabulsy, G. M. (2010). Working alliance as a moderator of the impact of mentoring relationships among academi- cally at-risk students. Journal of Applied Social Psychology, 40(10), 2656–2686.

6. Cialdini, R. B. (2021). Influence: The psychology of persuasion (rev. ed.). Harper Collins.

7. Markland, D., Ryan, R. M., Tobin, V., & Rollnick, S. (2005). Motivational inter- viewing and self- determination theory. Journal of Social and Clinical Psychology, 24, 811–831.

Ryan, R. M., & Deci, E. L. (2017). Self- determination theory: Basic psycho- logical needs in motivation, development, and wellness. Guilford Press.

Vansteenkiste, M., & Sheldon, K. M. (2006). There’s nothing more practical than a good theory: Integrating motivational interviewing and self- determination theory. British Journal of Clinical Psychology, 45(1), 63–82.

8. Barry, M. J., & Edgman- Levitan, S. (2012). Shared decision making— Pinnacle of patient- centered care. New England Journal of Medicine, 366(9), 780–781.

Elwyn, G., & Frosch, D. L. (2016). Shared decision making and motivational interviewing: Achieving patient- centered care across the spectrum of health care problems. Annals of Family Medicine, 12(3), 270–275.

9. de Almeida Neto, A. C. (2017). Understanding motivational interviewing: An evo- lutionary perspective. Evolutionary Psychological Science, 3(4), 379–389.

10. Miller, S. D., Bargmann, S., Chow, D., Seidel, J., & Maeschalck, C. (2016). Feed- back Informed Treatment (FIT): Improving the outcome of psychotherapy one per- son at a time. In W. O’Donohue & A. Maragakis (Eds.), Quality improvement in behavioral health (pp. 247–262). Springer.

Miller, S. D., Duncan, B. L., Brown, J., Sorrell, R., & Chalk, M. B. (2006). Using formal client feedback to improve retention and outcome: Making ongoing, real-time assessment feasible. Journal of Brief Therapy, 5(1), 5–22.

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Miller, W. R., & Rollnick, S. (2023). Motivational interviewing : Helping people change and grow. Guilford Publications. Created from liberty on 2026-03-02 04:55:49.

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