Addictions Case Study Part 1 Case Conceptualization

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CHAPTER 6

Evoking “Why Would You Go There?”

Authentic mirroring can only call forth what is already there.

—Richard Rohr

Energy follows attention. Wherever you place your attention, that is where the energy of the system will go.

—C. Otto Scharmer

Evoking literally means calling forth what is already present. Rather than trying to install motivation in people, MI invites them to give voice to

their own reasons and resources for change. People are usually more con- vinced by what they know and care about than by what you want for them. Motivations are already there to evoke. The evoking aspect of MI is a pri- mary vehicle for empowerment.

Sometimes ambivalence gets a bad name. The word can sound like indecisiveness, paralysis, or vacillation. Actually, as discussed in Chap- ter 2, ambivalence is one step in the direction of change. It is normal to think of both pros and cons when faced with a potentially better way of doing things, to want it and not want it simultaneously.1 Ambivalence thus includes some motivation for change and thereby represents progress beyond seeing absolutely no reason or value in it. When someone is ambiva- lent, a decisional balance is already in motion. One side of the balance is weighted by arguments favoring the status quo; the other side contains weights favoring change. The current balance of these pros and cons is one indication of a person’s readiness for change,2 and it predicts whether change is likely to happen.3 This pro/con balance also clearly responds to MI skills.4 It is something that you can influence.

Miller, William R., and Stephen Rollnick. Motivational Interviewing : Helping People Change and Grow, Guilford Publications, 2023. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/liberty/detail.action?docID=30602044. Created from liberty on 2026-02-02 05:42:43.

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Evoking the Why

Once you have a what—a change topic or focus (Chapter 5)—two major questions seem to arise: why and how, both of which influence whether someone will decide to proceed. This chapter considers the why, or the perceived importance of taking action. Remember that in focusing, the metaphoric question is “Where are we going?” In the evoking task, the underlying question is, “Why would you go there?” This “why” can take many forms:

• “Why do you want to do this?” • “How much does it matter to you?” • “What reasons are there for you to do it?” • “How important or necessary is it?”

Usually, people don’t begin considering how to do something unless they want, need, or see good reasons to do it. As the decisional balance tips toward the pros, the importance of change, then thoughts turn to how it might happen—which will be the subject of Chapter 7 on the planning task in MI.

Although people usually do consider the why before the how of change, there are exceptions. Sometimes they need to see that there is a how, a way, before they are even willing to consider the why. It’s no gift to dwell on an urgent need for change if there seems to be no hope to accomplish it. When people are unsure of possibility, they may raise how questions early in con- versations about change, well before answering the why.

The Language of Change

A first step in developing evoking skills is to learn what change sounds like as it is emerging. You already know a fair amount about this just by virtue of living around other people. When you ask someone to do something, you watch and listen carefully to what they say in response. You do that because the words in responding to your request contain important information about whether the person is going to do what you have asked. Suppose you plan to move to a new place to live and you ask friends or family to help you pack up and move your furniture and belongings. What might each of these responses tell you about whether you’ll get their help? For each response, does it sound more or less likely that the speaker will help you?5

• “I’d enjoy helping you.” • “I could help you.” • “I can help you.”

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Evoking: “why would You go There?” 85

• “You really need my help.” • “I wish I could help.” • “I’m willing to consider it.” • “I’ve already helped you move twice before.” • “Don’t count on me.” • “I’ll be there Friday morning.”

Each statement says something different about the person’s motivation and intention. Consciously or not, you pay close attention to these nuances of language.

In 40 years of MI research, we have learned much about the language of change.6 When speaking, people can literally talk themselves into (or out of) doing things. You can see the beginnings of this process happening in the examples above. As mentioned in Chapter 2, change talk is anything people say that tends to move them toward taking a particular action. To help attune your ear to change talk, here are some examples of seven dif- ferent kinds.

Preparatory Change Talk

The first four types we call preparatory change talk because you hear them when people are considering whether to do something. The four types reflect a person’s desire, ability, reasons, or need for the change. To help remember them, we use the acronym DARN.

desire

Desire is a universal human experience.7 Every language on earth has desire language—a way of saying, “I want.” Babies quickly learn how to sig- nal their desires even before they develop speech. Some examples of desire words about change are want, wish, like, and love, and you hear them in conversations about change.

• “I would love to lose some weight.” • “I wish I could quit smoking.” • “I want to be a kinder person.” • “I would enjoy traveling more.”

Desire language signals some inclination toward action.

ability

Unlike desire, ability language provides information about how confident people are that they would be able to take the action in question. Some

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ability words that you might hear in a conversation about change are can, could, able, and possible.

• “I can meet you there at 10:00.” • “I think I could be a good teacher.” • “I am able to do that for you.” • “Could I find a better job? Possibly.”

Consider that the statement, “I’ll try,” implies a desire to do some- thing, along with some doubt about the ability to do it.

reasons

A third kind of preparatory change talk states specific reasons for doing something. Reason language has an if–then quality. The reason might be a possible advantage of change or a disadvantage of not changing.

• “If I don’t start saving some money, I’ll never be able to afford a place of my own.”

• “I think I’d sleep better at night if I cut down on caffeine.” • “My family is counting on me to put food on the table.” • “Getting more exercise would help me stay healthy.”

need

Need language has an imperative quality emphasizing some urgency of change. Need statements imply that a change is important without specify- ing why (otherwise it would be a reason). Some common forms are:

• “I have to . . .” • “I need to . . .” • “I really must . . .” • “I’ve got to . . .”

A person might say, “I just can’t keep on like this,” or “Something has got to change.” That is need talk.

Mobilizing Change Talk

Three other types of change talk are things you hear as people are getting closer to actually changing. Mobilizing change talk tends to get people moving. For these three kinds of change talk, we use the acronym CATs: commitment, activation, and taking steps. As discussed below, the same

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Evoking: “why would You go There?” 87

kinds of speech (CATs) can also occur as sustain talk where its effect is immobilizing— increasing commitment to the status quo.

Commitment

To say that you want to, could, have good reasons to, or need to do some- thing is not to say that you are actually going to do it. Commitment lan- guage offers an assurance that it will happen. It is how we make promises to or contracts with each other. Perhaps the clearest and simplest commit- ment statement is “I will.” More emphatic versions include “I promise,” “I guarantee,” “I swear,” or “I give you my word.”

activation

In activation language, you hear people leaning toward action. They haven’t quite decided or committed to doing it, but they are almost there. Here are some examples:

• “I’m willing to.” • “I would consider it.” • “I’m thinking about it.”

These signal an openness but not quite a decision to do something. They are unsatisfactory answers to questions asking for a commitment, as in making wedding vows or responding to, “Will you tell the truth, the whole truth, and nothing but the truth?” When you are hearing activation language in everyday conversation, a natural next step is to ask for more specifics: When will you do it? What exactly are you prepared to do?

Taking Steps

As we were studying counseling sessions, we noticed another kind of change talk that didn’t fit into any of the preceding categories and yet sig- naled movement toward change. Taking-steps language is a form of speech indicating that the person has already taken some action in the direction of change.

• “I bought a pair of running shoes so I can exercise.” • “I filled that prescription yesterday.” • “I called three places about possible jobs today.”

Pay attention to any and all change talk that you hear. You might think that unless you hear commitment language a person will not change.

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Yet while stated intention to change is good,8 most research shows that all kinds of change talk favor subsequent change.9

Sustain Talk

Ambivalence is an inner debate between the arguments for and against change. Just as there is language supporting change there is also opposite speech that favors the status quo. As discussed in Chapter 2, we call the latter sustain talk, sometimes also termed counterchange talk.10 All seven types of change talk have a corresponding form of sustain talk expressing reasons not to change. Rather than repeating the DARN CATs for sustain talk, we will just offer you examples of each type. Like change talk, sustain talk is always in reference to a particular change. Suppose the topic is quit- ting tobacco.

Change talk Sustain talk

Desire “I want to quit smoking.”

“I really enjoy smoking.”

Ability “I think it’s possible for me to quit.”

“I don’t think I could stand the withdrawal.”

Reasons “My children are begging me to quit.”

“It’s the only way I have to relax.”

Need “I’ve got to quit smoking.”

“I need to be able to smoke.”

Activation “I’m willing to give it another try.”

“I plan to keep on smoking.”

Commitment “I’m going to quit.” “I have decided to keep on smoking.”

Taking steps “I bought some nicotine gum today.”

“I bought two cartons of cigarettes today.”

Read only the above change talk statements together (the left-hand col- umn) to get a sense of strong motivation to quit. Then read all the sustain talk statements together (right-side column) and you get a sense of strong motivation to continue smoking. Ambivalence involves a mixture of pros and cons— simultaneous conflicting motives. When someone is ambivalent, change and sustain talk often come tangled together in the same sentence, a classic example of mixed motives:

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Evoking: “why would You go There?” 89

• “I wish I could quit smoking, but I don’t think I can.” • “I’d like to go out with you, although I really need to stay home and

study for a test.” • “My parents would like me to become a lawyer, but I want to be an

artist.”

The balance between change talk and sustain talk in what people say is a pretty good predictor of whether change is going to happen. Perfect ambivalence is an equal counterbalancing ratio of 50% change talk and 50% sustain talk. The more sustain talk you hear, the less likely it is that

change will happen. The more change talk (and less sustain talk) you hear, the more likely it is to occur.

We suspect you already knew that, although you probably hadn’t thought about seven different kinds of change talk. Con- scious of it or not, you probably listen for

this decisional balance between change talk and sustain talk when you want to predict whether a person is going to do something. In fact, the ratio of change talk to sustain talk does predict how likely change is to happen.11 It’s common sense: people who sound more motivated for change are more likely to do it and succeed.

Furthermore, MI research revealed another important piece of the puzzle: that it is possible to influence that balance of change talk and sus- tain talk. Using the evoking skills of MI, interviewers can significantly increase the ratio of change talk to sustain talk,12 which in turn enhances the likelihood that change will occur.13 How does that happen?

The Evoking Task

The evoking of change talk involves three key skills: attending, inviting, and strengthening. First, you pay particular attention to the language of change so that when you hear change talk you recognize it as something important. Second, instead of simply waiting for change talk to happen spontaneously, you invite the person to offer more of it. Third, when you do hear change talk, you respond to it in particular ways in order to strengthen it. You are essentially helping people talk themselves into change.

Attending to Change Talk

Change talk reveals a person’s own meaningful motivations for change. You don’t need to plant or install it; rather you discover it. It’s already

For an ambivalent person, change and sustain talk come tangled together.

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there. When ambivalent people speak, they naturally express both change talk and sustain talk. Even without doing anything else, if you engage and listen well (Chapter 4) with a person who is ambivalent, you will hear some change talk. The key is to pay attention so that when you do hear it, you don’t miss it. Each bit of change talk is like a flower that you collect and hold. Remember the change talk you hear because you will need it later.

Sometimes there is change talk just beneath the surface of what you hear. We liken such comments to glowing embers or coals. If you breathe on them a bit, they may start to flame. We’ll come back to this issue when we discuss how to strengthen change talk.

When we hear the practice sessions of those who are learning MI skills, we are often struck by missed opportunities. There were change talk flowers right there to be picked or glowing coals just waiting to burst into flame, yet the interviewer passed right by them as though not even noticing them. Perhaps the interviewer was on a mission to gather information or was pursuing a certain idea about what was causing the person’s concerns. As in musical training, there is a certain ear training in MI so that you can notice what is happening. And bear in mind that what counts as change talk is specific to a particular goal or focus (Chapter 5). If you are focusing on alcohol use, these are examples of possible change talk.

• “I have to do something about my drinking.” (Need) • “It would be nice to wake up clear- headed in the morning.” (Reason) • “I think I could actually quit completely.” (Ability) • “I want to try cutting down on my drinking.” (Desire)

If a person who was referred to you to talk about drinking says, “I think my real problem is smoking,” that would count as change talk about smoking but not about drinking. Listen carefully.

Inviting Change Talk

You don’t need to wait for change talk to happen. There are particular things you can do that invite people to express it.

directional Questions

In essence, your task in MI is to evoke and strengthen the person’s own change motivations that are already present. Perhaps the simplest way to do this is to ask directional questions—open questions the natural answer to

Remember the change talk you hear because

you will need it later.

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Evoking: “why would You go There?” 91

which is change talk—and then listen well. When you ask such open ques- tions, you’re not the only one listening to the answers. In order to respond, people pause and listen to themselves as well.

You can use the DARN categories to generate such questions. For example, suppose you want to hear desire language about a possible change you are focusing on. You might ask questions such as, “How would you like for things to be different?” or “Why would you want to make this change?” To invite ability statements, you could ask something like, “If you did decide to do this, how might you go about it in order to succeed?” or “What strengths or abilities do you have that could help you make this change?” Reasons can be elicited with a straightforward question: “What would you say are the best reasons for you to do this?” Need language is about importance; to get it, ask things such as: “Why do you need to do this?” or “How important is this for you?”

Sometimes we ask evocative questions such as the following by using an importance ruler or scale (see Figure 6.1). “On a scale from 0 to 10, where 0 is ‘not at all important’ and 10 is ‘the most important thing in your life right now,’ how important would you say it is for you to make this change? What number would you say?” Once you hear a number— suppose the person says “4”—you then ask, “And why a 4 rather than 0?” The answer to this follow-up question is likely to be change talk. Notice that you don’t ask, “Why do you say 4 and not 8 or 10?” The answer to that question would be sustain talk. You could use the same method as a confidence ruler to ask about ability: “On a scale from 0 to 10, how

FIGURE 6 .1. Importance and confidence rulers.

From Motivational Interviewing, Fourth Edition: Helping People Change and Grow by William R. Miller and Stephen Rollnick. Copyright © 2023 The Guilford Press. Permission to photocopy this material, or to download and print enlarged versions (www.guilford.com/ miller2-materials), is granted to purchasers of this book for personal use or use with clients; see copyright page for details.

0 1 2 3 4 5 6 7 8 9 10

Not at all important

Extremely important

0 1 2 3 4 5 6 7 8 9 10

Not at all confident

Completely confident

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confident are you that you could do this if you decide to?” The follow-up question would then evoke confidence or ability language. These scaling questions are just one example of a structured way to invite change talk. Don’t use them always or automatically. There are countless ways to evoke change talk well.

While you are evoking the why of change, avoid asking questions the answer to which would be sustain talk. Don’t invite the person to add more weight to the status quo side while the balance of ambivalence is still in motion. A few examples of inopportune questions are:

• “Why haven’t you changed?” • “What keeps you from doing this?” • “What do you like about the way things are now?” • “Why can’t you just do it?”

If someone answers these questions literally, the expected result will be sustain talk. Later on, when considering the how of change (Chapter 7), it might be useful to explore potential obstacles, but it’s too early to dwell on these while the person is still weighing whether to make a change. If you want to remain neutral and give equal attention to pros and cons, a decisional balance intervention can be useful (see Box 6.1).

B OX 6 .1. Is a Decisional Balance Intervention a Good Idea?

The balance of perceived pros and cons is a good marker of where some- one is in readiness for change. Unfortunately, it became popular to have people do a decisional balance intervention by voicing or writing down all of their pros and cons to help them change. There never was a theo- retical or scientific reason to think that using this approach would help someone decide to change. In fact, constructing a decisional balance when someone is ambivalent actually decreases their commitment to change.14 This makes sense because the expected outcome of equally voicing pros and cons would be ambivalence and no change.15 In Chapter 9 we will discuss an appropriate use of decisional balance when your goal is to remain neutral and not encourage change in a particular direction. If you want to promote change, however, then doing a full decisional balance would be counterproductive from an MI perspective. Movement toward change is promoted by strengthening the pros and softening the cons of change.16

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Evoking: “why would You go There?” 93

Mi Consistency

Some aspects of MI’s spirit and method in themselves seem to evoke change talk. One of these aspects is emphasizing the person’s freedom of choice.17 Change talk tends to occur following counselor statements supporting

client autonomy.18 Affirmations can both increase change talk and diminish sustain talk.19 Understand that the specific techniques we describe here for evoking change talk are not meant to be used in isolation, but within the overall context of MI.

Exploring Extremes

Another strategy for inviting change talk is to explore possible extreme outcomes. If the person did make this change, what are the best possible benefits they can imagine? As you ask this question, respond with reflective listening and ask further open questions to help the person envision poten- tial positive outcomes. (Note that this would be change talk— probably Reasons.)

COUNSELOR: What good do you think might come of it if you did decide to come back to school and earn a degree? What might be best about doing that?

JANET: I’d feel good about it. [Change talk] COUNSELOR: In what ways? [Asking for elaboration] JANET: It would show that I can accomplish something when I want to.

[More change talk] COUNSELOR: Something to feel proud of. [Reflection] What else? JANET: Well, it would open up some possibilities for me. [More change talk] COUNSELOR: Probably so. Like what? [Asking for elaboration] JANET: I could get a better job, and not be stuck in what I’m doing now; I

could be doing something I enjoy more. [More change talk]

Exploring extremes can also be directed to the status quo. Suppose the person does not make the change. What are the worst things that could happen? Again, listen well and ask for some elaboration with open ques- tions.

COUNSELOR: So that’s something you could actually do, feel good about, and let you earn a better living. Now let me ask about the other side. What if you don’t go back to school? What’s the real downside of that?

Affirmations can increase change talk and diminish sustain talk.

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JANET: Like I said, I’m stuck in dead-end jobs. And I’d feel like I let myself down.

COUNSELOR: Disappointed yourself.

JANET: And some other people, too, but especially myself—not doing it when I know that I could.

COUNSELOR: You’re confident you can do it, and it would be disappointing to yourself to pass it up. You mentioned that some other people care about this too.

JANET: My brother really wants me to do it. He finished his degree and now is working in a doctor’s office.

COUNSELOR: He knows you can do it, too.

looking Back or Forward

Ask the person to look back to the time before current troubles emerged and tell you what life was like then. When working with distressed couples, we often ask them to explain how they met and what attracted them to each other in the first place. What was the joy or magic in their relationship back then? Talking about an earlier and better time may recover some of its positivity and hope. Sometimes, of course, there is no better time to be recalled, in which case this “better days” strategy is unhelpful.

Alternatively, you can ask people to look forward and imagine a future time after they have successfully made the changes they seek. Such a ques- tion from solution- focused therapy asks, “Imagine that a miracle occurs and when you wake up tomorrow your life is just as you would like it to be. What would be different? How would you know that the miracle has hap- pened?”20 This is envisioning of a possible positive future.

Exploring goals or Values

Sometimes there is buried treasure in exploring what matters most to the person and what they hold most dear. No one is unmotivated. What is most important to this person, and how is that related to the possible change being considered? With problem drinkers, for example, we might evoke a list of the person’s top five to ten values and then for each one ask (with curiosity, not as a challenge) whether their alcohol use helps them to achieve it, has no effect, or interferes with living that value. In Chapter 9, we explore in more depth how a person’s values can be a compelling con- sideration in motivation for change.

No one is unmotivated.

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FOR T HER A PIS T S: Why Does MI Work?

MI originated not from a psychological theory but from close observa- tion of and puzzling about clinical practice. Across the decades, how- ever, various theories have been proposed to explain why MI works.21 The usefulness of a theory is not just in making sense of what we already know but also in suggesting new ideas that, when tested, turn out to be true and help us extend our understanding.

One example that makes sense is self- regulation theory.22 Everyone has a notion of what is normal and acceptable versus what requires action. Based on how I am feeling, do I need to run, sleep, get something to eat or drink, or see a doctor? It’s a bit like a ther- mostat: when behavior gets outside the normal or expected range, self- regulation efforts kick in. Self- regulation is also influenced by the environment and comparison of oneself with others. How much alco- hol use is “normal”? Standards vary substantially across individuals and cultures, and as long as one’s drinking seems to be within accept- able limits, change is unlikely. Unsurprisingly, heavier drinkers perceive higher alcohol use to be normal and tend to associate with people who have similar drinking patterns. One way to think about how MI works, then, is that it triggers self- regulation by enhancing awareness of current behavior and judgment about its acceptability relative to important personal values.23 Motivational enhancement therapy (see Chapter 13)24 adds to MI some personal assessment feedback with normative comparison data, an example of the more general method of norm correction.25

Over the years, various other theories have been offered to account for why MI is effective. Explanations have been proposed from behavior analysis,26 constructivism,27 evolutionary psychology,28 a psychodynamic perspective,29 and self- determination theory.30 The original description of MI linked it to Carl Rogers’s humanistic perspec- tive,31,32 cognitive dissonance,33 and self- perception theory.34 MI has also been related to gestalt resolution of ambivalence,35 attachment theory,36 and the decisional balance of change talk versus sustain talk.37 These provide theoretical lenses through which to understand MI, and no one of them seems adequate to encompass the findings.

Strengthening Change Talk

To recap, first you learn to listen for (attend to), recognize, and remember change talk, knowing that you have just heard something important. Then you develop methods for inviting change talk rather than just waiting for

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it. A third key skill is that when hearing change talk, you respond in a way that strengthens it and invites more.

responding with oarS

If you have had some training in a person- centered style like the engaging skills described in Chapter 4, you were probably told to ask open ques- tions, use reflective listening statements, offer affirmations, and provide summaries of what you have heard. Often, however, little guidance is given about what to ask, reflect, affirm, or include in summaries. Of course, it does matter what you ask, as exemplified above by the questions that evoke either change talk or sustain talk. One guide to follow is that you are likely to get more of what you ask for. What you choose to reflect also makes a difference; you’ll probably hear more of whatever you attend to with reflec- tive listening. Psychotherapy research also shows that what you affirm mat- ters; you’re inviting more of it even if what you are affirming is unhealthy.38 Finally, summaries are neither neutral nor objective; what you choose to include in them has consequences. Invite change talk by asking directional questions; then reflect and affirm what you hear. Remember to listen for change talk and offer periodic summaries that pull the themes together, even if there are only two or three. For example, “Going back for your degree is something you would feel good about, and your brother would too. It could help you get a better job and one you enjoy more.”

In Chapter 4 we described the OARS skills that help you to engage in a collaborative working relationship. When you hear change talk, become interested and curious and use the same four skills to strengthen it. Ask open questions seeking elaboration or examples of the change talk. For instance, you might ask for elaboration: “In what way do you think your family would be happier?” You could ask for a specific example: “One downside of drinking for you has been the hangovers. When was the last time you woke up after drinking too much? Tell me what it was like.” Notice that the change talk in the latter case is about the disadvantages of the status quo (and implicitly an advantage of changing: no hangovers).

In addition to asking open questions (O) and reflecting (R) change talk, you can also affirm (A) what you hear and the person’s strengths that it implies. “You’re someone who deeply cares about your family.” “You have really thought this through.” “It sounds like once you put your mind to something you stick with it.” Pull the change talk together in summaries (S). You are using OARS to create more momentum.

directional reflections

A particular MI skill is being intentional and directional about what you choose to reflect. When you reflect something that a person has said, you

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are giving special attention to it and you’re likely to hear more about it. Thus, what you reflect matters. A directional reflection differentially mir- rors particular content—in the case of evoking, change talk. If you reflect change talk when you hear it, the next thing the person says is likely to be more change talk. Remember that when people are ambivalent, change talk often becomes entangled with sustain talk. Suppose a friend says to you, “I really don’t want to stop smoking. I know that I should, but I’ve tried before and it’s really hard.” Here are three perfectly good reflective listen- ing statements that you could offer upon hearing your friend’s statement. Each of them picks up and mirrors something that was said:

1. “You really don’t want to quit.” 2. “It’s pretty clear to you that you ought to quit.” 3. “You don’t think you can quit.”

Which of these reflections would be best from an MI perspective? Consider what your friend is likely to say next after each of these reflec- tions. With reflection 1 the person is likely to say more about not wanting to quit (sustain talk). With #3 your friend will probably elaborate on the difficulty of quitting, perhaps relating unpleasant prior experiences (sustain talk). If you offer reflection 2, however, you will probably hear more about why your friend thinks it would be best to quit (change talk). By what you choose to reflect, you can literally evoke more change talk or more sustain talk,39 and it matters which you do. If you evoke more sustain talk, change is less likely to happen.40

Or consider this example from a person who had been arrested for driving under the influence of alcohol: “See, the thing is, all my friends drink. It’s just what we do together. Some of them probably drink way too much, too, but if I quit drinking, then I don’t have any friends! I just stay home.” Do you see the change talk in this example? Some possible reflec- tions would be:

1. “That would be pretty lonely.” 2. “Quitting would cause a whole new problem for you.” 3. “And at the same time you recognize that you and probably some

of your friends are drinking way too much.”

All three of these responses focus on something the person has said, and in that sense they are legitimate reflections, but two of them are likely to be followed by more sustain talk. Only response 3 invites more change talk. And as we have stated, the more change talk you hear relative to the amount of sustain talk, the more likely it is that change will happen.41 By choosing what to reflect, you influence this balance of expressed change talk and sustain talk.

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Within the reflective method of continuing the paragraph (see Chap- ter 8), you can tentatively reflect change talk that clients have not yet spoken but that follows from what they have been saying. We call this technique lending change talk. You are in essence trying out change language that the client might be thinking. Be careful not to jump too far ahead of where your client seems to be. For example, when a person has been describing vexing difficulties in a relationship, you can try out a reflection such as, “You’re really ready for some change in this relationship.” The person’s response then tells you whether you are on the right track.

directional Summaries

Helping professionals often offer periodic summaries of what has been said. This can be done to review progress so far, making sure you have a common understanding, or to draw things together as you transition from one topic to another or at the end of a visit. In MI, summaries have a fur- ther important function of revisiting change talk. If you invite change talk, for example, with evocative questions, people first hear themselves say it. When you then reflect their change talk, they hear it again and usually say more. Using the analogy that evoking change talk is like collecting flowers, we can liken summaries to bouquets.42 When you have heard two or three change talk statements, you can put them together in a small bouquet (flo- rists call it a posy). As an interview progresses, you can assemble larger bouquets in which people hear their own change talk yet again. Be careful, though, not to be thinking like a prose- cutor as if you were assembling evidence to use against them. Interview with a mind of curiosity and acceptance, allow- ing people to reach their own conclu- sions.

Here are four possible summaries that could be offered from the very same interview. It is a published motivational interview with a man regard- ing his smoking,43 but you don’t need the transcript to understand the dif- fering impact these summaries would have. Just consider what he would probably be thinking and feeling depending on which of these hypothetical summaries he heard.

Summary 1

“You’ve shared a lot with me regarding how you feel about smoking. Sometimes you think it’s crazy how much trouble you go through just to get cigarettes. You’ve heard horror stories about how bad nicotine withdrawal can be, and you feel antsy just thinking about it even right now. It annoys you when people are rude and critical of you for

In change talk, people hear themselves argue for change.

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smoking, and you’re clear that nobody can make you quit. You dislike the idea of taking medication to help, and when you think about what your life would be without cigarettes it’s just a blank—you can’t even imagine it.”

This summary emphasizes some emotionally laden content that the man expressed during the interview. Perhaps this summary was guided by the idea that feelings are particularly important. However, most of the emotional content the man expressed was fairly negative, and that feeling tone would likely linger after this type of summary. Most of what was included in the summary was sustain talk, and it certainly doesn’t inspire change. If anything, he might feel like having a cigarette.

Summary 2

“It sounds like smoking doesn’t do much for you anymore. There’s all the social stigma, the cost and hassles, and maybe even damage to your health. You’re smoking more and enjoying it less. On the other hand, smoking is a normal part of your whole life, your character, so much so that you can’t even imagine yourself as a nonsmoker and you’ve never tried to quit. You don’t want to take medication and you’re wor- ried about how bad, how crazy, the withdrawal would be. In fact, liv- ing without smoking would feel pretty crazy.”

Summary 2 tries to be fair and balanced by reviewing the pros and cons of smoking that the man described. In that sense, it’s a summary of his ambivalence, rather like doing a decisional balance. It’s also significant that the pros of smoking are summarized after the cons. People are more likely to remember and respond to what you say last. The expected effect of this summary, then, would be ambivalence, with lingering reflection on the advantages of smoking.

Summary 3

“Clearly you are seeing plenty of downsides of your smoking. You don’t really enjoy it anymore; it has just become an expensive bad habit, and then there’s the social stigma. It’s more difficult to smoke now, and even the flavor, the taste is gone. You know it’s starting to affect your health, so you’re asking yourself what the return is for all these costs. You’re even beginning to look at the benefits of quitting: the money and hassles you’d save, and maybe that food would taste better. You’re getting ready and have said that you’re already halfway there, that it’s time and you know you’re going to quit.”

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Summary 3 is a classic MI summary of the same interview. It pulls together all of the change talk the man had expressed throughout the inter- view, where it had been intermixed with sustain talk. This summary sepa- rates the flowers from the weeds. In this bouquet, his change talk is bun- dled together. Can you feel the impact of offering a summary of this kind that pulls together all of his own self- expressed motivations for change? It would be a model MI summary for this interview.

Summary 4

“Well, it’s obvious to me that you’re addicted to nicotine. Even though you know that smoking is harming you, you still continue. You run out in the middle of the night driving around on icy roads to spend money on cigarettes that burn holes in your clothes and damage your health. Even thinking about quitting makes you feel so antsy that you want to light up right then. You say you’re worried about withdrawal but you’re not willing to take the medication that would help you get through it. So you keep putting it off.”

This is the prosecutor’s closing summary. These are all things that the smoker did admit during the interview, and here they are pulled together and used against him in hopes of shaming him into quitting. Needless to say, most people don’t respond well to such a confrontation.

All of these summaries are technically legitimate, though none was actually part of the original live interview. They are all about the same length and pull together things the client really said, but what a difference in their likely impact! It matters what you put into a summary.

responding to Change Talk

When you hear change talk, don’t just sit there. Use your OARS. MI involves recognizing and inviting change talk, and it is also about how you respond when you hear it. As noted earlier, what you say next after change talk (and sustain talk) influences whether you will hear more or less of it.44 How you respond to change talk is an important part of evoking it. Ask open questions (O) that invite elaboration or examples. Affirm change talk (A). Offer reflective listening statements (R), and pull the change talk together in summaries (S). The effect of all this is to strengthen change talk and invite more.

What about Insincere Change Talk?

Perhaps you have been thinking, “Can I really believe people’s change talk? Are they just telling me what they think I want to hear without really

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meaning it?” Dubious or tenuous change talk certainly happens, particu- larly when someone is on the short end of a power relationship.

It will not surprise you that we discourage confrontational responses like these:

“I don’t believe you!” “You’re lying. You don’t mean it.” “You’re being unrealistic. Get real!”

Such responses are likely to damage rapport and create discord. So what could you do instead?

One possibility is straightforward: to express your concern and discuss it with the person. You can introduce your doubts in an empathic way:

“I’m wondering how you really feel about doing this? I get the sense that you do mean what you’re saying, and also that part of you really doesn’t want to do it.”

“This has been a part of your life for so long that I worry when I hear you say you’re just going to stop, as if that would be simple.”

Follow this response, of course, with reflective listening. Dubious or tenuous change talk often focuses on generalities more

than specifics. You could also take people at their word and become inter- ested in the specifics. Vague and superficial change talk does not (yet) have the necessary depth to evoke motivation. Asking for elaboration, for more detail about why and how, can elicit more specific change talk and trans- form vague generalities into specific intentions. Do this exploring with a mindset of supportive curiosity, not of cynicism or trying to “catch” the person in deceit or self- deception.

CLIENT: No, I really am going to quit drinking. I want to.

INTERVIEWER: Why would you choose to do that? [Evocative question: Rea- sons]

CLIENT: I just am going to do it, that’s all.

INTERVIEWER: Great. What I’m curious about is why you would want to do this when drinking has been so important to you. [Evocative question: Desire]

CLIENT: Well, my family wants me to quit. It gets to me when my little girl says, “Please Daddy, don’t drink tonight!” Really tears me up.

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INTERVIEWER: It’s pretty hard to drink when she is begging you not to. [Reflection] You care about your kids. [Affirmation] What else? Why else would you choose to quit? [Evocative question]

CLIENT: Well, my doctor said that I should. INTERVIEWER: What do you think? CLIENT: I know she’s worried about me, those blood tests and all. She said

my liver is crying out for a break. INTERVIEWER: How important is that? [Evocative question: Need] CLIENT: Well, I don’t know too much about it, but I think if you kill off

your liver it’s not coming back, and really bad things happen. INTERVIEWER: You’d like to stay healthy. [Reflection] CLIENT: Sure. That’s why I’m going to quit. INTERVIEWER: What would a first step be?

The key here is to be curious and to help people be more specific about their desire, ability, reasons, need, and plans. A person’s voicing specific intentions makes change more likely to happen.45 Taking someone’s change talk at face value rather than challenging it can make change more plausible to them as well. Someone who starts out with vague assurances can end up committing to particular steps toward change. Specifics also increase accountability. General motivations and intentions don’t make change hap- pen as readily as specific intentions do.46

Ethical Considerations

One approach when working with ambivalent people is to maintain neu- trality and avoid even inadvertently encouraging the person in one direc- tion or another. Some helpers believe that they should always maintain neutrality so that clients make their own decisions about what changes they will make. In an existential sense, it is always the person’s own choice. Vik- tor Frankl, a survivor of the severe privations of Nazi concentration camps, observed, “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circum- stances, to choose one’s own way.”47 Even such extreme coercion ultimately cannot make others’ choices for them.

A fear sometimes expressed about MI is that it could be used to bypass an individual’s autonomy and values, much like common conceptions of posthypnotic suggestion or subliminal advertising. We believe MI cannot override a person’s own values, although this assertion cannot be proven but only disproven by a single example.

Psychological research clearly shows that it is possible to influence a

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