Discussion

Motivational Interviewing

Chapter 14

Allison Salisbury Doug Smith and Corey Campbell

LEARNING OBJECTIVES

By the end of this chapter, you should be able to:

•describe the historical underpinnings generating the motivational interviewing (MI) style,

•examine theories underlying MI principles,

•integrate core elements embodying the “MI spirit” into the four processes of MI,

•utilize MI-adherent micro-skills in a variety of situations,

•integrate MI into the generalist-eclectic approach, and

•evaluate the strengths and limitations of MI.

For many individuals, the status quo is comfortable and the prospect of behavior change sets up a process where they weigh options before acting. Individuals are sometimes unsure about change. On the one hand, they may not mind their current situation or they aren’t facing severe consequences, but on the other hand, they may experience a dull, nagging feeling that change would be beneficial. When you have a client experiencing ambivalence about change, regardless of behavior, MI is an appropriate approach to incorporate into your generalist-eclectic practice.

INTRODUCTION: OVERVIEW OF MOTIVATIONAL INTERVIEWING

Motivational interviewing (MI) is a communicative approach to encouragr clients who are resistant or ambivalent to make a behavior change. When applied correctly, skilled clinicians establish a collaborative, client-centered partnership before tackling their client’s self-identified target behavior. You may employ a variety of techniques to establish this collaboration, including listening to their narrative, empathizing with their story, and sharing responsibility for behavior change. A successful interpersonal relationship results in a brief yet effective approach to stimulate the natural change process. A skilled clinician trained in MI guides clients through ambivalence utilizing the therapeutic relationship grounded in the “MI spirit,” which involves overarching principles about the “feel” of the intervention. We will discuss these in greater detail later in the chapter. In addition to the “MI spirit,” we will discuss micro-skills, including techniques that help the client feel listened to and that evoke motivation to change.

To enhance your understanding of MI, we first review the historical development and theoretical constructs of the therapeutic relationship and behavior change. As we discuss the key components of the approach, we provide an array of case scenarios. We offer two hypothetical responses to each case scenario. The first example exhibits a non-MI adherent scenario, which is not recommended for MI clinicians because they risk increasing client resistance and fracturing of collaborative relationships. The second example exhibits an MI-adherent scenario. The clinician in these examples acts according to MI values and skill sets, which we note as presented. Finally, we summarize all topics discussed in each section, apply MI to the generalist-eclectic framework, and provide a full case example for you to practice your skills.

HISTORICAL DEVELOPMENT

MI applied social psychology theories about cognitive dissonance (Festinger, 1962) and self-perception (Bem, 1972) within a client-centered framework. Departing from prior models that viewed individuals with addictions as people in denial with flawed personalities, MI instead promoted strategies respecting the autonomy of clients to make decisions and using empathy instead of confrontation. It has evolved since its initial development in 1983 (Miller, 1983), as evidenced by tens of thousands of studies and the publication of three editions of the main MI sourcebook (Miller & Rollnick, 1991, 2002, 2012).

Moyers (2004) provides an excellent accounting of the early history of MI. What is striking is how the model developed from intense clinical observation of how clients responded to certain clinician behaviors. In social work, we would say this is the ultimate example of doing practice-informed research (Council on Social Work Education, 2015). That is, clinical observations drove hypotheses about what was happening in MI, which were later tested formally in research settings. For example, Miller and his associates likely observed that confronting clients resulted in their doubling-down on being “resistant,” but (highly learnable) empathy statements prompted clients’ contemplation of change. This emphasis on observation never waned, forming the basis for subsequent research and model revisions.

Early emphasis focused on mastering principles such as rolling with resistance, expressing empathy, developing discrepancy, and supporting client self-efficacy. The third edition of the MI sourcebook eliminated the principles of developing discrepancy and rolling with resistance (Miller & Rollnick, 2012). Part of this was due to people conflating MI with completing a pros and cons list, a decisional balance activity. Evidence suggested that pros and cons lists, which sometimes give equal weight to reasons for and against change, reinforce client ambivalence (Miller & Rollnick, 2009). Thus, MI focuses more on eliciting change talk (formerly called client self-motivational statements), which is defined in the following.

As MI gained in popularity, there existed increasing emphasis on using MI solely for the welfare of the client. Thus, Miller and Rollnick (2012) added the concepts of compassion and equipoise as elements of MI practice. Compassion is specifically defined as keeping the client’s interests central, without using MI to get clients to do something they don’t want to do, such as selling them something, including unwanted social work services. Instead, social workers implement strategies in MI designed to reduce ambivalence only when doing so benefits the client and balance this against client autonomy. Increasingly, ethical discussions define the inappropriate use of resolving ambivalence. Social workers should not sway clients to get divorces or donate organs, decisions for which the best course of action for the client appears hazy at best. In such situations, pros and cons lists may be appropriate, and the clinician may assume equipoise, defined as not actively shaping the client’s language in one direction (see the discussion following on eliciting and reinforcing change talk).

Another problem with MI’s growing success involves safeguarding practice and training standards. Research shows that many individuals claim to be using MI but in reality use approaches straying dramatically from key quality indicators. To that end, many research studies focused on what types of training lead to competent practice of MI, perhaps more than for any other therapeutic approach. Additionally, there exists a very large network of MI trainers dedicated to promoting best practices in training, called the Motivational Interviewing Network of Trainers (MINT; n.d.). Members must demonstrate competency in delivering the model, and there are efforts within MINT to develop practitioner and trainer certifications. Currently, standardized measures of both practitioner and trainer competencies exist (Moyers et al., 2014; Smith et al., 2017). For now, social workers should refrain from telling clients that they received certification in MI. If rigorously trained, however, it is acceptable to tell clients about the training process. The highest level of rigor involves didactic training and practice, followed by competent MI trainers reviewing samples of one’s clinical work (e.g., audio tapes) using established quality assurance standards.

Rollnick emphasized addressing ambivalence, and eventually the “MI spirit” was the target for attaining excellence in the approach (Moyers, 2004). MI offers a generalist perspective to social work practice because of its versatility in a variety of settings, including alcohol and other drug problems, healthcare, mandated treatment, consultations, fitness and weight loss, and schools.

CENTRAL THEORETICAL CONSTRUCTS

MI borrows concepts from social psychological theories of motivation, cognitive dissonance, attribution, and self-efficacy (Miller, 1983). This section reviews the theoretical view on client ambivalence and resistance, as well as the three theories related to motivation.

Conceptualization of Ambivalence and Resistance

Theoretically, MI assumes that ambivalence about change is a natural part of behavior change decisions. Although MI remains neutral on whether people pass through the stages of change sequentially, it shares common ground with the transtheoretical model (TTM) of change in recognizing ambivalence as a key factor in change (Prochaska & DiClemente, 1983; Prochaska et al., 1992). This contrasts with models that view reluctance to change as “denial,” “resistance,” or “lack of insight.” When applied to the addictions realm, the goal isn’t for the client to admit their addiction or to abstain from drinking; rather, the goal is to allow clients to make their own decisions (Moyers, 2014).

Motivation is construed as an interpersonal process. Consider the fact that one synonym of resist is “counter.” Thus, a client cannot resist in the absence of an opposing force. Thus, the goal of MI is for social workers to not provide an opposing force. Research clearly demonstrates that clients become “resistant” when therapists use confrontation, persuasion, or other punitive tactics. In other words, saying that resistance is interpersonal means that social workers have a modicum of control over how resistant their clients are, and replacing counterproductive behaviors may result in a smoother interaction. In lay terms, it’s on us social workers to not create resistant clients.

This is also to say that resistance doesn’t live inside the client. Consider the phrase “They are resistant to change.” In theory, MI does not view resistance as a personal attribute or trait. The implication of this view is that instead of telling clients they are in denial, haven’t “bottomed-out,” or are “unmotivated,” social workers practicing MI validate and try to resolve their ambivalence. Social workers communicate this in many ways, through the “MI spirit,” reflective listening, and strategic use of skills to elicit a client’s own motivation for change. We discuss these techniques in subsequent sections.

Counter-arguing against unsolicited advice comprises a natural reaction for ambivalent individuals. Let’s do a thought experiment. Take a minute to think about a discussion you had with a friend or family member who urged you to do something. Did you find yourself reacting to them with a statement that started with “Yeah that may work, but…”? Whatever follows the “but” is the natural product of ambivalence, not necessarily denial. Thus, social workers should expect mixed feelings toward change and perhaps some counter-argument from clients. In MI, we call such counter-arguments sustain talk, and we take measures to try to not meet it forcefully, but rather steer the conversation elsewhere.

Resistance is conceptualized slightly differently in MI. Whereas ambivalence pertains to the decision-making process, resistance involves the therapeutic relationship. Resistant behaviors in MI may include challenging the social worker’s credentials or experience, as well as not talking or talking about something off-topic to avoid doing therapeutic work. Social workers should not quickly judge these as indications of resistance. Sometimes, these indications represent feelings associated with coercion about a problem for which they have not yet decided to change. For example, individuals mandated to parenting classes sometimes present as resentful because they feel threatened and perceive professionals as judging their parenting as inadequate. Such an individual may challenge a social worker out of fear and ambivalence about change rather than a predisposition to being difficult or resistant. In MI, social workers would convey empathy about such fear and ambivalence.

Related Theories

Client-Centered Therapy

Client-centered therapy suggests the interpersonal conditions for behavior change consist of three pillars: genuineness, unconditional positive regard, and empathy (Rogers, 1957, 1974). Genuineness requires inner and outer congruence, or authenticity, with your client. In MI, you can model genuineness to enhance trust and subsequently the likelihood of clients sharing their story. Unconditional positive regard considers the therapist as accepting without judgment. Rather than evaluating and giving approval to your client on whether change occurs and about the decisions they make, you validate their experiences and support their goals. Empathy offers the opportunity for a clinician to portray meaning of their client’s experiences. A skilled clinician utilizes empathy in MI to consciously raise underlying substantive motives for client behaviors. These pillars are essential to the “feel” of MI, or the “MI spirit,” which is further discussed in a subsequent section.

Cognitive Dissonance

The theory of cognitive dissonance suggests that people feel uncomfortable when they sense a discrepancy between their values and current behavior (Festinger, 1962). Thus, when applied to ambivalence about change, it seems logical to generate discussion about the benefits of change and the consequences of persisting in some negative behavior. For example, if your client presents a sedentary lifestyle, they may share with you the plentiful concerns from their peers and family on their enhanced risk for poor cardiovascular health. If you confront your client’s enhanced risk for medical issues such as a heart attack, they may resist your genuine concerns and project feelings of discomfort, guilt, and shame. On the contrary, if you use strategies that elicit client speech about the benefits of change, it may help resolve this dissonance. That is, clients hear themselves talking about change, and behavior change may result as a solution to resolving internal tensions.

Self-Perception Theory

Self-perception theory (Bem, 1972) suggests that the more we talk about our values and beliefs, the more we form values surrounding such beliefs. In other words, there is something about articulating or talking out loud about something that can reinforce a belief. In MI, this influences the concept of training social workers to elicit and reinforce change talk, as well as any client speech that indicates a desire, ability, reason, or need for change. We discuss this reinforcement of change talk in a subsequent section. Additionally, clients may also express statements about their commitment to change, intentions to change (i.e., activation), and steps toward change on which they recently ventured. So, per self-perception theory, when clients talk about change, it reinforces their beliefs about the desirability of change.

COMPONENTS OF MOTIVATIONAL INTERVIEWING

The eternal “chicken or the egg” argument in MI is determining how it works. When considering this question, MI is divided into three main component areas: the “MI spirit,” highlighting the relational component; counseling strategies or “micro-skills” common to many therapies; and the specific, intentional use of these micro-skills to elicit and reinforce change talk (i.e., the technical component). Since the dawn of MI, debate has emerged over which components are sentinel to client change. We continue to debate exactly how MI works at this level. Is one component superior to the other, or do the components work in concert for the best results? In this section, we focus on the relational component, defining these concepts and providing case examples of the MI-adherent and MI non-adherent social worker statements. In subsequent sections, we introduce the micro-skills and the technical component of MI (i.e., change talk).

The Relational Component of the Motivational Interviewing Spirit

The relational component of MI states that the “MI spirit,” the overall “feel” of the approach, will be associated with client behavior change (Arkowitz et al., 2008; Miller & Rose, 2009). Let’s examine the four components embodying this spirit: partnership, acceptance, compassion, and evocation.

Partnership

Without a collaborative partnership involving input from both the clinician and client, there is no MI. Just like in other humanistic approaches, you treat clients as the experts in their own lives, coming to you for guidance in resolving their ambivalence. If they remain stuck on deciding whether to change, they aren’t looking for your advice on how to change. Rather, they seek resolution behind the why to the change (Moyers, 2014). Thus, a common MI faux pas is offering unsolicited suggestions prior to querying, and often amplifying, client intentions to change.

Let’s look at an example of detachment and an example of partnership (Exhibit 14.1). In this situation, you are working with an individual who was recently sentenced to 30 months of probation for their third conviction for driving under the influence.

EXHIBIT 14.1 Example of Detachment and Partnership

Example 1: Detachment

Client: I don’t want to be here, I was mandated to treatment as part of my probation (resistance).

Clinician: Well, you have to be here, so let’s not waste our time (expert stance). Why are you here today (open-ended question)?

Example 2: Partnership

Client: I don’t want to be here, I was mandated to treatment as part of my probation (resistance).

Clinician: I understand why it may be difficult to be here (sympathy), and knowing that, what you would you like to spend time on today (autonomy, open-ended question)? I’d like this to be helpful to you (partnership).

MI in criminal justice settings is complex. Not only is there ambivalence about participating in mandated treatment, there is additional ambivalence in engaging in criminalized behaviors (Ginsburg et al., 2002). Although the United States’ criminal justice system is notorious for punitive measures, you do not need to follow the status quo of coldness, coercion, and confrontation. In your role, you may create a case plan to address your client’s risk factors for engaging in a subsequent criminalized behavior, but that doesn’t mean you discount what your client considers important. In the first example, you immediately appear authoritarian, distant, and unapproachable by fixating on time wasting instead of possible ambivalence. In contrast, in the second example, you build on the partnership by communicating your investment while eliciting theirs. You additionally empathize with your client and offer autonomy for the client to focus on their priorities, which we discuss next.

Acceptance

Accepting your client includes displaying absolute worth, affirmation, accurate empathy, and autonomy (Miller & Rollnick, 2012). As we previously mentioned, these characteristics derive from Rogers’s client-centered therapy. In the previous examples, you displayed empathy by expressing the difficulty of your client’s situation and understanding their frustration. Empathy is similar to sympathy, but the former takes it a step further by incorporating non-verbal cues into the meaning of your client’s messages and feelings. Let’s use the previous example to further examine empathy. Whereas sympathy communicates feeling sorry for your client’s situation, empathy demonstrates one’s ability to see the other’s perspective. Although the previous situations took different directions, you know your client chose attending their first session with you despite disagreeing with the court mandate. Let’s examine how to capitalize your recognition of their frustrations (Exhibit 14.2).

In the first example, you attempt to empathize with your client, but you misinterpreted their feelings by reflecting their personal anger at you, which wasn’t present. The reflection missed the mark. It is alright if you are not always accurate, especially as you start out. You will learn over time how to detect meaning from your client’s messages and incorporate non-verbal cues. Instead, you can look at the second example for accurate empathy. In this example, you detect their fear of failure and of facing adverse consequences. You highlight their “on thin ice” metaphor and continue with it, examining their fear of messing up, “falling” if they make one mistake with their probation conditions or treatment requirements. Your client notices you picking up on how they’re feeling, and they continue the rapport building by sharing their resolution to attempt to follow their court-ordered conditions by attending your session.

EXHIBIT 14.2 Examples of Empathy

Example 1: Inaccurate Empathy

Client: I am just trying to avoid prison … I barely kept my job because I spent time in jail since I couldn’t afford bail. I’m already on thin ice, and it doesn’t help that I have to take time off work every week to come to treatment that I don’t want to be at.

Clinician: You seem angry with the court and upset with me because I’m making you be here. You want to get this over with so you can get back to work and the rest of your life (simple reflection).

Client: I’m not upset with you, and I know it’s my fault so I can’t be angry with the court for doing what they have to do … I do want to get this over with and move on, but my sentence is 30 months, which is a long time.

Example 2: Accurate Empathy

Client: I am just trying to avoid prison … I barely kept my job because I spent time in jail since I couldn’t afford bail. I’m already on thin ice, and it doesn’t help that I have to take time off work every week to come to treatment that I don’t want to be at.

Clinician: You are disappointed of the situation you’re in and scared of getting worse consequences, including losing your job and going to prison (empathy). You’re exhausted because you feel like one misstep and … BAM! You could fall through the ice at any moment (complex reflection).

Client: You’re right, I feel that I can’t make any mistakes, not even little ones. It’s a huge step, and I’m trying to please everyone. I came here, so that’s a start.

Although you may not understand your client’s behaviors, you should respect and attempt to understand their situation. Even if you don’t agree with your client, an empathic clinician understands and communicates their verbal and nonverbal feelings. It is essential to establish rapport and build trust for your client to feel comfortable in opening up, sharing their experiences, and examining their ambivalence. Wording matters.

EXHIBIT 14.3 Encouraging Autonomy

Example 1: Coercion

Client: I am here today because I received a court order for 30 hours of substance use disorder treatment, but I don’t have a problem with alcohol!

Clinician: In my experience, if it walks like a duck and quacks like a duck, it’s probably a duck (expert stance). Don’t you think a DUI means you have a problem (confrontation)? You must follow the conditions of the court if you don’t want to face further consequences, and that includes attending treatment. I’m your ally though, and I want to see you do well (expressing support).

Client: I know that, but I don’t have a problem with using alcohol, I messed up ….

Clinician: You were caught driving under the influence, and that seems to be the problem (confrontation).

Example 2: Autonomy Enhancement

Client: I am here today because I received a court order for 30 hours of substance abuse treatment. I don’t have a problem with alcohol!

Clinician: Although the court is requiring this treatment to successfully complete your probationary sentence, ultimately, it is your decision to attend and participate (autonomy). How do you feel about what the court is asking you to do (partnership, open-ended question)?

Client: I feel that I shouldn’t have to do this (sustain talk), but the other alternative is prison, which I want to avoid at all costs (change talk). I messed up, and I have to face the consequences.

Clinician: You are upset with this situation, yet you want to do something about it to avoid prison. You are here today, so you decided to avoid prison by attending treatment (reflection focusing on change talk).

Instilling a sense of client autonomy in decision-making is another way to accept your client’s experiences (Exhibit 14.3). You demonstrate autonomy by reflecting your client’s values and respecting their choices. We will use the previous example to illustrate autonomy. You know your client is sentenced to probation, which requires mandated alcohol treatment, and you know your client feels they do not have a say in attending this treatment. Let’s examine how to encourage autonomy in this situation.

You may recognize that the first example destructs the collaborative relationship. Your client already knows the conditions of their probation. They repeated themselves because they didn’t feel heard, and they further explained their situation with a sense of hopelessness. You selected their problem for them, which eliminated the client-centered relational aspect of MI. In contrast, in the second example, you recognize your client’s court-ordered mandate, but you also recognize your client’s choice in fulfilling that requirement. Your client does not have to complete treatment, and it is not your decision to make. You recognize their control in the decision and its consequences, positive and negative. In addition, you empathize with your client by recognizing their emotional reaction and establishing rapport, allowing them to explain their goals for attaining their choice behaviors.

Compassion

Miller and Rollnick (2012) recently emphasized compassion as a critical aspect of the “MI spirit.” The concept seems synonymous with the idea of communicating non-possessive warmth and overlaps greatly with the concept of enhancing client autonomy. That is, some individuals came to MI thinking that it could motivate or “get” their clients to change. Yet, that mindset runs contrary to the “MI spirit” of preserving client self-direction. One misconception of MI is that it is a set of “tricks” you can use to get your clients to change. This is particularly relevant to strategies involving eliciting and reinforcing change talk, which are described in subsequent sections.

Evocation

In MI, evocation suggests eliciting your client’s strongest reasons to change to increase the likelihood of change occurring (Moyers, 2014). As we mentioned earlier, most clients have some inherent motivation to change their target behavior. As a skilled clinician, you call out this motivation through the use of micro-counseling skills designed to elicit client change talk, which is discussed in greater detail in a subsequent section.

Summary of the Relational Component

The “MI spirit,” or the relational component of MI, aligns well with social work core values, especially integrity (partnership), dignity and worth of the person (acceptance and compassion), and importance of human relationships (National Association of Social Workers, 2017). Once you and your client establish a collaborative partnership, accept your client’s autonomy, present accurate empathy, illustrate compassion, and evoke change, you are ready to utilize MI-consistent techniques that promote change talk. In the next section, we tackle the four processes of MI and incorporate the micro-skills and technical components encompassing MI.

PHASES OF HELPING

Miller and Rollnick (2012) established four processes of MI: engaging, focusing, evoking, and planning. In this section, we present the micro-counseling skills and evocative strategies in the context of these four processes.

Engaging

If your client is not engaged, there is no platform to explore motivation and therefore no change. With an engaged client, it is easier to pinpoint their targeted goals for behavior change and elicit motivation to enact the change. Keep in mind the relational components we just discussed as you engage with your client.

Micro-skills such as open-ended questions, affirmations, reflections, and summaries (OARS) facilitate client engagement (Miller & Rollnick, 1991). Clinicians using MI strategically implement these skills to convey empathy and generate change talk. We review each skill independently. Note that there is a time and a place for each of these skills. Thus, rather than using them in a sequential, rigid manner, work toward flexibly rotating among them when appropriate.

The “O” in the OARS skill set stands for open-ended questions, which allow your client to freely share their story. Unlike close-ended questions, which typically are answered with “yes” or “no,” you can pull information from an open-ended question to elicit change talk that continues the conversation. If you ask close-ended questions, you may end up stuck in a “question-answer trap,” where you are unable to move the conversation forward. In addition, close-ended questions may remind a person of an interview because they are providing you information. Let’s examine an example comparing close-ended and open-ended questions with a client considering leaving their family and caregiving role to pursue an employment opportunity (Exhibit 14.4).

In the first example, two close-ended questions yielded no new information about your client’s needs or motivation. You are stuck in the question–answer loop, and you must ask a third question to elicit a response that continues the conversation. How inefficient! In the second example, you strategically ask one question, and you discover that your client is an instrumental caretaker in their family. However, this may lead to sustain talk because replies to questions may go anywhere. By asking about the job, you are posing a neutral question. You may have considered asking how the client feels about leaving their family, but this may lead to sustain talk. Other strategic questions include: “Could you tell me more?” “What are your thoughts on this?” “How has this been a problem for you?” and “What have you tried that works?”

EXHIBIT 14.4 Close-Ended Versus Open-Ended Comparisons

Example 1 (Question/Answer Trap):

Client: “I don’t know whether I should apply for this job (ambivalence). I am worried about leaving my family.”

Clinician: “Do you think it will be hard for your family to adjust to you leaving, should you get this job (close-ended question)?”

Client: “Yes.”

Clinician: “Do you think you would earn the job if you apply for it (close-ended question)?”

Client: “I think so.”

Example 2 (Open-Ended Questions):

Client: I don’t know whether I should apply for this job (ambivalence). I am worried about leaving my family.”

Clinician: “What are your thoughts about applying for this job (open-ended question)?”

Client: “I would be excited to take this job because it is in a city that I have always dreamed of visiting (change talk). However, I am worried that, if I leave, my parents won’t be able to take care of themselves and my younger siblings (sustain talk). I visit my parents a few times a week to babysit while they are at work. If I leave, they would have to find a babysitter, which isn’t affordable at the moment.”

EXHIBIT 14.5 Supporting Statement Versus Affirmation

Example 1: General Support

Client: “I want to be there for my family (ambivalence), but I think I would earn the job if I applied for it (change talk).”

Clinician: “That is great to hear (partnership).”

Example 2: Affirmation

Client: “I want to be there for my family (ambivalence), but I think I would earn the job if I applied for it (change talk).”

Clinician: “You have great pride in caring for your family. Your compassion can translate well into the position you are considering to applying for (affirmation).”

The “A” in the OARS skill set stands for affirmations, which help build a positive relationship with clients and can interrupt monotonous interactions. You may validate a personal attribute or behavior to express positive regard and empathy. However, you must be cautious to only use the same affirmation once, because subsequent times could reduce the effect of the affirmation. Let’s continue the story line from the previous examples. This time, we compare a supportive statement to an affirmation (Exhibit 14.5).

In the first example, you tell your client that it is great to hear they feel capable of earning the job they are considering. You can say this because it is positive and promotes a collaborative partnership, but it may be too general because you are not focusing on the client’s strengths. Notice the level of detail in the second example. Current thinking in the MI community is that short, cheerleading-type affirmations, such as the first example, are less effective for building positive relationships or nudging toward resolved ambivalence.

EXHIBIT 14.6 Comparing Questions and Reflections

Example 1: Open-Ended Question

Client: “I feel determined to improve my life. I feel that this job could get me out of this funk I have been feeling for so long (change talk).”

Clinician: “Can you explain this funk that you are talking about (question)?”

Example 2: Simple Reflection

Client: “I feel determined to improve my life. I feel that this job could get me out of this funk I have been feeling for so long (change talk).”

Clinician: Getting this job will help your mood and self-esteem (reflection).”

The “R” in the OARS skill set stands for reflecting back your client’s statements. Reflections are the preferred skill in MI (Moyers et al., 2014). Instead of asking questions, you can read your client’s verbal and nonverbal cues to guess how they feel. In the previous example, you realized that your client was feeling uncomfortable about making a decision that will impact their family. To express empathy, respond to resistance or sustain talk, and promote change talk, you can use a few types of reflections.

One type of reflection is a simple reflection, which allows you to repeat what your client has said in your own words. This allows you to check your understanding, and if you are incorrect, the opportunity for your client to correct you. Let’s continue the above conversations to compare questions and reflections (Exhibit 14.6).

In the first example, you ask for information about the “funk,” so it is not actually a reflection. Reflections are statements, not questions. The question serves to clarify an emotional state, so is less adroit at resolving ambivalence. This is not to say you should avoid asking questions; however, in the second example, by rephrasing your client’s statement and highlighting the change talk component, you move toward resolving ambivalence about taking a job (i.e., target behavior).

Another type of reflection is a complex reflection, which takes a deeper guess at client meaning, provides stronger emphasis on what clients said (i.e., amplification), or steers the conversation to new places. This type of reflection is the most difficult to accomplish because you want to be bold but also to be accurate. Let’s take a look at our examples, comparing an inaccurate to an accurate reflection (Exhibit 14.7).

EXHIBIT 14.7 Inaccurate Versus Accurate Reflections

Example 1: Inaccurate Reflection

Client: “I feel like I’ve done nothing with my life. All I have known is being with my family, putting my dream to visit this city on hold so I can watch my siblings grow up.”

Clinician: “You seem angry with your parents for pressuring you to stay in town.”

Client: “I don’t feel angry or pressured. My family is fully supportive of me. I just worry that they will struggle without the extra support, from being there physically and emotionally to providing extra income (ambivalence).”

Example 2: Complex Reflection

Client: “I feel like I’ve done nothing with my life. All I have known is being with my family, putting my dream to visit this city on hold so I can watch my siblings grow up.”

Clinician: “Balancing your conflicting roles as caretaker and worker will become more difficult if you apply for this job and leave town, but on the other hand you know this is the only way to achieve your professional goals (double-sided complex reflection)”.

Client: “This is the only way to achieve my professional goals (change talk). Family will always be there.

EXHIBIT 14.8 Summarizing

Example 1:

Clinician: “You’re experiencing this funk that may be solved by accepting this job. However, you’re worried too much about your family and you need to decide what to do (double-sided reflection).”

Example 2:

Clinician: “You’ve shared how important two areas of your life are conflicting: your family life and your professional life. You are dedicated to both and you are concerned whether your family will be fine if you leave. On the other hand, you could break through your funk, live in an exciting city, and grow professionally (double-sided reflection). You also said your family will support you if you apply for this job. This is a tough choice for you (empathy), and you have to make it for yourself (autonomy). Which way are your leaning (open-ended question)?”

In the first example, you misread your client’s intentions. It is acceptable to be incorrect, and it is expected to happen at times. Your client will correct you, and you guess again. In this example, your client feels inadequate and does not want to miss the opportunity to reach their potential. In contrast, in the second example, you recognize your client’s dilemma, with a double-sided complex reflection, which reflects both sides of ambivalence. You typically see a double-sided reflection in this format: “On the one hand, … and on the other hand ….” You may also see metaphors used to help clients relate to their feelings, as seen in the “thin ice” example in the “Relational Component” section. When you use a double-sided reflection, you want to start with the ambivalence and end with the potential change (i.e., change talk). This prompts the recency effect, which encourages your client to continue discussing the change and move past their resistance.

The “S” in the OARS skill set involves summarizing your client’s story, topic, or session. You want to select the important parts of your conversation with your client and use a reflection that captures the gist of your client’s ambivalence and feelings to change. Summaries are appropriate as you transition to a new theme or topic or as you end your session. Let’s look at these examples and summarize where your client stands with applying for the job (Exhibit 14.8).

In the first example, you are focusing against your client applying for the job, reducing their willingness to discuss a plan to pursue the option they idealize. In MI, we refer to this as reinforcing sustain talk (i.e., client speech about staying the same). In the second example, you state the ambivalence but selectively focus on change talk. However, this is balanced with empathy and autonomy-preserving statements, so it does not come on too thick. Social workers refrain from using high-pressure tactics to help clients with decisions about change. If your client responds positively, you can take this consolidated list of reasons to apply for the job before you transition into planning this change.

Let’s review the OARS skills that we learned. First, we discussed how to strategically ask open-ended questions to elicit information. Next, we affirmed our client by sharing a positive quality that can facilitate your client’s ability to change, should they choose to apply for the job? Then, we reflected on your client’s reasons to apply for the job. Finally, we summarized the conversation and set up the conversation to discuss the application process. We reviewed examples that were inconsistent (Example 1) and consistent (Example 2) with these skills to demonstrate how to guide your client to resolve their ambivalence in an MI-consistent manner

Focusing

When your client is engaged in the session, you can turn to focusing on the targeted behavior. It is imperative that you establish the therapeutic relationship before discussing your client’s target behavior; otherwise, you risk resistance to discussing this behavior. Focusing dictates that you and your client negotiate on a shared goal. You may think there is a clear focus, but your client may disagree, and you don’t know what they want until you discuss and clarify their goals. For example, your client may wish to reduce but not stop their substance use, but you believe they should attend treatment and stop their substance use. Discrepancy exists between these goals, but you may combine your client’s plans and your expertise to identify a shared, realistic goal.

There are a few techniques you can employ to focus on this shared goal. One technique is setting an agenda that involves the change process (Miller & Rollnick, 2012). Change brings up many emotions, positive and negative, and you want your client to be in the best position to handle these changes. Your client may feel angry or upset with reducing their substance use because this activity is a key part of their social circle. They may feel embarrassed attending treatment because they need to inform their boss when they miss work, or they don’t want their family knowing about treatment but don’t want them to worry about coming home an hour later twice a week. Your client may also feel excited about the change, hoping to improve their familial relationships and work productivity. Their expectations may vary, from having no concerns that they will not have any issues along the way to having concerns that every step will result in a mounting set of obstacles. You want to optimize on MI-consistent behaviors, including reflections and affirmations, when exploring these emotions.

Another technique often used in MI is providing personalized normative feedback, which highlights a discrepancy between your client’s behavior and their peer’s typical behaviors. Additionally, screening results that have suggested cutoffs for problems may be used. The goal of providing personalized normative feedback or cutoff-based information is to gently raise awareness about potential problems. When such information is used, it is often called motivational enhancement therapy (MET) or screening, brief intervention, and referral to treatment (SBIRT), which are both derivatives of MI. For example, when conducting a substance use screening with your client that indicates risky or problematic substance use, you want to check with your client before discussing potential changes. You can review the screening by first asking permission, an MI-adherent behavior, before comparing them to their peers or expressing concern. Asking permission further engages your client by allowing them to select whether or not to receive information (i.e., collaboration and autonomy). When discussing the screening findings, you want to link your client’s behaviors with the consequences they face and how change reduces the risk for experiencing these consequences. One such example involves your client sharing that they miss work the day after binge drinking because their biting hangover causes migraines. Their substance use screen indicates that they binge drink at a rate three times higher than the national average. You can utilize this information, with your client’s permission, to suggest that reducing their binge drinking to a comparable rate of their peer’s may reduce incidences of work absence. This activity provides rapid focus, so is often used in medical settings when time is short.

As you and your client focus on your shared goal, you want to keep in mind that you should guide, not direct or follow. Directing results in diminishing the client’s expertise and plans, and following results in reducing your expert input on resources and techniques for achieving the goal. Now that you and your client share a focused goal, we continue with the next process: evoking your client’s inherent motivation to change their target behavior.

Evoking

The third process involves evoking your client’s motivation to change their target behavior. This step requires skillful navigation of the technical component—cultivating change talk and softening sustain talk—in conjunction with the relational component. We will explore the technical component of MIg and offer techniques to optimize your “MI spirit.”

Change Talk

The technical component of MI comprises specific clinician behaviors intended to evoke and reinforce client change language. When a clinician uses MI-adherent skills—including open-ended questions, simple and complex reflections, and affirmations—their client is more likely to use change language (Arkowitz et al., 2008; Miller & Rose, 2009), and when your client voices change talk, you see a higher probability of behavior change (Magill et al., 2014, 2018). Essentially, you as a clinician are key for prompting and continuing your client’s change talk and facilitating change behavior. Let’s examine two key factors: cultivating change talk and softening sustain talk.

The first factor we will consider is change talk, which refers to “spontaneously occurring speech from the client that favors a desired change” (Moyers, 2014, p. 358). Formerly called client self-motivational statements, clinicians cultivate change talk because of data implicating its role in actual behavior change.

The second factor we will consider is sustain talk, which refers to client speech about avoiding change. Some sustain talk is unavoidable, and clinicians focus on softening it when they hear it. That is, completely ignoring sustain talk is indicative of low empathy, or not communicating an understanding of your client’s views. So, the clinician’s dilemma is how to communicate understanding while simultaneously inching toward client speech about change. A tall task! Double-sided reflections are good for simultaneous communication of empathy while also pivoting toward change talk. In short, softening sustain talk is a skill used in conjunction with cultivating change talk to shift the conversation away from status quo language to focus on change language (Moyers et al., 2014).

Micro-Skills Related to Change Talk

One way to cultivate change talk as you move to mobilizing change talk and a change plan is the readiness ruler. The readiness ruler highlights the importance, confidence, and readiness to change. Variations of the readiness ruler exist such as: On a scale of 1 to 10 … (1) “… how important is this change,” (2) “… how confident are you in this change?,” and (3) “… how ready are you for this change?.” If your client answers with a number greater than 1, there is a motivation to change. To hone in on change talk, ask your client why they selected their number over a lower number. Again, do not feel compelled to ask all three of these questions in a single session. It may not be appropriate. Use these questions when you identify the need to discuss either importance, client confidence, or readiness. For example, it makes little sense to use a readiness ruler to ask about the importance of change after extensive discussion of this topic. Timing and flexible use of these skills are key.

Types of Change Talk

In order to recognize what counts as change talk, consider the acronym “DARN CAT.” “DARN” stands for the desire, ability, reasons, and need for change. “CAT” stands for commitment, activation, and taking steps. In this section, we focus on preparatory change talk, or the “DARN” part of the acronym, and in the next section, we cover how to mobilize change talk or the “CAT” part of the acronym. This is because “DARN” typically appears first in sessions when you are focusing on a target behavior. Thus, it is sometimes referred to as preparatory change talk. Desire statements indicate your client’s wishes to change their target behavior (e.g., I wish I could eat better). Ability statements are about your client’s confidence about implementing changing (e.g., I think I can do this if I get some support). Sometimes, clients recognize the importance of change but have low confidence. Reasons are often about the benefits for changing or the consequences of not changing (e.g., my clothes would smell better and I’m tired of being unemployed and having no purpose). Need statements are often a bit more emphatic, compared to reasons or importance statements. A client expressing the words “ought,” “should,” “have to,” or “must” is probably talking about the need to change. Clinicians should train their ears to hear client speech about change, for the purpose of strategically reflecting it back to promote change.

Planning

Once your client expresses sufficient indication that change is needed, clinicians begin negotiating a change plan. Here, it is common to hear commitment language, or the “CAT” part of the acronym: commitment, activation, and taking steps. Commitment refers to client statements expressing their willingness to execute change (e.g., I am willing to work on this). Basically, listen for statements outlining intention, promise, and planning for change. Activation statements are a bit tricky but have to do with taking specific steps in the future (e.g., I will set a quit date of August 5). Your client may express the date and time, location, and action they plan to make in the impending future. Taking steps is change talk about actions already taken in the recent past (e.g., I went to all my required meetings this week). As clients share the steps they take, it is important to affirm their change to preserve motivation and influence further substantial change.

In addition to planning for change action, it is imperative to plan for follow-up to remind your clients of their commitment to change, and if change did not occur, to refocus. It is alright if your client changes their mind, something unexpected comes up, or they decide to not change the target behavior in the planned way. Refocusing allows you and your client to clarify the target behavior, reevaluate preparatory change talk, and modify action steps that align with the target behavior change. You should develop short- and long-term goals, encouraging your client to look forward into the future should the behavior change occur. If your client needs further guidance or you are not the best fit for meeting their goals, you can give what is called a “warm handoff” to another clinician. You can do this by introducing your client to the new clinician or offering to be present while your client makes the call to schedule an appointment with the new clinician. By connecting your client with a clinician best suited to help them achieve their goals, you are promoting the success of your client’s target behavior change.

ASSESSING YOUR ADHERENCE TO MOTIVATIONAL INTERVIEWING

To measure the degree of success that clinicians are utilizing the relational and technical components, we use two assessment tools. First, the Motivational Interviewing Treatment Integrity Scale 4.1 (MITI 4.1; Moyers et al., 2014, 2016) is a structured measure that codifies two components: global scores and behavior counts. The four global scores are rated on a 1 to 5 scale:; they are partnership, empathy, cultivating change talk, and softening sustain talk. Three is the default score, with 5 meaning that you missed no opportunity to execute and embody the score and 1 meaning that there was no effort in attending to or practicing the score. The behavior counts, on the other hand, are recorded as the number of times each particular skill is used. The skills counted include questions, simple reflections, complex reflections, affirmations, collaborative statements, emphasizing autonomy, giving information, persuasion, persuasion with permission, and confrontation. Emphasizing, seeking, and affirming are MI adherent, and persuasion and confrontation are MI non-adherent. To achieve a “fair” score, you want to obtain a 4 for the relational component (partnership and empathy), 3 for the technical component (cultivating change and softening sustain talk), a 40:60 percent ratio of complex-to-simple reflections, and a 1:1 reflection-to-question ratio. To achieve a “good” score, you want to obtain a 5 for the relational component, 4 for the technical component, a 50:50 percent ratio of complex-to-simple reflections, and a 2:1 reflection-to-question ratio (Moyers et al., 2014). As you begin practicing with MI, we encourage you to aim for a “fair” score and progressively aiming for a “good” score.

To achieve MI adherence, you want to avoid two problematic, non-adherent behaviors: confrontation and persuasion. Confrontation is telling someone that they have a problem. This is the opposite of collaboration and autonomy and often indicates the “righting reflex,” which you may enact by advising or using the expert approach to order a solution. Your client will resist confrontation because they feel they do not have a say in the target behavior and change plan. Similarly, persuasion involves convincing someone to do something to change a behavior. It may be well intended, but it comes across as an expert-learner role rather than a collaborator. Persuasion does not help your client overcome ambivalence; it instead encourages your client to take an external, passive role in their behavior change. You want your client to possess internal motivation to change, and you can achieve this by refraining from confrontation and persuasion and instead employing reflections, genuine interest, skillful questions, and evoking change talk.

COMPATIBILITY WITH THE GENERAL-ECLECTIC APPROACH

Training in MI is compatible with both generalist and specialized perspectives in social work education. First, because the fundamental skills are often learned in generalist social work courses, there is substantial overlap of training in MI and most generalist practice courses. Second, MI dovetails nicely with the core social work values and ethics, as well as student competencies defined by the Council on Social Work Education (CSWE). Thus, training in MI illustrates abstract concepts such as self-determination and the dignity and worth of the individual. As nearly all therapeutic models stress the role of empathy in clinical work, training in MI gives a concrete platform for developing student competencies in this area. Finally, CSWE (2015) specifies both engagement and use of empirically supported treatments as critical competencies for social work students.

MI makes specific use of micro-counseling skills that are driven by a specific and empirically supported model of behavior change. Thus, it can be used in specialized practice classes where students are expected to understand practice models and be able to anecdotally respond to case scenarios. Students trained in some generalist courses prior to receiving specialty training in MI often voice concerns about “putting words in their clients’ mouths” when learning about complex reflections. Additionally, they have been taught to check on the accuracy of their reflections (e.g., “You feel furious about this. Do I have this right?”) However, in MI, there is great emphasis on dropping such checking questions that appear after reflections because they are thought to inhibit conversation. Instead, you can incorporate a variety of theories, including unconditional positive regard, cognitive dissonance, and self-perception, into your practice.

CASE STUDY 14.1

You recently completed a course on MI and you are entering your field placement at your local health center. Your supervisor is a licensed clinical social worker and provides individual mental health therapy. You prepare to meet with your first client. You learn they scheduled this appointment because their adult children believe they are drinking too much, and it is causing strain among family members. They do not see their drinking as problematic; they drink a few beers every night to “wind down” after a long workday and help them fall asleep. They describe how they recently lost their father to an overdose and believe their children are concerned about them, despite their consistent pattern for 20 years. They don’t think they have a problem, but they don’t want to worry their family. You note their ambivalence and reflect on their story. They are unsure how to best solve this problem. They are engaged, and your next step is to guide them through their change talk. Review this case study and take note of MI-adherent and MI-inconsistent behaviors.

You:

So, if I hear you correctly, you really care about your kids and you don’t want to be the cause of more stress in their lives (complex reflection, raising values to reinforce change talk).

Client:

Yeah, I just don’t know what to do, I don’t want them to worry, but I don’t think I have a problem. I just have a couple of beers every night to relax after work.

You:

So, for you, your kids are so important that you would do anything to keep them from stressing out (amplified reflection).

Client:

Yeah, I would do anything for my kids, and especially my grandkids.

You:

So, on one hand you are hesitant to give up your best relaxation method, and on the other hand your family’s concerns are hitting home to you in some regard (double-sided complex reflection).

Client:

Well, they are worried that my drinking is too much, but I’ve been drinking like this for quite a long time, I think they are stressing more because my dad recently died of an overdose. I think this is their reason on why I should cut down.

You:

I’m sorry to hear that. You really feel like you’re in a pickle. You’re grieving your father, and now you have this stress of your family harping on you about your drinking (empathy, complex reflection). Yet, you came today and are expressing some willingness to explore your families concerns about your drinking (cultivating change talk). So, where do you think you should go from here regarding your drinking, based on what would be useful to you (open-ended questions, focusing on collaboration and autonomy)?

CRITIQUE

Strengths

MI is practical when a person is ambivalent about change. You will frequently see patients in primary healthcare, substance use, and mandated treatment settings. Thus, in addition to providing a platform for learning foundation practice skills, MI—when done well—can be useful when working with clients who typically get labeled as “resistant” or “in denial.”

Limitations

The greatest limitation of MI is that it is not always a stand-alone intervention (Miller & Rollnick, 2009). It is a practical model for use when change is warranted and ambivalence is present. MI is not practical for cognitive or social changes. Evoking requires change efforts in a particular direction, and you must be careful not to let this influence you too much, causing you to stray from your client’s agenda. Thus, striking a balance between evoking change talk and your client’s desires is always a point of controversy.

CONCLUSION

MI is a communication style that elicits your client’s inherent self-motivation to change their target behavior. It can easily be blended with other interventions at points in the clinical process when client ambivalence emerges. MI includes two components: the relational component, outlining key values that enhance rapport with your client; and the technical component, inherent in the evoking phase of guiding your client through their ambivalence. Within the framework of the “MI spirit,” certain micro-counseling skills are used, depending on the stage of the relationship, which is referred to in MI as the four processes: engaging, focusing, evoking, and planning. MI is useful in both generalist and specialist training settings in social work.

SUMMARY POINTS

•Conceptualize the historical underpinnings of ambivalence and resistance formulating the MI model,

•critically examine how the MI model incorporates the client-centered, cognitive dissonance, and self-perception theoretical frameworks,

•illustrate the knowledge, values, and skills embodying the components of the “MI spirit”: partnership, acceptance, compassion, and evocation,

•cultivate change talk and soften sustain talk as you engage with your client in the four processes of MI: engaging, focusing, evoking, and planning, and

•integrate MI-adherent micro-skills and techniques as you practice social work from a generalist-eclectic perspective.