How to do motivational interviewing - summary of an book by Matulich (2013)

How to do motivational interviewing
Matulich (2013)

Prologue: peparing for an Motivational interview session

Doing motivational interviewing starts before you see the client. You need to have an attitude of extreme respect for your client. You have to strive to work in partnership and see things from your client’s perspective. Your role si to explore your client’s own motivation and draw out his or her own solutions. The client alone is responsible for making decisions.

The spirit of motivational interviewing is: 1) partnership 2) acceptance 3) compassion 4) evocation.

Preparing your mind

In the motivational interviewing approach, you want to accomplish four things with your clients: 1) Resist; to resist the tendency to tell your clients what to do or try to ‘fix’ their problems 2) Understand: to uncover and understand your clients’ own motivations and solutions 3) Listen: be empathetic and listen carefully, striving to understand your clients’ perspectives 4) Empower: empower your clients and encourage their hope and optimism.

Preparing your space

De-clutter your mind of distractions, and do the same as the place where you see your client. Anything that could be a distraction should be dealt with, or at least planned for, before the session begins.

Act 1: openings and beginnings

Goals

The beginning of a session is important for setting the tone for working with your client. Goals of the first few minutes include establishing rapport and engaging your client.

The beginning of the session is a good time to express appreciation for the client coming in or keeping the appointment.

It is important to let the client know what to expect.

Engaging the client consists of four processes: 1) engaging 2) focusing 3) evoking 4) planning.

You should avoid: asking too many questions, as in doing some formal assessment, being the ‘expert’ in the relationship, labelling our client, assigning blame for the problem and chatting with the client rather than getting down to business.

Setting the agenda

Setting the tone during the opening session depends on your role and what needs to be accomplished during the session.

A good way to open a session is by introducing yourself, expressing appreciation, and explaining what your role is and what you hope to accomplish. The statement should include information about the amount of time you have to meet and any details or tasks that are required to be taken care of during the session. This beginning should end with an open question that invites your client to begin to discuss whatever is on her or his mind and/or freely respond to your opening statement.

Your client’s agenda

During the first part of the session, special consideration needs to be paid to the process of collaborative agenda setting. Focusing is an ongoing process of seeking and maintaining direction.

After the initial few minutes of a session, you will start to develop rapport and begin to learn what is on the client’s mind and what his or her aspirations for the session are. Attention needs to be paid to the client’s agenda at least as much as you’re the agenda of the professional.

In motivational interviewing, we generally take the position that the client’s agenda is the one to follow, at least in the beginning of the session. Listening to what is on your client’s mind and what his or her priorities are, helps to establish a useful rapport and engage your client. Be explicit in your appreciation of the client’s priorities in setting the agenda by simply asking an open-ended question that invites the client to talk.

Mandated agendas

Sometimes you don’t have the luxury of completely following your client’s agenda. In such cases, the motivational interviewing style is to present a menu of options for the client to choose from. The main idea is to find out what the client wants to discuss or address within the framework of your field of expertise while giving the client as much autonomy as possible.

Specific tools used in the beginning of a session

The specific motivational interviewing tools and techniques that are recommended for the beginning of a session include: 1) open questions 2) affirmations 3) reflections 4) summaries.

Open questions

Open questions can be used in the beginning for gathering information, identifying a target behaviour or focusing on a particular topic, and elicit change talk.

Open ended questions leave room for your client to talk about what is on his or her mind. They also put the responsibility for moving the conversation along on your client’s shoulders.

Closed questions

Closed questions are not banned entirely. It is generally better to ask more open questions than closed questions.

You will know if the ratio open to closed questions you are using is appropriate by your client’s responses and reactions.

Querying commands and useful closed questions

Querying commands are a kind of open questions stated as a command. For example ‘tell me about your life’.

A certain type of closed question has the same effect as asking an open question. For example ‘can you tell me about your life?’ Sometimes, these kinds of questions can seem a bit more polite than a querying command.

The problem with questions

The question-answer trap is a situation in which you are asking one question after another and your client is just answering them and waiting for the next question. This usually happens when the counsellor is relying mostly on closed questions. The client becomes more passive while the counsellor feels more pressure to come up with the ‘expert’ questions.

To avoid this trap, it is advisable to not only ask more open questions than closed questions but to follow up answers to open questions with reflective listening.

Reflections

Reflections are the most useful tool in motivational interviewing.

Reflections are statements made to the client that mirror, give back, repeat, rephrase, paraphrase, or otherwise manifest what you hear the client saying or see the client doing. They are guesses about what is going on in the client’s mind.

Keys to good reflections are that they are delivered confidently as statements with your voice inflection going down rather than up at the end.

A good way of using reflections early in a session is to rely more on simple reflections, such as repeating and rephrasing what you are hearing. More complex reflections are usually used after the session progresses.

The purposes of using reflections in the early part of a session are to convey what you are hearing and understanding what your client is telling you, gathering information and building rapport.

Listening to your client as you attempt reflections will give you all the information you need to get better at reflective listening.

Summaries

Summaries are long reflections during which you reflect some of what you’ve heard your client say during a significant portion of the session. Uses for summaries are: 1) if you seem to have exhausted a topic, you can summarize to transition to a new topic 2) you can highlight and reinforce significant client motivational statements 3) connect different things you’ve heard during a session 4) make sure that you are understanding what the client wants or expects during the session 5) Use them if you get stuck, to see if the client adds anything.

Often, summaries are followed by an open question which moves the conversation along to a new level or on to a different topic.  

With a summary, you can ask your client for feedback directly.

Affirmations

Affirmations are statements that you make to your client that recognize your client’s strengths, accomplishments and positive behaviour. They help build self-efficacy by pointing out what your client is accomplishing or has accomplished. In the beginning of the session, affirmations demonstrate respect and appreciation for your client and help to engage your client.

Target behaviour

The goal of focussing is to identify a target behaviour or a direction in which to proceed.

You may hear the client identify some behaviour (s)he seems to want to change almost immediately. It is worth being patient and exploring the apparent target behaviour to see if this is truly what the client wants.

Assessing motivation

You want to assess your client’s level of motivation. A good way to do this is by the use of scaling questions, and follow-up questions to the scaling questions.

Scaling questions

Two scaling questions you can ask are: 1) on a scale of 0 to 10, where 0 is not important at all and 10 is crucially important, how important is it for you to make this change? 2) on a scale of 0 to 10, where 0 is no confidence at all and 10 is completely confident, how confident are you that you can make the change?

These questions can give you a good measure of client motivation, and can reveal some interesting aspects about your client’s challenges in changing behaviour.

Two follow-up questions to ask after the above questions, if you want to begin to elicit change talk are: 1) Why did you pick ___ and not a lower number? 2) What would it take to motive it to a higher number?

When you ask these questions, you will begin to elicit speech that favours movement in the direction of change or ‘change talk’. You will begin to hear why the change is important. This is the kind of speech you want and you want to reinforce it an strengthen it with reflections.

Once you begin to evoke change talk, you know you’re getting into the ‘heart’ of the session. If all has gone well, you can follow your client’s lead in a truly client-centred way as the session progresses.

In follow-up questions, you should not: 1) ask why the number isn’t higher, this is likely sustain talk, and entrench you client more in the status quo 2) give in to the urge to ‘fix’ the problem by offering solutions or advice that hasn’t been asked for, you will likely discord in the relationship or disengage your client 3) Counsellor advocacy responses, arguing for change, assuming the expert role, criticizing, shaming, blaming, labelling, being in a hurry, or claiming pre-eminence 4) ordering or commanding 5) threatening 6) persuading with logic 7) moralizing 8) judging 9) agreeing 10) interpreting or analysing 11) humouring

ACT 2: the middle of the session

As the session progresses, you gain a deeper understanding of your client’s motivation. Your focus is on listening for change talk and ambivalence and your goal is to elicit and reinforce your client’s arguments for change. You amplify these arguments with the proficient use of OARS skills and guide the conversation toward a plan of action.

You explore ambivalence, bringing it to the table through the strategic use of reflections and summaries. Once it is explored, your responses tend to get more directive by selectively responding only to specific types of speech from the client. You select specific questions with the purpose of either eliciting change talk or exploring the client’s ambivalence. You rely more on reflective, emphatic listening.

Ambivalence

Ambivalence means feeling two ways about a decision or a potential change in behaviour. It is wanting and not waning something or wanting two incompatible things at the same time.

Avoidance perpetuates ambivalence and keeps people stuck. You want to hold your client in the anxiety producing ambivalent state long enough to explore both sides thoroughly until your client beings to tip the balance toward healthy behaviour change.

You don’t want to argue for change with an ambivalent client. People resist persuasion and believe what they hear themselves saying. Hearing his or her own arguments, your client may become less motivated.

Change talk

Change talk is speech that favours movement in the direction of behaviour change or clients’ own argument for change.

Five types of change talk are client speech that expresses: 1) desire 2) ability 3) reason 4) need 5) commitment.

Specific tools used in the middle of a session

The specific tools used in the middle part of the session are OARS. The purpose changes as you become more directive. 1) The open questions are more targeted and are used in conjunction whit specific strategies 2) the reflections are more complex and selective 3) the affirmations serve a purpose being establishing rapport 4) the summaries become strategic and are structured to move the client toward making a commitment.

Strategic open questions

One purpose for strategic open questions is to elicit change talk.

Six ways to elicit change talk by using open questions are: 1) evocative questions, asking for it, use an open question to ask directly for the kind of change talk you want. 2) Asking for elaboration, help to clarify change talk you’ve already heard. 3) Querying extremes, ask about the best and worst things that could happen if the client could change behaviour, or doesn’t change behaviour. 4) Looking back, ask about a time in the past when things were different 5) Looking forward, ask about an imagined time in the future if a change occurs, or if there is no change. 6) Exploring values and goals, ask about how the target behaviour fits with the client’s values and goals.

You know if your are open questions skilfully to get change talk by paying attention to the types of responses you are getting from your client.

Open questions are also used to explore ambivalence. One way to do this is by using a decisional balance worksheet. This asks four open questions 1) what are the advantages of changes? 2) what are the disadvantages of changing? 4) what are the advantages of the status quo? 4) what are the disadvantages of the status quo?

Use elaboration questions to get complete answers to these four questions. You could use a worksheet.

Questions vs. reflections

Reflections create momentum. Skillfull reflecting reinforces and creates more change talk, guiding the client to argue more for change. In motivational interviewing, we want the client to be responsible for change.

Complex reflections

Complex reflections include: double-sided reflections, paraphrasing, using metaphor, continuing the paragraph, reflecting feeling and taking more risky guesses as to what the client is meaning by what is being said.

Reflect as much change talk as you can.

You can use reflections to elicit change talk. If the client isn’t giving you clear speech in the direction of change but seems tentative, you can reflect back change talk that you assume the client is meaning to say. If the client agrees, you have change talk.

One of the most powerful uses of reflection is to use double-sided reflections to explore and resolve ambivalence. Simple making the ambivalence obvious, is sufficient to allow a person to begin to resolve the ambivalence on his or her own.

Reflecting feelings is important because change is unlikely if your client’s emotions aren’t engaged. When you tap into your client’s emotions, you tap into energy that can be used to help motivate change.

Mirror back to the client the change talk that you want to hear.

Affirm to strengthen confidence

Affirmation encourage and engage your client’s hope and optimism.

If your client’s confidence is low, your want to help to build it up. People’s confidence isn’t the same for all tasks.   Affirming accomplishments, strengths and other positive behaviour an increase a person’s confidence overall. Making the connection that our client can succeed in one area and may be able to apply some of the same strategies to succeed in another is a form of affirmation that can help build confidence in changing behaviour in a healthy direction.

Calling to past attempts to change target behaviour, and reframing those attempts as persistence can help increase confidence levels.

Your client will let you know if your affirmations have any effect.

Summarize strategically

Because you do not summarize everything you’ve heard and you get to select what to summarize, you can become directive. Ideally, this has the effect of focussing your client’s attention in the direction of change.

Resistance vs. discord

Clients have varying degrees of resistance upon first meeting you. Your job is to lower resistance while raising motivation.

Resistance is seen as a function or characteristic of the interaction styles between client and counsellor.

When considering change, people go through a stage of ambivalence. Statements that favour the status quo are not considered a sign of client resistance. You can use these statements to help your client understand his or her own ambivalence by reflecting them back in a double-sided reflection.

Discord is different from sustain talk and includes: 1) disagreement 2) not being on the same wavelength 3) talking at cross-purposes 4) a disturbance in the relationship.

Discord can be modified by what happens in the session. Using the OARS skilfully an reduce, or prevent discord.

Discord is a signal that something is amiss in the relationship, so you must change your approach.

One of the biggest sources of discord is the righting reflects. This is a situation in which the solution to the client’s issue becomes clear to you before it becomes clear to the client and you feel compelled to offer this solution, usually in the form of some kind of advice.

‘Yes butting’ is a sign that you are up against discord in the relationship. Other signs might be that you feel like you are arguing or wrestling with your clients or are working harder than your clients.

In motivational interviewing, we welcome discord as a signal that we are moving too fast or the timing is off. The solution is usually to: back off, examine what you are doing, ask yourself if you are moving too quickly or engaging in the righting response or telling your client what to do without permission and take a breath and go back to the basis of motivational interviewing.

Reflecting listening tends to reduce discord. Other techniques are acknowledging your client’s autonomy and to shift focus.

Giving advice and information

In motivational interviewing, the focus is on helping clients find their own internal motivation to pursue the solutions or behaviour changes that they already know are important. Often clients know what they need to do to reach the desired goal and once ambivalence is resolved, they can move one and be successful.

To provide necessary advice or information you should 1) make sure that the client is really asking for advice or at least has come to some impasse and lack of knowledge without which (s)he cannot continue to pursue his goal 2) deliver advice in an motivational interviewing coherent manner (collaboration, acceptance, evocation, and compassion). You may ask permission first

When you are required to give a certain amount of information, it is best to just say this to the client, but give the client as many options as you can.

ACT 3: commitment

The motivational interviewing approach is to summarize all the change talk you’ve heard up to this point and then ask a key question like ‘what is your next step?’, which brings you to the planning phase.

Another approach is to revisit questions that you’ve been asking throughout the session to get your client to verbalize his or her motivation and commitment, then follow a series of such questions with a key question to move into the planning phase.

Once you get an answer to the questions and the key question, you follow up with reflective listening to work out a change plan.

Change plan

A change plan consists of setting and clarifying goals, arriving at a plan, and eliciting commitment. You want to make the goal as clear as possible. If there are multiple goals, you may need to work with your client to prioritize them.

Use your skills to evoke your client’s own plan for changing. Your goal is to go form general ideas and goals about changing to a specific, workable plan of action.

SMART goal setting includes a goal that is 1) specific, focus on what exactly your client wants to do  2) measurable, there are clear methods for knowing whether or not the goal has been achieved or progress is being made 3) attainable, the goal should be something your client can accomplish. It needs to be challenging but achievable. 4) realistic, goals must be doable based on where your client is at currently 5) timely, there is a time frame for the accomplishment of the goal.

The last thing you want from your client is a clear statement of commitment, of agreement to the change plan. When this happens, the clients will change on their own. In other cases you both may agree to continue to work together so that you can support your client’s efforts.

End the session by expressing appreciation to your client. Acknowledge the hard work and express optimism and hope and encourage your client to pursue his or her goals.