Motivational Interviewing - Listening for Change Talk
Motivational interviewing (MI) is a counseling style that integrates an empathic, non-confrontational style of counseling with powerful behavioral strategies for helping clients convince themselves that they ought to change. MI is directive, but uses instruction as only a part of the counseling relationship. Motivational interviewing includes a number of techniques, which enable the clinician to develop careful, practiced listening skills which create a productive atmosphere in which the client can decide if, what, and when they choose to change.
An important aspect of motivational interviewing is the clinician’s reinforcement of change talk. Change Talk refers to the client’s mention and discussion of his or her Desire, Ability, Reason, and Need to change behavior and Commitment to changing. The point here is that when people talk about change themselves, they are more likely to change than if someone else (such as the clinician, a friend or relative) talks about it . In this way, change talk is self advocacy. You may have had the experience of struggling yourself with a problem, then discussing it with someone else and finding that when you state the solution, it is more powerful than when your listener does so. A part of the process of learning motivational interviewing is learning to recognize change talk when you hear it from your client, and then reinforce it.
Listening for and appreciating the client’s ambivalence about change is a key element of motivational interviewing. We are all ambivalent when confronted with the need for and possibility of making changes in our lives. To understand ambivalence, try thinking about a change you have been asked to make, or think you should make, in your own life. Are you sure you want to change? Are you sure you are able to change? For example, perhaps you would like to get more sleep, but find it hard to go to bed earlier. There’s just too much to do, or your favorite TV shows are calling you, or it’s just too nice being up after everyone else is asleep and the house is quiet. Another common example in people’s lives is wishing you could exercise more, to improve your health or to lose weight. It sounds like a good idea, but by the end of your work day, you’re tired and it’s hard to be motivated to exercise. You feel two ways in both examples. On one hand you have good reasons to make the change, but there are other equally compelling reasons not to. You are ambivalent about change, even if it is in your best interest. Our clients often feel the same way about the changes we are asking them to make. One key to listening for ambivalence is the “but” in the middle of the sentence. “I’d like to make that change, but…” When you hear ambivalence, you are also hearing change talk.
In substance abuse treatment, as in many other areas of health behavior change, we are asking clients to give up something very important in their lives, often for things they don’t understand or don’t like. It is important for the MI clinician to understand both sides of the client’s story, and to see things from their point of view, even if we disagree. Our goal as careful listeners is to selectively reinforce the client’s speech that is in the direction of change, or leaning towards change.
Change talk is heard in five categories, Desire, Ability, Reason, Need, and Commitment, or DARN-C. Learning to listen for the subtleties of meaning in your client’s conversation in these five categories is very important in Motivational interviewing. Using these questions can help to elicit change talk:
- Desire: Why would you want to make this change?
- Ability: How would you do it if you decided?
- Reason: What are the three best reasons?
- Need: How important is it? and why?
- Commitment: What do you think you’ll do?
Here are some examples of how conversations might go:
Clinician: If you were going to change your alcohol use, why would you do it?
Client: Well, my doctor’s been nagging me, and I’m beginning to think she’s right. I’ve got to do something or my liver just won’t take it anymore. Besides, my blood pressure’s just too high.
Clinician: So, you’re thinking your doctor might be right about your drinking too much, because of your liver and your blood pressure.
Clinician: I know you’re not ready to begin to change your marijuana use, but if you were, what are some things you would do?
Client: It would be very hard for me, because I love my weed. I’d have to start by cutting back to just smoking after work.
Clinician: While it would be hard for you to cut back, it seems like just smoking after work might be a place to start.
Clinician: Can you give me three good reasons why you might consider changing your drinking?
Client: Oh, if you talked to my wife she’d tell you at least three! She’s been nagging again. She says I’m not reliable and don’t come home when I say I will and that I don’t remember some conversations. I guess she’s right about those things.
Clinician: It seems that things might be more peaceful in your marriage if you were drinking less.
Clinician: How important would you say changing your drinking is right now?
Client: Not very.
Clinician: Why do you say that?
Client: I have so many other worries about my health.
Clinician: It seems to you that your drinking is not the most important thing right now. What would have to happen to make it more important?
Client: I think if I had another DUI and lost my driver’s license that might get my attention.
Clinician: What do you think you’ll do about changing your drinking? What ideas do you have for yourself?
Client: I’m not sure. I could try what my best friend is doing, to go to one AA meeting just to see what it’s like.
In each of these conversations, the clinician responded with reflective statements, which summarize the change talk statements the client made. It is important to understand that the clinician would acknowledge the statements that are the “no change” side of the ambivalence, but reinforce the change talk.
Motivational Interviewing is a very powerful style of counseling for many health behavior changes. Once learned, the MI style of appreciating the limits of trying to persuade our clients to change their behavior makes our job much easier. We are not responsible for whether or not our clients change, but for helping them decided if they want to or can change, and if so, how to do so.
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