If you have even a small track record of helping people change, you are familiar with the dynamics regarding change: client presents with problem (often precipitated by a crisis), becomes aware of compelling reasons to adopt a healthier lifestyle or cease harmful behaviours, and then hems and haws, straddling the fence with incomprehensible ambivalence.

Persuading the client with logic, browbeating them by outlining dire consequences if behaviour is not immediately changed, pulling rank as “the expert”, or even describing in glowing terms the wonderful life they can have if they adopt the good advice often come – frustratingly and bewilderingly – to nothing. Some of these strategies, in fact, have the opposite effect, building resistance and/or undermining the therapeutic relationship which could facilitate the change. Thus, commitment to a motivational interviewing approach must be accompanied by a clear sense of the operating principles, fleshed out with equally clear skills utilisation.

The spirit of MI can be translated into five central principles summarised by the acronym DEARS:

• Develop discrepancy
• Express empathy
• Amplify ambivalence
• Roll with resistance
• Support self-efficacy (Braastad, n.d.)

Develop discrepancy

John Galbraith once said that, given a choice between changing and proving that it is not necessary most people get busy with the proof (Latchford, 2010). The client comes (or is mandated to come) to see you because of needing to either change from unhealthy behaviour (such as drinking, smoking, or gambling) or to more healthy habits (such as taking up an exercise regime or adhering to medication). As you begin to establish relationship and a therapeutic alliance with your client, the truth of Galbraith’s words becomes evident; the client is acknowledging that something is not right in their world, but spending serious energy in session disavowing that they really need to change. Thus, your job becomes that of helping them think about change. You may protest that it would come up in the conversation anyway; after all, that is why they are in your rooms. This may be true, but when a potential change is highly charged with emotion, the natural human tendency is not to think about it, or at least some aspects of it. Your task is to ensure that there is an honest discussion about the consequences of not changing as well as changing.

Scaling questions

Techniques under the principle of developing discrepancy help you focus on the gap between where the person has been or currently is and where they want to be. Using the skills of MI (in the next section), you raise the client’s awareness of the problem. Some of the ways in which you can do this include the use of scaling questions; they are simple assessments which focus on two things crucial to change: importance (i.e., when the client understands, “I know I ought to change”) and confidence (“I know I can change”). A sample question to test for the former might go like: “How important do you think it is for you to change right now, on a scale of one to ten?” That can be followed up with a similar question about confidence: e.g., “How confident are you, on a scale of one to ten, of being able to change?” Such scaling questions are highly useful as they immediately focus the session on the present, and can highlight potential barriers to change long before they can disrupt your work together. A further follow-up question asks, “What would it take for you to be at X (a rating position a little higher than the number the client has given)?”

Decisional matrix

The whole process of MI is, in a way, a decision aid for clients deciding whether or not to change a behaviour. Your job is to bring out the scales, helping the client weigh up the pros and cons of changing and ensuring that weights placed on the side of change get an open, honest, “fair” hearing. The list below can assist this discussion:

Benefits of [staying the same] ____________________________
Costs of [staying the same] ____________________________
Costs of [changing] ____________________________
Benefits of [changing] ____________________________

A recommended way of moving through this is to start with the benefits of staying the same. That should get the discussion going, as most people have very good reasons for not changing! Then move to the costs of staying the same. From there move across to discussion of the costs of changing, finishing up with the benefits of changing. Bringing the costs of staying the same out into the open helps; it creates the cognitive dissonance that makes change much more likely. Of course, you must do it sensitively, in order not to create resistance (Latchford, 2010).

The Columbo approach

Proponents of motivational interviewing owe a debt of gratitude to the 1970s television series Columbo. The Columbo main character (played by Peter Falk) was a master of the skill of “deploying discrepancies”, and MI therapists/practitioners can use the same skill to get clients to help them make sense of their (the clients’) discrepancies. With the Columbo approach, an interviewer makes a curious enquiry about discrepant behaviours without being judgmental or blaming. In a non-confrontational manner, information that is contradictory is juxtaposed, allowing the therapist to address discrepancies between what clients say and their behaviour without evoking defensiveness or resistance. Wherever possible when deploying discrepancies, practitioners are encouraged to end the reflection on the side of change, as clients are more likely to elaborate on the last part of the statements. Here’s one intervention using the Columbo approach:

“It sounds like when you started using party drugs there were many positives. Now, however, it sounds like the costs, and your increased used of them, along with your partner’s complaints, have you thinking about quitting. What will your life be like if you do stop?” (Adapted from Sobell & Sobell, 2008)

In the following examples (also using the Columbo approach), the therapist may sound somewhat unsympathetic, but clients may find that preferable to being told they do not make sense!

“On the one hand, you say you want to live long enough to study music and become a famous pianist performing all over the world. On the other hand, you are not following the treatment and taking the medication for your diabetes. How will that help you to live longer?”

“Please help me understand. You say that you really want to create a secure and prosperous family life for your wife and young sons, but you also acknowledge that you have increased your visits to the casino, and that your gambling debts are mounting up quickly. I am wondering how continuing to gamble helps to creates security and affluence.”

“So, help me get this. On the one hand, you are tired of hassles and want a life without problems, but on the other hand, you were told to come here because of the drink-driving charge, and your employer has threatened to fire you if you are again found to be drunk at work. I am wondering how continuing in this way with alcohol will help keep your life problem-free.”

Sample interventions to help develop discrepancy:

• Tell me some good and not so good things about your behaviour.
• How do you think your life would be different if you were not ____ (drinking, smoking, skipping your medication, getting stressed out, etc)?
• How do you imagine your life to be like if you don’t make changes and continue to ____ (use, gamble, smoke, etc)?
• How does your _____ (risky behaviour) fit in with your goals?
• On one hand, you say that your _____ are important to you, yet you continue to _____. Help me to understand…
• What do you feel you need to change to achieve your goals?
• How will things be for you a year from now if you continue to _____ (have risky or compulsive sex, eat a high fat diet, let your blood sugar get out of control, etc)?
• Hypothetically speaking, if you were to make a change in any area of your life, what would it be? (Braastad, n.d.)

Express empathy

One of the most important elements of motivational interviewing is that of empathy: the ability to view the world through the eyes of our client, to step into their shoes, figuratively speaking, and to experience the world as they do. Through empathy, we come to deeply understand another’s concerns and their reasons for behaving as they do. When people feel understood, they are more likely to share their experiences with us, which makes us more able to determine where they need information and support. Empathic listening is vital to minimising resistance and has a major impact on a client’s willingness and capacity to change. High levels of empathy are associated with positive results across a broad range of different therapies (Braastad, n.d.).

In practical terms, empathic communication calls on our reflective listening skills and our capacity to accurately reflect the client’s perspective without judging, criticising, or blaming. To act with empathy is not to condone a client’s behaviour. Rather, it is to create an open and respectful exchange with the client, whom we approach with genuine curiosity about their feelings and values (Hall et al, 2012).

Sample expressions of empathy:

• I appreciate how difficult this is.
• Yes, making change is hard work: VERY hard work!
• That must have been hard on you.
• I know where you’re at with this.
• If I were experiencing what you are, I can imagine that I would feel similarly (Braastad, n.d.).

Amplify ambivalence

Closely related to the principle of developing discrepancy, amplifying ambivalence is about recognising and verbalising where the client is “of two minds” (diametrically opposed to one another). Ambivalence to change is normal, but MI is as effective a change technique as it is because the “to-ing and fro-ing” between the two poles can paralyse clients, causing them to remain stuck. As you bring the ambivalence out into the open and explore the two sides the client is dealing with, the client is enabled to work through it, opening the door to change. Put another way, when ambivalent feelings are not worked through, long-lasting behaviour change is unlikely.

Sample amplifying ambivalence interventions:

• How has your behaviour been a problem to you? How has it been a problem for others?
• What was your life like before you started having problems with ____ (compulsive shopping, smoking, drinking, etc)?
• If you keep heading down the road you’re on, what do you see happening (Braastad, n.d.)?

Roll with resistance

Like ambivalence, resistance is a normal reaction when people are considering change; as a helping practitioner, you must be prepared for a certain amount of it. Avoiding confrontation reduces but does not eliminate it. By paying attention to the client’s discourse patterns, you can spot the words and actions which indicate that the client is resisting. These include arguing, interrupting, denying, and ignoring. To look out for resistance overcome, particularly at the end of the session, pay attention to DARN: words that show Desire, Ability, Reason, and Need to change.

Typically, however, instead of hearing DARN words, you are likely to be confronted with resistance. So you may ask: how and when can you talk about change without increasing the resistance? A possible answer to this question is another question: to the client. It can be a permission-requesting question, something like, “Is it ok if we talk about ______ (the medication, your drunk-driving charge, your blood sugar problems) now?” This may elicit the well-worn phrases and thoughts (repeated thousands of times in the client’s head!) that represent resistance to change. Even broaching the problem behaviour with a question may prove to be quite sensitive, so your ability to handle resistance may be one of the most useful skills you can develop.

Note that the resistance may have been forming for a long time, so it is there, ready to spring into your conversation with the client, before you even say anything. Here are some examples of resistance talk:

• Disagreeing: “Yes, but . . . “
• Discounting: “I’ve already tried that”
• Interrupting: “But . . .”
• Sidetracking: “I know you want to talk about how I fell off the wagon (got drunk) last week, but have you noticed how faithful I’ve been about attending the AA meetings?”
• Unwillingness: “You want me to do that as well?”
• Blaming: “It’s not my fault. When my partner starts in with . . .”
• Arguing: “I don’t care what the research says. How do you know that’s true in my case?”
• Challenging: “Well, meditation might work for some people, but it doesn’t help me at all.”
• Minimising: “I’m not that overweight.”
• Pessimism: “I keep trying to do better on this, but nothing seems to help.”
• Excusing: “I know I should consume less sugar, but with my intense work schedule, there’s no bandwidth left over for micro-managing my food intake.”
• Ignoring: (The client turns away or changes topic, ignoring your interventions) (adapted from Latchford, 2010).

Avoiding “the righting reflex”

Understandably, as therapists and practitioners, the natural response to resistance talk such as the above tactics evokes in us a felt need to work harder to persuade the client, to let them know that they are wrong (we, of course are right). This “righting reflex” is to be resisted at all costs, as it is the prime response on our part which feeds an escalating spiral of resistance, to the total detriment of any possible change. Instead of playing into a power struggle, we can adopt a motivational interviewing stance, which would say that our job is to clarify and understand, inviting consideration and openness to new perspectives. By encouraging people to come up with their own solutions to situations as they define them, we invite them to new ways of thinking without badgering, lecturing, or imposing our views on them. Emphasising and allowing personal choice and control over their problems can help minimise resistance, as can statements about how normal resistance is.

Offering advice the MI way

Although discouraged from the righting reflex or other means of communicating “I’m right and you’re wrong”, MI practitioners nevertheless are encouraged to provide advice or feedback to clients. If you’re frantically trying to re-read that last sentence to figure out how it makes sense, rest easy. It is true: advice-giving is ok in motivational interviewing; you just have to do it in the right spirit. Clients often have either little information or else misinformation about their behaviour. Typically health practitioners have used only simple (direct) advice to relay information or get clients to change behaviour: the format, “If you continue _____ (unhelpful behaviour), you are going to have _____ (whatever dire health consequences)”. The effectiveness of this form of advice-giving is highly limited; estimates are that only 5 – 10 percent of smokers, for example, will quit when told to because smoking is bad for their health.

Why doesn’t it work? Researchers reckon that is because most of us do not like being told what to do. Rather, most people prefer being given choice in making decisions, particularly changing behaviours. MI helps people change because it recognises that how information is presented affects how it is received; thus new information must be presented in a neutral, nonjudgmental, or sensitive manner which empowers clients to make more informed decisions about change. One way therapists/practitioners can do this is by providing feedback which allows clients to compare their behaviour with that of others so that they know how their behaviour relates to national, and sometimes international, norms. Presenting personalised feedback in a motivational manner allows clients to evaluate the feedback for personal relevance.

You might open the possibility of advice by asking a client what they know about their risky/problem behaviour and how it affects other aspects of their life. They typically may claim not to know too much, followed by offering a brief fact or two. In the MI spirit of advice-giving, you could then follow that response with a question as to whether they are interested in learning more about the topic. If they are, you have permission to provide material about the effects of smoking, drinking, bingeing/purging, etc. Ending with a focus on the positives of changing is most effective. Note that some clients will not want more information. In these cases, any therapist use of scare tactics, moralising, warning of catastrophic consequences, or even lecturing will undermine the therapeutic relationship, causing clients to feel attacked and – probably – mean that they stop listening (Sobell & Sobell, 2008). Here are five sanctioned ways you can offer advice within MI:

• Ask permission: “If you’re interested, I have a recommendation (idea/suggestion/tidbit) for you to consider. Would you like to hear it?”
• Offer advice: “Based on my experience, I would encourage you to consider _____” or “From what I have observed, it seems that _____ might be a good option for you.” In cases where the client’s current situation is urgently harmful, you must try to get some action going right away. In this case, you may make a stronger statement: “As your _____ (psychotherapist/social worker/health care professional), I urge you to _____.” “In my best professional opinion, I must urge you to consider _____ now.”
• Emphasise choice: “Of course, it’s your decision.” “Naturally, it’s up to you.”
• Elicit response and more change talk: “What do you think about this suggestion?” “How do you think this might fit into your current situation?”
• Voice confidence: “I feel confident that if you decide to _____, you will find a way to do it” or “I feel certain that if you commit to doing this, you will have the will power to carry it through” (adapted from Berg-Smith, 2001).

Try the therapeutic paradox

180 degrees around from the righting reflex – in terms of therapist response, at least – is the therapeutic paradox, in which paradoxical statements are used with clients in an effort to get them to argue for the importance of changing. These are particularly useful for clients who have been coming to treatment (say, counselling sessions) for some time but have made little progress. Paradoxical statements are intended to be perceived by clients as unexpected contradictions. As MI practitioners, we hope that after clients hear such statements, they will seek to correct by arguing for change. Here’s how an exchange involving therapeutic paradox might go:

“Sally, I know you have been coming to these weight management program sessions for two months, but your food diary shows that you are still eating in the way that you were before you began, and you haven’t shed any weight. Perhaps now is not the right time for you to try to lose the weight?”

In employing this strategy, we hope that the client will counter with an argument indicating that he or she does want to change: something like, “No, I know my health demands that I lose the weight; it’s just tough following the new food rules.” Once the client has affirmed that s/he would like to change, the exchanges that follow can identify the reasons for which progress has been slow up to now. In the event that the client does not immediately produce the desired response – arguing for change – the therapist can suggest thinking about what was said between now and the next session. Sometimes the combination of the paradoxical statement with being asked to think about it is enough of an eye-opener for clients.

Because therapeutic paradoxes involve some risk – that is, the risk that the client will agree and argue against change – some MI experts prefer to reserve this strategy for times later in a treatment program when a client may not be making much progress, but may not be aware of that fact. Another reason to keep this strategy until some work has been undertaken is that paradoxical statements can have a negative effect on a client. Moreover, clients can be fatally offended if the therapist sounds insincere or sarcastic in expressing the paradox. Always, the therapist should be prepared that the client might decide that the therapist is right; now is not the time to undertake the change.

In such a case, the reasons can be discussed and the therapist can suggest a holiday from the treatment program. The therapist can then ring the client in a month or so to see what is happening with the client, and whether there is any change in the readiness for change (Sobell & Sobell, 2008). Ultimately, if we meet resistance, it is a signal that we should respond differently, rather than calling the client resistant (Braastad, n.d.). Here are some examples of rolling with it.

Sample rolling-with-resistance statements:

• It’s ok if you don’t want to quit; it’s your choice.
• Perhaps this new regime is just too much to adopt all at once.
• Maybe you aren’t ready to quit.
• What do you want to do? How do you want to proceed?
• Where do you want to go from here? (Braastad, n.d.)

Support self-efficacy

Even when someone is committed to making a change, the individual can be hugely frustrated by a lack of confidence about their ability to achieve the change. Thus one of the goals of motivational interviewing is to increase confidence, which helps to enhance self-efficacy: the person’s belief that they can achieve their goal. The central tenets of MI are designed to assist with this. Through the therapist/practitioner maintaining a stance of consistent respect for clients and their decisions, clients feel more secure in their choices. Through unyielding insistence on allowing the client to have responsibility for their own decisions, we as practitioners ensure that clients own those choices, and they are far more likely to have staying power. Other strategies assist with the overall goal of supporting self-efficacy as well. These include reframing and enhancing the creativity of the problem-solving process.

For many stuck in ambivalence or actively resistant to change, there is a history of anxiety, depression, or other mood issues which have impacted on past experience. These individuals may see current events and possibilities in a deeply negative light, so your ability to help such clients reframe toward a more positive (and more realistic) view of possible success is crucial. Creativity can come into the process when you help the client with brainstorming: including along with the client’s possible choices options that other clients have found useful. Beyond that, observance of normal “rules” for goal setting can be useful. By this we mean helping bridge from where the client is now to where they wish to be by breaking down large, seemingly unmanageable goals into smaller, more do-able tasks.

As a therapist/practitioner, you can be on the lookout for motivational statements the client may make. These may recognise the problem in a cognitive way, such as “I guess this is a more significant issue than I thought” or flag it in on an affective level, such as with, “I’m a little bit worried about what is happening to me.” The client can note an intention to change, such as when the individual may say, “I guess I’ve really got to do something about this” or the person may indicate an optimistic stance, with statements such as, “I’m pretty sure that I can do it if I try.”

Ways that you can support self-efficacy through eliciting statements of self-motivation include the mirror opposites of the above client statements. That is, you can ask about problem recognition (“What makes you think that this is a problem?”) or concern (“What is there about your ____ [drinking, spending, gambling, etc] that you or other people might see as reasons for concern?”). You can enquire about intention to change (“If you were totally successful and things worked out perfectly, what would be different?”). Finally, you can elicit optimism through questions such as, “What makes you think that, if you decide to make a change, you can do it?” (Latchford, 2010)

Sample support-self-efficacy statements:

• It seems as though you have put a lot of thought into these goals
• You have a good plan of action
• You indicate that you are still struggling with making these changes, and yet you have had some success at making these things happen
• It sounds like you have made real progress; how does that make you feel? (Braastad, n.d.)

This article was adapted from the MHA CPD course “Motivational Interviewing: The Basics”.

References

• Berg-Smith, S. (2001). Making brief patient encounters more effective. In Motivational Interviewing assessment: Supervisory tools for enhancing proficiency. Salem, OR: Northwest Frontier Addiction Technology Transfer Center, Oregon Health and Science University.
• Braastad, J. (n.d.). Using motivational interviewing techniques in SMART recovery. SMART Recovery: Get Smart FAST Distance Training Program. Retrieved on 13, May, 2014 from: hyperlink.
• Hall, K., Gibbie, T., & Lubman, D.I. (2012). Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Australian Family Physician, Vol. 41(9), Sept., 2012, pp 660-667.
• Latchford, G. (2010). A brief guide to motivational interviewing: Year 3 motivational interviewing workshop. NHS: The Leeds Teaching Hospitals. Retrieved on 13 May, 2014, from: hyperlink.
• Sobell & Sobell. (2008). Motivational interviewing strategies and techniques: rationales and examples. Retrieved on 16 May, 2014, from: hyperlink.