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Motivational Interviewing: A Guide to the Art & Skill




When I was going through residency training several years ago, I was introduced to somethingthing that produced a truly radical shift in me and my practice.


During residency, much of our didactic content was taught by Joe Godges. If you don’t know Joe or haven’t heard of him, he is an expert clinician in the truest sense of the word. Which, to me, means someone with a true beginner’s mind, which Joe certainly has.


Part of what he taught us in these courses was the communication style known as Motivational Interviewing.


Prior to being exposed to MI, I hadn’t realized that there are ways of talking with people that can help them get unstuck. This was a huge realization for me.


After this course, I fully nerded-out on MI for many years.


It started with buying the textbook [1] written by the creators of MI, Miller & Rollnick, and reading about two-thirds of it while I was forced to take time off from residency while recovering from eye surgery (kind of eye-ronic that I read a book while recovering from eye surgery. I considered it rehab, or something like that).


I then was able to take several courses and workshops that were offered through my hospital system, as well as shadow some rehab psychologists to see it in action.


Before I left Baltimore, I had the privilege of teaching the MI content to the residents during their didactic modules in a nice full-circle manner.


I want to share with you the gift of MI, while also helping you to avoid some of the ways that I’ve misunderstood, misinterpreted, and all-out fucked up when trying to implement MI in the clinic.


My hope is that you can leapfrog my mistakes and walk as smooth of a path as possible toward implementing MI in the clinic.


In this guide, we’ll talk through:

(Click the blue links to jump to that section of the guide)


Along the way, I’ll give you some exercises and ways of practicing and implementing the material.


My advice:

  • There’s A LOT of information in here. Choose one, maybe two exercises to focus on for several days or weeks, then layer on another when you have the first one down. Trying too much, too fast was unquestionably one of my first mistakes.

  • Another great way to practice is to try out these techniques in your daily life (shout out to my wife who endured my practicing MI on her for a good while before she started kindly telling me to fuck off— this just goes to show that I was focusing on the skills more than the mindset behind the skills, as we’ll discuss).

  • If you want some habit hacks to make the skills more likely to happen, you can use the infographic with 4 intention-setting practices in the Clinical Reasoning blog post.


That’s enough of a preface, don’t you think?



What is MI?


Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change.


It’s designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.


This second bit really speaks to the mindset or spirit of MI. The strategic aspects of MI are intended to help the person resolve dissonance and move toward their own goals. But a MASSIVE part of our ability to help them do this lies in our ability to create an atmosphere of acceptance and compassion.



When is MI helpful?


Motivational interviewing can be helpful any time we’re working with someone on changing their behavior.


How much of our job involves behavior change? Pretty much all of it.


Much of what we do involves behavior change in one way or another:

  • Activity modification

  • HEP performance, consistency

  • Lifestyle change

  • Adherence to precautions

  • Showing up on time

  • Response to pain

  • Problem-solving behaviors


All these things require the person to change their behavior in some way.


The problem with behavior change


The problem that we and our patients often run into is that behavior change is hard. It takes focus on a particular goal, commitment, and action toward that goal.


When people feel stuck on this path, one of the main culprits is often something called ambivalence. Ambivalence is simultaneously wanting and not wanting something, or wanting both of two incompatible things.


For example,

  • I could want to exercise and not feel like it at the same time

  • I could want to exercise and also want to binge-watch the office

  • I could want to be healthy and also want to eat pizza tonight

It’s quite common that we find ourselves feeling two ways about aspects of our lives, especially aspects that we regard as problematic. Resolving this ambivalence and helping people move toward aligned action is at the root of what MI is all about.


What does ambivalence look like?


When someone is ambivalent, it’s normal to hear two kinds of talk mixed together.

  • The first kind of talk is called Change Talk— the person’s own statements that favor change

  • The second kind of talk is called Sustain Talk— the person’s own arguments against change, or for the status quo

I like to think of little committee members having a meeting inside our heads. Sometimes the pro-change members speak, other times the anti-change members speak.


This mixture of language might sound like…

  • “I know I need to exercise to be healthy [change talk] but I’m exhausted after work [sustain talk].”

  • “I know I should do my exercises [change talk] but I just don’t have time [sustain talk].”

The BUT is a key indicator of ambivalence.


A thought experiment...

Think about something that you’re ambivalent about. Something that you feel two ways about. Try and hold that in your head as we talk through this thought experiment.


I’m going to use drinking as an example:

  • You know that you want to drink less, but you enjoy a beer or two after a long day as a way to unwind and relax.

  • Now, suppose you tell me this and in response, I say, “You know, alcohol is known to cause heart problems, digestive problems, cancer, weakening of the immune system, and can increase the likelihood of dementia… “

  • You’d probably tell me that you know most of that to be true… BUT [insert reason you still drink].

  • And I say, “Doesn’t that scare you? Isn’t your health important to you??”

  • You’d probably say, “Yes it does, and yes it is… BUT [insert competing desire].


Why would you respond in this way? Because you’re ambivalent! You have reasons to drink AND reasons not to drink.


And the more I try to voice the arguments against alcohol use, the more I elicit your reasons and arguments for alcohol use. This is a Fundamental Principle of MI: argue for one side and the ambivalent person is likely to take up and defend the opposite.


In this scenario, if my goal is to help you move toward what you said you want—drinking less—I have it exactly backward.


You’re much more likely to change your behavior if you’re the one voicing the reasons for change, not me. This is because of another Fundamental Principle of MI: most people tend to believe themselves and trust their own opinions more than those of others.


So, what if instead of telling you what you should do and why you should do it, I ask you some questions, like…

  • “What makes you want to drink less?”

  • “What is it about drinking that you don’t like?”

  • “What would help you to drink less if you decided to?”

These questions would likely elicit an entirely different response from you.


Let's explore why.


The Righting Reflex


The directing style that I presented first is an expression of what’s known as the righting reflex: the desire to fix what seems wrong with people and to set them promptly on a better course.


This reflex lives within most of us, especially those of us in helping professions. Helpers wanna help. We want to set things right, to get people on the road to health, wellness, and success.


The problem is that telling people what to do or giving people reasons that they should do something is likely to trigger a reaction in them, especially when they’re ambivalent.



MI shows us how to skillfully work with people to help them explore both sides of ambivalence in order to make the right decision for them.


And it all starts with our attitude.



The Spirit of MI


The mindset behind MI or the Spirit of MI, as the creators dubbed it, is the underlying perspective, attitude, or mindset, with which one practices MI.


If I’ve learned one thing about MI it’s that this is by far the most important aspect of MI. One of the biggest ways that I’ve misused MI in the past was by over-focusing on the skills and under-focusing on the attitude.


Miller & Rollnick put it this way:

"Without this underlying spirit, MI becomes a cynical trick, a way of trying to manipulate people into doing what they don’t want to do, a battle of wits in which the goal is to outsmart your adversary [1].

This is NOT what it’s about.


If you truly want to help people, which I’m certain that you do, it’s about helping people move toward their own self-identified goals within their own value system.


If you truly embody the spirit of MI, the skills will come naturally. And It doesn’t work the other way around.


The 4 Components of the Spirit of MI


1. Partnership


Motivational interviewing is based on active collaboration between partners, not an expert and a passive recipient.


A common metaphor here is that it should feel like dancing, not wrestling. Someone can lead the dance, and skillful guiding is certainly part of the art of MI, but the two must move and work together in order to avoid tripping and stepping on toes.


A common pitfall is what’s known as the expert trap: communicating—explicitly or implicitly—that you are the expert and you have the answers to the person’s dilemma.


Of course, we do have expertise and much to offer our patients, but our advice and expertise must fit within the context of their own life and values for it to be useful to them. This is where we need them to be an active participant, a partner.


Avoiding this trap includes letting go of the assumption that you are supposed to have and provide all the right answers. I don’t know about you, but I find this tremendously freeing.


2. Acceptance


Acceptance means:

  • Respecting the other as having worth in their own right

  • An ability to understand the other person’s frame of reference, and the conviction that it’s worthwhile to do so

  • Honoring and respecting the person’s autonomy

The beautiful thing about acceptance is that when we directly acknowledging a person’s freedom of choice, it typically diminishes defensiveness and can facilitate change.


Acceptance allows people to feel safe to change, without judgment. This requires our letting go of the idea and burden that we have to (or can) make people change. A relinquishing of a power that we never had in the first place.


What acceptance is not:

  • To accept a person in this sense does not mean that I necessarily agree or approve of the person’s actions.

  • My personal approval (or disapproval) is irrelevant. It’s not my life. I’m just here to help them in the way in which they want to be helped.

3. Compassion


Compassion is a sense of concern that arises when we are confronted with another’s suffering and feel motivated to see that suffering relieved [2].


To be compassionate is to actively promote the other’s welfare, to give priority to the other’s needs. Our services are, after all, for our patients’ benefit and not primarily for our own.


It’s always important to realize that we need not literally ‘suffer with’ in order to act with compassion. If someone chooses not to change, this is not our burden to bear, and it’s OK for people not to change if they’re not ready to change. This requires honest conversations, a part of good care.


4. Evocation


So much of what happens in professional consultations about change is based on a deficit model. A deficit model says, “This person is lacking something that needs to be installed.”


The spirit of MI starts from a strengths-focused premise. A strengths-focused premise says, “People already have within them much of what is needed. Our task is to evoke it, to call it forth.” It’s saying, “You have what you need, and together we will find it.


This can be quite the mind-shift for many of us, as it tends to run counter to much of our training and our cultural heritage here in the west.



Not only are these attitudes more important than the explicit skills, which we’ll cover next, but they can also be more difficult to adopt. This is because they’re essentially a belief system. They’re not things that you do, like a skill, they’re ways of thinking and being.


EXERCISE:

  • Think of someone right now who you find difficult to work with. Someone who you get a pit in your stomach when you see them on your schedule (we all have people like this).

  • Now ask yourself:

    • "How is my partnership with this person? Am I collaborating with this person as an equal?"

    • "How is my acceptance of this person? Am I honoring and respecting their freedom to make their own decisions?"

    • "How compassionate am I with this person? Am I giving priority to their needs during our time together?"

    • "Do I believe that this person has within them already what they need to succeed?"

Reflecting on these four components can be a simple way to boost your embodiment of the spirit of MI.


I find, pretty much without fail, that when I find someone challenging to work with or I feel like we aren’t working well together, at least one of these components could use some attention.


If you’d like more ways to train these attitudinal aspects of care, check out Law I of the Four Laws of Quality Care where I discuss using habit strategies to enhance our mindset.




The 4 Key Skills of MI


Now let’s get into the 4 key skills of MI. If you knew what MI was going into this episode, I’d guess this is what you first thought of.


The four key skills make up the acronym OARS, which stands for:

  • Open-ended questions

  • Affirmations

  • Reflective listening

  • Summarization

We’ll go through these one at a time, discussing the utility of the skill, what it can look like, and some nuances.


Then we’ll talk about how to put them into practice more specifically when we discuss the 4 processes of MI.


1. Open-ended questions


Open-ended questions are a key way to get good information. They invite the person to reflect and elaborate, and can help us to understand their point of view.


Recall that the purpose of MI is to elicit and explore someone’s own reasons for change and that they’re more likely to listen to themselves than they are to listen to you.


Asking open-ended questions is a key way to begin to understand the person’s values, their goals, and their reasons for change.


What are open-ended questions?

Open-ended questions are any questions that can’t be answered with a single word.


They tend to start with 1 of 5 stems:

  • How…? For example:

    • “How is this affecting your life?”

    • “How do you hope I can help you?”

  • What…? For example:

    • “What’s most important to you?”

    • “What are your strengths?”

  • Where…? For example:

    • “Where would you like to be in life a year from now?”

    • “Where does that leave you?”

  • Why…? For example:

    • “Why is that?”

    • “Why do you think that is?”

    • Quick tip: be cautious with this question, as it can sometimes come off as confrontational. I’ll often use, “How come?” Or, “What makes you say that?” instead of “Why?”

  • Tell me… which is not actually a question, but functions much in the same way. For example:

    • “Tell me more about… “

Open- vs. closed-ended questions

Closed-ended questions, on the other hand, can be answered in a single word. For instance…

  • Is this affecting your day-to-day life?

  • Is exercise important to you?

  • Do you hope to be better a year from now?

  • Does this show up when you walk?

  • Have you tried anything for the pain?

It’s not that closed-ended questions are bad. They—like open-ended questions—serve a purpose. But it’s important to realize the effect of our questions.


Open-ended questions tend to open up the conversation, to allow the other person the chance to tell their story, to elaborate, to reflect. Closed-ended questions, on the other hand, tend to narrow the range of possible answers.


If our intent is to explore the person’s own motivations for change, open-ended questions are a key way to do this.


Pitfalls of open-ended questions

The main pitfall I’ve seen in myself and mentees is asking open questions with a closed-ended tail. For example:

  • “So what do you think the next step is? ...Is it this, or that?”

  • “How are you hoping that I can help you? …with the pain or more function?”

Remember, when you ask open-ended questions, the person often has to think. This requires a pause. That’s OK. You don’t need to fill the space. It can feel awkward at first, but you’ll get used to it.



Asking open questions is a key way to invite the person to share their take; their own motivations, their own reasons, their values. This is critical in every stage of care and is a key way of helping people move toward living the life that they want to live.


EXERCISE

  • Start to pay attention to how many open-ended vs. closed-ended questions you ask

  • Notice the difference in the other person’s response when you ask an open vs. a closed-ended question


2. Affirmations


Affirmations are statements that reflect the person’s particular strengths, abilities, good intentions, and efforts.


They are directly related to the part of the evocation aspect of the spirit of MI, in the sense that they come from a place of finding what’s right, rather than what’s wrong with the person.


What do affirmations look like?

Let’s say someone shows up 15 minutes late to a 45-minute session with me. They apologize and tell me they had a hectic morning.


I could say something like, “That’s alright. We’ll do what we can with the time that we have remaining.”


There’s nothing wrong with the above statement. But there’s an opportunity here. This person had a hectic morning and was running late, but instead of throwing in the towel and canceling the appointment, or no-showing, they showed up.


Why did they do this? Likely, at least in part, because of their commitment to their health. This is worth commenting on.


An affirmation would be something like, “You had a hectic morning and you still decided to come. You’re clearly committed to your health.”


This statement results from being on the lookout for the person’s strengths, positive steps, and good intentions toward their own goals.


Affirmation nuances

1. Affirmations must be genuine. They should prize what is actually true about a person


2. Affirmations are not the same as praise. “I like that shirt” isn’t an affirmation. “I’m proud of you” isn’t technically an affirmation either, as it doesn’t reflect the person’s strengths, abilities, good intentions, or efforts. It reflects my feelings only. A good practice is to avoid beginning affirmations with “I.” Make it about the other person, not about you.


3. The holy grail: Eliciting self-affirmations from someone. Remember that people tend to believe what they say more than what you say. So facilitating someone affirming themselves (talking about their own strengths, good intentions, and positive steps), can be massively helpful. This ties in heavily with self-compassion, which I dedicated an entire post to if you’re interested in learning more on that.



Affirmations, the second part of the OARS acronym, are statements that come from the place of looking for people's strengths and virtues vs. their weaknesses and barriers.


EXERCISE

  • Give each patient you work with one affirmation the next time you’re in the clinic

  • Make sure it’s genuine and starts with “You,” not “I

  • Notice how the person responds


3. Reflective Listening


It’s been said that reflective listening is the cornerstone of patient-centered care.


Reflective listening was invented, or at least popularized by Carl Rogers, who said,

"It is astonishing how elements that seem insoluble become soluble when someone listens, how confusions that seem irremediable turn into relatively clear flowing streams when one is heard."

The purpose of reflective listening is to deepen our understanding and to facilitate patient reflection. It’s a way for us to check our understanding rather than assuming we already know (kind of like hypothesis testing), and it allows people to hear again the thoughts and feelings they are expressing and ponder them.


What does reflective listening look like?

Reflective statements make a guess about the meaning of what the person is saying.


This is important because a lot can get lost in translation when we’re communicating:

  • Communication starts with an idea

  • That idea then gets encoded into words that I speak

  • The words are heard by you, the listener

  • The words are then decoded, and you’re left with what you think I meant by what I said

Each of these steps has an opportunity for misunderstanding or misinterpretation.


Reflective listening adds one step to close the loop: a statement from you, the listener, giving your interpretation about the original meaning. This gives me, the speaker, an opportunity to tell you if your interpretation is wrong, and it allows me to hear my words again and reflect on them.


For example:

  • Let’s say I come in for my appointment and tell you, “I’m sorry, I haven’t done my exercises since our last visit, things have been crazy at work and I’ve been putting in 12-hour days.”

  • You reply with a reflective statement, “You’ve been super busy and haven’t had time for much of anything aside from work.”

A few things often happen when we use reflective listening

  • 1. The person feels heard

  • 2. The person feels validated (especially when we’re embodying acceptance and compassion)

  • 3. As a result, it’s not uncommon that reflective statements are followed by the person voicing their reasons for change

Continuing with our previous example…

  • As a result of your reflective statement, it wouldn’t be uncommon for me to say something like, “...Yea, but I still have 15 minutes I could put in each day for the exercises. They don’t take that long.”

  • You could follow up this change talk with an open-ended question: “Where in your day would those 15 minutes fit?” or an affirmation, “Wow, despite being quite busy, you’re still committed to improving!”


Reflective listening nuances

1. Reflective statements are just that— statements. Questions require answers and are more likely to provoke defensiveness.


2. You don’t really need to add stems, such as, “What I hear you saying is… “ or, “Sounds like… “ These can slow down the conversation unnecessarily and can create a feeling of excessive professionalism.


3. Good reflective listening tends to keep the person talking, exploring, and considering. And it tends to move the discussion forward, rather than merely repeating what the other person has said.


4. Good reflective listening is selective. You choose which aspects to reflect from all that the person has said. This can be used to skillfully guide the conversation.


A year or two after I went through residency, one of the residents at the time spent a day shadowing one of the rehab psychologists on staff. The next day, I asked him, “So how was it?” And he replied, “Man, I thought I knew what MI was, but that shit has layers!


This is one of those aspects of MI that definitely has some layers. Selecting which specific aspects to reflect back to the person from all that they’ve said can make a profound difference in the direction of the conversation.


Some common aspects that can be reflected are:

  • The meaning of what the person said

  • The associated feelings

  • What might be said next

Selecting which aspects to reflect is an art as much as a skill, and it takes practice, so as always, be nice to yourself in the learning process.


5. Reflections should generally not be longer than the statements they follow. Just make one guess and keep it simple.


One final tip

This is something that a rehab psychologist said at a course I took on psychologically informed PT practice that I continue to find very helpful.


He said,When I don’t know what to say, I reflect.”


This serves as a great reminder of the evocation aspect of the spirit of MI. This is the belief that the person has the answers and I’m merely here to call them forth.


This might be the easiest aspect of the Spirit of MI to forget. It’s so easy to get caught in the fixer or problem-solver role. When we’re in that role, we feel pressure to have answers and solutions. And oftentimes we don’t, especially when we understand the depth and complexity of the life of another person.


But not to fear, if you don’t know what to say and you feel the need to say something, you can always reflect.


EXERCISE

  • Use 1-2 reflective statements with each patient the next time you’re in the clinic

  • You could reflect:

    • The meaning of what the person said

    • The associated feelings

    • What may be said next

  • Remember, just make one guess and keep it simple

  • Notice how the person responds


4. Summarization


Summarization is the last of the 4 OARS skills.


Summaries are essentially bulk reflections. You are collecting things that the person has said and offering them up in a basket. All of the pieces come from the patient, but their simultaneous combination in a summary offers something new.


Summarization can be a great way to help people gain a new perspective. It’s so common when we’re struggling with something that we have all the pieces, but aren’t able to see them all together.


Summarization can also be helpful to:

  • Promote understanding

  • Demonstrate listening

  • Provide a “What else?” opportunity for the person to fill in anything that was missed


What do summaries look like?

There are a few different ways that you can use summaries.

  • You can summarize a series of interrelated items as they accumulate: e.g. summarizing what the patient tells you after you ask, “What do you hope your life will be like a year from now?” Asking “What else?” can facilitate further discussion/listing.

  • You can use summaries to link present information to past discussions/information: “So you’ve been noticing how your mood seems to relate to the pain, and at the last session, you mentioned how it also relates to your activity levels and the way you position your body. What other factors seem to relate to the pain?”

  • You can summarize a person’s dilemma, citing both sides of their ambivalence: “It sounds like you’re having quite the predicament. On one hand, you want to exercise and know that it will help with your pain and your stress, and on the other hand, you are swamped with work- and home-life right now.”

All of these options serve to collect what the person has said and present it to them, giving them a new perspective and allowing them to expand if necessary.


Other times summaries can be useful

I’m going to give you some tips similar to the reflection tip that we ended with:

  • When I feel that I’m getting confused or falling behind, I summarize: “Hang on one second, let me just make sure I’m still with you…” [then I give a summary of what I understand so far]

  • When I’m afraid that I’ll forget some key pieces of information, I summarize: “So we discovered that the pain comes on when you look up, turn your head left, and tilt your head left, and the pain gets better when you turn your head right or look down… “

  • Following key phases of testing, I summarize: “So we checked the flexibility and strength of your hip, and they both looked good, now let’s take a closer look at your back.”


Summaries serve to promote our understanding, demonstrate listening, and can help to offer a new perspective to the information that is being shared.


EXERCISE

  • Use one summary with each patient the next time you’re in clinic

    • You could link past and present information

    • You could summarize their aggravating and easing factors during history-taking

    • You could summarize salient exam findings as they accumulate

    • You could summarize someone’s ambivalence as it relates to a behavior they want to change

  • Notice what happens after the summary



The 4 Processes of MI


These four processes give conversations about change some structure so that we’re not just talking aimlessly about change and getting nowhere. They’ll also give us a framework within which we can use the 4 key skills intentionally.


The four processes are:

  • 1. Engaging

  • 2. Focusing

  • 3. Evoking

  • 4. Planning


2 key points about these processes before we get into what they mean…

  • 1. They are sequential. They build and depend on each other, so it will flow best if they are followed in order

  • 2. They are recursive. One doesn’t end when one begins. And sometimes you end up going forward, then backward, then forward again, like dancing on stairs


Let’s jump into these four processes to contextualize all that we’ve discussed so far.


1. Engaging


Engaging is simply the process of establishing a mutually trusting and respectful helping relationship.


The goals of this phase are to:

  • Establish rapport

  • Understand what help the person is seeking

  • Understand the person’s hopes and expectations


The OARS skills are incredibly useful in this process

  • Open-ended questions allow the person to share openly and show them that you want to hear their story, not just answers to your specific questions

  • Affirmations help the person to feel comfortable, validated, and show them that you see their strengths and virtues

  • Reflections and Summaries help the person feel heard and understood


This may seem like pretty basic stuff, but it’s crucial that this happens before you get into the next phase.


EXERCISE

  • Think about your patients on your caseload right now

  • Ask yourself, “Are there any that I need to re-engage with the next time they come in?

  • Whoever comes to mind, ask yourself:

    • “How is my rapport?”

    • “Do I have a clear understanding of the help that they seek?”

    • “Do I have a clear understanding of their hopes & expectations?”

  • Whichever area(s) seems deficient, spend a little extra energy on that at the next visit

  • Notice how the session goes


2. Focusing


This is the process of developing and maintaining a specific direction in the conversation about change.


Focusing is about determining the where, before tackling the how. The common metaphor is that of a traveler and a guide. In order to be an effective guide, you need to know where you’re headed. Ideally, there is a shared sense of direction, just as a guide and traveler have an agreement about where they’re going.


Essential in this process is clarifying direction & setting goals. Importantly, the direction and goals must be reflective of the person’s own values and desires, not yours.


This is one place where I’ve definitely fucked up in the past; not getting clear on what it is the patient wants, and instead focusing on what I think they want, or what I think is best for them. Go ahead and leapfrog that mistake if you can!


The OARS skills can be used in this process:

  • To set goals

    • Through open-ended questions:

      • “What does success look like to you?”

      • “If you could flip a switch and turn off your pain, what would you do?”

    • Through reflective statements:

      • “If you could walk 1 mile you’d be really happy with that”

  • Affirmations can be used throughout the focusing process to keep engagement up

  • Summaries can be used in the focusing process to collect information and present it

    • “It sounds like it’s been so long since you’ve been able to do what you want to do that you have trouble even imagining what could be. If the pain were suddenly gone, you would go for a walk with your daughter in the park, but you’re not sure that’s a realistic goal for the way things are right now. Did I get that right?”


Pitfalls of the focusing phase

A big pitfall in this phase is premature focusing. This could look like trying to focus before establishing a mutually trusting relationship (meaning: without engaging first). It could also look like pushing ahead with a particular focus without the person being fully with you.


The antidote: an unhurried mindset.

Slow is fast: if you act like you have only a few minutes, it may take all day; act as though you have all day, and it may only take a few minutes.


The focusing process is all about setting and maintaining a particular direction. It’s not uncommon at all to need to return to this phase if goals and priorities change. That’s why these processes are recursive.


EXERCISE

  • Think about your patients on your caseload right now

  • Ask yourself, “Are there any that I need to re-focus with the next time they come in?

  • Whoever comes to mind, ask yourself:

    • “Do we have a shared sense of direction?”

    • “Do we both agree on their goals?”

  • Whichever area(s) seems deficient, spend a little extra energy on that at the next visit

  • Notice how the session goes


3. Evoking


Evoking is where the magic of MI happens and what makes it different from other styles of communication. This is the process of eliciting the person’s own motivations and arguments for change.


A couple of key points before we get into this:

  • There must be a clear focus on a particular change before evoking can truly begin. Without a focus, we could talk for hours without getting anywhere

  • Not everyone needs this phase. Some people come fully prepared to change and are asking for advice on how to proceed. They can jump right to the planning phase


*MI Spirit Reminder:* “Do not memorize clever tricks/techniques to use with clients; listen with curiosity for the person’s own inherent motivations for change [1].”


How does evoking work?

Recall that when someone is ambivalent, it’s normal to hear two kinds of talk mixed together:

  • Change talk— the person’s own statements that favor change

  • Sustain talk— the person’s own arguments for not changing

The ratio of change talk to sustain talk has been shown to be a predictor of behavior change.


The process of evoking is simply bringing about change talk. How do we do this? We ask for it.


The simplest way to evoke change talk is to ask open-ended questions for which change talk is the answer. We’re inviting the pro-change members of the person’s internal committee to speak.


Ways of evoking change talk:

  • Asking about the desire to change:

    • “How would you like for things to change?”

    • “What do you hope to accomplish through working together?”

  • Asking about the ability to change:

    • “If you did decide to start exercising, how could you do it?”

    • “Where would these 15 minutes of movement fit into your day?”

  • Asking about the reasons for change:

    • “What are the advantages of doing the exercises?”

    • “What’s the downside of not following the surgical precautions?”

  • Asking about the need to change:

    • “How important is it for you to be able to get on the floor with your grandkids?”

    • “What do you think has to change?”

  • Asking about the past/future/hypotheticals:

    • “What were things like before the pain started?“

    • “What will your life look like if you don’t make any changes?”

    • “If you could flip a switch and turn the pain off, what would you do?”


*Notice how these questions speak to a genuine curiosity about the person, which also supports their autonomy.


Responding to change talk

How we respond to change talk when we hear it makes a big difference in the direction of the conversation.


We can respond with any of the OARS

  • Open questions allow us to ask more about it when we hear change talk. We could ask for elaboration or for an example.

    • If someone says, “I think I could start walking every day if I really decided to.” You could respond with, “Where would you walk?” or, “Tell me about a time when you made a decision and stuck to it.”

  • Affirmations help the person to see their strengths and virtues coming through in their change talk.

    • Responding to the same statement, “I think I could start walking every day if I really decided to.” An affirmation could be, “Once you make up your mind to do something, you get it done.”

  • Think of reflections like a mirror. You’ll generally get more of what you reflect. When you reflect change talk, the person is likely to continue with more change talk. If you reflect sustain talk, the person is more likely to respond with more sustain talk.

    • To the statement, “I think I could start walking every day if I really decided to.” A simple reflection that reflects change talk could be, “Your health is important to you.”

  • Summaries. When it comes to the evoking stage, think of each bit of change talk like a flower. You collect all of the flowers into a bouquet. With a few flowers in hand, you offer the bouquet to the person and ask for more flowers:

    • “So you want to improve your health because you want to be around long enough to see your grandkids grow up. You think walking could be a good way to move more. If you decide to walk, you feel that you could walk every day, and you could walk around your neighborhood in the mornings. What did I miss?”



So the evoking process is really just about asking and listening for the person’s own reasons for change and responding to that change talk in a way that keeps the conversation moving forward.


One simple heuristic

That was a lot of information. I’m going to bring this back down to earth give a plug for curiosity.


All of these strategies can be forgotten and replaced by simply being curious. Be curious about what the person wants, why they want it, how they could get there, and what could get in their way. Let your curiosity drive your questions and responses and you’ll do many if not all of what we just covered in the evoking process, naturally.


You don’t need to be clever and complex, just interested and curious [1].”

EXERCISE

  • Think about someone on your caseload right now who hasn’t been very committed to the process so far, despite having clear goals

  • At your next visit with this person,

    • Ask for change talk, using open-ended questions

    • Reflect change talk

    • Affirm change talk

    • Or summarize change talk

  • Notice what happens next


4. Planning


Planning is an ongoing process that encompasses developing commitment to change and formulating a specific plan of action.


This is the stage where we shift from talking about whether & why (as in the evoking process) to how & when.


The final MI Principle that I want to share with you states: People are most likely to follow through with change when they have a specific plan and express to another person their intention to carry it out.


Before diving deeper into the planning phase, we need to contextualize this briefly by discussing the difference between a change plan and a treatment plan.

  • The treatment plan, or plan of care, involves the things that we want to do to help the person reach their goals.

  • This is only one aspect of the change plan, which is broader, and addresses how they will proceed and how the change will fit into their life.

For example, to help someone reach their goal of walking 1 mile,

  • The treatment plan might include manual therapy and therex to address hip extension mobility deficits and neuro re-ed to address movement coordination impairments.

  • The change plan encompasses when they will walk, where they will walk, how much they will walk, & how they will address barriers as they come up.

The change plan is the linchpin to ongoing behavior change, rather than temporary behavior change because their PT told them to…


How does planning work?

As the person’s commitment becomes stronger and the path forward becomes clearer, we can get more specific with aspects of the change plan, asking and talking about:

  • Time and place

  • Where does the behavior fit into daily routines?

  • How will they remember?

  • Dosage

  • Identifying (& solving) potential barriers

If you read the article on effective habit formation strategies, this is the phase where these strategies fit perfectly.



If a clear path forward exists, it can be simple enough to summarize the initial plan and get more specific as needed:

  • “So it sounds like you could walk for 10 minutes around your neighborhood and progress by 5 minutes every 2 weeks. Where in your daily routine would this fit the best?”


On the other hand, if several clear options exist or no clear options exist, the process becomes working together to figure out the how before getting more specific using—you guessed it—the OARS skills. This involves:

  • Confirming their goals

    • “You definitely want to be more active, but you’re not sure exactly how to do it [reflective listening].

  • Discussing options & eliciting their preferences

    • “What are your ideas about ways that you could be more active [open-ended question]?”

    • “You could walk in the neighborhood, you could join a swim club, or you could join a group exercise club. Which one of these appeals to you the most [summary + open-ended question]?”

  • Getting specific

    • “Walking is a great option, it’s free, it’s convenient, and you can always add on other modes of exercise later. Where would you like to start walking [summary + open-ended question]?


A word on accountability

Once a plan is formed, accountability to that plan can be a powerful force driving people to stick with the change plan. As long as the plan fits squarely within the person’s values and preferences, holding people accountable is an important part of what we do.


However, if unanticipated challenges arise or priorities shift, we may need to revisit the focusing phase, the evoking phase, or the planning phase. This is normal.


It’s a fine line that we walk between accountability and flexibility. The key lies in assuring that the plan, whatever it may be, is in line with their values and preferences before holding them accountable.


EXERCISE

  • Think about someone on your caseload right now who hasn’t followed through with the plan despite vocalizing commitment to the plan

  • At your next visit with this person, get more specific with aspects of the change plan:

    • Time, place

    • Where does it fit into daily routines?

    • How will they remember?

    • Dosage

    • Identifying (& solving) potential barriers

  • Notice what happens next visit


In Summary

  • Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change

    • It’s designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion

  • MI can be helpful any time we’re working with someone on changing their behavior

  • But behavior change is hard, and when people feel stuck on this path, one of the main culprits is often ambivalence; feeling two ways about change

  • Rather than telling people what to do or giving people reasons that they should do something (which is likely to trigger a reaction in the ambivalent person) MI shows us how to skillfully work with people to help them explore both sides of ambivalence in order to make the right decision for them

  • It’s crucial that this exploration occurs in the Spirit of MI, which includes:

    • Partnership

    • Acceptance

    • Compassion

    • Evocation

  • Our 4 Key Skills to help us explore with people include:

    • Open-ended questions

    • Affirmations

    • Reflective listening

    • Summarizations

  • The 4 Key Processes that guide us through conversations about change are:

    • Engaging

    • Focusing

    • Eliciting

    • Planning


I really hope you’ve enjoyed this article. MI is such a powerful tool when used correctly. It’s made such a difference in my practice and I’m confident that it will in yours too.


Thanks for reading,

Andrew



References:

  1. Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford press.

  2. Jinpa, Thupten. A fearless heart: How the courage to be compassionate can transform our lives. Avery, 2016.

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