Interaction Techniques
The basic approach to interactions in motivational interviewing
is captured by the acronym OARS: (1) Open-ended questions, (2) Affirmations,
(3) Reflective listening and (4) Summaries. The acronym is a nice
image. It gives us power to move, yet it is not a powerboat. We
don't zip from one place to another, yet with sustained effort OARS
can take us a long way.
Open-ended questions are those therapist utterances that
client's cannot answer with a "yes", "no" or
"three times in the last week". Most people begin treatment
sessions with an open-ended question - "What brings you here
today?" or "Tell me about what's been happening since
we last met?" An open-ended question allows the client to create
the impetus for forward movement. Although close-ended questions
have their place - indeed are necessary and quite valuable at times
- the open-ended question creates a forward momentum that we wish
to use in helping the client explore change. For example, "So
what makes you feel that it might be time for a change?"
Affirmations are statements of recognition about client strengths.
We side firmly with Carlo DiClemente that many people who come for
our assistance are failed self-changers. That is, they tried to
alter their behavior and it didn't work. As a result, clients come
to us demoralized or at least suspicious of the assertion that change
is possible. This condition means that as therapists, we must help
clients feel that change is possible and that they are capable of
implementing that change. One method of doing this is to point out
client strengths, particularly in areas where they observe only
failure. We often explore prior attempts at change. For example,
"So you stayed sober for a week after treatment. How were you
able to stay sober for that week?" We also use resistance as
a source for affirmations. For example, "You didn't want to
come today, but you did it anyway. I'm not sure, but it seems like
that if you decide something is important enough, you are willing
to put up with a lot just to do it."
Affirmations can be wonderful rapport builders. For clients
suffering from addictions, affirmations can be a rare commodity.
However, they must be congruent and genuine. If the client thinks
you are insincere, then rapport can be damaged rather than built.
Reflective listening is the key to this work. The best
motivational advice we can give you is to listen carefully to your
clients. They will tell you what has worked and what hasn't. What
moved them forward and shifted them backward. Whenever you are in
doubt about what to do, listen. But remember this is a directive
approach. Unlike Rogerian therapists, you will actively guide the
client towards certain materials. You will focus on their change
talk and provide less attention to non-change talk. For example,
"You are not quite sure you are ready to make a change, but
you are quite aware that your drug use has caused concerns in your
relationships, effected your work and that your doctor is worried
about your health."
You will also want to vary your level of reflection. Keeping reflections
at the surface level may lead to that feeling that the interaction
is moving in circles. Reflections of affect, especially those that
are unstated but likely, can be powerful motivators. For example,
"Your children aren't living with you anymore; that seems painful
for you." If you are right, the emotional intensity of the
session deepens. If you are wrong or the client is unready to deal
with this material, the client corrects you and the conversation
moves forward.
The goal in MI is to create forward momentum and to then harness
that momentum to create change. Reflective listening keeps that
momentum moving forward. This is why Bill and Steve recommend a
ratio of three reflections for every question asked. Questions tend
to cause a shift in momentum and can stop it entirely. Although
there are times you will want to create a shift or stop momentum,
most times you will want to keep it flowing.
Finally, there are summaries. This is really just a specialized
form of reflective listening where you reflect back to the client
what he or she has been telling you. Summaries are an effective
way to communicate your interest in a client, build rapport, call
attention to salient elements of the discussion and to shift attention
or direction. Personal preference will determine how often you do
these, but we recommend doing them relatively frequently as too
much information from the client can bc unwieldy for the therapist
to digest and feedback. Also, if the interaction is going in an
unproductive or problematic direction (e.g., reinforcing status
quo talk, encountering resistance), the summary can be used to shift
the focus of the intervention.
The structure of the summary is straightforward. It begins with
an announcement that you are about to summarize, a listing of selected
elements, an invitation to correct anything missed and then usually
an open-ended question. If ambivalence was evident in the interaction
that proceeded the summary, this should be included in the summary.
Here's an example,
"Let me stop and summarize what we've just talked about.
Your not sure that you want to be here today and you really only
came because your partner insisted on it. At the same time, you've
had some nagging thoughts of your own about what's been happening,
including how much you've been using recently, the change in your
physical health and your missed work. Did I miss anything? I'm
wondering what you make of all those things."
The goal is not acquire ammunition, which is then turned on the
client in a defense-overwhelming manner, but instead is a reflection
of what the client has said and where the client is encouraged
to supply the meaning. This is an area where you need to watch
that your wisdom and experience doesn't keep you from listening
to your client's understanding of the problem. It is this understanding
that will guide their efforts at change or maintaining the status
quo.
The goal is using the OARS is to move the person forward by eliciting
change talk, or self-motivational statements. Change talk involves
statements or affective communications that indicate the client
may be considering the possibility of change. Miller and Rollnick
organize this talk into four categories: problem recognition, concern
about the problem, commitment to change and belief that change is
possible. Essentially, any statement oriented toward the present
or future, either in the cognitive or emotional realm, may represent
a self-motivational statement. For example,:"I think that using
may be causing problems" (present-cognitive); "I'm kind
of worried that things may be getting out of hand" (present-emotional);
"I'm definitely going to do something about that" (future-cognitive);
"You know, I'm starting to feel like this just might work out"
(future-emotional).
More on Reflections, Rolling with Resistance, Reframing
The following section focuses more on specific interaction techniques
for counselors to try in order to reduce client resistance once
it occurs.
Simple Reflection
One way to reduce resistance is simply to repeat or rephrase what
the client has said. This communicates that you have heard the person,
and that it is not your intention to get into an argument with the
person.
Client: But I can't quit drinking. I mean, all
of my friends drink!
Counselor: Quitting drinking seems nearly impossible because
you spend so much time with others who drink.
Client: Right, although maybe I should.
Amplified Reflection
This is similar to a simple reflection, only the counselor amplifies
or exaggerates the point to the point where the client may disavow
or disagree with it. It is important that the counselor not overdo
it, because if the client feels mocked or patronized, he or she is
likely to respond with anger.
Client: But I can't quit using. I mean, all of
my friends use!
Counselor: Oh, I see. So you really couldn't quit using because
then you'd be too different to fit in with your friends.
Client: Well, that would make me different from them, although
they might not really care as long as I didn't try to get them to
quit.
Double-sided Reflection
With a double-sided reflection, the counselor reflects both the current,
resistant statement, and a previous, contradictory statement that
the client has made.
Client: But I can't quit drinking. I mean, all
of my friends drink!
Counselor: You can't imagine how you could not drink with
your friends, and at the same time you're worried about how it's
affecting you.
Client: Yes. I guess I have mixed feelings.
Shifting Focus
Another way to reduce resistance is simply to shift topics. It is
often not motivational to address resistant or counter-motivational
statements, and counseling goals are better achieved by simply not
responding to the resistant statement.
Client: But I can't quit drinking. I mean, all
of my friends drink!
Counselor: You're getting way ahead of things here. I'm not
talking about your quitting drinking here, and I don't think you
should get stuck on that concern right now. Let's just stay with
what we're doing here - talking through the issues - and later on
we can worry about what, if anything, you want to do about it.
Client: Well I just wanted you to know.
Rolling with Resistance
Resistance can also be met by rolling with it instead of opposing
it. There is a paradoxical element in this, which often will bring
the client back to a balanced or opposite perspective. This strategy
can be particularly useful with clients who present in a highly oppositional
manner and who seem to reject every idea or suggestion.
Client: But I can't quit using. I mean, all of
my friends use!
Counselor: And it may very well be that when we're through,
you'll decide that it's worth it to keep on drinking as you have
been. It may be too difficult to make a change. That will be up
to you.
Client: Okay.
Reframing
Reframing is a strategy in which you invite clients to examine their
perceptions in a new light or a reorganized form. In this way, new
meaning is given to what has been said. For example, if a client reports
a spouse or loved one as saying, "You really need to get in treatment
and deal with these problems," the client may view this as "she's
such a nag" or "he is always telling me what to do." The counselor
can reframe this as "this person must care a lot about you to tell
you something he (or she) feels is important to you, knowing that
you will likely get angry with him (or her)."
Reframing can also be used to discuss the issue of tolerance. Clients
may report that they are especially good at holding their liquor,
or may view their substance use as non-problematic because they
don't "even really get high anymore." This gives the counselor the
opportunity to discuss notions about tolerance, and reframe it to
the client as not having a built-in warning system to indicate when
he or she has "had enough." Thus, what originally appears to support
the concept that there is no problem ("I can hold it") now supports
the concept that there may be a problem ("I'm at risk for overdoing
it without knowing it until it's too late").
