Motivational Interviewing Skills – A Beginning
Here are some ideas of how to elicit change talk from clients, especially when it isn’t occurring naturally.
The Readiness Ruler
Components of personal motivation for change include both the person’s perception of the importance of the change as well as his or her confidence that change can be achieved. Readiness to make a change is also important. The Readiness Ruler is a simple method for determining clients’ readiness to change by asking where they are on a scale of 1 to 10. The lower numbers indicate less readiness, and the higher numbers indicate greater readiness for change.
Depending on how ready to change clients think they are, the conversation can take different directions. The Readiness Ruler can be used periodically to monitor how motivation changes as change progresses. Remember that clients can move both forward and backward. Scaling for importance and confidence allows us to discover together where the client is at in terms of the components of readiness for change, and also allows the client to talk themselves into moving forward with strengthened willingness and ability.
For importance, you might ask:
- “On a scale of 1 to 10, with 1 being low and 10 being high, how important is it to you to stop hanging around with friends who are using?”
- Let’s say the client responds with “3.” We might follow up with, “What is it that makes it as low as a 3 for you?” and “If it were a 4 or 5 in terms of importance, what would you see yourself doing differently?” “What would it take to raise the level of importance to a 7?”
For confidence, you might scale similarly:
- “On a scale of 1 to 10, with 1 being low and 10 being high, how confident are you that you could make changes that you desire or see reasons for? and follow up with:
- “What strengths and abilities do you have that support your (client’s) number?” and “What might it take for you to feel more confident?” and “How confident would you need to be in order to take action for these changes?” and so on.
Here is a sample conversation between a peer specialist and the person s/he is serving. This explores the client’s response (selected a rating of 4 out of 10) in the Importance Readiness Ruler about not hanging around with using friends.
Peer Specialist: “Why didn’t you score the importance of this higher?”
Client: “Well, I really don’t think this is the key to my getting and staying clean and sober.”
Peer Specialist: “Don’t you see that you put yourself at risk every time you hang out with them?”
Client: “Maybe, but I know people who used to use and don’t any more that hang out with them. Anyway, I live there, and it’s hard to avoid them. I’ve hung out with them since we were kids.”
Peer Specialist: “So these friends are more important to you than staying clean and sober and getting off probation?”
Client: “You may not think much of them, but they’re all I’ve got.”
The conversation quickly takes on a pattern where the peer specialist argues for change, and the client argues against it. Since it is not the peer specialist, but rather, the client who needs to make the change, the outcome is not likely to be good.
If, instead of asking why the client didn’t score this item higher, the peer specialist turned the question on its head, it might come out like this:
Peer Specialist: “That’s interesting, why did you score the importance a 4 instead of a 2, 1, or zero?”
Client: “Well, even though these guys are about the only friends I have, I do have to admit that there is a risk for me if I hang out with them.”
Peer Specialist: “That makes sense. What would you like to do to reduce that risk?”
Client: “I don’t know. Short of bringing someone with me, I’m not sure what I can do.”
Peer Specialist: “Remember when we talked about some of those get-togethers at the club? Do you think if you connected with more people in recovery, it might be easier to spend less time with them?”
Client: “MMMM…. I guess so.”
Peer Specialist: “Do you want to give it a try and see if it makes a difference?”
Client: “I guess that makes sense….”
Peer Specialist: “Great! I definitely think it’s worth a try. Let’s see what’s coming up.”
When the question is turned on its head, the client will generally proceed to recite all the reasons he wants to make the change or feels s/he should do so. Suddenly, the conversation is about making rather than not making the change! That‘s a conversation where you can easily be on the client‘s side in helping him or her find solutions for the problem. Even if the client rates an item a 1, you can still ask why he or she did not rate it a 0. A similar conversation can take place about the confidence and readiness rates the client gave you.
As this example shows, while you may already know the solution to a problem a client is encountering, there may be times when it‘s most helpful to allow the client to discover or tell you the solution.
The basic process in guiding change in a neutral manner is to explore thoroughly the pros and cons of the available alternatives, and to do so in a balanced way. A common procedure is to elicit from the client the advantages and disadvantages of each option considered. This technique is called the Decisional Balance which was conceptualized by Janis and Mann[ii] (1977) as a decisional “balance sheet” of comparative potential gains and losses. People who are ambivalent about making a change vacillate between the two opposites of ‘No Change’ and ‘Change.’
The Decisional Balance strategy uses a set of questions to probe about the pros and cons of change as well as not changing:
- “What would be the downsides of not changing?”
- “What would be the positives of not changing?”
- “What would be the downsides of changing?”
- “What would be the positives or the benefits of changing?”
Ordinarily, we think of working with the client to discover the benefits of changing as the final step of the decisional balance strategy, principally due to the tendency for people to remember most strongly the last things they recall themselves saying. It makes sense, then, that we would want to leave the “change talk” emphasis or momentum last in the exploration process.
Video: Motivational Interviewing Decisional Balance (10 minutes)
Motivational Interviewing is simple but not easy. The practice of MI involves the integration of some quite complex skills. Someone who is good at MI makes it look fluid and easy; however, training and skill development in MI is not a one-shot event. This takes considerable practice with feedback from a supervisor or a coach who is competent as an MI practitioner. Research has shown that the first building blocks for MI require competence in two areas that should be already in your “toolbox” –
- Incorporating the spirit of MI into your daily practice: partnership, acceptance, compassion, and person-centeredness
- Having skill and comfort in reflective listening and client-centered OARS skills (O = Open Questions; A = Affirmations ; R = Reflective Listening; S = Summarizing)