Motivational Interviewing: What is Change Talk?

Presentation:

Johanna’s Motivational Interviewing Part 2 Presentation (PDF)

Other videos in series:

• Motivational Interviewing: Overview of Spirit & Skills
• Motivational Interviewing: What is Change Talk?
• The Four Processes of Motivational Interviewing

Welcome to the Community Education Series, hosted by The Recovery Village and Advanced Recovery Systems. With that being said, I’m going to introduce Johanna. She has 20 years of experience designing, implementing and evaluating innovative programs and community-based organizations and government entities, including courts, schools, probation, parole, prisons, community correction and behavioral health agencies. Some of these programs include trauma-informed and community-based victim services, reentry programs, justice reinvestment programs in the community, restorative practices in schools and courts for youth and families, specialized workforce development, programs for youth women and formerly incarcerated people.

She also has designed strength-based trainings, coaching and implementation models to support organizations, leading change initiatives and justice reform efforts. Johanna specializes in working with multiple systems to increase collective impact and tackle complicated problems. She holds a Master’s Degree in Educational Psychology with an emphasis on behavioral change from The University of Colorado at Denver, a Bachelor’s Degree in Cultural Anthropology and Education from The University of California at Santa Cruz, and is a professional coach as a member of the motivational interviewing network of trainers. She is also a current resident for Goleman EI, emotional intelligence certificate holder, workforce development specialist and a global career development facilitator. With that said, I’ll turn it over to Johanna for the second part of the motivational interviewing training.

Thank you, Candi. I appreciate those of you who joined a second time. This is the second of a four-part series in motivational interviewing, and as I mentioned last time, I’m a founder for the Alliance for Criminal Justice Innovation. We help organizations implement evidence-based practices, such as MI. I’ve been practicing MI for over 15 years; It’s one of my favorite topics because you really get to learn and grow with an international community of professionals who practice in fields from health care to justice and education. So, MI — there was over 30 years of research around MI and behavior change, and when you start using it, you can really start to see the impact it has on the people around you. With that said, let’s jump in.

In our last session, we focused on MI spirit, which is at the bottom of the pyramid; spirit encompassed partnership, autonomy and empathy. We discussed how active listening and an approach of curiosity are really the skills utilized to create an environment conducive of having a conversation about change. We also talked about reflections as being kind of the core skill of MI, and how the more complex or below the surface reflection goes, the more effective we are at really discovering the attitudes, thoughts and beliefs that keep people stuck, and also what their internal motivators are that drive change.

Today, we’re going to build upon those two pieces and really begin to tune our ear to what people say when they talk about change — to give us a clue into where they are in the change process, and when and how to use MI to move them toward lasting behavior change. So today, we are doing a couple of new things. We’re going to be listening to some audio clips using the chat function along the way to kind of chat out what you hear people saying in the clips. I’m also, right now, going to copy a link to some additional materials. You should have that there, if you want to follow along. One of the resources in that link is a typed-out transcript of one of the audio files we’ll listen to.

Let’s get started. So, when is the right time for an MI conversation? Behavior change is really complex work, and it’s a really important part of a practitioner’s craft to know when and how to use which skills they have with the most impact for clients. Sometimes, people have a lot of motivation, but maybe they lack the skills or ability or knowledge to accomplish their change goals. In those scenarios, MI might not be the right intervention. In the case where a person just has a knowledge or skills gap, maybe they just need a skill building or a cognitive behavioral intervention. Last time, we talked a little bit about MI is useful when you identify that change is a will issue, not necessarily a skill issue. MI is most effective when people seem like the most resistant and reluctant to change, or when they may not even see a reason to change at all.

You may be familiar with this stages of change model; it’s nothing new. When looking at behaviors that people were attempting to change, the researchers for Chaska and DiClemente found that people go through similar stages of readiness to change a behavior. If you look at this sort of pie model, precontemplation is not thinking that you have a problem at all, right? So it’s not knowing what you don’t know and seeing no reason to do anything differently. It might sound like someone saying, “I don’t have a problem,” or, “I don’t need to change.” Contemplation is early consideration that there might be some reasons to change. As you go around the circle, determination refers to the stage of change where a person is motivated to make change, and in the action stage, they’re actively taking steps to make that change. Then, action is followed by maintenance and often relapse. So when you’re looking at these stages, for me, it’s helpful to think of them less as distinct slices of a pie and more like a spectrum where people may move back and forth and through it over time.

The stages of change — it’s important to think that these are behavior specific. Someone might be precontemplative in one behavior and taking action in another behavior. One of the most common pitfalls of MI — when people think that MI doesn’t work in all situations — is that we may not be focused on the right target behavior. So in order for MI to be effective, that’s why we start with spirit. It’s really important that we’re solving the right problem to begin with. Motivational interviewing, I said earlier, is really helpful for people struggling with their own reasons and motivations to change, and it’s particularly true for people who are in that precontemplative and contemplative stage of change. So, what we’re going to practice today is really listening for where people are in the stages of change to kind of alert us as to whether that’s a good moment to jump in with our MI skills.

On the next slide, you’re going to hear an MI conversation with William. He’s a client whose relationship is suffering as a result of his drinking. While you’re listening, I want you to tune your ear for change. Think through — what do you hear him say to indicate where he is in the stages of change around drinking? I want you to chat that out in the box so you can put it real-time verbatim. What kinds of things is he saying that gives you an indication of whether he’s precontemplative, contemplative or in determination? Then listen for whether he is in the same stage of change at the end of the conversation as he is at the beginning. So, here are the two things you’re listening for. What do you hear him say? Chat it out — that might indicate what stage of change he’s in, and does he change over time? I’m going to mute myself while I play William.

Practitioner: So, I’m curious about what you think might need to change to make your relationship better?
William: Hmm. Well, I wish he trusted me more, but I mean, I guess, you know, a compromise has to be made from both ends. Or, I guess I could drink less. I don’t know. I could, you know, I don’t know. I guess that could be a solution.
Practitioner: So one idea you have is to compromise, and compromise might mean drinking less.
William: Yeah, I guess.
Practitioner: So, on a scale from zero to 10, where zero is not important at all and 10 is extremely important, how important do you think it is for you to begin drinking less?
William: Well, in my head I’d like to say that I’m a 10, ready and all that, but I feel honestly like zero. I mean, I don’t want to, I don’t think it’s necessary; then again, maybe it’s for the best. Maybe I should, but then again, I don’t see if I’m causing any damage other than the girl I’m with right now, who doesn’t agree with it.
Practitioner: So drinking has caused some problems with your girlfriend.
William: Yeah, but she used to drink more than me and she doesn’t drink anymore so she’s really sensitive, and that’s the way I see it right now. So in my head, yeah, I want to change, but really when I actually really think about it, I don’t see why I have to.
Practitioner: So it seems like on the one hand, you don’t see many reasons to quit drinking, and on the other, you’ve mentioned wanting to make your relationship better.
William: Yeah, I guess those are both true. My girlfriend did say she’d leave me if I don’t quit drinking.
Practitioner: And you don’t want her to leave?
William: No, she’s the best person; I’ve been with them a long time. I’m just not used to this, and I don’t know how to be with somebody like that.
Practitioner: And you’re having a hard time imagining that — being with someone like her, maybe not drinking.
William: Yeah, I guess. I mean, I’ve really never not drank. It’s been part of me and how I hang out with my friends, you know?
Practitioner: So it feels a little scary to think about, and also maybe something that could really change your life and relationship with your girlfriend.
William: Yeah. I mean, I don’t want her to leave me. I mean, I care about her and all that and she cares about me.
Practitioner: So it sounds like this relationship does mean a lot to you.
William: Yeah, it does. I mean, that’s all I’ve got really.
Practitioner: Tell me how would your relationship improve if you made this change?
William: Well, we wouldn’t fight as much, probably not at all because she doesn’t drink. I go out with friends to drink and that, you know, causes all of our problems. I stay out late, she worries, so I stay up later so I don’t come home drunk and then we end up arguing.
Practitioner: So you’d argue less, and maybe there would be a little more peace and calm in your relationship?
William: Yeah, for sure. I mean, those are the best times really. When there’s peace and calm; we’re just watching a movie and hanging out together without all the drama.
Practitioner: So you’re seeing some benefits that drinking less could have on your relationship?
William: I mean, if I don’t stop drinking, it’s over, and I don’t want that.
Practitioner: Earlier, I asked you on a scale of zero to 10, zero being not at all and 10 being extremely important, how important do you think it is for you to begin drinking less? Where would you rate yourself now?
William: Probably more like a five, maybe a six.
Practitioner: So, you’re a five or a six. How come you’re no longer a zero?
William: I don’t want to ruin my relationship. I mean, I’m tired of choosing friends that don’t really care about me and drinking over her. I guess I want to give this a try.

Johanna:
Thank you for all of these thoughtful chats; you all are right on. As you could hear early in the conversation, it does seem like William is rather precontemplated about his drinking, right? You heard a lot of, “I don’t want to, I don’t think it’s necessary, I don’t see that I’m causing any damage,” and then through time, he sort of shifts, right? It’s not super strong, but he moves a little more through contemplation towards determination. “I don’t want her to leave me, I guess I want to give this a try.” You can kind of tune your ear to hear how these shifts along in those stages. And you can hear the practitioner starting to develop some discrepancy between his present behavior (drinking), and his values and important goals, which are the relationship with his girlfriend.

As this conversation went on, that would probably be an advanced strategy that the practitioner would use to shift him through the stages even more strongly. “I don’t want to ruin my relationship, I’m tired of choosing friends that don’t really care about me and drinking over her.” Those are all verbatim statements from William that kind of indicate his shift. So, MI as an intervention is totally appropriate for somebody like William, right? That is in that early contemplation or precontemplation stage of change. And when we hear that — when we hear kind of excuses and justifications and other indicators of those early stages — we should have like a little bell go off in our head to think, “Ah, this is a really great time to identify the target behavior clearly and jump in with some MI.”

Let’s talk about change talk. Part of tuning our ears in MI is listening for what is called change talk. An acronym that’s sometimes helpful to learn change talk is “DARN CAT,” and DARN CAT simply stands for desire, ability, reason, need commitment, actuation and taking steps. What change talk is is someone’s argument to change. It’s their reasons, their desires, their needs or their abilities to change. So this could sound like, “I don’t want her to leave me.” I think you heard William say that, or, “Maybe it’s for the best,” or, “I think I might give this a try.” There are different strengths of change talk. Change talk isn’t always a really strong commitment, but we really wanted to tune our ears for any tiny reason why a person might want to make a change. Change theory will describe how we gradually become more committed to that which we give voice. When used skillfully, motivational interviewing can actually increase and strengthen a person’s own argument for change, to where they’re literally talking themselves into changing.

If change talk sounds like reasons to change, sustain talk is the opposite side of that coin. Sustain talk sounds like excuses for reasons to stay the same. You might hear excuses show up with people you work with or people around you as things like, “This is too hard. I don’t have time. I’m not hurting anyone. Everyone else is doing it. I’m just being set up to fail. I’ve tried that before. I don’t see a point,” and you can go on and on and on. If you think right now, I’m sure you can think of something maybe you’ve heard a million times when you’re trying to work with someone on behavior change. And as we talked about in the first session, part of motivational interviewing is tuning in to your own thoughts and attitudes about what people are saying instead of hearing sustain talk as excuses that may rub us the wrong way. When you’re thinking from an MI perspective — with curiosity — it should really make you think, “Oh, yes. I’m stumbling on the right thing. It’s time to jump into action.” So sustain talk is what we want to hear when we use MI.

I want to tune our ears a little bit to sustain talk and change talk, because oftentimes they’re really mixed together into a conversation about change. People will often argue both sides, reasons why change is too hard and they want to stay the same and reasons why they should or need to change. What we’re going to do is we’re going to listen to Oscar, and I want you to tune your ear for his reasons to change and tune your ear to his reasons to stay the same. They’re all kind of mixed up in there. Go ahead and just use the chat function again to chat out what you hear.

Oscar: One thing — I enjoyed smoking for a couple of years now, and it’s hard to quit smoking. I’ve been trying for a couple of years now. My wife is always on me about this and it drives me crazy. I really don’t need someone else telling me what to do. I know what I should do. I must’ve tried to hide it from her, smoking in the car or when she’s at work. Just hearing about it, I know I have no business smoking anymore. I’m getting older and I want to be healthy to get around for my kids as they grow up, and I really don’t want them to see me smoking either. I don’t want to be sneaking away to smoke and hiding it. Missing out on life. When my work is really stressful, smoking helps relax. If I don’t stop to smoke during the day, I never even take a break. I’m not going to do that to them. A thousand things all day long. And a cigarette at break helps me focus. I actually can’t even imagine working without smoking. Last time I tried to quit, I was less productive at work and I was anxious and grumpy. I can’t be like that. I’m in sales, and besides, I do enough of other healthy things in my life to keep that balance. I write, I exercise, I stopped drinking some months. Everyone has a vice. I even got to the doctor for checkups. I mean, it’s like my one thing. I enjoy smoking, and I worked so hard for everyone else and to provide for my family. So I felt like I deserved something too, and I don’t want to live life with no joy at all.

Johanna:
I’m watching your chats come in, and you are all right on. I really like, Katrina, how you describe the inner war. That’s a really great way to think about change talk and sustain talk, and the ambivalence that proceeds behavior change. “I deserve something. I don’t want to live life without joy.” He gets dramatic there at the end, right? But you can really hear both sides of the argument. “A lot around, I want to be there for my kids, I don’t want to be the kind of dad sneaking around.” These are all huge pieces of change talk, and then you hear the other side, right? Which is, “I do stuff for everyone else; I would never take a break if I didn’t smoke.” Those are all pieces of sustain talk.

Oscar’s showing how this inner war or battle is really quite typical, normal and a predictable part of the change process. Sometimes with scenarios like Oscar, it’s really easy to jump in and just start giving advice or relating or responding, saying things like, “Oh, you know, I used to smoke. You should try the patch or chew gum or eat carrots.” This is where motivational interviewing is really distinct from other typical conversations about change. MI skills are used strategically with someone ambivalent like Oscar, and what MI will start to do is reflect strategically back his change talk and basically ignore the sustain talk. That’s really how people talk themselves into change. So that inner war we talked about is called ambivalence in MI, and ambivalence, for the sake of today, I have defined as a conflict of ideas or attitudes.

It’s the presence of two opposing ideas, attitudes or emotions occurring at the same time. I would argue that ambivalence could be multivalence, or the presence of multiple ideas, attitudes or emotions — not just two. Oscar is a really good example of what ambivalence sounds like. Ambivalence is often confused with resistance, but what is important to understand about ambivalence is that it’s important and very typical in the change process. It really sounds like people with their one foot on the gas and one foot on the brake, and they may have really powerful and compelling reasons to change on the one hand and to stay the same on the other. Ambivalence is really what can keep us stuck — and can keep us stuck for years.

Because it’s such an uncomfortable place to be for a very long time in that war, our brains are really wired with a cognitive bias for a status quo for staying the same. It takes less work cognitively to just go back to the way you’ve always done things than it is to change. Among my practice practitioners, we tune our years and we listen for it, and when we hear it, we jump into action. That’s how we start to use reflections strategically and reflect back the change talk, ignore the sustain talk and really try to strengthen someone’s own argument for change. The research here is really clear that when change talk increases, behavior change increases.
This is how MI literally talks people into changing themselves by strengthening their own reasons and motivations. On the flip side of that coin, reflecting back sustain talk — hearing the same talk and responding to it with advice or teaching or suggestions — really gets people more entrenched and committed to staying the same. In MI, there’s a phrase people say, which is like, “Don’t ‘should’ all over people,” meaning, “You should do this, you should do that.” So in MI, “should” doesn’t work when it comes to reflecting change talk and ignoring sustain talk.

Alright, so how do we help clients move through ambivalence toward change? We are going to develop a specific set of skills over these next three sessions to develop discrepancy between present behavior and important goals in the future, and then strategically reflect that change, talk to increase their reasons and arguments to change. I want to practice that with you. So when we think about reflections — last time, we talked about going under the surface; the more complex, the better. Now, we’re adding another skill of getting strategic about which part of what people are saying we’re going to reflect back. Here’s an ambivalent statement: ”I really don’t want to stop smoking, but I know that I should. I’ve tried before and it’s really hard.” You can see in this statement that there’s some mix of sustain talk and change talk. The change talk is pretty weak. It kind of is reflected in the second part of that sentence.

So, “I really don’t want to stop smoking,” is sustain talk, but, “I know that I should,” is change talk, right? “I’ve tried before,” which seems like a strength that we could build upon, and, “It’s really hard.” Sustain talk. When you think about strategically reflecting, go ahead and put in your chat — what would you reflect back? You really don’t want to quit, A. B, you’re not sure if you can quit or C, you’ve noticed several reasons why you feel you should quit. Alright, yes, you’re all masters at this already. It’s helpful for me to think about, when you look at these three options, is that what we want to hear more of from the person you’re talking with? You could see that if you first reflect back, “A, you don’t really want to quit,” what you’re going to get is more sustain talk. You’re going to get all the reasons they don’t want to quit, right? If you reflect back, “B, you’re not sure if you can quit,” conversations can go in a lot of directions, but you’re likely to get many of the person’s doubts or insecurities about how successful that will be. And then, “C, you’ve noticed several reasons that you should quit.”

You’re probably going to hear several reasons, other motivators they have, that you might be able to listen for strengthen and leverage and reflect back. I love this reflection that Katrina chatted out: “A part of you really wants to quit and become healthy, but something in you is stopping you. I’m wondering if we can make contact with that part of you and find out what it has to say.” Wonderful. Love it. So, let us practice a few more of these.

This time, I want you to type a reflection in the chat so you guys can see all of the genius coming out of everyone’s heads. So here’s our change statement — again, there’s a lot of ambivalence in it. “I wish it were different and that I could afford everything that I need, especially to take care of my family, but it’s hard out there trying to find a job as a felon. It’s not like I’m not trying or don’t want to be working, but sometimes you do what you gotta do to get by.” What would be a reflection that would get you more change talk? Awesome. “It sounds like you’re trying hard to do what you need to do.” I’ll give you some inspiration. There again. In MI, there are no right or wrong answers in what you reflect, and the more that you practice, you just start getting better at it. These are great. “It sounds like you really care about your family. It sounds like you’re very, like, you’re a very motivated person and have the will and creativity to achieve many things.” That one’s awesome because it’s also an affirmation.

“Taking care of your family’s important to you, you’ve been trying really hard to find work, you want to be a provider for the people you love. You’re looking forward to things being different.” In that last one in particular — “You’re looking forward to things being different.” — it really is reflecting that present-future focus of MI, right? When we’re thinking strategically about what we’re listening for and what we’re reflecting, we’re always thinking about moving the conversation forward in the direction of change and in the direction of taking action on change. “You love your family, but you’re also discouraged and trying to find a job with a felony background.” So in that reflection that Trina chatted out, they showed both sides — the struggle and the love for the family.

Here’s another: “I don’t want to keep getting into trouble and letting my family down, but I just don’t think I can stay clean.” Show me what you’ve got in the chat. “It sounds like you’re ready to make a change, you want to be there for your family, you have reasons to stay clean, you care about your family.” Great. “It sounds like you want to make a change, you want to know how to stay clean.” I like that. “It sounds like you care about and want to change for your family. It’s important to stay out of trouble and stay clean, what your family thinks of you matters.” Ooh, that’s a good one. It’s a nice end goal. You get to see what’s really, really nice about practicing with other people. Even if we’re in this virtual world, it’s that you can really see and learn so much from how other people reflect, and it can show you other ways to reframe a conversation to move it toward change.

“Are there ways that MI simultaneously acknowledges the present suffering while also opening the door to future possibilities? Just wondering because when grief is not acknowledged, the person can stay stuck in grief.” That’s a really great question, right? Like, are there ways in MI to acknowledge suffering and also open the door to possibilities? MI is a trauma-informed approach in that it’s really strength based, it’s really person centered, it’s really present-future focused. In the early stages of strategy in the engagement phase — and we’re going to go into strategy in the next session and session three, even deeper — in the engagement phase, it is a time to explore what’s under the surface and build that trust relationship and sort of diagnose what’s keeping someone stuck. But MI really is a tool for making behavior change as opposed to reprocessing past the past, and so if you have a clinical background, that’s clearly in your toolbox for using other modalities to explore things like grief or childhood trauma. But it’s not necessarily a tool in MI. We can talk about that more off-channel if you’d like.

So we talked about listening for change talk. We talk about what we do when we hear it, right? We want to reflect more back, but we also want to ask for change talk, and we do that through what is called evocative questions. Evocative questions are really just asking for change talk. In the link that I posted for all of you, there’s actually a list of evocative questions that I find useful and handy. It’s nice to choose a few evocative questions you just have in your back pocket so that you can use them when you are having conversations about behavior change. Some of them that I like are up here on the screen. “What are you hoping will change? What are your hopes for the future? What are some reasons you need to change? Tell me how you can make things better. How would your life be better if you changed?”

One way I think of a good evocative question is to think backwards and to think about what I want to hear the person talk more about. So, what question would I ask to get someone to talk about what I really want to hear more of? If I want them to give me all the reasons their relationship with their kids will improve if they change, I might ask something like, “Tell me how your relationship with your kids would improve if you made that change.” So an evocative question is simply asking for change talk. Let’s practice that in the chat box — think about these two statements. “I can’t keep doing this because my health is suffering,” and, “I want to be around to see my grandkids.” This is going to kind of hurt your brain cause it’s backwards thinking — it’s kind of hard. What question could you ask to get a statement like that? In the first one, “I’m thinking I can’t keep doing this because my health is suffering,” a question I might ask is, “How do you wish things were different?”

Let’s see what you got. “What experiences do you want to share with your grandkids?” Awesome. “How do you see yourself five years from now? What are you hoping will change? What kind of person would you be if your health was awesome?” That’s a great question, Katrina — I love it. I’m gonna write that one down. “What do you want to do with your grandkids in the future?” Awesome, these are all great. “How could you improve your health? What would it feel like for your body to be healthy?” Another wonderful question, Sophia. I’m going to borrow that one too. “What opportunities might you have if you quit smoking?” These are great. You guys totally get it.

So, remembering the definition of MI that we went through in the last session, we talked about MI as both eliciting and strengthening intrinsic motivation for positive change. We start by tuning our ear, then we use reflections and evocative questions to elicit more change talk, and when we get it, we want to make sure we spend enough time strengthening it before we move on and immediately start jumping into making plans, action steps and setting goals. That’s really common in MI — once we hear change talk, we’re like, “Woo, high five. We did it,” and we’d start moving on to, “Alright, let’s put it in your plan.” Sit in change talk for a while, because while it may seem like we’ve been talking about this forever, as the person talking, it really can have a profound effect, right? Because they are talking themselves into change. So stay there and let them simmer for a little while before we move into problem solving, and summaries are a great way to sort of consolidate and strengthen change talk.

I like the metaphor of the bouquet; it’s used often in MI. As a bouquet of flowers, each flower kind of signals a desire and ability or reason or a need that your client has expressed during your conversation about their change goals. One thing you’re going to be doing as you listen for change talk is sort of collecting them, and at the end, you create a summary or a “bouquet” and sum up all their reasons to change together. Remember the conversation between William and his case manager or whoever that was — their practitioner. You can look at the transcript also in that link I chatted out.

But if we create a summary to consolidate and strengthen his change talk, it might sound like, “Let me tell you what I’ve heard so far. It sounds like you have many reasons to stop drinking. You’re tired of choosing your friends that don’t really care about you over your partner, you’re ready for less drama and less arguing, and you want to spend more time enjoying the peace and calm you feel with your girlfriend when you’re not drinking. And it sounds like you’re ready to make that relationship a priority in your life, did I get that right?” So that’s sort of the structure of a summary. A summary is a “let me tell you what I heard so far” or “let me check to see if I got this right,” and then it’s just a series of reflections. Reflecting back the change talk you heard and then checking in at the end and seeing if you got it right. The great thing about using reflections in a summary like this is it really does give the person you’re working with an opportunity to pause, reflect, clarify and really sort of metabolize that argument or reason for change.

Here we are at the end of our second session; we went through a lot. Next week in part three, we’re going to take everything we’ve done so far around reflections, spirit, ambivalence, change, talk and sustain talk, and we’re really going to jump into the four processes of MI, which are the MI strategy and what those four processes will help us get. It’s sort of the arc or roadmap for an effective conversation. So what is the beginning, middle and end of a really effective MI conversation, and what does that roadmap look like? So next week, we start to kind of pull all of these microskills that we’ve been isolating together and paint the bigger picture for all of you.

Thank you for watching this video. We hope you enjoyed the presentation.