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Based on the work of
W. Miller & S. Rollnick,
Motivational Interviewing: Helping people
change, 3rd edition
As is so often the case when logic dictates a course of
action yet is implemented without the benefit of empirical investigation, the intended
results are not forthcoming. In the case of addressing substance-using
behavior, this lack of results has historically been interpreted as a denial. In
other words, although intelligent, when presented with the facts regarding the
risks associated with high-risk use, students failed to change because they could
not or would not heed the warnings of those attempting to help. So ingrained
was this belief that high-risk users fail to change because of denial, that
confronting denial became the objective of interventions, not only with those
with substance use disorders but with all high-risk substance users, including
students.
A confrontation of denial inevitably places the interviewer
and the interviewee on opposite ends of a verbal tug of war. Ironically, the
harder interviewers “tug,” that is to say, try to engage interviewees in a
discussion about their behavior, the more these interviewees would “dig in” and
resist. Confirmation bias being what it is, those users who opted to change
were viewed as evidence that this confrontational approach was effective while
those who refused to acquiesce or would terminate contact with the interviewer
were viewed as “not ready to change.” Remarkably, this was an accurate
assessment of those terminating contact but not because they were incorrigible
but, rather, because they were in what is called a “pre-contemplative” stage of
readiness to change. In short, these users terminated contact because they felt
pushed to do “too much, too soon.”
Interestingly, we now understand that change is not so much
an event as it is the result of a process of movement through successive steps
in preparedness to change. The traditional approach to engaging high-risk users
and those with substance use disorders had been to try to motivate them to
change their behavior as though “change” was something that could be turned on
like a light with a switch. Understanding that change is a process and that one
needs to move through the successive stages of readiness to make a change has
given rise to a new strategy to guide interviewers working with students, or
anyone for that matter, to evoke change talk.
Recognizing that modifying one’s behavior results from one’s
movement through the successive stages of readiness to change rather than
something an interviewer imposes by making an interviewee pliable with
information about the risks associated with use has opened a new approach to
interviewing. Recognizing change as an “inside job” means that interviewers do
not “flick the switch” that initiates it but rather, they facilitate an
opportunity for self-reflection that then enables movement through these stages
of readiness. Not only does this difference in approach increase the likelihood
that users will move towards change it also alters the criteria interviewers
use to evaluate their effectiveness. If “your willingness to change” is not a
measure of “my effectiveness” as an interviewer then your movement from
refusing to see use as a problem—denial—to ambivalence about whether it “just
maybe” constitutes progress…effectiveness.
Strategies for
Evoking Change Talk
There are likely many
strategies for facilitating movements through the stages of readiness to change;the approach or “silver bullet” that will magically affect an
“about-face” for an interviewee. That said, one or several of these strategies
may increase the likelihood of creating an environment open to the user’s
consideration that perhaps the benefits received from maintaining the status
quo are not worth the costs required to receive them.
1.
Ask
evocative questions: In counselor speak an evocative question is an “open
question” or one that cannot be answered with a “yes” or “no”…or a brief one or
two-word reply. For example, a “closed” question might be, Did you drink last weekend? An “open question” that seeks to access
the same information but at the same time invite the individual to share his or
her story might be, Tell me a bit about
the role drinking played in last weekend’s socializing. Even if the person
being interviewed is loath to participate in the conversation and says, I didn’t drink, you can reply, Ah…thank you…how about for your friends?
2.
Ask for
elaboration and/or an example: Open questions invite interviewees to share
their stories and students are always more interested in sharing bits of their
stories than they are in telling you about their business. So, when an
interviewee responds to the open question suggested above with, well, me and my roommates went to a party,
had a couple drinks, but it was lame so we left early, the interviewer
might reply, Interesting…so you went out
with your roommates last weekend…what did you do after leaving the party?
Even if the reply to this open question is a short snippet of information that
includes a vague fact, that too can elicit a follow up from you like, Interesting…tell me more… Remember: evoking change talk is like building a
brick wall. It is accomplished not by focusing on the wall to be built but on laying
the next prick precisely.
3. Look back…look forward: No one has
engaged in a high-risk behavior from birth and likely not for “as long as I can
remember.” Because of this ask, Tell me a
bit about what your social life was like before you started _____ (whatever
behavior). True, a resistant interviewee may say, It was really boring but go back to suggestion #2, how was it boring or what makes it seem so boring now? If the
interviewee just does not want to go in this direction, move on. But often
engaging in a discussion about “life before” can interrupt the “normalcy” of
current high-risk behavior with a hint of nostalgia.
Like “look back,” “look forward” is
designed to move the student beyond the current routine of high-risk use. This
strategy is likely best saved for a bit later in the interview or relationship
with there is at least an openness to considering that change may be
appropriate at some time in the future. Ask,
tell me what will be going on in your life in the future when you have made a
change in your _____ behavior. Notice the phrasing of this question; it
“assumes” that a change will be made, and made successfully. This is an
important aspect of employing this type of question. Subtly, you are suggesting
that change is (1) coming, and (2) will be made successfully.
4.
Query
extremes: Change talk is often the result of creating opportunities for
individuals to see beyond the “boundaries of routine.” We all tend to habituate
to that which happens over and over. Need proof…how did you travel to
work/school today…same route, same means of transportation? Did you “think
about it” or did you just “follow the routine? Ask, what might be the worst thing that might happen if you do not alter
your current behavior or if you do
not change, what risks do you run?
Likewise, asking about the best things
that might happen if a change is made; if
you were to change your behavior, what benefit might follow from that decision
or what’s the best thing that could
happen if you changed?
There are, as I imply above, likely countless “related”
strategies or steps one can take to facilitate change talk. The point to keep
front-and-center, however, is that the interview is something done with the interviewee and not to him or her. Motivational Interviewing
is, in everyday language, a cooperative conversation based on the collaboration
of its participants. Such a relationship is designed to reinforce the
interviewee’s belief that change is both an option and possible. It is about
celebrating ambivalence as movement towards change rather than confronting it
as denial.
Conducting interviews
in this way necessitates recognizing that no one changes without coming to the
realization that to change one must give something up, however, that
“something” is not worth as much as what one receives in exchange for it. In
other words, change talk results when one conducts what economists call as
“cost-benefit analysis” and recognize that what I get by changing is of
greater value than what I give up to get it. Remember the parable in the New
Testament about the man who, finding a treasure in a field, buries it and then
sells all he owns so he can then buy
the field on which the treasure is buried. Successful, permanent change is
always the result of moving towards what one desires rather than away from what
one fears.
An interview with an
ambivalent changer
What follows is a series of questions that could be
presented in an interview with a hesitant changer, someone who recognizes that
change may be in the future, but certainly not right now. This is neither a
script for an interview nor a list of suggested questions from which to
construct an interview. What follows is simply an outline of what an interview
intended to evoke change talk might look like.
1.
“Tell me what motivates you to make (consider) this
change.”
a A. “In what way might such a change benefit you?”
i)
“Tell me more about this.”
2.
“Okay, so you have decided to make/are
considering this change. How might you go about it to ensure success?”
a A. “What sets you up for success?”
i)
“Ok, assume you succeed; what led to success?”
ii)
“What did you do/not do?”
i)
“What steps can you take to avoid this?”
3.
“Making this change means you have to give up something.
What might that be?”
a A. “Okay, what do you gain by giving up these
things?”
b B. “How is your life improved by trading what you
give up for what you get?” or “How is your life better for having made this exchange?”
4.
“The difference between making some headway
towards change and realizing total success can be measured, in part, by how
important the change is in the first place. How do you rate the importance of
making this change?” ¬ ask as an open question first
before going on
a A. “Quantify that…on a scale of 1 to 10 where 1 = of some importance and 10 = absolutely important, where would you
place the importance of making this change?”
b B. “why?”
i)
“Interesting; tell me more.”
ii)
“When was the last time you experienced something
like this?”
(1) “What
were you doing…or not doing…when you experienced this?”
5.
“Given what you have said/written in response to
my questions, what are you going to do now?
a A. “Be specific…list 3 to 5 things you will do or not do.”
b B. “what has to happen to make these things
realistic or make them happen?”
