Strategies for Evoking Change Talk

-->

Based on the work of W. Miller & S. Rollnick,

Motivational Interviewing: Helping people change, 3^rd edition

 Interviews of all types but especially those where the interviewer’s objective is to elicit a conversation about personal change are challenging when students see nothing in need of change. Traditionally, those conducting such interviews relied on an approach designed to help students recognize the risks inherent in their behavior. Their rationale for conducting interviews in this manner was a belief that intelligent students—and all students were presumed intelligent as evidenced by their matriculation in post-secondary education—when presented with the facts regarding the inherent risks associated with their behavior would opt for making changes. The insight students would glean from exposure to this non-judgmental information about risk would surely motivate them to lower the likelihood of experiencing untoward consequences by moderating if not abandoning their high-risk behavior.

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.

Motivational Interviewing is an approach to interviewing ever mindful of this. In this section, several approaches to eliciting “change talk,” that is, an indication by the person being interviewed that change, of any type, is “on the table” for discussion, are suggested. None is presented as

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?”

b           B.  “Okay, now assume you are unsuccessful. What led to this?” (called a premortem)

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?”