Motivational dialogue
In order to have helpful conversations, practitioners need to understand that how they talk to people matters very much. The goal of helpful conversations is to facilitate change.
Whether a conversation is helpful or not is to be judged by what an individual thinks, feels, does next. If no change occurs, we can assume that the conversation was not particularly helpful; we therefore make post hoc judgements about the helpfulness of a conversation.
The aim of Motivational dialogue is to…
elicit service user’s own thoughts
keep people engaged
help the practitioner to listen carefully
diminish the risk of people feeling they are being judged
reduce the risk of conflict and argument
assist in eliciting thoughts about change
make it more likely to result in making concrete commitment-to-change statements
So, how do we know we are moving towards change?
What service users say can be categorised into 1. ‘sustain talk’ or ‘resistance talk’ where the service user expresses acceptance of the status quo and/or active resistance to change 2. ‘change talk’ which denotes thinking about reasons for change 3. ‘commitment talk’ which denotes determination to change and action planning 4. ‘chat’ which is talk about anything irrelevant to the task in hand.
Change talk of itself does not predict behaviour change, but does make it more likely that a commitment will be articulated and the phrase ‘commitment talk’ was coined to distinguish this category of speech. Commitment talk has been shown to predict greater likelihood of subsequent behaviour change and is what the practitioner is trying to achieve.
It is self-evidently true that we cannot know the real intention behind utterances at the time they are made. In the clinical situation there are many factors that determine what someone will say: social desirability, the anticipation of help by expressing some feelings and not others, fear of consequences, maintenance of self-esteem. Thus it is likely that the true meaning will become evident post hoc and so, it follows, that categories of talk must be assigned provisionally until confirmed by actual behaviours.
Are motivational interviewing and motivational dialogue the same?
Motivational Interviewing, MI, is the name given to a form of treatment whereby the practitioner elicits a service user’s concerns as the means of changing their thoughts to build a commitment to change their substance use. Motivational dialogue recognises a style of interacting rather than an intervention, but uses the same techniques. In these videos Bill Miller talks about the evolution of MI…
Bill Miller, Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico
Bill Miller talks to Gillian Tober about his most recent thinking on motivational interviewing
You may also be interested in this video from the early days of motivational interviewing
Two essential skills for practitioners
Asking open questions to explore concerns, elicit intentions to change, and identify desired goals
Giving complex reflections as responses and to guide the content of the dialogue towards commitment talk.
Open questions
Open questions are the mainstay of motivational dialogue. With open questions you can…
➀ Better understand the motivation of all the participants, namely the person with a problem and anybody in their support network
➁ Explore the responses and check your understanding
➂ Use this understanding to guide your open questions and reflective listening
Remember you are aiming for change talk - statements such as: "Things cannot continue as they are"; "I want to change"; "I think I can do it"; "I think my life will be better if I change"
Once you have elicited change talk you want to be sure to attempt to elicit commitment talk: making an actual plan.
Ask a colleague or friend to help you practise open questions; tell them to stop you when they hear a question that requires a yes/no answer, (which would be a response to a closed question), when they hear a question with such intonation that the preferred answer is implicit in the question, in other words you make explicit what you wish the person to say, which is also not an open question. Questions that start with words like where, when, how and who are unlikely to have implied responses.
Complex reflections
Complex reflections make it more likely that expressions of commitment become a firm intention to change.
Complex reflections are useful in reflecting ambivalence: “on the one hand you are thinking about how to give up drinking because all your friends drink, and on the other hand you are thinking that you won’t have any friends left if you stop drinking”.
Complex reflections enable you to put in order the material elicited by ending the reflection with those statements consistent with the desire or need to change.
Complex reflections are arguably the most useful tool for conveying empathy.
Complex reflections are an opportunity for reframing the emphasis from the negative to the positive.
The difference between simple and complex reflections is that the former are no more than a repetition of something the service user has just said while a complex reflection brings in material that has been said at an earlier time, as well as a response to the recent utterances.
Hearing a complex reflection is testimony that the therapist has been giving their full attention to the service user, has remembered key things that have been said and is able to bring them together to help their service user make sense of what is going on.
Motivational dialogue is a style of discourse that can be used in most situations. The best outcomes will be from practitioners who have the characteristics of Helpful People and who understand the importance of determining a person’s motivation, or Stage of Change. Checking that your complex reflections are accurate is a critical part of therapy and the opening for collaborative work making positive changes.
Dr Gillian Tober demonstrates the use of open questions and complex reflections
Here is a role play using iSBNT with a father and daughter: the first video is about setting the drinking goal and the second explores alternatives to drinking and the third shows the use of complex reflections. You might want to count how many open questions you can spot and note how father and daughter respond. Notice that Gillian puts together different aspects of what has been said to make complex reflections. Finally, the video also shows that online sessions can be useful.
Dr Gillian Tober is a retired NHS Consultant Addiction Psychologist
The 1st video is about goal setting
The 2nd video is about treatment planning
The 3rd video is about complex reflections
Resistance to change
Resistance is a more entrenched form of unwillingness to change than the ambivalence that is normally encountered. Many people would say that this is the most challenging type of encounter with service users. Substance use has a perceived valued utility for some people…
Peace of mind - a relief from the stresses of life and from psychological distress
Life circumstances - an escape from living in poverty and deprivation
Interpersonal conflict - a way to ignore or avoid relationship problems
Identity - an existential attachment to an addiction lifestyle and values
Resistance may be expressed when, for example, someone is attending an appointment in an attempt to fend off relationship, employment or legal pressures to change.
Remember, from a psychological perspective, it is the immediate effects of taking a drug that are most powerfully reinforcing. Drinking, for example, rapidly causes a sense of relaxation and ability to deal with stress that most likely outweighs any concerns about liver disease at some time in the future. Where substance use has some utility then it will be more difficult to shift thoughts to a belief that life will be better without substance use.
Again open ended questions and complex reflections are the way to deal with resistance. Ask questions about how the service user would wish to get out of this conflict and explore in depth until a way forward that is consistent with positive change, is not threatening or impossible to contemplate and establishes your position as a helping agent who is on the side of the service user as well as family and concerned others, is found.
Example of dialogue
Practitioner: What has brought you here today?
Service user: I have come to see you because my husband has given me an ultimatum about stopping drinking.
P: And what are your own thoughts about stopping drinking?
SU: I like drinking. It stops me getting bored. He is away from home a lot and he expects me to be there whenever he returns so I can make his meals and keep the house clean.
P: And how would you prefer things to be?
SU: I want him to stop telling me what to do.
P: What about your own life. What do you want it to look like?
SU: I want to go out with my friends and have a nice time. I want to have a baby before too long, and I want to get my sewing business started back up.
At a point like this it is possible to explore what needs to be done to pursue those goals, and what short term measures might be taken about the drinking that the SU herself wants to put in place.
Bear in mind that if the practitioner can identify the cause of the resistance then this may be the target for any intervention and lead on to changes in substance use.
Keeping up momentum for change
Addictive behaviour is a form of being stuck, staying as I am is easier than changing (this is rather common in everyday life). To move forward, I have to believe that I can, and I have to believe that my life will be better if I do. I can be helped to believe these things by someone else asking me the right questions and encouraging a line of thought which is mine, and not by that person telling what to do, telling me what is good for me and for others.
Every practitioner will have experienced a service user making good initial progress and then getting stuck. The practitioner may have been able to elicit motivational statements in favour of change, but, at the same time, the service user may have thoughts about the difficulty or undesirability of change. There may be many reasons for this: enjoyment of drinking or drug taking, friends who are drinkers or drug takers for example. Getting around these motivational conflicts again needs the use of open ended questions and complex reflections.
Example of dialogue
Practitioner: Help me to understand what you get out of drinking
Service User: It makes me feel relaxed and less uptight. I can talk to people better and express what I think. I’m less worried about what people think of me.
P: How often do you find that happens?
SU: A lot of times that is what happens. But sometimes it goes wrong and I drink too much because I feel so good, and then I end up embarrassing myself.
P: Often you find that drinking helps you to feel relaxed and more confident at first, and it’s almost as if when this works well it can backfire and turn into the thing you most fear happening, that you are embarrassed.
This dialogue demonstrates a complex reflection which is used to clarify the service user’s perspective and lead them into thinking that they could find a better way to proceed.
Avoid bombarding the recipient with questions; use reflections to convey that you are closely following the dialogue. Complex reflections, that is reflections that combine different strands of what the service user has said, are the important sort to use. This way you will find that you can avoid parroting what the service user has said, and again you can convey interest and concern, while steering the dialogue towards an accumulating case for change.
more about effective practitioners…
