Introduction
How does one avoid such tongue wagging? What does it mean to have something real behind one’s words of influence? The answer, as we shall see in this chapter, is a paradox. What gives the realness behind one’s words of influence has little to do with one’s knowledge or expertise. Such expertise is not the realness that we seek. Indeed, the extent of our influence has less to do with the answers we tell patients and more to do with the questions we ask them. The art of influencing others is not so much the art of talking as it is the art of listening. Whether we are clinicians, parents, friends, or teachers, the ability to help others find motivation springs from our ability to listen with accuracy, empathy, and clarity.
In this chapter and in the next one, we will sequentially explore two innovative approaches to the collaborative interviewing strategies we first addressed in Chapter 2. One, Motivational Interviewing (MI), the subject of this chapter, has been around for a while, has been soundly empirically validated, and offers a wide range of interviewing strategies for helping people to find their internal motivations for change in a broad spectrum of arenas. The other, the Medication Interest Model (MIM), the subject of the next chapter, is much more recent, offers a fertile ground for future research, and provides immediately useful interviewing techniques for a specific area of great importance – helping patients to understand the pros and cons of medications, to choose wisely whether a medication is a sound choice for them, and, if so, to find personal motivation for maintaining their use in the healing process.
Both MI and the MIM represent prototypic person-centered models of interviewing. In actuality, they are more than the word “interviewing” may suggest. They are both on the very edge of relevance to a book on the initial clinical interview, for they are both approaches not limited to assessment interviewing but created as methods of ongoing counseling and therapy as well. They are presented in a book devoted to the initial interview because many of their strategies are not only of use in ongoing counseling but in the very first encounter with the patient. We shall also discover that their shared underlying spirits, both of which emphasize collaboration and compassion, resonate with the person-centered principles espoused in the pages of this book.
From the standpoint of practical clinical application, both MI and the MIM are far too sophisticated to be thoroughly summarized in a single chapter. Instead, my hope is to provide a concise introduction to each model that lays the foundation for their use, while providing a variety of interviewing strategies and techniques that can be immediately applied by the reader. Equally important, it is my hope to stimulate the reader to pursue the outstanding literature that exists for learning how to use MI and the MIM in a sophisticated fashion. Towards this end, I shall focus primarily upon the interviewing strategies from both models that are of immediate use in the initial interview, while pointing the door to the books created specifically as practical introductions to their use in both ongoing therapy and the initial interview.
Motivational Interviewing
People talk themselves into changing, and are commonly disinclined to be told what to do if it conflicts with their own judgment.2
William Miller and Stephen Rollnick
Introduction to Motivational Interviewing
Definition
MI is a style of interacting with people that is of clinical use anytime an interviewer is attempting to help a patient find motivation for change. It was developed by William Miller, from his years of work in helping people with substance use addictions, and Stephen Rollnick, based in Wales, who has been a long-time innovator in motivational work in primary care as well as mental health.
The term was first coined in an article in 19833 and was fully developed, integrated, and described in the ground-breaking book Motivational Interviewing: Preparing People to Change Addictive Behavior in 1991.4 Initially, as the title of the first edition suggests, MI was designed primarily for use in the field of addictions. Over the subsequent decades it has proven itself to be of use in a much wider range of situations, being utilized in arenas as diverse as exercise motivation, smoking cessation, dieting, wellness programs, and enhancing medication adherence; it is employed by health care providers ranging from mental health professionals to pharmacists.5–9 There have been over 200 clinical trials of MI and it has been cited in a staggering 25,000 articles.10 In my own personal opinion, MI represents one of the great advances in contemporary clinical interviewing. But what exactly is it?
From a practitioner’s standpoint, Miller and Rollnick define MI as follows:
Motivational interviewing is a person-centered counseling style for addressing the common problem of ambivalence about change.11
They add flesh to this definition by addressing the technical aspects regarding MI’s means of change and specific goals as below:
Motivational interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.12
From the above definitions one can see that MI is recognizable by two guiding qualities, its intentional use of a specific style of language and the spirit in which this language is used.
Spirit of MI
In the latest edition of their book, Miller and Rollnick emphasize that one cannot effectively employ the techniques of MI unless one understands and embraces the philosophy behind these techniques. In the preface to their third edition, they elegantly described this spirit, and I think it best to allow Miller and Rollnick to speak for themselves:
Like a musical theme and variations, there is a consistent motif running through these three editions … MI involves a collaborative partnership with clients, a respectful evoking of their own motivation and wisdom, and a radical acceptance recognizing that ultimately whether change happens is each person’s own choice, an autonomy that cannot be taken away no matter how much one might wish to at times. To this we have added an emphasis upon compassion …13
I would add that MI shares a trait seen with other interviewing models that show both innovation and the ability to influence fields over the passage of time. MI changes. The spirit of MI remains consistent and vibrant, while its techniques evolve as meets the needs of the times. Indeed, it can even change from patient to patient, as the unique needs of the patient dictate.
Development of MI
It is not possible to cleanly delineate a specific school of counseling or interviewing from which MI evolved. Rather it arose from a rich admixture of many fields of clinical intervention and schools of therapeutic thought. On the other hand, one can clearly state that MI crystallized into one of the major examples of collaborative interviewing. As mentioned in Chapter 2, it represents, along with solution-focused psychotherapy and the more recent MIM, a classic example of collaborative, person-centered practice.
With regard to fields of intervention, there is no question that the origins of MI lay in the field of addiction counseling. Yet it may be more accurate to say that MI arose in opposition to certain traditional aspects within the field of addiction counseling. Without trying to engender a stereotype, it is probably safe to say that, traditionally speaking, the field of addictions often emphasized the need for the counselor to “break-through the denial” of the client while “making” the client see the need for change. Rollnick states it cogently, “Addiction treatment in the United States was often highly authoritarian, confrontational, even demanding, relying on a heavily directing style of counseling.”14 MI was born as an effective antidote to this oppositional tendency in mainstream addiction counseling. We have already seen, in our chapter on transforming MADs (moments of angry disengagement) and PDQs (potentially disengaging questions), that moving against the patient’s beliefs on the Agreement Continuum is seldom productive. MI fits wonderfully with our previous perspectives both regarding our methods for transforming moments of potential disengagement and with our broader philosophy of adopting a person-centered perspective when interviewing.
With regard to specific influences, both Miller and Rollnick openly acknowledge their debt to the pioneering work of Carl Rogers, who had been energizing the fields of counseling and psychotherapy since the late 1950s with his client-centered approach (a clear precursor of both person-centered counseling and person-centered medicine and nursing).15,16 Indeed, one can see distinctive harbingers of the spirit of MI in the Rogerian belief that there exist three “necessary and sufficient” conditions for therapeutic transformation: accurate empathy, genuineness, and unconditional positive regard. According to Miller and Rollnick, the presence of these three Rogerian traits creates a “way of being” with clients that facilitates acceptance, experiencing of one’s actual self, and natural positive growth and change, all of which epitomize the spirit of MI.17
In addition to the above influences, MI grew out of, and further evolved, from a rich stew of theories regarding how people change, a stew that had been simmering for several decades. A partial list is provided by Butterworth.18 These theories explain behavioral change and motivation in relation to a wide range of factors including: priorities and values (values theory), perceived benefits and consequences (health belief model), self-efficacy (social cognitive theory), self-perception (Bem’s self perception theory), activation (patient activation model), planning and implementation (implementation intentions model), and stages of change (transtheoretical model).19–28 It is the latter model, the transtheoretical model, developed by Prochaska and DiClemente, that is most often associated with MI.
The reader will recall from Chapter 2 that the transtheoretical model (TTM) posits that people develop the ability to change along a continuum of five attitudinal shifts: pre-contemplation (little-to-no desire to change), contemplation (active thought about the potential need to change accompanied by the weighing of the pros and cons of changing), preparation (where planning and commitment are secured), action (behaviors towards change are implemented), and maintenance (transformative actions are secured longitudinally).
MI and TTM resonate nicely with one another, for they both view motivation as being an ongoing process with gradations of motivation and commitment as opposed to black/white theories suggesting that a patient is either motivated or not motivated. This belief in the graduated development of motivation (a belief that fosters in clinicians a non-judgmental attitude, which recognizes that change is often difficult for people to achieve) opened the door to the sophisticated development of several of the core qualities associated with effective MI counseling such as acceptance, patience, and compassion.
It is worth noting that MI did not evolve from TTM, which is a common misconception, nor is an understanding of TTM even necessary in order to effectively utilize MI. Miller and Rollnick describe the relationship as follows: “… TTM stages of change are not an essential part of MI. MI and TTM are compatible and complementary … and with apologies to our translator we describe them as ‘kissing cousins who never married.’”29
From the above we can see that MI evolved from a variety of motivational and collaborative influences interfacing at the time of its development. But I personally believe that, from the practical perspective of actually helping people to change behaviors, the innovative work of Miller and Rollnick is less an evolution from the theories extant at the time of its development, than it is a quantum leap. Let us now see how MI works and how it may be of use in the initial clinical interview.
Core Principles and Techniques of MI
Four Guiding Interviewing Principles
A nice place to begin a study of MI is by examining four interviewing principles that are utilized throughout the practice of MI, which Butterworth has summarized as follows: (1) resist the “righting reflex”; (2) understand and explore the patient’s motivations for change; (3) listen with empathy; and (4) empower the patient.30
1. Resist the Righting Reflex
This MI principle emphasizes the need for interviewers to be on the alert for a good-intentioned instinct that, paradoxically, may decrease the likelihood that a patient will be motivated for change. In short, it consists of resisting the impulse to correct or “make right” anything the clinician perceives as a misconception or bad decision by the patient. I have never seen it better described than in the following quotation from Susan Butterworth in which she addresses what happens when an interviewer encounters a patient who has concerns or disagrees with the clinician’s treatment recommendations, at which point:
… it seems natural to provide good arguments in support of the recommendations for the specified treatment or behavior. Therefore, the provider repeats the advice and appropriate information or instructions. This evokes a natural response in the patient to present reasons why they can’t, won’t, aren’t able to, or can’t see why they should follow the advice. This effect can be seen in what’s been called the ‘Yeah-But Dance’ between the provider and the resistant patient.31
In contrast to this righting reflex, the non-oppositional stance preferred by MI, can be encapsulated by the idea of “rolling with the patient’s concerns” as opposed to immediately challenging them, correcting them, or confronting them. Indeed, this ability to roll with the patient’s concerns belies an open-mindedness that may result in the interviewer discovering – sometimes to the interviewer’s surprise – that the patient is quite right to oppose the advice provided, in which case a better collaborative plan can be developed.
2. Understand and Explore the Patient’s Motivations for Change
The open-mindedness described above further expresses itself in the clinician’s ability to truly partner with the patient in the process of collaboratively exploring the patient’s personal reasons for change (or not to change). To do so, a clinician must develop a habit of “not jumping to the obvious” reasons for change from the clinician’s perspective. This principle harkens back to the opening epigram of our discussion of MI, “People talk themselves into changing, and are commonly disinclined to be told what to do if it conflicts with their own judgment.”
This principle is nicely demonstrated by a specific MI practice. When first addressing the patient’s pros and cons regarding drinking, MI interviewers tend to first ask the patient about the pros from the patient’s perspective as with, “Tell me a little bit about what drinking does for you in a good sense, for it clearly must make you feel better in some ways or you wouldn’t be doing it. So let’s see what it does that is, indeed, good.” The good points that are subsequently proffered by the patient – and there are almost always some genuinely good reasons provided by the patient for drinking such as decreasing their anxiety in social situations – are rarely challenged by the interviewer. Instead, there is a gentle acceptance of the positive role they play with comments like, “That makes sense to me, drinking helps you to feel more comfortable around people and that clearly is a benefit. I’m beginning to get a better feel for the reasons you enjoy drinking, I bet there are some others. What other ways do you think the drinking helps you?”
I have found in practice that such an open-minded exploration of the patient’s views of the benefits of drinking before exploring the problems with the patient’s drinking is much easier said than done. Well-intentioned and intuitive clinicians often have immediate gut instincts that accurately point out the glaring reasons why the patient should change his or her behaviors. As with the need to resist the “righting reflex,” interviewers, when using this second principle of MI, must resist the “problem reflex” in which the interviewer feels the need to immediately share the obvious problems associated with the patient’s drinking behaviors. Ultimately, for therapy to succeed, the patient must find his or her own reasons for change. It is not the clinician who must discover motivation. It is the patient.
3. Listen With Empathy
As with all clinical interviewing, empathy is critical. MI points out that empathy is sometimes hard to engender if the interviewer is frustrated by the patient’s lack of motivation (a patient mired in a pre-contemplation stage of change) or sees the severe damage done to others, as well as to the patient, if the patient continues his or her problematic behaviors (a person with alcoholism who continues to drink and abuse a spouse, a patient with manic bursts of irresponsibility who refuses lithium). Even in such moments, the clinician attempts to see the world through the patient’s eyes while maintaining a Rogerian unconditional positive regard. (This is not the same as empathically agreeing with the patient’s decisions; it is the same as compassionately attempting to understand how the patient arrived at his or her decisions.) It is easy to be empathic when someone does what you want. It is harder to be empathic if someone does the opposite of what you want.
4. Empower the Patient
Change is difficult – and therapy potentially frightening. In MI, an ongoing attempt is made to help patients feel good about their change efforts and about themselves for making such efforts. When employing MI, clinicians consistently attend to building self-confidence in the patient as well as self-efficacy. Part of this process entails positive feedback on skill building as well as acknowledging, with a genuine respect, the patient’s movements through the various stages of change. It also entails helping patients to remember their progress during times of slippage.
OARS: Pivotal Interviewing Techniques for Applying the Principles of MI
As we have seen with other aspects of clinical interviewing, to be most effective, interviewing principles must be translated into specific interviewing techniques. MI has a variety of effective interviewing techniques. Many of them are nicely grouped by the acronym OARS. This mnemonic acronym is usefully translated as asking Open questions, Affirming responses, Reflecting, and Summarizing.32
Asking Open Questions
As we discussed in great detail in Chapter 3 when we were delineating response mode systems, including the Degree of Openness Continuum (DOC), interviewing experts for many decades have described the power of open-ended questions (as well as their limitations). (For a well-delineated definition and a rich exploration of the nuances of open-ended questions and their use, the reader is referred to pages 78–81 of this book.) Following suit, Miller and Rollnick emphasize the value of open questions and capture their power with their statement, “An open question is like an open door. You do not know in advance where the person will go with it.”33
Open questions are particularly useful for effectively applying the principles described above, such as understanding and exploring the patient’s personal motivations for change as well as communicating empathy. As delineated earlier in this book, open questions generally begin with (or include) words such as “What” or “How” while simultaneously allowing great freedom of response from the interviewee as demonstrated by the following34:
1. “What do you like about drinking?”
2. “What brings you here today?”
3. “In the past, how have you overcome an important obstacle in your life?”
4. “What possible long-term consequences of diabetes concern you most?”
5. “What are the most important reasons why you want to stop injecting?”
Cautionary Note
Miller and Rollnick define open questions in a fashion that is consistent with other clinical interviewing experts, and they describe their use effectively in all of their writings. Unfortunately, as MI has been adopted/adapted over the past two decades, numerous “experts” have appeared that, in my opinion, do not always demonstrate the correct use of MI as delineated by Miller and Rollnick. Be wary as you read articles/chapters/books on MI to make sure that the principles of MI are not being misrepresented. One area where this is a problem is with the definition of open questions.
Some writers, who are not familiar with the extensive clinical interviewing literature regarding clinician response modes, mistake “swing questions” as being examples of open questions. If you will recall from Chapter 3, swing questions begin with words such as “Can you tell me …?” or “Could you say something about …?” These questions are not open-ended, for they can easily be answered with “Yes” or “No,” and are typically handled by angry or unwilling patients with a curt, “No” or “Not really.” In fact, with such patients, they are prone to create a further shut-down in conversation. Thus a question such as, “Can you tell me about some of your concerns about your drinking?” is not an open question. In my opinion, such swing questions should generally be avoided when employing MI.
One other small caveat is worth mentioning. Although some questions beginning with the word “Why” are technically open-ended, such as, “Why are you using cocaine?” as discussed earlier in Chapter 3, questions beginning with the word “Why” frequently create an immediate parent/child response in interviewees. I believe that this potentially disengaging parental quality to “why questions” is inconsistent with the spirit of MI. Consequently, when using MI I believe it is wise to avoid their use in most instances.
As mentioned in Chapter 3, such questions can easily be “de-parentified” by merely replacing the word “Why” with the words, “What are some of your reasons.” Instead of asking, “Why are you using cocaine?” the clinician can ask, “What are some of your reasons for using cocaine?” The phrase, “What are some of your reasons …” eliminates the parental (potentially condemning) quality of the first question while opening the door for the patient to answer as they see fit with minimal shame or guilt.
Affirming Responses
Affirmation, in the MI model, revolves around two epicenters: First, a competent MI interviewer, throughout the interview, affirms the inherent worth of the interviewee as a fellow human being. Second, a MI interviewer provides direct affirmation of the patient’s work and progress within the therapy itself.
Regarding the first affirming process – affirmation of the inherent worth of the patient – this process certainly reflects the concept of Rogerian unconditional positive regard. It also reminds me of two of my favorite quotations, below (the first from the pen of a philosopher – John Watson – and the second from the pen of a clinician – A. M. Nicholi, Jr.) in which the writers emphasize that we are all fellow travelers in a rather daunting world where we all make mistakes and we all do the best we can to deal with these mistakes:
Be kind; everyone you meet is fighting a hard fight.35
and
… whether the patient is young or old, neatly groomed or disheveled, outgoing or withdrawn, articulate, highly integrated or totally disintegrated, of high or low socioeconomic status, the skilled clinician realizes that the patient, as a fellow human being, is considerably more like himself than he is different.36
When interviewers can communicate that they do not view themselves as superior to the patient nor do they feel that they have all the answers, while simultaneously communicating a genuine respect for the wisdom inherent in each patient, the interviewer is well on the road to affirming the worth of the patient as a fellow human being.
From a technical standpoint, this affirmation is achieved through the numerous verbal and nonverbal engagement techniques that literally fill the previous hundreds of pages of this book. In this book we have consistently emphasized person-centered interviewing techniques and strategies that affirm our patient’s self-worth while communicating our understanding of the pain that lies beneath the abstraction of their diagnoses. In addition, from our emphasis upon cross-cultural diversity and our chapter devoted to interviewing techniques for uncovering wellness, strength and skills (Chapter 6), we have tried to set a vibrant foundation for affirmation of both patient worth and uniqueness.
There is no need for us to duplicate this material here. On the other hand, in this chapter we have an excellent opportunity to explore the specific interviewing techniques that can help us to affirm our patients with regard to their therapeutic journey.
Affirmations Created by the Interviewer
Numerous interview techniques are of use in affirming the work of our patients. Once again, I think it is valuable to initially turn our attention directly to the work of Miller and Rollnick in an effort to maintain a fidelity to their model and intentions. In the third edition of their text, they provide the following excellent examples of affirming statements37:
1. “You really tried hard this week!”
2. “Your intention was good even though it didn’t turn out as you would like.”
3. “Look at this! You did a really good job of keeping records this week.”
4. “Thanks for coming in today, and even arriving early.”
5. “So you made three calls about possible jobs this week. Good for you!”
As Miller and Rollnick emphasize throughout their book, the tone of voice with which the clinician delivers the above affirmations is critical to their effectiveness. All of these phrases should be said with a gentle respect (communicating a matter-of-fact acknowledgement of genuine progress) as opposed to a wild exuberance. Said in an exaggeratedly enthusiastic fashion, the interviewer can come across as patronizing to the patient, which can clearly undercut the process of affirmation and self-efficacy.
Miller and Rollnick also demonstrate the fashion in which an interviewer can deftly provide affirmation regarding the patient’s persistence despite not achieving their goals as with38:
1. “You got really discouraged this week and still you came back. You’re persistent.”
2. “Listening to all you’ve been through, I’m not sure if I would have been able to come out of that as well as you have. You’re a real survivor.”
I find the self-comparison admission, demonstrated by the interviewer in the second affirmation, to be particularly powerful and humanizing.
The above two examples create a nice bridge to a similar technique often used in MI that is directly borrowed from family therapy – reframing. In reframing the patient makes a disparaging or disappointing comment about himself or herself that the therapist transforms into an affirmation by demonstrating a positive quality that is suggested or implied by the initially negative frame of reference. This technique is perhaps best demonstrated by dialogue:
Pt.: Well to be honest, I simply am a failure in my efforts to be sober.
Pt.: Oh, I’ve been in and out of detox and rehab over twenty times (pauses) and I always pick up a bottle in the end.
Clin.: No doubt that has been greatly discouraging for you. (clinician does not confront the patient’s assertion) On the other hand, I am struck by something, something rather striking to me.
Clin.: You’re sitting here in my office. (pauses) You are trying again. (pauses) You know, Jim, the truth of the matter is that your alcohol dependence has knocked you down over twenty times, yet you still have enough guts and strength to fight it again. If you think about it, it is rather remarkable. Maybe this time, we’ll make the breakthrough. I like working with people who are tough, and you are most certainly tough. (a lovely reframing by the interviewer)
On an official MI website called the Motivational Interviewing Network of Trainers (MINT; http://www.motivationalinterviewing.org), created by Miller and Rollnick, the power of reframing is nicely illustrated as follows39:
Pt.: I have tried to lose weight so many times and failed.
Clin.: You are persistent, even though you are discouraged. This change must be important to you.
and
Pt.: I tried to quit smoking four times and never can stick with it.
Clin.: It seems to me that you have given this a lot of effort already. Everytime you try you get closer. The average number of attempts to quit smoking before most people quit is six times, so don’t give up!
By the way, the MINT website mentioned above provides a wealth of useful information regarding MI, much of it free of charge. I strongly recommend it and the various MI trainings offered on the site. A second very useful MI website can be found at www.motivationalinterview.net.40
Adding yet a another nuance, Kate Hall and colleagues provide illustrations of how clinicians can make affirmations regarding progress in therapy that generalize into powerful affirmations of the patient’s character itself as with41:
1. “I appreciate that it took a lot of courage for you to discuss your drinking with me today.”
2. “You appear to have a lot of resourcefulness to have coped with these difficulties for the past few years.”
In addition, they point out the effectiveness of affirmations that are based primarily on simply thanking the patient as illustrated by:
Once again, on an official MI website (MINT), referenced above, several statements that communicate therapist approval in a simple yet immediate fashion are listed:
Affirmations Created by the Patient
As we saw in Chapter 6, there are many questions and techniques that can help patients to express, and sometimes even discover for the first time, their strengths and skills. There is neither room nor need to repeat these techniques here. In the same vein, Miller and Rollnick emphasize that affirmation need not always originate from the interviewer. To some degree, it can be argued that as is the case with motivations, some of the most powerful affirmations are those that the patient discovers for him- or herself. A nice example of a technique for pulling forth from the patient his or her own strengths is provided by Miller and Rollnick in their second edition42:
“What is there about you, what strong points do you have that could help you succeed in making this change?”
Obviously, affirmations have been described and recommended for use by clinical interviewing experts for many decades, often viewed as a specialized type of empathic statement. MI has helped to emphasize the importance of their frequent and strategic use, thus advancing our understanding of their power and importance in training.
Reflective Listening
Reflecting responses (sometimes called reflective statements or simply “reflections” in MI literature) are one of the “bread and butter” techniques utilized in MI. It is hard to picture an interviewer being proficient in MI without a facile ability to utilize reflection.
According to Miller and Rollnick, the essence of a reflecting response is the intention of the interviewer to make a guess about what the interviewee meant. As they point out, there can be many messages hidden beneath a patient’s words. As explored earlier in our book (see Chapter 21), the concept of a hidden meaning lying below the surface of the patient’s words (and the value of uncovering this meaning) was elegantly delineated by Grinder and Bandler, forming the very cornerstone of neurolinguistic programming (NLP) in the 1970s.43 The innovative slant of MI is the fashion in which this material is uncovered.
Grinder and Bandler tended to uncover the meaning by asking generic questions (such as “What did you mean when you said …?”) or specific clarifications (“When you said your husband frequently got angry, what are some of the different ways he shows that anger?). In MI, the more typical way to uncover this hidden meaning is the use of a reflective statement. This frequent use of reflecting statements is called “reflective listening” in MI.
Reflective listening can be highly effective. It also can take a bit of practice to perfect, and when done poorly can be problematic. Thus, I feel it is wisest to let Miller and Rollnick describe its purpose and demonstrate its use themselves, for nobody describes it any better44:
… Most statements can have multiple meanings. Emotion words such as “depressed” or “anxious” can have very different meanings to different people. What could it mean for a person to say, “I wish I were more sociable”? Here are some possibilities:
“I feel lonely and I want to have more friends.”
“I get very nervous when I have to talk to strangers.”
“I should spend more time getting to know people.”
“I can’t think of anything to say when I’m with people.”
… When hearing any utterance one naturally considers and makes a guess about what it might mean. This decoding process happens quickly and often below consciousness. Many people then act as though this guess were the actual meaning and react to it. Reflective listening is a way of checking your guess rather than assuming that you already understand.
Reflective listening, then, involves responding to the speaker with a statement that is not a roadblock, but rather is one’s guess about what the person means. Often, but not always, the subject of the sentence is the pronoun you.
Miller and Rollnick then provide the following dialogue as an example of exemplary reflective listening. In it we will see a gifted interviewer talking with a patient who, because of partially blocked arteries had suffered a heart attack. The patient is now recovering from major heart surgery (coronary artery bypass) to unblock the arteries that had precipitated the heart attack. For a full and safe recovery, in such situations it is important for patients to follow the exercise routine recommended by their surgical and cardiac team. Thus from a motivational perspective, the issue facing the interviewer was to uncover the patient’s degree of motivation to proceed with an appropriate exercise regimen while compassionately understanding any hesitancies the patient might be having. Of course, ultimately, it is hoped that the patient will gain self-motivation to implement the potentially life-saving regimen suggested by the cardiac team.
In the dialogue, notice how the reflective responses accomplish a variety of goals depending upon their timing, ranging from communicating empathy and uncovering new material to actually helping the patient to self-challenge his own belief systems (belief systems that could disrupt the patient’s interest and follow-through with the exercise regimen). I can see why Miller and Rollnick like this excerpt, for it is a rather brilliant bit of interviewing, accomplishing the intended goals in a remarkably short bit of conversation.
Clin.: How have you been feeling lately, since your surgery?
Pt.: It was quite an ordeal, I can tell you. I’m lucky to be here.
Clin.: You could easily have died.
Pt.: They said there was 90% blockage, and at my age that kind of surgery is major, but I made it through.
Pt.: Yes, I have plenty to live for.
Clin.: I know your family is important to you.
Pt.: I love seeing the grandkids – two boys and two girls, you know, right here in town. I like doing things with them.
Pt.: I do. And I enjoy singing with the community chorus. They count on me; they’re short of tenors. I have a lot of friends there.
Clin.: You have a lot of reason to stay healthy.
Pt.: At least I’m trying. I’m not sure how much to do.
Pt.: I don’t want to overdo it. I played golf last week and I got this pain in my shoulder. The doctor said it was just muscle pain, but it scared me.
Clin.: You don’t want to have another heart attack.
Clin.: And sometimes you wonder how much exercise is good for you.
Pt.: Well, I know I need to stay active. “Use it or lose it” they say. I want to get my strength back, and they say regular exercise is good for your brain, too.
Clin.: So that’s the puzzle for you – how to be active enough to get your strength back and be healthy, but not so much that would put you in danger of another heart attack.
Pt.: I think I’m probably being too careful. My last test results were good. It just scares me when I feel pain like that.
Clin.: It reminds you of your heart attack.
Pt.: That doesn’t make much sense, does it – staying away from activity so I won’t have another one?
Clin.: Like staying away from people so you won’t be lonely.
Pt.: Right. I guess I just need to do it, figure out how to gradually do more so I can stick around for a while.
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