What works?
motivational dialogue
There is a natural history to substance use driven by social norms. Younger people typically drink more and experiment with drugs more than later in life when personal responsibilities take precedence. For people with an addiction problem social norms do not constrain drinking or drug taking and some other intervention is needed to bring about change. Any treatment or procedure can be undertaken in a motivational way.
Understanding a person’s motivational processes
Therapy sessions provide a context for bringing about motivational change and behaviour change. Motivational change is a series of processes starting with concerns leading to thinking about changing substance use, progressing to maintaining stable recovery. Once a decision to take a step forward is made, the therapist should listen to what the person sees as the challenges and benefits of change.
In order to have helpful conversations or helpful interactions practitioners need to understand that how they talk to people matters very much. We have used the term motivational dialogue to describe helpful kinds of interaction. Motivational dialogue will…
diminish the threat of conflict and argument
make it more likely to keep people engaged
assist in eliciting thoughts about change
make it more likely to result in making concrete commitment-to-change statements
Before exploring the art of motivational dialogue have a look at these videos about the importance of motivation.
The stages of change model
Like any good model stages of change is a simple tool, in this case helping practitioners identify a person's motivational processes...
✔︎ The five stages: precontemplation (motivated to carry on drinking or drug taking), contemplation (thinking about change), preparation (commitment and planning) action (implementing change), maintenance (strengthening and expanding changes made)
✔︎ Don't think of stages as boxes. Each stage is a series of tests, or things that need to get done
✔︎ Many different treatments are effective if they promote achieving the tasks that are needed
✔︎ Be specific about the goal you are talking about
✔︎ Mismatching can be detrimental - move forwards, not back to decisions already made
Take a look at these videos about how to use the model ➜
Carlo DiClemente, Professor of Psychology, Maryland University, USA
About motivational interviewing
Motivational Interviewing is the name given to a form of treatment whereby the the therapist elicits a service user’s concerns as the means of changing their thoughts to build a commitment to change their substance use. Many help-seekers remain highly motivated to carry on drinking or taking drugs and want to change the consequences of their substance use rather than the substance use itself. How to motivate these people is the challenge for practitioners.
Motivational interviewing
Motivational interviewing is the means of moving people onward. In essence it is about getting people to talk themselves into wanting to change...
✔︎ Ask open questions to convey interest and concern with the aim of learning what matters to the person seeking help
✔︎ Use complex reflections to show accurate empathy and help make sense of the current situation and thoughts about change.
In these videos Gillian Tober talks to Bill Miller about the development and application of motivational interviewing ➜
Bill Miller, Emeritus Distinguished Professor of Psychology and Psychiatry, University of New Mexico
This is how to use motivational dialogue…
Learning motivational dialogue is a skill rather like driving a car. To start with you have to consciously concentrate on developing your competence - as you become more experienced so the dialogue flows automatically. The key is to practice and to video record yourself so that you can see how what you are saying affects the responses that you get.
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.
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 open questioning, so questions that start with words like, where, when, how and who are safe bets.
The terms ‘change talk’ and ‘commitment talk’ have been coined in order to help researchers and practitioners identify what needs to happen to be more sure that change will occur. 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.
In the demonstration videos below Gillian Tober uses motivational dialogue in the role play of an iSBNT session. The session is with father and daughter. Here are their back stories…
Father
in his late 50's currently unemployed
drinking began to increase after being made redundant from his job in the merchant navy two years ago
used to just drink in the pub on 3-4 nights each week - over the last year has been drinking at home during the day
now drinks every day and has rarely had a day off drinking for the last 18 months
usually drinking super-strength lager having first drink at midday
spends all day at home watching TV and playing video games
caused embarrassment at daughter's 21st birthday - arrived drunk and got so drunk his wife had to take him home
lost driving licence last year through drink driving
several hospital admissions related to liver and stomach problems related to his drinking
Daughter
lives away from home
has one younger brother (15) who lives at home
works as a receptionist in a hotel
sees her boyfriend most weekends
telephones home every night - mainly because she worries about how mum is coping
very worried about dad's drinking and the effect it is having on his health and the family, particularly mum
family relations are very strained
doesn't like bringing boyfriend home because she is embarrassed by dad
wants to help dad sort out his drinking but doesn't really know where to start
Open ended questions
Open ended 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 their support network
➁ Explore this and check your understanding
➂ Use this understanding to guide your open questions and reflective listening
➃ 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"
➄ Once you have elicited change talk you want to be sure to attempt to elicit commitment talk: making an actual plan.
Gillian Tober demonstrates the use of open ended questions in this role play of an iSBNT session: the first video is about setting the drinking goal and the second explores alternatives to drinking.
What to look out for in the videos
It is clear that the drinking goal, at least in the first instance, should be abstinence. Father is resistant and his daughter is willing to go along with the idea of cutting down on drinking. To avoid eliciting resistance, Dr Tober does not reject the idea of cutting down, but ‘gives way’ to keeping it as an option pending returning to her agenda, using open ended questions, to get agreement that a period of abstinence is the best plan. The second video is about putting a plan in place that is likely to be effective at achieving the abstinence goal. Notice Dr Tober starts by getting ideas from father and daughter then keeps focussed until she is satisfied that a specific, realistic plan that is likely to be implemented, has been agreed. When watching the videos you might want to count how many open questions you can spot and note how father and daughter respond…
Goal setting (10 mins)
Making a plan (13 mins)
Complex reflections
The difference between simple and complex reflections is that the former is no more than a repetition of something the client 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. Complex reflections make the expression of commitment talk, a firm intention to change, more likely. 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.
Complex reflections are useful in reflecting ambivalence: “on the one hand you are thinking about how to give up drinking with your friends, and on the other hand you are thinking that you won’t have any friends left if things continue as they are” and helps to arrive at the most appropriate solution.
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, as illustrated above.
Complex reflections are arguably the most useful tool for conveying empathy.
Gillian Tober demonstrates the use of complex reflections in this next video from the father and daughter role play.
Complex reflections (12 mins) - what to look out for in the video
Dr Tober explores both sides of choosing a moderation or an abstinence drinking goal. The reflections of the anticipated consequences of setting a moderation goal as opposed to an abstinence goal are looked at and the resolution of the ambivalence is reached using reflections of both the father and the daughter.
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.
Good outcomes from motivational dialogue checklist…
✔︎ Did you gain an understanding of the motivational states of all participants in the therapy?
✔︎ Did you manage to elicit concerns about current behaviours and their consequences?
✔︎ Did you elicit thoughts about a better future?
✔︎ Did you elicit confidence in the possibility of change?
✔︎ Did you elicit a concrete intention to change?
