Motivational Dialogue

Looking Under the Hood at Resistance & Motivation

Motivation to change isn’t all internal, it’s in what happens interpersonally – so the evidence says

In the substance use treatment field, the emergence of Motivational Dialogue (Motivational Interviewing – MI) is arguably one of the most significant developments of the last 30 years. As the name implies, MI involves interviewing people about what motivates them. The purpose of any interview is not to get a person to say what you want them to say, but to learn about the person (and possibly more importantly, for the person to get to know more about themselves). It is a process that must be guided by authentic curiosity and openness. So MI isn’t about motivating someone to change – it’s about uncovering and exploring the motivation that a person might already have to make a change.

In Behavioural Interventions, the Person Doing the Behaviour is the Expert

In the 30 years since MI’s introduction to the substance use field, it has been increasingly used and researched in other fields – anywhere where client/patient behaviour change is an important consideration to health outcomes. In other words, Motivational Interviewing is not very helpful for a person who has a broken bone that needs to be set in a cast by an expert on the human skeleton, such as a doctor. MI is useful, however, in situations where the client/patient is the expert. When it comes to behaviours, the only person who has the potential to answer the question, “Why are you doing this?” or “Why aren’t you doing that?” is the person who is doing this or who isn’t doing that.

First Ingredient in Change: Ambivalence

Of course, everyone has, to some extent and on some level, been able to make changes to their behaviours without being interviewed about their motivations. Most of us learned to use a toilet without sitting down with a counsellor, for example. The problem is that with some issues we may be ambivalent – part of us motivated to change a behaviour, and another part motivated to sustain that behaviour. This is where being interviewed may help us better understand and use the various motivations – to change and sustain – we might have.

Change Talk vs. Sustain Talk

The most recent (third) edition of the book “Motivational Interviewing” differs in some significant ways from the previous editions, taking into account various convincing recent research findings. Key among these is a focus specifically on the difference between “change talk” (statements clients make that indicate a commitment, desire, ability, need, readiness or reasons to change) and “sustain talk” (statements clients make that indicate obstacles to commitment, desire, ability, need, readiness or reasons to change). 

What a person talks about affects their behaviour

What the research shows is that what clients talk about in a counselling session has a direct effect on the changes they make or don’t make in their behaviours. Generally speaking, if a client talks more about their motivations for sustaining a behaviour than their motivations for changing that behaviour, they are more likely to sustain that behaviour. Likewise, to the extent that there is more “change talk” than “sustain talk,” the likelihood of change grows.

Change is not a simple cost/benefit analysis

So, guided by this research, the chore of the counsellor working with a client who is ambivalent is not simply to elicit all the motivators a client might have for and against changing a behaviour (such as through a cost/benefit analysis). Were this the case, a counsellor’s only hope would be that, once laid out, the motivators for change clearly outweigh the motivators against it. In cases where clients are ambivalent, it doesn’t take much imagination to see how inconclusive such an activity might be. It might even set up a dynamic where a client, assuming which side a counsellor might be on, simply tries to please the counsellor, gaining no benefit for themselves – and possibly avoiding future counselling sessions, particularly if behaviours haven’t changed.

The evidence shows that eliciting the benefits of sustaining a problematic behaviour from a client, while sometimes appropriate (perhaps as a prelude to eliciting change talk in a client that can’t otherwise get there), could be harmful to that client’s chances for change. Typically, clients already know the benefits of notchanging. It’s obvious. Change is hard!

Careful Listening, Authentic Adjusting

So how can a counsellor elicit “change talk” from a client, thus improving their chances of making harm reducing behaviour changes? Various resources, such as the “Motivational Interviewing” book, provide some guidance on the spirit, style and techniques of the Motivational Interviewing approach (practitioners are likely to call it a “way of being” rather than an “approach”). But the most useful clues will come directly from the mouths of clients. The proof is in the pudding, so to speak. If clients are engaging in “change talk,” you’re on the right path. If they are engaging in “sustain talk,” then, for the sake of the client’s ability to make a change, the counsellor needs to adjust. 

From Motivational Interviewing, Third Edition by Miller & Rollnick

“Resistance” and motivation occur in an interpersonal context. This is now well demonstrated by research, and it is easy to observe in ordinary practice. By the way in which one counsels it is possible to increase and decrease client motivation (or reticence) like the volume control on a radio. “Denial” in addiction treatment is often not so much a client problem as a counselor skill issue. Counsel in a way that evokes defensiveness and counter-argument and people are less likely to change. It also confirms the clinician’s belief that these people are difficult, resistant, and intractable. It is a self-fulfilling prophecy.