1. Be curious, not an expert. Training and expertise can get in the way of our really hearing the client’s story. For example, a client says “I don’t think my drinking is a problem.” Some of us are indoctrinated in the concept that denial is a part of the addiction problem—and in this case we might automatically interpret this statement as denial and discount what the client has to say. An alternative approach is to try to dig in and really understand the client, opening with something like, “Okay, so for you, you don’t think it’s as big of a deal as other people are making it out to be.”
2. Listen more than you talk. This is advice we often hear, but it bears emphasizing because it’s easy to get into the trap of telling people what to do. But the motivational interviewing (MI) approach is about the clients articulating why they think they need to change and how they think they can do it—and then we offer our expertise to help them succeed. If you find yourself talking more than your client, then the wrong person is doing the talking.
3. Listen more than you ask questions. Ask questions to get the process going, but then get out of the way and listen. Use reflective statements to help move the client forward. Change is like a boulder that we help to get rolling with some initial questions, but too many questions tend to stop that momentum. They risk stopping clients in their tracks, forcing them to interrupt their flow of thought to come up with an answer.
4. Listen for what’s below the surface. I think about client statements like icebergs: There’s what’s sticking above the water, which is what they’ve said. But if all we do is reflect that surface bit of information, the conversation doesn’t go very far. Sometimes clinicians tell me, “I’ve tried reflective listening; it doesn’t work.” What this usually means is that they stayed on the surface. In other words, when a client says, “The medication isn’t doing anything,” we can respond to that statement on the surface and say, “So the medication doesn’t help.” If the client responds, “Yeah, that’s what I just told you,” that’s unproductive. A better option is to go below the surface and say, “So you’re wanting to explore more options around medication use.” And the client may say, “No, not really. What I really want to do is figure out some things I can do without medication.” Or maybe the client will say, “Yeah, I’m really interested in trying some additional medication; I just don’t think what I’m using now helps.” Or you might hear, “I just don’t like all the side effects it’s causing.”
5. Listening is a skill. Everyone has heard this before, and it’s easy to assume we’re good listeners by virtue of our training. Yet, it is a skill that is built and refined through deliberate practice. We don’t become excellent listeners because of a basic interviewing class or a couple days of MI training. Think about this like learning to play the piano. One doesn’t become a great pianist by taking a two-day course on the piano, or become great by just occasionally sitting down and playing. Or think of sports: It would be surprising to hear a world-class athlete say, “I don’t need to practice. I already know how to do that.” We might have some native talents, but it is through concerted effort, review of practice, and, yes, coaching that we get better.
6. Find out what the client knows before you offer information. Before you start talking about side effects, say, “Tell me what you know about the side effects of this medication.” If you are talking about assertiveness skills, say, “What do you know about what works for you when you’re trying to deal with somebody who is being aggressive?” Or if you’re focusing on relapse issues, you might ask, “How have you managed it in the past when you’ve experienced craving?” Find out what the client knows, then offer targeted information.
7. Ask the client’s permission before offering advice. The combination of tips #5 and #6 is referred to in the MI literature as “elicit, provide, elicit” or “E-P-E.” You elicit permission or what the client already knows about a subject, provide information or advice, then ask for the client’s perspective on this information. E-P-E works because substance-using clients can be defensive, and what you may think of as sincere advice might be interpreted as an unwelcome directive. So ask for permission first: “I have some thoughts about what I think you ought to do about this circumstance. Are you interested in hearing about that?” Occasionally you’ll get clients who say no; if so, you accept that. If they say yes, offer your advice and then be sure to follow up by asking for their perspective.
8. What you pay attention to matters. Clients will give you more of what you pay attention to. If you hear some change statements from your client, perk up and do plenty of reflecting—and you’ll hear more of those. If you hear sustain statements, be more silent—don’t reinforce this sustain talk by giving it lots of attention—be silent or alternatively look for the change element. It is surprising how readily clients may take cues from you, and the more you can reinforce change talk, the better.
9. Arguing is unproductive. If you find yourself arguing with the client, that’s a signal that something is not working and it’s time to change what you’re doing. As a clinician, you may feel that you have a really important point to get across, and you may be right—but how you say it matters the most. Arguing clients are unlikely to change their behavior in the way you are seeking.
For example, let’s say you have a client who is using too much Vicodin and telling you, “I don’t think I have an addiction; I can control it.” You could say, “In my experience, people who are using
10 Vicodin a day have built up a lot of tolerance, and you’re going to be in severe withdrawal if you lose your supply.” This may be important information, but the client may not be able to hear it at that point. Instead, go into E-P-E mode and say, “I have some concerns about that. Can I share those with you?”
Some clients will say yes. But others may say, “No, you’re just going to tell me what everybody else has told me, that this is way worse than I think it is. But I just don’t feel like it’s that bad.” You’ve now discovered your client acknowledges there might be a problem, because of the weak change statement, “I just don’t feel like it’s that bad.” You can gradually build on that insight. At that point, you reflect and say, “Okay, so from your perspective it feels like people are making way too much out of this. You can see the risks there; you just don’t think that you’re ready to do something about that now.”
10. Ambivalence is normal, not pathological. Part of being human is that change is difficult, and therefore ambivalence about change is normal. In our organization, we have a quip that goes like this: “Change is hard, you go first.” To understand how hard change can be, think about a health behavior that you have had difficulty changing. You should eat better. You should exercise more. You should give up smoking. You should get to bed sooner. You should spend more quality time with your kids. You should have date night with your spouse … and yet you don’t do those things. If you think about the reasons you haven’t been able to make these changes, you’ll find yourself making the same kinds of ambivalence statements we hear from our clients. Being sensitive to the challenge inherent in change helps us communicate the empathy that’s so important in MI—or in any kind of therapy.