Raymond Tafrate Explains

Recent Advances in Motivational Interviewing

By Lynn Mollick

            In his October workshop for NJ-ACT, Dr. Tafrate explained that Motivational Interviewing (MI) is a strategy that can be combined with any therapeutic approach. MI emphasizes listening, reflection, and drawing out and reinforcing the patient’s own motivation for change, rather than providing education, explanation, or disputation. MI asserts that instructing or even encouraging patients to change will increase resistance to change.

            The MI therapist does not attempt to “fix” or change patients. Instead, the MI therapist listens for “change talk,” statements reflecting the patient’s own motivation to change. The MI therapist then encourages patients to explore and expand their desire to change. Once MI has increased the patient’s motivation to change, cognitive and behavioral techniques can be used to help patients make changes.

            Dr. Tafrate gave the example of a patient who spent most of his session explaining why he didn’t want to stop smoking. At one point this patient casually mentioned that smoking did interfere with playing soccer, an activity he enjoyed. The therapist then explored the patient’s interest in soccer and his desire to play soccer, but the therapist did not argue that the patient should quit smoking in order to play soccer.

Four Basic Interventions in MI

           The acronym OARS summarizes the four basic interventions in MI: 

            O – open-ended questions

            A – affirmation of patients’ positive behavior

            R – reflective listening

            S – summarizing

 Open-ended questions and reflection draw the patient out. Affirmation and summarizing reinforce language that leads patients to their own arguments for change.

            MI is sometimes erroneously equated with Client-Centered Therapy. But Motivational Interviewing is actually a middle ground between Client-Centered Therapy and cognitive therapy. Traditional cognitive therapy directs patients to change; Client-Centered Therapy is totally non-directive, reflecting whatever patients express; but MI guides patients to change without directing

Preparatory Talk and Commitment Talk

            The MI approach assumes that patients are ambivalent about change. Therapists must search for glimmers of motivation by listening for patients’ expressions of emotional pain. When therapists respond to patients’ pain with reflections and empathy, resistance diminishes and patients begin to consider change seriously. Patients talk about change using “preparatory talk” and “commitment talk.”

            Preparatory talk is vague. The acronym DARN describes its components:

            D – desire

            A – ability (“I can change if I want to”)

            R – reasons (logical and rational)

            N – need (emotional imperatives)

Conclusion

            Expressing the need to change is a signal that patients are ready to change. Patients begin to use “commitment talk,” when they become specific and make a plan to change. When patients use “commitment talk,” therapists can follow up with questions like:

            “What are some reasons for making this change?”

            “What would be different about your life if you made this change?”

            “What is at stake if you do not change?”

            “If you decided to change, how would you go about it?”

            “What’s the next step?”

            If you are working with a patient who argues, disagrees, denies, refuses to talk, is inarticulate or shows any form of resistance, use MI techniques before attempting CBT. Until patients demonstrate preparatory and commitment talk, until they convince themselves that change is in their best interest, they will resist even the most skillful application of any empirically supported treatment.

MI Abandons The Stages of Change Model

            Earlier versions of Motivational Interviewing recommended tailoring therapeutic interventions to the patient’s stage of change, from “pre-contemplation” through “action.” Dr. Tafrate explained the MI has dropped this approach because patients do not progress systematically through identifiable stages of readiness to change -- patients move back and forth between stages, and sometimes skip stages completely.

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