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Are You Sure Your Client Is Ready To Change?

written by Laura L.C. Johnson April 25, 2009

Laura L.C. Johnson, MA, MBA, LMFT, LPCC is a Cognitive Behavior Therapist and the founder and executive director of the Cognitive Behavior Therapy Center of Silicon Valley and Sacramento Valley. She integrates positive psychology with cognitive behavior therapy and schema therapy, which have been shown to be effective for a wide variety of problems in hundreds of studies. Her clients learn skills to build positive emotions, optimism, and resilience while decreasing unhelpful thinking, behaviors, and emotions. Full bio. Laura's articles are here.



Editor’s Note: This article is part of this month’s optional theme of motivation and grit.

When clients come to us, whether in a coaching or counseling relationship, we assume they are ready to change, right? Otherwise, why would they call and make an appointment, drive in rush-hour traffic after work to our office and pay a fee for us to help them towards a solution?  When your clients arrive for the first session, you may be ready to guide them with positive psychology exercises to build positive emotions and a more meaningful life. Sometimes, after only a few sessions, you may find they aren’t reaching their goals or their motivation may be uneven.

Hard to Talk about Change

What can you do to get your client to talk more about change?  There is a counseling approach called Motivational Interviewing (MI) that can be defined as a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” according to William Miller and Stephen Rollnick, authors of Motivational Interviewing, Second Edition: Preparing People for Change. In Motivational Interviewing, ambivalence is regarded as a normal part of the change process.

MI was originally developed for increasing motivation to comply with substance abuse treatment. MI is now being explored for a wide range of behaviors including health behaviors such as diet, exercise, medication compliance, smoking cessation and chronic disease, mental health such as the treatment of eating disorders, and as an adjunct to cognitive-behavioral therapy for anxiety and depression and in other situations to enhance motivation for change.

Stages of Change

Unfurling Monarch Butterfly

Unfurling Monarch Butterfly

In the transtheoretical model developed by James Prochaska, five stages indicate a client’s readiness for change:

  1. Pre-contemplation – client has no intention to take action and may be uninformed about the consequences of their behavior.
  2. Contemplation – client becomes aware a problem exists and intends to change in the next six months but has not yet made a commitment to take action.
  3. Preparation – client is intending to take action in the next month, may have already tried to change, and may have a plan of action in mind.
  4. Action – client has begun to make overt behavioral or environmental changes.
  5. Maintenance – client is working to prevent relapse and maintain gains.

 

Principles of Motivational Interviewing

One of the major goals of MI is to elicit change talk from the client. MI views resistance not as a client characteristic but as an indicator of the relationship and rapport between the client and counselor or coach. Miller and Rollnick indicate that the client’s verbalization of his or her intent to change can be a powerful predictor of change.  The counselor, in seeking change talk, goes through the following four principles that guide MI (as summarized by Theresa Moyers and Stephen Rollnick):

  1. Expressing empathy – using reflective listening to convey understanding of the client’s message.
  2. Developing discrepancy – between the client’s most deeply held values and current behavior they want to change.
  3. Supporting self-efficacy – building confidence that change is possible.
  4. Rolling with resistance – meeting resistance with reflection rather than confrontation.

Match Strategies with the Stage of Change

Most clients, when they first see a professional, are not at the action stage. About 80% are in one of the first three stages and only 20% are in action or maintenance, according to John Norcross and James Prochaska in the Harvard Mental Health Letter. In the MI model, resistance arises when the counseling or coaching strategies are incompatible with the client’s stage of change (Chanut, Brown & Dongier, 2005).

For example, imagine you are encouraging your client to implement a positive psychology exercise such as recording three good things each evening or engaging in more pleasurable activities, and you are hearing “yes, but” when you follow up to see if they’ve been doing the assignment. In MI, this is often a signal to re-examine the client’s stage of change and adjust strategies appropriately.

Motivational Interviewing and Positive Psychology

Motivational interviewing can be integrated with the stages of change model to help clients explore ambivalence and increase motivation for a variety of behavior changes, including those targeted with positive psychology. MI can increase motivation in the early stages by helping clients understand why they want to change. MI can then be followed with positive psychology exercises in the action stage that help clients acquire the skills for change.

Is Motivational Interviewing Effective?

Research is starting to show that motivational interviewing may be as effective as other types of therapy but at less time and less cost, according to the Harvard Mental Health Letter in 2005. A meta-analysis of 30 well-controlled clinical trials concluded that MI produced significant beneficial effects in the moderate range (effect size = .25 to .57) in three problem areas: alcohol and drug abuse, diet, and exercise. These results were comparable to results seen in psychotherapy in general but at far smaller dosages (under 100 minutes) (Burke, Arkowitz & Menchola, 2003).  Hopefully, there will be new research about combining motivational interviewing and the positive psychology approach, as this could help move both areas forward.
 


 

References:

Britt, E., Blampied, N.M. & Hudson, S.M. (2003). Motivational interviewing: A Review. Australian Psychologist, 38, 193-201.

Burke, B.L., Arkowitz, H. & Menchola, M. (2003). The efficacy of motivational interviewing: A meta-analysis of controlled clinical trials. Journal of Consulting and Clinical Psychology, 71, 843-61.

Chanut, F., Brown, T.G. & Dongier, M. (2005). Motivational interviewing and clinical psychiatry. Canadian Journal of Psychiatry, 50, 548-555.

Harvard Mental Health Letter (2005). Motivational interviewing: An approach to counseling for behavior change attracts growing interest.

Markland, D., Ryan, R.M., Tobin, V.J. & Rollnick, S. (2005). Motivational interviewing and self-determination theory. Journal of Social and Clinical Psychology, 24: 811-831.

Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing, Second Edition: Preparing People for Change. New York: Guilford.

Motivational Interviewing http://www.motivationalinterview.org/

Moyers, T.B. & Rollnick, S. (2002). A motivational interviewing perspective on resistance in psychotherapy. Journal of Clinical Psychotherapy, 58, 185-193.

Norcross, J.C. & Prochaska, J.O. (2002). Using the stages of change. Harvard Mental Health Letter.

Prochaska, J.O., Norcross, J.C. & Diclemente, C.C. (1994). Changing for Good: A Revolutionary Six-Stage Program for Overcoming Bad Habits and Moving Your Life Positively Forward. New York: HarperCollins.

Transtheoretical Model http://www.uri.edu/research/cprc/TTM/detailedoverview.htm

Images:

Trees of Heaven, North Carolien by moonjazz

Unfurling Monarch Butterfly courtesy of Carmelo Aquilina

The Impact of Change by Kwerfeldein

ripples courtesy of Zesk-pk

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5 comments

Nicholas Hall April 26, 2009 - 4:35 am

Hi Laura,
Terrific article! I never heard of motivational interviewing before. It sounds very “positive psychology.” Eliciting specifically framed language from the client… and paying attention to what stage they’re in and tailoring your approach to it. Very interesting. The inclusion of your last paragraph was smart. I love seeing just how effective approaches like these are. Your links to wikipedia and others that explain more about MI is very helpful, too. Thanks so much for this article! 🙂
Nick

Reply
Laura Johnson April 28, 2009 - 8:16 am

Hi Nick,

Yes, I agree that eliciting “change talk” from the client and tailoring the approach to the client’s stage of change are some of the most helpful parts of MI.

Thanks for commenting on my article!

Best, Laura

Reply
Kathryn Britton May 4, 2009 - 11:02 am

Laura,
This is a great reminder that people may be at different stages with respect to change — and different stages need different support. That’s a theme I return to often — no one-size-fits-all answers.
Kathryn

Reply
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