Advanced Motivational Interviewing Skills

Once users feel comfortable in working in a motivational interviewing ethos, as well as reasonably competent at using the basic reflections (i.e. simple and complex) and questioning (open and closed) techniques, they can then begin to experiment with some of the more advanced skills. Again remember that it can take years for professionals to practice motivational interviewing skills to a highly proficient level. We ask carers to experiment with the techniques and use combine their own creativity with curiosity and an open mind! The remainder of this section will outline some of the more advanced techniques in motivational interviewing.

Giving Information

Giving information is probably the most commonly used tool in health care communication. Rollnick et al. (2008) offer more detailed guidelines on how to inform within the motivational interviewing model.

Asking permission

Informing is most likely to elicit resistance when the individual is not ready or unwilling to receive it. Although caution should be used when giving advice, there are ways to give advice that are within the motivational model, e.g. first asking what the person knows already or what ideas he/she may have for how to proceed. In general, it is fine to inform when the individual asks you to do so but giving solutions or advice should be avoided. Asking permission has several positive effects; first of all it honours and reinforces the person’s autonomy, secondly it emphasizes the collaborative nature of the relationship and thirdly, it also lowers resistance.

Offer choices

Whenever informing, offer a series of choices, if possible. Again, this supports autonomy. If possible, offer several options simultaneously in order to avoid the person diligently crossing one off at a time and finding oneself being pushed back into the persuasion trap, e.g. “Your meal plan states that you need to have a muesli bar for your mid afternoon snack. In order to stick with your plan, it would seem your choices are either to have the muesli bar, substitute something else with the same calorific content or have a high calorie drink. What options, if any, can you add to this?”

Elicit-Provide-Elicit (EPE)

Rollnick et al. (2008) propose this guideline for information exchange that is more congruent with the principles of motivational interviewing. In the clinical context, it places considerable value on drawing from the patients what they need and want to know and what new information means to them. This again emphasizes patients’ active involvement in their own health care and is intended to enhance motivation for behaviour change.

Elicit: “What do you already know about the consequences of having an eating disorder?”

The second part of the EPE cycle involves providing information in a manageable chunk.

Provide: “I picked up some leaflets the other day from the clinic where young people are describing their experiences and their recovery process. I feel that this is quite relevant.”

Elicit: “How would you feel about me sharing this information with you?”

Here information is provided and then elicits the carer’s own concerns, ideas, opinions and interests in expanding their knowledge base. This framework is one way of conducting or guiding the discussion so that the sufferer is an active participant in making decisions about their wellbeing.

Eliciting self-motivating statements

When supporting a loved one with an eating disorder, it is often helpful if carers reflect on those statements that feed back to the sufferer their own motivation to change. Carers can gently encourage by highlighting the discrepancy between current behaviour and any utterance that reflects plans, dreams and aspirations for the future. These statements can be offered in an encouraging manner and with the belief that the sufferer themselves have the ability and creativity to come up with their own positive solutions and options.

The carer can help the sufferer come to realize the possible benefits in change. One should avoid arguing about why change is necessary, as well as any labelling or blaming. The question/answer trap should also be avoided to avoid the sufferer becoming more and more passive as the carer takes control, assuming the role of the expert Ultimately, the carer’s role lies in listening to the sufferer providing gentle guidance in the direction of change. The following techniques illustrate how to elicit self-motivating statements:

Ask evocative questions

Questions that evoke problem recognition:

In what ways has this been a problem for you?
Questions that evoke concern:

What concerns do you have in this area?
What’s the down side of what you’re doing right now?
In what way does/has this affected your life in a negative/positive way?
In what ways does it bother you?
Questions that evoke intention to change:

What advantages would there be for you?
Exploring the pros and cons

This technique allows the person to say what they like and what they don’t like.

What are the positive gains from your eating disorder?
What’s not so great about living with an eating disorder?
If your eating disorder is still here in say, 5 years time, what would be gains in your life?
What will you have missed out on if your eating disorder is still with you in 5 years time?
Asking for elaboration

By asking for elaboration on what is being said, the carer shows the person that they are really being listened to, as well as enhancing a greater understanding in terms of the other person’s perspective. It is an extension of reflective listening. Some examples are as follows:

I found what you just said really interesting. Can you take me through an example of your frustration and what triggers these episodes?
When was the last time this happened?
I’m interested in, I’d like to know more, if that’s OK with you.
Imagining extremes

Another technique involves asking the person to imagine extremes in the safety of a supportive and empathic discussion. Discussing hypothetical situations can help individuals think ”out of the box” so to speak, activating their own creative thought processes and problem solving abilities.

What’s the worst thing that could happen?
What would it feel like to work on fighting your anorexia?
How do you think it would feel if you could manage your anxiety better?
Let’s imagine that this change had ridiculously positive outcomes, what’s the best thing that could come out of making a change like this?
Visualization techniques

Visualization techniques are used by therapists with sufferers, often in writing exercises. The following exemplifies two forms: looking forward and looking back.

Looking forward

This is where the person, for example, with the eating disorder is asked to try and visualize his/her life in 1 year, 2 years, 5 years time with an eating disorder, then without the eating disorder. How does it feel? What are they doing? Who are they with? This requires very careful listening after you’ve asked the question. The slightest hint of any change talk can then be handed back through careful reflective listening.

Think ahead 5 years. What would your life be like if the eating disorder has left your life?
Suppose things don’t change, where do you think you’ll be five years from now? What will you be doing?
Looking back

Ask the person to compare the present situation with the past happier times. Often old family photographs depicting happier times can be used.

What do you remember about you felt 5 years ago?
What was happening?
How does this contrast with the present?