One of the basic principles of Motivational Interviewing’s communication skills are OARS, active listening with open questions, affirmations (or praise), reflective listening and summarizing. These skills are used to gain more information in order to understand any ambivalence in change. Carers can then continue to help nudge their loved ones in the direction of considering change.
The use of OARS…
OPEN questions – not short-answer, yes/no, or rhetorical questions
AFFIRM the person – comment positively on strengths, effort, intention
REFLECT on what the person is saying: ‘active listening’
SUMMARIZE: collecting what the person has been saying and offering it back in a basket.
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Open questions: Closed questions which elicit monosyllabic answers should be avoided in favour of open questions which open the opportunity for the patient to speak and elaborate on how he/she is feeling. Overall questions should be limited (never more than 3 in a row), otherwise it may feel like an interrogation exercise. Voice tone is also important when working with open questions. When using motivational interviewing in a professional setting, therapists aim for a ratio of 2:1 reflections:questions.
Edi: I really feel you make me feel different from everybody else in our family.
Carer: I guess your illness makes me more protective. Does that make you unhappy?
(Closed question eliciting a yes/no answer)
Carer: That’s interesting you say that. In what ways do I make you feel different? Help me understand why you think this?
(Open question eliciting greater elaboration
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Affirmations: Affirmations help build a person’s self-belief and self-confidence. A simple affirmation comments on something specific that the person has done or said:
“You handled that really well.”
“You recognized the warning signs and took action.”
Simple affirmations are relatively easy, although if over-used they may come over as insincere. In contrast, a complex affirmation focuses on an enduring strength or admirable attribute. They are about the person and go beyond simple actions to more positive characteristics:
“The way you handled that situation took real courage.”
“Once you make your mind up that you’ll do something, you show real stamina and determination.”
An affirmation is also a guess. Another tip is to leave out the word “I” when affirming as the affirmation is about the recipient as opposed to the person giving the affirmation and may be interpreted as patronizing or of having parental overtones which may result in resistance.
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Reflective listening: Listening is the most essential ingredient of OARS. Carers are encouraged to use reflective listening as an implicit mark of listening which may encourage their loved one to pause for thought. Complex reflections move the conversation forward and direct it towards change by drawing upon emotional energy, enhance self-efficacy or emphasing effective change strategies.
Edi: I don’t deserve to eat dinner tonight. I only ran a couple of miles, and I usually run five.
Carer: …so because you didn’t run as far as you usually run, you don’t deserve to eat
(Simple reflection involves repeating back, not adding much to utterance)
Carer: From what you’ve just said, it sounds as if your anorexic voice is a real bully and tyrant to you and your wellbeing.
(Complex reflection involves adding more strength)
A simple misconception of reflective listening is that you are merely repeating whatever the person has just said, perhaps restating it in slightly different words. Skillful listening, however, includes hearing not only what the other person says, but also what has not yet been said and might be true. It’s like reading between the lines of what you heard. It is important not to jump too far ahead of where the person is – just take a small step forward from what has already been said. Sometimes just a word or two will be enough to plant a seed:
Edi: I’m just so fed up with everybody watching my every move over dinner.
Mum: And this makes you really, really angry.
Another way of looking at simple and complex reflections is to imagine them as an iceberg.
A simple reflection is limited to what shows above the water, the content that has already been expressed, whereas a complex reflection makes a guess about what lies beneath the surface.
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Summarizing: Summaries allow you to guess what the person means and then summarize this as a statement, e.g. “So, what you mean is….”. This way, people are less likely to feel interrogated and more likely to feel understood and hopefully more likely to offer more information.
- “Do you mind if I run that back by you, just to check on my understanding of what you’ve just told me……”