Dr. Rosengren: What the research would say is it starts to change what’s going on at a hormonal level. Barbara Fredrickson, who is a leading thinker in the area of positive emotions, would say there is an opening up of the visual field and that we literally see more when we are experiencing positive emotions. People begin to see connections in things they wouldn’t otherwise see. And the positive emotions allow them to build bonds and connections with others, and thereby build resilience when the difficult times come. She puts it in the context of the evolutionary theory of emotions: Negative emotions serve to protect us in the moment, and positive emotions serve to broaden and build our resources for when stressful times come. And let’s face it, when we talk about what has been going wrong in our life, that’s a stressful sort of conversation (Fredrickson B. Positivity. New York, NY: Crown Books; 2009).
CATR: Okay, that makes sense. You mentioned earlier that there are four phases of motivational interviewing, and that engaging is the first phase. Can you talk about the focus phase?
Dr. Rosengren: There are different ways to find the right focus for a session. We’re all busy, and we don’t have unlimited time to spend with patients, so I find it useful to have a piece of paper that you use to plan the agenda with your patient. I will write down the common things that we tend to talk about. I’ll say, “Let’s look at the page here. Given the amount of time we have today, what do you want to focus on?” This is useful, because it’s a way to focus their attention and it’s a way to focus our attention. It also allows us to more gracefully introduce difficult subjects that we may need to talk about. For example, in addiction work, you might have a positive urinalysis that you need to talk about. You can put that on your menu of options and say, “So one of the things I need to talk about is your UA results.” And then once we have our agenda, I say, “So where would you like to begin?”
CATR: What else do you put on your agenda menu?
Dr. Rosengren: It depends on the type of patient, but for addictions the list will typically include work, family relationships, stress management, cravings, meeting attendance, and fun. I always like to put fun on the list because it’s one of those things that people don’t usually focus on, and yet we know how important it is that patients are creating opportunities to have enjoyable things happen in their lives. I typically draw circles on a sheet of paper, and I put the words in different circles. I also leave a couple of circles blank and say, “These circles are for things that you feel are important to talk about that aren’t on here.” You can also use a simple checklist, but I find the visual effect of circles to be more engaging.
CATR: What about giving the list to patients before they come into the session?
Dr. Rosengren: That can work well. Patients can get into a routine of completing it in the waiting room. Someone can greet patients in the waiting room and hand them out, or you can leave a stack there. There is actually some research to suggest this can prime patients to do good work once they get into session.
CATR: After focusing comes the evoking phase?
Dr. Rosengren: Yes, and this is really where the art of motivational interviewing comes in. You listen for what sorts of change statements that people are making. In MI, we put everyday language into three different categories: change talk, neutral talk, and sustain talk. Change talk means patient statements in favor of the possibility of change. The two subcategories of change talk are preparatory change talk and mobilizing change talk. During preparatory change talk, people say they’re thinking about the possibility of change, but aren’t necessarily ready to move on it yet. You will hear things like, “Yeah, I think my life would be better if I did something about this.” That is a desire statement. Or they may say, “Well, if I made up my mind, I think I could do it.” That’s an ability statement. Or they might say, “Things are just getting worse and worse, and so I can’t continue doing what I’m doing.” This would be a need statement, where you hear about a negative consequence that impels people towards change. On the other hand, a reason statement is more positively framed; for example, “If I stopped going to the bar, I’d have money to spend on some of the things I’d like to do in the long term.”
CATR: This is fascinating; there’s a whole linguistic world out there that we can tune into. All these statements are examples of preparatory change talk, but I suppose we want to hear more mobilizing talk, is that right?
Dr. Rosengren: Both are important. Preparatory change statements do predict change for patients, but studies have shown that mobilizing language tends to predict change more strongly. Mobilizing language has three parts (Moyers TB et al, Alcohol: Clin Exp Res 2007; 31(Suppl 3):40S–47S) (Moyers TB et al, J Consult Clin Psychol 2009;77(6):1113–1124). There’s commitment—people saying, “Yup, I’m gonna do it,” or, “I’m done with it,” or, “I’m not doing it anymore.” Those are all active statements about what people are going to do, and that predicts change well. The second category is activation, which is saying, “I’m ready” or, “I’m willing to do something.” It’s not quite the same as commitment, but it indicates that people are on that path. And the third is taking steps, which is when people are beginning to experiment with the behavior. I refer to this as the “health club phenomenon” where you’ve made your New Year’s resolution to get fit and joined the health club. You go once or twice. It’s a good thing, but you’re not exercising regularly; you’re just experimenting with it. These kinds of statements are all indicative of change talk.