CATR: We’ve gone through the different kinds of change talk, and the point here is that we should be keeping our ears open for these kinds of statements because they bode well. But when we hear them, what should we do? Reflect back on them? Encourage them?
Dr. Rosengren: We should do both. Reflective listening is a particularly effective way to encourage further talk about change. There is research showing therapist behavior influences the appearance of change talk, and change talk begets more change talk (Barnett E, Psychol Addicti Behav 2014;28(4):1212–1219).
CATR: Can you describe the other kinds of statements we should be listening for?
Dr. Rosengren: The flip side of change talk is sustain talk—all the reasons why people want to maintain the status quo or why change is too hard for them. Neutral talk means statements that are neither for or against change. You’re finding out about your patient’s family life and they are telling you about their kids and their partner and those kinds of things. It’s neither for nor against change—just neutral information. But it can quickly become change talk. For example, the person is telling you about last week when they went to the local baseball game. At that point it’s fairly neutral. But then they may say, “Well, I didn’t have a beer, which is normally what I would do.” That’s change talk, and you can follow up with a reflective statement or question, like, “And when you chose not to have that beer, what was going through your mind?”
CATR: That makes sense.
Dr. Rosengren: Finally, there is a kind of sustain talk called discord, which used to be called “resistance.” Discord happens when we start pushing on sustain talk to try and get people to change their behavior more quickly—when we push on a patient’s initial ambivalence and the patient pushes back. For example, if a patient isn’t taking their medication regularly, it might be easy for us to say, “You’re not going to get the benefits if you don’t take the medication consistently.” And then the patient says, “Yeah, but then I get side effects I don’t like, so I’m only going to take it when I need it.” We want to avoid statements that are going to elicit more sustain talk. When I’m training counselors, I often say that discord isn’t a patient problem; it’s our problem because it’s about us pushing on them.
CATR: That’s a useful way of looking at the statements a patient could make. Are you suggesting that in most of our sessions we should be thinking in these terms—thinking of categorizing statements in these buckets?
Dr. Rosengren: I would say yes. What we want to do is tune our ears to hear what our patients say and allow that to guide us, especially when we hear weak change talk.
CATR: What do you mean by weak change talk?
What we’re trying to do with motivational interviewing is direct the energy and movement in a way that’s likely to be productive … we’re trying to figure out their agenda and see if we can get our agenda to work well with theirs.
~ David Rosengren, PhD
Dr. Rosengren: A patient says something like, “So I really don’t think this is all that big a deal.”
CATR: But that sounds more like sustain talk, like they’re not interested in making a change.
Dr. Rosengren: You can read it that way. But there’s also a change element within that statement. The patient’s not saying the issue isn’t a problem; they are just saying the problem’s been overblown by other people. So the art of motivational interviewing involves hearing that little element, and paying more attention to that compared with other parts of the statement.
CATR: It sounds like things can get pretty complicated, but I guess during the actual conversation you’re getting a feel for where a patient is going with these statements.
Dr. Rosengren: When our work with patients is going well, there’s energy and movement. What we’re trying to do with motivational interviewing is direct that movement in a way that’s likely to be productive. We want to help the patient achieve what they want to achieve, and align our goals with theirs. That doesn’t mean we don’t disagree with patients, but we’re trying to figure out their agenda and see if we can get our agenda to work well with theirs.
CATR: What happens when we have a really resistant patient—one who doesn’t want see us at all? How are we supposed to get our agendas in sync?
Dr. Rosengren: That can be tough, but a good way to approach such patients is to identify one of their goals and try to align with it, even if it seems contrary to yours. I’ll give you an example from my previous work with adolescent boys. In 15 years, I never had even one who actually wanted to be in treatment; it was always because so-and-so sent them, and their typical “goal” was to stop seeing me. So I would ask these kids, “What do you have to do to not see me anymore?” We’d figure that out, and it would boil down to something like how did they need to change in order to get their parents off their backs. For folks who are coming in for addiction, your probation officer is on your back; your spouse is on your back; you’re about to lose your job—so what do you have to do in order to be able to keep your job, and how does the alcohol or drug use fit into that? Those are the kinds of questions to ask, and which will help you to agree on goals and get your patient motivated.
CATR: That’s helpful advice. Thank you for your time, Dr. Rosengren.