Motivational interviewing and behavioral change in clinical practice

by Lauril Sachet, MS, CCC-SLP
TISLP Staff

Maybe you’ve heard the buzz about Motivational Interviewing (MI) but are wondering, “what is it and how is it applicable to me?” This blog explores exactly that! My aim is to share the evidence, framework, application, and benefits of MI from an SLP perspective.
 
Any of these situations sound familiar to you?

1. Clinician: “How did your home practice go?” Client: sheepish grin, blank stare, fill-in-the-blank excuse, hands over a partially completed homework log, etc.
2. You steel yourself for a challenge after repeatedly reading the phrase “non-compliant” in your chart review.
3. In order to improve access and quality of care, you’re advocating for a new program or protocol in your facility (e.g., oral care, FEES, integrating AAC use throughout the school day…)
4. You’ve educated your patient, family, and care team repeatedly but are still having a hard time getting everyone on board with recommendations.
5. All of the above

 
What do all these scenarios have in common? They all involve some relationship to behavioral change. As SLPs, we address change on a fundamental and often physiologic level: swallowing, voicing, language, respiration, motor speech, cognition, emotional regulation... These functions may be so ingrained that it takes a massive effort and steadfast dedication to alter them. And yet, our field exists precisely because change is possible!

Why then do we learn so little about the mechanisms and processes surrounding change and how to counsel our patients? Within the therapeutic relationship, who is responsible for inciting and enacting change? The clinician? The client? Change does not happen simply because we detailed the why and how in our recommendations.
 
On the other hand, placing the sole responsibility on the patient means only those with that intrinsic magical combination of motivation, dedication, and support will be successful. If a client fails, is it because we failed to support them in some way? Does having the clinical skillset alone ensure client success? What does evidence-based practice have to say about the therapeutic dynamic and facilitating change? If these questions resonate with you or excite you, then welcome, you are a MI nerd!
 
Motivational Interviewing in a Nutshell
MI is an exploration of the art and science surrounding the pursuit of change within the therapeutic context. For the SLP, it offers a guide towards facilitating change and a path to becoming more effective and efficient clinicians. At its core, MI is a collaborative, “conversation about change” intended to, “strengthen a person’s own motivation and commitment to change.” It originally came from the field of addiction counseling where it was discovered that, “people are more likely to be persuaded by what they hear themselves say.” And in fact, “when a helper [i.e., clinician] uses a directing style and argues for changes with a person who is ambivalent, it naturally brings out the person’s opposite arguments.”
 

Motivational Interviewing Terminology

​Before diving into why MI works, let’s look at some terminology:

• Continuum of conversational styles:

​          Where would you place yourself on this continuum and what factors influence this?

• Ambivalence: “simultaneously wanting and not wanting something or wanting both of two incompatible things” (e.g., like me wanting to exercise and snuggle up on the couch for an Outlanders marathon).
• The righting reflex: “the desire to fix what seems wrong with people and set them promptly on a better course, relying in particular on directing.” Basically, identifying a problem and then providing solutions. Wait, isn’t that what we’re supposed to do? Isn’t that what we’re paid for? Hold that thought, we’ll come back to it.
• Sustained talk: “a person’s own arguments for not changing, for sustaining the status quo.”
• Change talk: “the person’s own statements that favor change.” This is talk that promotes momentum towards a goal.

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Get your research fix!

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​Fun fact: Over 1400 clinical trials have be conducted on MI to date!
 
Change talk predicts actions: In a study by Amrhein et al. (2003), they found that client language (either sustained talk or change talk) actually predicted behavioral outcomes. Similar findings were repeated and expanded upon by other studies which informed the different types of change talk and trajectories which we’ll go over in the future posts.
 
Clinician language impacts change talk: An important piece of the equation is looking at how counselor language influences client production of sustained talk and change talk. Multiple studies concluded that MI consistent language promoted greater change talk, while MI inconsistent language was more likely to result in sustained talk.
Example:
MI inconsistent: “Your hoarseness is caused by silent reflux, tell me why you’re not taking your medications?” This will elicit reasons for why they are not changing. Remember, what comes out of their mouth is what they are most likely to do.
MI consistent: “Why is it important to you to improve your voice?” This will elicit reasons for changing while inviting partnership.
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Ready for more?

In our membership site, future topics will include:

• The Spirit of MI: Qualities inherent to SLPs which both help and hinder
• Conversational processes: How to elicit change talk
• Tools of MI: Growing change talk and maintaining momentum
• Providing education and feedback in an MI consistent way

Let us know what you need most, and we'll come back and provide links once they're published!