Communication Skills

Active listening skills are central to motivational interviewing and functional imagery training. They can be remembered as OARS: Open questions, Affirmation, Reflection and Summarising.

This section will also explore the key listening skills of working with ambivalence and recognising change talk and sustain talk.

Open questions

The use of open questions gives clients the autonomy to talk about the things that matter most to them, as well as encouraging them to reflect before answering. Practitioners should aim to have two reflections per question to allow the client to fully reflect on their behaviours.

The use of closed questions should be avoided as much as possible as they can inhibit engagement and steer the conversation to the interviewer’s rather than client’s perspective.

Affirmation

Affirmation is acknowledging clients worth as well as encouraging and supporting them. Affirmations should be honest, which require the practitioner to listen and understand the client. Affirmation helps build a positive relationship between the practitioner and the client, reducing defensiveness and encouraging confidence in ability to change.

 

Although many affirmations come from the practitioner, some may come from the client by asking them to describe their strengths, good efforts and past success.

Reflection

Reflection is a critical component of active listening. It is the means by which the interviewer works to understand the client’s meaning and demonstrate their understanding of what the client is saying. Reflection is also an important means of eliciting further explanation or exploration from the client. Simple reflections repeat or paraphrase what the client said. Importantly for progressing the conversation, reflections draw out the critical aspects of what the client said, particularly the emotions underlying what they said. Complex reflections also do this but encourage or challenge the client to ‘take sides’ on an issue about which they feel ambivalent:

Client: “I do want to stop drinking, but there are evenings at the moment where I really need a drink to calm me down” [ambivalent]

Interviewer: “You are too stressed at the moment. It would be silly to try and change anything” [here the reflection challenges the client by presenting a more extreme stance]

Client: “Well, I do need to change. If I could get control, it might help with the stress too. Maybe I could cut down just a little” [client argues for change]

Summarising

Summaries are reflections that sum up what the client has told the practitioner. They can be used to present several related discussion points to show the bigger picture or to mark a transition, for example, to close a session by mentioning the most important points covered or confirming a shift to a new behaviour.

Summaries help the client to reflect on their experiences and hear the practitioner reflect back on these same experiences in an encouraging manner. They allow the practitioner to focus the conversation on change, but they also give the client an opportunity to re-direct the conversation. Summaries thus ensure the conversation stays focused on what is important to the client.

Ambivalence

Ambivalence is central to understanding behaviour change. It is normal to find one’s current behaviours and habits reassuring, particularly if they are shared by friends and family. The MI practitioner works with this ambivalence, helping the client to explore the discrepancy between their current behaviour and their core values. In contrast, simply providing information and advice can backfire. If health information makes someone feel guilty or anxious about their behaviour, it feeds their need for the reassurance provided by continuing with what is familiar. Giving advice on change can encourage clients to justify their current behaviour, putting them in the position of arguing for the status quo. Instead, MI practitioners work collaboratively with clients, eliciting their ideas and arguments for change so that it is the client who talks themself into changing.

In MI, only the client knows the answer to their problem. The MI practitioner must be as open to the possibility that the client decides to sustain their current behaviour as to the possibility that they decide to change. The practitioner’s job is solely to help the client make the decision that is right for them. Therefore it is important for the practitioner to listen for and recognise change and sustain talk.

Change talk is the client’s argument for why they should change their behaviour. The practitioner should actively listen and reflect back the client’s arguments for change.

In preparatory change talk, the client might talk about wanting to change, being able to change, their reasons for change, or needing to change.

Client: I’d like to cut down, but…

Mobilizing change talk is a signal that the client is becoming committed to changing and may be ready to think about how to go about it.

Client: I could try cutting down this week

In contrast, sustain talk is the client’s arguments about why they should not change or should maintain their current behaviour.

Client: It would be really hard while work is so busy

Practitioners should be cautious asking reflecting back sustain talk as this can reinforce clients’ ideas about the difficulty of change. Instead, reinforce their autonomy and, if there is discrepancy between the client’s current behaviour and their core values or goals, then try to redirect the conversation to change talk by exploring the issue from another angle.

Not surprisingly, the more time the client spends talking about change relative to sustaining their current behaviour, the more likely they are to change. The MI practitioner can help steer the conversation in the direction of change.