Imagery Based Motivational Interviewing

The first part of a FIT interview works on strengthening motivation for change eliciting commitment to the goal. It focuses on exploring ambivalence by discussing the client’s core values and current behaviours. FIT uses affectively charged sensory imagery throughout, to increase awareness of discrepancy and make valued goals more concrete.

Listen for and reinforce change talk. If the client is talking more about reasons to continue their current behaviour, (‘sustain talk’), reinforce their autonomy, emphasising that it is their choice what they do. Make it clear that the imagery exercises are about exploring hypothetical situations. Do not move onto discussing or imagining concrete goals and plans until the client is ready.

Begin with helping the client to become more aware of the discrepancy between their current behaviour and their core values and goals, using imagery of ideal self and future downsides of continuing current behaviour.

Ideal Self

Interviewer: Would it be okay if we start by talking about you? I’m interested to know what you like best about yourself…

Even if the client mentions things they don’t like about how they are at the moment, use reflection to reinforce the positive things.

Interviewer: You are someone who can [positives] and you would like to be that person more in the future.

IMAGERY EXERCISE:

Here, and throughout FIT, talk the client slowly through the imagery exercises, encouraging imagery in different modalities while they are doing the exercise and drawing attention to positive emotions. Sample imagery prompts are provided here. You may find it helpful to ask the client to ‘go into imagery mode’, giving them permission to close their eyes or gaze into the distance.

Interviewer:Would it be okay to do an imagery exercise now? Imagine those things that you really like about yourself… your ideal self. Imagine a specific time in the future [or in the past, if the client has said that they used to be like this] when you are living up to that ideal. [use prompts to help your client develop a vivid image]

How did that feel?[use reflection and affirmation to maximise the positive emotion]

If they discount it—e.g. saying that they will never be like that—say that is what these sessions are about.

Downsides

The next step is to develop discrepancy by using imagery to explore the downsides of the current behaviour.

Note that this is the only place in FIT where negative imagery is elicited. Although fear of future problems might motivate change in the short-term, there is considerable evidence that so-called ‘fear appeals’ are ineffective in the longer term. A key tenet of FIT, and of its foundations in Elaborated Intrusion theory, is that people continue imagining an idea because doing so brings them some of the pleasure or reward of actually putting that idea into practice. Positive imagery should be self-sustaining while negative imagery will soon fade.

Interviewer:I’d really like to hear more about your experiences with [current problem]. Would it be ok if we talk about that now?

Client talks about problems they attribute to their behaviour but also the benefits they feel it brings. Reflect back the emotion associated with any downsides mentioned, e.g.:

Interviewer: That is really worrying you.

Upsides

Develop discrepancy between the client’s ideal self image and the downsides they have mentioned by using imagery to explore what could get better if they changed their behaviour.

Avoid suggesting possible positive outcomes to the client. It is up to the client to reflect and come up with their own ideas for what might get better for them. Remember to respect their autonomy to make their own choices.

Interviewer:What might get better if you [changed your behaviour]?

Try to elicit several ideas, and pick something that might get better quite soon.

Interviewer:So you earlier said that as a result of being overweight, you feel less fit and that that impact your energy levels. You also said that if you were to make changes you would definitely feel better straight away and that you would expect to see more long term changes, such as weight loss and increased ability to play with your kids without getting tired. Is that right?

Client:Yeah that’s spot on. I would also feel more confident with myself and feel better in my own skin.

Interviewer: I can understand how losing weight can help boost your confidence. Do you think there are any other reasons why you wish to change?

Client:Yeah, I also would like to change because of my health. I know obesity is linked to many other diseases such as cardiovascular ones. I just want to avoid as much as possible those diseases so I can have a good quality of life. Also I think this is also linked to my family. You see I feel as if my kids get embarrassed of me because of my size. I do not want my kids to get bullied at school because their parent is fat. It’s unfair really. For that reason I avoid going to any school events but I really wish I could. I wish I could see my child in plays that the school organises or go to parents evening. I think that is definitely a massive motivator as to why I would like to change. 

Interviewer: This is hard for you, with your kids. It is not an easy situation to be in but you feel it could improve quite soon if you started eating healthily. You would feel more confident and that would help you get out and about doing things with your children. I am wondering if we could continue using imagery for the next part of the discussion.  

Interviewer: Great! If you would like to make yourself comfortable and find a point to gaze it, I would like to imagine the following. Imagine that you have succeeded at decreasing your portion size and achieving your goal. Try to imagine how you will feel when that happens…visualise where you are…what is happening around you…how your body is feeling….and how you feel within yourself, emotionally. How does that feel?

Client: That was good. Yeah, it felt really really nice. I looked how I wanted to and just felt amazing getting to the point I always imagined myself to be like. Interacting with other people without worrying about what they think of me, felt like a massive relief. I felt so confident.

Building motivation by imagining hypothetical change

Imagining hypothetical change helps the client explore possible benefits of change without committing to a particular course of action yet. Even though this section deals with hypothetical scenarios, the use of imagery makes them more concrete, better ‘fleshed out’, and more emotive than they would be through verbal discussion alone.

Interviewer: If you were going to [change], what would you do?

Guide the client to imagine what it would be like to do the things they suggest, drawing attention to how the hypothetical change could bring them closer to their ideal self

If the client has been favouring the status quo, this may be pushing them too far. Instead, there may be value in asking them to imagine a hypothetical scenario where the change had happened anyway (‘suddenly there were no cigarettes’, for instance). Ask how the imagery felt. If there are some positive aspects, draw those out using reflection. If the client seems to warm to the idea of change, take small steps forward, focusing for example on whether there are small changes they could make that would bring some of those positives without losing what they enjoy about their current behaviour.

Hypothetical imagery can serve as a confidence booster, particularly if the client is concerned that change will bring unwanted consequences as well as benefits. Images of future events draw on our memories of past events, so there is a tendency for the imagined future scenario to be more similar to the individual’s current situation than they might fear when just talking about it.

Interviewer: You’ve told me that you would like to reduce your drinking and you’d feel more in control of things if you did, but you are worried about how you will cope with the stress you are under if don’t have a drink. Is that right? [summarising before moving on].

Client: Yes, there are some evenings where I’m so tense…

Interviewer: Would it be okay if we use imagery again to think about what an evening would be like, if you weren’t drinking?

Client: Yes, that’s okay

Interviewer: If you’d like to go into imagery mode… imagine you are coming home from work…what do you do when you get home…who is there with you… what it is like not to drink…Imagine you succeed in not drinking for an hour…imagine what happens, how you are feeling …

How was that?

Client: I imagined I was feeling quite stressed and getting under my wife’s feet because I couldn’t go and pour a drink. She got cross and said go for a walk or something. So I went and walked round the block a couple of times and you know, it was okay, I was feeling calmer when I got home.

Interviewer: Just imagining going for a walk helped you feel calmer. And you didn’t pour that drink. That’s great. Can you tell me a bit more about how that felt?

Client: It was hard, but in my mind I managed it. I imagined my wife being pleased

Building confidence by imagining past successes

This section builds motivation and confidence by reflecting on past successes and recreating those feelings of achievement through mental imagery. The aim at this point is to reinforce the client’s feeling that they are able to succeed and will feel good when they do. We return to these successes later, as a source of strategies, ideas and strengths that might be useful for overcoming obstacles in the current behaviour change attempt.

Ask the client if they have tried to make this change before, or if they have done something else that needed motivation – it could be something quite different, like learning to drive or studying for an exam. Reinforce any positives: even if the attempt ultimately failed, use reflection to evoke any initial feelings of success.

Guide the client in recreating that earlier success in their imagination [see Prompts to evoke imagery]. Encourage them to make it as vivid and detailed as possible, focusing on a specific time when they were succeeding. At the end, ask them how it felt.

Reinforce the positives, and ask what the client did, that time, that helped them to succeed. You will come back to these ideas shortly.

This exercise aims to increase the client’s confidence in their ability to change, in general. If the client is comfortable talking about change at this point, the next step is to develop a specific plan for changing. If there is still ‘sustain talk’, keep working on motivation in general rather than rushing them into a specific plan while they are ambivalent about change.

Developing a concrete plan and setting sub-goals

Ask the client to pick one of the ideas they suggested earlier, when talking about hypothetical change.

Ask what would they need to do to get started.

Guide them to imagine taking those first steps, focusing on how they feel as they do so, and how they will feel afterwards.

Encourage them to project forward, to the end of the first week.

Ask how that felt and reflect the positives.

Elicit commitment by asking the client to summarise what they plan to do.

Ask the client to rate their confidence:

Interviewer: How confident are you that you could do that for (say) a whole week, on a scale of 0 being that you are not at all confident, to 100% being that you are completely sure you could do it?

If the client is reasonably confident, affirm that and reassure that you don’t have to be 100% confident to get started.

If they are not at all confident, you might want to explore their concerns using your MI skills – and possibly encourage them to choose an easier sub-goal – before moving on to the next phase, which aims to build confidence further.

If delivering FIT over several sessions, this might be a good place to end the first session.