client: I’ve been eating out a lot. I went to this one restaurant the
other day and you wouldn’t believe the portions they served! I
wanted to split a meal with my wife, but she wanted to order
oysters. I don’t like oysters. The last time I ate oysters was during
Engaging and Focusing 57
this cruise we took 10 years ago and I got really sick. I was sick
for 7 of the 10 days we were on the boat. My poor wife had to go
do all of the activities without me while I lay in bed. Talk about
cabin fever! Those rooms are so small, and when you’re not feel-
ing well . . . it was the pits.
pRactitioneR: That must have put a real damper on your vacation.
You mentioned some unfortunate eating out experiences. Help me
understand how your recent eating out experiences inspired you
to do more meal planning.
In this example, the practitioner acknowledges the client’s story and
gently draws him back into the focus of the appointment.
While the practitioner and client never really leave the engaging pro-
cess, they do move on into other processes. With a specific behavior change in mind the conversation can transition gracefully into evoking and planning to discuss the motivators and “how to’s” of change.
chAPter 4
Evoking
What people really need is a good listening to.
—maRy loU caSey
The third process of MI is evoking. Here, the practitioner uses open-ended questions to invite the client to consider personal interest and motivations for a behavior change.
While making a healthy behavior change may seem like the right thing
to do, there are many cogent and convincing reasons not to change. Therefore, clients are often conflicted about adopting new behaviors. In the evoking process, the practitioner guides the client to examine this ambivalence
toward change. The practitioner uses evocative questions to bring to light the client’s mixed feelings about change.
Evocative questions are asked in a nonjudgmental fashion, support-
ing that it is ultimately the client’s decision whether to change. The goal of the evoking process is to inspire motivation. Telling a client why he should change is often ineffective in promoting long-lasting behavior change.
Instead, an MI practitioner invites a client to voice his personal motivations for change. While evoking may occur throughout the counseling sessions, evoking change talk, which we defined in Chapter 1 as comments made
by the client that support change, is especially useful before the “how to change” or planning is discussed.
Counseling strategies we review
in this chapter include identify-
Telling a client why he should
ing and responding to ambivalence,
change is often ineffective in
evoking language from the client
promoting long-lasting behavior
about change, assessing readiness to
change.
change, and transitioning the client
to the fourth process, planning.
58
Evoking 59
MovIng through AMBIvAlence
It’s normal to have mixed feelings about change. When a client is ambivalent or contemplative about a certain behavior, help him take a look at this behavior from different angles. While helping the client explore ambivalence, it is important to do so without judgment or bias. If a client feels pressured into working on a particular behavior change, you may find his motivation fizzles. Maintain an aura of curiosity and exploration. The client will then feel comfortable being honest with his feelings and opinions surrounding the issue at hand.
Identifying Ambivalence
How can you tell if your client is ambivalent? You can detect his ambivalence in his verbal and nonverbal communication. Pay close attention to the client’s spoken words, his facial expressions, and his body language to assess ambivalence.
When you ask a client to discuss his feelings about making a behav-
ior change, his responses typically fall into one of two categories: change talk or sustain talk. Change talk is when the client expresses a desire to change, comments on his ability to change, mentions a reason and need
for change, or shares a commitment to change. In addition, the client may already be actively taking steps to change. A simple acronym can help you recall what change talk sounds like: DARN CAT, which stands for Desire, Ability, Reason, Need, Commitment, Activation, and Taking steps (Rollnick , Miller, & Butler, 2008; see Figure 4.1).
The “DARN” part of the acronym represents preparatory change talk, whereas the “CAT” part represents mobilizing change talk. At first, a client DaRN Cat
Desire to change: “I real y want to stop binging.”
abilities to change: “I can do this.”
Reasons to change: “If I stop binging, I won’t feel as bloated.”
Needs for change: “I need to stop binging—it makes me feel bloated in the morning.”
Commitment to change: “I am going to start eating more throughout the day so I don’t feel like binging at night.”
activation: “I bought some snack foods that I feel safe with.”
taking Steps: “I didn’t binge the other day, even though we had Hal oween candy in the house.”
FIgure 4.1. Change talk.
60
THE FOUR PROCESSES OF MI
may only express preparatory change talk, but as he becomes more inter-
ested in making a behavior change, you may begin to hear more mobilizing change talk (see Figure 4.2).
A second category is sustain talk, which is a client’s statement that
favors the status quo over movement toward change. Here are examples of client statements that are considered sustain talk:
“I just can’t eat breakfast, because I don’t feel hungry in the morning.”
“I need my energy drink in the morning or else I just feel “off” the rest of the day.”
“I can’t afford a gym membership, and it’s not safe in my neighbor-
hood to walk.”
“I know how many carbohydrates are in rice, but I can’t give it up. It’s my main dish.”
You can identify ambivalence when change talk and sustain talk are
both present in client comments. For example, a client might say, “I know I need to change the way I eat. I can’t live like this anymore. I just can’t get on track, though. I am good all day long and then one thing goes wrong and I blow it. I don’t know what goes wrong; I just can’t control myself. What can I say, I like food. I just do.” In this client response, both sustain talk and Preparatory change talk
Mobilizing change talk
Client statement
type (DaRN Cat) Client statement
type (DaRN Cat)
“I don’t want to end
Desire
“I’m going to start
Commitment
up like my uncle who
training with my
had a heart attack.”
girlfriend for a 10K
run.”
“I’ve cut down on
Ability
“I’m wil ing to cut back Activation
soda before, so I
my eating out habit to
know I can do it
3 days a week.”
again.”
“I hate the fact that
Reason
“I bought a new
Taking steps
the gym makes
swimsuit that would
money off of me
be perfect for doing
because I never go.”
some laps.”
“I real y need to cut
Need
back on the amount
of caffeine I
drink. I
think it’s affecting my
sleep at night.”
FIgure 4.2. Examples of preparatory and mobilizing change talk.
Evoking 61
change talk are present. Comments such as “I can’t live like this anymore”
sound like change talk, whereas “I just can’t control myself” and “What can I say, I like food” exemplify sustain talk. Some clients may be aware of and surprisingly honest about their ambivalence; others may be less aware.
Obvious Ambivalence
At times, clients are quite honest and up-front regarding their mixed feelings. For example, a client may state, “I know I’m supposed to work out all the time, but it’s too hard to stick with it, so I don’t even know why I bother.”
No Signs of Ambivalence
Often clients are unaware of the challenges involved with a behavior
change, and come across overly confident. For example, a client may state,
“I’m tired of feeling so tired all the time. So I’m really hoping you can help me change my diet. I’m willing to do whatever it takes. Just give me a plan and I’ll do it!” Overly ambitious clients can be ambivalent on the inside, but eager to please their practitioners. Therefore, even with an eager client, it can be useful to invite her to explore motivations for change.
Mixed Messages
Clients may express verbally that they are ready to make a behavior change, but their non-verbal cues suggest otherwise. For example, a client might say, “Sure, I guess I could try that.” But at the same she is making inconsistent eye contact, shrugging, blowing out long sighs, or making negative facial expressions. These nonverbal cues may be signs that the client is not ready to change.
Below is a series of brief clinical dialogues demonstrating the different forms of ambivalence.
Obvious Ambivalence
client 1: I know I’m supposed to work out all the time, but it’s too
hard to stick with it, so I don’t even know why I bother.
pRactitioneR: You’ve noticed that it’s challenging to maintain a reg-
ular exercise routine with your busy schedule, and you’re aware
that exercising has many benefits. You’d like to experience those
benefits again.
client 1: Yes. I know that when I was younger and I was running
62
THE FOUR PROCESSES OF MI
regularly, I felt like a million bucks. I had more energy and I just
felt better about myself in general.
pRactitioneR: You’d like to get back to that place.
No Signs of Ambivalence
client 2: I’m tired of feeling so tired all the time. So I’m really hoping you can help me change my diet. I’m willing to do whatever it
takes. Just give me a plan and I’ll do it!
pRactitioneR: You’re motivated to make a change that improves your
energy. What else is important to you about making this change?
client 2: I just don’t think I’m getting the nutrition I need since I eat out all the time. I want to be healthier.
pRactitioneR: Your health is important to you. How would your life
be different if you did decide to change up your diet a bit?
client 2: I’d probably have to start cooking more. I’m a pretty decent
cook, I’ve just gotten lazy lately and it has been easier to eat out.
But the foods I’m eating at restaurants are not the healthiest and I
always leave restaurants feeling sluggish and bloated.
pRactitioneR: While eating out is easier, you see yourself cooking
more because you feel better when you eat meals at home.
Mixed Messages
pRactitioneR: What ideas do you have for quick easy snacks to eat
right after your practices?
client 3: I have no idea. What are athletes supposed to eat after
workouts?
pRactitioneR: Some of my clients have found it easiest to keep non-
perishable foods in their lockers like granola bars or trail mix.
That way they can get started on refueling their muscles right
after practice. What are your thoughts on that idea?
client 3: Sure, I guess I could try that.
pRactitioneR: It sounds like you’re somewhat interested, but I also
get the feeling that you have some hesitations.
client 3: Yeah, it could work, but I’m sure the guys will give me a
hard time about it in the locker room.
pRactitioneR: It sounds like loading up your locker with food isn’t
exactly “cool.”
client 3: No. And while they’re making fun of me, they’ll be asking
me for some too.
Evoking 63
pRactitioneR: Yes, and I bet you don’t want to be giving away all
of your food. Those are some legitimate concerns. You’d like to
increase your performance and you recognize that eating after
practice might help. You also have some barriers to making it hap-
pen. What ideas do you have?
client 3: I could keep food in my car.
pRactitioneR: Great idea. By keeping food in your car, maybe you
wouldn’t have to worry about your teammates.
responding to Ambivalence
In the examples above, the practitioner responded to change talk and sustain talk by repeating back pieces of what the client was saying. Reflective listening is an excellent way to cue clients into their ambivalence. Following are some specific strategies for responding to ambivalence. More examples of reflective listening are provided in Chapter 8.
Reflecting Both Sides
When you hear or see ambivalence, it’s useful to reflect both sides of it.
For example, the practitioner responded to Client 1 above with, “You’ve noticed that it’s challenging to maintain a regular exercise routine with your busy schedule, and you’re aware that exercising has many benefits.
You’d like to experience those benefits again.” In this reflection, the practitioner mentions both the sustain talk and the change talk; therefore, the client hears that she has mixed feelings about the behavior.
Emphasizing Change Talk
While it’s appropriate at times to reflect both the sustain talk and change talk to help the client see she has mixed feelings about change, it’s best to focus most of your reflective listening statements on the change talk. If the client expresses change talk, or even hints at change talk, highlight that piece when reflecting.
In the Client 1 example above, the practitioner ends the reflection on
a positive note, taking a guess that the client is interested in the benefits of exercise. By ending with the change talk, the client is focused on that piece and may well continue to speak of the benefits experienced when she was younger. Instead of dwelling on having a hard time fitting exercise into her busy schedule, she is moving forward by focusing on feeling better when she is active.
Here’s another example of a client statement followed by a practitioner response that highlights the change talk:
64
THE FOUR PROCESSES OF MI
client: Giving up my energy drinks is going to be hard. I’ll probably
be dragging for a few days. But I quit smoking a few years ago and
nothing can be as hard as that was.
pRactitioneR: You recognize that while it may be hard at first, you
know you have what it takes to make this change.
This is another example of how highlighting the client’s change talk
builds motivation and affirms that he has what it takes to make a behavior change.
evoking change talk
In the evoking process the practitioner asks strategic open-ended ques-
tions to elicit change talk from the client and then highlights the change talk using reflective lis
tening techniques. In asking these evocative open-ended questions, the practitioner invites the client to consider his personal motivation for change and how making this change might improve his
life. The following open-ended questions are useful in evoking change
talk:
“What was it like to receive that diagnosis?”
“What are the best and worst parts?”
“What is important to you about this change? What does it mean to
you?”
“What would have to be different for the importance to be higher?”
“How would your life be different after this change?”
“How might this particular change get you what you want?”
“What concerns do you have about what you are doing now? What
bothers you most about it?”
“What don’t you like about [negative behavior]?”
“Who would be able to support you in this change? Who would like
this change?”
“How is what you’re doing right now not working for you?”
“How would your life be different if you did decide to make changes?”
“How would changing make your life better?”
While the majority of questions asked in the evoking process are to
elicit change talk, now and then the practitioner may ask a question with the intention of eliciting sustain talk. Examples of evocative questions that elicit sustain talk include:
“What might make it hard for you to make this change?”
“What do you like about your current way of doing things?”
Evoking 65
These types of questions may be used now and then to invite the client
to consider current barriers to making a behavior change. However, the
goal of an MI session is to elicit as much change talk as possible. Therefore, use questions that elicit sustain talk sparingly.
PuttIng the PIeces together:
evokIng And reFlectIng chAnge tAlk
The following dialogue includes three of the four processes of MI. The
appointment begins with engaging, followed by focusing. Once the client has selected a specific behavior he is interested in changing, the practitioner attempts to build motivation by evoking and reflecting change talk.
Throughout this dialogue the change talk is bolded and the sustain talk is underlined.
Engaging
pRactitioneR: What brings you in today? [open-ended question]
client: I’m just here because my doctor told me he wanted me to try
Motivational Interviewing in Nutrition and Fitness Page 9
