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Tuesday, August 19, 2014

Motivational Interviewing: Fostering Behavioral Change in Older Clients

Motivational Interviewing is about helping people overcome ambivalence in making important life decisions. Advisors are in a position to guide their clients through the process.

One of the most common conditions to the human experience is ambivalence, the experience of having “mixed feelings.” Ambivalence is often the root of difficulty that
people have in committing to a decision. Any commitment we make has consequences, both good and bad. Think of many of the thoughts you have had, and the commitments you have wanted to make in your lifetime. These could include losing weight, financial
planning, calling or writing that friend you’ve been thinking about. Losing weight sounds lovely, but it also comes with hard work and sacrifice, as does financial planning. Chances are, you know intimately the experience of ambivalence. You also likely know the
frustration of working with an ambivalent person. We all have an internal pull to resolve the ambivalence of others, to push a little harder or to justify a little more the reason for change in the face of statements like “yes, but,” and “well, I’m not really sure.” 

As a therapist, I work with a lot of ambivalence, and as advisors, I am sure that you do as well. There is a tool we use in my industry known as Motivational Interviewing (MI). Initially developed by Dr. William Miller (1983) as a method of aiding people with addictions in resolving their ambivalence around sobriety, MI has developed into one of the most productive and widely used set of clinical tools in the world of healthcare. MI is founded on the belief that all people are more ambivalent than they seem about a particular thought or anticipatory commitment. It also assumes that people have motivation for these thoughts and commitments that we, as advocates, can aid them in understanding, fostering, and eventually transmitting into action. MI is a collaborative conversation that strengthens someone’s own motivation for and commitment to change
(Miller 1983). 

The mission of the Society of Certified Senior Advisors (SCSA) is to “improve the lives of seniors by providing an integrated approach to working with senior clients.” (SCSA 2014.) One of the foundational aspects of this mission is building relationships with seniors and their support networks. Relationships foster the mutual trust, commitment, and willingness necessary to participate in the reciprocal nature of the advisor-client contract. Embedded within these professional relationships is the belief that the advisor knows the needs and motivations of the client, and aspires to act in the best interest of the client. MI is a phenomenal method of fostering relationships through understanding motivation for change and aiding the client’s goal setting. 

You do not need to be a clinician to use MI. It does not require years of training or specialized certification. But it does take a shift in mindset and a degree of patience and self-control that is often a new experience for practitioners. This starts by understanding the “Spirit of Motivational Interviewing” (Miller 1983) and then using the tools of the method. Rollnick and Miller (1995) describe the “spirit of MI” as: 
  • collaborative (versus confrontational or authoritative), 
  • evoking the client’s own motivation (rather than trying to bestow it),
  • honoring the clients’ independence and autonomy in making decisions in their own lives.
The Spirit of MI
Collaboration. MI is a partnership. This is an occasion where you step down from the role as “expert” and step into the role of partner and guide to the ultimate viewpoint and experiences of the client. It really doesn’t matter what you think about the change or
your idea of how to enact it. It matters what the client thinks, wants, and is willing and able to do. 

Evoking the client’s own motivation. Motivation comes in many shapes, sizes, and forms. We often use the terms intrinsic (coming from within, like an aspiration to do something due to a desire to be a “better person”), or extrinsic (an outside motivator, like money, fame, or acknowledgement). Try not to judge motivators; they all serve the same purpose, and don’t be quick to assume that one size fits all. Motivation is often deeply personal and individual. Your task is to discover what motivates your client.

Honoring the client’s autonomy. We must never forget that the true power for change is within the client. Clients have a right to their thoughts, feelings and decisions. They’re the ones who are going to do the work and live with the outcomes. That means we
respect where they are coming from, what they are thinking, what they want and are willing to do to get it, even if we disagree (within legal and ethical boundaries,
of course).

Now that you understand the spirit of the method, let’s talk about the tools you will use to help your clients achieve the change they hope for and often need. The “Principles of MI” ( 2014; Miller 1983) are overarching concepts, which
each has a set of tools that will guide your work with your clients. These principles are thematic for a reason. You already have your own innate personality styles, methods of communication, and advocacy. Be guided by the principles, while maintaining your own authenticity in interacting with your clients. Remember the principles are not necessarily sequential. You can use all of the principles each time you interact with your client or just one if the situation serves. 

The Principles of MI
Empathy. Change is hard and conflicting. You have to do different things, give things up, and it stresses the status quo of your life. Begin first with acknowledging this for your clients and really trying to see the world from their viewpoint. Why is this particular decision hard for them? What are they feeling conflicted about? Express that empathy. Join, reflect, summarize, and affirm. Show them that you’re listening, you care, and
you understand.

Client: I just never thought we would reach this point. I never thought I would have to make decisions for my dad. 

Advisor: What a hard place to be in. You want to respect your father’s right to make decisions for himself, but you also want to help him and make sure he gets what he needs. I think this is a difficult position for all adult children.

Foster self-efficacy. In the end, it is the client who has to follow through with the commitment. This means that clients need to believe they are capable of achieving the changes hoped for. In MI, we support this self-efficacy by reminding them of previous successes: “I remember when I first met you, you told me about how you…” and highlighting abilities the client already has. “I’ve always been impressed by your ability to….”


Client: I just don’t know if I can do it. Downsizing, selling my things, moving to a new home. It all feels so overwhelming.

Advisor: I think it would feel overwhelming for everyone. Tell me about another time in your life when you felt overwhelmed. What did you do then? 

Roll with resistance. This is perhaps the hardest and easiest part of MI. Hard in the beginning, and so much easier as time goes by. You are just there to support the client. If you start getting the “yes, buts…,”its time to back off and change tactic. Go back to empathy. You’re pushing too hard. The more the client fights against you, the more they are justifying the reasons not to change. Your actions in MI should always move the client in the direction of the positive change they originally expressed to you.

Client: Yes, but I don’t know if I need to get a living will now. I mean it’s not like I’m going to die tomorrow.  

Advisor: I understand. You feel that you don’t need to draft a living will until you know you’re going to need it. Let’s talk about that. What will things look like when you’re ready to draft a living will? 

Develop discrepancy. This may feel like the most counterintuitive principle of MI, but it is perhaps the most powerful. People do not like ambivalence. It is uncomfortable, and they can only take it for so long. They are compelled to anchor. Fostering this discrepancy
in your clients between their values, who they want to be, what they want to do, and where they are now is key. It is the proverbial fire underneath the frying pan. Discrepancy should be gradual—that is, don’t lose your supportive, empathic style in the process
of heating things up. Move slowly in the direction of helping your clients see that their current actions are actually inhibiting, rather than supporting their end goals. These tools are fun to use, and can foster amazing results, but remember you need your clients
to know first that you are on their side, you believe they can do it, and you’re willing to be flexible and roll with their concerns. Once you have this foundation, give some of these tools to aid in developing discrepancy a try:

Using the ruler as a tool: Ask your client, “On a scale of 0-10 with zero being “it’s not going to happen” to ten being ’I’m going to follow through right after we’re done!’ where are you right now?” Suppose the client responds with a three. “Okay, what would it take for you to move one step closer to a ten?” Remember, there is no wrong point on the ruler, and ALWAYS ask what it would take to move closer to the goal. Never reinforce
the reasons not to. 

Query extremes: Ask your client, “What is the worst part about the way things are now?” What is the best?” What if you chose not to….” Notice the emotion and discomfort behind these questions. That’s healthy. Remember you’re targeting the current behavior (what the client is already doing) to elicit a desire to change to the goal behavior.
Query values and the congruence of current behavior: Ask you client, “If I were to ask, what your top three values are, what would you say?” “Where does your current behavior fit in with these values?” 

In the beginning, MI can feel like more work, because it is often hard to hold back on all of that insight and knowledge we have. However, think back to those times in your life when you were ambivalent. Did you need someone to tell you why what you wanted
was important to you? Did you need someone to tell you how and when to enact this change in your busy schedule? Chances are, you were already aware of these things, but you weren’t as aware of the true values and reasons for wanting to commit to this goal. You weren’t aware of that spark that you needed to move forward with the commitment. This is the foundation you are providing for your clients through the use of MI—increasing
their awareness of what they truly value and motivates them to achieve their goals.
Once this foundation is established, your expertise can truly shine and will be sought out and appreciated due to its contribution to their already strong motivation and commitment. As advisors to older adults, you have the knowledge they and their families need to make decisions, commitments, and achieve goals. The skill of motivational interviewing will aid you in working with clients with clearer focus and stronger commitment to the use of your services in achieving their goals. •CSA

Carilyn Ellis is a psychology intern at the Salt Lake VA Medical Center, specializing in Palliative Care,Geriatric Home-Based Primary Care, OutpatientMental Health and Neuropsychology. She has a master’s degree in clinical psychology and is a Psy.D. (doctor of psychology) candidate at George Fox University in Newberg, Oregon. She can be reached at

Motivational Interviewing: Fostering Behavioral Change in Older Clients was recently published in the Spring 2014 edition of the CSA Journal.

Blog posting provided by Society of Certified Senior Advisors