Evergreen Treatment Services is training all clinic staff—from counselors to public safety—in the practice of motivational interviewing (MI). ETS believes in having a common language and approach for our team that is based on the core values of this approach: express empathy through reflective listening, avoid argument and direct confrontation, adjust to participant resistance rather than opposing it directly, and supporting self-efficacy and optimism.
We sat down with MI trainer, researcher, and consultant Jonnae Tillman to learn more about what MI is and why it’s so important in behavioral health settings like ETS. Jonnae is the former clinical director of four research trials at the University of Washington, where she provided MI training, supervision, and monitoring with military personnel, adults, and adolescents with marijuana dependence and alcohol abuse. Jonnae has also written online courses for MI to improve the treatment of Type 2 Diabetes in primary care settings and provides webinar training for organizations throughout the country.
ETS: Thanks for taking the time to speak with us today, Jonnae. We’d like to start with a definition. What is motivational interviewing?
Jonnae Tillman: Motivational interviewing, MI for short, is an approach to behavior change that focuses on the language we use and our style of communication. We know from research on six continents that people make changes when they use their own words to describe what they value, what the positive and negative outcomes to making a change could be, and how they want their lives to be different.
We also know that when people are talking about how they make changes in regard to complex health-related issues, the way they talk about these issues and the language they use matters. In MI, we call this “change talk,” because it helps people make positive changes in their lives more often than other traditional behavioral change approaches.
This may seem deceptively easy. We know speaking in this way helps people make difficult changes, so we just need to get people to do it, right? The challenge is, MI requires that you change—especially the way you think about your role in another person’s life. Even if you are an expert healthcare provider who knows the solution to people’s health challenges, you need a mental shift away from giving information, advising, and trying to solve problems, to evoking from the other person how they see their situation. Once they start thinking about it, they start talking about it. And as noted, it’s the talking about it that makes change possible.
So, MI is an approach, but it’s an approach for changing your mindset, not the mindset of the person you are there to serve. There are two main components to MI, the skillset—including how to ask open-ended questions, reflective listening, etc. But the harder shift for people in using MI is what we call the “spirit” of MI—the tone, intention, and set of beliefs you must have about the person you’re working with.
This spirit includes curiosity about people’s lives and their motivations. Everyone is the expert of their own life and only they can make the changes in their behavior that will bring about a better and healthier way of living. We’re not here to tell people the best way to improve their health and well-being, even if we feel our solutions will make their lives better. We’re here to learn how they’re going to make the changes that matter to them.
How did your first few trainings at ETS clinics go?
We have just done the trainings at the South Sound Clinic and South King County Clinic. We were scheduled to train people at the Seattle Clinic and REACH as well, but then COVID-19 happened, and we had to rethink.
ETS made quite a progressive decision to train everybody who works in a clinic, from accounting to security to counselors to the front desk staff. The vision is to see MI as a fundamental way people experience services at ETS. This will have a huge impact because it sends an important message to their clients about how the organization values them as people with agency and the ability to manage their lives.
At ETS, I’ve been incredibly impressed with the public safety staff and non-medical staff within the clinic, like those at the front desk. These people often have informal conversations with patients as they wait to receive treatment. Many of these staff members have skillfully taken to this approach. I want to stress that MI is not counseling. It’s a way of communicating that centers the expertise of the patient. Anyone within an organization can contribute to recognizing the power of patients to make changes in their own lives and this will add up to people feeling supported.
What MI often brings to an organization like ETS is relief. They don’t have to fix people; that’s not their job. A lot of the feedback I have gotten is that with this relief comes excitement. This way of working feels so much more natural and more comfortable because those who use it do not feel responsible for other people’s actions—they just get to help them tap into their own wisdom.
In fact, one counselor approached me after the training and said that she’s been a counselor for more than 30 years and this is the first time she’s been excited about her job in quite a while. Engaging in this approach is a choice to open the door, pull back the curtain, and be curious: “What does this person believe? What do they want? What’s been going on in their lives? How do they make changes? What’s going to trip them up?” It’s a choice to be excited and curious about every single conversation. That’s a more enlivening way to be with people, and it’s contagious. That’s what makes me excited to do this work and drove me to set up my own consulting service to bring this approach to others.
What does MI look like in practice?
With an MI approach, an MI facilitator, or “helper” as I call them, doesn’t take sides on a change the person they’re working with is considering, like whether or not to continue drug use, instead, they ask: “How would you feel if you make that change?” You can hear the autonomy in the language. It’s not “empowering” because the power has always rested with the person who is acting. Instead, this question recognizes the person’s role in their own lives to determine what to do.
When someone starts to talk about making a change, a helper will explore both directions, not just why the person wants to change, but what keeps them from making the change. In every situation, people must be prepared for what they will lose as much as they look forward to what they will gain.
People have wisdom about their own lives. They often know what the best course of action is but are rarely asked to articulate what they think. MI helps people sort out what they think and how they make decisions. My role is to lead them through this thought exercise and repeat back to them what they’re saying. That’s where reflective listening comes in. When they can articulate why they want to make a change and these reasons are reinforced by someone who’s really listening to them, change becomes much more likely.
What this all boils down to is that no one likes to be told what to do, period. The belief that people make the “wrong” decision because they do not have enough information is prevalent and seductive. The solution to that problem is easy—just present good information. But we all know that telling someone that smoking is bad for them, for example, does not encourage people to quit smoking.
In many healthcare settings, the person who questions or doesn’t follow healthcare professionals’ advice is considered “resistant.” But, to interrogate whether an approach will work in the context of a one’s life isn’t “resistant,” it’s human. Patients aren’t “other;” they’re us and they work just like we do. We all want to act in a way that aligns with our values and is good for us. And we want to do it of our own volition.
Any final thoughts?
I want to stress that you don’t have to be a counselor or work in a healthcare setting for this approach to enrich your life. MI can deepen any behavior change you or a loved one wants to make.
In fact, try this out: The next time someone mentions a change they want to make in their lives, like “I’m going to get more exercise,” or “stop eating sugar,” instead of doing what most people do in this situation—give advice, tell their story about when they started yoga, or say “good for you!”—ask a question: “What’s brought that to mind?”
The answer to this question is change talk. By asking this question, you will reinforce the person’s agency instead of cutting it down. That’s the best support you can give to someone looking to change.
If you’d like more information about MI training, you can reach Jonnae Tillman at www.jtillmantraining.org.