How Integrating Motivational Interviewing with the Transtheoretical Model of Behavior Change Can Make Your Coaching Better
“In a way, what Motivational Interviewing was thought to do in the beginning was to help people become ready. In the addiction field we were blaming people for not getting better, saying ‘well, come back when you’re ready.’ Well, we don’t do that with cancer. That’s not good enough. So, what can you do if a person doesn’t seem to be ready? Well, that’s what Motivational Interviewing was designed to do in the first place…and the Transtheoretical Model and Motivational Interviewing grew up together, in the early eighties.”
William Miller – Nov. 2024 Real Balance Monthly Webinar - Motivational Interviewing and Coaching: A Conversation with William Miller and Michael Arloski (https://realbalance.com)
Having an effective knowledge base in the works of Miller & Rollnick (https://www.guilford.com/books/Motivational-Interviewing/Miller-Rollnick/9781462552795?srsltid=AfmBOoqCX9zd0LcdYKsMAf4My4O7xwQ2WWTKBzGyBbm5K8qYtId7F057) and James Prochaska and associates (https://jprochaska.com/books/all-books/) is essential for every health & wellness coach. Understanding how to integrate both into your coaching can be a smooth process because the two are so complementary.
For this blog I’ll dispense with a review of the basics of both Motivational Interviewing (MI) and The Transtheoretical Model of Behavior Change (TTM) and assume you’re professionally familiar with both. What I want to convey here is how a coach can draw upon the way the two overlap and can help your ambivalent client succeed at lifestyle change.
Change is a process, not an event.
James Prochaska
Meeting People Where They Are At
The research done by James Prochaska and his colleagues found that only 20% of the time the client in front of us is in the Action Stage of Change for a particular behavior. Your client is much more likely to be in the Preparation, Contemplation or even Precontemplation Stage. In Changing to Thrive(https://www.simonandschuster.com/books/Changing-to-Thrive/James-O-Prochaska/9781616496296) the Prochaskas discuss how we can work with 100% of our clients, not just the 20% who are “ready”. This is where we draw upon what they call the First Principle of Progress: Increasing Pros to Move from Precontemplation to Contemplation – including Decisional Balance.
So, how do we help our clients to weigh the pros and the cons of making a change? The key is the WAY in which we do this, and here is where the Spirit of Motivational Interviewing and other principles of it come in.
Our way of exploring pros and cons with our client will be a reflection of our way of being – our coaching presence – and, fortunately, the “Spirit of M.I.” and the Cornerstones of Coaching(https://learn.coactive.com/co-active-coaching-book-4th-edition-chapter-download) such as holding our clients to be naturally creative, resourceful and whole, are in complete congruence and rooted in the firm foundation of Roger’s Client-Centered (or Person-Centered) Approach.
As we recognize our client’s need to weigh the pros and cons, we can employ the M.I. process of listening to, not challenging or arguing with what M.I. calls SUSTAIN TALK – what clients say that supports sustaining their current situation and behavior. James Prochaska loved to say that clients will make the case for why they cannot change. In M.I. Sustain Talk is considered perfectly normal as an accepting attitude held by the M.I. counselor is that ambivalence about change is quite natural.
So, when the coach is hearing all of the reasons the client continues to smoke, snack late at night, or continues to be sedentary, instead of putting forth a counter-argument or attempting to persuade the client to change, the coach acknowledges what the client is saying and conveys that they are hearing their client and understand.
Motivational Interviewing emphasizes the importance of Rolling with Resistance. Yet, in our webinar William Miller spoke about how their colleague Theresa Moyer, helped him and Stephen Rollnick see how “resistance” was not the most accurate term to be using here, given their posit that ambivalence and Sustain Talk is normal and to be expected. No matter what you call it, the wise coach learns how to ROLL WITH IT!
In our webinar, Bill Miller emphasized how neutral the coach needs to be as they listen to their client and reflect back to them in ways that are devoid of any sarcasm. Miller went on to point out that this can also be a time for an amplified reflection – “So, drinking doesn’t seem to cause you any problems.” To which the client is likely to respond, “Well, no. When you drink as much as I do, you’re going to have problems!” The amplified reflection thus brought out CHANGE TALK.
As the process of Decisional Balance continues, the coach is listening for Change Talk and requests the client to say more about it. As Change Talk increases the scales begin to tip towards the Pros of changing – TTM’s First Principle of Progress.
The M.I. Hill
“Don’t be unnecessarily concerned with classifying the change talk you hear.
The important thing is to recognize it. Just by virtue of being social animals people already have an intuitive sense of how this works. As another metaphor we suggest that change talk is a bit like walking up one side of a hill and down the other.”
Miller & Rollnick
Motivational Interviewing 3rd Ed.
Miller and Rollnick are continually reminding us of how natural the way whole process of change works and how natural and normal it is. This metaphor is a strong one that can guide your thinking as you work with your client and recognize how they are experiencing this journey. The beginning is very much like an effortful, uphill climb. Should I even try to climb this hill (perhaps again)? Self-doubt and self-efficacy are a huge factor now. We see the language of the person in Pre-Contemplation that TTM talks about: Doubt and Delay, “Don’t know how (to change), Demoralized, and Defending (justifying the current behavior which, of course, equals Sustain Talk). The Sustain Talk in this stage of change is initially strong, and, again, not surprising. You’re going to hear this side of ambivalence often in this stage. The client will recall their previous attempts at change and quite likely their repeated failures.
If we listen patiently and neutrally, reflecting with compassion and unconditional positive regard, we help our client to explore and talk more about what they are facing. Weighing the pros and cons, we will see them ascend this side of the hill into the Stage of Contemplation.
Remember the coach’s entire goal in working with Pre-Contemplation is to help the client to move into Contemplation, that is, to just help them begin to CONSIDER CHANGE.
PREPARATORY CHANGE TALK SIDE OF THE HILL
On this side of the hill we see that Preparatory Change Talk is all about what MI calls DARN:
Desire, Ability and Reasons.
DESIRE: Wanting something to be different, to change. This is about wanting, wishing, hoping. It’s about how the person would like things to be better.
Sure, I want to drop a few pounds.
I’d love to get better sleep.
You know, I’d like a day where I wasn’t so stressed.
I hope I can get my blood sugar under better control.
ABILITY: The person’s self-perceived ability to achieve the change desired. Here we are listening to language that signals that change seems possible.
I’d like to eat less meat and more of a plant-based diet, but I don’t think I can give up steak.
I’ve had so many injuries; I doubt I can ever get the pain under control.
REASONS: Stating specific reason to make changes happen. Listen here for how the client imagines they would benefit from changing. These statements often take an “if…then” structure.
If I was more active, I might have more energy.
Not overeating would make me a better role model for my children.
I want to be healthy enough to be here for my grandchildren.
This is where the Decisional Balance of TTM comes into play. Exploring the reasons for change allow a discussion about the Pros and Cons of change. And, here again, we may need to employ the MI approach of Rolling with Resistance.
NEED: “A fourth component of motivation is reflected in imperative language that stresses the general importance or urgency of change. Need statements don’t say specifically why change is important (otherwise, it would probably be a reason.) (MI 3rd Ed.)
The need to change is expressed with an emotional urgency.
“I’ve got to do something here!”
“I can’t keep living this way!”
“I need to quit being stuck and get going!”
A key to remember here, as the client is in Preparatory Change Talk (here in the Pre-Contemplation and Contemplation Stages) is that DARN doesn’t always show up in that order. You may hear Needs or Desires, first, second, or last, etc. And, as Miller and Rollnick remind us, “We refer to them as preparatory change talk because none of them, alone or together, indicate that change is going to happen.” (MI 3rdEd.)
CRESTING THE HILL: MOBILIZING CHANGE TALK
As Change Talk strengthens, we start to hear language that is shifting from the doubting and “Maybe…” and “If…” into speech that reflects the movement towards proceeding towards resolution of ambivalence and progress towards change. The Mobilizing Change Talk side of the hill is now in the Stages of Preparation (for change) and taking Action. Here again, the wise coach continues to hold the hill metaphor in their mind, recognizing that the client may have some trepidation as they view the downhill slope ahead. “What am I getting myself into? What if I fail again? Will my family/friends go along with this? Am I making changes too fast?” Explore the fears (or call them concerns) your client may have about making these changes.
It’s also worth pointing out that for all of our reliance on theory, change and we human beings in particular, don’t proceed with our thoughts, feelings and lives in nice, sequential and predictable ways. Yes, perhaps we explored fears in the Contemplation Stage, but that doesn’t mean we’re done with them! To throw another metaphor at you: On your client’s journey, you both can look at the road map you’ve co-created but keep your eyes on the road!
On this side of the hill we see that Mobilizing Change Talk is all about what MI calls CAT: Commitment, Activation and Taking Steps.
COMMITMENT: Language that signals the likelihood of change happing. Both Prochaska and Miller & Rollnick are fond of saying that just because someone wants to change, has good reasons and knows they need to, doesn’t mean that they will.
In the Contemplation Stage we heard a lot of language about Intention to Change. Now we are listening for something more. The language of intention shows some commitment but there is still a lingering doubt heard in what the client is saying.
When coaches partner with their clients to make agreements for what they are going to work on between this appointment and the next we often refer to them as commitments. A key is to always set the commitment in a way where it is Stage Appropriate. On this side of the hill a Preparation Stage commitment could be to check out three different Yoga classes in the next week. An Action Stage commitment would be to enroll in one.
ACTIVATION: Language that indicates a movement towards action but does not actually constitute a commitment to it yet. This is the “almost there” language of change.
Activation language is what we will hear in the Preparation Stage of Change like we saw in the stage appropriate “commitment” example above of checking out different Yoga classes for the one that would suit the client best. It almost sounds like the beginning of a negotiation with the self about mobilizing change. “Well, I’d be willing to try…”.
TAKING STEPS: Language that shows that the client has already done something in the direction of making changes. This is the client who reports that they have already done some research on eating a more plant-based diet, has already found an app for tracking their medication adherence, has already returned to swimming at their Senior Center, etc.
Taking Steps in the right direction may be the best way to think of this. Such steps may be categorized as residing in either the Preparation or as Action Stages.
THEORY AND THINKING ON YOUR FEET
Integrating both TTM and MI into your coaching allows you to meet your client where they are at. Understand that even more important than all of the acronyms and ways of dividing up these theories we have to remember Miller and Rollnick’s admonishment “DARN and CAT’s are not all of the possible forms of change talk, just examples. The key is to listen for language that signals movement toward change.” (MI 3rd Ed.)
As William Miller reminded us in the webinar I recently did with him, the WAY in which we work with people carries far more weight than all of the techniques and skills we may practice. Models of behavior change can guide us, but their real value is in how they allow us to better think on our feet in the coaching session.
Michael Arloski, Ph.D., PCC, NBC-HWC is CEO and Founder of Real Balance Global Wellness – a world leader in health and wellness coach training (https://realbalance.com/). Doctor Arloski is a pioneering architect of the field of health and wellness coaching. He and his company have trained thousands of coaches around the world.
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