Motivating people to make changes (ii)

The second of a series about using values and empathy to help people make choices

The first installment in this series looked at why people might not be doing what we think they ‘should’ and how they might show this. This installment looks at developing rapport and reviews the essential interpersonal skills that are needed.

Rapport – what does it really mean? Is it just making small talk so the person calms down and is ready to listen to what we want to say? Or is it something much deeper?

Superficially, rapport is really about ensuring you and the other person are on the same wavelength. It can be as simple as asking them about the weather, or did they have a good day, or ‘what can I do for you?’ Done glibly it can be shallow and forced – and you know the person will only tell you what they think you want to hear (until they are just walking out the door and say ‘oh by the way…’!)

If we want to go a little deeper, it is about becoming empathic towards that person. Remember that empathy can be described as ‘walking in another man’s moccasins’ which suggests taking another point of view and beginning to appreciate the importance and confidence with which that person takes action.

To respect this person’s situation, we need to believe that they have made the best possible choices given the resources they had at that time, and that to them their choices made sense at least once. Something about their choice was important to them at the time

• perhaps being in the ‘in’ crowd was more important than lung health when they started smoking
• perhaps having the house tidy and feeling more in control is more important than pacing (and never finishing a job)

Although there are specific skills to help develop rapport, the first and most essential element is actually an attitude: ask yourself ‘Do I really respect this person?’ Respect means accepting that although the person is different, and has made choices that are different from yours, you can honour their position and understand that they have done so to make the best possible decision at the time.

Some skills that can help:

• Observation – note the nonverbal elements of this person’s presentation and respond sensitively to the emotional content
• Open-ended questions – that require more than a ‘yes’ or ‘no’ answer
• Reflection – paraphrasing and confirming that you have understood what the person has said (or intended to convey)
• Affirmation – responding to attempts by the person to manage even in difficult circumstances
• Summarise – draw together what the person has said about their situation, both good and not so good

Part of establishing rapport is appreciating that this person has put aside some time to see you – but that seeing you may not be the most important thing on their mind. Perhaps they had difficulty finding a park, or they are worrying about how a child is doing at school, or they have just had an argument with someone at work. It may be useful to check whether they are really ‘present’ at the beginning of your appointment, and asking whether they have something specific they want to discuss before you begin on your agenda.

Reflective listening is a basic skill taught (usually) early on in health professional training. It’s often assumed by both ourselves and others that we know how to use reflective listening, but sometimes our skills haven’t developed since we first learned them!

Some notes on reflection from William Miller (originator of Motivational Interviewing)

A reflection seeks to summarize what the person means; it makes a guess.

A good reflection is a statement, not a question

There are several levels of reflection for the statement ‘I’ve tried everything for my pain, and I’m just fed up right now’

Repeat – Direct restatement of what the person said

‘So you think you’ve tried everything you know of, and you’re fed up’

Rephrase – Saying the same thing in slightly different words

‘If I’ve understood you right here, you’ve given everything you’ve been offered a good go, and now you’re frustrated’

Paraphrase – Making a guess about meaning; continuing the paragraph; usually adds something that was not said directly

‘It sounds like you think there are no other options and you’re frustrated and perhaps a bit pessimistic about your situation’

Other types of reflection

Double-sided reflection – Captures both sides of the ambivalence (… AND …)

‘So on the one had you’ve tried everything you know of, and feel frustrated because they haven’t worked, but on the other hand you have a sense of hope and you don’t want to give up’

Amplified reflection – Overstates what the person says

‘You doubt that there is anything anywhere that will make any difference to your pain and you’re angry that nothing will ever change’

This last reflection needs to be used with caution because it can be misinterpreted, but other times it can bring the person around to moderating their initial statement, identifying ambivalence and providing you with an opportunity to support a more optimistic view. This promotes change talk.

Reading this may feel like a very basic review, and to a certain extent it is. Try recording yourself with a client (with their permission) and noting every time you use reflection – and then every time you didn’t use reflection. Check with yourself: did you really understand and ensure the person knew you understood their position? Unless you hear yourself paraphrasing what they have said and checking with the person that you’ve got it right, chances are they won’t believe you really listened.

The next installment in this series will review two ways to establish self motivation by offering choices.

Date last modified: 1 March 2008