- Identify statements the young adult makes about their desire, ability, reasons and need for change. These come before they take steps to change.
- Reinforce these statements by reflecting them back to the young adult.
- Be cautious not to turn reflections into questions or judgements.
The first step of strengthening the motivation to change is to recognize it in the language of emerging adults. We call this change talk.
In the first few miles of the journey of change, you will hear change talk without strong commitment. These are expressions of the young person’s desires, abilities, reasons, and needs to alter an unhealthy behavior or adopt a healthy behavior. Statements of desire begin with words such as "I want," "I wish," "I am motivated," and "I would like to." Statements about ability to change convey confidence but do not have to include a declaration of readiness, such as “I think I could do that, but I am not sure I am ready to.” Typical items include "I could," "I am able to," and "It’s possible." Desire and ability statements may also take the form of things the young person has tried to do: “I tried to talk to my boyfriend about condoms.” Regardless of the success of the attempt, the act of trying indicates motivation and is considered change talk.
Statements of need add a sense of urgency to the situation and consist of words such as "I need," "I must," "I have to," "I have got to," and "I cannot keep doing this." Statements about reasons for change can include desire and need but add specificity to the content. Thus, reason statements can indicate that the young person may be less ambivalent and further along in the journey of change. For example, a statement such as “I have to do this” conveys a need to change. In contrast, a reason statement would convey a need paired with a specific rationale for the change. For example, “I need to do this for my health.” Later you will hopefully hear stronger change talk indicative of commitment, I will or I tried. Here are some examples.
“I want to stop smoking; you don’t know how hard it is.” (Desire)
“I wish I could lose some weight to be thin like everyone else.” (Desire)
“I can take my medicine on my own without my parents reminding me all of the time.”
“I could cut back on the weed if I wanted to.”
“I really don’t want to end up on dialysis.”
“If I get another dirty UA, they’ll kick me out of this place.”
“I need to lose some serious weight.”
“I’ve got to get my blood sugar totally down from where it is.”
Remember, the young person’s reasons for change may not be consistent with yours or those of other adults. The reasons may also not be realistic (such as “I need to quit smoking so I can play professional basketball”), and you may even be tempted to laugh at the rationales some young people offer (e.g., “I need to cut back on drinking so I can save my money for this new video game”). Be sure to maintain a nonjudgmental stance; the end result is increased motivation for change.
Reinforcing Motivation to Change
Once you have learned to recognize change talk, how do you respond to it? The main way to reinforce change talk is to reflect it back. There are two main kinds of reflections: simple reflections and complex reflections. You might consider these reflections as a menu of options from which to choose what feels most right to you in the moment. Sometimes you might want to do what feels comfortable, and sometimes you might want to try something new. The goal is to reinforce change talk and to “pluck the change talk out of the jaws of ambivalence” by highlighting change talk and de-emphasizing talk against change.
When you repeat or paraphrase the young person’s change language, you highlight change talk with a simple reflection. The reflection is “simple” because you do not add any specific meaning or emphasis on the content of what has been said. For example, when a young person says, “I don’t want to come to therapy, but I really don’t like the constant fighting with my mom,” a paraphrase might sound like, “You really don’t like the conflict at home.”
If you are using a repeating reflection, you may want to repeat only part of the verbiage to avoid engendering a frustrated or sarcastic response, such as “That’s what I just said.” Consider: “You really don’t like it” instead of a full repetition. You can also alternate your use of simple reflections with other types of more complex reflections described below to avoid sounding like a parrot. The idea is that by reinforcing change talk with a reflection, you can elicit more change talk without the use of open questions.
Tip for Simple Reflections: Avoid Turning Reflections into Questions
Inflection—how you use your tone of voice at the end of a statement (turning it up into a question versus stating it in a neutral tone that smacks of a flat-sounding statement)—can make or break the impact of your reflection. Your goal should be to maintain a neutral tone in your use of reflections, as they can easily be turned into questions without careful monitoring. Turning reflections into closed-ended questions can suggest you are not listening and may be interpreted by the young person as judging their behavior. For example, if a person describes his drinking frequency, you might reflect, “You drank a case of beer,” and lower the inflection to sound straightforward. If you say, “You drank a case of beer?” the young person may feel judged because you sound surprised and even disappointed. Try this out loud and see how it sounds. As another example, in the case of a teenage girl who expresses sadness about her boyfriend’s behavior, a neutral reflection, such as “You felt sad when your boyfriend did not show up” would be better received than if you said, “You felt sad?” By turning the reflection into a question you convey a sense of not really listening and, in the worst case, could give the impression that her feelings were invalid or unreasonable for the situation.
There are a menu of complex reflections you can use to reinforce change talk. A reflection of the person’s true meaning expresses the implication of the person’s statement. It sometimes feels as if you are continuing the paragraph your client has started. For example, if a young person is talking about the multiple appointments he has to attend because of his probation, you might respond with a statement such as “You are tired of people telling you what to do.” A double-sided reflection emphasizes ambivalence when you reflect both sides of the young person’s mixed feelings about change. It serves to point out the discrepancy between the adolescent’s values or goals for change and how her behavior(s) may detract from helping her to attain these outcomes. For example, in the case of an emerging adult who smokes cigarettes but is considering quitting, a double-sided reflection might sound like “On the one hand you really like smoking, and on the other hand it is costing you a lot of money.” With these types of reflections, it is also especially strategic to end with the positive side of change to increase the likelihood that the young person to respond to the latter portion of your response.
You can also reflect client feeling if you have a reasonably close relationship with the young person. In this way, you reflect emotions the person either described. For example, in the case of a young person seeking to lose weight and expressing concerns about avoiding activities due to her weight, you might respond, “You’re disappointed when you miss out on things like participating in sports or going to the gym class because of your weight.” As long as you are actually responding to what the young person has expressed or implied (and not straying too far from it), he or she still has the choice to either accept the reflection or clarify whether what you said was accurate. If your relationship is less close or even conflictual it may be better to use a lower-intensity word (a little sad) instead of a high-intensity word (really depressed). Using different types of reflections not only demonstrates that you are truly listening without judgement or opinion but also is the way to reinforce motivation with words.