The art of Motivational Interviewing and why “selling” is a crucial skill for all health care professionals
|Michael A. Harvey, PhD, ABPP, is a clinical psychologist and trainer in Framingham, Mass; and consultant faculty at Pennsylvania College of Optometry, School of Audiology. His most recent books are The Odyssey of Hearing Loss: Tales of Triumph and Listen with the Heart: Relationships and Hearing Loss, both published by Dawnsign Press.|
Patients routinely come to my psychotherapy practice wanting to make positive changes without having to make positive changes. In other words, if improvement could happen magically, without sacrifice or expending significant effort, and if one could be guaranteed that improvement, then it would be a done deal.
But instead, all I can offer is a version of “No pain, no gain,” and to add insult to injury, I cannot even guarantee how much gain there will be. Common patient responses: “Why do we have to talk about my depression when taking a pill is so much easier?” “Why do I have to be vulnerable to improve my marriage?” “Why do I have to talk about my feelings?” “How will I know I’ll be happier if I do all of these things?
I didn’t become a psychologist to be a salesman. People come to me asking for help and I render treatment. Psychotherapy is a healing process, isn’t it? More respectable than “selling snow to the Eskimos”—persuading people to buy things they don’t need. Although thankfully I don’t attempt to persuade people to make psychological changes that I judge to be unnecessary, nevertheless I do attempt to persuade. I try to “sell” people on the advantages of positive self-talk, stress reduction training, esteem-building activities, etc.
How do I help motivate those who request my assistance after they learn that improved emotional health may be achieved only after sacrifice and, by the way, without a guarantee?
Motivational Interviewing is a protocol to assist people who are ambivalent about change. It was originally designed by two psychologists for motivating persons to recover from alcohol and drug dependence, as such persons are typically highly resistant to maintaining abstinence.1
As elaborated in previous publications,2-4 Motivational Interviewing is also a useful tool for hearing care professionals to assist patients who are resistant to using hearing aids. Hearing care professionals have extensive diagnostic and prescriptive tools at their disposal, but may not have ample psychological tools to deal with patient ambivalence and resistance.
A cardinal tenet of Motivational Interviewing:
“It is a probing strategy and must start by uncovering Implied Needs [a vague acknowledgement of a problem], but it can’t stop there. Successful questioning in the large sale [my italics] depends, more than anything else, on how Implied Needs are developed—how they are converted by questions into Explicit Needs—a specific want or desire.”5
Note the reference to “large sale.” In fact, although this quotation is a cardinal tenet of Motivational Interviewing, it is not taken from the Motivational Interviewing literature. Rather, it is taken from a popular book on selling, entitled SPIN Selling (Situation—Problem—Implication—Need-payoff). My point here is that, although selling may have a negative connotation, sales techniques are integral to any professional helping endeavor, such as psychotherapy and hearing care.
Imagine my great surprise when I happened to read about sales techniques while preparing a lecture on Motivational Interviewing and noticed the overlap between the psychological literature and how-to-sell literature. Although I don’t attempt to persuade people to make psychological changes that I judge to be unnecessary, I do nevertheless attempt to persuade; I try to sell people on the advantages of the courses of action I’m recommending to them.
As an example, consider the following hypothetical transcript between an audiologist and a patient. It should be familiar to the reader. Prior to this interview, Dr Smith had conducted auditory testing for a 75-year-old woman, Mary, and had found a symmetrical mild gradually sloping to moderately severe sensorineural loss with below-average single-word speech recognition ability at her most comfortable listening levels. Tympanometry confirmed normal middle ear pressure and function, and acoustic reflex thresholds were present at normal levels ipsilaterally for both ears.
The audiologist could recite this technical jargon in his sleep, counsel Mary on the degree and communicative significance of her hearing loss, reassure her that it is consistent with the aging process/presbycusis, and make appropriate recommendations. But he knew that, before that phase of their discussion, there was important and often overlooked groundwork to be laid.
Presently, the task was to ask guided questions to elicit “self-motivational” statements from Mary: namely, statements having to do with problem recognition, expression of concern, intention to change, and the degree of self-efficacy to change. Or, in sales lingo, to elucidate the problem and problem implications.
Audiologist: [Eliciting expression of concern] “How does your hearing loss affect you?”
Patient: “It’s really no big deal. I cope the best I can. Anyway, doesn’t everyone have some hearing loss?”
Audiologist: [He realizes he had moved too quickly and falsely assumed that Mary recognized the problem. Therefore, he asks a question to elicit problem recognition.] “I thoroughly agree we all have some hearing loss. I know we’ve discussed this, but I want to make sure I said it clearly. What’s your understanding about your particular hearing loss from when I had tested your hearing?”
Patient: “You showed me my audiogram and I know I’m not completely deaf, but I guess I’m somewhere in the middle.”
Audiologist: “I guess the $64,000 question is how much your hearing loss is a problem for you.”
Patient: “As I just said, it’s not a problem for me.” She shows mild irritation.
Audiologist: [Again, he realized he moved too quickly and must backtrack a bit to protect their rapport.] “I see. You’re right; you did say that. I’m sorry. And you did say that you cope with it the best you can, did I get that right?” [smile]
Patient: “Yeah.” [smile]
Audiologist: “Got it. Mary, do you mind if I ask you some questions about what exactly you cope with?” [An important principle: always ask patients for their permission to bring up topics.]
Audiologist: “In what situations do you have the most difficulty?”
[Mary then lists some common situations, such as difficulty participating in large group gatherings, particularly with her adult children and grandchildren; use of the telephone with unfamiliar persons; understanding conversations in many restaurants; and arguing with her husband about the volume of the TV.]
Audiologist: [Eliciting expression of concern] “Thanks, I get it. I’m curious, would you rate these situations from most concerning to you to least concerning?”
Patient: “That’s easy,” she quickly responds. “When my kids and their kids come over is the worst; then may come going out to dinner; then the telephone; and then my husband.”
Audiologist: [laughs] “My wife and I never agree on TV as well. And could I ask you to say more about how you feel not being able to understand your kids and their kids when they come over?”
Patient: “I feel like I’m left out, that I’m missing something.”
Audiologist: “How does that feel?”
Patient: “Aren’t you a parent? You must know!” she responded with irritation and tears.
Audiologist: “I am a parent and yeah, I recall a million-and-a-half priceless things that have come out of my kids’ mouths over the years. And for you to know you’re missing all that has to be very hard.”
Patient: “You got that right, doc.” she replies.
Audiologist: “Now I know my needs and values having to do with being able to hear my children and grandchildren, but I don’t want to be presumptuous. I don’t know you as well as you know you. Would you give me a snapshot of what need or value of yours it would fulfill to be able to understand what comes out of your kids’ mouths?”
Patient: “It feels lousy, of course.” Mary doesn’t answer Dr Smith’s need/value question and instead replies with simply an expression of how she feels: lousy. It would be important for the audiologist to elicit what explicit need or value of Mary is being impeded by her untreated hearing loss in order to properly set the stage for later interventions.
Audiologist: “Communication with your kids is important to you as a parent and grandparent?”
Patient: “Very important.”
Audiologist: “We have limited time, but would you at least begin to tell me why it’s important to you?”
Patient: “I have always prided myself on being a good mother, and I can’t be a good mother if I can’t understand what my kids are saying!”
Audiologist: “You being a good mother depends on your ability to understand your children. Did I get that right?”
Mary nodded her head and her tears became more pronounced. Dr Smith offers her Kleenex and remains silent. He has learned to be comfortable with patients showing their emotional pain and resists the temptation to talk and deprive her of this important moment. Mary was giving a voice to her loss of connection and intimacy with her family and was feeling validated by her audiologist.
Many months later, she would remember this important moment as “transformative”—as an emotional turning point in her life. Although Dr Smith was not practicing psychotherapy, this moment could easily be among the gems in the therapy annals. Author’s note: The emotional context of the audiological visit and Dr Smith’s questions catalyzed this shift. These potential “transformative moments” are common because of the context of the audiology visit, having to do with space and time. Further explanation is beyond the scope of this article and can be found in Harvey.6-8
It is worthwhile to note that Dr Smith has yet to mention hearing aids. He was cognizant of what “stage of change” Mary was in, as depicted in Table 1.
Stages of change
TABLE 1. Stages of change.
She acknowledged that she had a hearing loss, so she was beyond what the Motivational Interviewing literature refers to as the Precontemplation Stage, characterized as the denial of any difficulty. Judging from her awareness of her hearing loss and ambivalence about the need for treatment, she was in the second stage, called the Contemplation Stage. Therefore, Dr Smith correctly assessed that giving Mary prescriptive advice would be counterproductive.
Not coincidently, this principle is also consistent with established sales techniques. Marketing consultant Neil Rackham5 advises salespeople to avoid discussing solutions—what he termed “need-payoff questions”—for a large sale too early in a sales call. There is important groundwork to be done before problem-solving and suggesting solutions.
As another audiologist reflected:
“When I first started seeing patients, my first reaction would be to ‘fix’ the problem by amplification. I think in school we are not taught to really listen to the patient and troubleshoot from all angles. We live in a hurried world of appointments and schedules, and we try to address what we think are problems instead of asking questions and really listening to the patient.”
Eliciting feelings and listening to the patient are important, but there are professional boundary issues and limited appointment time. Thus, the frequent concern from hearing care professionals is that asking patients emotional or psychological questions—questions about their feelings, needs, or values—may “open up a can of worms” for which they have neither the training nor the time. My typical response to these very valid concerns is that hearing care professionals can be emotionally therapeutic without conducting psychotherapy, and in a minimum of time. Note that, in this hypothetical transcript, Dr Smith frequently made references to the boundaries of time by using phrases such as “We have limited time, but would you at least begin to tell me…?” and “Would you give me a snapshot of how you feel about…?” Also note that the sequence culminating in the moment that Mary will never forget—when she nodded her head to “You being a good mother depends on your ability to understand your children”—would require only a couple of minutes.
Back to our hypothetical example. Having established rapport via their commonality as parents, humor, and validation and having converted Mary’s implied need (better hearing) to an explicit need (understanding her children more), Dr Smith can now propose fitting her with hearing aids. As he had done in the previous stages of change, his task would largely be to ask specifically tailored questions—but now with a focus on helping Mary give voice to her ambivalence for audiologic treatment.
In the Motivational Interview model, these questions are called “eliciting intention to change” and “eliciting degree of self-efficacy to change.” In a sales model, these questions may be called “need-payoff” and “closing the deal.”
Audiologist: [Eliciting intention to change] “Would you like to discuss how I can help you hear better so you can understand your children?”
Patient: “I don’t want hearing aids,” she immediately retorted.
Audiologist: [laughs] “I don’t think anyone aspires to one day get hearing aids. You know, like ‘I hope one day I’ll be lucky enough to get a pacemaker.'”
Patient: [smiles] “I have one, because I’d be dead without it.”
Audiologist: [A lucky break because of this analogy] “So in addition to being a good mother by understanding your children the best you can, being alive is another important value? You don’t want a pacemaker, but it’s a necessary negative to fulfilling that need. You don’t want hearing aids, but let me ask you: if a hearing aid helped you to be privy to the million-and-a-half gems from your children’s mouths, what would change for you?”
Mary’s eyes dilated and almost instantaneously her face beamed with a wide smile.
The rest is relatively easy—or at least more straightforward. Mary had “arrived” at the third stage of change: The Determination Stage. This is when a patient requests change. Diagnostic and prescriptive tasks work well here, and Dr Smith was well prepared.
Imagine my great surprise when I happened to read about sales techniques while preparing a lecture on Motivational Interviewing and noticed their overlap. My emotional outburst wasn’t logical and you, as the reader, may be thinking, “What took you so long to figure out that trying to motivate people to improve their lives is essentially selling?” You have a point.
Admittedly, my outburst had to do with the negative, immature stereotypes that I had of salespeople—a sentiment that I have also heard many times from hearing care professionals. As audiologist Robert Sweetow put it in his book, Counseling for Hearing Aid Fittings, “Some readers… believe it is beneath our profession to emphasize the importance of selling hearing aids. … But selling and counseling cannot be separated. … The word ‘sale’ may have four letters in it, but it is not a dirty word.”9
I never wanted to be a salesman, but here I am.
- Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 2nd ed. New York: The Guildford Press; 2002.
- Beck DL, Harvey MA, Schum DJ. Motivational interviewing and amplification. Hearing Review. 2007;14(11):13-20.
- Harvey MA. Audiology and motivational interviewing: a psychologist’s perspective. Available at: www.audiologyonline.com. Accessed October 20, 2008.
- Harvey MA. When a patient requests hearing aids but doesn’t want them: psychological strategies of managing ambivalence. Feedback. 2003;14(3):7-13.
- Rackham N. SPIN Selling (Situation–Problem–Implication–Need-payoff). New York: McGraw Hill; 1988.
- Harvey MA. A dying father helps his daughter to live. Hearing Review. 2003;10(4):34-37,80.
- Harvey MA. The transformative power of an audiology visit. Hearing Journal. 2000;53(2):43-47.
- Harvey MA. The transformative power of an audiology visit. Feedback. 1999;10(9):13-21.
- Sweetow R. Counseling for Hearing Aid Fittings. San Diego: Singular Publishing Group Inc; 1999.
Correspondence can be addressed to or Michael Harvey, PhD, at .
Citation for this article:
Harvey MA. I never wanted to be a salesman, but here I am. The Hearing Review. 2008;15(12):18-20.