In 2014, I was invited to address the annual conference of the “Association québécoise des intervenants auprès des personnes amputées” (AQIPA) on the subject of Motivational Interviewing (MI). There were about 100 people in the room, all of whom were providing services of one kind or another to people who had had an amputation. I asked, “How many of you have heard that up to 75% of the effectiveness of any therapeutic approach is due to the quality of the therapeutic alliance?” From where I stood, 100 hands when up. Then I asked, “How many of you were explicitly taught how to create that relationship?” Zero hands went up. ZERO. Even accounting for a very generous 10% of any given group that does not respond when asked a question, and counting that percentage as responding in the positive, that would leave a dismal 90% of participants in that group who were not taught this important skill. This exercise has been repeated with similar results across Canada and elsewhere. This, to me, would be the equivalent of telling surgeons that laparoscopy is the most efficient type of surgery (over and over), but never teaching them how to do it. It just seems…wrong.

MI is an approach in which the people are considered the experts on themselves, and the practitioners are the experts on change and whatever professional knowledge they have acquired. Much of the focus of this approach is on developing an attitude of gentle curiosity and weaving that all-important therapeutic alliance. So how do you weave it?

The first step is to intentionally relinquish one’s attitude of being the “expert” on what is right and best for the person. This is often a scary step that provokes questions in practitioners like “Why, then, did I study for all those years?” and “What am I supposed to be doing?” The response to the first question is: You studied for all those years so you could learn what you need to know to be helpful, but they forgot to teach you one important thing, creating that therapeutic alliance! The response to the second: Sometimes, what is most powerful is to simply try and understand what the people are experiencing, without leaping to try to fix it. This requires restraint and being able to sit with the very uncomfortable feeling of helplessness, without losing one’s sense of purpose. Despite the practitioner’s concern, it is not unhelpful to the clients.

One of the best ways to establish the alliance with clients, then, is to listen deeply, to try to hear what they mean by what they’re saying, and to understand their point of view—to get beyond the words and delve below the surface. Using reflection (look for an upcoming blog post on reflections) is a good way of assuring that you are hearing the person correctly. It is the main tool in accurate empathic listening.

Most practitioners in the helping professions learn about reflections at some point during their studies. What they usually learn is limited to a simple repetition or rephrasing of what the person has said, sometimes called a reformulation. This type of repetition is useful in small doses to assure that the practitioner’s auditory system is catching what the person is saying and tune in to the language use of the client, but it is generally too superficial to show the practitioner’s understanding of the person’s meaning. The great workhorse of accurate empathic listening and weaving the therapeutic alliance is the type of reflection made when the practitioner listens for, and reflects, the person’s deeper meaning back to the person.

Some of the types of reflections used in MI are:

• Reflecting the underlying emotion of a statement
• Reflecting the value that supports the client’s statement
• A double-sided reflection in which the practitioner presents two incongruous statements that the client has made, with an ‘and’ between them
• Continuing the paragraph (or going a little farther than the client down the same road of thought)
• Overshooting or amplifying the client’s statement
• Undershooting or reducing the intensity of the client’s statement
• Supporting the client’s statement
• Supporting the client’s autonomy

Using these types of reflections often elicits from the person a verbal acknowledgement of being heard and understood, for example, “Yes, that’s it!” If the reflection is not accurate, either by being a little or way off the client’s meaning, the most frequent client response is for them to offer a correction of the practitioner’s statement. When this happens, the most important thing for the practitioner to do is to correct course and align with the client’s expressed meaning.

While the skill of deep listening and reflection is not easy to master, it is teachable and learnable. Taking a course in Motivational Interviewing is one of the ways to learn it and practicing with feedback both during and after the workshop is a very helpful way of integrating the practice.