What Miller and Rollnick (2002) used to describe as resistance to change, in the third edition of Motivational Interviewing (2013) they describe as “sustain talk.” Sustain Talk is not resistance to change, but expressions people make about their ambivalence about change. (Miller & Rollnick 2013 pp.196–197). The use of the language of resistance has the tendency to pathologize the normal ambivalence people have about change and lead to negative identity conclusions about the person who is more in favor of not changing. As Miller & Rollnick (2013) state:
A helpful distinction emerged from Theresa Moyer’s research examining interactive processes within MI. She pointed out that we had lumped within “resistance” what we now call sustain talk — the client’s own motivations and verbalizations favoring the status quo. There is nothing inherently pathological or oppositional about the status quo. It is simply one side of ambivalence. Listen to an ambivalent person and you are likely to hear both change talk and sustain talk intermingled. When ambivalent, people naturally voice sustain talk in response to their own or others’ arguments for change. To call this “resistance” is to pathologize what is a perfectly natural part of the process of change. (p. 197)
Resistance can also be seen as a behavior that is evoked in the interaction between consumer and provider when the provider is taking the position of changing the status quo when the consumer is not ready to make a change. So if “resistance” shows up (e.g. in the form of the consumer interrupting or challenging the provider, the consumer arguing for the status quo, or anger about having been mandated to counseling) it is up to the provider to shift his/her stance from arguing for change to a reflective listening position in which the consumer returns to the center of the conversation. In previous versions of MI this is called “Rolling with Resistance.”
Change Talk and Sustain Talk
What Miller and Rollnick (2002) previously described as “Self-Motivating Statements” is now described as “Change Talk.” Selective reflective listening, open-ended questions, summarizing, and affirmations are all strategies designed to shape conversations with consumers to move them towards expressing “change talk.” In the most recent evolution of MI Miller and Rollnick identify seven kinds of “Change Talk” to pay attention to and reflect back to the client (Miller & Rollnick 2013 pp 162–163 and Rollnick, Miller & Butler pp 35–40).
- Change talk is any client speech that favors movement in the direction of change
- Previously called “self-motivational statements”
- Change talk is by definition linked to a particular behavior change target (Miller & Rollnick, 2010)
DARN-CAT Change Talk
The seven kinds of change talk are summarized by the acronym DARN-CAT:
DARN: The Foundation of Change Talk
Desire — What people want to do
Statements about preference for change: “I want, like, wish…”
Ability — How people can change
Statements about capability: “I can, could…”
Reasons — Why they would change
Specific arguments for change (recognition of disadvantages of status quo and advantages of change): “If I…then…”
Need — How important it is to change
Statements about feeling obliged to change: “I need, have to, got to…”
CAT: Change Talk
Statements about the likelihood of action: “I am willing, ready, preparing to…”
Statements that indicate movement toward action, but are not quite a commitment: “I intend, decided, promise to…”
Statements about action already taken
Examples of Change Talk
Desire: “I want to exercise.”
Ability: “I think I can quit smoking.”
Reasons: “If I try to lose weight I will feel better about myself.”
Need: “I have to stop drinking, it’s not helping me relax, it’s making me more stressed.”
Commitment: “I am going to AA, it’s the only thing that will work for me.”
Activation: “I am ready to start exercising.”
Taking Steps: “I stopped smoking last week.”
Sources: Miller & Rollnick 2013 pp 162–163 and Miller & Rollnick, 2010
Any statement that can be made in favor of change can also be made in favor of not changing or the status quo. A predominance of sustain talk (or equal sustain talk and change talk) in a conversation predicts no change. A predominance of change talk predicts change. While it may be important, at times, to acknowledge sustain talk (i.e. “roll with resistance”), the goal of the clinician is to evoke change talk and reflect that back to the client, but avoid getting caught up in the status quo side of the consumer’s ambivalence about change.
Examples of Sustain Talk
Desire: “I don’t want to exercise.”
Ability: “I’ve tried, and I don’t think I can quit smoking.”
Reasons: “If I try to lose weight I will just gain it back.”
Need: “I have to drink, it’s the only thing that helps me relax.”
Commitment: “I am not going to AA, it’s not for me.”
Activation: “I am just not ready to start exercising.”
Taking Steps: “I went back to smoking last week.”
Strategies for Responding to Sustain Talk
- Reflective Listening
Complex reflections of feelings or meaning, amplified reflection (amplifies the status quo side of the ambivalence), and double-sided reflections that offer the change side of the ambivalence last are reflective listening responses that acknowledge sustain talk and often serve to evoke change talk, shifting the conversation toward the change side of the ambivalence
- Strategic Responses
Strategic responses to sustain talk include emphasizing personal autonomy (highlighting the consumer’s choice), reframing (suggesting a different meaning or perspective), agreeing with a twist (a simple reflection followed by a reframe), and coming alongside (join with the person’s sustain talk with a bit of amplification) (Miller & Rollnick, 2013, pp. 200–204).
Examples of Strategic Responses to Sustain Talk
Consumer: “I really don’t want to exercise.”
Interviewer: “It’s really up to you. It’s your choice. I wonder what you will do?”
Consumer: “I don’t know if I can quit drinking.”
Interviewer: “It would be quite a challenge for you– really hard work.”
Agreement with a Twist
Consumer: “I can’t imagine myself not smoking weed. It’s part of who I am.”
Interviewer: “You just wouldn’t be you with out it! It’s so important to you that you may just have to keep smoking weed no matter what it costs.”
Consumer: “I’ve tried to give up smoking before. It doesn’t work for me. I always get anxious and gain a lot of weight. It’s not for me.”
Interviewer: “It really may be too difficult for you. Quitting may not be worth the discomfort. Maybe it’s better to just stay where you are.”
Source: Miller & Rollnick, 2013, pp. 164–165, 198–204
Rounder: Reflective Listening and Strategic Responses to Sustain Talk Video
This 16-minute video is a classic role play of a client who is mandated to counseling as a result of an OUI. Theresa Moyers, a longtime colleague of William Miller and Motivational Interviewing researcher uses reflective listening and strategic responses to “Rounder’s” sustain talk. As you watch the video, see if you can identify the specific types of reflective listening and strategic responses Terry uses to defuse Rounder’s anger and respond to his sustain talk. How does Rounder respond to Terry’s use of reflective listening and strategic responses to his anger and his expressions of ambivalence about changing his drinking?
Watch this Voice Thread PowerPoint slide show for a detailed description of change talk and some MI strategies for evoking change talk.
Click the play button to begin the slide show.
Make sure your sound is turned on (you may need to turn up the volume).
You can drag the speaker image if it blocks the view of the PowerPoint slide.
Evoking Reasons for Change and Commitment Exercise Video
This 12-minute role-play video demonstrates a number of strategies for evoking change talk (including commitment to change) with a woman who is considering exercising more. See if you can identify the different strategies for evoking change talk and which kinds of change talk are expressed by the women being interviewed.