Evoking Change Talk in MI

Talking to Change · MI Practice Companion

What we ask about, what we choose to reflect, and how explicitly we support autonomy can influence the language that emerges in a Motivational Interviewing conversation.

In Episode 51 of Talking to Change, researcher April Carcone joins Glenn Hinds and Dr Sebastian Kaplan to explore what detailed analysis of MI conversations can teach practitioners about the dynamics of change talk. The discussion moves from work with African American adolescents and their caregivers to healthcare conversations with emerging adults, and then into the opportunities and limitations of technology-assisted communication coding.

This Practice Companion focuses on the practical question beneath that research: how can we become more intentional about the language we invite and strengthen, while remaining careful not to treat change talk as a simple technique or guarantee of behaviour change?

Listen to the full conversation

This Companion highlights selected ideas and practice implications. The original episode contains the full discussion, research context and qualifications.

Listen to Episode 51: Lessons from the Lab – The Dynamics of Change Talk →

In this Practice Companion

Why practitioner language matters
Three communication strategies linked with change talk
What you ask about matters
What you choose to reflect matters
Supporting autonomy, particularly with adolescents
Why the same MI skills may have different emphases in different settings
What the research does and does not establish
Change talk as one part of a larger behaviour-change puzzle
Deliberate-practice activities for developing your own responses

From knowing the skills to using them strategically

Learning MI often begins with distinguishing open and closed questions, practising reflective listening, giving affirmations and summarising. Those foundations matter. April’s research invites a further question: what are we using those skills to invite?

An open question is not automatically useful simply because it is open. A reflection is not automatically directional simply because it accurately captures something the person has said. In an MI conversation, the content we select and the direction we invite can influence what the person says next.

This connects with the Knowledge Centre resources on Change Talk in Motivational Interviewing, Reflective Listening and Evoking.

Three practitioner behaviours linked with change talk

Discussing an initial study with African American adolescents participating in a home-based weight-management intervention, April identifies three practitioner behaviours that were associated with subsequent change talk:

asking questions whose expected response would be change talk;
reflecting change talk that the person had already expressed;
making statements that emphasised the person’s decision-making autonomy.

In that work, the same practitioner behaviours were also associated with commitment language. The important point is not to turn these findings into a formula. The study concerned a particular population, intervention and context. It does, however, give practitioners a useful lens for examining what we are doing moment by moment.

Audio extract 1 · Three Behaviours That Evoke Change Talk

April describes the three communication strategies identified in the adolescent study.

Practice question

Think about a recent conversation in which someone was considering change. Were your questions, reflections and autonomy-supportive statements likely to invite the person to talk about their own reasons for change, or did they mainly gather information?

What you ask about matters

One of the clearest practical lessons in the episode comes when April reflects on the content of practitioners’ questions. Questions about reasons for change, desire, ability, importance or possible benefits make different conversational invitations from questions that focus mainly on barriers, problems or reasons not to change.

This is not an argument for ignoring difficulties. Sustain talk, barriers and concerns can be highly important and deserve accurate listening. The distinction is that practitioners can become more aware of the direction created by repeated questioning. If most of our questions invite explanations of why change is difficult, we should not be surprised when the conversation contains more language in that direction.

That makes a useful advanced-practice distinction: rather than asking only “Is this an open question?”, we can also ask “What is this question inviting the person to talk about?”

Audio extract 2 · What You Ask About Matters

April explains why the content of the question matters when practitioners want to evoke change talk.

Compare these questions

Person: “I know I need to be more active, but by the time I finish work I am exhausted.”

Question A: “What gets in the way of exercising after work?”

Question B: “What might be different for you if you found a way of being a little more active?”

Both questions may be legitimate. They simply invite different kinds of language. A skilled practitioner chooses deliberately rather than mechanically.

What you choose to reflect matters too

Reflections do more than demonstrate listening. They also select what receives emphasis in the conversation.

If someone says, “I hate taking medication every day, but I can see that my mood has been steadier,” there are several accurate possibilities:

“Taking medication every day really bothers you.”
“You have noticed that things have been more stable.”
“You dislike needing the medication, and at the same time you can see a difference when you take it.”

Each response is plausible. Each may be useful at a different moment. What matters is recognising that reflection is not a neutral copying exercise. Our selection can deepen one side of ambivalence, hold both sides together, or invite further exploration in the direction of change.

Explore further: Working with Ambivalence in Motivational Interviewing and Sustain Talk in Motivational Interviewing.

Supporting autonomy is more than saying “it is up to you”

April gives concrete examples of community health workers making autonomy explicit with adolescents: no one can make the young person change, choices about food or activity remain theirs, and the practitioner’s role is to help rather than command.

She connects this with adolescent development. Young people are actively forming identity, testing independence and moving towards adult responsibility. In that context, an overtly autonomy-supportive stance can feel very different from many other adult interactions in which teachers, parents or professionals tell them what to do.

This also connects with Empowerment in Motivational Interviewing and the broader MI Spirit. Supporting autonomy does not mean withdrawing professional expertise, avoiding safeguarding responsibilities or pretending every option is equally safe. It means recognising that lasting change ultimately requires the person’s participation and choice.

Try this

Rewrite each statement so that it retains the professional concern while making choice and agency clearer.

“You need to stop smoking.”
“You have to take this medication every day.”
“You should start exercising three times a week.”

Then ask yourself whether your revised version simply adds the words “it’s up to you”, or whether it genuinely changes the relational stance.

The same skills may not have the same emphasis everywhere

April’s discussion is valuable because she does not present one universal ranking of MI skills. In the adolescent study, open questions and autonomy support were particularly prominent. With caregivers, reflections of change talk and open questions were more strongly associated with change talk, while autonomy support remained relevant.

In another study involving young adults attending an HIV clinic, April describes a further nuance: questions whose content was likely to invite change talk were important, but whether the question was technically open or closed appeared less important in that setting. Reflections were again strongly associated with change talk.

This should not be read as evidence that practitioners can stop developing open questions. A more useful interpretation is that form and function are not identical. A beautifully open question that invites the wrong conversation is not automatically more helpful than a brief, focused question that evokes personally meaningful change language.

Research should make us more precise, not more certain than the evidence allows

A particularly important part of the episode comes later when April carefully distinguishes different levels of evidence. Her work can identify moment-to-moment associations between certain practitioner behaviours and subsequent change talk. That is not the same as demonstrating that one particular communication sequence directly produces a later health or behaviour outcome.

She explicitly describes this as a research dilemma. Human behaviour is influenced by many factors, and the expression of change talk is only one component. This is an important corrective to an overly mechanical view of MI.

Important distinction

It is reasonable to practise ways of evoking and strengthening change talk. It is not reasonable to assume that producing more change talk automatically guarantees behaviour change. Practitioner skill, relationship, context, opportunity, resources, competing pressures and many other factors can matter.

Audio extract 3 · Change Talk Is One Part of the Puzzle

April cautions against treating change talk as the whole explanation for behaviour change.

Technology can help us see conversations differently

The episode also explores April’s collaboration with computer scientists to automate aspects of communication coding. The attraction is clear: traditional behavioural coding requires substantial human time and expertise. Machine-learning approaches may make it possible to analyse much larger numbers of conversations and identify patterns that would otherwise be difficult to study.

For practitioners, the immediate lesson is not that technology can replace careful listening or human coaching. It is that detailed analysis of real conversations can make invisible interaction patterns more visible. That same principle underpins coding, supervision, recorded-practice review and deliberate practice.

Turn the learning into deliberate practice

1. Direction of questions

Write five questions you commonly ask in your own setting. Beside each one, note the kind of client language it is most likely to invite: change talk, sustain talk, information, emotion, planning, or something else.

2. Reflection selection

Take an ambivalent statement and write three reflections: one that focuses on the sustain side, one on the change side, and one that holds both sides together. Notice how each might influence what comes next.

3. Autonomy support

Practise responding to a person who says, “Everyone keeps telling me what I should do.” Develop three responses that communicate respect for choice without becoming passive or indifferent.

4. What would you say next?

Person: “I know my drinking is affecting my sleep, but it is also the one thing that helps me switch off.”

Before reading on, write down what you would say next.

Things to notice: Does your response invite the person to defend drinking, argue for stopping, or explore their own experience? Could a reflection hold both the relief and the concern? Could an evocative question invite them to consider what better sleep might offer?

5. Avoid the outcome shortcut

After a conversation in which someone expresses strong change talk, ask yourself: “What else would need to be in place for this change to become possible?” This helps keep MI connected to real-world context rather than treating client language as an outcome in itself.

Practice takeaways

Practitioner language can influence the language that follows.
Not every open question serves the same purpose.
The content of a question may matter as much as its grammatical form.
Reflecting change talk can invite further exploration of change.
Reflections are selective and therefore potentially directional.
Explicit autonomy support can be especially important when people regularly experience others directing them.
Findings from one population or setting should not automatically be assumed to apply identically everywhere.
Change talk is associated with change, but it is not a guaranteed pathway from one utterance to one outcome.
Research can help practitioners become more intentional without reducing MI to a set of tricks.
Recorded practice, coding and feedback can help us notice conversational patterns that are difficult to see while we are in the interaction.

Episode guide

00:00 Introduction and episode preview
06:25 April’s introduction and early MI story
09:45 What works to evoke change talk from African American youth?
15:45 Forming research questions and testing MI mechanisms
21:00 Working with young people and caregivers
23:00 Why what you ask about matters
27:40 Autonomy support and examples of evocative questions
35:45 Communication patterns in healthcare settings
40:40 Developing computerised coding methods
51:45 What the research can and cannot establish about outcomes
1:00:20 eHealth along a continuum of care
1:05:25 Developing an eHealth prevention programme for childhood cancer survivors

About April Carcone and episode resources

April Carcone is Professor (Research) in Family Medicine and Public Health Sciences at Wayne State University. A social worker by training, her research includes patient-provider communication, the mechanisms of Motivational Interviewing, behavioural interventions, eHealth and implementation science.

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About this series: Talking to Change: MI Practice Companion articles turn selected podcast conversations into practice-focused learning. Each Companion distinguishes the guest’s contribution from broader practice interpretation, links to related Knowledge Centre resources and includes opportunities to reflect and practise.

Podcast

Evoking Change Talk in Motivational Interviewing: Practice Lessons from April Carcone