An episode of “Changing the Conversation” podcast
Tyrel Starks and host Ali Hall discuss using Motivational Interviewing strategies with couples.
January 23, 2023
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Ali Hall, Host (00:05): Welcome to Changing the Conversation. I’m your host, Ali Hall, calling today from San Francisco, California where I am a full-time trainer and consultant in motivational interviewing, a member of the Motivational Interviewing Network of Trainers or MINT and MINT certified trainer. I’m delighted to welcome Dr. Tyrel Starks who is an associate professor in psychology at Hunter College of the City University of New York where he is calling in from New York. Welcome, Tyrel.
Tyrel Starks, Guest (00:36): Thanks so much for having me.
Ali (00:37): Yeah, this is really exciting. You’ve made so many contributions to the world of MI, and not the least of which is sort of your more recent one, which is motivational interviewing or MI with couples. So that brings up an immediate question to me, why do we need MI for couples? I mean, I’m really excited about it, but tell us more about that.
Tyrel (00:59): I think the way I think about that question is that there’s this whole motivational context that is sort of uniquely relevant for folks who are in relationships together. I think there’s kind of two pieces to that context. The first one may be the one that we think of most often, which is that if I’m in a relationship with somebody, and I don’t like what they’re doing, I may try in some way to influence their behavior. I’m going to encourage them to do something different. I’m going to suggest some other options and this will play out in health behavior too. Maybe I’m worried about my partner, and so I remind them to take their medication, or I sort of nag and nudge them a little bit to eat better, that sort of thing. So I think that’s the pathway of influence that maybe we think about first.
(01:58): There’s also a second pathway of influence, which is that the relationship gets internalized. If I’m in a relationship long enough, eventually being part of that relationship becomes a piece of my identity. I start to think of myself as somebody’s son or parent or friend or husband or lover or boyfriend or whatever, but my role in that relationship becomes integrated into my sense of self. At that point, I’m then willing to do things that protect and preserve my ability to continue to engage in that relationship because it’s a part of my identity that I value.
(02:47): I begin to sort of take joy and pride in my partner’s successes, and I’m upset when they’re upset, and I’m worried when they’re worried and that sort of thing. So that is the point at which the interpersonal becomes personal. When I was thinking about motivational interviewing with couples, I sort of began by thinking about how can we incorporate more attention to those two sources of motivation that don’t get focused on so much in individual interventions sometimes.
Ali (03:21): Yeah, thanks for that. I can see it gets complicated really quickly. I mean, when we think about the individual change trajectory just in and of itself, there’s me. I think about how I am in the world. I self explore. I think about who I want to be. My important roles and responsibilities and the connections that I have now become a deeper part of that consideration. It almost sounds like in MI with couples, there might be almost three in a room. There’s me, the other person and there’s the relationship, and there’s maybe interaction between those things. But so you’re suggesting too that as relationship partners, we influence one another’s behavior, both in positive and maybe not so helpful ways.
(04:05): Maybe there are ways that we nag or worry about the other person that may or may not be helpful, so despite our best intentions to motivate good behavior within our partner and within the relationship itself. What are some things from your perspective that make couples MI different from either MI with individuals, which is more the way we think about the practice of MI? So we’ve got MI with individuals, we’ve got MI with groups, but specifically here you’re talking about MI with couples. What makes that different?
Tyrel (04:34): I’m a huge fan of individual MI, and I’m also a huge fan of the work that has been done around MI with couples. I think there’s sort of proven utility in both of those things. As I was thinking about with couples, I had no desire to undo any of the good work that had been done in those areas. But MI as it was originally sort of put forward really was kind of implicitly or really is sort of implicitly an individually focused intervention. All of the linguistic techniques, all of the conversational strategies that we teach counselors for evoking change talk and that sort of thing are really developed assuming that you’re talking to a person.
(05:30): MI with individuals runs into trouble particularly in instances where you’re talking to a couple in which the partners feel differently about change. One person is kind of uncomfortable with the amount of drinking that’s happening in the relationship and the other person thinks that what they’re doing is just fine. One person is using drugs and the other partner has a big problem with that and thinks it shouldn’t be happening. One person is comfortable with the idea of having sex with partners outside the relationship and the other person doesn’t think that’s such a great idea. One person thinks we should be a vegetarian and the other person isn’t so fond of that.
(06:14): But in the moment where two people feel differently about change, MI with individuals, that set of strategies can break down fairly quickly because the stuff that will get you change talk from one person in the couple will get you counter change talk from the other person. There’s sort of no strategic thing to say when the two people feel differently. There were some attempts. I wasn’t the first person to try out the idea of doing MI with couples. Those initial attempts I think sort of got a little bit stuck on that question of what do you do when the partner argues against change. So that was one big challenge that we set out to wrestle with in developing MI with couples.
(07:19): I thought early on about reaching for some of the ideas and the strategies and the concepts that Wagner and Ingersoll put forward in their work with MI groups. The problem there is that a couple is not just a group of two. The reason for that is in a therapy group, quite commonly, the boundaries of relationships are fairly clear. The counselor who is leading the therapy group often has some degree of control over who may be in the group and who is excluded from the group. There are often sort of group rules and norms about whether group members can associate with one another outside of group. There are sometimes restrictions placed on that to sort of preserve the distinction of the relationships within the group and limit the potential for dual relationships among group members.
(08:28): But none of that really works with couples. Couples come into a session part of a relationship that existed before they got there and that will carry on when this session is done. By virtue of the nature of that relationship, partners in a couple have lots and lots of ways that they may influence one another and rely on each other and interact with each other outside of that session. So a counselor working with a couple needs a framework that can sort of guide practice when you’re working with this dyad in which you can’t control who’s part of this group of two. As the counselor, we don’t get to decide that. You can’t inherently limit the way they interact with or influence each other outside of their interaction with you.
Ali (09:31): So I’m really getting that individual MI, group MI, they share some common elements with couples MI, but they’re also really different animals. I mean, the couple in and of itself is an entity. I guess even you’re talking about some of the tensions that happen within that partnership. I’m imagining sometimes even things coming from really good intentions, being concerned about a partner’s health or wanting them to eat this or don’t eat that maybe after a health scare. It could be any behavior really, but it could be that there’s a lot of reactance going on within couples that gets generated. We think about this when we try to constrain another’s autonomy or persuade or confront them into change, it creates a pushback that didn’t have to be that way. I’m guessing it might even be more intense in the couple’s situation. I wonder if you could say a little bit about that.
Tyrel (10:27): There’s a lot of truth in what you’re saying that often when we’re training MI counselors, we think about relationship discord and we think about the way that our utterances in certain situations may lead to pushback from clients if we end up kind of leading or pulling or getting ahead of them and out of line with their goals. That same phenomena can happen between the partners in a session. If one partner is really advocating for change, if one partner is really advocating for their side of the story and the other partner feels differently, it can actually lead to an amplification of that argument.
(11:16): It’s another place where we really had to come up with strategies that would help therapists and counselors navigate that pitfall. Because the danger is that if the counselor sides with one of the partners in the couple, you can then actually become complicit in amplifying the reactance or the counter change talk from the other person in the room and it sort of can become this kind of two on one thing that ultimately doesn’t serve the couple well and potentially amplifies motivation for one person at the expense of the other or in ways that are sort of counterproductive. So yes, we needed a solution to that challenge.
Ali (12:02): Well, yeah, and thanks for bringing it because I’m guessing that many of our listeners are at least a bit familiar with MI, if not considerably. I’m guessing many of our listeners are also familiar, to some extent if not a large extent, with couples counseling. It really sounds like MI with couples is a very different thing. What are some of the techniques or strategies or approaches that you think are distinctive to MI with couples? Maybe you could talk about a couple of them.
Tyrel (12:31): Interestingly, the things that I think differentiate couples MI from other forms of couples therapy are less about the rhetorical techniques because I think folks who have a lot of experience in couples therapy generally may see some things that are familiar and that feel familiar in couples MI and they should. There are some pieces that couples MI has in common with things like Gottman method therapy or behavioral couples therapy or emotion focused couples therapy. One of the biggest differences actually is what we might think of as sort of the end goal of counseling.
(13:24): In motivational interviewing, sort of whatever your practice base is, you’re often used to thinking about a target behavior. We want to know the change that we are considering. Then so much of the counselors, and we think of that as the focusing process, the focusing process is figuring out now that we’ve established the working alliance, how are we going to use our time together? What’s the targets of our conversation? In couples motivational interviewing, we also have that behavioral target and relationship functioning, right? How satisfied, how committed, how emotionally invested someone is in their relationship, how skillful the partners in a relationship are at talking to one another.
(14:19): Those elements of relationship functioning are seen as a resource that the couple draws on in order to accomplish change or to achieve their goals around the target behavior. In contrast, a lot of couples therapies often are sort of designed to think about relationship functioning as the end goal of the treatment unto itself. A couple comes because they’re unhappy with each other and they’re fighting a lot and maybe they’re thinking about ending their relationship or something. The end goal of the counseling is to improve relationship functioning. That has a lot of merit. I don’t want to discount the value of that.
(15:10): But for counselors who are maybe thinking about incorporating couples work into substance use treatment or into HIV prevention, sexual health interventions, pregnancy health related interventions for couples, for people who are thinking about doing intervention work with couples where the goal is a health related behavior, the MI paradigm generally is amazing for that. It was designed to think about a target behavior, but to bring the MI paradigm to couples, we’ve got to be able to think about relationship functioning as a resource to be drawn onto accomplish change as opposed to its end goal in and of itself. So the real difference between MI with couples and these other couples therapies is sort of where we position relationship functioning in the arc of what is happening in this session.
Ali (16:08): Well, what a rich and fascinating discussion. I know we’re just barely getting into some specifics. I know that our show notes will list some resources, not only the group book that you mentioned, but also yours. I’m hoping that our listeners will dive into that and get some more specifics because I know that this is a really fascinating topic. I’m just curious, what advice would you have for practitioners who are interested in providing services to couples, particularly using the couples MI point of view or positioning?
Tyrel (16:42): So my first piece of advice would be around skill acquisition and skill practice. In the book, I talked throughout about a handful of skills that are sort of unique to talking to a couple. We sort of developed some OARS, open-ended questions, affirmations, reflections and summaries, some OARS strategies that are developed to be couple level utterances. What makes an utterance a couple level utterance is that it is literally directed to the couple. You are speaking to both people as opposed to one partner or the other and it contains information that is relevant to both partners.
(17:23): So it’s either a question that is about the two of them and what they do, or it’s a reflection that captures content that’s coming from both partners, or it is an affirmation of the strengths in their relationship and their relationship functioning, right? So some of it is giving yourself time to practice the actual act of speaking to a couple. There’s also some processes that are unique to MI with couples, specifically the process of facilitating relationship functioning. We often think about the engagement process or the development of a working alliance between the counselor and the clients or the person being interviewed.
(18:08): In couples MI, we also want to give some space to developing the alliance between the partners to literally drawing out and intentionally amplifying the strengths in their relationship, what they value about one another and their capacity to work together for change. That’s critical because in those moments of conflict, one of the strategies for responding to conflict is to reflect back what the partners value about their relationship. That tends to motivate folks to respond in ways that are a little bit more productive and a little less likely to produce sort of unproductive conflict in the session.
(18:59): There are other conflict strategies as well that we have identified and defined, but there’s different things to listen for, there’s different ways of speaking. I think giving yourself some time to practice those things is really critical. For anybody who’s thinking about starting couples work or integrating couples work into their practice, I would encourage them to spend some time thinking upfront about what they need to do to prepare for that. You can’t necessarily just repeat all of your procedures for individual clients twice. If you’re going to start working with couples, what does that mean for your informed consent procedures? How are you going to handle informed consent? Are you going to do it with a couple together or with partners individually?
(19:44): Are you someone who is open to seeing partners separately and then also together as a couple? Or do you want to work strictly with a couple together and not do individual sessions? Do your screening procedures include procedures for identifying and referring couples who may report intimate partner violence and how are you going to handle that if you identify it? So there’s a set of things to also think about structurally in your practice to make sure that you’re ready to start seeing couples in ways that ensure the adequacy of consent and client protection. While that may sound like a lot, it’s some skills to practice and also some procedures to put in place.
(20:27): I guess the third thing that I would say is I really, truly, genuinely believe that it’s worth it. From so many couples that engage in services through my research studies and my intervention development work, the most consistent thing we hear when we ask couples what they appreciate about doing a session together or doing MI together is number one is that it made them take time to just sit down and talk about stuff that they don’t always make time for. Two, that it was really, really helpful to have a neutral third party there when they did it, that there are things that you as the interviewer can ask that people in that relationship may want to talk about, but they don’t know how to get the conversation started.
(21:14): There are ways in which you may be able to scaffold and support a conversation that a couple has tried to have, but it has gone sideways when they’ve done it on their own. So if you’re someone who thinks it would be great to do couple’s work, but it sounds like an awful lot, I do think there’s some work to be done in terms of making sure that you are ready both structurally and skill wise, but also I really, really, truly believe that it’s worth it.
Ali (21:42): Thank you, Tyrel. I agree, it does sound like a lot and it really does sound worth it. I certainly have found my eyes and ears and heart being open by this thoroughly nourishing approach that’s going to tap into the resilience and transformational abilities of individuals and partners in that partnership to be able to make some really profound changes. I’m really excited to hear about this and thank you so much.
Tyrel (22:09): Thanks, Ali.
Ali (22:10): To our listeners, join us next time on Changing the Conversation.
Erika Simon, Producer (22:14): Visit c4innovates.com and follow us on Twitter, Facebook, LinkedIn, and YouTube for more resources to grow your impact. Thank you for joining us. This episode was produced by Erika Simon and Christina Murphy. Our theme song was written and performed by Peter Hanlon. Join us next time on Changing the Conversation.
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