190 | 神经心理学家的动机性访谈——与丹尼尔·穆林博士的对话

所以最后你会得到一批特别全面、特别细致的神经心理学专家。

And so you're you're gonna end up with expert neuropsychologists who are are really comprehensive and thorough.

我觉得你说得对，你确实注意到了这里有个潜在的矛盾——动机访谈的原则其实不建议你这么做。

I think you're right that you're you're noticing a potential source of friction here between some of the principles of MI, which would say, you know, you don't wanna use this.

如果一个人只对一两个建议感兴趣，你却扔给他二三十条，这确实太压人了。

You don't wanna bury someone in in twenty or 30 recommendations if they're only motivated or interested in one or two.

说实话，现在让我马上想个解决办法，我还真没现成的答案。

I'll tell you, on the spot, I don't have an easy way to reconcile that.

我觉得关键还是看你在反馈时怎么跟对方聊这个事。

I think I think a lot of it would come down to how you discuss this during a feedback.

你要让对方明白，听好了。

And you recognize for the person saying, look.

让我跟你说说这份报告的用意。

Let me tell you the purpose of this.

这份报告是给你看的，但同时也是给推荐你来的医生看的。

Like, this report is for you, but it's also for the doctor that referred you.

所以这份报告里头内容可多了。

So it includes many, many things.

哪些内容对你最重要、最吸引你，由你来决定。

You're the one who gets to decide which of these are most relevant and which ones you're most excited about.

我们一个个看的时候，你随时可以说：‘这个我不感兴趣。’

So as we go through the list, you should feel free to say, I'm not interested.

这个我就不打算做了。

I'm not gonna do that.

你这么说，我一点儿都不介意。

Like, that doesn't hurt me.

也不会让我觉得被冒犯。

That doesn't offend me.

相反，这能帮我更好地理解你。

In fact, it helps me to understand.

咱们一起过一遍，把那些真正打动你、对你最重要的条目圈出来、标出来。

And let's go through and sort of circle and underline the the ones that really connect with you and are your priority.

所以我在讨论反馈之前，先明确一点——就像我们说的，自主权：你才是那个做决定的人。

So that's me sort of prefacing the discussion of the of the feedback with an MI, we would say, autonomy, making an explicit statement that you're the one that gets to choose.

因为最终做选择的是你，我又不能跟你回家。

You're the one that has to choose because I don't I don't go home with you.

而强调自主权，也意味着你有权利拒绝我的建议。

And and then part of that emphasizing autonomy is sort of giving people permission to reject your ideas.

比如说，如果你的建议是：‘我强烈建议你彻底戒酒，一点酒精都别碰。’

And then I think when the person you know, if if your recommendation says, like, I'd really recommend this person stop drinking entirely and eliminate alcohol entirely.

结果对方说：‘你知道吗？’

If they say, you know what?

我可不打算这么干。

Not gonna do it.

每到周日我看球赛，我的习惯就是喝三瓶啤酒。

Every time when I watch football on Sunday, my routine is I have three beers.

我就控制在三瓶，不多喝。

I limit myself to three beers.

我就是不打算改。

I'm not gonna do it.

我第一反应是，作为神经心理学家，我会说声谢谢。

My first response is the neuropsychologist would be to say thank you.

谢谢你对我这么坦诚。

Say thank you for being honest with me.

很多人处在你这种位置，都觉得得撒谎，说医生想听的话，但能知道真相真的很有帮助。

A lot of people in your shoes feel like they have to lie and tell the doctor what they wanna hear, and it it's just helpful to know that.

看得出来，你确实想把自己限制在三杯啤酒以内。

You seem committed to limiting yourself to three beers.

我知道我希望你回答‘零杯’，但更重要的是，你觉得自己能说实话。

You know that I I'd like you to say zero, but the more important thing is that you feel like you can be honest.

所以，这再次体现了尊重自主权，也巩固了这种让你能讲真话的关系。

So that again, that's the emphasizing autonomy and and reinforcing the kind of relationship where this person feels like they can speak the truth.

如果你是为了继续教育学分在听这个，第一个暗号是‘木星’。

If you're listening to this for CE credits, the first code word is Jupiter.

木星。

Jupiter.

动机式访谈真的能给我们带来很多启发，尤其是在反馈环节。

MI has so much to offer us and particularly in feedback sessions.

我对此特别有感触。

I feel very strongly about that.

丹，我简单跟你讲讲我平时怎么给反馈和提建议，你听听看觉得怎么样？

Let me run by you, Dan, quickly my general approach to feedback and recommendations in these situations and see what you think.

比如说，在反馈过程中，我会说：你来找我，是想改善大脑健康，这正是我的核心工作，我也特别感谢你配合完成了所有测试和回答了这么多问题。我们一块儿确实收获了不少信息，刚才也都聊过了。

You know, I might say something like, at some point in the feedback session, you came here to see me to help with your brain health, that's major part of my job and I really appreciate you going through all this testing and answering all the questions, I think we've learned quite a bit together which we've covered.

我觉得，我的另一项职责是和你一起动脑筋，想想有哪些办法可能对你大脑健康有帮助。

I also, I feel like part of my job is to brainstorm and come up with a few ideas of things that I think might help with your brain health.

我想问问，我跟你分享几个想法，你介意吗？你挑几个听起来靠谱的，不感兴趣的也直说，咱们再接着往下聊。对了，我一般不会列二十个、三十个。

I'm wondering, is it okay, would you mind if I share a few of those and then you tell me which which ones sound of interest and which ones don't and you can, you know, we can go from there and then I might list, by the way, never 20 or 30.

我尽量控制在三到八个左右，但我也不会硬性逐条念完报告里的所有建议——那些内容都在报告里，最后选哪些方向，你或者家人也可以一起参与决定。

I try to keep it to three to eight ish, but I also don't feel like I must go through every word and every recommendation that's in my report, those are in there and then the patient can help and or family can help decide which direction we're going in in the feedback session.

我不觉得自己被那份建议清单绑住了，你知道吗？比如我给了他们三四条建议——像约翰说的，运动、睡眠卫生、睡眠呼吸暂停、营养这些——我征得同意后简单提一下，重点强调他们的自主权，让他们自己挑哪条想聊，或者有没有别的想法。

I don't feel like a prisoner of my recommendation list, you know, if I give them three or four things, like John said, you know, exercise and sleep hygiene and sleep apnea and nutrition, something like that, I could briefly list those after asking permission and then emphasizing autonomy, you know, let them choose which we talk about or if they have another idea.

我觉得大多数患者其实心里都清楚，他们踏进这扇门，就是为了做记忆测试、关注脑健康，这事儿大家都明白。

I feel like most patients, you know, they've already come to us, sign in the door, they know they're here for memory testing and brain health, that's understood.

他们有动力，这点我们心知肚明，也已经配合完成了评估，所以这种做法效果一直不错。

They've got some motivation, we know that, they've gone through the evaluation with us, so that that sort of technique has worked fairly well.

不过我想听听你有没有什么建议。

But I'm curious if you have any tips.

嗯，我觉得你那种控制数量的直觉特别对。

Well, yeah, I think your your instinct to limit it is a good one.

你对反馈的表达方式和目的的把握，真的很有帮助。

The the framing of the feedback and the purpose, I think, is really helpful.

我还在想，做动机式访谈时，我们总说要聚焦目标行为，那我们到底想通过这次对话改变哪个具体行为呢？

Another thing that I think about is in MI, we talk about the target behavior and what is the behavior that we're trying to modify with our MI conversation.

最近我一直在琢磨，哪怕是最理想的动机式访谈，五分钟、十分钟，顶多一小时，我们能实际促成的改变其实很有限，得现实一点。

And I've been thinking a lot lately about being realistic about what we can hope or seek to change in even the very best MI in five minutes or ten minutes or sixty minutes at the very best MI.

你指望能改变什么？

What can you hope to change?

举个例子，比如帮人减重和控制肥胖。

And I think a good example here is helping people around obesity and weight loss.

我看过的研究都表明，哪怕是最顶尖的动机式访谈，哪怕只花五分钟、二十分钟，也很难带来真正有临床意义的减重效果。

My reading of the evidence suggests that it's really unusual that even the very, very best MI in the world delivered in five minutes or twenty minutes will result in in clinically meaningful weight loss.

这行为太复杂了。

It's too complex of a behavior.

想靠一次谈话就让人彻底改变并坚持下来，实在太难了。

It's too hard of a change to make and sustain for any single conversation to move the needle.

那问题来了，好吧。

And so the question is, okay.

那你觉得该聚焦在哪儿？

So then what would you focus on?

我觉得你应该重点帮他们建立动力，去对接一个系统的减重项目。

And I think what you would focus on then is and you build that person's motivation to connect with a structured weight loss program.

所以在这种情况下，你真正想改变的行为，并不是指望在这次对话里让这个人减掉体重。

So your target behavior in that case is technically not, I'm trying to get this person to lose weight in this conversation.

我真正想做的，是帮他们建立起去参加系统性减重项目的动力。

What I'm trying to get them to do is to build their motivation to connect with a structured weight loss program.

比如糖尿病预防项目，或者医院合作的减重门诊，又或者是像Weight Watchers这样的项目，或者健身房之类的。

So, you know, be that the diabetes prevention program or a weight loss clinic affiliated with your your hospital or something like Weight Watchers or a gym or something.

但你也得现实一点，别高估自己能做的事。

But, you know, be realistic about what you can accomplish.

有时候，在一次性的短暂咨询里，你唯一能做成的，就是激发他们去联系这些项目的意愿。

And and sometimes in a single one off consultation, all you can accomplish is is building their motivation to connect.

同样的道理也适用于戒烟。

You could use the same thing for, again, for tobacco cessation.

你想想，真能靠五分钟的对话就让戒烟有起色吗？

You say, am I gonna move the needle with a five minute conversation on on this?

可能行，也可能不行。

Maybe, maybe not.

大概率不行。

Probably not.

但我至少可以让他们去拨打戒烟热线，或者参加更深入的治疗项目。

But what I might be able to do is get them to call, a tobacco cessation program or to get into that deeper treatment.

如果我们回过头看，动机式访谈最初就是这么在八九十年代的酒精治疗领域发展起来的。

And if we look back, that's that's really where MI comes from in the alcohol treatment space in the in the eighties or nineties.

他们从来不是指望在一次对话里就让人彻底戒酒。

They weren't trying always to get someone to to quit drinking in a single conversation.

他们做的是激发对方去接受更系统的戒酒治疗的意愿。

What they were doing was building their motivation to connect with more intensive alcohol treatment.

对我来说，理解动机式访谈的一个绝佳角度就是：无论你用什么循证干预方法，只要加上动机式访谈，就能让更多人愿意参与，也让这些方法更有效。

And for me, this is one of the great ways to think about MI is if you take any evidence based approach and you add MI to it, you increase the number of people that will engage with that approach and the effectiveness of that approach.

你可以把动机式访谈当作很多深度治疗项目的前置引导。

You kinda you put MI in front of a lot of other more intensive programs.

如果我要琢磨怎么让反馈谈话更有效，我就会回到减肥那个例子再想想。

And if I was trying to figure out how do I effectively have these feedback sessions, I would I I let me go back to the weight loss example.

我才不想一上来就一股脑儿给他们讲一堆建议，比如换无糖饮料啊、注意份量啊、食物金字塔啊这些。

I wouldn't wanna spend it trying to pepper them with advice about, well, switch from, you know, regular soda to diet, and let me tell you about portion sizes and the food pyramid.

你别指望五分钟内就能让他们有大改变。

You don't try to move the needle in five minutes.

关键是先建立起他们和更深入治疗项目的联系，那种真正能帮上忙的项目。

Try to build that connection to a more intensive treatment program that'll that can actually help.

是的。

Yeah.

这能给我们减压不少。

They take some of the pressure off of us.

我们不用非得把减肥的每个环节都讲全了，感觉压力没那么大了。

We don't have to kind of feel so overwhelmed to cover every aspect of the weight loss process.

这个说法我喜欢。

I like that.

而且，也许这五分钟我们可以用来多引导他们表达改变的意愿，帮他们想清楚为什么要去那个减肥中心。

And also, maybe we can spend those five minutes on eliciting more change talk and just kind of get them to connect with the reasons why they would go to that weight loss center.

因为五分钟内，我们就能做到这一点。

Because in five minutes, we can do that.

虽然我们没法面面俱到，但至少能在激发改变的对话上有所推进。

Whereas, we won't be able to cover everything, we can move the needle in that sense for talking about change.

顺便说一句，那个密集的减重项目什么的，其实也可以融入动机式访谈。

And by the way, that intensive weight loss program or whatever it is can also incorporate MI.

对吧？

Right?

所以它完全可以贯穿整个治疗过程。

So it can be present along the pathway.

是的。

Yeah.

理想情况下，确实应该这样。

Ideally, it does.

没错。

Yes.

你们俩刚才其实已经提到我们一直讨论的一个点——提建议，这其实是动机访谈的一个部分。

And then both of you had already kinda started talking about one of the things we've been talking about is is advice giving, which can be an aspect of MI.

我特别喜欢你们俩都用了‘先问再讲’的方式，就是那种‘问—告知—再问’或者‘问—提供—再问’的套路。

And I like how both of you couched it in asking permission, you know, we have this ask, tell, ask or ask, offer, ask approach.

你们要不要再聊聊这个方法，或者分享点别的提建议的小技巧？

I wonder, if you want to say anything else about that approach or any other tips about advice giving.

没错。

Yeah.

说实话，这技能是我刚开始接触动机访谈时最难掌握、最不敢试的一招。

I mean, this was one of the skills that was most difficult for me to learn and to experiment with when I was first exposed to MI.

就是说，在你告诉别人该怎么做、给建议之前，得先问问人家愿不愿意听，比如：‘我这边有几个想法，可能对你这个事儿有帮助，你有兴趣听听吗？’

This idea that before you tell someone what to do or give them advice, you should ask permission to say, so I have some ideas that might help you related to this issue.

这个问题得是真心的，不能装样子。

Are you interested in hearing them?

关键是，这问题得发自内心，不能是套路。

It's important that the question be authentic and real.

偶尔会有人直接说：不，别说了。

Every once in a while, someone will say, nope.

我不想听。

Don't wanna hear it.

更多时候，他们既不说‘好’，也不说‘不好’。

Or more often, they won't say, yes.

他们心里其实想听，但又不肯点头。

I wanna hear it, but they also won't say no.

我觉得这背后也挺值得琢磨的。

And I I think that's worth getting curious about too.

有时候，他们直接说‘不’会觉得特别害怕。

Sometimes it it's scary for them to just outright say no.

但一旦他们同意了，你就可以把想法说出来，比如说睡眠呼吸暂停和呼吸机这件事。

But when they do give you permission, you go ahead and you you give them your ideas, and you say, like, let let's take the example of sleep apnea and CPAP.

你懂的？

You know?

所以我听出来，你对这些问题挺担心的。

So I hear that you're concerned about these problems.

你最近感觉不太舒服。

You're not feeling great.

你怕不管是什么情况，症状都会越来越糟。

You're worried that whatever it is, your your symptoms are gonna get worse.

我要跟你说的最重要的一件事，就是每天晚上都要戴上这个CPAP设备。

What I would tell you is the single most important thing you can do for yourself is to find a way to wear that CPAP each night.

如果你是我家人，或者是我关心的人，我一定会一遍又一遍地跟你说这句话。

If you were my family member, if it was someone I cared about, that would be the thing I would tell them over and over again.

我们得想办法让这事儿行得通，因为你这样缺氧，脑子和身体根本撑不住。

We gotta find a way to make this work because your your brain and your body can't function when you're deprived of oxygen in this way.

所以呢，我会这样掏心窝子地劝你，说完之后，我就会把它当成头等大事来抓。

So, you know, that that would be me giving that advice, giving that sort of impassioned speech, and then I make it a priority.

但在那之前，我会先问你能不能这么做。

But before I did that, I asked for permission.

我说：你愿意听听我的想法吗？

I said, do you wanna hear what I have to say?

大多数人这时候都会说愿意。

Again, most people will say yes.

大多数人会说：当然好啊。

Most people will say, sure.

你有什么高见？

What do you got?

如果有人直接说‘不，我不想听’，那你必须尊重他的决定。

If somebody says no, as they say, no, I don't wanna hear it, then it's really critical that you accept that.

你就回：行，我明白。

And you say, alright.

很高兴你能跟我讲真话。

I'm glad you felt like you could you could tell me the truth.

你觉得怎样才帮得上忙？

What would be helpful?

咱们该重点聊什么？

What should we focus on?

如果你觉得非得跟人说点什么，不管对方想听不想听，别先问人家能不能说。

If you feel like you have to tell someone something, whether they wanna hear it or not, don't ask permission.

最糟的就是先问：‘我能跟你说件事吗？’

Because the the worst thing you can do is to say, can I tell you?

人家说不行，你还是硬说下去。

They say no, and you plow ahead anyway.

别这么干。

Don't do that.

说完CPAP有多重要之后，下一步是问问他们是从哪儿听说这建议的。

And then after you tell them, you know, about the CPAP being important, then the other part of it is to to ask how they heard that advice.

对。

Yes.

或者，你会怎么在最后提第二个问题？

Or how would you've couched the second ask at the end?

是的。

Yeah.

我觉得，说实话，这对每个人都很重要。

I think, I mean, I think this is important for everyone.

所以你问：‘你想听吗？’

So so you ask, do you wanna hear it?

你给出建议，然后说：‘我刚说了这些，你有什么想法？’

You offer the advice, and then you say, so now that I've shared that, what are your thoughts?

你现在心里在想什么？

What's going through your head?

我觉得这么做的原因有两个。

I think there's two reasons to do that.

第一个很常见，就是看看对方接不接受。

One, the the very common reason is just to see how does it land?

看看这些建议对他们有什么影响，或者他们会问什么问题。

How does it impact their motivation or what questions do they have?

但说到这对神经心理学的意义，你知道，你打交道的这些人，可能在信息处理、理解或表达语言方面都有困难。

But I I you know, when I think about the relevance, of this for neuropsychology, I mean, you're explicitly working with people who might have problems with processing information with receptive or expressive sort of language.

所以更需要你时不时确认一下：他们到底听懂了多少？

And so all the more reason that you need to check-in and say, what did they hear?

他们记住了什么？

What are they retaining?

他们从我的建议里得到了什么？

What are they getting out of my advice?

因为我们都知道，就算我们已经尽力说得清楚了，有时候还是不够明白，或者因为其他原因，对方就是没跟上。

Because we know even when we're trying as hard as we can to be clear, sometimes we're we're not very clear, and sometimes for other reasons, people don't quite follow us.

所以你给出建议之后，

So you give the advice.

就要主动问：那你对这个有什么想法？

You're you're checking and say, so what are your thoughts about that?

如果对方不同意，或者觉得没用，我第一反应通常是说声‘谢谢’。

And if the person disagrees or finds it unhelpful, again, my go to response is is something like a thank you.

在动机访谈里，真诚特别重要。

Authenticity is big in MI.

我们既要真诚，也要让患者觉得在我们面前能做真实的自己。

We're trying to be authentic, but we're also trying to form relationships with patients where they feel like they can be authentic and real for us.

咱们真不想浪费别人的时间，看着他们只是敷衍我们，或者光说我们想听的话。

You know, we we really don't wanna waste people's time by feeling like people are just placating us or or telling us what they think we wanna hear.

所以，正如我们之前说的，激发才是动机访谈的核心。

So evoking is really the center of the bull's eye in MI as we've highlighted.

我想再深入一点。

So I'd like to lean in a little bit.

我们从大量实证研究里知道，当患者表达出改变的意愿时，往往预示着之后的行为改变——这可不是魔法，就像你说的，丹，不可能五分钟内让人说几句‘我要多运动’，然后生活就天翻地覆了，但这个关联确实存在。

We know, as we've mentioned from a great deal of empirical literature, that voicing change talk predicts later behavior change, it's not magic, like you said, Dan, it's not like in five minutes, we can get somebody to talk about exercising more and then suddenly their life totally changes, but the relationship is still there.

所以我们可以根据手头的时间和我们跟对方的关系，设定切实可行的目标。

So we can plan based on the nature of the time we have and our relationship with the person and we can set reasonable goals.

作为临床工作者，我们通过开放式提问、回应和总结来引导对方说出改变的想法。

As a clinician, we elicit change talk through evocative questions, reflections and summary statements.

所以开放式问题可以问患者，他们希望怎么改变，对自己能改变有多大的信心，为什么想在生活里做这件新事，以及打算怎么去做。

So open ended questions could be asking patients how they would like to change, how confident they are that they will change, why they want to do this new thing in their life, how they will go about doing it.

我们问的问题，答案应该是能带出改变的对话，通常——虽然也有例外——我们会避开那些容易让人一直找借口的问题，比如：‘你为啥还不多运动？’

We're asking questions, the answer to which is change talk and we are typically, although there are exceptions, we're typically avoiding questions that naturally elicit sustained talk like, why haven't you started exercising more?

而回应时，不管是简单还是复杂的反射式回应，都能进一步引导出更多改变的对话。

And the reflections end, you can use simple or complex reflections to further change talk as well.

打个比方，假设约翰来找我说：‘瑞安，这周末我真想帮你洗车打蜡，但我太累了，就想一整天打游戏，你知道的。’

So hypothetically, imagine that John comes to me and says, Ryan, I'd really love to wash and wax your car this weekend, but I'm tired and I just wanna play video games all day, you know.

在这句话里，我会把前半句当成‘改变对话’，后半句——就是‘但’之后的部分——就是‘维持对话’。

In that statement, I'd identify the change talk as the first part of the sentence, the sustain talk is the second part, everything that came after the word but.

我可以做个简单的回应，比如：‘你这周末要是真帮我洗了车，肯定感觉特别棒。’然后就停在这儿。

So I could do a simple reflection with a statement like, it would feel really good for you to wash my car this weekend and and stop there.

约翰听到这样的回应，很可能会自然地接着说更多想改变的话。

The natural response that John would likely have to that reflection is more change talk.

他可能会说：‘嗯，瑞安，你为我做了这么多，我真的想让你开心一点。'

He might say, well, yeah, you know, Ryan, you do so much for me and I really wanna brighten your day.

这都是我该为你做的，诸如此类。

This is the least I can do for you and so on.

当然，这只是一个例子，我和约翰的关系可不一样，我们绝不会去操控患者，这根本不可能。

Of course, this is just an example, unlike my friendship with John, we aren't manipulating Very unlikely.

我们不会像我总想操控约翰那样，为了自己的私利去操纵病人。

So we're not manipulating our patients the way I like to manipulate John for our own personal goals.

总的来说，关于开放式提问、反映和总结，我们该知道些什么，才能更好地激发改变的对话？

But in general, what should we know about open questions, reflections, and summaries to enhance change talk?

对。

Yeah.

我觉得这很好地总结了这些技巧。

I think that's a good summary of the skills.

我觉得动机访谈的一个关键洞见是，当人们对改变感到矛盾时，他们内心的一部分想改变，另一部分又不想。

I think one of the insights that MI offers is that, right, when people are ambivalent about change, part of them wants to change, part of them doesn't.

当他们谈到想改变的那部分时，我们就称之为改变对话。

When they're talking about the part that wants to change, we call that change talk.

他们在说那个不想改变的部分。

They're talking about the part of them that doesn't wanna change.

我们管这个叫维持对话。

We call that sustain talk.

在动机访谈之前，我们把维持对话当成是否认。

Prior to MI, we thought of sustain talk as being denial.

那是很老的说法了。

That would be the very old concept.

那时候总觉得这个人是在否认，还带点病理化的意味。

And the I the idea is this person's in denial, and that was sort of pathologized.

但在动机访谈里，我们说：不对。

In MI, we say, no.

这根本不是否认。

That's not denial.

这其实就是同一种表达。

That's just the same talk.

这太正常了。

That's perfectly normal.

它本身根本不是什么病态的表现。

It in itself is not pathological.

我觉得有个很有用的认知是：和别人聊天的时候，你会听到多少他们想改变的表述，又会听到多少维持现状的说法，其实很大程度上取决于你说了什么、没说什么——你完全有能力引导对话走向，要么把焦点引向他们想要改变的意愿上，要么就卡在维持现状的死胡同里。

I think one of the helpful insights is that if you're having a conversation with someone, the amount of change talk or sustained talk you're gonna hear has a lot to do with what you say or what you don't say as to help, that you have the ability to influence the conversation and shine the spotlight on the change talk or shine the spotlight on the system.

总的来说，要是你开始反驳、跟对方争论，或是硬讲道理去否定他们不想改变的想法，反而只会让这种抗拒的情绪越来越强烈。

And in general, when you start to argue with or debate or use logic to try to refute sustained talk, you actually just give it more energy, more power.

你只会让它不断强化。

You just you grow it.

反过来也一样：如果你对对方的改变言论抱有好奇，用主动倾听的技巧把它复述出来，带着好奇和耐心去追问更多和改变相关的想法，你就会让这份改变的意愿越来越强。

And that the reverse is true, that when you are curious about the change talk and you either reflect it, you repeat back with, like, what we would just call active listening skills, and you you're curious and thoughtful and you ask more about the change talk, you grow it.

一般来说，人们花越多时间聊起、抒发、分享自己想要改变的想法，他们就会越坚定地去落实这份改变。

And in general, the more time people talk about and express and share their change talk, the more committed they become to that.

还有这么一套理论。

There's this concept.

我们往往相信自己说出口的话。

We tend to believe the things that we hear ourselves say.

当你在说话的时候，你最能说服的人其实是你自己。

That when we're talking, the person we are convincing the most is ourself.

你是在说服自己。

We're persuading ourself.

这就是这里的关键：当我们帮病人说出他们想改变的原因时，其实是在让他们自己说服自己，改变对他们很重要。

And that's the principle that's in play here that when we help patients talk about why they wanna change, they are persuading themselves that change is important to them.

他们是在强化这种信念。

They're strengthening that.

先不谈具体细节，我觉得咱们可以想想，这在日常生活中是怎么体现的。

Without getting into any specifics, I think, you know, we can think about how this plays out in everyday life.

想想政治话题，那些政治讨论。

Think about politics and political conversations.

你上一次和一个跟你政见不同的人聊政治，是谁说服了谁？

When's the last time you had a conversation about politics with someone that you disagreed with and they changed your mind or you changed their mind.

最有可能的情况是，如果你在聚会上跟一个你特别不同意的人聊了十五分钟政治，聊完之后，你反而会比之前更坚信自己原来的观点，而对方也会一样。

The most likely thing is that if you're at a party and you spend fifteen minutes talking with someone about politics, someone you really disagree with, that you will walk away from that conversation even more convinced of the things you believed before the conversation, and that that they'll do the same.

你说了这么多、试图说服对方，其实根本没改变他们，反而让你自己更加坚定了原有的信念。

That all of your talking and persuading didn't move them at all, but it just further entrenched your commitment to the things that you believed before.

类似的情况还有很多，但核心就是这个道理：我们往往更容易相信自己说出口的话。

And there's a lot of other similar examples to that, but that that's that idea that we we tend to persuade we we tend to believe what we hear ourselves say.

我们其实是在说服自己。

We're persuading ourselves.

所以我们才用这些技巧——开放式提问、复述、澄清和总结——尽可能多地引导患者自己说出他们为什么想要改变。

So we use these skills, these open ended questions, these reflections, formations, and summaries to focus as much of the conversation as possible in getting the patient to tell us why they might wanna change.

对。

Right.

很多情况下，我们只是把那些他们潜意识里已经有的想法，帮他们清晰地意识到：原来我之所以想改变，是因为这些原因。

A lot of this is just like bringing what might be subconscious or unconscious to somebody into their conscious awareness of the reasons why they wanna change.

他们可能早就心里嘀咕过，但没真正意识到自己在这么想，我们只是帮他们把这些想法浮出水面。

They might have been kicking it around but kinda not fully aware that they were doing that and we're just bringing it to the surface.

而且，就像你说的，有时候想说服别人改变真的很难，甚至根本不可能，所以我们更想做的，是通过倾听，让他们在自己说话的过程中慢慢想通，自己决定改变。

And, yeah, like you said, it's it's hard or maybe impossible sometimes to talk someone into changing, so what we wanna do is listen them into changing while they're talking themselves into it, basically.

对。

Yeah.

而且要对他们的想法保持好奇。

And be curious about it.

你知道吗，有时候这挺让人害怕的，因为我们总觉得自己必须得说点什么，得告诉他们。

And and I you know, sometimes that's scary because sometimes we we we just feel like, well, this this person has to I I have to tell them.

总觉得得有人站出来，跟他们讲清楚这有多重要。

Someone has to tell them why this is important.

我总是提醒自己，几乎每个人身边都已经有人在跟他们说‘你该改了’。

I always remind myself that almost everyone already has people in their life telling them why they need to change.

比如说，如果你喝酒喝得太多，你身边肯定有人已经跟你说过‘少喝点’了，配偶、父母、法官、社工，都可能说过这话。

I mean, if if you drink too much, there's probably people in your life that have already told you you need to drink less, you know, spouse or a parent or a judge or a social worker have told you you need to drink less.

但这些人往往缺的，是一个能不带评判、只是认真听他们说话的人。

Often, what these people don't have is someone that will just listen in a nonjudgmental way.

而这种倾听的角色，往往在那个人的生活中是缺失的。真正能坐下来不打断、不纠正、不急着给人建议的，其实需要非常专业的技巧。

And that that's a function or a role that is often not being met in that person's life, and it actually does take a a highly skilled professional to sit and listen and not jump in and correct and not jump in and tell someone what to do.

如果光靠跳出来告诉别人该怎么做有用的话，早该有效了。

If if jumping in and telling them what to do was gonna work, it probably already would have worked.

其实生活中，大多数人早就有人在对他们这么说教了。

And most people in their life already have that covered.

说得太到位了。

Very well said.

没错。

Yep.

好的倾听和自我克制，这种能力常常被严重低估。

The skill required in good listening and restraint can be really overlooked.

如果你仔细观察真正高水平的动机式访谈，看起来好像特别简单——这个咨询师好像什么都没做，就只是重复几句话、问几个开放性问题。但其实，要练到这种程度，得花大量时间和精力。这也正好带出下一个话题：OARS，这是动机式访谈里四个核心技巧的缩写，我们之前一直在讲，但还没正式提过。

MI can can appear if you watch it, watch really skilled MI, it might appear super easy, like this person isn't doing this provider, this helper isn't doing anything fancy or magical, know, these reflections and open ended questions like but it really takes time and effort to build those skills, which is a good transition, good this is a good time to mention OARS, the acronym in MI representing the four key skills which we've been talking about but haven't mentioned explicitly.

O代表开放性问题，A代表肯定，R代表反射式倾听，S代表总结。

O for open ended questions, a for affirmations, r for reflective listening and s for summaries.

这些技巧贯穿在四个治疗过程之中。

These skills are woven in throughout the four therapeutic processes.

我们之前已经提到过一些了。

We've already been touching on them.

不过我们还没怎么聊过肯定式表达。

We haven't talked so much about affirmations.

如果你还想多说点，我很好奇，你能不能举个例子，说明在医疗场景里怎么好好用这些OARS技巧？

In case you wanna say anything more there, generally, I'm wondering if you can provide any examples of good use of OARS in healthcare settings.

是的。

Yeah.

开放式提问，通常是想引导对方说出他们想改变的原因。

Well, the open ended questions are often trying to evoke people's reasons for why they might wanna change.

不是说封闭式提问就错或者有害。

It's not that closed ended questions are wrong or harmful.

只是开放式提问更能帮我们发现对方的动机，让他们更愿意谈自己改变的理由。

It's just that open ended questions tend to be better at identifying people's motivations and getting them to talk more about their motivation for change.

说到肯定，我总觉得质量比数量重要得多。

When I think about affirmations, I always think of quality is more important than quantity.

你可能跟一个人聊了十到二十分钟，就只给了一句肯定，但你得确保这句话是真心的，发自内心的。

You might have a a ten or twenty minute conversation with someone and only offer one affirmation, but you wanna make sure that it's genuine and not so that's authentic.

我觉得肯定和表扬、加油打气是两回事。

I think of affirmations as being different than praise or cheerleading.

当然，表扬和加油打气也不是什么坏事。

You know, it's not that praise or cheerleading are harmful or bad.

说实话，咱们每个人生活中都该多一点这种东西。

I I think we'd all could use a little bit more of that in our lives.

但表扬和加油打气听起来像是：‘我真为你骄傲’。

But praise and cheerleading sound like, I'm so proud of you.

我相信你能做到。

I know you can do it.

如果你仔细想想‘我真为你骄傲’这种话，就会发现，这本质上其实是一种评判。

If you really think critically about statements like, I'm so proud of you, you'll notice that that that technically is a form of judgment.

这其实是我在评判你，说我觉得你做得不错。

It's it's me sitting in judgment of you and saying, I think you're doing a good job.

当然，这也不是说有什么害处，但它的力量远不如说：你是个一定要做最好父亲的人。

And that's again, it's not that it's necessarily harmful, but it's not quite as as powerful as saying you're someone who it's really important to be absolutely the best father you can be.

我能清楚地看到，你一直在尽全力成为最好的父亲，活出这样的生活。

And I can see you clearly doing everything you can to be the best father you can be and live your life in that way.

对吧？

Right?

这才是肯定，因为它认可了你的行为和你内心看重的价值是一致的。

That's an affirmation because it's acknowledging the person's behavior is aligned with the values that they identify as being important.

不是我在说‘我认可你的选择’。

It's not me saying I approve of your choices.

而是在说：你是个有价值观、并愿意为之付出的人，这份坚持值得被看见。

It's me saying you are a person who has a value and commits yourself to that value, and that that should be recognized.

这往往才是最有力的肯定。

That's often the the best form of affirmation.

我们最常讨论的，其实就是这种反射式回应。

A reflection is what we've been talking about the most.

你可以把它简单理解为积极倾听。

You know, you can think of it just as active listening.

就是把对方说的话，再复述一遍。

You can think of as repeating back what you hear the person say.

当你慢慢掌握动机访谈技巧后，就会发现，病人说话时，其实有很多地方都能回应，但你不能啥都回。

As you begin to develop MI skills, you notice that when a patient is talking, there's many, many different things that you could reflect, and you don't wanna reflect everything.

你不是法庭速记员，没必要把每一句话都原样重复。

You're not a court stenographer that repeats back everything they say.

你得自己判断，哪些话值得回应，哪些可以跳过。

You you're you're making choices about what do I reflect and what don't I reflect.

这时候，你最有机会引导对话方向——只要选择性地回应那些关于改变的表述。

And here's where you have the greatest opportunity to guide or nudge the conversation by choosing to reflect the change talk that you hear.

只要听到对方提到为什么想做出更健康的选择或改变，就用反射的方式把它反馈回去。

Using to reflect back whenever you hear an example of why this person might wanna make a healthier choice or change.

那总结呢，其实就是把好几个反馈或者肯定整合到一起，一次性把你理解的内容转述给对方。

And then a summary is simply just putting multiple reflections or affirmations together and giving them all back to the person at once.

这个方法用来推进对话特别好用，尤其是临床医生如果担心时间不够，要换话题之前，你可以先把听到的所有内容整理成一段大概三四句话的内容反馈给对方，这能非常清楚地传递出你真的听懂了。

It's a really good way to transition a conversation, especially if you're worried about time as the clinician before you try to change the subject, sometimes if you can just reflect back sort of everything you've heard in one paragraph of, you know, maybe three or four sentences, that really communicates an understanding.

之后你还可以在总结的末尾加个问句，类似说‘好了，那’。

And then often you can end that summary with a question and sort of say, okay.

咱们接下来聊聊别的吧。

Now let's let's move on to the next subject.

以上就是我对OARS这几项技巧的理解。

So that's how I think about those OARS skills.

其实OARS并不是动机访谈（MI）独有的。

I think OARS are not completely unique to MI.

很多人际沟通的场景里都会用到这些技巧。

Like, lots of ways of communicating with people involve these OARS skills.

但OARS在动机访谈里的独特之处，在于你会重点聚焦于对方的改变意愿，用这些技巧去引导对方说出想要改变的原因，同时对这些原因保持好奇。

What makes it unique to MI is when you're differentially focused on the change talk, when you're using these skills to give reference to and and curiosity about why this person might change.

我很喜欢把总结比作一束花。

The summary statements, I love the analogy of the bouquet.

你一边聊天一边收集这些‘花’，最后把所有花凑成一束送给他。

You're collecting flowers as you go along and then giving them the bouquet, which is all of the flowers together at the end.

所以这些‘花’就是你在对话中听到的所有改变的言语吗？

And the the flowers are the change talk that you've heard throughout the conversation?

是的。

Yep.

完全没错。

Absolutely.

说到肯定，我听过史蒂夫·罗林克说，要试着用‘优点眼镜’去看客户，而不是总盯着他们的缺点。

And also regarding affirmations, I've heard Steve Rollnick describe this as trying to look up to our clients or putting on strengths glasses rather than deficits glasses.

你真正想看到的是这个人的独特之处和重要价值，就像你刚才说的，他们和自身价值观的连接。

Know, you're really trying to see the unique and important aspects of this person, how they connect to their values like you said.

我看过一些研究，说肯定有时候在激发改变对话上甚至比其他方法更有效，因为它能点燃行为改变，凸显价值观，增强自我效能感，还能改善治疗关系。

And I've seen research that suggests that affirmations might even be more powerful in change talk sometimes and because it sparks behavior change, it highlights values, it bolsters their self efficacy, improves the therapeutic relationship.

一个真诚有效的肯定，其实包含很多层面。

There are so many aspects to a to a good authentic affirmation.

就像你说的，不是那种随口一说的‘干得漂亮’，而是真正发自内心地说：‘你真的很在乎你和妻子的关系。’

Like you said, not just a quick, oh, like, great job cheerleading, but a really authentic you know, you're somebody who really cares about your relationship with your wife.

这样的话，特别能打动人。

That can land so well.

是的。

Yeah.

对接受肯定的人来说，这种肯定力量特别大。

The the affirmations are very powerful for the individual receiving them.

很多时候，患者在听到肯定之后，接下来会说出非常有力的话，表达他们想做得更好、想改变的动机。

Often, the next thing a patient will say after receiving an affirmation is a really strong statement about why they wanna do even better or change.

他们会说：‘谢谢，你说得对。’

They'll say, well, yeah, thank you.

我知道自己已经在尽力了，但我还得做得更好。

I I know I am trying to do the best I can, but I need to do even better.

这对我来说甚至更重要。

It's even important to me.

真的特别有力量。

It it it's really energizing.

我还觉得，当给予肯定时，它其实也会改变医生自己。

I also have this sense that affirmations, when they're given, they change the clinician.

我觉得这是一种对抗确认偏见的方式。

I think they're a way of compensating for confirmation bias.

你可以试着想想，有没有哪个同事或者病人让你特别烦、特别不爽，甚至根本不想跟他打交道？这时候，强迫自己去想，或者干脆说出来，夸他一句真正认可他优点的话。

So one way to think about this is think about a colleague or a patient that you have that's really, really frustrating or irritating or upsetting to you, someone that frankly maybe you don't really like or get along with, and force yourself to think of or even say out loud an affirmation about that person that recognizes their strength.

你一旦这么说，就会开始注意到他身上那些更值得敬佩、更可取的优点。

When you say that, you will begin to then notice things about them that are more admirable or desirable or strengths.

我觉得，当面对特别难搞的人时，这种做法能有效抵消那种负面的确认偏见。

And I I think it it has a way of compensating for for negative confirmation bias when there's someone that that's really difficult for us.

MI从业者常用的一个工具是重要性量表或者信心量表，我特别喜欢这个方法。

A common tool that MI practitioners sometimes use is an importance ruler or a confidence ruler, and I do like this a lot.

这招特别管用。

It can be very effective.

比如，从0到10打分，0代表完全不重要，10代表是你这辈子最重要的事，你觉得锻炼或者你打算做的那个改变有多重要？

For example, on a scale from zero to 10, where zero is not important at all, 10 is the most important thing in your life, how important would you say that exercise is or x, you know, insert or whatever change.

假设对方说是个3分，也就是10分里只给了3分。

And then imagine they answer three, it's an importance of a three out of 10.

你可以说：挺有意思的。

And you say, that's interesting.

你为啥给3分，而不是2分或者1分呢？

Like why why'd you say three and not a two or a one?

就是为了多引导他说出想改变的想法。

To, again, try to bolster this change talk.

信心这块儿也可以用同样的方法。

And you could do the same thing with confidence.

我们一般不建议反过来问。

We generally want to avoid asking the opposite question.

为什么不是五分或者六分呢？

Why why wasn't it a five or a six?

要是你这么问，就只会引导出对方坚持不改的说法了。

Because then you're gonna elicit sustained talk if you do that.

不过我还挺好奇，关于这个量表工具，你还有没有别的要补充的？你一般会建议怎么用这些方法？

But just curious if you have anything else to say about the ruler as a tool and how you would recommend using these.

对的。

Yeah.

我觉得那套评分标尺确实能帮你高效又快速地引导对方说出愿意改变的话。

I mean, I think the rulers can help you efficiently and quickly get to change talk.

比如你问某个人，你对完成这个改变的意愿有多强？

You know, if if you were to ask someone how important is is it to you to make this change?

要是对方给你打了6分，你接下来就可以接着问，

And let's say they give you a six, and then your follow-up question is, okay.

那要怎么做才能把分从6提到8，甚至提到9呢？

What what would it take to raise from a a six to an eight or a six to a nine?

接下来这个人肯定会说到改变的动机，或者至少非常接近了。

The next thing that person is gonna say is gonna be change talk or very close to change talk.

他们会说：‘如果我能确定吃这个药真的能降低我中风的风险，那对我而言就更重要了’，诸如此类的理由。

They're gonna say, well, it would be more important to me if, blank, if I if I really knew that, you know, taking this medicine would reduce my chances of getting a stroke or, you know, whatever it might be.

所以，这其实是个捷径，能帮你快速弄清楚为什么这个人觉得改变值得去做。

So there there's sort of a shortcut for finding out why might a person think that this change is is worth making.

我觉得大多数人会觉得用重要性量表比用信心量表更容易上手。

I think people often find it easier to do the importance ruler than the confidence.

关键是要注意到‘重要性’和‘信心’之间的区别。

It's just helpful to notice the difference between importance and confidence.

对吧？

Right?

你可以想象一个烟民，觉得戒烟对他来说重要性是满分10分，但信心却只有1分。

You can imagine a cigarette smoker who thinks it's 10 out of 10 important for me to quit, but it's one out of 10.

我真有把握能戒掉吗？

Am I confident that I can quit?

想想看，这有多有用。

Just think about how helpful that is.

这个人根本不需要别人告诉他吸烟有多害处。

That that's a person who doesn't need any education about the harms of cigarette smoking.

他自己都说重要性是十分满格了，他真正需要的，是帮他提升信心，把那个倒过来。

They already told you it's 10 out of 10 important, and what they need is help figuring out how to increase their confidence and reverse that.

想象一个重度饮酒的人，他说戒酒对他的重要性只有一分，但要是真逼他，他有十分的信心能戒掉。

So imagine someone who's a heavy drinker who says it's one out of 10 important for me to quit drinking, but I'm 10 out of 10 confident that if I had to, I could do it.

也许他的信心有点盲目，但光是这句话，已经说明了很多问题。

Now maybe their confidence is misplaced, but still it's told you a lot.

这说明他缺的是为什么改变行为很重要，这些理由，才是我该重点下功夫的地方。

It's told you that what this person needs is reasons why modifying their behavior is important, and that's where I should put my energy.

最后一个步骤是规划。

The last process is planning.

这时候我们要建立改变的承诺，制定行动计划，具体想想怎么把之前说的改变落到实处。

So here we're developing commitment to change, creating an action plan, we're considering how to actually make the change as we've referenced.

就像动机访谈的其他部分一样，医生不该自己替病人制定计划然后告诉他们怎么做，而是要一起合作制定计划。

Just like anything with MI, the clinician shouldn't be creating the plan for the patient and then telling them how to do it, we co create plans together.

正如你提到的，丹，每个人在改变的准备程度上差异真的很大。

Also important is that as you've mentioned, Dan, people vary greatly on where they're at in terms of readiness to change.

有时候，我们得花很多时间做前期工作，才谈得上制定计划；但对有些人来说，他们一来就已经下定决心要改，这时候他们需要的是帮他们完善并落实计划的支持。

Sometimes there could be a lot of work together before even considering the planning phase, but for other people, they might come in having already decided to make the change and they're in need of support in developing and implementing the plan.

所以我们得灵活一点，真正站在他们的角度去配合。

So we need to be flexible and really meet them where they're at.

你提到用那两个量表——重要性和信心——其实已经部分点到了这一点。

Your comments about using the two rulers, importance and confidence, partially gets at this.

关于怎么更好地做计划，你还有别的建议吗？

Any other tips for how we should do planning well?

是的。

Yeah.

我的意思是，到了制定计划这一步，还是得搞清楚每个人具体打算怎么改，别太死板地强加方案。

I mean, I I think when you're in the planning phase, it's still important to figure out in the individual exactly how they might make the change and not to be overly prescriptive.

你知道，那个问题——我该怎么改？

You know, the question, how should I change?

这个问题还是得由他们自己来回答，而不是医生替他们决定。

They should still be the person answering that question instead of the clinician.

这时候你当然可以提出自己的想法。

It is a place where you can offer your ideas.

但你还是得先征得他们的同意。

You'd still wanna ask permission.

比如说：好吧。

Say, alright.

我帮过很多和你情况类似的人。

I I've helped a lot of people in your situation.

我可以跟你分享一下，我了解到哪些方法比较有效吗？

Could I tell you what I've learned about what works?

你可以给出改变的建议，但一定要先问对方愿不愿意听。

You you can give your advice on how to change, but but ask permission.

我觉得我还是得回到之前说的，得搞清楚目标行为是什么，而且要现实一点。

I think I would go back to what I said earlier about being clear about what is the target behavior and being realistic.

如果你在谈减重这件事，你真能指望在五分钟内教会人家怎么改饮食吗？

If you're talking about something like weight loss, are you really gonna try to try to tell them how to do the diet modification in five minutes?

还是说，‘怎么改变’其实应该是：我怎么帮你对接到真正能深入解决这个问题的人？

Or is the how to change gonna be, how am I gonna connect you with the people who are really gonna go in-depth on this issue?

我觉得很多时候，我们更该想的是后者——帮他们跟这类资源搭上线。

I think a lot of times we should be thinking about the latter with, you know, helping them connect to something like that.

这一点对神经心理学家来说特别贴切。

That's super relevant for neuropsychologists, by the way.

我们在做反馈和建议的时候，经常就是帮患者衔接下一阶段的治疗。

You know, in our feedback sessions and recommendations, we are often connecting people with the next stage of treatment of some kind.

所以这个建议我很认同。

So, yeah, I appreciate that suggestion.

关于这点，还有别的想说的吗？

Anything else to say about that?

没有。

No.

我也不行。

I no.

我觉得规划方面就这些了。

I think that's all for planning.

对。

Yeah.

动机性访谈在全球各地、各种文化和环境中都被广泛应用。

So MI is used all over the world in many different settings across nations and cultures.

当然，当我们讨论改变话题时，文化因素是非常重要的。

Of course, there are many important cultural considerations when we think about conversations about change in general?

我想听听你聊聊，总的来说，动机性访谈在不同背景人群中的应用效果如何？我们该注意哪些方面，才能更好地根据患者和他们的家人调整方法？

I'm curious to hear you talk through, you know, how well broadly speaking has MI fared in people from varying backgrounds and what should we know about how to adapt it for our patients and their families?

是的。

Yeah.

动机访谈最有趣的地方之一，就是它在全球范围内的广泛应用，世界各地都有动机访谈的培训师。

It's one of the more interesting parts of MI is is how much it is spread around the world, and there are MI trainers all over the world.

我觉得，无论来自什么样的背景，动机访谈对大家都特别有共鸣。

I think the sense is that it it's highly relevant to people from very different backgrounds.

尤其是当你跟边缘化群体打交道时，这种方法可能特别有效。

There is a sense that in particular, when you're working with people who are members of marginalized communities, it might be particularly effective.

特别是它强调自主权，让对方掌握对话的主导权，也掌握自己想做出改变的主动权。

Particularly, the the part that focuses on emphasizing autonomy and giving that person power and choice and control over both the conversation that you're having, but also the changes that they might attempt to make.

有时候，这需要时间，尤其是当对方过去在医疗或心理治疗环境中经历过歧视或伤害的时候。

I'll say that sometimes that takes time, particularly if the person has experienced discrimination or harmful behavior in medical settings or in mental health settings in the past.

你带着一身动机访谈的本事进来，心想：‘我一定要尊重这个人我得尊重。’

You might come in with your best MI skills thinking I'm gonna respect this person.

我得尊重他的自主性。

I'm gonna respect their autonomy.

但他可能一进来就想着：‘唉，又要被伤害了’，毕竟以前吃过亏。

But they might come in expecting to be harmed again, having been harmed in the past.

要让他们相信你真的想听他们的真心话，觉得和你意见不同也没关系，这可能需要一点时间。

And it might it can take time to convince them that you really wanna hear their true opinion and that it's really safe for them to disagree with you.

但一旦做到了，你会发现这种方法真的非常有效。

But once you do that, I think that the evidence is that this works really well.

有时候，因为性格或者文化原因，确实会有患者希望你直接告诉他们该怎么做。

Now sometimes, either for personality reasons or cultural reasons, you do need a patient who really wants you to just tell them what to do.

你就直接告诉我怎么做，我照做就行。

Just tell me what to do, and I'll do it.

这完全没问题。

That's perfectly fine.

如果他们真的想听你的建议，你完全可以给。

If they really wanna hear it, you can go ahead and do it.

这是他们主动要求的。

They've given you permission.

他们就是冲着这个来的。

That's what they're asking for.

这完全没问题。

So there's nothing wrong with that.

但我们的默认做法应该是先征得对方同意再提建议，试着帮他们说出自己的动机。

But our our default position should be sort of asking permission to give advice and trying to get them to name their motivations.

我觉得在动机式访谈里泛化文化群体有点冒险，因为群体内部的差异往往比群体之间的差异更大。

You know, I I think it's a little risky to generalize about cultural groups in MI because there there's always more variation within than between.

不过说实话，我以前跟德国的动机式访谈培训师合作过，他们说美国式的肯定方式简直太夸张了。

But, yeah, you know, I I've worked with MI trainers in Germany, for example, and they'll tell you that American affirmations are completely over the top.

我们太温柔、太情绪化了。

We're so soft and so touchy feely.

如果你对德国人说这种美国式的肯定，他们会觉得怪怪的，觉得你太肉麻、太软绵绵了。

And if you said an American affirmation to a German, they would think it was weird because you were just overly, you know, overly flowery or or soft or gentle.

我跟日本、韩国那边的人聊过，东亚地区有时候确实有特别的挑战，比如很难挑战权威，很多时候更重要的是表现出对权威的尊重和顺从。

You know, I think having talked to people from Japan or Korea, East Asia, you know, there are there are particular challenges sometimes, ultimately, with arguing with authority, or it's even more important often to show respect and deference for authority.

所以，要是你敢跟医生唱反调，他们根本接受不了。

And so the idea that you would disagree with a doctor, it it's hard to accept.

在这些情况下，你可能得额外花点心思，让对方真正感受到——你随时欢迎他们说出心里话。

And and and maybe in those spaces, you might have to put in extra effort to really show the person that it's okay to tell me what you really think.

你不用非得同意我的观点。

You don't have to agree with me.

所以，这些都是一些大致的想法，但别忘了，群体内部的差异往往比群体之间的差异更大。

So, you know, those are some general ideas always with the asterisks that there's more variation within than between.

如果你是为了继续教育学分在听这个，第二个关键词是‘仪式感’。

If you're listening to this for CE credits, the second code word is ceremony.

仪式感。

Ceremony.

有些人可能会把动机式访谈和迪克莱门特与普罗查斯卡的跨理论行为改变模型搞混，比如那个包含‘无准备、犹豫、准备、行动、维持’这几个阶段的模型。

Some people might confuse MI with the transtheoretical model of behavior change by DiClemente and Prochaska, including stages of change like pre contemplation, contemplation, preparation, action, maintenance.

我们当然也可以在动机式访谈里用这些概念，但你能简单说说这两者到底有什么区别吗？

And we can use this in MI, but can you just us a little bit about the distinction between those two?

对。

Yeah.

我最近有幸在明尼阿波利斯举办的动机访谈大会上听了比尔·米勒讲这个话题。

I so I just had the privilege of seeing Bill Miller talk about this at the Motivational Interviewing Conference in Minneapolis.

他说，本的理论模型是在八十年代和动机访谈同时发展起来的。

And what he says is that Ben's theoretical model was emerging in the nineteen eighties at the same time that MI was emerging.

这两者是不一样的。

They are distinct.

它们的目标不同，但其实非常兼容。

They have different purposes, but they're also quite compatible.

我觉得这样理解会很有帮助。

And I think it can be helpful.

简单来说，你可以这样想：动机访谈是一种沟通技巧，帮助人们化解对改变的矛盾心理。

The very, very short version would be to think about, oh, MI is a a communication skill for helping people resolve their ambivalence about change.

尤其是在改变的前期和思考阶段，可能还有准备阶段，人们最容易有矛盾心理，这时候动机访谈最管用。

And particularly in the pre contemplation and contemplation, maybe the preparation stages of change, that's when you would expect to encounter the greatest ambivalence, and that's when MI would be most relevant.

但当一个人真的准备好要改变，进入行动或维持阶段时，就不怎么需要动机访谈了，因为动机访谈的核心是解决对改变的矛盾，而不是推动已经下定决心的人。

But when someone is truly ready to change and making change in the action or maintenance phase, it's probably not when you need MI because MI is about resolving ambivalence, about change.

所以具体来说，如果有人走进医生办公室，说：我想戒烟。

So, you know, to be concrete about it, if someone walks into a doctor's office and says, I want to quit smoking.

我今天就开始戒。

I'm quitting smoking today.

麻烦现在给我贴个尼古丁贴片。

Please give me a nicotine patch today.

这种人根本不需要动机式访谈。

That person doesn't need MI.

他已经进入行动阶段了。

They are in the action phase.

有研究表明，在这种情况下用动机式访谈反而可能适得其反——一个人明明已经下定决心要改变，你再去跟他探讨犹豫不决，不仅浪费时间，还可能把他的动力给搞没了。

And there's some evidence that using MI in those settings might actually be counterproductive, that starting to explore ambivalence in someone who is already fully committed to making a change, it's not a great use of time, and you run the risk of actually undoing some of their motivation.

我想到的唯一例外是，如果帮他做点计划会有帮助的话。

The only exception I could think of is if some planning would help for that person.

比如他知道自己要戒，但具体怎么戒、什么时候开始、细节怎么安排，这些卡点可能正是他需要突破的。

Like, they know they want to do it, but some some extent of talking through the how, when, the specifics, maybe that's the barrier to them.

是的

Yeah.

我觉得这话说得特别好。

I think that's that's a great point.

对。

Yeah.

就拿我刚才举的例子来说，你完全可以这么说：‘听到你这么有决心，真替你高兴。’

Even in the example that I just gave, you could say, so happy to hear you're so committed.

咱们可以一起想想，像你这样想戒烟的人，我有一些办法可以帮到你。

Let's think about I I have ideas about how to help people quit smoking like you.

我能想到四五个不同的方法。

I can think of four or five different strategies.

你想听听我的建议，还是想先说说你自己的想法？

Do you wanna hear my thoughts, or do you wanna tell me what you think?

好。

Yep.

有些障碍是患者自己没意识到的，但医生知道这些很常见，咱们得和患者一起把这些障碍捋一捋。

There could be barriers that the person doesn't foresee, but that the clinician knows are very common, and you you want to talk through those barriers with the person.

对。

Yep.

咱们接下来几问，稍微贴近一下神经心理学吧。

Let's maybe bring this a little closer to neuropsychology for the next couple of questions.

我想聊聊一些常遇到的情况，比如怎么用动机式访谈帮有认知障碍的患者？

I want to think through some considerations that come up frequently, such as how do we recommend using MI with patients who have cognitive impairments?

比如记忆力严重下降、执行功能差、语言有困难的人。

People with significant memory loss, poor executive functioning, language problems.

那我们该怎么调整动机式访谈的方法，来适应这些人呢？

How do we tailor what we do in MI for those people?

是的。

Yeah.

这确实挺有挑战的。

This is tough.

我经常被人问到，有没有哪种人是动机访谈完全不适用的？

You know, I will often get the question of, is there anyone for whom MI doesn't work?

总的来说，就像任何疗法一样，你得有基本的表达和理解能力，还得有记忆力，才能把对话里的内容转化成实际行为改变。

And in general, you like any therapy, you need a baseline level expressive and receptive language skills and memory in order to translate what's happening into behavior change.

还有啊，冲动控制、执行功能这些也挺关键的。

And, yeah, I suppose impulse control and executive functioning and and so on.

要说一条明确的规则来排除谁，我真说不上来，但我觉得关键是要敏感一点，留意这些情况。我觉得作为神经心理学家，你有个别人没有的优势——你能用客观数据看出他们强在哪、弱在哪。

I mean, it's very hard for me to rattle off a single rule or a single guide for what would exclude, but I think it's it's important just to be sensitive to that and to take you know, I I imagine as a neuropsychologist, like, you have the advantage that a lot of clinicians don't as you have some objective measurement of what their strengths and weaknesses are.

我想到的一个办法是，把谈话内容写成摘要，把他们自己说过的改变动机再反馈给他们。

You know, I'm thinking about giving them summaries of the discussion in writing that emphasize their own change talk back to them.

比如在反馈时说：‘我们刚才聊了这些，那些点你都提到了。’

So we discussed this and this in the feedback session.

你还自己列出了三个你特别想这么做的重要理由。

You identified these as the three reasons why it was important to you to do this.

说实话，这种做法对谁都管用，哪怕认知完全正常的人也受益，但对记忆力差的人，那简直太重要了。

I frankly, that would help everybody even with fully intact, you know, a fully intact functioning, but especially important probably to do it with people with memory deficits.

我觉得我们总是可以做得更好，把病人的家人、照护者，还有其他相关的人更多地纳入进来。

I think we always need to do a better job of including family members, caregivers, relevant other people in the lives of the people we're caring for.

要说我对医疗模式最大的批评，那就是我们太把人当个体来看了，没怎么把家人纳入治疗过程。

If I had I think one of my major criticisms of the the medical model is we we treat people too much as individuals and don't do a good enough job of including family members.

所以我觉得，让照护者和家人一起参与对话特别重要，他们能帮病人记住自己之前说过的话。

And and so I think, having these conversations with caregivers, family members present makes a lot of sense in them to take on a role of reminding the individual of the things that they said.

那些话，说不定真能帮上忙。

The things that they said might be helpful.

是的。

Yeah.

我想这些就是我目前能想到的几点。

I think those are some of the things that come to mind.

我确实一直在临床工作中接触阿尔茨海默病和其他类型的痴呆患者。

I I do think there is a, you know, I I work clinically with people with dementia, with an Alzheimer's dementia.

有时候你跟他们聊得特别有成效，但下次再见，又好像一切从头开始。

And there becomes a point at which you can have these conversations and you feel like it was really productive, but you're you're back at square one next time you meet them.

在这种情况下，动机访谈中的共情部分依然是充满关怀的。

In that setting, the empathy part of MI is still compassionate.

没错。

It's.

很温和的。

It's kind.

他们还是会回应共情，但如果你没法让他们记住对话内容，光有共情也换不来行为改变。

They're still going to respond to empathy, but they're not you're not gonna be able to translate that into behavior change if if they're not retaining the content of the conversation.

所以在这种情况下，你可以把动机访谈理解成罗杰斯疗法加上对‘改变对话’的特别关注。

And so in those cases, you know, think of MI as Rogerian therapy plus this focus on change talk.

遇到记不住信息的人，我就只能退回到单纯地用温和、有同理心的方式沟通，不再指望这能带来行为上的改变。

When I get into someone who can't retain information, now I'm just I'm just falling back on just sort of kind, compassionate communication skills without the expectation that's gonna it's gonna lead to behavior change.

但我认为，我们其实有很多方式可以调整对他们的做法。

But I think there's so many ways that we can modify what we do for people.

就像你说的，我们通常已经做过评估，很清楚他们记忆、执行功能、语言能力等方面的具体情况。

And like you said, we probably will have just tested them and know exactly where they are at in terms of their memory, their executive functioning, language, etcetera.

我们可以发挥他们的优势，同时帮他们弥补那些明显比较吃力的方面。

And we can play to their strengths and we can try to prop up the areas that we know might be more difficult for them.

如果他们处理信息慢，我们就把节奏放得更慢一点。

If processing speed is an issue, we're gonna slow down a lot.

如果记性不好，我们就反复讲，再给他们书面总结。

If memory is an issue, we're gonna repeat things, give them the written summaries.

我们可以多用视觉辅助，比如用图片来解释我们的比喻。

We can make things more visual, use more pictures to describe our analogies.

要是他们对‘价值观’这种概念理解起来有点抽象、抓不住，我们可以用价值观卡片排序法，拿一叠卡片，上面写不同的价值观，让他们挑出最看重的几项——这样就能具体引导他们聊聊自己的价值观了。

If they're having trouble thinking about the concept of values and it's not too concrete a little abstract, we can use the values card sort and have a card deck with different values and ask them to choose, you know, which ones of these would you prioritize, and then there's a concrete example of how we can help them to talk more about their values.

所以我觉得，我们能调整的地方其实特别多。

So, I think there are lots of ways that we can modify it.

而且总的来说，神经心理学家都很擅长根据患者的需求调整方法。

And neuropsychologists, by and large, I think are good at adapting to the needs of our patients.

对。

Right.

对于那些因阿尔茨海默病或痴呆导致严重记忆障碍的患者，我们不会指望他们能深入讨论改变的问题。这时候，他们通常有配偶或家人陪同——就像你之前提到的，丹，那种情况是不一样的。但我特别认同你的观点：我们要充分考虑患者的认知强项和弱项，在反馈时尽力帮他们用优势弥补短板。

And we're not going to be expecting a conversation about change in somebody who has densely amnestic profile due to Alzheimer's disease, dementia, know, at that stage, hopefully they have a spouse or family member with them and that's sort of a different setting that you referenced, Dan, but we I like the idea of considering our patient strengths and weaknesses cognitively and doing what we can to help them compensate for the areas where they're struggling in our feedback session.

我也很喜欢你提到的，让亲近的家人一起参与关于改变的对话。

I also like that you referenced these conversations about change with a close family member present.

这种情形我遇到过好几次了。

I've had that happen a number of times.

我想到一个例子，发生过不止一次：配偶特别希望患者能按照我的建议改掉某些行为，但他们根本没接受过动机式访谈的训练，这一点一眼就能看出来。他们总是忍不住想‘纠正’患者，这其实很自然，天天都在发生。

The example that comes to mind, it's happened more than once, is a spouse who very much wants the patient to make the behavior change that I have in my recommendations list, but of course has not been trained in MI and that's very obvious and salient to me and they're doing a lot of the fixing reflex, which is natural and happens, you know, all the time.

我试过一些办法，效果还不错：就在配偶或家人面前，示范一个基于动机式访谈的对话方式——不是指着他们说‘你该这么做’，也不是让他们觉得被批评，而是让他们亲眼看到：换一种方式跟患者谈改变，效果真的会好很多，远比那种老是想‘纠正’的做法强。

I've found some success in modeling an MI informed conversation with the patient in front of the spouse or, you know, other family member in a way that I hope without, you know, rubbing their nose in it or telling the spouse what to do either, but showing them, you know, this alternative way of talking to their spouse, the patient about change that can be much more successful than the fixing reflexes so many people do.

是的。

Yeah.

这招挺聪明的。

I think that's smart.

我觉得在这种情况下，你的动机式访谈重点，有时候反而该放在帮助照顾者自己身上：提升他们的动力，给他们支持和指导，帮他们缓解压力，学会更好的沟通技巧。

I think then in in that situation, the focus of your MI might sometimes be trying to build the motivation of the caregiver to get their own support or coaching and managing caregiver stress and thinking through the communication skills.

所以，是这样的，你能帮他们明白吗？以前跟配偶这样沟通也许有点用，但现在进入新阶段了。

So, yeah, can you help them see that, alright, may maybe this approach of talking to your spouse was somewhat helpful in the past, but you're moving into a new phase.

也许换种方式会更有效。

Maybe a different approach would be helpful.

你觉得找一些专门学过如何跟类似你配偶这种情况的人打交道的专家来帮忙或指导，怎么样？

What are your thoughts about getting support or coaching from people who learned how to do this with one that has your spouse's condition?

对。

Yep.

我还想分享另一个例子，就是那些说话特别绕的患者。

One more example that I wanna share that comes to mind in these situations are patients who are highly tangential.

他们可能没有严重的记忆或执行功能障碍，但就是很难把话说得有条理，老爱绕弯子，讲一堆离题的长篇大论——这事儿在神经心理学之外也挺常见的。

They might not be cognitively impaired per se in terms of totally amnestic or just executive, but have a lot of trouble being linear and there's a lot of circumlocutions, long winded off topic stories, this can happen, you know, outside of neuropsychology for sure.

我想知道，你对跟这种特别绕的患者做动机访谈，有什么特别的技巧或心得吗？

I'm curious you have any tips or pearls of wisdom about MI in a situation with a patient who's highly tangential.

对。

Yeah.

其实有几种方式，可以在不违背动机访谈原则的情况下打断对方。

There are ways to interrupt people that are MI consistent.

如果你还不太会打断别人，或者觉得这很难，那真值得好好练一练。

If you haven't learned to interrupt someone or it's hard for you to learn, it's worth getting better at it.

我挺喜欢这种说法，比如先说一句：‘等一下。’

I kinda like the idea of something along the lines of, hold on.

等一下。

Hold on.

我得打断你一下。

I need to interrupt you.

你刚才说的很重要。

What you're saying is important.

我想确保我完全听懂了。

Wanna make sure I understand it.

开头先说明，你打断不是为了打断，而是为了搞清楚对方想表达的关键点。

Beginning your interruption that the message that that a function of your interruption is to understand the important thing that they're trying.

可能并不是最重要的，但我想让你知道，我并不是想不尊重你。

Now it may not always actually be the most very important, but you're you're communicating that I I'm not trying to be disrespectful.

我打断你，是因为我真的想搞清楚你在说什么。

My my interruption comes from a place of wanting to make sure I understand.

你说话时想法特别多，不如直接问一句：我可以打断你吗？

Being explicit and asking permission say, you're someone that has a lot of different ideas in our conversation.

我可以打断你一下吗？

Is it okay if I interrupt you?

那些总爱跑题的人，其实自己也知道老跑题。

Most people that go off on a lot of tangents know that they go a lot on the tangents.

他们平时肯定经常被别人打断。

And I I think they get interrupted a lot in their lives.

我们不如直接问一声，给对话加点结构，也没啥不好。

And I I think we can just ask permission to to do that and to provide some structure.

说到这个，我记得我们之前聊过，MI 的一个重点就是专注。

I think this is you know, when we talked about that the task of MI, one of them was focusing.

我们去拜访时，能带去的一点就是专注。

And that's one of the things that we can bring to the visit is focus.

要高效地跟那些爱跑题的人交流，就得学会适时打断，还要能坦然地打断。

And in order to do that in a time efficient way with someone that's that's very tangential, learning to interrupt and being comfortable interrupting difference.

有道理。

Makes sense.

没错。

Yep.

这些问题可都不是随便问问的，我们抛出的几个问题，几乎都没法轻易回答，尤其是关于认知障碍的那个。

These are not softballs that we are throwing you some of these questions, and we're they're almost impossible to answer the question about cognitive impairment.

谢谢你愿意配合我们。

So I appreciate you humoring us.

这些建议都很棒。

These are good tips.

我想知道，你有没有更多想说的？比如MI和其他方法结合的效果，像我们把它和CBT、ACT融合，特别是对神经心理学家做认知康复时，特别有用。

I wonder if there's anything more you'd like to say about how well MI works with other approaches, like we infuse it with CBT or ACT or especially relevant for neuropsychologists cognitive rehabilitation.