For many years colleagues have been asking the question: why just focus on behaviour change? Why not focus MI on change more broadly, with a change in behaviour merely being a consequence of a constructive conversation that might start more broadly with change. Bill Miller and I have taken enthusiastically to this widening of the MI tent, and I have been feeling inspired and very challenged by what feels like a radical step. What aspects of MI could or should be adjusted in the light of this suggestion? Bill and I are currently re-writing the basic text on MI.
If you start more broadly, how do you proceed in a manner that is MI-consistent? Let's take a concrete example, a fairly common struggle met by clinicians in primary care, mental health or even addiction treatment settings. I met variations of this dilemma in countless clients over the years. A parent feeling overwhelmed and in trouble with panic, alcohol and child management. Its just a short step up from the routine stress faced by many parents. Very normal, and its become very distressing.
She had a crisis
She has these two very active young boys (aged 5 & 7), one of whom tends to “run wild” unpredictably. Her husband leaves for work early, and she’s found it very difficult to get them to school. She gets anxious when out of the house. Recently she had found that a glass of wine gave her the courage to go out, and then it happened: she had a couple of glasses, stepped out of the house, and had to shout a lot at the boys to prevent an accident on the way to school. When she got to the gates she found it difficult to breathe, and the School Head referred her for help in managing the children in the mornings. Her husband has been telling her to just "pull your socks up", i.e. stop being nervous and get on with the job.....
If you use MI with a case like this, where and how do you start? The presenting problem in the referral letter was about managing the children, an understandable focus for a school head. But what would you want to discuss? What direction would you go in? Your client?
MI focuses on strengths not just problems, so why argue with oneself about which problem to focus on (alcohol, panic, child behaviour, even the marriage)? Perhaps the starting point could be "feeling more in control of my life".
Bill Miller and I settled on the concept of 'focusing' to describe this process of finding direction. if I asked ten clinicians exactly how they imagined proceeding in a case like this, how much consensus would there be? It worries me that an almighty discussion would break out!
See what you think. I might return with some very tentative guidelines, if anyone is interested.....
Steve
A a start, I think acknowledging to the client her life seems challenging, that she is struggling, and why she was referred. Then asking her what she would like to talk about, what concerns her the most. In his book on Mi, David Rosengren refers to it as "setting the agenda".
My answer is to help the client brainstorm broadly how her life could be better (by her standards), then move toward that by narrowing focus to specific issues/habits/patterns that she can change, while also deepening focus to help her continue to clarify her values/hopes/concerns. I wouldn't only focus on long-term changes, however, but invite her to consider if there are simple things that can reduce some of the pressure/stress while she works toward the longer-term changes she is interested in making happen in her life.
This is a test comment, please ignore
I like the idea of focusing to help find direction. Initially a broader focused conversation helps them think about the big picture (like maybe the long term outcome) rather than the temptation to prematurely focusing on a singular behavior. In our retention work with high school and college students, I find the broader focus in a conversation about the value they place on making it through high school or college is important. Then the conversation can move into one of multiple directions that will result in more short term behavioral change conversations, i.e. long-term career goals, academic issues, financial issues, time issues and constraints related to one or more of these.
I think MI can inform social change. Individual think and group think have some parallels. One group of people (based on identity, nationality, ethnicity, "race," religion...) respond to words similar to an individual and react accordingly. Like you suggest in the "Change is in the Air" activity.
This, I think, is where the dance really takes place. There are so many ways a clinician COULD go, which way is best? The answer - no-one knows in advance. Sure, primal scream therapy and dowsing may not be your first (or last) choice - but there are many things you could do, could offer, all of which might help. But we also know that client choice makes a big difference to outcomes, and so I think this early dance involves sharing with the client the range of things which might prove helpful (building hope and confidence) whilst helping them come to some kind of decision. In CBT this might be done by working with the client to generate a list of problems, and then prioritise them for solving - not a bad way to start. My guess is that in MI this is a more interative process still - perhaps even generating a list of strengths which the person can draw upon. As my son might say....'just spitballling here'. Tim
I wish I undrstood the ununderstood issue......Is it the English or the subtext?
We (the client and I) go where ever he choose within the area I work.
We can go to the track where he points he feels it is most painfull and needs relief and we also can go to the track where he or we assume we will recieve more positive reinforcements (such that fit the commom core values we share).
So what do I don't understand?
Moria
How about this question:
If a client sees five MI counsellors, engages well in 5-10 minutes with each, and tells a story about, let's just say, concerns about his relationship, shoplifiting trouble and an tendency to check the door locks a bit too much, would each of the five MI counsellors proceed down the same path? How might each of them decide what horizon to move towards?
Is that a helpful question? ive been wondering about the answer.
Steve