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Thoughts on Improved Practice (TIP) #1938
Sometimes, it’s just not possible, or ethical to use a “pure MI” stance with a client. Sometimes, the guiding and steering functions of MI should not be engaged – especially when neither the helper nor the client know the best direction to pursue! In such cases, learning to poise yourself in such a way as to give equal attention to both the pros and cons of the argument for AND the argument against change is the only way to help a client resolve ambivalence. Once the client has evolved her ambivalence into a decision, then MI can kick in again, and the two of you can move forward in a specified direction e.g. the direction decided by the client in the equipoise phase of the conversation.
“Equipoise” in MI work (eck-wah-poyz)
So – let’s examine two questions related to Equipoise work in MI conversations:
- What is the “Equipoise” stance in MI work? and
- In what circumstance would an MI helper assume an equipoise stance?
Guiding client’s in the direction of positive and healthy change is a laudable thing to do when it is obvious as to what constitutes “positive” for the client. Such is almost always the case when your client:
- Is not taking a necessary medication as prescribed,
- Is consuming alcohol or other drugs with painful and dangerous consequences.
- Your jailed client is not sure he has what it takes to give up his involvement in gang activity so that he can be a better role model to his kids.
- Is a teenager who knows that her bullying behavior is wrong, and yet is having trouble escaping the pressure to conform to the norms set by her bullying peers.
The “guiding” stance that is so central in most M.I. work is easy to adopt when the direction the conversation needs to take is obvious. Sometimes however, the positive choice, the right choice, or the healthy choice is much more difficult to determine. This is especially true in the early stages of an MI conversation. Consider, for example, the following situations:
- A 50 year old father and business-owner can’t decide whether or not to fire his son who is a manager in the family business. He says that son recently stole a significant amount of money from the company
- A married couple (Mary, age 38, and Don, age 29) are arguing a lot these days and they say their marriage is in serious trouble. Don wants them to have their first baby this year, and Mary has just begun a new degree program that will require her full time commitment for the next four years. At the same time, she is concerned that her “biological clock” is ticking.
- Catherine is thinking of writing her daughter, Katie, out of her will. Catherine recently gave Katie a large sum of money to buy a new house so that the grandchildren would be able to grow up in a home close to their Grandma. Katie accepted the money, but now is planning to buy a house in another province because she has a new boyfriend there. Catherine is angry but feels bad about how the impact her decision to take Katie out of the will may have on her other two adult children.
- Trina is 5 months pregnant with her first child. She has developed a life-threatening illness, and the doctor has told her that she may die within the next 2 months if emergency surgery is not done immediately. Trina has been told that if she has the surgery now, there is only a very slim chance that the baby will live. If she waits another 8-10 weeks, the birth has a good chance of success, but Trina’s illness may have progressed to a “hopeless” stage by then.
- Mike had an affair on his wife four years ago. She knows nothing about it and due to the unique circumstances, his wife will likely never know. Even so, Mike says that his guilt and shame are becoming overwhelming. His wife has always said that the marriage would be over, without any discussion, it she ever heard about any infidelity on his part. Mike says, “I feel damned If I do and damned if I don’t”.
In MI-3 (2013, p. 231-242), Miller and Rollnick describe a helping stance that can be taken in such situations. The term for counseling people when a clear “best choice” is not available, or at least obvious, is “equipoise”. It means “equaling out” or bringing balance to conflicting positions. The less formal term for this approach to helping people resolve their ambivalence about two or more options is “counselling with neutrality”.
As part of motivational interviewing for healthcare, adopting an equipoise stance allows professionals to support clients in exploring their own motivations without steering them toward a predetermined outcome.
When using an equipoise stance, the interviewer “stays neutral”. In fact, the interviewer works very hard to “stay out of it” – while the client wrestles with the pros and cons of the various decisions and the consequences of each of those decisions.
Adopting an equipoise stance involves the helper reflecting back to the client, with “equal weight”, both the pro and con side of an argument about a potential change. At the same time, when practicing equipoise, the helper gives equal reflection of the upside and downside of maintaining the status quo (not changing).
For those pursuing a certificate in motivational interviewing, understanding when and how to apply an equipoise stance is an essential skill that can be particularly useful in complex decision-making scenarios.
The “Equipoise” approach is the logical way to be helpful when the client is “stuck” in their thought process and can’t decide, one way or another, what motivation is the right motivation in a particular situation. Sometimes, maintaining a balance between the various options by rigorously maintaining an equipoise posture can be much more useful, and ethical, than taking on the guiding/directional work of MI.
Counselling with neutrality is not a typical, or usual posture in MI work. Normally, MI helpers know the general type of motivation and the nature of the change that they are wanting to enhance. Still, in some situations, it is important to help a client resolve their ambivalence and come to a decision about changes around which we, frankly, have no business being involved. Of course, the directional work of MI kicks in once a clear decision has been made by the client. At that point, we can switch into MI mode and help guide the client toward the plans and the goals they establish.
A few tips about how to initiate equipoise:
- Know that the decision to “stay neutral” means “staying out of it”. Even though you may have an opinion about what you think the client ought to do, you can choose to “stay out of it”.
- You know that you are “staying out of it” when you ensure that you are reflecting with equal weight, both the pros and cons of a given option; when you are not favoring one option over another.
- Always share with your client that you intend to give them “ a darned good listening to” and that your intention is to avoid influencing their decision in any way (so that they know what to expect, and not expect from you in the way of advice).
Be sure that it is ethical for you NOT to have an opinion in the matter at hand. (Staying neutral about a decision where the client is trying to decide whether or not to suicide, or to abuse a child, is not an ethical/appropriate place to assume the equipoise stance).
For those seeking Motivational Interviewing Consulting, working with an experienced professional can provide valuable insights into balancing guidance with neutrality in complex cases.
See y’all next time! (Remember – you’re welcome to call, anytime, with questions or ideas for future T.I.P.s).
Paul Burke Training & Consulting Group (www.paulburketraining.com)