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Beyond training: Looking at learning MI in a whole new light!
Thoughts on Improved Practice (TIP) #2313
Dr. Miller and his colleague, Dr. Gary Rose, co-authored a paper entitled “Motivational Interviewing and Decisional Balance: Contrasting Responses to Client Ambivalence”. The e-version is now available from the journal “Behavioral and Cognitive Psychotherapy” (Call # RC489.B4 B45). The hard copy of that article is also in print.
In my opinion, this is one of the most important pieces of research concerning MI that’s been written since MI-3 was published (by the way … the FOURTH edition of the MI text is about to be published! It will be out in August).
Why is the decisional balance research so important to our work with clients? Here’s why — because in my review of the published research on the issue, Drs. Miller and Rose are definitely saying that doing Decisional Balance (DB) work with a client who has not yet made a decision to change could be harmful to the client. That’s a heavy-duty statement, but it makes good sense on an intuitive level. So – let’s explore the idea a little bit.
Before 2013, and back in the days of the previous version of the main MI text (MI-2), Motivational Interviewing was defined as “a client centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence” (p. 24, italics added here for emphasis). Last year, when the MI-3 version of the text came out, the reference to ambivalence resolution was removed.
And for good reason. The authors of this important review of research outcomes related to decisional balance work state that “as a therapeutic procedure . . . decisional balance seems to be both theoretically and empirically indicated with ambivalent people when the goal of treatment is to foster change” (p. 8). Such is not the case, they note, when working with clients where there is no pre-determined outcome, or goal, at the end of the metaphoric rainbow.
Thus, there is simply no need for Motivational Interviewers to be ambivalent about the process of doing “pros and cons” work with people who are ambivalent (or even pre-contemplative) about making positive change. The cons of doing the cons-of-change simply make doing such work a useless exercise, at best, and possibly even a harmful one (p. 9), at worst. This fascinating new journal article explains how, and why, it is that “research to date rather consistently shows that for people who have not yet committed to change, a decisional balance [exercise] can significantly decrease goal commitment and subsequent behavior change” (p. 8).
Many of us used to think that if someone was ambivalent, it meant that they were in the process of “weighing the pros and cons” of change. That part, the literature suggests seems to be true. What is not true, however, is the idea that helping people explore the downside of change and the upside of maintaining the status quo in any way helps them to resolve ambivalence. Miller and Rose point out that “from an MI perspective, if evoking the client’s self-motivational reasons for change is the path out of ambivalence, then causing the client to voice arguments against change would seem to be contraindicated” (p. 2).
When I first learned MI (going back to 1994 and the MI-1 version of the text – just to date myself here!), I was taught how to systematically and routinely help clients who were contemplating change to think through (and even record) a thorough list of “pros and cons” to pursuing a potential change. The thinking was that clients need to go through such a process with the “pros and cons” – in order for the decisional balance scales to tip in favor of change (that is, so long as the change was a good one in terms of adding value to the well-being of the client). It seemed to make sense in theory. In practice however, it was often the case that as my clients heard themselves thinking and talking about the downside of changing – the decisional balance tipped in favor of just such a “no-change “decision! Not exactly what I was shooting for in the name of a “motivational” counselling session!
In retrospect, I have to ask myself “why was I doing anything to cause my clients to focus more on the “no” side of the argument?
Miller and Rose explain that:
The strategic emphasis in MI is on differentially evoking clients’ change talk – their pro-change arguments – and responding to any expressed cons of change (sustain talk) in a way that respects but does not strengthen them. DB and MI, therefore, represent two contrasting approaches that differ primarily in the extent to which one would intentionally evoke and explore the client’s motivations against change . . . from the perspective of MI, eliciting counter-change arguments would be counterproductive (p. 6). in the same way that “We can stand up” was ability for all.
It makes good sense to follow the advice of these two researchers when they tell us that with clients who are already ambivalent (e.g. those who are contemplating specific changes), the way to encourage change is to evoke change talk by exploring the “upside” of change. The wisdom in working to favor the pros of change is reflected in Miller and Rose’s statement that “giving equal weight and airtime to pros and cons would be contraindicated if the goal is to promote change” (p. 7).
Oddly, and an equally fascinating aspect to these new findings is that decisional balance work does seem to have a positive impact on people once they have already made a decision to change!
“So – what the heck is that all about”, you may ask. I queried that too, and the answer that Miller and Rose provide makes very good sense as well. But – that’s fodder for a future T.I.P. For now, suffice it to say that when a person is committed to changing, and when you then ask him or her to talk about the downside of pursuing that change, s/he will often argue even more adamantly that the earlier decision to pursue the change was a good one! It appears that people can become even more strongly motivated to pursue a positive change if they hear themselves defending their decision to launch into the change in the first place!
One of the things I like most about MI is that it does not come from theory. After twenty years in print, we are now on our third version of the MI text and on our third definition of what this thing is all about! A fourth edition (2023) is expected to be published any day now! The practice of MI and the explanation for how it works changes and adapts to the findings of new research and other evidence that constantly evolves. As new evidence is discovered that might inform and influence the practice of this approach, its developers, William Miller, and Stephen Rollnick, have the humility to embrace the need for change. For that reason, MI is an organic, living, and ever-learning approach to helping. It’s a way of helping that adapts as it goes – all for the purpose of becoming more efficient and effective for those that it serves.
See you next week! Call or e-mail me anytime!
Team Leader,
Paul Burke Training & Consulting Group