Paul Burke Training Group
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Beyond training: Looking at learning MI in a whole new light!
Thoughts on Improved Practice (TIP) #1708
The “spirit” (or “context”) within which an MI conversation can emerge yields a number of “vital signs” which, when all operating and synchronized, facilitate the purpose or intention of this form of “motivational midwifery”. Evidence of partnership is one such vital sign
MI “…is not something done by an expert to a passive recipient; a pupil, a master to a disciple. In fact, it is not done “to” or “on” someone at all. MI is done “for” and “with” a person. It is an active collaboration between experts. People are the undisputed experts on themselves. No one has been with them longer, or knows them better, than they do themselves . . . . The method of MI involves exploration more than exhortation, interest and support rather than persuasion or argument. The interviewer seeks to create a positive interpersonal atmosphere that is conducive to change but not coercive.” (MI-3, Miller & Rollnick, 2013, p. 15)
A Few Thoughts on “Treatment Compliance”
These days, at almost every MI workshop I facilitate, someone asks if we can do some role play work involving the issue of “treatment compliance”, or “medication compliance”, depending on the setting for the training. That concept needs to be wrestled with a little, in order to understand its relationship to MI generally, and more specifically, to core MI practice (promise) of partnership/collaboration.
An online dictionary offers some hints as to why the concept of compliance pokes at my value system a little when it comes to MI work. For example, it says that compliance is “the act of conforming”, or “a tendency to yield readily to others, especially in a weak and subservient way”. It goes on to suggest that compliance is an act of acquiescing; of conformity, and of “obedience”.
Yikes!
I suspect that most of us would prefer that our clients/patients make decisions about their behaviour and their health based on internal motivations, and not because of a need to “obey” their helper! Most of us would not want our clients to behave in a “weak or subservient way”. To the contrary, those who practice the art and science of Motivational Interviewing work hard to support the autonomy of our clients. We look for every opportunity to affirm their competencies, and not to highlight or pay undue attention to their shortcomings, or weakness. MI is all about understanding and empathizing with people’s motivations (motives) for engaging in various behaviors. It is not about finding ways to bend people to the will of a treatment provider, or of a treatment plan.
When a client/patient is not following through on a previously agreed-to treatment regimen of some kind (regular use of a prescription medication, involvement in a counselling program, or doing recommended physiotherapy exercises at home every week, between appointments), the critical issue in MI work is to examine the “motives” behind such lack of follow-through. People engage in change when they are (1) ready to, (2) willing to, and (3) able to. These are the three critical ingredients that, together, create motivation to pursue a specific change, even when that change is adherence to a treatment plan. Thus, when a client is faltering a little (or a lot) with follow-through on a plan for which they previously showed commitment, the helpful question is not “why is this person not obeying?” Rather, when it appears that a client has become motivated to break their adherence to any sort of planned action, it’s important for a Motivational Interviewer to explore “what motivational obstacle is getting in the way of my client sticking with this plan?” Is it:
- that she is not ready to engage with this strategy (meaning, perhaps, that she has lost her awareness of its importance, or that other variables in her life have become more important and are now taking priority for her)?
- that she is not willing to continue the treatment protocol (meaning, perhaps, that she has identified a down-side to continued engagement, and an upside to discontinuing)
- that she is not able to adhere to the regimen – for any of a huge menu of reasons including such real challenges as lack of money, lack of time, competing demands for her attention, clinical depression that has triggered fatigue, lethargy or lack of hope
Really, when it comes right down to it, “failure to comply” simply means that the motivation for continuing has been turned to the “off” position. When that is the case, there is always a reason, and only very rarely is it because the client has decided to frustrate you into an early retirement! Likewise, “non-compliance” rarely implies that the person has no interest in achieving success by overcoming the problem s/he is working with you to address. It means that something has come along that has gotten in the way of staying on track. There’s been an obstacle on the path somewhere along the line. Working with your client to discover that obstacle (readiness, willingness, or ability), rather than trying to force compliance and subservience, is the what
partnership is all about. It’s the “stuff” of Motivational Interviewing, and it’s a wonderful way to develop empathy for your client’s perspective, when her motivational switch has flipped to “off”.
Sadly, I often hear folks in workshops explain that they hope that learning MI will help them to “get better compliance”. These people often have an obvious tone of defeat in their voice, and they almost always seem frustrated – sometimes, seemingly, to the point of exhaustion. Years ago, I was conducting a workshop for a group of folks who work with people with Type II diabetes, someone in the group said “I just don’t know what to do anymore. I’ve tried everything I can think of to talk this patient into complying with the medication regimen that her doctor has ordered.”
Amongst the learning group, we debriefed the situation a little. We decided that in the next meeting with the patient, it might be helpful to “try on” the useful MI posture of “intense curiosity”. The idea there is not to assume that it is logical for the patient to comply, but instead that, for some unknown reason, it has become logical for this patient not to comply! The useful track, that can then guide the way you interview the client, then begin to center around things like:
- What is the downside for this client in staying on top of this plan?
- What is the upside (through her eyes) for not following-through? (These two questions help to determine what might have to be done to “tip” the scales of ambivalence in favor of getting back on track.
- How important is it for her to get back on track (the Importance Ruler works well here, as this helps assess whether or not more awareness, patient-education, or consciousness raising is needed)
- How confident is she that she can, indeed, get back on track and maintain long-term followthrough (The Confidence Ruler can work well here to surface any kind of ability obstacle that may be getting in the way).
Taking a collaborative approach to working with clients who have fallen away from a previously agreedupon plan of action means exploring, listening, understanding, inquiring, encouraging, supporting, reengaging, focusing, evoking, and planning. And – that’s a whole lot of verbs!
Yep – working to help people get back on track, or to adjust the track, if that is part of the
problem, is more work than warning, threatening, cajoling, persuading, and brow-beating! Giving people a darned good talking to is easy – but it’s rarely effective! It eventually spawns frustration – for both you and your clients! The antidote is helper curiosity. It involves walking alongside your client in an atmosphere of safety, respect,
autonomy support, empathy, and compassion while your client explains the logic behind her decision to break with the treatment regimen that she previously agreed to undertake.
Until next week …
Paul Burke Training & Consulting Group (www.paulburketraining.com)