Facilitating Discrepancy Copy

Topic Progress:

According to Miller and Rollnick (2013) change happens when a person perceives a significant discrepancy between important goals or values in their lives and the status quo or the current situation. In order for a discrepancy to enhance motivation to change it must be big enough to encourage change, but not too big so it overwhelms the person’s ability to make change (p. 254).

Facilitating discrepancy is an aspect of focusing the conversation in the MI method that is particularly useful and important when you are working with people who are in the pre-contemplation stage of the stages of change (i.e. don’t see that there is a problem or express no desire to change the health risk behavior), they are unable or unwilling to identify a target behavior that they are willing to discuss or they have identified a target behavior, but express a great deal of ambivalence about changing that behavior.

There are a number of strategies in MI that are useful in facilitating discrepancy.

Strategies to build discrepancy include:

  1. Explore goals and values: identify goals and values that are in conflict with the health risk behavior; clarify goals and values that are in conflict with the health risk behavior; amplify goals and values that are in conflict with the health risk behavior
  2. Exchange information about the effects of the health risk behavior in a permission-asking way
  3. Provide feedback about the health risk behavior in a non-judgmental way
  4. Explore others’ concerns about the consumer’s health risk behavior (Miller & Rollnick, 2013, pp. 243–254)
  5. Explore the pros and cons of the health risk behavior

One simple strategy for information exchange from MI that is particularly useful in brief interventions is Elicit—Provide—Elicit (Miller & Rollnick, 2013, pp. 139–145).


Motivational Interviewing for Brief Intervention Settings • Elicit — Provide — Elicit

ELICIT

Ask permission — Ask what the patient/client/consumer knows or would like to know or if it’s okay if you offer them information.

“What do you know about…”

“Do you mind if I express my concerns?”

“Can I share some information with you?”

“Is it okay with you if I tell you what we know?”

PROVIDE

Provide information in a neutral, non-judgmental fashion. Avoid “I…” and “You…” statements.

“Research suggests…”

“Studies have shown…”

“Others have benefited from…”

“Folks have found…”

“What we know is…”

ELICIT

Elicit the patient/client/consumer’s interpretation or understanding of the information.

“What does this mean to you?”

“What do you make of this?”

“Where does this leave you?”

Tips for Using Elicit—Provide—Elicit

  • Use Neutral Language as much as possible and avoid jargon.
  • Avoid sentences starting with “I” or “You”
  • Use conditional words rather than concrete words — “might,” “perhaps,” or “consider” vs. “should” or “must”
  • Utilize the “Spirit” of MI
  • When “instructing” is necessary, recognize “where” your patient/client/consumer is and only provide relevant advice/information
  • Give small amounts of information with time to reflect
  • Acknowledge the freedom for the patient/client/consumer to disagree
  • Present what you know without interpretation

 

Example of E—P—E with a Person Who Smokes

ELICIT

Ask what the patient/client/consumer knows or would like to know or if it’s okay if you offer them information:

“What do you know about the effects of second-hand smoke on children?”

“Is it okay with you if I share what we know?”

“Would you be open to learning more?”

“Do you mind if I express my concerns?”

“Can I share some information with you?”

PROVIDE

Provide information in a neutral, non-judgmental fashion.

MI Consistent Response
“Research suggests that second-hand smoke is especially harmful to children because…”

Non-MI Consistent Response
“Every time you smoke around your child, you put them at risk…”

ELICIT

Elicit the patient/client/consumer’s interpretation or understanding of the information.

MI Consistent Response
“What does this mean to you? What do you make of this?”

Non-MI Consistent Response
“It’s obvious from this information that you need to quit.”

Adapted from: MotivationalInterviewing.org

Another strategy to facilitate discrepancy is to explore the pros and cons of the status quo (i.e. engaging in the current health risk behavior). A decisional balance sheet can be a handy tool to help explore the pros and cons of the status quo and also the pros and cons of changing. It is important to note that as more more recent research on how MI works has found that clients have better treatment outcomes when they express more change talk than sustain talk in sessions and that a decisional balance might actually evoke more sustain talk than change talk if both sides of the ambivalence are explored equally (Miller & Rose, 2015). So if you do a decisional balancing exercise with clients, remember to focus more on the cons of continuing the health-risk behavior and the pros of change, which will elicit more change talk. A variation on the pros and cons is the strategy of “Looking Forward,” which helps people clarify their values and goals.

Decisional Balance for Smoking Crack

Benefits/Costs of Continuing to Smoking Crack

What do you like about smoking crack? (Benefits)

What are the not so good things about smoking crack? (Costs)

How has smoking crack stopped you from doing what you want in life? (Costs — Looking Forward)

Benefits/Costs of Quitting

What would your life to be like five years from now if you quit smoking crack? (Benefits — Looking Forward)

What would be hard for you if you quit smoking crack? (Costs)


The Stressed-Out Drinker: Facilitating Discrepancy in a Screening, Brief Intervention, and Referral to Treatment (SBIRT) Interview Video

This 9-minute interview demonstrates a number of MI strategies including giving feedback in a non-judgmental way, a variation on E—P—E information exchange, and exploring the pros and cons of drinking as a means to facilitate discrepancy between this consumer’s drinking and her goal of alleviating stress in her life. As you watch the video, jot down some of your thoughts about how the clinician used OARS and the above strategies to facilitate discrepancy and guide the conversation toward the possibility of change.