In the third edition of Motivational Interviewing Miller and Rollnick (2013) state:
…change is often not a linear process. Motivation to initiate and persist in change fluctuates over time regardless of the person’s stage of readiness. From the client’s perspective, a decision is just the beginning of change” (p. 293). Some changes happen quickly, like setting a quit date to stop smoking; but many changes “require sustained attention and effort over time. (Miller & Rollnick, 2013, p. 294)
So helping people develop a change plan is just the beginning of an ongoing process of making long-term, permanent lifestyle changes in service of the goal of health and wellness.
In addition, there are often setbacks in the process of change. In the addiction treatment field this is often referred to as a relapse. Unfortunately that language has become infused with many negative connotations, including the idea of a revolving door “client” who goes to treatment over and over again, and is then labeled as non-compliant. This person then becomes the “resistant client.” This perspective is not consistent with the spirit of MI, which emphasizes the idea that the change process is not a linear one, because ambivalence and motivation fluctuate in a person’s life. So setbacks on the road to permanent change or re-occurrences of the “target behavior” are seen as normal and not a reflection of a person’s identity or lack of “willpower.”
The supportive, non-confrontational, non-pathologizing approach of MI can support people’s persistence in their efforts to make difficult behavioral and lifestyle changes in their lives as long as we remember the person-centered skills (accurate empathy, unconditional warmth, and genuineness) underlying the counseling strategies of MI and continually support the person’s ownership of the change process.
Miller and Rollnick (2013) emphasize the importance of “flexible revisiting” by re-engaging in the 4 processes of MI: 1) Engaging; 2) Focusing; 3) Evoking and 4) Planning (p. 297). Their strategies for supporting and sustaining change include:
Perhaps the most common aspect of flexible revisiting in the change process is to re-engage in the collaborative development of a revised or new change plan that isn’t working. The same methods used in the initial planning phase are appropriate in replanning. The idea is to investigate what is working and what is not working then ask, “What could be tried instead?” (p. 297)
Sometimes the obstacle to sustaining change is the re-emergence of ambivalence or loss of confidence in ability to which often expresses itself in vacillating commitment to the change goal established in the change plan. It can be helpful to re-evoke DARN change talk and remind people about their reasons for change. A recapitulation summary of the change talk previously stated by the person might be useful if it prefaced by, “Let me see if I can remember the reasons you gave me for making this change…” In addition, revisiting the importance ruler might be a helpful reminded of the person’s values and why it is important to make this change in spite of how difficult it might be (pp. 297–298).
Sometimes people’s priorities change and the original change goal turns out not to be a priority anymore. If this happens, then the goal itself needs to be adjusted and the clinician needs to refocus the conversation in order to explore values and clarify the new goal (pp. 298–299).
When a consumer seems to be disengaged (e.g. misses an appointment) it can be helpful to return to the fundamental MI skills of OARS to re-initiate contact and to reengage the consumer in the therapeutic conversation about their needs and desire for support in making change. It is very helpful to get feedback from consumers after each session regarding their experience in the session and what was helpful or supportive. This communicates your intention to keep him or her in the center of the conversation. Another way to reengage consumers is to schedule a follow-up visit with them after the initial consultation period has ended (p. 299).
Clinical Scenario Flexible Revisiting of the Change Plan: Bob
During the initial consultation with Bob, a 42-year-old, married engineer, he expressed clearly that he wanted to stop drinking. He reported that he had been drinking heavily on a daily basis for many years, but the drinking was interfering with his relationship with his wife. This relationship meant more to him than anything else in his life. Bob clearly had a behavior change goal in mind so the focus of the conversation was to clarify the next step for him and discuss obstacles. He was willing to commit to his plan of reducing his drinking by one or two drinks the first week, then another one or two drinks the next week until he quit completely.
Bob was able to follow-through on his plan the first week, but then his drinking picked up to previous levels. So the conversation shifted to replanning. We worked on revising the specific steps he was willing, ready and able to take in order to achieve his goal of quitting drinking. The revised plan included seeing his PCP about the possibility of outpatient detox and medication to ease his cravings and to call the inpatient detox program at the local hospital to find out more about their program. Bob was an anxious guy and felt quite ambivalent about going to the hospital.
With each follow-up visit Bob became more and more clear in his own mind that he could not stop drinking on an outpatient basis. He entered the detox and then began attending AA as part of his continuing care plan. During our final consultation he expressed his commitment to regular attendance at AA and reported that his relationship with his wife had improved a great deal. We met a total of 6 sessions.
Right from the start, Bob had a clear goal in mind, however, the specific steps to achieve his goal of abstinence were not working. So my goal was to engage in “flexible revisiting” with Bob around the specific steps he might be willing to take in order to achieve his goal. In the spirit of MI some of those conversations required focusing the conversation and helping Bob resolve his ambivalence, not about quitting drinking, but what steps he would take to get to his goal. For example, he expressed a great deal of ambivalence about going to an inpatient detox program. So while the goal was clear I was mindful of the need to refocus on helping Bob resolve his ambivalence about going to the hospital. Once we climbed to the top of the mountain of ambivalence with regard to going to a hospital, the walk down the other side of the mountain happened quickly and smoothly.
This completes our third class lesson.
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