When health professionals take on the process of motivational interviewing, we enjoy the client-centered paradigm. As we use the skills within the spirit of MI, the client takes a more active role, and therefore change is more likely. We also discover that it allows us to work less hard, the sessions go more smoothly, and we feel more successful. Then there are the moments when things seem to be going well, and a client says, “Just tell me what to do. You are the expert.” If you have fully taken on the spirit of MI, this can be disappointing and even upsetting. This is one of the most common concerns that comes up in my training workshops.
You know how advice is.
You only want it if it agrees with
what you wanted to do anyway.
Be careful what you ask for
because you just might get it!
Let’s step back and take a look at this moment in a client contact. Each client is unique, and this statement, which sounds like a simple request, is most likely not that simple. One way to look at this is what is called “discord” in MI. (Review Tip # 130 for more on discord and how to respond to it.) In all cases, it is useful to take a pause to acknowledge to yourself that something has shifted. I find an extra breath or a gentle sigh is useful.
Find a way to acknowledge this shift to the client. Perhaps this will sound like an apology first. “I’m sorry, I seem to have made some assumptions here.” Or “I hear that my questions do not seem useful to you.”
Offer to back up and discuss how to proceed. You may include a brief summary: “Let’s back up a minute. You called to come in today because you are worried about your blood pressure and want to do what you can to avoid medication. You read up on the web and are well informed about which diet changes will help. So far, you are struggling with how to make these changes since you eat out a lot. Have I got that right?”
Many of our clients have tried to make these same changes before. Knowing this, you may have planned to evoke more of their motivations and what they may have learned from the past. The client may not be aware of the complexity of making lasting changes and may be expressing frustration at all this preparation. This may be a time to offer information about what is true about how people make lasting changes. If you do, be sure to ask permission first: “I’d be glad to share with you what others have found (or research tells us) about how people successfully make permanent changes. Might that be useful?” When you get permission, here is one way to respond: “We find that people are most successful when they take a moment to explore their reasons to make changes.” Or “People often do take specific ideas for change from professionals, AND it works best when they both make sure the person is ready to take on the ideas and has a chance to consider whether each idea will actually fit for them.” Or “I find that when people come up with their own ideas, with my support, they are most likely to follow through.”
Some clients, before you offer them advice, will need a few words about the care you are taking to understand them. A promise to provide the advice soon can go a long way. “I do have loads of information and suggestions for you. I want to make sure they will fit for you. I need your help in sorting out what will work and what will not.” We know that it is more than our gaining understanding of the client. This process evokes change talk (Tip #69). The more change talk the client voices, the more apt he is to make changes.
When you sense the client has agreed to explore more before the advice portion of the session, use open questions and reflections to explore. Depending on what has emerged so far, your questions may guide toward more reasons to change (examples of questions in Tip #60) and/or toward reviewing past successes. For example, “Tell me a bit more about your experience making changes before.” Follow up with elaboration questions such as, “Tell me more about how that worked.” “What happened next?” “How did that feel?”
You may find additional useful examples in Tip #138, Working with Discord in HAES® Counseling.
Here is another perspective on “tell me what to do” statements. Let’s pretend we can look inside the client’s mind as we did in the movie Inside Out. We could get curious about which part of the client said, “Tell me what to do.” We make a guess and voice it, or we could ask. If you think you understand where this came from, you could go out on a limb and state it. This would fit into the MI concept of rolling with resistance. This could be, “I see you want to keep this visit short and to take the information home to consider it.” Or “You’re feeling urgent about making changes for your health.” Or “You’re frustrated with how complicated it seems to make changes.”
Finally, it may be that the client asks to be told what to do because this is a cultural expectation when seeing a professional. In these situations, you can acknowledge this expectation while also inviting collaboration. For example, “I am glad to tell you my opinion about this. I also respect your expertise about yourself (and your child). Perhaps together we can develop a plan.”
When you get such a statement from a client, take care of yourself. It is quite likely that you will feel unsatisfied or off-kilter after such a session. Acknowledge this, to yourself and perhaps to a colleague. Assure yourself that you did the best you could. Then perhaps think of wording you might use in the future, and practice it out loud.