In the last three Tips, we have looked at important processes that occur in all motivational interviews. The first three processes – engaging, focusing and evoking – are always present in true MI sessions. The fourth one, planning, ideally does occur, but only if the client is ready and willing.
A good plan is like a road map:
it shows the final destination and
usually the best way to get there.
H. Stanley Judd
The loftier the building
the deeper the foundation must be.
Thomas ã Kempis
It is well known that when a client leaves a session with a concrete, specific plan for change, the change is more likely to occur than if the change has been discussed only in general terms. Further, MI research has shown thatthe more clients talk about their plan the more likely they will do it. So it is part of our job to encourage the process of forming a plan and to reinforce it by reflecting it back and summarizing it. (Tips #95 and #72)
We have lots of experience with food behavior change and have specific behavioral goals easily at our fingertips. It may be tempting to suggest a plan to a client: “How about this week you work on walking at lunch?” or “If you leave off the soda, this would make a big difference.” When the client develops and voices his own plan, follow-through is more likely. We may elicit resistance if our ideas don’t fit for the client. The more resistance the client shows in a session, the less likely the change will happen. (See Tip #59 for effective ways to provide advice.)
So how to do our part of the planning process without eliciting resistance? First, it is important to move to planning only when the client signals readiness. Sometimes this is obvious. For example, when we hear:
- “You know I might be able to get in to work a bit earlier and go to the corporate gym.”
- “Do you think it would help if I cooked at home more?”
- “I like that idea of slowing down to ask myself if I am hungry.”
When we hear these kinds of statements, we can proceed to planning by reflecting what we have heard and asking open-ended questions (Tips #60 and #108) to encourage the client to make the plan more concrete. For example, “Yes, cooking at home would give you more control over food choices. Tell me more about how you see yourself doing that.”
When we are not sure if the client is ready, we can test the waters by asking open-ended questions that may elicit more advanced change talk (Tip #69) than we have heard so far.
Here’s an example of testing the waters:
Counselor: You are worried about your health and want to feel less tired. You know that your low energy is partly because of high blood sugar. You are well informed about carb portions and their effect on blood sugar. (Summary of previous discussion and agreed-upon focus on carb portions) What do you see as a first step? (Key question)
Client: Well, I have kept food records before and it did help me eat less carbs. (Suggesting a focus for change)
Counselor: So you are able to keep track of your carbs and you know it helps. (Reflection of ability) What might you do this week? (Open-ended question to evoke more specific change talk)
Client: I have a new phone app and it can tell me carb portions. I could start putting my food in it. (Ability statement)
Counselor: So your plan is to use that new app this week. (Reflection)
Here the counselor has gone out on a limb by reflecting an ability statement as commitment. If the client does indeed feel ready to make this commitment, this will reinforce it and the plan has been made. If the counselor has gone too far, the client will correct her.
Client: Well, I don’t know about that. This is going to be a crazy week with travel.
Counselor: I hear that this is not the ideal week to begin using that app. What do you see yourself doing this week? (Rolling with resistance and asking another open-ended question)
Client: Well, I haven’t really checked it out yet. I know I have time do that when I’m waiting for a flight. I’ll play with it to get the hang of it. (Continuing with the same focus and taking a smaller step)
Counselor: So you’ve decided to experiment with the app this week so you are familiar with it. (Reflection)
Client: Yes, I like the idea of figuring out how it works. (Talking himself into change)
To complete this conversation, the counselor will summarize again with the plan at the end. The more times the client says change talk or hears it reflected back, the more likely he is to change. (Tip #72 has more detail on summaries.)
Often a client will seem to commit to a plan that seems too big or vague. For example, if a client says she will “exercise more,” that is too vague to be compelling. To encourage a more specific plan: “Tell me more about how that will look,” or “Run me through your week to see where it will fit in.”
Some clients seem to resist every suggestion and even change the subject when we ask open-ended questions to elicit commitment to a plan. If there is time, the counselor will reengage by going back to summarize whatever change talk was voiced. There may be a way to refocus on a new topic and evoke more change talk. If time runs out before any plan is formed, the counselor will summarize what has been discussed with attention to what little change talk emerged and then ask permission to open this discussion again in the future.