Making real, lifestyle change is tough and usually involves many steps and setbacks. To make the permanent changes we recommend takes persistence on our client’s part and ours.
If you do not change direction,
you may end up where you are heading.
It may be that when we no longer know what to do
we have come to our real work,
and that when we no longer know which way to go
we have come to our real journey.
The mind that is not baffled is not employed.
The impeded stream is the one that sings.
It is tempting to think of motivational interviewing as useful only in the first stages of work with clients. Once change has begun it’s easy to focus only on the specifics of the change, such as recipes, shopping lists and cooking processes. Real change is rarely so linear that we can let go of the client-centered, collaborative process and expect good results.
How can we support our clients through the sometimes messy process of real change? When the client’s behavior slips it is human nature to look at this as “all or nothing,” either perfection or complete relapse. We can reframe “relapse” as a setback to learn from. When the client says he “blew it,” we can respond, “That’s interesting. What might we learn from this experience?” Unexpected obstacles do come up and we can normalize this. Perhaps the changes led to unintended consequences that will need to be worked through. For example, a spouse or children may react in non-supportive ways. Perhaps the client has yet to shift his sense of self to include the new behavior. For example, in order for exercise to become consistence and persistent, the client will need to see himself as someone who exercises, not just someone who is doing it for the time being.
Here are some other things to do to help clients for the long haul:
Replanning: When the client comes in saying the plan formed at the last session didn’t happen it’s time to revisit the plan and redo it. There may be a need to reframe first as described above. Then, rather than going right into advice for getting back on track, (Tip #65) ask the client for his ideas and review his resources. It is just as important to carefully do the planning process in a collaborative fashion in the tenth session as it is in the first.
Refocusing may involve moving beyond successful plans to new ones that move the whole process along. You might offer a summary of the first plan and how it has become a habit and then ask, “If there were another change you are ready for, what would it be?” Sometimes things have changed in the client’s life or it’s a new season and it’s necessary to refocus on a new goal or behavior. Refocusing may also mean shifting to a smaller step. Even when both you and the client believed that the chosen plan was realistic, life may have intervened to make it harder than expected. Rather than giving up, you could offer, “Perhaps there is a small step that you are ready for that will move you toward that goal.”
Re-evoking the client’s commitment can be important when working with clients long-term. Doing this in an MI manner would mean avoiding such language as, “But you said that you…” or “Let me remind you that…” Instead you remind with respect, “Let me see if I remember the reasons you told me in September tell me how they sound now…” Or “Remind me what you hope to get from making this change.” You could also redo the importance scale (Tip #76).
It may be tempting to let go of the spirit and style of MI after working with a client for a while, especially if the change process seems to be going well. For example, you might fall into a more directive style of giving advice. Consistently using the Elicit, Provide, Elicit format (Tip #59) supports ongoing change by evoking client solutions. Also, resistance will be less likely. Continued affirmation throughout our work strengthens confidence and persistence.
Engagement (Tip #115) can slip at any time during our work. Attend to warning signs which may feel like resistance (Tip #130). There are some ideas for beginning a discussion of this “discord” in Tip #103). You can then ask for input on how to be more supportive.
MI assumes that all change is client change. Continued use of the skills and spirit of MI increases likelihood clients will take ownership of their own change process.