Motivational interviewing – the tension points

Finding the rub

Attending the International Symposium on Motivational Interviewing: Beyond an Effect Size: Innovations in Thinking & Practice, was such a stimulating experience that it got me thinking about where MI sits in relation to other approaches. Is MI an approach out there all by itself? Is MI the precursor to others things? Is there a right way to do MI and are those of us that bring into play other approaches (narrative, strength-based, cognitive behavioural theory, mindfulness) fudging it and undermining the integrity of the key ideas. At the heart of MI are reflection, noticing, and elicitation. MI is about a way of being with people that recognises their autonomy, self-directedness, and inherent strength. The approach is based in the humanist traditions of collaboration, evocation, compassion and genuineness.

It is the edges where theory and approach rub up against each other in practice that is really interesting. The friction caused leads us to think about, debate and clarify theory as well as practice.

In my view the following six areas where the interface does not sit easily are:

1. When MI is used as an entrée to interventions – one of the debates is around what are we motivating people for? Is it for an overall aspect of a change within a person’s life (e.g. a healthy lifestyle – an overall change), to change an aspect (e.g. drinking) or to create a willingness to engage in another piece of work (e.g. attend an intervention). Do we therefore do MI then forget about it when we have engaged the person? The latter would clearly work against the spirit of MI which is as much about an approach to the work, as a technique.
2. Maintaining integrity of the MI principles – any approach can be watered down and lose its integrity. As people move further away from the people who developed the ideas, don’t have feedback on the correct implementation of the ideas, and are not supported to maintain best practice, then slippage in integrity occurs.
3. Who sets the direction?  MI is a directional process that assists the person to move through the change process toward a goal. It is encouraging evocation of beliefs and ideas that are supportive of change (change talk), a new direction, or new set of behaviour. One of the challenges in MI is around the degree of self-directedness versus other-directedness. Who sets the direction and focus of the change? At times many of us are required to hold a line around the focus. For example, I need to work with men who are abusive in their relationships and work from within the frame of family safety. Sometimes the clients’ goals can be different from the goals of others. A partner might want a man to develop a separated and caring relationship with their children. He might want to be back in the relationship. Where does MI come into play is shaping for change and where do we have to holding the line when the direction may appear to diverge.
4. New and older kids on the block – where does MI and other approaches fit. It takes time to work through how different approaches fit with each other. Approaches have their own history, ideas, basis and bias. Taking the time to carefully consider ‘added versus detracted value’ is a task that I don’t see enough reflection around.
5. What happens with limited time and resources? One of the debates is whether or not MI is a luxury in terms of time and resources. I would argue that we waste significant time on working ‘on’ people rather than working ‘with’ people. We are asking people to trust us with their inner-most thinking. This is something that is not our right to expect by the nature of our position but needs to be gained through our behaviour.
6. Finding room for the views of others – is motivation all about individual intrinsic motivation? (Another blog is coming around this issue). How much is our own motivation a product of the motivation of others? Accountability-based approaches work on the practice of ensuring that the views of others are incorporated within the conversation. How much does current MI practice reflect an individual-centric rather than family-centric approach? These are questions that really interest me in particular coming from a narrative tradition.

As a result of attending the ISMI symposium I am now committed to exploring these ideas in much greater depth. I am looking forward to conversations around these issues with you and others. What do you think? Love to hear.

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