MI is not a decisional balance

In their 2009 paper, ‘Ten Things that Motivational Interviewing Is Not’ Miller and Rollnick, noted that one of the things that MI is not is the notion of decisional balance, or what is commonly referred to as the cost benefit analysis. For those unfamiliar with the tool the facilitator or counsellor evokes from the client information relevant to four positions: 1) the benefits of change, 2) the benefits of maintaining the existing problem behaviour, 3) the costs of change, and 4) the costs of staying the same. The real risk in taking an even-handed approach according to Miller and Rollnick is that it can encourage as much sustain talk as it can change talk.

One of the core skills of motivational interviewing is of course to evoke change talk, while minimising or restraining the amount of sustain talk, thereby allowing the person to talk themselves into change. This got me thinking about this tool. It is one I have used in a number of settings for many years. One of those settings is with men who engage in intimate partner violence (IPV). I have found it highly effective in getting a range of ideas visibly on the table (we do it on a whiteboard in a group setting). So how do we use a tool that is useful, while at the same time maintaining the integrity of the MI approach?

The short answer is quite strategically. It is my view that our conversations are never neutral. We bring our own bias, perspective and nuance to the task at hand. I have no desire to reinforce attitudes and beliefs that are likely to increase stuckness with patterns of behaviour that create danger and risk for others. I have come to the view that in fact I don’t need to have a conversation around the benefits of maintaining the status quo or the costs of change. Rightly or wrongly I am making an assumption that these conversations happen with the man’s peers, family and also in his own head. This sustain talk conversation has restrained the man’s ability to engage in change work as he is often fused with intoxicating and dangerous ideas. By shifting my gaze to the more fertile ground of conversations which explore the benefits of change and the costs of maintaining the same behaviour, we can talk to what is often unspoken. This is not to say that men engaging in IPV do not consider these alternative views, frames, or ideas at times, but they do not often have an audience to hear the part of them that wants to enhance the wellbeing of others. This change talk is often in relation to the wellbeing of their children.

Starting with the benefits of change, which in my mind links with strength based practice, allows energy to the conversation and enhances the ability to dream about what life would be like without the problem behaviour exerting such influence. Exploring the costs of the no change then creates a stark contrast and the reality that problem behaviour is never static but a dynamic and ever changing factor. It is either getting worse or better.

I developed a short video clip describing how I work with the tool. Take a look. Would love to hear your thoughts.

Further reading:

Miller, W. R. & Rollnick, S. Ten Things that Motivational Interviewing Is Not, Behavioural and Cognitive Psychotherapy, 2009, 37, 129–140

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