Motivational Interviewing Questions: Responding to Discord

I believe it is important to start by discussing how Motivational Interviewing initially thought about disharmony between a client and a clinician as they explored change. When the first edition of Motivational Interviewing: Helping People Change by Miller and Rollnick was released, the term “resistance” was chosen to represent the phenomenon of disagreement, tension, or “not being on the same page.” The key here is that that the responsibility for disharmony in the therapeutic relationship was almost always placed on the client, and never the clinician. However, “discord” can sometimes be caused by our mood or approach. Perhaps like any other human being, we may feel tired, stressed, overwhelmed, or distracted, and may bring some of these experiences into our sessions with our clients. It may also be that we, as clinicians, are working harder than the client, wanting change to occur badly for the client, and/or we are trying to move the client along faster than they are ready.

The way it was suggested to respond to this “resistance” was to “roll with resistance” by reflecting what the client was saying, perhaps asking an opened ended question about their concern, and to explore this “resistance.” In the most recent edition (3rd) on MI by Miller and Rollnick, they have used the term “discord” to describe this phenomenon that can exist between the client and clinician. It is important to note that “discord” involves both parties and that it is like a fire (or at least smoke) in the therapeutic relationship.

Interestingly, responding to “discord” in an MI-consistent way is similar to how we have been talking about “change talk” and “sustain talk” in that we often reflect back what the client has said, ask an open-ended question, and spend some time exploring what could be occurring in the relationship. For example, if the client was questioning an age difference between you and them, a sample response from Miller and Rollnick may look something like this:

CLIENT: How old are you? How can you possibly understand me?

CLINICIAN: You’re looking for some support, and you’re not really sure if I’m the right person to provide it.

CLINICIAN: If someone was able to help and support you, what would they ask you about or what would it look like if someone was able to understand you?

Again, in this example, there appears to be some concern on behalf of the client that may signal some “discord” in the relationship. At the same time, if we, as the clinician, step on our client’s toes or say something that was insensitive or perhaps hurt the client’ feelings, we can simply say we are “sorry.” It acknowledges and models that we are taking responsibility for our actions, that we are invested, and that this relationship is important. Examples from Miller and Rollnick include:

“Oh, I’m sorry, I must have misunderstood you.”

“It sounds like I must have insulted you there.”

“I didn’t mean to lecture you.”

So, when there is “discord” we need to remember that it involves both parties and that the focus is on the therapeutic relationship and not the behavior. However, the way we respond in an MI-consistent way is similar to how we respond to “change talk” and “sustain talk” by reflecting back what the client has said, asking an open-ended question, and spending some time exploring what could be occurring in the relationship. And by responding in this way, it is likely to keep the client engaged in the possibility of change and increasing trust in the therapeutic relationship.

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For more information about Motivational Interviewing or related services, contact Steve Bradley-Bull, LPC, by phone, (919) 812-9203, or by email, unc.cfar.mi@gmail.com.

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