Engaging is the first of the four processes in MI (engaging, focusing, evoking, and planning) and lays the groundwork for the first session and the sessions to follow. And as you likely know from experience, engagement can occur with some clients in a matter of minutes, and with other clients, it may take more than one session. There can be lots of reasons for the length of time it takes to engage with the client, and many that are out of the control of the clinician. For example, it may be the culture of the organization where you work, or the client may come to the session feeling very fearful, angry, or confused.
The products that come from engagement usually include the client returning for more sessions, and the development of a working relationship between the client and clinician. And when there is a working relationship, many times there is an favorable outcome for the client. In order to create this working relationship, there are several factors to be aware of as you begin the process of engaging. Miller and Rollnick talk about early “traps” a clinician can fall into, and should become familiar with, before the first session begins. These include:
The Assessment Trap
Clients can quickly become alienated from engaging with the clinician if they experience or believe an “assessment” is required prior to receiving treatment. And as a clinician, it is good to remember that we are able to support and be present with the client even without a lot of information. Below is an example of how a clinician can create a controlling relationship by asking the client many questions that result in short answers:
Interviewer: You’re here to talk about your gambling, is that right?
Client: Yes, I am.
Interviewer: Do you think that you gamble too much?
Client: Probably.
Interviewer: What is your favorite game?
Client: Blackjack.
Interviewer: Do you usually drink when you gamble?
Client: Yes, I usually do.
Interviewer: Have you ever gone seriously into debt because of gambling?
Client: Once or twice, yes.
In this example provided by Miller and Rollnick, there is a dynamic being established by reinforcing the client to provide short answers rather than allowing the client to elaborate on their own experiences, feelings, or thoughts. It also offers little opportunity for the client to come up with their own motivations for change and what might work best for them.
The Expert Trap
If the “Assessment Trap” is initially established with the client, it will typically lead to the “Expert Trap” where the clinician is usually seen as the one in control of the session, and that once the clinician collects enough information, they will have an answer/solution for the client. This kind of relationship may be beneficial in acute medical care, where there is a clear power differential between the provider and patient, but not so much when the goal is personal change and you want to collaborate with the client and remind them that they are the “experts” of their own experience.
The Blaming Trap
Another situation that can come up in the initial session is that the client can blame someone else or find fault for the challenges they are experiencing. A great deal of time and energy can be spent listening to the client if this issue arises in the session. I have found Miller and Rollnick’s approach to this scenario to be highly effective in my work with clients. They talk about saying to the client, “It sounds like you’re worried about who’s to blame here. I should explain that counseling is not about deciding who is at fault. That’s what judges do, but not good counselors. Counseling has a no-fault policy. I’m not interested in looking for who’s to blame, but rather what’s troubling you, and what you might be able to do about it.” Again, you could adapt this statement to fit your unique style, and perhaps make it more appropriate to the situation, but the key is for the client to spend more time on coming up with their own solutions.
Again, these are several factors to be aware of as you began the process of engaging with the client. It is all practice as no two clients are ever the same. However, having some basics and ways to think about certain situations, especially when thinking about the initial session, can be helpful. We will continue our blog series next month on “conversations about change” and will discuss, listening, which is one of the most fundamental skills in MI. I hope you all have a great month and have opportunities to use and practice Motivational Interviewing!
For more information about Motivational Interviewing resources, contact Eunice Akinyi Okumu, by phone (919) 843-2532, or by email, eunice_okumu@med.unc.edu