Motivational Interviewing: Elitist and Judgmental?

I never thought I’d have to defend MI…

…but I appreciate any opposition to allow me to express my beliefs and ideas about behavior change coaching. First, motivational interviewing is not a magic bullet.

It is my goal to help physical therapists, clinicians, students, and coaches get better at coaching behavior change.

As clinicians are becoming more and more of a frontline healthcare provider, I believe there is a missed opportunity in the clinic to help people with behavior change.

I've also hitched my wagon to motivational interviewing, as I think it is a unique methodology for framing dialog around change talk. Although not new, of course.

READ ON BELOW VIDEO.

In his post, he talked about how MI can ironically lead coaches to be elitist and judgmental.

This idea is absolutely true if, as a coach, you let it.

A straightforward rule defeats this idea. I offer the long upheld practice of don't be an asshole.

I first want to say, I've followed Dr. Ben House for a while now and appreciate his insights, he posts some cool stuff, and he has a sick tattoo sleeve if you haven't checked it out head over to his page.

While I agree with some of his ideas, I also don't agree with some others. Most importantly, If you head over to his IG thread, you'll see some more of his ideas about this, and he's pretty open-minded.

In his post, he talked about how MI can ironically lead coaches to be elitist and judgmental. This idea is absolutely true if, as a coach, you let it.

A straightforward rule defeats this idea. I offer the long upheld practice of don't be an asshole.

It's conceivable that like anything, MI taken to an extreme can lead to a religious-like vernacular and cult-like behavior.

One MI practicing coach could scoff at another coach's style, "why would you give advice? That's NOT MI! That's so against behavior change coaching. Let the client take the lead!."

From my understanding, his point here is that coaches can be elitist and judgmental of other coaches. But, practicing MI with a patient or client is quite the opposite. I believe Ben knows that.

Which leads me to my next point in Ben's post, "I'm sorry to say this to your teddy bear, but it doesn't outperform advice as well as you think."

To which, my argument is that knowledge without action is still inaction. On top of that, giving advice IS apart of MI. How do we know for sure that "advice alone" versus a "MI specific clinical method to enhance personal motivation for change" has better outcomes or outperforms the latter? We don't know for sure. If anyone has any literature that I'm unaware of, I'd love for you to please share!

Ben continues that MI is a relatively "convoluted methodology built for subjects who have high ambivalence and low desire to change."

I don't think there's anything convoluted about it. Once you understand the principles or spirit of MI, even if you are sloppily engaged in conversation, you would always be steering the person back to an active role in seeking their actions towards change. It's only as complex as you make it.

I do agree with Ben that it CAN backfire…

…if you don't know how to manage someone's expectations. If someone has a very high level of ambivalence and low desire for change, then exploring their ambivalence could very well change their level of desire for change within a 15-minute session.

On the other hand, if someone has low ambivalence and a strong desire for change, you may very well jump straight on the advice train and help them plan for change. If someone is ready, willing, and able for change and ready for action, but you just continually asking open-ended questions, yeah - you will make some people angry.

But, what is the opportunity cost here for using the principles of MI?

I don't particularly see it as a start to finish "technique" necessarily. (Neither do Rollnick and Miller.)If you are great at actively listening, reflecting, and communicating in a client-centered narrative - you can get there. But, think about those patients and clients who were "really difficult" or "not following through on their home exercise program," or, "not following your advice."

In my experience, here is what I have found most useful in trying to get better at motivational interviewing. I have found the endeavor alone has made me recognize when and when not to find time to engage in behavior change coaching.

With practice, it has helped me listen for change talk and guide people to hearing and enhancing their intrinsic motivations to change. I don't really think these days; "now I'm doing MI. I'm sitting down and doing MI." You start asking the right questions with curiosity and accurate empathy, and before you realize it, the person has opened up, and you are on your way to guiding them to action.

At the end of the day, it's about understanding the ebb and flow of the approach and maintaining the principles of MI throughout the dialog.