What a challenge this common conundrum is - when a client insists that you 'just tell me what to do!'. When it comes to engaging in a sound Evoking process - this is a surefire derailment.
Given the evidence is clear about the unhelpfulness of advising ambivalent clients, how do we skilfully reply?
In this issue we will be spending some time exploring how Motivational Interviewing may encourage us to respond to this request in a manner most likely to open a more fruitful discussion for our client's benefit.
Read on to colour in some context to this question, learn about when giving information is good work and what we might do when it is NOT such good work.
February's Issue 36 introduced the concept of 'change language' and the first steps in working with this important aspect of dialogue with clients. Readers were encouraged to start by simply identifying Change Talk in their client's speech and to simply reflect it and ask for elaboration. This vital aspect of client perspective is at the core of the third process of Motivational Interviewing: Evoking. In this issue we will be exploring more about getting Change Talk alive and kicking in session. It is so obvious it seems too simple........just ASK FOR IT!
If you are feeling stuck with a client who is clinging to the status quo in their dialogue with you – it may prove fruitful to have a look at what you are asking for.
In January's Issue 35 we explored the Righting Reflex - the part of us that wants 'good things' for our client and the paradoxical impact this desire may have on promoting unhelpful behaviours for our ambivalent clients.
We can manage our Righting Reflex by many skillful means. One such means is being able to attend to the 'change language' of our client. In this issue we are going to take a toe dip into what we mean by change language to equip you with some starting points if you are practising implementing MI into your counselling skill repertoire. Read on for more...
This editorial will be picking up the thread from Issue 33 in October which was the last newsletter to be exploring Focusing - the second process in Motivational Interviewing.
Once you have found a useful direction for a session with a client, what follows next? I am going to be exploring how things can quickly derail from this point, even though we have the very best intentions. In fact, maybe because of our best intentions! Puzzled? Read on for more.
This issue is our last for 2016. Keeping with tradition of 2014 & 2015 this edition collates a synopsis of the year's issues with handy links to each issue's full editorial and completes with a CPD Quiz. You can buy the quiz to test your knowledge and for APDs - convert your dedicated reading of Practice Pavestones into assessed CPD hours for your APD renewal.....just around the corner.
But I have some sad news folks..............this will be the last year that the CPD Quiz will be published for subscribers unless there is a big increase in uptake. Do you have APD mates who are struggling to fill their assessed CPD hours for 2016? At $9.95 the 2016 Pavestones Quiz would have to be the most affordable assessed CPD on the market - not to mention fun, useful and super practical.
Please support Pavestones by sending on to APD colleagues who may be looking for great value assessed self-study in this vital area of clinical practice.
Read on to get a great summary of the years content and link to the Quiz...
This is the last issue exploring the second process in Motivational Interviewing: Focusing. I will be presenting two different styles for finding a meaningful session direction with your client.....and a soundtrack featuring a canine friend who just can't seem to find one! You can play with some focusing templates available as downloads in the editorial. What's your Focusing style? Tick a Box or Free Fall? or something unique to you?
In any modality of behaviour change counselling we need a direction, something to focus on with our client in order to be producitve. What is particularly emphasised in Motivational Interviewing is the HOW and the WHY of finding a focus.
In the HOW, MI encourages that it is very important that we find direction collaboratively with the client. Asking the client what matters to them and what they would appreciate help with is central to demonstrating the spirit of Motivational Interviewing.
The HOW of Focusing may sound pretty straight forward. Something has brought your client into your office and so we may assume they have something they want to focus on with us. Well, as they say: 'It ain't necessarily so!'.
Last week I received a fabulous question from a subscriber which brought a possible Focusing challenge to life. With her permission I will share her question here:
Could you please direct me to a past issue of Pavestones that might look at how to move forward with client who says they are 'doing everything but not getting results' but who I suspect isn't [doing everything]?
How on earth do we stay along side our client and find something to work on when they present as 'all good' and we have well founded concerns things are not going so well? Read on to find out more.
Once we have joined with our client in a strong engagement it's time to do something directional. This issue we are going to be exploring how to shift gears from the process of Engagement to the process of Focusing without crunching the gear box and bunny hopping through a session.
Download this issue to found out what the clutch sounds like and for a few more cheesy metaphors!
For those of you that are just joining the conversation, we are currently exploring the first process in the Four Processes of MI introduced back in Issue 28. This important starting point for MI is referred to as Engagement and we completed an introduction to what this really means and what helps it to happen last issue. Engagement is much much more than a friendly warm greeting.
Have you ever considered that your 'job' may get in the way of you doing good work? In this issue we are looking at how some of our workplace requirements and role expectations can really limit our effectiveness in facilitating behaviour change by blocking client engagement. While taking a look at these challenges I will be exploring some alternative ideas and options to consider. Read on to learn more and have a laugh at Christopher Pyne....
Engagement – what does that actually mean?
I wonder if we can take for granted that we understand what 'to engage' our client means?
Here are some synonyms of the verb 'engage' from Prof Google, to expand and bring this word to life.
Capture ….catch ……….arrest ….seize……… draw ……..attract ……….captivate ……hold….. grip…… engross…… occupy …….absorb
When I first read through this list I was struck by how dynamic these words are. Full of energy, activity, purpose and intent. In our work with a client, engaging is not simply the warm up chat we do before getting to the advice bit.
So what energy or 'spirit' are we using when we are engaging our client and what is our intention and purpose?
Read on to find out more, consider some sample questions that embody this purpose and spirit and appreciate some reflections about engagement from colleagues.
This issue was in part inspired by a skillful supervisee who came to supervision curious about the impact of working on increasing her reflections in client sessions. Her concerns were more of a hunch than anything concrete; a sense that she may not be holding the purpose of the session clearly enough by engaging in more reflective listening. Was something being lost or diluted in the work via the impact of reflections? Was she at risk of jumping up and down on the spot with the client?
This is such a useful enquiry for our consideration and very timely. I had earmarked the next chapter of issues to commence an exploration of the uniquely directive nature of Motivational Interviewing best encapsulated by the Four Processes of MI. So let's jump in and find out some more.........
This issue's editorial will be wrapping up our 'Question Series' commenced back in Issue 21 September 2015. This chapter of issues has presented different views of the power of well considered questions with some enthusiasm. To reinforce our balanced perspective, I will be discussing some cautions in the tale of buoyant questioning as we close the discussion today.
Last issue we spent time exploring how questions can be used to seek exceptions to a problem behaviour. Uncovering these exception experiences can reveal overlooked or dismissed resources. Reconnecting our clients to these resources is a powerful intervention that can reinforce our client's competence and autonomy in the change process. If you'd like to have a quick revision you can access Issue 25 below
Sue Zbornik APD demonstrated a beautiful application of the exception idea at her Appetite Workshops in February. I invited Sue to contribute to this issue and talk a little about this special form of conversation she has with her clients.
Read on to engage with this wonderfully creative application of the 'Exception Question'
So let's see, in Issue 24 we spent some time thinking about directive questions that pull out our client's preferred future by eliciting resources, strengths and visions of change. Broadly called 'Solution Focused' questions these types of questions are a powerful tool in the kit bag of behaviour change therapists.
Travelling along a similar vein in this issue, I am inviting exploration of questions that look for exceptions to the problem. These types of questions may offer a much more subtle and client focused alternative to imposing a new thought about change. 'Exception Questions' may do this by inviting the client to sift through their own experiences with a lens that captures times when the problem has been less of an influence.
Read on to explore more about what this angle of enquiry may have to offer your clients and what it may sound like in session...
I'd like to start with a story from a book I am currently enjoying. The story is called 'The Dog I Feed Most'. It goes like this:
A Native American elder described his inner struggle in this manner: 'Inside of me there are two dogs. One is mean and evil; the other dog is good. The mean dog fights the good dog all the time'. When his grandson asked him which dog won, the elder replied: 'The one I feed most'
From: 101 Solution Focused Questions for Anxiety. 2015 Fredrike Bannink
In this issue we are exploring what sort of questions 'feed the good dog' in our client? ......questions that elicit information that is of most benefit to our client's forward movement and successful behaviour change process.
Following in the footsteps of the first anniversary edition this issue collates a synopsis of the year's issues with handy links to each issue's full editorial. Due to the popularity of the 2014 CPD Quiz a 2015 CPD Quiz has been included in the Purple Pavestone box at the end of the issue summaries. You can buy the quiz to test your knowledge and convert your dedicated reading of Practice Pavestones into assessed CPD hours for your APD renewal.....just around the corner. Please support Pavestones by sending on to APD colleagues who may be looking for great value assessed self-study in this vital area of practice.
As mentioned in the wrap up of last issue, this editorial will be exploring in more detail the formulation of open questions and we'll get some practice in converting closed to open questions using handy word stems.
'Word Stems' for Open Questions
Typical choices for getting your questions off to an open start include:
This is in contrast to these typical closed question openers:
Read the rest of the issue to consider some examples of using these word stems in effective open question formulation
For a stunning 'Captain Obvious' I'll start with this definition of a question from The Oxford Dictionary:
a sentence worded or expressed so as to elicit information.
Pretty straight forward. But do we stop to think what kind of information is most beneficial to our client to elicit?
Most health professionals receive lengthy training in assessment and are well rehearsed in asking questions. But what about asking questions with purpose beyond our intake form? If a primary focus of client centered work is to explore our client's ideas and experience, how can we be aware of the type of questions that can open up exploration and those that can close it down?
To answer this, it can be helpful to consider questions in two basic classes: Closed and Open. Let's take a quick tour of the difference and pros and cons of each. Download this issue to find out more
A central tenet of client centered work is that the client’s understanding of themselves and their lives is privileged over what the counselling professional may think or believe they ‘know’ about the client. The client is considered the expert in their lives.
This core idea can guide all aspects of our communications with our client. This includes the skill of affirming. When we focus on our client's ideas and knowledge of their strengths and positive qualities we are potentially opening up a powerful new aspect to this very helpful micro-skill. We are inviting co-creation and autonomy in affirming.
You may be able to hear the invitation for autonomy and co-creation in affirming in this quote from Motivational Interviewing 3rd ed :
‘The spirit of MI starts from a [….] strengths-focused premise, that people already have within them much of what is needed, and your task is to evoke it, to call it forth. The implicit message is ‘You have what you need, and together we will find it’ p21
Miller and Rollnick
So, in this issue we are exploring merging these two principal MI ideas:
Calling forth the client's knowledge and emphasising their autonomy (this reduces resistance and enhances empowerment in the change process)
Affirming our client's strengths (this increases hope and confidence to change)
Read on to discover more about this powerful skill mash up!
For those of you who are seasoned practitioners, you will be familiar with the very bumpy road that is characteristic of our clients' behaviour change process. If you are new to facilitating change in others I am sure that a minute of self reflection will confirm that even (or particularly!) for ourselves, 'being' different and 'doing' different is hard work requiring energy, focus and commitment.
It is not uncommon for our clients to share 'problem saturated stories' of repeated experiences of failure, lack of hope or even reluctance to be visiting our office to meet with us. It can be a genuine challenge to our skill of affirming to seek out our clients' strengths to reflect back to them when there's seemingly nothing 'going right'. The paradox is of course, that this can be a powerful time to do it. Demonstrating our willingness to notice capacity and capability in our client when they cannot see it for themselves can be a strong alliance builder.
So where to start?
I recently had a series of very humbling experiences.....listening to recordings of myself at work with clients. I was required to record several client sessions to analyse my skills for a training application that was due this month. In this process of listening and self analysis (and with mentoring from my Skills Coaches), I discovered that my affirming needed some work.
One thing I was surprised to learn is that when I engage in affirming I can sometimes inadvertently ask a question by ending the affirmation with an upward voice inflection. Easily done (especially if you are an Aussie). Not necessarily harmful but also not particularly helpful.
These recent experiences of mine got me thinking about this next issue. Now that I have lead the way, I thought we might explore ways that we accidentally stuff our affirmations up.
Quick Menu of Affirmation 'Stuff Ups'
Here's a wee check list of three easy ways we might go off track when trying to practise the skill of affirming:
Download this issue to read some examples of what these 'stuff ups' may sound like and some strategies for correcting them...
In Issue 16: Working With Our Clients' Strengths, I finished up with the following suggestion for reflection:
If you are new to affirming you may like to practice by:
Following on from a group discussion in the last training workshop, I thought it may be valuable to list some examples of strengths and attributes we may encounter in our clients.
Below is a list you may like to consider and reflect on. It is largely inspired by 'The Library of Strengths' in Stephanie Dowrick's book Choosing Happiness (Penguin 2007). Download to contemplate more.....
For most people struggling with change, being really heard is a very encouraging and positive experience. Past issues of Practice Pavestones have featured lots of discussion about the power of reflective listening in assisting our clients this way. Affirming takes the skill of reflective listening one step further to amplify the positive effects of being heard and understood.
In the course of a session, clients can say an awful lot to us. What we select from our clients' statements to reflect back to them can have a real influence on our client and the direction of the conversation in session. As we become more skilled at active listening we can become more deliberate in what we highlight to our client in our reflective responding.
Affirming is the intentional act of reflecting back to our client something about:
Here's a great definition from David Rosengren:
'Affirmations are statements of appreciation for the client and his or her strengths. ....The statements are strategically designed to anchor clients to their strengths and resources as they address their problem behaviour' p 62
When we affirm, we sift through our clients dialogue and actions and creatively highlight aspects of forward movement. To read more on what this may sound like and the practitioner attributes involved go for the download!
In this issue we are going to be exploring a little about clients who talk more than others and the challenges this may place on our practice of reflective listening.
We are all familiar with the scenario. We invite our client to speak and within a short period of time we are getting that uneasy feeling.........'whoa...where is this going?' . We may start to panic, there is time to keep, the next client will be here in 15 minutes, we need to 'get to the point' but we know the value of reflecting and attending. It can all get us a bit overwhelmed.....
It can be very hard to know what to attend to and what to reflect when the client has done the metaphoric, story-telling equivalent of turning their handbag upside down and letting gravity work its magic. Or man-bag. It would be dangerous to assume that it is only our female clients who can be the talkative ones.
A Strategy to Consider
There are many reasons why some clients talk a lot. One is anxiety. Meeting with a Dietitian or talking about stressful behaviours can be extremely anxiety provoking. Long and complex stories are often a symptom of a hyper-aroused state and can be (unconsciously) functional in providing a great distraction.
Anxiety in our client is important to acknowledge as it points to some ways we can be helpful in this situation. Here's a handy acronym to get a handle on things:
Read on to find out more
Responding reflectively to our clients can be a challenging skill to develop when we are trained in advisory and solution focused models. In the counselling skills training group this week we brainstormed together all of the possible road blocks to reflecting with our clients.
Here is a summary of what was collated:
To bring these road blocks to life, let's consider how these challenges may appear in response to the following client statement:
'My last diet resulted in me gaining 5 kg more than I started with. It was a disaster.'
Read on to learn more.........