MI Macro Stack #2
Welcome Back to The MI Macro Stack!
In our first post, we described a little about “Motivational Interviewing” (MI), what we mean by “Macro MI,” and our hopes for these writings.
Here, we offer a (very, very) brief sketch of MI, some possible limitations or critiques and responses around traditional MI, highlighting why Macro MI may be helpful for navigating change, and closing with an example application. Next time we will offer overviews of socially engineered trauma (SET) and the “SHARP” (1) framework. Subsequently we will get much, much more deeply into SET, SHARP and what it may mean to be a structurally competent MI practitioner.
First, a very (very) brief sketch of MI:
MI has been described as “a particular way of talking with people about change and growth to strengthen their own motivation and commitment” or “a person-centered counseling style for addressing the common problem of ambivalence about change.” (2) With more than forty years and over 1900 clinical trials later, MI demonstrates its power to positively affect behavior change and, in most cases, the durability of those changes over time. (3) MI remains effective as a stand-alone intervention, joined with other approaches, and as an engagement approach to other treatment. (4) Further, studies have revealed those defined as “least ready to change” experience the largest effect. (5)
According to the most recent formulation, in the 4th edition text, MI is expressed through a well-described heart- and mind-set. This way of being is often called “MI spirit” and is comprised of partnership, acceptance, compassion, and empowerment. We can think of this as an autonomy supportive, prizing treasure hunt stance that conveys “you have what you need and together we will find it.”
An MI conversation is facilitated in a guiding style—in contrast with following and/or directing—using a combination of skills including open questions, affirming statements, reflective statements, and summaries (OARS) across four tasks of engaging, focusing, evoking, and planning. Via MI spirit and skill, a practitioner works with the person about a behavior change as the person sets an aim for themselves. Typically, the practitioner selectively and differentially cultivates the person’s change talk (talk that favors movement toward change) toward the person’s chosen horizon line while softening sustain talk or status quo language and navigating any interpersonal discord.
Confrontation, persuasion, the fixing reflex (the well-intended impulse providers have to install their expertise, advocate for change or control the change process), advice without permission and similar conversation roadblocks are not employed within the context of MI and are considered MI inconsistent behaviors. These sorts of behaviors come not from a strengths-based perspective, but more from a deficit detective assumption that conveys “you don’t have what you need—but, lucky for you, I do!”
Second, what may be possible limitations or critiques and responses around a traditional MI approach?
Despite this ubiquitous success across behaviors and disciplines, MI has been critiqued in a couple of ways. One, some have asserted that MI is merely a way of getting people to do what the “helper,” organization or government instrumentality wants them to do, with compliance or adherence to others’ aims as a goal. (6) Bill Miller, who described MI, has repudiated these claims by referring to such motives as “unethical” when the target of change is not emanating from the individual receiving MI. (7) We could also note that compassion, or prioritizing the person’s needs and benevolently to help them move through and beyond suffering, is a key element of MI style or spirit.
A second critique arises from the MI’s emphasis on cultivating change talk, suggesting that this ignores or glosses over possibly relevant status quo or reluctance talk or structural barriers, and may border on persuasion-in-disguise. However, once a person has expressed a change or growth horizon line to which they would like to travel, the efficient, effective and compassionate thing for a helper to do is be a good guide or partner in this journey. The more a person speaks to their change in preliminary and especially in mobilizing ways, the more likely they are manifest it. From this point of view, spending unnecessary time and energy exploring the downsides of change, reasons to stay the same or dwelling on barriers is counterproductive at best. (8)
A third critique of traditional MI is that it focuses too assiduously on problems placed within individuals, ignoring the larger context, particularly as relates to socially engineered trauma (SET). SET is described as the nonrandom distribution of trauma exposure within an unequal society. Yet, MI may be part of an effective approach to bridge this gap, as described in recent writings that propose macro-level MI applications. Macro MI, as the authors have called it, proposes using the “SHARP” framework. SHARP involves practitioners addressing awareness of structural oppression, historical context, analysis of role, reciprocity and mutuality, and power within the context of therapeutic interactions such as MI. Such an approach centers the person’s experience within their much wider context and opens up effective possibilities for joining toward individual and collective liberation. (9)
Working from the Macro perspective, a practitioner may transcend each of the traditional MI critiques described above. In addition to opening the conversation to consider structural challenges the person experiences, the practitioner can approach with interest and curiosity various imposed instrumentalities from a deeply autonomy supportive and liberatory stance as well as work flexibly with what we often consider status quo or sustain talk (“I can’t do that,” “This is just not important to me,” “There’s really no point in that,” and so on) or discord (“No way and no one can make me do that,” “Who are you people to think you know what’s best for me,” “You don’t understand,” and so on).
These sustain talk and discord language cues may point beyond individual behavior considerations to structural or socially engineered traumas that have relational and collective potential for effective action. For example, “I can’t go to the doctor. And what’s the point, they don’t listen to me anyway,” may sound like sustain talk in a traditional MI conversation yet highlight or express structural challenges and intersectional invalidations that could be explored within a macro conversation. Depending on the provider’s structural competence or openness to macro considerations, these two conversations would be quite different in facilitation, path and result.
Anyway, much more on SHARP and SET in our next post!
Third, an example Macro MI application:
Let’s imagine a concerned parent whose child is struggling with respiratory distress and seeking relief. At an individual level, an examining physician practicing traditional MI may engage the parent skillfully toward a shared understanding and plan for using medications such as inhalers for regular and acute symptoms. The parent may have concerns around medication expense, side effects of long-term use and the ability of their child to use the medication as prescribed. The provider and parent may be able to figure all that out.
A Macro MI approach may look at the larger picture as the provider, parent and child consider a shared focus and path forward. What other factors are present? Do the parent and child live in a place (inside the home or the larger environment) that may be causing distress? If so, what are some more collective paths forward? Joining with other residents for petitioning the building owner/manager around mold or mildew mitigation? Are there other housing options made unavailable to the family that could be challenged or accessed? Are other environmental justice actions or avenues available? Are there referrals to effective action groups or allyships the physician might make? If medication access seems like at least a temporary priority, are there affordability actions the parent might take alongside the provider as a partner in change?
Please join us next time for much more about SET and SHARP!
For now—please enjoy some additional material:
Current Reading Suggestions:
Backtalker: An American Memoir by Kimberlé Crenshaw
Lessons from Cats for Surviving Fascism by Stewart Reynolds (sample chapters: Knock Things Over Strategically, Refuse to Wear Collars, Demand Food with Assertiveness and Take Over Spaces Not Yours)
Art:
Some poses suggest a striving for courtly manners and beauty ideals, as celebrated within those times...and perhaps beyond into ours. Below we see an example of comportment that prized sprezzatura, a contrived insouciance, as well as reinforcing a culture-structure which arguably confined young women affianced as innamorate or platonic beloveds. What is the ongoing cost of such?
Portrait of Young Woman with Unicorn is a painting by Raphael (Raffaello Sanzio), which art historians date to 1505 or 1506
Song:
Quote:
“It was like standing outside a building that is structurally unsound and wondering why the door won’t budge open.
The door is not the problem. The building is condemned.”
Natasha Levinger
Footnotes:
(1) SHARP: A Framework for Addressing the Contexts of Poverty and Oppression During Service Provision in the United States (Shaia, 2019) & Macro MI: Using Motivational Interviewing to Address Socially-engineered Trauma (Avruch & Shaia, 2022)
(2) Miller, WR and Rollnick, S. (2023). Motivational Interviewing: Helping Others Change (Guilford Press) p. 328 and p. 21.
(3) Miller, WR and Rollnick (2023).
(4) Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient education and counseling, 93(2), 157-168.
(5) Heckman, C. J., Egleston, B. L., & Hofmann, M. T. (2010). Efficacy of Motivational Interviewing for smoking cessation: a systematic review and meta-analysis. Tobacco Control, 19(5), 410-416. https://doi.org/10.1136/tc.2009.033175
(6) Andersen, N. Å., & Pors, J. G. (2019). When no is not an option: The immunization against silence in a motivational interview about marijuana use. Social Theory & Health, 17(4), 443-462. https://doi.org/10.1057/s41285-019-00112-1; Carton, T. (2014). The spirit of Motivational Interviewing as an apparatus of governmentality. An analysis of reading materials used in the training of substance abuse clinicians. Sociology Mind, 4 (2), 192-205. DOI:10.4236/sm.2014.42019
(7) Miller, W. R., & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and cognitive psychotherapy, 37(2), 129-140. https://doi.org/10.1017/S1352465809005128
(8) Frey, A. J., Lee, J., Small, J. W., Sibley, M., Owens, J. S., Skidmore, B., ... & Moyers, T. B. (2021). Mechanisms of motivational interviewing: A conceptual framework to guide practice and research. Prevention Science, 22, 689-700. https://doi.org/10.1007/s11121-020-01139-x; Magill, M., Apodaca, T. R., Borsari, B., Gaume, J., Hoadley, A., Gordon, R. E. & Moyers, T. (2018). A meta-analysis of motivational interviewing process: Technical, relational, and conditional process models of change. Journal of consulting and clinical psychology, 86(2), 140. https://doi.org/10.1037/ccp0000250
(9) SHARP: A Framework for Addressing the Contexts of Poverty and Oppression During Service Provision in the United States (Shaia, 2019) & Macro MI: Using Motivational Interviewing to Address Socially-engineered Trauma (Avruch & Shaia, 2022)