Section III - Narrowing and Focusing on the Target Behavior

 

The Four Processes

Focusing, the second of our four processes of Motivational Interviewing, will be reviewed in the next section.  As an important caveat, the progression in MI is not always one in which we move through a wholly predictable, or linear process.  It is not as though engaging comes to an end and we move invariably on to focusing. 

The Motivational Interviewing practitioner is never to lose sight of engaging.  The therapeutic relationship always remains the top priority in our interactions with clients in Motivational Interviewing.  As the client’s concerns become clearer and we are beginning to hypothesize about what the target of change will be, we start to ask some of the following questions… 

“What is the target behavior? 

“What is helping to maintain the status quo?”

“What is this client ambivalent about?"

We discussed earlier Bordin’s three aspects of positive engagement, but really the agreement on treatment goals is addressed and arrived at within the focusing stage. (Bordin, 1979)   However, when we are focusing, it is not the clinician’s view of what the problem is - and what the change needs to be - but a collaborative process with the client.  The client and the clinician work together to determine what needs to be worked on, and/or what the client willing to work on, reaching some kind of agreement on treatment goals and the nature of the collaborative relationship. This work represents the central component of the focusing phase of the motivational interviewing process, as it defines where the change work is going to occur, from which the action steps will be made clearer.

 

Three Sources of Focus

There are three variables that help to identify the focus of our intervention with the client.  The first of these foci is what the client sees as the focus.  The client might present and say…

“Listen, I just think that really the only problem is that people are giving me a hard time, that people just won’t accept my lifestyle, they won’t accept the fact that I’m smoking marijuana”.

Other times, a client might come in and say, 

“Yeah, I know I need to make this change, I know I need to do things different”.

The second source of focus is derived from the setting where we are meeting with the client.  Sometimes we work in a setting where the focus is very clear.  For example, if I work in a suicide prevention hotline, the focus is going to be safety, or on avoiding self-harm.  In settings working with court-mandated clients, the focus will be at least partially determined by the requirements of the court: abstinence, clean drugs screens, etc.

This second source contains the potential for differences in perspectives that may enter into the shared work of defining the change goals.  The client may not see smoking marijuana as a problem, but within an abstinence-based only substance use treatment program, the client’s goals will differ from those of the treatment setting.  The treatment will then involve working to resolve the differences in the two perspectives by examining them with the client within the MI process.

The third and final source of focus in the clinician’s clinical expertise.  This is where your valued clinical experience comes into play as a significant contributor to the process in which a mutually agreed up target behavior is established – one that improves the well-bring of the client.  Your clinical experience might lead you to see the focus through one lens while the client sees it through another. The focusing process challenges the clinician and the client to come to a place where there is a collaborative agreement that includes all three sources of focus.

 

Three Styles of Focusing

There are three distinct styles of focusing that a clinician can choose from: directing, following, and guiding.  Let’s examining all three styles to learn which style is applicable under what sets of conditions.

Directing is often an approach utilized by a clinician who has an unfettered vision of what the problem is - and the optimal solution for that problem.  The client’s perception of the focus for treatment might be heard, but not fully considered in developing a plan for intervention.

The second style of focusing is following.  This approach might be utilized by a clinician practicing from a genuine, unfiltered, humanistic vantage point.  The clinician’s expertise and insight might be thought to have very little value in the interaction.  The clinician just simply follows the client, while actively listening and going in whatever direction the client seems most interested in pursuing.  This is perhaps the antithesis of the directing style. 

Somewhere between the stylistic extremes of directing and following is a guiding style.  The guiding style is what a Motivational Interviewing clinician aspires to. In thinking about a guiding style of intervention, I like to think of the role of a tour guide.  If I were to book a vacation to visit historical European landmarks, I might seek the assistance of a tour guide.  While the goal of my vacation is to visit these sights that hold great historical importance and I might have a vision, or an idea of the things that I would like to see, I would also rely on the tour guide’s expertise to maximize this experience.  A good tour guide wouldn’t simply tell me what I need to do, or watch me wonder around aimlessly.  The ideal tour guide would walk with me side by side, explaining details, exploring my motivations for making this trip, offering guidance based on their experiences and knowledge when requested.

 

Focusing Scenarios

The clinician and client are likely to encounter several types of focusing scenarios.  The first scenario is when the focus is entirely clear, and the client knows exactly what they need or want to do.  The setting in which the treatment is occurring should be conducive to this focus.  If it is not, a referral should be made to a setting that will be appropriate for this focus. 

Example…

Client- “I am here today because I ended up in the emergency room again, because I let my blood-sugar get out of control.  I know I need to get back into treatment with the Nutritionist and my Endocrinologist.” 

In the second focusing scenario, the client and clinician agree that something needs to change, but also recognize that there are number of different ways to get there. Several options exist, so the client and clinician are challenged with deciding – in a collaborative manner - which target is the best fit, based on time and place, the clinician’s clinical experience and knowledge, and the client’s knowledge about them themselves. 

The client will assist in the process by providing insight on to what they have experienced and/or anticipate to be most the effective course of action.  A structured tool that a clinician can utilize with a client in this second scenario is a ‘bubble sheet’.  The process of completing and discussing the ‘bubble sheet’ is referred to as agenda mapping.  

One example of  a bubble sheet within an agenda mapping format may be found at the following link:    https://www.nicotinedependenceclinic.com/English/teach/SiteAssets/Pages/OLA-toolkit/4-9%20MI%20Cheat%20Sheet%202.pdf

There are several ways in which we can use this exercise.  You may simply provide the client with a sheet with a number of blank circles drawn on, and then ask them to write within the circles some of the areas on which they’d like to focus their treatment.  It could be the things such as physical health, substance use, finances, or employment.  This allows for a visual representation of all of the areas that may be part of the treatment and helps when it is time to prioritize and sequence the change work. After the client has filled out the bubbles, the clinician has the opportunity to add some insight, which might be focused on the setting or the clinician’s expertise.

 

Case Example # 1

Clinician- “I have a sheet here that I was hoping you might be able to fill out with me.  While it might seem pretty silly and simple, it can actually be very helpful for us in figuring out what exactly you are hoping to work on during our time together.  So, what I would like for you to do, is just simply fill in these bubbles with areas that you feel are necessary to make some changes to.”

Mr. A- “Fine, whatever” (Fills in the bubble sheet)

Clinician- “Thank you for taking the time to complete this worksheet. I recognized that you hadn’t included legal problems, would it be okay if I put that in here?  Also, I noticed you hadn’t mentioned substance use, and we’re meeting in the context of substance use treatment, so I think it might be important for us to include that. Would that be okay?”

Mr. A- “Yeah, I guess so. But alcohol is not really a problem for me.”

The clinician may also choose to pre-populate some of the bubbles as to communicate some of the expected foci based on the setting.  For example, if I am meeting with a client for outpatient substance use treatment, I may want to pre-populate one of the bubbles with “substance use”.  While we do this to incorporate the expectations of the setting, we want to always make sure to convey a truly open-minded and collaborative approach to identifying a target behavior.

The third focusing scenario that the clinician and client might encounter is one in which the focus is unclear. 

Client- “You know, I know I need to come in here, I know that there are problems, but frankly I don’t know where to begin, there’s so many different things.” 

I often work with clients often who can relate to the above experience.  They are faced with so many psychosocial needs, that the primary focus of their concern might just be that they do not know where to begin.  The interrelated nature of the psychosocial problems might not have obvious links.  This third focusing scenario, perhaps the most complicated, might result in some glaring examples of differing goals between the agency, client, and clinician.

When goals differ, it is important for the clinician to consider four broad guiding ethical values.  The first of these is non-maleficence or doing no harm.  Not unique to the practice of Motivational Interviewing, this is a guiding ethical principle in the helping professions that directs us to avoid guiding a client towards somebody, something that may result in any type of harm. 

Beneficence, our second guiding ethical principle simply reminds the clinician that, whatever the intervention or direction of treatment, it should not be inspired by any benefit the clinician may experience.  The action should always be for the benefit of the client. 

The third ethical principle is support for the client’s autonomy. Motivational Interviewing clinicians should honor, and support, a client’s autonomy - their ability to make their own decisions.

The final ethical principle is justice.  Recognizing that sometimes whatever challenges might be faced the client, the origination source for those challenges might not come from a place that is entirely just or fair.  At times clinicians may be required to advocate for the client in a way that gives him/her the best option to approach this particular issue.

When providing training in Motivational Interviewing, I am often asked ‘How can I incorporate my clinical expertise in this style that seems to preclude providing my opinion, guidance, or advice.”  This is a common misconception about Motivational Interviewing. MI encourages and values the clinician’s expertise, knowledge, experience, skills, and insights, however through the use of an approach that retains the principles of engaging and respect for the client’s autonomy. 

The model used in MI for providing insights, concerns, advice, guidance to a client is referred to as Elicit – Provide - Elicit (EPE).  We start by asking (Elicit) the client what they already know about the problem, or its solutions. 

Case Example # 2

Mr. B.- “I am here today because I am thinking about stopping smoking.  My doctor and my family are really worried about my smoking and I guess they might have a point.”   

Clinician- “What do you already know about ways in which people most effectively stop smoking?”  

Rather than the clinician providing the client with solutions or options, we start by conveying the belief that the client may already have some valuable knowledge about this particular issue. 

Mr. B- “Well I don’t know much about the different approaches.  I know that one of my friends stopped smoking, after he took a new medication.  I have another friend who swears by this clinical hypnosis program, but I don’t know if any of those things might be good for me.  Honestly, I am not sure what will be helpful for me.  It has been so long since I last stopped smoking.” 

Now that the client has provided us with their understanding of treatment options, I next want to ask for permission to provide them with additional information.

Clinician- “Would it be okay if I share some information with you about the programs we offer that other patients have found to be helpful?”

Mr. B- “Sure!”

The clinician then offers (Provide) them with the information that we have that might be helpful.  In this case perhaps the clinician provides the client with a menu of treatment options that are provided at the agency.

Clinician- “Our program offers, as you mentioned, smoking cessation clinics, where you can meet with a nurse practitioner who can talk to you about medication options.  We also have clinical hypnosis, as your other friend found to be helpful.  We also have some folks who’ve really benefitted from using things like patches, or chewing gum, or lozenges.  So, we really have a variety of different programs here that can be helpful.  Our smoking cessation groups are well attended, and people have mentioned how it has been helpful for them being around somebody who’s able to relate to the struggle that they’re faced with.”

After the clinician has provided the information, they want to complete the process of the Elicit-Provide-Elicit model by asking (Elicit) the client what they make of the information that was shared.

Clinician- “Hearing all of those different options that are provided here at the agency, what are your thoughts?”

Mr. B- “Well, I must stay that I don’t like the idea of taking any more medications than I have to, but I have never really thought about that.  I guess that wouldn’t be too bad.  And I am already coming down here to meet with my other group a few times per week, so I guess it wouldn’t be too much out of my way to get involved with a group.”

Clinician- “You would like to meet with the Nurse Practitioner to talk about medication options, and you would like to get involved with our smoking cessation groups.  Let me take a look at the schedule here and get you set up with some appointments.   What do you think of that?"

Mr. B- “Sounds good!”

In this example, we provided the client with information, but another use of this approach might consist of expressing a concern to a client.  The example below shows a clinician offering concerns with a client followed with providing relevant clinical information.

 

Case Example # 4

Mr. Diamond - “I know you all keep telling me that aftercare is important, but I need to get back to work.  I really need to take care of my family and I just do not have any time in my schedule for treatment.”

Clinician- “Tell me a little bit about what you know about aftercare.  Why might someone like me think it is important for a client to engage in aftercare?” 

Mr. Diamond- “Well I mean I understand why you guys think I should do it and honestly, if I could I probably would.  I know it is not a good idea to go straight from residential treatment, where I have focused on nothing but my recovery for 28 days, to no treatment at all. I just have bills to pay and all of the treatments that I know about happen during my work schedule.”

Clinician- “Going from such an intense level of treatment to no treatment is concerning.  You are absolutely right.  Would it be okay if I shared some other concerns with you?”

Mr. Diamond- “Sure”

Clinician- “I am concerned that without having some plan in place for aftercare, you are not putting yourself in the most ideal position to maintain the gains you have reported to having made in treatment.”

Mr. Diamond- “Yeah, I am worried about that too.  I just don’t know what to do.  It’s not like I can just go home and not work, you know?”

Clinician- “You feel like if there was some type of treatment available that you could participate in and not sacrifice your employment in any way you would definitely want to participate.”

Mr. Diamond- “Yeah, absolutely…but all of these programs you guys are talking about are right in the middle of the day.”

Clinician- “What do you know about programs or other types of support that might be available during non-traditional hours?”

Mr. Diamond- “None really…I guess some AA and NA meetings are on the weekends”

Clinician- “You are right there are AA and NA meetings and I have a long list of meetings throughout the community.  There is also a new “Rehab After Work” program on the other side of town.  There are also several other groups and individual providers in the community that offer some non-traditional hours and childcare.  What are your thoughts about that?”

Mr. Diamond- “That sounds great, I honestly knew nothing about some of those things.”

 

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